DOP36 Non-invasive assessment of postoperative disease recurrence in Crohn’s Disease: A multicenter, prospective cohort study

Abstract Background Prevention of postoperative recurrence is a critical goal in Crohn’s disease (CD) management. Currently, postsurgical CD management and treatment are based on endoscopic monitoring performed within the first year after surgery. However, colonoscopy (CS) is an invasive and expensive procedure, unpleasant to patients. A non-invasive and patient friendly approach is required. Methods Consecutive CD patients who underwent ileo-cecal resection from July 2017 to January 2020 were prospectively enrolled in three Italian Centers and performed CS and bowel ultrasound (US) after six months from the surgery, in a blinded fashion. The patients also underwent complete clinical assessment and blood and stool samples were obtained for C-reactive protein (CRP), and fecal calprotectin (FC) measurements. The disease was considered clinically active if the Harvey–Bradshaw Index (HBI) was higher than 4. Uni- and multivariable analyses were used to assess the correlation between non-invasive parameters, including bowel US findings and FC values and endoscopic recurrence, defined by a Rutgeerts’s score (RS) > 2. Sensitivity, specificity, accuracy, PPV and NPV of bowel US parameters alone and in combination with FC in assessing endoscopic recurrence were calculated. Results Seventy patients were enrolled, 45 patients (64%) had an endoscopic recurrence (RS > 2) at 6 months. Thirteen out of 45 (29%) were symptomatic (HBI > 4). Bowel wall thickness (BWT), bowel wall flow (BWF, presence of vascular signals at color Doppler), the presence of mesenteric hypertrophy, the presence of limph-nodes and FC values significantly correlated with the endoscopic recurrence (p < 0.005). Independent predictors for endoscopic recurrence were BWT (for 1-mm increase: OR 2.63; 95% CI 1.136.12; p= 0.024), presence of lymph-nodes (OR 23.24; 95% CI 1.85291.15; p= 0.014) and FC > 50 µg/g (OR 11.86; 95% CI 2.60–54.09; p= 0.001). Sensitivity, specificity, accuracy, PPV and NPV of bowel US and/or FC are showed in Table 1. Table 1: Diagnostic accuracy of Bowel US and/or FC compared to CS in assessing endoscopic activity (CI 95%): per-patient analysis Conclusion Combined use of bowel US and FC is accurate in assessing endoscopic recurrence at 6 months in CD patients and represent a valid alternative to endoscopic assessment after surgery

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Postoperative Management of Crohn’s Disease: What Can We Do to Prevent Recurrence?

Internal Medicine Review ◽

10.18103/imr.v2i11.266 ◽

2016 ◽

Vol 2 (11) ◽

Author(s):

Adriana Georgiana Olariu ◽

Liliana Bordeianou

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Disease Recurrence ◽

Postoperative Recurrence ◽

Postoperative Management ◽

Chronic Inflammatory Bowel Disease ◽

Ileocecal Resection ◽

Endoscopic Recurrence ◽

Relapsing Remitting ◽

Patients Experience

Crohn’s disease (CD) is a chronic inflammatory bowel disease with a relapsing, remitting course. Approximately one in four CD patients requires surgery within five years of diagnosis. Unfortunately, surgery is rarely curative and up to 70% of CD patients experience endoscopic recurrence and 40% have clinical disease recurrence within 18 months after surgery. This review is aimed at providing internists and gastroenterologists a foundation for the management of patients who underwent ileocecal resection for CD. We provide an overview of the current definitions of postoperative recurrence and prognostic factors for postoperative CD recurrence. As recent studies raised concerns about the value of these factors, we examine the evidence behind the current risk stratification algorithm and pharmacologic treatment recommendations. Lastly, we discuss future directions for research.

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Anastomotic Ulcers After Ileocolic Resection for Crohn’s Disease Are Common and Predict Recurrence

Inflammatory Bowel Diseases ◽

10.1093/ibd/izz224 ◽

2019 ◽

Vol 26 (7) ◽

pp. 1050-1058 ◽

Cited By ~ 3

Author(s):

Robert P Hirten ◽

Ryan C Ungaro ◽

Daniel Castaneda ◽

Sarah Lopatin ◽

Bruce E Sands ◽

...

