Current preventive treatment for recurrence after curative hepatectomy for liver metastases of colorectal carcinoma: A literature review of randomized control trials

To review the preventive approaches for recurrence after curative resection of hepatic metastases from colorectal carcinoma, we have summarized all available publications reporting randomized control trials (RCTs) covered in PubMed. The treatment approaches presented above include adjuvant intrahepatic arterial infusion chemotherapy, systemic chemotherapy, neoadjuvant chemotherapy, and immunotherapy. Although no standard treatment has been established, several approaches present promising results, which are both effective and tolerable in post-hepatectomy patients. Intrahepatic arterial infusion chemotherapy should be regarded as effective and tolerable and it increases overall survival (OS) and disease free survival (DFS) of patients, while 5-fluorouracil-based systemic chemotherapy has not shown any significant survival benefit. Fortunately chemotherapy combined with hepatic arterial infusion and intravenous infusion has shown OS and DFS benefit in many researches. Few neoadjuvant RCT studies have been conducted to evaluate its effect on prolonging survivals although many retrospective studies and case reports are published in which unresectable colorectal liver metastases are downstaged and made resectable with neoadjuvant chemotherapy. Liver resection supplemented with immunotherapy is associated with optimal results; however, it is also questioned by others. In conclusion, several adjuvant approaches have been studied for their efficacy on recurrence after hepatectomy for liver metastases from colorectal cancer (CRC), but multi-centric RCT is still needed for further evaluation on their efficacy and systemic or local toxicities. In addition, new adjuvant treatment should be investigated to provide more effective and tolerable methods for the patients with resectable hepatic metastases from CRC.

Natural history, treatment and prevention of hepatitis C recurrence after liver transplantation: Past, present and future

Hepatitis C virus(HCV)-related liver disease, including cirrhosis and hepatocellular carcinoma is the main indication for liver transplantation(LT) worldwide. Posttransplant HCV re-infection is almost universal and results in accelerated progression from acute hepatitis to chronic hepatitis, and liver cirrhosis. Comprehension and treatment of recurrent HCV infection after LT have been major issues for all transplant hepatologists and transplant surgeons for the last decades. The aim of this paper is to review the evolution of our knowledge on the natural history of HCV recurrence after LT, including risk factors for disease progression, and antiviral therapy. We will focus our attention on possible ways(present and future) to improve the final longterm results of LT for HCV-related liver disease.

Network meta-analysis of the prognosis of curative treatment strategies for recurrent hepatocellular carcinoma after hepatectomy

BACKGROUND Recurrent hepatocellular carcinoma(rHCC)is a common outcome after curative treatment.Retreatment for rHCC is recommended,but no guidelines exist.AIM To compare curative treatments such as repeated hepatectomy(RH),radiofrequency ablation(RFA),transarterial chemoembolization(TACE)and liver transplantation(LT)for patients with rHCC after primary hepatectomy by conducting a network meta-analysis(NMA).METHODS From 2011 to 2021,30 articles involving patients with rHCC after primary liver resection were retrieved for this NMA.The Q test was used to assess heterogeneity among studies,and Egger’s test was used to assess publication bias.The efficacy of rHCC treatment was assessed using disease-free survival(DFS)and overall survival(OS).RESULTS From 30 articles,a total of 17,11,8,and 12 arms of RH,RFA,TACE,and LT subgroups were collected for analysis.Forest plot analysis revealed that the LT subgroup had a better cumulative DFS and 1-year OS than the RH subgroup,with an odds ratio(OR)of 0.96(95%CI:0.31-2.96).However,the RH subgroup had a better 3-year and 5-year OS compared to the LT,RFA,and TACE subgroups.Hierarchic step diagram of different subgroups measured by the Wald test yielded the same results as the forest plot analysis.LT had a better 1-year OS(OR:1.04,95%CI:0.34-03.20),and LT was inferior to RH in 3-year OS(OR:10.61,95%CI:0.21-1.73)and 5-year OS(OR:0.95,95%CI:0.39-2.34).According to the predictive P score evaluation,the LT subgroup had a better DFS,and RH had the best OS.However,meta-regression analysis revealed that LT had a better DFS(P<0.001)as well as 3-year OS(P=0.881)and 5-year OS(P=0.188).The differences in superiority between DFS and OS were due to the different testing methods used.CONCLUSION According to this NMA,RH and LT had better DFS and OS for rHCC than RFA and TACE.However,treatment strategies should be determined by the recurrent tumor characteristics,the patient’s general health status,and the care program at each institution.

