Expert Guidance on Pediatric Postoperative Crohn’s Disease

A recent NASPGHAN clinical report (JB Splawski et al JPGN 2017; 65: 475-86) updates recommendations to lower the rate of postoperative recurrence in pediatric Crohn Disease (CD).  In this report, after review of a number of studies, the authors provide a management algorithm (Figure 1).  In addition, they review risk factors for surgery/postoperative recurrence in CD.

Key points:

  • “Endoscopic recurrence precedes clinical recurrence, and is a better predictor of the risk for future surgery.”
  • “Anti-TNF agents appear to be the most effective treatment in preventing postoperative recurrence.”  These agents “can be started as early as 4 weeks after surgery.”
  • “Prophylactic treatment to prevent recurrence rather than treating after the disease recurs, appears to be more effective in preventing further surgery.”
  • “Early postoperative surveillance for disease recurrence allows for a change in management to prevent complications that may lead to further surgery.” The authors note that fecal calprotectin (and lactoferrin) return to baseline around 2 months after surgery, and “monitoring disease activity postsurgery with these tests may help determine appropriate selection for more invasive testing such as endoscopy.”

My take: The authors emphasize that “whatever treatment is chosen, early surveillance for disease recurrence is clearly needed.”  In addition, anti-TNF agents are most likely to lower risk of further surgery.

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