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06-06-2010, 08:48 PM   #1
David in Seattle
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Postoperative Crohn's Disease: Prevention and Treatment

Expert Rev Gastroenterol Hepatol. 2009;3(3):249-256. © 2009

Abstract and Introduction
Abstract

Crohn's disease is a chronic, relapsing–remitting inflammatory disease of the intestinal tract that commonly requires surgical treatment. Unfortunately, the majority of patients will ultimately develop postoperative disease recurrence and require subsequent surgery. A number of medications have been researched for the maintenance of postoperative remission. Of these, few have demonstrated consistent efficacy. A recently published randomized, controlled trial indicated that infliximab is effective in the maintenance of postoperative remission.
Introduction

Crohn's disease (CD) is a chronic, relapsing–remitting inflammatory disease that affects the entire GI tract. As many as 50–80% of CD patients will ultimately require surgery for complications such as fistulas, strictures, abscesses and perforations.[1–4] Surgery is often required early in the disease course, as demonstrated by Bernell et al., who found that 44% of patients underwent operations within the first year of diagnosis.[1]

Surgery does not cure CD and many patients suffer postoperative relapse at or just proximal to the surgical anastomosis. The behavior of CD recurrence, that is, whether the disease is stricturing or fistulizing, is usually the same as the primary indication for the initial surgery.[4–9]

At least 20% of patients who have undergone surgical resection will require a subsequent operation.[2,10] Data suggest that up to 50% of patients undergo reoperation after 20 years.[11–13] Efforts to reliably predict which patients will suffer recurrence have been only modestly successful; thus, researchers have tried to identify effective prophylaxis of relapse among postsurgical CD patients.[14]

Definition of Recurrence

Recurrence among CD patients has been defined in a variety of ways. Most commonly, postoperative recurrence is defined by the presence of radiographic, endoscopic or pathologic CD.[6,11] It is important to note that this definition is not predicated on the presence of clinical symptoms. Endoscopic recurrence at the ileocolonic anastomosis or neoterminal ileum has been quantified using a scoring system developed by Rutgeerts et al. (Box 1).[14,15] In addition to providing real-time recurrence assessment, the Rutgeerts score provides prognostic information: 80–85% of patients with a score of i-0 or i-1 will be asymptomatic 3 years after surgery compared with fewer than 10% of those with a score of i-3 or i-4.[2,14,15] Among those with a score of i-0 or i-1, the chance of clinical recurrence at 3 years is less than 5%, whereas endoscopic scores of i-2, i-3 and i-4 correlate with 3-year clinical recurrence rates of 15, 40 and 90%, respectively.[14] Endoscopic recurrence heralds clinical recurrence; therefore, many clinical trials consider recurrence as any score of i-2 or greater.[8,16,17]

Natural History of Postoperative CD Recurrence

Active CD can develop in the neoterminal ileum within a few weeks of surgical resection.[4,6,15] Olaison et al. have observed that the natural course of postoperative CD progresses from early aphthous ulcer formation to larger ulcers and then fistulas or strictures.[4–6] It is postulated that CD recurrence is triggered by a luminal factor that elicits inflammation and its sequelae.[6,18,19] Rutgeerts et al. found no new CD lesions among postoperative patients who had ileostomy and diversion of the fecal stream away from the distal ileocolonic anastomosis. When bowel continuity was reinstated, however, ulcers developed in the neoterminal ileum and CD progression ensued.[6,18,19] D'Haens et al. showed that intestinal contents elicited CD recurrence in the neoterminal ileum through both mucosal invasion by inflammatory cells and activation of lymphocytes.[20] The details of this process remain obscure. It is clear, however, that the subsequent disease course correlates to the severity of these early lesions.[4,15]

In a meta-analysis performed by Pascua et al., the 1-year postoperative pooled clinical recurrence rate was 56% and the endoscopic recurrence rate was 58%.[16] Other studies report 1-year postoperative endoscopic recurrence rates of between 73 and 93%, with clinical recurrence as low as 30%.[4,5,11,21] The need for repeat surgery 3 years after the initial intestinal resection ranged from 15 to 45% and was as high as 80% 20 years later.[8,13]

