Ileorectal anastomosis for ulcerative colitis

Ileorectal

Anastomosis

for Ulcerative

Colitis*

WILEY F. BARKER, M.D.AND ROBERT S. OZERAN, M.D., Los Angeles, California From tbe Department of Surgery, University of CaliJornia Medical Center, and Wadswortb General Hospital, Veterans Administration Center, Los Angeles, CaliJornia.

LEOSTOMY, with partiaI or compIete coIectomy (Fig. IA and B), has been so successfu1 as the treatment for chronic uIcerative coIitis that few American surgeons have sought to preserve ana function in the process of sur-

I

gica1 treatment. CertainIy some patients who have ukerative coIitis can hope to have their ana function restored and hope not to have an iIeostomy a11 their Iife. Which patients can, and what technic might be used are the subjects of this paper. If uIcerative coIitis did not invoIve the rectum, there wouId be no probIem. There is

A

FIG. I. A, ileostomy and total coIoproctectomy. B, ileostomy, colectomy and retention of rectosigmoid segment, with mucous fistuta. C, anaI iIeostomy. D, ileosigmoidostomy. * Presented

at the annuaI meeting of the Pacific Coast SurgicaI Association,

3-6 1963. American

Journal of Surgery,

Vorume rd.

August

1963

348

PaIm Springs, CaIifornia,

February,

IIeorectaI

Anastomosis

TABLE OPERATION

C:ase --

Patient, Age (yr.) and Sex

I

H. A. J., 30, M

II

F. D. B., 35, M

I11

J. A. F., 56, M

IV

I. M., 39, F

V

R. B., 24, M

VI

J. B., 31, M

‘VII

E. E. R., 33, M

VIII

H. G., 42, M

IX

L. W. F.,

X

R. D. E., 32, M

XI

G. N., 38, F

XII

G. W., 18, F

XIII

W. S., 57, M

xxv

S.

xv

J. M., 32 F

H.,

21,

21,

M

M

I

TO RESTORE

-

ANAL

FUNCTION

FoIIow-Up Period

Operation

IIeostomy; Iater cotectomy and ileosigmoidostomy (Fig. ID.) Total coIectomy and anaI ileostomy (Fig. IC.) Unprotected ileosigmoid (Iow) anastomosis (Fig. ID.) IIeostomy; later colectomy; Iater iIeorecta1 anastomosis (Fig. 2A.) Ileostomy and coIectomy; Iater unprotected iIeorecta1 anastomosis (Fig. 2A.) IIeostomy and colectomy; Iater unprotected iIeorecta1 anastomosis (Fig. 2A.) Unprotected iIeorecta1 anastomosis (Fig. 2B.) Colectomy and high, primary unprotected iIeorecta1 anastomosis (Fig. 2B.) CoIectomy and high, primary iIeorectaI anastomosis; proximal Ioop iIeostomy (Fig. 2C.) CoIectomy and high, primary iIeorecta1 anastomosis; proxima1 Ioop iIeostomy (Fig. 2C.) Colectomy and iIeorectaI anastomosis with proxima1 end ileostomy (Fig. 3A.) six mo. later, cIosure of ileostomy, and ileoiIeostomy (Fig. 3B.) Colectomy, iIeorecta1 anastomosis with proxima1 end iIeostomy (Fig. 3A.) seven mo. later ileoileostomy (Fig. 3C.) three mo. Iater, cIosure of iIeostomy and iIeoiIeostomy (Fig. 3D.) CoIectomy, ileosigmoidostomy (Fig. ID.) two yr. later, ileorectal anastomosis and proxima1 end ifeostomy (Fig. 3A.) CoIectomy, ileorecta1 anastomosis and proximal end iIeostomy (Fig. 3A.) CoIectomy, iIeorecta1 anastomosk and proximaI end ileostomy (Fig.

Three mo.

Recta1 fistuIa forced abdomina1 ileostomy Cramps and severe excoriation forced abdomina1 iIeostomy Good, but Iost to fohow-up after seven mo. Excellent, but has had gastric uIcer and pyelonephritis Severe anorectal recurrence forced abdomina1 iIeostomy

Two mo. Seven mo. Four yr. Four mo.

