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Meta-analysis of early bowel resection versus initial medical therapy in patient's with ileocolonic Crohn's disease

Abstract

Background

Early bowel resection (EBR) in ileocolonic Crohn’s disease (CD) may be associated with more durable remission compared with initial medical therapy (IMT) even when biologic therapy is included.

Aim

To compare the efficacy of EBR versus IMT for ileocolonic CD

Methods

A systematic search was performed to identify studies that compared EBR (performed < 1 year from initial diagnosis) or IMT for the management of ileocolonic CD. Log hazard ratios (InHR) for relapse-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots and pooled using the inverse-variance method. Dichotomous variables were pooled as odds ratios (OR). Quality assessment of the included studies was performed using the Newcastle-Ottawa (NOS) and Jadad scales.

Results

A total of 7 studies with 1863 CD patients (EBR n = 581, 31.2%; IMT n = 1282, 68.8%) were eligible for inclusion. There was a moderate-to-high risk of bias. The median NOS was 8 (range 7–9). There was a reduced likelihood of overall (OR, 0.53; 95% confidence interval (95% CI), 0.34, 0.83; p = 0.005) and surgical (OR, 0.47; 95% CI, 0.24, 0.91; p = 0.03) relapse with EBR. There was also a less requirement for maintenance biologic therapy (OR, 0.24; 95% CI, 0.14, 0.42; p < 0.0001). Patients who underwent EBR had a significantly improved RFS than those who underwent IMT (HR, 0.62; 95% CI, 0.52, 0.73; p < 0.001). There was no difference in morbidity (OR, 1.67; 95% CI, 0.44, 6.36; p = 0.45) between the groups.

Conclusion

EBR may be associated with less relapse and need for maintenance biologic therapy than IMT. ‘Upfront’ or early resection may represent a reasonable and cost-effective alternative to biologic therapy, especially in biologic-resistant subpopulations.

Trial registration

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Ryan, É.J., Orsi, G., Boland, M.R. et al. Meta-analysis of early bowel resection versus initial medical therapy in patient's with ileocolonic Crohn's disease. Int J Colorectal Dis 35, 501–512 (2020). https://doi.org/10.1007/s00384-019-03479-9

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Keywords

  • Surgery
  • Resection
  • Inflammatory bowel disease
  • Crohn’s disease
  • Medical therapy
  • Immunosuppression
  • Biologic therapy
  • Infliximab