Factors affecting recurrence following resection for Crohn's disease

Results of the Eighth Scientific Workshop of ECCO: Prevention and Treatment of Postoperative Recurrence in Patients With Crohn's Disease Undergoing an Ileocolonic Resection With Ileocolonic Anastomosis

Despite the introduction of biological therapies, an ileocolonic resection is often required in patients with Crohn's disease [CD]. Unfortunately, surgery is not curative, as many patients will develop postoperative recurrence [POR], eventually leading to further bowel damage and a decreased quality of life. The 8th Scientific Workshop of ECCO reviewed the available scientific data on both prevention and treatment of POR in patients with CD undergoing an ileocolonic resection, dealing with conventional and biological therapies, as well as non-medical interventions, including endoscopic and surgical approaches in case of POR. Based on the available data, an algorithm for the postoperative management in daily clinical practice was developed.

Predictors of postoperative recurrence in a cohort of Tunisian patients with Crohn’s disease

Background:

The aim of our study was to evaluate the frequency and risk factors of clinical postoperative recurrence in Tunisian patients with Crohn’s disease (CD).

Methods:

Clinical data of 86 patients with CD who underwent ileocolonic resection at University Hospital of Sahloul in Tunisia were retrospectively reviewed. Continuous data are expressed as median (interquartile range), and categorical data as frequencies and percentages. Multivariate Cox proportional hazard regression analysis was conducted to identify the risk factors of postoperative clinical recurrence.

Results:

A total of 86 patients with CD were included in this study. During follow-up, 21 patients (24.4%) had clinical recurrence. The cumulative clinical recurrence rate was 9.3% at 1 year and 20.9% at 5 years. In univariate analysis, predictive factors of postoperative clinical recurrence were active preoperative smoking (p = 0.008), ileal location of the disease (p = 0.01), active CD [Crohn’s Disease Activity Index (CDAI) > 150] (p = 0.04), duration of disease before first surgery <9.5 months (p = 0.027), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.005). In multivariate analysis, only smoking (p = 0.012), duration of disease before first surgery <9.5 months (p = 0.048), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.046) were confirmed to be independent factors of clinical relapse.

Conclusion:

Smoking, duration of disease before first surgery <9.5 months, and limited resection margins (<2 cm) from macroscopically diseased bowel were independent risk factors for clinical recurrence. Based on these factors, patients could be stratified in order to guide postoperative therapeutic options.

Predictability of simple endoscopic score for Crohn's disease for postoperative outcomes in Crohn's disease

BACKGROUND AND AIM

Approximately half of patients with Crohn's disease (CD) who have surgery will experience clinical recurrence within 10 years of their surgery. This study aimed to assess the postoperative outcomes according to disease location and validated the simple endoscopic score for CD (SES-CD) to predict disease-related outcomes.

METHODS

We retrospectively assessed medical records of CD patients who underwent ileocolonoscopy within 12 months after surgery at the University of Chicago between 2005 and 2016. We defined patients with postoperative colonic inflammation at the first postoperative ileocolonoscopy or had Montreal classification L2 as colon-dominant disease and patients without colonic involvement or who had L1 as small intestine (SI)-dominant disease. The outcomes included clinical and surgical recurrence.

RESULTS

Among 207 CD patients, 51 (24.6%) and 156 (75.4%) patients had colon-dominant and SI-dominant disease, respectively. Patients with colon-dominant disease had a greater risk of postoperative clinical recurrence compared with those with SI-dominant disease (P = 0.018). Colon-dominant disease was a risk of earlier surgical recurrence compared with SI-dominant disease, although there were no significant differences in the recurrence-free survivals. SES-CD > 2 at the first postoperative ileocolonoscopy was a significant risk of clinical recurrence on log-rank test (P < 0.001) and Cox proportional hazards model (hazard ratio = 2.25; 95% confidence interval = 1.14-4.47; P = 0.020). An SES-CD of 1 was an appropriate cut-off to predict the clinical recurrence of SI-dominant disease, but a higher SES-CD cut-off value of 5 was required for colon-dominant disease.

CONCLUSIONS

We demonstrated that SES-CD predicts postoperative clinical recurrence of CD, regardless of disease location.

Characterization of Crohn's disease patients in Egypt: Risk factors for postoperative recurrence (A cohort study)

BACKGROUND

The aim of study to identify the characterizations of Crohn's disease in Egyptian patients and to determine its predictors for postoperative recurrence.

METHODS

We conducted a retrospective observational cohort study on 15 patients diagnosed as Crohn's disease with surgical interventions. Different characteristics of studied patients were analyzed to determine the risk factors for postoperative recurrence such as age at diagnosis, gender, smoking, main presenting symptom, Montreal classification, perianal disease, laboratory findings and protocol of management including surgical characteristics like age at operation, surgical indication, preoperative medication, surgical approach, and operative findings.

RESULTS

Nine of the studied patients (60%) suffered from clinical postoperative recurrence with mean duration of 23.5 ± 40.6 months. In comparison the demographic, clinical, operative, and medical treatment data between patients with postoperative recurrence of Crohn's disease and those without recurrence, age at diagnosis (mean age 42.9 years) and age at operation (mean 44.7 years) were found statistically significant in postoperative recurrence group (p-value = 0.001). According to Montreal classification of Crohn's disease, patients >40 years were significantly found in postoperative recurrence group, while patients between 17 and 40 years were significantly found in postoperative non-recurrence group (p-value=0.007) and ileal location of Crohn's disease was found significantly in postoperative recurrent group (p-value=0.044). Postoperative biological therapy significantly decreased the incidence of postoperative recurrence in the current study (p-value= 0.041).

CONCLUSIONS

Age at diagnosis, age at operation, ileal location of Crohn's disease can significantly predict postoperative recurrence. Also, postoperative biological therapy can significantly decrease the incidence of postoperative recurrence.

What are the predictors for recurrence of Crohn's disease after surgery?

Surgical resection is an unavoidable part of the current treatment options for Crohn's disease (CD), and more than half of patients develop recurrence. The aim of this study was to investigate the predictors for recurrence in the long-term follow-up of CD patients after surgery.Medical records of consecutive CD patients who were operated on between January 2003 and January 2015 were retrospectively analyzed. Data including demographic and clinical characteristics of the patients were recorded. Recurrence was evaluated based on the Crohn's Disease Activity Index or endoscopic findings.The majority of 112 patients were males (n = 64, 57.1%), and 61 (54.4%) of them were active smokers. The median follow-up was 113 (range: 61-197) months. Disease recurrence occurred in 16 (14.3%) patients at a median of 13.5 months. The endoscopic recurrence rate was 8% (n = 9) at 1 year, 12.5% (n = 14) at 5 years, and 13.4% (n = 15) at 10 years. One (0.9%) patient underwent colonoscopic balloon dilatation at 1 year, and 7 (6.3%) patients needed re-resection at a median of 36 months. The age of the patient at the time of diagnosis (P = .033), penetrating disease behavior (P = .011), intra-abdominal abscess (P = 0.040) and, concomitant fistula and intra-abdominal abscess (P = .017) were associated with disease recurrence.Our study results suggest that the patients' age at the time of diagnosis, penetrating disease, intra-abdominal abscess, and concomitant fistula and abscess are the risk factors for CD recurrence after surgery.

