Temporal trends in surgery for Crohn’s disease: A ten-year single-center retrospective study

doi:10.21203/rs.3.rs-2743047/v1

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Temporal trends in surgery for Crohn’s disease: A ten-year single-center retrospective study

https://doi.org/10.21203/rs.3.rs-2743047/v1

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Journal Publication

published 26 Aug, 2023

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Purpose: Crohn’s disease (CD) is a chronic inflammatory bowel disease that requires surgery in many cases. The characteristics of CD surgical patients and the temporal trends in surgical management in China has not been well studied. This article aims to investigate the changes related to CD surgery in China over 10 years

Methods: The data of patients underwent abdominal surgery for CD between 2013 and 2022 were collected prospectively. Data were compared between two periods (2013–2017 and 2018–2022).

Results: A total of 1059 individuals underwent 1176 surgical procedures, of which 67.1% were male. The median age of patients at the time of surgery was 36.0 years, and an overall increasing trend was observed in surgical volume. The proportion of patients treated with biologics increased from the first period (2013-2017) to the second (2018-2022), rising from 35% to 46% (p< 0.001). In the second stage, the proportion of patients who underwent surgery for abscesses or fistulas increased (47.8% vs. 40.0%), while the percentage of emergency surgeries declined (3.0% vs. 7.1%). Furthermore, there was a rise in the proportion of laparoscopic surgeries (76.5% vs. 63.7%), coupled with a decrease in stoma rates (15.4% vs. 30.5%) and postoperative complications (23.0% vs. 30.5%).

Conclusion: The frequency of biologics usage in CD surgery have increased over time, and the proportion of penetrating patients has grown. Minimally invasive surgical methods have become the norm, and surgical outcomes have markedly enhanced, evidenced by a substantial reduction in both stoma rates and complication rates.

Crohn

Surgery

Trend

Laparoscopy

Complication

Crohn’s disease (CD) is a chronic inflammatory bowel disorder characterized by the presence of transmural granulomatous inflammation, which can manifest in any segment of the gastrointestinal tract. In recent decades, the medical armamentarium available for treating CD has expanded dramatically. Nevertheless, surgery continues to play a crucial role in its management, and the number of patients necessitating surgical intervention for this condition remains steady[1]. Over the past decades, surgical treatment for CD has undergone a profound transformation, owing to the advent of minimally invasive techniques, preoperative optimization, and enhanced recovery after surgery protocols. As the lifestyle shifts towards a more westernized style, the incidence and prevalence of CD in China have been on the rise[2]. Notably, there exist substantial distinctions in the phenotype, clinical features, treatment response, and prognosis of CD between Chinese and Western populations[3].

This article aims to investigate the changes related to CD surgery in China over 10 years, encompassing surgical indications, procedure, and outcomes. The primary objective is to elucidate the salient characteristics of CD surgical patients and the time trends in surgical management of CD.

The individuals who received abdominal surgery for CD at the Department of Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, between January 2013 and December 2022, were identified. The diagnosis of CD was established through comprehensive assessment of clinical, ileocolonoscopic, histopathologic, and radiologic findings. Excluded from the analysis were cases involving only perianal surgery, abscess drainage, stoma closure, and surgeries performed to address postoperative complications. The data collected encompassed variables such as gender, age, body mass index (BMI), history of prior intestinal surgery, smoking status, and medical treatment. The phenotype of CD was evaluated at surgery using the Montreal classification, which takes into account the location (L1-L4) and behavior of the disease (B1-B3)[4]. Surgical data, such as indication, location, phenotype, emergent setting, type of approach, and stoma creation were documented, along with postoperative morbidity.

Descriptive statistics were reported as median (interquartile range) for continuous variables and frequencies or percentages for categorical variables. Two time periods of same duration (2013–2017 and 2018–2022) were compared. The χ² test was used to analyze categorical variables. Statistical significance was set at a p-value of 0.05 or lower. The statistical analysis was conducted using the SPSS software (version 21.0, SPSS, Inc., Chicago, IL, USA). Information was provided and written agreement was obtained from all patients. The study was approved by the Ethics Committee of Sir Run Run Shaw Hospital.

