Comparison of two strategies for the management of postoperative recurrence in Crohn’s disease patients with one clinical risk factor: A multicentre IG‐IBD study

Abstract

Background The management of postoperative recurrence (POR) in Crohn's disease (CD) after ileo‐colonic resection is a highly debated topic. Prophylactic immunosuppression after surgery is currently recommended in the presence of at least one clinical risk factor. Objective Our aim was to determine whether early immunosuppression can be avoided and guided by endoscopy in CD patients with only one risk factor. Methods CD patients with only one risk factor for POR, including previous intestinal resection, extensive small intestine resection (>50 cm), fistulising phenotype, history of perianal disease, and active smoking, were retrospectively included. Two groups were formed based on whether immunosuppression was started immediately after surgery (“prophylaxis group”) or guided by endoscopy (“endoscopy‐driven group”). Primary endpoints were rates of any endoscopic recurrence (Rutgeerts ≥ i2a) and severe endoscopic recurrence (i4) within 12 months after surgery. Secondary outcomes were clinical recurrence rates at 6, 12 and 24 months after surgery. Results A total of 195 patients were enroled, of whom 61 (31.3%) received immunoprophylaxis. No differences between immunoprophylaxis and the endoscopy‐driven approach were found regarding any endoscopic recurrence (36.1% vs. 45.5%, respectively, p = 0.10) and severe endoscopic recurrence (9.8% vs. 15.7%, respectively, p = 0.15) at the first endoscopic evaluation. Clinical recurrence rates were also not statistically different (p = 0.43, p = 0.09, and p = 0.63 at 6, 12, and 24 months, respectively). Conclusions In operated CD patients with only one risk factor for POR, immediate immunoprophylaxis does not decrease the rate of early clinical and endoscopic recurrence. Prospective studies are needed to confirm our results.

Management of Post-Operative Crohn’s Disease: Knowns and Unknowns

“…Interestingly, a wide numerical difference in the rate of clinical POR at 3 years was seen in a sub-cohort of patients with ≥3 ECCOdefined risk factors compared to patients managed with endoscopy-driven therapy (28.6% vs. 62.5%; p = 0.11, respectively), suggesting a cumulative impact associated with the presence of multiple risk factors [85]. Again, in the retrospective study by Dragoni et al, in CD operated patients with only one risk factor for POR, immediate prophylaxis did not significantly decrease the rate of endoscopic recurrence (prophylaxis group 36.1% vs. endoscopic-driven approach 45.5%; p = 0.10) or severe endoscopic recurrence (prophylaxis group 9.8% vs. endoscopic-driven approach 15.7%; p = 0.15) within 12 months after surgery [86]. On the other hand, a recent prospective cohort study of 213 CD patients undergoing ICR showed that clinical risk stratification (high-risk patients if ≥1 risk factor: active smoking, penetrating disease, prior ICR) had an acceptable predictive value in terms of endoscopic recurrence (Rutgeerts score ≥ i2b) at 6 months.…”

The Management of Postoperative Recurrence in Crohn’s Disease

“…Myenteric plexitis (defined as the presence of at least one inflammatory cell in an enteric ganglion or nerve bundle) at the proximal resection margin was a predictive factor for early endoscopic recurrence at 3 and 12 months; however, more research is required to fully understand these findings [ 86 ]. Regarding the patient’s risk profile, a multicenter Italian study compared the outcomes of 195 CD patients with one risk factor for POR who either received immediate immunosuppression (prophylaxis group) or treatment guided by endoscopy findings (endoscopy-driven group) following ICR [ 87 ]. No significant differences were observed between the approaches regarding endoscopic (36.1% vs. 45.5%, p = 0.10) or clinical recurrence (17.9% vs. 34.8%, p = 0.09) rates at 12 months.…”

Anti-TNF Agents and New Biological Agents (Vedolizumab and Ustekinumab) in the Prevention and Treatment of Postoperative Recurrence After Surgery in Crohn’s Disease

“…Some observations favour step-up treatment guided by early endoscopic evaluation with prophylactic treatment reserved for carefully selected high-risk patients, in order to avoid potential overtreatment of a significant number of patients [ 122 ]. In this respect, in a very recent study, CD patients with only one risk factor for POR (including previous intestinal resection, extensive small intestine resection, fistulising phenotype, history of perianal disease, and active smoking), were retrospectively included [ 123 ]. Two groups were formed based on whether immunosuppression was started immediately after surgery (“prophylaxis group”) or guided by endoscopy (“endoscopy-driven group”).…”

“…No differences between the immune-prophylaxis and the endoscopy-driven approach were found regarding any endoscopic POR, although a statistical beta error cannot be excluded due to the small sample size of the study. The authors concluded, nevertheless, that, in operated CD patients with only one risk factor for POR, immediate immune-prophylaxis does not decrease the rate of early clinical and endoscopic POR [ 123 ].…”