Current considerations in the management of rectovaginal fistula from Crohn’s disease

Rectovaginal fistulas are dreaded complications of Crohn's disease. Accurate assessment is essential for planning management. Treatment options range from observation to medical therapeutics to the need for surgical intervention. Ultimately, establishing reasonable expectations is mandatory when treatment algorithms are considered. In this article, we review the evaluation of these fistulas and the current options to consider in the treatment of Crohn's related rectovaginal fistula.     

Martius advancement flap for low rectovaginal fistula: short‐ and long‐term results

Aim Many surgical approaches have been described for the treatment of low rectovaginal fistulae (LRVF); however, all are associated with a high recurrence rate and a poor function. The Martius flap technique was first described in 1928 and has since been modified for the treatment of LRVF. The aims of this study were to evaluate the short‐ and long‐term results of the Martius flap procedure. Method Twenty patients who underwent the Martius flap procedure between 2000 and 2010 were retrospectively included. Operative results and morbidity were evaluated. Quality of life (SF‐12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and anal continence (Wexner score) were determined. Results Crohn’s disease was the predominant aetiology (n = 8, 40%). The Martius flap was mostly harvested from the left side (n = 14, 66.7%). The morbidity rate was 15% (n = 3), and the mean hospital stay was 7.7 ± 3.7 days. At a mean follow up of 35 months, the success rate was 65%. Seven patients still had an LRVF: in patients with Crohn’s disease the success rate was 50% (4/8). Fifteen patients (75%) answered the three questionnaires. Quality of life score was in the normal range: physical component summary score (PCS: 46.7 ± 9) and mental component summary score (MCS: 44.7 ± 11.3). The median (range) FSFI score was 5 (2–31.7). Eight patients (53%) deemed cured suffered no incontinence. The Wexner score was significantly higher in the presence of a persisting LRVF (2.6 ± 5.5 vs 13.4 ± 3.78) (P = 0.0018). Use of a right‐sided flap was associated with a higher success rate (P = 0.0442). Conclusion The Martius flap procedure for LRVF, had a success rate of about 60% and a low morbidity.     

Results of combined medical and surgical treatment of recto‐vaginal fistula in Crohn’s disease

Aim Surgical repair of recto‐vaginal fistula (RVF) in Crohn’s disease (CD) has been associated with high rates of failure. The aim of this study was to compare the outcome in patients with CD who underwent RVF surgery with or without infliximab infusion. Method A retrospective review was carried out of 51 consecutive patients with CD treated for a symptomatic RVF between March 1998 and December 2004. Results Fifty‐one patients (mean age 39 years) underwent 65 procedures, including seton drainage (n = 35), advancement flap (n = 8), fibrin glue injection (n = 8), transperineal repair (n = 6), collagen plug placement (n = 4) and bulbocavernosus flap (n = 4). All patients were on medical treatment at the time of surgery and 26 patients had received preoperative infliximab treatment (minimum of three infusions, 5 mg/kg). Ten patients underwent preoperative diversion. At a mean follow up of 38.6 months, 27 fistulas (53%) had healed and 24 (47%) had recurred. Fistula healing occurred in 60% of patients treated with preoperative diversion, whereas 51% of nondiverted repairs were successful. Neither active proctitis nor infliximab therapy significantly affected fistula healing. Fourteen (27%) patients eventually required proctectomy. Conclusion RVF in CD is difficult to treat. Failure rates are significant despite repeated surgical interventions and concomitant medical treatment.     

Laparoscopy for recurrent Crohn’s disease: how do the results compare with the results for primary Crohn’s disease?

