Improved diagnostic capability, rather than biologics, reduces surgical rates in Chinese Crohn’s disease patients: A multicenter study

BACKGROUND: Surgical rates for Crohn's disease (CD) are declining globally. However, the driving factors remain unclear, particularly in newly industrialized countries. We aimed to evaluate the impact of diagnostic capacity and treatment with biologics on surgical rates among Chinese CD patients. METHODS: Data of CD patients from January 2000 to January 2024 were extracted from 8 sites of the Chinese database for inflammatory bowel disease. Trends in cross-sectional imaging use, surgically diagnosed proportion, medical treatment, and surgery for CD were described. Cumulative surgical rates were compared using Kaplan-Meier method with log-rank test. Time-dependent Cox models were used to identify factors associated with surgery risk, and propensity score matching (PSM) was applied to validate the findings. RESULTS: In total, 1354 patients were included, with a median follow-up of 5.99 years. The cumulative 5-year surgical rate decreased from 30.96% in 2000-2012 to 21.57% in 2013-2024 (log-rank P <0.001). The use of cross-sectional imaging increased from 2.00% in 2000-2004 to 82.81% in 2020-2024. The proportion of surgically diagnosed patients declined from 13.68% in 2000-2012 to 6.21% in 2013-2024. Multivariate Cox analysis showed that diagnosis in 2013-2024 (hazard ratio [HR] 0.74, 95% confidence interval [CI]: 0.59-0.91, P = 0.006) was independently associated with a lower risk of surgery, whereas biologic use (HR 0.93, 95% CI: 0.71-1.22, P = 0.604) was not. Sensitivity analyses excluding surgically diagnosed patients demonstrated similar surgical rates between the two cohorts. PSM and subgroup analyses confirmed these trends. CONCLUSIONS: Surgical rates among Chinese CD patients have significantly decreased over the past two decades, in parallel with improvements in diagnosis. Enhancements in diagnostic pathways within broader systemic healthcare upgrades are strongly associated with reduced surgical risk, whereas increased use of biologics is not.