Intestinal Behçet's disease: A review of clinical diagnosis and treatment

Behçet's disease(BD)is a chronic inflammatory disorder prone to frequent re-currences,with a high predilection for intestinal involvement.However,the ef-ficacy and long-term effects of surgical treatment for intestinal BD are unknown.In the current issue of World J Gastrointest Surg,Park et al conducted a retrospec-tive analysis of 31 patients with intestinal BD who received surgical treatment.They found that elevated C-reactive protein levels and emergency surgery were poor prognostic factors for postoperative recurrence,emphasizing the adverse impact of severe inflammation on the prognosis of patients with intestinal BD.This work has clinical significance for evaluating the postoperative condition of intestinal BD.The editorial attempts to summarize the clinical diagnosis and treatment of intestinal BD,focusing on the impact of adverse factors on surgical outcomes.We hope this review will facilitate more precise postoperative management of patients with intestinal BD by clinicians.

TREATMENT OF LOCAL RECURRENCE OF NASOPHARYN-GEAL CARCINOMA WITH REIRRADIATION

From 1975 to 1987, 112 patients with loco-regional recurrence of nasopharyngeal carcinoma (N P C) were treated again with radiation at our hospital. All cases were proven histologically by biopsy. Of these patients, 92 had their recurrence in the nasopharynx only, 13 had additional involvement of the base of the skull, and 7 had tumor recurrences simultaneously in the nasopharynx as well as the cervical lymph nodes. Radiotherapy adopted in this series was 60Co external irradiation (X R Te) and/ or betatron in 96 patients, X R Te plus intracavitary 60Co irradiation (X R Ti) in 12 patients and X R Ti alone in the other 4 patients. The 1-, 3-, and 5-year survival rates were 86.3%, 45.8% and 30.2% respectively after the start of recurrence retreatment. The 63 patients who survived for 5 years or more were analyzed. The prognosis of the patient was related to the histological type, clinical stage, modality of treatment, and disease interval to recurrence and site of recurrence. No serious complications occurred. It is suggested that re-irradiation is appropriate in the treatment of loco-regional recurrent N P C.

THE FACTORS AND TREATMENT OF LOCAL RECURRENCE AFTER RADICAL RESECTION RESERVING THE ANUS IN THE PATIENTS WITH RECTAL CANCER

Of seventy-one patients with rectal cancer after radical resection retaining the anus, 15 developed local recurrence with a recurrence rate of 21.1%. Local recurrence was correlated with improper safety margin from the lower edge of cancer to the anal end. There was statistical significant difference between 3 cm or more and 2 cm or less. The local recurrence was also related to the pathologic stage, histologic differentiation and implant of free cancer cells. It is suggested that the surgical indication of saving the anus be strict and without stretching, the safety margin from the lower edge of cancer to the anal end should not be less than 2 cm in early rectal cancer and not less than 4 cm in advanced lesions. During the operation, no touching tumor technique, thorough rinsing of the peritoneal cavity and pre- or post-operative radiotherapy are important for prevention of local recurrence. Early local recurrent rectal cancer can be detected by periodic examinations.

Therapeutic strategy for postoperative recurrence in patients with non-small cell lung cancer

Postoperative recurrence occurs in approximately half of patients with non-small cell lung cancer(NSCLC), even after complete resection. Disease recurrence after surgical resection reduces the patient's life expectancy sharply. The prognosis after postoperative recurrence is considered to largely depend on both the mode of first recurrence(distant, locoregional or combined) and the treatment modality:(1) The majority of cases of postoperative recurrence involve distant metastasis with or without locoregional recurrence. Platinum-based systemic chemotherapy is practically accepted as the treatment for these diseases on the basis of evidence for original stage Ⅳ disease. The advent of both pemetrexed and molecular-targeted drugs has improved the survival of nonsquamous NSCLC and changed the chemotherapeutic algorithm for NSCLC;(2) Among patients with distant metastatic recurrence without locoregional recurrence at the primary tumor site, the metastasis is often limited in both organ and number. Such metastases are referred to as oligometastases. Local therapy, such as surgical resection and radiotherapy, has been suggested to be the first-line treatment of choice foroligometastatic recurrence; and(3) While locoregional recurrence is likely to cause troublesome symptoms, it is a potentially limited disease. Therefore, providing local control is important, and radiation is usually beneficial for treating local recurrence. In order to obtain better control of the disease and provide treatment with curative intent in patients with limited disease, the administration of concurrent platinum-based chemoradiotherapy is recommended according to the results of originally nonresectable stage ⅢA and ⅢB disease.

