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Postoperative recurrence of Crohn’s disease is common and requires a multidisciplinary approach between surgeons and gastroenterologists in the perioperative and postoperative period to improve outcomes in this patient population. Endoscopic recurrence precedes clinical and surgical recurrence and endoscopic monitoring is crucial to guide postoperative management. Risk stratification of patients is recommended to guide early prophylactic management, and follow-up endoscopic monitoring can guide intensification of therapy. This review summarizes evidence behind postoperative recurrence rates, disease monitoring techniques, nonbiologic and biologic therapies available to prevent and treat postoperative recurrence, risk factors associated with recurrence, and postoperative management strategies guided by endoscopic monitoring.

Objectives Familial adenomatous polyposis (FAP) patients with Spigelman stage IV polyposis should be considered for prophylactic duodenectomy. Post‐surgical pancreaticobiliary complications occur and may require management via endoscopic retrograde cholangiopancreatography (ERCP). We aimed to assess the success and adverse events of ERCP in FAP patients after pancreas‐sparing duodenectomy (PSD) and pancreaticoduodenectomy (PD). Methods A retrospective review of FAP patients who underwent ERCP after PSD or PD from 1992 to 2020 at a quaternary referral center was completed. The technical success of ERCP was defined as the ability to identify the anastomosis and cannulate the duct. Post‐procedural adverse events were defined by bleeding, perforation, pancreatitis, or cholangitis. Clinical outcomes included the need for surgical intervention and recurrent pancreatitis after ERCP were assessed. Results Of 84 FAP patients with duodenectomy, 12 patients with PSD and two patients with PD underwent 17 ERCPs for pancreatic indications and five for biliary indications. The technical success of ERCP in patients with PSD and a single neoampullary complex for pancreatic (n = 6) and biliary (n = 5) indications was 100% but for those with PD (n = 2) or PSD reconstruction with pancreatic divisum or separate anastomoses (n = 3), it was 0%. Surgical intervention was required in 50% of patients with technically failed ERCP after PSD (2/4) and PD (1/2). There were no adverse events. Conclusions ERCP is expected to be therapeutically successful for biliary complications following PSD. Assessment and potential therapy for pancreatitis post‐PSD are best in the setting of a single neo‐ampullary complex rather than in PD or PSD with pancreatic divisum.

Surgical management of Crohn's disease (CD) is common. Postoperative complications include anastomotic stricturing (AS). The natural history and risk factors for AS have not been elucidated. A retrospective cohort study of patients with CD who underwent ileocolonic resection (ICR) with ≥1 postoperative ileocolonoscopy between 2009 and 2020. Postoperative ileocolonoscopies with corresponding cross-sectional imaging were evaluated for evidence of AS without neoterminal ileal extension. Severity of AS and endoscopic intervention at time of detection were collected. Primary outcome was development of AS. Secondary outcome was time to AS detection. A total of 602 adult patients with CD underwent ICR with postoperative ileocolonoscopy. Of these, 426 had primary anastomosis, and 136 had temporary diversion at time of ICR. Anastomotic configuration consisted of 308 side-to-side, 148 end-to-side, and 136 end-to-end. One hundred ten (18.3%) patients developed AS with median time of 3.2 years to AS detection. AS severity at time of detection was associated with need for repeat surgical resection for AS. On multivariable Cox proportional hazard regression, anastomotic configuration and temporary diversion were not associated with risk of or time to AS. Preoperative stricturing disease was associated with decreased time to AS (adjusted hazard ratio 1.8; P = 0.049). Endoscopic ileal recurrence before AS was not associated with subsequent AS detection. AS is a relatively common postoperative CD complication. Patients with previous stricturing disease behavior are at increased risk of AS. Anastomotic configuration, temporary diversion, and ileal CD recurrence do not increase risk of AS. Early detection and intervention for AS may help prevent progression to repeat ICR.

INTRODUCTION:Following ileocolic resection (ICR), the clinical importance and prognostic implications of histologic activity on biopsies in Crohn's disease (CD) patients with endoscopic remission are not well defined. The aim of this study was to determine if histologic activity in patients with endoscopic remission is associated with future risk of endoscopic and/or radiologic postoperative recurrence (POR).METHODS:In this multicenter retrospective cohort study, adult patients with CD who underwent ICR between 2009 and 2020 with endoscopic biopsies of ileal mucosa from Rutgeerts i0 on index colonoscopy were included. The composite rate of endoscopic (Rutgeerts score ≥i2b) and radiologic (active inflammation on imaging) recurrence was compared in patients with and without histologic activity using a Kaplan-Meier survival analysis. A multivariable Cox proportional hazard regression model including clinically relevant risk factors of POR, postoperative biologic prophylaxis, and histology activity was designed.RESULTS:A total of 113 patients with i0 disease on index colonoscopy after ICR were included. Of these, 42% had histologic activity. Time to POR was significantly earlier in the histologically active versus normal group (P = 0.04). After adjusting for clinical risk factors of POR, histologic activity (HR 2.37, 95% CI 1.17-4.79; P = 0.02) and active smoking (HR 2.54, 95% CI 1.02-6.33; P = 0.05) were independently associated with subsequent composite POR risk.DISCUSSION:In patients with postoperative CD, histologic activity despite complete endoscopic remission is associated with composite, endoscopic, and radiographic recurrence. Further understanding of the role of histologic activity in patients with Rutgeerts i0 disease may provide a novel target to reduce disease recurrence in this population.