When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn’s disease?



The aims of this study were to determine risk factors for morbidity associated with laparoscopic ileocolic resection (LICR) for Crohn’s disease (CD) and whether the addition of a diverting ileostomy is associated with reduced morbidity.


Patients undergoing LICR for primary CD at our institution from 2005 to 2015 included in a prospectively maintained database were assessed. The decision to perform a diverting ileostomy was left at the discretion of the operating surgeon. Demographics, disease-related, and treatment-related variables were evaluated using univariate and multivariate analyses as possible factors associated with diverting ileostomy creation and 30-day perioperative septic complications (anastomotic leaks and/or abscess). Use of any immunosuppressive medication was defined as use of steroids, biologics, and immunomodulators either alone or in combination.


For 409 patients, mortality was nil, overall morbidity rate was 40.6%, conversion rate 9.3%, and septic morbidity rate 7.6%. A diverting stoma was created in 22% of cases and was independently associated with BMI < 18.5 kg/m2 (P = 0.001), low serum albumin levels (P = 0.006), and longer operative time (P = 0.003). Use of any immunosuppressive medication was the only variable independently associated with septic complications, both in the overall population (OR 2.7, P = 0.036) and in the subgroup of undiverted patients (OR 3.1, P = 0.031). There was no association between septic morbidity and ileostomy creation, anastomotic configuration, penetrating disease, combined procedures (other resection or strictureplasty), BMI, albumin levels, and operative times.


LICR is safe in selected cases of complex penetrating disease, including when combined procedures are necessary. Our data are unable to prove that a diverting stoma is associated with reduced morbidity.

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  1. 1.

    Myrelid P et al (2009) Thiopurine therapy is associated with postoperative intra-abdominal septic complications in abdominal surgery for Crohn's disease. Dis Colon Rectum 52(8):1387–1394

    PubMed  Article  Google Scholar 

  2. 2.

    Dasari BV, McKay D, Gardiner K (2011) Laparoscopic versus Open surgery for small bowel Crohn's disease. Cochrane Database Syst Rev 1:Cd006956

    Google Scholar 

  3. 3.

    Patel SV et al (2013) Laparoscopic surgery for Crohn's disease: a meta-analysis of perioperative complications and long term outcomes compared with open surgery. BMC Surg 13:14

    PubMed  PubMed Central  Article  Google Scholar 

  4. 4.

    Gajendran M et al (2018) Ileocecal anastomosis type significantly influences long-term functional status, quality of life, and healthcare utilization in postoperative crohn's disease patients independent of inflammation recurrence. Am J Gastroenterol 113(4):576–583

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Maartense S et al (2006) Laparoscopic-assisted versus open ileocolic resection for Crohn's disease: a randomized trial. Ann Surg 243(2):143–149

    PubMed  PubMed Central  Article  Google Scholar 

  6. 6.

    Stocchi L, Milsom JW, Fazio VW (2008) Long-term outcomes of laparoscopic versus open ileocolic resection for Crohn's disease: follow-up of a prospective randomized trial. Surgery 144(4):622–627

    PubMed  Article  Google Scholar 

  7. 7.

    Eshuis EJ et al (2010) Long-term outcomes following laparoscopically assisted versus open ileocolic resection for Crohn's disease. Br J Surg 97(4):563–568

    CAS  PubMed  Article  Google Scholar 

  8. 8.

    Kristo I et al (2016) Minimal-invasive approach for penetrating Crohn's disease is not associated with increased complications. Surg Endosc 30(12):5239–5244

    PubMed  PubMed Central  Article  Google Scholar 

  9. 9.

    Pokala N et al (2005) Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases. Surg Endosc 19(2):222–225

    CAS  PubMed  Article  Google Scholar 

  10. 10.

    Alves A et al (2007) Risk factors for intra-abdominal septic complications after a first ileocecal resection for Crohn's disease: a multivariate analysis in 161 consecutive patients. Dis Colon Rectum 50(3):331–336

    PubMed  Article  Google Scholar 

  11. 11.

    Aberra FN et al (2003) Corticosteroids and immunomodulators: postoperative infectious complication risk in inflammatory bowel disease patients. Gastroenterology 125(2):320–327

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    El-Hussuna A et al (2013) The effect of anti-tumor necrosis factor alpha agents on postoperative anastomotic complications in Crohn's disease: a systematic review. Dis Colon Rectum 56(12):1423–1433

    PubMed  Article  Google Scholar 

  13. 13.

