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Ileorectal anastomosis for inflammatory disease of the large bowel
Ileorectal Anastomosis for Inflammatory Disease of the Large Bowel MALCOLM C VEIDENHEIMER, MD, Boston, Massachusetts THOMAS H DAILEY, MD, New York, New York WILLIAM A MEISSNER, MD, Boston, Massachusetts
Proctocolectomy with ileostomy remains the most popular surgical procedure for chronic ulcerative colitis and transmural or Crohn’s disease of the colon [I--3]. However, several reports have been made of excellent results after ileorectal anasto’mosis performed for these diseases. The advocates of this operation have been in the minority, but Aylett [4] and Hughes and Russell [5] have reported sizable numbers of patients who are well and free from the nuisance of ileostomy care after ileoproctostomy. Material
and Methods
The surgeons of the Lahey Clinic Foundation have not been quick to adopt ileoproctostomy for the treatment of chronic ulcerative colitis or transmural disease of the large bowel. Between May 1956 and April 1968, thirtysix patients underwent this operation. During the same period, 3.51 patients underwent ileostomy and total proctocolectomy for inflammatory disease of the colon. The thirty-six patients with anastomoses are the subject of this present study. These patients represent 9.3 per cent of all patients with colectomy performed by Lahey Clinic surgeons for inflammatory diseases of the colon. Of these patients, twenty-three were women and thirteen were men. The average age at onset of disease was thirty-one years with a range from five to sixty-nine years. The time interval from the onset of symptoms to the time of operation varied from three weeks to twenty years. Pathologic Findings. The pathologic material on all of the specimens was reviewed. The types of inflammatory lesions were classified according to the usually accepted macroscopic and microscopic criteria of chronic ulcerative colitis and of transmural colitis (Crohn’s disease of the colon, regional colitis) and are summarized as follows: (1) Chronic ulcerative colitis (Figures 1 and 2) is primarily a mucosal disease with hyperemia, active inflammation, and undermining linear ulcers and crypt abscesses; the zones of bowel involvement tend to be continuous, and the terminal few centimeters of ileum are frequently involved. (2) Transmurd colitis (Figures 3 and 4), in contrast, primarily involves the submucosa and deeper tissues and causes considerable scarring of the entire bowel wall; granulomatous foci are frequent, and Presented at Surgical Society, 1969.
Vol. 119, April
the Fiftieth Portsmouth,
1970
Annual New
Meeting Hampshire,
of
the New September
England 25-27,
the disease tends to be segmental with “skip” areas of uninvolved normal mucosa between the involved segments. The proximal and distal margins of the resected specimens were reviewed to determine whether they were involved in the basic disease process. The clinical course of the patients was then correlated with the state of the anastomosed ends of the bowel. Surgical Technic. Although a variety of operative maneuvers were used, the patients may be broadly classified in two groups. In fourteen patients, ileorectal anastomosis was performed subsequent to colectomy and ileostomy. The other twenty-two patients underwent primary ileorectal anastomosis at the time of total colectomy. In none of the patients was the anastomosis protected by a temporary ileostomy. The level of the anastomosis varied from the middle of the rectum to the low portion of the sigmoid colon. All anastomoses were end to end and were performed within reach of the 25 cm sigmoidoscope. None of the patients received steroid treatment after operation, either systemically or by enema, although two patients later required short courses of prednisone for diarrhea. Results
Of the thirty-six patients, twenty-seven had ulcerative colitis (eight men and nineteen women) ; seven patients had Crohn’s disease (three men and four women) ; and after careful review of the histologic findings, it was not possible to classify the inflammatory changes in one man and in one woman. With the exception of those who died, all patients were followed up by their family physician or by us. All cases have been reviewed within the past six months. The results of operation have been assessed as follows: (1) excellent [no complaints by the patient and no medication]; (2) good [no complaints by the patient but some medication required]; (3) fair [some problems even while the patient was receiving medication]; (4) failure [patients required subsequent ileostomy]; and (5) death during the postoperative period. The number of bowel movements varied from one to ten per day in the patients reporting good and excellent results. Most patients had two to four movements per day. 375
Veidenheimer,
Dailey,
and Meissner
Figure 1. Crypt abscess typical of chronic ulcerative colitis. The collection of inflammatory cells at the base of glandular crypts is one of the ear/y lesions of ulcerative colitis. (Hematoxylin and eosin stain; original magnification x 150.)
