A.4. Crohn’s disease: postoperative recurrence

 

Up to 80% of all CD patients will require surgery at some point in life due to stricturing or fistulizing complications of the disease. Postoperative recurrence generally at the level of the anastomosis is common, with endoscopic recurrence in 70% of the cases one year after surgery. The severity of endoscopic recurrence is associated with early clinical recurrence and the need for repeat surgery. At present, postoperative endoscopic revision from 6-12 months after surgery has been protocolized with the purpose of detecting early recurrences and of introducing the best possible treatment.

 

Figure 1. Patient with stricturing ileocolic CD requiring surgery. Early postoperative clinical recurrence. Colonoscopy: ileocolic anastomosis with superficial ulcerations that were passed without difficulty, revealing extensive ulcerations with geometrical margins distributed within the neocolon, compatible with Rutgeerts score i4 endoscopic recurrence.
 

In the region of the surgical anastomosis it is common to observe ulcerations and a certain degree of stricturing, in some cases related to surgery itself rather than to recurrence of the disease. For adequate assessment of recurrence it is advisable to explore both the anastomosis and the ileal loop.

 

Figure 2. End-to-side ileocolic anastomosis. Superficial ulcers are seen in the surgical pocket or remnant. In the ileal loop only some occasional aphthoid erosions are seen. Endoscopic findings compatible with Rutgeerts score i2 mild recurrence. Incorrect examination of the ileal loop could lead to over-estimation of these lesions.
 

In some cases stricturing at the anastomosis does not allow passage and the correct evaluation of disease recurrence.

 

Figure 3. Postoperative stricture at the ileocolic anastomosis in a patient with CD. Apparently only the anastomosis is affected, though the evaluation of recurrence is incomplete.
 

 

Figure 4. Patient operated on for CD with ulcerated stricturing of the ileocolic anastomosis.
 

 

Figure 5. The study was completed with magnetic resonance enterography (MRE), showing evidence of moderate inflammation, though confined to the surgical anastomosis.
 

In patients operated on for CD it is common to find anastomotic strictures that cannot be passed with the endoscope. The use of complementary techniques completes the study, facilitating adequate assessment of the patient and treatment selection. (references 3 and 4. Clinical case 4)

Endoscopic capsule evaluation of the small bowel allows the assessment of postoperative disease recurrence (Clinical case 5). In routine clinical practice, the need to rule out strictures, and the introduction of new radiological techniques for studying CD limit its use. (MRE atlas)

 
 

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