Surgery in Crohn’s Disease: Current Concepts

Surgery in Crohn’s Disease: Current Concepts

January 23, 2025

Introduction: 

The objectives of this presentation were to review the options in surgery for Crohn’s disease (CD), discuss the role and importance of optimizing nutrition prior to surgery, examine new data on early versus late surgery, and explore the use of robotic surgery. Key themes that emerge on this topic are the need for a multidisciplinary approach and the evolving role of earlier surgery.

Surgical Indications and Preoperative Optimization

A range of indications for surgery in CD have been identified through studies and clinical experience, providing clearer guidance for clinicians (see Figure 1).

Surgical indications in 2024

The “surgical enemies” in CD management include steroids, sepsis, malnutrition, anemia, inadequate surgical technique, hostile abdominal environments, delays in surgical intervention, and surgeon’s vanity, some of which are modifiable. One important modifiable risk factor that is often neglected is pre-operative nutritional optimization. As highlighted in the 2024 European Crohn’s and Colitis Organization (ECCO) Guidelines on Therapeutics in CD: Surgical treatment, it is recommended to assess preoperative nutritional status for patients who need surgery and consider enteral nutrition when feasible for preoperative optimization.1

Frequently, gastroenterologists encounter clinical scenarios of late consideration of surgery, with failure of multiple biologic treatments leading to more organ involvement, and more complicated cases. This has been demonstrated in a study of patients undergoing bowel resections for perforating ileitis showing that delay of surgery was significantly associated with increased postoperative complications.2 Furthermore, the rate of surgical and medical complications is higher in patients over 5 years of disease duration (from diagnosis to surgery) versus those within 5 years after diagnosis.3

Over time, there has been a shift towards a top-down strategy in IBD with the use of early biologic therapy. This shift was supported by results from an open randomized trial in patients with newly diagnosed CD that showed superior outcomes with the early use of combined immunosuppression (infliximab and azathioprine) versus conventional management (sequenced therapy moving from corticosteroids to azathioprine plus infliximab) for induction of remission and reduction of steroid use.4 In addition, the CALM study supports the concept of a raised “therapeutic ceiling”, showing higher rates of mucosal healing and deep remission in early CD when treated with a target of biomarker levels compared to symptom-driven clinical management.5

Surgical Resection in CD

The question then becomes where surgery fits into the top-down treatment approach, given the potential for a durable surgically induced remission. Important information provided by the LIR!C randomized, controlled, open-label trial showed that laparoscopic ileocaecal resection is associated with similar quality-of-life outcomes as treatment with infliximab in patients with non-stricturing and immunomodulator-refractory ileocaecal CD.6 A subsequent retrospective long-term follow-up (median follow-up of 63.5 months), found that 26% of patients in the resection group started anti-TNF therapy, none required a second resection, and 42% did not require additional CD-related medication. This is compared to the infliximab group, in which 48% of patients had a CD-related resection, and the remaining patients maintained, switched, or escalated their anti-TNF therapy.7

The potential benefits of early surgery in CD are supported by real-world data from the retrospective SURGICROHN-LATAM study that showed that earlier surgery in ileocecal CD is associated with reduced postoperative complications, reoperations, anastomotic fistulas, and hospital stays.8 Similar results were seen in the expanded multi-centre global study, Crohn’s(urg), which included 2013 patients operated on for primary ileocecal CD, and showed that patients presenting with an inflammatory phenotype had better outcomes compared to patients with a complicated phenotype (see Figure 2).9

Main operative results in inflammatory Crohn’s disease (ICD) and complicated Crohn’s disease (CCD)9

Furthermore, data from a population-based cohort (PREDICT Study) demonstrated that ileocecal resection for CD improved long-term outcomes compared to anti-TNF. Specifically, the risk of the composite outcome including hospitalization, repeat CD-related surgery, systemic corticosteroid exposure, and perianal CD was 33% lower with ileocecal resection compared to anti-TNF as primary therapy. Of those individuals who underwent ileocecal resection, approximately half were on no treatment at 5 years of follow-up.10 Overall, these results support surgery being more broadly offered and discussed as a first-line therapeutic option in early ileal/ileocaecal CD.

Putting these data into practice, up-front surgery has a lot of advantages versus delayed procedures (see Figure 3). However, better predictors of response are still needed, to better identify factors associated with non-response to pharmacotherapy, emphasizing the need for earlier surgery.11

Surgical characteristics of upfront (earlier) surgery vs. delayed procedures in ileal CD12

Current and Future Surgical Methods in CD

Current surgical techniques for ileocolonic anastomosis include a range of options such as end-to-end, side-to-side isoperistaltic, and side-to-side-peristaltic anastomosis. The newest method, the Kono-S anastomosis, has demonstrated potential advantages including preventing postsurgical recurrence,13 and in practice tends to be used in second or third recurrences. More data on the role of Kono-S is still a medical need.

