Ulcerative colitis and Crohn's disease, collectively known as inflammatory bowel disease (IBD), are estimated to affect 2–6% of the population of the United States. Despite advances in medical therapy and a larger number of effective medications for treatment of this disease, up to 46% of patients with ulcerative colitis and 80% of patients with Crohn's disease ultimately require surgery.1,2 While many of the operative procedures have remained the same, the approach has changed with the advent of minimally invasive surgery. Laparoscopic colorectal surgery, initially reported in the 1990s, has increased in frequency and is associated with a faster recovery, potentially less complications, better cosmesis, and a shorter length of stay.
The goals of medical therapy for IBD include controlling symptoms of the disease, inducing remission, improving quality of life, and minimizing the complications of the disease and treatment. While surgical intervention is aimed at treating both complications of IBD and intractability to medical management, the timing and role of surgical therapy has become more complex. Surgery should be aimed at optimizing quality of life and at not unnecessarily delaying the inevitable if an operation is required. Additional considerations include the role of biologic agents and the optimal timing of surgery. Furthermore, the Internet has increased access to information for patients and providers, and patients appear to be better educated about their disease and about further therapies. These additional considerations mandate close interaction and consultation with the patient and all providers, including the gastroenterologist, surgeon, primary care physician, and enterostomal nurse.
The cause of IBD remains elusive, but there is increasing evidence of a genetic predisposition to ulcerative colitis and Crohn's disease. The association is strongest in patients with Crohn's disease where three mutations of the NOD2/CARD15 gene affecting the short arm of chromosome 16 have been identified as being associated with the disease.3,4 Mutations in the gene are found in 10–30% of patients with Crohn's disease and are associated with ileal disease, earlier age of onset, and possibly fibrostenosing characteristics. The relative risk of developing Crohn's disease in patients with such mutations is 10–40 times that of the general population.5 Genetic predictors of patients who have medically refractory ulcerative colitis are also being explored.6
A major development in the treatment of IBD in the last two decades has been a number of randomized clinical trials on the use of infliximab, both for Crohn's disease and more recently for ulcerative colitis. Infliximab was shown to be effective for inflammatory disease in 1997 and for perforating disease in 1999.7,8 Infliximab was subsequently shown to be effective for maintenance therapy in Crohn's disease in 2002.9 More recently, it has proven effective for use in ulcerative colitis.10
The role of infliximab is best defined in patients with Crohn's disease where it has been used to treat and induce remission in patients with moderate to severe Crohn's disease. Infliximab is ...