Rate of Surgery in Patients With Crohn Disease, Patients With Ulcerative Colitis

In this podcast, Benjamin Cohen, MD, speaks about counseling patients with inflammatory bowel disease (IBD) before surgery, the rates of surgery in patients with Crohn disease and in patients with ulcerative colitis up to 10 years after a diagnosis, the risks for post-operative complications, and ensuring the best outcome for patients. Dr Cohen also spoke on these topics at the American College of Gastroenterology Annual Scientific Meeting 2022 during a session titled “Why Choose Surgery? Counseling Patients About the Indications and Role of Surgery in IBD.”

Additional Resource:

• Cohen B. Why choose surgery? Counseling patients about the indications and role of surgery in IBD. Talk presented at: ACG 2022; October 21-26, 2022; Charlotte, NC. Accessed October 12, 2022. https://acgmeetings.gi.org/

Benjamin Cohen, MD, is the co-section head and clinical director of the Department of Inflammatory Bowel Disease at The Cleveland Clinic.

TRANSCRIPTION:

Jessica Bard: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator Jessica Bard with Consultant360 Multidisciplinary Medical Information Network. 

Although biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease, surgery continues to play a major role.

Dr Benjamin Cohen is here to speak with us today about his session at ACG 2022 titled “Why Choose Surgery? Counseling Patients About the Indications and Role of Surgery in IBD.”

Dr Benjamin Cohen: Hi, I'm Benjamin Cohen. I'm the co-section head and clinical director for inflammatory bowel disease at the Cleveland Clinic.

Jessica Bard: Just to start off here, how do you talk about surgery with your patients and make sure that they're fully informed?

Dr Benjamin Cohen: Yes, I think this is a key point that we don't necessarily grasp as gastroenterologists. We think so much about medical therapies these days and we have more and more medical therapies available to help us treat IBD, but surgery's still a reality for many of our patients. There have been studies looking at the rates of surgery in the biologic era. I talk about this a little in my talk, but over a quarter of Crohn's disease patients are still going to have surgery by 10 years after their diagnosis. And up to 15% of ulcerative colitis patients are still going to have surgery up to 10 years after their diagnosis. So this is a reality, and I think one of the key pearls is that we don't want to talk about surgery as a failure because this really shapes the psychology of patients. And many of our patients have a lot of underlying depression and anxiety, and if we're talking about them as a failure, then they head into surgery with negative connotations.

Even though overwhelmingly, patients have improved quality of life after surgery. When patients have been surveyed after surgery, most of them, the overwhelming majority are happy that they went through it. But when they were asked about their perceptions of surgery prior to surgery, they were overwhelmingly negative. And I think we have an opportunity to really shape how patients view surgery. It's the appropriate therapy for many patients, and we should talk about it as such. There have been surveys where patients have said that the reasons for surgery were not even shared with them over a third of the time in a large multi-country survey in Europe of Crohn's disease patients. So I think whenever I'm talking about the therapeutic options for patients, I'm actually including surgery in that very early on, even if surgery is not something we're really thinking about. Because if you introduce the idea early, then it's easier for the patient to weigh risk benefits later on when surgery may be sort of at the top of their therapy list.

I think another key point is to really involve the multidisciplinary team when you're talking to a patient about surgery. So you want them to meet the surgeon early, it's always better to have an elective discussion about surgery rather than meeting the surgeon when they're rolling into the operating room. You want them to meet with stoma nurses, psychologists, dieticians, that all play a role in their care around surgery. And I think that sets you up for great outcomes. And then the other, I think, key pearls are, you don't want to save surgery as a last resort for patients. You're always going to have better outcomes if you identify early who should be going to surgery and treat them that way.

Jessica Bard: Wow. A third of the time, that's a major study and a significant portion of patients there. What would you say are the risks for postoperative complications and how do you make sure the patient has the best outcomes possible?

