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Clin Colon Rectal Surg 2022; 35(01): 072-077
DOI: 10.1055/s-0041-1740031
Review Article

Surgery versus Medical Therapy in Luminal Ileocecal Crohn's Disease

Michele Carvello
1   Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
2   Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
,
Silvio Danese
1   Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
3   Department of Gastroenterology, IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
,
Antonino Spinelli
1   Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
2   Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
› Author Affiliations Funding None.
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Abstract

The deeper understanding of the inflammatory process which gradually evolves into irreversible fibrosis and tissue damage has provided a precise picture of the disease course of luminal ileocecal Crohn's disease. According to the model of progressive structural damage, ideal time windows for medical and surgical treatment have been identified. While complicated disease clearly profits from surgical treatment, uncomplicated disease has become, in the last years, the most debatable setting in terms of different approaches including early surgery. On one hand, the rationale of traditional escalating medical therapy (step-up approach) has been undermined by the top-down medical approach. Indeed, the step-up approach has the possible drawback of delaying, up to a later disease stage, the use of more effective agents such as anti-tumor necrosis factors. Conversely, the top-down approach might expose patients to an overtreatment along with side effects including hypersensitivity to biologic agents. More recently, it has been shown how early surgery could be a valid option in this subset of patients being more cost-effective than medical therapy. Involving the surgeon at an early stage is considered now a good clinical practice and, in this scenario full of possibilities, the surgeon should be included into the decision-making process from the very beginning of patient management.

Keywords

surgery - ileocectomy - Crohn's disease - top-down

Authors' Contributions

M.C. revised the literature and drafted the manuscript, S.D. and A.S. critically revised the manuscript.