Twenty patients had excellent results, eight reported good results, and one patient had a fair result after operation. In five patients, the anastomosis failed and ileostomy was required. Two patients died as a result of operation, an operative mortality of 5.6 per cent. Of the patients who underwent ileoproctostomy, failure occurred in 15 per cent and ileostomy was required. Aylett [#I reported a 5 per cent failure in his series of 300 patients. In Table I, results are related to the type of disease.
tomosis. In each instance, death was a consequence of sepsis, resulting from an anastomotic leak in one pntient and from peritonitis probably secondary to an anastomotic leak in the other. Both patients had involvement of the rectal margin of anastomosis by chronic ulcerative colitis at the time of ileoproctostomy. Three of the five patients with failures had Crohn’s disease. At the time of ileorectal anastomosis, all had involvement of one or both anastomosed ends of bowel by inflammatory disease. Tn one patient, the involvement was of the ileum only; in three patients, it was of the rectum only; and in one patient, the involvement was of both the ileal and rectal margins. In all instances of failure, ileostomy was required either because of an anasto’motic leak or perianal sepsis. In three patients, colectomy with ileoproctostomy was the initial surgical treatment of the disease. The other two failures occurred in patients who had undergone ileoproctostomy some months or years after colectomy and ileostomy. Four of the failures occurred within five months of ileorectal anastomosis. The other failure resulted in a patient with ileostomy performed eight years after ileo’proctostomy. It has been impossible to correlate the prognosis after ileoproctostomy with the histologic evidence of involvement of the anastomosed ends of the bowel. It is true, however, that all the failures and deaths occurred in patients having one or both margins involved by disease. None of the failures or deaths occurred in patients in whom both margins of anastomosis were free of inflammatory change. However, many of the patients having excellent and good results from operation had evidence of anastomotic involvement by either transmural disease or chronic ulcerative colitis. (Table II.) Three patients having excellent results had
Comments The
major importance of this study relates to the type of inflammatory disease and the extent of involvement of the bowel at the site of anastomosis. In nearly one half of the patients with Crohn’s disease of the colon an ileoproctostomy could not be maintained, whereas only one seventh of those with an anastomosis for chronic ulcerative colitis had failure of the ileostomy or died after operation. Both deaths in this series occurred in patients with chronic ulcerative colitis. Each patient had undergone ileostomy that resulted in a period of improved health; subsequently, each patient underwent ileorectal anas376
Figure 2. Ulcerative colitis extending to the margin of specimen. The disease is limited primarily to the mucosa and submucosa. In one focus of the mucosa there is an undermining ulcer, which is typical of the disease. (Hematoxylin X 50.) and eosin stain; original magnification The
American
Journal
of
SurgeW
lleorectal
Transmural colitis. The granulomatous inflamFigure 3. matory process in this instance involves the serosa at the margin of resection. (Hematoxylin and eosin stain; original magnification X 50.)
Transmural colitis. Figure 4. same field as in Figure 3 shows like” granulomas, together with cell infiltrate. (Hematoxylin and fication x 150.)
both
TABLE
ileal and rectal margins of the anastomosis involved and could logically have been expected to have had poor results from operation. From this small series, it appears that the ileoproctostomy will be successful if no marginal involvement of the rectum or ileum occurs. What is perhaps more interesting is the finding that many patients with an anastomosis involving diseased bowel have done well. This is compatible with findings in other reports [4,5]. Nevertheless, the routine use of rectal biopsy is a useful adjunct to the preoperative assessment of the patient. When anastomoses have been performed in the presence of disease, the inflammatory changes have been minor and often recognized only microscopically. Certainly none of this group had anastomosis in the presence of perianal sepsis or rectal stricture. None of our patients had ileorectal anastomosis at the time of colectomy performed for acute fulminating colitis. TABLE
I
Results Related to Type of Disease
Pathology
Excellent
Good
Fair
Failure
Death
Chronic ulcerative colitis Transmural
colitis
Unclassified Vol. 119, April
1970
16
6
1
2
2
3
1
0
3
0
1
1
0
0
0
II
Anastomosis
A higher magnification of the characteristic “sarcoida nonspecific inflammatory eosin stain; original magni-
Results Related to Anastomotic
Involvement
Involvement
Results Excellent* (20 cases) Good (8 cases) Fair (lease) Failure (5 cases) Death (2cases)
* Five patients examination
lleal
Rectal
Both lleal and Rectal
Neither lleal nor Rectal
2
5
3
5
1
3
...
