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

Are the New Biologics Effective in the Management of Postoperative Crohn's Disease?

BACKGROUND

Despite the growing therapeutic armamentarium, at least half of the patients with Crohn's disease will require surgery during their lifetime. Current evidence for the prevention and treatment of postoperative Crohn's disease supports the use of anti-tumor necrosis factor agents with limited data about the use of the newer biologics, vedolizumab and ustekinumab.

METHODS

We performed a systematic review of available data to determine the efficacy of the newer biologics in the management of postoperative Crohn's disease. We included noncomparative and comparative studies. The main outcomes of interest were clinical and endoscopic postoperative recurrence rates.

RESULTS

The search strategy identified 1231 citations, with 32 eligible for review. Several studies showed that the postoperative Crohn's disease recurrence rates with the use of the newer biologics were comparable to previously published results with the use of anti-tumor necrosis factor agents, while other studies failed to show their efficacy. It is important to note that the studies were heterogeneous and included a relatively small sample size, making it difficult to draw a definite conclusion about the efficacy of the newer biologics in the management of postoperative Crohn's disease.

CONCLUSION

The newer biologics do play a role in the management of postoperative Crohn's disease. After our review, we proposed an updated algorithm on the role of newer biologics in the approach to patients with postoperative Crohn's disease. Yet, until we have better-designed studies, their definite positioning remains to be determined.

Single-balloon Enteroscopy for Evaluation of Small Bowel Crohn Disease Strictures: Peripheral Blood Lymphocytes As a Risk Factor for Strictures

BACKGROUND

Few reports have focused on single-balloon enteroscopy (SBE) for evaluation of small bowel Crohn disease (CD) strictures. The aim of this study was to analyze the relationships between peripheral blood inflammatory markers and small bowel CD strictures observed by SBE.

MATERIALS AND METHODS

CD patients who underwent SBE between January 2016 and December 2020 were enrolled. The clinical characteristics and peripheral blood inflammatory markers were collected and analyzed to screen for predictive factors significantly associated with small bowel CD strictures.

RESULTS

A total of 221 CD patients underwent SBE. The lymphocyte (LC) counts in peripheral blood were significantly lower in the active group (n=178) than in the inactive group (n=43) according to the simple endoscopic score for CD (SES-CD), P =0.011, and was correlated with the SES-CD ( r =-0.134, P =0.047). The LC levels were significantly lower in the stricture group (n=116) than in the nonstricture group (n=105) based on whether small bowel strictures developed, P =0.000, and LC was a risk factor for strictures in the multivariate analysis [hazard ratio (HR), 2.332; 95% CI, 1.102-4.937; P =0.027]. In the subgroup analysis, LC levels notably decreased after stricture aggravation ( P =0.000). Forty-seven patients who underwent small bowel resection underwent SBE at 6 to 12 months after surgery. The LC level was significantly lower in the postoperative patients with strictures ( P =0.025), and LC (HR, 4.444; 95% CI, 1.265-15.617; P =0.020) was a risk of postoperative strictures by univariate analysis, but the age at diagnosis (HR, 6.462; 95% CI, 1.272-22.560; P =0.022) was an independent risk factor by multivariate analysis.

CONCLUSION

Peripheral blood LC levels were correlated with SES-CD and gradually decreased as the intestinal stricture increased in small bowel CD patients. The LC level was also significantly lower in the postoperative CD patients with strictures. The level of LC was a risk factor for small bowel strictures. These results suggest that peripheral blood LC could be a novel marker of small bowel CD strictures to guide CD diagnosis and therapy.

Health Care Maintenance in Patients with Crohn's Disease

Health care maintenance is critical for patients with inflammatory bowel disease (IBD), particularly for those receiving immunosuppressive medications. Vaccination recommendations for potentially preventable diseases, cancer prevention recommendations, and assessment of bone health and mood disorders are discussed in this article. Staying up to date with health care maintenance is of utmost importance, and all gastroenterologists caring for patients with IBD should be able to make recommendations regarding preventative care of these patients.

