Editorial: Re-evaluating early surgery in Ileocaecal Crohn's disease

IF 6.6 1区 医学 Q1 GASTROENTEROLOGY & HEPATOLOGY Alimentary Pharmacology & Therapeutics Pub Date : 2024-10-07 DOI:10.1111/apt.18290
Leshni Pillay, Britt Christensen
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Abstract

Since the introduction of biologics, treatment strategies for Crohn's disease (CD) have focused on initial medical management, reserving surgery for patients who fail medical therapy or who develop complications. Despite this, most patients with ileal involvement, a key risk factor for progression to stricturing and penetrating complications, still require at least one surgical resection within 10 years of diagnosis.1-3

The 2017 LIR!C trial challenged this approach, demonstrating that early ileocecal resection was non-inferior to initial anti-TNF therapy in patients who failed conventional treatments in terms of quality of life, treatment effectiveness and disease complications.4 Moreover, early surgery reduced the need for advanced medical therapies and disease-related complications and morphological recurrence on long-term follow-up.5 These findings prompted questions about whether early surgery should play a more prominent role as first-line therapy in ileal CD.

The retrospective study by Grellier et al.6 aimed to provide further insight into this ongoing debate. This study compared outcomes in patients undergoing early (within 6 months of diagnosis), intermediate (6 months to 2 years) and late (2–5 years) ileal resection for CD. For the primary outcome, cumulative risk of second surgery at 10 years, there were no significant differences among the three arms (25%, 17% and 23%, respectively). This was despite the early resection group tending to have more complicated diseases and a higher proportion of smokers. Notably, 69% of early surgery patients were medical therapy-naïve compared to just 16% and 8% in the intermediate and late groups.

Consistent with LIR!C and data of Agrawal et al.7 the study highlighted important differences in disease progression in those undergoing early surgical resection versus initial medical therapy. Compared to the later surgical arms, patients with early resection were less likely to require advanced medical therapies postoperatively (median survival 3.7 years vs. 0.92 years) and had less morphologic recurrence at 5 years (54.4% vs. 68.2%; p = 0.02). Importantly, anti-TNF exposure before surgery was also associated with higher risk of second ileal resection (HR: 2.82; p < 0.001), suggesting that biologics may influence CD biology and long-term surgical outcomes.

The study's limitations include high dropout rate, retrospective analysis and exclusion of patients who did not undergo surgery within 5 years of diagnosis, limiting the generalizability of the results.

Despite these limitations, it has added valuable insight into the growing body of evidence that early surgery in ileal CD does not lead to worse long-term outcomes. On the contrary, early resection may offer protective benefits by altering CD biology resulting in reduced need for advanced therapies and lowering morphological recurrence. These findings strengthen the argument for considering surgery as an early intervention in select patients with ileal CD.

With this accumulating evidence, it may be time to rethink the current treatment paradigm that reserves surgery for patients with complicated or refractory CD. Although further prospective research is needed, the future of CD management might involve a more integrated approach, combining early surgery with advanced medical therapies to help patients achieve long-term symptom control and disease clearance.

Leshni Pillay: Writing – original draft; writing – review and editing; conceptualization. Britt Christensen: Writing – review and editing; conceptualization; supervision.

This article is linked to Grellier et al papers. To view these articles, visit https://doi.org/10.1111/apt.18247 and https://doi.org/10.1111/apt.18320.

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社论:重新评估回盲部克罗恩病的早期手术治疗。
自生物制剂问世以来,克罗恩病(CD)的治疗策略一直侧重于初始药物治疗,为药物治疗失败或出现并发症的患者保留手术治疗。尽管如此,大多数回肠受累的患者仍需要在确诊后 10 年内至少进行一次手术切除,而回肠受累是进展为狭窄性和穿透性并发症的关键风险因素。1-3 2017 年的 LIR!C 试验对这一方法提出了挑战,试验表明,对于常规治疗失败的患者,早期回盲部切除术在生活质量、治疗效果和疾病并发症方面均不优于初始抗肿瘤坏死因子治疗。此外,早期手术减少了对高级药物疗法的需求,也减少了长期随访中与疾病相关的并发症和形态学复发。5 这些发现引发了关于早期手术是否应作为回肠 CD 一线疗法发挥更重要作用的问题。这项研究比较了因 CD 而接受早期(诊断后 6 个月内)、中期(6 个月至 2 年)和晚期(2-5 年)回肠切除术的患者的预后。就主要结果(10 年后第二次手术的累积风险)而言,三组之间没有显著差异(分别为 25%、17% 和 23%)。尽管早期切除组患者的病情更复杂,吸烟者比例更高,但这一结果并不明显。值得注意的是,69% 的早期手术患者没有接受过药物治疗,而中期组和晚期组分别只有 16% 和 8% 的患者没有接受过药物治疗。与后期手术组相比,早期切除的患者术后需要高级药物治疗的可能性较低(中位生存期为 3.7 年 vs. 0.92 年),5 年后的形态学复发率较低(54.4% vs. 68.2%;P = 0.02)。重要的是,术前接触抗肿瘤坏死因子也与第二次回肠切除术的风险较高有关(HR:2.82;p = 0.001),这表明生物制剂可能会影响 CD 的生物学特性和长期手术预后。该研究的局限性包括高辍学率、回顾性分析以及排除了确诊后5年内未接受手术的患者,从而限制了研究结果的推广性。尽管存在这些局限性,但该研究为越来越多的证据增添了宝贵的见解,即早期手术治疗回肠CD不会导致更差的长期预后。相反,早期切除可能会通过改变 CD 的生物学特性提供保护性益处,从而减少对先进疗法的需求并降低形态学复发率。这些研究结果加强了将手术作为回肠CD患者早期干预措施的论点。有了这些不断积累的证据,也许是时候重新思考目前将手术保留给复杂或难治性CD患者的治疗模式了。虽然还需要进一步的前瞻性研究,但未来的CD治疗可能会采用更综合的方法,将早期手术与先进的药物疗法相结合,帮助患者实现长期的症状控制和疾病清除:写作--原稿;写作--审阅和编辑;构思。布里特-克里斯滕森:写作--审阅和编辑;构思;指导。本文链接到格雷利尔等人的论文。要查看这些文章,请访问 https://doi.org/10.1111/apt.18247 和 https://doi.org/10.1111/apt.18320。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
15.60
自引率
7.90%
发文量
527
审稿时长
3-6 weeks
期刊介绍: Alimentary Pharmacology & Therapeutics is a global pharmacology journal focused on the impact of drugs on the human gastrointestinal and hepato-biliary systems. It covers a diverse range of topics, often with immediate clinical relevance to its readership.
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