Postoperative Medical Management of Crohn’s Disease: Prevention and Surveillance Strategies

Abstract

Postoperative Crohn’s disease recurrence can be defined as histologic, endoscopic, radiographic, clinical, or surgical. Recurrence rates may also vary according to the methodology of the individual study, for example randomized controlled trial versus observational and referral center experience versus a population-based cohort. Clinical and endoscopic recurrence rates are the most commonly reported postoperative Crohn’s disease measures. Clinical recurrence is defined by symptoms, such as diarrhea, weight loss, and abdominal pain. A variety symptom scores have been adapted to postoperative Crohn’s disease and include, the Inflammatory Bowel Disease Questionnaire or the Crohn’s disease activity index or Harvey-Bradshaw Index. The subjective nature of these symptom-based scores lends to a large variability of clinical recurrence rates across studies. Endoscopic recurrence that is defined at or above the ileocolonic anastomosis by ileocolonoscopy is a more objective measure. Endoscopic recurrence, defined by the Rutgeerts score, predicts subsequent clinical and surgical recurrence.5 The Rutgeerts score defines ileal lesions within 10 cm of the ileocolonic anastomosis as follows: i0: no lesions; i1: ≤5 apthous lesions; i2: >5 apthous lesions with normal mucosa between lesions, or skip areas of larger lesions, or lesions confined to the ileocolonic anastomosis <1 cm in length; i3: diffuse apthous ileitis with diffusely inflamed mucosa, and; i4: diffuse inflammation with already larger ulcers, nodules, or narrowing. At 3 years of follow-up, i0 and i1, i2, i3, and i4 scores are associated with 90 % likelihood of clinical recurrence, respectively.5 A recent comprehensive review looked at the incidence of endoscopic and clinical recurrence.6 These authors reported overall 5-year endoscopic recurrence rates of 89 and 58 % in patients from referral centers and population-based cohorts, respectively, and 5-year clinical recurrence rates of 41 and 30 %, respectively. Surgical recurrence generally follows clinical recurrence, and the surgical recurrence rates in population-based studies have decreased over time according to a recent review.7 Investigations conducted after 1980 demonstrated a 10-year surgical recurrence rate of 33 % [95 % confidence interval (CI): 31–35 %] compared to earlier studies that reported a rate of 45 % (95 % CI: 38–53 %). The enhancement of medication efficacy, employment of prophylactic medical therapy, and initiation of endoscopy-stimulated treatment likely influenced this reduction. The strongest predictors of postoperative recurrence are active cigarette smoking,6,8 penetrating disease behavior, and recurrent resectional surgery for Crohn’s disease. Other risk factors include perianal disease, extensive (>50 cm) small bowel disease, and early onset, aggressive disease.6