Is stoma always required in patients with Crohn disease undergoing ileocecal resection in the setting of a psoas abscess? A case series

BACKGROUND: In the presence of a penetrating or stricturing–penetrating phenotype of Crohn disease, the formation of a psoas abscess is possible. Ileocecal resection is the most common surgical procedure for complicated Crohn disease. The feasibility of performing an anastomosis in the presence of a psoas abscess remains controversial. The lack of clear management algorithms for Crohn disease with psoas abscess and the rarity of this condition in pediatric patients determine the relevance of the present study.

AIM: To evaluate treatment outcomes and the necessity of stoma formation in patients with complicated Crohn disease undergoing ileocecal resection in the setting of a psoas abscess.

METHODS: The study included data from 8 patients with complicated Crohn’s disease who underwent ileocecal resection in the setting of a psoas abscess. In 6 of 8 patients (75%), no stoma was formed, whereas the remaining patients underwent a two-stage procedure with stoma creation. Intestinal anastomosis was constructed manually using an end-to-end two-layer technique. Broad-spectrum antibacterial therapy was administered preoperatively in 7 of 8 patients (87.5%) for 7–14 days, with a positive clinical and laboratory response.

RESULTS: In half of the patients, the abscess size did not exceed 3 cm, and this group received conservative antibacterial therapy prior to surgery. In 2 patients, the abscess was detected intraoperatively and surgical sanitation was performed. Before ileocecal resection, 7 of 8 patients did not receive glucocorticosteroid therapy; only 1 patient received a minimal dose of prednisolone (5 mg). Partial parenteral nutrition and albumin transfusion for nutritional correction were required in 4 of 8 patients (50%) for 7–14 days. Infectious complications occurred in 4 of 8 patients (50%) and were superficial in nature, not exceeding Grade I on the Clavien–Dindo classification.

CONCLUSION: The presence of a psoas abscess is a potential risk factor for intestinal anastomotic failure but is not a reliable predictor of an unfavorable surgical outcome. When a psoas abscess is identified prior to planned ileocecal resection, conservative treatment or percutaneous drainage is recommended (depending on abscess size), with clinical response assessment over 5–7 days (resolution of fever and reduction in inflammatory laboratory markers). In such cases, we consider primary intestinal anastomosis feasible within 7–14 days.