Postoperative Surveillance

Given the fact that postoperative endoscopic CD recurrence correlates with future clinical recurrence and the need for repeat surgery, there is increasing emphasis on endoscopic evaluation 6–12 months after surgery.[4,6,22]

Colonoscopy and wireless capsule endoscopy (WCE) are the two primary modalities to assess for mucosal recurrence. Bourreille et al. recently compared the effectiveness of WCE and ileocolonoscopy and found that ileocolonoscopy was more sensitive in detecting neoterminal lesions. However, efforts are underway to more formally assess small bowel CD and establish a scoring system for WCE.[4,14,23] A recent publication by Gralnek et al. offers such a scoring system that looks at three different parameters: villous edema, ulcers and stenosis.[24] Capsule retention is an additional concern in the use of WCE to monitor postoperative CD patients. While WCE is generally safe, capsule retention necessitating surgical extraction occurs in 10–13% of CD patients. At present, colonoscopy with inspection of the ileocolonic anastomosis and neoterminal ileum is the test of choice for the evaluation of postoperative CD. WCE should be reserved for patients with mid-small bowel surgical anastomosis or anastomosis at other sites outside of the reach of the standard colonoscope.

Last edited by David in Seattle; 06-06-2010 at 08:52 PM.
06-06-2010, 08:48 PM   #2
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Risk Factors for Disease Recurrence

Most patients will develop postoperative CD recurrence; however, a small percentage do not. Determining the risk factors that predispose a patient to recurrent CD may help identify those most likely to benefit from prophylactic medication.[12] Risk factors are divided into three categories, described as follows.[12]
Patient-related Risk Factors

Cigarette smoking has been associated with an increased risk of developing CD and a higher likelihood of requiring surgical resection, and is the only identified patient-related risk factor for postoperative recurrence of CD.[13] After surgery, persistent smoking increases the risk of relapse.[25] Cottone et al. have demonstrated that smoking increased endoscopic, clinical and surgical relapse among postoperative CD patients.[26] Furthermore, data suggest a dose–response pattern, with heavy smoking (defined as use of > 15 cigarettes per day) leading to worse relapse rates than mild smoking (defined as use of < 15 cigarettes per day).[13] The reported 5-year risk of reoperation among nonsmokers was 20%, whereas, amongst smokers this rate was 36%.[4,20,27–29] It is important to note that smoking cessation effectively lowers the risk of relapse.[13]

Among smokers, women have a higher risk of recurrence. Cosnes et al. found that female smokers who had undergone surgery for CD had a 52% recurrence rate requiring immunosuppressant treatment 10 years after surgery, compared with a 24% risk among nonsmokers.[25]
Disease-related Risk Factors

Disease-related risk factors include the patient's age at disease onset, the duration and course of the disease prior to surgery, CD phenotype (i.e., stricturing or penetrating), disease severity and extension.[12]

Some data suggest that patients with perforating disease or those with a short and severe preoperative disease course are more likely to suffer recurrence after resection.[30] Poggioli et al. observed that patients with disease duration shorter than 6 years before surgery were more likely to recur than those with longer disease duration.[31] This was confirmed in other studies, which reported higher relative relapse rates among those undergoing surgery within 3–10 years of diagnosis.[13,32] However, other investigators have not identified such a correlation.[13] Lautenbach et al. retrospectively assessed 88 patients who had required at least two CD surgeries and found that a long preoperative duration of CD actually increased the likelihood of earlier surgical recurrence.[8]

Similarly, studies of the impact of disease location on postoperative CD recurrence have yielded mixed results. Some studies have demonstrated higher recurrence rates in patients with ileocolonic anastomosis compared with those with colocolonic or ileoileal anastomosis, while other studies have not.[1,13,17] Michelassi et al. found that multisite disease involvement predicted at least a 2.5-fold higher surgical relapse rate than single-site disease.[10] There is also controversy, although no conclusive evidence, about whether or not resection of a large portion of bowel (usually defined as > 100 cm) increases the risk of disease recurrence.[13,14]

