David Hudesman, MD, on Postoperative Management of Crohn Disease
David Hudesman, MD, gives an recap of his presentation on postoperative management of patients with Crohn disease, which he gave at the Advances in Inflammatory Bowel Disease virtual regional management on September 12.
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David Hudesman, MD, is codirector of the Inflammatory Bowel Disease Center at NYU-Langone Health in New York City.
David Hudesman: Hi, my name's Dr. David Hudesman. I am co‑director of the Inflammatory Bowel Disease Center and Associate Professor of Medicine at NYU Langone.
I'm going to summarize and give some key takeaways from the talk I gave at the AIBD regionals at UNC Chapel Hill on postoperative Crohn's disease. Some of the key takeaways is first, knowing the risk of postoperative Crohn's.
Anywhere from over 70% as high as 90% of patients may have endoscopic recurrence of Crohn's disease after surgery, after they're reconnected. Knowing that high rate, it's really important that we risk-stratify our patients and decide who needs therapy when.
What I mean by that is, do we start therapy shortly after surgery within 4 weeks, to prevent recurrence? Or do we wait until a colonoscopy when we start seeing endoscopic recurrence? The way we do that is we risk-stratify our patients.
Our patients that are at higher risk for recurrence for these risk factors include penetrating disease or fistulizing Crohn's, patients that are smokers, and patients with prior surgical resection.
Our lower risk group includes patients that have had disease for a very long time before they had surgery, a shorter amount of small bowel that's involved, and more of a fibrostenotic phenotype. Based on our current data, really our best data that supports use to prevent recurrences with our anti TNF agents, we have good data with both infliximab and adalimumab.
In practice, what I'm doing now with patients that are at higher risk for recurrence ‑‑ so again patients that have penetrating phenotype, smokers, past resections ‑‑ I am starting them on an anti‑TNF within about 4 weeks, give or take, to prevent recurrence, versus patients that are in my lower risk group—again, long history of disease, short stricture—I'm going to just closely monitor those patients with a colonoscopy at 6 months.
Another important takeaway, and there was a nice trial done with adalimumab called the POCER Trial, but the importance of doing a colonoscopy after surgery. Really, in my practice, I'm doing it in about 6 months after surgery, is when I'm looking at and evaluating for recurrence.
Whether I started somebody on an anti‑TNF to prevent recurrence, or whether I have them on no therapy at all, I'm doing that colonoscopy at about 6 months and then assessing. If there is endoscopic recurrence, adjusting therapy if they're on therapy, or starting new therapy if they're not.
At the end of my talk, I brought up some recent data that's been published on postop recurrence, or presented at our national meetings in the past year, just about key questions and important clinical questions that come up which we don't have great data for, as of yet.
One topic I briefly discussed, is what about our newer biologic agents such as ustekinumab or vedolizumab. There's not much data yet. At NYU Langone, as well as Cleveland Clinic, we had our retrospective study that we had in abstract presented this past year, looking at this. We showed that using anti‑TNFs have lower rates of recurrence in patients that have used vedolizumab or ustekinumab. However, this was, again, 2 tertiary centers. It was retrospective. We need more data before we say that, but this is something that when our newer agents that come to market, we need to have more data on using those to prevent recurrence.
Another topic I discussed was anastomotic ulceration. There is some recent data showing that ulceration at the ileocolonic anastomosis may be a sign. It may predict further recurrence and something that needs to be monitored.
The last topic is that we do your colonoscopy 6 months after surgery, what about monitoring it afterwards? There's also been some recent data suggesting that there's up to 40% of patients that had a normal first colonoscopy after surgery, they actually develop recurrence down the road.
One colonoscopy is not enough. You're going to have to do this serially, and in my practice I'm doing it every 3 years.
Again, just to summarize, patients with Crohn's are high risk for recurrence. We want to risk-stratify them. That will help determine whether we closely monitor with colonoscopy or start therapy within 4 weeks. Then we want to continue to monitor these patients long‑term. Thank you very much.