Endoscopy after surgery in inflammatory bowel disease: Crohn’s disease recurrence and pouch surveillance

ABSTRACT

Introduction

Crohn’s disease (CD) and ulcerative colitis (UC) are immune-mediated disorders characterized by a chronic inflammation, with intermittent exacerbations of symptoms and inflammation. In both diseases, medical treatment has made revolutionary steps forward. Nevertheless, surgery is still required in many cases due to inefficacy of multiple medical therapies. It is not clear whether surgery rates in inflammatory bowel diseases (IBD) are currently decreasing despite all improvements.

Areas covered

Multidisciplinary management is critical in surgical patients to improve long-term outcomes. Endoscopy plays a crucial role, both before and after surgery, in planning therapeutic strategies and stratifying risk of recurrence. Aim of this review is to provide a deeper insight into the central role of endoscopy in the postoperative management of IBD patients, focusing on recent research advances, future challenges and unresolved questions.

Expert opinion

Both UC and CD surgical patients need endoscopy to define the correct therapeutic choice, predict subsequent disease course and adopt the correct surveillance strategy. In the next future, newer endoscopic techniques could be systematically applied in IBD patients after surgery, to assess early postoperative inflammation, response to treatment, or, regarding UC, to provide enhanced pouch surveillance, allowing for early detection of inflammation and dysplasia.

KEYWORDS:

• Endoscopy
• surgery
• inflammatory bowel disease
• postoperative
• Crohn’s disease
• recurrence
• ulcerative colitis
• pouch surveillance
• IBD
• pouchitis

Article highlights

• Despite newer and highly efficient medical treatments, surgery is performed in a high percentage of IBD patients during their lifetime

• Endoscopy is a cornerstone in pre- and postoperative decision-making and in the multidisciplinary care of surgical patients, both in Crohn’s disease (CD) and ulcerative colitis (UC).

• Rutgeerts’ score (RS) was developed to predict the risk of clinical recurrence after ileocecal resection according to endoscopic findings at the anastomosis.

• The significance of some features of the RS, such as the subclassification of i2 grade and the finding of anastomotic and ileal blind-end ulcers, is uncertain and yet to be prospectively studied.

• Endoscopic surveillance of the pouch after ileal pouch-anal anastomosis (IPAA) in UC is under debate as long-term data regarding malignancy risk are contradictory.

• Screening pouchoscopy at 1 year for all UC-IPAA patients, followed by an algorithm of subsequent evaluation which takes into account risk factors for neoplasia and severity of endoscopic signs of inflammation, might improve long-term outcomes.

• Newer and increasingly used endoscopic techniques, such as videocapsule endoscopy and virtual chromoendoscopy, could play a role in postoperative evaluation and risk stratification of postoperative patients.

Declaration of interest

F Furfaro received consulting fees form MSD and Abbvie and lecture fees from Janssen and Pfizer. M Allocca received consulting fees from Nikkiso Europe and lecture fees from Janssen and Pfizer. G Fiorino received consultancy fees from Ferring, MSD, AbbVie, Takeda, Janssen, Amgen, Sandoz, Samsung Bioepis, Celltrion. D Gilardi as served as speaker or consultant for Nikkiso, Sofar Spa, Boiler Spa, J&J, Pfizer, Takeda, Roche. M Argollo has served as speaker, consultant and advisory board for Abbvie, Janssen, Takeda and Pfizer. S Danese has served as a speaker, consultant, and advisory board member for Schering-Plough, AbbVie, Actelion, Alphawasserman, AstraZeneca, Cellerix, Cosmo Pharmaceuticals, Ferring, Genentech, Grunenthal, Johnson and Johnson, Millenium Takeda, MSD, Nikkiso Europe GmbH, Novo Nordisk, Nycomed, Pfizer, Pharmacosmos, UCB Pharma and Vifor. The other authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This paper was not funded.