DOI: 10.1002/ueg2.12381 EDITORIAL Editorial: Postoperative management of Crohn's disease: One size does not fit all It was in the late eighties and early nineties that the Leuven's group led third strategy defends that the decision to start prevention or wait for by Paul Rutgeerts published a series of landmark studies describing endoscopic monitoring should be based on the presence or absence of the natural history of postoperative Crohn's disease (CD). These au- risk factors. However, with the available risk factors in daily clinical thors introduced the concept of postoperative recurrence (POR) as practice, this strategy seems to be useless in improving postoperative defined by the development of disease‐related mucosal lesions at the outcomes.8 Recently, a prospective French research project on neoterminal ileum after a “curative” ileocecal resection. They showed different POR issues found that the more risk factors, the higher the that this phenomenon occurs early after surgery in up to 80% of pa- risk of endoscopic POR.9 As a consequence, these investigators tients within the first 12 months and that there is a clear correlation decided to establish a decision‐making protocol of POR prevention between the severity of these lesions seen at ileocolonoscopy and the based on the number of risk factors. Unfortunately, this “stratification risk of developing symptoms (clinical POR), which in some patients strategy” led to similar rates of endoscopic POR between those pa- may lead to a new intestinal resection (surgical POR).1–3 tients with no, one, or more than one risk factor in whom no pre- Since then, many randomized, controlled studies have been per- vention, thiopurines, and anti‐TNF agents were started after surgery, formed to assess the efficacy of a number of drugs to prevent POR. To respectively.10 date, only thiopurines and anti‐TNF agents have been demonstrated In this issue of United European Gastroenterology Journal, Dragoni to be useful in the prevention of early endoscopic POR.4 et al11 explore a somewhat different aspect of this complex clinical But bearing in mind that not all the patients will develop POR (and scenario. The Italian Group in Inflammatory Bowel Disease designed a in a significant proportion of those who will, only intermediate lesions retrospective study to assess whether primary prevention or carrying a low risk of clinical and surgical POR will occur) and that the endoscopy‐driven strategies work better in patients meeting only one use of immunosuppressive therapies carries a risk of adverse effects, risk factor for POR. Almost 200 adult CD patients who underwent the best strategy after intestinal resection is still under debate. ileocolic resection, met only one out of five well‐established POR risk Systematic prevention with thiopurines and anti‐TNF agents is factors (i.e. previous intestinal resection, >50 cm small bowel resec- supported by their demonstrated efficacy. Moreover, most of these tion, fistulising phenotype, history of perianal disease, or active patients already developed disease‐related complications that drove smoking), and had at least one available ileocolonoscopy 6–12 months them to surgery; therefore, leaving them without any maintenance after surgery were included. The main endpoint was endoscopic POR therapy is against the current therapeutic goals that promote within 12 months after surgery. The authors did not observe any dif- intensive treatment in those patients at risk of disabling disease. ference in the rates of endoscopic POR (defined by a Rutgeerts On the other hand, some authors propose the so‐called “endos- score > i2a), severe endoscopic POR (Rutgeerts score i4), and clinical copy‐driven strategy”. Based on the benefits of treatment escalation POR between the two study groups. in case of advanced endoscopic lesions,5 this strategy proposes early Although the study has some gaps related to its retrospective endoscopic monitoring and treatment with thiopurines or anti‐TNF design (lack of central review of endoscopic examinations, different agents only in case of endoscopic POR. Although a statistically un- timings for endoscopic assessment, and different drug therapies derpowered study found no differences in the rate of endoscopic in the primary prevention group), the observed results warrant a POR after 2 years between this strategy and systematic prevention,6 prospective evaluation of new decision‐making approaches in it is also true that there is a risk of being late to reverse mucosal the postoperative setting of CD. Both primary prevention and damage, leading to persistence or progression of mucosal lesions in endoscopy‐driven therapy strategies seem to be useful in the suit- up to 30%–50% of patients.7 able patient…but how do we identify the patient? Maybe it is time to Finally, given that there are some epidemiological and clinical bring in histologic12,13 and microbiological14 data for decision‐ features that have been associated with a higher risk of early POR, the making. - This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, pro- vided the original work is properly cited. © 2023 The Authors. United European Gastroenterology Journal published by Wiley Periodicals LLC. on behalf of United European Gastroenterology. United European Gastroenterol J. 2023;11:267–268. wileyonlinelibrary.com/journal/ueg2 267 268 - EDITORIAL K E YW O R DS 3. D'Haens GR, Geboes K, Peeters M, Baert F, Penninckx F, Rutgeerts P. Crohn's disease, endoscopy, gastroenterology, inflammatory bowel Early lesions of recurrent Crohn's disease caused by infusion of in- disease, surgery testinal contents in excluded ileum. Gastroenterology. 