Introduction

Post-operative recurrence (POR) is common in patients with Crohn’s disease (CD) who have undergone surgery. Endoscopy, mainly based on Rutgeerts’ score, is crucial for the diagnosis of POR, showing also high prognostic value. More recently, several studies have suggested that the current endoscopic score system could be affected by the ischemic (not inflammatory) nature of some anastomotic ulcers, particularly at the level of the mucosal inverted stapled line, so overestimating the prevalence of the “real” anastomotic POR. However, these studies, based on the comparison between CD patients and subjects undergone right-side resection for colon cancer (CRC), included a very small population.

Aims & Methods

Starting from these considerations, we performed a retrospective study aimed to directly compare the prevalence of anastomotic POR in CD with that of patients operated of right-side resection for CRC in a wide population. ​A retrospective studies was conducted at 4 Italian Institutions (3 with high volume of IBD admissions; 2 with high volume CRC admissions). All patients performed endoscopy within 8 months from surgery. We selected all consecutive CD and CC patients undergone a surgical resection with an anisoperistaltic stapled L-L anastomosis. The diagnosis of POR of CD was made in accordance with the modified Rutgeerts’ score (i0, i1, i2A, i2B, 3, 4). The global prevalence of PSR (Rutgeerts’s score >2) was recorded. Furthermore, we directly compared the prevalence of the isolated anastomotic ulcers of CD (Rutgeerts i2A) to that detected in CC patients.

Results

At the end of the study, we enrolled 221 CD patients and 72 CRC subjects. POR was recorded in 127 CD patients (57%). According to the endoscopic grade system, POR was scored as i0: 56 pts (25%), i1: 38 pts (17%); i2A: 42 pts (19%), i2B: 26 pts (12%), i3: 20 pts (9%), i4: 39 pts (18%). In the CRC group, endoscopy detected anastomotic ulcers in 2 out of 72 patients (3%); 1 case (1.4%) of CRC early recurrence was observed. When comparing the prevalence of isolated anastomotic ulcerations in CD (i2A) vs those in CRC patients, the prevalence of ulcerations was significantly higher in CD patients (19% vs 3%; p<0.01; O.R. 6.3).

Conclusion

Our study confirms the high prevalence of early recurrence in CD patients, so confirming the role of early (within 6-8 months) post-operative endoscopy in CD setting. The prevalence of anastomotic (ischemic) ulcers in CRC patients is very low and, as a consequence, this issue should not represent a real diagnostic matter if shifted into the POR setting of CD. Prospective, multicentre and directly comparative studies are needed to confirm our results.

Introduction

The Rutgeerts score is the most commonly used score for assessing endoscopic recurrence after ileocolic resection in Crohn’s disease. However, a significant drawback of this score is that it combines lesions localized to the anastomosis with those in the neo-terminal ileum in the same category, assigning them equal prognostic significance.

Aims & Methods

The aim of this study was to evaluate the performance of the REMIND score in predicting postoperative recurrence of Crohn's disease and compare its performance with the Rutgeerts score.
We conducted a monocentric, retrospective, evaluative study of patients operated for Crohn’s disease. All patients had a follow-up colonoscopy within one year of surgery. The REMIND score was derived from endoscopic details documented in the colonoscopy reports. Clinical relapse was defined by the Crohn’s disease related symptoms or complications, such as intra-abdominal collection or occlusion, or subsequent surgery Postoperative. Statistical analysis was performed using SPSS.25 for Windows.

Results

Eighty patients were included, with a mean age of 35.7 years, and a gender ratio H/F=2,2. Median follow-up was 5 years from surgery. Clinical recurrence-free survival was significantly shorter in patients with ileal lesions whatever their severity was I(1,2,3,4)A(x), compared with patients without ileal lesions I(0)A(x): p<0,001 and not significantly different between patients without anastomotic lesions I(x)A(0) and patients with anastomotic lesions whatever their severity was I(x)A(1,2,3): p=0,2. However, patients with at least semicircumferential anastomotic ulcerations A(2,3) had more anastomotic occlusive complications than patients classified A0 or A1: A0 VS A2 p=0,01 A0 VS A3 p<0,001 A0 VS A1 p=0,9. The I(x) score, compared with the Rutgeerts and A(x) scores, had the best values in terms of discriminative capacity (Area under the curve= 0,83 VS 0,73 VS 0,61), monotonicity (linearity test χ2 of 26,77 VS 12,36 VS 3,89), and homogeneity (likelihood ratio χ2 of 33,91 vs 18,45 VS 5,49).

