Prevention of postsurgical recurrence in Crohn’s disease: is it possible?

Abstract

Crohn’s disease (CD) is diagnosed in about 20 % of patients before the age of 18 years. Its phenotype is more complicated than in adult-onset CD and requires more aggressive therapy, including surgery. Surgery rates in pediatric CD range between 10 and 72 %. Indications for surgery include medically refractory disease (especially with growth failure) and complicated behaviour. Surgery is crucial, allowing children to catch up in growth and height before late puberty. However, surgery is not curative and post-operative recurrence (POR) is almost inevitable. Even if pediatric data are scarce, clinical recurrence has been reported in 50–94 % and re-operation in 18–54 % of cases, depending on the follow-up time. Thus, prevention of POR has a decisive role in managing CD. Several strategies have been used to decrease POR, with only some being efficacious and not in all cases. Therefore, currently, no standard of care for the management of postoperative CD does exist. The published studies in adults, systematic reviews and meta-analyses have shown efficacy for thiopurines, nitroimidazole antibiotics and anti-TNFα agents, while budesonide, probiotics and interleukin-10 were not effective. Although safe, mesalazine is of little benefit and not recommended, except in few selected patients. Since no randomized-controlled trial has been performed in children, data have to be extrapolated from adults and enteral nutrition may play an important role. In the prevention of recurrence, it is imperative to consider its risk factors, how it should be assessed, and what medication to use in relation to risk factors and cost-efficacy, based on actual evidence.