Risk Factors For Endoscopic Recurrence Research Articles

P190 Identification of clinical risk factors for postoperative endoscopic recurrence in Crohn’s disease: a prospective, multicenter cohort study

Abstract Background Further refinement of clinical risk stratification for postoperative endoscopic recurrence in patients with Crohn’s disease is required to identify patients who will benefit from prophylactic therapy. Therefore, we aimed to assess risk factors for endoscopic recurrence in a large prospective, multicenter cohort study. Methods CD patients (≥16 years) scheduled for ileocolic (re-)resection (ICR) and those who underwent an ileocolonoscopy at 6 months following ICR were included. Primary outcome of the study was endoscopic recurrence (modified Rutgeerts’ score ≥ i2b at 6 months). Multivariable logistic regression was performed to identify clinical risk factors. The model included a random effect for the study center to correct for potential correlation between treating center and the outcome. Results In total, 298 patients underwent ICR (79.2% primary ICR, 20.8% re-resection) after a median disease duration of 5.3 years (IQR 1.0 – 12.4). 60.4% of patients were female with a median age at surgery of 34.1 years (IQR 25.7 – 50.5). 67.8% of the patients were exposed to ≥1 biological prior to surgery. Postoperative prophylactic medication (<12 weeks to ICR) was initiated in 85/298 (28.5%) patients; 24.7% immunomodulator, 29.4% anti-TNF, 27.1% combination therapy [immunomodulator with anti-TNF agent], 4.7% vedolizumab, 14.1% ustekinumab. Mean time to postoperative ileocolonoscopy was 6.2 months (SD 1.3). Endoscopic recurrence was diagnosed in 37.9% of the patients. Multivariable logistic regression identified active smoking (adjusted OR [aOR] 3.12; 95% CI 1.63 – 5.98) and penetrating disease behaviour (aOR 1.92; 95% CI 1.04 – 3.57) as risk factors for endoscopic recurrence, whilst ileocolic disease (versus ileal disease; aOR 0.27; 95% CI 0.15 – 0.49) and postoperative prophylactic medication (aOR 0.24; 95% CI 0.12 – 0.47) were identified as protective factors for endoscopic recurrence (Table 1). Conclusion Active smoking and penetrating disease behaviour at time of surgery were identified as risk factors for early postoperative recurrence in Crohn’s disease. Reversely, ileocolic disease at time of surgery and initiation of postoperative prophylactic medication were identified as protective factors for early endoscopic recurrence. Young age at surgery, perianal disease and a prior intestinal resection, included as risk factors in the current international guidelines, were not associated with early endoscopic postoperative recurrence in this large prospective cohort study.

P284 Prophylactic medication for the prevention of endoscopic recurrence after ileocolonic resection in Crohn’s disease: a prospective study based on clinical risk stratification

Abstract Background In patients with Crohn’s disease (CD), postoperative prophylactic medication based on clinical risk stratification is recommended in international guidelines to prevent recurrence after ileocolonic resection (ICR). This study aimed to evaluate the risk of endoscopic recurrence after implementation of a predefined management algorithm after ICR incorporating clinical risk stratification. Methods In this multicenter, prospective clinical cohort study, CD patients (≥16 years) were included who were scheduled for ICR and gave informed consent. Endoscopy-guided treatment (no prophylactic medication directly after ICR) was recommended in patients at low risk (LR) of postoperative recurrence, and prophylactic medication (immunosuppressant/biological) in high risk (HR). HR was defined as ≥1 risk factor: smoking, penetrating disease, re-resection. Clinical and histologic risk factors for endoscopic recurrence (Rutgeerts’ score ≥i2) were assessed using logistic regression models and ROC curves based on predicted probabilities. Results In total 213 CD patients were included (median age 34.5 years, 65.3% women): 93 (43.7%) at LR and 120 (56.3%) at HR (smoking 45 (21.3%); penetrating disease 51 (23.9%); re-resection 51 (23.9%)). Adherence to the proposed management algorithm was 65%; 76/93 (81.7%) in the LR (no prophylaxis) and 61/120 (50.8%) in the HR population (prophylaxis). Endoscopic recurrence in LR patients was 69% without prophylaxis versus 48% with prophylaxis (p=0.070); in HR 78% without prophylaxis versus 55% with prophylaxis (p=0.019). Clinical risk stratification corresponded with an area under the curve (AUC) of 0.64 (95%CI 0.55–0.73) (Figure 1). Clinical factors combined with histology (active inflammation, granulomas, plexitis in resection margins) increased the AUC to 0.69 (95% CI 0.61–0.88) (Figure 1). Conclusion This prophylactic medication algorithm in CD patients based on clinical risk stratification after ICR, results in an absolute risk reduction of endoscopic recurrence of 23% in HR versus 21% increase in LR patients in whom medication is omitted. For this latter population, further refinement of risk stratification is required, and may include histologic assessment.

