Beyond 'early surgery': Reframing Ileocaecal resection as strategic care in Crohn's disease

The concept of 'early surgery' for ileocaecal Crohn's disease (CD) has gained traction since the LIR!C trial demonstrated that laparoscopic ileocaecal resection is a cost-effective alternative to infliximab for uncomplicated terminal ileitis. However, the term 'early' is imprecisely defined, temporally misleading and difficult to operationalise in clinical practice. This article aims to propose a more useful clinical framework for the timing of ileocaecal resection in CD.

We critically appraised the 10-year follow-up of the LIR!C trial, together with population-based and pooled observational data comparing ileocaecal resection with continued medical therapy.

Current evidence suggests that resection may be superior to continued medical therapy in selected patients. It is associated with higher rates of therapy-free remission and less need for subsequent surgery. Operating before complications develop is also associated with better perioperative outcomes. We propose distinguishing between reactive surgery, meaning operating in response to complications that have already developed, and strategic surgery. Strategic surgery is a proactive, multidisciplinary decision to offer ileocaecal resection at the optimal point in the disease course. It is based on phenotype, patient condition and shared decision-making, rather than on elapsed time or biological exposure alone.

The evidence underpinning this position is largely retrospective and subject to selection bias. Substantial clinician, patient and health-system barriers stand in the way of implementation. Prospective data are needed before guideline revision is warranted.