Aim To assess the feasibility and outcomes of reoperative laparoscopic‐assisted surgery for recurrent Crohn’s disease compared with index laparoscopic resections. Method A retrospective analysis of a prospectively maintained database was performed from 2001 to 2008 on patients who had primary laparoscopy (group I) or reoperative laparoscopy for Crohn’s disease (group II). Data collection included demographic and surgical data, and postoperative outcomes. Results One hundred and thirty patients were included in this study, distributed as follows: group I, 80 patients with a mean age of 35 years; and group II, 50 patients with a mean age of 42 years. Preoperative American Society of Anesthesiologists score and body mass index were similar in both groups. Patients in group II had a longer period of disease (15.5 vs 8.9 years in groups I and II, respectively; P = 0.0002). Immunosuppressive therapy had been utilized in 66 (82.5%) and in 42 (84%) patients in groups I and II, respectively. Ileocolic resection was the most commonly performed procedure in both groups (82%), followed by subtotal colectomy. Conversion rates were 18.7 and 32% in groups I and II, respectively (P = 0.09). The mean operative time (182 vs 201 min) and mean blood loss (161 vs 202 ml) were not significantly different (P > 0.05); however, the overall incisional length was significantly longer in group II (6.7 vs 11.4 cm, P = 0.045). A stoma was created in 17 and 16% of patients in groups I and II, respectively. Overall, early postoperative complications were not statistically significantly different between the two groups (P > 0.05); anastomotic leak occurred in four (5%) and one (2%) patients (P = 0.65), and abdominal abscess in three (3.75%) and four (8%) patients (P = 0.56), in groups I and II, respectively. Reoperative rates were 10 and 6% (P = 0.53), and mean hospital stay was similar in groups I and II respectively (6.7 vs 7.5 days, respectively; P = 0.3266). There was no mortality. Conclusion The results of laparoscopic‐assisted resection for recurrent Crohn’s disease are similar to those for primary resection.     

Faecal diversion in the management of perianal Crohn’s disease

Aim Severe perianal Crohn’s disease remains an uncommon but important indication for faecal diversion (FD). The advent of biological therapy such as infliximab for Crohn’s disease is considered to have improved the outcome for these patients. The aim of this study was to assess the outcome of patients undergoing FD for perianal Crohn’s disease and the impact of biological therapy (infliximab). Method Retrospective chart review was undertaken of patients who underwent FD for management of perianal Crohn’s disease at two tertiary centres between 1990 and 2007. Patient demographics, disease extent and use of biological therapy were recorded. Subsequent surgery was assessed. The impact of infliximab on rates of proctocolectomy and restoration of intestinal continuity was assessed. Results Twenty‐one patients (one male, 20 female), median age 34 years (range 21–67 years), underwent FD for perianal Crohn’s disease. At a median follow‐up time of 22 months (range 4–121 months), four patients had undergone stoma closure, 11 had had proctocolectomy and six had a stoma in situ. The effects of the procedure on severity of perianal disease were no effect in four (19%), temporary improvement in six (29%), initial improvement with later plateau in seven (33%) and healing in four patients (19%). Eleven patients (52%) received infliximab. In this group, four underwent proctocolectomy and two had intestinal continuity restored. This was not significantly different from the noninfliximab group. Conclusion Patients undergoing FD for perianal Crohn’s disease have <20% likelihood of restoration of intestinal continuity. This is not improved with biological therapy.     

Combined modality treatment for complex fistulating perianal Crohn’s disease

Aim Perianal disease affects 33% (range 8–90%) of patients with Crohn’s disease. Fistulae are often complex and their management is often difficult and unsatisfactory. This study was a retrospective assessment of a combination of surgical treatment with a standardized protocol of infliximab (IFX) therapy. Method A consecutive series of patients with complex perianal Crohn’s disease, presenting between January 2003 and June 2008, were included. Acute sepsis was initially treated with antibiotics and/or surgical drainage (MRI guided when appropriate) and loose seton insertion. IFX was given at 5 mg/kg, at 0, 2 and 6 weeks. End‐points were complete, partial or no response. Setons were empirically removed after the second cycle of IFX. Results Forty‐eight patients, average age 46 (range 24–82) years, with perianal Crohn’s disease were identified. Three patients stopped IFX after the second infusion, either because of allergy (two patients) or for failure to respond (one patient). Fourteen patients were given maintenance IFX at 8‐weekly intervals. Results were recorded for 48 patients, of whom 14 (29%) had a complete response, 20 (42%) had a partial response and 14 (29%) had no response to treatment. Outpatient follow‐up was for a median of 20 months. Conclusion Combining surgical procedures with IFX resulted in complete and partial remission in 29% and 42% of patients, respectively. No serious side effects occurred. Using a combined, intensive medico‐surgical approach, good initial control of perianal disease was achieved safely.     