Prophylaxis of Crohn's disease recurrence: A surgeon's perspective

Management of inflammatory bowel disease has evolved extensively in the last three decades. We have learnt a lot about the pathophysiology and natural history of the disease. New effective classes of drugs with the associated potential morbidity have been introduced. New surgical techniques have been popularized leading to a better understanding of the optimal timing of surgery. The result is a very complex subspecialty of gastroenterology and colorectal surgery called the "IBDologist." Only if we manage these complex patients in the context of a multi-disciplinary team will we be able to obtain outstanding outcomes, specifically with high and sustained remission rates for these patients.

Treatment to target in patients with inflammatory bowel disease. What is the evidence?

Background: Inflammatory bowel diseases (IBD) are chronic, progressive diseases of the gastrointestinal tract. Current therapy has not been able to change the long-term course of the disease, but treatment to a specific therapeutic target could be a game-changer.Objectives: To assess the evidence of a treat to target (T2T) algorithm being superior to clinical management in the treatment of IBD, a systematic review of the literature is conducted.Search methods: A comprehensive survey of PubMed and Embase covering the period April 2018 to July 2019 including articles referenced in relevant studies.Selection criteria: Both randomized clinical trials (RCT) and observational studies were included. To be eligible for inclusion, the studies had to describe or analyze the effects of T2T on remission and/or recurrence of disease in patients with IBD.Main results: Twenty-two studies were included in this review, seven RCTs, eight comparative and seven non-comparative observational studies. Large heterogeneity between T2T algorithms applied, type of IBD investigated and outcomes evaluated characterized the studies.Authors' conclusions: The comprehensive search identified only 22 heterogeneous studies. Out of these, a total of 14 indicated a positive effect of a T2T algorithm. Out of the seven RCT studies, four indicated a positive effect. Thus, T2T algorithms may be superior to the clinical management of IBD. However, the evidence is sparse and inconsistent.

Previous colonic resection is a risk factor for surgical relapse in Crohn's disease

BACKGROUND

Despite the improvement of medical therapies, nearly half of patients with Crohn's disease require surgery within 10 years after diagnosis. However, intestinal resection is not curative and recurrence may occur.

AIMS

To evaluate post-surgical outcomes for patients with Crohn's disease in a large monocentric cohort, and to identify variables associated with clinical and surgical relapse.

METHODS

Patients with Crohn's disease who had surgery for ileal and colonic Crohn's disease between 2004 and 2016 and on at least one-year follow-up following surgery were included.

RESULTS

One hundred ninety-three patients were included in the study. Crohn's disease recurrence concerned 53% of patients after a median 56-month (6-158) follow-up and 29% of patients required a second surgical intervention. At logistic regression analysis, active smoking and young age at diagnosis were identified as independent risk factor for post-surgical relapse (p = 0.01), while colonic or ileocolonic resection was recognized as a risk factor for surgical Crohn's disease relapse (p = 0.003).

CONCLUSIONS

Post-surgery recurrence is frequent for patients with Crohn's disease. Active smoking and young age at diagnosis are risk factors for Crohn's disease recurrence. As compared with patients undergoing small-bowel surgery, patients with colonic resection are proner to relapse requiring a second surgical intervention.

Inclusion of the Mesentery in Ileocolic Resection for Crohn's Disease is Associated With Reduced Surgical Recurrence

BACKGROUND AND AIMS

Inclusion of the mesentery during resection for colorectal cancer is associated with improved outcomes but has yet to be evaluated in Crohn's disease. This study aimed to determine the rate of surgical recurrence after inclusion of mesentery during ileocolic resection for Crohn's disease.

METHODS

Surgical recurrence rates were compared between two cohorts. Cohort A [n = 30] underwent conventional ileocolic resection where the mesentery was divided flush with the intestine. Cohort B [n = 34] underwent resection which included excision of the mesentery. The relationship between mesenteric disease severity and surgical recurrence was determined in a separate cohort [n = 94]. A mesenteric disease activity index was developed to quantify disease severity. This was correlated with the Crohn's disease activity index and the fibrocyte percentage in circulating white cells.

RESULTS

Cumulative reoperation rates were 40% and 2.9% in cohorts A and B [P = 0.003], respectively. Surgical technique was an independent determinant of outcome [P = 0.007]. Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher [12.25 ± 13 versus 2.4 ± 2.9, P = 0.002]. Advanced mesenteric disease predicted increased surgical recurrence [Hazard Ratio 4.7, 95% Confidence Interval: 1.71-13.01, P = 0.003]. The mesenteric disease activity index correlated with the mucosal disease activity index [r = 0.76, p < 0.0001] and the Crohn's disease activity index [r = 0.70, p < 0.0001]. The mesenteric disease activity index was significantly worse in smokers and correlated with increases in circulating fibrocytes.

CONCLUSIONS

Inclusion of mesentery in ileocolic resection for Crohn's disease is associated with reduced recurrence requiring reoperation.

High Incidence of Recurrent Crohn's Disease Following Colectomy for Ulcerative Colitis Revealed with Long Follow-Up

BACKGROUND AND AIMS

Ulcerative colitis (UC) patients with progression of their disease despite optimized medical therapy may warrant "curative" proctocolectomy with end ileostomy or ileo-anal pouch (IPAA) anastomosis. The aim of our study was to assess the incidence of later recurrent ileitis that lead to altering the initial diagnosis to Crohn's disease (CD).

METHODS

A retrospective analysis was conducted on the inflammatory bowel disease database at Lenox Hill Hospital. The database consisted of patients that were diagnosed with UC or CD based on clinical assessment, endoscopic appearance, gross and histological examination, and imaging between 1960 and 2015. The post-colectomy follow-up period was at least 10 years. Recurrent disease was classified by evidence of transmural inflammation in the distal ileum, fistulizing disease, or stricturing disease.

RESULTS

From our IBD database, we identified 128 patients who underwent elective or urgent colectomy with the preoperative diagnosis of UC. Thirty-two (25%) had either an IPAA or end ileostomy with documented recurrence of inflammation in the small bowel mucosa consistent with CD. There was no significant difference between the type of surgical approach and the chance of recurrent disease (p = .20). The average time to clinically significant recurrence was 5 years.

CONCLUSION

The incidence of recurrent CD following colectomy for ulcerative colitis, when followed postoperatively for an average of 20 years, was 25%, considerably more than previously reported. Patients who come to colectomy for ulcerative colitis and are followed for at least 10 years show a high incidence of recurrent Crohn's disease in the ileostomy or ileo-anal pouch. Extended follow-up should be included in patients coming to colectomy for ulcerative colitis before they should be considered cured of their disease.