Looking at the future, robotic surgery is predicted to become the gold standard as more platforms become available. Evidence from a recent meta-analysis of robotic surgical techniques in IBD showed a reduction in morbidity as well as technical advantages and better control of mesentery compared to laparoscopic surgical techniques.14

Conclusions

From a practical perspective, it is important to discuss all localized ileocolic CD patients in multidisciplinary teams to address the potential role of surgery. When discussing with patients, provide them with the pros and cons of earlier surgery. If surgery is chosen, it is crucial to optimize nutritional status pre-operatively, and document the type of anastomosis for future endoscopists. The surgical landscape will continue to evolve as robotic surgery becomes the gold standard, providing more options for patients.

Clinical Case

Jenna is a 22-year-old female in graduate school who has presented to the emergency department with vomiting. On further questioning she has had several months of post prandial bloating and more recent abdominal pain for which she has been taking regular NSAIDs. An abdominal x-ray demonstrates air fluid levels. She is managed conservatively and fortunately there is resolution of the obstruction. A CT shows thickening of 5 cm of the terminal ileum with proximal dilatation. She subsequently has a colonoscopy during which a ‘stricture’ is identified in the terminal ileum which does not permit passage of the scope. The endoscopist notes no colonic nor perianal disease but refers her to the IBD centre where you work. She also has a family history of rheumatoid arthritis.

Commentary

  • Most gastroenterologists would arrange a different form of imaging at this point.
  • There remains the clinical challenge of individualizing treatment and identifying patients that would benefit from early surgery vs. pharmacotherapy.
  • From the surgeon’s perspective, they would rather operate when the patient is just starting to decline, as the success of surgery depends on the state of the patient.

Case Evolution

You obtain a bowel ultrasound and decide not to repeat the colonoscopy yet. The ultrasound demonstrates 7 mm wall thickening over a 5 cm span of the terminal ileum, associated hyperemia, and persistent prestenotic dilatation. Before her presentation to the ER, she had 3–4 loose bowel movements a day with no blood, and now reports 1 bowel movement per day. Her fecal calprotectin is 229 ug/g, and C-reactive protein (CRP) 1.8 mg/L. A pre-biologic work-up is completed. Jenna’s symptoms settle down with an 8-week course of budesonide and she returns for a follow up visit. Repeat sonography demonstrates 6 mm wall thickening over a 5 cm span of the terminal ileum, mild hyperemia but persistent prestenotic dilatation.

Commentary

  • The majority of gastroenterologists would start an advanced therapy, while several would refer to surgery.
  • In practice they find some surgeons want gastroenterologists to try multiple treatments before moving to surgery. This underlines the importance of developing multidisciplinary relationships, include surgeons in discussions on the pros and cons of delayed surgery.
  • For patients with tight strictures, given they will eventually require surgery, it could be argued that upfront surgery may be the best option.

Case Evolution

As Jenna is feeling better, she wishes to watch and wait and declines the options above. She returns in 4 months and tells you that she is moving to Europe in 6 months to undertake post graduate training for at least 2 years and does not want to get sick whilst abroad. She wants to ‘get on’ with a more definitive therapy as her nausea, bloating, and intermittent post-prandial discomfort have returned. You have read the LIR!C trial, which studied the effect of ileocecal resection and refer her for surgery. You try and demonstrate you know what you are talking about, so you engage in discussion with the surgeon regarding the potential advantages of a Kono-S anastomosis, the SPICY trial with extensive mesenterectomy, etc., but it becomes apparent to both you and your surgeon that you are out of your depth!

Commentary

  • Surgical intervention remains an essential component in the management of CD, with key decisions centered around the type and timing of surgery.
  • The majority of gastroenterologists would choose to start advanced therapy prior to surgery given the unpredictable wait times for surgery.

Case Evolution

Jenna recovers well from surgery and leaves for Europe as planned without any maintenance therapy. She extends her time away and completes her PhD and unfortunately misses the opportunity for close post-operative monitoring for disease recurrence. Jenna returns 5 years from first meeting you with perianal discomfort but no abdominal symptoms. She has fluctuant erythema in the perianal area and CT confirms a single perianal abscess. You call the surgeon, who proceeds to perform an incision and drainage with good effect. On colonoscopy there is minimal post-operative ileal disease recurrence (Rutgeerts i1) and she declines vedolizumab despite discussion of the REPREVIO trial. A year later, her perianal disease progresses with MRI confirming complex perianal fistulizing disease. She is keen to be on an oral therapy as she travels frequently.