Long‐term outcome of loose seton for complex anal fistula: a two‐centre study of patients with and without Crohn’s disease

Objective Complex anal fistulas traverse a significant portion of the external sphincter muscle, making their treatment a surgical challenge. Several surgical options are used with conflicting results. The aim of this study was to analyse the results of permanent loose seton in the management of high anal fistulas in Crohn’s disease (CD) patients and two‐stage seton fistulotomy in patients without CD. Method We retrospectively reviewed the clinical records of 77 patients with complex anal fistula treated by loose seton over a 4‐year period, in two medical centres. Recorded parameters included demographics, medical history, type of fistula, disease duration, previous surgery, morbidity, recurrence and mortality. Results Sixty patients without CD underwent 107 fistula‐related surgical procedures, and 17 CD patients underwent 29 procedures. Early postoperative complications were recorded in eight (10%) patients. Perioperative complications, mainly local sepsis or bleeding, were recorded in eight (10%) patients. Long‐term complications were observed in nine non‐CD and four CD patients. During a median follow‐up period of 24 months, the recurrence rate was 40% in CD patients and 47% in patients without CD. Five patients (four non‐CD patients and one CD patient) developed some degree of faecal incontinence. Conclusion The fistula recurrence rate following two‐stage seton fistulotomy in non‐CD patients was high. In CD patients the use of permanent loose seton is effective in controlling local sepsis in about half of patients and has low rates of subsequent incontinence.     

Biological immunomodulators improve the healing rate in surgically treated perianal Crohn’s fistulas

Aim The role of biological therapy in perianal fistulas associated with Crohn’s disease (CD) is uncertain as available data are confused and conflicting. In order to provide some clarity to the issue we have examined a large cohort of patients with perianal fistulas and CD and stratified them according to use of biological agents. Method Patients with perianal Crohn’s fistulas treated between June 1999 and June 2009 were stratified according to use of biological agents and outcome was examined. Healing was defined as absence of fistula or drainage. Prior to surgery perianal sepsis was eradicated with drains or setons. Endpoints were defined as either complete healing, improvement (minimal symptoms and drainage) or unhealed, as noted at subsequent outpatient follow‐up. Variables assessed were age, body mass index, smoking, perineal involvement with Crohn’s granuloma and type of procedure. Fisher’s exact test and χ² test were used for analysis. Results Two hundred and eighteen patients had anal fistulas and CD. Mean follow‐up was 3.2 ± 3 years with mean age 38.8 ± 12.2 years and body mass index of 25.3 ± 6. One hundred and seventeen patients (53.7%) underwent surgery alone (Group A) and 101 patients (46.3%) underwent surgery and biological immunomodulator treatments (Group B). Demographic data and CD history were similar between groups. Surgeries included seton drainge (n = 90), fistulotomy (n = 22), rectal advancement flap (n = 39), fistulotomy plus seton (n = 47) and others (n = 20). Overall improvement in Group A was in 42 patients (35.9%) vs 72 patients (71.3%) in Group B (P = 0.001). There was no significant difference in other studied variables between both groups. Conclusions There is a definite role for biological therapy as an adjuvant to surgery in patients with perianal fistulas and CD.     

