Anti-TNF therapy escalation cut pediatric IBD surgical resection rates by 72% over 18 years

Inflammatory Bowel Disease (IBD), encompassing Crohn's disease (CD) and ulcerative colitis (UC), is a chronic, debilitating condition often diagnosed in childhood. Historically, a significant proportion of pediatric IBD patients required surgical interventions like resections or strictureplasties due to disease progression or complications. Anti-tumor necrosis factor (anti-TNF) biologics target the pro-inflammatory cytokine TNF-alpha, playing a crucial role in managing IBD by reducing inflammation and promoting mucosal healing. Despite their established efficacy, the real-world impact of increasing anti-TNF deployment and earlier initiation on surgical rates in a population-based pediatric cohort remained an important area of investigation.

This retrospective cohort study analyzed prospectively maintained electronic data from a regional UK pediatric gastroenterology center (2007-2024), including 1538 children (≤17 years) with modified Porto IBD diagnoses. The study tracked annual prevalent IBD population, abdominal surgery rates (strictureplasty, resection, primary stoma), and anti-TNF administration. Three anti-TNF epochs were defined by guideline changes: Epoch-1 (2007-2013; <20% anti-TNF prevalence), Epoch-2 (2014-2020; 20-50%), and Epoch-3 (2021-2024; >50%). Kaplan-Meier analysis with log-rank testing compared surgery-free survival between early and later anti-TNF treatment groups.

Over the study period, the prevalent IBD population increased from 253 to 597 patients. Anti-TNF-treated prevalence rose significantly across epochs: 5.9% in Epoch-1, 31.9% in Epoch-2, and 61.1% in Epoch-3 (p<0.001). Concurrently, overall surgical resection rates declined from 3.93% in Epoch-1 to 1.57% in Epoch-2, and further to 1.09% in Epoch-3 (p=0.003). This represents a 72% reduction from Epoch-1 to Epoch-3.

Specifically, Crohn's disease surgery rates significantly decreased from 4.9% to 1.7% to 1.5% across the epochs (p=0.006), demonstrating a clear benefit. However, the decline in resection rates did not reach statistical significance between Epoch-2 and Epoch-3 (p=0.217), suggesting a plateau. Trends in ulcerative colitis rates also did not reach significance (1.89%, 1.55%, 0.56%; p=0.314). The median time from diagnosis to anti-TNF initiation decreased substantially from 1.2 years in Epoch-1 to 0.8 years in Epoch-2, and to just 0.26 years in Epoch-3 (p=0.008). Interestingly, early versus later anti-TNF initiation was not associated with surgery-free survival in this cohort.