Acute recurrent pancreatitis:Etiopathogenesis, diagnosis and treatment

Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland, however, an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The aetiology of ARP can be identified in the majority of patients. Most common causes include common bile duct stones or sludge and bile crystals; sphincter of oddi dysfunction; anatomical ductal variants interfering with pancreatic juice outflow; obstruction of the main pancreatic duct or pancreatico-biliary junction; genetic mutations; alcohol consumption. However, despite diagnostic technologies, the aetiology of ARP still remains unknown in up to 30% of cases: in these cases the term &#x0201c;idiopathic&#x0201d; is used. Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases, cholecystectomy, and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80% of patients. Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge. In uncertain cases toxin botulin injection may help in identifying some sphincter of oddi dysfunction, but this treatment is not widely used. In the last twenty years, pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction, independently from the cause of obstruction, and has been widely used instead of more aggressive approaches.

Targeting of circulating hepatocellular carcinoma cells to prevent postoperative recurrence and metastasis

Currently,the main treatment for hepatocellular carcinoma(HCC)involves the surgical removal of tumors or liver transplantation.However,these treatments are often not completely curative,as they are associated with a risk for postoperative recurrence and metastasis.Circulating tumor cells(CTCs)are increasingly recognized as the main source for recurrence and metastasis after radical hepatectomies are performed.Many studies have demonstrated the association between the presence of either pre-or postoperative CTCs and an increased risk for HCC recurrence.To improve the therapeutic outcome of HCC,a personalized,comprehensive and multidisciplinary approach should be considered,involving the application of appropriate diagnostic and therapeutic measures targeting HCC CTCs in different stages throughout the course of treatment.This article proposes some HCC CTC-based strategies for the treatment of HCC,including the monitoring of HCC CTCs before,during and after radical hepatectomy,therapeutic targeting of HCC CTCs,prevention of the generation and colonization of CTCs,as well as the use of CTC indexes for the selection of indications,prediction of prognoses,and planning of individualized therapeutic regimens.Innovation and technological development of therapies targeting CTCs,as well as their translation into clinical practice,will help to effectively reduce postoperative recurrence and metastasis,and significantly prolong the survival of HCC patients.

Impact of treatment modalities on patients with recurrent hepatocellular carcinoma after liver transplantation:Preliminary experience

Background:Post-liver transplantation(LT)hepatocellular carcinoma(HCC)recurrence still occurs in approximately 20%of patients and drastically affects their survival.This study aimed to evaluate the efficacy of various treatments for recurrent HCC after LT in a Chinese population.Methods:A total of 64 HCC patients with tumor recurrence after LT were enrolled in this study.Univariate and multivariate analyses were performed to identify factors affecting post-recurrence survival.Results:Of the 64 patients with recurrent HCC after LT,those who received radical resection followed by nonsurgical therapy had a median overall survival(OS)of 20.9 months after HCC recurrence,significantly superior to patients who received only nonsurgical therapy(9.4 months)or best supportive care(2.4 months).The one-and two-year OS following recurrence was favorable for patients receiving radical resection followed by nonsurgical therapy(93.8%,52.6%),poor for patients receiving only nonsurgical therapy(30.8%,10.8%),and dismal for patients receiving best supportive care(0%,0%;overall P<0.001).Median OS in sorafenib-tolerant patients treated with lenvatinib was 19.5 months,far surpassing the patients that discontinued sorafenib or were treated with regorafenib after sorafenib failure(12 months,P<0.001).Compared with tacrolimus-based immunosuppressive therapy,OS was significantly increased with sirolimus-based therapy at one and two years after HCC recurrence(P=0.035).Multivariate analysis showed radical resection combined with nonsurgical therapy for recurrent HCC and sorafenib-lenvatinib sequential therapy were independent favorable factors for post-recurrence survival.Conclusions:Aggressive surgical intervention in well-selected patients significantly improves OS after recurrence.A multidisciplinary treatment approach is required to slow down disease progression for patients with unresectable recurrent HCC.