Self‐reported depressive symptoms and suicidal feelings in perianal Crohn’s disease

Aim  Crohn’s disease is a chronic inflammatory condition that has been associated with high rates of mental illness. Perianal lesions are prevalent; however, their specific impact on depression has not been studied. The aim of our study was to investigate the prevalence and associations of self‐reported depressive symptoms in the subset of Crohn’s patients with perianal disease. Method  Patients with perianal Crohn’s disease from one institution were surveyed to elicit the frequency of self‐reported depressive symptoms. Patients completed a questionnaire and consented to medical records audit. Results  Of the 130 patients invited, 69 (53%) returned a survey. Depressive symptoms were self‐reported at very high rates, with 73% reporting feeling depressed and 13% reporting feeling suicidal at some point. Associations were found between depressive symptoms and duration of disease, prior surgery, past or present stoma, and anal stenosis. Patients who self‐reported depressive symptoms had lower overall utilities, and were willing to trade very significant proportions (upwards of 15%) of their life expectancy for disease cure. Conclusion  This study suggests that many patients with perianal Crohn’s disease experience significant emotional distress that impairs their overall quality of life. Further controlled studies are required to assess the impact of perianal disease and to address the need to target interventions to meet the mental health needs of this population.     

The differences between American and Chinese patients with Crohn’s disease

Aim The effect of race on Crohn’s disease (CD) remains uncertain. This study compared the characteristics of American white patients and Chinese patients with CD. Method A retrospective chart review was conducted for patients who required management of colorectal CD between 1985 and 2004 at either Cleveland Clinic Florida (CCF) or at the 301 Hospital in China. Data included a family history of CD, smoking history, location of the CD and histopathology. Results The mean age of onset in the 153 patients was 29.8 ± 16.4 years for American white patients and 32.4 ± 15.3 years for Chinese patients (not significant). Sixty per cent of American white patients were women vs 37% of Chinese patients (P = 0.003). Twelve per cent of American white patients vs 1% of Chinese patients had a family history of CD (P = 0.016). American white patients had significantly higher rates of arthritis (32%vs 4%), abscess (19%vs 0%), rectal and perineal fistula (52%vs 0%), and disease involving the colon and rectum when compared with Chinese patients (all P < 0.05). American white patients had more colorectal sites involved and higher rates of extraintestinal diseases (40%vs 20%) than Chinese patients (all P < 0.05). Chinese patients had higher rates of ileocaecal disease (82%vs 52%) and deep ulcers (66%vs 24%) in the colorectum (all P < 0.001). There were no statistical differences in the incidence of smoking, perforation, intra‐abdominal fistula, stenosis, bowel obstruction, toxic megacolon or granuloma formation. Conclusion This study found that colorectal CD had a more severe clinical presentation and pathological involvement in American white patients than in Chinese patients.     

Laparoscopic surgery for recurrent ileocolic Crohn’s disease is as safe and effective as primary resection

Aim The safety and short‐term outcome of laparoscopic surgery for recurrent ileocolic Crohn’s disease was compared with the outcome following primary resection. Method Between June 2002 and June 2010, 59 consecutive unselected patients (30 of whom had recurrent disease) underwent laparoscopic ileocolic resection. Four primary resections and one revision were performed as a single incision laparoscopic surgery (SILS) procedure. Results There was no difference between the two groups in terms of age, body mass index, American Society of Anesthesiology (ASA) grade or the presence or absence of fistulating disease. The median operating time was significantly longer for the revision group (125 min vs 85 min; P < 0.001). The rate of conversion was 8.5%, morbidity was 20% and mortality was 0% (P = not significant between groups). Risk factors for conversion included a complex fistula, fibrosis and the need to carry out multiple stricturoplasty. Patients in whom surgery was converted had a longer hospital stay and a higher morbidity (40%). The median hospital stay was 3 days, the return to theatre rate was 5% and the re‐admission rate was 5% (P = not significant between groups). Conclusion Laparoscopic surgery for recurrent ileocolic Crohn’s disease is safe and can lead to significant short‐term benefit, including earlier discharge. Conversion increases the length of stay in hospital and the overall morbidity.     

