Postoperative Crohn's disease recurrence as assessed by conventional vs alternative non invasive techniques

Background Ileocolonoscopy (IC) is the gold standard for assessing Crohn’s Disease (CD) recurrence after ileo-colonic resection The frequency of recurrence in Crohn’s CD patients after curative resection different from the ileo-colonic is undefined. Aims. Prospective Study: We aimed to compare, in a prospective longitudinal study, findings related to CD recurrence as assessed by procedures visualizing either the luminal surface (i.e. ileocolonoscopy or SBFT) or the extraluminal surface (SICUS) in a cohort of CD patients prospectively followed up at 1, 2 and 3 years after ileo-colonic resection. Retrospective Study:In an different cohort of CD patients, we also aimed to assess, in retrospective analysis, the frequency, pattern and risk factors of postoperative recurrence in CD patients with “curative” resection different from ileo-colon. Methods. Prospective Study: From 2003 to 2008, 25 CD patients undergoing ileo-colonic resection were enrolled. Clinical assessment (CDAI) was performed at 1, 2 and 3 years. IC was performed at 1 (n=25) and 3 years (n=15), SBFT at 2 years (n=21) and SICUS at 1 (n=25), 2 (n=21) and 3 years (n=15). Recurrence was assessed by SBFT and SICUS (bowel wall thickness, BWT) when using IC as gold standard. Retrospective Study: In a retrospective study, clinical records of 537 CD patients under regular follow up from January 2001 to August 2007 were reviewed. The outcome after surgery was assessed on the basis of clinical records prospectively recorded. Results. Prospective Study: At 1 year, all patients were inactive and recurrence was detected by IC in 24/25 (96%) and by SICUS in 25/25 patients. At 2 years, 6/21 patients (29%) were active and recurrence was detected by SBFT in 12/21 (57%) and by SICUS in 21/21 patients. At 3 years, 5/15 patients (33%) were active, IC showed recurrence in 14/15 (93%), and SICUS in 15/15 patients. The endoscopic score at 1 year was higher in patients developing relapse at 2 years (n=5) than in patients maintaining remission (n=10)(median: 4, range 3-4 vs 2, range 0-3; p=0.003). The same finding was not observed by using SICUS (median BWT at 1 year: 5, range 4-7 vs 3.7, range 3.5-6; p=0.19). Retrospective Study Previous resection was observed in 183/537 (34%) patients, including the ileo-colon in 145 (79%) and other GI segments in 38 (21%). Recurrence was detected in 16/38 (42%) patients (all symptomatic) including: 5/14 (35%) with ileostomy, 5/5 (100%) with ileo-rectal, 3/11 (27%) with ileo-ileal, 1/4 (25%) with colo-rectal and 2/3 (33%) with duodenum-jejunal anastomosis. Ileo-colonic resection was reported in 145/183 (79%) patients, showing recurrence in 128 (88.3%), symptomatic in 47 (36.7%) patients. The frequency of recurrence was higher in patients with ileo-colonic resection than in patients with other types of resection (128/145, 88% vs 16/38, 42%, p<0.001). The frequency of symptomatic recurrence was lower in patients with ileo-colonic resection than in those with other resections (47/128, 37% vs 16/16, 100%; p<0.001). Risk factors for recurrence were comparable in the 2 subgroups (smoke: OR 1.5 vs 1.4; appendectomy: OR 0.32 vs 0.33; familial IBD: OR 0.43 vs 1.26 Conclusions. Although IC and SICUS provide a different view of the bowel wall, in experienced hands SICUS provides findings compatible with endoscopic recurrence after ileo-colonic resection for CD. Post-operative recurrence is observed in a high proportion of CD patients after resection different from ileo-colon (including ileostomy), although out a lower frequency than observed after ileo-colonic resection