Three Surgical Approaches Yield Comparable Results in Crohn’s Disease

While surgery types in Crohn’s disease are associated with mostly comparable outcomes, small bowel resection had greater odds of post-op wound complications.

Three surgical approaches used in Crohn’s disease (CD), including small bowel resection (SBR), strictureplasty, and combined surgery with resection plus strictureplasty, are associated with mostly comparable outcomes. However, small bowel resection was associated with greater odds of postoperative wound complications, according to results published in the International Journal of Colorectal Disease.

“Despite advances in medical therapy and treatment guidelines that aim to avoid surgery, 33% of [patients with CD] will need surgery 5 years after initial diagnosis, [and] 47% will need surgery at 10 years,” Burt Cagir, MD, FACS, and colleagues wrote. “Although many studies have described ileocecectomy and colon resection, far fewer have evaluated surgical intervention on other regions of the small bowel, especially strictureplasty.”

The researchers used the National Surgical Quality Registry (NSQIP) from the American College of Surgeons to examine 30-day outcomes associated with these surgical approaches for CD. The authors obtained NSQIP data from 2015 to 2020 for all patients undergoing open or laparoscopic resection of small bowel or strictureplasty for CD based on CPT and IC-CM 10 codes. Outcomes included length of stay, discharge disposition, wound complications, 30-day related readmission rates, and reoperation.

Resection, Combined Surgery & Strictureplasty

The analysis included 2,578 patients with CD, most of whom (87%) underwent small bowel resection (SBR). A much smaller percentage of patients underwent strictureplasty (SPX; 8%) or combined surgery (SBR plus strictureplasty [CSX]; 5%).

Regarding patient characteristics, those who underwent any type of surgery were more often younger (ages 18-40, 46%; ages 41-65, 42%; ages 65 and older, 12%). Receipt of SPX was more common for White patients (9.0%) compared with Black patients (4.2%).

Patients treated with SBR were more likely to have higher BMI compared with other surgical groups, while those undergoing CSX were less likely to have hypertension (8%) compared with those in the SBR (18.2%) and SPX (15.4%) groups. Rates of smoking differed across groups: 20.3% for SBR, 13.5% for SPX, and 6.4% for CSX.

In terms of surgical procedures, CSX was associated with the longest operating time (P=0.002). Patients undergoing SBR had the longest length of stay (P=0.030), the highest incidence (44%) of superficial/deep wound infection (P=0.003), and the highest incidence (3.5%) of sepsis (P=0.03). SBR was associated with greater odds of wound complications versus combined surgery (OR, 2.09; P=0.024) or strictureplasty (OR, 1.9; P=0.005).

Comparable Results Across Surgery Types

Among the study’s strengths was its use of a cross-national sample with patient data from a range of hospitals in the NSQIP database, Dr. Cagir and colleagues noted, which serves to “counterbalance a positive publication bias in previous primary research and its secondary inclusion in systematic reviews and meta-analyses.”

Limitations included the comparison of surgeries for which there are different indications, according to the researchers, and a lack of assessment of the impact of several certain pre-operative factors, including medical therapy for CD and nutritional status.

“Measured outcomes for all three surgical techniques were comparable for 30-day related reoperation and readmission,” the researchers noted in the discussion. “Likewise, all three surgical approaches showed similar outcomes for patient disposition on hospital discharge. Patients undergoing SBR for CD showed greater odds of any wound complication and sepsis versus CSX and SPX. However, we also found pre-operative clinical characteristics in the SBR cohort typically associated with worse surgical outcomes.”