Helicobacter pylori antibody responses in association with eradication outcome and recurrence： a population-based intervention trial with 7.3-year follow-up in China

Objective： To identify serum biomarkers that may predict the short or long term outcomes of anti-Helicobacter gylori （H. pylori） treatment, a follow-up study was performed based on an intervention trial in Linqu County, China. Methods： A total of 529 subjects were selected randomly from 1,803 participants to evaluate total anti-H, pylori immunoglobulin G （IgG） and 10 specific antibody levels before and after treatment at 1-, 2- and 7.3-year. The outcomes of anti-H, pylori treatment were also parallelly assessed by 13C-urea breath test at 45-d after treatment and 7.3-year at the end of follow-up. Results： We found the medians of anti-H, pylori IgG titers were consistently below cut-off value through 7.3 years in eradicated group, however, the medians declined in recurrence group to 1.2 at 1-year after treatment and slightly increased to 2.0 at 7.3-year. While the medians were significantly higher （〉3.0 at 2- and 7.3-year） among subjects who failed the eradication or received placebo. For specific antibody responses, baseline seropositivities of FliD and HpaA were reversely associated with eradication failure [for FIiD, odds ratio （OR）=0.44, 95% confidence interval （95% CI）： 0.27-0.73; for HpaA, OR=0.32, 95% Ch 0.I7-0.60]. The subjects with multiple positive specific antibodies at baseline were more likely to be successfully eradicated in a linear fashion （Ptrend=0.006）. Conclusions： Our study suggested that total anti-H, pylori IgG level may serve as a potential monitor of long- term impact on anti-H, pylori treatment, and priority for H. pylori treatment may be endowed to the subjects with multiple seropositive antibodies at baseline, especially for FliD and HapA.

Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy's lesion

AIM： To analyze the effectiveness of the endoscopic therapy and to identify prognostic factors for recurrent bleeding. METHODS： Retrospective study of patients with gas- trointestinal bleeding secondary to Dieulafoy＇s lesion （DL） from 2005 to 2011. We analyzed the demographic characteristics of the patients, risk factors for gastro- intestinal bleeding, endoscopic findings, characteristics of the endoscopic treatment, and the recurrence of bleeding. We included cases in which endoscopy de- scribed a lesion compatible with Dieulafoy. We exclud- ed patients who had potentially bleeding lesions such as angiodysplasia in other areas or had undergone other gastrointestinal endoscopic procedures. RESULTS： Twenty-nine patients with DL were identi- fied. Most of them were men with an average age of 71.5 years. Fifty-five percent of the patients received antiaggregatory or anticoagulant therapy. The most common location for DL was the stomach （51.7%）. The main type of bleeding was oozing in 65.5% of cases. In 27.6% of cases, there was arterial （spurting） bleeding, and 6.9% of the patients presented with an adherent clot. A single endoscopic treatment was ap- plied to nine patients （31%）, eight of them with adren- aline and one with argon, while 69% of the patients received combined treatment. Six patients （20.7%） presented with recurrent bleeding at a median of 4 d after endoscopy （interquartile range = 97.75）. Within these six patients, the new endoscopic treatment ob- tained a therapeutic success of 100%. The presence of arterial bleeding at endoscopy was associated with a higher recurrence rate for bleeding （50% vs 33.3% for other type of bleeding） rP = 0.024, odds ratio （OR） = 8.5, 95% CI = 1.13-63.87]. The use of combined en- doscopic treatment prevented the recurrence of bleed- ing （10% vs 44.4% of single treatment） （P = 0.034, OR = 0.14, 95% CI = 0.19-0.99）. CONCLUSION： Endoscopic treatment of DL is safe and effective. Adrenaline monotherapy and arterial （spurting） bleeding are associated with a high rate of bleeding recurrence.

