Precision grading of surgical strategies for small bowel Crohn's disease: An R0–R3 individualized framework based on lesion severity and functional preservation

Abstract

Small bowel Crohn's disease (SBCD) presents unique surgical challenges due to segmental lesions and the need to balance radical resection with bowel function preservation. Current guidelines lack standardized surgical classifications, leading to variable outcomes. This study proposes a four-tier surgical strategy (R0-R3) tailored to lesion severity and functional preservation. R0 involves complete resection for localized mild lesions (creeping fat, no fibrosis) with ≥ 3 meters of residual bowel, using wide resection margins and anti-TNF-α therapy postoperatively. R1 preserves mild (non obstructive fibrotic) lesions and resects moderate to severe segments, with imaging surveillance support. R2 combines resection of severe lesions (fibrotic strictures/obstruction) with strictureplasty or partial preservation of moderate lesions to avoid short bowel syndrome. R3 employs temporary stoma creation for extensive complex lesions or high-risk patients, deferring definitive surgery until stabilization. This framework emphasizes individualized decision-making, prioritizing anatomical clearance, bowel conservation, and postoperative biologics to reduce recurrence. Compared to traditional approaches, the R0-R3 system enhances flexibility in managing heterogeneous SBCD, particularly in extensive disease. Future validation through multicenter trials and biomarker-driven predictive models is recommended to optimize long-term outcomes and quality of life. This strategy aligns with personalized surgical trends, addressing gaps in current guidelines by integrating lesion severity, functional prognosis, and staged interventions.