Five mo.

Thirty-five

mo.

Six mo.

Twenty-nine

mo.

Severe anorecta1 recurrence and hemorrhage forced abdomina1 iIeostomy PseudopoIyposis, twelve stooIs a day, active bIeeding, but is we11 Fair; fissure, some bIeeding

Fair; rectal stricture, ileostomy not cIosed

Thirty mo.

Fair; shght inffammation, tomy not cIosed

iIeos-

Sixteen mo.

Good; occasional

Six mo.

Excellent in six mo. closure of ileostomy

Fifteen mo.

Fair, rectal inflammation iIeostomy not cIosed

Four mo.

Fair, but too earIy to judge; iIeostomy not closed

Two mo.

Fair, in spite of necrosis of ilea segment

constipation

since

fina

persists,

3A.)

uIcerative cohtis, but who had the form of regiona enteritis occasionaIIy found restricted to the coIon and mistaken for typical ulcerative colitis. Many technical tricks have been tried, however, to accompIish restoration of ana continuity. Ravitch [2] has puIIed the ileum through the ana sphincter (Fig. IC), and various surgeons have performed iIeosigmoid

usualIy some invoIvement, however, and the surgeon is faced with the need to attempt an anastomosis in diseased bowe1, and to expect it to heal whiIe carrying the feca1 stream. Dukes and Lockhart-Mummery [I] have recently suggested that iIeorecta1 anastomosis was apt to be successfu1 only in those patients who did not actuaIIy have chronic idiopathic 349

Barker

and Ozeran

C

FIG. 2.

A, side to end iIeorecta1 anastomosis. B, end to end iIeorecta1 anastomosis. C, side to end iIeorecta1 anastomosis with proximal Ioop iIeostomy. D, “inverted g” iIeoiIeostomy and iIeorecta1 anastomosis.

anastomoses [3,4]. (Fig. ID.) These latter attempts to preserve anal continuity have never gained complete acceptance. AyIett [5], Brown, Turnbull and Diaz [6] and FaIIis, Barron and Camacho [7] have reported iIeorectaI anastomoses at a low level in the rectum. Aylett has commonly used a complementary Ioop ileostomy to protect the ileorectal anastomosis. (Fig. zC.) Fallis introduced the “inverted-g” loop to take the pressure off the small anorectal pouch. (Fig. 2D.)

sigmoid colon. In March 1952, the majority of the coIon was resected, the iIeostomy taken down, and an iIeosigmoidostomy performed. (Fig. ID.) In June of 1952, a serious recta1 fistuIa deveIoped and required restoration of an abdomina1 ileostomy. One year Iater he was working and doing weII. CASE II. In F. D. B., a thirty-five year oId man, uIcerative colitis deveIoped in 1950. TotaI coIectomy and ana iIeostomy (Fig. IC) were performed in January 1952. Cramping, diarrhea and perinea1 excoriation forced the construction of an abdomina1 iIeostomy in ApriI 1953. The patient has done well since that time.

During the Iast thirteen years we have encountered fifteen patients in whom some form of operation could be performed to restore ana function. Their cases are summarized below and in Table I. CASE

CASE III. J. A. F., a fifty-six year oId man, was first admitted to the hospita1 for acute ulcerative coLtis in January 1957. BIeeding and severe pseudopoIyposis Ied to performance of a partiaI colectomy and a Iow iIeosigmoidostomy (Fig. ID) in November 1957. He was doing weI1, having onIy two or three stooIs a day in June 1958.

