Postoperative Therapy for Crohnʼs Disease

Abstract

Prevention of the postoperative recurrence of Crohn's disease (CD) remains a challenging clinical problem. The majority of patients with CD will need surgery for treatment of the disease, most of these patients will develop recurrent symptoms within 5 years postoperatively, and many patients will need reoperation within 10 years. In patients with an ileocolic anastomosis, endoscopic recurrence precedes clinical recurrence and the severity of endoscopic recurrence correlates with the risk of clinical recurrence. Despite multiple studies, the best postoperative prophylactic therapy remains uncertain. Numerous randomized controlled trials of 5-aminosalicylates have shown only modest effect. Antibiotics, including metronidazole and ornidazole, decrease short-term, but not long-term endoscopic recurrence and are limited by side effects. Immunomodulators have yet to be extensively evaluated, although limited data suggest possible efficacy in preventing postoperative recurrence, particularly in high-risk patients. This review will evaluate the current state of the art therapy for postoperative prophylaxis in CD, with an emphasis on critical analysis of the available randomized controlled trials.

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

“…Patients who have evidence of a more advanced endoscopic disease, that is i2 (>5 aphthous ulcers in the neoterminal ileum), i3 (deep ulcers with more extensive inflammation) or i4 (severe inflammation, nodularity and stenosis), have a clinical recurrence rate of 15%, 40% and 90% respectively, 3 years after surgery. 45,138 In our opinion the type of disease, although it is not certainly predictive as smoking, since there is no univocal scientific evidence, can be regarded as an important risk factor in selected patients (perforating disease).…”

Postoperative Crohn’s disease: prevention and treatment

“…It is important to note that this definition is not predicated on the presence of clinical symptoms. Endoscopic recurrence at the ileo colonic anastomosis or neoterminal ileum has been quantified using a scoring system developed by Rutgeerts et al (Box 1) [14,15]. In addition to providing real-time recurrence assessment, the Rutgeerts score provides prognostic information: 80-85% of patients with a score of i-0 or i-1 will be asympto matic 3 years after surgery compared with fewer than 10% of those with a score of i-3 or i-4 [2, 14,15].…”

“…Endoscopic recurrence at the ileo colonic anastomosis or neoterminal ileum has been quantified using a scoring system developed by Rutgeerts et al (Box 1) [14,15]. In addition to providing real-time recurrence assessment, the Rutgeerts score provides prognostic information: 80-85% of patients with a score of i-0 or i-1 will be asympto matic 3 years after surgery compared with fewer than 10% of those with a score of i-3 or i-4 [2, 14,15]. Among those with a score of i-0 or i-1, the chance of clinical recurrence at 3 years is less than 5%, whereas endoscopic scores of i-2, i-3 and i-4 correlate with 3-year clinical recurrence rates of 15, 40 and 90%, respectively [14].…”

“…Data suggest that up to 50% of patients undergo reoperation after 20 years [11][12][13]. Efforts to reliably predict which patients will suffer recurrence have been only modestly successful; thus, researchers have tried to identify effective prophylaxis of relapse among postsurgical CD patients [14].…”

Consensus guidelines for the management of inflammatory bowel disease

“…Cases included in the i0 to i2 groups may remain unmedicated, whereas in cases i3 or i4 the introduction of AZA or 6-MP is recommended at regular doses. Next, a control colonoscopy every 1-2 years is recommended ) (10,17,64,65) .…”