Faecal Calprotectin from Ileostomy Output Is Sensitive and Specific for the Prediction of Small Bowel Inflammation in Patients with Crohn's Disease

BACKGROUND

Severe Crohn's disease [CD] can result in extensive bowel resections and need for creation of an ileostomy. Faecal calprotectin [FC] is well studied in CD management, though its role in patients who have an ileostomy is unclear. Our aim is to understand if FC is a useful adjunct to radiographic or endoscopic studies in identifying recurrent CD after surgery in patients with an ileostomy.

METHODS

Between January 1, 2017, and September 30, 2020, we searched the Mayo Clinic electronic medical record retrospectively for adult patients with ICD-10 code for CD, and a surgical history of an ileostomy. Patients were included in the analysis if they had at least one FC measured and a concomitant radiographic imaging and/or endoscopic procedure. An abnormal FC was defined as greater than 60 µg/g.

RESULTS

Of 51 patients who met our inclusion criteria, 17 had an FC level >60 µg/g. Of these 17 patients, 14 had imaging and/or an ileoscopy confirming the presence of small bowel inflammation, with a sensitivity of 87.5%. Of the remaining 34 patients with an FC level ≤60 µg/g, 32 patients had imaging and/or ileoscopy demonstrating no small bowel inflammation, with a specificity of 91.4%. FC from an ileostomy effluent had a positive predictive value of 82.3%, a negative predictive value of 94.1% and test diagnostic accuracy of 90.1%.

CONCLUSION

FC from an ileostomy effluent is a highly sensitive and specific test for the assessment and monitoring of small bowel inflammation and disease recurrence in patients with CD.

Small Bowel Crohn's Disease Recurrence is Common After Total Proctocolectomy for Crohn's Colitis

BACKGROUND

Surgical intervention for Crohn's disease involving the colon is often a total proctocolectomy with end ileostomy. There are limited data regarding postoperative small bowel recurrence rates in the recent era.

OBJECTIVE

The purpose of this study was to determine the rate of small bowel Crohn's disease recurrence following total proctocolectomy and secondarily define risk factors for disease recurrence.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at four hospitals within a single healthcare system.

PATIENTS

Patients were those with Crohn's disease undergoing total proctocolectomy with end ileostomy between 2009-2019.

MAIN OUTCOME MEASURES

Main outcome measures were clinical, endoscopic, radiographic, and/or surgical Crohn's disease recurrence.

RESULTS

In total, 193 patients were included with a median follow-up of 1.8 years (IQR 0.4-4.6). Overall, 74.6% (n = 144) of patients had been previously exposed to biologic therapy, and 51.3% (n = 99) had a history of small bowel Crohn's disease. Postoperatively, 14.5% (n = 28) of patients received biologic therapy. Crohn's disease recurrence occurred in 23.3% (n = 45) of patients with an estimated median 5-year recurrence rate of 40.8% (95% CI' 30.2-51.4). Surgical recurrence occurred in 8.8% (n = 17) of patients with an estimated median 5-year recurrence rate of 16.9% (95% CI' 8.5-25.3). On multivariable analysis, prior small bowel surgery for Crohn's disease (HR 2.61; 95% CI' 1.42-4.81) and Crohn's diagnosis at age <18 years (HR 2.56; 95% CI' 1.40-4.71) were associated with Crohn's recurrence. In patients without prior small bowel Crohn's disease, 14.9% (n = 14) had Crohn's recurrence with an estimated 5-year overall recurrence rate of 31.1% (95% CI' 13.3-45.3) and 5-year surgical recurrence rate of 5.7% (95% CI' 0.0-12.0).

LIMITATIONS

The study was limited by its retrospective design and lack of consistent follow-up on all patients.

CONCLUSIONS

Greater than one third of patients who underwent total proctocolectomy for Crohn's disease were estimated to have small bowel Crohn's recurrence at 5 years after surgery. Patients with a history of small bowel surgery for Crohn's and diagnosis at any early age may benefit from more intensive postoperative surveillance and consideration for early medical prophylaxis. See Video Abstract at http://links.lww.com/DCR/B762.

