Early versus late surgery for ileo‐caecal Crohn’s disease

Abstract

Summary Background Surgical resection is almost inevitable in Crohn’s disease. Surgery is usually performed for refractory or complicated disease: no studies appear to have been carried out, so far, to evaluate the potential benefits of performing surgery early in the course of the disease. Aim To compare the long‐term course of Crohn’s disease following ileo‐caecal resection performed at the time of diagnosis (early surgery) or during the course of the disease (late surgery). Patients and methods Overall 207 patients with ileo‐caecal Crohn’s disease at their first resection were reviewed: 83 patients underwent surgery at the time of diagnosis (early surgery), while 124 underwent surgery 54.2 months (range 1–438) after diagnosis (late surgery). The mean follow‐up after surgery was 147 months (range 12–534). The primary endpoint was clinical recurrence, defined as need for corticosteroids for symptomatic disease in the presence of endoscopic and/or radiologic recurrence. Secondary endpoints were need for immunosuppressants and surgical recurrence. Statistical analysis: Kaplan–Meier survival method and Cox proportional hazards regression model. Results Within 10 years after surgery, the cumulative probability of clinical recurrence was significantly lower in the early surgery group (Log Rank test P = 0.01). A trend was observed regarding the need for immunosuppressants (P = 0.05). No difference was observed regarding surgical recurrence. At multivariate analysis, early surgery was the only independent variable associated with a reduced risk of clinical recurrence (Hazard ratio, HR = 0.57; 95% CI 0.35 to 0.92, P = 0.02), but not with need for immunosuppressants and surgical recurrence (HR = 0.51; 95% CI 0.20 to 1.30, P = 0.15; HR = 0.66; 95% CI 0.33 to 1.35, P = 0.25, respectively). Conclusion Early surgery prolongs clinical remission compared to surgery performed during the course of the disease, but the natural history of disease is not modified.

Clinical literature review of 1858 Crohn's disease cases requiring surgery in China

“…In complicated cases of CD, surgery at an early stage is a valid alternative to other types of medical therapies. According to a study of 207 patients with CD, early surgery prolongs clinical remission compared with surgery that is performed during the course of the disease within 10 years of the disease onset [30] . The complexity and heterogeneity of the disease and the different options for medical or surgical treatment are all so diverse that it is even more important to discuss each case in multidisciplinary clinical conferences.…”

Early Crohn disease: a proposed definition for use in disease-modification trials

“…Two trials have evaluated the use of early surgical intervention 39 40. This idea has limited appeal because it permanently alters the gastrointestinal physiology and function.…”

A changing trend in the management of patients with newly diagnosed Crohn’s disease

“…Another limitation of our study was the non-availability of genetic markers related to disease behaviour and outcomes. Genetic factors including NOD2, IL-23R and ATG16 genes have been implicated in CD and to a lesser degree in ulcerative colitis [25][26][27][28]. These factors, however, do not account for the striking rise in the incidence of IBD seen over the course of the twentieth century raising a strong possibility for an environmental hypothesis in IBD [29].…”