Prevention of Postoperative Recurrence in Crohn's Disease Jonathan P. Terdiman  Clinical Gastroenterology and Hepatology  Volume 6, Issue 6, Pages 616-620 (June 2008) DOI: 10.1016/j.cgh.2007.08.020 Copyright © 2008 AGA Institute Terms and Conditions

Figure 1 Rates of endoscopic, clinical, and surgical recurrence after intestinal resection in Crohn's disease. Clinical Gastroenterology and Hepatology 2008 6, 616-620DOI: (10.1016/j.cgh.2007.08.020) Copyright © 2008 AGA Institute Terms and Conditions

Figure 2 Suggested management strategy for the prevention of postoperative recurrence in Crohn's disease. (1) Low risk is defined as long-standing, short-segment fibrostenotic disease with minimal active inflammation. High risk is defined as all other patients, especially those with ongoing tobacco use, history of prior resection, use of an immune modulator or anti–TNF-α agent before the surgery, perforating disease, or extensive disease requiring greater than 50 cm of bowel to be removed. (2) Consideration can be given to starting low-risk patients on metronidazole at a low dose, such as 250 mg 3 times per day, or mesalamine at a dose of 2–4 g/day. High-risk patients should be started on azathioprine (aza) with a target dose of 2.5 mg/kg/day, or 6-MP with a target dose of 1.5 mg/kg/day. The benefit of adding a second prophylactic drug to 6-MP or AZA, such as metronidazole or mesalamine, is uncertain. Consideration should be given to continuing anti–TNF-α drug in patients using one before the resection, or to starting an anti–TNF-α drug immediately in patients who clearly progressed despite adequate treatment with 6-MP or AZA preoperatively. (3) If anastomosis is not accessible by ileocolonoscopy, consider use of computerized tomography enterography and/or capsule endoscopy to assess. (4) No lesions or minimal recurrence corresponds with an endoscopy score of 0 or 1, whereas moderate or severe lesions refers to an endoscopy score of 2–4 (see Table 1). (5) Management strategy needs to be individualized, and might include changing the immune modulator or biological agent, or using combination medical therapy. Clinical Gastroenterology and Hepatology 2008 6, 616-620DOI: (10.1016/j.cgh.2007.08.020) Copyright © 2008 AGA Institute Terms and Conditions