P329 Which should come first? Surgery or biologic therapy for ileocaecal Crohn’s disease in biologic naïve patients
Witjes, C.(1,2);Patel, A.(1,3);Zocche, D.(1);van 't Hullenaar- , C.(1);Cripps, S.(4);Travis, S.(5);George, B.(1);
(1)Oxford University Hospital- NHS Foundation Trust- Oxford, Department of Colorectal surgery, Oxford, United Kingdom;(2)Ijsselland Hospital, Department of General Surgery and Colorectal Surgery-, Capelle aan den IJssel, The Netherlands;(3)University hospital of Coventry and Warwickshire NHS Trust, Department of Colorectal surgery, Coventry, United Kingdom;(4)Oxford University Hospital- NHS Foundation Trust, Pharmacy Department – Gastroenterology/Hepatology, Oxford, United Kingdom;(5)Oxford University Hospital- NHS Foundation Trust, Translational Gastroenterology Unit, Oxford, United Kingdom;
The L!RIC trial confirmed that surgical treatment of limited ileocaecal Crohn’s disease (ICCD) has comparable outcomes to antiTNF therapy. However, strict exclusion criteria for a randomised controlled trial make it difficult to determine if results can be generalised to a wider population. We therefore compared clinical outcomes between surgical resection or antiTNF or other biologic therapy amongst biologic-naïve patients with ileocaecal Crohn’s disease to provide real world experience.
All patients with ICCD who were naïve both to biologic therapy and surgery, treated at our institution between January 2011 and December 2018 were identified from surgical and pharmacy databases. Electronic case records were used to obtain data on patient characteristics retrospectively and treatment-specific outcomes. The 5-year cumulative recurrence rate was calculated after composite consideration of endoscopic recurrence, recurrence on imaging, switch to different therapy, or surgical re-intervention.
Overall, 222 patients were identified.149 (67%) underwent surgical resection first, of whom 54 patients (36%) subsequently required antiTNF or other biologic therapy. 73 patients were treated with antiTNF or other biologic therapy first, of whom 29(40%) subsequently required surgical resection (p=0.60). There were 95/149 patients (64%) who were successfully treated by a surgical resection first approach alone.
There was no difference in 1- and 5-year cumulative recurrence rates between the two treatment approaches (17%, 55% for surgery vs 14%, 54% for biologics (p=0.53)), median follow-up was 74 months (0-406) and 71 months (13-235), respectively.
There was no significant difference in time to switch from surgery to biologic or vice versa (p=0.10). Patients who underwent surgery more likely need post-operative biologic therapy if female (p=0.010), obstructive symptoms (p=0.028), or smoker (p=0.030). Patients on biologic therapy more likely undergo surgery if the disease was limited to terminal ileum (p=0.001), was stricturing or penetrating rather than inflammatory and if the patient had obstructive symptoms (p=0.003). Only 3/149 patients required endoscopic dilatation because of an anastomotic stricture. None of the patients needed a second surgical resection.In comparison, 26 patients (20%) reported side effects from biologic therapy and as result of these side-effects or due to loss of response (n=9), biologic agents was changed in 28 patients (22%).
This real world experience confirms the findings of the L!RIC trial, demonstrating that surgical intervention can be considered at an early stage in the disease process, rather than restricting it to patients who develop complications of Crohn’s disease.