P348 Top down versus step-up strategies to prevent postoperative recurrence in Crohn’s disease
Buisson, A.(1);Blanco, L.(1);Manlay, L.(1);Reymond, M.(1);Rouquette, O.(1);Dubois, A.(1);Pereira, B.(1);
(1)University Hospital Estaing, Department of Gastroenterology- IBD Unit, Clermont-Ferrand, France;
Background
The best management after ileocolonic resection is still unknown in Crohn’s disease (CD).
We compared step-up and top-down approaches to prevent short and long-terms postoperative recurrences in CD patients.
Methods
From a comprehensive database, consecutive CD patients who underwent intestinal resection (2014-2021) were included. Top-down (biologics started within the first month after surgery) or step-up strategies (no biologic between surgery and colonoscopy at 6 months) were performed with systematic colonoscopy at 6 months and therapeutic escalation if Rutgeerts index was ≥i2a (endoscopic postoperative recurrence). Propensity score analysis (Inverse probability of treatment weighting) was applied for each comparison adjusted on the following parameters: gender, prior history of bowel resection, smoking habits, CD location, CD behaviour, resection length > 30 cm, age and the number of biologics before surgery.
Results
Among 115 CD patients, top-down was the most effective strategy to prevent endoscopic postoperative recurrence (Rutgeerts index ≥ i2a) (46.8% vs 65.9%, p=0.042) and to achieve complete endoscopic remission (Rutgeerts index = i0) (45.3% vs 19.3%, p=0.004) at 6 months. The median time of follow-up (ending at the time first progression of bowel damage or last follow-up) was 41.9 months [21.4-76.2]. We did not observe any significant difference between the two groups regarding clinical postoperative recurrence (hazard ratio (HR) = 0.86 [0.44-1.66], p=0.66) and progression of bowel damage (HR = 0.81 [0.63-1.06], p=0.12). Endoscopic postoperative recurrence (Rutgeerts index ≥ i2a) at 6 months was associated with increased risk of clinical postoperative recurrence (HR = 1.97 [1.07-3.64], p 0.029) and progression of bowel damage (HR = 3.33 [1.23-9.02], p=0.018). Among the subgroup without endoscopic postoperative recurrence (Rutgeerts index = i0 or i1) at 6 months, the risks of clinical postoperative recurrence and progression of bowel damage were significantly improved in the top-down group compared to step-up (HR = 0.59 [0.37-0.94], p = 0.025) and HR = 0.73 [0.63-0.83], p<0.001, respectively). In contrast, when focusing on patients experiencing endoscopic postoperative recurrence (Rutgeerts index ≥ i2a) at 6 months, top-down approach was associated with higher likelihood of clinical postoperative recurrence (HR = 1.92 [1.02-3.59], p = 0.042) and progression of bowel damage (HR = 1.58 [1.03-2.42], p = 0.035).
Conclusion
Top-down strategy should be preferred to step-up approach to prevent endoscopic postoperative recurrence as well as clinical postoperative recurrence and progression of bowel damage in most of the patients with Crohn’s disease after bowel resection.