Doppler‐guided haemorrhoidal artery ligation in patients with Crohn’s disease

Aim: The outcome of Doppler‐guided haemorrhoidal artery ligation (DGHAL) was assessed in patients with Crohn’s disease (CD) suffering from grade III haemorrhoids. Method: A retrospective study was carried out of patients with CD and symptomatic Grade III haemorrhoids treated by DGHAL. Perioperative and follow‐up data were retrieved from our database of patients undergoing DGHAL. Results: The study included seven men and six women. The mean age was 34 years old. All had CD without anorectal involvement. The median duration of haemorrhoidal symptoms was 6.3 years. There was no mortality, new incontinence, faecal impaction, urinary retention, abscess formation or persistent pain following the procedure. Mean pain score based on a visual analogue scale (VAS) decreased from 2.4 at 24 h postoperatively to 1.6 on the seventh postoperative day. All patients had completely recovered by the third postoperative day. At 18 months, three (77%) of the patients were asymptomatic and three had recurrent symptoms. Conclusion: Doppler‐guided haemorrhoidal artery ligation is safe and effective in treating Grade III haemorrhoids in patients with CD without rectal involvement.     

Split stoma in resectional surgery of high‐risk patients with ileocolonic Crohn’s disease

Aim The aim of this retrospective study of ileocolonic resection in patients with Crohn’s disease was to compare the outcome of primary anastomosis with that of split stoma and delayed anastomosis in a high‐risk setting. Method From 1995 to 2006, 132 patients had 146 operations for ileocolonic Crohn’s disease. Preoperative data, including risk factors for complications, were obtained from a prospectively registered database. Operations on patients who had two or more preoperative risk factors (n = 76) were considered to be high‐risk operations and formed the main study. Primary outcome variables were postoperative anastomotic complications and the alteration in the number of preoperative risk factors achieved by a delayed anastomosis. Secondary outcome was time in hospital and the number of operations performed. Results Early anastomotic complications were diagnosed in 19% (11/57) of patients receiving a primary anastomosis compared with 0% (0/19) of patients after a delayed anastomosis (P = 0.038). The mean number of risk factors in the split stoma group was 3.5 at the time of resection and 0.2 when the split stoma was reversed (P < 0.0001). The total number of operations was 1.9 ± 1.5 (mean ± SD) after a primary anastomosis and 2.0 ± 0.2 after a split stoma (P = 0.70). Total in‐hospital time for all operations was 20.9 ± 35.6 days after a primary anastomosis and 17.8 ± 10.4 days after a delayed anastomosis (P = 0.74). Conclusion Delayed anastomosis after ileocolonic resection in high‐risk Crohn’s disease patients was associated with a reduction in the number of preoperative risk factors and fewer anastomotic complications. Hospital stay and number of operations were similar after delayed and primary anastomosis in high‐risk patients.     

Colorectal carcinoma in inflammatory bowel disease: a comparison between Crohn’s and ulcerative colitis

Aim The study assessed the clinicopathological features and survival rates of inflammatory bowel disease (IBD) patients with colorectal carcinoma (CRC), which accounts for ～15% of all IBD associated death. Method The medical records of patients operated on for CRC in three institutions between 1992 and 2009 were reviewed, and those with Crohn’s colitis (CC) and ulcerative colitis (UC) were identified. Data on age, gender, disease duration, colitis severity, surgical procedure, tumour stage and survival were retrieved. Results Fifty‐three patients (40 UC and 13 CC, 27 men, mean age at operation 54 years) were found. All parameters were comparable between the groups. Mean disease duration before CRC was 22.7 years for UC and 16.6 years for CC patients (P = 0.04). CRC was diagnosed preoperatively in 43 (81%) patients. Twenty‐eight patients had colon cancer, 23 had rectal cancer and two patients had more than one cancer. All malignancies were located in segments with colitis. Over one‐half were diagnosed at an advanced stage (36% stage III; 17% stage IV). At a mean follow up of 56 ± 65 months, 60% were alive (54% disease free) and 40% were dead from cancer‐related causes. The 5‐year survival rate was 61% for the UC and 37% for the CC patients (P = NS). Conclusion CRC in IBD patients is frequently diagnosed at an advanced stage, a factor that contributes to poor prognosis. The risk of CRC in CC patients is comparable to those with UC. Long‐term surveillance is recommended for patients with long‐standing CC and UC.     