A family history of CD has not been definitively shown to increase the risk of postoperative CD recurrence. Some studies found that a positive family history of CD increased the likelihood of a subsequent reoperation;[13,33] however, another found that a positive family history of CD had no effect on the postoperative CD recurrence rate.[32]

Penetrating CD is an aggressive form of the disease that may present as an acute or chronic perforation, abscess or fistula. Postoperative recurrence is likely to occur in patients with penetrating disease, and repeated surgery is common.[4,7,8,28] Although most studies show a significant increase in postoperative CD recurrence in patients with penetrating disease, one study did not find a higher rate of recurrence.[31] However, a recent study by Sachar et al. did show a strong tendency for early postoperative recurrence in patients with penetrating disease as compared with patients with stricturing disease.[30]
Surgery-related Risk Factors

The relationships between surgical factors and postoperative CD recurrence have been examined, including the type of anastomosis, the width of the surgical margins, perioperative complications, the presence of granulomas and the need for blood transfusion.[12,13]

Data do not consistently implicate the type of anastomosis (i.e., hand-sewn vs stapled), the extent of resection (radical vs limited) or the presence of microscopic disease at the resection margins in postoperative CD recurrence.[12] In a multicenter study by Ewe et al., nonradical bowel resection was less likely to be related to recurrence than radical surgery, although the surgical approaches may reflect the disease severity. The risk of postoperative relapse does not seem to be affected by the width of the resection margin.[34] Yamamoto et al. compared relapse rates among CD patients undergoing resection with stapled end-to-end anastomoses and those undergoing hand-sewn end-to-end anastomoses. They found that stapled anastomoses were associated with significantly lower cumulative 5-year reoperation rates.[35] Caprilli et al. reported that patients with end-to-side and side-to-side anastomoses following ileocecal resection fared better that those with end-to-end anastomoses. They postulated that bacterial overgrowth and colonic reflux into the neoterminal ileum may account for these differences.[36] Data published by Scarpa et al. suggest that ileocolonic resection accompanied by side-to-side anastomosis may lead to lower surgical site recurrence rates, and may delay the need for repeat surgery.[37] While laparoscopic resection is associated with a lower incidence of subsequent small bowel obstructions compared with resections performed with an open approach, the two approaches do not differ in the associated 5-year CD recurrence rates.[38]

Conflicting data have emerged about the role, if any, that postsurgical complications may play in recurrence rates. Scarpa et al. found that postsurgical anastomotic leakage, bleeding and obstruction correlated with higher relapse rates, while work by Poggioli et al. found no such effect.[31,37]

Conflicting data exist about the roles of the presence of granulomas in the resected surgical specimen, and the effects of blood transfusions.[13] A pooled analysis could find no protective effect associated with perioperative blood transfusions.[13]

Given the conflicting risk-factor data, the emphasis on postoperative risk stratification has been on the two factors for which consistent and strong data exist: the presence of perforating disease and cigarette smoking. As the only potentially modifiable risk factor, and one strongly correlated with recurrence, all patients who smoke should be counseled and supported in their smoking cessation efforts.[12]
06-06-2010, 08:49 PM   #3
David in Seattle
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Treatment Options for Decreasing Recurrence

There have been a variety of medications evaluated for the prevention of postoperative CD recurrence, and the efficacy of these agents has varied widely (Table 1).[39]
5-aminosalicylate

Aminosalicylates (ASAs) were among the first medications studied for prophylaxis of postoperative CD. The large European Cooperative CD Study IV compared the efficacy of mesalamine (4 g/day) to that of placebo in reducing the rate of postoperative CD recurrence and found no significant differences between the two groups.[4,40] Results reported by Mcleod et al. differed, demonstrated a reduction in surgical recurrence when patients received mesalamine (3 g/day).[41] Brignola et al. conducted a randomized, double-blind, placebo-controlled, multicenter study comparing recurrence rates between postoperative CD patients who received either mesalamine (3 g/day) or placebo, and found a reduction in the frequency and severity of endoscopic recurrence. Clinical recurrence rates remained similar between the groups.[42] In a double-blind, randomized, multicenter, prospective comparison trial of mesalamine (4 g/day) and mesalamine (2.4 g/day), Caprilli and colleagues were unable to show any significant difference in clinical relapse rates at 1 year.[43]

