Postoperative Crohn's Disease: Preventive Therapy
Postoperative Crohn's Disease: Preventive Therapy
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.
Despite continued advances in the medical management of Crohn's disease, up to 75% of patients will undergo an intestinal resection during their disease course. Furthermore, postoperative disease recurrence is common, with 70–90% of patients having endoscopic recurrence within 12 months of surgery. Endoscopic recurrence precedes clinical recurrence, and 10 year re-operation rates range between 30 and 70%. Several risk factors for postoperative disease recurrence have been identified, though few are modifiable. No model currently exists to effectively predict postoperative recurrence, other than mucosal assessment during ileocolonoscopy. Current recommendations include performing an ileocolonoscopy 6–12 months postoperatively, which provides prognostic information regarding the risk of clinical recurrence. This review will highlight recent developments in the postoperative assessment and care of patients undergoing surgery for Crohn's disease.
Abstract and Introduction
Abstract
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.
Introduction
Despite continued advances in the medical management of Crohn's disease, up to 75% of patients will undergo an intestinal resection during their disease course. Furthermore, postoperative disease recurrence is common, with 70–90% of patients having endoscopic recurrence within 12 months of surgery. Endoscopic recurrence precedes clinical recurrence, and 10 year re-operation rates range between 30 and 70%. Several risk factors for postoperative disease recurrence have been identified, though few are modifiable. No model currently exists to effectively predict postoperative recurrence, other than mucosal assessment during ileocolonoscopy. Current recommendations include performing an ileocolonoscopy 6–12 months postoperatively, which provides prognostic information regarding the risk of clinical recurrence. This review will highlight recent developments in the postoperative assessment and care of patients undergoing surgery for Crohn's disease.