4
...
..,
1
...
1
3
1
..*
...
2
...
...
with excellent results of the anastomotic margins.
had
-
no microscopic
Summary The cases of thirty-six patients undergoing ileorectal anastomosis for inflammatory disease of the colon have been reviewed. No anastomosis using healthy bowel failed, and all these patients did well clinically. Pathologic involvement of the anastomosed bowel leaves the patient liable to failure of the anastomosis, but does not mean that the anastomosis is doomed. One half of the patients with Crohn’s disease did not tolerate ileorectal anastomosis. The results of ileoproctostomy performed for chronic ulcerative colitis were much better 377
Veidenheimer,
Dailey, and Meissner
than those achieved in Crohn’s disease. The incidence of failure or postoperative death is significant. Reconstitution of bowel continuity in an ileostomy patient is an exciting possibility, but the risks associated with this operation must be considered carefully before undertaking ileoproctostomy. References 1. Glotzer DJ, Stone PA, Patterson JF: Prognosis after surgical treatment of granulomatous colitis. New Eng J Med 277: 273, 1967. 2. Goligher JC: Surgical treatment of ulcerative colitis. Brit Med J 2: 671, 1968. 3. Swinton NW, Crozier RE: The surgical treatment of ulcerative colitis. Abdominal Operations, 5th edition, vol 2, p 1464 (Maingot R, ed). New York, AppletonCentury-Crofts, 1969. 4. Aylett SO: Three hundred cases of diffuse ulcerative colitis treated by total colectomy and ileo-rectal anastomosis. Brit Med J 1: 1001, 1966. 5. Hughes ES, Russell IS: lleorectal anastomosis for ulcerative colitis. Dis Colon Rectum 10: 35, 1967.
Discussion BENTLEY P COLCOCK (Boston, Mass): I have been interested in inflammatory diseases of the colon for many years and have operated on a number of the patients in this report, but I had not seen the material summarized before. I would like to emphasize that what Dr Veidenheimer has presented does not imply that we, at the Clinic, believe that this is the operation of choice for most patients with ulcerative colitis or Crohn’s disease. It is a good operation, however, particularly for selected patients with ulcerative colitis. There are three factors that we should keep in mind. The first is the proper selection of cases. We have not used this procedure for patients with rectal fistulas or stenosis, and I am sure in this situation that it would fail. As might be expected, it is not particularly good for the treatment of Crohn’s disease. When one is forced to perform subtotal colectomy (and an ileorectal anastomosis) for this condition, one is dealing with extensive disease. The fact that results were good in even a few of these patients is remarkable. The second point to remember is that the bowel is never normal in patients with ulcerative colitis. Even though the rectum may appear to he the least involved, it is nevertheless diseased. If the surgeon performs the anastomosis with this in mind and exercises particular care, in my experience there is very little risk of leakage. The last point is the need for a prolonged follow-up study. As you noticed, one of the patients with Crohn’s disease had a recurrence after seven or eight years. This need for follow-up study is even more important in patients with ulcerative colitis, especially when the rectum has not been removed. Otherwise, the surgeon may be chagrined to have one of these patients return with fatal carcinoma of the rectum. WILLIAM SILEN (Boston, Mass): The authors are to he congratulated on their attempt to correlate the pathology of the disease with the treatment. Dr Donald Glotzer has recently completed a survey of the experiences with ulcerative colitis and Crohn’s disease of the colon in our 378
hospital. I think his findings are rather interesting, even though the results are somewhat at odds with those that have been presented by Dr Veidenheimer. In essence, Dr Glotzer, working in cooperation with the Department of Pathology, discovered that the sharp distinction between Crohn’s disease and ulcerative colitis that Turnbull has described is really blurred, and thus the two unclassified cases that Dr Veidenheimer reported tend to corroborate our experience. Almost half of our cases, however, fall into a group that we find very difficult to classify pathologically. In other words, there are large groups of patients who have mucosal disease, confined to the mucosa, who have granulomas typical of Crohn’s disease, and vice versa, those who have transmural disease and who seem in every other way to have ulcerative colitis. We have to continue the attempts to distinguish these two diseases. Our