Food‐specific IgG4‐guided exclusion diets improve symptoms in Crohn’s disease: a pilot study

Aim Exclusion diets have been shown to prolong remission in Crohn’s disease (CD). We assessed IgG4‐targeted exclusion diets in patients with CD. Method Forty patients with symptomatic CD were recruited. Their sera were tested for IgG4 antibodies to 14 specific food antigens and each subject’s four most reactive foods were excluded for 4 weeks. Disease activity was assessed using a modified CD activity index (mCDAI). Questionnaire and inflammatory markers were measured before and on completion of the exclusion diet. Results Eleven patients did not complete the study, leaving 29 for analysis. Of these, 26 (90%) reported symptomatic improvement with a reduction in mCDAI from a mean of 171–97.5 (P = 0.0001). The ESR fell from 23 to 17 mm/h (P = 0.021) and the IgG4 titres for the excluded foods fell from a mean of 3015–2306 mcgA/l (P = 0.003). Conclusion IgG4‐guided exclusion diets resulted in significant symptomatic improvement with an objective fall in an inflammatory marker. This approach may be useful in clinical practice.     

Open vs laparoscopic approach for reversal of Hartmann’s procedure: a systematic review

Aim A meta‐analysis of published literature comparing open vs laparoscopic Hartmann’s reversal. Method MEDLINE, EMBASE, CINAHL, PubMed and the Cochrane databases were searched from January 1993 to August 2008. The bibliography of selected trials was scrutinized and relevant references obtained. A systematic review was performed to obtain a summative outcome. Results Eight comparative studies involving 450 patients were analysed. One hundred and ninety‐three patients were in the laparoscopic and 257 in the open group. Laparoscopic reversal has a significantly reduced complication rate (z = −2.92, P < 0.01), intra‐operative blood loss (z = −7.34, P < 0.001) and hospital stay (z = −3.16, P < 0.01) compared with the conventional approach. No difference in leak rates was found. Conclusion Laparoscopic reversal of Hartmann’s procedure is safe, has fewer complications and shorter hospital stays. This approach may be considered for reversal, however, randomized controlled trials are required to strengthen the evidence.     

A meta‐analysis of randomized controlled trials comparing antibacterial therapy with placebo in Crohn’s disease

Aim Background Antibacterial therapy has been investigated in several randomized, clinical trials compared with placebo for the management of Crohn’s disease. Evidences for the efficacy of intervention are increasingly required. Objectives To conduct a meta‐analysis of randomized trials to compare the effects of antibacterial therapy versus placebo in patients with Crohn’s disease. Method Search strategy A systematic literature search of Pubmed, EMBASE, Cochrane Library (April 1966 to July 2009) was conducted using specific search terms. Selection criteria Eligible studies were randomized controlled trials comparing antibacterial (antimycobacterial and broad‐spectrum antibiotic) therapy with placebo. Data collection and analysis Studies were reviewed to determine the number of participants, mean follow‐up, and the odds ratios (OR) for primary end point of clinical remission and clinical response were also abstracted. The meta‐analysis was performed using a fixed‐effects model or a randomized‐effects model according to the degree of heterogeneity. Results Eleven randomized placebo‐controlled clinical trials with 668 participants (364 patients in the treatment group and, 304 patients in the placebo group) were identified. Antimycobacterial agents were used in four of the trials and broad‐spectrum antibiotics were used in the other seven trials. Pooled analysis showed no significant differences in the rates of clinical remission [OR = 1.28, 95% confidence interval (CI): 0.87–1.90, P = 0.214] and clinical response (OR = 1.52, 95% CI: 0.91–2.55, P = 0.108) after receiving antibacterial treatment for 3 months or longer. Conclusion In this meta‐analysis, no evidence of benefit for antibiotics in patients with Crohn’s disease was found.     

