Background: Post-operative recurrence (POR) is common in patients with Crohn’s disease (CD) who have undergone surgery. Endoscopy, mainly based on Rutgeerts’ score, is crucial for the diagnosis of POR, showing also high prognostic value. More recently, several studies have suggested that the current endoscopic score system could be affected by the ischemic (not inflammatory) nature of some anastomotic ulcers, particularly at the level of the mucosal inverted stapled line, so overestimating the prevalence of the “real” anastomotic POR. However, these studies, based on the comparison between CD patients and subjects undergone right-side resection for colorectal cancer (CRC), included a very small population. Starting from these considerations, we performed a retrospective study aimed to directly compare the prevalence of anastomotic POR in CD with that of patients undergone right-side resection for CRC in a wide population.
Methods: A retrospective study was conducted at four Italian Institutions (2 with high volume of IBD admissions; 2 with high volume CRC admissions). All patients performed endoscopy within 8 months from surgery. We selected all consecutive CD and CRC patients undergone a surgical resection with an anisoperistaltic stapled L-L anastomosis. The diagnosis of POR of CD was made in accordance with the modified Rutgeerts’ score (i0, i1, i2A, i2B, 3, 4). The global prevalence of POR (Rutgeerts’s score >2) was recorded. Furthermore, we directly compared the prevalence of the isolated anastomotic ulcers of CD (Rutgeerts i2A) to that detected in CRC patients.
Results: At the end of the study, we enrolled 221 CD patients and 72 CRC subjects. POR was recorded in 127 CD patients (57%). According to the endoscopic grade system, POR was scored as i0: 56 pts (25%), i1: 38 pts (17%); i2A: 42 pts (19%), i2B: 26 pts (12%), i3: 20 pts (9%), i4: 39 pts (18%). In the CRC group, endoscopy detected anastomotic ulcers in 2 out of 72 patients (3%); 1 case (1.4%) of CRC early recurrence was observed. When comparing the prevalence of isolated anastomotic ulcerations in CD (i2A) vs those in CRC patients, the prevalence of ulcerations was significantly higher in CD patients (19% vs 3%; p<0.01; OR=6.3).
Conclusions: Our study confirms the high prevalence of early recurrence in CD patients, so confirming the role of early (within 6-8 months) post-operative endoscopy in CD setting. The prevalence of anastomotic (ischemic) ulcers in CRC patients is very low and, as a consequence, this issue should not represent a real diagnostic matter if shifted into the POR setting of CD. Prospective, multicentre and directly comparative studies are needed to confirm our results.

Giovanni Domenico De Palma

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