Abstract
Introduction
Ileocecal resection (ICR) is the most common procedure for primary Crohn’s disease. While outcomes of ICR have been extensively studied in Europe and North America, data from North Africa remains scarce. This study reports a 17-year Tunisian experience, evaluating the feasibility of laparoscopic ICR in a low-income country in comparison to open surgery.
Methods
This retrospective, single-center study reviewed patients who underwent ICR for histologically confirmed Crohn’s disease between 2004 and 2020. Postoperative outcomes of laparoscopic and open approaches were compared. The endpoint was postoperative morbidity and mortality, intraoperative parameters, and recovery metrics.
Results
A total of 336 patients underwent surgery for non-recurrent ileocecal Crohn’s disease, with laparoscopic resection performed in 80% of cases. Conversion to open surgery occurred in 14.9%, mainly due to hemorrhagic dissection. Postoperative complications occurred in 9.2% of patients, with anastomotic leakage being the most frequent surgical issue. Medical complications were rare (1.2%). Laparoscopy was associated with faster recovery, shorter hospital stays, and lower analgesic requirements, although complication rates were not significantly different. The only significant predictor of anastomotic fistula was low body mass index (BMI) (P < .001). Postoperative mortality was 0.5%.
Conclusion
In low-income countries, including North Africa, access to laparoscopy has expanded, with outcomes such as conversion rates and operative times approaching international standards. In our 17-year Tunisian experience, laparoscopic ICR proved feasible, reproducible, and safe. These findings contribute to the limited regional evidence and support the broader adoption of laparoscopy as the preferred surgical approach for Crohn’s disease.
Keywords: Crohn’s disease, surgery, laparoscopy, open, postoperative complications, retrospective
Introduction
First described in 1932 in the United States by gastroenterologist Burrill Bernard Crohn, Crohn’s disease (CD) is a chronic inflammatory condition of the intestine characterized by relapsing and remitting episodes.1 This inflammation is segmental and transmural, most commonly affecting the terminal ileum but potentially involving any part of the gastrointestinal tract.2
Despite recent advances in medical treatments, more than 60%-70% of patients with CD will require surgery within 10 years of diagnosis.3 Surgery remains a key component of the therapeutic arsenal for CD. The primary indications for resection include symptomatic strictures, inflammatory masses, and fistulas, particularly when medical therapy has failed. In the absence of postoperative complications, surgical intervention leads to significant improvements in quality of life as early as 1 month after the procedure.4
The most commonly performed surgical procedure is ileocecal resection (ICR).
Most of the available data on surgical outcomes in CD come from high-income countries in Europe and North America, while reports from low- and middle-income countries, particularly in North Africa, remain scarce. This underrepresentation limits the understanding of regional disease patterns, access to care, and long-term outcomes.
In this context, the present study reports a 17-year experience with ICR for primary CD in a Tunisian tertiary care hospital. Our objective is to evaluate the feasibility of laparoscopic ICR, assess its impact on short- and medium-term postoperative outcomes, and compare it with open surgical approaches in a region where data remain limited. The study is based on the assumption that laparoscopic ICR is feasible and advantageous in a resource-limited environment, offering recovery, morbidity, and anastomotic leak outcomes equivalent to international standards.
This work was reported in line with the STROBE guidelines.5
Methods
We conducted a retrospective, single-center study that reviewed the records of patients who underwent surgery for ileocecal CD at the General Surgery Department “A” of Rabta Hospital in Tunis over a 17-year period, from January 1, 2004, to December 31, 2020. Patients were identified via the institutional surgical registry and cross-checked with electronic and paper records. Data were extracted independently by 2 investigators, with discrepancies resolved by consensus with a senior surgeon.
The Ethics Committee approved the study and waived informed consent due to its retrospective nature.
The study included a descriptive analysis to detail the epidemiological, clinical, therapeutic, and evolutionary characteristics of the patients. Additionally, an analytical study was performed to evaluate the outcomes of the laparoscopic approach and compare them with those of laparotomy.
This study included:
All consecutive patients aged 10 years or older who underwent surgery for ileocecal CD in the General Surgery Department A of Rabta Hospital in Tunis.
Histological criterion: CD had to be histologically confirmed on the resection specimen. Two senior gastrointestinal pathologists confirmed the histologic diagnosis
Site of involvement: We included only patients with terminal ileal involvement, confirmed on the resection specimen. According to the Montreal classification, only L1 disease was retained; cases classified as L2, L3, or L4 were excluded unless the terminal ileum represented the predominant site of disease.
Patients who had not undergone a prior ICR.
The primary outcome measure was postoperative morbidity and mortality following ICR:
Operative mortality: Defined as death occurring within 30 days of the procedure or during the same postoperative hospitalization, regardless of its duration.
Specific postoperative morbidity: Included anastomotic dehiscence (manifesting as a well-contained fistula or localized/generalized postoperative peritonitis), wound complications, and postoperative hemorrhagic complications. These complications were classified according to the Clavien-Dindo classification.
