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.