Surgical timing in the management of Crohn's disease in the era of biological drugs.

Background The indications and the timing for surgery are obviously related to the type of complications; but a key role, in choosing the most appropriate time to perform surgery, is played not only by factors related to patient but also by the evaluation of disease intrinsic characteristics: stenosing/penetrating/inflammatory disease, disease activity, extension, prevalent localization and the response to medical therapy. Methods The authors analyzed the literature of the past two decades by integrating it with their personal experience. The authors have paid attention above all to Crohn’s disease management. Results Advances in medical therapy over the past two decades have substantially altered the management of patients with IBD. The introduction of more aggressive regimens (top down strategy) resulted in a change of surgery, which is no longer seen as “a last resort”, to be reserved for the treatment of a longstanding disease with more serious complications, but should also be seen as “early surgery”, able to induce remissions faster and perhaps more durable, at least in the short to medium term. It is logical to wonder whether this is also a result of a change in the natural history of the disease under the influence of new therapies. Biological drugs have proved to be able to induce remission (60%), to keep it free from steroids for short-medium periods and to return the integrity of the mucosa, which is important to control the disease. Mucosal healing leads to a decrease of complications’ rate, fewer hospitalizations and thus a possible reduction in the rate of surgical interventions. There are still doubts about the real reduction of the need for surgery. Biological drugs have positive response only in 60% of cases and it is also possible to develop antibody reactions and resistance to the drug (10%). In addition, the disease often presents as a stenosing form, for which biologics are little or no effective and so surgery, even early, is required. Prolonged periods of remission are achieved only in 15% of cases. Borrowing the positive effects of antiTNF in the treatment of rheumatic diseases, we wondered if the use of biologics in Crohn’s disease may result in a change of the natural history of the disease. This problem remains unsolved. Doubts also remain about the actual reduction in the rate of hospitalization and in the need for surgery. Conflicting data emerge from randomized trials and observational studies. Conclusions There is still no evidence of a real reduction in the rate of interventions. Even today, the ideal treatment of Crohn’s disease is an unclear argument. Surgery plays a leading role and should not be considered only as “a last resort”; early surgery may indeed allow faster and more lasting remissions