Discussion

Relapse after resection, whether endoscopic, clinical, or surgical, remains to be defined. The evidence that any therapy prevents clinical recurrence of CD after surgery is limited. Studies are variously limited by insufficient power, suboptimal dosing, discontinuous follow-up of insufficient duration, diverse definitions, inter-observer variation in endoscopic assessment, different scoring systems, and post hoc subgroup analysis. Meta-analyses will not make up for poorly designed or conducted studies. The benefit of mesalamine may be overestimated, nitroimidazole antibiotics are not well tolerated,⁴ and the benefit of thiopurines is yet to be determined. However results from the recently concluded Trial Of Prevention of Post-operative Crohn’s disease (TOPPIC) in 234 patients should provide evidence supporting or refuting MP therapy for this indication.²¹ Anti-TNF therapy appears to offer some hope, and debate on the optimal postoperative maintenance will likely continue. No single design variable was predictive of the placebo endoscopic recurrence rate. It is notable that the opinion of the Faculty changed after presentation of the evidence in the systematic review.