The discrepancies in results between the various mesalamine studies likely stem from both the use of a range of mesalamine formulations and dosages, and the use of varying definitions of recurrence.[4] In aggregate, most studies, including multiple randomized clinical trials and a meta-analysis by Cottone et al., show only a minimal benefit of 5-ASA compared with placebo.[3,4,6,12,43–47] Thus, 5-ASA formulations probably play only a limited role in preventing postoperative CD recurrence.
Corticosteroids

In a recent Cochrane review of three large, randomized, controlled trials, corticosteroids were ineffective in maintaining remission.[14,48] Two randomized, controlled trials comparing placebo and budesonide (one: 3 mg/day; and the other: 6 mg/day) failed to demonstrate any differences the in maintenance of remission among postoperative CD patients.[49,50] Thus, no evidence supports the role of steroids in preventing postoperative CD recurrence.[6]
Probiotics

The intestinal flora has been implicated in CD recurrence after surgery. Altering the gut flora with antibiotics or probiotics could decrease postoperative recurrence of CD.[14,18] Despite this, clinical trials using different strains of lactobacilli (Lactobacillus johnsonii and Lactobacillus GG) have failed to show effectiveness in preventing disease recurrence.[22,45,51,52] Whether other strains of different bacteria may ultimately provide a benefit remains to be seen.
Nitroimidazole Antibiotics

In a randomized, placebo-controlled trial, metronidazole (20 mg/kg/day), started within 7 days postoperatively and continued for 12 weeks, was associated with significant reductions in severe endoscopic CD recurrence.[53] An evaluation of another nitroimidazole antibiotic, ornidazole (1 g/day), for 1 year demonstrated similar significant reductions in clinical and endoscopic recurrence rates.[44,54] Despite their promising efficacy, the long-term use of these antibiotics is limited by their side effects, including peripheral neuropathy.[3,4,6] Disease returns once these medications are stopped and, therefore, nitroimidazole antibiotics have a limited role in maintaining postoperative remission.[3,6]
Mercaptopurine & Azathioprine

Many data support the use of 6-mercaptopurine (6-MP) and azathioprine (AZA) to induce and maintain remission in moderately severe CD.[55–57] Furthermore, in a retrospective study of more than 2500 CD patients, the use of immunosuppressants did not reduce the need for overall surgery, but did reduce large intestine resections.[58] The researchers concluded that these findings likely reflected a delay in the initiation of immunosuppressant therapy rather than a lack of efficacy.[58] Based on these data, immunomodulators have been evaluated in the setting of postoperative CD prophylaxis.

In a multicenter study, 6-MP (50 mg/day) was more effective than placebo in the prevention of clinical and endoscopic postoperative CD recurrence over 2 years.[9,44] This study, however, had a large dropout rate; only 69% of those enrolled could be evaluated at the end of 2 years. Another factor that potentially limits the broader generalizability of these findings is that the medication dosage prescribed was lower than the previously established effective dose (1.5 mg/kg/day), which may underestimate the effectiveness of the drug. In addition, rates of clinical recurrences were greater than endoscopic recurrences.[3,4,44] Other studies failed to show a similar benefit. In an open-label study, Ardizzone et al. compared AZA (2 mg/kg/day) to mesalamine (3 g/day) over a 24-month period.[59] No differences were found in the study's end points of clinical recurrence or surgical relapse.[6,59] In a different study, the use of AZA (2–2.5 mg/kg/day) appeared to merely delay the need for escalation of medical therapy or surgery, rather than to prevent it.[60] In a trial of combination therapy by D'Haens et al., patients were all treated with 3 months of metronidazole, with half also receiving AZA for 1 year and the other half recieving placebo. Patients receiving combination therapy suffered recurrence rates of 43.7% after 1 year compared with 69% in the placebo arm.[61] In summary, the trials on immunomodulators appear to report a modest effect on decreasing postoperative recurrence of CD.[12,58,60]
Infliximab

