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Ileal pouch-anal anastomosis for Crohn’s disease
  1. R K S PHILLIPS
  1. Consultant Surgeon and Dean,
  2. St Mark’s Academic Institute,
  3. Harrow HA1 3UJ, UK

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Over the past 10 years ileal pouch-anal anastomosis has become the operation of choice for most patients with ulcerative colitis. Although pouch surgery in ulcerative colitis does have a moderate complication rate, so do the alternatives of proctocolectomy and ileostomy.1 The very real advantage of avoiding a stoma along with the inherent curability of ulcerative colitis by excisional surgery help to explain the attractiveness of this operation.

In Crohn’s disease the situation is notably different as the condition is not curable by surgery, and all operations in Crohn’s disease are followed by a higher complication rate and fairly frequent recurrence. Indeed, recurrence is often seen when a permanent stoma is avoided and an anastomosis constructed.

Patients with Crohn’s disease are just as averse to a stoma as those with ulcerative colitis, and so for very good reasons stomas are often avoided even though both patient and doctor are well aware that this puts the patient at increased risk of recurrence and further surgery. Thus, it would be standard practice to offer a patient with terminal ileal Crohn’s disease right hemicolectomy and some patients with large bowel Crohn’s disease colectomy and ileorectal anastomosis. As a consequence of restorative surgery, clinical recurrence is seen within 10 years in 50–80% of these patients.2 3 Figure 1 makes the point quite dramatically: the upper curve represents recurrence rates after colectomy and ileorectal anastomosis, whereas the lower shows how infrequent it can be when a permanent stoma is used instead of an anastomosis. Yet despite this high rate of recurrence, restorative surgery in these circumstances is generally accepted by the surgical and medical community. Does such a policy result in undue loss of small intestine? One study of 82 patients who underwent colectomy and ileorectal anastomosis found that 46 (56%) subsequently underwent …

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