Safety and feasibility of the bowel-first versus conventional approach in intra-abdominal penetrating Crohn’s disease: a propensity score-matched study

Penetrating Crohn’s disease (CD) is a severe phenotype marked by fistulae, abscesses, and complex intra-abdominal inflammation, often necessitating surgical intervention. Surgical management is particularly challenging in the presence of dense adhesions and severe mesenteric thickening. The bowel-first approach—where the diseased bowel is transected prior to mesenteric dissection—has been proposed as an alternative to conventional techniques, yet comparative evidence remains limited. We conducted a retrospective cohort study of adult patients with penetrating CD who underwent elective intestinal resection at our center between January 2019 and December 2022. Patients were categorized into bowel-first or conventional groups according to the surgical technique used. Propensity score matching (1:1) was performed based on demographic, laboratory, and disease-related variables to balance baseline characteristics. The primary outcomes were overall and major postoperative complication rates. Secondary outcomes included total operative time, bowel resection and anastomosis time, intraoperative blood loss, and length of postoperative hospital stay. A total of 122 patients were included (91 conventional, 31 bowel-first). After matching, 31 patients remained in each group with well-balanced baseline characteristics. Total operative times were comparable between the bowel-first and conventional groups (211.13 (55.84) min vs. 239.39 (67.20) min; P = 0.077). However, bowel resection and anastomosis time was significantly shorter in the bowel-first group (48.71 (9.83) min) compared to the conventional group (65.81 (17.56) min; P < 0.001). No significant differences were observed in intraoperative blood loss (80 [50, 150] mL vs. 100 [50, 200] mL; P = 0.492) or postoperative hospital stay (10 [8, 20] days vs. 9 [8, 15] days; P = 0.676). Rates of overall postoperative complications (35.48% vs. 32.26%; P = 0.788) and major complications (6.45% in both groups; P = 1.000) were also similar. The bowel-first approach is a safe and feasible alternative to conventional surgery for intra-abdominal penetrating Crohn’s disease. This technique significantly reduces bowel resection and anastomosis time without increasing operative risk or length of hospital stay and may be especially advantageous for patients with severe mesenteric thickening or complex adhesions. Further prospective studies are warranted.