Optimizing Endoscopic Assessment of Postoperative Crohn's Disease: A Scoping Review

Postoperative endoscopic recurrence after ileocecal resection in Crohn's disease (CD) occurs frequently and typically precedes clinical and surgical relapse. Endoscopic scoring systems are central to postoperative management, yet their optimal use remains debated. The aim was to provide a summary and critical appraisal of established and novel endoscopic scoring systems used for recurrence in adult CD.

A scoping review was conducted based on a systematic search in PubMed, EMBASE, and the Cochrane Library databases. Following qualitative synthesis, narrative reviews and studies involving pediatric or animal populations were excluded. Remaining evidence was integrated and critically appraised. The interpretation of findings was further refined through expert discussion within the IMPACT consortium.

The Rutgeerts score (RS) remains the most widely used index in clinical studies, but shows important limitations, including moderate interobserver reproducibility, limited differentiation between anastomotic and ileal lesions, and reduced applicability to modern anastomotic configurations. Modified and updated RS variants, as well as newer indices, emphasize lesion location and postoperative anatomy, and may improve prognostic stratification in selected cohorts. The choice of postoperative endoscopic index and the threshold used to define recurrence has major clinical implications. Heterogeneity in anatomic lesions considered, cutoffs for adapting treatments, and reproducibility limit the universal adoption of any single index.

Endoscopic indices remain essential for classification and standardization for postoperative disease recurrence in CD but should be interpreted together with their current level of validation. These findings highlight the need for further validation, harmonization of definitions, and refinement of postoperative endoscopic evaluation.