Introduction
Early surgical intervention in Crohn’s disease (CD) with inflammatory (B1) phenotype has been shown to be equally successful compared to biologic treatment in the LIR!C study. A recent work by PREDICT IBD group reconfirmed these findings. On the other hand, the prospective multicenter CREOLE study demonstrated long term (>4 years) surgery free survival in stricturing (B2) CD in over 50% of patients, treated with medical and endoscopic therapy. These conflicting findings complicate decision making in the individual patient, and data on conservative management of penetrating CD is lacking.
Aims & Methods
To compare long term outcomes between the early surgery and conservative treatment approach in patients presenting with penetrating (B3) CD.
This was a retrospective, single tertiary center study, including adult CD patients hospitalized with penetrating abdominal CD, between 1/8/2010 to 30/6/2018. Demographic and clinical data including medical treatment, hospitalization duration, medical and surgical treatments during hospitalization and subsequent hospitalizations and treatments were collected from hospital records. Patients were divided into 2 groups: (1) early surgery (<12 weeks from index hospitalization), and (2) conservative treatment.
Multivariable logistic regression model adjusted for age, sex and smoking status was used for statistical analysis.
Results
A total of 43 CD patients [21 male (48.8%), age 37.9±15.1 years, disease duration 14.1±12.0 years] were hospitalized during the study period for first presentation of penetrating CD [14 (32.6%) with a sinus tract and 29 (67.4%) with an abscess]. Twenty-three patients (53.5%) underwent early surgery (69.5% of whom manifested with abscesses), and the rest were managed non-surgically.
Both groups were similar in terms of CD Montreal classification, smoking status, and type of penetrating complication. Follow up duration was comparable (median 5.2±2.3 years vs 5.3±2.3 years for early surgery vs conservative treatment, respectively, p=0.855).
Exposure to biologics, immunomodulators and glucocorticoids was comparable between the groups before and after index hospitalization.
During the follow up after discharge from the index hospitalization, patients in the surgical group had significantly lower incidence rates of recurrent abscesses (45% vs 4.5%, odds-ratio (OR) 0.04, 95% confidence interval (CI) 0.003-0.40, p=0.006), need for recurrent courses of antibiotics (55.0% vs 14.3%, OR 0.09, 95% CI 0.02-0.53, p=0.07) and recurrent hospitalizations (70.0% vs 39.1%, OR 0.16, 95% CI=0.03-0.72, p=0.017). Two patients (8.7%) in the early surgery group underwent abdominal surgery during follow-up compared to six patients (30.0%) of the conservative treatment group (OR 0.11, 95% CI 0.01-0.92, p=0.04).
Conclusion
In CD patients hospitalized with a penetrating complication, early surgery resulted in significantly less adverse long-term outcomes, such as recurrent abscesses, need for antibiotic treatment, hospitalizations, and surgeries than patients managed conservatively over a median follow up period of 5 years.