1998;114(2): 262–7. https://doi.org/10.1016/s0016‐5085(98)70476‐7 4. Beelen EMJ, Nieboer D, Arkenbosch JHC, Regueiro MD, Satsangi J, C O N F LI C T S O F I N T E R ES T S T AT EM E N T Ardizzone S, et al. Risk prediction and comparative efficacy of anti‐ The corresponding author confirms on behalf of all authors that there TNF vs thiopurines, for preventing postoperative recurrence in have been no involvements that might raise the question of bias in the Crohn's disease: a pooled analysis of 6 trials. Clin Gastroenterol work reported or in the conclusions, implications, or opinions stated. Hepatol. 2022;20(12):2741–52.e6. https://doi.org/10.1016/j.cgh. 2021.10.021 Eugeni Domènech has served as a speaker or has received research or 5. De Cruz P, Kamm MA, Hamilton AL, Ritchie KJ, Krejany EO, Gorelik educational funding or advisory fees from AbbVie, Adacyte Thera- A, et al. Crohn's disease management after intestinal resection: a peutics, Biogen, Celltrion, Galapagos, Gilead, Janssen, Kern Pharma, randomised trial. Lancet. 2015;385(9976):1406–17. https://doi.org/ MSD, Pfizer, Roche, Samsung, Takeda, Tillots; Míriam Mañosa has 10.1016/S0140‐6736(14)61908‐5 6. Ferrante M, Papamichael K, Duricova D, D'Haens G, Vermeire S, served as a speaker and has received research or educational funding Archavlis E, et al. Systematic versus endoscopy‐driven treatment from MSD, AbbVie, Takeda, Janssen, Faes Farma, Ferring and Pfizer; with Azathioprine to prevent postoperative ileal Crohn's disease Margalida Calafat has served as a speaker for Takeda, Janssen, Faes recurrence. J Crohns Colitis. 2015;9(8):617–24. https://doi.org/10. Farma, and MSD. 1093/ecco‐jcc/jjv076 7. Cañete F, Mañosa M, Pérez‐Martínez I, Barreiro‐de Acosta M, 1,2 González‐Sueyro RC, Nos P, et al. Antitumor necrosis factor agents Eugeni Domènech to treat endoscopic postoperative recurrence of Crohn's disease: a Míriam Mañosa1 nationwide study with propensity‐matched score analysis. Clin Margalida Calafat1 Transl Gastroenterol. 2020;11(8):e00218. https://doi.org/10.14309/ ctg.0000000000000218 1 8. Joustra V, van Sabben J, van der Does de Willebois E, Duijvestein M, IBD Unit, Gastroenterology Department, Hospital Universitari de Boer N, Jansen J, et al. Benefit of risk‐stratified prophylactic Germans Trias i Pujol, Catalonia and Centro de Investigación treatment on clinical outcome in post‐operative Crohn's disease. Biomédica en Red de Enfermedades Hepáticas y Digestivas J Crohns Colitis. 2022:jjac139. https://doi.org/10.1093/ecco‐jcc/ (CIBEREHD), Badalona, Spain jjac139 2 9. Auzolle C, Nancey S, Tran‐Minh ML, Buisson A, Pariente B, Stefa- Facultat de Medicina, Universitat Autònoma de Barcelona, nescu C, et al. Male gender, active smoking and previous intestinal Bellaterra, Spain resection are risk factors for post‐operative endoscopic recurrence in Crohn's disease: results from a prospective cohort study. Aliment Correspondence Pharmacol Ther. 2018;48(9):924–32. https://doi.org/10.1111/apt. 14944 Eugeni Domènech, 10. Hammoudi N, Auzolle C, Tran Minh ML, Boschetti G, Bezault M, Gastroenterology Department, Hospital Universitari Germans Trias i Buisson A, et al. Postoperative endoscopic recurrence on the Pujol, Carretera del Canyet, s/n, Badalona 08916, Catalonia, Spain. neoterminal ileum but not on the anastomosis is mainly driving Email: eugenidomenech@gmail.com long‐term outcomes in Crohn's disease. Am J Gastroenterol. 2020;115(7):1084‐93. https://doi.org/10.14309/ajg.0000000000 000638 D A TA A V A IL A BI L IT Y S T A T EM E N T 11. Dragoni G, Castiglione F, Bezzio C, Pugliese D, Spagnuolo R, Viola A, Author elects to not share data. et al. Comparison of two strategies for the management of post- operative recurrence in Crohn’s disease patients with one clinical risk factor: a multicentre IG‐IBD study. United Eur Gastroenterol J. ORCID 2023. Eugeni Domènech https://orcid.org/0000-0002-2315-7196 12. Li Y, Zhu W, Zuo L, Shen B. The role of the mesentery in Míriam Mañosa https://orcid.org/0000-0002-9051-2581 Crohn's disease: the contributions of nerves, vessels, lymphatics, and Margalida Calafat https://orcid.org/0000-0003-2335-3792 fat to the pathogenesis and disease course. Inflamm Bowel Dis. 2016;22(6):1483‐95. https://doi.org/10.1097/MIB.00000000000 00791 REFERENCES 13. Tandon P, Malhi G, Abdali D, Pogue E, Marshall JK, de Buck van 1. Rutgeerts P, Geboes K, Vantrappen G, Kerremans R, Coenegrachts Overstraeten A, et al. Active margins, plexitis, and granulomas in- JL, Coremans G. 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