    Yamamoto T, Allan RN, Keighley MR (2000) Risk factors for intra-abdominal sepsis after surgery in Crohn's disease. Dis Colon Rectum 43(8):1141–1145

    CAS  PubMed  Article  Google Scholar 

  14. 14.

    Mege D et al (2017) Does faecal diversion prevent morbidity after ileocecal resection for Crohn's disease? Retrospective series of 80 cases. ANZ J Surg 87(9):E74–e79

    PubMed  Article  Google Scholar 

  15. 15.

    Appau KA et al (2008) Use of infliximab within 3 months of ileocolonic resection is associated with adverse postoperative outcomes in Crohn's patients. J Gastrointest Surg 12(10):1738–1744

    PubMed  Article  Google Scholar 

  16. 16.

    Gastinger I et al (2005) Protective defunctioning stoma in low anterior resection for rectal carcinoma. Br J Surg 92(9):1137–1142

    CAS  PubMed  Article  Google Scholar 

  17. 17.

    Matthiessen P et al (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246(2):207–214

    PubMed  PubMed Central  Article  Google Scholar 

  18. 18.

    Silverberg MS et al (2005) Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol 19:5a–36a

    PubMed  Article  Google Scholar 

  19. 19.

    Beaupel N et al (2017) Preoperative oral polymeric diet enriched with transforming growth factor-beta 2 (Modulen) could decrease postoperative morbidity after surgery for complicated ileocolonic Crohn's disease. Scand J Gastroenterol 52(1):5–10

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    PubMed  PubMed Central  Article  Google Scholar 

  21. 21.

    Heneghan HM et al (2013) Laparoscopic colorectal surgery for obese patients: decreased conversions with the hand-assisted technique. J Gastrointest Surg 17(3):548–554

    PubMed  Article  Google Scholar 

  22. 22.

    Myrelid P et al (2012) Split stoma in resectional surgery of high-risk patients with ileocolonic Crohn's disease. Colorectal Dis 14(2):188–193

    CAS  PubMed  Article  Google Scholar 

  23. 23.

    Delaney CP et al (2001) 'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 88(11):1533–1538

    CAS  PubMed  Article  Google Scholar 

  24. 24.

    Beyer-Berjot L et al (2013) Laparoscopic approach is feasible in Crohn's complex enterovisceral fistulas: a case-match review. Dis Colon Rectum 56(2):191–197

    PubMed  Article  Google Scholar 

  25. 25.

    Aytac E et al (2013) Factors affecting morbidity after conversion of laparoscopic colorectal resections. Br J Surg 100(12):1641–1648

    CAS  PubMed  Article  Google Scholar 

  26. 26.

    Bollegala N, Jackson TD, Nguyen GC (2016) Increased postoperative mortality and complications among elderly patients with inflammatory bowel diseases: an analysis of the national surgical quality improvement program cohort. Clin Gastroenterol Hepatol 14(9):1274–1281

    PubMed  Article  Google Scholar 

  27. 27.

    Yang SS et al (2012) Risk factors for complications after bowel surgery in Korean patients with Crohn's disease. J Korean Surg Soc 83(3):141–148

    PubMed  PubMed Central  Article  Google Scholar 

  28. 28.

    Huang W et al (2015) Risk factors for postoperative intra-abdominal septic complications after surgery in Crohn's disease: a meta-analysis of observational studies. J Crohns Colitis 9(3):293–301

    PubMed  Article  Google Scholar 

  29. 29.

    Brouquet A et al (2018) Anti-TNF therapy is associated with an increased risk of postoperative morbidity after surgery for ileocolonic Crohn disease: results of a prospective nationwide cohort. Ann Surg 267(2):221–228

    PubMed  Article  Google Scholar 

  30. 30.

    Soop M et al (2009) Safety, feasibility, and short-term outcomes of laparoscopically assisted primary ileocolic resection for Crohn's disease. Surg Endosc 23(8):1876–1881

    PubMed  Article  Google Scholar 

  31. 31.

    Goyer P et al (2009) Impact of complex Crohn's disease on the outcome of laparoscopic ileocecal resection: a comparative clinical study in 124 patients. Dis Colon Rectum 52(2):205–210

    PubMed  Article  Google Scholar 

  32. 32.

    Nguyen SQ et al (2009) Laparoscopic resection for Crohn's disease: an experience with 335 cases. Surg Endosc 23(10):2380–2384

    PubMed  Article  Google Scholar 

  33. 33.

