When should a patient with Crohn's disease and a tight terminal ileum (TI) stricture causing obstruction, currently on biologic therapy, be referred to a surgeon?

Surgical Referral for Terminal Ileum Stricture in Crohn's Disease on Biologics

Refer to a surgeon immediately if the patient has symptomatic obstruction that fails to respond to medical therapy (including biologics) within 72 hours, or if the stricture is not amenable to endoscopic balloon dilation. 1

Immediate Surgical Referral Criteria

Absolute indications for urgent surgical consultation:

• Free perforation with pneumoperitoneum and peritoneal signs – requires emergency surgical exploration 1
• Hemodynamic instability or signs of bowel ischemia – elevated lactate, persistent fever, leukocytosis despite resuscitation 1
• Complete bowel obstruction with clinical deterioration after 24-48 hours of medical management – surgery is mandatory 1
• Toxic megacolon or signs of strangulation – do not delay surgery 1

Elective Surgical Referral Criteria

Surgery is mandatory for symptomatic intestinal strictures that meet these criteria: 1

• Medically-resistant stenosis – persistent obstructive symptoms despite optimized biologic therapy 1
• Fibrotic strictures – imaging (MRI enterography) shows predominantly fibrotic rather than inflammatory stricture, as medical therapy cannot reverse fibrosis 1
• Not amenable to endoscopic dilation – strictures >5 cm in length, multiple strictures, or presence of adjacent fistula/abscess are poor candidates for endoscopic therapy 2, 3

Assessment Before Surgical Referral

Determine if endoscopic balloon dilation (EBD) is appropriate first: 1, 2

• EBD is preferred for: short anastomotic strictures (<5 cm), single strictures without fistulization, and strictures accessible by endoscopy 1, 2
• EBD should only be attempted with surgical backup available 1
• Technical success rate is 89-92% for appropriate candidates 4

Imaging characteristics that favor surgery over endoscopy: 1

• Stricture length >5 cm 2
• Multiple strictures in close proximity 1
• Associated abscess or phlegmon 1
• Asymmetric, nodular stricture or soft tissue extension (concern for malignancy) 1
• Any colorectal stricture requires endoscopic biopsies to exclude malignancy before proceeding 1

Timeline for Surgical Referral

Conservative management trial duration: 1, 4

• Initial trial of medical optimization with biologics is appropriate for inflammatory strictures 1
• If symptomatic obstruction persists despite 72 hours of conservative management (NPO, NG decompression, IV fluids, water-soluble contrast), surgery is indicated 1, 4
• Do not delay surgery beyond 72 hours in patients with persistent obstruction – increases morbidity and mortality 4

Surgical Options to Discuss

The surgeon will determine the appropriate procedure based on: 1

• Strictureplasty – preferred for multiple jejunoileal strictures, previous extensive resection (>100 cm), short-bowel syndrome, or recurrent strictures to preserve bowel length 1
• Segmental resection with wide-lumen stapled side-to-side anastomosis – preferred for localized ileocecal disease with fibrotic stricture 1
• Laparoscopic approach is preferred when appropriate expertise is available 1

Common Pitfalls to Avoid

• Do not continue escalating medical therapy indefinitely for a predominantly fibrotic stricture – biologics cannot reverse established fibrosis, and delaying surgery risks complete obstruction or perforation 1
• Do not assume all strictures in Crohn's patients are from Crohn's disease – consider malignancy (obtain biopsies), ischemia, radiation, or other etiologies, especially if the stricture location differs from previous disease distribution 1, 5
• Do not attempt endoscopic dilation without surgical backup – perforation risk is 3% and requires immediate surgical intervention 1, 2
• Recognize that patients on biologics may have blunted inflammatory response – absence of fever or leukocytosis does not exclude ischemia or perforation; rely on clinical examination, lactate levels, and imaging 1