SURGICAL ASPECTS OF INFLAMMATORY BOWEL-DISEASE

In temperate, developed countries, the principle indications for surgical intervention in inflammatory bowel disease are 1) for the removal of bowel severely damaged by acute or chronic colitis, either Crohn's disease or ulcerative colitis; and 2) for small-bowel Crohn's disease, to overcome the effects of fibrous stenosis and its sequelae, such as abscess or fistula. Unresponsive acute colitis that necessitates emergency surgical intervention involves a total colectomy, end ileostomy, and a mucous fistula of the rectosigmoid above the symphysis pubis. Once the diagnosis is confirmed, a pouch can be considered for patients with ulcerative colitis and an ileorectal anastomosis or proctectomy for those with Crohn's disease. For socially inconvenient colitis (when life with chronic colitis becomes intolerable because of urgency, frequency, or chronic ill health), the patient with ulcerative colitis can be offered proctocolectomy with pouch-to-anus anastomosis as a primary procedure, providing the anal sphincter and pelvic floor function normally. For patients with Crohn's disease, total colectomy and an ileorectal anastomosis can be considered if the rectum is not grossly diseased, and if the anal sphincter has a squeeze pressure of 100 cm and the rectum is capable of holding the balloon distended to 200 ml. It should be noted that better early medical therapy has already led to fewer operations for patients with acute colitis and that safer operations will tend to induce earlier referral for surgery; specifically, safer pouches will induce earlier referrals for patients who have chronic incapacitating diarrhoea. Despite improvement in medical control of the disease, small-bowel Crohn's disease will still tend to be associated with gradual stenosis of the bowel. However, better stenosis detection before symptoms arise or complications develop will permit the possibility of medical manipulation by balloon dilatation. © 1990 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.