P557 Long-term outcomes following laparoscopic ileocecal resection without any residual lesion for Crohn’s disease: a single-center observational study

Abstract Background To describe the characteristic of Crohn’s disease (CD) patients undergoing ileocecal resection, and to analyze the long-term outcomes following surgery. Methods A retrospective study on patients undergoing ileocecal resection without any from residual disease in the remnant intestine from July 2011 to March 2020 was conducted. The clinical data and the following outcomes were evaluated. Results Among 86 CD patients, the mean disease duration was 33.4 months, 40 patients had perianal fistula. 53 patients underwent surgery due to stricture, 26 was perforation, and 7 was failure of medical therapy. 27 (31.4%) patients suffered postoperative complications. Mean follow-up was 44.4 months, 47 (54.7%) patients had an endoscopic recurrence with 9 were non-anastomotic recurrence, 20 were anastomotic recurrence, and 18 were both anastomotic and non-anastomotic recurrence, and 4 patients had a surgical recurrence. Furthermore, 41 (47.7%) had postoperative prophylaxis with 22 (25.6%) azathioprine and 17 (19.8%) infliximab. 45 (52.3%) patients were without postoperative prophylaxis, 19 (42.2%) had an endoscopic recurrence, and 26 (57.8%) had none endoscopic recurrence. The penetrating disease and lower skeletal muscle index were independent risk factors for endoscopic recurrence. Conclusion CD patients with penetrating disease or lower skeletal muscle index were suggested to have earlier postoperative prophylaxis after ileocecal resection without any from residual disease in the remnant intestine.

Predictors of endoscopic recurrence in resected patients with Crohn's disease in a long-term follow-up cohort: History of multiple previous resections and residual synchronous disease in the remnant intestine.

This study aimed to determine the predictors of endoscopic recurrence in a cohort of patients with Crohn's disease (CD) with prior intestinal resections. The charts of the patients with CD were reviewed in a retrospective manner. Eighty-three patients were eligible for the final analysis. Demographic features of these patients and time between resection and colonoscopy, presence of any macroscopic residual disease in the remnant intestine, and postoperative medications were noted. Rutgeerts score was used to define postoperative endoscopic recurrence. The patients' mean age±SD at their final colonoscopy was 42.81±11.99 yr; and 37 of 83 patients (45%) were female. The mean follow-up time between resection and the final colonoscopy was 51.16±51.08 months. A total of 51 of 83 patients (61%) were in endoscopic remission (i0, i1); whereas 32 (39%) had an endoscopic recurrence (i2, i3, i4). History of multiple resections (χ2=6.12; p=0.013) and the presence of any postoperative residual disease in the remnant intestine (χ2=5.86; p=0.015) were risk factors; whereas the regular use of azathioprine (AZA) was significantly more common among patients without recurrence (χ2=4.515; p=0.034). In an age-sex adjusted Cox regression analysis history of multiple resections, presence of any postoperative residual disease proved to be independent risk factor for endoscopic recurrence, whereas the regular use of AZA proved to be ineffective. In a retrospective long-term follow-up cohort of resected patients with CD, having multiple resections for CD and the presence of any residual synchronous disease after ileocolonic resection were identified as risk factors for endoscopic recurrence; the latter was never reported in previous studies.

Real-World Experience with AGA Guidelines in the Management of Crohn's Disease following Ileocolonic Resection: A Retrospective Cohort Study.

Background Postoperative endoscopic recurrence (PER) is common in patients with Crohn's disease (CD) after surgery. The impact of the American Gastroenterological Association (AGA) guideline adherence on PER in real life remains unclear. Methods The postoperative management of CD patients undergoing ileocolonic resection with anastomosis from 2017 to 2018 was conducted based on the AGA guidelines. Colonoscopies were performed within one year after surgery. Clinical data and risk factors for endoscopic recurrence were analyzed focusing on postoperative pharmacological prophylaxis. Results All patients were at a high risk of postoperative recurrence according to the AGA guidelines. PER occurred in 29 (28.7%) of these patients. The overall PER rate was 39.2% at one year. The PER rate in patients treated with nitroimidazole, thiopurines, infliximab, or a combination of thiopurines and infliximab for postoperative prophylaxis was 88.1%, 34.1%, 20.5%, and 0%, respectively. Cox regression showed that smoking at the time of surgery and AGA guideline adherence were independent factors associated with PER (HR: 3.75, 95% CI: 1.36-10.33, P = 0.01; HR: 0.36, 95% CI: 0.15-0.86, P = 0.02). In addition, further investigation revealed that educational background was the main factor related to patients' nonadherence to AGA guidelines. Conclusions The majority of CD patients who undergo surgery in clinical practice may be at a high risk of disease recurrence. Thiopurines and infliximab are effective in preventing endoscopic recurrence. Guideline nonadherence is associated with PER at one year, thus indicating that there is room for improvement in adherence to the AGA guidelines.