RECURRENCIA FRECUENTE DE LA ENFERMEDAD DE CROHN DEL INTESTINO DELGADO DESPUS DE LA PROCTOCOLECTOMA TOTAL POR COLITIS DE CROHN

ANTECEDENTES:La cirugia para la enfermedad de Crohn que involucra el colon es a menudo una proctocolectomía total con ileostomía terminal. Hay datos limitados con respecto a las tasas de recurrencia posoperatoria de la enfermedad de Crohn del intestino delgado en la actualidad.OBJETIVO:Buscamos determinar la tasa de recurrencia de la enfermedad de Crohn del intestino delgado después de la proctocolectomía total y, en segundo lugar, definir los factores de riesgo de recurrencia de la enfermedad.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Cuatro hospitales de un mismo sistema sanitario.PACIENTES:Pacientes con enfermedad de Crohn sometidos a proctocolectomía total con ileostomía terminal entre 2009-2019.PRINCIPALES MEDIDAS DE VALORACIÓN:Recurrencia clínica, endoscópica, radiográfica y / o quirúrgica de la enfermedad de Crohn.RESULTADOS:Se incluyeron 193 pacientes con un seguimiento promedio de 1,8 años (IQR 0,4-4,6). El 74,6% (n = 144) de los pacientes habían recibido previamente terapia biológica y el 51,3% (n = 99) tenían antecedentes de enfermedad de Crohn del intestino delgado. Después de la operación, el 14,5% (n = 28) de los pacientes recibieron terapia biológica. La recurrencia de la enfermedad de Crohn ocurrió en el 23,3% (n = 45) de los pacientes con una tasa de recurrencia media estimada a los 5 años del 40,8% (IC del 95%: 30,2-51,4). La recidiva quirúrgica se produjo en el 8,8% (n = 17) de los pacientes con una tasa de recidiva media estimada a los 5 años del 16,9% (IC del 95%: 8,5-25,3). En el análisis multivariable, la cirugía previa del intestino delgado para la enfermedad de Crohn (HR 2,61, IC del 95%: 1,42-4,81) y el diagnóstico de Crohn a la edad <18 (HR 2,56, IC del 95%: 1,40-4,71) se asociaron con la recurrencia de Crohn. En pacientes sin enfermedad previa de Crohn del intestino delgado, el 14,9% (n = 14) tuvo recurrencia de Crohn con una tasa de recurrencia general estimada a 5 años del 31,1% (IC del 95%: 13,3-45,3) y una tasa de recurrencia quirúrgica a 5 años del 5,7% (IC del 95%: 0,0-12,0).LIMITACIONES:Diseño retrospectivo, falta de seguimiento constante de todos los pacientes.CONCLUSIONES:Se estimó que más de un tercio de los pacientes que se sometieron a proctocolectomía total tenían recurrencia de Crohn del intestino delgado a los 5 años después de la cirugía. Los pacientes con antecedentes de cirugía por enfermedad de Crohn del intestino delgado y diagnóstico a una edad temprana pueden beneficiarse de una vigilancia posoperatoria más intensiva y la consideración de una profilaxis médica temprana. Consulte Video Resumen en http://links.lww.com/DCR/B762. (Traducción- Dr. Ingrid Melo).

Rate and risk factors of postoperative endoscopic recurrence of moderate- to high-risk Crohn's disease patients - A real-world experience from a Middle Eastern cohort

BACKGROUND

Crohn's disease (CD) frequently recurs after intestinal resection. Azathioprine (AZA) and biological therapies have shown efficacy in preventing postoperative recurrence (POR). Data on POR from Middle Eastern populations is lacking. This study aimed to evaluate the rate of endoscopic POR in a cohort of CD patients who underwent ileocecal resection (ICR), and to assess the effectiveness of AZA and biological therapies in reducing the risk of disease recurrence.

