The Role of Inflammation in Crohn’s Disease Recurrence after Surgical Treatment

Abstract

Introduction. Postoperative recurrence after surgery for Crohn’s disease (CD) is virtually inevitable, and its mechanism is poorly known. Aim. To review the numerous factors involved in CD postoperative recurrence (POR) pathogenesis, focusing on single immune system components as well as the immune system as a whole and highlighting the clinical significance in terms of preventive strategies and future perspectives. Methods. A systematic literature search on CD POR, followed by a review of the main findings. Results. The immune system plays a pivotal role in CD POR, with many different factors involved. Memory T-lymphocytes retained in mesenteric lymph nodes seem to represent the main driving force. New pathophysiology-based preventive strategies in the medical and surgical fields may help reduce POR rates. In particular, surgical strategies have already been developed and are currently under investigation. Conclusions. POR is a complex phenomenon, whose driving mechanisms are gradually being unraveled. New preventive strategies addressing these mechanisms seem promising.

Mesenteric closure with polymer-ligating clips after right colectomy with complete mesocolic excision for cancer and mesentery-based ileocolic resection for Crohn’s disease

“…This approach entails resection of all nodes draining the affected bowel along with the bowel itself, with a medial-to-lateral approach, following established principles for oncologic resection in colorectal surgery (Fig. 3) [23].…”

Long-term Outcomes and Factors Predicting Outcome of Ileal Pouch-Anal Anastomosis When Used Intentionally for Well-Defined Crohn’s Disease

“…21,22 The exact mechanism of CD of the pouch is not fully established, although some speculate that fecal stasis with surgically induced ischemic injury in genetically susceptible patients might tip the balance toward inflammatory processes, 11 whereas others focus on inflammatory cells migrating from the mesenteric lymph nodes to the healthy anastomotic mucosa to perpetuate the inflammatory status. 23 The ileal pouch procedure has 2 long linear lines and 1 circular staple line (in a double-stapled anastomosis), providing a perfect environment for disease recurrence. Although still common, the incidence of overall disease recurrence and fistulizing disease was considerably lower in the current cohort than reported in other series.…”

Proposal of novel staging system CNM (Crohn’s primary site, nodes, mesentery) to predict postoperative recurrence of Crohn’s disease

“…Mesenteric lymph nodes act as a driver for POR in CD as memory T- lymphocytes migrate from the lymph nodes to the anastomotic site after resection to initiate inflammation leading to future recurrence [ 32 ]. Hence resection of all draining lymph nodes along with affected bowel is termed as “patho-physiological excision of CD.”…”