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American Journal of  Medical 
Science and Innovation (AJMSI) 

Indications and Outcome of  Surgical Treatment of  Crohn’s Disease in Gastroenterology 
and Hepatology Hospital 

Raafat Raoof  Alturfi1, Zakaria Yahia Al Khazraji1*

Volume 4 Issue 1, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i1.4347
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: January 10, 2025
Accepted: February 12, 2025
Published: March 10, 2025

Crohn’s disease of  both varieties (abdominal and perineal) may lead to many surgical 
complications treated by different procedures. The role of  surgery has a paramount 
importance in treating Crohn’s disease complications despite medical therapy. The purpose 
of  this study is to investigate the indications, types, and outcomes of  surgical therapy for 
Crohn’s disease at gastroenterology and hepatology hospitals. This is a longitudinal sectional 
prospective study that was conducted in Gastroenterology and Hepatology Hospital from 
March 2020- May 2022, involves 35 patients of  Crohn’s disease were diagnosed relying 
on clinical, radiological, and histopathological result based on endoscopic biopsy and/or 
surgical specimen. Current study demonstrated that the most common indication of  surgery 
in abdominal Crohn’s disease cohort is intestinal obstruction with 23 patients (65.71%) 
treated by ileocecal resection. Intestinal fistula 7 patients (20%). Failure of  medical treatment 
3 patients (8.57%). Malignancy 2 patients (5.71%). Psoas abscess drainage 1 patient (2.85%). 
Most common Indication of  surgery in peri-anal Crohn’s disease is intractable perianal fistula 
to medical treatment 5 patients (14.28%), Perianal abscess  patients (8.57%). Although the 
medical treatment is the corner stone in management of  Crohn’s disease but early referral 
to digestive surgeon is preferable to decrease the suffering of  the patients and improve the 
outcome. 

Keywords
Acute Appendicitis, Crohn’s 
Disease, Intestinal Obstruction, 
Ileocecal Resection, Liver Resection

1 Gastroenterology and Hepatology, Teaching Hospital Medical City, Baghdad, Iraq
* Corresponding author’s e-mail: drnihadkhalawe@gmail.com

INTRODUCTION
Crohn’s Disease (CD) is a chronic inflammatory intestinal 
disease, first described as regional ileitis by Crohn, 
Ginzburg and Oppenheimer in a case series presented at 
American Medical Association annual meeting in 1932 
(Baumgart et al., 2007). Crohn’s disease is defined a chronic 
inflammatory bowel disorder characterized by a transmural 
inflammatory reaction and non-caseating small granulomas 
and may involves all parts of  the gastrointestinal (GI) tract 
from the mouth to the anus (Stangl et al., 2002; Vanek et al., 
1988; Haddad  et al., 1993; Prieto-Nieto et al., 2002), Several 
subtypes are recognized, depending on the area of  the GI 
tract most affected (Crohn et al., 2000; Abraham et al., 
2066). Crohn’s disease is grouped with other inflammatory 
bowel diseases (IBDs) such as ulcerative colitis (Nasseri-
Moghaddam et al., 2012) is distinguishing features include 
discontinuous, transmural inflammation involving the 
whole thickness of  the bowel wall, and an inflammatory 
response associated with lymphoid aggregates and 
granulomas (Rodriguez et al., 2020).
A cure remains elusive, and efficient management of  
Crohn’s disease is essentially multidisciplinary and 
interprofessional (Mazal et al., 2014). 
Treatment of  Crohn’s disease is multidisciplinary: medical 
treatment is focused on mucosal healing and reduction 
of  symptom; surgery maintains a key-role in treating 
complications such as stenosis, perforations, fistulas and 
abscesses (Bednarz et al., 2008; Frolkis et al., 2013).
The main treatment is medical, while surgery is indicted 
only for complications of  the disease and treatment 

(Shaffer & Wexner, 2013 ). 
Absolute indications for surgery in Crohn’s disease include 
cancer, or suspicious, perforation, toxic megacolon and 
major life threatening gastrointestinal tract (GIT) bleeding.
Relative indications include strictures, phlegmon, fistulae, 
intra-abdominal abscesses, GIT bleeding, dysplasia-
associated lesion or mass (DALM), high grade dysplasia 
detected on surveillance, growth retardation in children 
and failure of  medical therapy. 
Patients with Crohn’s disease often may have multiple 
intestinal surgery (Van Koperen et al., 2009; Michelassi 
et al., 1993). 
The aim of  current study is to study the indications, 
types and outcomes of  surgical therapy in the treatment 
of  Crohn’s disease in gastroenterology and hepatology 
hospital.