REPORTS

CASE I. H. A. J., a thirty year oId man, had ulcerative colitis since 1948. An ileostomy was performed in 1951 because of a perforation in the

350

IIeorectaI

Anastomosis

CASE IV. 1.. M., a thirty-nine year oId woman was first seen in January 1958. IIeostomy had been performed in another hospitaI in 1957 after about six years of intestina1 disease. After a partiaI coIectomy and revision of the iIeostomy in January 1958, an iIeoproctostomy (Fig. 2A) was performed in October 1958. The rectum appeared substantiaIly normaI at this time. The iIeoproctostomy healed promptly and has been satisfactory since that time with two to four formed stooIs a day. She has suffered other serious probIems, however with acute gastric ulcerations, chronic pyeIonephritis and nephroIithiasis. CASE v. R. W. B., a twenty-four year oId man, had had ulcerative coIitis since 1953. He was treated by iIeostomy and coIectomy in December 1957. He did weII, but because of the apparent innocence of his recta1 segment an iIeorecta1 anastomosis (Fig. 2A) without a diverting iIeostomy was performed in December 1958. The rectum at the level of anastomosis was grossly normaI, but showed considerabIe fibrosis microscopicalIy. A severe recurrence of symptoms of colitis forced a recreation of the iIeostomy and an abdominoperineal resection of the rectum was performed in March 1959. The patient made an uneventfu1 recovery and has been we11 since. CASE VI. E. E. R., a thirty-three year old man, had had uIcerative colitis for eIeven years before a perforation of the coIon forced an iIeostomy (doubIe barrelled) in October 1958. After a stormy postoperative period, he did we11 and gained weight; in January 1959, a partia1 coIectomy and iIeorecta1 anastomosis (Fig. 2B) was performed. PostoperativeIy, there was temporary adrena faiIure, a later bout of massive recta1 bIeeding and pseudopoIyposis, and continued disease. In December x962, he was having ten to tweIve stooIs a day, occasiona bleeding, but maintaining his weight and is weII.

treated by ileostomy at another hospital. PartiaI coIectomy was performed in June 1959, and an iIeorecta1 anastomosis was performed at the same time. (Fig. 2B.) He had one bout of intestinal adhesions, and some minor trouble with an anaI fissure and proctitis; however, when last seen in December 1959, he was doing weII. CASE IX. In L. W. F., a twenty-two year oId man, uIcerative colitis deveIoped in 1957. An iIeorecta1 anastomosis and partia1 coIectomy were performed in May 1960. A doubIe barreIIed ileostomy was made proxima1 to the anastomosis. No disease, other than a few petechial hemorrhages, was seen in the rectum. (Fig. 2C.) In October 1962 he was found to have a miId recta1 stricture. The rectal mucosa was paIe and fragiIe, but did not show any uIcerations. His ileostomy is not compIetely diverting and spiIIs into the recta1 segment when his bag is full. The iIeostomy has not yet been cIosed.

CASEx. R. D. E., a twenty-one year old man, was operated upon in May 1960 for an uIcerative coIitis that had been present for two years. A partia1 coIectomy was performed. The iIeum was sutured to the upper rectum, and the anastomosis was protected by a proxima1, “doubIe-barreIIed,” diverting iIeostomy. (Fig. 2C.) Minimal evidence of rectal disease was present at the time of operation. The patient made an uneventfu1 recovery; but when last seen in December 1962, he stiI1 had pain and bIeeding with mildly active inflammation in the rectum. The ileostomy, however, has not been cIosed. CASE XI. G. N., a thirty-eight year old woman, had had uIcerative coIitis for fifteen years. In June 1960, a partiaI coIectomy was performed. The ileum was anastomosed to the rectum. The iIeum was compIeteIy divided about 5 inches proxima1 to the anastomosis. (Fig. 3A.) The distal end was cIosed, and the proximal end brought out as an ileostomy. In February 1961, the ileostomy was taken down and an iIeoiIeostomy performed. (Fig. 3B.) The rectum appeared SubstantiaIIy norma at both operations. The patient made an uneventfu1 recovery and has done we11since that time.

CASE VII. J. B., a thirty year old man, was operated upon in February 1958 after seven years of chronic uIcerative colitis. An iIeostomy was performed with partial coIectomy. In December 1958, the patient experienced an episode of intestinal obstruction due to an adhesive band. An iIeorecta1 anastomosis (Fig. 2A) was performed at this time without any protecting iIeostomy. The rectum appeared entireIy norma at that time. The patient did fairly we11 for a short time, but experienced massive hemorrhage from the ana segment; the abdominal ileostomy had to be restored in May 1959. He has been we11 since that time except for a recurrent stoma1 stricture.

