eP258 - The Fall of Stricturoplasty? National Trends in Surgical Management of Duodenal Crohn's Disease, a Review of the NIS Database

Purpose/Background: Isolated duodenal Crohn’s (DC) is a rare manifestation of the disease, comprising only 0.5-4% of adult patients. Surgical options have included stricturoplasty, bypass, and less commonly resection. Management guidelines have been based on a handful of studies, frequently single case reports with only a few case series >10 surgical patients, usually accrued over decades. These studies have produced conflicting results, favoring either stricturoplasty or bypass, likely in part to the rare incidence of DC. The purpose of this study was to compare the outcomes of these traditional approaches in a larger contemporary cohort.Methods/Interventions: The National Inpatient Sample (NIS) database, a representative sampling of 20% of all inpatient hospital encounters in the United States, was used to extract relevant hospitalizations from 2012 to 2018. Hospitalizations for small intestinal Crohn’s disease were identified by ICD9 and ICD10 diagnosis codes and further selected by procedure codes for surgery of the duodenum. Cohorts were stratified by surgical treatment type (stricturoplasty, bypass, resection). Annual incidence and length of stay were primary variables of interest.Results/Outcomes: Of 50 million inpatient encounters, 39505 hospitalizations for intestinal Crohn’s disease were identified, yielding a weighted sample of 420 cases of surgically treated duodenal Crohn’s. The annual incidence of DC ranged from 0.1% to 0.4% per year. The cohorts were comparable with respect to age, gender, race, comorbid conditions, insurance status, and elective/non elective admission. Of those cases, 220 (52.4%) underwent bypass (gastro-jejunal, duodenal-jejunal, duodenal-duodenal), 120 (28.6%) underwent resection (gastroduodenal, duodenal), and 80 (19%) underwent stricturoplasty. Bypass remained the most popular choice for treatment each year (29-78%). Stricturoplasty remained the least popular treatment choice with a decreasing trend each year (0-36%). There were no mortalities reported. There were no significant differences in mean length of stay (Bypass: 10.5 days, Resection: 12.2 days, Stricturoplasty: 9.9 days, p=0.59). At a hospital level, bed size, urban/rural location, public/private status, and teaching/non-teaching facility did not significantly impact the choice of surgery. The choice of surgery did not impact discharge disposition. Patients were 88-91% likely to be discharged home, regardless of the surgical approach.Conclusion/

Discussion: This is the largest study to date of duodenal Crohn’s disease. Treatment of this contemporary cohort reveals DC occurs less frequently than historically reported. Stricturoplasty has become less common as bypass continues to be the most frequent surgical option. All three options appear safe with respect to mortality, length of stay, and likelihood of routine discharge despite differences in hospital environment and patient comorbidities, thus allowing surgeons to tailor their approach based on their practice patterns and patient specific characteristics.