Non-specific postoperative morbidity: Included medical complications such as thromboembolic events, cardiac, respiratory, renal, and infectious complications.
The secondary outcome measures included intraoperative data and medium- to long-term postoperative outcomes:
Intraoperative data: Included the duration of surgery and blood loss.
Postoperative data: Included the time to return of bowel function, type of analgesia used, time to resumption of oral intake, and length of hospital stay.
Data collection
For each patient, the following data were collected on a standardized form.
Epidemiological data
Age, sex, smoking status, and past medical history, including the American Association of Anesthesiology (ASA) score (and any prior abdominal surgeries with details on the type of incision used.
Clinical history data
Age at disease onset and disease duration in months (interval between CD diagnosis and surgery).
Clinical and morphological data
Assessment of CD extent and presence of extraintestinal manifestations.
Physical examination findings, including calculation of body mass index (BMI). Malnutrition was defined as a BMI <18.5 kg/m2. Abdominal examination included assessment for masses or enterocutaneous fistulas.
Biological data
Hemoglobin (Hb) levels (g/dL): Anemia was defined as Hb <10 g/dL.
Albumin levels (g/L): Hypoalbuminemia was defined as albumin <30 g/L.
Biological inflammatory syndrome (BIS): Defined as a white blood cell count >10 000/mL and/or C-reactive protein (CRP) >5 mg/L.
Therapeutic data
Type of medical treatment.
Interventional radiology combined with antibiotic therapy in cases of CD complicated by intra-abdominal abscess (ultrasound- or computed tomography-guided drainage).
Technical data (surgical procedure details)
Surgical approach, conversion to open surgery, reasons for conversion, lesion characteristics (site, type, and length of resected diseased bowel), presence and type of digestive fistulas, length of remaining bowel, performed procedures, type of continuity restoration (one- or two-stage reconstruction), type of anastomosis (end-to-end, end-to-side, or side-to-side), and duration of surgery.
Blood loss (defined as ≥100mL or hemodynamic instability
Need for red blood cell transfusion.
Length of postoperative hospital stay.
Postoperative outcomes
Immediate outcomes: Duration of analgesia, time to return of bowel function, time to resumption of oral intake, presence of uncomplicated or complicated recovery, morbidity (complications within 30 days post-surgery), severity of surgical complications classified using the Clavien-Dindo classification, and mortality (defined as death during the same hospitalization or within 30 days post-surgery).
Disease assessment
A detailed lesion assessment specifying the nature (stenosis, fistula, or inflammatory form) and topography of the lesions was mandatory. This evaluation was clinical and required a thorough examination of the anal margin to identify potential ano-perineal lesions, along with documentation of any extraintestinal manifestations.
The choice of investigations depended on the symptomatology and the location of the disease:
Ileo-colonoscopy: In cases of terminal ileitis (the most common lesion site), this investigation was used to determine the presence or absence of sigmoid colon involvement (diseased or affected segment). These findings influenced the surgical strategy.
Contrast-enhanced enterography (CT enterography)/magnetic resonance enterography (MR enterography): This imaging study was performed to assess the extent of lesions in the small bowel and to evaluate the characteristics of any stenosis. The type of ileal stenosis was classified by senior abdominal radiologists who reviewed CT/MR enterography images. Inflammatory strictures were identified by mural hyperenhancement, oedema, high T2 signal, comb sign, and perienteric inflammation, whereas fibrotic strictures showed low T2 signal, poor enhancement, and minimal vascular engorgement. In cases with overlapping features, a consensus “mixed phenotype” classification was assigned.
In cases of Crohn’s abscess, broad-spectrum antibiotic therapy combined with percutaneous drainage were indicated if the abscess size exceeds 4 cm. A follow-up CT scan was performed 5-7 days after the initial intervention. If the drainage were successful, an ICR was subsequently undertaken. In cases of failure, a resection with a closed approach was performed.
Perioperative protocol
Perioperative management adhered to standardized institutional practices. Antibiotic prophylaxis was administered in accordance with ASHP guidelines (American Society of Health-System Pharmacists), and venous thromboembolism prevention was ensured through low-molecular-weight heparin. Early mobilization was routinely encouraged, and oral intake was advanced based on patient tolerance. Notably, a formal Enhanced Recovery After Surgery (ERAS) program was not available during the study period.
Descriptive study
We calculated simple frequencies and relative frequencies (percentages) for qualitative variables. For quantitative variables, we calculated means, medians, and standard deviations, and identified extreme values.
Statistical analysis
We conducted a bivariate analysis based on the following:
For qualitative variables:
Percentage comparisons were performed using the Chi-square test when the assumptions for its application were met, and the Fisher’s exact test was used when they were not.
For quantitative variables:
All qualitative variables were categorized into 2 modalities. Mean comparisons for unpaired series were carried out using the Student’s t-test when the normality of distribution was verified, and the non-parametric Mann-Whitney U test was used when normality was not confirmed.