CASE XII. G. W., a seventeen year oId girl, had suffered from a chronic enteritis for at Ieast seven years prior to the deveIopment of peritonea1 and vagina1 fistuIas which Ied to colectomy, iIeorecta1 anastomosis and proxima1 iIeostomy in November 1961. (Fig. 3A.) Although a rectovagina1 fistula was present, the remaining recta1 mucosa appeared normaI. There was some doubt as to the identity of the pathologic condition of the disease process. The fistula healed promptIy and because of her urgent wish to return to coIIege without an ileos-

CASE VIII. In H. G., a forty-two year old man, acute ulcerative colitis deveIoped in 1958, and was 351

Barker

and Ozeran

B

FIG. 3. A, ileorectal anastomosis with proxima1 end iteostomy. B, compIetion of stage A by closure of iIeostomy and iIeoiIeostomy. C, side to end iIeoiIeostomy above ileorectat anastomosis with persisting iIeostomy serving as dista1 vent. D, completion of stage “C” by c Iosure of iIeostomy as iIeoiIeostomy to form an “inverted 9” loop above the iIeorecta1 pouch.

tomy the first step, iIeoiIeostomy (Fig. 3C) was performed in July 1962. The recta1 mucosa accepted the fecal exposure without reaction, aIthough the dista1 iIeostomy served as the major vent. The fma1 step in the cIosure of the iIeostomy was performed in September 1962, by turning the end of the iIeum back into the side of the iIeum. (Fig. 3D.) The patient registered in coIIege six days Iater and has been we11since without bowe1 symptoms or recurrence of the fistuIa.

completely diverting proximal end ileostomy. (Fig. 3A.) The iIeostomy functions weI1, but the presence of occasiona episodes of anorecta1 inflammation makes it undesirabIe to attempt closure yet. CASE XIV. S. J. H., a twenty-one year oId man, was operated upon in November 1962 because of uIcerative coIitis of three years’ duration. A partia1 coIectomy and iIeorecta1 anastomosis was performed with a proxima1 end iIeostomy. (Fig. 3A.) The rectum appeared atrophic, but was not invoIved in the severe form of the disease that affected the remainder of the coIon. He has to date made an uneventfu1 recovery.

CASE XIII. W. S., a fifty-nine year oId man, had suffered from ulcerative colitis for fourteen years. Two years previously a partia1 coIectomy and an iIeosigmoid (Fig. ID) anastomosis, had been performed eIsewhere. This was foIIowed by an uncontroIIabIe diarrhea, and the deveIopment of a recta1 fissure. In August I 94 I, a Iower anastomosis was performed between ileum and rectum; the rectum was miIdIy inflamed but not deepIy ulcerated. The anastomosis was protected by a

CASE xv. J. M., a thirty-two year oId woman, had had ulcerative colitis for thirteen years. The rectum was substantiaIIy norma in appearance, and so partiaI coIectomy, iIeorecta1 anastomosis, and proxima1 end iIeostomy (Fig. 3A) were per-

352

IIeorectaI

Anastomosis

formed in December 1962. The patient’s course was compIicated by necrosis of the ilea Ioop attached to the rectum, but after sloughing and discharging this piece of boweI, healing has pro-