MATERIALS AND METHODS
This study was done in gastro enterology and hepatology 
center from March 2020- May 2022 of  prospective of  
35 patients case series,These patients of  Crohn’s disease 
diagnosed depending on clinical, and radiological and 
histopathological finding on the basis of  endoscopic 
biopsy or surgical specimen or both. Also patients 
send for routine investigations including hematological 
, biochemical, and radiological which include (U/S, CT 
scan of  abdomen with i.v and oral contrast).  
Pelvic MRI study indicated if  Crohn’s disease involving 
peri-anal region especially perianal fistula.  
Patients admitted to surgical ward then categorized 



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Am. J. Med. Sci. Innov. 4(1) 84-89, 2025

into either emergency condition (subacute intestinal 
obstruction) or elective one, prepared and assessed in 
following preoperative measure:

1- Routine investigations as mentioned above.
2- Nutritional assessment including body mass index, 

s.albumin, if  body mass index less than 18.5 or s.albumin 
less than 3.5 mg/dl then enteral or total parenteral 
nutrition started, correction of  electrolyte and blood 
transfusion for anemia.

3- Antibiotics indicated if  there was focus of  infection. 
4- Prophylactic dose of  low molecular heparin was given.
5- Cessation of  smoking. 
6- Discussion with gastroenterologist about withdrawal 

of  biological therapy and steroid.

7- Two patients with intra-abdominal abscess 
diagnosed by U/S and CT scan submitted for drainage 
under radiological guidance.
Inclusion criteria, all patient of  Crohn’s disease underwent 
surgery in gastrointestinal tract during period of  disease.
Statistical Analysis: The stats of  this project were 
performed using Microsoft excel. This study relied on the 
total number of  patients.

RESULTS AND DISCUSSIN
This study included 35 patients, 23 male (65.71%), female 12 
(34.28%), male to female ratio was 1.9:1, results in table-1 
showed the most common age between 20-29 year and the 
least between 10-19 years. 18 patients were smoker (51.42%).

Table 1: Patients demographic data 
Demographic data Number of  patients %
Gender
Male 23 65.71
Female 12 34.28
Duration of  disease
< 1 year 2 5.7
1-5 year 24 68.5
5-10 year 3 8.5
10-20 year 6 17.14
Mode of  treatment
Immunomodulation treatment 9 25.71
Biological treatment 7 20
Both 19 54.28
Smoking
-ve 17 48.57
+ve 18 51.42
Frequency of  surgery
Two surgery 23 65.71
Single surgery 12 34.28
Age( years)
10-19 2 5.71
20-29 17 48.57
30-39 8 22.85
40-50 8 22.85
Crohn’s disease predominancy
Abdominal Crohn’s disease 28 80
a-Obstructing 23 65.71
b-Penetrating 5 14.28
Perineal Crohn’s disease 3 8.57
Both 5 14.28

Mode of  treatment including both biological and 
immunomodulation were 19 patients (54.28%), 
immunomodulation alone 9 patients (25.71%), while 
biological alone were 7 patients (20%).Patients underwent 
two surgical operations in their period of  disease were 

23 patients (65.71%), while those underwent only one 
surgery were 12 patients (34.28%).
Abdominal Crohn’s disease predominates in 28 patients 
(80%), while perineal involvement were 3 patients 
(8.57%), while both were 5 patients (14.28%).



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Results in table-2 showed the most common indication 
of  surgery in abdominal Crohn’s disease cohort was 
intestinal obstruction 23 patients (65.71%), While fistula 

8 patients (22.85%), malignancy was an indication of  
surgery in 2 patients (5.71%). 2 patients were colonic 
carcinoma, and 1 patient was gastric carcinoma.

Table 2:  Indications of  surgery in abdominal Crohn’s Disease
Indications Number of  Patients Percentage
Intestinal obstruction 23 65.71
a. Ileocecal cause 18 51.42
b. Small bowel cause 5 14.28
Failure to medical treatment such as: 3 8.57
a-Bleeding per rectum 1 2.85
b-Sever perianal fistulation disease 2 5.71
Intestinal fistula: 7 20
a-Entero-cutaneous (penetrating) 5 14.28
b-Entero-vesical fistula 2 5.71
Malignancy 2 5.71
Psoas abscess 1 2.85

Table -3 regarding perineal Crohn’s disease fistula in 
ano predominate the indication of  surgery in 5 patients 

(14.28%), while the other were perianal abscess 3 patients 
(8.57%).

