Crohn’s Surgical Options

Crohn’s surgery is usually used when inflammation has caused strictures, fistulas, or infections that medicines alone cannot safely control. Common operations include bowel resections, strictureplasty to widen narrowed segments, and procedures for perianal disease such as abscess drainage and seton placement. Understanding these options helps patients and families weigh benefits, risks, and long term planning with their care team.

Key Takeaways

• Surgery in Crohn’s is mainly for complications such as obstruction, perforation, abscess, or medically resistant disease. (journals.lww.com)

• Resection removes a short diseased bowel segment, often using minimally invasive techniques, and joins the ends back together. (ncbi.nlm.nih.gov)

• Strictureplasty widens fibrotic strictures in the small intestine while preserving bowel length, which helps prevent short bowel syndrome. (ncbi.nlm.nih.gov)

• Perianal Crohn’s surgery focuses first on draining infection, usually with setons, alongside biologic and antibiotic therapy. (pmc.ncbi.nlm.nih.gov)

• Crohn’s can return after surgery, so endoscopic follow up and preventive medicines are key, especially in higher risk patients. (journals.lww.com)

Why surgery is used in Crohn’s

Crohn’s disease is a long term inflammatory condition. Medicines are the first choice, but surgery often becomes important over a lifetime.

Guidelines suggest surgery when there is uncontrolled bleeding, bowel perforation, repeated or lasting obstruction from strictures, abscesses, complex fistulas, cancer or precancerous changes, or disease that does not respond to strong medical therapy. (journals.lww.com)

Surgery in Crohn’s usually aims to relieve specific problems and improve quality of life, not to “cure” the underlying immune condition.

Resection surgery: removing a diseased segment

A resection is removal of a short piece of diseased intestine, followed by joining the healthy ends together (an anastomosis). In Crohn’s, surgeons try to remove only the visibly affected bowel with very small margins, rather than long segments with lymph node removal as in cancer surgery. (ncbi.nlm.nih.gov)

Common resections include:

• Ileocolic or ileocecal resection, removing the terminal ileum and nearby right colon

• Segmental small bowel resection, removing a short diseased part of small intestine

• Segmental colonic resection, for localized Crohn’s in the colon

These operations are often done for fibrostenotic strictures that block the intestine or for penetrating disease with internal fistulas or abscesses. (journals.lww.com)

Most centers now use laparoscopic or robotic techniques when anatomy and prior surgery allow. Studies show that minimally invasive ileocolic resections lead to faster return of bowel function, shorter hospital stays, and similar or fewer complications compared with open surgery. (pubmed.ncbi.nlm.nih.gov)

Sometimes a temporary or permanent ostomy (ileostomy or colostomy) is created, for example when the risk of leakage is high or severe pelvic disease needs time to settle. (pubmed.ncbi.nlm.nih.gov)

Typical risks of resection include bleeding, infection, anastomotic leak, small bowel obstruction from scar tissue, and hernias. The exact risk profile depends on nutrition, steroids or biologics, smoking, and previous operations.

Strictureplasty: widening narrow segments without removing bowel

A stricture is a narrowed segment of bowel. In Crohn’s this may be largely fibrotic (scar tissue) rather than purely inflamed. When several short strictures are present in the small intestine, or when a person has already had significant resections, surgeons may choose strictureplasty.

In a strictureplasty, the surgeon opens the narrowed segment lengthwise then closes it crosswise or side to side. This widens the passage but leaves the bowel segment in place, preserving length and reducing the risk of short bowel syndrome. (ncbi.nlm.nih.gov)

Strictureplasty is usually reserved for:

• Multiple short fibrotic strictures in the small intestine

• Patients with prior major resections or existing short bowel

• Noninflamed, nonperforated strictures

It is generally avoided when there is an abscess, fistula, perforation, very thick inflammatory mass, suspicion of cancer, or colonic strictures, because leak or cancer risk would be higher. (ncbi.nlm.nih.gov)

When used in the right setting, strictureplasty can relieve obstruction with acceptable leak and recurrence rates, while preserving precious bowel length. (ncbi.nlm.nih.gov)

After bowel surgery: recurrence and prevention

Crohn’s is driven by the immune system, so inflammation often returns over time, typically at or near the anastomosis after resection. Postoperative guidelines recommend a colonoscopy or ileocolonoscopy about 6 to 12 months after surgery to look for early recurrence that may be silent. (journals.lww.com)

