Management of patients with inflammatory bowel disease [IBD] has become increasingly complex, but at the same time very exciting and challenging. For a long time, surgery in IBD has been considered as a last resort, and although ‘multidisciplinary treatment’ has always been a popular term, involving a surgeon in daily practice was frequently limited to therapy-refractory patients. The most exciting change over the last few decades is probably the fact that involving a surgeon at an early stage of the disease is now considered good clinical practice, and is part of most quality-control parameters. Medical treatment from a surgical perspective Medical treatment still remains the first choice for most IBD patients, with anti-TNF–based drugs forming the core of medical therapy. Surgeons have seen gastroenterologists struggle with how to use these powerful and expensive drugs in an appropriate way. The relative ineffectiveness of anti-TNFs could partly be explained by a lack in expertise using these complex drugs. It has taken some years to acknowledge the proper dosing, and the concept of the development of antibodies to these drugs. Therapeutic drug monitoring has proven to be the key to success for those who have both the skills and kits to assess drug levels and antibodies. Untimely initiation of anti-TNFs when complications are already present, has also contributed to reduced efficacy of these drugs. Hence, those who master the art of anti-TNF therapy can achieve good response in a little over two out of three patients, with a loss of response of 5–10% annually. This unsatisfying situation fuelled the development of new biologics and molecules, making medical therapy even more complex. Indeed, dose escalation, switching, and swapping of drugs has become a true martial art. For this reason, it can be questioned whether every gastroenterologist should be licensed to use these types of drugs, taking out a part of the immunologic defence system in the process of trying to induce and maintain remission in the IBD patient. We ‘ain’t seen nothing yet’ with respect to the long-term consequences of all the new kids on the block. The importance of registries is therefore clear. Only large registries, preferably including all patients treated with these new drugs and combinations thereof, can show whether they are really safe with respect to complications, development of malignancies, and increased perioperative morbidity. Improvement of surgical techniques Over the past two decades, surgery for IBD has been revolutionized especially in dedicated and modern units. Surgeons have subspecialised from general surgeon to colorectal surgeon, and now to even more highly specialised IBD surgeons. The uptake of minimally invasive surgery in combination with enhanced recovery programmes have been shown to reduce both complications, and hospital stay. Recovery after surgery to full capacity is now often achieved within 2–4 weeks, thanks to the use of minimal incision,s preserving body image, functions, and cosmesis. At the same time, short- and long-term complications [such as adhesions-related problems and incisional hernias] have been largely reduced. This makes limited surgery, e.g. ileocolic resection, and even extensive surgery, e.g. proctocolectomy and pouch reconstruction important alternatives to drug-centered maintenance therapy. Comparative studies suggest that quality of life is better in patients undergoing surgery than in those on maintenance biologic treatment, and this may be resulting from the ongoing chronic disease element that is still experienced by those on maintenance therapy, because complete remission is infrequently achieved.1,2 Of course it is not only improvements in surgery that have improved outcomes for IBD patients. Imaging techniques have become so advanced that both pre-operative planning and postoperative follow-up can be more stringent. Postoperative medication can now be commenced at the first hint of recurrence, rather than when complications due to recurrence become untreatable. At the same time, it has become clear that prolonged medical therapy without the desired effect can also induce harm. In fistulising Crohn’s disease, such prolonged medical therapy might result in increased loss of healthy organs if the inflammatory process that is not responding to treatment affects innocent bystander organs.3 These evolving insights should position quality of life–preserving surgery earlier in the clinical decision-making algorithm, choosing what is best for the individual patient. It is therefore of great importance that gastroenterologists and surgeons appreciate each other’s therapeutic capabilities and incapabilities. Working together in multidisciplinary teams to find the best solution for the individual patient is therefore key in optimizing care for IBD patients. Ideally, there would be specialized IBD units in which different specialists are working together. Last but not least, patients should be counselled by the IBD team, providing them with an honest and balanced picture of their therapeutic possibilities, including surgery. This discussion is no longer about ‘my patient’, but about ‘our patient’. A properly informed patient empowered by a shared decision-making model is one of the benefits of the multidisciplinary management team. Surgery first, drugs later? It is clear that if one therapy is superior to the other, the superior therapy should be chosen in principle. Uncomplicated IBD still in its inflammatory stage, without a doubt, requires medical therapy. Likewise, in complicated IBD where surgery would result in extensive loss of small bowel, or permanent ostomies, causing disability and