crohn s disease is a chronic inflammatory disease that manifests throughout the full - thickness of the gastrointestinal layer . early diagnosis is difficult in many cases , and small - bowel lesions are often accompanied by fistula and stenosis on the first examination and require surgery . the reoperation rate is high , and internal therapy , based on evaluation of the small - bowel lesions and endoscopic treatment of the stenosis of the small intestine , may be important to avoid surgery . once healing of the intestinal mucosa has been achieved , the intestinal condition tends to be maintained thereafter in many reported cases . the effects of biological agents and immunomodulators in the treatment of crohn s disease have been demonstrated , and a high therapeutic efficacy can be expected with multiple drug administrations when the pathology is accurately evaluated , even for intractable cases . double - balloon endoscopy ( dbe ) has enabled precise diagnosis and endoscopic intervention deep within the small bowel . using dbe , endoscopic findings of crohn s disease can be observed closely , facilitating understanding of the lesions . dbe also enables close observation of the anastomosed sites after surgery for crohn s disease and after endoscopic balloon dilatation of the stenotic lesions . the objective of this study was to retrospectively review patients who underwent evaluation of the anastomosed sites of the small bowel using dbe after surgery , and to elucidate the characteristics and factors involved in recurrence at the anastomosed sites . the subjects were crohn s disease patients who underwent dbe assessment of the small bowel mucosa at the anastomosed sites following surgery at our hospital . dbe was performed as reported previously , and the findings were reviewed in the dbe database of our hospital , including endoscopic images , and medical records . the condition of the anastomosed lesion site was evaluated in 5 steps , grades 04 , using the endoscopic scoring reported by rutgeerts et al . , and the following 2 items were investigated : of the anastomosed lesions classified , those graded 2 , 3 , and 4 were regarded as endoscopic recurrence , and recurrence - related factors were investigated using univariate analysis . of the anastomosed lesions classified , those graded 0 , 1 , 2 , and 3 were regarded as clinical remission and the grade 4 lesions were regarded as clinical recurrence . the analyzed items included the disease type , anastomosis procedure , frequency of surgery , time to endoscopy after surgery , the presence or absence of treatment with 5-aminosalicylic acid ( 5-asa ) , immunomodulators , steroids , maintenance administration of infliximab , and an elemental diet that required the ingestion of 900 kcal or more per day . since the efficacy of anti - tnf antibody has been reported recently , the outcome of the anastomosed lesions was analyzed between the groups that were treated with and without postoperative anti - tnf antibody . data from forty - eight patients at our hospital were reviewed ( table 1 ) . at the time of the first admission to our hospital , the mean age was 37.4 years and the mean duration of illness was 9.3 years . there was a greater number of male patients , and the disease type was small bowel in 32 and small and large bowel in 16 patients , showing that there were more patients with the small bowel type . the disease was symptomatic at the time of the first dbe in 31 patients , including abdominal pain and abdominal fullness , and remained asymptomatic in 17 patients . the conditions of the anastomosed sites were classified according to the endoscopic score reported by rutgeerts et al . characteristics of patients of whom anastomotic sites was evaluated by double - balloon endoscopy rutgeerts scores of 168 anastomotic sites evaluated by dbe the factors related to endoscopic recurrence at anastomosed sites were investigated . a time to dbe after surgery of 1.5-year or longer and the absence of 5-asa administration were found to be significant factors leading to endoscopic recurrence ( table 2 ) . factors for affecting endoscopic recurrence ( rutgeerts score 1 vs. 2 ) on analysis of factors leading to clinical recurrence , similar to endoscopic recurrence , a duration to dbe of 1.5-year or longer after surgery and the absence of 5-asa administration were found to be significant ( table 3 ) . factors for affecting clinical recurrence ( rutgeerts score 3 vs.4 ) the 48 postoperative patients were divided into two groups , with and without administration of anti - tnf antibody , which were comprised of 22 and 26 patients , respectively . the anti - tnf antibodies were infliximab in 21 patients and adalimumab in 6 patients ( 5 patients overlapped ) . the outcomes during the follow - up period ( median duration : 51 months ) were analyzed using the kaplan - meier estimate and the log rank test . the conditions leading to clinical recurrence were avoided more often in the anti - tnf antibody - treated group compared with the non - treated group ( figure 2 ) . 
