Biography
Biography: Vito Annese
Abstract
Statement of the Problem: Postoperative recurrence of CD is common; rates may vary depending on definition used. If untreated endoscopic recurrence will be 80%-100% within 3 years and clinical recurrence 20%-25% within 2 years. The purpose of this study is to review the strategy of risk stratification and better management of recurrence prevention.
Methodology: Extensive literature search.
Findings: Severity of endoscopic lesions used as predictive marker for future recurrence rates with a scoring system derived from seminal study by Rutgeerts. Risk factors for postoperative recurrence are: Smoking, prior intestinal surgery, absence of prophylactic treatment (EL1), penetrating disease at index surgery, perianal location (EL2), granulomas in resection specimen (EL2) and myenteric plexitis (EL3). Standard of care for preventing recurrence are: Endoscopic monitoring 6 to 12 months after surgery, prophylactic treatment with mesalamine (5-ASA), nitroimidazole antibiotics and thiopurines. Although safe, 5-ASA has high NNT to avoid clinical recurrence (=12) and endoscopic recurrence (=8). Using nitromidazole antibiotics reduced relapse rates, however, twice as many patients had adverse events and the effect is not sustained beyond 12 months. Thiopurines (AZA or MP) have shown variable benefit in reducing relapse rates in patients with postoperative, but with greater serious AEs than 5-ASA. Studies of postoperative treatment with anti-TNFα have significantly reduced endoscopic and surgical recurrence but not clinical recurrence (see figure).
Conclusion & Significance: Results from large recent trials (e.g. POCER, PREVENT, TOPPIC) have redefined frequency of endoscopic recurrence (±50% at 1 year; ±80% at 2 year) and its implications (clinical recurrence ±25% at 2 year) if untreated. Until more evidence is evaluated, the current standard of care includes: Smoking cessation, colonoscopic assessment within 1st year after resection, individualized prophylaxis for patient-to-patient basis.