Dr Benjamin Cohen: This has been an area that I've had particular interest in over the last several years because we ultimately want to set our patients up for success, whether it's medical therapy or surgical therapy. There are some risk factors that are not as modifiable for the patient, so those may be if they're having an urgent or emergent admission to the hospital, older patients have other comorbidities that may put them at a little bit higher risk when they're undergoing a surgery. And then the experience of the surgeon or the hospital where they're having surgery at, does play a role in their overall outcomes. But you can think about those things to identify the patients who may be higher risk who you have to keep a closer eye on. Also, the idea of sending them to surgery at the appropriate time rather than waiting till they've been on multiple medical therapies that are not working on steroids and being very sick, that's when you have the urgent or emergent admission.

Dr Benjamin Cohen: So it's talking about surgery earlier helps you avoid those things. In terms of the modifiable risk factors, I think there are several key ones that have been associated with poor postoperative outcomes. One, malnutrition is a big one. So it's really important to involve your dietitians early in the care of patients who are going to go to surgery. And you can take measures to try and optimize them prior to surgery, whether it be using methods like exclusive enteral nutrition in Crohn's disease patients who are going to surgery for stricturing disease, for example. And then still involving those dieticians in the care postop to make sure that they're gaining weight appropriately postoperatively. Another factor that's been associated with poor outcomes is anemia. We can try and identify patients who are anemic beforehand and treat them, for example, with IV iron potentially, that's a strategy that still needs to be studied prospectively.

Smoking has been associated with poor postoperative outcomes in large data sets. We also know that smoking is associated with worse Crohn's disease, so obviously, trying to do smoking cessation interventions in patients before they go to surgery potentially could have a big impact. And then I think the other area that's been publicized a lot over the last 10 years has really been the role of medications in terms of postoperative outcomes. There had been some thinking that, for example, biologic drugs like tumor necrosis factor inhibitors were associated with more complications. But we just published a very large prospective cohort study with the Crohn's and Colitis Foundation, Clinical Research Alliance of the PUCCINI study, which included 947 patients with Crohn's disease and ulcerative colitis undergoing surgery, 40% of whom were on a TNF inhibitor preoperatively. And we found no association with postoperative infectious outcomes with the exposure to TNF inhibitors, both using the patient-reported exposure as well as using serum drug levels of the TNF inhibitors around the time of surgery, and the key factors that were associated with infectious complications where diabetes, smoking, prior history of surgery, and most importantly, steroid use.

So really steroids are the big risk factor for postoperative complications. We want to try and minimize the use of steroids leading into a surgery. I try and taper patients down off steroids if possible before surgery and I don't put patients on steroids unless absolutely necessary prior to a surgery.

Jessica Bard: Now in your session, you mentioned some specific clinical scenarios. Could you provide us with some specific clinical scenarios on medicine versus surgery?

Dr Benjamin Cohen: I think one that we deal with a lot, which I talked about is when you're dealing with strictures in Crohn's disease. So if we have ileal stricture, is this something that we can try and treat endoscopically as well as with medical therapy versus when is it time to go to surgery? I think a key point here is that we can use cross-sectional imaging, so enterography either as a CT scan or an MRI to get a better look at the features of that stricture to identify if this is somebody that's going to do well if we don't do surgery versus somebody who's going to need surgery now. And some of the features that you look for on imaging would be prestenotic dilation of the bowel above the stricture. That's usually a sign of long-standing stricture. Pseudosacculation is another imaging feature that is associated with a chronic stricture that's probably not going to respond as much to medical therapy.

You can look at the length of the stricture. So if a stricture's over five centimeters, that's not something you're going to safely dilate endoscopically and that's just probably a patient that needs to go to surgery. I think this is important because we see a lot of patients who are put on biologic after biologic for a stricture that really should have just been operated on. And then what you're doing is you're exposing patients to these medications unnecessarily that they may not be able to use again in the future because they've already been exposed to them. It's important to use the cross-sectional imaging to really help you identify the appropriate patient. Another scenario is penetrating Crohn's disease with an abscess. Again, the cross-sectional imaging really helps you identify the patient that should go to surgery by the size of the abscess, the presence of a stricture, and the setting of the abscess, that's usually going to be somebody that needs to go to the OR.

