BackgroundTreatment of patients with Crohns disease has evolved in recent decades, with increasing use of immunomodulatory medication since 1990 and biologicals since 1998. In parallel, there has been increased use of active disease monitoring. To what extent these changes have influenced the incidence of primary and repeat surgical resection remains debated. MethodsIn this nationwide cohort study, incident patients of all ages with Crohns disease, identified in Swedish National Patient Registry between 1990 and 2014, were divided into five calendar periods of diagnosis: 1990-1995 and 1996-2000 with use of inpatient registries, 2001, and 2002-2008 and 2009-2014 with use of inpatient and outpatient registries. The cumulative incidence of first and repeat abdominal surgery (except closure of stomas), by category of surgical procedure, was estimated using the Kaplan-Meier method. ResultsAmong 21273 patients with Crohns disease, the cumulative incidence of first abdominal surgery within 5years of Crohns disease diagnosis decreased continuously from 548 per cent in 1990-1995 to 404 per cent in 1996-2000 (P<0001), and again from 198 per cent in 2002-2008 to 173 per cent in 2009-2014 (P<0001). Repeat 5-year surgery rates decreased from 189 per cent in 1990-1995 to 160 per cent in 1996-2000 (P=0009). After 2000, no further significant decreases were observed. ConclusionThe 5-year rate of surgical intervention for Crohns disease has decreased significantly, but the rate of repeat surgery has remained stable despite the introduction of biological therapy. AntecedentesEl tratamiento de pacientes con enfermedad de Crohn ha evolucionado en las ultimas decadas con un uso cada vez mayor de medicamentos inmunomoduladores desde 1990 y tratamientos biologicos desde 1998. Al mismo tiempo, ha aumentado la utilidad de la vigilancia activa de la enfermedad. Hasta que punto estos cambios han influido en la incidencia de la reseccion quirurgica primaria y repetida sigue siendo objeto de debate. MetodosEstudio de cohortes a nivel nacional de pacientes incidentes con enfermedad de Crohn de todas las edades identificados en el registro sueco nacional de pacientes entre 1990-2014, que se dividio en cinco periodos de diagnostico: 1990-1995 y 1996-2000 con el uso de registros de pacientes hospitalizados, 2001, y 2002-2008 y 2009-2014 con uso de registros de pacientes ambulatorios y hospitalizados. Se estimo la incidencia acumulada de la primera cirugia abdominal y de las cirugias abdominales subsiguientes (excepto el cierre de estomas), por categoria de procedimiento quirurgico, mediante el metodo de Kaplan-Meier. ResultadosEntre 21.273 pacientes con enfermedad de Crohn, la incidencia acumulada de la primera cirugia abdominal durante los 5 anos posteriores al diagnostico de la enfermedad disminuyo continuamente del 54,8% en la cohorte 1990-1995 al 40,4% en la cohorte 1996-2000 (P < 0,001) y nuevamente del 19,8% en cohorte 2002-2008 al 17,3% en la cohorte 2009-2014 (P < 0,001). Las tasas cirugias iterativas a los 5 anos disminuyeron de 18,9% en la cohorte 1990-1995 a 16,0% en la cohorte 1996-2000 (P = 0,017). Despues del 2000, no se observaron mas disminuciones significativas. ConclusionLa tasa de intervencion quirurgica a los 5 anos para la enfermedad de Crohn ha disminuido significativamente, pero la cirugia iterativa se ha mantenido estable a pesar de la introduccion de la terapia biologica.

Aim Temporary faecal diversion after ileocolic resection (ICR) for Crohns disease reduces postoperative anastomotic complications in high-risk patients. The aim of this study was to assess if this approach also reduces long-term surgical recurrence. Method This was a multicentre retrospective review of prospectively maintained databases. Patient demographics, medical and surgical details were collected by three specialist centres. All patients had undergone an ICR between 2000 and 2012. The primary end-point was surgical recurrence. Results Three hundred and twelve patients (80%) underwent an ICR without covering ileostomy (one stage). Seventy-seven (20%) had undergone an ICR with end ileostomy/double-barrel ileostomy/enterocolostomy followed by closure (two stage). The median follow-up was 105 months [interquartile range (IQR) 76-136 months]. The median time to ileostomy closure was 9 months (IQR 5-12 months). There was no significant difference in surgical recurrence between the one- and two-stage groups (18% vs 16%, P = 0.94). We noted that smokers (20% vs 34%, P = 0.01) and patients with penetrating disease (28% vs 52%, P amp;lt; 0.01) were more likely to be defunctioned. A reduced recurrence rate was observed in the small high-risk group of patients who were smokers with penetrating disease behaviour treated with a two-stage strategy (0/10 vs 4/7, P = 0.12). Conclusion Despite having higher baseline risk factors, the results in terms of rate of surgical recurrence over 9 years are similar for patients having a two-stage compared with a one-stage procedure.

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.