Risk of postoperative recurrence and postoperative management of Crohn's disease

Crohn's disease (CD) is a chronic inflammatory disease of the digestive tract with systemic manifestations. Etiology is unknown, even if immunological, genetic and environmental factors are involved. The majority of CD patients require surgery during their lifetime due to progressive bowel damage, but, even when all macroscopic lesions have been removed by surgery, the disease recurs in most cases. Postoperative management represents therefore a crucial mean for preventing recurrence. Several drugs and approaches have been proposed to achieve this aim. Endoscopic inspection of the ileocolic anastomosis within 1 year from surgery is widely encouraged, given that endoscopic recurrence is one of the greatest predictors for clinical recurrence. A strategy should be planned only after stratifying patients according to their individual risk of recurrence, avoiding unnecessary therapies when possible benefits are reduced, and selecting high-risk patients for more aggressive intervention.

Recurrence after resection of hepatocellular carcinoma

Objective: To assess the relevant factors of prognosis and the proper treatment of recurrent hepatocellular carcinoma (HCC). Methods: From January 1983 to January 1997, 135 patients with recurrent HCC were analyzed in terms of host condition, tumor characteristics, and surgical procedures. Surgical treatments of these patients were compared. Results: Alpha-fetoprotein (AFP) level>1000 μg/L in the initial operation, tumor size larger than 5 cm in diameter, tumor embolization in the portal veins, 0 surgical margin, and no chemoembolization before the operation were the main factors directly affecting the prognosis in a year after recurrence. Repeat hep- atectomy and liver transplantation were performed to obtain better results. Conclusions: Tumor characteristics and surgical treatment are the main factors affecting the prognosis after the recurrence of HCC. Liver transplantation plays an important role in patients with poor liver function or multi-recurrent sites.

Update on the prevention of local recurrence and peritoneal metastases in patients with colorectal cancer

The prevention of a disease process has always been superior to the treatment of the same disease throughout the history of medicine and surgery. Local recurrence and peritoneal metastases occur in approximately 8% of colon cancer patients and 25% of rectal cancer patients and should be prevented. Strategies to prevent colon or rectal cancer local recurrence and peritoneal metastases include cytoreductive surgery and hyperthermic perioperative chemotherapy (HIPEC). These strategies can be used at the time of primary colon or rectal cancer resection if the HIPEC is available. At institutions where HIPEC is not available with the treatment of primary malignancy, a proactive second-look surgery is recommended. Several phase II studies strongly support the proactive approach. If peritoneal metastases were treated along with the primary colon resection, 5-year survival was seen and these results were superior to the results of treatment after peritoneal metastases had developed as recurrence. Also, prophylactic HIPEC improved survival with T3/T4 mucinous or signet ring colon cancers. A second-look has been shown to be effective in two published manuscripts. Unpublished data from MedStar Washington Cancer Institute also produced favorable date. Rectal cancer with peritoneal metastases may not be so effectively treated. There are both credits and debits of this proactive approach. Selection factors should be reviewed by the multidisciplinary team for individualized management of patients with or at high risk for peritoneal metastases.

Prevention of hepatitis C recurrence after liver transplantation:An update

Hepatitis C related liver failure and hepatocarcinoma are the most common indications for liver transplantation in Western countries.Recurrent hepatitis C infection of the allograft is universal and immediate following liver transplantation,being associated with accelerated progression to cirrhosis,graft loss and death.Graft and patient survival is reduced in liver transplant recipients with recurrent Hepatitis C virus(HCV) infection compared to HCV-negative recipients.Many variables may impact on recurrent HCV liver disease.Overall,excess immunosuppression is believed to be a key factor;however,no immunosuppressive regimen has been identified to be more beneficial or less harmful.Donor age limitations,exclusion of moderately to severely steatotic livers and minimization of ischemic times could be a potential strategy to minimize the severity of HCV disease in transplanted subjects.After transplantation,antiviral therapy based on pegylated IFN alpha with or without ribavirin is associated with far less results than that reported for immunocompetent HCV-infected patients.New findings in the field of immunotherapy and genomic medicine applied to this context are promising.

