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Copyright ©2008 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol. Sep 28, 2008; 14(36): 5540-5548
Published online Sep 28, 2008. doi: 10.3748/wjg.14.5540
Postoperative Crohn’s disease recurrence: A practical approach
Pilar Nos, Eugeni Domènech
Pilar Nos, Eugeni Domènech, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Spain
Pilar Nos, Servicio de Medicina Digestiva. Hospital Universitario La Fe, Valencia, Spain
Eugeni Domènech, Servicio de Aparato Digestivo, Hospital Universitari Germans Trias y Pujol, Badalona (Catalonia), Spain
Author contributions: Nos P and Domènech E contributed equally to this work.
Correspondence to: Pilar Nos, MD, PhD, Gastroenterology Unit, Hospital Universitario La Fe. Avenida Campanar 21. 46009 Valencia, Spain. pnosm@meditex.es
Telephone: +34-96-3862700 Fax: +34-96-1973065
Received: August 18, 2008
Revised: August 26, 2008
Accepted: September 3, 2008
Published online: September 28, 2008
Abstract

Crohn's disease is a chronic inflammatory condition that may involve any segment of the gastrointestinal tract. Although several drugs have proven efficacy in inducing and maintaining disease in remission, resectional surgery remains as a cornerstone in the management of the disease, mainly for the treatment of its stenosing and penetrating complications. However, the occurrence of new mucosal (endoscopic) lesions in the neoterminal ileum early after surgery is almost constant, it is followed in the mid-term by clinical symptoms and, in a proportion of patients, repeated intestinal resections are required. Pathogenesis of postoperative recurrence (POR) is not fully understood, but luminal factors (commensal microbes, dietary antigens) seem to play an important role, and environmental and genetic factors may also have a relevant influence. Many studies tried to identify clinical predictors for POR with heterogeneous results, and only smoking has repeatedly been associated with a higher risk of POR. Ileocolonoscopy remains as the gold standard for the assessment of appearance and severity of POR, although the real usefulness of the available endoscopic score needs to be revisited and alternative techniques are emerging. Several drugs have been evaluated to prevent POR with limited success. Smoking cessation seems to be one of the more beneficial therapeutic measures. Aminosalicylates have only proved to be of marginal benefit, and they are only used in low-risk patients. Nitroimidazolic antibiotics, although efficient, are associated with a high rate of intolerance and might induce irreversible side effects when used for a long-term. Thiopurines are not widely used after ileocecal resection, maybe because some concerns in giving immunomodulators in asymptomatic patients still remain. In the era of biological agents and genetic testing, a well-established preventive strategy for POR is still lacking, and larger studies to identify good clinical, serological, and genetic predictors of early POR as well as more effective drugs (or drug combinations) are needed.

Keywords: Crohn’s disease, Postoperative recurrence, Smoking, Aminosalicylates, Nitroimidazolic antibiotics, Thiopurines