Who Still Needs Surgery? Defining the Modern Surgical Phenotype in Inflammatory Bowel Disease

Background Inflammatory bowel disease (IBD), affecting over 2 million individuals in the United States, is associated with substantial morbidity, recurrent hospitalizations, and need for long-term immunosuppressive therapy. Although biologic therapies have been associated with declining operative rates in IBD, a clinically significant subset of patients continues to progress to surgery despite biologic exposure. Methods This retrospective cohort study evaluated surgical intervention rates among patients with Crohn’s disease (CD) and ulcerative colitis (UC) across two biologic treatment eras using the TriNetX Research Network, a multi-institutional database of de-identified electronic health records. Adult patients (ages 18-90) receiving biologic therapy were divided into two cohorts: 2004-2014 and 2014-2024. Surgical intervention following biologic initiation was used as a surrogate for treatment failure, and propensity score matching was performed to reduce confounding. Results After matching, 9822 patients remained in each cohort. Surgical intervention occurred in 8.4% of patients in the earlier cohort compared with 5.9% in the contemporary cohort, corresponding to a 29.8% relative reduction in operative intervention (RR 1.426, 95% CI 1.285-1.583; P < 0.001). Patients in the earlier cohort also demonstrated significantly higher risk of surgery within 1 year of biologic initiation. Within the contemporary cohort, CD patients continued to demonstrate higher operative risk compared with UC. Discussion Contemporary biologic therapy was associated with reduced operative intervention over time; however, persistent operative burden remains despite biologic exposure, particularly among patients with CD and nutritional compromise.