Is hemorrhoidal surgery really unsafe in inflammatory bowel disease? Results from the HEAD-IBD multicenter study on behalf of IG-IBD

Background Surgical management of hemorrhoidal disease (HD) in patients with IBD remains controversial because of concerns about impaired outcomes. This study aimed to evaluate the safety and IBD-related outcomes of surgical treatments for HD in patients with IBD and to explore factors potentially associated with postoperative complications and IBD flare. Methods HEAD-IBD is a retrospective cohort study promoted by the Italian Group for the study of IBD (IG-IBD). Adults with established ulcerative colitis (UC) or Crohn’s disease (CD) who underwent surgery for HD between 2004 and 2024 and had at least 12 months of follow-up were included. Surgical techniques, 1-, 6-, and 12-month complications, IBD flares (6 months), new onset perianal disease, and continence outcomes were analyzed. Results A total of 38 patients were included (21 UC, 17 CD), 55% male. Clinically active disease at the last gastroenterology visit prior to surgery was present in 24% of UC and 41% of patients with CD. Open excisional hemorrhoidectomy was the most frequently performed procedure in both groups (66% UC, 73% CD), while non-excisional techniques were used in approximately one-third of cases. No 30-day or 6-month surgical complications occurred in patients with CD. Postoperative surgical complications were observed exclusively in patients with UC (5/21, 24%) and were mostly mild. Within 6 months after surgery, IBD flares occurred in 6 patients (16%), proportionally comparable between CD and UC. During overall follow-up, new-onset perianal disease developed in 5 patients (13%), predominantly in CD (4/5 cases), while new-onset incontinence was observed in 2 (5%) patients, both managed conservatively. Conclusions In this largest European multicenter cohort, surgical treatment of HD in IBD was associated with low morbidity and preservation of anorectal function. These findings support a more individualized approach and underscore the need for prospective studies.