The role of surgery in inflammatory bowel disease: six case histories: submitted for the Pattison Prize in Clinical Surgery, 1986

The cases that have been described illustrate some of the many ways in which surgery may be employed in the management of patients with inflammatory bowel disease. Initially, laparotomy may be the only certain means of distinguishing Crohn's disease from a more sinister disgnosis such as lymphoma. Once a diagnosis of inflammatory bowel disease has been made some of the difficulties in differentiating between Crohn's disease and ulcerative colitis have been discussed along with the implications of each diagnosis for future management. Surgical treatment is often neces- sary for some of the many complications associated with these diseases, such as intestinal obstruction, perianal abscesses and anal fistulae. The great debates in the literature at present, however, involve the definitive excisional operative procedures. Most of the cases described demonstrate the difficulties involved in the decision to operate, each demanding that certain questions be answered. At what stage, if at all, in the acute and chronic forms of each disease should operation be performed and which type of procedure should be followed? Should prophylactic colectomy be performed routinely to eliminate the risk of carcinoma? Dose chronic Crohn's colitis warrant intervention? If a prophylactic procedure is to be performed, at what stage in the illness and what criteria or method of surveillance should be used to determine this point? Although some attempt has been made to answer these questions drawing on evidence emerging from these six cases and from a review of the lit- erature it is impossible to reach definitive conclusions. Treatment policies dependent upon the experience and opinion of individual surgeons continue to be the norm until deeper inroads have been made into the establishment of the aetiology and exact pathogenesis of the inflammatory bowel diseases. The tragic case of the patient who unexpectedly presented with inoperable carcinoma at the age of 41 superimposed on a history of mild stress related colitis confirms this general lack of understanding of these diseases. The many cases of unexplained hepatobiliary disease, arthritis and perianal problems, along with the chronic misery of uncomplicated forms should fuel an active desire among the medical profession to uncover more of the hidden secrets of inflammatory bowel disease