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Suboptimal Guideline Adherence and Biomarker Underutilization in Monitoring of Post-operative Crohn’s Disease

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An Invited Commentary to this article was published on 07 August 2023

Abstract

Background

Crohn’s disease recurrence after ileocecal resection is common. Guidelines suggest colonoscopy within 6–12 months of surgery to assess for post-operative recurrence, but use of adjunctive monitoring is not protocolized. We aimed to describe the state of monitoring in post-operative Crohn’s.

Methods

We conducted a retrospective study of patients with Crohn’s after ileocolic resection with ≥ 1-year follow-up. Patients were stratified into high and low risk based on guidelines. Post-operative biomarker (C-reactive protein, fecal calprotectin), cross-sectional imaging, and colonoscopy use were assessed. Biomarker, radiographic, and endoscopic post-operative recurrence were defined as elevated CRP/calprotectin, active inflammation on imaging, and Rutgeerts ≥ i2b, respectively. Data were stratified by surgery year to assess changes in practice patterns over time. P-values were calculated using Wilcoxon test and Fisher exact test.

Results

Of 901 patients, 53% were female and 78% high risk. Median follow-up time was 60 m for LR and 50 m for high risk. Postoperatively, 18% low and 38% high risk had CRPs, 5% low and 10% high risk had calprotectins, and half of low and high risk had cross-sectional imaging. 29% low and 38% high risk had colonoscopy by 1 year. Compared to pre-2015, time to first radiography (584 days vs. 398 days) and colonoscopy (421 days vs. 296 days) were significantly shorter for high-risk post-2015 (P < 0.001). Probability of colonoscopy within 1 year increased over time (0.48, 2011 vs. 0.92, 2019).

Conclusion

Post-operative colonoscopy completion by 1 year is low. The use of CRP and imaging are common, whereas calprotectin is infrequently utilized. Practice patterns are shifting toward earlier monitoring.

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Funding

Jordan Axelrad receives research support from the Crohn’s and Colitis Foundation, the Judith and Stewart Colton Center for Autoimmunity, and the NIH NIDDK Diseases K23DK124570. Edward Barnes receives research support from the NIH NIDDK K23DK127157.

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Authors and Affiliations

  1. Department of Internal Medicine, NYU Grossman School of Medicine, New York University Langone Health, 550 First Avenue, New York, NY, USA

    Terry Li

  2. Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

    Benjamin Click

  3. Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Salam Bachour

  4. Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark

    Michael Sachs

  5. Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA

    Edward L. Barnes

  6. Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA

    Benjamin L. Cohen

  7. Inflammatory Bowel Disease Center, New York University Langone Health, New York, NY, USA

    Susell Contreras & Jordan Axelrad

Authors
  1. Terry Li
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  2. Benjamin Click
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  3. Salam Bachour
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  4. Michael Sachs
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  8. Jordan Axelrad
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Contributions

Guarantor: JA and TL. Study concept and design: JA, TL, BC, and ELB. Acquisition of data: TL, SB, and SC. Writing the first draft of the manuscript: TL. Critical revision of the manuscript for important intellectual content and approval of final version: All co-authors. All authors approved the final version of the article, including the authorship list.

Corresponding author

Correspondence to Terry Li.

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Conflict of interest

Jordan E. Axelrad reports research grants from BioFire Diagnostics; consultancy fees, honorarium, or advisory board fees from BioFire Diagnostics, Janssen, Pfizer, Bristol Myers Squibb, Adiso, and Abbvie. Terry Li reports no disclosures. Salam P. Bachour reports no disclosures. Michael C. Sachs reports no disclosures. Edward L. Barnes reports consulting for AbbVie, Gilead, Pfizer, and TARGET-RWE. Benjamin L. Cohen receives financial support for advisory boards and consultant for Abbvie, Celgene-Bristol Myers Squibb, Pfizer, Sublimity Therapeutics, Takeda, and TARGET-RWE; CME Companies: Cornerstones and Vindico; and Speaking: Abbvie. Benjamin Click reports consulting fees for IBD Education Group, TARGET-RWE, and Takeda. Susell Contreras reports no disclosures.

Ethical approval

The institutional review board approved this study at participating centers. All ethical principles laid out in the Declaration of Helsinki were followed.

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Li, T., Click, B., Bachour, S. et al. Suboptimal Guideline Adherence and Biomarker Underutilization in Monitoring of Post-operative Crohn’s Disease. Dig Dis Sci 68, 3596–3604 (2023). https://doi.org/10.1007/s10620-023-08044-7

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