Dr Regueiro discusses the prevalence of postoperative recurrence of Crohn disease, why it happens, how it can be prevented, and how it can be treated and managed, in this video recap of his talk from the American College of Gastroenterology 2020 clinical meeting and postgraduate course. 

Miguel Regueiro, MD, FACG, is chair of the Department of Gastroenterology, Hepatology, and Nutrition at Cleveland Clinic in Cleveland, Ohio, and a Section Editor for IBD for Gastroenterology Learning Network.

Transcript:

My name is Dr. Miguel Regueiro. I'm chair of gastroenterology, hepatology, and nutrition at Cleveland Clinic in Cleveland, Ohio. At ACG 2020, I gave a talk on postoperative Crohn's disease management and recurrence. Why is this important, and what are the take-home points?

One take-home point is that recurrence of Crohn's disease after an ileocolonic resection is quite high. What that means is that nearly 30% to 50% of patients within a year of surgery and an anastomosis will have clinical symptoms, clinical recurrence.

We know that up to 90%  of patients will have an endoscopic recurrence, meaning even without symptoms, doing a colonoscopy, looking at the ileocolonic anastomosis and the neoterminal ileum above the anastomosis, 90% of patients will have recurrence in that neoterminal ileum at the anastomosis or just above. That's probably the biggest take-home point.

The other take-home points, and what I discussed in my talk, were that there are risk factors for recurrence, meaning not all patients recur and not all patients recur severely.

Why is this important? While we know surgery is not a cure for Crohn's disease — we know it can recur — it would be nice to predict who has a high likelihood of recurrence and more severe recurrence and who does not or who has a milder recurrence.

Another key take-home point that we've realized and that I've presented are that there are certain factors associated with recurrence, namely cigarette smoking. Patients who smoke prior to surgery continue smoking after surgery. That's a risk factor. Obviously, not only for Crohn's but for health reasons, we ask them to quit. We want them to quit.

A second risk factor is penetrating disease, meaning patients who have fistula, internal abscesses, perforations from their Crohn's disease, especially if it is not linked or associated with a stricture. These are patients who have a very high rate of recurrence after surgery. These would be patients we would consider about targeting medicines to start after surgery to prevent recurrence. I'll come to the medicines in a minute.

Then, the final high risk for recurrence is somebody who's had not just one surgery, but they're on their second, third, or greater surgery. They've had this repeated pattern of Crohn's recurrence, a complication that then needs surgery, and another surgery, and another surgery. Recurrent surgery is probably the number one highest risk factor for recurrence of Crohn's.

What does that mean? That means that patients who've had multiple surgeries, have penetrating disease, cigarette smokers—these are the patients that we know predictably will have recurrence, probably severe, may need another surgery if we don't do something after surgery to prevent this recurrence.

What we have found is that certain medicines can prevent recurrence. Another key take-home point are that there have been different medicines evaluated, from antibiotics, like metronidazole, to thiopurines, that would be 6-MP or azathioprine, to biologic therapies like anti-TNFs.

Without going through all the details of every postoperative medicine study, we've actually learned that probably thiopurines are not effective or that effective at preventing recurrence. Metronidazoles and antibiotics work very well. Maybe the gut microbiome plays a role in recurrence. The problem is it's hard to take that long term, especially at high doses.

What does that leave us? One thing that I talked about at ACG 2020 is that anti-TNFs, which is a biologic, like infliximab, that's actually been studied. I was fortunate enough over the years to run many of these studies with many of you out there.

We have found that this actually can prevent or reduce recurrence to almost 20%. Rather than have a 90% chance of recurrence, it ends up being 20% —not a cure but much better. This prevents future surgery, prevents future complications.

To end, how do I approach Crohn's disease? I really split it into two categories. The low risk for recurrence would be patients with their first surgery after a long period of time who have a short stricture, scarred tissue with some Crohn's. Probably that course of disease, which took many years to get to the point that somebody needs surgery, we probably don't need to put them on postoperative medications, but we do want to monitor them after surgery.

Another key take-home point is in our postoperative Crohn's patients, doing a colonoscopy at 6 months to look at the anastomosis and the ilium is quite important. Maybe doing a fecal calprotectin at 3 months as a surrogate marker for inflammation is important.

Low risk not necessarily need medicines, but monitor. If they have recurrence at 6 months, then we should initiate medicines before it gets too late.

Then finally, the high-risk patients, perforating, penetrating disease, multiple surgeries, cigarette smoking, these are the patients that I would start on biologics after surgery. Infliximab has been studied the most, although there are studies with ustekinumab and vedolizumab after surgery.

We should start and initiate treatment 2 to 4 weeks after surgery -- don't wait too long -- and then again fecal calprotectin at 3 months, colonoscopy at 6 months to make sure the patient isn't having recurrence.

Thank you all for attending ACG 2020. I hope this discussion on postoperative Crohn's disease recurrence and management was helpful. I also hope to see all of you some day soon in person, hopefully, but at least in 2021. Thank you very much.