Surgical conservatism led to the principles of management still held today which involve treating specific complications (i.e.,  refractory obstruction, perforation) of the disease, and conserving as much bowel as possible. Stricturoplasty as a technique to relieve stricture was reportedly first employed in 1961 by Bryan Brooke and has subsequently been shown to be a useful adjunct to surgical management. The first case of Crohn’s disease treated with stricturoplasty was published by Lee and Papaioannou in 1982.

They noted that many others were already describing this technique at meetings, but were reticent to publish their results due to fears that this technique would not provide long-term benefit, and would result in high morbidity due to the risks of leak and fistula.  Their data,  however, confirmed its safety.

The reduction of surgical morbidity has continued with the advent and dissemination of minimally invasive techniques. Contained perforation resulting in abscess formation is now readily managed with image-guided drainage. More recent advances in surgery have brought about the era of laparoscopic surgery for Crohn’s disease. Laparoscopic ileocecal resection is now a well-validated option without any significant disease specific outcome disadvantages.

Major advances in the medical treatment of Crohn’s disease have paralleled improved understanding of its pathophysiology. The initial treatment was believed to be surgical with therapeutic nihilism being the standard of care between relapses and supportive care for chronic symptoms. High rates of recurrence, need for reoperation, and medical consequences of wide resection (i.e., B12 deficiency, bile salt deficiency, chronic malnutrition,  anemia)  were frequently reported.  Furthermore,  because of the morbidity associated with extensive small bowel resections,  patients with “jejunoileitis” were largely considered non-operative cases.

In the 1950s and 1960s, groups reported the first cases of remission with use of ACTH and corticosteroids .  The side effects of chronic steroid use,  however,  provided the impetus for study of non-steroid agents to induce and maintain remission, and also led to the development of steroid medication with low systemic absorption such as budesonide, which was evaluated with a double-blind randomized trial in the early 1990s. Immunomodulatory agents including methotrexate,  cyclosporine,  azathioprine,  and 6-mercaptopurine were tested throughout the 1980s and 1990s. With design and scaled production of monoclonal antibodies,  development of anti-TNF- α  antibodies has had significant success at inducing remission in steroid resistant patients with severe active disease.

Despite over 80 years of familiarity with the many facets of Crohn’s disease, medical and surgical decision making remains challenging. Our current ability to provide a precise treatment to those affiicted with this disease mirrors our ability to define the precise mechanisms of disease.   

  Acknowledgments   The authors wish to acknowledge the invaluable contributions made by Arthur H. Aufses, Jr., M.D., who was kind enough to critically review the manuscript, and who provided us with access to his personal photographs,  and by Barbara J.  Niss,  Archivist of the Mount Sinai Medical Center, who provided us with access to the Mount Sinai Levy Library Archives. 

### J. E. Bornstein , MD
Division of Colon and Rectal Surgery, Department of Surgery , Icahn School of Medicine at Mount Sinai , New York , NY 10029 , USA R. M. Steinhagen , MD
Division of Colon and Rectal Surgery , Mount Sinai Medical Center , One Gustave L. Levy Place , Box 1259 , New York , NY 10029 , USA

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