Editorial: Re-Evaluating Early Surgery in Ileocaecal Crohn's Disease. Author's Reply

Abstract

We fully agree with the conclusions presented in the editorial by Drs. Pillay and Christensen [1], on our work (the ERIC study) [2], which emphasised the importance of early surgical intervention in certain cases of Crohn's disease (CD). We also believe that surgery should always be discussed in an integrated way for complicated CD but also for pure inflammatory ileal CD given the findings of the LIR!C trial [3, 4]. The results of our study provide more insights on the potential benefit of early ileocecal resection and particularly the absence of poor prognostic factors associated with early surgery. We share Dr. Pillay's and Dr. Christensen's view that we currently face an ambitious challenge to combine surgery and advanced medical therapies at the right time for the right patient.

As highlighted by the reply, we acknowledge the limitations raised, particularly the dropout rates and generalisability concerns. While 77 patients were lost to follow-up due to the tertiary centre setting, a large cohort of 393 patients was included in our analysis with a median follow-up of 9.4 years (IQR 5.5–13.7), which allowed us to present robust and fair data.

Our work strengthens the relevance of early surgical intervention for complicated disease and addresses a gap not covered by other studies. Furthermore, the ERIC study answered a question that neither the LIR!C trial nor the Danish population study by Agrawal and colleagues answered, namely the natural history of early complicated disease requiring surgery [5]. With the ERIC study, we have brought additional insight into this specific subset of patients with CD.

As evidence of the benefit of early ileocecal resection in patients with CD grows, it is important to remember the impact of surgery on patients' day-to-day symptoms despite the reassuring findings of the LIR!C trial on quality of life [6]. Disabling symptoms are common after ileocecal resection due to bile acid diarrhoea and the loss of the ileocecal valve. Nearly two-thirds of patients will have diarrhoea daily and many will experience urgency independent of CD recurrence [7, 8]. These symptoms may be masked by anti-diarrhoeal medications, but some may be irreversible.

Finally, while our findings and the editorial both support the role of early surgery, more prospective studies are needed to identify the right timing and candidates for this intervention. Balancing the benefits of surgery with potential risks is crucial for optimising outcomes and ensuring that the decision to operate is made with a comprehensive understanding of the patient's condition and long-term prognosis.

Nathan Grellier: writing – original draft. Julien Kirchgesner: writing – review and editing. Philippe Seksik: writing – review and editing.

J.K. Lecture fees from Pfizer and Janssen, consulting fees from Roche, Pfizer and Gilead. P.S. received consulting fees from Takeda, Abbvie, Merck-MSD, Biocodex, Janssen, Amgen, Astellas and Pfizer and grants from Biocodex and Janssen.

The authors declare no conflicts of interest.

This article is linked to Grellier et al papers. To view these articles, visit https://doi.org/10.1111/apt.18247 and https://doi.org/10.1111/apt.18290.