Marked Decline in 5-Year Surgery Rates Seen for Ulcerative Colitis, Crohn Disease

Investigators analyzed the surgical risk for ulcerative colitis and Crohn disease in contemporary, population-based inception cohorts vs 20th century cohorts.

The contemporary cumulative 5-year risk for surgery in patients diagnosed with ulcerative colitis (UC) and Crohn disease (CD) in the 21st century was found to be “substantially lower” than that for patients diagnosed in the 20th century, according to data from a systematic review published in Clinical Gastroenterology and Hepatology. Presently (after 2000), the cumulative 5-year risk for surgery is 7.0% and 17.8% in patients with UC and CD, respectively. Before 2000, the 5-year risk for surgery was 9.5% for UC and 35.7% for CD.

“In this systematic review of 44 population-based cohort studies, we estimated cumulative risk of surgery in patients with UC and CD and observed that short- and long-term risk of surgery was 25% [to] 50% lower in patients diagnosed with IBD in the last 2 decades than prior decades,” the study authors said. They added that the observed declines may be related to earlier disease detection and/or better treatment.

The investigators conducted a systematic review of the MEDLINE, Embase, Cochrane, Scopus, and Web of Science databases from inception to September 3, 2019 for population-based cohort studies that reported the cumulative risk of major abdominal surgery since the time of diagnosis with at least 1 year of follow-up in patients with incident UC and CD. Eligible studies were those that “investigated the entire population in a defined geographical area in a defined time period, used appropriate sampling techniques to infer risk for the entire population, or used national registries capturing nearly the entire population in a region (>90%).” The studies must have also reported the cohort size, calendar year of cohort recruitment, and cumulative surgery risk by Kaplan-Meier estimates.

The primary outcome was the cumulative 1, 5-, and 10-year risk of major abdominal surgery in patients with UC and CD (and repeat surgery in those with CD). Major abdominal surgery was defined as colectomy with or without an ileal pouch anal anastomosis in patients with UC. In patients with CD, it was defined as intestinal resection.

The investigators also calculated the 5- and 10-year risks of repeat major abdominal surgery in patients with CD who underwent initial resection. An analysis of cohorts in which most patients (>90%) were diagnosed after 2000 was conducted to estimate contemporary risks of surgery in the 21st century. Time-trend mixed-effects regression was performed to assess changes in surgery risk over time.

A total of 44 publications were included in meta-analyses, comprising 26 cohorts of patients with UC, 22 cohorts of patients with CD, and 8 cohorts of patients with CD with prior intestinal resection. Among patients with UC, the cumulative risk of colectomy 1, 5, and 10 years after diagnosis was 4.0% (95% CI, 3.3-5.0), 8.8% (95% CI, 7.7-10.0), and 13.3% (95% CI, 11.3-15.5), respectively.

 A decline in surgery risk was observed over time, with contemporary (post-2000) UC cohorts displaying significantly lower risks for surgery than those diagnosed in prior decades (P <.001). Specifically, the 1-, 5-, and 10-year contemporary risks were 2.8% (95% CI, 2.0-3.9), 7.0% (95% CI, 5.7-8.6), and 9.6% (95% CI, 6.3-14.2), respectively.

In patients with CD, the cumulative 1-, 5-, and 10-year risk of surgery was 18.7% (15.0-23.0), 28.0% (24.0-32.4), and 39.5% (33.3-46.2), with risk decreasing over time (P <.001). The corresponding contemporary risks were 12.3% (95% CI, 10.8-14.0), 18.0% (95% CI, 15.4-21.0), and 26.2% (95% CI, 23.4-29.4). Among patients with CD with prior resection, cumulative risk of second resection was 17.7% (95% CI, 13.5-22.9) and 31.3% (95% CI, 24.1-39.6%) at 5 and 10 years post-resection, respectively.

Results from this study indicate that patient-level risk for major surgery has declined significantly over time in both UC and CD cohorts. The primary study limitations were between-study heterogeneity and lack of information on patient treatment exposure.

 Further research is necessary to confirm these findings, the study authors stated. “Factors contributing meaningfully to these decreased risks…merit further evaluation, including the impact of newer biologics and treat-to-target strategies, to promote value-based care,” they concluded.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of the authors’ disclosures.

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Tsai L, Ma C, Dulai PS, et al. Contemporary risk of surgery in patients with ulcerative colitis and Crohn’s disease: a meta-analysis of population-based cohorts. Clin Gastroenterol Hepatol. Published online October 27, 2020. doi: 10.1016/j.cgh.2020.10.039