Conclusion

In contrast to the Rutgeerts and A(x) scores, the I(x) score seems to exhibit superior performance in predicting postoperative recurrence. Therefore, the use of a score describing separately ileal and anastomotic lesions might be more appropriate to define postoperative endoscopic recurrence.

References

Hammoudi N, Auzolle C, Tran Minh ML, Boschetti G, Bezault M, Buisson A, et al. Postoperative endoscopic recurrence on the neoterminal ileum but not on the anastomosis is mainly driving long-term outcomes in crohn’s disease. Am J Gastroenterol. 2020 Jul;115(7):1084-93.

Introduction

Features and management of post operative recurrence (POR) of Crohn’s Disease (CD) after ileocecal resection (ICR) are well defined, but POR after colectomy is scarcely described.

Aims & Methods

Multicenter, nationwide, retrospective study promoted by the Spanish Working Group on Crohn's and Colitis (GETECCU). CD patients who underwent segmental colectomy (SC) or subtotal colectomy (STC) between 2012 and 2023 were included. Primary endpoint was clinical POR, defined as CD-related symptoms requiring salvage therapy despite POR prophylaxis. Secondary endpoints included endoscopic POR (anastomotic and/or perianastomotic CD-associated lesions at endoscopy), association between clinical and endoscopic POR, comparison of clinical and endoscopic POR-free survival among different types of colectomy, surgical recurrence (need for reoperation) depending on colectomy subtypes; and identification of factors associated with post-colectomy POR.

Results

224 patients were included: 157 (70%) underwent SC and 67 (30%) underwent STC. In the SC group, patients were older [44 (SD 15) vs 39 (SD 14) years old, p=0.01] and B3 phenotype was more frequent [68/157 (43%) vs 14/67 (21%), p = 0.003]. POR prophylaxis was prescribed in 119/157 (76%) SC patients and in 47/67 (70%) STC patients, with no significant differences regarding the choice of agent (main baseline characteristics of the study population are described in Table 1). The main indication for surgery was stenosing disease [both in SC group (83/157, 53%) and STC group (34/67, (51%)]. Median follow-up was 19.5 [3.7–67.9] months to clinical POR and 14.0 [5.9–54.1] months to endoscopic POR. Clinical POR developed in 60/157 (38%) in the SC group and 42/67 (63%) in the STC group (p = 0.001). Endoscopic evaluation was available in 190/224 patients (85%) [131/157 SC (83%) and 59/67 (88%) STC]; endoscopic POR was detected in 66/131 (50%) SC patients and 42/59 (71%) STC patients (p=0.012). Among patients with endoscopic POR, 76/108 (70%) also presented clinical POR: 43/66 (65%) patients in the SC group and 33/42 (79%) in the STC group (p=0.203). Clinical and endoscopic POR-free survival was higher for SC than for STC (p log-rank <0.05). Surgical recurrence occurred in 17/157 patients (11%) in the SC group and in 8/67 patients (12%) in the STC group (p=0.992). Multivariate stepwise Cox proportional hazards regression showed significant association of STC, smoking and myenteric plexitis with both clinical POR (HR 2.36, 95%CI [1.45 - 3.82]; HR 1.34, 95%CI [1.03 - 1,75] and HR 1.71, 95%CI [1.01 - 2.91] respectively) and endoscopic POR (HR 2.47, 95%CI [1.49 - 4.10], HR 1.36, 95%CI [1.03 - 1.79] and HR 1.83, 95% CI [1.01 - 3.29], respectively); and immunomodulator prophylaxis with endoscopic POR (HR 1.72, 95%CI [1.02 - 2.90]) (all p-values <.05).

Conclusion

POR remains common after colectomy in patients with CD. Clinical and endoscopic POR rates are higher following STC compared to SC in patients under similar prophylactic regimes. Although prospective research is still warranted, our data support favoring segmental resection of colonic CD when feasible.

Disclosure

J.L.R.G. has received financial support for traveling and educational activities or has received fees as a speaker from Abbvie, Kern Pharma, Janssen, Takeda, Pfizer, Lilly, Galapagos, Adacyte, Ferring, Tillotts Pharma, Faes Farma, Norgine and Casen. C.S.F. has received financial support for traveling and educational activities or has received fees as a speaker or consultant from Abbvie, Kern Pharma, Lilly, Ferring, MSD, Janssen, Takeda and Tillotts Pharma. YZ has received financial support for travelling and educational activities from or has served as an advisory board member for AbbVie, Adacyte, Alfasigma, Almirall, Amgen, Boehringer Ingelheim, Dr Falk Pharma, Faes Pharma, Fresenius Kabi, Ferring, Galapagos, Janssen, Johnson&Johnson, Kern, Lilly, MSD, Otsuka, Pfizer, Sanofi, Shire, Takeda, and Tillotts Pharma. The rest of the authors have no conflicts of interest to declare regarding this study.