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Multivariable Analysis ◽

Disease Recurrence ◽

Ileocolic Resection ◽

Anastomotic Ulcer ◽

Endoscopic Recurrence ◽

Academic Center ◽

Endoscopic Remission ◽

The Impact

Abstract Background Crohn’s disease recurrence after ileocolic resection is common and graded with the Rutgeerts score. There is controversy whether anastomotic ulcers represent disease recurrence and should be included in the grading system. The aim of this study was to determine the impact of anastomotic ulcers on Crohn’s disease recurrence in patients with prior ileocolic resections. Secondary aims included defining the prevalence of anastomotic ulcers, risk factors for development, and their natural history. Methods We conducted a retrospective cohort study of patients undergoing an ileocolic resection between 2008 and 2017 at a large academic center, with a postoperative colonoscopy assessing the neoterminal ileum and ileocolic anastomosis. The primary outcome was disease recurrence defined as endoscopic recurrence (>5 ulcers in the neoterminal ileum) or need for another ileocolic resection among patients with or without an anastomotic ulcer in endoscopic remission. Results One hundred eighty-two subjects with Crohn’s disease and an ileocolic resection were included. Anastomotic ulcers were present in 95 (52.2%) subjects. No factors were associated with anastomotic ulcer development. One hundred eleven patients were in endoscopic remission on the first postoperative colonoscopy. On multivariable analysis, anastomotic ulcers were associated with disease recurrence (adjusted hazard ratio [aHR] 3.64; 95% CI, 1.21–10.95; P = 0.02). Sixty-six subjects with anastomotic ulcers underwent a second colonoscopy, with 31 patients (79.5%) having persistent ulcers independent of medication escalation. Conclusion Anastomotic ulcers occur in over half of Crohn’s disease patients after ileocolic resection. No factors are associated with their development. They are associated with Crohn’s disease recurrence and are persistent.

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The Correlation between Vitamin D Levels and the Risk of Postoperative Recurrence in Crohn’s Disease

Digestion ◽

10.1159/000513589 ◽

2021 ◽

pp. 1-9

Author(s):

Akihiro Yamada ◽

Yuga Komaki ◽

Fukiko Komaki ◽

Haider Haider ◽

Dejan Micic ◽

...

Keyword(s):

Vitamin D ◽

Crohn’S Disease ◽

Crohn's Disease ◽

Postoperative Recurrence ◽

Recurrence Rates ◽

Reactive Protein ◽

Endoscopic Recurrence ◽

Vitamin D Levels ◽

Endoscopic Remission ◽

The University

Background and Aims: Vitamin D deficiency has been associated with disease activity in Crohn’s disease (CD). We assessed whether there is a correlation between vitamin D levels and the risk of postoperative recurrence in CD. Methods: CD patients who underwent surgery were identified from a prospectively maintained database at the University of Chicago. The primary endpoint was the correlation of serum 25-hydroxy vitamin D levels measured at 6–12 months after surgery and the proportion of patients in endoscopic remission, defined as a simple endoscopic score for CD of 0. Clinical, biological (C-reactive protein), and histologic recurrences were also studied. Results: Among a total of 89 patients, 17, 46, and 26 patients had vitamin D levels of <15, 15–30, and >30 ng/mL, respectively. Patients with higher vitamin D levels were significantly more likely to be in endoscopic remission compared to those with lower levels (23, 42, and 67% in ascending tertile order; p = 0.028). On multivariate analysis, vitamin D >30 ng/mL (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.07–0.66, p = 0.006) and anti-tumor necrosis factor agent treatment (OR 0.25, 95% CI 0.08–0.83, p = 0.01) were associated with reduced risk of endoscopic recurrence. Rates of clinical, biological, and histologic remission trended to be higher in patients with higher vitamin D levels (p = 0.17, 0.55, 0.062, respectively). Conclusion: In the present study, higher vitamin D level was associated with lower risk of postoperative endoscopic CD recurrence. Further, studies are warranted to assess the role of vitamin D in postoperative CD recurrence.