NASPGHAN Clinical Report on Postoperative Recurrence in Pediatric Crohn Disease

Pediatric Crohn disease is characterized by clinical and endoscopic relapses. The inflammatory process is considered to be progressive and may lead to strictures, fistulas, and penetrating disease that may require surgery. In addition, medically refractory disease may be treated by surgical resection of inflamed bowel in an effort to reverse growth failure. The need for surgery in childhood suggests severe disease and these patients have an increased risk for recurrent disease and potentially more surgery. Data show that up to 55% of patients had clinical recurrence in the first 2 years after initial surgery. The current clinical report on postoperative recurrence in pediatric Crohn disease reviews the risk factors for early surgery and postoperative recurrence, operative risk factors for recurrence, and prevention and monitoring strategies for postoperative recurrence. We also propose an algorithm for postoperative management in pediatric Crohn disease.

Risk factors for postoperative recurrence of Crohn's disease with emphasis on surgical predictors

Intestinal resection for Crohn’s disease is not curative and postoperative recurrence rates remain high. Early detection of indices associated with recurrence and risk stratification are fundamental for the postoperative management of patients. Early endoscopy at 6-12 months is the “gold standard” procedure, whereas other modalities such as fecal calprotectin and imaging techniques can contribute to the diagnosis of recurrence. The purpose of this review is to summarize current data regarding risk factors correlated with postoperative relapse. Smoking is a well-established, modifiable risk factor. There are sufficient data that correlate penetrating disease, perianal involvement, extensive resections, prior surgery, histological features (plexitis and granulomas), and improper management after resection with high rates for recurrence. The literature provides conflicting data for other possible predictors, such as age, sex, family history of inflammatory bowel disease, location of disease, strictureplasties, blood transfusions, and postoperative complications, necessitating further evidence. On the other hand, surgical factors such as anastomotic configuration, open or laparoscopic approach, and microscopic disease at specimen margins when macroscopic disease is resected, seem not to be related with an increased risk of recurrence. Further recognition of histological features as well as gene-related factors are promising fields for research.

Association of granulomas in mesenteric lymph nodes in Crohn's disease with younger age and transmural inflammation

BACKGROUND AND AIMS

Mesenteric lymph nodes were usually removed during bowel resection surgery for Crohn's disease (CD). Mesenteric lymph node (MLN) granuloma predicted postoperative disease recurrence in patients with CD after ileocolic resection (ICR). This study was aimed to identify factors associated with MLN granulomas in a cohort of CD patients who underwent ICR.

METHODS

The study group consisted of 18 patients with CD who underwent the index ICR between 2004 and 2012 and had MLN granulomas. The control group included 32 cases negative for MLN granulomas, which were randomly selected from the same period. Clinicodemographic and histological features were compared in these two groups.

RESULTS

The presence of MLN granuloma was associated with younger age, perianal disease, and ileocolic disease. Gender, body mass index, smoking status, disease duration, extraintestinal manifestation, length of bowel resected, total number of nodes examined, medical treatment, and indications for surgery were not significantly different between the groups. The presence of MLN granuloma was associated with mural granuloma, transmural inflammation, mural abscess, hypertrophy of the muscularis propria, fibrosis of the muscularis propria, and serosal fibrosis in the small bowel. The multivariable analysis confirms that MLN granuloma was associated with age and transmural inflammation.

CONCLUSIONS

In CD patients who underwent the index ICR, the presence of MLN granuloma was associated with younger age and transmural inflammation. Our current results suggest that the detection of MLN granulomas may be enhanced in patients at higher risk, that is, younger patients or those with transmural inflammation on imaging or histopathology.

The mesentery in Crohn's disease: friend or foe?

PURPOSE OF REVIEW

This article assesses the role of the mesentery in Crohn's disease.

RECENT FINDINGS

The mesentery is centrally positioned both anatomically and physiologically. Overlapping mesenteric and submucosal mesenchymal contributions are important in the pathobiology of Crohn's disease. Mesenteric contributions explain the topographic distribution of Crohn's disease in general and mucosal disease in particular. Operative strategies that are mesenteric based (i.e. mesocolic excision) may reduce rates of postoperative recurrence.

SUMMARY

The net effect of mesenteric events in Crohn's disease is pathologic. This can be targeted by operative means.

VIDEO ABSTRACT

http://links.lww.com/COG/A18.

Surgical Treatment of Crohn Colitis Involving More Than 2 Colonic Segments: Long-Term Outcomes From a Single Institution

The incidence of primary Crohn colitis is uncommon and surgical treatment has remained controversial, although most patients with Crohn colitis eventually require surgical intervention. This study aims to compare the operative outcomes of patients who underwent segmental versus either total colectomy or total proctocolectomy for Crohn colitis and to assess potential risk factors associated with clinical and surgical recurrence-free survivals.This is a retrospective study of 116 patients who underwent primary surgery for Crohn colitis between August 1997 and July 2011. Patients were classified based on the type of surgery: segmental colectomy (SC group; n = 71) or either total colectomy or total proctocolectomy (TC group; n = 45).There were no significant differences in postoperative complications or the nutritional state between the SC and TC groups. Patients in TC group had a significantly higher clinical recurrence-free survival (CRFS). Among the 54 patients with multisegmental Crohn colitis, the TC group had a significantly increased CRFS and surgical recurrence-free survival (SRFS), compared with patients in the SC group (5-year CRFS: 82.0% ± 5.8% vs 22.2% ± 13.9%, P = 0.001; 5-year SRFS: 88.1% ± 5.0% vs 44.4% ± 16.6%, P = 0.001). By multivariate analysis of patients with multisegments involved, SC was a risk factor for SRFS and CRFS (hazard ratio [HR] = 4.637, 95% confidence interval [CI] = 1.387-15.509, P = 0.013 and HR = 32.407, 95% CI = 2.873-365.583, P = 0.005).TC patients have significantly increased CRFS and TC in patients with multisegment involvement may affect improved SRFS and CRFS. Among patients with multisegmental Crohn colitis, SC is an independent risk factor for CRFS and SRFS.

A Practical Approach to Preventing Postoperative Recurrence in Crohn's Disease

Postoperative Crohn's disease recurrence remains common, and preventing additional surgery remains a challenge. A critical step to postoperative management of Crohn's disease is being able to identify patients who should receive immediate postoperative therapy from the patients who can wait for recurrence prior to starting medications. All patients, regardless of their risk for recurrence, are advised to undergo a colonoscopy at 6 to 12 months after surgery to evaluate for endoscopic evidence of Crohn's disease. Further management of patients depends on symptoms and the presence or absence of endoscopic recurrence.

Colectomy with Permanent End Ileostomy Is More Cost-Effective than Ileal Pouch-Anal Anastomosis for Crohn's Colitis

BACKGROUND

Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients.

AIMS

We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD.

METHODS

We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness.

RESULTS

IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy.

CONCLUSIONS

In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.

Biologics for the prevention of postoperative Crohn's disease recurrence: A systematic review and meta-analysis

AIM

To evaluate the efficacy and safety of biologics in the prevention of postoperative recurrence of Crohn's disease.

