Esophagus to Small Intestine
Inflamm Bowel Dis. 2023;29(2):185–94
Top-down versus step-up strategies to prevent postoperative recurrence in Crohn’s disease
Background: The best management after ileocolonic resection is still unknown in Crohn’s disease (CD). The authors compared step-up and top-down approaches to prevent short- and long-term postoperative recurrences in CD patients.
Methods: From a comprehensive database, consecutive CD patients who underwent intestinal resection (2014–2021) were included. Top-down (biologics started within the first month after surgery) or step-up strategies (no biologic between surgery and colonoscopy at 6 months) were performed with systematic colonoscopy at 6 months and therapeutic escalation if Rutgeerts index was ≥ i2a (endoscopic postoperative recurrence). Propensity score analysis was applied for each comparison.
Results: Among 115 CD patients, top-down was the most effective strategy to prevent endoscopic postoperative recurrence (46.8% vs. 65.9%, p = 0.042) and to achieve complete endoscopic remission (Rutgeerts index = i0; 45.3% vs. 19.3%; p = 0.004) at 6 months. The authors did not observe any significant difference between the 2 groups regarding clinical postoperative recurrence (hazard ratio [HR] = 0.86, 95% confidence interval [CI]: 0.44–1.66, p = 0.66) and progression of bowel damage (HR = 0.81, 95% CI: 0.63–1.06, p = 0.12). Endoscopic postoperative recurrence at 6 months was associated with increased risk of clinical postoperative recurrence (HR = 1.97, 95% CI: 1.07–3.64, p = 0.029) and progression of bowel damage (HR = 3.33, 95% CI: 1.23–9.02, p = 0.018). Among the subgroup without endoscopic postoperative recurrence at 6 months, the risks of clinical postoperative recurrence and progression of bowel damage were significantly improved in the top-down group (HR = 0.59, 95% CI: 0.37–0.94, p = 0.025, and HR = 0.73, 95% CI: 0.63–0.83, p < 0.001).
Conclusions: Top-down strategy should be the preferred management to prevent short- and long-term postoperative recurrence in Crohn’s disease.