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. 2023 Apr 3;17(3):318-328.
doi: 10.1093/ecco-jcc/jjac139.

Benefit of Risk-stratified Prophylactic Treatment on Clinical Outcome in Postoperative Crohn's Disease

Vincent Joustra  1 , Joris van Sabben  1 , Eline van der Does de Willebois  2 , Marjolijn Duijvestein  3 , Nanne de Boer  4 , Jeroen Jansen  5 , Jarmila van der Bilt  2 , Wytze Lameris  2 , Willem Bemelman  2 , Christianne Buskens  2 , Geert D'Haens  1
Affiliations

Benefit of Risk-stratified Prophylactic Treatment on Clinical Outcome in Postoperative Crohn's Disease

Vincent Joustra et al. J Crohns Colitis. .

Abstract

Background and aims: Whereas immediate postoperative treatment has shown effectiveness in reducing endoscopic postoperative recurrence [POR], evidence regarding the clinical benefit is limited. We compared rates of clinical POR in Crohn's disease [CD] patients receiving immediate prophylactic treatment with rates in patients receiving endoscopy-driven treatment.

Methods: We retrospectively collected data from 376 consecutive CD patients who underwent an ileocaecal resection with anastomosis between 2007 and 2018 with at least 3 years of follow-up at three sites. Subsequently, high- and low-risk patients categorised by established guidelines, who underwent endoscopy within 12 months postoperatively, were grouped according to a prophylactic- or endoscopy-driven approach and compared for incidence and time till endoscopic and clinical POR.

Results: Prophylactic treatment reduced rates of and time till endoscopic POR within 1 year in high-risk (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.27-0.86, p = 0.04, number needed to treat [NNT] = 5) but not low-risk [HR 0.90, 95% CI 0.32-2.56, p = 0.85] patients. Conversely, no significant differences in clinical POR within 3 years between prophylactic- and endoscopy-driven low-risk [HR 1.17, 95% CI 0.41-3.29, p = 0.75] and high-risk patients were observed [HR 1.06, 95% CI 0.63-1.79, p = 0.82, NNT = 22]. However, a large numerical albeit not statistical significant difference in 3-year clinical POR [28.6% vs. 62.5%, p = 0.11] in a subset of high-risk patients with three or more ECCO-defined risk factors was observed, indicating a cumulative effect of having multiple risk factors.

Conclusion: Our observations favour step-up treatment guided by early endoscopic evaluation with prophylactic treatment reserved for carefully selected high-risk patients, in order to avoid potential overtreatment of a significant number of patients.

Keywords: Inflammatory bowel disease; postoperative recurrence; prevention; risk stratification.

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Conflict of interest statement

VJ, JS, EW MD, JJ, JB, AM, WL, WB, CB, GD: none to declare. NdB has served as a speaker for AbbVie and MSD and has served as consultant and/or principal investigator for TEVA Pharma BV and Takeda. He has received [unrestricted] research grant from Dr Falk, TEVA Pharma BV, MLDS, and Takeda, all outside the submitted work.

Figures

Graphical Abstract
Graphical Abstract
Figure 1.
Figure 1.
Flowchart demonstrating the selection of patients.
Figure 2.
Figure 2.
Bar charts showing the rates of clinical POR within 3 years [a] and endoscopic POR within the first year following surgery [b] for the risk-stratified prophylactic in red and endoscopy-driven in blue. POR, postoperative recurrence.
Figure 3.
Figure 3.
Kaplan–Meier survival plot showing the endoscopic- and clinical POR-free survival rates between the low-risk [3a and 3b] prophylactic- [n = 11] and endoscopy-driven [n = 44] as well as high-risk [3c and 3d] prophylactic- [n = 37]- and endoscopy-driven [n = 111] treatment strategies. Time till event is calculated as either weeks or years from surgery till objectified endoscopic and clinical POR, respectively. POR, postoperative recurrence.
See this image and copyright information in PMC

Comment in

References

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