Crohn’s disease (CD) is a chronic inflammatory disease of the gastrointestinal tract, with increasing incidence worldwide. In the UK, it is predicted that the prevalence of inflammatory bowel disease (IBD) will be 1% by 2030. Medication such as oral immunosuppressants and biologics are the mainstay of treatment for CD, however, surgery continues to have a role in disease management.
The main indications for surgery are stricturing disease, penetrating complications and medication-refractory inflammatory disease. There is some suggestion that the current more aggressive treat to target approach has reduced surgical rates. Despite this 23-47% of patients still require surgery at some stage in their disease course. Some patients also require repeated surgery.
Surgery may be the preferred first line treatment as per the LIR!C study which showed that primary ileocaeal resection in patients with isolated ileocaecal disease had similar quality of life scores one year after surgery as compared to medical treatment. The European Crohn’s and Colitis Organisation (ECCO) and European Society of Coloproctology (ESCP) consensus guidelines suggest surgery should be considered at an early stage in those with penetrating or fistulising disease and those with localised ileocecal disease and obstructive symptoms but no significant active inflammation.
Exclusive Enteral Nutrition (EEN) is the term used when a patient replaces their habitual diet with an exclusive liquid diet for a defined period of time. EEN is widely used in paediatric CD as first line therapy for induction of remission without the use of steroids. Six to eight weeks is the recommended duration of EEN with induction of remission of CD occurring in 60-80% of children and adolescents. To date, there have been no randomised controlled trials (RCT) looking at the ability of EEN to induce remission in adults compared to usual unrestricted diet, and a Cochrane review showed that EEN was effective, but inferior to steroids; perhaps due to lack of compliance with EEN.
The National Institute of Clinical Excellence (NICE) as well as surgical, nutrition, and gastroenterological societies in the UK and internationally have highlighted the need for prospective RCT to determine whether pre-operative EEN is beneficial in surgical outcomes for CD. The James Lind alliance also highlighted the importance of research into the role of diet and EEN in CD.
Surgery remains an important part of the management of CD and cost-effective measures that may reduce complications and ensure proper resource utilisation need to be investigated. Evidence for the pre-operative use of EEN from systematic reviews has highlighted that there is sufficient indication from retrospective studies that EEN may be effective and hence a large prospective RCT is now required to inform future care.
This prospective multicentre randomised study aims to define the role of EEN in the pre-operative management of CD.