results in patients with Crohn’s disease have been somewhat better than those reported by Dr Veidenheimer. I believe that we have had four or five patients with ileorectal anastomoses who have stayed well for long periods of time. I would like to know if it is fair to indict Crohn’s disease per se as a causative factor in the recurrences. What percentage of patients with Crohn’s disease in this series had resection in which there was disease a~ the margin as opposed to those who had primary ulcerative colitis and disease at the margins? JOHN R BRINKS (Boston, Mass) : It seems to me that the crux of the mortality in Dr Veidenheimer’s series is in the line of anastomosis; yet Dr Meissner is able to interpret accurately frozen sections taken during the operation. MALCOLM C VEIDENHEIMER (closing) : Doctor Brooks, some patients with Crohn’s disease have had so many resections that we are willing to anastomose bowel if it is not too badly diseased, and as you know, many of these patients do well. We have not made a point of basing our decisions on frozen sections; rather, they are largely based upon the macroscopic appearance of the bowel. Doctor Silen emphasized the difficulties in differentiating Crohn’s disease and ulcerative colitis. I should tell you that the slide showing the crypt abscess which is so typical of ulcerative colitis and the slide showing a granuloma typical of Crohn’s disease are of the same patient; this was one of the unclassified cases. One of the most striking aspects of this review was that in our enthusiasm for performing an anastomosis we were overlooking the usefulness of maintaining an ileostomy as a temporary safeguard. If we are going to perform anastomoses in these patients, it might be wise to maintain an ileostomy above the anastomosis until we see how the patient is going to do. I think that the two deaths might have been avoided, had this been done. Another interesting point is this: I wrote an article about a year ago on inflammatory diseases, and at that time I estimated that we anastomosed bowel in only 5 per cent of our patients. In this present study, I was surprised to find that the actual incidence of anastomosis was nearly 10 per cent. I suppose that we are getting more venturesome, but these patients still represent a small group when we consider the total number of operative cases. The
American
Journal
of
Surgery
Proctocolectomy with ileostomy remains the most popular surgical procedure for chronic ulcerative colitis and transmural or Crohn’s disease of the colon [I--3]. However, several reports have been made of excellent results after ileorectal anasto’mosis performed for these diseases. The advocates of this operation have been in the minority, but Aylett [4] and Hughes and Russell [5] have reported sizable numbers of patients who are well and free from the nuisance of ileostomy care after ileoproctostomy. Material
and Methods
The surgeons of the Lahey Clinic Foundation have not been quick to adopt ileoproctostomy for the treatment of chronic ulcerative colitis or transmural disease of the large bowel. Between May 1956 and April 1968, thirtysix patients underwent this operation. During the same period, 3.51 patients underwent ileostomy and total proctocolectomy for inflammatory disease of the colon. The thirty-six patients with anastomoses are the subject of this present study. These patients represent 9.3 per cent of all patients with colectomy performed by Lahey Clinic surgeons for inflammatory diseases of the colon. Of these patients, twenty-three were women and thirteen were men. The average age at onset of disease was thirty-one years with a range from five to sixty-nine years. The time interval from the onset of symptoms to the time of operation varied from three weeks to twenty years. Pathologic Findings. The pathologic material on all of the specimens was reviewed. The types of inflammatory lesions were classified according to the usually accepted macroscopic and microscopic criteria of chronic ulcerative colitis and of transmural colitis (Crohn’s disease of the colon, regional colitis) and are summarized as follows: (1) Chronic ulcerative colitis (Figures 1 and 2) is primarily a mucosal disease with hyperemia, active inflammation, and undermining linear ulcers and crypt abscesses; the zones of bowel involvement tend to be continuous, and the terminal few centimeters of ileum are frequently involved. (2) Transmurd colitis (Figures 3 and 4), in contrast, primarily involves the submucosa and deeper tissues and causes considerable scarring of the entire bowel wall; granulomatous foci are frequent, and Presented at Surgical Society, 1969.
