Management of Post-Operative Crohn's Disease: Knowns and Unknowns

Abstract

Crohn's disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract characterized by relapsing-remission phases. CD often requires surgical intervention during its course, mainly ileo-cecal/ileo-colonic resection. However, surgery in CD is not curative and post-operative recurrence (POR) can happen. The management of CD after surgery presents challenges. Ensuring timely, effective, and safe therapy to prevent POR is essential but difficult, considering that approximately 20-30% of subjects may not experience endoscopic POR and that 40-50% will only exhibit intermediate lesions, which carry a low risk of mid- and long-term clinical and surgical POR. Currently, there are two accepted intervention strategies: early post-operative prophylactic therapy (systematically or based on the patient's risk of recurrence) or starting therapy after confirming endoscopic POR 6-12 months after surgery (endoscopy-driven prophylactic therapy). The risk of overtreatment lies in exposing patients to undesired adverse events, along with the costs associated with medications. Conversely, undertreatment may lead to missed opportunities to prevent bowel damage and the necessity for additional surgery. This article aims to perform a comprehensive review regarding the optimal strategy to reduce the risk of POR in CD patients and the current therapeutic options.

Keywords: Crohn’s disease; ileo-colonic resection; post-operative recurrence; prophylaxis strategy; risk factors.

Figure 1

Overview of the main pathophysiological mechanisms behind post-operative recurrence.

Figure 2

Possible strategies to prevent post-operative recurrence. * risk factors: smoking, prior intestinal surgery, penetrating disease at index surgery, granulomas in resection specimen, myenteric plexitis, <30 years old patient, extensive (>50 cm) bowel disease (adapted from ECCO, AGA, and BSG guidelines).