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Postoperative Crohn’s: What’s changed?

The concept of reusing anti-TNF therapy after surgery is gaining traction.

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Even in the age of advanced medical therapy, surgery remains a fundamental part of Crohn’s disease care.

During the 2026 Crohn’s & Colitis Congress®, a partnership of AGA and the Crohn’s & Colitis Foundation, held in Las Vegas, Jordan Axelrad, MD, MPH, co-director of the Inflammatory Bowel Disease Center at NYU Langone Health, reviewed new data on who is most likely to relapse after surgery, which therapies may best prevent recurrence, and how postoperative monitoring is evolving.

Although biologics and small molecules have transformed Crohn’s disease management, about one in four patients still require intestinal resection at 10 years. “Recurrence can happen very quickly,” Dr. Axelrad said. “We can sometimes see histologic changes within one week after a resection.” Endoscopic recurrence is often evident within one year, before symptoms develop. Without intervention, this progression can lead to repeat surgery.

Not all patients recur, however. A nationwide cohort study that Dr. Axelrad conducted with Swedish colleagues showed that about 21% of patients with Crohn’s disease remained free of medical therapy five years after surgery. Older age and longer disease duration were associated with this lower-risk group, suggesting that some patients may be managed with careful monitoring alone.

Endoscopy remains the cornerstone of postoperative assessment, with the Rutgeerts score guiding risk stratification. Patients with i0 to i2a findings are considered in endoscopic remission, while those with i2b lesions —disease extending beyond the anastomosis —  face a significantly higher risk of progression. Data from a U.S. multicenter consortium confirmed that patients with i2b disease are more likely to advance to severe recurrence, reinforcing the need for closer follow-up and earlier treatment escalation.

AGA recommendations have simplified postoperative risk categories. Lower-risk patients tend to be older, nonsmokers undergoing their first surgery with limited bowel resection. “High-risk patients are going to be younger, active smokers, and those who've had a history of surgery for their Crohn's disease,” Dr. Axelrad said. Still, he highlighted prospective data showing that recurrence rates approach 50% even among patients classified as low risk. Importantly, medical prophylaxis reduced recurrence in both low- and high-risk groups.

According to Sara Horst, MD, MPH, Professor of Medicine, Gastroenterology, Hepatology, & Nutrition and Vanderbilt University Medical Center, Nashville, who moderated the session, “some data suggests high-risk patients also include those who have been on advanced therapies in the past as well as those with fistulizing or stricturing complications,” she told GI & Hepatology News.

Anti–tumor necrosis factor (anti-TNF) agents remain the most studied option for postoperative prophylaxis. While antibiotics such as metronidazole have been used historically, many clinicians now favor biologics. Newer data suggest that vedolizumab and ustekinumab perform similarly in preventing recurrence, although patient selection is key. In one analysis conducted at two medical centers, early initiation of anti-TNF therapy — within four weeks of surgery — was associated with the lowest rates of endoscopic recurrence, giving anti-TNF agents a potential advantage when they are safe and appropriate.

The concept of reusing anti-TNF therapy after surgery is also gaining traction. According to Dr. Axelrad, patients who undergo surgery for complications such as strictures, rather than true biologic failure, may still benefit from continuing or restarting anti-TNF treatment. By contrast, he said, data show that patients with clear primary nonresponse before surgery are better candidates for switching drug classes.

“The key here is starting advanced therapy in those high-risk patients who need it,” Dr. Horst added. “Also, educating our patients on the importance of close monitoring after surgery is extremely important.”

Postoperative monitoring strategies are also expanding. A landmark trial showed that colonoscopy at six months, with treatment adjustment based on findings, reduces later recurrence. Biomarkers now play a larger role as well. Updated guidance suggests that patients at low risk, or those receiving prophylactic therapy with fecal calprotectin levels below 50 µg/g, may be able to defer the six-month colonoscopy.

According to Dr. Axelrad, intestinal ultrasound and cross-sectional imaging offer additional, non-invasive ways to detect early recurrence.

He concluded his presentation by noting that postoperative Crohn’s disease management starts before the operating room. “Early risk assessment, timely selection of prophylactic therapy, and structured monitoring can help clinicians intervene earlier — and potentially reduce the need for repeat surgery,” he said.

Dr. Axelrad disclosed that he has received consultancy fees, honorarium, or advisory board fees from several pharmaceutical companies. He has also received research grants from BioFire Diagnostics, Genentech, Janssen, and Takeda. Dr. Horst disclosed that she is a consultant to Johnson & Johnson, AbbVie, Takeda, Pfizer, and Biocon. She has also received educational grants from AbbVie and Takeda.

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