Then the scenario I talk about in ulcerative colitis is really mostly about severe UC and the importance of making timely decisions in going to surgery. Lengthy hospital stays on high doses of IV steroids have been associated with worse outcomes in ulcerative colitis patients. You really want to make a decision within three days of putting somebody on IV steroids about whether you're going to try a medical rescue therapy like Infliximab or Cyclosporin or going to surgery and not let them be on IV steroids for over three days without some exit plan for it, because that's when you're going to run into trouble.

Jessica Bard: Sure, that makes sense. Now, moving along to after surgery, how do you survey patients after they've had surgery?

Dr Benjamin Cohen: Unfortunately, surgery is not a cure in most cases for our patients. Especially in Crohn's disease, they're likely to still have to deal with Crohn's disease even after having surgery though the clinical recurrence of Crohn's disease usually takes longer than the endoscopic recurrence. And we've learned a lot more in recent years through the POCER trial that doing a six month colonoscopy postop really helps us risk stratify who may need an escalation of a therapy. Now there are going to be some patients that go on medical therapy because they had severe disease heading into surgery. Those are going to be the younger patients, people who are smokers, people who have had multiple prior surgeries before, maybe people who presented with abscess. But if you don't have those severe features and you're on the fence about whether to start a postoperative biologic therapy, you can use that six month colonoscopy to really get a sense of who's going to recur early and then start medical therapy on them.

And in ulcerative colitis, patients with a J pouch, I think, were a little bit still all over the map in terms of our guidelines. I show a slide where we have guidelines for multiple different societies, all of which are different. So it becomes a little bit hard to make sense of it, but there is a high-risk group that I think needs to have more frequent pouchoscopies. Those are people who had surgery because of cancer or dysplasia, patients with PSC, which we know is associated with higher risk of both pouchitis and dysplasia. And then people who have chronic pouchitis, that's also a setup for dysplasia and other poor outcomes. So those are people that you would want to do more frequent surveillance in.

Jessica Bard: What would you say are the overall take-home messages from your session and from our conversation today?

Dr Benjamin Cohen: I think the key themes that I tried to take the audience through are one, how we talk about surgery with the patient, bringing it up earlier, involving the multidisciplinary team in those discussions that patients are fully informed and that's going to lead to a better confidence in the plan, a better state of mind, and ultimately better outcomes for the patient. Then two, to recognize what the risk factors are for poor postoperative complications and intervening where we can, whether it's involving dieticians, correcting anemia, stopping smoking, and avoiding steroid use perioperatively. Then in terms of the key scenarios, using cross-sectional imaging to help us risk stratify patients, particularly with Crohn's disease, about who needs surgery now versus maybe who we can do more medical therapy and making timely decisions in ulcerative colitis patients who are hospitalized and not leaving them on IV steroids for long periods of time without either moving to a medical rescue therapy or a surgical approach.

And then lastly, just making sure we have a surveillance plan in place because unfortunately, recurrence with disease is a reality for many patients, and we want to make sure that we intervene early so that we can hopefully avoid multiple surgeries in the future.

Jessica Bard: Well, thank you so much for your time today. I appreciate you being here. Is there anything else that you'd like to add today that you think that we missed?

Dr Benjamin Cohen: No, I think the key is not to fear surgery. It's a great treatment for many of our patients. The most important thing is when you get into practice, is to identify a surgeon you trust because you're going to be working with them a lot and we rely on each other. So it really does require a team to take care of the IBD patients.

Jessica Bard: Absolutely. Well, thank you again for being here.

Dr Benjamin Cohen: Thanks a lot.