Between January 2013 and December 2022, a total of 1059 individuals underwent 1176 procedures. Among these, 946 patients received a single abdominal surgery, while 113 received multiple surgeries. Demographic and CD characteristics are outlined in Table 1. Of the patients, 789 were male (67.1%), with a median age at the time of surgery of 36.0 years. A perianal disease was present in 351 patients (29.8%), and 458 patients (38.9%) had a history of abdominal surgery.

Table 1

Patient characteristics of included CD patients undergoing surgery.
Patient characteristics
N	1176
Male (N,%)	789 (67.1%)
Age at surgery (years) (median, IQR)	36.0 (28.0;46.0)
BMI (median, IQR)	18.7 (17.0;20.8)
Smoking (N,%)	121 (10.3%)
Disease duration (months) (median, IQR)	36.0 (10.0;96.0)
Perianal disease	351 (29.8%)
Surgery history	458 (38.9%)
Disease location
L1	357 (30.4%)
L2	91 (7.8%)
L3	708 (60.2%)
L4	48 (4.1%)
Disease behavior
B1	36 (3.1%)
B2	604 (51.4%)
B3	536 (45.6%)
Medication use ever prior to surgery
Steroids	364 (30.9%)
5-ASA	576 (49.0%)
Immunomodulator	399 (33.9%)
Anti-TNF	342 (29.1%)

The annual surgical volume and proportion of biologics administered are presented in Fig. 1, demonstrating a general increase in both surgical volume and biologic use. With respect to surgical indications, the number of patients with penetrating CD has increased, the proportion of patients with stenosis is slightly decreasing, and the proportion of emergency surgeries has decreased (Fig. 2). Regarding surgical procedures, the number of laparoscopy has increased significantly, while the proportion of open surgeries is decreasing year by year (Fig. 3). Over time, the proportion of stoma creation and incidence of postoperative complications have decreased (Fig. 4).

Table 2 demonstrates the change in the study population over time. The utilization of biologics among patients exhibited a noticeable increase from the initial timeframe spanning 2013–2017 to the subsequent one covering 2018–2022, surging from 35–46% (p < 0.001). In the second stage, the proportion of patients who underwent surgery for abscesses or fistulas increased (47.8% vs. 40.0%), while the percentage of emergency surgeries declined (3.0% vs. 7.1%). Furthermore, there was a rise in the proportion of laparoscopic surgeries (76.5% vs. 63.7%), coupled with a decrease in stoma rates (15.4% vs. 30.5%) and postoperative complications (23.0% vs. 30.5%).

Table 2

Change in surgical characteristics of patients in two periods of time.
		2018–2022 (812)	p value
Use of biologics	70 (19.2%)	272 (33.5%)	< 0.001
Surgical indication			0.028
Intestinal obstruction or stricture	206 (52.2%)	391 (44.4%)
Abscess or fistula	158 (40.0%)	421 (47.8%)
Failure of drug therapy	31 (7.8%)	68 (7.8%)
Emergence surgery	26 (7.1%)	24 (3.0%)	0.001
Surgical approach			< 0.001
Laparoscopic	232 (63.7%)	621 (76.5%)
Conversion to open	51 (14.0%)	115 (13.8%)
Open	81 (22.3%)	79 (9.7%)
Ileostomy or colostomy	111 (30.5%)	125 (15.4%)	< 0.001
Complication	111 (30.5%)	187 (23.0%)	0.007

We conducted an analysis of the trends in CD surgery and uncovered intriguing findings. Over time, the frequency of CD surgery has been rising, plateauing in the past four years. Furthermore, the utilization of biologics has become more prevalent, and the proportion of penetrating patients has grown. Minimally invasive surgical methods have become the norm, and surgical outcomes have improved considerably, with a significant reduction in stoma rates and complication rates.