Outcome and long‐term function of restorative proctocolectomy for Crohn’s disease: comparison to patients with ulcerative colitis

Aim Restorative proctocolectomy (RPC) is the most common operation for chronic ulcerative colitis (CUC), as it provides excellent functional outcome. However, among patients with Crohn’s disease (CD), RPC is generally not recommended, as outcome and long‐term function may be poor. Our purpose was to compare matched cohorts of CD and CUC patients to determine whether there are differences in outcome or function. Method We queried our prospectively maintained database of patients who underwent RPC from 1991 to 2008. We identified patients who underwent RPC for CD and compared them with a matched cohort of patients who underwent RPC for CUC. Results We identified 13 patients with CD (seven women, median age 34 years) and 39 patients with CUC (21 women, median age 35 years). The patients were well matched for gender, clinical and demographic variables. Seven patients (54%) with CD had proctitis, but none had perianal or ileal disease. There were four (30.8%) postoperative complications and no anastomotic leaks. The CD group experienced significantly fewer median daily bowel movements (P = 0.02), incontinence for liquids (P < 0.01) and pouchitis (P < 0.01). With a median follow up of 44 months, pouch excision rate was significantly higher in the Crohn’s group (2 vs 0%, P < 0.01). Conclusion In patients with CD, RPC may result in fewer daily bowel movements, less liquid incontinence and a lower incidence of pouchitis compared with CUC patients who undergo RPC. However, risk of pouch loss is higher in patients with CD. Therefore, in properly selected patients with CD, RPC provides an acceptable long‐term functional outcome.     

Postoperative recurrence of Crohn’s disease: impact of endoscopic monitoring and treatment step‐up

Aim Eighty per cent of patients with Crohn’s disease require surgery, of whom 70% will require a further operation. Recurrence occurs at the anastomosis. Although often recommended, the impact of postoperative colonoscopy and treatment adjustment is unknown. Method Patients with a bowel resection over a 10‐year period were reviewed and comparison made between those who did and did not have a postoperative colonoscopy within 1 year of surgery, and those who did or did not have a step‐up in drug therapy. Results Of 222 patients operated on, 136 (65 men, mean age 33 years, mean disease duration 8 years, median follow‐up 4 years) were studied. Of 70 patients with and 66 without postoperative colonoscopy, clinical recurrence occurred in 49% and 48% (NS) and further surgery in 9% and 5% (NS). Eighty‐nine per cent of colonoscoped patients had a decision based on the colonoscopic findings: of these, 24% had a step‐up of drug therapy [antibiotics (n = 10), aminosalicylates (n = 2), thiopurine (n = 5), methotrexate (n = 1)] and 76% had no step‐up in drug therapy. In colonoscoped patients clinical recurrence occurred in 9 (60%) of 15 patients with, and 23 (49%) of 47 without step‐up and surgical recurrence in 2 (13%) of 15 and 4 (9%) of 47 (NS). Conclusion Clinical recurrence occurs in a majority of patients soon after surgery. In this cohort, there was no clinical benefit from colonoscopy or increased drug therapy within 1 year after operation. However, the response to the endoscopic findings was not standardized and immunosuppressive therapy was uncommon. Standardizing timing of colonoscopy and drug therapy, including more intense therapy, may improve outcome, although this remains to be proven.