Surgery and medical therapy in Crohn’s disease Improving treatment strategies

This thesis addresses the multidisciplinary treatment of inflammatory bowel disease (IBD), especially Crohn’s disease (CD).
Part I describes the epidemiology of IBD in a population-based cohort and revealed that prevalence is still increasing in the Netherlands.
In Part II treatment of terminal ileitis in CD is described. In the randomised controlled LIR!C trial, laparoscopic ileocecal resection was compared to infliximab showing that at 12 months, resection was comparable in restoring quality of life. Furthermore, we demonstrated that over time patients were treated more intensively with immunosuppressive medication since the introduction of anti-TNF. As a result, time from diagnosis to surgery increased. However, optimization of medical treatment protocols did not result in more limited resections. Surgical techniques have evolved throughout the years. In an international multicentre study we observed that postoperative pain scores and analgesia requirement were significantly lower after single port ileocecal resection compared to multi-port resection.
Part III describes treatment of perianal fistulas in CD. A literature study showed that closure and recurrence rates of perianal fistulas after treatment with seton drainage or anti-TNF vary widely. The PISA trial, was conducted to assess the efficiency of anti-TNF compared to surgical strategies. Furthermore, we demonstrated that perineal complications occurred significantly more frequent in CD compared to ulcerative colitis patients, especially following close rectal dissection compared to total mesorectal excision. This may be explained by increased pro-inflammatory myeloid cell populations with decreased wound healing macrophages. This suggests that excision of mesorectum at time of proctectomy is of crucial importance in CD.