65to reach significance (OR 1.58, 95% CI 0.97–2.57, p = 0.06) which the authors felt
was likely due to study heterogeneity (Cochran Q: 12.36, p = 0.03, I: 59.6%). Lastly,
interleukin-10 has been studied by Meresse et al. in a group of 36 postoperative CD
patients and did not detect any association with endoscopic recurrence [ 28 ].
Consequently, there likely exists various genetic signatures which may predispose
patients to POR; however, the current strength of data is suboptimal, and larger
cohort studies with defined and consistent protocols are needed.
Disease Factors
Disease behavior is a frequently cited risk factor for surgical resection with strictur-
ing and penetrating phenotypes at increased risk of surgery. However, relating dis-
ease behavior to postoperative recurrence is difficult given the fluctuating nature of
CD and changes in the behavior pattern over time and in response to medical ther-
apy. In a meta-analysis of 12 studies examining postoperative recurrence, Pascua
et al. found that penetrating/fistulizing phenotype was a risk factor for endoscopic
recurrence (OR 1.59, 95% CI 1.37–1.84 for every 10% placebo-treated patients with
fistulizing disease) [ 29 ]. In the same study, patients who had prior surgery for CD
indications were at significantly increased risk of POR (OR 1.14, 95% CI 1.04–1.26
for every 10% increase). This risk association has been replicated in other studies as
well. Simillis et al. demonstrated that patients who have surgery with a particular
disease behavior often have recurrence of that same behavior requiring reoperation
[ 30 ]. It follows that any history of CD-related surgeries, regardless of disease behav-
ior, is a strong predictor of postoperative recurrence. However, it should be noted
that most studies did not differentiate between penetrating complications related to
stricturing disease and de novo perforating disease without stricture.
The requirement of certain medications prior to surgery has also been shown to
predict the risk of postoperative recurrence. The use of anti-TNF therapy presurgery
has been associated in several studies to predict higher rates of POR [ 31 , 32 ]. The
medication themselves are not likely responsible for the disease recurrence, but they
are more likely a reflection of disease activity, severity, or complication(s) prior to
resection.
Surgical Technique/Findings
Anastomotic technique has been suggested as influencing POR. A difference in
outcomes has been postulated from the wider luminal capacity of a stapled anasto-
mosis preventing fecal stasis and bacterial overgrowth compared to a hand-sewn
end-to-end anastomosis. Yamamoto et al. followed 45 patients who underwent sta-
pled side-to-side anastomosis (“functional end to end”), and 78 underwent conven-
tional sutured end-to-end anastomosis and found that cumulative 1-, 2-, and 5-year
ileocolonic recurrence rates requiring reoperation were significantly lower in the
5 Use of Biologics in the Postoperative Management of Crohn’s Disease