Spotlight on surgical management of IBD

Recent studies focused on the surgical management of inflammatory bowel disease (IBD).

The first study found that Black patients are at increased risk of morbidity after surgery for both ulcerative colitis and Crohn's disease compared with patients from other racial/ethnic groups. Researchers used the National Surgical Quality Improvement file from 2012 to 2019 to identify a retrospective cohort of patients undergoing elective surgical management with a diagnosis of ulcerative colitis or Crohn's disease. Patients self-identified as non-Hispanic White, Black, Asian, or Hispanic White. The researchers used Current Procedural Terminology codes to identify colorectal surgical procedures and used ICD-9/ICD-10 codes to identify patients diagnosed with ulcerative colitis and Crohn's disease. They analyzed outcomes by the intended surgical approach, open or minimally invasive (robotic or laparoscopic), regardless of conversion to open, to attribute the morbidity of the conversion event to the selected surgical approach. The primary outcome was composite postoperative morbidity, defined as one or more of the following events in the first 30 postoperative days: organ/space surgical-site infection, anastomotic leak, reoperation related to index procedure, sepsis/septic shock, pulmonary embolism, stroke or cerebrovascular accident, myocardial infarction, death, or index length of stay longer than the 90th percentile. Results were published Oct. 17 by the Journal of Gastrointestinal Surgery.

Among 12,043 patients with Crohn's disease who underwent surgical resection, 86.2% identified as non-Hispanic White, 9.9% as Black, 1.0% as Asian, and 2.9% as Hispanic. After multivariate adjustment, composite postoperative morbidity was highest for Black patients (27.5%), followed by Hispanic patients (21.1%), with White and Asian patients having the lowest (17.4% and 15.2%, respectively; P<0.001). Among 6,699 patients with ulcerative colitis, 87.3% identified as non-Hispanic White, 4.6% as Black, 2.2% as Asian, and 5.9% as Hispanic. After adjustment, composite postoperative morbidity was highest for Black patients (26.1%), followed by Asian patients (21.2%), with White and Hispanic patients having the lowest (18.2% and 17.8%, respectively; P<0.005). The study was limited by its retrospective design and a lack of data on use of biologics and immunomodulators before surgery, as well as information on medical care, insurance status, and level of social support, the authors noted. “Actionable items such as expediting access to surgery, providing access to specialized surgical IBD care for adequate decision making on surgical approach and preoperative optimization due to minority patients having a higher rate of comorbidities are needed to decrease postoperative morbidity,” they wrote.

The second study found that patients with Crohn's disease who had surgical resection within 29 days of diagnosis had lower cumulative risk of reoperation and lower cumulative exposure to immunomodulators in the initial years after surgery. Researchers used the Danish National Patient Registry to identify adult patients diagnosed with Crohn's disease in Denmark from 1997 through 2015 and used the Danish National Prescription Registry to assess medication data. From this cohort, they identified 2,483 patients who underwent an intestinal resection due to their Crohn's disease and who were followed for a median of 11 years. They divided the population into three groups: group 1, those resected within 29 days (n=493; 19.9%); group 2, those resected between 30 and 180 days (n=472; 19.0%); and group 3, those resected after 180 days from diagnosis (n=1,518; 61.1%). The main outcomes were the cumulative risk of reoperations, IBD medications, and hospitalizations after the initial surgery. Results were published Oct. 17 by Digestive and Liver Disease.

The cumulative risk of reoperation was lower among patients from group 1 (five-year risk, 16.5% vs. 18.2% in group 2 and 21.2% in group 3; P=0.004). Compared to group 1, fewer patients from groups 2 and 3 required hospitalization (66.8% vs. 56.5% and 52.8%, respectively; P<0.001); however, they had a higher number of hospitalizations per patient. Patients in group 3 had a higher cumulative use of immunomodulators in the first three years after initial surgery (one-year risk, 24.6% vs. 19.4% in group 1 and 17.0% in group 2; P<0.001). Limitations of the study include a lack of data on symptoms, any diagnostic delays, disease location, or smoking habits, the authors noted. “Further studies are needed to elaborate on the prognoses of early- and late-resected [Crohn's disease] patients, and especially prospective studies with access to data on disease phenotypes, in order to identify patient groups who will benefit most from early surgery,” they wrote.