Ileocolic resection versus medical therapy for Crohn’s disease in the post-biologic era: a systematic review

Background: Crohn's disease (CD) is a chronic, idiopathic inflammatory bowel condition with increasing incidence globally. For a long time, the treatment for ileal disease relied on surgery for complications or refractoriness to conventional clinical management. With the advent of immunobiological agents, the natural history of the disease has been altered, establishing a new treatment paradigm. This study aimed to perform a systematic review (SR) depicting the role of surgical resection in the post-biological era, especially as initial therapy for limited disease. Methods: A comprehensive search of PubMed, PubMed PMC, BVS/BIREME, CINAHL, Web of Science, Embase, Cochrane Library, and ProQuest databases was performed, including studies published up to July 2025. Results: Six retrospective and two prospective studies were included, all developed in Europe, except for one in Canada. Only one included a pediatric population. Of the eight studies, two directly compared ileocolic resection with biological therapy. The remaining studies assessed only surgical outcomes. Five studies evaluated complications after surgical treatment and one after medical treatment, with median rates of 10% and 3%, respectively. Five studies analyzed clinical remission rates, and five assessed endoscopic remission at varying follow-up times. At approximately 1 year of follow-up, endoscopic remission rates ranged from 29% to 79% in the surgical group and from 48% to 84% in the biologics group. Clinical remission was assessed only in the surgical group, with rates of 60%, 83.7%, and 92% at 1 year, and 74% and 88% at 10 years. In the direct comparison of surgery versus biological therapy, only one study evaluated the subsequent need for additional biological treatment during follow-up, and this need was similar among the groups. Conclusions: Ileocolectomy is an effective and viable therapeutic alternative to primary biological therapy for localized and refractory ileal CD. Early surgery can offer more sustained control for specific phenotypes, reducing the need for long-term treatment. The decision should be individualized, taking into account risks, disease phenotype, and patient preferences. Further randomized trials are needed to refine recommendations.