Infliximab is a monoclonal antibody directed against TNF-α. It has been successfully used for the induction and maintenance of remission of CD, and has recently been the subject of investigation regarding the prevention of postoperative CD recurrence. In a 2006 report by Sorrentino et al., a 23-year-old female who began infliximab 2 weeks following surgical resection of a fibrotic sigmoid stricture maintained clinical and endoscopic remission 4 years later.[62] The same group performed a small open-label study comparing a combination of infliximab and methotrexate with mesalamine monotherapy.[63] Seven patients received infliximab (5 mg/kg/day) and methotrexate (10 mg/week orally) while 16 patients received mesalamine (2.4 g/day). After 2 years, none of the patients who received the infliximab/methotrexate combination had recurrence, while 75% of the mesalamine-treated group suffered recurrence.[63]

The results of the first randomized, double-blind study of infliximab for the prevention of postoperative CD recurrence were recently published by Regueiro et al..[64] In this study, 24 patients were randomized to receive placebo or infliximab (5 mg/kg) within 4 weeks of surgery; infusions were at 0, 2 and 6 weeks, followed by every 8 weeks for 1 year.[64] The primary end point of the study was endoscopic recurrence 1 year after surgery, with clinical recurrence and histologic recurrence as secondary end points. Corticosteroids and antibiotics were discontinued within 12 weeks of surgery, whereas 5-ASAs or immunomodulators were continued postoperatively if the patient had been receiving a stable dose for at least 12 weeks or longer prior to surgery. Endoscopic recurrence developed in only one (9.1%) infliximab-treated patient compared with an endoscopic recurrence rate of 84.6% among those who received placebo. Among patients who had endoscopic recurrence, those who did not receive infliximab suffered more severe recurrence, with endoscopic scores of i-2 in 30.8%, i-3 in 23.1% and i-4 in 30.8% of patients. Clinical recurrence occurred in none of the patients receiving infliximab, whereas clinical recurrence occurred in five out of the 13 placebo-treated patients. The data from this small study suggest that infliximab is effective in preventing CD relapse after curative surgical resection.[64] Further larger studies are required to confirm this finding and explore whether all anti-TNF-α medications confer similar benefits.
Others

Other approaches to prevent postoperative CD recurrence have been explored, including the use of recombinant human IL-10, omega-3 fatty acids and enteral nutrition.[22,45,65] Of these, positive results have been published only for enteral nutrition; in a nonblinded prospective study by Yamamoto et al., patients who were treated with nocturnal elemental infusion and restricted low-fat daytime diets had significantly less endoscopic recurrence than patients who had unrestricted diets and received no nocturnal enteral feeding.[14,66]
06-06-2010, 08:51 PM   #4
David in Seattle
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Approaches to Patient Management

Currently, our ability to reliably predict patients at risk for postoperative CD recurrence is limited. Attempts to use serum markers, such as the erythrocyte sedimentation rate and C-reactive protein levels, have been disappointing. Data are accruing on the use of stool calprotectin levels, antibody panels and genetic testing for Nod2/CARD15; however, at this stage, all remain experimental.[12]

To date, guidelines for the prevention of postoperative CD do not exist. Therefore, the authors propose risk-stratifying patients into very low-risk, low-to-moderate risk and high-risk groups, based on clinical factors such as the number of surgeries, the disease duration prior to surgery, severity and phenotype. Based on the risk of postoperative CD recurrence we offer the following postoperative prevention strategy (Figure 1). It is our opinion that colonoscopy with inspection of the ileocolonic anastomosis and neoterminal ileum is the most effective way to identify postoperative CD recurrence. It has become our practice to perform colonoscopy within 1 year of surgery and then at defined intervals (1–3 years) thereafter depending on the patient's symptoms and medical treatment.

