Medical or Surgical Treatment? Clinical Factors to Consider in Patients With Crohn Disease
Although there are several medical therapies currently available to treat patients with Crohn disease, many patients still undergo surgical treatment. According to Benjamin Cohen, MD, co-section head and clinical director of the Department of Inflammatory Bowel Disease at The Cleveland Clinic, over 25% of patients with Crohn disease will have surgery up to 10 years after their diagnosis. In this Q&A, Dr Cohen reviews a few of the clinical factors patients should consider before choosing between medical and surgical treatment as well as some of the ways clinicians can survey their patients after surgery.
Jessica Bard: Could you provide us with some specific clinical scenarios on medicine vs surgery for patients with Crohn disease?
Benjamin Cohen, MD: I think a clinical scenario that we deal with a lot, which I talked about, is when you are dealing with strictures in Crohn disease. So if we have ileal stricture, is this something that we can try and treat endoscopically as well as with medical therapy vs when is it time to go to surgery? I think a key point here is that we can use cross-sectional imaging, so enterography either as a computerized tomography (CT) scan or a magnetic resonance imaging (MRI) to get a better look at the features of that stricture to identify if this is somebody that is going to do well if we do not do surgery vs somebody who is going to need surgery now. And some of the features that you look for on imaging would be prestenotic dilation of the bowel above the stricture. That is usually a sign of long-standing stricture. Pseudosacculation is another imaging feature that is associated with a chronic stricture that is probably not going to respond as much to medical therapy.
You can look at the length of the stricture. So if a stricture is over 5 cm, that is not something you are going to safely dilate endoscopically and that is just probably a patient who needs to go to surgery. I think this is important because we see a lot of patients who are put on biologic after biologic for a stricture that really should have just been operated on. And then what you are doing is you are exposing patients to these medications unnecessarily that they may not be able to use again in the future because they have already been exposed to them. It is important to use the cross-sectional imaging to really help you identify the appropriate patient. Another scenario is penetrating Crohn disease with an abscess. Again, the cross-sectional imaging really helps you identify the patient that should go to surgery by the size of the abscess, the presence of a stricture, and the setting of the abscess. If the abscess is large, associated with a stricture, or not easily drainable that's usually going to be somebody that needs to go to the operating room.
Jessica Bard: What would you say are the risks for postoperative complications and how do you make sure the patient has the best outcome possible?
Dr Benjamin Cohen: This has been an area that I have had particular interest in over the last several years because we ultimately want to set our patients up for success, whether it is medical therapy or surgical therapy. There are some risk factors that are not as modifiable for the patient, so those may be if they are having an urgent or emergent admission to the hospital, older patients have other comorbidities that may put them at a little bit higher risk when they're undergoing a surgery. And then the experience of the surgeon or the hospital where they're having surgery at, does play a role in their overall outcomes. But you can think about those things to identify the patients who may be higher risk who you have to keep a closer eye on. Also, the idea of sending them to surgery at the appropriate time rather than waiting till they have been on multiple medical therapies that are not working on steroids and being very sick, that's when you have the urgent or emergent admission.
In terms of the modifiable risk factors, I think there are several key ones that have been associated with poor postoperative outcomes. Malnutrition is a big one. So it is really important to involve your dietitians early in the care of patients who are going to go to surgery. And you can take measures to try and optimize them prior to surgery, whether it is using methods like exclusive enteral nutrition in patients with Crohn disease who are going to surgery for stricturing disease, for example. And then still involving those dieticians in the postoperative care to make sure that they're gaining weight appropriately after surgery. Another factor that has been associated with poor outcomes is anemia. We can try and identify patients who are anemic beforehand and potentially treat them, for example, with IV iron; though that's a strategy that still needs to be studied prospectively.
Smoking has been associated with poor postoperative outcomes in large datasets. We also know that smoking is associated with worse Crohn disease, so obviously, trying to do smoking cessation interventions in patients before they go to surgery potentially could have a big impact. And then I think the other area that has been publicized a lot over the last 10 years has really been the role of medications in terms of postoperative outcomes. There had been some thinking that, for example, biologic drugs like tumor necrosis factor inhibitors were associated with more complications. But we just published a very large prospective cohort study (PUCCINI) with the Crohn's and Colitis Foundation, Clinical Research Alliance, which included 947 patients with Crohn disease and ulcerative colitis undergoing surgery, 40% of whom were on a tumor necrosis factor (TNF) inhibitor preoperatively to answer this question. And we found no association with postoperative infectious outcomes with the exposure to TNF inhibitors, both using the patient-reported exposure as well as using serum drug levels of the TNF inhibitors around the time of surgery, and the key factors that were associated with infectious complications were diabetes, smoking, prior history of surgery, and most importantly, steroid use.
So, really steroids are the big risk factor for postoperative complications. We want to try to minimize the use of steroids leading into a surgery. I try and taper patients down off steroids,, if possible, before surgery and I do not put patients on steroids unless absolutely necessary prior to a surgery.
Jessica Bard: How do you survey patients after they have had surgery?
Dr Cohen: Unfortunately, surgery is not a cure in most cases for our patients. Especially in Crohn disease, they are likely to still have to manage their Crohn disease even after having surgery though the clinical recurrence usually takes longer than the endoscopic recurrence. And we have learned a lot more in recent years through the postoperative Crohn's endoscopic recurrence (POCER) trial that doing a 6 month colonoscopy post-op really helps us risk stratify who may need an escalation of a therapy. Now, there are going to be some patients that go on medical therapy because they had severe disease heading into surgery. Those are going to be the younger patients, people who are smokers, people who have had multiple prior surgeries before, maybe people who presented with abscess. But if you do not have those severe features and you are on the fence about whether to start a postoperative biologic therapy, you can use that 6 month colonoscopy to really get a sense of who is going to recur early and then start medical therapy on them.
Additional Resource:
Cohen B. Why choose surgery? Counseling patients about the indications and role of surgery in IBD. Talk presented at: ACG 2022; October 21-26, 2022; Charlotte, NC. Accessed October 12, 2022. https://acgmeetings.gi.org/
Benjamin Cohen, MD, is the co-section head and clinical director of the Department of Inflammatory Bowel Disease at The Cleveland Clinic.