1. Agree completely
2. Agree with minor reservations
3. Agree with major reservations
4. Reject with reservations
5. Reject completely

Statement Rationale and Definition

Crohn’s disease (CD) commonly recurs after surgery, although the rate varies according to the definition used, ie, clinical, endoscopic, or surgical recurrence. Without treatment, the endoscopic recurrence rate is 80% to 100% within 3 years of an ileocolic resection, with clinical recurrence at 20% to 25% per year.¹ The severity of endoscopic lesions has been used as a marker of clinical recurrence largely based on a seminal single-center study in 1990.^1,2 Rutgeerts et al studied 89 patients treated for ileocolic resection for CD between 1979 and 1984 to examine the natural course of early postoperative lesions. Recurrent lesions were observed endoscopically in the neoterminal ileum in 73% of patients within 1 year of surgery, although only 20% of patients had symptoms. Three years after surgery, the endoscopic recurrence rate was 85%, and symptomatic recurrence occurred in 34% of patients. The postoperative scoring system i0 to i4 in current use was derived from this study. A meta-analysis of randomized placebo-controlled trials of postoperative maintenance therapy between 1990 and 2006 found that the pooled estimate of the placebo relapse rate was 24% (95% confidence interval [CI], 13–35) and severe endoscopic recurrence rate was 50% (95% CI, 28–73), with marked heterogeneity among studies.³

Risk factors for postoperative recurrence and further surgery include smoking, early endoscopic relapse, and histories of fistulizing disease and prior resection.¹ Endoscopic monitoring and prophylactic treatment with mesalamine, nitroimidazole antibiotics, and/or thiopurines were considered the standard of care for managing postoperative recurrence^1,4 until infliximab (IFX) was shown to reduce endoscopic recurrence at 12 months, at least in a small pilot study.⁵ A subsequent randomized controlled trial was terminated early.⁶