P. Bossuyt*1, 2, C. Debeuckelaere1, T. Billiet1, I. Cleynen3, A. de Buck van Overstraeten4, A. Wolthuis4, M. Ferrante1, G. Van Assche1, A. D’hoore4, S. Vermeire1
1University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium, 2Imelda GI Clinical Research Centre, Department of Gastroenterology, Bonheiden, Belgium, 3KU Leuven, Human Genetics, Leuven, Belgium, 4UZ Leuven, Campus Gasthuisberg, Department of Abdominal Surgery, Leuven, Belgium
The hallmark of Crohn’s disease (CD) is transmural inflammation of the bowel wall leading to stricturing and penetrating complications in a majority of patients. Stricturing disease phenotype has been associated to NOD2 genotype. Overall, factors increasing the need for and influencing timing of surgery in patients with stricturing CD are understudied. Those predictors could prioritise surgery and prevent unnecessary expensive biologic therapies. The aim of the study is to define whether a specific profile of stricturing CD could be identified that is associated with ultimate need for surgery.
All computed tomography (CT) or magnetic resonance (MR) scan performed at our institution (tertiary referral centre) for CD between 2005 and 2015 were reviewed. The electronic charts of all patients with ileal stricturing CD were retrospectively reviewed for smoking, Montreal classification, first stricture presentation, penetrating complications, CD therapy, C-reactive protein, previous surgery, imaging features of stricturing CD, endoscopic dilation, clinical symptoms, and hospitalisation. The NOD2 variants were genotyped.
In total, 1 803 CT or MR scans were performed in 957 CD patients. Further, 244 patients were diagnosed with an ileal stricturing disease. Nine patients were excluded for missing data. Overall, 161 patients (68.5%) needed surgery for stricturing CD. In 99 patients (61.5%), this was the first surgery. In multivariate regression analysis, stenosis length > 5cm (p = 0.0007, OR 3.31 [1.65–6.62]), prestenotic dilation (p = 0.006, OR 2.74 [1.33–5.62]), symptomatic stricturing CD (p = 0.03, OR 3.18 [1.12–9.09]) and hospitalisation for stricturing CD (p = 0.04, OR 2.04 [1.05–3.99]) significantly impacted on the need for surgery. The interval between diagnosis of stricturing CD on imaging and surgery was only influenced by the length of stenosis with a greater delay for longer stenosis (p = 0.048, OR 1.825 [1.01–3.32]). No correlation was found between need for and timing of surgery according to NOD2 genotype. Risk stratification according to the number of significant factors resulted in an increasing risk for surgery of 23%, 51%; 65%, 77%, 91%, and 100% for patients with, respectively, 0, 1, 2, 3, 4, and 5 risk factors.
The necessity for abdominal surgery in stricturing ileal CD is mainly linked to clinical and imaging factors. Using these, a clinically valid risk stratification model can be built to aid physicians in deciding on surgery in CD patients with small bowel stenoses and might prevent unnecessary delay of surgery.