To Treat or Not To Treat: Jami Kinnucan, MD, on Post-Op Crohn Disease

Surgery should not be viewed as a “last resort” option for management of Crohn disease (CD), Jami Kinnucan, MD, said at the Advances in Inflammatory Bowel Diseases regional meeting in Boston on June 11, 2022. When medical management fails to control disease, when patients experience intestinal obstruction or penetrating complications, surgery may offer the best outcomes.

Dr Kinnucan is a senior associate consultant in the Section of Gastroenterology and Hepatology at the Mayo Clinic in Jacksonville, Florida.

Patients who undergo surgery for CD should be risk-stratified to determine the appropriate post-operative medical regimen. If a patient is at low risk of disease progression or recurrence, she said, “consider metronidazole and close monitoring. If high risk, immunosuppression or biologic therapy would be most appropriate.”

Treatment options should be individualized to each patient and if the disease does recur, “the key is monitoring with optimization of therapy.”

Dr Kinnucan referenced the results of the LIR!C trial that compared health-related quality of life at 12 months among patients who underwent laparoscopic ileocecal resection (ICR) vs patients treated with infliximab for terminal ileitis. A long-term follow-up study of 143 patients who participated in the trial revealed that 48% of the infliximab group later required ICR, while 26% of the ICR group required treatment with infliximab (48% received prophylactic immunomodulator treatment.)

She also addressed the issue of whether exposure to preoperative anti-tumor necrosis factor (TNF) therapy may increase the risk of postsurgical complications? The answer is simply no, she said. In a large multi-center collaboration involving 947 patients, including 382 with current anti-TNF exposure, there were no associated infections or surgical site infections. Such infections were associated with corticosteroids, smoking, diabetes, and past surgery.

The risk of clinical postoperative recurrence of CD is 20% to 40% at 1 year following surgery and 50% at 5 years, while endoscopic recurrence is 90% within 12 months and 100% eventually, Dr Kinnucan stated. “Endoscopic recurrence is not uncommon. You can expect endoscopic recurrence rates of about 45%, even with postoperative medications and monitoring.”

The risk of surgical recurrence is 25% at 5 years and 35% at 10 years.

Risk stratification for postoperative recurrence is a key factor in choosing what, if any, therapy should be used following surgery. Patients with a history of penetrating complications, less than 10 years between diagnosis and first surgery, 2 or more prior surgeries, and smokers are at high risk, Dr Kinnucan explained. Upper GI and perianal disease, a diagnosis of CD at age 30 or younger, positive margins at resection, and granuloma all place patients in a higher risk group as well, she said.

Patients over 50 years of age, nonsmokers, those having a first surgery, and those whose surgery involves removal of a short segment (less than 10 cm) are considered lower risk.

For these patients, no therapy may be needed. However, she noted, some 80% of patients in a study who received low-dose metronidazole (250 mg TID x 3 months) had no recurrence at 12 months postop and the medication was well tolerated. The control group that did not receive metronidazole had a recurrence rate of 54%.

Thiopurine therapy has been “extensively studied in postop prevention with conflicting results,” Dr Kinnucan stated. A Cochrane analysis showed thiopurines significantly reduced recurrence compared to placebo and was superior to mesalamine. However, there were significantly more adverse events leading to drug withdrawal.

When choosing postoperative therapy for high-risk patients, she said, there are important questions that must be addressed. “What were they taking prior to surgery? What were findings at the time of resection? When do you restart therapy?”

Referring to clinical guidelines from the American Gastroenterological Association, Dr Kinnucan pointed out conditional recommendations with moderate quality of evidence that call for the use of anti-TNFs and/or thiopurines over other agents; endoscopic monitoring at 6 to 12 months postop; and initiating or optimizing anti-TNF and/or thiopurine therapy over continued monitoring alone.

“Anti-TNF therapies are effective in preventing postoperative recurrence” of CD, she stated. “Multiple studies have shown their effectiveness in comparison with placebo, antibiotics, probiotics, budesonide, and 5-ASAs.”

However, she added, an anti-TNF might not be the most effective option among patients who had exposure to these therapies prior to surgery. As alternative, Dr Kinnucan said, both vedolizumab and ustekinumab have shown efficacy in preventing and treating postoperative recurrent of CD. Among a cohort of 58 patients from the Sicilian Network for IBD with postoperative colonoscopy Rutgeerts scores of >i2 who were treated with vedolizumab, 47.6% achieved the primary outcome of reduction of Rutgeerts assessment at colonoscopy >1.

The retrospective USTEK Post-Op Study Group in 9 centers found that among patients treated with ustekinumab postoperatively, 28.0% showed endoscopic recurrence at 6 months following surgery vs 54.5% of patients who were treated with azathioprine, Dr Kinnucan reported.

The best way to assess CD postoperatively is by ileocolonoscopy 6 to 12 months after surgery, she stated.

“What do you do with patients with a modified Rutgeerts score of i2a?” Dr Kinnucan asked.

Once considered “isolated anastomotic lesions to be ischemic or postsurgical complications,” other studies have shown that ileal recurrence is associated with clinical recurrence and worse clinical long-term outcomes. “Other studies have shown that i2a is equal to i2b disease for rate of postoperative recurrence. Don’t ignore those patients with i2a. Continue surveillance and disease monitoring, and consider drug optimization.”

—Rebecca Mashaw

Reference:

Kinnucan, J. Approach to post-operative Crohn’s disease: To treat or not to treat. Presented at: Advances in Inflammatory Bowel Disease regional meeting. June 11, 2022; Boston.