22-05-2025
Managing Crohn's After Surgery: Expert Insights
This transcript has been edited for clarity.
Hello. My name is Robert Battat. I am an associate professor of medicine at the University of Montreal and a gastroenterologist. I'm also the director of the Center for Clinical Excellence and Translational Research in Inflammatory Bowel Diseases at the University of Montreal Hospital Center.
Today, we're going to be talking about postoperative care in Crohn's disease. The most common surgery that is performed is an ileocolonic resection or an ileocecal resection with primary ileocolic anastomosis.
The first question that we want to ask is, who needs an operation? As effective therapies have entered into the market, there has been less need for surgery overall, but there's a greater need for surgery, particularly, in patients with Crohn's disease who have strictures.
The two typical profiles of patients who are going to undergo surgery are patients who have severe stricturing disease at the onset, or selected patients who have nonstricturing Crohn's disease, but either because of patient preference or for other reasons that you may not want to try to treat the condition medically, surgery is attempted as a first option, which is reasonable in selected cases.
Once a patient undergoes surgery, this is a critical period because patients have lost bowel, and according to clinical trials where they've tested drugs — particularly in the PREVENT trial, which tested the efficacy of infliximab vs placebo for prevention of recurrence — we saw that 60% of patients who received placebo had recurrence 6 months after the operation, as was indicated on a colonoscopy. We're seeing similar data in the recent REPREVIO trial, which tested the efficacy of vedolizumab vs placebo.
If you give nothing overall, in the general postoperative Crohn's population, approximately 60%-65% of patients will have lesions, which can be seen on a colonoscopy. It doesn't mean that you're going to have symptoms. That's an important point — that patients, often, after surgery will not feel the recurrence, but definitely the recurrence will have happened.
Being vigilant is very important for that reason. We have data that show that one of the most important things that you can do for a patient after surgery, even before thinking about another treatment, is planning to do a colonoscopy 6 months postoperatively.
There was a randomized clinical trial called the POCER trial, which compared two treatment approaches. One treatment arm was based on doing a colonoscopy postoperatively and another treatment arm was based on standard of care. The treatment arm that used colonoscopy postoperatively had lower recurrence rates and better long-term outcomes just by the act of 'looking' early [with colonoscopy] and acting early if there was a recurrence than when a colonoscopy was done further out. We saw that just doing a colonoscopy early on was associated with lower rates of recurrence in the long run.
When I have a patient who has a surgery, the first thing I'm thinking is, well, I have to look or [do a colonoscopy] 6-8 months after the surgery is done. That's nonnegotiable for all patients, unless there's some reason that I should not do the procedure for safety reasons.
The other question that comes up is, 'Do I give the patient a postoperative prophylactic medication?' In my practice, because I tend to see higher-risk patients, I tend to give most patients prophylaxis against recurrence. However, there are ways that you can manage the use of prophylaxis because there are some patients who may not end up needing a medicine after surgery.
The most recent data come from a large, multicenter international Inflammatory Bowel Disease Genetics Consortium cohort based out of Toronto showing that the highest risk factors for recurrence are being male, smoking, and having had previous surgeries. Those are three factors that are highly associated with recurrence. Interestingly, having fistulae in multiple cohorts was not [a risk factor]. For people who have those previously noted risk factors, those are patients for whom you definitely would want to try to give prophylaxis.
A protective factor against recurrence is obviously treatment. What are the treatments that we give? There are older data on immunomodulators, such as azathioprine or 5-aminosalicylic acid (5-ASA) molecules, and although there is some mixed evidence for prevention of recurrence with these drugs, the main agents that are used in 2025 are biologic agents.
The two biologic agents with the most robust data are infliximab, from the PREVENT trial that we previously described, and vedolizumab. Both agents were effective in preventing postoperative endoscopic recurrence. Both agents work, and I think the proof of concept really is that most biologic agents are likely to work. If you want to rely on only the highest level of evidence, those two agents are the most well studied.
In terms of other considerations for postoperative Crohn's disease patients, there are some data for antibiotics. However, particularly for metronidazole, the issue is that giving it long term is not only not associated with long-term prevention with recurrence but also is associated with side effects such as neuropathy.
You also want to start to think about non–IBD-related issues, such as vaccinations and absorption. If you have ileal resection, which is the most common site of resection, you do want to be ensuring that B12 levels in the blood are adequate, particularly if you've had more than 20 cm of ileum removed.
Often, patients will get diarrhea and knowing that there are other causes of diarrhea is important. It can be the Crohn's disease; however, it could also be bile salt diarrhea or bile acid diarrhea, and so that should be on the differential diagnosis.
The last thing I'd like to point out is that a useful tool to differentiate symptoms of Crohn's from other entities is the fecal calprotectin level. Fecal calprotectin indicates whether there is intestinal inflammation. Typically, I use it at 3 months postoperatively to risk-stratify patients. I use a value of 150 µg/g; if it's less than 150 µg/g, I assume it not to be postoperative recurrence causing the symptoms, but more likely bile salt diarrhea. If it is elevated, it may prompt an ileal colonoscopy to try to optimize therapy.
Thank you.
