Postoperative Crohn’s Disease Recurrence and Role of Endoscopy

Introduction

Many patients with Crohn's disease (CD) will require intestinal resection surgery at some point in their disease course. Overall rates of surgery for CD as high as 80% when including tertiary care centers have been reported while a recent systematic review of population-based studies found that risk of requiring surgery after a diagnosis of CD was 16% at 1 year, 33% at 5 years, and 47% at 10 years. Unfortunately such surgery is usually not curative as CD typically recurs. The frequency of postoperative recurrence depends on definitions used. Recurrence is typically first detected on endoscopic or radiologic studies and has been noted as early as 3 months postoperatively ( endoscopic recurrence ) while recurrence of symptoms ( clinical recurrence ) and the need for further surgical resection ( surgical recurrence ) typically follow later in the postoperative course. Endoscopic recurrence rates can be as high as 70%–90% at 1 year following surgery, clinical recurrence rates can be as high as 20%–30% at 1 year, and the need for repeat surgery occurs in anywhere from 35% to 70% of patients at 10 years.

There have been many studies trying to elucidate risk factors for postoperative CD recurrence often with conflicting results. Among these potential factors, current smoking, pathologic findings of granulomas or myenteric plexitis, a perforating disease phenotype, presence of perianal disease, and the creation of an anastomosis appear to be most predictive for an increased risk of disease recurrence. Among these factors, the only modifiable one is smoking. A metaanalysis demonstrated a twofold increase in postoperative clinical recurrence and a 2.5-fold increase in the risk of further surgery by 10 years in smokers compared to nonsmokers. Furthermore, smoking cessation has been correlated with a decreased risk of postoperative recurrence.

The other main issue in management of postoperative CD relates to deciding which patients need postoperative medical therapy, the timing of such treatment, and which therapy to use. There have been multiple studies evaluating postoperative medical therapy, sometimes with conflicting results.

In this review, we will discuss the approaches to optimal management of CD following surgery with a particular focus on the diagnostic and therapeutic role of colonoscopy in this setting. Review of recently published key medical prophylaxis clinical trials and guidelines will be discussed.