Decrease in primary but not in secondary abdominal surgery for Crohns disease: nationwide cohort study, 1990-2014

BackgroundTreatment of patients with Crohns disease has evolved in recent decades, with increasing use of immunomodulatory medication since 1990 and biologicals since 1998. In parallel, there has been increased use of active disease monitoring. To what extent these changes have influenced the incidence of primary and repeat surgical resection remains debated. MethodsIn this nationwide cohort study, incident patients of all ages with Crohns disease, identified in Swedish National Patient Registry between 1990 and 2014, were divided into five calendar periods of diagnosis: 1990-1995 and 1996-2000 with use of inpatient registries, 2001, and 2002-2008 and 2009-2014 with use of inpatient and outpatient registries. The cumulative incidence of first and repeat abdominal surgery (except closure of stomas), by category of surgical procedure, was estimated using the Kaplan-Meier method. ResultsAmong 21273 patients with Crohns disease, the cumulative incidence of first abdominal surgery within 5years of Crohns disease diagnosis decreased continuously from 548 per cent in 1990-1995 to 404 per cent in 1996-2000 (P<0001), and again from 198 per cent in 2002-2008 to 173 per cent in 2009-2014 (P<0001). Repeat 5-year surgery rates decreased from 189 per cent in 1990-1995 to 160 per cent in 1996-2000 (P=0009). After 2000, no further significant decreases were observed. ConclusionThe 5-year rate of surgical intervention for Crohns disease has decreased significantly, but the rate of repeat surgery has remained stable despite the introduction of biological therapy. AntecedentesEl tratamiento de pacientes con enfermedad de Crohn ha evolucionado en las ultimas decadas con un uso cada vez mayor de medicamentos inmunomoduladores desde 1990 y tratamientos biologicos desde 1998. Al mismo tiempo, ha aumentado la utilidad de la vigilancia activa de la enfermedad. Hasta que punto estos cambios han influido en la incidencia de la reseccion quirurgica primaria y repetida sigue siendo objeto de debate. MetodosEstudio de cohortes a nivel nacional de pacientes incidentes con enfermedad de Crohn de todas las edades identificados en el registro sueco nacional de pacientes entre 1990-2014, que se dividio en cinco periodos de diagnostico: 1990-1995 y 1996-2000 con el uso de registros de pacientes hospitalizados, 2001, y 2002-2008 y 2009-2014 con uso de registros de pacientes ambulatorios y hospitalizados. Se estimo la incidencia acumulada de la primera cirugia abdominal y de las cirugias abdominales subsiguientes (excepto el cierre de estomas), por categoria de procedimiento quirurgico, mediante el metodo de Kaplan-Meier. ResultadosEntre 21.273 pacientes con enfermedad de Crohn, la incidencia acumulada de la primera cirugia abdominal durante los 5 anos posteriores al diagnostico de la enfermedad disminuyo continuamente del 54,8% en la cohorte 1990-1995 al 40,4% en la cohorte 1996-2000 (P < 0,001) y nuevamente del 19,8% en cohorte 2002-2008 al 17,3% en la cohorte 2009-2014 (P < 0,001). Las tasas cirugias iterativas a los 5 anos disminuyeron de 18,9% en la cohorte 1990-1995 a 16,0% en la cohorte 1996-2000 (P = 0,017). Despues del 2000, no se observaron mas disminuciones significativas. ConclusionLa tasa de intervencion quirurgica a los 5 anos para la enfermedad de Crohn ha disminuido significativamente, pero la cirugia iterativa se ha mantenido estable a pesar de la introduccion de la terapia biologica.Funding Agencies|Swedish Medical Society; Karolinska Institutet FoundationsKarolinska Institutet; Stockholm County CouncilStockholm County Council; Karolinska InstitutetKarolinska Institutet; JanssenJohnson & Johnson USAJanssen Biotech Inc; TakedaTakeda Pharmaceutical Company Ltd; MSD; Ostergotland County