Introduction

Article Outline

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Inflammatory bowel disease (IBD) is an idiopathic inflammatory disease of the intestinal tract consisting of ulcerative colitis (UC) and Crohn’s disease (CD). Despite years of intensive research, the cause of IBD is still unknown. Researchers suspect that it is due to an environmental influence in the genetically susceptible patient. What that environmental influence is, however, is still unknown, although many believe it to be an infectious agent. Even though there has been more progress in determining the susceptibility genes in IBD, there is still much that is unknown. NOD2/Card15 is the first gene linked to susceptibility in CD. It is known as IBD1 and is found on Chromosome 16. Mutations in this protein are associated with an increased risk of CD but not UC. Mutations in this gene account for only about 30% of CD and there are many people without CD who have NOD2 mutations, suggesting that IBD is a complex trait with many genes involved. All of this underlines the multifactorial nature of IBD.

Not only is the cause of IBD unknown but also there is no cure for CD. UC can only be cured surgically by removing all the at-risk mucosa, but there is no medical cure and patients may still suffer from the extra-intestinal manifestations of IBD. In the late 1990s Infliximab was first used clinically and we entered a new era of medical management of IBD. Many thought that Infliximab would cure IBD but unfortunately this has not turned out to be the case. Although many patients improve on Infliximab, the effects may be temporary or limited by the side effects of Infliximab. Drs. Sheikh and Plevy discuss the use of Infliximab in conjunction with surgical management of IBD. The success of Infliximab also triggered an increase in research in the use of other biologics such as anti-CD3 monoclonal antibodies. Drs. Keohane, Sibartie, and Shanahan discuss the use of a different type of biological agent, probiotics for IBD.

IBD has proven to be not only a medically complex disease, but also a surgically complicated disease. There are still many controversies about what is the best surgical management for the complications of IBD. Perianal fistulas, including rectovaginal fistulas, can be the most difficult complications of CD to treat. Not only are they disabling to the patient but they can also be frustrating to the surgeon. Dr. Koltun discusses a paradigm for the treatment of perianal CD that stresses cooperative medical and surgical management of this complex disease. Drs. Person and Nogueras review the complex management of rectovaginal fistulas in IBD.

Other controversies exist in the management of the colon in CD, such as, should the entire colon be removed in segmental colitis or should just the involved segment be resected? Drs. Larson and Wolff discuss operative management of colonic CD. A total abdominal colectomy with end ileostomy Hartmann’s pouch is often performed for patients with severe UC or severe colonic and perianal CD. Leaving the rectum in situ can result in distinct complications that are discussed by Dr. Poritz.

Ileal pouch anal anastomosis (IPAA) continues to be the standard of care for appropriate patients with UC. Despite the fact that the operation has been commonly performed by colon and rectal surgeons for over 20 years, there still exists some controversies. Although laparoscopy has been incorporated into the majority of surgeons’ armamentaria for ileocolonic CD, its use for IPAA has been less widespread. Dr. Ross’s article reviews the results and discusses some techniques for the performance of this complex operation. Perhaps the most controversial issue in the surgical treatment of IBD is whether or not IPAA should be done in patients with known CD. Drs. Sagap and Remzi discuss this contentious subject in their article. Finally in the last few years the issue of female fertility and sexuality after IPAA has become a central issue. Many of the women who undergo IPAA are young and would like to start a family. The issues involving fertility and pregnancy for these patients are discussed by Drs. Johnson and McLeod.

In my opinion IBD continues to be one of the most complex and interesting diseases that colon and rectal surgeons treat. Although we know so much about the disease, we also know so very little.