Impact of medical therapy on patients with Crohn’s disease requiring surgical resection

Fu, Nancy; Hong, Thomas; Round, Andrew M.; Bressler, Brian

doi:10.3748/wjg.v20.i33.11808

Cited by 7 publications

(8 citation statements)

References 37 publications

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“…significantly increased rates of small bowel fistula repair, postoperative infections and anastomotic related complications . The proportion of patients with perforating disease (27.3%) in the present study is relatively low compared to the 43.9% perforating disease reported in a meta‐analysis . In addition, there was no significant difference in the number of fistulas between the groups with and without anti‐TNF, suggesting that the threshold for the gastroenterologist to refer the patient to the surgeon is relatively low with adequate discussion of patients in a multidisciplinary team.…”

Section: Discussioncontrasting

confidence: 64%

“…In addition, no reduction in length of inflammation in clinical nonresponders was observed (decrease from 15.6 to 15.6 cm, P = 0.98) [7]. In the previously mentioned study by Fu et al, no significant difference in the length of resected small bowel was found in patients treated with anti-TNF vs patients without anti-TNF (mean 23.0 vs 21.5 cm, P = 0.92) [6].…”

Section: Discussionmentioning

confidence: 76%

“…The overall median time from diagnosis to ileocolic resection was 39.0 months. In a recent study from Canada by Fu et al evaluating the impact of medical therapy on CD patients in a tertiary referral centre between 1995 and 2010, a median time from diagnosis to resection of 72 months was observed [6]. In accordance with the present study, these authors also observed a significant difference in time from diagnosis to surgery in patients treated with anti-TNF (n = 38) compared to patients without anti-TNF (n = 76) between 2005 and 2010 (mean 90 vs 48 months, P = 0.02) [6].…”

Section: Discussionmentioning

confidence: 99%

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The association between intensified medical treatment, time to surgery and ileocolic specimen length in Crohn's disease

et al. 2017

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Aim During the last decade, treatment protocols have changed for patients with ileocolic Crohn's disease. Antitumour necrosis factor (anti-TNF) has become part of standard medical treatment, usually in a step-up approach. The aim was to analyse if improved medical treatment has resulted in more limited ileocolic resections and a longer interval between diagnosis and surgery.Method Patients undergoing ileocolic resection for Crohn's disease were included (1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014). Patient characteristics were compared to the results of a population-based study (between 2004 and 2010) previously performed in the catchment area of the present tertiary referral centre. Time trends were analysed using the Cochrane-Armitage trend, Spearman's correlation coefficient and linear regression. ResultsIn total, 195 patients undergoing ileocolic resection were included. Patient characteristics were not significantly different from the background cohort, confirming a representative study group. Sixty-three patients were men (32.3%, median age at surgery 30.0 years, interquartile range 23.0-40.0). Anti-TNF and immunomodulator use prior to surgery increased significantly during the study period (v 2 = 49.1,Over the years, a significant increase in time from diagnosis to operation was found (median Conclusion This study demonstrated that over time patients with ileocolic Crohn's disease who eventually underwent ileocolic resection have been treated more intensively medically; however, this did not result in reduced specimen size.Keywords Crohn's disease, ileocolic resection, medical therapyWhat does this paper add to the literature? This study demonstrated that over time patients were treated more intensively with different types of drug combinations. As a result, the time interval from initial diagnosis to surgery increased. The optimization of medical treatment protocols did not result in more limited resections throughout the years as is sometimes argued as one of the benefits of extensive treatment. Timely surgery in patients who do not respond to optimal medical therapy will prevent complications, e.g. fibrosis and progressive enteral fistulization.

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Section: Discussioncontrasting

confidence: 64%

Section: Discussionmentioning

confidence: 76%

Section: Discussionmentioning

confidence: 99%

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The association between intensified medical treatment, time to surgery and ileocolic specimen length in Crohn's disease

et al. 2017

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“…Given that no specific anti‐fibrotic therapy exists, these patients are often initially treated with the best available medical anti‐inflammatory therapy. Strikingly, despite the revolutionary emergence of biologic agents over the past two decades, estimates for surgical resection of fibrostenotic disease either remain unchanged, 4 or have shifted from less emergent to more elective procedures 5,6 …”

