Letter in Response to: ‘Early Ileal Resection in Crohn's Disease Is Not Associated With Severe Long-Term Outcomes: The ERIC Study’

Abstract

We read with interest the article by Grellier et al. [1]. The authors clearly demonstrated that early surgical intervention is not only accompanied by significantly reduced rates of ileal re-resection, but also with reduced requirement for postoperative immunosuppressive therapy. In addition, the risk of morphological recurrence revealed by endoscopy or radiology was also significantly lower.

Based on these data, the study strongly strengthens the available evidence towards primary surgical therapy in patients suffering from complicated or uncomplicated (i.e., isolated) ileocecal Crohn's disease, in line with previously published prospective and retrospective data [2-5]. Given this growing evidence, surgeons specialised in inflammatory bowel disease (IBD) need to advocate strongly for a primary surgical approach for patients with isolated ileocecal Crohn's disease. However, treatment strategies for patients with IBD are complex and include different specialties. Therefore, multidisciplinary IBD boards should always discuss individual treatment strategies. These boards comprising gastroenterologists, gastrointestinal surgeons, radiologists, pathologists and psychologists ensure that patients receive personalised and evidence-based therapy. It would be helpful if the authors could provide information about the use of IBD boards in the study before therapy was initiated and which criteria were used for decision-making to perform early or late resection. Furthermore, it would be interesting if there were any differences in short-term outcomes regarding postoperative morbidity.

From a surgical point of view, we would like to emphasise that all patients were operated on before 2012, where an open approach was more common than minimally invasive surgery. It can be presumed that, today, perioperative results of ileocecal resection would be even better with reduced morbidity, faster recovery and improved postoperative quality of life due to modern surgical and non-surgical approaches [6]. In addition to these obvious therapeutic advantages for early surgery, evaluation of differences for therapeutic strategies regarding quality of life and healthcare-related costs should also be considered during short- and long-term follow-up. It would have been interesting to include patient aspects by collecting data about differences in quality of life since this is the most relevant patient-related outcome measure. Unfortunately, this very important issue is often neither the primary endpoint nor even reported in IBD-treatment studies.

In conclusion, we congratulate Grellier et al. for their study since the results improve our current evidence about primary treatment options in ileocecal Crohn's disease. However, despite growing evidence, there is still a great need for prospective, randomised studies respecting patient-centred outcome measures to ensure that all requirements of the complexity and heterogeneity of IBD are addressed properly.