METHODS

Published papers and conference literatures were screened for suitable studies. The main outcome measures were clinical, endoscopic recurrence and adverse events.

RESULTS

Seven controlled trials met the inclusion criteria for this meta-analysis. At one year postoperation, the biologic therapies showed significant preventative effects in clinical recurrence (RR=0.36, 95% CI: 0.16-0.79; P=0.01), endoscopic recurrence (RR=0.16, 95% CI: 0.07-0.34; P<0.01) and severe endoscopic recurrence (RR=0.17, 95% CI: 0.04-0.71; P=0.02) when compared with the control arms. Similarly, two years postresection, the use of biologics significantly reduced the risk of clinical, endoscopic and severe endoscopic recurrence relative to the controls. Although the biologic agents were not more effective than azathioprine in preventing clinical recurrence (P=0.14), they were more effective in preventing endoscopic recurrence (RR=0.09, 95% CI: 0.02-0.47; P<0.01). Moreover, administration of the biologics was not associated with any significant difference in the rate of adverse events (RR=1, 95% CI: 0.75-1.34; P=0.99) or severe adverse events (RR=1.03, 95% CI: 0.33-3.26; P=0.96) when compared with controls.

CONCLUSION

Biologics are superior to azathioprine and traditional therapies and are not associated with increased adverse events in the postoperative treatment of Crohn's disease.

Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches

One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.

Histologic features predicting postoperative Crohn's disease recurrence

Recurrence of Crohn's disease (CD) after ileal or colonic resection is common. Many studies have tried to identify predictors of postoperative recurrence (POR) in CD. A wide range of histologic features have been identified, but for most of them, the literature provided conflicting data. In last years, several studies have suggested that histologic findings including inflammatory changes within the enteric nervous system of the resection margin may be associated with CD recurrence. Herein, after briefly summarizing pathophysiology of POR, we review all histological features that have been studied so far: granulomas, histologic appearance at the margin of resection, plexitis, lymphatic vessel density in proximal margin of resection, and morphological analysis of Paneth cells. Granulomas and chronic inflammation at the margin of resection do not seem to predict POR in CD. Active disease at the margin of resection, plexitis, lymphatic vessels density, morphological analysis of Paneth cells may predict POR. Most of these histological features await replication in independent studies. Available evidence indicates that histological findings may be taken into account when developing strategies aimed at preventing postoperative CD recurrence.

Tailored treatment according to early post-surgery colonoscopy reduces clinical recurrence in Crohn's disease: a retrospective study

BACKGROUND

After intestinal resection for Crohn's disease, the severity of endoscopic recurrence in the first year following surgery is predictive of clinical outcome. Aim of the study was to assess the impact on clinical recurrence of tailored therapy based on endoscopic findings in the first year following surgery for Crohn's disease.

METHODS

All patients who underwent an intestinal resection for Crohn's disease between 1995 and 2005 at Saint-Louis Hospital were retrospectively included. Time-to-clinical recurrence was compared in two groups: patients who had systematic ileocolonoscopy 6-12 months after intestinal surgery with tailored treatment according to the severity of endoscopic lesions (group C) and patients without systematic endoscopic evaluation (group NC).

RESULTS

132 patients (group C=90, group NC=42) were included. Probabilities of clinical recurrence were significantly lower in group C (21% and 26% at 3 and 5 years, respectively) compared with group NC (31% and 52% at 3 and 5 years respectively, p=0.01).

CONCLUSION

Tailored treatment according to endoscopic assessment after ileocolonic resection is significantly associated with reduced clinical recurrence rate.

Intraoperative enteroscopy detects more lesions but is not predictive of postoperative recurrence in Crohn’s disease

BACKGROUND

The aim of this investigation was to elucidate the clinical value of intraoperative enteroscopy (IOE) for Crohn's disease, and to determine the value of IOE in predicting recurrent disease.

METHODS

In this study 27 patients requiring surgery were examined by both preoperative radiography and IOE. The findings obtained by these procedures in the remnant small intestine were compared. In 19 patients, the clinical course and colonoscopic or radiographic findings after surgery were analyzed.

RESULTS

Intestinal lesions were identified in 23 patients by IOE, and in 19 patients by radiography. Longitudinal ulcers were equivalently detected by IOE (63%) and radiography (56%), whereas small ulcers and inflammatory polyps were less frequently detected by radiography than by IOE (37% vs 74% and 19% vs 33%, respectively). Neither the presence nor the distribution of IOE findings was related to postoperative recurrence.

CONCLUSIONS

Whereas IOE demonstrates small intestinal lesions in detail, the procedure alone cannot predict postoperative recurrence in Crohn's disease.

Laparoscopy in Crohn's disease

In Crohn's disease (CD) surgical management, laparoscopic approach offers several theoretical advantages over the open approach. However, the importance of inflammatory lesions associated with CD, and the frequent presence of adhesions from previous surgery have initially questioned its feasibility and safety. In the present review article we will discuss the role of laparoscopic approach for Crohn's disease surgical management, along with its potential benefits as compared to the open approach.

Preliminary Results of the Influence of the In Vivo Use of a Lymphatic Dye (Patent Blue V) in the Surgical Treatment of Crohn’s Disease

Introduction. Recently, the lymphatic vessels has been considered to play a key role in the pathophysiology and, consequently, in the treatment of Crohn’s disease (CD). The aim of this study is to show that the evaluation of lymphatic anomaly might be a useful tool in the recognition of the pathological involvement of the intestinal wall in CD. Material and methods. Fourteen patients with CD who underwent surgical treatment for distal ileum critical stenosis were prospectively evaluated. During surgery, 0.05 to 0.1 mL of Patent Blue V was injected into the subserosal layer of the antimesenteric edge of ileum and colon. The intestinal section was performed just beneath the outflow of the vital dye where it seemed to be normal (≤2 minutes), as a index of healthy intestinal wall. A comparison between the lymphatic alterations and the macroscopic aspects was performed. Results. Out of 14 patients, 13 were electively operated on, whereas 1 was treated in emergency. In 8 patients (57%), laparoscopic approach was chosen in the first instance. One patient needed laparotomic conversion. When comparing the Patent Blue V outflow time with the macroscopic and microscopic evidence of CD, we found an absolute integrity of the intestinal wall with an outflow ≤2 minutes. Mean follow-up was 110 months with a recurrence rate of 14%. Conclusion. We can conclude that this method may be of utility to distinguish between normal and diseased intestine in CD. The possible consequences in postsurgical recurrences of this evidence are critical.

Surgical management of IBD--from an open to a laparoscopic approach

Surgery is a key feature of IBD management. Up to 70% of patients with Crohn's disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohn's disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.

Ciprofloxacin for the prevention of postoperative recurrence in patients with Crohn's disease: a randomized, double-blind, placebo-controlled pilot study

BACKGROUND

The commensal bacterial flora plays a critical role in the postoperative recurrence of Crohn's disease (CD). We conducted a randomized, double-blind, placebo-controlled 6-month pilot trial of ciprofloxacin for the prevention of endoscopic recurrence in patients with CD who underwent surgery.

