In favour of early surgery in Crohn's disease: A hypothesis to be tested

Abstract

Crohn's disease (CD) is a chronic relapsing inflammatory bowel disease (IBD) most frequently affecting the terminal ileum and right colon, with a high rate of stricturing or penetrating complications.1 Twenty years ago, the surgeon was often the main actor in the management of CD, but today's physicians (and consequently their patients) are tempted to see surgery as ‘the end of the road’ rather than part of a management strategy. The question is whether this displacement of surgery is appropriate, or necessarily in the best interests of patients. Although the mortality attributable to CD is relatively low, the chronic and relapsing course of the disease often results in substantial morbidity, poor quality of life, frequent use of health services and high direct and indirect costs of care.2–4 Surgery is an almost inevitable event in the natural history of ileal or ileocolic disease. The challenge facing physicians treating CD is, of course, not just to alleviate symptoms and prolong periods of remission, but also to reduce the need for surgery. Nevertheless, gastroenterologists have to recognise that no current medical approach has been shown to reduce the need for surgery in the long term. 70–90% of patients with ileocolic CD require an intestinal resection, at least once within 15 years of diagnosis, with a 20–40% probability of surgery during the first year of the disease.1–3,5–9 There are encouraging short-term data on reducing the need for abdominal surgery for CD within 1 year10,11 after treatment with anti-tumour neerosis factor alpha (anti-TNFα) antibody therapy, but it is long term follow up that is needed. However, surgery is not curative, because lesions and symptoms almost inexorably recur after resection.5,6,12 Mesalazine prophylaxis may reduce the postoperative recurrence rate, …