Maintenance of Surgically Induced Remission of Crohn’s Disease

Abstract

At 1 year after a first resection, up to 80% of patients show an endoscopic recurrence, 10–20% have clinical relapse, and 5% have surgical recurrence. Smoking is one of the most important risk factors for postoperative recurrence. Preoperative disease activity and the severity of endoscopic lesions in the neoterminal ileum within the first postoperative year are predictors of symptomatic recurrence. Mesalazine is generally the first-line treatment used in the postoperative setting but still provokes considerable controversy as to its efficacy, in spite of the results of a meta-analysis. Immunosuppressive treatment (azathioprine, 6-mercaptopurine) is based on scant evidence but is currently used as a second-line treatment in postsurgical patients at high risk for recurrence, with symptoms or with early endoscopic lesions in the neoterminal ileum. Nitroimidazole antibiotics (metronidazole, ornidazole) are also effective in the control of active Crohn’s disease in the postoperative setting. Given their known toxicity, they may be used as a third-line treatment as initial short-term prevention therapy rather than in the long term. Conventional corticosteroids, budesonide or probiotics have no proven role in postoperative prophylaxis. Infliximab has not as yet been studied for use in the prevention of relapse after surgery.

Post-operative recurrence in Crohn's disease. Critical analysis of potential risk factors. An update

“…23,47 The effectiveness of azathioprine and 6-mercaptopurine for the prevention of POR was recently analyzed. 15,98,99 In a prospective randomized study involving 142 patients divided into 2 groups (Group A1: patients treated with azathioprine 2 mg/kg/die; Group A2: patients treated with mesalamine 3 g/day for 24 months) Ardizzone et al found that the risk of recurrences was comparable in both groups. Although we cannot observe any significant difference in the percentage of recurrence for the two groups, analyzing the results based on other parameters, azathioprine is more effective than mesalamine in preventing clinical recurrences in patients with previous bowel resection.…”

“…15,43,98,107 Faecal bacteria in fact have been implicated in the genesis of recurrence in patients operated for CD. 108 The role of metronidazole was investigated in a study including 60 patients, divided randomly into two groups: group A e patients treated with metronidazole for 3 months, starting from the first week after ileal resection, group B e patients treated with placebo.…”

“…14e20 The identification of risk factors in specific patient groups may be useful in clinical practice to identify those who are at high risk of recurrence and so to plan strategies for medical treatment after surgery hoping to outline an effective pharmacological prophylaxis for POR. 5,15,18,19,24,25 Definition Postoperative recurrence is defined as the return of endoscopic and/or symptomatic (clinical) features of CD following attempted curative resection. Surgical recurrence refers specifically to the need for repeat surgery.…”

Multidisciplinary Management of Gastrointestinal Fibrotic Stenosis in Crohn’s Disease

“…Main indications for endoscopic dilatation are short, isolated, and non-fistulizing strictures that are within the reach of a standard colonoscope, with many amenable strictures localized at the site of the ileocecal anastomosis after ileocecal resection [107]. An immediate technical success of endoscopic dilation, a stricture length B4-cm, and the absence of ulcers in the stricture are positively associated with successful dilatation [87,108,109].…”

Effectiveness of Mesalazine, Thiopurines and Tumour Necrosis Factor Antagonists in Preventing Post-Operative Crohn's Disease Recurrence in a Real-Life Setting

“…The best treatment for the prevention of post-operative CD recurrence is yet to be established. The efficacy of mesalazine in preventing post-operative recurrence is only slightly superior to the efficacy of a placebo [8,9,10], and the efficacy of thiopurines, such as azathioprine and mercaptopurine (MP), remains a subject of debate [11,12,13,14,15]. A meta-analysis showed that purine analogues were more effective than placebo in preventing endoscopic recurrence (defined by Rutgeerts score [Rs] ≥i2) but not for preventing very severe endoscopic recurrence (Rs = i3-i4).…”