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Non-invasive diagnosis and grading of postsurgical endoscopic recurrence in Crohn's disease

Journal of Crohn s and Colitis ◽

10.1016/j.crohns.2010.03.002 ◽

2010 ◽

Vol 4 (5) ◽

pp. 537-545 ◽

Cited By ~ 26

Author(s):

José María Paredes ◽

Tomás Ripollés ◽

Xavier Cortés ◽

María Dolores Reyes ◽

Antonio López ◽

...

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Non Invasive ◽

Endoscopic Recurrence

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The Role of Inflammation in Crohn’s Disease Recurrence after Surgical Treatment

Journal of Immunology Research ◽

10.1155/2020/8846982 ◽

2020 ◽

Vol 2020 ◽

pp. 1-14

Author(s):

B. Sensi ◽

L. Siragusa ◽

C. Efrati ◽

L. Petagna ◽

M. Franceschilli ◽

...

Keyword(s):

Crohn’S Disease ◽

Immune System ◽

Crohn's Disease ◽

Disease Recurrence ◽

Postoperative Recurrence ◽

Preventive Strategies ◽

Mesenteric Lymph Nodes ◽

Surgical Strategies ◽

Driving Mechanisms

Introduction. Postoperative recurrence after surgery for Crohn’s disease (CD) is virtually inevitable, and its mechanism is poorly known. Aim. To review the numerous factors involved in CD postoperative recurrence (POR) pathogenesis, focusing on single immune system components as well as the immune system as a whole and highlighting the clinical significance in terms of preventive strategies and future perspectives. Methods. A systematic literature search on CD POR, followed by a review of the main findings. Results. The immune system plays a pivotal role in CD POR, with many different factors involved. Memory T-lymphocytes retained in mesenteric lymph nodes seem to represent the main driving force. New pathophysiology-based preventive strategies in the medical and surgical fields may help reduce POR rates. In particular, surgical strategies have already been developed and are currently under investigation. Conclusions. POR is a complex phenomenon, whose driving mechanisms are gradually being unraveled. New preventive strategies addressing these mechanisms seem promising.

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AF.154 NON-INVASIVE ASSESSMENT OF POSTOPERATIVE DISEASE RECURRENCE IN CROHN’S DISEASE: A MULTICENTER, PROSPECTIVE COHORT STUDY

Digestive and Liver Disease ◽

10.1016/s1590-8658(21)00717-9 ◽

2021 ◽

Vol 53 ◽

pp. S206

Author(s):

F. Furfaro ◽

A. Zilli ◽

V. Craviotto ◽

A. Aratari ◽

C. Bezzio ◽

...

Keyword(s):

Cohort Study ◽

Crohn’S Disease ◽

Crohn's Disease ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Disease Recurrence ◽

Non Invasive ◽

Multicenter Prospective Cohort Study ◽

Multicenter Prospective Cohort

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P274 The clinical significance of anastomotic ulcers after ileocolic resection to predict postoperative recurrence of Crohn’s disease

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjz203.403 ◽

2020 ◽

Vol 14 (Supplement_1) ◽

pp. S288-S288

Author(s):

J Y Kim ◽

S H Park ◽

Y J Kim ◽

J C Park ◽

S Noh ◽

...

