Introduction

Surgical management of hemorrhoidal disease (HD) in patients with inflammatory bowel disease (IBD) remains controversial due to concerns about impaired wound healing and disease flare, especially in Crohn’s disease (CD). In Europe, current evidence is mainly based on small historical single-center case series.¹

Aims & Methods

We sought to evaluate the safety and effectiveness of surgical treatments for HD in IBD patients and identify potential risk factors for complications. HEAD-IBD is a retrospective cohort study promoted by the Italian Group for the study of Inflammatory Bowel Disease (IG-IBD) and the Italian Society of Colorectal Surgery (SICCR). Patients with established IBD who underwent surgery for HD between December 2004 and March 2024 were included. Data were collected across multiple centres using the REDCap system. IBD activity was measured by the Harvey-Bradshaw Index for CD and the partial Mayo score for ulcerative colitis (UC). Surgical techniques, short- and long-term complications, disease flare, and continence status were analyzed. Only patients with ≥1 year follow-up were considered.

Results

A total of 38 patients were initially identified from 8 centres. Two patients with unclassified IBD were excluded from stratified analysis, leaving 36 patients (Table 1): 21 (58%) with UC and 15 (42%) with CD. Overall, 53% were male. The median age at surgery was 49 years (IQR 13) in UC and 37 years (IQR 22) in CD. At the time of surgery, biologic therapy was ongoing in 10% of UC and 40% of CD patients. Clinically active disease at the last gastroenterology visit was reported in 6 CD patients (40%) and 5 UC patients (24%). The time interval between the last IBD evaluation (clinical or endoscopic) and surgery was significantly longer in UC compared to CD patients (table 1). Distribution of Goligher grade suggested a higher proportion of grade III–IV disease in UC (72%) than in CD (53%). Open hemorrhoidectomy was the most frequent procedure in both groups (66% UC, 73% CD). Non-excisional techniques (DG-HAL +/- mucopexy) were used in 29% of UC and 27% of CD patients. Stapled hemorrhoidopexy was performed only in UC (10%). Median hospital stay was 1 day (IQR 1) in both groups. No 30-day or 6-month postoperative complications were reported in CD, while 14% of UC patients experienced early or mid-term complications. One UC patient experienced IBD flare at 6 months. At 12-month follow-up, one UC patient reported new-onset soiling; continence was otherwise preserved in all cases.

Conclusion

This multicenter study represents the largest European series on surgical treatment of HD in patients with IBD, confirming its safety, with low complication rates and no new perianal disease. Short- and mid-term complications occurred only in UC patients, possibly reflecting both more advanced HD (Goligher grade III–IV) and less intensive preoperative monitoring. These findings highlight the need for close gastroenterological pre-operative assessment and shared decision-making. The ongoing HEAD-IBD II prospective study will provide further insight into optimal management strategies.

References

1. Grossi U, Gallo G, Di Tanna G, et al. Surgical Management of Hemorrhoidal Disease in Inflammatory Bowel Disease: A Systematic Review with Proportional Meta-Analysis. J Clin Med. 2022 Jan 28;11(3):709. doi: 10.3390/jcm11030709

Disclosure

None