P497 Is early bowel resection better than medical therapy for ileocolonic Crohn’s disease? A systematic review and meta-analysis
Husnoo, N.(1);Gana, T.(2);Hague, A.G.(2);Khan, Z.(2);Morgan, J.L.(1);Wyld, L.(1);Brown, S.R.(2)*;
(1)University of Sheffield, Oncology and Metabolism, Sheffield, United Kingdom;(2)Sheffield Teaching Hospitals NHS Foundation Trust, General Surgery, Sheffield, United Kingdom;
Background
At least one third of patients with Crohn's disease (CD) have isolated ileocaecal disease. For a long time, surgery in this context has been seen as the "last resort" measure that is adopted when medical options have been exhausted. There is emerging evidence supporting early bowel resection (EBR) for ileocaecal CD as an alternative to conventional escalation of medical therapy (MT). We present a systematic review and meta-analysis of studies comparing the outcomes of EBR with those of MT in ileocolonic CD, with a focus on ileocaecal disease.
Methods
The MEDLINE, Embase, CINAHL and Cochrane Central Register of Controlled Trials databases were searched for studies reporting the outcomes of EBR versus MT for ileocolonic CD. The Cochrane tools for assessment of risk of bias were used to assess the methodological quality of studies. The primary outcomes were recurrence rate and time to recurrence. Data on factors influencing duration of treatment effect, morbidity (including stoma rates), mortality and quality of life were extracted where available.
Results
Nine records (from 8 studies, with a total of 1867 patients) were included in the analysis. Six studies were observational and two were randomised controlled trials. Three observational studies were at serious risk, and one RCT was at high risk of bias. There was a reduced need for drug therapy in the EBR arm. The rate of intestinal resection at 5 years was 7.8% in the EBR arm and 25.4% in the MT group with a pooled OR of 0.32 (95% CI 0.19, 0.54; p<0.0001). The EBR group had a longer resection-free survival (HR 0.56, 95% CI 0.38, 0.83; p=0.004). The time to repeat resection following the initial surgery was longer also in the EBR group (HR 0.65, 95% CI 0.47, 0.91; p=0.01). The need for surgery at 5 years remained in favour of EBR in a subgroup analysis of patients with ileocaecal disease (HR 0.18; 95% CI 0.04, 0.88; p=0.03). Morbidity and quality of life scores were similar across the two groups.
Conclusion
EBR is associated with a more stable remission compared to initial MT for Crohn’s disease. Despite the paucity of relevant studies within the literature, and the studies being of variable methodological quality, there is enough evidence to support EBR as an alternative to escalation of medical therapy in selected patients with limited ileocaecal disease. EBR should be discussed with patients at an early stage to allow them to make an informed treatment choice.