METHODS

We performed a retrospective cohort study on 105 CD patients followed at our center, who underwent ileal resection and were at moderate to high risk for POR. Clinical and laboratory data were collected; the primary endpoint was post ICR endoscopic recurrence at 24 months defined by Rutgeerts' score of i2 or more despite treatment.

RESULTS

In total, 105 patients with Crohn's disease met our inclusion criteria; 76.2% were in remission and did not have endoscopic POR at 24 months. Further, 41.9% were on biological therapy, and 34.3% were mainly on AZA. Out of the 28.2% who had POR, approximately 15% were on biological therapies. Penetrating phenotype was the only predictive factor for decreasing POR (OR = 0.19, 95% CI: 0.04-0.98, P = 0.04) as identified in multiple logistic regression analysis.

CONCLUSIONS

The use of biological therapies post-surgery was not superior than AZA in reducing the endoscopic POR for mod- high risk CD patients. Only penetrating behavior of the CD was associated with significantly lower risk of endoscopic recurrence. This finding is worth further investigation in more robust study designs and among larger samples of patients.

Health Maintenance for Adult Patients with Inflammatory Bowel Disease

PURPOSE OF REVIEW

This review serves as a summary of healthcare maintenance items that should be addressed when managing patients with inflammatory bowel disease (IBD). This manuscript discusses vaccine-preventable illnesses, cancer prevention recommendations, and other screenings that are important to gastroenterologists and primary care physicians caring for patients with IBD.

RECENT FINDINGS

Patients with IBD often require immunomodulator agents and/or biologics to induce and maintain disease remission which can increase the risk of developing several infections. Also, subsets of patients with IBD are at an increased risk for a number of malignancies including colon, cervical, and skin cancers.

SUMMARY

Staying up-to-date with health care maintenance of patients with IBD is critical, especially given their increased risk for vaccine-preventable infections as well as comorbidities such as cancers, bone health, and mood disorders. Gastroenterologists and primary care physicians should familiarize themselves with the required screenings and vaccines that are recommended for adult patients with IBD, particularly those who are immunosuppressed.

Altered Expression of the Epithelial Mucin MUC1 Accompanies Endoscopic Recurrence of Postoperative Crohn's Disease

BACKGROUND

MUC1-glycoprotein is expressed at low levels and in fully glycosylated form on epithelial cells. Inflammation causes MUC1 overexpression and hypoglycosylation. We hypothesized that overexpression of hypoglycosylated MUC1 would be found in postoperative Crohn's disease (CD) recurrence and could be considered an additional biomarker of recurrence severity.

METHODS

We examined archived neo-terminal ileum biopsies from patients with prior ileocecal resection who had postoperative endoscopic assessment of CD recurrence and given a Rutgeerts ileal recurrence score. Consecutive tissue sections were stained using 2 different anti-MUC1 antibodies, HMPV that recognizes all forms of MUC1 and 4H5 that recognizes only inflammation-associated hypoglycosylated MUC1.

RESULTS

A total of 71 postoperative CD patients were evaluated. There was significant increase in MUC1 expression of both glycosylated/normal (P<0.0001) and hypoglycosylated/abnormal (P<0.0001) forms in patients with severe endoscopic CD recurrence (i3+i4), ileal score i2, compared with patients in endoscopic remission (i0+i1). Results were similar regardless of anti-TNF-α use. Although MUC1 expression and Rutgeerts scores were in agreement when characterizing the majority of cases, there were a few exceptions where MUC1 expression was characteristic of more severe recurrence than implied by Rutgeerts score.

CONCLUSIONS

MUC1 is overexpressed and hypoglycosylated in neo-terminal ileum tissue of patients with postoperative CD recurrence. Increased levels are associated with more severe endoscopic recurrence scores, and this is not influenced by anti-TNF-α use. Discrepancies found between Rutgeerts scores and MUC1 expression suggest that addition of MUC1 as a biomarker of severity of postoperative CD recurrence may improve categorization of recurrence status and consequently treatment decisions.

