Surgical treatment of inflammatory bowel disease

This overview of surgical treatment of inflammatory bowel disease focuses on several controversial issues. Optimal resection margins in Crohn's disease have long been debated. Only recently has the first prospective randomized trial of conservative versus wide margins been done, showing no advantage in terms of reduced recurrence rates for wide margins, Also, recurrence rates were not increased with microscopic Crohn's disease at the resection margins in the reported study. For patients with multiple symptomatic small bowel strictures in Crohn's disease, strictureplasty has proved an effective treatment. Recent studies from Oxford and Cleveland have shown matured data indicating comparability of reoperative rates to historical reports of resectional treatment. Contrasting with these ''messages'' of conservatism have been new reports of definitive and palliative surgery for perianal Crohn's disease. Fistulotomy has been successful in selected patients; in others, especially where incontinence poses a risk with definitive operation, long-term noncutting setons have had notable effectiveness in preventing recurrent sepsis and avoiding or delaying fecal diversion. The role of laparoscopy in treatment of Crohn's disease is also addressed, but no clear role has yet emerged. In ulcerative colitis, several reviews examine operative issues and cyclosporin use. Surgeons generally believe complications are more likely in patients needing colectomy while taking cyclosporin. A recent report suggests these concerns may be excessive. Most of the controversial issues surround the restorative proctocolectomy procedure (RP). Studies of the role of RP in patients with severe distal colitis, an entity generally managed well by medical means, have shown a value comparable to that of RP for symptomatic pancolitis. Other issues reviewed include techniques of pouch construction, stapled versus hand-sewn anastomosis, malignant potential of preserved anal canal, influence of steroids in RP cases and outcome, Rounding out this year's review is an examination of various instruments for studying quality of life issues in inflammatory bowel disease.