Is early surgery associated with a more benign disease course in Crohn's disease? Surgery rates in a population-based inception cohort from western Hungary between 1977–2009

Background and Aims: Crohn's disease (CD) is a chronic relapsing inflammatory bowel disease (IBD) most frequently affecting the terminal ileum and right colon, with a high rate of stricturing or penetrating complications. Early surgery may represent a valid alternative to medical therapy, particularly in patients with isolated stenotic ileocaecal CD. Our aim was to analyze the disease course and need for surgery in patients with (within the year of diagnosis) and without an early resective surgery in the population-based Veszprem province database.

Methods: Data of 506 incident CD patients were analyzed (age-at-diagnosis: 31.5 SD13.8years). Both hospital and outpatient records were collected and comprehensively reviewed.

Results: Overall 73 patients (14.4%) required resective surgery within the year of diagnosis. Ileal (OR: 7.88, p<0.001) or ileocolonic (OR: 3.21, p=0.035) disease location, stricturing (OR: 4.91, p<0.001) or penetrating (OR: 7.62, p<0.001) disease behavior at diagnosis and tendencially early age at onset were associated with the need of early resective surgery in a multivariate analysis. Patients with early surgery required less steroids during the course of the disease (p=0.001, OR=0.45). In a multivariate Cox-regression analysis, early resective surgery (p<0.001, HR: 0.27), ileal or ileocolonic disese liocation (p=0.006, HR: 1.87 and p=0.02, HR 1.71) and stricturing or penetrating disease behavior at diagnosis (p<0.001, HR: 3.50 and HR 3.93) were significantly associated with the time to intestinal resection/reoperation after excluding cases with extensive early resections. In addition, early limited resective surgery was significantly associated with the time to intestinal surgery in CD patients (HR: 0.23, 95% CI: 0.11–0.48, p<0.001) after matching on propensity scores for the need for early resection. Reoperation rates were also significantly lower in patients with early surgery (5- and 10-year probability 7.5% vs. 12.9% and 16.5% vs. 36.3%, p=0.038) in a Kaplan Meier analysis.

Conclusions: This population-based inception cohort has shown that early limited resective surgery may be associated with a more benign disease course after index surgery, requiring less surgical interventions and less steroids during follow-up compared to patients without an early resection.