The place of surgery in Crohn's disease.

In the early years after the recognition of regional enteritis by Crohn and his colleagues1, surgical treatment was considered curative and excision of the affected bowel the ideal treatment. During the next 10 years the high recurrence rate after surgery worried physicians and disillusioned surgeons and so Crohn's disease came to be regarded as something of a surgical enigma2. The surgeon encounters Crohn's disease either as an acute emergency (often when the diagnosis has not been made before operation) or as a premeditated operation after the patient's condition has been carefully evaluated. The proportion of patients presenting as emergencies varies depending on whether the unit with the major interest in the disease is surgical or medical. In reports from surgical units approximately 20% of the patients reported have presented as acute emergencies3'4, whereas from medical units the proportion has been less than 10%5'6'7. Acute Ileitis The clinical picture is often similar or identical to that of acute appendicitis and because of the dangers of neglecting acute appendicitis it is sometimes unsafe to make a confident preoperative diagnosis. The condition is usually diagnosed at laparotomy on the appearance of a thickened, inflamed terminal ileum. Views on the correct management vary; the conservative view8'9"10'1' is that nothing further should be done and the abdomen should be closed9""1'12'13. The results, however, do not support this conservative view. From centres with a large experience with acute ileitis a total of 93 patients were reported, 83 of whom had appendicectomy performed. Only two patients went on to develop fistula"'4 "i. Studies of patients who have developed faecal fistulae after appendicectomy have shown that the majority arise from the adjacent terminal ileum3"14' '5" and it seems reasonable to assume that when a fistula occurs it is usually because of the laparotomy rather than the fact that the appendix was removed. Is acute ileitis always due to Crohn's disease? Some patients initially diagnosed as having acute ileitis undoubtedly progress to the typical chronic Crohn's disease with recurrence and the characteristic histological features. However, it appears that over 90% of patients diagnosed as acute ileitis at laparotomy never manifest the signs of chronic Crohn's disease15. The typical findings of Crohn's disease may be absent, there may be no oedema of the mesentery and histological examination of excised appendices and regional nodes may not show the histological features of chronic Crohn's disease3. An interesting epidemiological study was reported among …