Decreasing Trends in Intestinal Resection and Re-Resection in Crohn's Disease

Abstract

Objective: To assess time trends in intestinal resection and re-resection in Crohn's disease (CD) patients. Summary of Background Data: CD treatment has changed considerably over the past decades. The effect of these advances on the necessity of intestinal resections and the risk of re-resection is unclear. Methods: In this nationwide cohort study, adult CD patients with ileocolonic, small bowel, colon, or rectum resections between 1991 and 2015 were included. Data were retrieved from the Dutch nationwide network and registry of histopathology and cytopathology (PALGA). Time trends were analyzed with a broken stick model and Cox proportional hazard model with smoothing splines. Results: The identified cohort comprised 8172 CD patients (3293/4879 male/female) in whom 10,315 intestinal resections were performed. The annual intestinal resection rate decreased nonlinearly from 22.7/100,000 CD patients (1991) to 2.5/100,000 (2015). A significantly steeper decrease was observed before 1999 (slope −1.56) as compared to subsequent years (slope −0.41) (P < 0.001). Analogous trends were observed for ileocolonic, small bowel, and colon resections. Overall cumulative risk of re-resection was 10.9% at 5 years, 18.6% at 10 years, and 28.3% at 20 years after intestinal resection. The hazard for intestinal re-resection showed a nonlinear decreasing trend, with hazard ratio 0.39 (95% confidence interval 0.36–0.44) in 2000 and hazard ratio 0.25 (95% confidence interval 0.18–0.34) in 2015 as compared to 1991. Conclusion: Over the past 25 years, intestinal resection rate has decreased significantly for ileocolonic, small bowel, and colonic CD. In addition, current postoperative CD patients are at 75% lower risk of intestinal re-resection.

Decrease in primary but not in secondary abdominal surgery for Crohn's disease: nationwide cohort study, 1990–2014

“…Studies from Denmark 12,13 , Manitoba 8 , UK primary care 14 and the Netherlands 15 have all reported decreasing rates of intestinal resection for CD over time. The Dutch group even noted decreasing surgical rates for all anatomical locations and repeat resections during the entire period.…”

“…The Dutch group even noted decreasing surgical rates for all anatomical locations and repeat resections during the entire period. Of note, the incidence of surgery was, however, based on an estimated, rather than known prevalence of CD in the Netherlands 15 . Other studies have reported conflicting data.…”

“…Population-based studies [3][4][5][6][7][8][9][10][11][12][13][14][15] of the incidence of abdominal surgery for CD have shown conflicting results, although a decreasing trend was most often reported (Table S1, supporting information). However, the incidence of specific surgical procedures for CD and the risk of repeat surgery remains unknown.…”

Intestinal resection rates in Crohn’s disease decline across two different epidemiological areas: a consistent observation not merely due to introduction of anti-TNFα

“…1 Despite the difference in the source of data between both studies (Canada: health administrative data and the Netherlands: nationwide pathology database), a declining rate of intestinal resections in Crohn's disease has been confirmed in Canada, at equal rates as the decline that has been observed in the Netherlands. 2 The authors used an advanced statistical method to analyse the impact of anti-TNFα introduction on (among other end points) the rate of intestinal resection. However, in our opinion, the hypothesised direct relationship between introduction of anti-TNFα and a decline in intestinal resection rate is vastly oversimplified for two important reasons.…”

“… 1 Despite the difference in the source of data between both studies (Canada: health administrative data and the Netherlands: nationwide pathology database), a declining rate of intestinal resections in Crohn’s disease has been confirmed in Canada, at equal rates as the decline that has been observed in the Netherlands. 2 …”