Surgical technique
Two operative approaches were used: laparoscopy and open surgery. The laparoscopic technique followed a standardized protocol used consistently throughout the study period. After a four-trocar setup, the ileocecal region was mobilized using a retro-mesenteric dissection, which provided a reproducible and safe exposure of the terminal ileum while preserving the mesenteric vasculature. Once mobilization was completed, the specimen was exteriorized through a small right iliac fossa incision, where bowel division and anastomosis were performed extracorporeally. The mesentery was divided close to the bowel to preserve intestinal length, and resection was limited to macroscopically diseased tissue with disease-free margins.
For patients undergoing open surgery, a conventional midline approach with lateral-to-medial mobilization of the right colon was used. The same principles of limited mesenteric resection, bowel preservation, and extracorporeal anastomosis were applied. Anastomotic reconstruction (end-to-end, end-to-side, or side-to-side; hand-sewn or stapled) was chosen based on intraoperative findings and surgeon preference.
The choice between laparoscopic and open surgery depended on disease severity, prior abdominal operations, surgeon experience, and equipment availability. Conversion to open surgery was performed when dense inflammation, bleeding, or inadequate visualization prevented safe laparoscopic progress.
Results
Demographics
Over the 17-year period from January 2004 to December 2020, 336 patients underwent surgery for non-recurrent ileocecal CD. The median age at operation was 31 years (range: 11-73 years), with the 20-30-year age group being the most represented (34.90%). In the preoperative phase, 22 patients (6.55%) were receiving corticosteroids, while no patient was on immunosuppressive agents or biologic therapy. Nutritional and biological assessments showed malnutrition in 50 patients (14.88%), anemia in 66 (19.64%), hypoalbuminemia in 82 (24.40%), and elevated inflammatory markers in 187 (55.65%). Preoperative optimization frequently involved RBC transfusion (8.33%), intravenous iron therapy (11.31%), and albumin infusion (21.43%).
Ileocecal disease complicated with abdominal abscesses was present in 125 patients (37.20%). Small abscesses (<4 cm) were managed medically (69.6%), whereas larger or drainable collections were treated with radiological drainage in 34 cases (27.2%), and 4 patients (3.20%) required surgical drainage.
Baseline characteristics including sex, age, ASA score, BMI, and smoking status were comparable between the laparoscopic and open groups (Table 1).
Table 1.
Demographics.
| Laparoscopy (N = 269) | Laparotomy (N = 67) | P | |
|---|---|---|---|
| Sex, n (%) | |||
| Male | 140 (52%) | 47 (70.1%) | .1 |
| Female | 129 (48%) | 20 (29.9%) | |
| Age, mean ± SD | 30.6 ± 12.3 | 36.6 ± 12.3 | .06 |
| ASA score, n (%) | |||
| ASA 1 | 225 (83.6%) | 36 (53.7%) | .6 |
| ASA 2 | 43 (16%) | 31 (46.3%) | |
| ASA 3 | 1 (0.4%) | 0 (0%) | |
| ASA 4 | 0 (0%) | 0 (0%) | |
| BMI (kg/m²), median (range) | 19.8 (14-37) | 19.9 (14-32) | .958 |
| Smoking, n (%) | 71 (29.4%) | 27 (40.3%) | .06 |
Abbreviations: ASA: American Association of Anesthesiology; BMI: body mass index.
Operative outcome
The majority of procedures were performed electively, with 302 patients (89.9%) undergoing scheduled surgery. Thirty-four patients (10.1%) required urgent intervention, primarily for subacute bowel obstruction or persistent intra-abdominal sepsis despite medical or radiological management.
Laparoscopic surgery was performed in 269 patients (80.06%), with conversion to open laparotomy in 40 cases (19.94%).
The main causes for conversion were dissection difficulties causing hemorrhage (32.5%), inflammatory phenomena (25%), and bowel distension (12.5%).
The evolution of conversion rate through the years is described in Figure 1, showing a peak in the conversion rate between 2010 and 2014, attributed to the recruitment of young surgeons at the beginning of their learning curve. The conversion rate subsequently declined as the surgeons gained experience.
Figure 1.
A diagram showing the evolution of conversion rate throughout the years.
Open laparotomy was performed in 67 patients (20%). No statistically significant difference was observed between the 2 groups regarding intraoperative bleeding risk or operative time (Table 2).
Table 2.
Operative outcome.
| Laparoscopy (N = 269) | Laparotomy (N = 67) | P | |
|---|---|---|---|
| Operative time, mean ± SD | 144.5 ± 37.4 | 142.8 ± 39.5 | .75 |
| Intraoperative bleeding, n (%) | 13 (4.8%) | 2 (3%) | .084 |
| Intraoperative transfusion, n (%) | 3 (1.1%) | 1 (1.5%) | .1 |
Fecal diversion was rare (0.6%).