the diffIcuIty in fitting a proper appIiance. A further probIem with the Ioop Jeostomy is that it is not adequately diverting, as indicated in patient, Case x. For this reason, we prefer the end iIeostomy that is compIeteIy diverting as shown in Figure 3A. This aIIows heaIing of the iIeorecta1 anastomosis without the necessity of supporting a feca1 current. If healing fails, and colitis in the recta1 segment persists, then resection can be performed with the sacrifice of onIy a few inches of terminal iIeum. If healing is satisfactory, closure of the ileostomy can be performed by a reIativeIy simpIe iIeoiIeostomy, attaching healthy iIeum to heaIthy iIeum. In patient (Case XII), the desirabiIity of cIosing the iIeostomy at an earIy date caused us to accept a compromise. Because a recta1 fistula had existed previousIy, we avoided cIosing a we11 functioning ileostomy without some protection. An iIeoiIeostomy was made, between the side of the termina1 iIeum severa inches proxima1 to the ileostomy, and the end of the iIea1 cap that had been attached to the rectum, as in Figure 3C. The functioning iIeostomy served to decompress the anorecta1 segment. After three months the recta1 segment showed no inffammation. The iIeostomy was taken down, and the potential bIind end of the iIeum was returned to serve as part of described by the “inverted 9” anastomosis FaIIis. (Fig. 3D.) The patient made a prompt recovery. The principIe described in the previous paragraph might be applied to the cIosure of an iIeostomy if the patient has a simpIe mucous fistuIa. (Fig. IB.) This particuIar modification has not yet been performed by us. A side to end iIeorecta1 anastomosis (Fig. 4A) wouId Ieave the functioning iIeostomy as a protecting vent. If healing occurs, then the iIeostomy could be cIosed by turning the end of the iIeum back into the side of the iIeum, as in either Figure 4B or Figure zD. It is anticipated that such a procedure wouId carry Iess risk than direct cIosure in one stage. If colitis recurs, the rectum might be removed and continuity restored without destroying the functioning iIeostomy. We have not been able to cIarify the question of the pathoIogic nature of disease suitabIe for iIeorecta1 anastomosis. CertainIy, there is some question as to the nature of the pathoIogic process in Cases IV, XII and XIII.

gressed uneventfuIIy. RESULTS

OnIy six of the patients who have been operated on have maintained ana restoration. Four others have had to have an abdomina1 iIeostomy restored. Five patients have been operated upon who stiI1 have a defunctionahzing ileostomy. Two of these patients have Ioop ileostomies; one of these is not adequateIy defunctionaIizing; neither patient has a recta1 segment free enough of inflammation to aIIow cIosure of the iteostomy. Of the three patients with an iIea1 Ioop attached to the rectum and a compIeteIy defunctionalizing iIeostomy, one has some evidence of inflammation in the recta1 segment, one had been operated upon too earIy to be a definitive test; and the third is a technica faiIure from necrosis in the iIea1 segment that was attached to the rectum because of impairment of the mesenteric supply to that Ioop. Patients (Cases I, III and XIII) were subjected to successful iIeosigmoidostomies. This operation, however, is generaIIy unsatisfactory. AyIett has documented the observation that the severe form of uIcerative coIitis often faiIs to invoIve the actual recta1 segment; this is one expIanation for the frequent faiIure of ileosigmoidostomy and the frequent success of iIeoproctostomy. Patient (Case II), whose ana iIeostomy had to be removed and repIaced by an abdomina1 iIeostomy is representative of the faiIures reported by Ravitch and MandeIbaum [8]. Two of five patients subjected to direct iIeoproctostomy without a protecting ileostomy suffered prompt recurrence and failure, even though in the two faiIures the colon adjacent to the anastomosis was reported at the time of the operation to be free of disease. A third patient with this operation shows persistent disease, but maintains the anastomosis and his genera1 heaIth is good. It seems desirabIe to foIIow the Iead of AyIett and DunIop and perform a diverting proxima1 iIeostomy. Our other experience with the Ioop ileostomy has Ied us to believe that it is not satisfactory because of a greater risk of proIapse, the diEiculty in cIosing the IateraI gutter, and 353

Barker

and Ozeran

FIG. 4. A, side to end iIeorectaI anastomosis with persisting iIeostomy serving as dista1 vent. B, completion of stage A by closure of ileostomy as iIeoileostomy to form an “inverted 9” Ioop.

