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. 2022 Jun;36(6):4290-4298.
doi: 10.1007/s00464-021-08773-8. Epub 2022 Jan 5.

Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary?

Daniel K Peyser  1 , Heather Carmichael  2 , Adrienne Dean  1 , Vanessa M Baratta  3 , Anthony P D'Andrea  1 , Gurpawan Kang  1 , Deepika Bhasin  1 , Alexander J Greenstein  1 , Sergey K Khaitov  1 , Randolph M Steinhagen  1 , Patricia Sylla  4
Affiliations

Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary?

Daniel K Peyser et al. Surg Endosc. 2022 Jun.

Abstract

Background: Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection.

Methods: A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed.

Results: Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups.

Conclusions: In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.

Keywords: Abscess; Complications; Crohn’s disease; Drainage; Ileocolic resection; Laparoscopy.

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Conflict of interest statement

Patricia Sylla is a consultant for Ethicon, Medtronic, and Olympus. Randolph Steinhagen has received payment for expert testimony. Daniel Peyser, Heather Carmichael, Adrienne Dean, Vanessa Baratta, Anthony D’Andrea, Gurpawan Kang, Deepika Bhasin, Alexander Greenstein, and Sergey Khaitov have no conflicts of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Overall management and outcomes of patients with complicated ileal CD
Fig. 2
Fig. 2
Overall management and outcomes of patients with intraabdominal abscess
See this image and copyright information in PMC

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