Postoperative outcome
Three hundred and five patients had an uncomplicated postoperative course (90.8%), while 31 patients experienced postoperative complications (9.2%).
Medical complications
Four patients experienced a medical complication (1.2%): 1 patient with pulmonary embolism requiring anticoagulant therapy at a curative dose, 1 patient with thrombosis of a dialysis arteriovenous fistula requiring the placement of a new dialysis catheter, 1 patient with an epileptic seizure requiring anticonvulsant treatment, and 1 patient with an acute postoperative hepatitis.
Surgical complications
Thirty patients (8.9%) experienced a surgical complication, including: 10 patients with a wound abscess (3%), 1 early postoperative bowel obstruction requiring reoperation (0.3%), anastomotic leakage in 5.7% of cases, 7 well-contained anastomotic fistulas (2.1%), 10 postoperative collections, 2 of which required percutaneous radiological drainage (3%), and 2 cases of postoperative peritonitis due to leakage, requiring reoperation (0.6%).
With laparoscopy, postoperative complications were lower, though without a statistically significant difference (P = .6): medical complications (P = .03); surgical complications (P = .6) (Table 3).
Table 3.
Comparison of postoperative complications.
| Laparoscopy (N = 269) | Laparotomy (N = 67) | P | OR | |
|---|---|---|---|---|
| Complications, n (%) | 24 (8.92%) | 7 (10.44%) | .6 | 1.038 [0.851; 1.265] |
| Medical complications, n (%) | 3 (1.11%) | 4 (5.97%) | .03 | 1.887 [0.801; 4.44] |
| Surgical complications, n (%) | 24 (8.92%) | 6 (8.95%) | .6 | 1.038 [0.851; 1.265] |
| Anastomotic fistula, n (%) | 16 (5.94%) | 3 (4.47%) | .7 | 0.948 [0.770; 1.160] |
Bold values are statistically significant.
Abbreviation: OR: odds ratio.
In bivariate analysis, malnutrition and low BMI were the only predictive factors for overall morbidity, with a statistically significant difference (P < .001) (Table 4).
Table 4.
Summary table of the analysis of multiple variables with overall morbidity.
| Overall morbidity |
P | ||
|---|---|---|---|
| Yes (N = 31) | No (N = 305) | ||
| Sex, n (%) | |||
| Male | 17 (54.8%) | 170 (55.7%) | .535 |
| Female | 14 (45.2%) | 135 (44.3%) | .535 |
| Smoking, n (%) | 5 (16.1%) | 93 (30.5%) | .009 |
| Malnutrition, n (%) | 21 (67.7%) | 29 (9.5%) | <.001 |
| ASA score, n (%) | |||
| 1 | 26 (83.9%) | 235 (77.1%) | .5 |
| 2 | 5 (16.1%) | 69 (22.6%) | .5 |
| 3 | 0 (0%) | 1 (0.3%) | .9 |
| Laparotomy, n (%) | 4 (12.9%) | 30 (9.8%) | .5 |
| Laparoscopy, n (%) | 3 (9%) | 32 (10.5%) | .5 |
| Previous appendectomy, n (%) | 4 (12.9%) | 45 (14.8%) | .5 |
| Anemia, n (%) | 10 (32.2%) | 56 (18.4%) | .06 |
| Hypoalbuminemia, n (%) | 6 (19.4%) | 76 (24.9%) | .4 |
| High inflammatory markers, n (%) | 18 (58.1%) | 169 (55.4%) | .8 |
| Abdominal mass, n (%) | 8 (25.8%) | 45 (14.8%) | .09 |
| Abscess, n (%) | 16 (51.6%) | 109 (35.7%) | .08 |
| Conversion, n (%) | 4 (12.9%) | 36 (11.8%) | .7 |
| Anastomosis type, n (%) | |||
| End-to-end | 0 (0%) | 12 (3.9%) | .6 |
| End-to-side | 16 (51.6%) | 124 (40.7%) | .2 |
| Side-to-side | 13 (41.9%) | 127 (41.6%) | .5 |
| Age (years), mean ± SD | 31.4 ± 11.3 | 31,5 ± 12.8 | .3 |
| Disease evolution (months), median (range) | 42.4 (0-228) | 35.3 (0-312) | .5 |
| BMI (kg/m2), mean ± SD | 17.6 ± 3.7 | 20.6 ± 3.2 | <.001 |
| Albumin (g/L), mean ± SD | 33.7 ± 6.3 | 33.4 ± 6 | .8 |
| Hemoglobin (g/dL), mean ± SD | 11.4 ± 2.4 | 11.5 ± 1.7 | .7 |
| Mass dimension (cm), median (range) | 7 (3-15) | 6 (2-18) | .5 |
| Length of resected small bowl (cm), median (range) | 37.3 (10-100) | 32.4 (5-200) | .3 |
| Operative time (minutes), mean ± SD | 135 ± 28.6 | 145 ± 38.6 | .2 |
Bold values are statistically significant.
Abbreviations: ASA: American Association of Anesthesiology; BMI: body mass index.
