What the Surgeon Should Really Know

The large bowel of the IBD patient is not an isolated organ (as was our rabbit colon in vitro) but is strictly connected to the PNEI-G system via reciprocal interactions. Therefore, if the surgeon wants to cure the patients and not simply "repair" his/her colon and see him or her "broken" again after a short while, the surgeon must take into consideration this entire complex system. This is called a holistic approach, which usually is not taught at university. The harmonic balance among intrinsic and extrinsic nerves, brain, immunoendocrine system, intestinal flora and genetic pattern, all connected through neurotrans-mitters and other substances, maintain homeostasis of the patient. A localised failure of this complex system may favour the onset of IBD. The so-called brain-gut system, when altered, may trigger psychiatric illness, and vice versa.

Complete understanding of this system is difficult because it is based on a number of complex mechanisms involving both structures and substances, which are not yet well known. Among them are energy and emotions. A better understanding of such mechanisms may assist physicians in identifying particular subsets of patients who may respond to novel forms of adjunctive treatments for IBD, including hypnosis and meditation. At present, there is evidence to suggest that cognitive behavioural psychological group treatment for outpatients is a feasible and effective approach for the reduction of psychological distress in IBD patients [50]. In conclusion, trying to answer the questions asked in the introduction on the basis of scientific evidence:

- NO, it is unlikely that emotional distress causes IBD (the father with the penile foot might not himself have caused ulcerative colitis by abusing his son), but a significant proportion of Crohn's patients have psychiatric disturbances before the onset of their disease. On the other hand, IBD frequently causes major psychological disorders in the first year of the disease.

- YES, stressful events can exacerbate the course of IBD by precipitating an acute attack (the emotional distress due to my sudden departure to the US might have caused the toxic megacolon of poor Angela F.).

- YES, family and social problems may well worsen the prognosis of a patient with IBD. Therefore, clinicians should take care not only of the in-hospi-tal postoperative course but also of the patient's social and family life after discharge from the hospital.

- YES, depression is more likely to affect a patient with Crohn's disease rather than a patient with another medical disease. Patients with Crohn's disease, unlike those with ulcerative colitis, have lifetime psychiatric disorders, and stress may influence their recurrence rate.

And finally:

- YES, the psychotherapist may well help the surgeon to improve the prognosis of patients with IBD.

As quite a few patients refuse psychiatric consultation, the surgeon needs to know how to approach the IBD patient from a psychological and emotional point of view, if he or she is keen to improve the results of surgery.

Acknowledgements. The author wishes to thank Dr. G. Tornusciolo, psychiatrist, and Dr. C. Miliacca and Dr. A.M. Lombardi, psychologists, who kindly revised the manuscript, and Dr. M. Fiorino, who helped with references.

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