  long - term outcome with or without anti - tnf antibody ( follow - up median : 51 months , range : 5 - 194 months ) crohn s disease patients frequently undergo intestinal resection , and surgery is performed for stenotic lesions in many cases . to avoid re - surgery , we propose the periodic evaluation of anastomosed sites and current lesions with endoscopy . based upon our investigation of the 48 postoperative patients with crohn s disease , whose course was followed using dbe at our department , 5-asa may be effective as a base therapeutic drug , and it may be important to endoscopically evaluate anastomosed sites to determine the therapeutic effect using dbe within 1.5 years after surgery . as figure 2 showed , the anti - tnf antibodies were effective for postoperative patients to avoid small bowel stenosis , though the analysis for each lesion did not have same results ( table 2 , 3 ) . ulcerative lesions were observed at most of the anastomosed sites in the group not treated with 5-asa . ulcer of the anastomosed region can develop due to the state of crohn s disease or can be induced by mild ischemia following anastomosis , and 5-asa was judged as effective for both conditions . if the anastomosed region has not been observed for a long time after surgery , the therapeutic strategy will be investigated based on symptoms . however , when symptoms become evident , the condition has already progressed to grade 4 of the classification established by rutgeerts et al . in many cases . early diagnosis of recurrence at the anastomosed region by endoscopy early after surgery can lead to the prevention of later reoperation . in addition , maintenance administration of anti - tnf antibody after surgery may be effective in maintaining remission of the anastomosed lesion and preventing stenosis . improvement of postoperative treatment is essential for patients who have previously undergone surgery , because clinical activity may be or may have been high , however , the patients themselves may not consider it necessary due to the absence of symptoms . in such cases , however , this scoring system is limited to the evaluation of anastomosed sites and their surroundings , which is not appropriate for evaluation of the entire small intestine after surgery . indeed , in many cases , the ulcer tends to be limited to the anastomosed region even while the other intestinal region is in remission after ileocecal resection . however , the primary lesion may be present in regions other than the anastomosed region in patients with high disease activity . the establishment of a scoring system capable of evaluating the entire small intestine after surgery is anticipated . in conclusion , dbe was thought to be useful for the accurate diagnosis of small - bowel lesions after surgery .
abstractdouble - balloon endoscopy ( dbe ) has enabled precise diagnosis and endoscopic intervention deep within the small bowel . in this study , we determine the factor related to the risk of endoscopic and clinical recurrences in the diagnosis of postoperative lesions including anastomosis for the patients with crohn s disease . 
 forty - eight patients ( 40 men and 8 women ) had undergone small bowel resection previously and anastomotic sites were evaluated by rutgeerts endoscopic scoring . 
 the factors related to endoscopic and clinical recurrences at anastomosed sites were investigated . 
 the analyzed items included the disease type , anastomosis procedure , frequency of surgery , time to endoscopy after surgery , the presence or absence of treatment with 5-aminosalicylic acid ( 5-asa ) , immunomodulators , steroids , maintenance administration of infliximab , and an elemental diet that required the ingestion of 900 kcal or more per day . 
 outcome of the anastomosed lesions was analyzed in the groups treated with and without postoperative anti - tnf antibody including infliximab and adalimumab . 
 dbe was performed 133 times , and 168 anastomosed lesions were observed for enrolled patients . 
 univariate analysis showed that time to dbe after surgery of 1.5-year or longer and the absence of 5-asa administration were found to be significant factors leading to both endoscopic and clinical recurrences . 
 the results of kaplan - meier estimate and the log rank test demonstrated that the clinical recurrence was avoided more often in the anti - tnf antibody - treated group compared with the non - treated group . in conclusion , dbe was useful for accurate diagnosis of small - bowel lesions after surgery . 
 anti - tnf antibody may help to decrease the postoperative recurrence rate of crohn s disease .