Postoperative mortality: 2 postoperative deaths were recorded (0.5% mortality rate)
One patient succumbed to septic shock following an anastomotic leak complicated by postoperative generalized peritonitis. Another patient suffered from acute postoperative hepatitis of unknown origin, leading to multiple organ failure.
A statistically significant advantage was observed in favor of laparoscopy regarding postoperative rehabilitation and hospital stay, with lower use of level 2 analgesics (Table 5).
Table 5.
Postoperative outcome.
| Laparoscopy (N = 269) | Laparotomy (N = 67) | P | |
|---|---|---|---|
| Median time to bowel transit recovery (days) | 2 | 3.1 | <.001 |
| Median time to resumption of oral intake (days) | 1 | 3 | <.001 |
| Median hospital stay (days) | 5 | 7.9 | .01 |
| Usage of level 2 analgesics, n (%) | 98 (33.1%) | 59 (88.1%) | <.001 |
Bold values are statistically significant.
Predictive factors for anastomotic fistula
BMI was the only significant predictive factor for anastomotic fistula (P < .001) (Table 6).
Table 6.
Comparison of anastomotic fistula with quantitative variables.
| Variables | Anastomotic fistula |
P | |
|---|---|---|---|
| Yes | No | ||
| Age (years), mean ± SD | 34.2 ± 10.8 | 33.8 ± 12.8 | .9 |
| Disease duration (months), median (range) | 27.7 (0-228) | 36.5 (0-312) | .5 |
| BMI (kg/m²), mean ± SD | 16.1 ± 1.7 | 20.6 ± 3.3 | <.001 |
| Albumin (g/L), mean ± SD | 35.3 ± 6.8 | 33.3 ± 6 | .2 |
| Hb (g/dL), mean ± SD | 12.1 ± 2.5 | 11.4 ± 1.7 | .08 |
| Mass size (cm), mean ± SD | 7 ± 2.4 | 6.4 ± 2.5 | .6 |
| Length of resected small bowel (cm), median (range) | 38.9 (10-100) | 32.5 (5-200) | .2 |
| Operative duration (minutes), mean ± SD | 141.3 ± 31.3 | 144.3 ± 38.2 | .7 |
Bold values are statistically significant.
Discussion
This study represents one of the largest series reported in Tunisia addressing the laparoscopic approach for ileocecal CD. Additionally, the study duration was sufficiently long to analyze the outcomes of laparoscopy in ICR for CD. The surgical technique used in our department was standardized and reproducible.6
The era when surgery was believed to cure CD is long gone. Surgery can provide patients with a symptom-free interval, but recurrence remains inevitable. Our study included patients with non-recurrent ileal or ileocecal involvement. Today, aside from complicated cases, several therapeutic strategies can be considered for the same patient (step-up, top-down approaches).7 Therefore, timely indicated surgery does not contradict medical treatment but rather helps achieve remission and improves quality of life. For surgical indications, isolated stenosis was the most frequent reason for surgery (45%).
Preoperatively, nutritional status is assessed based on the severity of malnutrition, albumin, and hemoglobin levels. Enteral and parenteral nutrition is necessary in cases of severe malnutrition and hypoalbuminemia (strictly below 30 g/L), as these are risk factors for anastomotic fistula formation.8–10 According to Adamina et al., preoperative nutritional optimization significantly reduces postoperative morbidity (21.9% vs. 73.2%, Odds Ratio (OR) 0.09, 95% CI, 0.06-0.13, P < .001). Preoperative corticosteroid dose tapering may reduce postoperative complications and the need for a stoma. However, discontinuation of anti-TNF alpha is not necessary.11 Preoperative sepsis control helps decrease postoperative septic complications.
Our study demonstrated that laparoscopic surgery for ileocecal CD is feasible and reproducible using a standardized technique that ensures retro-mesenteric, pre-duodenal dissection from bottom to top. We observed an acceptable conversion rate (14.9%), with difficult and hemorrhagic dissection being the primary reason for conversion (32.5% of cases, P < .001). A 2018 study by Medge et al., involving 427 patients, reported a conversion rate of 21.6%, with difficult dissection as the main cause (34% of cases).12
Laparoscopy is now considered the standard surgical approach, even for complex ileocecal CD.13 A 2022 study by Connelly et al. demonstrated the feasibility of laparoscopy for complex cases.14 The reproducibility of a surgical intervention is crucial for its validation, with blood loss and operative time serving as key indicators.15 In our study, laparoscopy and laparotomy were statistically comparable in terms of intraoperative bleeding (P = .1) and operative time (P = .75). Both groups also had similar intraoperative transfusion rates. Studies comparing laparoscopic and open approaches for ileocecal CD have generally found comparable intraoperative bleeding, though laparoscopic procedures are often reported to take longer.16–22 However, our study showed comparable operative times for both approaches, likely due to the retro-mesenteric approach, which is straightforward and well-mastered by our team, preventing prolonged operative duration. Studies showed also that laparoscopy is comparable to robotic-assisted approach in terms of complications and long-term outcome.23
Postoperative morbidity for CD is estimated at 25%, primarily due to the patients’ overall condition and immunosuppressive treatment with corticosteroids.24 Following ICR, nonspecific complications are rare, while specific complications, such as wound abscesses and anastomotic fistulas, are more common. The study by Ponsioen et al. reported an anastomotic leak rate of 4% in 70 patients,25 while Celentano et al. found a 3.7% rate in 427 patients,26 which was independent of the anastomotic technique but associated with ASA scores ≥3, penetrating disease phenotype, and ileocolic involvement. In our study, the postoperative morbidity rate was 9.2%, with an anastomotic leak rate of 5.7%, which aligns with literature findings. Two cases of postoperative acute peritonitis (0.5%) required reoperation. The postoperative mortality rate was 0.5%. Univariate analysis identified malnutrition as the only significant risk factor for anastomotic leakage (P < .001).