A review of endoscopic scoring systems and their importance in a treat-to-target approach in inflammatory bowel disease (with videos)

Endoscopic assessment is currently the criterion standard for the diagnosis and assessment of mucosal disease activity, prognosis and monitoring for dysplasia, and assessment of response to therapy. Wider appreciation of the potential disconnect between symptoms and objective measures of disease activity and evidence that uncontrolled inflammation may lead to progressive intestinal injury and irreversible bowel damage with adverse events has led to the concept of treating to target. Treating to target is defined as treating patients with high risk for disease progression early to prevent or limit intestinal injury or disability. Endoscopic remission (mucosal healing) has emerged as a key goal of therapy. Although there are no currently validated definitions of endoscopic mucosal remission, the use of endoscopic scoring systems add uniformity and objectivity and aid standardization with reporting of mucosal appearance, augmenting clinical decision making. A plethora of scoring systems exist to define activity, response, and remission in both Crohn's disease and ulcerative colitis. In this review, we discuss the most commonly used endoscopic scoring systems and proposed definitions of response and remission, and how they can be integrated into a treat-to-target approach to optimize patient outcomes.

Computed Tomography and Magnetic Resonance Small Bowel Enterography: Current Status and Future Trends Focusing on Crohn's Disease

Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) are presently state-of-the-art radiologic tests used to examine the small bowel for various indications. This article focuses on CTE and MRE for the evaluation of Crohn disease. The article describes recent efforts to achieve more standardized interpretation of CTE and MRE, summarizes recent research studies investigating the role and impact of CTE and MRE more directly for several different clinical and research issues beyond general diagnostic accuracy, and provides an update on progress in imaging techniques. Also addressed are areas that need further exploration in the future.

The Use of Vedolizumab in Preventing Postoperative Recurrence of Crohn's Disease

BACKGROUND

Clinical and endoscopic recurrence are common after surgery in Crohn's disease (CD). Vedolizumab has been increasingly used to treat CD, however, its effectiveness in preventing postoperative recurrence remains unknown. We aimed to investigate the use of vedolizumab in the postoperative setting and compare the risk of recurrence between patients receiving vedolizumab and anti-tumor necrosis factor (TNF)-α agents.

METHODS

Medical records of CD patients who underwent surgery between April 2014 and June 2016 were reviewed. We first analyzed how frequently vedolizumab is used to prevent postoperative recurrence and compared the patient characteristics with those being treated with other therapies. Furthermore, the rates of endoscopic remission, defined as a simple endoscopic score for CD of 0, at 6-12 months after surgery were compared between patients receiving vedolizumab and anti-TNF-α agents. Clinical, biological, and histologic outcomes such as Harvey-Bradshaw index, C-reactive protein, and histologic inflammation also were compared between the 2 groups. Risks of recurrence were assessed by univariate, multivariate, and propensity score-matched analyses.

RESULTS

Among 203 patients that underwent a CD related surgery, 22 patients received vedolizumab as postoperative treatment. There were 58, 38, and 16 patients who received anti-TNF-α agents, immunomodulators, and metronidazole, respectively, whereas 69 patients were monitored without any medication. Patients receiving vedolizumab were young and frequently had perianal disease. Patients postoperatively treated with vedolizumab or anti-TNF-α agents were mostly treated with the same agent pre- and postoperatively. Rate of endoscopic remission at 6-12 months in the vedolizumab group was 25%, which was significantly lower as compared to anti-TNF-α agent group (66%, P = 0.01). Vedolizumab use was the only factor that was associated with an increased risk of endoscopic recurrence on both univariate (odds ratio (OR) 5.58, 95% confidence interval (CI) 1.51-24.3, P = 0.005) and multivariate analysis (OR 5.77, 95%CI 1.71-19.4, P = 0.005). The results were supported by a propensity score-matched analysis demonstrating lower rates of endoscopic remission (25 vs 69%, P = 0.03) in patients treated with vedolizumab as compared to anti-TNF-α agents.