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Clinical Significance ◽

Multivariable Analysis ◽

Postoperative Recurrence ◽

Ileocolic Resection ◽

Single Centre ◽

Endoscopic Recurrence ◽

Endoscopic Remission

Abstract Background The Rutgeerts score (RS) is used to predict postoperative recurrence in Crohn’s disease (CD) patients after ileocolic resection primarily based on endoscopic finding at the neoterminal ileum. However, assessing anastomotic ulcers (AUs) is still a matter of debate. Our aim was to investigate the clinical significance of AUs on endoscopic recurrence in postoperative CD patients. Methods This was a single-centre retrospective study analysing postoperative CD patients with the RS of i0 to i1 at the first ileocolonoscopy within 1 year after ileocolic resection between 2000 and 2016 and those who underwent subsequent ileocolonoscopic follow-up. The study outcome was the clinical significance of AUs predicting endoscopic recurrence (RS ≥ i2b). Results Among 116 patients who were in endoscopic remission at the index postoperative ileocolonoscopy, 84.5% (98/116) underwent subsequent ileocolonoscopies. During the 30.0 months (interquartile ranges, 21.3–53.3) of median follow-up periods after the index ileocolonoscopy, 56.1% (55/98) showed endoscopic recurrence. Furthermore, 65.8% (48/73) with AUs and 75.5% (40/53) with major AUs defined as ulcer occupying ≥ 1/4 of the circumference or ≥ 3 ulcers confined to anastomotic ring, or any ulcers extended to ileocolic mucosa showed endoscopic recurrence. On multivariable analysis, the presence of AUs (adjusted hazard ratio [aHR], 4.33; 95% confidence interval [CI], 1.87–10.0; p < 0.001) and major AUs (aHR, 3.64; 95% CI, 1.95–6.79; p < 0.001) were associated with endoscopic recurrence, respectively. Conclusion AUs are associated with a significantly higher risk of endoscopic recurrence in postoperative CD patient who are in endoscopic remission.

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P112 CORRELATION OF FECAL CALPROTECTIN TO COLONOSCOPIC FINDINGS FOR DETECTION OF RECURRENCE OF CROHN’S DISEASE IN THE POST-OPERATIVE SETTING AT A SINGLE ACADEMIC CENTER

Inflammatory Bowel Diseases ◽

10.1093/ibd/zaa010.040 ◽

2020 ◽

Vol 26 (Supplement_1) ◽

pp. S17-S17

Author(s):

Anil Sharma ◽

Georgia Morrison ◽

Kian Keyashian ◽

Rebecca Matro

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Small Sample Size ◽

Rank Correlation ◽

Fecal Calprotectin ◽

Small Sample ◽

Operating Characteristics ◽

Repeat Surgery ◽

Endoscopic Recurrence ◽

Noninvasive Biomarkers

Abstract Introduction Patients with Crohn’s disease (CD) who undergo a first surgery are at higher risk of having a subsequent surgery in light of recurrence of disease. Significant evidence suggests that a postoperative colonoscopy evaluating recurrence at the anastomosis using the Rugeerts score (RS) can predict risk of repeat surgery. Given the invasive nature of colonoscopy, there has been increasing interest in using noninvasive biomarkers to predict disease recurrence. Studies have shown variability in the operating characteristics of the fecal calprotectin (FC) assay with sensitivities and specificities for detecting recurrence ranging widely from 48–95 and 58–79%, respectively. A recent meta-analysis demonstrated a pooled sensitivity of 70% when using an optimal FC cut-off of 150 ug/g. We sought to delineate how FC correlates with RS at our institution and to identify a cutoff for significant recurrence. Methods We performed a retrospective review of adult patients with CD who underwent ileocecectomy followed by a colonoscopy within 18 months of surgery, with the additional inclusion of FC testing within 2 weeks of the colonoscopy. Patients were identified at our institution via ICD 9 and 10 codes and the electronic medical record. The primary outcome of interest was a comparison of mean FC for those without endoscopic recurrence (defined as RS i0-i1) to those with significant endoscopic recurrence (defined as RS i2-i4). Other variables assessed included gender, disease location and phenotype, and extent of surgery (Table 1). Results A total of 12 patients met the inclusion criteria. 7 patients (58.3%) were female. Age at time of surgery ranged from 21 to 73 years (mean 37.9). Only 1 patient (8.3%) had a nonstricturing, nonpenetrating phenotype. After surgery, 11 patients were on biologic or combination therapy and 1 patient was not on any medical therapy. 5 patients (42%) demonstrated endoscopic recurrence by RS with mean FC of 883.7 ug/g, as compared to mean FC of 83.6 ug/g for those without recurrence. There was a positive correlation between FC and RS with a Spearman’s rank correlation coefficient of 0.86 (p = 0.0004). Conclusions Our results demonstrate a strong correlation between FC and RS. Using a cutoff for FC of 150 ug/g, we demonstrate sensitivity and specificity of 100%. This further supports the possibility of using FC as a surrogate to possibly defer colonoscopy in those post-operative CD patients with low FC. Study limitations include the retrospective nature and small sample size, recognizing that in years past FC was not as readily available or used in this setting. Future considerations include larger, prospective studies looking at FC and other noninvasive biomarkers in this post-operative setting.

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