In our cohort, patient recovery was faster after laparoscopic surgery compared to open surgery: bowel function recovery (2 days vs. 3 days, P < .001) and oral intake resumption (3 days vs. 4 days, P < .001). The total length of hospital stay was also shorter (5 days vs. 7.9 days, P < .001). A meta-analysis including 2 randomized controlled trials confirmed the benefits of laparoscopy in postoperative recovery.21,27,28 Advantages of laparoscopy include faster bowel function recovery, shorter hospital stays, and lower morbidity rates. This has been confirmed by an American national registry study analyzing 49 609 resections for CD.29
With laparoscopy, we also observed a significant reduction in postoperative use of level 2 and level 3 analgesics (P < .001 and P = .03, respectively). Pak et al. reported lower postoperative pain scores in laparoscopic patients compared to open surgery (1.4 vs. 2.3, P < .001).30
Postoperative complications were lower in the laparoscopic group (8.9%) compared to the laparotomy group (10.4%), though this difference was not statistically significant (P = .6). However, nonspecific complications were significantly lower in the laparoscopic approach (P = .03), while surgical complications were comparable between groups (8.92% vs. 8.95%, P = .6).
Studies by Polle et al. and Tilney et al. found no significant differences in postoperative outcomes.20,21 However, a more recent meta-analysis by Patel et al. analyzing 30 studies with 1079 laparoscopic and 1221 open surgery patients demonstrated that laparoscopy significantly reduced postoperative morbidity risk (Risk Ratio 0.71, 95% CI, 0.58-0.86, P = .001).31 Pak et al. reported a significantly lower overall postoperative complication rate for laparoscopic resection compared to laparotomy (13.7% vs. 32.4%, P = .003).30 Intra-abdominal abscesses and anastomotic fistulas were significantly less frequent in the laparoscopic group (P = .035 and P = .014, respectively). Laparoscopy also showed advantages in terms of reduced blood transfusion rates (P = .021) and reoperation rates (P = .029).
Limitations of the study
This study has several limitations that should be acknowledged. Its retrospective design inherently limits the control of confounding variables, introduces potential selection bias, and depends on the completeness and accuracy of medical records, particularly during earlier years of the study period. Although all data were extracted independently by 2 investigators, some variables—such as comorbidities, nutritional metrics, and preoperative medical therapy—were occasionally incomplete, and no multivariate analysis was performed, restricting the ability to adjust for interacting risk factors. Surgeon-related variability, including different levels of laparoscopic experience, may also have influenced operative and postoperative outcomes despite our sensitivity analysis showing no significant differences. The inclusion of a small number of younger patients (≥10 years) managed within an adult surgical unit may limit comparability with purely adult cohorts. Additionally, the absence of biologic therapy in this North African setting reflects local resource constraints and limits the generalizability of our findings to countries where biologics are widely used before surgery. Preoperative imaging interpretation and intraoperative assessment were not standardized across radiologists and surgeons, potentially introducing classification variability, particularly in differentiating inflammatory from fibrotic stenosis. Although postoperative outcomes up to 30 days were consistently available, the study lacked long-term follow-up, preventing assessment of recurrence, quality of life, or late complications such as stenosis or reoperation rates. Finally, the availability and use of enhanced recovery programs were limited, and their absence may influence the comparability of postoperative recovery metrics with centers that routinely implement ERAS protocols. These limitations reflect both the retrospective nature of the study and the realities of a lower-middle-income healthcare system, and they should be considered when interpreting our findings.
Conclusion
The surgical management of CD has undergone substantial evolution over the past 2 decades, with ICR remaining the most frequently performed procedure. Despite therapeutic advances, surgery continues to play a pivotal role in disease management. The advent and progressive adoption of laparoscopy have further consolidated its importance, particularly among younger patients. While laparotomy remains necessary in complex cases, laparoscopy is increasingly regarded as the standard approach for ICR, provided that it demonstrates safety, feasibility, and reproducibility, with acceptable conversion rates and outcomes equivalent to or superior to open surgery.