P644 Post-operative Crohn’s disease recurrence in Glasgow: How common is it and does deprivation matter?

Abstract Background 50% of patients with Crohn’s disease (CD) will have surgery within the first 10 years, with 35% requiring additional surgery in the following decade. The REMIND cohort-linked male gender, smoking and previous resection to recurrence1. The link between CD and deprivation is debated, while its influence on recurrence is unknown. We aimed to define our local post-operative CD population, highlighting recurrence rates and associated risk factors. Methods CD resections between 2008 and 2014 were identified from NHS Greater Glasgow and Clyde Pathology Archive. Data including gender, age at diagnosis/resection, Montreal classification and smoking status was obtained from the Electronic Patient Record (EPR). Scottish Index of Multiple Deprivation (SIMD) score was determined by postcode and was ranked 1–5 (most to least deprived). Five years of follow-up data were collected. The type of recurrence was recorded as clinical recurrence - symptom flare requiring a course of steroids or inpatient admission; biochemical recurrence—faecal calprotectin >250 µg/l; endoscopic recurrence; or surgical recurrence—the need for further Crohn’s disease-related surgery. Results 304 patients (59.5% female) were included. Median age at diagnosis was 29 (range 3–82 years) and at resection was 43 (range 17–85 years). 52.9% of patients were never-smokers, 16.5% were ex-smokers and 30.6% were current smokers. 33.6% of patients had a SIMD score of 1. Eighty-two per cent had ileal, colonic or ileocolonic involvement. 46.7% of patients had clinical recurrence, 48.7% biochemical recurrence and 31.6% endoscopic recurrence. 15.8% required further surgery for CD. For clinical recurrence, younger age at diagnosis (p = 0.012, and younger age at resection (p = 0.002) were significant determinants. Gender, smoking and SIMD were not significantly associated with recurrence. Chemical recurrence showed similar associations. Similarly, for surgical recurrence, younger age at diagnosis (p = 0.030, and younger age at resection (p = 0.003) were significant determinants. Male gender was the only risk factor for endoscopic recurrence (OR=1.88, 95% CI: 1.13–3.08). Conclusion Our data suggest rates of post-operative recurrence in line with published data. Risk factors were similar to those identified in the REMIND study, with younger age at diagnosis/resection associated with higher rates of recurrence. Our data suggest sociodemographic deprivation does not influence recurrence rates; however,, more work is needed to validate this. References

Risk factors for recurrence after bowel resection for Crohn's disease.

BACKGROUNDComplications of Crohn’s disease such as intestinal obstruction, fistula or perforation often need surgical treatment. Nearly 70%-80% patients with Crohn’s disease would receive surgical treatment during the lifetime. However, surgical treatment is incurable for Crohn’s disease. The challenge of recurrence postoperatively troubles both doctors and patients. Over 50% patients would suffer recurrence postoperatively. Some certain risk factors are associated with recurrence of Crohn’s disease.AIMTo evaluate the risk factors for endoscopic recurrence and clinical recurrence after bowel resection in Crohn’s disease.METHODSPatients diagnosed Crohn’s disease and received intestinal resection between April 2007 and December 2013 were included in this study. Data on the general demographic information, preoperative clinical characteristics, surgical information, postoperative clinical characteristics were collected. Continuous data are expressed as median (inter quartile range), and categorical data as frequencies and percentages. Kaplan-Meier method was applied to estimate the impact of the clinical variables above on the cumulative rate of postoperative endoscopic recurrence and clinical recurrence, then log-rank test was applied to test the homogeneity of those clinical variables. Multivariate Cox proportional hazard regression analysis was performed to identify the risk factors of postoperative endoscopic recurrence and clinical recurrence.RESULTSA total of 64 patients were included in this study. The median follow-up time for the patients was 17 (9.25-25.75) mo. In this period, 41 patients (64.1%) had endoscopic recurrence or clinical recurrence. Endoscopic recurrence occurred in 34 (59.6%) patients while clinical recurrence occurred in 28 (43.8%) patients, with the interval between the operation and recurrence of 13.0 (8.0-24.5) months and 17.0 (8.0-27.8) mo, respectively. In univariate analysis, diagnosis at younger age (P < 0.001), disease behavior of penetrating (P = 0.044) and preoperative use of anti-tumor necrosis factor (TNF) (P = 0.020) were significantly correlated with endoscopic recurrence, while complication with perianal lesions (P = 0.032) and preoperative use of immunomodulatory (P = 0.031) were significantly correlated with clinical recurrence. As to multivariate analysis, diagnostic age (P = 0.004), disease behavior (P = 0.041) and preoperative use of anti-TNF (P = 0.010) were independent prognostic factors for endoscopic recurrence, while complication with perianal lesions (P = 0.023) was an independent prognostic factor for clinical recurrence.CONCLUSIONDiagnostic age, disease behavior, preoperative use of anti-TNF and complication with perianal lesions were independent risk factors for postoperative recurrence in Crohn’s disease.

