Letter: Early Inflammatory Benefit Is Not Yet Equivalent to Durable Surgical Advantage After Colectomy in Colonic Crohn's Disease

We read with great interest the RESECOL study by Rueda García et al. 1, which compares segmental colectomy (SC) and sub-total colectomy (STC) in colonic Crohn's disease. This large multicentre analysis is timely and clinically relevant, but its implications require more careful definition. What matters here is not whether SC appears favourable, but what kind of advantage the study actually shows. Clinical post-operative recurrence (POR) occurred in 38.2% after SC versus 62.7% after STC, and endoscopic POR in 50.4% versus 71.2%, with better 1- and 5-year clinical POR-free survival after SC (82% and 64.8% vs. 67.6% and 39%). These are important differences. However, comparative data in the biologic era have focused mainly on long-term surgical recurrence and stoma-related outcomes, rather than early inflammatory endpoints alone 2. In RESECOL, the harder downstream outcomes did not separate in the same way: radiologic POR was not significantly different (43.1% vs. 60.0%, p = 0.1), surgical recurrence was nearly identical (10.8% vs. 11.9%, p = 0.992), and even after IPTW, surgical POR remained similar (13.0% vs. 14.1%). Most importantly, the apparent protective effect of SC for endoscopic POR was time-dependent, remaining significant at 12 months but not thereafter 3. In our view, these data support less early inflammatory recurrence after SC, but not yet a clearly superior long-term surgical strategy. The harder problem is attribution. The principal threat to inference here is not retrospective design alone, but confounding by indication. The two groups were not clinically exchangeable: SC patients were older, had more B3 disease (43% vs. 21%), and differed materially in operative indication, with more medically refractory disease in STC (25% vs. 8.3%) and more fistulising disease in SC (32% vs. 12%). This matters because symptoms after surgery are notoriously difficult to interpret, and clinical remission has limited sensitivity for excluding ongoing inflammation; endoscopy remains central to meaningful post-operative assessment 4. The manuscript also acknowledges that the number of involved colonic segments was not captured, even though disease extent directly influences both procedure choice and long-term risk. In addition, pathology-level drivers such as positive resection margins have recently been linked to increased endoscopic and surgical recurrence, further complicating procedure-level attribution when extent and pathology are incompletely standardised 5. These results should therefore be read as strong signals, not definitive proof of procedural superiority. Taken together, RESECOL advances a neglected field and provides useful contemporary data. Our comments are intended constructively. The study would be strengthened by a narrower conclusion and by further stratified analyses according to disease extent and surgical indication. That would sharpen its real clinical message: SC may offer an early inflammatory advantage when feasible, but its durable strategic superiority remains unproven. Jiacheng Li: conceptualization, writing – original draft, writing – review and editing, funding acquisition. This study was supported by the Suzhou ‘Science Education and Health’ Top-level Project (MSXM2024028); the Suzhou Applied Basic Research (Medical and Health) Science and Technology Innovation Project (SYW2024135); the Suzhou Young Science and Technology Talent Support Program (QRC2507); the Nanjing University of Chinese Medicine 2025 Clinical Teaching Special Research Project (NZYJY2025-L-45); and the Natural Science Foundation of Nanjing University of Chinese Medicine (QKY25088). The author has nothing to report. The author declares no conflicts of interest. This article is linked to Rueda García et al. papers. To view this article, visit https://doi.org/10.1111/apt.70608. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.