In recent years, access to laparoscopy has steadily expanded in low-income countries, including North Africa, with improved results reflected in decreasing conversion rates and operative times comparable to international series. In our experience, the laparoscopic approach to ICR proved both feasible and reproducible, particularly when combined with adherence to the principle of intestinal conservation. On this basis, we strongly recommend laparoscopy as the preferred technique and specifically advocate the total retro-mesenteric approach for its consistency and reliability.
This 17-year Tunisian experience contributes to the limited body of evidence from North Africa and underscores that favorable outcomes can be achieved in low-resource settings. By providing robust regional data, our study enriches the global literature on the surgical management of CD and supports the broader adoption of laparoscopic strategies.
Contributor Information
Souhaib Atri, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Mahdi Hammami, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Ahmed Ben Mahmoud, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Amine Sebai, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Houcine Maghrebi, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Wael Rebai, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Youssef Chaker, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Amine Makni, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Amine Daghfous, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Rachid Ksantini, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Mohamed Jouini, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Anis Haddad, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Montassar Kacem, Department of General Surgery A, Hopital la Rabta, Tunis, Tunisia.
Funding
None declared.
Conflicts of interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Ethical approval
Our institutions require no ethical approval for retrospective studies.
References
- 1. Crohn BB. Regional ileitis: a pathologic and clinical entity. JAMA. 1932;99:1323. 10.1001/jama.1932.02740680019005 [DOI] [PubMed] [Google Scholar]
- 2. Mills SC, von Roon AC, Tekkis PP, Orchard TR. Crohn’s disease. BMJ Clin Evid. 2010;2010:0416. [PubMed] [Google Scholar]
- 3. Tsai L, Ma C, Dulai PS, et al. Contemporary risk of surgery in patients with ulcerative colitis and Crohn’s disease: a meta-analysis of population-based cohorts. Clin Gastroenterol Hepatol. 2021;19:2031-2045. 10.1016/j.cgh.2020.10.039 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Ha FJ, Thong L, Khalil H. Quality of life after intestinal resection in patients with Crohn disease: a systematic review. Dig Surg. 2017;34:355-363. 10.1159/000453590 [DOI] [PubMed] [Google Scholar]
- 5. Elm EV, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335:806-808. 10.1136/bmj.39335.541782.AD [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Chebbi F, Ayadi MS, Rhaiem R, et al. Laparoscopic ileo-cecal resection: the total retro-mesenteric approach. Surg Endosc. 2015;29:245-251. 10.1007/s00464-014-3666-8 [DOI] [PubMed] [Google Scholar]
- 7. Cushing K, Higgins PDR. Management of Crohn disease: a review. JAMA. 2021;325:69-80. Available from: https://jamanetwork.com/journals/jama/fullarticle/2774686 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Schwartz E. Perioperative parenteral nutrition in adults with inflammatory bowel disease: a review of the literature. Nutr Clin Pract. 2016;31:159-170. 10.1177/0884533615594011 [DOI] [PubMed] [Google Scholar]
- 9. Lakananurak N, Gramlich L. The role of preoperative parenteral nutrition. Nutrients. 2020;12:1320. 10.3390/nu12051320 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Adamina M, Gerasimidis K, Sigall-Boneh R, et al. Perioperative dietary therapy in inflammatory bowel disease. J Crohns Colitis. 2020;14:431-444. 10.1093/ecco-jcc/jjz160 [DOI] [PubMed] [Google Scholar]
- 11. Adamina M, Bonovas S, Raine T, et al. ECCO guidelines on therapeutics in Crohn’s disease: surgical treatment. J Crohns Colitis. 2020;14:155-168. 10.1093/ecco-jcc/jjz187 [DOI] [PubMed] [Google Scholar]
- 12. Mege D, Michelassi F. Laparoscopy in Crohn disease: learning curve and current practice. Ann Surg. 2020;271:317-324. 10.1097/SLA.0000000000002995 [DOI] [PubMed] [Google Scholar]
- 13. Bemelman WA, Warusavitarne J, Sampietro GM, et al. ECCO-ESCP consensus on surgery for Crohn’s disease. J Crohns Colitis. 2018;12:1-16. 10.1093/ecco-jcc/jjx061 [DOI] [PubMed] [Google Scholar]
