American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Featured Commentary

Our online subscription format, SRGS Connect, features 10 commentaries on recently published articles in top medical journals with each new edition. The commentaries are by practicing surgeons and focus on the strengths and weaknesses of the research and its contribution to advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of SRGS Connect, What You Should Know.


Cruz P, Kamm MA, Hamilton AL et al. Crohn's disease management after intestinal resection: a randomized trial. Lancet. 2015;385(9976):1406-1417. doi: 10.1016/S0140-6736(14)61908-5.

Commentary by: Allesandro Fichera, MD, FACS, FASCRS

Despite improvement in medical therapy, Crohn disease (CD) remains a surgical disease; up to 80% of patients will require surgical intervention during their lifetime.1 Furthermore postoperative endoscopic recurrence has been documented in up to 84% of patients.2 Since CD patients are usually diagnosed at a young age, multiple resections may lead to short bowel syndrome or permanent fecal diversion. Risk factors for surgical recurrence have been identified from retrospective studies. They include: smoking,3 early age of diagnosis, multifocal small bowel disease, perforating disease, and multiple previous resections. There has been significant interest in using these well-known factors to risk stratify patients and tailor medical therapy after surgical resection both in the US and in Europe.4,5

This manuscript presents a prospective and randomized experience from 17 centers in Australia and New Zealand. Patients were assigned to either active care and underwent a colonoscopy at six months or standard of care with no endoscopic evaluation. All the patients received three months of metronidazole and high-risk patients received either a thiopurine or adalimumab if they were intolerant to thiopurine. The results were in line with previous findings: 1) smoking was the primary culprit and significantly increased the risk endoscopic recurrence; 2) tailoring treatment based on risk stratification combined with early colonoscopy to further adjust therapy based on endoscopic findings was more effective in preventing postoperative endoscopic CD recurrence than medical therapy alone; 3) delaying initiation of immunosuppression postoperatively did not compromise efficacy of treatment; 4) clinical risk factors predicted endoscopic recurrence; however even patients in the low risk group could present with early endoscopic recurrence and required surveillance; 5) while early recurrence was very common, early remission did not preclude the possibility of late recurrence suggesting that these patients should be monitored; 6) lastly, adverse events did not differ between active and standard of care. The study design cleverly included average and high-risk patients in both groups. This gave the authors the opportunity to carefully study and characterize the natural history of the whole spectrum of postoperative CD.

Perhaps one important limitation of the study was the lack of a cost analysis between the active and the standard of care. Given the cost of new therapeutic agents this is an important issue. The term standard of care also would not necessarily apply to the group described in this study, since endoscopic surveillance of endoscopically accessible anastomosis in postoperative CD patient is routine practice in the US.

This manuscript has three important take-home messages: 1) postoperative endoscopic recurrence is common and guidelines should be developed for surveillance and prevention; 2) smoking is an important predictor of endoscopic recurrence and an aggressive campaign should be waged against smoking in CD patients given the risk of multiple resections and the cost and side effects of the therapeutic agents needed for prevention of recurrence; 3) risk stratification and individualization of medical therapy are mandatory given significant costs and serious side effects of medical therapy.

References

  1. Michelassi, F., et al. Primary and recurrent Crohn's disease. Experience with 1379 patients. Ann Surg. 1991;214(3):230-238. Free full text
  2. Rutgeerts, P., et al. Predictability of the postoperative course of Crohn's disease. Gastroenterology. 1990;99(4):956-963.
  3. Reese, G.E., et al. The effect of smoking after surgery for Crohn's disease: a meta-analysis of observational studies. Int J Colorectal Dis. 2008;23(12):1213-1221.
  4. Regueiro, M., et al. Infliximab prevents Crohn's disease recurrence after ileal resection. Gastroenterology. 2009;136(2):441-450 e1; quiz 716.
  5. Regueiro, M. Management and prevention of postoperative Crohn's disease. Inflamm Bowel Dis. 2009;15(10):1583-1590.