Minima1 invoIvement of the rectal segment is an essentia1 criterion in choosing cases for operation. At Ieast two reconstructions on patients with SubstantiaIIy norma rectums at the time of operation subsequentIy broke down, and one reconstruction in a patient who actuaIIy had had a recta1 fistuIa apparentIy heaIed (in the presence of proxima1 diversion). AyIett denies that compIete innocence of recta1 disease is a prerequisite to successfu1 anastohowever, to use mosis. We wiI1 continue, reIative freedom from disease as an important criterion for the seIection of candidates for this operation. We, therefore, beIieve that unless specific indications are present for removal of the anorecta1 segment, it shouId be preserved for possibIe future anastomosis.

2.

3.

4

5.

6.

7.

SUMMARY

8.

Experiences with fifteen patients in whom an attempt was made to restore ana continuity are presented. A diverting or at least protecting ileostomy is an important factor in safeguarding the anastomosis. SeveraI variations of technic are needed to meet the specia1 anatomica probIems which are invoIved.

DISCUSSION W.

C.

PracticaI

B.

HUTCHINSON (SeattIe,

Wash.):

I have

enjoyed Dr. Barker’s paper very much and have been intrigued by the many ingenious ways that he has used to protect the iIeorecta1 anastomotic line. No matter how .satisfactory abdominal Seostomy may be, it does not replace the norma mechanism of defecation in a young

REFERENCES I. DUKES,

treatment of uIcerative coIitis. A critica review. Brit. J. Surg., 45: 25, 1957. RAVITCH, M. Anal iteostomy with sphincter preservation in patients requiring total coIectomy for benign conditions. Surgery, 24: 170, 1948. MAYO, C. W. and BRODERS, C. W. The results of subtota1 coIectomy and iIeoproctostomy in the treatment of chronic uIcerative coIitis. Surg. Gynec. ti Obst., 104: 180, 1957. KARLSON, K. E. and DENNIS, C. The elimination of postoperative morbidity in the surgica1 management of chronic idiopathic ulcerative coIitis. Am. J. Gastroenterol., 24: 436, x9.55. AYLETT, S. Total coIectomy and ileorecta1 anastomosis in diffuse uIcerative colitis. Brit. M. J., I : 4.89,1957. BROWN, C. H., TURNBULL, R. B., JR. and DIAZ, R. Ileorectal anastomosis in ulcerative coIitis. Results in twenty-seven patients. Am. J. Digest. Dis., 7: 585, 1962. FALLIS, L. S., BARRON, J. and CAMACHO,E. Restoration of intestina1 continuity after subtota1 colectomy for uIcerative colitis. West. J. Surg., 69: 148, 1961. RAVITCH, M. M. and MANDELBAUM,I. The evoIution of the surgica1 approach to the therapy of idiopathic chronic uIcerative cotitis. S. Clin . North America, 35: 1401, 1955.

and LOCKHART-MUMMERY, H. E. points in the pathoIogica1 and surgica1 E.

354

IIeorectaI age group affected by chronic uIcerative cohtis. Any attempt at an improvement is commendabIe. Our problem has a1way.s been to pick the proper candidate if anything but an abdomina1 iIeostomy is to be done. Once agreement is reached that an anastomosis between iIeum and Iower bowe1 is feasibIe, it is important to make the connection beIow the sigmoid. We are not as positive as some are that excision of the entire coIon removes the great buIk of diseased tissue, and puts the patient in condition to combat the residua1 infection in the rectum. Patients with previous abscesses, fistulas, stricture and pseudopoIyposis will obviousIy be rejected. Like the bards song in My Fair Lady, proper seIection seems to depend on “a IittIe bit of luck.” Our first patient with anal ileostomy compIeted in 1947 and presented at this Society’s 1951 meeting was extremeIy successfu1. Her condition, was a curiosity until her death four months ago, as a resuIt of an auto accident. Every subsequent ana iIeostomy in chronic uIcerative coIitis was a faiIure in spite of sphincters that were abIe to contract weI1. Beoproctostomy that is currentIy being featured, perhaps overfeatured, in the United States and EngIand, is not new and has been used on occasions by many surgeons when the rectum seemed reIativeIy free of disease. A higher percentage of successes wiI1 be obtained in this so-caIIed disease free group as compared to those with some definite recta1 invoIvement. I have had Iess experience with i!eoproctostomy in the group with recta1 invoIvement; however, when attempted, women were seIected as candidates and decompression of the suture Iine was carefuIIy maintained. In contrast to Dr. Barker’s various anastomoses, we simpIy anastomosed end of iIeum to end of rectum at. the peritonea1 IeveI and obtained decompression with a carefuIIy attended coIon tube inserted at the time of operation. Thus, at Ieast one operative procedure is eIiminated without sacrificing a safety factor. Stricture has not been a major probIem in our cases in contrast to many reports. The essayists have one case, a thirty-nine year old woman (L. M.) who wouId meet our criteria for success postoperativeIy. She has two other major diffrcuIties, but has maintained her present lower gastrointestina1 tract for four years. Less observation time folIowing iIeoproctostomy for chronic uIcerative coIitis wouId seem entireIy inadequate. Future Iong-time foIIow-up study of Dr. Barker’s patients would be of extreme interest to me. The crux of this entire probIem seems to Iie in the proper seIection of a candidate for iIeoproctostomy, which we do poorIy at present. The mechanics of successfu1 completion of the procedure have been contributed by this fine paper.

