Challenging Crohn’s Disease: Surgical Complexity and Outcomes in Colonic vs Non-Colonic Resections in a Large Single-Centre Cohort

AIM: The surgical management of colonic Crohn’s disease (CD) remains controversial, with segmental resections possibly associated with a higher rate of recurrence and postoperative complications, while total proctocolectomy reduces recurrence but increases the risk of permanent stoma formation. This study compares surgical outcomes and complications in CD patients undergoing colonic resections (any colectomy with or without concomitant ileal/ileocaecal surgery) vs non-colonic resections (ileal or ileocaecal resections and/or small-bowel strictureplasties without colectomy), with particular emphasis on intra-abdominal septic complications (IASC), non-IASC events, and length of stay (LOS) in hospital. METHODS: This monocentric observational study analysed consecutive adult patients with histologically confirmed CD who underwent intestinal surgery between January 2012 and April 2024 at Luigi Sacco University Hospital. Patients were divided into two groups according to the index operation. Group A included patients undergoing colonic resection, with or without concomitant ileal or ileocaecal resections and/or small-bowel strictureplasties. Group B included patients undergoing ileal or ileocaecal resection and/or small-bowel strictureplasties without any associated colonic resection. Outcomes included 30-day postoperative complications, LOS, and readmission rates. Statistical analysis was performed using chi-square, Wilcoxon rank-sum tests, and regression models. RESULTS: Of 461 patients, 90 (19.5%) underwent colonic resections (Group A), while 371 (80.5%) had non-colonic resections (Group B). Overall, complications occurred in 36.2% of patients, with significantly higher rates in Group A than in Group B (48.9% vs 33.2%; p = 0.005). IASC were more frequent in Group A (18 out of 90 patients, 20.0%) than in Group B (37 out of 371 patients, 10.0%) (p = 0.008). The median LOS was 11 days overall, with a statistically significant difference between the groups (Group A: 12 days; Group B: 11 days, p = 0.012). In addition, we observed a significantly higher 30-day reoperation rate in Group A compared with Group B (14.4% vs 6.5%; p = 0.012). Thirty-day readmission rates were low and did not differ significantly between the groups (3.3% vs 1.3%, p = 0.365). Colonic resection, disease phenotype, and American Society of Anesthesiologists score were identified as independent risk factors for postoperative complications and prolonged LOS. There were no significant differences in the 30-day readmission rates among the groups, and no 30-day mortality cases were observed. CONCLUSIONS: In this large single-centre cohort, colonic resections were associated with higher postoperative complication rates, increased IASC and longer LOS compared with non-colonic resections. These differences likely reflect greater baseline disease complexity and operative burden in patients requiring colonic resection, rather than a causal effect of the resection site alone, highlighting the need for individualised, phenotype-informed surgical decision-making. Further multicentre research is recommended to refine the surgical management of colonic CD.