Letter: Early Ileal Resection in Crohn's Disease Is Not Associated With Severe Long-Term Outcomes: The ERIC Study: Authors' Reply

Abstract

We thank Drs. Kelm and Flemming for their insightful letter [1] regarding our article [2]. We appreciate their remarks and would like to address their questions.

First, we would like to clarify a crucial point regarding our findings in relation to the primary outcome. Contrary to what Drs. Kelm and Flemming suggested, we found no statistically significant difference between the early resection group (< 6 months) and the other groups (6 months–2 years and 2–5 years) for the risk of a second ileocecal resection. However, patients who underwent early ileocecal resection required fewer post-operative treatments and demonstrated less morphological recurrence, supporting early resection as an effective treatment to maintain remission.

Second, accumulating evidence supports early ileocecal resection as a valuable approach for maintaining long-term remission in Crohn's disease isolated to the terminal ileum [3]. The challenge lies in identifying a safe approach that minimises recurrence risk while potentially reducing the need for subsequent immunosuppressive therapies. However, the key issue remains the stratification of recurrence risk and the selection of optimal surgical candidates.

The two centres involved in our study conduct weekly multidisciplinary IBD board meetings. Decisions regarding surgery for patients with IBD were always preceded by these discussions. Addressing the question regarding decision-making criteria for surgery versus advanced therapy is challenging in a retrospective setting. However, considering surgical indications, 95% of patients in the early resection group had complicated disease, compared to 82% in the late resection group. This suggests that patients who had early resection underwent surgery primarily out of necessity due to abscess or obstruction. These surgeries took place before the LIRIC trial, which later established laparoscopic ileocecal resection as a viable option for uncomplicated localised ileal Crohn's disease. In addition, the use of advanced therapies for complicated diseases was less standardised in the study period than it is today [4, 5].

As pointed out, we did not report perioperative morbidity or the potential impact of surgery on quality of life and post-operative digestive symptoms. These limitations are due to the retrospective nature of our study. Data in the immediate post-operative period were not collected comprehensively, and quality of life was not assessed systematically, particularly for patients who underwent surgery in the early 2000s. We acknowledge that surgery should only be considered when it is safe and associated with minimal adverse outcomes [6]. The main challenge for future studies will be to identify predictors of optimal quality of life after ileocecal resection, and the timing of surgery may be an important factor to consider. It remains to be addressed which patients will benefit most from surgery rather than medical therapy, not only in terms of preventing recurrence, but also in terms of quality of life, free from post-operative complications or post-operative diarrhoea due to surgery.

In conclusion, we appreciate the editorial's valuable insights. Further prospective studies are necessary to refine patient selection criteria and optimise long-term surgical outcomes in Crohn's disease.