Table 3:  Indication of  surgery in peri-anal Crohn’s disease
Type of  indication Number of  Patients Percentage
Intractable perianal fistula to medical treatment: 5 14.28
a-High type 3 8.57
b- Low type 2 5.71
Perianal abscess 3 8.57

Table 4:  Types of  Surgery (abdominal and perianal Crohn’s disease)
Types of  Surgery Number of  Patients Percentage
Ileocaecal resection 23 65.71
a. Subacute intestinal obstruction 18 51.42
b. Intractable enterocutaneous fistula (post-appendecectomy) 5 14.28
Stricturoplasty (small bowel) 3 8.57
Small bowel resection 2 5.71
Right hemicolectomy 1 2.85
Fecal diversion (ileostomy) 2 5.71
Liver resection 1 2.85
Total proctocolectomy and permanent ileostomy 1 2.85
Drainage of  abscess 4 11.42
1. Perianal abscess 3 8.57
2. Psoas abscess 1 2.85
Partial cystectomy (Enterovesical Fistula) 

Results in table-4 showed the most common surgical 
procedure done in abdominal Crohn’s disease cohort was 
ileocecal resection 23 patients (65.71%) of  obstructing 
group including ileocecal resection, stricturoplasty and small 
bowel resection. The least ones were ileostomy, colostomy, 

liver resection, and total proctocolectomy with permanent 
ileostomy 1 case for each (2.85%).The liver resection was 
performed because of  metastatic colonic tumor, While 
surgery was done for penetrating (fistulating) manifested as 
enterocutaneous fistula group includes ileocecal resection.

Results in table 5: showing morbidity in form of  
anastomotic dehiscence and intestinal obstruction of  
adhesive type were 2 patients for each (5.71%). Wound 

infection was occurred in 10 patients (28.55%), Other 
morbidity in form of  pulmonary complications was zero 
as well as mortality rate.



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About 70% to 90% of  people with Crohn’s disease (CD) 
will ultimately need surgery (Shaffer et al., 2013). Once 
the need for surgical intervention has been established 
in CD, the surgical strategy will vary depending on the 
intestinal segment affected (Beck et al., 2014). Depending 
on patient’s general condition,severity of  disease, and the 
involvement of  intestinal segments, surgical treatment of  
CD may include ileocecal resection, subtotal colectomy 
with ileorectal anastomosis, total proctocolectomy, 
segmental small bowel resection, and stricturoplasty 
(Beck et al., 2014). Stoma may be added to these 
procedures when necessary. ileocecal resection the most 
surgical proceger (Mühe et al., 1981).   Surgical recurrens 
is highly in C.D , so multiple operations may be needed 
(McNamara et al., 1990; Van Koperen et al., 2009).
1) Michelassietal (1993) and Farmer et al. (1975), in this 
study, we found that (65.71%) of  patients had more than 

one operation. The terminal ileum is the most common 
Crohn’s affected site requiring surgery (Michelassi et al., 
1993; Farmer et al., 1975 ).
In this study, the incidence of  involvement of  terminal 
ileum was (65.71%), bowel obstruction from stricture 
is the most common reason for surgery in CD (Kühn et 
al., 2005). Stricturing phenotype of  CD is most common 
in ileal disease and in patients diagnosed with CD at a 
younger age. In this study, 23 patients (65.71%) had an 
incidence of  obstruction, including 5 patients (14.28%) 
with subacute intestinal obstruction post-appendicectomy. 
The most common surgery for stricturing disease in CD 
is ileocolic resection for ileocaecal or distal ileal disease 
(Kühn et al., 2005). This study showed the incidence 
of  ileocecal resection is (80%). An ileocolic resections 
high proportion for Crohn’s disease is performed in the 
emergency setting (Kühn et al., 2005 ).

Table 5:  Morbidity and Mortality
Complications Numberof  Patients Percentage
Anastomosis dehesaience 2 5.71
Intestinal obstruction (Adhesive type) 2 5.71
Wound infection 10 28.55
Mortality Zero 0

Figure 1: CT scan with oral contrast of  patient with Crohn’s disease showing ileovesical fistula (contrast material 
filling the urinary bladder)

Figure 2: Specimen of  ileocecal resection of  a patient with Crohn’s disease showing fat wrapping and mass in 
ileocecal region