Section: Introductionmentioning

confidence: 99%

Systematic review: medical therapy for fibrostenosing Crohn’s disease

Lu¹,

Baraty²,

Robertson³

et al. 2020

Aliment Pharmacol Ther

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Background: Medical therapy and/or endoscopic balloon dilation with intralesional therapies are options for the treatment of small bowel fibrostenotic Crohn's disease (CD). Aim: To perform a systematic review summarising evidence for efficacy of systemic and endoscopic intralesional medical therapy in established small bowel strictures in adult CD patients. Methods: A systematic search of MEDLINE, EMBASE, CENTRAL and Scopus was conducted. Primary outcomes were rates of surgical resection and repeat endoscopic dilation. Pooled event rates from random effects models across studies with 95% confidence intervals were reported.Results: Ten studies describing systemic medical therapy and eight studies of intralesional injection were included. One randomised controlled trial each for systemic therapy and intrastricture injection were identified. Only observational studies were found for systemic biologic therapies, which exclusively included tumour necrosis factor (TNF) antagonists, while intralesional therapies all involved corticosteroids except for one study that evaluated infliximab. Pooled event rates for surgical resection after systemic and intralesional therapy were 28.3% (95% CI: 18.2%-41.3%) and 18.5% (95% CI: 8.3%-36.2%), respectively over a median follow-up of 23 months (range 5.5-105.8), and 21.8 months (range 5-47). Risk of repeat endoscopic balloon dilation in those with intralesional therapy was 58.3% (95% CI: 36.6%-77.3%) over a median follow-up of 21.8 months (range 5-47). Conclusions:There are no favoured therapies for patients with stricturing small bowel CD. Data are lacking for ustekinumab and vedolizumab. No endoscopic intralesional medications provided a clear benefit for prevention of repeat EBD or surgery.

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“…As a result, it is difficult for Korean patients in an earlier phase of CD to obtain infliximab, a factor that might interfere with the ability to demonstrate an association between infliximab use and better treatment results. In fact, another study failed to demonstrate a reduction in the reoperation rate following the use of anti-TNF-α antibodies and indicated a need for earlier infliximab treatment [ 26 ]. Additional studies have suggested that top-down therapy might be more effective than conventional management for patients in remission [ 27 28 ], although the effect of top-down therapy on the CD reoperation rate is not yet well established.…”

Section: Discussionmentioning

confidence: 99%

Long-term Outcomes and Risk Factors for Reoperation After Surgical Treatment for Gastrointestinal Crohn Disease According to Anti-tumor Necrosis Factor-α Antibody Use: 35 Years of Experience at a Single Institute in Korea

Lee

Han

et al. 2015

Ann Coloproctol

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PurposeCrohn disease is characterized by high rates of recurrence and reoperations. However, few studies have investigated long-term surgical outcomes in Asian populations. We investigated risk factors for reoperation, particularly those associated with anti-tumor necrosis factor-α (anti-TNF-α) antibody use, and long-term follow-up results.MethodsWe reviewed the records of 148 patients (100 males and 48 females) who underwent surgery for gastrointestinal Crohn disease and retrospectively analyzed long-term outcomes and risk factors.ResultsThe mean age at diagnosis was 28.8 years. Thirty-eight patients (25.7%) received monoclonal antibody treatment before reoperation. A small bowel and colon resection was most commonly performed (83 patients, 56.1%). The median follow-up was 149 months, during which 47 patients underwent reoperation. The median interval between the primary and the secondary surgeries was 65 months, with accumulated reoperation rates of 16.5%, 31.8%, and 57.2% after 5, 10, and 15 years, respectively. Obstruction was the most common indication for reoperation (37 patients, 25.0%). In a multivariable analysis, age <17 years at diagnosis (A1) (odds ratio [OR], 2.20; P = 0.023), penetrating behavior (B3) (OR, 4.39; P < 0.001), and no azathioprine use (OR, 2.87; P = 0.003) were associated with reoperation. Anti-TNF-α antibody use did not affect the reoperation rate (P = 0.767).ConclusionWe showed a high reoperation rate regardless of treatment with anti-TNF-α antibody, which indicates that recurrent surgery is still needed to cure patients with gastrointestinal Crohn diseases. Younger age at primary operation, penetrating behavior, and no azathioprine use were significant factors associated with reoperation for gastrointestinal Crohn disease.

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Impact of medical therapy on patients with Crohn’s disease requiring surgical resection

Cited by 7 publications

References 37 publications

The association between intensified medical treatment, time to surgery and ileocolic specimen length in Crohn's disease

The association between intensified medical treatment, time to surgery and ileocolic specimen length in Crohn's disease

Systematic review: medical therapy for fibrostenosing Crohn’s disease

Long-term Outcomes and Risk Factors for Reoperation After Surgical Treatment for Gastrointestinal Crohn Disease According to Anti-tumor Necrosis Factor-α Antibody Use: 35 Years of Experience at a Single Institute in Korea

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