Factores de riesgo y optimización del manejo de la recurrencia postquirúrgica en la enfermedad de Crohn

Laburpena

Introduction: In the first year after ileocecal resection with anastomosis a high percentage of patients with Crohn’s disease (CD) develop mucosal inflammatory lesions in the neoterminal ileum, a phenomenon known as postoperative recurrence (POR). This percentage ranges between 40-70% in patients without or with preventive therapy prescribed after surgery, respectively. The development of mucosal lesions involves a greater risk of developing symptoms and complications and a greater risk of requiring new surgical interventions during follow-up, which increases the risk of loss of intestinal function. Aims: To evaluate the natural history of the development of endoscopic POR in patients receiving prophylactic maintenance therapy with thiopurines, when initially they have prevented the appearance of early endoscopic POR in the first 6-12 months after surgery, and to evaluate the efficacy of the anti-TNF agents (infliximab or adalimumab) for the prevention and treatment of endoscopic POR after ileocecal resection with anastomosis. Methods: Three retrospective studies have been performed from cohorts of patients consecutively and prospectively included. The first study included all patients with intestinal resection and ileocolonic anastomosis who started preventive therapy with thiopurines after surgery with a first endoscopic assessment without endoscopic POR, to evaluate the long-term outcomes of POR in these patients. The second study was a multicenter, nationwide study that included a cohort of patients identified from the ENEIDA registry, in whom preventive therapy of POR with anti-TNF agents (adalimumab or infliximab) was prescribed within 3 months after ileocolonic resection and who had an endoscopic assessment within 18 months after surgery, to assess the efficacy of anti-TNF agents. Finally, a third multicenter study included a cohort of patients who had started treatment with anti-TNF agents (infliximab or adalimumab) after the diagnosis of established endoscopic POR (defined by an index of Rutgeerts >i1), to assess the efficacy of anti-TNF agents. Conclusions: Thiopurines are effective in preventing long-term endoscopic POR when they have been effective in preventing early endoscopic POR. Anti-TNF agents (infliximab and adalimumab) are effective in preventing POR, with no differences between the two anti-TNF agents, and are also effective in improving and reverting postoperative mucosal lesions (established POR). Concomitant treatment with thiopurines and infliximab therapy are associated with greater therapeutic efficacy in reverting mucosal lesions.