Severity of surgical histopathological fibrosis predicted postoperative recurrence in Crohn’s disease: a multi-center retrospective cohort study

Abstract Background Despite treatment advances, intestinal surgery remains common in Crohn’s disease (CD), with over half of patients experiencing postoperative recurrence. Intestinal fibrosis represents a key pathological feature underlying this clinical course. This study aimed to investigate the relationship between fibrosis severity and the risk of postoperative recurrence. Methods A multi-center retrospective cohort study included CD patients undergoing intestinal resection. Histopathological slides from lesion sites and resection margins were analyzed using Masson’s trichrome staining to quantify the proportion of collagen fiber area, representing fibrosis extent. Postoperative endoscopic and clinical recurrence data were collected via electronic medical records and patient follow-up interviews. Multivariable Cox regression models estimated hazard ratios (HRs) with 95% confidence intervals (CIs) for the associations between fibrosis severity and recurrence risk. Results Among 268 patients, endoscopic recurrence occurred in 84 (31.3%) and clinical recurrence in 91 (34.0%). The degree of transmural intestinal fibrosis was positively associated with postoperative endoscopic recurrence (lesion site: HR per SD = 1.46, 95% CI 1.18–1.80; resection margin: HR per SD = 1.35, 95% CI 1.12–1.63) and clinical recurrence (lesion site: HR per SD = 1.95, 95% CI 1.59–2.39; resection margin: HR per SD = 1.29, 95% CI 1.09–1.54). Significant associations persisted when analyzing fibrosis in the mucosal, submucosal, and muscularis propria layers individually. Conclusion The severity of intestinal fibrosis in both lesion site and resection margin independently predicted an increased risk of postoperative endoscopic and clinical recurrence in CD. Histopathological fibrosis assessment may help identify high-risk individuals prone to postoperative recurrence, potentially informing personalized postoperative management strategies.