Vol. 119, April
the Fiftieth Portsmouth,
1970
Annual New
Meeting Hampshire,
of
the New September
England 25-27,
the disease tends to be segmental with “skip” areas of uninvolved normal mucosa between the involved segments. The proximal and distal margins of the resected specimens were reviewed to determine whether they were involved in the basic disease process. The clinical course of the patients was then correlated with the state of the anastomosed ends of the bowel. Surgical Technic. Although a variety of operative maneuvers were used, the patients may be broadly classified in two groups. In fourteen patients, ileorectal anastomosis was performed subsequent to colectomy and ileostomy. The other twenty-two patients underwent primary ileorectal anastomosis at the time of total colectomy. In none of the patients was the anastomosis protected by a temporary ileostomy. The level of the anastomosis varied from the middle of the rectum to the low portion of the sigmoid colon. All anastomoses were end to end and were performed within reach of the 25 cm sigmoidoscope. None of the patients received steroid treatment after operation, either systemically or by enema, although two patients later required short courses of prednisone for diarrhea. Results
Of the thirty-six patients, twenty-seven had ulcerative colitis (eight men and nineteen women) ; seven patients had Crohn’s disease (three men and four women) ; and after careful review of the histologic findings, it was not possible to classify the inflammatory changes in one man and in one woman. With the exception of those who died, all patients were followed up by their family physician or by us. All cases have been reviewed within the past six months. The results of operation have been assessed as follows: (1) excellent [no complaints by the patient and no medication]; (2) good [no complaints by the patient but some medication required]; (3) fair [some problems even while the patient was receiving medication]; (4) failure [patients required subsequent ileostomy]; and (5) death during the postoperative period. The number of bowel movements varied from one to ten per day in the patients reporting good and excellent results. Most patients had two to four movements per day. 375
Veidenheimer,
Dailey,
and Meissner
Figure 1. Crypt abscess typical of chronic ulcerative colitis. The collection of inflammatory cells at the base of glandular crypts is one of the ear/y lesions of ulcerative colitis. (Hematoxylin and eosin stain; original magnification x 150.)
Twenty patients had excellent results, eight reported good results, and one patient had a fair result after operation. In five patients, the anastomosis failed and ileostomy was required. Two patients died as a result of operation, an operative mortality of 5.6 per cent. Of the patients who underwent ileoproctostomy, failure occurred in 15 per cent and ileostomy was required. Aylett [#I reported a 5 per cent failure in his series of 300 patients. In Table I, results are related to the type of disease.
tomosis. In each instance, death was a consequence of sepsis, resulting from an anastomotic leak in one pntient and from peritonitis probably secondary to an anastomotic leak in the other. Both patients had involvement of the rectal margin of anastomosis by chronic ulcerative colitis at the time of ileoproctostomy. Three of the five patients with failures had Crohn’s disease. At the time of ileorectal anastomosis, all had involvement of one or both anastomosed ends of bowel by inflammatory disease. Tn one patient, the involvement was of the ileum only; in three patients, it was of the rectum only; and in one patient, the involvement was of both the ileal and rectal margins. In all instances of failure, ileostomy was required either because of an anasto’motic leak or perianal sepsis. In three patients, colectomy with ileoproctostomy was the initial surgical treatment of the disease. The other two failures occurred in patients who had undergone ileoproctostomy some months or years after colectomy and ileostomy. Four of the failures occurred within five months of ileorectal anastomosis. The other failure resulted in a patient with ileostomy performed eight years after ileo’proctostomy. It has been impossible to correlate the prognosis after ileoproctostomy with the histologic evidence of involvement of the anastomosed ends of the bowel. It is true, however, that all the failures and deaths occurred in patients having one or both margins involved by disease. None of the failures or deaths occurred in patients in whom both margins of anastomosis were free of inflammatory change. However, many of the patients having excellent and good results from operation had evidence of anastomotic involvement by either transmural disease or chronic ulcerative colitis. (Table II.) Three patients having excellent results had
Comments The
major importance of this study relates to the type of inflammatory disease and the extent of involvement of the bowel at the site of anastomosis. In nearly one half of the patients with Crohn’s disease of the colon an ileoproctostomy could not be maintained, whereas only one seventh of those with an anastomosis for chronic ulcerative colitis had failure of the ileostomy or died after operation. Both deaths in this series occurred in patients with chronic ulcerative colitis. Each patient had undergone ileostomy that resulted in a period of improved health; subsequently, each patient underwent ileorectal anas376
Figure 2. Ulcerative colitis extending to the margin of specimen. The disease is limited primarily to the mucosa and submucosa. In one focus of the mucosa there is an undermining ulcer, which is typical of the disease. (Hematoxylin X 50.) and eosin stain; original magnification The
American
Journal
of
SurgeW
lleorectal
Transmural colitis. The granulomatous inflamFigure 3. matory process in this instance involves the serosa at the margin of resection. (Hematoxylin and eosin stain; original magnification X 50.)
