Early or late surgery for patients with ileocecal Crohn's disease?

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Abstract

BACKGROUND

The majority of patients with Crohn's disease require surgery during the course of their disease. It is not clear if performing surgical resection early rather than later in the course of Crohn's disease is beneficial in terms of postoperative disease course.

OBJECTIVE

To evaluate long-term disease course after early or late ileo-cecal resection in patients with Crohn's disease.

DESIGN AND INTERVENTION

This European, multicenter, retrospective study included the records of patients with an established diagnosis of Crohn's disease who had undergone ≥1 radical surgical resection for ileal disease with or without right colon involvement. Patients were categorized into those in whom surgery was performed at the time of disease diagnosis (early surgery) and those in whom surgery was performed during the course of the disease (late surgery). All patient clinical and demographic data were recorded. Study investigators evaluated post- operative course of disease including clinical recurrence (defined as requirement for cortico- steroids for symptoms of Crohn's disease with endoscopic or radiologic evidence of disease recurrence), need for immunosuppressant therapy and need for further surgery.

OUTCOME MEASURES

The primary end point was clinical recurrence. Secondary end points were requirement for further surgery or immunosuppressant therapy.

RESULTS

In total 207 patients were included in the study (83 patients underwent early surgery and 124 patients underwent late surgery). Late surgery was performed a mean of 54.2 months (range 1-438 months) after disease diagnosis. Patients in the late surgery group had received the following treatment for Crohn's disease before surgery was performed: at least one course of systemic corticosteroids (69%), immuno suppressant therapy (13%) and mesalazine and/or antibiotics (13%). Patients who underwent early surgery received post- operative mesalazine treatment for prevention of recurrence significantly less frequently than patients who underwent late surgery (55% versus 79%, P = 0.0005). Mean post- operative follow-up was 147 months (range 12-534 months). Late surgery was associated with a significantly shorter postoperative disease course free from clinical recurrence than was early surgery (P = 0.01) and a significantly greater need for immuno suppressant therapy (P = 0.05). The requirement for surgery was similar between patients who underwent early or late surgery. Multivariate analysis revealed that early surgery was the only indepen dent variable associated with a reduced risk of clinical recurrence (hazard ratio [HR] 0.57 [95% CI 0.35-0.92], P = 0.02). However, early surgery was not associated with a reduced risk of need for immuno- suppressant therapy (HR 0.51 [95% CI 0.20-1.30], P = 0.15) or repeat surgery (HR 0.66 [95% CI 0.33-1.35], P = 0.25).

CONCLUSION

Clinical remission seems to be prolonged in patients with Crohn's disease who undergo early rather than late surgical resection.

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