Complex Crohn's Disease: Primum non nocere

Michael A. Valente, DO, FACS, FASCRS

In this volume of Clinics in Colon and Rectal Surgery, the diverse topic of complex Crohn's disease will be presented, with an emphasis on some of the most difficult-to-treat maladies that the surgeon may encounter when caring for patients with this incurable and unrelenting disease. The authors have all been selected based on their vast experience, knowledge, and research on the various surgical and medical nuisances that accompany patients with complex conditions associated with Crohn's disease.

The Latin maxim Primum non nocere (first, do no harm) is, in the author's opinion, one of the single most important tenets that dictates the surgical care of the patient with complex Crohn's disease. There are few disease processes that this fundamental principle holds truer. We surgeons, as vessels of health and healing, must understand that sometimes the best treatment in these complex patients is the least invasive surgery or, possibly, no surgery at all. Having the privilege to work in a quaternary inflammatory bowel disease referral center, I have seen firsthand the complications and subsequent suffering that may arise from wielding the scalpel in these patients. Surgical management, when absolutely necessary, must be well thought out and coupled with knowledge, technical skill, creativity, foresight, and, most importantly, humility.

I am indebted to each of the authors for sharing their wealth of experience and knowledge on these difficult subjects. Each has done a masterful job on specific topics that, at first glance, may seem difficult to comprehend and even more difficult to treat. The aim of this volume is to expose the reader to the most challenging Crohn's disease–related conditions and to offer logical, stepwise management and technical tips to successfully heal these patients.

Jean Paul Achkar from Cleveland Clinic starts off the edition with an excellent synopsis and proposed algorithm of the postoperative, medical management of complex Crohn's patients. Next, the reader will gain a sound understanding on the underreported and even less well-recognized Crohn's disease of the foregut, which is beautifully reviewed by Drs. Schwartzberg, Brandstetter, and Grucella, from Cleveland Clinic and New York University. The topic of bowel conservation therapy is of the utmost importance when discussing Crohn's disease of the small bowel, and Dr. Scott Strong from Northwestern University authoritatively describes the science and art of strictureplasty techniques. The controversial topic of segmental colectomy in Crohn's colitis is discussed next by Drs. Alexander Heriot and Philip Smart from Melbourne, Australia, in which they describe their experience and make recommendations in regard to operative decision making.

Drs. Bolshinsky and Church from Cleveland Clinic have written an excellent and systematic treatise on complex perianal Crohn's disease as well as the less well understood perineal Crohn's disease. This is followed by Drs. DeLeon and Hull from Cleveland Clinic, who masterfully discuss one of the most troublesome and feared complications in the female patient: Crohn's disease–associated rectovaginal fistula. This review highlights both operative and nonoperative treatment strategies on these notoriously difficult-to-treat fistulae.

Dr. Luiz Felipe de Campos-Lobato from Brasilia, Brazil, and Dr. Ravi Kiran from Columbia University in New York City explore some of the more challenging complications of fistulizing Crohn's disease with their excellent synopsis on complex Crohn's enteric fistulae.

Little has been published on the exact role, long-term success, and natural history of fecal diversion in complex Crohn's disease. Dr. John Burke from Beaumont Hospital in Dublin, Ireland, delivers an excellent article on this controversial topic. Another controversial topic that is addressed in this edition is the role of ileal pouch anal anastomosis in Crohn's disease. Drs. Lopez, Zaghyian, and Fleshner from Cedars Sinai in Los Angeles provide the current state of the literature and guidelines in this evolving topic in Crohn's disease surgery.

Reoperative surgery in Crohn's disease is of paramount importance, as many patients will undoubtedly undergo a repeat operation at some point along their disease course. Drs. Leinicke and Dietz from University Hospitals in Cleveland have written an excellent and authoritative review on this complex topic. Complementing open, reoperative surgery is the minimally invasive approach, as described by Drs. Sapci and Gorgun from Cleveland Clinic. Their article focuses on laparoscopic and robotic modalities for reoperative and complex Crohn's disease patients.

Dr. Evie Carchman from the University of Wisconsin discusses the rare sequelae of gastrointestinal and nongastrointestinal carcinomas secondary to the inflammatory mediators in Crohn's disease. This topic is seldom written about and less commonly understood. The edition finishes with Dr. Armen Aboulien from Kaiser Permanete in Los Angeles, with a beautiful description of common and rare ostomy complications specifically related to Crohn's disease.

On a personal note, I wish to thank the Editor in Chief, Dr. Scott R. Steele, for his ongoing mentorship to me as an academic surgeon and also for the privilege to contribute to this volume as guest editor. Most importantly, I am indebted to Stephanie Valente (mother–wife–surgeon) and to my children Rocco, Francesca, and Arianna for their unwavering support and love, for without them, none of this would be possible or worthwhile.