Transmural colitis. Figure 4. same field as in Figure 3 shows like” granulomas, together with cell infiltrate. (Hematoxylin and fication x 150.)
both
TABLE
ileal and rectal margins of the anastomosis involved and could logically have been expected to have had poor results from operation. From this small series, it appears that the ileoproctostomy will be successful if no marginal involvement of the rectum or ileum occurs. What is perhaps more interesting is the finding that many patients with an anastomosis involving diseased bowel have done well. This is compatible with findings in other reports [4,5]. Nevertheless, the routine use of rectal biopsy is a useful adjunct to the preoperative assessment of the patient. When anastomoses have been performed in the presence of disease, the inflammatory changes have been minor and often recognized only microscopically. Certainly none of this group had anastomosis in the presence of perianal sepsis or rectal stricture. None of our patients had ileorectal anastomosis at the time of colectomy performed for acute fulminating colitis. TABLE
I
Results Related to Type of Disease
Pathology
Excellent
Good
Fair
Failure
Death
Chronic ulcerative colitis Transmural
colitis
Unclassified Vol. 119, April
1970
16
6
1
2
2
3
1
0
3
0
1
1
0
0
0
II
Anastomosis
A higher magnification of the characteristic “sarcoida nonspecific inflammatory eosin stain; original magni-
Results Related to Anastomotic
Involvement
Involvement
Results Excellent* (20 cases) Good (8 cases) Fair (lease) Failure (5 cases) Death (2cases)
* Five patients examination
lleal
Rectal
Both lleal and Rectal
Neither lleal nor Rectal
2
5
3
5
1
3
...
4
...
..,
1
...
1
3
1
..*
...
2
...
...
with excellent results of the anastomotic margins.
had
-
no microscopic
Summary The cases of thirty-six patients undergoing ileorectal anastomosis for inflammatory disease of the colon have been reviewed. No anastomosis using healthy bowel failed, and all these patients did well clinically. Pathologic involvement of the anastomosed bowel leaves the patient liable to failure of the anastomosis, but does not mean that the anastomosis is doomed. One half of the patients with Crohn’s disease did not tolerate ileorectal anastomosis. The results of ileoproctostomy performed for chronic ulcerative colitis were much better 377
Veidenheimer,
Dailey, and Meissner
than those achieved in Crohn’s disease. The incidence of failure or postoperative death is significant. Reconstitution of bowel continuity in an ileostomy patient is an exciting possibility, but the risks associated with this operation must be considered carefully before undertaking ileoproctostomy. References 1. Glotzer DJ, Stone PA, Patterson JF: Prognosis after surgical treatment of granulomatous colitis. New Eng J Med 277: 273, 1967. 2. Goligher JC: Surgical treatment of ulcerative colitis. Brit Med J 2: 671, 1968. 3. Swinton NW, Crozier RE: The surgical treatment of ulcerative colitis. Abdominal Operations, 5th edition, vol 2, p 1464 (Maingot R, ed). New York, AppletonCentury-Crofts, 1969. 4. Aylett SO: Three hundred cases of diffuse ulcerative colitis treated by total colectomy and ileo-rectal anastomosis. Brit Med J 1: 1001, 1966. 5. Hughes ES, Russell IS: lleorectal anastomosis for ulcerative colitis. Dis Colon Rectum 10: 35, 1967.
