Crohn’s Surgical Options

Crohn’s surgery treats problems that medicines cannot fix, such as narrowings, fistulas, or abscesses. The main operations are resections, where diseased bowel is removed, and strictureplasties, where narrow segments are widened without removing bowel. Perianal disease often needs a combined plan. Good recovery care and prevention of future flare-ups are as important as the operation itself.

Key takeaways

• Surgery controls complications. It does not cure Crohn’s, so prevention of recurrence starts right after surgery.

• Resection removes damaged bowel. Strictureplasty widens fibrotic strictures and preserves length, which lowers short bowel risk. Colon strictureplasty is generally avoided. (academic.oup.com)

• When feasible, a laparoscopic approach shortens hospital stay and lowers complications. Enhanced Recovery After Surgery (ERAS) programs also speed recovery. (pmc.ncbi.nlm.nih.gov)

• After resection, most teams schedule a colonoscopy at 6 to 12 months to check for early recurrence and adjust medicines. Smoking markedly increases recurrence risk. (gastro.org)

• For perianal Crohn’s, drain any abscess, place setons when needed, and use effective medical therapy, often an anti‑TNF. Fistulotomy suits only simple, low tracts. Stem cell injection is not FDA approved in the United States and was withdrawn from the EU market in December 2024. (academic.oup.com)

How surgeons think about Crohn’s operations

The goals are to relieve blockages, control infection, remove severely damaged segments, and preserve as much bowel as possible. Decisions consider disease location, behavior, prior surgeries, nutrition, smoking status, and the patient’s recovery supports at home. Minimally invasive surgery is common for right‑sided or limited ileal disease when anatomy and inflammation allow. Laparoscopic resection usually means fewer complications and a shorter stay with similar long‑term outcomes compared with open surgery. ERAS pathways reduce length of stay and overall complications across colorectal procedures. (pmc.ncbi.nlm.nih.gov)

Resection

Resection removes a short, very diseased segment, most often the terminal ileum and cecum. It is used for strictures that cannot be safely dilated, deep ulcers, fistulas that involve unhealthy bowel, perforation, bleeding, or cancer or dysplasia. The ends are rejoined with a stapled or hand‑sewn connection called an anastomosis. Side‑to‑side stapled anastomosis is widely used. A hand‑sewn antimesenteric “Kono‑S” anastomosis may lower endoscopic recurrence in some studies, but results are mixed, and larger trials are ongoing. Ask the surgeon which technique fits the situation and why. (pubmed.ncbi.nlm.nih.gov)

Sometimes a temporary ostomy is needed to let the connection or perianal wounds heal. A permanent ostomy is uncommon after limited small‑bowel resections, but it may be required for severe, refractory perianal disease or damaged rectum.

Strictureplasty

Strictureplasty widens a scarred narrowing without removing bowel. It is most helpful for multiple short small‑bowel strictures caused by fibrosis, especially in patients who have had prior resections. It preserves length and lowers the risk of short bowel syndrome.

Common techniques by stricture length:

• Heineke–Mikulicz: strictures under about 10 cm.

• Finney: strictures about 10 to 25 cm.

• Side‑to‑side isoperistaltic (Michelassi): long or multiple close strictures, up to about 60 to 70 cm. (academic.oup.com)

Strictureplasty is generally not done in the colon, when cancer is suspected, during active perforation or uncontrolled sepsis, or when inflammation is very severe at that site. Long‑term data show low, site‑specific recurrence at the strictureplasty itself, with good preservation of bowel. (academic.oup.com)

Resection vs strictureplasty at a glance

Approaches to perianal Crohn’s

Perianal disease includes abscesses and fistulas. Care is shared by colorectal surgery and gastroenterology.

• Imaging and mapping: MRI pelvis and an exam under anesthesia help define tracts and look for abscess.

• Drain infection: Abscesses must be drained quickly. A soft draining seton often stays in place to keep tracts open and prevent re‑accumulation. (academic.oup.com)

• Combine with medical therapy: Anti‑TNF therapy, especially infliximab, improves closure and reduces relapse when induction and maintenance are continued. Combination with immunomodulators may help. (ovid.com)

• Choose closure procedures carefully: Fistulotomy is reserved for simple, low tracts to protect continence. For complex tracts, options include advancement flap or LIFT in selected patients, usually after inflammation is controlled. Diversion or proctectomy is a last resort for severe, refractory disease. (guidelinecentral.com)

• Stem cell injection status: Darvadstrocel is not FDA approved in the United States. The European Medicines Agency announced withdrawal of Alofisel from the EU market on December 13, 2024 after a confirmatory trial did not show benefit. (ema.europa.eu)

After surgery: preventing and detecting recurrence

Crohn’s often returns at or near the connection after ileocolic resection. Risk is higher in people who smoke, have penetrating or perianal disease, or have had prior resections. Most teams use a risk‑based plan that may include starting anti‑TNF or a thiopurine soon after surgery for high‑risk patients, and scheduling a colonoscopy at 6 to 12 months to check the neoterminal ileum. If ulcers are seen, therapy is started or intensified even if symptoms are quiet. Stopping tobacco is one of the most effective steps to lower recurrence risk. (gastro.org)

Recovery basics

• Laparoscopic surgery, when possible, usually means a shorter hospital stay and faster return to activity. (pmc.ncbi.nlm.nih.gov)

• ERAS programs use scheduled pain control, early feeding, and early walking to reduce complications and length of stay. (ncbi.nlm.nih.gov)

• Nutrition matters. Teams often optimize iron, vitamin D, B12, and protein before and after surgery.

• Call the care team for fever above 101°F, worsening belly pain, vomiting, heavy bleeding, or new drainage that smells foul.

FAQs

Will surgery cure Crohn’s

No. Surgery treats complications and can reset the clock. Medicines and monitoring are still needed to keep inflammation quiet long term. (gastro.org)

How do surgeons choose between resection and strictureplasty

They consider where the strictures are, how long they are, how inflamed the tissue is, prior resections, and the risk of short bowel. Strictureplasty is favored for multiple fibrotic small‑bowel strictures. Resection is chosen when tissue is very damaged or unsafe to preserve. (academic.oup.com)

Is there one best anastomosis to prevent recurrence

There is interest in the Kono‑S technique, and some studies show less endoscopic recurrence. Other data do not show a clear advantage. Technique choice depends on surgeon experience and case details. (pubmed.ncbi.nlm.nih.gov)

What if perianal fistulas keep coming back

Care often includes seton drainage, long‑term biologic therapy, and, in selected cases, procedures like an advancement flap or LIFT. Diversion is sometimes used for severe, refractory symptoms. Stem cell therapy is not available in the United States and is no longer marketed in the EU. (guidelinecentral.com)