We define very low-risk patients as those undergoing their first surgery for long-standing (> 10 years), nonperforating CD complicated by a less than 10 cm stricture. For these patients, it is reasonable to use no postoperative medical therapy, and to reassess disease activity at 6–12 months using ileocolonoscopy. If no disease is found on postoperative colonoscopy, then we recommend that the patient remain on a surveillance regimen of endoscopic evaluation every 1–3 years. For those whose initial follow-up evaluation shows disease recurrence, an immunomodulator or infliximab should be considered, with the latter reserved for those with evidence of a more severe recurrence.

We define low-to-moderate risk patients as those with CD for fewer than 10 years before their first surgery, with an inflammatory CD phenotype or a long stricture. We recommend that this group receive postoperative immunomodulators, with or without nitroimidazole antibiotics, for the first 3 months. A follow-up ileocolonoscopy should still be performed 6–12 months after surgery. If no recurrence is found then we recommend continuing immunomodulators; if evidence of CD is found then an anti-TNF agent should be added. We recommend endoscopic surveillance every 1–3 years for those in remission, and for treatment to be altered for those patients with significant endoscopic recurrence.

We define high-risk patients as those with perforating disease or those having required more than two CD surgeries. We recommend postoperative anti-TNF therapy for these patients. If there is no disease recurrence at the 1-year follow-up ileocolonoscopy, it is the authors' opinion that anti-TNF treatment should be continued. Whether anti-TNF therapy is required indefinitely or may be stopped after a period of time is not currently known. If CD recurs on follow-up colonoscopy, then we recommend that the dose be increased or the dosing interval be decreased, or switching to another biologic treatment. Again, we recommend endoscopic surveillance every 1–3 years.

Figure 1.

Assessment and management of postoperative Crohn's disease.
*Long–standing Crohn's disease, first surgery, short stricture.
‡Less than 10 years of Crohn's disease, long stricture or inflammatory Crohn's disease.
§Penetrating disease, more than two surgeries.
Reproduced with permission from [40].

fig-1.jpg
06-06-2010, 08:52 PM   #5
David in Seattle
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We define very low-risk patients as those undergoing their first surgery for long-standing (> 10 years), nonperforating CD complicated by a less than 10 cm stricture. For these patients, it is reasonable to use no postoperative medical therapy, and to reassess disease activity at 6–12 months using ileocolonoscopy. If no disease is found on postoperative colonoscopy, then we recommend that the patient remain on a surveillance regimen of endoscopic evaluation every 1–3 years. For those whose initial follow-up evaluation shows disease recurrence, an immunomodulator or infliximab should be considered, with the latter reserved for those with evidence of a more severe recurrence.

We define low-to-moderate risk patients as those with CD for fewer than 10 years before their first surgery, with an inflammatory CD phenotype or a long stricture. We recommend that this group receive postoperative immunomodulators, with or without nitroimidazole antibiotics, for the first 3 months. A follow-up ileocolonoscopy should still be performed 6–12 months after surgery. If no recurrence is found then we recommend continuing immunomodulators; if evidence of CD is found then an anti-TNF agent should be added. We recommend endoscopic surveillance every 1–3 years for those in remission, and for treatment to be altered for those patients with significant endoscopic recurrence.

We define high-risk patients as those with perforating disease or those having required more than two CD surgeries. We recommend postoperative anti-TNF therapy for these patients. If there is no disease recurrence at the 1-year follow-up ileocolonoscopy, it is the authors' opinion that anti-TNF treatment should be continued. Whether anti-TNF therapy is required indefinitely or may be stopped after a period of time is not currently known. If CD recurs on follow-up colonoscopy, then we recommend that the dose be increased or the dosing interval be decreased, or switching to another biologic treatment. Again, we recommend endoscopic surveillance every 1–3 years.

Conclusion

Crohn's disease patients frequently require surgery for a complication of their disease, such as a fibrostenotic stricture or penetrating disease. Disease recurrence postoperatively is the norm rather than the exception. Regardless of postoperative therapy, we recommend surveillance ileocolonoscopy 6–12 months after surgery and, in the case of significant endoscopic recurrence, the therapy be intensified or changed. Cigarette smokers must quit smoking and aggressive efforts should be made to assist in cessation efforts. Medications vary in their efficacy for postoperative CD prevention, and the choice of treatment should be made based on the likelihood of recurrence. Recent data suggest that infliximab is effective at preventing postoperative CD recurrence and should be considered in patients at high risk for recurrence, that is, those with perforating disease or with two or more resections.

