Mild neoterminal ileal post‐operative recurrence of Crohn’s disease conveys higher risk for severe endoscopic disease progression than isolated anastomotic lesions

Abstract

Summary There are conflicting data assessing the impact of isolated post‐operative anastomotic inflammation on future disease progression. The aim of this study was to determine the relative risk of severe disease progression in post‐operative Crohn’s disease (CD) patients with isolated anastomotic disease. Methods Retrospective cohort study of adult CD patients undergoing ileocolonic resection between 2009 and 2020. Patients with a post‐operative ileocolonoscopy ≤18 months from surgery and ≥1 subsequent ileocolonoscopy were included. Disease activity was assessed using the modified Rutgeerts’ score (RS). Primary outcome was severe endoscopic progression, defined as i3 or i4 disease, on immediate subsequent ileocolonoscopy and during entire post‐operative follow‐up. Secondary outcome was surgical recurrence. Results One hundred and ninety‐nine CD patients had an ileocolonoscopy ≤18 months from surgery, index RS of i0‐i2b and ≥1 subsequent ileocolonoscopy. At index ileocolonoscopy, 34.7% had i0 disease, 16.1% i1, 24.6% i2a and 24.6% i2b. On multivariable logistic regression, i2b disease was associated with severe endoscopic progression compared to i0 or i1 (aOR 5.53; P < 0.001) and i2a disease patients (aOR 2.63; P = 0.03). However, i2a disease did not confer increased risk compared to i0 or i1 disease (P = 0.09). Furthermore, i2b patients experienced severe endoscopic progression significantly earlier than i0 or i1 disease (aHR 4.68; P < 0.001), whereas i2a disease did not differ from i0 or i1 disease (P = 0.25). Surgical recurrence was not associated with index RS i0‐i2b (P = 0.86). Conclusion Post‐operative ileal disease recurrence, not isolated anastomotic inflammation, confers increased risk for severe endoscopic disease progression. Location of CD recurrence may impact optimal management strategies.

Prognostic Value of the Modified Rutgeerts Score for Long-Term Outcomes After Primary Ileocecal Resection in Crohn's Disease

“…Current American and European guidelines recommend escalation or initiation of medication in patients with an RS ≥ i2 (20,21). Refinement of these recommendations into mRS ≥ i2b seems indicated based on the findings of this study and previous observations on long-term outcomes of anastomotic lesions (14,17,18). The more indolent disease course in patients with anastomotic lesions when compared with ileal inflammation regarding progression to severe endoscopic lesions has also been shown in 2 retrospective multicenter studies (14,17).…”

“…Bak et al (14,17,18). The more indolent disease course in patients with anastomotic lesions when compared with ileal inflammation regarding progression to severe endoscopic lesions has also been shown in 2 retrospective multicenter studies (14,17).…”

“…Bak et al (14,17,18). The more indolent disease course in patients with anastomotic lesions when compared with ileal inflammation regarding progression to severe endoscopic lesions has also been shown in 2 retrospective multicenter studies (14,17). In addition, Hammoudi et al (18) reported a shorter clinical recurrence-free survival in patients with ileal lesions at index ileocolonoscopy when compared with patients with lesions confined to the anastomosis.…”

“…The nature of anastomotic lesions (i2a) is unknown and may be related to a postischemic surgical phenomenon or related to staples, instead of CD recurrence (11). Several studies have reported conflicting clinical outcomes of anastomotic lesions on several measures of postoperative recurrence (clinical recurrence, surgical recurrence, and/or progression to [severe] endoscopic recurrence) (12)(13)(14)(15)(16)(17)(18). In a recently published individual participant data meta-analysis, no difference was observed between i2a and i2b lesions for clinical recurrence and/or a surgical reintervention (19).…”

Editorial: time to modify practice and use the modified Rutgeert’s score

“…Bachour et al 3 studied a relatively large and rigorously defined population of post‐surgical CD patients and found that a modified Rutgeert’s score (mRS) i2B is predictive of endoscopic disease progression independent of other common risk factors and biologic therapy. The authors also reported that mRS i2A lesions were not associated with severe endoscopic recurrence, although increased the risk of developing subsequent i2B lesions.…”