Initial and repeat surgeries for Crohn’s disease (CD) significantly fell over the decade from 1994 to 2003, a British database study showed.
The proportion of CD patients requiring a first surgery within 10 years of diagnosis fell from 44% to 21% during the period from 1994 to 2003 (χ2 for trend, P<0.05). Repeat resections in the subsequent 10 years, also declined -- from 40% in 1994 to 17% in 2003 (χ2 for trend, P<0.05).
“Whether this reduction is due to improved, co-coordinated clinical care, patient education, reduction in smoking, or alternative factors is uncertain, but the disease course appears to have changed, with newly diagnosed individuals being less likely to need surgery than those in the past,” wrote Venkataraman Subramanian, MD, of the University of Leeds, England, and colleagues in Clinical Gastroenterology and Hepatology.
Drawing on the U.K.’s national ResearchOne primary-care database, the researchers studied CD patients diagnosed from 1994 through 2013.
The mean age at CD diagnosis for those having initial resection was 41, and 42 for those having a second surgery. The median duration of CD at first resection was 8 years and 12 years at second resection.
Approximately 52% of the overall cohort was female. Smoking at any time was reported by 57% of patients undergoing a first surgery and 64% of those having a second surgery.
Immunomodulators had been prescribed to 44% and 52% of first-and second-resection participants, respectively.
Among 3,059 incident cases of CD, 611 patients had surgery, with 13%, 21%, and 26% undergoing resection after 1, 5, and 10 years, respectively. Of patients with an initial resection, 20% required an additional operation when followed for 10 years after the initial resection.
The first surgery was ileocolonic resection in 322 patients (53%), isolated small bowel resection in 183 (30%), and isolated colonic resection in 106 (17%). The median time to first resection was 189 days.
Duration of disease, younger age at diagnosis, smoking, and immunomodulator use were positively associated with first surgeries. Not surprisingly, disease duration was significantly associated with the risk of a second resection.
The use of immunomodulators was likely to be associated with a more severe disease phenotype increasing the need for surgical management, according to the researchers. They suggested the general decline in smoking rates may have accounted for some of the overall reduction in surgeries.
The U.K. study confirmed reports from Denmark and from Canada showing declines in primary surgeries for these patients, but it added novel data on second resections.
The Canadian study observed a paradigm shift in which elective CD resections are now more common than emergent surgeries. The Danish analysis found that despite an overall decline, there was no specific surgery-sparing effect from newer treatments such as thiopurines and biologics.
“The results are consistent with several population-based studies in the Western world that show advances in medical management at the turn of the 21st century have led to fewer surgeries for patients with CD. The current paper strengthens the consistency of previously published literature,” commented Gilaad G. Kaplan, MD, MPH, of the University of Calgary, Alberta.
Kaplan, who was not involved in this research but co-authored the Canadian study as well as a meta-analysis of second resections, told MedPage Today that the U.K. study was well-designed.
The Leeds authors wrote that with CD incidence on the rise, “It is important for clinicians and patients to be aware of the risks of surgery to help inform discussions about long-term management and patient expectations.”
Among the study’s limitations, they noted that diagnoses were drawn from primary-care data relying on computer entries derived from secondary-care correspondence and results, which could lead to under- or over-estimation. Moreover, the database provided no phenotypic data on disease location or extent or on the use of anti-tumor necrosis factor medications, which are typically used for more severe disease.
The work was supported by a grant from Crohn’s and Colitis UK and a grant from the Leeds Teaching Hospitals NHS Trust Charitable Foundation.
The authors disclosed no competing interests.
Kaplan disclosed no conflicts of interest in relation to his comments.