Surgery for adult Crohn's disease: what is the actual risk?
- 1Inserm UMR991, Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, Rennes, France
- 2Inserm U954, Department of Hepato-Gastroenterology, University Henri Poincaré 1, University Hospital of Nancy, Vandoeuvre-les-Nancy, France
- Correspondence to Professor Laurent Peyrin-Biroulet, Inserm U954, and Department of Hepato-Gastroenterology, University Hospital of Nancy, Allée du Morvan, 54511 Vandœuvre-lès-Nancy, France;
- Revised 11 April 2011
- Accepted 2 May 2011
- Published Online First 24 May 2011
When Crohn and his colleagues first described regional ileitis in 1932,1 intestinal resection was the only effective treatment available for these patients. Until the introduction of steroids during the 1950s, medical treatments for Crohn's disease (CD) were limited to digestive rest or ‘High vitamin, high protein, high carbohydrate, low residue diet with liver, iron and calcium supplements and the judicious use of sedatives and antispasmodics’.2 3
In the mid-1990s, the advent of antitumour necrosis factor α (TNFα) agents changed the treatment of CD refractory to standard medications.4 5 In 2011, the ultimate therapeutic goal in CD should be to reduce the long-term risk for intestinal resection. Despite an increasing use of immunosuppressants and anti-TNFα treatments, surgery is still required for many patients with CD. Whether these drugs impact on reducing the long-term requirement for surgery remains debated.
The aim of this article is to review the risk of surgery before and in the era of biologics (based on infliximab approval in 1998) and to discuss the impact of medications on this risk, with a focus on adult luminal CD. Data were analysed using three types of studies—randomised controlled trials, referral centre studies and population-based studies (table 1).
Randomised controlled trials
Before the era of anti-TNFα
To our knowledge, only one randomised controlled trial has reported the rate of surgery in adult CD before the advent of anti-TNFα therapy. In this randomised crossover study of 11 patients who were treated with azathioprine at a maintenance dose of 50 mg, one patient in each group flared and required surgery (figure 1A and table 1).6