RATES OF SURGERY FOR STRICTURING CROHN'S DISEASE IN THE BIOLOGIC ERA
Kush M. Fansiwala*1, Shaya Noorian1, Ellen Spartz1, Lauren C. DeDecker1, Andrew R. Roney1, Joanna Turkiewicz2, Christopher Soriano1, Elizabeth Dente1, Alejandro Sarabia Gonzalez1, Siotame Lasitani1, Jamie O. Yang1, Jenny S. Sauk3, Mary Kwaan1, Berkeley N. Limketkai3
1University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 2UCLA Medical Center Olive View, Sylmar, CA; 3Center for Inflammatory Bowel Diseases, Vatche & Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, CA
Prior studies have demonstrated declining rates of surgery for both ulcerative colitis (UC) and Crohn's disease (CD) with the advent of biologic therapies. Although current biologic agents cannot reverse existing fibrotic strictures, limited data suggest that early control of intestinal inflammation might prevent progression toward stricturing disease. Given the unclear overall impact of biologics on stricturing disease, we hypothesized and evaluated whether nationwide rates of surgery for obstruction in the setting of CD decreased since the introduction of infliximab for CD in 1998.
The National Inpatient Sample from 1998-2018 was queried to identify patients with CD and those who underwent bowel resection surgery using ICD-9 and ICD-10 codes in all diagnosis and procedure positions. Those who underwent surgery were further stratified into surgery for indication of obstruction. Both emergency and elective admissions for surgery were included for small bowel and colon resections. Longitudinal trends were plotted and tested for trends while adjusting for age, sex, race, comorbidity, primary payer, income quartile, hospital bed size, and hospital type.
A total of 291,692 patients with CD were admitted for surgery out of 3,472,436 total hospitalizations for CD. Those admitted for surgery were younger (44.25 vs. 49.37 years; p<0.01) and more likely to be male (46% vs. 41%; p<0.01). Table 1 further outlines differences in demographics between the surgical and non-surgical hospitalizations, with significant differences in race, Charlson comorbidity index, primary payer, income quartile, and hospital characteristics between the two groups. From 1998-2018, the proportion of all hospitalized CD patients who underwent any IBD-related surgery decreased from 12.0% to 6.5%, (p trend<0.01), while the proportion of CD surgeries for only obstruction significantly increased from 10.8% to 26.4% (p trend=0.02). In adjusted analyses, there was a trend for decrease in all surgeries (OR 0.98, 95% CI 0.97– 0.98; p trend<0.01) and increase in surgeries obstructive indication (OR 1.02, 95% CI 1.0 – 1.03; p trend=0.03) per year.
In the era of biologics, there has been a significant decrease in the rate of hospitalized CD patients undergoing surgery; of those hospitalizations, however, a larger proportion underwent surgery for obstructive indication. Our findings suggest that advances in medical therapy may have decreased overall surgical rates, yet have had a limited impact on stricturing disease, leading to continued reliance on surgical treatments.
Table 1: Patient and hospital characteristics for hospitalizations for Crohn's Disease from 1998-2018
Figure 1: Annual percentages of all bowel resection surgeries in hospitalized Crohn's disease patients and obstruction-related surgery amongst all hospitalized Crohn's disease bowel resection surgeries from 1998-2018
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