Surgery & Complications
Up to 80% of people with Crohn's disease will need surgery at some point. If you're facing that possibility, the number of procedures, terms, and unknowns can feel overwhelming. This guide walks through the major surgical options, when each one applies, what recovery actually looks like, and the critical steps for preventing recurrence afterward.
When Surgery Becomes Necessary
Surgery for Crohn's disease is typically reserved for complications that medications can't adequately control. The most common reason is intestinal strictures, where scar tissue narrows the bowel enough to cause repeated obstructions. Other indications include fistulas (abnormal tunnels between the intestine and other structures), abscesses that don't resolve with antibiotics or drainage, perforation of the intestinal wall, and medication failure or intolerable side effects.
Some patients elect surgery to address dysplasia (precancerous changes) found during surveillance colonoscopy, since Crohn's carries a higher risk of colorectal cancer than the general population. In every case, the decision involves weighing the risks of continued medical management against the benefits of surgical intervention, and that calculation is different for every patient.
Bowel Resection: Removing the Damaged Section
Bowel resection is the most common Crohn's surgery. The surgeon removes the diseased segment of intestine and reconnects the healthy ends, a procedure called anastomosis. The most frequent version is an ileocecal resection, which removes the terminal ileum and the cecum, the area where Crohn's most often concentrates.
How much bowel can safely be removed matters. The small intestine is roughly 6 meters long, and patients generally maintain near-normal bowel function after losing a third or less. Losing more than 50% of the small bowel raises the risk of short bowel syndrome, a condition where the remaining intestine can't absorb enough nutrients and fluids. This is why surgeons aim to remove as little as possible and why strictureplasty exists as a bowel-preserving alternative.
Strictureplasty: Widening Without Removing
When strictures are the problem but the bowel tissue between them is relatively healthy, strictureplasty offers a way to open the narrowed areas without removing any intestine. The surgeon cuts along the length of the stricture and sews it closed in the opposite direction, widening the passage. The most common technique, the Heineke-Mikulicz strictureplasty, works well for short strictures. Longer narrowings may require a Finney or side-to-side isoperistaltic approach.
Strictureplasty is particularly valuable for patients who have already had previous resections or who have multiple strictures spread across a long segment. The overall complication rate is about 13%, with septic complications occurring in only 4% of cases. By preserving bowel length, strictureplasty reduces the cumulative risk of short bowel syndrome across a lifetime that may involve multiple surgeries.
Fistula and Abscess Surgery
Fistulas and abscesses require their own surgical approaches. For abscesses, the first step is drainage, either percutaneously (through the skin using imaging guidance) or surgically. Percutaneous drainage has a technical success rate of about 96%, and in roughly half of patients, it avoids the need for open surgery in the short term.
For perianal fistulas, seton placement is the most common procedure, especially for complex tracts. A seton is a surgical thread looped through the fistula tract to keep it open and draining, preventing abscess formation while the surrounding inflammation is treated with medication. Fistulotomy, which lays the tract open to heal from the inside out, achieves closure rates around 90% but is generally limited to simple, superficial fistulas. Combination therapy, using surgical drainage alongside biologic medications like anti-TNF agents, achieves complete fistula remission in about 52% of cases compared to 43% for either approach alone.
Ileostomy: Temporary or Permanent Diversion
Sometimes the best option is to divert stool away from a damaged or healing section of bowel entirely. An ileostomy brings the end of the small intestine through the abdominal wall, where waste collects in an external pouch. A temporary ileostomy gives a surgical site time to heal before the bowel is reconnected. A permanent ileostomy may be necessary when perianal disease is severe or when too much colon has been removed.
The data on quality of life is more encouraging than many patients expect. In a cross-sectional study of Crohn's patients, those with an ostomy were more likely to be in clinical remission (48.5% vs. 31.3%) and showed no measurable difference in quality of life, sexual function, anxiety, depression, or sleep compared to those without one.
Recovery: What the Timeline Looks Like
Most Crohn's surgeries require a 3 to 7 day hospital stay, with planned procedures on the shorter end. Full recovery takes 4 to 12 weeks depending on the surgery type, the patient's nutritional status, and whether they were on immunosuppressive medications beforehand. Many patients return to desk work within 2 to 4 weeks and more physical jobs within 6 to 8 weeks.
The early weeks after surgery are a period of adjustment. Bowel habits will be different, especially after resection. Frequent, looser stools are common initially and typically improve over the first several months as the remaining bowel adapts.
Recurrence Prevention: The Step Most Patients Miss
Here is the fact that changes everything about Crohn's surgery: it is not curative. Endoscopic recurrence in the first year after surgery occurs in 35% to 85% of patients. Clinical recurrence rates reach 17% to 55% at five years, 32% to 76% at ten years, and up to 73% at twenty years. The need for a second surgery ranges from 11% to 32% at five years.
This makes post-surgical monitoring and prophylactic treatment essential. Current guidelines recommend starting biologic therapy within 2 to 4 weeks of surgery, particularly for patients with risk factors like smoking, perforating disease, or prior surgeries. A colonoscopy at 6 to 12 months post-surgery checks the anastomosis site for early signs of recurrence, when it's most treatable.
Smoking is the single most modifiable risk factor for post-surgical recurrence. For patients who smoke, quitting is as important as any medication in the prevention protocol.
If you're considering surgery or recovering from it, track your symptoms from day one. Post-surgical monitoring is critical for catching recurrence early, and having a clear baseline helps your surgeon assess recovery and adjust your prevention plan.