N016 Postoperative Crohn’s care: a consistent approach?
H. Yarrow*1, M. O’Connor2, N. Ding2, N. Arebi2
1St Mark’s Hospital, IBD Unit, London, United Kingdom, 2St Mark’s Hospital, London, United Kingdom
Surgery for Crohn’s disease is inevitable for many patients, with 80% needing intestinal resection at some stage (ECCO, 2010). Recurrence rates vary depending on risk factors, and there has been much interest in predicting post-operative recurrence.
Our team have created an algorithm based on ECCO consensus. To assess its use, an audit following the outcomes of patients who have had intestinal resections has been completed.
In total, 20 patients were selected from a database of surgical cases between January 2010 and November 2014. The cases were reviewed retrospectively, using medical records to obtain data. The data collected was specific to the algorithm that was being assessed. Therefore, the main focus was surrounding assessment of recurrence, medical therapies used (and adhered to) post-operatively, and whether the patient was considered to be at low or high risk for disease recurrence.
Metronidazole was given in 40% of cases, with 1 patient only prescribed for 5 days. Of the 40%, metronidazole was reported to be tolerated and adhered to by 75% of cases, with 1 (12.5%) patient not able to tolerate it because of nausea and lack of appetite. One case was not reported so, it is unknown if that patient completed the course. Endoscopic assessment was completed between 4–40 months, with a mean of 8.65 months. Further, 2 (10%) patients did not have a scope completed. In addition, 35% were smokers; 35% of patients were considered to be low risk, with 65% as high risk because of smoking, concomitant colonic / perianal disease, previous resections, and perforation. Moreover, 15 (75%) patients had thiopurines throughout, with 4 (20%) also requiring anti-TNF between 1–12 months after surgery. Two (10%) patients had mesalazine only, and one (5%) refused medical therapy.
This audit has shown that there is not a consistent approach to assessing and predicting recurrence after intestinal resectional surgery. Calprotectin was not used; however, the hospital has only had access to this test in the last 12 months. The algorithm being used states that metronidazole should be prescribed for 3 months after surgery, but this was not done in 60% of cases. Additionally, endoscopic assessment is suggested within 12 months of surgery, and this was not achieved in 10% of cases.
Establishing a dedicated nurse-led clinic to follow-up the post-op patient is planned. The IBD CNS will see the patient in the outpatient clinic to ensure calprotectin is monitored and endoscopic procedures are requested. The IBD nurse is in a prime position to ensure appropriate medical therapies are prescribed and adhered to and that the patient has appropriate assessment to reduce the risk of postoperative recurrence. Emerging evidence in this field will guide development of our algorithm and provide the basis for future audits.