- 14. Connelly TM, Clancy C, Duraes LC, et al. Laparoscopic surgery for complex Crohn’s disease: perioperative and long-term results from a propensity matched cohort. Int J Colorectal Dis. [Internet]. 2022;37:1885-1891. https://link.springer.com/10.1007/s00384-022-04218-3 [DOI] [PubMed] [Google Scholar]
- 15. Liu W, Zhou W. Minimally invasive surgery in Crohn’s disease: state-of-the-art review. Front Surg. 2023;10:1216014. 10.3389/fsurg.2023.1216014 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Bemelman WA, van Hogezand RA, Meijerink WJ, Griffioen G, Ringers J. Laparoscopic-assisted bowel resections in inflammatory bowel disease: state of the art. Neth J Med. 1998;53:S39-46. 10.1016/s0300-2977(98)00122-3 [DOI] [PubMed] [Google Scholar]
- 17. Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Is laparoscopic ileocecal resection a safe option for Crohn’s disease? Best evidence topic. Int J Surg. 4;12:22-25. 10.1016/j.ijsu.2013.11.00 [DOI] [PubMed] [Google Scholar]
- 18. Dasari BV, McKay D, Gardiner K. Laparoscopic versus open surgery for small bowel Crohn’s disease. Cochrane colorectal cancer group, editor. Cochrane Database Syst Rev. 2011:CD006956. 10.1002/14651858.CD006956.pub2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Tan JJY, Tjandra JJ. Laparoscopic surgery for Crohn’s disease: a meta-analysis. Dis Colon Rectum. 2007;50:576-585. 10.1007/s10350-006-0855-0 [DOI] [PubMed] [Google Scholar]
- 20. Polle SW, Wind J, Ubbink DT, Hommes DW, Gouma DJ, Bemelman WA. Short-term outcomes after laparoscopic ileocolic resection for Crohn’s disease. Dig Surg. 2006;23:346-357. 10.1159/000097950 [DOI] [PubMed] [Google Scholar]
- 21. Tilney HS, Constantinides VA, Heriot AG, et al. Comparison of laparoscopic and open ileocecal resection for Crohn’s disease: a metaanalysis. Surg Endosc. 2006;20:1036-1044. 10.1007/s00464-005-0500-3 [DOI] [PubMed] [Google Scholar]
- 22. Luglio G, Cricrì M, Tropeano FP, De Palma GD. Crohn’s disease: is minimally invasive surgery the gold standard? A narrative review. Ann Laparosc Endosc Surg. 2023;8:21-21. 10.21037/ales-22-75 [DOI] [Google Scholar]
- 23. Zaman S, Mohamedahmed AYY, Abdelrahman W, et al. Minimally invasive surgery for inflammatory bowel disease: a systematic review and meta-analysis of robotic versus laparoscopic surgical techniques. J Crohns Colitis. 2024;18:1342-1355. 10.1093/ecco-jcc/jjae037 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Luglio G, Pellegrini L, Rispo A, et al. Post-operative morbidity in Crohn’s disease: what is the impact of patient-, disease- and surgery-related factors? Int J Colorectal Dis. 2022;37:411-419. 10.1007/s00384-021-04076-5 [DOI] [PubMed] [Google Scholar]
- 25. Ponsioen CY, de Groof EJ, Eshuis EJ, et al. LIR! C Study Group. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: a randomised controlled, open-label, multicentre trial. Lancet Gastroenterol Hepatol. 2017;2:785-792. 10.1016/S2468-1253(17)30248-0 [DOI] [PubMed] [Google Scholar]
- 26. Celentano V, Pellino G, Spinelli A, et al. on behalf of the Italian Society of Colorectal Surgery SICCR. Anastomosis configuration and technique following ileocaecal resection for Crohn’s disease: a multicentre study. Updates Surg. 2021;73:149-156. 10.1007/s13304-020-00918-z [DOI] [PubMed] [Google Scholar]
- 27. Stocchi L, Milsom JW, Fazio VW. Long-term outcomes of laparoscopic versus open ileocolic resection for Crohn’s disease: follow-up of a prospective randomized trial. Surgery. 2008;144:622-628. 10.1016/j.surg.2008.06.016 [DOI] [PubMed] [Google Scholar]
- 28. Eshuis EJ, Slors JFM, Stokkers PCF, et al. Long-term outcomes following laparoscopically assisted versus open ileocolic resection for Crohn’s disease. Br J Surg. 2010;97:563-568. 10.1002/bjs.6918 [DOI] [PubMed] [Google Scholar]
- 29. Milson JW, Hammerhofer KA, Böhm B, Marcello P, Elson P, Fazio VW. Prospective, randomized trial comparing laparoscopic vs. conventional surgery for refractory ileocolic Crohn’s disease. Dis Colon Rectum. 2001;44:1-8. 10.1007/BF02234810 [DOI] [PubMed] [Google Scholar]
- 30. Pak SJ, Kim YI, Yoon YS, Lee JL, Lee JB, Yu CS. Short-term and long-term outcomes of laparoscopic vs open ileocolic resection in patients with Crohn’s disease: propensity-score matching analysis. World J Gastroenterol. 2021;27:7159-7172. 10.3748/wjg.v27.i41.7159 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Patel SV, Patel SV, Ramagopalan SV, Ott MC. Laparoscopic surgery for Crohn’s disease: a meta-analysis of perioperative complications and long term outcomes compared with open surgery. BMC Surg. 2013;13:14. 10.1186/1471-2482-13-14 [DOI] [PMC free article] [PubMed] [Google Scholar]