Contemporary Management of Postoperative Crohn's Disease after Ileocolonic Resection

Abstract

Surgery remains an important treatment modality in the multidisciplinary management of patients with Crohn's disease (CD). To illustrate the recent advances in the management of postoperative CD we outline the contemporary approach to treatment: diagnosing disease recurrence using endoscopy or noninvasive methods and risk stratification underlying decisions to institute treatment. Endoscopic scoring indices are being refined to guide treatment decisions by accurately estimating the risk of recurrence based on endoscopic appearance. The original Rutgeerts score has been modified to separate anastomotic lesions from lesions in the neoterminal ileum. Two further indices, the REMIND score and the POCER index, were recently developed with the same intention. Noninvasive monitoring for recurrence using a method with high negative predictive value has the potential to simplify management algorithms and only perform ileocolonoscopy in a subset of patients. Fecal calprotectin, intestinal ultrasound, and magnetic resonance enterography are all being evaluated for this purpose. The use of infliximab for the prevention of postoperative recurrence is well supported by data, but management decisions are fraught with uncertainty for patients with previous exposure to biologics. Data on the use of ustekinumab and vedolizumab for postoperative CD are emerging, but controlled studies are lacking.

Keywords: endoscopy; fecal calprotectin; intestinal ultrasound; magnetic resonance enterography; noninvasive monitoring; prophylaxis; surgery.

Figure 1

Comparison of endoscopic indices for the assessment of postoperative Crohn’s disease. (A). The neoterminal ileum is free of ulceration, two ulcers, one of them deeper than 2 mm, are present at the anastomosis and cover more than 50% of the circumference. (B). There are more than five aphthous ulcers with normal intervening mucosa in the neoterminal ileum. The anastomosis is free of ulceration. (C). The neoterminal ileum is diffusely inflamed with large ulcers. The anastomosis is superficially ulcerated along more than 50% of its circumference. (D). The anastomosis is impassable due to stenosis. A superficial ulcer covers less than 25% of its circumference. Note that an anastomotic stenosis should be scored as i2 on the Rutgeerts score and i2a on its modified version. Only a stenosis in the neoterminal ileum should be scored as i4.

Figure 2

Proposed management algorithm for Crohn’s disease after ileocolonic resection, based on current guidelines (American Gastroenterological Association, British Society for Gastroenterology, European Crohn’s and Colitis Organization). Text in blue denotes potential changes to the algorithm in the near future. Abbreviations: MR—magnetic resonance; TNF—tumor necrosis factor; US—ultrasound.