METHODS

Thirty-three patients with CD, who had undergone surgery with ileocolonic anastomosis within the previous 2 weeks, were randomized to treatment with ciprofloxacin (500 mg twice daily) or placebo tablets for 6 months. Endpoints were endoscopic recurrence at 6 months and safety and tolerability of long-term ciprofloxacin therapy.

RESULTS

Thirty-three patients were randomized; 14 patients discontinued the study early. Significant endoscopic recurrence was observed in 3 of 9 patients (33%) in the ciprofloxacin group and 5 of 10 patients (50%) in the placebo group at 6 months after surgery (P < 0.578). The intention-to-treat analysis demonstrated endoscopic recurrence in 11 of 17 patients (65%) in the ciprofloxacin group and 11 of 16 patients (69%) in the placebo group at month 6 (P < 0.805). Thirty-six adverse events occurred in 19 of 33 patients (58%). Possible drug-associated adverse events occurred significantly more often in the ciprofloxacin group (P < 0.043), leading to study drug discontinuation in 24% (4 of 17) and 6% of patients (1 of 16) in the ciprofloxacin and placebo groups, respectively (P < 0.166).

CONCLUSIONS

In this pilot study, ciprofloxacin was not more effective than placebo for the prevention of postoperative recurrence in patients with CD. Long-term ciprofloxacin therapy is limited by drug-associated side effects. Future studies in postoperative prevention of CD should evaluate antibiotic approaches with a more favorable safety profile.

The evolving management of postoperative Crohn's disease

Two-thirds to three-quarters of Crohn's disease patients require intestinal surgery for medically refractory disease or complications. Surgery is not a cure and most patients develop recurrent Crohn's disease and require additional intestinal resections. There are a number of medications that have been investigated for preventing and treating recurrence. Risk factors for postoperative disease recurrence help guide the physician in determining the appropriate treatment strategy after Crohn's disease surgery. The approach to Crohn's disease treatment has evolved over the years. No longer should surgery be considered a failure of treatment, rather an important intervention to correct irreversible disease. In combination with a better understanding of postoperative medication strategies, patients with Crohn's disease may achieve longer term remission than previously realized. This review elucidates current understanding of the natural course of postoperative Crohn's disease, monitoring for recurrence, the risk factors for recurrence, and provides insight into an evolving new paradigm for postoperative Crohn's disease treatment.

Evaluation for postoperative recurrence of Crohn disease

Disease recurrence following resective surgery for Crohn disease remains a challenging clinical problem, and more studies are needed to better define risk stratification and treatment recommendations in the postoperative setting. Endoscopy remains the gold standard for the assessment of postoperative disease recurrence, and all Crohn disease patients who undergo surgery should undergo ileocolonoscopy within 6 to 12 months of surgery. The degree of endoscopic recurrence in the neoterminal ileum during this procedure provides prognostic information regarding the severity of the future disease course. WCE, MRE, and SICUS are all promising noninvasive modalities to assess for postoperative Crohn disease activity. However, further studies are needed to better define scoring systems, operating characteristics and variability, and prognostic data for each of these modalities. In patients at risk for early disease recurrence, more aggressive prophylactic therapy should be considered, in hopes of delivering true “top-down” therapy that may offer maximum impact in altering the natural history of Crohn disease.

Strictureplasty and intestinal resection: different options in complicated pediatric-onset Crohn disease

BACKGROUND/PURPOSE

Surgical resection or strictureplasty (SP) are different options for intestinal Crohn disease (CD) strictures. The aim of this article is evaluation of long-term outcome of SP and resection.

METHODS

From 1996 to 2011, 39 patients (23 male, 16 female) with symptomatic ileal and ileocolonic CD strictures resistant to medical/nutritional therapy and treated with surgery in 2 different surgical units were reviewed. The mean age at diagnosis was 11.82 years (range, 4-17 years). Mean age at surgery was 15.94 years (range, 4-24 years). Mean follow-up was 6.88 years (range, 0.5-15 years). Patients underwent resection (group A) or different SP techniques (group B).

RESULTS

Twenty patients underwent intestinal resection (ileal or ileocolonic resection), and 19 patients underwent SP (jejunal, ileal, or ileocolic). Early postsurgical complications were observed in 2 patients of group A. Follow-up of group A patients revealed that 1 patient needed emergency treatment after 8 months surgery because of adhesions and 1 patient developed recurrence treated with medical therapy. In the follow-up group B, 3 patients experienced disease recurrence, 2 of them at the site of previous surgery.

CONCLUSIONS

At long-term follow-up, no significant difference in relapsing rate was observed between the 2 groups. Strictureplasty and resection represent an effective treatment of pediatric CD strictures. Strictureplasty could represent the first option for intestinal preservation.

Postoperative recurrent luminal Crohn's disease: a systematic review

Despite improved immunosuppressive therapy, surgical resection is still often required for uncontrolled inflammatory disease and the stenosing and perforating complications of Crohn's disease. However, surgery is not curative. A majority of patients develop disease recurrence at or above the anastomosis. Subclinical endoscopically identifiable recurrence precedes the development of clinical symptoms; identification and treatment of early mucosal recurrence may therefore prevent clinical recurrence. Therapy to achieve mucosal healing should now be the focus of postoperative therapy. A number of clinical risk factors for the development of earlier postoperative recurrence have been identified, and reasonable evidence is now available regarding the efficacy of drug therapies in preventing recurrence. This evidence now needs to be incorporated into prospective treatment strategies.

Review article: the natural history of postoperative Crohn's disease recurrence

BACKGROUND

Surgical resection of the diseased bowel in Crohn's disease is unfortunately not curative, and postoperative recurrence remains a problem in these patients.

AIM

To review the rates of and risk factors for clinical and endoscopic recurrence in population-based studies, referral centres and randomised controlled trials.

METHODS

We searched MEDLINE (source PUBMED, 1966 to September, 2011).

RESULTS

In randomised controlled trials, clinical recurrence in the first year after surgery occurred in 10-38% of patients, whereas endoscopic recurrence in the first year was reported in 35-85% of patients. In population-based studies, approximately half of patients experienced clinical recurrence at 10 years. In referral centres, 48-93% of the patients had endoscopic lesions (Rutgeerts' score ≥1) in the neoterminal ileum within 1 year after surgery, whereas 20-37% had symptoms suggestive of clinical recurrence. Three years after surgery, the endoscopic postoperative recurrence rate increased to 85-100%, and symptomatic recurrence occurred in 34-86% of patients. Smoking is the strongest risk factor for postoperative recurrence, increasing by twofold, the risk of clinical recurrence. Prior intestinal resection, penetrating behaviour, perianal disease and extensive bowel disease (>50 cm) are established risk factors for postoperative recurrence. Risk factors for postoperative recurrence remain poorly defined in population-based cohorts.

CONCLUSION

Endoscopic and clinical postoperative recurrence remains common in patients with Crohn's disease, and the identification of risk factors may allow targeted strategies to reduce this recurrence rate.

