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Introduction: During their life, 80% of patients affected by Crohn’s disease (CD) require at least one surgical procedure. All CD patients assume lifelong medical therapy and this therapy may have several severe side effects that can affect the outcome after surgery. The aim of this study was to evaluate the role of preoperative medical therapy in the outcome of intestinal surgery for CD.
Patients and methods: In our department, 453 surgical procedures for intestinal CD were performed from 1982 to 2011. Adequate data about preoperative therapy (6 months before the operation) were available for 100 patients that were thus enrolled in this retrospective study. They were 40 women and their median age was 35 (IQR: 18-44). The median CD duration was 92 (IQR: 33-160) months and 26 patients presented a fistulizing phenotype. Medical therapy before the operation (use and dose of sulphasalazine, mesalazine, azathioprine, prednisone, beclometasone, budesonide, anti-TNFalpha) was used as possible predictor of postoperative outcome. Surgical predictors (video assisted intestinal surgery, strictureplasty, stoma creation, ileal resection and colonic resection) as well as clinical predictors (age, gender, CD duration, activity and localization, recurrent CD) were also evaluated. Outcome measures were medical and surgical complication, reoperation, day of first bowel movement, postoperative hospital stay. Univariate and multivariate analysis were performed.
Results: Preoperative rectal administration of beclometasone was the only independent predictor of the anastomotic leak (beta=0.36, p<0.001) in a model that also included minimally invasive surgery, colonic resection, obstructing phenotype, type of suture and end-to-end anastomosis (R2=0.29, p<0.001). Preoperative therapy with budesonide was the only independent predictor of the delayed canalization after surgery (beta=0.44, p<0.001) in a model that also included minimally invasive surgery, patients gender, disease activity, ileocolonic resection, stricturoplasty, and therapy with mesalazine and beclometasone (R2=0.29, p=0.003). Postoperative rectal bleeding was independently predicted by azathioprine dose (beta=0.29, p=0.012) while reoperation in the first month was independently predicted by the use of budesonide (beta=0.25, p=0.044). No adverse effect on surgical outcome were observed after the use of anti TNFalpha therapies.
Conclusions: Severe CD require adequate and important medical therapy thus this is an almost unavoidable variable affecting the surgical outcome of these patients. Curiously enough, “topic” steroids seemed to be associated to poor outcome after intestinal surgery while oral steroid seemed to not affect it. Azathioprine association to postoperative rectal bleeding may be due to a decreased platelets count that sometimes occurs during the use of this immunomodulator .