Discussion BENTLEY P COLCOCK (Boston, Mass): I have been interested in inflammatory diseases of the colon for many years and have operated on a number of the patients in this report, but I had not seen the material summarized before. I would like to emphasize that what Dr Veidenheimer has presented does not imply that we, at the Clinic, believe that this is the operation of choice for most patients with ulcerative colitis or Crohn’s disease. It is a good operation, however, particularly for selected patients with ulcerative colitis. There are three factors that we should keep in mind. The first is the proper selection of cases. We have not used this procedure for patients with rectal fistulas or stenosis, and I am sure in this situation that it would fail. As might be expected, it is not particularly good for the treatment of Crohn’s disease. When one is forced to perform subtotal colectomy (and an ileorectal anastomosis) for this condition, one is dealing with extensive disease. The fact that results were good in even a few of these patients is remarkable. The second point to remember is that the bowel is never normal in patients with ulcerative colitis. Even though the rectum may appear to he the least involved, it is nevertheless diseased. If the surgeon performs the anastomosis with this in mind and exercises particular care, in my experience there is very little risk of leakage. The last point is the need for a prolonged follow-up study. As you noticed, one of the patients with Crohn’s disease had a recurrence after seven or eight years. This need for follow-up study is even more important in patients with ulcerative colitis, especially when the rectum has not been removed. Otherwise, the surgeon may be chagrined to have one of these patients return with fatal carcinoma of the rectum. WILLIAM SILEN (Boston, Mass): The authors are to he congratulated on their attempt to correlate the pathology of the disease with the treatment. Dr Donald Glotzer has recently completed a survey of the experiences with ulcerative colitis and Crohn’s disease of the colon in our 378
hospital. I think his findings are rather interesting, even though the results are somewhat at odds with those that have been presented by Dr Veidenheimer. In essence, Dr Glotzer, working in cooperation with the Department of Pathology, discovered that the sharp distinction between Crohn’s disease and ulcerative colitis that Turnbull has described is really blurred, and thus the two unclassified cases that Dr Veidenheimer reported tend to corroborate our experience. Almost half of our cases, however, fall into a group that we find very difficult to classify pathologically. In other words, there are large groups of patients who have mucosal disease, confined to the mucosa, who have granulomas typical of Crohn’s disease, and vice versa, those who have transmural disease and who seem in every other way to have ulcerative colitis. We have to continue the attempts to distinguish these two diseases. Our results in patients with Crohn’s disease have been somewhat better than those reported by Dr Veidenheimer. I believe that we have had four or five patients with ileorectal anastomoses who have stayed well for long periods of time. I would like to know if it is fair to indict Crohn’s disease per se as a causative factor in the recurrences. What percentage of patients with Crohn’s disease in this series had resection in which there was disease a~ the margin as opposed to those who had primary ulcerative colitis and disease at the margins? JOHN R BRINKS (Boston, Mass) : It seems to me that the crux of the mortality in Dr Veidenheimer’s series is in the line of anastomosis; yet Dr Meissner is able to interpret accurately frozen sections taken during the operation. MALCOLM C VEIDENHEIMER (closing) : Doctor Brooks, some patients with Crohn’s disease have had so many resections that we are willing to anastomose bowel if it is not too badly diseased, and as you know, many of these patients do well. We have not made a point of basing our decisions on frozen sections; rather, they are largely based upon the macroscopic appearance of the bowel. Doctor Silen emphasized the difficulties in differentiating Crohn’s disease and ulcerative colitis. I should tell you that the slide showing the crypt abscess which is so typical of ulcerative colitis and the slide showing a granuloma typical of Crohn’s disease are of the same patient; this was one of the unclassified cases. One of the most striking aspects of this review was that in our enthusiasm for performing an anastomosis we were overlooking the usefulness of maintaining an ileostomy as a temporary safeguard. If we are going to perform anastomoses in these patients, it might be wise to maintain an ileostomy above the anastomosis until we see how the patient is going to do. I think that the two deaths might have been avoided, had this been done. Another interesting point is this: I wrote an article about a year ago on inflammatory diseases, and at that time I estimated that we anastomosed bowel in only 5 per cent of our patients. In this present study, I was surprised to find that the actual incidence of anastomosis was nearly 10 per cent. I suppose that we are getting more venturesome, but these patients still represent a small group when we consider the total number of operative cases. The
American
Journal
of
Surgery