Mistakes in... 2022 - 15

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Mistakes in... 2022
Mistakes in the management of postoperative Crohn's disease and
how to avoid them
Eugeni Domènech and Míriam Mañosa
Crohn's disease is a chronic immune-mediated inflammatory condition that usually
produces cumulative transmural intestinal damage. Disease-related complications,
such as intestinal strictures and intra-abdominal penetrating complications (including
enteric fistulae, inflammatory masses and abscesses), are mostly managed via a surgical
approach, with ileocecal resection plus ileocolic anastomosis being the most common
procedure.1,2
Despite the curative intention of surgery, however, up to 70% of patients
develop new mucosal lesions in the neoterminal ileum within the first year
of intestinal resection if no preventive therapy is started early after surgery.3
This
postoperative recurrence (POR) can be described as endoscopic, clinical or surgical.
Endoscopic POR-defined as the presence of mucosal lesions in the neoterminal ileum,
as assessed by ileocolonoscopy-precedes the development of symptoms (clinical POR),
which may lead to the need for new surgical resections (surgical POR).
Here we discuss the errors to avoid when managing patients with Crohn's disease in
the postoperative setting. The discussion is based on evidence, whenever possible, as
well as on our clinical experience and perception of the field.
Mistake 1 Failing to recommend smoking
cessation
Many risk factors for POR have been reported, such
as a penetrating disease pattern, prior intestinal
resections and perianal disease (figure 1). However,
active smoking alone has been repeatedly
identified as a risk factor for POR in retrospective
and prospective studies. Indeed, active smoking
confers a 2.5-fold increase in the risk of POR
compared with not smoking after surgery.4
In
addition, active smoking is the only risk factor
that can be reverted, thus reducing the risk of
POR.5
Therefore, giving up smoking is the only
preventive measure that is universally accepted
and all patients who smoke should be advised to
give up once intestinal resection is planned.
Mistake 2 Prescribing ineffective drugs for
the prevention of postoperative disease
recurrence
Nowadays, there are two accepted strategies
for the management of Crohn's disease in the
postoperative setting. With the first strategy, the
treatment decision is driven by the findings
of early endoscopic monitoring (preferably
performed 6 months after surgery). Alternatively,
the second strategy is to begin preventive therapy
© UEG 2022 Domènech and Mañosa
Cite this article as: Domènech E and Mañosa M. Mistakes in the
management of postoperative Crohn's disease and how to avoid
them. UEG Education 2022; 22: 5-7.
Eugeni Domènech is Head of the Gastroenterology and
Hepatology Department, and Míriam Mañosa is Head of the
Gastroenterology Unit, Hospital Universitari Germans Trias i Pujol,
Mistake 3 Monitoring faecal calprotectin
concentrations too soon after surgery
Faecal calprotectin has proved to be a good
surrogate marker of ileal mucosal lesions in
Crohn's disease patients after they've undergone
ileocecal resection and anastomosis.8-10
faecal calprotectin levels can remain high
during the first 2-3 months after surgery,
probably related to the surgical insult.11
For this
reason, faecal calprotectin concentrations should
not be measured during this early period to
monitor the development of POR, although it is a
useful noninvasive tool thereafter. Furthermore,
it is also important to remember that there are
Badalona, Catalonia, Spain. Centro de Investigación Biomédica
en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD),
Madrid, Spain.
Image: courtesy of E. Domènech and M. Mañosa.
Illustrations: J. Shadwell.
Correspondence to: eugenidomenech@gmail.com
Conflicts of interest: ED has served as a speaker for, or has
early after surgery (within the first 4 weeks).
Although many drugs have been evaluated for
their potential to prevent POR in randomized
controlled trials (RCTs), regrettably, only
thiopurines and anti-tumour necrosis factor
agents (anti-TNFs)-but not aminosalicylates,
Corticosteroids or probiotics-demonstrated
efficacy in preventing endoscopic and clinical POR.
In fact, two recent guidelines on the management
of postoperative Crohn's disease recommend
the use of these drugs and no others for early
prevention in patients who have risk factors
for POR.6,7
many other gastrointestinal diseases, and some
medication-related and even lifestyle factors,
that can alter faecal calprotectin concentrations.
These alternative influences should always be
taken into account when interpreting faecal
calprotectin concentrations.12
Mistake 4 Performing endoscopic
monitoring too late after surgery
Currently, endoscopic examination of the
terminal ileum remains the gold standard to
define subclinical POR, with the severity of
the endoscopic ileal lesions detected driving the
need for treatment escalation, as outlined in
the available guidelines.6,7
Some prospective
studies have observed that lesions were already
present 6 months after surgery in most of the
patients who went on to develop POR within the
first year.13,14
Moreover, in studies that have
However,
evaluated the efficiency of anti-TNF agents in
cases of endoscopic POR, mucosal lesions were
reverted in less than half of cases.15
From this
perspective, an endoscopic examination should
be scheduled for 6 months after surgery as part
of the discharge process, as doing so will ensure
early detection of POR and treatment escalation
in all Crohn's disease patients undergoing
intestinal resection with anastomosis.
received research or education funding or advisory fees from,
AbbVie, Adacyte Therapeutics, Biogen, Celltrion, Gilead, Janssen,
Kern Pharma, MSD, Pfizer, Roche, Samsung, Takeda, and Tillots.
MM has served as a speaker, consultant and advisory member for,
or has received research funding from, AbbVie, Gilead, Janssen,
MSD, Pfizer, Shire Pharmaceuticals, Faes, Takeda and Tillots.
Published online: February 17, 2022.
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