Influence of hyperbaric oxygenation treatment (HBOT) on clinical outcomes (recurrent myocardial infarction and survival rate) during five-year monitoring period after acute myocardial infarction

Surgical treatments of acute myocardial infarction (MI) possess a high clinical effectiveness, but there are fixed limitations, related to the patient’s state, which are limited by medical resources and organizational problems. The development of new medical technologies provides a better and effective non-surgical treatment of acute MI and increases long-term prognosis in this category of patients. The study aims to investigate the influence of hyperbaric oxygenation treatment on clinical outcomes (survival rate and recurrent myocardial infarction (rMI)) during the five-year period of monitoring. The study involved 697 patients who suffered from acute MI, having undergone the standard treatment. The patients were randomly divided into two groups: Group 1 (reference, n = 363);Group 2 (test, n = 334). Patients of Group 2 were given the traditional treatment, accompanied with HBOT (isopression for forty minutes at a working pressure of 0.03 MPa). HBOT was applied first through the fifth day following MI. The treatment course included six cycles, once per day. The clinical assessment was focused on clinical outcome: rMI and mortality related to cardiovascular events. HBOT application that accompanied the acute MI with traditional pharmacotherapy has been proved to reduce rMI within five years following inpatient discharge (rMI rate was 14% in the reference group and 5.4% in the test group, χ2 = 13.3, р < 0.05). The combination of HBOT with traditional methods in treating acute MI makes it possible to raise the five-year survival rate from 84.4% up to 95.9%.

G-CSF in Peg-IFN induced neutropenia in liver transplanted patients with HCV recurrence

AIM:To evaluate the efficacy of granulocyte colony stimulating factors(G-CSF)in liver transplanted patients with hepatitis C(HCV)recurrence and Pegylated-IFN α-2b induced neutropenia,and to evaluate the impact of G-CSF administration on virological response. METHODS:Sixty-eight patients undergoing antiviral treatment for post-liver transplantation(OLT)HCV recurrence were enrolled.All patients developing neutropenia received G-CSF. RESULTS:Twenty three(34%)received G-CSF.Mean neutrophil count at the onset of neutropenia was 700/mmc(range 400-750/mmc);after 1 mo of G-CSF it increased to 1210/mmc(range 300-5590/mmc) (P<0.0001).Three patients did not respond to G-CSF. Treatment duration was similar in neutropenic and non-neutropenic patients.No differences in the rate of discontinuation,infections or virological response were observed between the two groups.G-CSF was protective for the onset of de novo autoimmune hepatitis(P<0.003). CONCLUSION:G-CSF administration is effective in the case of Peg-IFN induced neutropenia increasingneutrophil count,prolonging treatment and leading to sustained virological response(SVR)rates comparable to non-neutropenic patients.It prevents the occurrence of de novo autoimmune hepatitis.

Temozolomide plus rituximab in the treatment of recurrent central nervous system lymphoma:Case report and literature review

Objective： The aim of our study was to investigate the treatment of recurrent central nervous system lymphoma. Methods： A case of recurrent central nervous system lymphoma in a 46-year-old male was treated with temozolomide 150 mg/m2 per day for 5 days; rituximab 750 mg/m2 on dl and d8, injected from Ommaya capsule to lateral ventricle, cycles were repeated every 28 days. Results： The patient achieved complete remission and the side effects was light after the treatment. Conclusion： Using this therapy method had certain curative effect on recurrent central nervous system lymphoma. Further studies should be needed on its indication.

Prevention of post-operative recurrence of Crohn's disease

Endoscopic and clinical recurrence of Crohn&#x02019;s disease (CD) is a common occurrence after surgical resection. Smokers, those with perforating disease, and those with myenteric plexitis are all at higher risk of recurrence. A number of medical therapies have been shown to reduce this risk in clinical trials. Metronidazole, thiopurines and anti-tumour necrosis factors (TNFs) are all effective in reducing the risk of endoscopic or clinical recurrence of CD. Since these are preventative agents, the benefits of prophylaxis need to be weighed-against the risk of adverse events from, and costs of, therapy. Patients who are high risk for post-operative recurrence should be considered for early medical prophylaxis with an anti-TNF. Patients who have few to no risk factors are likely best served by a three-month course of antibiotics followed by tailored therapy based on endoscopy at one year. Clinical recurrence rates are variable, and methods to stratify patients into high and low risk populations combined with prophylaxis tailored to endoscopic recurrence would be an effective strategy in treating these patients.