CONCLUSION

In the present retrospective cohort study of real-world experience, vedolizumab was shown to be commonly used as postoperative treatment for CD especially in high risk patients. Multivariate and propensity score-matched analyses showed that postoperative endoscopic recurrence in CD was higher with vedolizumab than with anti-TNF-α agents, but further investigation including controlled trials is required before determining the utility of vedolizumab in preventing postoperative recurrence of CD.

Knowledge Gaps in the Management of Postoperative Crohn's Disease: A US National Survey

BACKGROUND

Postoperative recurrence (POR) of Crohn's disease (CD) is common. Guidelines on POR management have recently been issued, but clinical practice may vary.

AIMS

To examine the current clinical practice of POR management in the USA METHODS: A web-based survey was sent to all members of the American Gastroenterological Association and the American College of Gastroenterology. The survey consisted of multiple-choice questions with clinical scenarios to assess how participants manage POR.

RESULTS

A total of 189 responses were received from practices in 34 states. 44% of participants were from academic settings. The median number of CD patients seen each month was 20-30 patients per participant. The majority of participants considered smoking, prior intestinal surgery, penetrating disease, perianal fistula, early disease onset, and long extent of disease as high-risk factors for POR. To diagnose and grade endoscopic recurrence, 57% of participants used an endoscopic scoring system; 86% defined clinical recurrence using a combination of symptoms and endoscopic findings; and 79% of participants routinely performed colonoscopy after surgery. In high-risk patients, 65% offered medical prophylaxis-most often biologics and/or immunomodulators-immediately after surgery, while 34% offered medical prophylaxis regardless of the patient's risk of POR. 64% of participants never stopped medical prophylaxis once initiated.

CONCLUSIONS

Most gastroenterologists routinely perform colonoscopy to guide POR management. The majority of these providers continue medical prophylaxis indefinitely regardless of subsequent endoscopic findings. Further research is needed to determine the risks and benefits of continuing versus deescalating therapy in patients with potentially surgically induced remission.

Monitoring of small bowel Crohn's disease

In recent years, the therapeutic paradigm in Crohn's disease has shifted from a mere symptom-oriented approach, to aiming to healing of the underlying inflammation and prevention of long-term structural complications. Such 'treat-to-target' approach may allow for a more stable disease course with less hospitalizations, lower requirement for surgery and improved quality of life. In Crohn's disease, the small bowel is affected in the majority of patients; frequently, Crohn's involves only the small bowel, which remains inaccessible to conventional ileocolonoscopic techniques. Thus, non-invasive monitoring techniques are crucial for accurate disease assessment. Areas covered: This review addresses the indications and clinical implications of non-invasive small bowel monitoring modalities (magnetic resonance enterography, intestinal ultrasound, capsule endoscopy) in the assessment and management of Crohn's disease. Expert commentary: This review addresses the limitations of the current knowledge and future areas of research, including the possible utilization of transmural healing as an imaging target and the need to establish clear quantitative target values to guide treatment by imaging findings in Crohn's disease.

The Association Between Drug Levels and Endoscopic Recurrence in Postoperative Patients with Crohn's Disease Treated with Tumor Necrosis Factor Inhibitors

BACKGROUND

Endoscopic recurrence is associated with a risk of clinical recurrence in patients with Crohn's disease after ileocecal or small bowel resection. Drug levels and presence of antidrug antibodies are associated with important clinical and endoscopic outcomes in patients with Crohn's disease treated with tumor necrosis factor inhibitors, such association was not evaluated for endoscopic postsurgical recurrence.

METHODS

Consecutive patients with Crohn's disease treated with anti-tumor necrosis factors after surgery were identified in the databases of the participating centers. Anti-tumor necrosis factor levels and antidrug antibodies were correlated with Rutgeerts score on colonoscopy performed ≥6 months postoperatively. Significant endoscopic recurrence (SER) was defined as Rutgeerts score >2.

