Risk Factors for Small Bowel Crohn’s Disease Recurrence after Total Proctocolectomy

BACKGROUND: Surgical management of Crohn's disease of the colon and rectum frequently requires total proctocolectomy with end ileostomy. There is limited data on the need for Crohn's disease-directed therapy and the prevalence of recurrence after surgery. OBJECTIVE: To determine the risk of small bowel Crohn's disease recurrence and evaluate risk factors for postoperative recurrence after total proctocolectomy with end ileostomy. DESIGN: Retrospective cohort study. SETTINGS: Multistate tertiary healthcare system. PATIENTS: Adult patients with Crohn's disease undergoing total proctocolectomy with end ileostomy between 2014-2023. MAIN OUTCOME MEASURES: The primary outcome was small bowel Crohn's disease recurrence. RESULTS: A total of 193 patients with a median age of 45 years (IQR, 34-61) were included. Over half of the patients (n = 102, 52.9%) had a history of small bowel Crohn's disease and the majority (n = 134, 69.4%) received biologic therapy prior to surgery. The median follow-up time was 4.8 years (IQR, 2.0-7.6). Postoperatively, 30.6% of patients (n = 59) received biologic therapy. Thirty-five patients (18.1%) had small bowel Crohn's disease recurrence for an estimated 5-year recurrence-free rate of 80.2% (95% CI, 73.0-85.7). Seven patients (3.6%) developed small bowel Crohn's disease recurrence requiring surgery for an estimated 5-year surgical recurrence-free rate of 94.7% (95% CI, 89.0-97.5). On multivariable analysis, history of small bowel Crohn's disease (HR 2.17; 95% CI' 1.04-4.54) and diagnosis at age <18 years (HR 2.31; 95% CI'1.1-4.86) were associated with small bowel Crohn's disease recurrence. LIMITATIONS: Retrospective design and non-standardized follow-up. CONCLUSIONS: Patients undergoing total proctocolectomy with end ileostomy for Crohn's disease have approximately a 20% risk of small bowel recurrence at 5 years but a low risk of requiring surgical intervention. Patients with a history of small bowel Crohn's disease and younger age at diagnosis have a higher risk of recurrence and may warrant consideration of more frequent surveillance and medical prophylaxis. See Video Abstract.