Clinical and pathological analysis of colonic Crohn's disease, including a subgroup with ulcerative colitis-like features

Little is known regarding the clinical and, in particular, pathological manifestations of patients with isolated colonic Crohn's disease. The purpose of this study was to evaluate the clinical and pathological features of patients with Crohn's disease limited to the colon at initial presentation, and to determine whether there are any histological features that are predictive of outcome after surgery. The clinical features, outcome after surgery, and pathological features of colonic resection specimens of 73 patients who presented initially with isolated colonic Crohn's disease were evaluated and compared with 45 Crohn's disease patients who presented initially with both ileal and colonic involvement. Clinically, patients with isolated colonic Crohn's disease presented at a significantly older age at the time of diagnosis, and had a significantly shorter duration of colitis before surgical resection, than did patients with ileocolonic Crohn's disease at disease onset. Pathologically, patients with isolated colonic Crohn's disease showed a significantly higher proportion of cases with subtotal, total, or left-sided colitis, and significantly fewer strictures/stenosis, pericolonic adhesions, pyloric metaplasia, and cases with proximal worse than distal colonic disease. Overall, patients with isolated colonic Crohn's disease showed a trend toward a lower number of major microscopic Crohn's disease features. A small proportion of patients from both Crohn's disease groups (14% and 13%, respectively) showed inflammatory disease limited to the mucosa, without mural involvement, reminiscent of ulcerative colitis, and these were termed 'ulcerative colitis-like Crohn's disease'. These patients were significantly younger than those with mural involvement. Overall, 44% of patients from both Crohn's disease groups developed at least one adverse outcome, and neither the number nor the type of major Crohn's disease features correlated with adverse outcome. Patients with isolated colonic involvement have distinctive clinical and pathological features. A small subgroup of Crohn's patients shows only mucosal involvement reminiscent of ulcerative colitis.

Current strategies in the management of intra-abdominal abscesses in Crohn's disease

Crohn's disease is characterized by inflammation that involves the full thickness of the bowel wall, which can lead to serious complications including intra-abdominal and pelvic abscesses. The combination of an intra-abdominal abscess with active Crohn's disease poses a particular dilemma for the treating physician, who must weigh the benefits of using immunosuppressive therapies for the inflammatory bowel disease against the risks of immunosuppression in the presence of serious abdominal infection. Traditionally, Crohn's-related abscesses were managed with early surgery, which often involved external drainage procedures, bowel resection, and the creation of diverting ostomies in acutely ill patients. Today such abscesses often can be managed initially with antibiotics and percutaneous drainage, with evaluation for the need for delayed surgery in selected patients. With delayed surgery performed electively, the surgeon frequently can resect the diseased bowel and create a primary anastomosis, thus avoiding emergency operations and multistage procedures. In highly selected cases, surgery might be avoided entirely. This report reviews the literature on the pathophysiology and management of intra-abdominal abscesses in Crohn's disease (including the roles of percutaneous drainage, immunosuppressive therapy, and surgery), and provides a suggested approach to the management of patients with this difficult problem.

Predicting, treating and preventing postoperative recurrence of Crohn's disease: the state of the field

The majority of patients diagnosed with Crohn's disease eventually require surgical intervention. Unfortunately, postsurgical remission tends to be short lived; a significant number of patients experience clinical relapse and many require additional operations. The pathogenesis of this postoperative recurrence is poorly understood and, currently, there are no reliable tools to predict when and in whom the disease will recur. Furthermore, the postoperative prophylaxis profiles of available Crohn's disease therapeutic agents such as 5-aminosalicylates, immunomodulators, steroids and probiotics have been disappointing. Recently, the combination of antibiotics and azathioprine in selected high-risk patients has demonstrated some potential for benefit. The goal of the present article is to provide a coherent summary of previous and new research to guide clinicians in managing the challenging and complex problem of postoperative Crohn's disease recurrence.

Postsurgical recurrence of ileal Crohn's disease: an update on risk factors and intervention points to a central role for impaired host-microflora homeostasis

BACKGROUND

A pressing need exists to identify factors that predispose to recurrence after terminal ileal resection for Crohn's disease (CD) and to determine effective prophylactic strategies. This review presents an up-to-date summary of the literature in the field and points to a role for bacterial overproliferation in recurrence.

METHODS

The literature (Medline, Embase, and the Cochrane Library, 1971-2009) on ileal CD and postoperative recurrence was searched, and 528 relevant articles were identified and reviewed.

RESULTS

Smoking is a key independent risk factor for recurrence. NOD2/CARD15 polymorphisms and penetrating phenotype are associated with aggressive disease and higher reoperation rates. Age at diagnosis, disease duration, gender, and family history are inconsistent predictors of recurrence. Prophylactic 5-aminosalicylic acid therapy and nitromidazole antibiotics are beneficial. Combination therapies with immunosuppressants are also effective. Anti-TNFalpha-based regimens show benefit but the evidence base is small. Corticosteroid, interleukin-10, and probiotic therapies are not effective. Wider, stapled anastomotic configurations are associated with reduced recurrence rates. Strictureplasty and laparoscopic approaches have similar long-term recurrence rates to open resection techniques. Length of resection and presence of microscopic disease at resection margins do not influence recurrence. A lack of consensus exists regarding whether the presence of granulomas or plexitis affects outcome.

CONCLUSIONS

Current evidence points to defects in mucosal immunity and intestinal dysbiosis of either innate (NOD2/CARD15) or induced (smoking) origin in postoperative CD recurrence. Prophylactic strategies should aim to limit dysbiosis (antibiotics, side-to-side anastomoses) or prevent downstream chronic inflammatory sequelae (anti-inflammatory, immunosuppressive, and immunomodulatory therapy).

Preventive therapy in postoperative Crohn's disease

PURPOSE OF REVIEW

Recurrence of Crohn's disease following surgical resection is common, but the optimal strategy to assess, prevent, and treat postoperative recurrence remains unclear. Recent developments in the prevention and management of postoperative recurrence have provided additional information.

RECENT FINDINGS

Predictors of Crohn's disease recurrence after surgery include cigarette smoking, disease behavior, number of prior resections, family history, anastomotic type, and time to first surgery. Only penetrating disease behavior and continued cigarette smoking after surgery remain clear predictors of postoperative Crohn's disease recurrence. Ileocolonoscopy is the only modality to detect mucosal recurrence after surgery; however, surrogate markers of inflammation, specifically stool lactoferrin and calprotectin as well as small intestine contrast ultrasound, are promising. Due to the high rate of surgery for the treatment of complications of Crohn's disease, prevention of postoperative disease has received considerable attention. Recent studies of azathioprine/6-mercaptopurine, nitroimidazole antibiotics, and infliximab have broadened the spectrum of medication options postoperatively.

SUMMARY

Smoking cessation and ileocolonoscopy for early detection of Crohn's disease recurrence should be part of any postoperative management strategy. The selection of medication and optimal time to initiate treatment after surgery is less certain. Postoperative immunomodulators and antitumor necrosis factor agents may prevent Crohn's disease in those at high risk for recurrence. Treatment of patients by predictors of recurrence and personalization of management based on genotypes/phenotypes will be the focus of future study.

