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The optimal management of Crohn's disease remains complicated and controversial. In common with other benign conditions, treatment is dependent on a balance between therapeutic risk and benefit. Unfortunately, in surgery the risk arm of the risk/benefit balance appears to predominate. Clinicians, both surgical and medical, seem preoccupied by the complications of surgical intervention, including disease recurrence, anastomotic breakdown, enterocutaneous fistula, and short bowel syndrome. In response to this, “conventional wisdom” currently dictates that the initial management of uncomplicated Crohn's disease should be medical, and only when complications, such as obstruction or fistulation, are apparent either at presentation or develop following a period of medical management is surgery indicated. This approach fails to appreciate the benefits of early surgery and the potentially detrimental effects of delaying surgery. For many years the mainstay of medical management in Crohn's disease has been corticosteroids and 5-ASAs. The increasing use of immunosuppressive therapy in Crohn's and more recently the emergence of a number of novel therapies such as interleukin 10 and anti-tumour necrosis factor (TNF) antibody may serve only to demote surgery further down the management pathway and further support the physician's mistaken belief that medical management may in future be able to cure Crohn's disease and obviate, entirely, the need for surgical intervention.
There is an extensive body of literature to support the precept that surgical intervention in Crohn's disease is not without risk.1,2 However, it is apparent that approximately 80% of patients presenting with ileal …