People at higher risk of recurrence include those who:

• Smoke cigarettes

• Have penetrating or stricturing disease behavior

• Have already needed prior bowel resections

Studies suggest that starting thiopurines or biologic therapy such as infliximab or vedolizumab soon after ileocolic resection lowers endoscopic and surgical recurrence rates in higher risk groups. (academic.oup.com)

Importantly, smoking cessation after ileocolic resection is linked with a markedly lower need for repeat surgery, compared with continued smoking. (pubmed.ncbi.nlm.nih.gov)

Surgery for perianal Crohn’s disease

Perianal Crohn’s involves problems around the anus such as abscesses, fistulas, fissures, and skin tags. It often requires close teamwork between colorectal surgeons and gastroenterologists.

Key goals are to control infection, protect the anal sphincter muscles and continence, and improve day to day comfort and quality of life, rather than closing every tract at any cost. (pmc.ncbi.nlm.nih.gov)

Detailed mapping with pelvic MRI and examination under anesthesia helps define the paths of fistulas and the amount of rectal inflammation. This planning guides decisions about setons, more definitive repairs, and the timing of biologic drugs and antibiotics. (pmc.ncbi.nlm.nih.gov)

Abscess drainage

A perianal abscess is a pocket of pus that must be drained, usually in the operating room. Drainage reduces pain, protects against sepsis, and lowers the risk of new fistula tracts. Surgeons often leave a small drain or a seton through the cavity so it can continue to empty while inflammation settles. (pmc.ncbi.nlm.nih.gov)

Setons and fistula procedures

A fistula is an abnormal tunnel from the bowel to the skin or another organ. In Crohn’s, many perianal fistulas are complex and cross important sphincter muscle.

A noncutting seton is a soft loop of material passed through the fistula and tied loosely. It keeps the tract open so it can drain, which helps prevent recurrent abscesses and allows time for medicines such as anti‑TNF drugs to work. Setons can sometimes stay in place for months or even long term when symptom control is the main goal. (pmc.ncbi.nlm.nih.gov)

Recent guidelines advise against using cutting setons in Crohn’s, because tightening them to slowly cut through the sphincter increases the risk of incontinence. Chronic loose setons used alone, without additional repair or medical therapy, are reserved mainly for palliative situations. (academic.oup.com)

For simple, low fistulas with no active rectal inflammation, surgeons may consider fistulotomy (laying open the tract) or tissue‑sparing procedures such as advancement flaps or LIFT procedures. In Crohn’s, these are chosen very cautiously to avoid damaging sphincter muscles and worsening continence. (bmcgastroenterol.biomedcentral.com)

Diversion or proctectomy for severe disease

In severe, multi‑tract, or nonhealing perianal disease, a temporary diverting ileostomy may be created. Stool is rerouted to an abdominal bag so the rectum and perianal area can rest while setons, drainage, and biologic therapy continue. This approach can reduce pain, discharge, and infection risk, and sometimes allows later reversal. (pmc.ncbi.nlm.nih.gov)

When symptoms remain disabling despite all available medical and local surgical options, or when there is severe rectal involvement and loss of continence, a permanent ostomy with removal of the rectum (proctectomy) may offer better long term comfort and control of sepsis. This is a major life decision that is usually made after thorough counseling and planning with stoma nurses and the wider care team. (pmc.ncbi.nlm.nih.gov)

FAQs

Does surgery cure Crohn’s disease?

Surgery does not cure Crohn’s disease, because the underlying immune tendency remains. Many people, however, enjoy long symptom‑free periods after a well‑timed resection or successful perianal surgery, especially when effective medical therapy continues and smoking is avoided. (journals.lww.com)

How do surgeons choose between resection and strictureplasty?

The choice depends on how many strictures are present, where they are located, and whether they are mainly scar tissue or actively inflamed. Short, fibrotic small bowel strictures in someone who has already lost bowel length are often managed with strictureplasty, while long segments, colon involvement, or areas with abscess, fistula, or perforation usually require resection. (ncbi.nlm.nih.gov)

Can biologic medicines still be used around the time of surgery?

Modern care often combines surgery with biologic or small molecule therapy, especially for perianal fistulas and to prevent postoperative recurrence after ileocolic resection. The exact timing of doses before and after surgery is individualized and planned jointly by the gastroenterologist and surgeon to balance infection risk against the risk of uncontrolled inflammation. (pubmed.ncbi.nlm.nih.gov)