Prevention of Crohn's Disease Recurrence After Surgery: On the Road to Recovery.

Dear Editors, we have read with interest the paper by Regueiro et al (1) regarding long term Infliximab (IFX) use as maintenance therapy to prevent Crohn’s disease (CD) recurrence after ileo-colonic resection. This study is the continuation of a previous randomized, two armed trial, that evaluated the rate of endoscopic recurrence at one year after surgery, in patients randomized to IFX or placebo. The proportion of endoscopic recurrence was lower in the IFX group compared with placebo (9% vs. 85%) (2). In the current open-label study, the same patients, according to their endoscopic findings at one year, were given the option to continue, to stop, or to start IFX therapy. Then patients were followed for at least 5 years after surgery. Patients on long-term IFX therapy, irrespective of original assignment to IFX or placebo, presented higher rate of endoscopic remission and lower rate of surgical recurrence compared with other patients during the whole follow-up period. These data are important because confirm that starting anti-TNFα immediately after surgery (3-5) or shortly after endoscopic recurrence (6-7) permits to obtain a low recurrence rate in the long-term. Moreover, the Authors demonstrated that early anti-TNFα treatment is associated to a lower need for additional surgery compared to patients who started the treatment in response to endoscopic recurrence. This study is particularly relevant considering the paucity of data currently available in medical literature on the role of anti-TNFα drugs in the post-surgical setting. However, not all the data available in literature have been quoted as we have recently published the first randomized three armed study evaluating the rate of endoscopic recurrence at two years follow-up in patients treated with Adalimumab (ADA), azathioprine or mesalamine. Also in our study, the rate of endoscopic recurrence was significantly lower in ADA group compared with azathioprine and mesalamine, (6.3% vs. 64.7% vs. 83.3%, respectively (8). Moreover, we provided a follow-up period of two years with detailed clinical, radiologic and endoscopic data at 1 and 2 years after surgery and, further, we directly compared the anti-TNFα treatment with the most traditional drugs, such as mesalamine and azathioprine. Therefore our data and those published by Regueiro et al confirm that patients with risk factors for disease recurrence and additional surgery, such as cigarette smoking, young age, ileocolonic involvement, penetrating/fistulizing disease behavior, early immunomodulator administration and short disease duration before surgery should be considered to start treatment with anti TNFα shortly after surgery