Surgery for Crohn's disease in the era of biologicals: a reduced need or delayed verdict?

World J Gastroenterol. 2012 Aug 7;18(29):3828-32. doi: 10.3748/wjg.v18.i29.3828.


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: Anti-tumor necrosis factor drugs; Biological agents; Crohn’s disease; Remission; Surgery.

Publication types

  • Review

MeSH terms

  • Antibodies, Monoclonal / therapeutic use
  • Biological Products / therapeutic use*
  • Crohn Disease / drug therapy*
  • Crohn Disease / surgery*
  • Humans
  • Infliximab
  • Randomized Controlled Trials as Topic
  • Recurrence
  • Tumor Necrosis Factor-alpha / antagonists & inhibitors


  • Antibodies, Monoclonal
  • Biological Products
  • Tumor Necrosis Factor-alpha
  • Infliximab