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Background The L!RIC trial confirmed that surgical treatment of limited ileocaecal Crohn’s disease (ICCD) has comparable outcomes to antiTNF therapy. However, strict exclusion criteria for a randomised controlled trial make it difficult to determine if results can be generalised to a wider population. We therefore compared clinical outcomes between surgical resection or antiTNF or other biologic therapy amongst biologic-naïve patients with ileocaecal Crohn’s disease to provide real world experience. Methods All patients with ICCD who were naïve both to biologic therapy and surgery, treated at our institution between January, 2011 and December, 2018 were identified from surgical and pharmacy databases. Electronic case records were used to obtain data on patient characteristics retrospectively and treatment-specific outcomes. The, 5-year cumulative recurrence rate was calculated after composite consideration of endoscopic recurrence, recurrence on imaging, switch to different therapy, or surgical re-intervention. Results Overall, 222 patients were identified.149 (67%) underwent surgical resection first, of whom, 54 patients (36%) subsequently required antiTNF or other biologic therapy., 73 patients were treated with antiTNF or other biologic therapy first, of whom, 29(40%) subsequently required surgical resection (p=0.60). There were, 95/149 patients (64%) who were successfully treated by a surgical resection first approach alone. There was no difference in, 1- and, 5-year cumulative recurrence rates between the two treatment approaches (17%, 55% for surgery vs, 14%, 54% for biologics (p=0.53)), median follow-up was, 74 months (0–406) and, 71 months (13–235), respectively. There was no significant difference in time to switch from surgery to biologic or vice versa (p=0.10). Patients who underwent surgery more likely need post-operative biologic therapy if female (p=0.010), obstructive symptoms (p=0.028), or smoker (p=0.030). Patients on biologic therapy more likely undergo surgery if the disease was limited to terminal ileum (p=0.001), was stricturing or penetrating rather than inflammatory and if the patient had obstructive symptoms (p=0.003). Only, 3/149 patients required endoscopic dilatation because of an anastomotic stricture. None of the patients needed a second surgical resection.In comparison, 26 patients (20%) reported side effects from biologic therapy and as result of these side-effects or due to loss of response (n=9), biologic agents was changed in, 28 patients (22%). Conclusion This real world experience confirms the findings of the L!RIC trial, demonstrating that surgical intervention can be considered at an early stage in the disease process, rather than restricting it to patients who develop complications of Crohn’s disease.

P329 Which should come first? Surgery or biologic therapy for ileocaecal Crohn’s disease in biologic naïve patients