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

Background and aimsEarly Crohn’s disease (CD) treatment involves anti-tumor necrosis factor (TNF) agents, while ileocecal resection (ICR) is reserved for complicated CD or treatment failure. We aimed to compare long-term outcomes of primary ICR and anti-TNF therapy for ileocecal CD.MethodsUsing cross-linked nationwide registers, we identified all individuals diagnosed with ileal or ileocecal CD between 2003 and 2018, treated with ICR or anti-TNF agents within one year of diagnosis. The primary outcome was a composite of one or more of the following: CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD. We conducted adjusted Cox proportional hazards regression analyses and determined cumulative risk of different treatments following primary ICR or anti-TNF therapy.ResultsOf 16,443 individuals diagnosed with CD, 1,279 individuals fulfilled the inclusion criteria. Of these, 45.4% and 54.6% of individuals underwent ICR and received anti-TNF, respectively. The composite outcome occurred in 273 individuals (IR 110/1000 person years (PY)) in the ICR group and in 318 individuals (IR 202/1000 PY) in the anti-TNF group. The risk of the composite outcome was 33% lower with ICR, compared to anti-TNF (aHR 0.67; 95% CI 0.54, 0.83). ICR was associated with reduced risk of systemic corticosteroid exposure and CD-related surgery, but not other secondary outcomes. The proportion of individuals on IMM, anti-TNF, who underwent subsequent resection, or on no therapy 5 years post-ICR was 46.3%, 16.8%, 1.8%, and 49.7%, respectively.ConclusionThese data suggest that ICR may have a role as first-line therapy in CD management and challenge the current paradigm of reserving surgery for complicated CD refractory or intolerant to medications. Yet, given inherent biases associated with observational data, our findings should be interpreted and applied cautiously in clinical decision-making.