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Does Smoking Cessation Reduce Surgical Recurrence After Primary Ileocolic Resection for Crohns Disease?
Oxford Univ Hosp Natl Hlth Serv Fdn Trust, England.
Linköpings universitet, Institutionen för biomedicinska och kliniska vetenskaper, Avdelningen för kirurgi, ortopedi och onkologi. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken US. Linköpings universitet, Medicinska fakulteten.
Oxford Univ Hosp Natl Hlth Serv Fdn Trust, England.
Oxford Univ Hosp Natl Hlth Serv Fdn Trust, England.
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2020 (Engelska)Ingår i: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 63, nr 2, s. 200-206Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Tobacco smoking is a known risk factor for recurrence of Crohns disease after surgical resection. OBJECTIVE: This study assessed the effect of smoking cessation on long-term surgical recurrence after primary ileocolic resection for Crohns disease. DESIGN: A retrospective review of a prospectively maintained database was conducted. SETTINGS: Patient demographic data and medical and surgical details were combined from 2 specialist centers. After ethical approval, patients were contacted in case of missing data regarding smoking habit. PATIENTS: All patients undergoing ileocolic resection between 2000 and 2012 for histologically confirmed Crohns disease were included. Those with previous intestinal resection, strictureplasty for Crohns disease, leak after ileocolic resection, or who were never reversed were excluded. MAIN OUTCOME MEASURES: The primary end point was surgical recurrence measured by Kaplan-Meier survival analysis and secondary medical therapy at time of follow-up. RESULTS: Over a 12-year period, 290 patients underwent ileocolic resection. Full smoking data were available for 242 (83%) of 290 patients. There were 169 nonsmokers (70%; group 1), 42 active smokers at the time of ileocolic resection who continued smoking up to last follow-up (17%; group 2), and 31 (13%) who quit smoking after ileocolic resection (group 3). The median time of smoking exposure after ileocolic resection for group 3 was 3 years (interquartile range, 0-6 y), and median follow-up time for the whole group was 112 months (9 mo; interquartile range, 84-148 mo). Kaplan-Meier survival analysis showed a significantly higher surgical recurrence rate for group 2 compared with group 3 (16/42 (38%) vs 3/31 (10%); p = 0.02; risk ratio = 3.9 (95% CI, 1-12)). In addition, significantly more patients in group 2 without surgical recurrence received immunomodulatory maintenance therapy compared with group 3 (12/26 (46%) vs 4/28 (14%); p = 0.01; risk ratio = 3.2 (95% CI, 1-9)). LIMITATIONS: The study was limited by its retrospective design and small number of patients. CONCLUSIONS: Smoking cessation after primary ileocolic resection for Crohns disease may significantly reduce long-term risk of surgical recurrence and is associated with less use of maintenance therapy. See Video Abstract at http://links.lww.com/DCR/B86.

Ort, förlag, år, upplaga, sidor
Lippincott Williams & Wilkins, 2020. Vol. 63, nr 2, s. 200-206
Nyckelord [en]
Crohns disease; Ileocolic resection; Smoking cessation; Surgical recurrence
Nationell ämneskategori
Kirurgi
Identifikatorer
URN: urn:nbn:se:liu:diva-163660DOI: 10.1097/DCR.0000000000001547ISI: 000509508700011PubMedID: 31842162Scopus ID: 2-s2.0-85077761704OAI: oai:DiVA.org:liu-163660DiVA, id: diva2:1394184
Anmärkning

Funding Agencies|National Institute for Health Research Oxford Biomedical Research CentreNational Institute for Health Research (NIHR)

Tillgänglig från: 2020-02-18 Skapad: 2020-02-18 Senast uppdaterad: 2021-01-22Bibliografiskt granskad
Ingår i avhandling
1. Surgery and stomas in Crohn's disease
Öppna denna publikation i ny flik eller fönster >>Surgery and stomas in Crohn's disease
2021 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

This study investigates the evolution of abdominal surgery in treatment of Crohn´s disease (CD) in the era of immunomodulatory drugs and biologicals. It concerns risk of abdominal surgery overall and sub-categories of abdominal surgery, risk of repeat surgery and factors that affect this risk, and risk of getting a stoma. Surgical recurrence is a major clinical problem as repeat procedures are more complex and expose the patients to a higher medical risk both in conjunction with surgery and afterwards. Updated information on abdominal surgery for CD will be of use when making decisions about medical vs surgical interventions.