clear loss of quality of life,4 prolonged medical therapy is indicated, which often means switching from one drug to another with the aim of achieving effective therapy. Surgery is then indicated when the disability caused by continued extensive medical therapy is greater than the disability caused by the surgical alternative. Complicated IBD where the surgical alternative is a limited low-risk operation associated with an improved quality of life justifies surgery [e.g. laparoscopic ileocolic resection for limited disease, instead of anti-TNF].2 In the case of non-inferiority of the interventions, it makes sense that the least expensive one should be chosen.5 Cost-effectiveness will drive health care more and more in the near future. In many countries, hospitals budget for expensive therapies. Surgery has proved to be cost-effective with respect to limited Crohn’s disease of the terminal ileum.2 Surgery first for those who already have complicated disease, or for those who have apparently uncomplicated disease, enabling the gastroenterologist to have a fresh start, is an important consideration. Close endoscopic follow-up and quick initiation of medical therapy if inflammation recurs might provide the better option for both the patient and penny-wise the society. Combined medical and surgical therapy Surgeons are generally not happy to operate on patients who have had steroids or biologics recently. There is accumulating, sometimes controversial, evidence that these drugs are associated with increased postoperative morbidity, forcing surgeons to a different strategy, i.e. staged surgery.6–9 There are however indications where the combination of surgery and biologics might benefit patient and surgical outcomes alike. For instance, the majority of Crohn’s perianal fistulae will probably never close permanently when treated with drugs alone, because only the external opening closes under biologics therapy, while the internal opening and tract remains patent. Surgical closure of the internal opening in combination with medical therapy inducing mucosal healing and optimizing healing conditions of the fistula tract will probably improve outcomes. The scientific surgeon Investigator-initiated research has been the cornerstone of surgical research in IBD. Lacking industrial sponsors, these trials have been self-supported or supported by governmental grants. An initiative coming from the European Society of Coloproctology [ESCP] has given insight into the European results for ileocolic resection in Crohn’s disease by applying the so-called snapshot design—cross-sectional collaborative population-based research.10 This design enables gathering of large amounts of data on a particular topic in a short period of time, showing practice and outcome trends. A future project will focus on the management of acute ulcerative colitis. Apart from research coming from institutional initiative, the S-ECCO and IOIBD networks are growing. Collaborative research generated by surgeons and gastroenterologists working in international IBD units will push IBD science even further forward. A great step forward in this is the ‘surgical page’ in the UR-CARE database set up by ECCO. IBD surgery: the unmet needs As described previously, surgery is currently playing an increasingly prominent role in the treatment of IBD patients. As surgery can now be considered an alternative treatment strategy instead being of a last-resort alternative, it is time to reconsider the primary end point of most medical studies. The success of anti-TNF drugs has frequently been described as a reduction in surgery [always considered a ‘failure’ in medical studies], hospitalization, or continuation of the drug.11,12 Current surgical results indicate that avoiding surgery should no longer be the ultimate goal in IBD treatment, and that referring patients for a surgical resection should no longer be viewed as a failure. Therefore, different outcome parameters for measuring success [e.g. improvement in quality of life or reduction in disability] should be established,4,13 much in line with the growing awareness of the importance of patient-reported outcomes. By the same token, we as surgeons, have the obligation to provide the most optimal surgical care. Several initiatives have been undertaken in order to identify key performance indicators so as to reduce variation across services and to improve quality of care.14 Inflammatory bowel disease surgery remains a highly demanding area, requiring specialized surgical technical and non-technical skills. There is a clear parallel with the care of the oncologic patient. In oncology, even the smaller units have established quality systems, e.g. regular multidisciplinary team meetings, while health-care regulatory bodies demand adherence to norms for time to treatment and case volume. None of this exists for the IBD patient. To this end, the unpopular discussion about the volume–outcome relationship, with a plea for centralization of services, should be conducted. For instance, pouch surgery is still done in [too] many units that only perform a few procedures annually.15 Public awareness of IBD patients must be raised to a similar level as for oncology patients in order to fuel the development of norms for maximum waiting times for surgery and for the enforcement of caseload norms, e.g. based on the surgical guidelines of ECCO.16 Considering the complexity of the management of the IBD patient, subspecialized gastroenterologists and surgeons should ideally provide IBD care, working in specialized IBD units, collaborating as a team to optimize the integration of medical management and surgery. Joint outpatient clinics, joint wards, and