OPERATIVE AND PERIOPERATIVE TREATMENT OF INFLAMMATORY BOWEL-DISEASE

Significant advances have occurred in the operative and perioperative treatment of patients with inflammatory bowel disease since this topic was last reviewed in this journal. The ileoanal pouch is the preferred operative treatment for most patients with ulcerative colitis and it continues to be the subject of the greatest investigative interest. Technical improvements in the construction of the ileoanal pouch continue to appear. However, with the many different types of pouch operations still being performed, it is concluded that the "ideal pouch" has yet to be developed. Controversy continues as to the necessity of anorectal mucosectomy. The benefits of completely eliminating premalignant and inflamed mucosa are contrasted with apparent increased postoperative morbidity with mucosectomy. Construction of a pouch in the presence of acute illness now appears feasible in selected patients and avoids a three-stage operative treatment. The increasing incidence of the iatrogenic disease "pouchitis" is enigmatic. Ongoing investigations of pouchitis may help elucidate the pathogenetic mechanisms of inflammatory bowel disease. Conservatism continues to be the underlying principle of operative treatment for patients with Crohn's disease. This principle is supported by increasing evidence of very early postoperative recurrence of Crohn's disease in many asymptomatic patients. The presence of initial disease at multiple intestinal sites and mucosal contact with the fecal stream are important determinants of postoperative recurrent disease. Published reports are beginning to appear concerning the inadvertent creation of ileoanal pouches in patients with Crohn's disease. Significant complications occur in these patients, underscoring the need for thorough preoperative evaluation and accurate diagnosis in all patients in whom pouches are being considered. Similar to other areas of surgery, advances in the perioperative treatment of patients with inflammatory bowel disease continue to be demonstrated. The efficacy for restrictive use of perioperative antibiotics in patients undergoing restorative proctocolectomy is now documented. improved regimens to replete vitamin D losses following extensive ileal resections have been reported.