P353 Endoscopy-based management within the first year after surgery decreases the risk of clinical and surgical postoperative recurrences in Crohn’s disease
A.-L. Boucher1, B. Pereira2, S. Decousus3, M. Goutte1, 4, F. Goutorbe1, A. Dubois5, J. Gagnière5, C. Borderon6, J. Joubert3, D. Pezet5, M. Dapoigny1, P. Dechelotte3, G. Bommelaer1, 4, A. Buisson*1, 4
1University Hospital Estaing, Gastroenterology Department, Clermont-Ferrand, France, 2DRCI, Biostatistics Unit, Clermont-Ferrand, France, 3University Hospital Estaing, Pathology Department, Clermont-Ferrand, France, 4UMR 1071 Inserm/Université d’Auvergne; USC-INRA 2018, Microbes, Intestine, Inflammation and Susceptibility of the host, Clermont-Ferrand, France, 5CHU Estaing, Department of Digestive surgery, Clermont-Ferrand, France, 6University Hospital Estaing, Paediatrics Department, Clermont-Ferrand, France
As surgical resection is not curative in Crohn’s disease (CD), postoperative recurrence (POR) remains a crucial issue. Although often recommended, the effect of postoperative colonoscopy remains poorly investigated. Although 2 retrospective studies reported no effect of an endoscopy-based management (EBM),1,2 EBM was associated with a decreased risk of clinical POR at 3 years in a retrospective cohort3 and decreased rate of endoscopic POR at 18 months after surgery in the POCER trial.4 However, the long-term effect of EBM on the risks of clinical and surgical POR remains unknown. We aimed to investigate whether an endoscopy-based management could prevent the long-term risk of POR in CD.
From the pathology department database, we retrospectively retrieved the data of all the patients operated on for CD in our centre (1986–2015). Surgical POR was defined as reoperation for CD. Clinical POR was defined as recurrence of CD symptoms leading to hospitalisation or therapeutic modifications. Endoscopic POR was defined as Rutgeerts score ≥ i2. Endoscopy-based management was defined as systematic postoperative colonoscopy in patients with no clinical POR at the time of endoscopy.
From 205 patients who underwent surgery, 161 patients (follow-up > 6months) were included. The prevalence of endoscopic, clinical and surgical POR is given in Figure 1.
Figure 1. Kaplan–Meier curves representing the prevalence of surgical, clinical, and endoscopic postoperative recurrence in Crohn’s disease patients undergoing intestinal resection in our centre (1986–2015).
The POR risk factors are listed in Table 1.
Table 2. Postoperative risk factors (results were retrieved from multivariate analysis [Cox model]; HR = hazard)
|Risk factors in multivariate analysis||Endoscopic postoperative recurrence||Clinical postoperative recurrence||Surgical postoperative recurrence|
|Previous intestinal resection||HR 1.7, CI 95% [1.00– 2.92]; p = 0.05||2||HR 1.7, CI95% [1.00–2.72]; p = 0.05|
|Prior exposure to anti-TNF therapy before surgery||HR 3.59, CI 95% [1.65– 5.50]; p < 0.001||HR 2.60, CI 95% [1.23– 4.31]; p = 0.009|
|Fistulising phenotype (B3 according to Montreal classification)||HR 1.78, CI 95% [1.04–3.04], p = 0.003|
|Previous perianal abscess/fistula (other perianal lesions excluded)||HR 1.48, CI 95% [1.01– 2.19]; p = 0.048|
Amongst the 49 patients included in the EBM-group (median time to perform endoscopy = 9.5 months), endoscopic POR occurred in 18 patients (36.7%) who underwent step-up therapeutic strategy. In multivariate analysis, an EBM decreased the risk of clinical POR (HR 0.4 CI95% [0.25–0.66]; p < 0.001) (Figure 2A) and surgical POR (HR 0.30 CI 95% [0.13–0.70]; p = 0.006) (Figure 2B).
Figure 2. Long-term effect of endoscopic-based management (EBM) on and clinical (A) and surgical (B) postoperative recurrence in Crohn’s disease.
Endoscopy-based management should be recommended in all CD patients within the first year after surgery as it highly decreases the long-term risk of clinical recurrence and reoperation.
 Bordeianou et al. Immediate vs tailored prophylaxis to prevent symptomatic recurrences after surgery for ileocecal Crohn’s disease. Surgery 2011;149:72–78.
 De Cruz et al. Postoperative recurrence of Crohn’s disease: impact of endoscopic monitoring and treatment step-up. Colorectal Dis 2013;15:187–97.
 Baudry. Tailored treatment according to early post-surgery colonoscopy reduces clinical recurrence in Crohn’s disease: a retrospective study., Dig Liver Dis 2014;46:887–92.
 De Cruz et al. Crohn’s disease management after intestinal resection: a randomised trial. Lancet 2015;385:1406–17.