Editorial: Beyond Resection—Rethinking Postoperative Management in Colonic Crohn's Disease

Approximately 25% of patients with colonic Crohn's disease (cCD) eventually require colonic resection; however, no consensus exists regarding the optimal surgical approach, as the available data are limited and influenced by unaddressed confounders, reflected in heterogeneous guidelines 1-3. Surgical recurrence is the main long-term outcome, with about one-third of patients requiring reoperation 4, leaving open the question of whether segmental colectomy (SC) or subtotal colectomy (STC) is more effective over time. The RESECOL study 5, prior cohorts 6, 7 and the SCOTCH study 8 reported lower surgical recurrence after SC, while earlier meta-analyses 9, 10 found no difference, with Tekkis reporting ~4.5 years earlier recurrence after SC 9. The RESECOL study 6 was also the first to evaluate clinical, endoscopic and radiological recurrence in cCD, showing lower clinical and endoscopic recurrence after SC compared with STC, with similar radiological outcomes; however, these results should be interpreted cautiously. A major issue is defining endoscopic recurrence: the RESECOL study defined it as lesions at or near the anastomosis, yet in cCD, no standardised criteria exist, the Rutgeerts' score is not applicable and the prognostic significance of colonic lesions is unknown; the same applies to radiological recurrence, which is not assessed with validated scoring or in all patients. Timing of surveillance also remains an unanswered question: should colonoscopy follow the 6–12 month interval as for ileal CD, or is a different schedule warranted? In the RESECOL study, postoperative intervals, with a wide interquartile range, limit reliability and sensitivity analyses within 12–24 months are likely underpowered. Alongside this, faecal calprotectin was also explored as a cCD recurrence marker, albeit not systematically nor in all patients. The RESECOL study, did not report involved segments, complications or stoma risk, all relevant factors for surgical planning: multi-segment disease may require multiple resections, even if STC may have lower recurrence and SC higher complications and lower stoma risk 6, 9, 10; systematic evaluation of these factors is essential for surgical decision-making. The RESECOL study identified positive margins and myenteric plexitis as risk factors for endoscopic recurrence, and smoking and myenteric plexitis for clinical recurrence; previous studies have highlighted female sex, younger age, three-segment involvement, perianal disease and omission of postoperative treatment 6-8, the latter being a critical factor in the current era of advanced therapies. Other variables also warrant investigation, including surgical setting (emergency vs. elective), preoperative optimisation and surgical indication (refractory or complicated disease). These uncertainties highlight the challenges of predicting postoperative recurrence in cCD and applying a tailored, multidisciplinary approach. Patient preferences should also be considered: SC may offer functional quality-of-life benefits, but these must be balanced against the long-term durability of the ileorectal anastomosis and disease extent 7, 8. To gain insight into the postoperative cCD course, prospective studies incorporating surgical randomisation where feasible, standardised recurrence definitions, systematic risk factor assessment, structured postoperative monitoring—including faecal calprotectin as in ileal CD—and evaluation of prophylactic treatments are needed; until then, the optimal approach remains unresolved. In conclusion, the GETECCU Young Group underscores the challenges of postoperative cCD recurrence, contributing to this underexplored field and providing valuable insights to inform future research. Stefano Festa: conceptualization, writing – review and editing. Annalisa Aratari: conceptualization, writing – review and editing. The authors have nothing to report. This article is linked to Rueda Garcia et al. paper. To view this article, visit https://doi.org/10.1111/apt.70608. The authors have nothing to report.