Expert Commentary

The management of inflammatory bowel disease continues to evolve rapidly. Increasingly, it appears that phenotypic disease manifestations may relate to differences in the underlying pathophysiology that, in turn, relate to the efficacy of various therapeutic approaches. Currently, we have few reliable indicators to identify which patients may benefit from a given therapy or an early 'top-down' approach compared with a progressive 'step-up' treatment. Developments are occurring rapidly to help assist in these clinical decisions and, in parallel, the range of available treatments continues to expand.

Postoperative CD offers a unique model of the natural course of disease recurrence. Specifically, at the time the surgeon leaves the operating room from performing an intestinal resection of macroscopically active CD, the patient is 'cured.' Invariably, with time, the CD recurs at or just above the anastomosis. To date, we have not been able to uniformly prevent recurrence or identify clear-cut factors that predict disease recurrence. However, recent data suggest that, for patients with aggressive disease (more than two surgeries and penetrating disease), postoperative anti-TNF therapy, prevents 1-year recurrence. For what length of time to continue anti-TNF after surgery is not known. Patients in the postoperative infliximab study are being followed long-term; patients in remission 1 year after surgery who stop their infliximab are of particular interest in determining whether infliximab may be stopped. Regardless of the treatment approach, we believe that colonoscopy within the first year is important for detecting endoscopic recurrence and guiding subsequent therapy. The unanswered question is whether treatment initiated in response to endoscopic recurrence is as effective as treatment initiated prophylactically in the immediate postoperative setting.

Five-year View

Predicting the future of inflammatory bowel disease treatment is difficult but in 5 years there will likely be additional data on the efficacy of anti-TNF therapy and other biologics in the postoperative setting. These studies will likely confirm the early findings on the benefit of postoperative administration of anti-TNF therapy and this treatment strategy will become more widely adopted.

In 5 years, there will probably be research designed to evaluate surgical resection as the true 'top-down' approach. This means that CD patients newly diagnosed with advanced disease, especially those with penetrating complications, may undergo surgical resection followed by anti-TNF therapy as their first therapeutic intervention. Additionally, there will be a greater understanding of the genotypes and other biologic signals that may predict the disease course of CD and the patients' response to treatment.
06-07-2010, 04:26 PM   #6
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Thank you for posting this David.
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Mum of 2 kids with Crohn's.
06-07-2010, 09:01 PM   #7
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David until Steven Hawkins passes,your the second smartest person on earth, that was great post for me,I was dx in Nov 09 with a narrow spot about 3 in long, in my colon about 7 in from my small intestine, put me on Humira did another colonoscopy May 29 still the same my doc said lets cut it out,those stats you posted is what he was telling me he wants to do,I think he wants do 6mp after the surgery he also said because of my age (dx at 53) my chances increase 2 fold of the crohnie not comming back,I havent meet the surgeon yet but i checked him out he has been a gut cutter for 20+ years Loma Linda trained. I took a shot of Humira June 2 i think you have to be 30 days clean so July i'm ready lets start this party. Great post David thanks.
06-08-2010, 08:01 PM   #8
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David until Steven Hawkins passes,your the second smartest person on earth...
WOW, Thanks! Can I get that in writing?

I'm glad you guys found the information helpful!
07-11-2010, 03:53 AM   #9
Adi
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David,
I'm 35 years old, diagnosed with Crohn for 17 years. First 15 were very quiet. Only took Pentasa.
Last 2 years with more pains so started with Prednisone.
Since January situation deteriorated. Had abscess due to perforation in the terminal ileum and when nothing helped went through laparoscopic surgery 5 weeks ago.
20 cm of my terminal ileum were removed, the rest of the colon looks clean and healthy.
My gastroenterolog is pondering should I start taking Humira.
What's your suggestion based on the chart?

Thanks,
Reply

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