Risk of surgery in the era of biologics

November 9, 2021

Issue 21

Clinical Question

Have biologics changed the risk of surgery in IBD?

Editor’s Bottom Line

The outcomes of IBD, as measured by requirement for surgical intervention, have improved over time. However surgical rates remain high and more work is still required improve the course of IBD.

Reference

Tsai L, Ma C, Dulai PS, et al. Contemporary Risk of Surgery in Patients With Ulcerative Colitis and Crohn’s Disease: A Meta-Analysis of Population-Based Cohorts. Clin Gastroenterol Hepatol. 2021;19(10):2031–45; https://doi.org/10.1016/j.cgh.2020.10.039

Synopsis

This systematic review included 44 population-based cohort studies reporting abdominal surgery rates 1, 5 and 10 years after a diagnosis of either ulcerative colitis (UC) or Crohn’s disease (CD). Data were divided by diagnosis before or after 2000, when biologic agents were introduced to clinical practice.

The overall risks of colectomy 1, 5, and 10 years after an UC diagnosis were 4% (95% Confidence Interval [CI], 3.3–5.0), 8.8% (95% CI, 7.7–10.0), and 13.3% (95% CI, 11.3–15.5), respectively (P<.001). The risks of colectomy at 1, 5 and 10 years dropped to 2.8% (95% CI, 2.0–3.9), 7% (95% CI, 5.7–8.6), and 9.6% (95% CI, 6.3–14.2), respectively, after 2000. Disease extent, geography and patient sex did not affect colectomy risk estimates in UC.

Among patients with CD, the overall 1-, 5-, and 10-year risks of abdominal surgery were 18.7% (95% CI, 15.0–23.0), 28% (95% CI, 24.0–32.4), and 39.5% (95% CI, 33.3–46.2) (P<.001), respectively, falling to 12.3% (95% CI, 10.8–14.0), 18% (95% CI, 15.4–21.0), and 26.2% (95% CI, 23.4–29.4), respectively, since 2000. These surgical risk rates were 48%, 50% and 44% lower after 2000. Gender, disease extent and disease phenotype did not impact overall resection rates in this population, although one-year resection rates remained unchanged among studies including more patients with ileum-dominant CD.

Among CD patients who had undergone previous resection, the overall cumulative risk of a second resection at 5 and 10 years was 17.7% (95% CI, 13.5–22.9) and 31.3% (95% CI, 24.1–39.6), respectively, while the same rates specifically since 2000 were 14.8% (95% CI, 11-19.7) and 25.5% (95% CI, 11.9-46.6), respectively. These differences were not significant.

Details

Study Design: Systematic review

Funding: The American Gastroenterological Association, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health, the American College of Gastroenterology and the Crohn’s and Colitis Foundation

Allocation: Not applicable

Setting: Multicenter

Level of Evidence: 2a