Optimizing Treatment Strategies to Manage Inflammatory Bowel Disease - Episode 9

Surgical Intervention in IBD

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Indications for surgery in treating patients for ulcerative colitis (UC) and Crohn disease.

Remo Panaccione, MD, FRCPC: We know that there has been a decrease in many studies, observational cohorts, population studies, and surgical rates in the biologic era, but surgery does play a role in the management of IBD [inflammatory bowel disease], both for patients with Crohn disease and patients with ulcerative colitis [UC]. Who are those patients that you’re considering surgery for? I might push a bit based on some DDW [Digestive Disease Week] data that have come out that we need to get more information on. Jessica, let’s start with you. Who needs to go to surgery despite all the therapies that we have?

Jessica Allegretti, MD, MPH: Ulcerative colitis and Crohn indications for surgery are different. For someone with UC—we gave an earlier scenario of a patient who has already burned through a TNF [tumor necrosis factor] blocker like ustekinumab or tofacitinib. If the patient has no response, their albumin is low, or they’re anemic, then you want to be pointing that patient toward surgery. Ultimately, there is a fear of surgery. Patients feel like they have failed; you feel like you have failed. It’s one of the first things I’ve mentioned to patients. Even when I’m first meeting somebody, I put surgery on the table as one of their viable therapeutic options, along with all the other biologics, so that it doesn’t terrify them when I bring it up again the next time. It’s something that I’m talking about often, even before they need it, to try to minimize that surgery fear. I have them meet with surgeons early so they can develop that relationship, because ultimately, there are patients who just do not respond to the available therapies that we have. To put them on a therapy that you’re going to wait 5 to 6 months to confirm that it doesn’t work—to delay the inevitable does not do the patient any favors, especially if you’re going to be embarking on a yearlong, 3-stage surgery journey with them.

There are different indications in Crohn disease. If you have a patient with fibrotic stricturing disease who you have treated and have not made much headway in terms of opening that patient up—maybe a little, but they are still symptomatic—they may need isolated resections or a strictureplasty. Other indications include fistulizing disease that isn’t healing and abscess formation. There are various indications as to when a patient will require surgery, in addition to medically refractory disease. I’ve had to do total colectomies for patients with Crohn because they do not respond to anything and it is for treating the inflammatory disease. Crohn is a bit more nuanced in that there are many reasons as to why patients may need surgery, whereas it’s slightly more straightforward in UC.

Remo Panaccione, MD, FRCPC: We have moved to a policy with our colorectal surgeons when treating UC. If you’re going onto a second advanced therapy, we introduce you to the surgeon. It does not mean you need surgery, but we do this so that our patients have the discussion with the surgeon. They can ask the pertinent questions that are relevant; even though we know the information, it should be coming from the surgeon themselves.

Ed—when we were all together—if somebody has a stricture, an upstream dilatation, and a complication, we would usually send those patients to surgery. That is still my bias and my practice, but there is some discussion: Perhaps, can we rescue some of these patients? What are your thoughts on the new data, and will they change your practice?

Edward Loftus Jr, MD: Everything is a continuum, and there are patients that have a little proximal dilation, not 6 cm or 5 cm, but maybe they are 2.5 or 3 cm. Some of those patients can be managed with radiologic drainage, along with the control of the abscess and the institution of biologics. The answer is always somewhere in the middle. There is a role in some patients’ treatment for biologic therapy, but you are right, there is a gray area. How much proximal dilatation is too much? Maybe that is not an accurate reflection of which strictures are going to open up with therapy and which are not.

William Sandborn, MD: Those data sets are biased. It’s not that they’re not useful in some way, but they are retrospective, and that reflects—is it a surgeon-dominant institution or a medical therapy–dominant institution, or are they balanced? How are you using CT or MRI? How good is the radiologist calling out—and not just good, but also how willing are they to make the call, to say, “There’s lots of hot inflammation here,” or “There’s a lot of stricture?”

My experience is, if you take that view of “We have this stricturing disease, so you’re going to get a biologic after surgery anyway,” why not see if you can turn it around, even if they’ve got prestenotic dilation? If you can’t turn it around, it’s not a big deal to operate in the face of the biologic. Just operate, then keep going.

There was a spectrum within our group of people that would have a low threshold and go to surgery. Then there was me and Ed at the other end. Once you have drained an abscess, it is not an abscess. It’s an enterocutaneous fistula. That is an indication for anti-TNF therapy. When we published it, some of the patients turned out well and nothing went bad.

Jessica Allegretti, MD, MPH: If a patient comes in with an abscess, stricture or not, no one is going straight to surgery. They are getting drained. We are reimaging. If we have source control, they are getting on therapy. Then you’re watching that patient; you might get into trouble later, and you may end up with surgery anyway. You try to medically manage them and stave off a potential resection, but sometimes, that is what it comes to.

Remo Panaccione, MD, FRCPC: Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming peer exchanges and other great content right to your inbox. I am sure you will see the folks in front of you on future programs. With that, thank you very much.

Transcript edited for clarity.