A recent study has provided an extensive comparison of surgical approaches for Crohn's disease. 

In the study, published in the International Journal of Colorectal Disease, researchers used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to analyze the 30-day outcomes of patients undergoing small bowel resection (SBR), strictureplasty (SPX), or combined surgery (CSX) for Crohn's disease.

The researchers queried the ACS-NSQIP database for 2015 to 2020, identifying patients who underwent open or laparoscopic resection of small bowel or strictureplasty for Crohn's disease using CPT and ICD-10 codes. A total of 2,578 patients were included—87% (n = 2,245) of whom underwent SBR, 5% (n = 125) of whom underwent CSX, and 8% (n = 208) of whom underwent SPX.

Among the key findings were:

• SBR was associated with a higher odds of wound complications compared with CSX and SPX.
• SPX demonstrated a lower odds of prolonged hospital stay compared with SBR.
• There were no statistically significant differences in the 30-day related reoperation, readmission, or discharge disposition among the three surgical approaches.
• Postoperative wound complications were strongly associated with an increased risk of 30-day reoperation, readmission, and prolonged hospitalization.
• Laparoscopic procedures were associated with a decreased risk of wound complications and prolonged hospitalization.

Demographic and Clinical Characteristics:

• Mean age: SBR (44.8 years), CSX (41.0 years), SPX (43.1 years), (P = .016)
• Age groups: 18 to 40 years (46%), 41 to 65 years (42%), older than 65 years (12%)
• Gender distribution: Female (46.8% SBR, 41.6% CSX, 47.1% SPX), (P = .522)
• Smoking rates: SBR (20.3%), CSX (6.4%), SPX (13.5%), (P < .001)
• Hypertension: SBR (18.2%), CSX (8%), SPX (15.4%), (P = .010)
• Mean body mass index (BMI): SBR (25.1), CSX (23.2), SPX (23.9), (P < .001)
• Preoperative steroid use: SBR (56.1%), CSX (72%), SPX (69.2%), (P < .001)
• Modified frailty index (mFI) scores ≥ 2: SBR (2.4%), CSX (0%), SPX (0.5%), (P = .012)
• Diabetes: No statistically significant differences among the groups (P = .306)
• Chronic obstructive pulmonary disease: SBR (2.0%), CSX (0.8%), SPX (0%), (P = .084)
• Weight loss > 10% in 3 months: SBR (11.0%), CSX (11.2%), SPX (9.6%), (P = .823).

ASA Classification:

• Class 1 to 2: SBR (52.6%), CSX (58.4%), SPX (54.3%)
• Class 3 to 4: SBR (47.1%), CSX (41.6%), SPX (45.2%)
• (P = .222).

Operative Characteristics:

• Elective procedures: SBR (65.6%), CSX (80%), SPX (79.8%), (P < .001)
• Laparoscopic approach: SBR (72.2%), CSX (81.6%), SPX (100%), (P < .001)
• Mean operative time: CSX (209.6 minutes), SPX (198.6 minutes), SBR (182.5 minutes), (P = .002).

Wound Classification:

• Clean: SBR (1.0%), CSX (0.8%), SPX (0.5%)
• Clean/contaminated: SBR (55.0%), CSX (64.8%), SPX (60.1%)
• Contaminated: SBR (24.1%), CSX (22.4%), SPX (29.8%)
• Dirty/infected: SBR (20.0%), CSX (12.0%), SPX (9.6%)
• (P = .003).

Postoperative Outcomes:

• Mean hospital stay: SBR (8.8 days), CSX (7.8 days), SPX (7.5 days), (P = .030)
• Sepsis: SBR (3.5%), CSX (0%), SPX (1.4%), (P = .033)
• Superficial SSI: SBR (4.1%), CSX (2.4%), SPX (1.9%), (P = .204)
• Deep SSI: SBR (4.5%), CSX (1.6%), SPX (1.9%), (P = .066)
• Organ/space SSI: SBR (10.2%), CSX (6.4%), SPX (6.2%), (P = .077)
• Septic shock: SBR (1.0%), CSX (0%), SPX (0%), (P = .179)
• Transfusion rates: SBR (1.2%), CSX (0%), SPX (1.0%), (P = .431)
• Ventilator use: SBR (0.3%), CSX (0%), SPX (0%), (P = .594).

Discharge Destination:

• Home: SBR (95.6%), CSX (97.6%), SPX (98.1%)
• Skilled care/rehabilitation: SBR (2.8%), CSX (0.8%), SPX (1.5%)
• (P = .961).

30-Day Outcomes:

• Related readmission: SBR (13.1%), CSX (7.2%), SPX (9.6%), (P = .067)
• Related reoperation: SBR (5.7%), CSX (4.8%), SPX (5.3%), (P = .879).

Multivariate Analysis:

• SBR vs CSX: odds ratio [OR] for wound complications = 2.09 (95% CI = 1.10–3.97, P = .024)
• SBR vs SPX: OR for wound complications = 1.9 (95% CI = not provided, P = .005)
• SPX vs SBR: OR for prolonged hospital stay = 0.60 (95% CI = 0.44–0.80, P = .031)
• Postoperative wound complications: OR for 30-day reoperation = 16.98 (95% CI = 10.81–26.67, P < .001), OR for 30-day readmission = 6.80 (95% CI = 5.08–9.10, P < .001), OR for prolonged hospitalization = 2.85 (95% CI = 2.25–3.61, P < .001)
• Laparoscopic procedures: OR for wound complications = 0.42 (95% CI = 0.30–0.59, P < .001), OR for prolonged hospitalization = 0.55 (95% CI = 0.43–0.71, P < .001)
• Emergency vs elective surgery: OR for prolonged hospitalization = 2.63 (95% CI = 1.91–3.64, P < .001)
• Weight loss: OR for prolonged hospitalization = 2.14 (95% CI = 1.61–2.85, P < .001)
• Higher ASA category: OR for prolonged hospitalization = 1.80 (95% CI = 1.48–2.20, P < .001)
• Age older than 65 years vs 18 to 40 years: OR for nonroutine discharge = 9.09 (95% CI = 4.35–20.00, P < .001).

The findings revealed a potential racial disparity, with Black patients undergoing SPX at lower rates compared with White patients (4.1% vs 9.1%, P < .001). This may warrant further investigation into access to care and treatment options for patients with Crohn's disease across different racial groups.

The comprehensive analysis of NSQIP data provided valuable insights into the outcomes of different surgical approaches for Crohn's disease. While SBR was associated with higher rates of wound complications and prolonged hospital stays, all three surgical approaches demonstrated comparable results in terms of 30-day reoperation and readmission rates. The study underscored the importance of careful patient selection, preoperative optimization, and consideration of laparoscopic approaches when feasible to minimize postoperative complications in Crohn's disease surgery.

The authors declared no competing interests.