Background: Up to half of the patients with Crohn's disease require at least one surgery during their life-time. Without therapy, recurrence is expected to occur in up to 50%, and is higher in patients meeting specific unfavorable prognostic factors (ex. smoking, structuring or penetrating behavior). Anti-TNF therapy has proven to be the most effective therapy in preventing postoperative endoscopic and clinical recurrence. However, the weight of the different prognostic factors in patients under anti-TNF has not been adequately assessed. Our aim was to study the predictors of anti-TNF failure in postoperative Crohn's disease.
Methods: Patients with Crohn's disease under anti-TNF therapy for prevention of postoperative recurrence were retrospectively reviewed. Clinical recurrence was defined as the need to escalate or discontinue therapy. A logistic regression analysis was performed to evaluate potential predictors of surgical recurrence.
Results: A total of 240 patients with Crohn's disease were evaluated. Anti-TNF therapy included Infliximab in 160 patients and Adalimumab in 80 patients. The median follow-up was 5.4 (0–19.1) years. Clinical recurrence occurred in 106 patients (44.2%) and surgical recurrence in 30 patients (12.5%). Predictors of surgical recurrence included active smoking (OR 7.429 95% CI 1.006–54.851, p=0.049), upper gastrointestinal disease (OR 2.61 95% CI 0.99–6.9, p=0.05), structuring or penetrating disease (OR 4.39, 95% CI 1.54–12.49, p=0.005), perianal disease (OR 2.69 95% CI 1.14–6.37, p=0.024) and clinical recurrence (OR 4.79, 95% CI 1.90–12.07, p=0.001). Each additional risk factor increased the risk of surgical recurrence by 103% (OR 2.798 95% CI 1.85–4.23, p=0.000). Surgical recurrence occurred in 2.3% of patients with one or fewer risk factors but in 46.7% of those with four or more risk factors (p=0.000). A model including all 5 risk factors would predict surgery with 87.1% accuracy (AUC 0.902, 95% CI 0.862–0.942, p=0.000).
Conclusions: Response to anti-TNF therapy is influenced by disease location, behavior, perianal disease and clinical recurrence. Patients presenting all these factors are potential candidates for non-anti-TNF driven therapies.