Surgery is a core but non-curative treatment in Crohn’s disease (CD). Up to approximately 70% of patients require at least one intestinal resection during their disease course. Recurrence at or proximal to the anastomosis is expected rather than exceptional.^[1] Endoscopic recurrence develops in 70–90% of patients within the first postoperative year.^[2] The principal indications for surgery are:

• Medically refractory disease.
• Fibrostenotic obstruction.
• Penetrating disease.
• Free perforation.
• Hemorrhage.
• Neoplasia.^[1]

In selected patients with limited ileocecal disease, early laparoscopic ileocecal resection is now a reasonable first-line alternative to anti-TNF therapy rather than a salvage procedure.^[3][4] Contemporary management emphasizes:

• A minimally invasive, bowel-sparing operation.
• Preoperative optimization to avoid emergency surgery.
• Risk-stratified, endoscopy-guided postoperative prophylaxis.^[1][5]

Surgery for perianal fistulizing disease is covered in the fistulizing disease microchapter.

The American Society of Colon and Rectal Surgeons (ASCRS, 2020) and the American College of Gastroenterology (ACG, 2025) agree on the core operative indications in CD.^[1][3]

• Elective resection carries substantially lower mortality than emergency surgery.^[5]
• Timely referral and preoperative optimization are therefore aimed at converting potential emergencies into planned operations.
• Surgery is not a failure of medical therapy.
• Early surgical consultation is appropriate for patients with strictures or penetrating complications.^[3]

• The ACG 2025 guideline lists early ileocecal resection as a reasonable first-line alternative to anti-TNF therapy for selected patients with localized ileocecal disease.
• The choice should be individualized to disease extent, phenotype, and patient preference.^[3]

• Inflammatory strictures: intensified medical therapy is first-line.^[3]
• Fibrostenotic strictures: managed endoscopically or surgically.^[1]
• Endoscopic balloon dilation:^[1]
  • Indication: symptomatic short-segment (<5 cm), non-inflammatory small-bowel or anastomotic strictures without associated penetrating disease (strong recommendation, 1C).
  • Technical success: approximately 90%.
  • Perforation or hemorrhage: 2–4%.
  • Repeat dilation is needed in 41–73%, and about one-third of patients require surgery within 2–5 years.
  • Intralesional steroid injection during dilation does not improve outcomes.
• Resection:
  • Indicated for strictures refractory to medical and endoscopic therapy.
  • Resect only about 2 cm of grossly normal bowel proximal and distal to the disease.
  • Microscopically negative margins do not reduce recurrence and waste bowel length.^[1]
• Strictureplasty:^[1][6]
  • Preserves bowel length.
  • Preferred for multiple strictures separated by normal bowel and for patients at risk of short bowel syndrome.
  • Contraindicated with perforation, phlegmon, fistulizing disease, malignancy, dysplasia, or severe malnutrition.
  • Suspicious lesions (mass, ulcer) should be biopsied before strictureplasty.
  • Complications occur in 4–18%.
  • 5-year recurrence (~25–30%) is broadly comparable to resection, with site-specific recurrence of only ~3%.
• Colonic strictures:^[1]
  • Strictures that cannot be adequately surveyed endoscopically should be resected according to oncologic principles.
  • 2–6% harbor occult dysplasia or cancer.
  • Colonic strictureplasty is discouraged.

^[1][6]

• Intra-abdominal abscess:^[1][6]
  • Initial management is antibiotics with or without percutaneous drainage, followed by interval elective resection or continued medical therapy, depending on the clinical situation and patient preference (weak recommendation, 2B).
  • Small abscesses (<3 cm) may respond to antibiotics alone.
  • Larger abscesses generally require percutaneous drainage.
• Why delay resection after drainage:^[6]
  • Allows nutritional and clinical recovery.
  • Fewer septic complications.
  • Lower stoma rate.
  • Higher rate of laparoscopic surgery and a more limited resection.
• Enteric fistulas:^[1][6]
  • Fistulas with localized or systemic sepsis persisting despite appropriate medical therapy should be considered for surgery (strong recommendation, 1C).
  • Anti-TNF therapy with or without an immunomodulator avoids surgery in more than half of patients with intra-abdominal fistulas over 5 years.
  • Asymptomatic entero-enteric fistulas are generally not operated on in isolation.
  • Symptomatic enterovesical and enterovaginal fistulas usually require surgery.
• Operative principle: resect the diseased bowel; for the target organ receiving the fistula, excise only the tract and close the opening.^[6]

