Editorial: Re-evaluating early surgery in Ileocaecal Crohn's disease

Since the introduction of biologics, treatment strategies for Crohn's disease (CD) have focused on initial medical management, reserving surgery for patients who fail medical therapy or who develop complications. Despite this, most patients with ileal involvement, a key risk factor for progression to stricturing and penetrating complications, still require at least one surgical resection within 10 years of diagnosis.^1-3

The 2017 LIR!C trial challenged this approach, demonstrating that early ileocecal resection was non-inferior to initial anti-TNF therapy in patients who failed conventional treatments in terms of quality of life, treatment effectiveness and disease complications.⁴ Moreover, early surgery reduced the need for advanced medical therapies and disease-related complications and morphological recurrence on long-term follow-up.⁵ These findings prompted questions about whether early surgery should play a more prominent role as first-line therapy in ileal CD.

The retrospective study by Grellier et al.⁶ aimed to provide further insight into this ongoing debate. This study compared outcomes in patients undergoing early (within 6 months of diagnosis), intermediate (6 months to 2 years) and late (2–5 years) ileal resection for CD. For the primary outcome, cumulative risk of second surgery at 10 years, there were no significant differences among the three arms (25%, 17% and 23%, respectively). This was despite the early resection group tending to have more complicated diseases and a higher proportion of smokers. Notably, 69% of early surgery patients were medical therapy-naïve compared to just 16% and 8% in the intermediate and late groups.

Consistent with LIR!C and data of Agrawal et al.⁷ the study highlighted important differences in disease progression in those undergoing early surgical resection versus initial medical therapy. Compared to the later surgical arms, patients with early resection were less likely to require advanced medical therapies postoperatively (median survival 3.7 years vs. 0.92 years) and had less morphologic recurrence at 5 years (54.4% vs. 68.2%; p = 0.02). Importantly, anti-TNF exposure before surgery was also associated with higher risk of second ileal resection (HR: 2.82; p < 0.001), suggesting that biologics may influence CD biology and long-term surgical outcomes.

The study's limitations include high dropout rate, retrospective analysis and exclusion of patients who did not undergo surgery within 5 years of diagnosis, limiting the generalizability of the results.

Despite these limitations, it has added valuable insight into the growing body of evidence that early surgery in ileal CD does not lead to worse long-term outcomes. On the contrary, early resection may offer protective benefits by altering CD biology resulting in reduced need for advanced therapies and lowering morphological recurrence. These findings strengthen the argument for considering surgery as an early intervention in select patients with ileal CD.

With this accumulating evidence, it may be time to rethink the current treatment paradigm that reserves surgery for patients with complicated or refractory CD. Although further prospective research is needed, the future of CD management might involve a more integrated approach, combining early surgery with advanced medical therapies to help patients achieve long-term symptom control and disease clearance.

Leshni Pillay: Writing – original draft; writing – review and editing; conceptualization. Britt Christensen: Writing – review and editing; conceptualization; supervision.

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.18320.