Meta-analysis of the role of granulomas in the recurrence of Crohn disease

PURPOSE

This study used meta-analytical techniques to compare the recurrence of granulomatous vs nongranulomatous Crohn disease.

METHODS

Comparative studies published between 1954 and 2007 of granulomatous vs nongranulomatous Crohn disease were included. Using a random effects model, end points evaluated were the number of recurrences and reoperations, and the time to recurrence and reoperation, of granulomatous vs nongranulomatous Crohn disease. Heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection.

RESULTS

Twenty-one studies (14 nonrandomized retrospective, 7 nonrandomized prospective) reported on 2236 patients with Crohn disease, of whom 1050 (47.0%) had granulomas (granulomatous group) and 1186 (53.0%) had no granulomas (nongranulomatous group). The number of recurrences and reoperations was found to be significantly higher in the granulomatous group compared to the nongranulomatous group (odds ratio 1.37, P = .04; odds ratio 2.38, P < .001; respectively), with significant heterogeneity between studies (P = .06; P < .001; respectively). The time to recurrence and reoperation was significantly shorter in the granulomatous group compared with the nongranulomatous group (hazard ratio 1.63, P = .001; hazard ratio 1.62, P = .002; respectively), with no significant heterogeneity between studies. The number of recurrences and reoperations remained significantly higher in the granulomatous group compared to the nongranulomatous group during sensitivity analysis of higher-quality studies, more recent studies, and studies with a larger group of patients.

CONCLUSIONS

Granulomatous Crohn disease appears to be associated with a higher number of recurrences and reoperations and a shorter time to recurrence and reoperation compared to nongranulomatous Crohn disease. Because of significant heterogeneity between studies, further studies should be undertaken to confirm these findings.

Azathioprine and 6-mercaptopurine for the prevention of postoperative recurrence in Crohn's disease: a meta-analysis

OBJECTIVES

To evaluate the efficacy and safety of purine analogs (azathioprine, 6-mercaptopurine (6-MP)) in the prevention of postoperative recurrence in Crohn's disease (CD).

METHODS

We searched MEDLINE, the Cochrane Library, and EMBASE. The primary end points, clinical and endoscopic recurrence at 1 and 2 years, and safety were analyzed by the methods of Peto and Der Simonian and Laird.

RESULTS

Four controlled trials enrolled 433 patients and compared azathioprine (n=3) or (6-MP) (n=1) with control arms (placebo with or without antibiotic induction therapy or mesalamine). In the overall analysis, purine analogs were more effective than control arms in preventing clinical recurrence at 1 year (mean difference, 95% confidence interval (CI): 8, 1-15%, P=0.021, number needed to treat (NNT)=13) and 2 years (mean difference, 95% CI: 13%, 2-24%, P=0.018, NNT=8). In sensitivity analyses, the efficacy of purine analogs was superior to that of placebo for the prevention of clinical and endoscopic recurrence at 1 year (mean differences, 95% CI: 13, 1.8-25%, P=0.025, NNT=7, and 23%, 9-37%, P=0.0016, NNT=4, respectively). At 1 year, in the overall analysis, purine analogs were more effective than control arms were in preventing severe (i2-4) endoscopic recurrence (mean difference, CI 95%: 15, 1.8-29%, P=0.026, NNT=7), but they were not effective in the prevention of very severe (i3-4) recurrence. The rate of adverse events leading to drug withdrawal was higher in thiopurine-treated patients than in control arms (17.2 vs. 9.8%, respectively, P=0.021).

CONCLUSIONS

Purine analogs are more effective than placebo in preventing both clinical and endoscopic postoperative recurrence in CD, but they are associated with a higher rate of adverse events leading to drug withdrawal.

Postoperative Crohn's disease: prevention and treatment

Crohn's disease is a chronic, relapsing-remitting inflammatory disease of the intestinal tract that commonly requires surgical treatment. Unfortunately, the majority of patients will ultimately develop postoperative disease recurrence and require subsequent surgery. A number of medications have been researched for the maintenance of postoperative remission. Of these, few have demonstrated consistent efficacy. A recently published randomized, controlled trial indicated that infliximab is effective in the maintenance of postoperative remission.

Postoperative Crohn’s disease recurrence: A practical approach

Crohn's disease is a chronic inflammatory condition that may involve any segment of the gastrointestinal tract. Although several drugs have proven efficacy in inducing and maintaining disease in remission, resectional surgery remains as a cornerstone in the management of the disease, mainly for the treatment of its stenosing and penetrating complications. However, the occurrence of new mucosal (endoscopic) lesions in the neoterminal ileum early after surgery is almost constant, it is followed in the mid-term by clinical symptoms and, in a proportion of patients, repeated intestinal resections are required. Pathogenesis of postoperative recurrence (POR) is not fully understood, but luminal factors (commensal microbes, dietary antigens) seem to play an important role, and environmental and genetic factors may also have a relevant influence. Many studies tried to identify clinical predictors for POR with heterogeneous results, and only smoking has repeatedly been associated with a higher risk of POR. Ileocolonoscopy remains as the gold standard for the assessment of appearance and severity of POR, although the real usefulness of the available endoscopic score needs to be revisited and alternative techniques are emerging. Several drugs have been evaluated to prevent POR with limited success. Smoking cessation seems to be one of the more beneficial therapeutic measures. Aminosalicylates have only proved to be of marginal benefit, and they are only used in low-risk patients. Nitroimidazolic antibiotics, although efficient, are associated with a high rate of intolerance and might induce irreversible side effects when used for a long-term. Thiopurines are not widely used after ileocecal resection, maybe because some concerns in giving immunomodulators in asymptomatic patients still remain. In the era of biological agents and genetic testing, a well-established preventive strategy for POR is still lacking, and larger studies to identify good clinical, serological, and genetic predictors of early POR as well as more effective drugs (or drug combinations) are needed.

Risk factors for surgical recurrence after ileocolic resection of Crohn's disease

PURPOSE

We evaluated the effect of potential clinical factors on surgical recurrence of ileal Crohn's disease after initial ileocolic resection.

METHODS

One hundred seventy-six patients with ileal Crohn's disease who underwent an ileocolic resection with anastomosis were identified from our database. The outcome of interest was time from first to second ileocolic resection. Survival analysis was used to assess the significance of the Montreal phenotype classification, smoking habit, a family history of inflammatory bowel disease and other clinical variables.

RESULTS

In our final Cox model, a family history of inflammatory bowel disease (hazard ratio 2.24, 95 percent confidence interval 1.16-4.30, P = 0.016), smoking at time of initial ileocolic resection (hazard ratio 2.08, 95 percent confidence interval 1.11-3.91, P = 0.023) was associated with an increased risk of a second ileocolic resection while postoperative prescription of immunomodulators (hazard ratio 0.40, 95 percent confidence interval 0.18-0.88, P = 0.022) was associated with a decreased risk of a second ileocolic resection.

