Initial surgery may beat medical therapy for CD-related abdominal abscess

Last Updated: 2015-02-03

By Megan Brooks

NEW YORK (Reuters Health) - Upfront surgical management appears superior to medical management in patients with intra-abdominal abscesses related to Crohn's disease (CD), hint results of a meta-analysis of retrospective case series.

This meta-analysis likely provides "the strongest level of evidence" regarding management of CD-related abscesses, given that a randomized controlled study may not be feasible due to a low rate of abscess development in CD, Dr. Douglas L. Nguyen from University of California Irvine and colleagues say.

Their analysis included nine retrospective studies with a total of 603 patients that compared initial surgical versus medical approaches to CD-related abscesses.

The pooled analysis showed an overall rate of abscess resolution of 80.7% in the surgical group compared with 56.6% in the medical group.

There was over a three-fold higher likelihood (OR, 3.44; p<0.001) of durable abscess resolution with initial surgical management (laparotomy with or without bowel resection) compared with initial medical management (antibiotics alone or with percutaneous drainage).

The number needed to treat with surgery compared with medical therapy to prevent an abscess recurrence was four, Dr. Nguyen and colleagues report in the March issue of the European Journal of Gastroenterology and Hepatology, available online now.

The fact that more than half of patients in the medical group achieved abscess resolution is noteworthy, they say. "Unfortunately, the included studies do not uniformly document which subset of patients at the time of presentation who underwent initial medical therapy were able to achieve durable abscess resolution," they note.

The analysis also showed a three-fold higher rate of needing a temporary stoma created in the surgery group compared with the medical group.

Dr. Nguyen and colleagues say it's not clear whether this is related to more severe illness at the time the abscess was diagnosed requiring immediate surgical intervention when patients have not yet been "medically optimized."

"However, it is also feasible that in some instances, medical management using percutaneous drainage might serve as a bridge to scheduled surgery that can be performed in better conditions (i.e. when patients are less sick). In theory, percutaneous drainage would reduce the abscess size, reducing risk for peritoneal contamination and allowing for successful primary anastomosis and thus reduce need for stoma creation," they say.

In an email to Reuters Health, Dr. Nguyen said, "Our perception is that in selected patients medical therapy should be attempted first. Once there is abscess drainage, we recommend initiation of disease-modifying therapy like infliximab to prevent future complications of Crohn's such as abscess recurrence. This is supported by my previous findings published in Clinical Gastroenterology and Hepatology," he said. That paper is available here: http://bit.ly/1zwkwLu.

Limitations of the current analysis include the retrospective nature of all nine studies and not knowing which patient characteristics predict success of the initial strategy, the researchers say.

"As new studies are published in the era of improved medical therapy for CD, this meta-analysis will need to be updated to demonstrate that the initial surgical management remains superior to initial medical management," they conclude.

The study had no funding and the authors have no conflicts of interest.

SOURCE: http://bit.ly/1BPcMRD

Eur J Gastroenterol Hepatol 2015;27:235-241.