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Editorial: Surgery in Crohn's disease.

The surgeon who operates for Crohn's disease cannot promise his patient a good result: indeed follow-up studies show that a third of all patients submitted to operation need further surgery later.' However, operation may become mandatory when there are severe symptoms of subacute obstruction or when fistulae and other complications are causing persistent serious ill-health. Clinicians are sometimes loath to consider surgery in this condition because they fear that loss of intestine can only aggravate the nutritional disturbances; but N. H. Dyer and A. M. Dawson have suggested from their study2 of 63 patients that the high incidence of malnutrition is related not so much to malabsorption as to the "toxic mass" of the disease. They argued that major surgery should not be avoided for reasons ofnutrition, since resection ofan extensive segment of diseased bowel is likely to improve the patient by removing the source of gastrointestinal loss of blood, protein, water, and electrolytes. When surgery is indicated, resection rather than short circuit has always been favoured in Britain though the reverse has tended to be the case in the U.S.A. Certainly J. A. Williams and his colleagues3 in Birmingham found a much higher recurrence rate in patients submitted to bypass than those treated by resection, while J. D. Frank and B. A. Shorey,4 who recently reviewed 28 cases ofcarcinoma ofthe small bowel complicating Crohn's disease, found that no fewer than 11 of these had developed the tumour in a surgically bypassed segment of intestine. Recurrence after resection of Crohn's disease of the small intestine eventually occurs in a high proportion of cases, though it may be delayed for many years. There is much controversy on the optimum extent of the resection. Some surgeons believe that a generous segment should be removed on either side of the affected area, others are more conservative; some advocate excision of all enlarged adjacent nodes, even if this means the sacrifice of a length of apparently normal gut, while others are content to leave enlarged nodes in situ; but there are no controlled studies to tell us which of these views are correct.5 The prognosis following colonic Crohn's disease seems to be rather better than in the small intestine. When there is extensive disease of the whole of the large bowel including the rectum there appears to be no alternative but total colectomy with excision of the rectum and with a permanent ileostomy. Unlike the patient with ulcerative colitis, who can at least be guaranteed freedom from recurrence once having undergone this procedure, the patient with Crohn's disease is still at risk of ileal recurrence-though the frequency of this complication