15 Intestinal Resection Versus Medical Treatment for Ileocecal Crohn's Disease in the Post-Biological Era: A Systematic Review of the Literature

Background: Ileocecal Crohn’s disease (CD) is a common presentation of inflammatory bowel disease. In the pre-biological era, surgery was the main therapeutic option after treatment failure. With the advent of anti-TNFα agents, the paradigm shifted, and surgical approaches were reserved for more complex cases. However, growing evidence suggests that early surgery, such as ileocecectomy, may be more effective than primary medical treatment, although no consensus has yet been reached. Therefore, we conducted a systematic review (SR) comparing clinical outcomes of ileal/ileocecal resections with biological therapy in patients with ileocecal CD, focusing on recurrence and complication rates. Methods: A SR was conducted following strict exclusion criteria (PRISMA 2020). Screening adhered to predefined eligibility criteria, with independent dual review, including studies published between 1995 and 2024. A strategic search was performed in PUBMED, PUBMED PMC, BVS/BIREME, CINAHL, WEB OF SCIENCE, EMBASE, COCHRANE LIBRARY, and PROQUEST using descriptors related to Crohn’s disease, ileocecectomy, and immunobiologicals. Results: Eight original studies were included (7 retrospective, one prospective), 7 were developed in countries from Europe, and one was in Canada. Only one included a pediatric population. Of the 8 studies, 2 directly compared ileocolic resection with biological therapy. The remaining studies assessed only surgical outcomes. Five studies evaluated complications after surgical treatment and 1 after medical treatment, with median rates of 10% and 3%, respectively. Five studies analyzed clinical remission rates, and 5 assessed endoscopic remission at varying follow-up times. At approximately 1 year of follow-up, endoscopic remission rates ranged from 29%, 53%, and 79% in the surgical group, and 48% and 84% in the biologics group. Clinical remission was assessed only in the surgical group, with rates of 60%, 83.7%, and 92% at one year, and 74% and 88% at 10 years. CD recurrence after intestinal resection was evaluated in 6 studies, and in 2 of these, it was also possible to assess recurrence in the biologics group. In the direct comparison, surgery vs biological therapy, only one study evaluated the subsequent need for additional biological treatment during follow-up, and it was similar among the groups. Conclusions: Recurrence rates after ileocecal/ileocolic resection for CD varied among studies and were influenced by factors such as smoking, penetrating phenotype, urgent surgery, and upper gastrointestinal tract involvement. Fewer complications occurred after biological therapy; however, the need for additional medical treatment was similar in both approaches. Pediatric patients presented with early postoperative recurrence compared to data from adult patients in the literature. Intestinal resection for ileocecal or isolated ileal CD is an effective alternative to primary biological therapy, particularly in stricturing or complicated disease. These findings suggest that early surgery may also provide significant clinical benefits. Further randomized long-term studies are required to confirm these results.