    Morar PS et al (2015) Determining predictors for intra-abdominal septic complications following ileocolonic resection for Crohn's disease-considerations in pre-operative and peri-operative optimisation techniques to improve outcome. J Crohns Colitis 9(6):483–491

    PubMed  Article  Google Scholar 

  34. 34.

    Pinto RA et al (2011) Laparoscopy for recurrent Crohn's disease: how do the results compare with the results for primary Crohn's disease? Colorectal Dis 13(3):302–307

    CAS  PubMed  Article  Google Scholar 

  35. 35.

    Aytac E et al (2012) Is laparoscopic surgery for recurrent Crohn's disease beneficial in patients with previous primary resection through midline laparotomy? A case-matched study. Surg Endosc 26(12):3552–3556

    PubMed  Article  Google Scholar 

  36. 36.

    Li Y et al (2016) Association of preoperative narcotic use with postoperative complications and prolonged length of hospital stay in patients with Crohn disease. JAMA Surg 151(8):726–734

    PubMed  Article  Google Scholar 

  37. 37.

    Valizadeh N et al (2017) Impact of preoperative steroid or immunosuppressant use on short-term outcomes following colectomy in Crohn's disease patients. Tech Coloproctol 21(3):217–223

    CAS  PubMed  Article  Google Scholar 

  38. 38.

    Ihnat P et al (2016) Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection. Surg Endosc 30(11):4809–4816

    PubMed  Article  Google Scholar 

  39. 39.

    Li W et al (2017) Factors associated with hospital readmission following diverting ileostomy creation. Tech Coloproctol 21(8):641–648

    CAS  PubMed  Article  Google Scholar 

  40. 40.

    Geltzeiler CB et al (2015) Trends in the surgical management of Crohn's disease. J Gastrointest Surg 19(10):1862–1868

    PubMed  Article  Google Scholar 

  41. 41.

    Neary PM, Aiello AC, Stocchi L, Shawki S, Steele SR, Delaney CP, Hull T, Holubar S (2019) High risk elective ileocolic anastomosis for Crohn’s disease; when is diversion indicated? J Crohns Colitis 13(7):856–863

    PubMed  Article  Google Scholar 

  42. 42.

    Nguyen GC, Elnahas A, Jackson TD (2014) The impact of preoperative steroid use on short-term outcomes following surgery for inflammatory bowel disease. J Crohns Colitis 8(12):1661–1667

    PubMed  Article  Google Scholar 

  43. 43.

    Lee Y et al (2012) A laparoscopic approach reduces short-term complications and length of stay following ileocolic resection in Crohn's disease: an analysis of outcomes from the NSQIP database. Colorectal Dis 14(5):572–577

    CAS  PubMed  Article  Google Scholar 

  44. 44.

    Gionchetti P et al (2017) 3rd European evidence-based consensus on the diagnosis and management of Crohn's disease 2016: part 2: surgical management and special situations. J Crohns Colitis 11(2):135–149

    PubMed  Article  Google Scholar 

  45. 45.

    Gardenbroek TJ et al (2013) Single-port versus multiport laparoscopic ileocecal resection for Crohn's disease. J Crohns Colitis 7(10):e443–e448

    PubMed  Article  Google Scholar 

  46. 46.

    Lee JS et al (2016) The importance of the Crohn's disease activity index in surgery for small bowel Crohn's disease. J Visc Surg 153(5):339–345

    PubMed  Article  Google Scholar 

  47. 47.

    Zerbib P et al (2010) Pre-operative management is associated with low rate of post-operative morbidity in penetrating Crohn's disease. Aliment Pharmacol Ther 32(3):459–465

    CAS  PubMed  Article  Google Scholar 

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Correspondence to Luca Stocchi.

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Dr Gorgun is a consultant for Boston Scientific and Lumendi. Dr Delaney has been a consultant for Takeda and Merck in 2018. Drs Yoon, Stocchi, Holubar, Aiello, Shawki, Steele, and Hull have no conflicts of interest or financial ties to disclose.

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Yoon, Y.S., Stocchi, L., Holubar, S. et al. When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn’s disease?. Surg Endosc (2020). https://doi.org/10.1007/s00464-020-07670-w

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  • Crohn’s disease
  • Surgery
  • Laparoscopy
  • Outcomes
  • Treatment