The Influence of Microscopic Inflammation at Resection Margins on Early Postoperative Endoscopic Recurrence After Ileocaecal Resection for Crohn's Disease.

The pathogenesis and risk factors for early postoperative endoscopic recurrence of Crohn's disease [CD] remain unclear. Thus, this study aimed to identify whether histological inflammation at the resection margins after an ileocaecal resection influences endoscopic recurrence. We have prospectively followed up patients with CD who underwent ileocaecal resection at our hospital between January 2012 and January 2018. The specimens were histologically analysed for inflammation at both of the resection margins [ileal and colonic]. We evaluated whether histological results of the resection margins are correlated with endoscopic recurrence of CD based on colonoscopy 6 months after ileocaecal resection. Second, we assessed the influence of known risk factors and preoperative therapy on endoscopic recurrence of CD. A total of 107 patients were included in our study. Six months after ileocaecal resection, 23 patients [21.5%] had an endoscopic recurrence of CD. The histological signs of CD at the resection margins were associated with a higher endoscopic recurrence [56.5% versus 4.8%, p < 0.001]. Disease duration from diagnosis to surgery [p = 0.006] and the length of the resected bowel [p = 0.019] were significantly longer in patients with endoscopic recurrence. Smoking was also proved to be a risk factor for endoscopic recurrence [p = 0.028]. Histological inflammation at the resection margins was significantly associated with a higher risk of early postoperative endoscopic recurrence after an ileocaecal resection for CD.

P073 Male gender, smoking and stenosis are risk factors for postoperative endoscopic recurrence after ileocaecal resection for Crohn's disease

BACKGROUND: Colonoscopy is an important exam for diagnosis and follow-up of Crohn’s disease (CD). It has a relevant role in the management of patients after ileocaecal resection (IR), evaluating ileocolonic endoscopic recurrence (ER), performing biopsies and endoscopic dilations. This study describes the colonoscopies performed in patients previously submitted to IR for CD complications, evaluating its impact in the management and evolution of the disease. METHODS: Between January 2014 and May 2018, a total of 116 colonoscopies were performed in 62 patients with previous IR for CD. This study describes demographic data, personal and family history, use of medications, Harvey-Bradshaw index (HBI), endoscopic findings, post-colonoscopy alterations of medical treatment and need of new surgery. For endoscopic classification, Rutgeerts index for severity of post-operative CD was used, and ER was defined as scores 3i2. For statistical analysis, software SPSS 20.0 was used. It was considered statiscally significant values of p£0.05. RESULTS: Among all patients, 38.7% were male gender, which was a risk factor for ER (P &lt; 0.05). Mean time of CD was 156 months (12–385). Prevalence of smoking was 17.7%, which also was a risk factor for ER (P &lt; 0.05). Family history for CD was positive in 9 cases (14.5%). HBI showed low sensibility for predicting ER. Forty-five patients refered regular use of medication prescribed, while eight patients were in irregular use. Nine patients were without medication. Although there was no statistical significance (P = 0.15), the use of combotherapy was less associated with ER, when compared to other therapies. Regarding ER, 36 cases were i0; 18 cases i1, 38 cases i2; 5 cases i3; and finally, 16 cases i4. On follow-up, patients with ER more frequently had drug optimization or change of medication (P &lt; 0.05). None of the patients classified as i0, i1, i2 e i3 needed new surgery on follow-up. Two cases classified as i4 had indication of new surgery. Ileocolonic stenosis was a risk factor for ER (P &lt; 0.05): in a total of 23 cases, 16 were active disease with ulcerated stenosis. One balloon dilation was done in a patient with non-ulcerated ileocolonic stenosis. There were no cases of bleeding and perforation. CONCLUSION(S): Postoperative endoscopic follow-up after ileocaecal resection should be routinely performed. In our study, approximately 46% of the patients were in endoscopic remission. In contrast with previous reports, the majority of our i3 and i4 cases were managed clinically, with a low rate of new surgery (around 5%) Male sex, smoking and stenosis were risk factors for ER.

