“Gut first” is a safe and feasible surgical approach for Crohn’s disease patients with internal fistulas

Abstract Purpose: To evaluate the safety and feasibility of the "gut first" approach in Crohn’s disease (CD) patients with internal fistulas based on our institutional experience. Methods: A retrospective cohort study was conducted at a tertiary referral teaching hospital in China from January 2018 to December 2022. Consecutive CD patients undergoing surgery for internal fistulas were categorized by surgical approach: conventional versus gut-first. Demographic data, fistula characteristics, and perioperative details were recorded and analyzed. Results: The study included 122 patients, 91 of whom were treated conventionally and 31 via the gut-first approach. There were no significant differences in baseline characteristics. The gut-first approach was associated with a higher prevalence of severe mesenteric thickening (58.1% vs. 24.2%, p < 0.001). The conversion to open surgery (p=0.81), the operation time (p=0.39), the blood loss (p=0.52), the length of the intestinal resection (p=0.09), the stoma formation (p= 0.93), the postoperative stay (p=0.10) and the rate of severe morbidity (p=0.72) were comparable between the two approaches. Conclusion: The gut-first approach is a safe and feasible alternative in the surgical management of fistulizing CD, particularly in patients with severe mesenteric involvement.