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Predictive factors for endoscopic recurrence after ileocolic resection for Crohn's disease.

These days, despite the increased use of immunomodulators and biologic agents, approximately 70%-80% of patients with Crohn's disease (CD) undergo surgical resection and up to 70% of these require a second operation due to continuing inflammation (1). Therefore, postoperative recurrence (POR) still remains a crucial issue. The mechanism of POR is not exactly known, but it may be mediated by luminal contents. POR can be determined and measured clinically and endoscopically (2).

Clinical POR can be defined as the recurrence of symptoms leading to treatment changes or hospitalization after the exclusion of other causes such as bile salt diarrhea, bacterial overgrowth, and obstruction due to adhesions (3). Clinical POR rates are lower than endoscopic recurrence rates. Clinical POR develops within 1 year after surgery in approximately 25% of patients (4).

Endoscopic POR is generally considered to precede clinical recurrence and has been reported to occur in 58%-72% of patients within 1 year postoperatively (4). The mucosa proximal to the intestinal anastomosis (neoterminal ileum) is at a particularly high risk of recurrence. Endoscopic POR can be quantified using Rutgeerts endoscopic score, and endoscopy-based management can be applied (5). Based on this score, five recurrence risk groups have been defined (Table 1). Endoscopic recurrence is generally defined as Rutgeerts score of [greater than or equal to]i2 (5).

In the present article, a retrospective single-center study was conducted; it included 42 patients with CD who had undergone ileocolic resection between 2003 and 2014 (6). The endoscopic POR rate within 6-12 months after ileocolic resection was 59.5% (25 of 42 patients). This recurrence rate was comparable with that in other studies that have reported endoscopic recurrence rates in 54%-75% of patients within 1 year after surgical resection (6).

Currently, there is no agreement on the optimal approach to reduce POR in patients with CD. Patient stratification according to Rutgeerts scoring system is still the cornerstone in patients with CD within the first year after surgical resection (5). As the result of endoscopy is obtained within 6-12 months after surgery, it does not help physicians determine the best therapeutic approach during the early postoperative period. During this period, some predictive factors can be used to discriminate high-risk patients (7). Smoking, prior intestinal resection, penetrating disease behavior, perianal disease, extensive bowel disease (>50 cm), preoperative corticosteroid use, postoperative immunomodulatory or biologic medical treatment, the presence of granulomas, myenteric plexitis, and fecal calprotectin have been found to be risk factors for POR (1,2,4,7-9). However, the POCER trial, in which smoking, penetrating disease behavior, and prior intestinal resection were accepted as high risks for endoscopic recurrence, reported that almost half of the low-risk patients experienced endoscopic POR 18 months after surgery (9). Therefore, the impact of predictive factors still remains limited (7). In the present article, most of these factors previously cited were not significant in increasing endoscopic POR. Perianal disease and the shorter duration of CD have been found to be the only predictive factors for endoscopic POR (6).

Our efforts should continue to identify high-risk patients for endoscopic POR with the hope of a better prognosis that can allow a targeted approach and beneficial therapeutic prophylaxis.

REFERENCES

(1.) de Barcelos IF, Kotze PG, Spinelli A, et al. Factors affecting the incidence of early endoscopic recurrence after ileocolonic resection for Crohn's disease: a multicenter observational study. Colorectal Dis 2017; 19: 39-45. [CrossRef]

(2.) Connely TM, Messaris E. Predictors of recurrence of Crohn's disease after ileocolectomy: a review. World J Gastroenterol 2014; 20(39):14393-406. [CrossRef]

(3.) Boucher AL, Pereira B, Decousus S, et al. Endoscopy-based management decreases the risk of postoperative recurrences in Crohn's disease. World J Gastroenterol 2016; 22: 5068-78. [CrossRef]

(4.) Fortinsky KJ, Kevans D, Qiang J, et al. Rates and predictors of endoscopic and clinical recurrence after primary ileocolic resection for Crohn's disease. Dig Dis Sci 2017; 62: 188-96. [CrossRef]

(5.) Hashash JG, Binion DG. Endoscopic evaluation and management of the postoperative Crohn's disease patient. Gastrointest Endosc Clin N Am 2016; 26: 679-92. [CrossRef]

(6.) Monteiro S, Curdia Goncalves T, Boal Carvalho P, Moreira MJ, Cotter J. Updating predictors of endoscopic recurrence after ileocolic resection for Crohn's disease. Turk J Gastroenterol 2017; June 7. doi: 10.5152/tjg.2017.16721. [Epub ahead of print]. [CrossRef]

(7.) Decousus S, Boucher AL, Joubert J, et al. Myenteric plexitis is a risk factor for endoscopic and clinical postoperative recurrence after ileocolonic resection in Crohn's disease. Dig Liver Dis 2016; 48: 753-8. [CrossRef]

(8.) Wright EK, Kamm MA, De Cruz P, et al. Cost-effectiveness of Crohn's disease post-operative care. World J Gastroenterol 2016; 22: 3860-8. [CrossRef]

(9.) De Cruz P Kamm MA, Hamilton AL, et al. Crohn's disease management afterintestinal resection: a randomised trial. Lancet 2015; 385: 1406-17. [CrossRef]

Hale Akpinar

Division of Gastroenterology, Department of Internal Medicine, Dokuz Eylul University School of Medicine, Izmir, Turkey

Cite this article as: Akpinar H. Predictive factors for endoscopic recurrence after ileocolic resection for Crohn's disease. Turk J Gastroenterol 2017; 28: 241-2.

Address for Correspondence: Hale Akpinar E-mail: haleakpinar05@gmail.com

[c] Copyright 2017 by The Turkish Society of Gastroenterology * Available online at www.turkjgastroenterol.org
Table 1. Definition of Rutgeerts postoperative endoscopic ileal score
(4)

Score  Definition

i0     No lesions
i1     [less than or equal to]5 aphthous lesions
i2     >5 aphthous lesions with normal mucosa between the
       lesions or skip areas of larger lesions or lesions confined to
       the ileocolonic anastomosis
i3     Diffuse aphthous ileitis with diffusely inflamed mucosa
i4     Diffuse inflammation with already larger ulcers, nodules, and/or
       narrowing
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Author:Akpinar, Hale
Publication:The Turkish Journal of Gastroenterology
Article Type:Report
Date:Jul 1, 2017
Words:919
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