Pa ge 1 Pa ge 84 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 Pa ge 85 https://journals.e-palli.com/home/index.php/ajmsi 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%). Pa ge 86 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 84-89, 2025 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. Pa ge 87 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 84-89, 2025 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 Pa ge 88 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 84-89, 2025 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. REFERENCES Abraham, C., & Cho, J. H. (2009). Inflammatory bowel disease. New England Journal of Medicine, 361(21), 2066- 2078. Atkinson, C., McQuillan, D. M., & Balfour, W. D. (2006). A child with fever, hip pain, and limp. Canadian Medical Association Journal, 174(7), 924. Baumgart, D. C., & Sandborn, W. J. (2007). Inflammatory bowel disease: Clinical aspects and established and evolving therapies. The Lancet, 369(9573), 1641-1657. BBeck, D. E., Herfarth, H. H., & Williams, J. T. (2014). Outcome of surgical treatment for Crohn’s disease. Pa ge 89 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 84-89, 2025 Diseases of the Colon & Rectum, 57(6), 758-764. Bednarz, W., Szymczak, A., & Kaczmarek, A. (2008). Analysis of results of surgical treatment in Crohn’s disease. Hepatogastroenterology, 55(84), 998-1001. Broe, P. J., Bayless, T. M., & Cameron, J. L. (1982). Crohn’s disease: Are enteroenteral fistulas an indication for surgery? Surgery, 91(3), 249-253. Crohn, B. B., Ginzburg, L., & Oppenheimer, G. D. (2000). Regional ileitis: A pathologic and clinical entity. Mount Sinai Journal of Medicine, 67(3), 263-268. (Original work published 1932) Farmer, R. G., Hawk, W. A., & Turnbull, R. B., Jr. (1975). Clinical patterns in Crohn’s disease: A statistical study of 615 cases. Gastroenterology, 68(4 Pt 1), 627-635. Frolkis, A. D., Dykeman, J., Negrón, M. E., et al. (2013). Risk of surgery for inflammatory bowel diseases has decreased over time: A systematic review and meta- analysis of population-based studies. Gastroenterology, 145(5), 996-1006. Greenstein, A. J., Sachar, D. B., & Moser, S. E. (1987). Spontaneous free perforation and perforated abscess in 30 patients with Crohn’s disease. Annals of Surgery, 205(1), 72-76. Haddad, M., Lataire, J., & De Bie, W. (1993). Crohn’s disease of the appendix. European Journal of Surgery, 159(3), 191-192. Jess, T., Frøslev, T., & Nielsen, D. K. (2006). Survival and cause-specific mortality in patients with inflammatory bowel disease: A long-term outcome study in Olmsted County, Minnesota, 1940-2004. Gut, 55(9), 1248-1254. Kühn, F., Nixdorf, M., & Klar, E. (2015). The role of surgery in Crohn’s disease: Single-center experience from 2005-2014. Gastroenterology, 148(Suppl 1), S-1167. Mazal, J. (2014). Crohn disease: Pathophysiology, diagnosis, and treatment. Radiologic Technology, 85(3), 297-316; quiz 317-320. McNamara, M. J., Inoue, S., & Kuo, J. T. (1990). Surgical treatment of enterovesical fistulas in Crohn’s disease. Diseases of the Colon & Rectum, 33(4), 271-276. Michelassi, F., Voudouris, J. M., & Maggiore, G. (1993). Incidence, diagnosis, and treatment of enteric and colorectal fistulae in patients with Crohn’s disease. Annals of Surgery, 218(5), 660-666. Munkholm, P., Pedersen, N., & Rasmussen, H. (1994). Frequency of glucocorticoid resistance and dependency in Crohn’s disease. Gut, 35(3), 360-362. Mühe, E., Sommer, R., & Möller, K. (1981). Surgery of Crohn’s disease: A study of 155 patients after intestinal resection (author’s transl). Deutsche Medizinische Wochenschrift, 106(6), 165-170. Nasseri-Moghaddam, S. (2012). Inflammatory bowel disease. Middle East Journal of Digestive Diseases, 4, 77- 89. Prieto-Nieto, I., García-Arranz, M., & García-Sánchez, S. (2001). Crohn’s disease limited to the appendix. American Journal of Surgery, 182(5), 531-533. Rodriguez, T., & Kwon, D. (2020). P314 C-Reactive protein is associated with depression and anxiety in patients with inflammatory bowel disease. Journal of Crohn’s and Colitis, 14(Suppl 1), S311. Rastogi, V., Saxena, M., & Juyal, R. (2018). Abdominal physical signs and medical eponyms: Movements and compression. Clinical Medicine & Research, 16(3-4), 76- 82. Shaffer, V. O., & Wexner, S. D. (2013). Surgical management of Crohn’s disease. Langenbeck’s Archives of Surgery, 398(1), 13-27. Stangl, P. C., Selby, D. J., & Christensen, R. D. (2002). Crohn’s disease of the appendix. Virchows Archiv, 440(4), 397-403. Tekkis, P. P., Heriot, A. G., & Thompson, M. R. (2006). A comparison of segmental vs subtotal/total colectomy for colonic Crohn’s disease: A meta-analysis. Colorectal Disease, 8(2), 82-90. Tzivanakis, A., et al. (2012). Influence of risk factors on the safety of ileocolic anastomosis in Crohn’s disease surgery. Diseases of the Colon & Rectum, 55(5), 558-562. Van Koperen, P. J., Bemelman, W. A., & Cuesta, M. A. (2009). Outcome of surgical treatment for fistula in ano in Crohn’s disease. British Journal of Surgery, 96(6), 675-679. Vanek, V. W., Vargo, G., & Lopatka, D. (1988). Isolated Crohn’s disease of the appendix: Two case reports and a review of the literature. Archives of Surgery, 123(1), 85-87. Zhang, W., et al. (2014). The respective role of medical and surgical therapy for enterovesical fistula in Crohn’s disease. Journal of Clinical Gastroenterology, 48(8), 708-711. Zohar, M. (2013). Inflammatory bowel disease. New England Journal of Medicine, 361(21), 2066-2078.