Prevention of post-operative recurrence of Crohn’s disease

Abstract

Endoscopic and clinical recurrence of Crohn’s disease (CD) is a common occurrence after surgical resection. Smokers, those with perforating disease, and those with myenteric plexitis are all at higher risk of recurrence. A number of medical therapies have been shown to reduce this risk in clinical trials. Metronidazole, thiopurines and anti-tumour necrosis factors (TNFs) are all effective in reducing the risk of endoscopic or clinical recurrence of CD. Since these are preventative agents, the benefits of prophylaxis need to be weighed-against the risk of adverse events from, and costs of, therapy. Patients who are high risk for post-operative recurrence should be considered for early medical prophylaxis with an anti-TNF. Patients who have few to no risk factors are likely best served by a three-month course of antibiotics followed by tailored therapy based on endoscopy at one year. Clinical recurrence rates are variable, and methods to stratify patients into high and low risk populations combined with prophylaxis tailored to endoscopic recurrence would be an effective strategy in treating these patients.

Keywords: Inflammatory bowel disease, Crohn’s disease, Postoperative recurrence, Medical treatment, Biologics

Core tip: This review summarizes and updates the current state of the field of post-operative prevention of Crohn’s disease (CD) after surgery. This review starts by discussing the natural history of postoperative recurrence followed by a summary of the most consistent and evidence based risk factors. We then discuss the evidence for medical prophylaxis of CD highlighting new data regarding biologics. Finally we discuss cost effectiveness and provide a potential novel treatment algorithm for a clinician to use practically when caring for a patient with CD after surgery.