Primary Surgery vs. Anti-TNF in Crohn’s

Review by Prof. Mark Topazian (USA)

Background

The dominant treatment paradigm for ileocecal Crohn’s disease (CD) is medical therapy first, including anti-tumor necrosis factor (anti-TNF) therapy, with surgical ileocecal resection (ICR) reserved for treatment failures or local complications of disease. These authors previously challenged this paradigm by conducting a randomized clinical trial of anti-TNF vs. ICR as primary treatment for newly diagnosed ileocecal CD, finding that quality of life was comparable at 1-year follow-up; at 5 years, most of the patients in the ICR group were on no treatment. In this study, a population-based Danish registry was studied to assess real-world outcomes of anti-TNF vs. ICR as initial therapy for ileocecal CD.

Findings

Of 1,279 patients fulfilling enrollment criteria, 45% underwent ICR and 55% received anti-TNF as primary treatment. During a median follow-up of 1.86 years, the rate of a composite outcome of CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery and/or perianal CD was 33% lower in the ICR group. The proportion of patients on immunomodulator, anti-TNF, who underwent surgical resection, or were on no therapy 5 years post-ICR were 46.3%, 16.8%, 1.8% and 49.7%, respectively.

Commentary 

This study further supports the use of ICR as a reasonable first-line therapy for CD. Primary surgery may be a particularly important option in resource-limited settings given the cost of anti-TNF and the need for ongoing treatment. Surgery might also be favored in locations where latent tuberculosis (a contraindication to anti-TNF therapy) is common. Surgical morbidity and mortality are likely to be lower when surgery is offered before disease complications and malnutrition occur. Among CD patients treated primarily with ICR, protocolized follow-up to diagnosis and treat disease recurrence at early, pre-symptomatic stages is important.

Citation

Agrawal M, Ebert AC, Poulsen G, Ungaro RC, et al. Early ileocecal resection for Crohn’s disease is associated with improved long-term outcomes compared to anti-tumor necrosis factor therapy: a population-based cohort study. Gastroenterology 2023:165,976-985.

https://pubmed.ncbi.nlm.nih.gov/37321356/

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