title: Surgery for Crohn's disease in the era of biologicals: a reduced need or delayed verdict?
abstract: Crohn's disease (CD) is a chronic inflammatory bowel disease that can affect the entire gastrointestinal tract. Ultimately, up to 70% of all patients will need surgery, despite optimized medical therapy. Moreover, about half of the patients will need redo-surgery because of disease recurrence. The introduction of anti-tumor necrosis factor (TNF) drugs (Infliximab in 1998) revolutionized the treatment of CD. Different randomized trials assessed the efficacy of anti-TNF treatment not only to induce, but also to maintain, steroid-free remission. Furthermore, these agents can rapidly lead to mucosal healing. This aspect is important, as it is a major predictor for long-term disease control. Subgroup analyses of responding patients seemed to suggest a reduction in the need for surgery at median-term follow up (1-3 years). However if one looks at population surveys, one does not observe any decline in the need for surgery since the introduction of Infliximab in 1998. The short follow-up term and the exclusion of patients with imminent surgical need in the randomized trials could bias the results. Only 60% of patients respond to induction of anti-TNF therapy, moreover, some patients will actually develop resistance to biologicals. Many patients are diagnosed when stenosing disease has already occurred, obviating the need for biological therapy. In a further attempt to change the actual course of the disease, top down strategies have been progressively implemented. Whether this will indeed obviate surgery for a substantial group of patients remains unclear. For the time being, surgery will still play a pivotal role in the treatment of CD.
authors.affiliation: Department of Abdominal Surgery, University Hospital Gasthuisberg Leuven, Leuven, Belgium.
authors.forename: Anthony
authors.initials: A
authors.lastname: de Buck van Overstraeten
authors.forename: Albert
authors.initials: A
authors.lastname: Wolthuis
authors.forename: André
authors.initials: A
authors.lastname: D'Hoore
mesh_terms: D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D001688:Biological Products / Q000627:therapeutic use*; D003424:Crohn Disease / Q000188:drug therapy* / Q000601:surgery*; D006801:Humans; D000069285:Infliximab; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D000911:Antibodies, Monoclonal; D001688:Biological Products; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab