Probability of Stoma in Incident Patients With Crohn's Disease in Sweden 2003-2019: A Population-based Study.

BACKGROUND: Surgery rates in patients with Crohn's disease have decreased during the last few decades, and use of antitumor necrosis agents (anti-TNF) has increased. Whether these changes correlate with a decreased probability of stoma is unknown. The objective of this study was to investigate the incidence of stoma in patients with Crohn's disease over time. METHODS: Through linkage of national registers, we identified patients who were diagnosed with Crohn's disease in 2003-2014 and were followed through 2019. We compared formation and closure of stomas over the calendar periods of diagnosis (2003-2006, 2007-2010, and 2011-2014). RESULTS: In a nationwide cohort of 18,815 incident patients with a minimum 5 years of follow-up, 652 (3.5%) underwent formation of a stoma. This was mostly performed in conjunction with ileocolic resection (39%). The 5-year cumulative incidence of stoma formation was 2.5%, with no differences between calendar periods (P = .61). Less than half of the patients (44%) had their stoma reversed. Stomas were more common in elderly-onset compared with pediatric-onset disease: 5-year cumulative incidence 3.6% vs 1.3%. Ileostomies were most common (64%), and 24.5% of the patients who underwent stoma surgery had perianal disease at end of follow-up. Within 5 years of diagnosis, 0.8% of the incident patients had a permanent stoma, and 0.05% had undergone proctectomy. The time from diagnosis to start of anti-TNF treatment decreased over calendar periods (P < .001). CONCLUSIONS: Despite increasing use of anti-TNF and a low rate of proctectomy, the cumulative incidence of stoma formation within 5 years of Crohn's disease diagnosis has not decreased from 2003 to 2019.

Does Smoking Cessation Reduce Surgical Recurrence After Primary Ileocolic Resection for Crohn's Disease?

BACKGROUND: Tobacco smoking is a known risk factor for recurrence of Crohn's disease after surgical resection. OBJECTIVE: This study assessed the effect of smoking cessation on long-term surgical recurrence after primary ileocolic resection for Crohn's 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 Crohn's disease were included. Those with previous intestinal resection, strictureplasty for Crohn's 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 Crohn's 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. ¿DEJAR DE FUMAR REDUCE LA RECURRENCIA QUIRÚRGICA DESPUÉS DE LA RESECCIÓN ILEOCÓLICA PRIMARIA PARA LA ENFERMEDAD DE CROHN?: Fumar tabaco es un factor de riesgo conocido para la recurrencia de la enfermedad de Crohn después de la resección quirúrgica.Evaluar el efecto de dejar de fumar en la recurrencia quirúrgica a largo plazo después de la resección ileocólica primaria para la enfermedad de Crohn.Revisión retrospectiva de una base de datos mantenida prospectivamente.Se combinaron datos demográficos del paciente, así como detalles médicos y quirúrgicos de dos centros especializados. Después de la aprobación ética, se contactó a los pacientes en caso de falta de datos sobre el hábito de fumar.Todos los pacientes sometidos a resección ileocólica entre 2000 y 2012 por enfermedad de Crohn confirmada histológicamente. Se excluyeron aquellos con resección intestinal previa, estenosis por enfermedad de Crohn, fuga después de resección ileocólica o que nunca se revirtieron.La principal variable fue la recurrencia quirúrgica medida por análisis de supervivencia de Kaplan-Meier, terapia médica secundaria en el momento del seguimiento.Durante un período de 12 años, 290 pacientes fueron sometidos a resección ileocólica. Se dispuso de datos completos sobre el tabaquismo para 242/290 (83%). Hubo 169 no fumadores (70%) (grupo 1), 42 (17%) fumadores activos en el momento de la resección ileocólica que continuaron fumando hasta el último seguimiento (grupo 2) y 31 (13%) que dejaron de fumar después de resección ileocólica (grupo 3). La mediana del tiempo de exposición al tabaquismo después de la resección ileocólica para el grupo 3 fue de 3 años (IQR 0-6) y la mediana del tiempo de seguimiento para todo el grupo fue de 112 meses (9 años) (IQR 84-148). El análisis de supervivencia de Kaplan-Meier mostró una tasa de recurrencia quirúrgica significativamente mayor para el grupo 2 en comparación con el grupo 3 (16/42 (38%) frente a 3/31 (10%), p = 0.02; razón de riesgo 3.9 (IC 95% 1-12)). Además, un número significativamente mayor de pacientes del grupo 2 sin recurrencia quirúrgica recibieron terapia de mantenimiento inmunomoduladora en comparación con el grupo 3 (12/26 (46%) frente a 4/28 (14%), p = 0.01; razón de riesgo 3.2 (IC 95% 1-9)).Diseño retrospectivo y pequeño número de pacientes.Dejar de fumar después de la resección ileocólica primaria para la enfermedad de Crohn puede reducir significativamente el riesgo a largo plazo de recurrencia quirúrgica y se asocia con un menor uso del tratamiento de mantenimiento. Consulte Video Resumen en http://links.lww.com/DCR/B86. (Traducción-Dr. Gonzalo Federico Hagerman).