| Invited Lecture(JSGS) |
| Sat. November 23rd 9:00 - 9:30 Room 1: Kobe International Exhibition Hall No.2 Building Hall (North) |
| Post-operative management of Crohn's disease, review and real world experience | |||
| Shu Chen Wei | |||
| Department of Internal Medicine, National Taiwan University Hospital | |||
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| Even with the progress in medical treatment of IBD in recent decades, about a half of Crohn’s disease (CD) patients still received surgery, and the post-operative recurrence rate is high according to the natural history of CD. The initiation or continuation of medical therapy with an intent to decrease the risk and severity of the recurrence is referred to as “prophylaxis.” The decision to utilize prophylactic therapy, and the choice of such therapy, should be guided by the patient’s risk for CD recurrence and patient preference. High-risk patients include patients with penetrating disease, two or more previous surgeries, active smoking, duration of less than 10 years between diagnosis and surgery, young age at diagnosis, extensive bowel involvement, and failure of prior immunomodulator or biologic therapy. All patients who are actively smoking should be advised strongly to quit smoking. In these high-risk patients, biologic therapy should be started, ideally within 4 weeks after surgery, to help prevent or minimize post-operative recurrence. Anti-TNFα therapy is the most effective in preventing post-operative recurrence. Vedolizumab is commonly used although less effective than anti-TNFα agents in a retrospective study. Data on ustekinumab is just emerging. The intermediate risk patients are non-smokers who have penetrating disease without a history of prior surgical resection and are naïve to immunomodulators or biologics. These patients can be treated with the biologics, or with immunomodulators ± metronidazole. Patients at low risk are those with long-standing disease, never had a prior surgical resection, are not active smokers, mostly with indication for surgery as the fibro-stenotic disease. These patients may not initially need routine post-operative medications and can be offered mesalamine, antibiotics, or the agents mentioned above. It is highly recommended that patients should undergo a subsequent ileocolonoscopy (ideally 3 to 6 months) post- surgery. Patients without post-operative recurrence on surveillance colonoscopy (Rutgeerts’ score i0 or i1) should continue periodic colonoscopic monitoring and/or fecal calprotectin monitoring. Those with recurrent disease (Rutgeerts’ score i2 or higher) should be started on effective therapy or have their current therapy optimized. |
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