Current Treatment Modalities Associated With Decline in Reoperation in Crohn’s Disease Patients

Kenneth R. McQuaid, MD, FASGE reviewing Shinagawa T, et al. Clin Gastroenterol Hepatol 2019 July 20.

It has been almost 20 years since anti-TNF agents became available for the treatment of Crohn’s disease (CD). Although these and other biologics unquestionably lead to clinical improvement, their impact on reduction in need for single or multiple surgical resections is less clear. This is a retrospective study of 1871 CD patients followed in 10 Japanese IBD centers since 1960 who had undergone initial curative intestinal resection. The primary goal was to determine the time trends and risk factors for a second resection. Two cohorts of patients were compared. Cohort 1 included those who underwent initial operation between 1982 and April 2002 (before anti-TNF agents were available). Cohort 2 included those undergoing initial operation between May 2002 and 2016. Patient characteristics, including preoperative and postoperative use of immunomodulators (eg, azathioprine) and/or anti-TNF agents, were assessed. Univariate and multivariate analyses were used to estimate risk factors for reoperation.

Among all patients, the 5- and 10-year reoperation rates were 23.4% and 48.0%. Preoperative smoking, ileocolonic disease, and perianal disease were significant risk factors for reoperation. Postoperative use of immunomodulators (HR, 0.60; 95% CI, 0.44-0.81) and anti-TNF therapy (HR, 0.71; 95% CI, 0.57-0.88) were associated with lower reoperation rates. When comparing the two cohorts, cohort 2 had significantly lower reoperation rates compared with cohort 1 at 5 years (18.5% vs 29.4%) and 10 years (40.9% vs 54.9%), which was confirmed on multivariate analysis (HR, 0.77; 95% CI, 0.61-0.86).


Comment:
CD patients with intestinal resection constitute a high-risk group, as evidenced by reoperation in nearly half of the patients within 10 years. Therefore, the significant decline in CD reoperation rates since 2002 is gratifying and likely attributable to a number of factors, including the advent of biologic agents, earlier top-down therapy, optimization of immunomodulators, combination therapy, and reduced use of corticosteroids.
Note to readers:
At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Kenneth R. McQuaid, MD, FASGE
Bio and Disclosures

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Citation(s):
Shinagawa T, Hata K, Ikeuchi H, et al. Rate of reoperation decreased significantly after year 2002 in patients with Crohn’s disease. Clin Gastroenterol Hepatol 2019 July 20. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2019.07.025)