Stoma formation for Crohn’s disease in the post‐biologic era, Ma <i>et al.</i>

Up to one-third of patients with Crohn’s disease will require major abdominal surgery over the first 5 years of their disease and most Crohn’s patients will have a Crohn’s related operation at some time in their lifetime 1. Nonetheless, as surgeons we notice a trend towards less referrals for operations for Crohn’s disease, where the patients tend to present later and often in a poorer condition. It has been suggested that this change in surgical practice is due to the introduction of biologic medications for Crohn’s disease in the first half of the 2000s. However, despite the increasing use of novel biologic agents, counterintuitively the incidence of Crohn’s disease related surgery does not appear to be reducing 2. A recent large population based cohort study from Alberta, Canada, showed a decrease in emergency surgery but an increase in elective surgery 3. This might explain why surgeons get the sense that the burden for Crohn’s related surgery is less. One could expect that more elective surgery is related to earlier referral, a better condition of the patient at the time of surgery and therefore less stoma formation. In this month’s Editor’s choice study, Ma et al., from the same Canadian group, are looking at trends in stoma formation after the introduction of biologics in management of Crohn’s disease 4. In order to assess the need for stoma creation in the biological era, the authors queried an administrative population database from their area, serving 1.4 million inhabitants. They identified 545 patients who underwent bowel resection and stoma formation for Crohn’s disease between 2002 and 2011. They found a time based reduction in stoma rates from 2.30 stomas per 100 person-years to 1.51 stomas per 100 person-years. The number of emergency and temporary stomas decreased over time, whereas the number of elective permanent stomas remained stable. Except for severe perianal fistulising disease, elective stoma formation for Crohn’s disease becomes necessary where primary anastomosis is technically impossible or if there is a high risk for anastomotic breakdown. Unfortunately, this study was not able to identify the reason the stoma was indicated 4. Well-known risk factors for anastomotic complications in Crohn’s patients include recurrent clinical episodes, steroid use, and malnutrition 5. Nowadays, gastroenterologists have a wide range of medical therapies available to avoid intestinal resection. This might cause a delay to progress to surgery, which may result in a progressively more complex disease phenotype at the time of surgery. If this delay occurs, the patient’s condition deteriorates, and this forces the surgeon to elect for a stoma to avoid an anastomotic complication. The study by Ma et al. reminds us of the importance of appropriate and timely surgery, especially in the biologic era. Therefore, the IBD surgeon should be involved in the management of the Crohn’s patient from the first onset of the disease, as a member of an IBD multidisciplinary team.

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