RESULTS

Seventy-three consecutive patients (32-infliximab, 41-adalimumab) were included in the study. The colonoscopies were performed after a median of 15 (7-43) months after surgery and 8 (6-15) months from treatment onset. SER was demonstrated in 26/73 (35.6%) of the patients. The need for dose optimization, as well as trough infliximab levels (2.4 μg/mL [0.45-4.1] versus 1.1 (0-0.6), P = 0.008) and presence of antidrug antibodies (1/18 [5.6%] versus 10/14 [71.4%], P = 0.0001) were significantly associated with a risk of SER. The optimal cutoff infliximab level for prediction of SER was 1.8 μg/mL. No association between adalimumab levels and antiadalimumab antibodies was demonstrated.

CT Enterography for Surveillance of Anastomotic Recurrence within 12 Months of Bowel Resection in Patients with Crohn's Disease: An Observational Study Using an 8-Year Registry

OBJECTIVE

To investigate the diagnostic yield and accuracy of CT enterography (CTE) for early (< 12 postoperative months) surveillance of anastomotic recurrence after bowel resection for Crohn's disease (CD).

MATERIALS AND METHODS

We analyzed 88 adults (60 males and 28 females; mean age, 31.4 ± 9.6 years) who underwent bowel surgery for CD that created ileocolic anastomosis without enteric stoma, and underwent CTE for surveillance of CD recurrence/aggravation within 12 post-operative months. The CD activity index (CDAI) at the time of CTE was < 150 (i.e., clinically silent) in 51 patients, and ≥ 150 in 37 patients. Diagnostic yields of CTE regarding CD recurrence in the ileocolic anastomosis and extraluminal penetrating complications were determined. CTE-related step-up therapy was recorded. These outcomes were compared between the two CDAI groups after accounting for major risk factors for CD recurrence. In a subgroup of 31 patients who underwent both CTE and ileocolonoscopy within 1 month, CTE accuracy for anastomotic recurrence was assessed using the Rutgeerts scoring as the reference standard.

RESULTS

CTE diagnostic yield was 35.2% (31/88) for the anastomotic recurrence and 9.1% (8/88) for penetrating complications. 20.5% (18/88) of the patients underwent step-up therapy after CTE detection of anastomotic recurrence. These outcomes were not significantly different between CDAI < 150 and CDAI ≥ 150, except that CTE yield for extraluminal penetrating complications was significantly higher in CDAI ≥ 150 (16.2% [6/37] vs. 3.9% [2/51]; multivariable-adjusted p = 0.029). CTE showed 92.3% (12/13) sensitivity and 83.3% (15/18) specificity for anastomotic recurrence.

CONCLUSION

CTE may be a viable option for the early postsurgical surveillance of recurred disease in CD patients.

Management of post-operative Crohn's disease in 2017: where do we go from here?

Postoperative recurrence (POR) of Crohn's disease is common after surgical resection. How to best manage POR remains uncertain. Areas covered: In this review, we will first describe the natural course and the best modalities to diagnose this surgical sequela. We will then focus on the potential risk factors for relapse and highlight the main shortcomings in the current study designs and endoscopic and clinical scoring systems, which may partly explain the unexpected outcomes of recent clinical trials. Finally, we will propose a strategy to address the management of POR. Expert commentary: Anti-tumor necrosis factor (Anti-TNF) agents are the most effective therapy to prevent POR in Crohn's disease. Patient risk stratification and active monitoring with scheduled ileocolonoscopy are cornerstones of optimal POR management. Further studies are needed to address areas of uncertainty including timing and duration of therapy and the role of therapeutic drug monitoring in this setting.

Endoscopic Evaluation and Management of the Postoperative Crohn's Disease Patient

Approximately 70% of patients with Crohn's disease (CD) undergo surgical resection for the treatment of medically refractory disease or its complications. The sickest cohort of CD patients experience rapid postoperative relapse at the anastomotic site. Over the past 2 decades, the types of surgical anastomoses used in CD reconstruction have changed; end-to-side and end-to-end anastomoses have been surpassed by the more rapidly created side-to-side anastomoses. This article provides a review of the timing and purpose of endoscopic evaluation in postoperative CD patients and pragmatic information regarding interpretation of endoscopic findings at the different types of surgical anastomoses after ileocecal resection.