Introduction

Recent studies have demonstrated the efficacy of ileocolonic resection in the treatment of ileal Crohn’s disease (CD). Stratification based on risk of recurrence is current standard of care, with international guidelines recommending prophylaxis to high-risk patients. Existing data indicate suboptimal adherence to these guidelines, potentially leading to increased healthcare costs. This study aimed to evaluate (1) guideline adherence in the postoperative setting, and (2) the impact of guideline driven prophylaxis on post-operative endoscopic recurrence (POR).

Aims & Methods

We performed a retrospective cohort study of patients who underwent ileal or ileocolonic resection and anastomosis for CD between 2017 and 2021 in four Australian centres. Adherence to three specific guideline aspects was assessed: (1) colonoscopy within 12 months, (2) documentation of a Rutgeert’s score at colonoscopy, and (3) prophylactic therapy prescription in high-risk patients. High-risk patients were defined as those with one or more of the following risk factors for recurrence: postoperative smoking, prior CD-related intestinal resection, presence of penetrating or perianal disease, or presence of granulomas in the resection specimen. Early POR (defined as a Rutgeert’s score of ≥ i2 within 12 months of surgery) was assessed; if this was not documented, it was inferred from the report text and available images.

Results

A total of 180 patients were analysed, with a median age of 46 years, and of whom 55% were female. Disease was confined to the ileum in 59% of patients, and 18% had additional perianal involvement. Disease behaviour was stricturing in 66% and penetrating in 30%. 32% of the cohort had undergone prior ileocolonic resection, and 25% were smokers.122 (68%) underwent colonoscopy within 12 months, and 162 (90%) had a colonoscopy during the follow-up period (median 240 days, IQR: 174 – 402 days). A Rutgeert’s score was documented in 89/162 (55%). Of the 142 (79%) patients with at least one risk factor for recurrence, 98 (69%) received prophylactic therapy. Early POR occurred in 54 of 122 patients (44%) who underwent timely colonoscopy (high-risk group 43/94, 46%; low-risk group 11/28, 39%, p = 0.55). Prophylactic therapy in the high-risk group did not reduce early POR (28/62, 45% vs 15/32, 47%, p = 0.87).

Conclusion

Adherence to guidelines in the management of postoperative Crohn’s is suboptimal, particularly in the documentation of a Rutgeert’s score. Irrespective of prophylactic therapy prescription in our cohort, early POR remains high, and guideline driven prophylaxis did not significantly reduce this rate. Additionally, recurrence was still high in patients without traditional risk factors for recurrence. This invites further investigation into alternative risk-stratification and treatment strategies to reduce POR in Crohn’s disease.

Introduction

Recurrence of Crohn’s disease (CD) lesions after surgery remains high. Identifying patients at high risk of recurrence who may benefit from prophylactic therapy would be relevant. However, data on specific preoperative risk factors remain scarce, while onset and severity of Post Operative Recurrence (POR) are assessed with the Rutgeerts score (RS)(1). Still, the value of early endoscopic lesions, and RSi2, to predict the later course of the disease and the risk of late (from 1 to 10 years) POR in any individual patient is unclear. Non-invasive Small Intestine Contrast Ultrasonography (SICUS) assesses intramural extension of CD lesions, their progression, and is as effective as RS in detecting early POR lesions (2).

Aims & Methods

1. To develop a risk score based on pre-operative clinical predictors to estimate POR likelihood;
2. to identify predictors of severity of mucosal lesion according to RS;
3. to assess the overtime progression of transmural lesion.
Prospective cohort study (1998-2022). CD patients were evaluated at ileo-colonic surgery and every 6-12 months thereafter. Sex, age at diagnosis/surgery, active smoking, CD behaviour (B)/location (L), perianal disease (PD), length of resected bowel, steroids, immunosuppressants/biologics therapy use, and CD duration before surgery were analysed using multivariable proportional hazards regression. Cumulative POR rates and risk score were calculated with Poisson models, taking for each predictor the integer part of the Poisson model parameter.