Commentary

  • At this point, a similar proportion of gastroenterologists would start treatment with an anti-TNF or upadacitinib.
  • Given no risk factors for post-op recurrence, close monitoring and watch and wait was a reasonable approach, however in this case unfortunately close monitoring was not done.

References

    1. Adamina M, Minozzi S, Warusavitarne J, et al. ECCO Guidelines on therapeutics in Crohn’s disease: Surgical treatment. J Crohns Colitis. 2024;18(10):1556–82.
    2. Lesalnieks I, Kilger A, Glass H, et al. Perforating Crohn’s ileitis: delay of surgery is associated with inferior postoperative outcome. Inflamm Bowel Dis. 2010;16(12):2125–30.
    3. Gallo G, Kotze, PG, Spinelli A. Surgery in ulcerative colitis: When? How? Best Pract Res Clin Gastroenterol. 2018;Feb-Apr:32-33:71–78.
    4. D’Haens G, Baert F, van Assche G, et al. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn’s disease: an open randomised trial. Lancet. 2008;371(9613):660–7.
    5. Colombel J-F, Panaccione R, Bossuyt P, et al. Effect of tight control management on Crohn’s disease (CALM): a multicentre, randomised, controlled phase 3 trial. Lancet. 2017;390(10114):2779–89.
    6. Ponsioen CY, de Groof EJ, Eshuis EJ, et al; LIR!C study group. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: a randomised controlled, open-label, multicentre trial. Lancet Gastroenterol Hepatol. 2017;2(11):785–92.
    7. Stevens TW, Haasnoot ML, D’Haens GR, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastroenterol Hepatol. 2020;5(10):900–7.
    8. Avellaneda N, Coy CSR, Fillmann HR, et al. Earlier surgery is associated to reduced postoperative morbidity in ileocaecal Crohn’s disease: Results from SURGICROHN – LATAM study. Dig Liver Dis. 2023;55(5):589–94.
    9. Avellaneda N, Pellino G, Maroli A, et al. Short-term outcomes of surgical treatment for primary ileocaecal Crohn’s disease: Results of the Crohn’s(urg) study, a multicentre, retrospective, comparative analysis between inflammatory and complicated phenotypes. Colorectal Dis. 2024;26(7):1415–27.
    10. Agrawal M, Ebert AC, Poulsen G, et al. Early ileocecal resection for Crohn’s disease is associated with improved long-term outcomes compared with anti-tumor necrosis factor therapy: A population-based cohort study. Gastroenterology. 2023;165(4):976–85.
    11. Vieujean S, Louis E. Precision medicine and drug optimization in adult inflammatory bowel disease patients. Exp Op Pharmacother. 2023;16:1756284823117333.
    12. Gustavo Kotze P. The role of upfront surgery in the management of ileal Crohn’s disease. Can IBD Today [Internet]. 2024;2(2):5–9.
    13. Kono T, Fichera A. Surgical treatment for Crohn’s disase: A role of Kono-S anastomosis in the west. Clin Colon Rectal Surg. 2020;33(6):335–43.
    14. Zaman S, Mohamedahmed AYY, Abdelrahman W, et al. Minimally Invasive Surgery for Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis of Robotic Versus Laparoscopic Surgical Techniques. J Crohns Colitis. 2024;18(8):1342–55.

    Editor-in-Chief

    John K. Marshall, MD MSc FRCPC CAGF AGAF
    Professor, Department of Medicine
    Director, Division of Gastroenterology
    McMaster University
    Hamilton, ON

    Contributing Author

    Paulo Gustavo Kotze,MD MSc PhD
    Adjunct Senior Professor of Surgery
    Health Sciences Postgraduate Program
    Colorectal Surgery Unit
    Cajuru University Hospital of the Catholic University of Paraná
    Curitiba, Brasil

    Mentoring in IBD Curriculum Steering Committee

    Alain Bitton, MD FRCPC, McGill University, Montreal, QC
    Karen I. Kroeker, MD MSc FRCPC, University of Alberta, Edmonton, AB
    Cynthia Seow, MBBS (Hons) MSc FRACP, University of Calgary, Calgary, AB
    Jennifer Stretton, ACNP MN BScN, St. Joseph’s Healthcare, Hamilton, ON
    Eytan Wine, MD PhD, FRCPC, University of Alberta, Edmonton, AB

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