joint research should overcome the last borders between gastroenterologists and surgeons, and provide tailored and best evidence–based management for the individual IBD patient. Surgery before or after medical therapy, with or without a biologic umbrella, is not the issue. What counts is what is best for the individual IBD patient. Funding There is no funding source with respect to this article. Conflict of Interest The author does not have a conflict of interest in any way with respect to this opinion paper. Author Contributions WB wrote the article, and all collaborators read the article and suggested alterations and improvements. S-ECCO collaborators [alphabetic order] Michel Adamina, Department of Surgery, Kantonsspital Winterthur, University of Basel, Suisse; Christianne Buskens, Department of Surgery, Academic Medical Center, University of Amsterdam, Netherlands, Andre DHoore; Department of Abdominal Surgery, University of Leuven, Belgium; Paulo Gustavo Kotze, Colorectal Surgery Unit Catholic University of Paraná, Curitiba, Brazil; Tom Oresland, Department of Surgery, Ahus University hospital, Oslo, Norway; Yves Panis, Department of Surgery, Beaujon Hospital, Clichy, Paris, France; Gianluca Samprieto, Department of Surgery, University of Milan, Milan, Italy; Antonino Spinelli, Department of General and Minimal Invasive Surgery, Humanitas University, Milan, Italy; Hagit Tulchinsky, Department of Surgery, Sourasky Medical Center, Tel Aviv, Israel; Janindra Warusavitarne, Department of Surgery, St Marks Hospital, London, UK; Oded Zmora, Department of Surgery, Herziliya Medical Center, Tel Aviv, Israel. References 1. van Gennep S, Sahami S, Buskens CJet al. Comparison of health-related quality of life and disability in ulcerative colitis patients following restorative proctocolectomy with ileal pouch–anal anastomosis versus anti-tumor necrosis factor therapy. Eur J Gastroenterol Hepatol 2017; 29: 338– 44. Google Scholar CrossRef Search ADS PubMed 2. Ponsioen CY, de Groof EJ, Eshuis EJet al. ; LIR!C study group. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: a randomised controlled, open-label, multicentre trial. Lancet Gastroenterol Hepatol 2017; 2: 785– 92. Google Scholar CrossRef Search ADS PubMed 3. Iesalnieks I, Kilger A, Glass H, Obermeier F, Agha A, Schlitt HJ. Perforating Crohn’s ileitis: delay of surgery is associated with inferior postoperative outcome. Inflamm Bowel Dis 2010; 16: 2125– 30. Google Scholar CrossRef Search ADS PubMed 4. Lo B, Prosberg MV, Gluud LLet al. Systematic review and meta-analysis: assessment of factors affecting disability in inflammatory bowel disease and the reliability of the inflammatory bowel disease disability index. Aliment Pharmacol Ther 2018; 47: 6– 15. Google Scholar CrossRef Search ADS PubMed 5. Pillai N, Dusheiko M, Burnand B, Pittet V. A systematic review of cost-effectiveness studies comparing conventional, biological and surgical interventions for inflammatory bowel disease. PLoS One 2017; 12: e0185500. Google Scholar CrossRef Search ADS PubMed 6. Waterland P, Athanasiou T, Patel H. Post-operative abdominal complications in Crohn’s disease in the biological era: systematic review and meta-analysis. World J Gastrointest Surg 2016; 8: 274– 83. Google Scholar CrossRef Search ADS PubMed 7. Selvaggi F, Pellino G, Canonico S, Sciaudone G. Effect of preoperative biologic drugs on complications and function after restorative proctocolectomy with primary ileal pouch formation: systematic review and meta-analysis. Inflamm Bowel Dis 2015; 21: 79– 92. Google Scholar CrossRef Search ADS PubMed 8. Sahami S, Bartels SA, D’Hoore Aet al. A multicentre evaluation of risk factors for anastomotic leakage after restorative proctocolectomy with ileal pouch–anal anastomosis for inflammatory bowel disease. J Crohns Colitis 2016; 10: 773– 8. Google Scholar CrossRef Search ADS PubMed 9. 2015 European Society of Coloproctology Collaborating Group. Risk factors for unfavourable postoperative outcome in patients with Crohn’s disease undergoing right hemicolectomy or ileocaecal resection. An international audit by ESCP and S-ECCO. Colorectal Dis 2017;doi: 10.1111/codi.13889. 10. Brouquet A, Maggiori L, Zerbib Pet al. ; GETAID chirurgie group. Anti-TNF therapy is associated with an increased risk of postoperative morbidity after surgery for ileocolonic Crohn disease: results of a prospective nationwide cohort. Ann Surg 2018; 267: 221– 8. Google Scholar CrossRef Search ADS PubMed 11. Bouhnik Y, Carbonnel F, Laharie Det al. ; GETAID CREOLE Study Group. Efficacy of adalimumab in patients with Crohn’s disease and symptomatic small bowel stricture: a multicentre, prospective, observational cohort (CREOLE) study. Gut 2018; 67: 53– 60. Google Scholar CrossRef Search ADS PubMed 12. Mao EJ, Hazlewood GS, Kaplan GG, Peyrin-Biroulet L, Ananthakrishnan AN. Systematic review with meta-analysis: comparative efficacy of immunosuppressants and biologics for reducing hospitalisation and surgery in Crohn’s disease and ulcerative colitis. Aliment Pharmacol Ther 2017; 45: 3– 13. Google Scholar CrossRef Search ADS PubMed 13. Kim AH, Roberts C, Feagan BGet al. Developing a standard set of patient-centred outcomes for inflammatory bowel disease—an international, cross-disciplinary consensus. J Crohns Colitis 2018; 12: 408– 18. Google Scholar CrossRef Search ADS PubMed 14. Morar PS, Hollingshead J, Bemelman Wet al. 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For permissions, please email: firstname.lastname@example.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Journal of Crohn's and Colitis – Oxford University Press
Published: May 3, 2018
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