CONCLUSIONS

Both a family history of inflammatory bowel disease and smoking at the time of the initial ileocolic resection are associated with an increased risk of a second ileocolic resection. Postoperative prescription of immunomodulators is associated with a reduced risk of surgical recurrence. This study supports the concept that both genetic and environmental factors influence the risk of surgical recurrence of ileal Crohn's disease.

Management of postoperative Crohn's disease

Three-quarters of the patients with Crohn's disease (CD) require surgery involving a resection in the course of their disease. Even if all macroscopically involved bowel is removed, the disease usually recurs proximal to, and at, the anastomosis. This often leads to the recurrent need for treatment of active disease, complications, and reoperation. Ileocolonoscopy has an important place in the assessment of postoperative Crohn's recurrence. The limited available data regarding drug therapy in the postoperative setting suggest that optimal management should include identification of high-risk patients earlier and more widespread use of immunosuppressive therapy than was previously recommended, and colonoscopic monitoring. Such strategies to prevent recurrence then need to be prospectively evaluated. This article examines the evidence for medical prophylaxis of postoperative CD, and proposes a treatment strategy based on current evidence.

A meta-analysis comparing incidence of recurrence and indication for reoperation after surgery for perforating versus nonperforating Crohn's disease

OBJECTIVE

This study used meta-analytical techniques to compare the incidence of recurrence and the indication for reoperation in patients with Crohn's disease (CD) who underwent their first operation, due to perforating disease versus patients who underwent their first operation due to nonperforating disease.

METHODS

Comparative studies published between 1988 and 2005 of perforating versus nonperforating CD were included. Using a random effects model, end points evaluated were recurrence of CD given as reoperation, and the indication for reoperation, i.e., perforating or nonperforating. Heterogeneity (HG) was assessed and a sensitivity analysis was performed to account for bias in patient selection.

RESULTS

Thirteen studies (12 nonrandomized retrospective, 1 nonrandomized prospective) reported on 3,044 patients, of which 1,337 (43.9%) had perforating indications (P group) and 1,707 (56.1%) had nonperforating indications (NP group) for surgery. The recurrence was found to be significantly higher in the P group compared to the NP group (HR 1.50, P= 0.002), with significant HG among studies (P < 0.001). The recurrence remained significantly higher in the P group compared with the NP group during sensitivity analysis of high-quality studies (HR 1.47, P= 0.005) and more recent studies (HR 1.51, P= 0.05), but still demonstrating significant HG (P= 0.08 and P < 0.001, respectively). At reoperation, concordance was found in the disease type of those patients re-presenting with perforating disease (OR 5.93, P < 0.001, without significant HG among studies P= 0.15) and those with nonperforating disease (OR 5.73, P < 0.001, with significant HG among studies P < 0.001). Concordance in disease type remained when considering only high-quality studies (P: OR 7.48, P < 0.001; NP: OR 7.48, P < 0.001) and more recent studies (P: OR 5.95, P < 0.001; NP: OR 5.95, P < 0.001), both not associated with HG among studies (P= 0.47 and P= 0.60, respectively).

CONCLUSIONS

The indication for reoperation in CD tends to be the same as the primary operation, i.e., perforating disease tends to re-present as perforating disease, and nonperforating as nonperforating. Also, perforating CD appears to be associated with a higher recurrence rate compared with nonperforating CD. However, because of significant HG among studies, further studies should be undertaken to confirm this finding.

Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis

PURPOSE

This study was designed to review safety and efficacy of strictureplasty for Crohn's disease.

METHODS

A literature search was performed to identify studies published between 1975 and 2005 that reported the outcome of strictureplasty. Systematic review was performed on the following subjects separately: 1) overall experience of strictureplasty; 2) postoperative complications; 3) postoperative recurrence and site of recurrence; 4) factors affecting postoperative complications and recurrence; 5) short-bowel syndrome; and 6) cancer risk. Meta-analysis of recurrence rate after strictureplasty was performed by using random-effect model and meta-regressive techniques.

RESULTS

A total of 1,112 patients who underwent 3,259 strictureplasties (Heineke-Mikulicz, 81 percent; Finney, 10 percent; side-to-side isoperistaltic, 5 percent) were identified. The sites of strictureplasty were jejunum and/or ileum (94 percent), previous anastomosis (4 percent), duodenum (1 percent), and colon (1 percent). After jejunoileal strictureplasty, including ileocolonic strictureplasty, septic complications (leak/fistula/abscess) occurred in 4 percent of patients. Overall surgical recurrence was 23 percent (95 percent confidence interval, 17-30 percent). Using meta-regressive analysis, the five-year recurrence rate after strictureplasty was 28 percent. In 90 percent of patients, recurrence occurred at nonstrictureplasty sites, and the site-specific recurrence rate was 3 percent. Two patients developed adenocarcinoma at the site of previous jejunoileal strictureplasty. The experience of duodenal or colonic strictureplasty was limited.

CONCLUSIONS

Strictureplasty is a safe and effective procedure for jejunoileal Crohn's disease, including ileocolonic recurrence, and it has the advantage of protecting against further small bowel loss. However, the place for strictureplasty is less well defined in duodenal and colonic diseases.

Frequency of epithelioid granulomas in colonoscopic biopsy specimens from paediatric and adult patients with Crohn's colitis

AIMS

To test the assumption that epithelioid granulomas found in colonoscopic biopsy specimens in patients with Crohn's colitis are markers of a different clinical behaviour.

METHODS

Sections from colonoscopic biopsy specimens from 352 consecutive patients (119 children and 233 adults) were investigated.

RESULTS

A total of 1117 colonoscopies were performed: 293 in children (mean 2.46 per patient) and 824 in adults (mean 3.53 per patient) (p<0.05). Granulomas at initial colonoscopy were recorded in 67.2% (43/64) of children and 65.9% (27/41) of adults (p>0.6), and at subsequent colonoscopies in 53.8% (64/119) of children and 17.6% (41/233) of adults (p<0.05). Surgical intervention was required in 6.3% (4/64) of the children having previous granuloma, but also in 14.5% (8/55) of those without previous granuloma, the rate for operated adults being 26.8% (11/41) and 24.5% (47/192), respectively (p>0.6).

CONCLUSIONS

Granulomas in entry and/or in subsequent colonoscopic biopsy specimens in patients with Crohn's colitis did not predict the need for subsequent surgical intervention. The fact that the frequency of granulomas was significantly higher in children than in adults with Crohn's colitis (despite a higher mean number of colonoscopic biopsies in adults), and that granulomas were present in colonoscopic biopsy specimens but not in the subsequent surgical specimens from 50% of the paediatric and 36% of the adult patients strengthen the conviction that granulomas in Crohn's colitis might evolve or regress at different time intervals during the course of the disease. This behaviour would reflect a particular immunological reaction, an epiphenomenon from immature tissues-as in children-when challenged by the so far elusive aetiological agent responsible for Crohn's disease.