Table 3.

Current state of knowledge and future perspectives in the management of postoperative Crohn’s disease. Abbreviation: MRE—magnetic resonance enterography; TNF—tumor necrosis factor.

Aspect of Management	Current State of Knowledge	Future Perspectives
Risk stratification	Stratification on clinical and histological risk factors Not prospectively validated Uncertainty about the risk threshold for instituting prophylaxis	Prospective risk factor validation Development of refined clinical prediction models Risk-benefit analysis of upfront prophylaxis vs. step-up treatment in prospective cohorts
Diagnosing recurrence	Ileocolonoscopy at 6–12 months as the gold standard Endoscopic assessment using the Rutgeerts score Uncertainty about the prognostic implications of anastomotic lesions Uncertainty about the performance of emerging endoscopic indices (POCER, REMIND) Emerging role of noninvasive diagnostic modalities for diagnosing recurrence (stool- and serum-based biomarkers, MRE, intestinal ultrasound)	Defining the prognosis of lesions in the neoterminal ileum vs. lesions confined to the anastomosis in large prospective cohorts Comparison of the impact of different endoscopic indices on treatment outcomes Comparison of performance of endoscopic indices with different configurations of surgical anastomoses Full validation of POCER and REMIND indices Development of noninvasive monitoring algorithms with less reliance on endoscopy
Treatment	No drug has regulatory approval for the prevention of postoperative recurrence of Crohn’s disease No dedicated regulatory guidance for clinical trial design for this indication Infliximab is best supported by evidence, but was superior to placebo for the endoscopic, not clinical endpoint Drugs with tenuous evidence base (metronidazole, thiopurines, aminosalicylates) remain widely used No controlled studies of biologics other than TNF antagonists Little data to guide treatment decisions after TNF antagonist failure	Development of regulatory guidance incorporating and endoscopic primary endpoint Performance of controlled trials for biologics other than TNF antagonists with particular emphasis on patients after TNF antagonist failure