Anastomotic configurations and early endoscopic recurrence following ileocolonic resection in Crohn’s disease: systematic review and meta-analysis

PURPOSE: Crohn's disease (CD) frequently requires surgery, with ileocolonic resection being the most common procedure. Postoperative endoscopic recurrence remains a major concern, and the role of anastomotic configuration is still debated. This systematic review and meta-analysis aimed to evaluate the impact of different anastomotic techniques on early endoscopic recurrence following ileocolonic resection for CD. METHODS: A systematic search of PubMed, Embase, and Web of Science was performed up to July 2025. Studies comparing stapled side-to-side anastomosis (SSA), handsewn end-to-end anastomosis (EEA), and Kono-S anastomosis (KSA) with postoperative endoscopic follow-up at 6-12 months were included. Study quality was assessed using the Newcastle-Ottawa Scale. Pooled analyses were conducted to compare recurrence rates across anastomotic types. RESULTS: Eleven studies were included (four comparing SSA vs. EEA; seven comparing KSA vs. SSA), for a total of 1505 patients. Most were retrospective, with three randomised controlled trials available. In pooled analysis, no significant difference was found between SSA and EEA (48.5% vs. 46.7%, test for overall effect Z = 0.41, p = 0.6795). KSA showed a trend towards lower recurrences compared with SSA (31.8% vs. 39.8%, test for overall effect Z = -1.96, p = 0.0495), although heterogeneity in study design, definitions, and postoperative management limits firm conclusions. CONCLUSIONS: Current evidence does not support a difference in early endoscopic recurrence between SSA and EEA and a potential but weak overall association with lower recurrences for KSA compared to SSA. Large, high-quality prospective trials with standardised definitions, postoperative medical therapy, and follow-up protocols are warranted to clarify the true impact of anastomotic configuration on outcomes in CD.