Sx vs. medical Tx for ileocecal CD

September 18, 2023

Issue 18

Clinical Question

Should surgery be first-line treatment for ileocecal Crohn’s disease?

Editor’s Bottom Line

These data support early surgery as an effective option for a subset of patients with Crohn’s disease. However, inferences about the relative success of surgical vs. medical therapy are limited by the observational study design.

Reference

Agrawal M, Ebert AC, Poulsen G, et al. Early Ileocecal Resection for Crohn’s Disease Is Associated With Improved Long-term Outcomes Compared With Anti-Tumor Necrosis Factor Therapy: A Population-Based Cohort Study. Gastroenterology. Epub ahead of print June 13, 2023; https://www.gastrojournal.org/article/fulltext

Synopsis

This study compared outcomes following medical or surgical first-line treatment for ileocecal Crohn’s disease (CD). Researchers analyzed the Danish Civil Registration System, a prospective database that is also cross-linked with national medical and prescription databases, including data from 1,279 individuals diagnosed with ileal or ileocecal CD between 2003 and 2018.

Roughly 45% of these patients underwent ileocolonic resection as first-line treatment, while 54.6% received an anti-tumor necrosis factor (TNF) agent as first-line treatment in the year following diagnosis. Ninety-one percent of those who received first-line anti-TNF therapy were given infliximab.

Surgical and medical patients were a median 30 and 22 years of age, respectively, at the time of diagnosis. Surgical patients were more likely to have complicated CD (21.2% vs. 1.7%), defined as the presence of a stricture, ileus, internal fistula or abscess.

After 2,474 patient-years of follow-up, the primary measure—a composite of one or more of CD-related hospitalization or surgery, systemic corticosteroid exposure or perianal disease—occurred at rates of 110 per 1,000 person-years and 202 per 1,000 person-years in the surgery and anti-TNF groups, respectively.

Analyses adjusting for prior hospitalizations, number of unique prescription medications, systemic corticosteroid treatment and immunomodulator exposure found the risk of the composite primary measure was significantly lower after surgical first-line treatment, compared to first-line anti-TNF treatment (adjusted Hazard Ratio [aHR]: 0.67; 95% Confidence Interval [CI], 0.54–0.83).

When they analyzed the risk of each of each component of the composite endpoint separately, authors found that first-line surgical treatment was associated with a significantly reduced risk of systemic corticosteroid exposure (aHR: 0.61; 95% CI, 0.49–0.77) and of CD-related surgery (aHR: 0.49; 95% CI, 0.36–0.67) during follow-up, but was not significantly associated with a lower risk of hospitalization risk or perianal disease. Several additional analyses adjusting for a range of possible confounders confirmed these correlations.

Five years after first-line surgical treatment, 46.3%, 16.8%, 1.8%, and 49.7% of individuals in this group had initiated an immunomodulator, an anti-TNF, required additional surgical resection or received no therapy, respectively. Among those treated with infliximab as first-line therapy, 17.7%, 40.8%, and 47.3% underwent ileocecal resection within five years, switched to a different biologic or continued infliximab, respectively.

Details

Study Design: Nationwide cohort analysis

Funding: The Danish National Research Foundation.

Allocation: Not applicable

Setting: Multicenter

Level of Evidence: 2b