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In current study, the incidence of  acute appendicitis is 
(37.74%). The treatment of  choice for appendiceal CD 
is appendectomy. Acute appendicitis diagnosis in CD is 
frequent, but the atypical symptom (Vanek et al., 1988). 
In 1% –30% of  cases, free perforation is the earliest 
indication of  CD (Greenstein et al., 1987). In this study, 
the free perforation was 2.82% in form of  perforated 
appendicitis.
Failure of  medical treatment defined as failure of  complete 
clinical response with 8-12 wk. of  oral steroids and other 
agents. Approximately 20%-30% of  CD patients do not 
respond to steroids, and up to 45% of  CD patients will 
relapse on weaning of  steroids (Munkholm et al., 1994) as 
well as failure of  medical treatment manifested as bleeding 
per rectum (2.85%) treated by total proctocolectomy and 
permeant ileostomy, another indication of  surgery failure 
of  medical treatment was severe perianal fistulating, 
two patients (5.71%), one patient treated by diversion 
ileostomy and second one treated by fistulotomy.  
In general, intestinal fistulae are the primary indication to 
surgical treatment if  they connect with the genitourinary 
tract, if  their drainage is cause for personal embarrassment 
and discomfort, or if  they create a bypass of  such 
magnitude as to cause intestinal malabsorption.
Majority of  intra-abdominal fistulae undergo intestinal 
resection and primary anastomosis (Broe et al., 1982), 
also colocutaneous and enterocutaneous fistulae usually 
require surgical intervention (Zhang et al., 2014).
Intestinal fistula that was (20%) divided into 
enterocutaneous (14.28%) treated by ileocecal resection, 
those patients who developed this complication post-
appendicectomy and entero-vesical fistula (5.71%) which 
was manifested by recurrent urinary tract infection 
treated by segmental resection of  diseased bowel and 
partial cystectomy.     
A common large bowel fistula is the ileosigmoid fistula 
which is a well-known manifestation of  CD. These 
patients require ileocolic resection and either primary 
repair or segmental resection of  the sigmoid, or a subtotal 
colectomy (Van Koperen et al., 2009). 
The risk of  cancer ranges from 1%-5% in CD, representing 
a 2-3 times increased risk of  developing colorectal cancer 
and > 18 times increased risk of  developing small bowel 
cancer (Van Koperen et al., 2009).
The transmural inflammation of  Crohn’s disease 
increases the risk for bowel perforation and formation of  
fistula that can lead to psoas abscess formation. Although 
psoas abscess is most commonly present in longstanding 
Crohn’s disease, it can also be its first manifestation 
(Rastogi et al., 2018; Atkinson et al., 2006). In this study, 
the incidence of  psoas abscess is (2.85%), it was the first 
symptom of  Crohn’s disease treated by drainage under 
ultrasound guidance with antibiotics.
Perianal pathology can be occured in 40%-80% of  
patients with CD. Colonic and rectal CD phenotypes 
are associated with increased risk of  perianal disease 
(Atkinson et al., 2006; Toh et al., 2016). 

In this study, the incidence was 8.57% including fistula in 
ano was dominant about (14.28 %) including high type 
(8.57%) treated by seton staged surgery and low type 
(5.71%) treated by fistulotomy. perennial absesse (8.57%) 
treated by drainage.Medical therapy is the cornerstone 
treatment for perianal fistulas. Surgical intervention is 
reserved for individuals with abscesses or sepsis (Toh, et 
al., 2016). 
Low CD perianal fistulas are amenable to fistulotomy 
treatment. Complex or high CD fistulae should be treated 
with long-lasting setons (Toh et al., 2016), so diversional 
stoma for perianal disease should be reserved for difficult 
cases refractory to medical therapy and drainage (Toh et 
al., 2016).
In the present study, demonstrated that (65.71%) 
of  patients required more than one surgery, the vast 
majority for abdominal Crohns. Intestinal obstruction in 
the form of  stricture treated by stricturoplasty (8.57%) 
because stricturoplasty has the advantage of  small bowel 
preservation and prevention of  short bowel syndrome.
 Wound infection occurs postoperatively in our Crohn’s 
disease patients is (28.55%) because of  multifactorial 
include complication of  medical treatment and 
malnutrition. Risk factors for anastomotic complication 
include intra-abdominal abscess, fistula, malnutrition, 
steroid usage, and recurrent clinical episodes.  

CONCLUSION
✤ Although the medical treatment is the corner stone 

in management of  Crohn’s disease but early referral to 
digestive surgeon is preferable to decrease the suffering 
of  the patients and improve the outcome. 
✤ The ileocecal region is the most common site of  

involvement by Crohn’s disease, hence, the surgery for this 
area is the most frequent in form of  ileocecal resection. 
✤ The role of  fecal diversion (ileostomy) is important in 

plan of  surgical management of  Crohn disease especially 
in malnourished patients and long term of  steroid therapy. 
✤ Our goal in managing small bowel Crohn’s disease 

is to preserve as much as we can length of  the bowel 
by performing stricturoplasty rather than resection to 
prevent short bowel syndrome.
✤ Conservative surgery in perianal involvement is 

preferred rather than the radical one. 

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