Improving the quality of care for patients with ileocolonic Crohn’s disease undergoing surgery

Abstract

This thesis provides a comprehensive overview of the variability seen at time of surgery for patients with ileocolonic Crohn’s disease. It questions the validity of the Montreal classification in the setting of surgery. It provides a consensus for how a surgical service provision and the multidisciplinary team can be standardised to enhance the quality of care for patients with ileocolonic Crohn’s disease. Through meta-analysis, this thesis demonstrates that surgery is an inevitable end-point in 75% of patients who undergo endoscopic balloon dilatation for Crohn’s strictures within a 5-year follow-up period. It raises the profile of surgery as an intervention for ileocolonic Crohn’s disease, as opposed to a ‘failure of medical therapy’ and goes on to devise key performance indicators to monitor and enhance the quality of surgery for patients with ileocolonic Crohn’s disease.

This thesis demonstrates that Montreal B3 (penetrating disease) and peri-operative biological therapy were both independent predictors of intra-abdominal septic complication. Further clarification is required to determine if fistulating or perforating disease specifically contributes to this effect. The newly devised, end-user informed staging tool provides distinct stages to aid this effect. Validity and reliability testing of this staging tool against a cohort of surgical patients has demonstrated it can reliably be used to pre-operatively stage patients and inform surgical decision-making and estimate post-operative morbidity.

The thesis has also found that re-resectional surgery and Montreal L3 disease (ileocolonic disease) are independent predictors of recurrent disease following surgery. Montreal L3 disease is a novel finding previously un-reported and should be considered in risk stratification models for post-operative prophylactic therapy.