Escalating anti-tumour necrosis factor exposure with reductions in surgical resection rates in paediatric inflammatory bowel disease: an 18-year real-world population-based cohort study

Abstract

Objective: To evaluate the relationship between anti-tumour necrosis factor (TNF) use and surgical resection rates in a regional paediatric inflammatory bowel disease (IBD) cohort. Methods: This retrospective cohort study used prospectively maintained electronic data from a regional UK paediatric gastroenterology centre (2007–2024). Included were individuals with modified Porto IBD diagnosis, aged ≤17 years. Annual prevalent IBD population was estimated using incident diagnoses and transition to adult services. Abdominal surgery rates (strictureplasty, resection, primary stoma) and anti-TNF administration were collected and prevalence calculated. Three anti-TNF epochs, defined by the European Crohn’s and Colitis Organisation/European Society of Paediatric Gastroenterology, Hepatology and Nutrition guidelines in 2014 and 2020, were compared: Epoch-1 (2007–2013; <20% anti-TNF), 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. Results: One thousand five hundred and thirty-eight children were included (915 Crohn’s disease (CD), 529 ulcerative colitis (UC) and 94 IBD-unclassified). Median age at diagnosis was 13.3 years, and the prevalent population increased (253–597 patients). Anti-TNF-treated prevalence rose across epochs (5.9%, 31.9%, 61.1%; p<0.001). Resection rates declined 3.93%, 1.57% and 1.09% (Epoch 1–3) (p=0.003). Rates did not significantly decrease from Epoch 2 to 3 (p=0.217). CD surgery significantly decreased (4.9%, 1.7%, 1.5%, p=0.006); trends in UC rates did not reach significance (1.89%, 1.55%, 0.56%, p=0.314). Time to anti-TNF from diagnosis decreased (1.2, 0.8 and 0.26 years, p=0.008). Early vs later anti-TNF initiation was not associated with surgery-free survival. Conclusion: We report a significant increase in anti-TNF prevalence, with earlier deployment. Surgical resection rates have declined and plateaued; reflecting reduced CD surgery. Future research should focus on optimised anti-TNF and second-line biologic deployment to move beyond current levels of surgery.