^[1]

• Minimally invasive approach: a laparoscopic approach should typically be considered for abdominal CD surgery.^[1]
  • Associated with earlier recovery and fewer complications.
  • Fewer adhesions and incisional hernias.
  • Preserved body image and fertility.^[6]
• Center volume: IBD surgery is best performed at high-volume centers.^[5]
• Diverting ileostomy: should be considered when performing ileocolectomy in patients with multiple risk factors.^[1]

• Taper corticosteroids whenever possible to reduce septic complications.^[7]
• Biologic therapy can generally be continued up to surgery.^[7]
• Correct malnutrition and replete iron before elective surgery.^[7]
• Provide venous thromboembolism prophylaxis.^[7]
• Counsel on smoking cessation, which may reduce postoperative morbidity.^[1]
• In septic, malnourished, or otherwise high-risk patients, use staged procedures (diverting stoma, Hartmann-type procedures).^[7]

• Enhanced recovery after surgery (ERAS) pathways are standard for colorectal surgery under the ASCRS/SAGES 2023 guideline.^[8]
• A systematic review supports ERAS feasibility and safety in IBD surgery, with the highest evidence level for ileocecal resection in CD.
• IBD-specific evidence nonetheless remains limited.^[9]

• Endoscopic recurrence: 70–90% within the first year.^[2]
• Clinical recurrence: approximately 50% by 5 years.^[1]
• Surgical recurrence: approximately 25% by 5 years and up to ~35% at 10 years.^[1]

^[3]

• Ileocolonoscopy: perform 6–12 months after surgery, graded with the Rutgeerts score.^[3]
  • Scores i0–i2a indicate low risk of clinical recurrence.
  • Scores i2b–i4 indicate higher risk and warrant treatment escalation, even in asymptomatic patients.
• Fecal calprotectin: values above about 100–150 μg/g correlate with endoscopic recurrence and serve as a useful non-invasive adjunct.^[3]
• POCER trial: risk-stratified treatment with colonoscopy at 6 months and step-up therapy for recurrence was superior to conventional drug therapy alone for preventing postoperative recurrence.^[10]

• Low-risk patients without residual disease:^[3]
  • Routine pharmacologic prophylaxis is not mandatory.
  • Nitroimidazole antibiotics (metronidazole or ornidazole, limited to ~3 months) are an option.
• High-risk patients or residual disease:^[3]
  • Start prophylaxis within 2–4 weeks after surgery, provided there is no active infection.
  • Typically an anti-TNF agent with or without a thiopurine.
• Comparative efficacy (network meta-analysis of 42 studies):^[2]
  • Adalimumab and infliximab were the most effective agents for preventing postoperative recurrence, followed by vedolizumab.
  • Thiopurines and antibiotics ranked lower.
  • Curcumin, vitamin D, and probiotics showed no efficacy.
• PREVENT trial (infliximab 5 mg/kg every 8 weeks vs placebo):^[11]
  • Reduced endoscopic recurrence (30.6% vs 60.0%; Rutgeerts ≥i2: 22.4% vs 51.3%).
  • Did not reduce clinical recurrence.
• Data for ustekinumab and vedolizumab as prophylaxis remain limited.^[3]

^[3][10]

• Resect only about 2 cm of grossly normal bowel; chasing microscopically clear margins wastes bowel.^[1]
• Drain the abscess first (antibiotics ± percutaneous drainage), then operate electively.^[6]
• Taper steroids before surgery; biologics can usually be continued.^[7]
• Scope at 6–12 months after surgery.^[3]
• A Rutgeerts score of i2b or higher drives escalation even in asymptomatic patients.^[3]
• Total abdominal colectomy with end ileostomy is the emergency operation of choice for fulminant Crohn’s colitis.^[1]

• Delaying referral in limited ileocecal disease by treating surgery only as a last resort.^[3]
• Attempting strictureplasty with phlegmon, perforation, dysplasia, or a non-surveyable colonic stricture.^[1]
• Omitting prophylaxis in high-risk patients.^[3]
• Relying on symptoms alone rather than surveillance endoscopy and calprotectin.^[3]
• Over-resecting bowel in patients with prior resections, precipitating short bowel syndrome.^[6]
• Operating emergently when preoperative optimization could have converted the case to an elective procedure.^[5]