Penetrating ileocolic Crohn disease with intra-abdominal abscess: diagnose, drugs, drain, divert?

BACKGROUND: Penetrating terminal ileal Crohn disease may result in intra-abdominal abscesses prior to ileocolic resection. Literature on the perioperative management of these abscesses is scarce. We aimed to identify the association between preoperative abscess management and intraoperative and postoperative outcomes. METHODS: We performed a retrospective case-control study at a single inflammatory bowel disease (IBD) referral center (2012-2022) with propensity score matching of adult patients with Crohn disease with and without abscesses who underwent ileocolic resection, as identified from a prospectively maintained database. The primary outcome was the postoperative diverting ileostomy rate; secondary outcomes included anastomotic leakage and postoperative abscess rates. RESULTS: A total of 1372 patients were analyzed, of whom 163 (12%) had preoperative abscesses. Patients with abscesses, compared to patients without abscess, had a 1.24 relative risk (RR) of undergoing a surgical diversion procedure (95% CI, 1.14-1.34, P < .001). Patients with known abscesses not drained preoperatively, compared to no abscess, had an RR of 1.69 for diversion (P < .001, 95% CI, 1.28-2.22). Patients who had a drain removed prior to surgery had a 1.7 RR for diversion (95% CI, 1-2.91, P = .05). However, patients who had a drain placed and kept until surgery did not have a significantly different rate of diversion compared to those without an abscess (P = .16). CONCLUSIONS: Penetrating terminal ileitis with abscesses was associated with adverse outcomes after ileocolic resection for Crohn disease. Optimal management includes preoperative diagnosis with repeated imaging at appropriate intervals preoperatively, antibiotic therapy, percutaneous drainage when indicated with maintenance of the drain until surgery, and selective diversion.