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Copyright ©2012 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastroenterol. Aug 7, 2012; 18(29): 3828-3832
Published online Aug 7, 2012. doi: 10.3748/wjg.v18.i29.3828
Surgery for Crohn’s disease in the era of biologicals: A reduced need or delayed verdict?
Anthony de Buck van Overstraeten, Albert Wolthuis, André D’Hoore
Anthony de Buck van Overstraeten, Albert Wolthuis, André D’Hoore, Department of Abdominal Surgery, University Hospital Gasthuisberg Leuven, 3000 Leuven, Belgium
Author contributions: de Buck van Overstraeten A, Wolthuis A and D’Hoore A all participated in the literature study, along with the writing and revision of this manuscript.
Correspondence to: André D’Hoore, MD, PhD, Department of Abdominal Surgery, University Hospital Gasthuisberg Leuven, Herestraat 49, 3000 Leuven, Belgium.
Telephone: +32-16-344265 Fax: +32-16-344832
Received: February 6, 2012
Revised: April 13, 2012
Accepted: April 20, 2012
Published online: August 7, 2012

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.

Keywords: Crohn’s disease, Surgery, Biological agents, Anti-tumor necrosis factor drugs, Remission