Publication History

Article published online:
17 January 2022

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  • References

  • 1 Rieder F, Latella G, Magro F. et al. European Crohn's and colitis organisation topical review on prediction, diagnosis and management of fibrostenosing Crohn's disease. J Crohn's Colitis 2016; 10 (08) 873-885
    CrossrefPubMedGoogle Scholar
  • 2 Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG clinical guideline: management of Crohn's disease in adults. Am J Gastroenterol 2018; 113 (04) 481-517
    CrossrefPubMedGoogle Scholar
  • 3 Van Assche G, Lewis JD, Lichtenstein GR. et al. The London Position Statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn's and Colitis Organisation: safety. Am J Gastroenterol 2011; 106 (09) 1594-1602 , quiz 1593, 1603
    CrossrefPubMedGoogle Scholar
  • 4 Bemelman WA, Warusavitarne J, Sampietro GM. et al. ECCO-ESCP consensus on surgery for Crohn's disease. J Crohn's Colitis 2018; 12 (01) 1-16
    PubMedGoogle Scholar
  • 5 Rutgeerts P, Feagan BG, Lichtenstein GR. et al. Comparison of scheduled and episodic treatment strategies of infliximab in Crohn's disease. Gastroenterology 2004; 126 (02) 402-413
    CrossrefPubMedGoogle Scholar
  • 6 Feagan BG, Panaccione R, Sandborn WJ. et al. Effects of adalimumab therapy on incidence of hospitalization and surgery in Crohn's disease: results from the CHARM study. Gastroenterology 2008; 135 (05) 1493-1499
    CrossrefPubMedGoogle Scholar
  • 7 Mao EJ, Hazlewood GS, Kaplan GG, Peyrin-Biroulet L, Ananthakrishnan AN. Systematic review with meta-analysis: comparative efficacy of immunosuppressants and biologics for reducing hospitalisation and surgery in Crohn's disease and ulcerative colitis. Aliment Pharmacol Ther 2017; 45 (01) 3-13
    CrossrefPubMedGoogle Scholar
  • 8 Holubar SD, Holder-Murray J, Flasar M, Lazarev M. Anti-tumor necrosis factor-α antibody therapy management before and after intestinal surgery for inflammatory bowel disease: a CCFA position paper. Inflamm Bowel Dis 2015; 21 (11) 2658-2672
    CrossrefPubMedGoogle Scholar
  • 9 Iesalnieks I, Kilger A, Glass H, Obermeier F, Agha A, Schlitt HJ. Perforating Crohn's ileitis: delay of surgery is associated with inferior postoperative outcome. Inflamm Bowel Dis 2010; 16 (12) 2125-2130
    CrossrefPubMedGoogle Scholar
  • 10 Spinelli A, Bazzi P, Sacchi M. et al. Short-term outcomes of laparoscopy combined with enhanced recovery pathway after ileocecal resection for Crohn's disease: a case-matched analysis. J Gastrointest Surg 2013; 17 (01) 126-132 , discussion 132
    CrossrefPubMedGoogle Scholar
  • 11 Pariente B, Cosnes J, Danese S. et al. Development of the Crohn's disease digestive damage score, the Lémann score. Inflamm Bowel Dis 2011; 17 (06) 1415-1422
    CrossrefPubMedGoogle Scholar
  • 12 Cosnes J, Cattan S, Blain A. et al. Long-term evolution of disease behavior of Crohn's disease. Inflamm Bowel Dis 2002; 8 (04) 244-250
    CrossrefPubMedGoogle Scholar
  • 13 Mantarro A, Scalise P, Guidi E, Neri E. Magnetic resonance enterography in Crohn's disease: how we do it and common imaging findings. World J Radiol 2017; 9 (02) 46-54
    CrossrefPubMedGoogle Scholar
  • 14 Moy MP, Sauk J, Gee MS. The role of MR enterography in assessing Crohn's disease activity and treatment response. Gastroenterol Res Pract 2016; 2016: 8168695
    PubMedGoogle Scholar
  • 15 Vespa E, Furfaro F, Allocca M. et al. Endoscopy after surgery in inflammatory bowel disease: Crohn's disease recurrence and pouch surveillance. Expert Rev Gastroenterol Hepatol 2020; 14 (09) 829-841
    CrossrefPubMedGoogle Scholar
  • 16 Danese S, Fiorino G, Fernandes C, Peyrin-Biroulet L. Catching the therapeutic window of opportunity in early Crohn's disease. Curr Drug Targets 2014; 15 (11) 1056-1063
    CrossrefPubMedGoogle Scholar
  • 17 Yacoub JH, Obara P, Oto A. Evolving role of MRI in Crohn's disease. J Magn Reson Imaging 2013; 37 (06) 1277-1289
    CrossrefPubMedGoogle Scholar
  • 18 Rimola J, Rodriguez S, García-Bosch O. et al. Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn's disease. Gut 2009; 58 (08) 1113-1120
    CrossrefPubMedGoogle Scholar
  • 19 Amitai MM, Klang E, Levartovsky A. et al. Diffusion-weighted magnetic resonance enterography for prediction of response to tumor necrosis factor inhibitors in stricturing Crohn's disease. Abdom Radiol (NY) 2018; 43 (12) 3207-3212
    CrossrefPubMedGoogle Scholar
  • 20 Moran GW, Dubeau MF, Kaplan GG. et al; Alberta Inflammatory Bowel Disease Consortium. Phenotypic features of Crohn's disease associated with failure of medical treatment. Clin Gastroenterol Hepatol 2014; 12 (03) 434-42.e1
    CrossrefPubMedGoogle Scholar
  • 21 Samimi R, Flasar MH, Kavic S, Tracy K, Cross RK. Outcome of medical treatment of stricturing and penetrating Crohn's disease: a retrospective study. Inflamm Bowel Dis 2010; 16 (07) 1187-1194
    CrossrefPubMedGoogle Scholar
  • 22 Celentano V, O'Leary DP, Caiazzo A. et al. Longer small bowel segments are resected in emergency surgery for ileocaecal Crohn's disease with a higher ileostomy and complication rate. Tech Coloproctol 2019; 23 (11) 1085-1091
    CrossrefPubMedGoogle Scholar
  • 23 de Groof EJ, Gardenbroek TJ, Buskens CJ. et al. The association between intensified medical treatment, time to surgery and ileocolic specimen length in Crohn's disease. Colorectal Dis 2017; 19 (06) 551-558
    CrossrefPubMedGoogle Scholar
  • 24 Wasmann KA. IBD study group Amsterdam UMC, location AMC. Complications while waiting for IBD surgery-short report. J Crohn's Colitis 2020; 14 (02) 277-280
    CrossrefPubMedGoogle Scholar
  • 25 Ricart E, García-Bosch O, Ordás I, Panés J. Are we giving biologics too late? The case for early versus late use. World J Gastroenterol 2008; 14 (36) 5523-5527
    CrossrefPubMedGoogle Scholar
  • 26 Panaccione R, Löfberg R, Rutgeerts P. et al. Efficacy and safety of adalimumab by disease duration: analysis of pooled data from Crohn's disease studies. J Crohn's Colitis 2019; 13 (06) 725-734
    CrossrefPubMedGoogle Scholar
  • 27 Irvine EJ. Review article: patients' fears and unmet needs in inflammatory bowel disease. Aliment Pharmacol Ther 2004; 20 (Suppl. 04) 54-59
    CrossrefPubMedGoogle Scholar
  • 28 Muller KR, Prosser R, Bampton P, Mountifield R, Andrews JM. Female gender and surgery impair relationships, body image, and sexuality in inflammatory bowel disease: patient perceptions. Inflamm Bowel Dis 2010; 16 (04) 657-663
    CrossrefPubMedGoogle Scholar
  • 29 Spinelli A, Carvello M, D'Hoore A, Pagnini F. Psychological perspectives of inflammatory bowel disease patients undergoing surgery: rightful concerns and preconceptions. Curr Drug Targets 2014; 15 (11) 1074-1078
    CrossrefPubMedGoogle Scholar
  • 30 Bemelman WA. S-ECCO collaborators. Evolving role of IBD surgery. J Crohn's Colitis 2018; 12 (08) 1005-1007
    CrossrefPubMedGoogle Scholar
  • 31 Mui M, An V, Lovell J, D'Souza B, Woods R. Patients' perspective on bowel resection for inflammatory bowel disease. Int J Colorectal Dis 2018; 33 (02) 219-222
    CrossrefPubMedGoogle Scholar
  • 32 Latella G, Caprilli R, Travis S. In favour of early surgery in Crohn's disease: a hypothesis to be tested. J Crohn's Colitis 2011; 5 (01) 1-4
    CrossrefPubMedGoogle Scholar
  • 33 Berg DR, Colombel JF, Ungaro R. The role of early biologic therapy in inflammatory bowel disease. Inflamm Bowel Dis 2019; 25 (12) 1896-1905
    CrossrefPubMedGoogle Scholar
  • 34 Khanna R, Bressler B, Levesque BG. et al; REACT Study Investigators. Early combined immunosuppression for the management of Crohn's disease (REACT): a cluster randomised controlled trial. Lancet 2015; 386 (10006): 1825-1834
    CrossrefPubMedGoogle Scholar
  • 35 D'Haens G, Baert F, van Assche G. et al; Belgian Inflammatory Bowel Disease Research Group, North-Holland Gut Club. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn's disease: an open randomised trial. Lancet 2008; 371 (9613): 660-667
    CrossrefPubMedGoogle Scholar
  • 36 Ippoliti A, Devlin S, Mei L. et al. Combination of innate and adaptive immune alterations increased the likelihood of fibrostenosis in Crohn's disease. Inflamm Bowel Dis 2010; 16 (08) 1279-1285
    CrossrefPubMedGoogle Scholar
  • 37 Aratari A, Papi C, Leandro G, Viscido A, Capurso L, Caprilli R. Early versus late surgery for ileo-caecal Crohn's disease. Aliment Pharmacol Ther 2007; 26 (10) 1303-1312
    CrossrefPubMedGoogle Scholar
  • 38 Ponsioen CY, de Groof EJ, Eshuis EJ. et al; LIR!C study group. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: a randomised controlled, open-label, multicentre trial. Lancet Gastroenterol Hepatol 2017; 2 (11) 785-792
    CrossrefPubMedGoogle Scholar
  • 39 de Groof EJ, Stevens TW, Eshuis EJ. et al. Cost-effectiveness of laparoscopic ileocaecal resection versus infliximab treatment of terminal ileitis in Crohn's disease: the LIR!C trial. Gut 2019; 68 (10) 1774-1780
    CrossrefPubMedGoogle Scholar
  • 40 Stevens TW, Haasnoot ML, D'Haens GR. et al; LIR!C study group. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastroenterol Hepatol 2020; 5 (10) 900-907
    CrossrefPubMedGoogle Scholar
  • 41 Annese V, Daperno M, Rutter MD. et al; European Crohn's and Colitis Organisation. European evidence based consensus for endoscopy in inflammatory bowel disease. J Crohn's Colitis 2013; 7 (12) 982-1018
    CrossrefPubMedGoogle Scholar
  • 42 Lee Y, Fleming FJ, Deeb AP, Gunzler D, Messing S, Monson JRT. A laparoscopic approach reduces short-term complications and length of stay following ileocolic resection in Crohn's disease: an analysis of outcomes from the NSQIP database. Colorectal Dis 2012; 14 (05) 572-577
    CrossrefPubMedGoogle Scholar
  • 43 Carvello M, de Groof EJ, de Buck van Overstraeten A. et al. Single port laparoscopic ileocaecal resection for Crohn's disease: a multicentre comparison with multi-port laparoscopy. Colorectal Dis 2018; 20 (01) 53-58
    CrossrefPubMedGoogle Scholar
  • 44 Maggiori L, Tuech JJ, Cotte E. et al. Single-incision laparoscopy versus multiport laparoscopy for colonic surgery: a multicenter, double-blinded, randomized controlled trial. Ann Surg 2018; 268 (05) 740-746
    CrossrefPubMedGoogle Scholar
  • 45 De Cruz P, Kamm MA, Prideaux L, Allen PB, Desmond PV. Postoperative recurrent luminal Crohn's disease: a systematic review. Inflamm Bowel Dis 2012; 18 (04) 758-777
    CrossrefPubMedGoogle Scholar
  • 46 Holubar SD, Dozois EJ, Privitera A. et al. Laparoscopic surgery for recurrent ileocolic Crohn's disease. Inflamm Bowel Dis 2010; 16 (08) 1382-1386
    CrossrefPubMedGoogle Scholar