Endoscopic Recurrence 6 Months After Ileocecal Resection in Children With Crohn Disease Treated With Azathioprine

Intestinal surgery is an important part of Crohn disease (CD) treatment in children. The aim of the present study was to compare the rate of endoscopic recurrence at the sixth month after ileocecal resection (ICR) in children with CD treated with azathioprine between patients who received prior antitumor necrosis factor alpha (anti-TNF-α) therapy and those who were not administered this therapy. Moreover, we tried to identify the potential risk factors for disease recurrence and describe the schedule of long-term follow-up after surgery. We prospectively collected data from pediatric patients with CD, who underwent ICR between October 2011 and June 2015 at our hospital and were treated with azathioprine monotherapy after ICR. We evaluated the endoscopic recurrence (Rutgeerts score) at the sixth month after ICR in all included patients. Among 21 included patients, 13 achieved endoscopic remission (Rutgeerts score < i2) at the sixth month after ICR. No difference was found between patients who received prior anti-TNF-α therapy and those who did not. We did not find any clinically relevant factors associated with endoscopic recurrence rate at the sixth month. Prior anti-TNF-α therapy does not seem to be a strong risk factor for endoscopic recurrence within 6 months after ICR. Further studies on large sample of patients are needed to identify potential predictors of disease recurrence.

Visceral adiposity predicts post-operative Crohn's disease recurrence.

Excessive visceral adipose tissue has been associated with poorer outcomes in patients with inflammatory bowel disease. To determine whether body composition is associated with outcome in a prospective study of post-operative Crohn's disease patients. The POCER study evaluated management strategies for prevention of post-operative Crohn's disease recurrence; subjects were enrolled after resection of all macroscopic Crohn's disease and were randomised to early endoscopy and possible treatment escalation, or standard care. The primary endpoint was endoscopic recurrence at 18 months. 44 subjects with cross-sectional abdominal imaging were studied, and body composition analysis performed using established techniques to measure visceral adipose tissue area, subcutaneous adipose tissue area, and skeletal muscle area. The body composition parameter with the greatest variance was visceral adipose tissue. Regardless of treatment, all subjects with visceral adipose tissue/height2 >1.5 times the gender-specific mean experienced endoscopic recurrence at 18 months (compared to 47%) [relative risk 2.1, 95% CI 1.5-3.0, P = 0.012]. Waist circumference correlated strongly with visceral adipose tissue area (ρ = 0.840, P < 0.001). Low skeletal muscle was prevalent (41% of patients), but did not predict endoscopic recurrence; however, appendicular skeletal muscle indices correlated inversely with faecal calprotectin (ρ = 0.560, P = 0.046). Visceral adiposity is an independent risk factor for endoscopic recurrence of Crohn's disease after surgery. Sarcopenia correlates with inflammatory biomarkers. Measures of visceral adipose tissue may help to stratify risk in post-operative management strategies.

Sa1203 Appendiceal Orifice Histology and Its Prognostic Significance in Patients With Ulcerative Colitis

G A A b st ra ct s lesions confined to the ileocolonic anastomosis). Secondary outcome was to identify risk factors like Montreal classification, smoking behavior, previous resection(s), gender, family history of inflammatory bowel disease (IBD), surgery indication, type of anastomosis, ileum length resected and postoperative use of medication. Results In the 105 included patients, the overall endoscopic recurrence rate was 38.1%. The recurrence rate in patients who used postoperative biologics was 26.3%, 23.8% in patients who used immunomodulators and 51.9% in patients without postoperative medication. Only smoking the year before surgery (OR; 3.590, 95% CI 1.269-10.233, p=0.017) seemed to be a significant risk factor in the multivariate analysis for risk factors for endoscopic recurrence. Postoperative use of medication was a protective factor (not significant, but a trend OR; 0.381, 95% CI 0.142-1.018, p=0.054), which reduced the risk with 61.9%. Conclusion This is the first study that used the modified Rutgeerts score to evaluate endoscopic recurrence. In this retrospective multicenter cohort study, the endoscopic recurrence rate found was lower than in previous studies. Based on this study, special attention should be paid in the preoperative phase to patients with smoking habits. Postoperatively, an early start with immunomodulators or anti-tumor necrosis factor (TNF) therapy should be taken into consideration.