Results

Over a median follow-up of 7.6 years (IQR 4.1–12), 78 patients (32 F; median age 30 years; 60% smokers) were analysed. CD characteristics: B1 8%; B2 67%; B3 25%; L1 63%; L3 36%; PD 22%; immunosuppressive/biologics 17%; median CD duration pre-surgery 4.7 years; median resected bowel length 28 cm. Cumulative POR rates were 51.8% (IQR,41%-63.4%), 65.2% (54.4%-75.7%), 69% (58.6%-79%), 75.9% (65.8% -84.8%), 78.9% (69.0%-87.3%), at 1, 2, 3, 4, and 5 years. POR risk factors included active smoking, age ≥35 years at surgery, and marginally B1 (Table). Predictors of RS were PD (HR=3.39; 95% CI 1.12-10.26; p=0.03 and CD duration ≥5 years pre-surgery (3.45; 1.15–10.32; p=0.03). The estimated cumulative probability of POR increased with higher risk scores (from 1 to 3) being 22%, 58%, 83% and, respectively, 43%, 80% and 100% at 1 and 4 years. Lesion length at POR varied by RS (median, IQR): RSi1 (32%): 0.5 cm (0.5-0.5), RSi2 (35%): 4 cm (0.5-7), RSi3 (15%): 15 cm (8.5-21.5), RSi4 (5%): 16 cm (9.5-23.5). Lesions remained stable in patients with RSi1 and RSi3 (45%) but fluctuated in those with RSi2 and RSi4 (31% increased, 24% decreased).

Conclusion

The present score based on preoperative factors predicts the risk of postoperative recurrence. Patients with preoperative higher risk scores or RSi2 at recurrence would require early and close monitoring due to significant transmural lesion progression.

References

1.Rutgeerts R et al. 1990; 2. Pallotta N et al. 2010.

Disclosure

Nothing to disclosure

Introduction

Transmural healing (TH) has been proposed as a therapeutic target in Crohn’s Disease (CD) with studies showing a better prognosis than endoscopic healing (EH). However, EH is not always accompanied by TH and vice versa.

Aims & Methods

We aimed to evaluate the endoscopic and radiological factors associated with the discordance between EH and TH, the impact of earlier biological initiation on this mismatch and the long-term effect on prognosis. Multicentric retrospective study in patients with CD under biologic therapy who had a baseline computed tomography enterography (CTE) or magnetic resonance enterography (MRE) before therapy initiation and a follow-up ileocolonoscopy and MRE at 12±6 months. EH was defined as an SES-CD<3 or absence of ulcers and TH as the complete normalization of mural and extra-mural inflammation. All radiologic examinations were reviewed by expert radiologists after a consensus and the analysis was performed by inflamed intestinal segments using the McNemar’s test. The impact of the time of biological therapy initiation was assessed using logistic regression. After 5 years of follow-up, we assessed for the presence of long-term bowel damage defined as the need for intestinal resection or progression in disease phenotype (presence of new stenosis or fistula or worsening of previously existing stenosis or fistula).

Results

84 patients were included (52% females) with a median age at diagnosis of 27 yo (IQR 22-37). Half had ileocolonic involvement, 42% isolated ileal disease and 8% colonic disease; most had inflammatory phenotype before treatment (51%) and a median disease duration of 15 months (IQR 4-84). Almost half of the patients (49%, n=41) achieved EH and of those 63% (n=26) did not achieve TH; 23% (n=19) attained TH, of whom 21% (n=4) did not achieve EH. Most of the patients who achieved EH but not TH had persistent disease in the small bowel when compared to the large bowel (88.5% vs 11.5%, p<0.01). Among patients who achieved EH, 71 intestinal segments with signs of inflammation before treatment initiation were analysed. Only the presence of a stricture had a non-significant variation with therapy when compared with the baseline assessment (Table 1). Among the endoscopic variations in patients who achieved TH, only the presence of endoscopic stenosis did not achieve a significant variation and remained persistent (Table 1). There were no differences according to the time of initiation of biological therapy. The persistence of a radiological stricture in patients with EH was associated with long-term bowel damage (13% vs 67%, p=0.02).

Table 1 – Persistent radiological and endoscopic lesions in patients with EH and TH, respectively.

Conclusion

In patients with CD who achieved EH, the persistence of radiological lesions is frequent and does not seem to be modified by earlier biological therapy. The persistence of a radiological stricture is associated with long-term bowel damage. The evaluation of the endoscopic changes in patients with TH was limited by the small sample size.