Introduction

In his landmark article titled "Regional Ileitis: A Pathologic and Clinical Entity" [1], Crohn wrote: "Medical treatment is purely palliative and supportive. . . . THE PROPER APPROACH TO A COMPLETE CURE IS BY SURGICAL RESECTION of the diseased segment of the small intestine and of the ileocecal valve with its contiguous cecum".

The enthusiasm aroused by considering surgical therapy as a decisive treatment for Crohn's disease (CD) faded away. Knowledge acquired over time revealed the peculiar inclination of this disease to affect the entire intestine tract ubiquitously and to be connected with frequent extra-intestinal manifestations. Medical treatment has then become the mainstay of therapy for patients with CD. Introduction of new classes of drugs, such as immunosuppressants/ immunomodulators, led by recognition of the role of the immune system in the disease pathogenesis, increased the success both in controlling the disease in its acute phase and in maintaining the quiescent phase. Regardless, approximately 70-80% of patients suffering from CD requires surgical treatment during the course of the disease; this percentage has been constant over the last 40 years according to data given by the literature [2, 3]. While intestinal perforation, sepsis, intestinal obstruction, continuous bleeding, fistulae and abscesses are clear and unambiguous conditions indicating the need of surgical treatment, on the contrary, there is a considerable percentage of patients falling into a "grey area" that, in clinical practice, foments the age-old argument between gastroenterologists and surgeons regarding timing of the surgical operation [4]. It is therefore clear that the therapeutical trend is to try to identify patients with a higher risk of complications to be then surgically treated [5] in order to delay surgical treatment as long as possible through more and more aggressive medical therapies [6, 7] or mini-invasive therapeutical approaches, such as percutaneous draining of abscesses or, more rarely, dilation of stenoses or haemolysation in the case of haemor-

rhagic events [8]. However, the risk connected with too conservative an approach is leading compromised patients towards surgical treatment with the resulting complications.

As Delaney recently pointed out [9], the absence of complications leads to a fast improvement of patients' quality of life after surgical treatment (in his study quality of life was assessed both preoperatively and 30 days postoperatively). Patients not only judged surgical therapy positively, but they even suggested applying it earlier and proposing it as a primary option in the case of disease relapse.

Application of the principle stated by the Birmingham group (as recurrence is almost inevitable, the main aim being to save as much intestinal tissue as possible [10]), certainly made surgical treatment increasingly conservative, emphasising the importance of attempting to avoid intestinal resection or at least reduce the width used in the past

From all this, we now understand that an appropriate multidisciplinary approach is essential when treating CD, a disease that, despite much enthusiasm and new therapeutical options, seems to have a clinical history that has changed very little over the last 40 years if , as Wolters concluded in a recent systematic review of the literature [11]: "structured literature review provides no hard evidence for change in disease outcome in Crohn's disease during the last four decades".

The aim of this chapter is to analyse the state of the art of surgical options in the treatment of CD, attempting to especially emphasise correct indications, surgical techniques and correct surgical timing.

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