Surgical Management of Crohn's Disease

Publication Date: July 1, 2020
Last Updated: April 18, 2022

Recommendations

OPERATIVE INDICATIONS

Medically Refractory Disease

1. Patients who demonstrate an inadequate response to, develop complications from, or are nonadherent with medical therapy should typically be considered for surgery. (1C)
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Inflammation

1. Patients with severe acute colitis who do not adequately respond to medical therapy or who have signs or symptoms of impending or actual perforation should undergo surgery. (1C)
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Stricture

1. Endoscopic dilation may be considered for patients with short-segment, noninflammatory, symptomatic small-bowel or anastomotic strictures. (1C)
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2. Surgery is indicated for patients with symptomatic small-bowel or anastomotic strictures that are not amenable to medical therapy and/or endoscopic dilation. (1C)
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3. Patients with strictures of the colon that cannot be adequately surveyed endoscopically should be considered for resection. (1C)
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Penetrating Disease

1. Patients with a free perforation should undergo surgical resection of the perforated segment. (1B)
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2. Patients with penetrating Crohn’s disease with abscess formation may be managed with antibiotics with or without drainage followed by interval elective resection or medical therapy depending on the clinical situation and patient preferences. (2B)
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3. Patients with enteric fistulas that persist despite appropriate medical therapy should be considered for surgery. (1C)
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Hemorrhage

1. Stable patients with gastrointestinal hemorrhage may be evaluated and treated by endoscopic and/or interventional radiologic techniques. Unstable patients, despite resuscitation efforts, should typically undergo operative exploration. (1C)
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Colorectal Dysplasia and Cancer

1. Patients with long-standing Crohn’s colitis involving at least one-third of the colon or more than 1 segment, should typically undergo endoscopic surveillance at regular intervals. (1B)
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2. Patients with visible dysplasia that is completely excised endoscopically should typically undergo endoscopic surveillance. If dysplasia is not amenable to endoscopic excision, is also found in the surrounding flat mucosa, or is multifocal, or if colorectal adenocarcinoma is diagnosed, total colectomy or total proctocolectomy is typically recommended. (1B)
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3. Patients with invisible, indefinite dysplasia should typically be referred to an experienced endoscopist for repeat colonoscopy using enhanced imaging with repeat random biopsies within 3 to 12 months. (1C)
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4. Patients with invisible, low- or high-grade dysplasia on routine surveillance colonoscopy should typically be referred to an experienced endoscopist for high-definition colonoscopy with chromoendoscopy with repeat random biopsies within 3 to 6 months. Patients found to have invisible, low- or high-grade dysplasia at the time of high-definition colonoscopy with chromoendoscopy should typically undergo total colectomy or proctocolectomy. (1B)
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5. Suspicious lesions (eg, mass, ulcer) identified in patients with Crohn’s disease should be biopsied, especially when considering small-bowel or colonic strictureplasty. (1C)
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SITE-SPECIFIC OPERATIONS

1. Patients with symptomatic disease of the stomach or duodenum despite medical therapy should typically be considered for endoscopic dilation, bypass, or strictureplasty. (1C)
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2. Patients with medically refractory disease isolated to the jejunum, ileum, or ileocolon without existing or anticipated short-bowel syndrome should typically undergo escalation of medical therapy or resection of the affected bowel, ideally, as determined by a multidisciplinary team. For patients undergoing an operation with multifocal disease, strictureplasty should be considered. (1C)
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3. The procedure of choice for emergency surgery in Crohn’s colitis is a total abdominal colectomy with end ileostomy. (1C)
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4. Patients with colonic disease and rectal sparing who proceed with elective surgery may undergo segmental colectomy for single-segment disease or total colectomy for more extensive disease. (1B)
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5. For patients undergoing elective surgery for rectal disease, total proctocolectomy with end ileostomy or proctectomy with creation of a colostomy should typically be performed. (1C)
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6. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) may be offered to selected patients with Crohn’s disease without perianal or small-bowel disease, recognizing that long-term pouch failure rates are increased in this population. (2C)
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PREOPERATIVE CONSIDERATIONS

1. Preoperative high-dose glucocorticoids increase the risk of postoperative infectious complications and attempts should typically be made to wean glucocorticoids before surgical intervention. Immunomodulators are not associated with increased risk of postoperative infectious complications and do not typically need to be held before surgery. (1C)
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2. Whether or not preoperative exposure to monoclonal antibody therapy influences outcomes remains controversial, but delaying surgical intervention based on monoclonal antibody therapy alone is not typically recommended. (2C)
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3. Preoperative nutritional support for patients with malnutrition may decrease postoperative morbidity. (2C)
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4. Smoking cessation may reduce postoperative morbidity in patients with Crohn’s disease. (1C)
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OPERATIVE CONSIDERATIONS

1. A minimally invasive approach to Crohn’s disease surgery should typically be considered. (1B)
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2. A diverting ileostomy should be considered when performing ileocolectomy in patients who have Crohn’s disease with multiple risk factors. (1B)
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3. The extent of mesenteric excision during resection for Crohn’s disease remains controversial. (2C)
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4. Following ileocecal resection, reconstruction using side-to-side, side-to-end, or end-to-end handsewn or stapled anastomosis based on surgeon preference and experience is reasonable. (1C)
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POSTOPERATIVE CONSIDERATIONS

1. After surgery for Crohn’s disease, patients should be considered for medical therapy to treat residual active disease or to maintain disease remission. (1B)
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Recommendation Grading

Overview

Title

Surgical Management of Crohn's Disease

Authoring Organization

American Society of Colon and Rectal Surgeons

Publication Month/Year

July 1, 2020

Last Updated Month/Year

September 30, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Prevention

Diseases/Conditions (MeSH)

D003424 - Crohn Disease

Keywords

Crohn's disease, surgical management, Clinical Practice Guidelines

Source Citation

Lightner AL, Vogel JD, Carmichael JC, Keller DS, Shah SA, Mahadevan U, Kane SV, Paquette IM, Steele SR, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn's Disease. Dis Colon Rectum. 2020 Aug;63(8):1028-1052. doi: 10.1097/DCR.0000000000001716. PMID: 32692069.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
312
Literature Search Start Date
January 1, 2014
Literature Search End Date
December 1, 2019