Crohn's disease: a population-based study of surgery in the age of biological therapy

Abstract

Purpose: Despite primary conservative therapy for Crohn's disease, a considerable proportion of patients ultimately needs to undergo surgery. Presumably, due to the increased use of biologics, the number of surgeries might have decreased. This study aimed to delineate current case numbers and trends in surgery in the era of biological therapy for Crohn's disease.

Methods: Nationwide standardized hospital discharge data (diagnosis-related groups statistics) from 2010 to 2017 were used. All patients who were admitted as inpatient Crohn's disease cases in Germany were included. Time-related development of admission numbers, rate of surgery, morbidity, and mortality of inpatient Crohn's disease cases were analyzed.

Results: A total number of 201,165 Crohn's disease cases were included. Within the analyzed time period, the total number of hospital admissions increased by 10.6% (n = 23,301 vs. 26,069). While gender and age distribution remained comparable, patients with comorbidities such as stenosis formation (2010: 10.1%, 2017: 13.4%) or malnutrition (2010: 0.8%, 2017: 3.2%) were increasingly admitted. The total number of all analyzed operations for Crohn's disease increased by 7.5% (2010: n = 1567; 2017: n = 1694). On average, 6.8 ± 0.2% of all inpatient patients received ileocolonic resections. Procedures have increasingly been performed minimally invasive (2010: n = 353; 2017: n = 687). The number of postoperative complications remained low.

Conclusion: Despite the development of novel immunotherapeutics, the number of patients requiring surgery for Crohn's disease remains stable. Interestingly, patients have been increasingly hospitalized with stenosis and malnutrition. The trend towards more minimally invasive operations has not relevantly changed the rate of overall complications.

Keywords: Crohn’s disease; IBD; Immunotherapeutics; Surgery.

Fig. 1

Development of inpatient cases with Crohn’s disease in Germany. a The total number of inpatient cases in Germany increased significantly over the study period. b Secondary diagnoses in 2010 compared to 2017 (relative numbers per year) with a significant increase of relative numbers for stenosis and malnutrition (p < 0.05 = *; p < 0.01 = **; p < 0.001 = ***)

Fig. 2

Development of ileocolonic resections for Crohn’s disease from 2010 to 2017. Absolute numbers of ileocecal resections (left) and right-sided hemicolectomies (right) for Crohn’s disease from 2010 to 2017 are depicted. The surgical approach (open vs. laparoscopic) has changed significantly over time (p < 0.05 = *; p < 0.01 = **; p < 0.001 = ***)

Fig. 3

Postoperative complications following surgery for Crohn’s disease. Intestinal obstruction, anastomotic leakage, wound dehiscence, and surgical site infection are shown as postoperative complications following ileocecal resection or right-sided hemicolectomy. Laparoscopic ileocecal resection was associated with a lower rate of wound dehiscence and surgical site infection compared to an open approach. Postoperative complication rates tended to be higher with right-sided hemicolectomy (p < 0.05 = *; p < 0.01 = **; p < 0.001 = ***), NA, no data available

Fig. 4

Postoperative length of stay. Distribution of cases with ileocecal resection or hemicolectomy relative to the length of stay. Cases with laparoscopic procedures had a significantly shorter length of stay. Additionally, cases with ileocecal resection tended to have shorter length of stay than cases with right-sided hemicolectomy (p < 0.05 = *; p < 0.01 = **; p < 0.001 = ***). %, proportion of overall cases