In a nationwide cohort of 21 273 patients with CD during the years 1990-2014, the cumulative incidence of abdominal surgery within five years of diagnosis decreased continuously down to 17.3% for patients diagnosed with CD during the last calendar period of study, 2009–2014. Ileocecal resection was the most common primary procedure. The incidence of colectomy was low in all calendar periods and continuously decreased. The incidence of proctectomy was very low even after decades with the disease, 3.0% for patients diagnosed 1990-1995 with a median follow-up of 21 years. Incidence of repeat abdominal surgery within five years of primary procedure decreased in the 90s down 16.0% in the 1996– 2000 period with a risk of ileocolic reresection of 4.4%. After 2000, despite introduction of biologicals in 1998, no further significant decrease in repeat surgery was observed.

In a retrospective review of prospectively maintained databases at three university hospitals, the rate of surgical recurrence for 389 patients with CD who had been treated with a primary ileocecal resection between 2000-2012 was investigated. The patients were operated receiving either a temporary stoma (20%) or a primary anastomosis (80%) with a median follow-up time of 105 months. Patients selected to temporary stoma had a higher prevalence of baseline risk factors usually associated with an increased risk of recurrence such as penetrating disease behaviour. Despite this, there was no difference in long-term surgical recurrence between the one- and two-stage groups; 18% vs 16%.

In a retrospective review of prospectively maintained databases at two university hospitals, the effect of smoking cessation on rate of surgical recurrence was assessed. 242 patients were included with a median follow-up of 112 months. Surgical recurrence rate for smokers vs quitters was 16/42 (38%) vs 3/31 (10%); p = 0.02; risk ratio = 3.9 despite a median time for smoking exposure after the primary procedure of three years. Among the non-smokers 28/169 (17%) had a surgical recurrence at last follow-up. 8 out of 11 smoking patients who needed a second resection went on to need a third resection. Of the patients who were free of surgical recurrence at follow-up, those who had quit smoking were significantly less likely to have been put on medical therapy compared with smokers with a risk ratio of 3.2.

In an observational study of a nationwide cohort of 19 146 patients with incident CD 2002- 2013 and followed through 2017, the incidence and prevalence of stoma was investigated. The cumulative incidence of stoma formation within five years was 2.4% and remained constant from 2002 and onwards although cumulative ever-use of biologicals increased and time to start with treatment with biologicals decreased. 48% of all stomas were reversed. Ileostomies encompassed about two-thirds of all stomas and risk of stoma was higher among patients with elderly-onset CD and among patients with perianal manifestations of the disease. 28% of the patients who underwent surgery with formation of a stoma had perianal disease. 0.6% of all incident patients had a permanent stoma five years after diagnosis.

Ort, förlag, år, upplaga, sidor
Linköping: Linköping University Electronic Press, 2021. s. 88
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1768
Nationell ämneskategori
Kirurgi
Identifikatorer
urn:nbn:se:liu:diva-172781 (URN)10.3384/diss.diva-172781 (DOI)9789179297336 (ISBN)
Disputation
2021-02-12, Online through Zoom and YouTube (contact par.myrelid@liu.se) and Belladonna, Building 511, Campus US, Linköping, 13:00 (Svenska)
Opponent
Handledare
Anmärkning

Funding agency: The Research Fund from the University Hospital in Linköping – ALF

Tillgänglig från: 2021-01-22 Skapad: 2021-01-22 Senast uppdaterad: 2021-01-26Bibliografiskt granskad

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