The incidence and prevalence of CD have increased in China since the end of the 20th century, which has might been attributed to rapid urbanization and industrialization. Additionally, differences in the clinical manifestations have been observed between the East and West. For instance, CD tends to have a higher male predominance, more perianal involvement, and fewer extraintestinal manifestations in Asia[5]. This study examined the clinical data of patients who underwent surgery, revealing a male-to-female ratio of 2:1, which was higher than that reported in US literature but consistent with previous findings in China[6^,7]. Regarding the site of disease involvement, the ileocolon was the most commonly affected area, whereas in reports from the US, the ileum was the most frequently involved site[8]. The shorter duration of disease in the patients in this study, compared to those in the Western study, might be due to poor disease control and more rapid disease progression[9]. It was also observed in an epidemiological survey conducted in the Asia-Pacific region that the severity of CD was more pronounced in Asian patients as compared to those in the Western countries[10].

The management of CD has undergone a noteworthy transformation in recent years, characterized by the broadened use of immunomodulators and the introduction of anti-tumor necrosis factor (anti-TNF) agents. The anti-TNF agents have demonstrated superior effectiveness compared to earlier medications in the CD treatment arsenal, with the potential to promptly heal the intestinal mucosa. A recent study that investigated medication utilization and treatment patterns in Chinese patients revealed a shift from traditional medicines to IFX[11]. Additionally, the study reported an increase in the proportion of patients using biologics over time. The administration of biological agents alters the natural course and phenotype of the disease[12]. Our research showed a decline in the percentage of patients requiring stenotic surgery and emergencies, and an increase in patients with the penetrating type as surgical indications, consistent with previous findings[13]. This could be attributed to our center managing more complicated forms of CD, or the fact that biological agents may alleviate the obstruction symptoms in CD patients[14]. As a result of early diagnosis and enhanced medical management, the frequency of emergency surgery for Crohn's disease has decreased. CD patients who necessitate urgent surgical intervention are at an elevated risk of postoperative morbidity, mortality, and stoma formation[15]. Therefore, the shift towards performing more elective procedures in the surgical management of CD is a crucial advancement in the care of these patients.

The proportion of laparoscopic procedures is increasing, and the rate of stoma and complications is gradually decreasing. This is partly due to improved preoperative optimization, increased surgical experience, and better selection of surgical candidates. Laparoscopic surgery is now being used for more complicated and recurrent cases, and there has been a significant decrease in the need for conversion to open surgery[16]. In cases of severe abdominal inflammation, such as abdominal abscess with intestinal fistula, preoperative enteral nutrition is routinely performed to alleviate abdominal inflammation[17]. The optimization of preoperative nutrition, drainage of localized sepsis, and appropriate timing of surgery have also contributed to a favorable surgical outcome. In terms of anastomosis, the kono-s anastomosis has been found to reduce postoperative anastomotic recurrence and significantly decrease the occurrence of postoperative complications, specifically the anastomotic leak rate which was lower (1.8% vs 9.3% respectively).[18]. This is likely due to the protective effect of the support column for the anastomotic morphology, which reduces tension on the anastomosis. Additionally, the anastomosis is positioned far from the mesenteric side, which minimizes the influence of the cutting edge on the anastomosis. For patients with a high risk of anastomotic leakage, the kono-s anastomosis may be a viable option. The decrease in the annual rate of stoma formation is indicative of better surgical outcomes in CD. Various factors are potentially responsible for the shift in stoma formation trends. Firstly, advancements in surgical techniques may be altering the approach to operative intervention in CD. Secondly, improvements in medical therapy that prioritize early attainment of mucosal healing and target specific objectives, as opposed to solely symptom relief, may be transforming the natural course of CD[19].

There are some limitations in our study. Firstly, the retrospective and single-center design can be attributed to the absence of a national registry in China. Therefore, it is imperative to develop a comprehensive IBD registry system in the near future. Secondly, our research only delved into the trend of CD surgery without examining the underlying reasons and influential factors. Hence, this aspect will be explored in further study.

In conclusion, the frequency of biologics usage in CD surgery in China have increased over time, and the proportion of penetrating patients has grown. Minimally invasive surgical methods have become the norm, and surgical outcomes have markedly enhanced, evidenced by a substantial reduction in both stoma rates and complication rates.

Conflict of interest

The authors declare no competing interests.

Funding Declaration

The authors did not receive any grant from any funding agencies.

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No competing interests reported.

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Journal Publication

published 26 Aug, 2023

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Editorial decision: Major revision
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Temporal trends in surgery for Crohn’s disease: A ten-year single-center retrospective study

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