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

Abstract

Summary 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.

Impact of Endoscopic monitoring in postoperative Crohn’s disease patients already receiving pharmacological prevention of recurrence

“…Since surgery is not curative, clinical PR occurs in a significant proportion of the patients who have undergone any kind of surgical resection (2); moreover, endoscopic recurrence of the disease is even much more frequent and may affect a majority of the patients in the first year after surgery and almost all of the patients after three years (5,6). Even though prophylaxis of PR in postoperative CD patients remains an unresolved issue in many aspects, it is widely accepted that patients with bad prognosis criteria should receive immunomodulators, and the immunosuppressive load should be selected according to the risk of clinical recurrence (2,11).…”

“…Moreover, postoperative CD patients in clinical remission may have endoscopic recurrence (5)(6)(7). Clinical relevance of mucosal healing in CD is widely accepted and is associated with better outcomes (8,9), and a recent prospective and randomized trial has shown that individualized immune suppression, adjusted for early endoscopic recurrence, leads to disease control in most cases (10); in spite of that, the need of endoscopic monitoring along the follow up in the postoperative scenario of patients who are already receiving treatment to prevent PR remains unclear.…”

Fecal calprotectin in the prediction of postoperative recurrence of Crohn's disease in children and adolescents

“…Recurrent mucosal inflammation is observed in endoscopy in 70-90% of adult CD patients within a year of surgery although only one third present with symptomatic relapse of the disease [1,[8][9][10]. Histological activity may develop at the site of the anastomosis as soon as after a week of bowel resection [11].…”

“…Even though longer postoperative remission periods are reported for children, most studies have monitored clinical recurrence rates instead of endoscopic follow-up [2,[12][13][14][15]. As clinical symptoms are frequently absent and serum biochemical markers normal until significant inflammatory changes have developed, ileocolonoscopy with histological verification should be considered as the gold standard for assessing disease activity and postoperative recurrence [6,[8][9][10]16].…”

Letter: management of post‐operative Crohn's disease ‐ thiopurines vs adalimumab– authors' reply

“…We acknowledge that perianal disease, extensive intestinal resection, and in particular myenteric and submucosal plexitis at the proximal margin of the resection are also considered to be risk factors for earlier post-operative recurrence 5 However, the clinical factors (smoking, previous surgery, and penetrating disease) used in the POCER study to stratify patients have, in cohort studies, reflected the highest increased risk of recurrence. 6 They are easily identifiable pre-operatively in clinical practice.…”