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Although occurrence of free perforation in Crohn's disease (CD) is rare, clinical observation led to the question whether anti-TNF treatment is a risk factor for free perforation. Hypothetically, anti-TNF treatment hinders the development of an encapsulating inflammatory mass. Aim was to investigate the relation between anti-TNF treatment and occurrence of free perforations leading to emergency surgery.In this case control study, emergency operations from 1999-2009 in CD patients were investigated forpresence of free perforation. These cases were compared to 78 controls derived from our CD patients' database and matched for age, gender, Montreal classification and surgical stage. Cases and controls were then compared regarding exposure to anti-TNF treatment.Thirteen patients underwent emergencyprocedure for free perforation. Eight patients (61.5%) had been treated with anti-TNF within 5 months before perforation. In the matched controls, 29 (37.2%) had been or were still treated with anti-TNF. The odds for a free perforation were more than two times higher in anti-TNF treated CD patients (OR: 2.703; 95% CI: 0.808- 9.048).Anti-TNF therapy was not significantly associated with a higher rate of free perforation in CD patients, although a trend is apparent. Larger studies are needed to confirm our data.