Report from IIS Award Winner 2020: Toer Stevens

At one year, a laparoscopic ileocaecal resection was cost effective and at least as good in terms of quality of life when compared to infliximab induction and maintenance treatment [1, 2]. However, it remained unknown how the disease course was affected by these entirely different strategies beyond the one-year endpoint of the trial. Hence, the aim of the current study was to assess the long-term outcome of patients enrolled in the LIR!C trial. We performed a retrospective observational study in which long-term outcome data were collected by medical chart review. Outcomes of interest were (1) the need for (second) surgery and use of anti-TNF in both groups, (2) the duration of effect of both strategies and (3) the identification of factors associated with the duration of effect.

The median (interquartile range) follow-up of the LIR!C cohort was 63.5 (39.0–94.5) months. In the resection group, 26% of the patients required anti-TNF and 32% required additional corticosteroid or immunomodulator treatment; none required a second resection, and 42% did not require any additional CD-related treatment for a disease flare. Of note, half of the patients in this last group received a prophylactic immunomodulator upon enrolment in the trial. In the infliximab group, 48% of the patients moved on to a CD-related resection and 14% required other medical treatment, while 38% did not require any additional treatment but were continued on their anti-TNF treatment. There was no difference in the duration of treatment effect as defined by the need to start additional CD treatment due to a disease flare or treatment intolerance (log-rank P=0.521). Median time to additional treatment was 33 months in the resection group, compared to 34 months in the infliximab group. Finally, using Cox regression analysis, we identified that in both groups the use of a prophylactic immunomodulator in conjunction with the allocated treatment significantly decreased the risk of requiring additional later treatment (resection group: HR 0.34, 95%CI 0.16–0.69; infliximab group: HR 0.49, 95%CI 0.26–0.93).

These results corroborate the initial results of the LIR!C trial and further support the use of a laparoscopic ileocaecal resection in CD patients with limited and predominantly inflammatory terminal ileitis who fail conventional treatment. This long-term follow-up study should be taken into consideration when counselling patients and may contribute to a shared decision-making process.

References

1. Ponsioen CY, de Groof EJ, Eshuis EJ, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: a randomised controlled, open-label, multicentre trial. Lancet Gastroenterol Hepatol. 2017;2:785–92.
2. de Groof EJ, Stevens TW, Eshuis EJ, et al. Cost-effectiveness of laparoscopic ileocaecal resection versus infliximab treatment of terminal ileitis in Crohn’s disease: the LIR!C trial. Gut. 2019;68:1774–80.

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