Is Medicine or Surgery the Best Treatment for Crohn’s Disease?
For patients with Crohn’s disease and intra-abdominal abscesses, nonsurgical and surgical management strategies result in similar rates of abscess recurrence and complications, according to the April issue of Clinical Gastroenterology and Hepatology.
Crohn’s disease can progress from inflammation and ulceration to bowel damage that includes formation of abscesses, phlegmon, and fistulas. Patients who develop an intra-abdominal abscess are treated with long courses of antibiotics, percutaneous drainage, or surgery. Little is known about which approaches are most effective, or the effects of other types of medical therapies for these patients.
Drugs that inhibit tumor necrosis factor (TNF)-α, such as infliximab, adalimumab, and certolizumab can induce remission in patients with Crohn’s disease, although there are not much data on their short- and long-term effects in patients with intra-abdominal abscess following PTD.
Douglas Nguyen et al. analyzed data from patients with Crohn’s disease and abdominal abscess (confirmed by radiology). Fifty-five were treated with nonsurgical methods (percutaneous drainage) and 40 underwent surgery (laparotomy and bowel resection).
The authors found that the 5-year cumulative probability of abscess recurrence did not differ significantly between groups: 31.2% for patients who did not receive surgery and 20.3% for those who did (see figure).
Among the patients that did not receive surgery, treatment with the anti-TNF agents reduced the risk of abscess recurrence (particularly when given in combination with immunosuppressive therapy), compared with those that received no drugs after the drainage procedure. Immunosuppressive drugs alone following the drainage procedure also reduced the risk for abscess recurrence, although not as much as the anti-TNF agents.
Furthermore, patients who underwent surgery stayed in the hospital for an average of 15.5 days, compared with 5.0 days for patients who did not.
How does the medical therapy work? The authors propose that the percutaneous drainage converts an intra-abdominal abscess (a contraindication for anti-TNF therapy) into an enterocutaneous fistula (an indication for anti-TNF therapy). This procedure allows the abscess cavity to drain safely while the anti-TNF agent reduces inflammation and promotes fistula healing. The desired outcome would be abscess resolution and tract closure without surgery.
Because this was a retrospective study, the authors admit that selection biases were likely to exist between groups—patients with more severe, acute disease were more likely to have been treated with surgery. Nguyen et al. state that there is clearly a subset of patients, such as those with hemodynamic instability or long-standing fibrostenotic disease, who are better served by surgery.
Furthermore, the study was not designed to identify the optimal medical treatment regimen after drainage—additional studies are needed to investigate the ideal timing and types of pharmacologic therapies.
The authors conclude that anti-TNF therapies can reduce the incidence of abscess recurrence and should be considered for patients at risk. Furthermore, initiation of anti-TNF and/or immunosuppressive therapy when abscesses resolve might protect against intra-abdominal penetrating disease.
Read the article online.
Nguyen DL, Sandborn WJ, Loftus EV, et al. Similar outcomes of surgical and medical treatment of intra-abdominal abscesses in patients with crohn’s disease. Clin Gastroenterol Hepatol 2012;10:400–404.