Surgery in Inflammatory Bowel Disease: A different point of view

This thesis describes multiple surgical treatment options in patients with ulcerative colitis (UC) and perianal Crohn’s disease (CD). An appendectomy is suggested to have a beneficial effect on UC, however, some recently published data reported an increased risk of colorectal cancer (CRC). Part I confirms that a higher proportion of colectomies after appendectomy in UC is undertaken for CRC, but less for active colitis. We found an 84% decrease in colectomies and a delay in surgery. Furthermore, an appendectomy resulted in a clinical response in 46%, and 25% were in endoscopic remission after 4 years. Since the colon is longer in situ, the risk of CRC remains, which emphasises the importance of endoscopic surveillance. Part II describes the results after restorative proctocolectomy and ileal pouch-anal anastomosis. Our research demonstrated that both techniques of double-end ileosigmoidostomy and end ileostomy with closed rectal stump are safe and effective. With respect to small bowel obstruction, the modified 2-stage IPAA seems the safest. In case of anastomotic leakage, long-term pouch function can be preserved with endo-sponge assisted early surgical closure. Part III evaluates treatment options for high perianal fistulas in CD. We found that the knotless SuperSeton is a feasible novel technique which significantly improves fistula related quality of life. Definitive closure of the perianal fistulas can be achieved by the endorectal advancement flap and ligation of the intersphincteric fistula tract with comparable success and recurrence rates. Finally, the different treatment options were head-to-head compared in the randomised PISA-trial, which showed inferior outcomes for chronic seton drainage.