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Prophylactic Medication After Ileocolonic Resection Prevents Endoscopic Crohn’s Disease Recurrence in Low- and High-Risk Patients: A Clinical Management Algorithm

Marietta Iacucci, MD, PhD, FASGE reviewing Arkenbosch JHC, et al. J Crohns Colitis 2022 Sep 12.

A significant proportion of patients with Crohn's disease will require surgery at some point in their disease course. However, up to 80% of patients will demonstrate endoscopic recurrence in the neoterminal ileum within 12 months of surgery. Identifying predictive high-risk factors to prevent a postoperative recurrence remains challenging and is not yet standardized.  

This prospective multicenter study included 213 CD patients after ileocolonic resection (ICR). A standardized postoperative prophylactic therapeutic management algorithm based on the presence or absence of risk factors was proposed. The high-risk factors were active smoking, penetrating disease, and previous ICR. 

Six months after surgery, 181 patients (84.9%) underwent ileocolonoscopy. Endoscopic recurrence (Rutgeerts’ score ≥i2b) was higher in patients without than with prophylactic therapy in both low-risk (45% vs 16%, respectively; P=.012) and high-risk (49% vs 26%, respectively; P=.019) groups. For clinical risk factors incorporated into the management algorithm of this study, the area under the curve (AUC) for endoscopic recurrence was 0.70 (95% confidence interval [CI], 0.61-0.79). Combining histologic elements with the clinical risk factors resulted in an AUC of 0.73 (95% CI, 0.64-0.81).


Comment:

Current guidelines advise starting prophylactic medication after ICR in patients at high risk of recurrence to prevent postoperative endoscopic recurrence. However, it is more challenging to have a balance between undertreated and overtreated patients, especially in the low-risk group. Risk stratification using the risk factors considered the most important predictors of early postoperative recurrence after ICR would help to identify patients who would benefit most from early prophylactic therapy after resection. These risk factors include smoking, prior intestinal surgery, absence of prophylactic treatment, penetrating disease, perianal disease, extensive small bowel resection, granulomas in resection specimens, and myenteric plexitis.

Further studies are required to refine risk stratification, especially for patients at low risk of postoperative Crohn’s disease recurrence.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
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Marietta Iacucci, MD, PhD, FASGE

Bio and Disclosures

Citation(s):

Arkenbosch JHC, Beelen EMJ, Dijkstra G, et al. Prophylactic medication for the prevention of endoscopic recurrence in Crohn’s disease: a prospective study based on clinical risk stratification. J Crohns Colitis 2022 Sep 12. (Epub ahead of print) (https://doi.org/10.1093/ecco-jcc/jjac128)