Anastomosis JOSEPH W. NADAL read by ALLEN M. BOYDEN (PortIand, Ore.): Dr. NadaI had to Ieave because of iIIness in his famiIy, and asked me to read his comments: In the past few years, a consensus is growing among pathoIogists and some surgeons that Crohn’s disease, even when Iimited to the colon, can be distinguished from chronic uIcerative colitis on the basis of its distinct pathologic appearance. Dr. Oyama, of the Department of PathoIogy at St. Vincent’s HospitaI, and Dr. NadaI restudied cases of Crohn’s disease and chronic uIcerative coIitis at St. Vincent’s from 1951 to 1960. The study yieIded 139 verified cases of one or the other of the two diseases. Seven cases previousIy cIassihed as chronic ulcerative coIitis had to be redassified as Crohn’s disease. One case had to be recIass&ed from the Crohn’s disease group to the chronic uIcerative coIitis group. AI1 seven cases had extensive invoIvement of the Iarge bowel and the original diagnosis of chronic uIcerative colitis had been based primariIy on this fact. This experience, and that of others (Lockhart, Mummery and Morson), suggests that in Crohn’s disease of the Iarge intestine there is a Iesser tendency for recurrence foIIowing IocaIized resection of the diseased part of the bowe1 than in Crohn’s disease of the smaI1 intestine or than in chronic uIcerative colitis. CouId it be that in a few of the cases reported by Doctors Barker and Ozeran they were deahng with Crohn’s disease? They stated that in three of the cases there was “some question as to the nature of the pathoIogic process” (patients, Cases IV, XII and XIII). It seems to us that in certain patients, particuIarIy those in whom the diagnosis is questionabIe, the surgeon is justified in avoiding, or at Ieast deferring, proctectomy. To add a comment of my own, our pathoIogists, Dr. Oyama and Dr. NoIgren, believe that they can teI1 the difference between these two diseases, perhaps with the heIp of frozen sections. If so, in patients suspected of having Crohn’s disease, it certainIy wouId seem wise to save the rectum temporarily. I am certain that our pathoIogists wouId be most interested in reviewing the sections from patients who have been successfu1 in the series reported today. WILEY F. BARKER (Los AngeIes, Calif.): I have appreciated the kind comments of Doctors Hutchinson, Boyden, and NadaI expressed by Dr. Boyden. We have had no stricture in any of the anastomoses that we have seen. I must say I certainly agree with Dr. Hutchinson that we need a longer foIIow-up period before we know the merits of these procedures. The four years that the patient

355

Barker

and Ozeran

L. M. has had is just a beginning. However, one must start somewhere. Dr. Boyden, we have not been able to cIearIy distinguish these two as effectiveIy as Dr. Oyama has, perhaps. I am very much interested in their abiIity to do this at the operating tabIe by frozen section, because that is the time that we wouId need this kind of information. I wilI be hoping to hear more from them about their criteria for this decision.

356

I certainIy must cIose by saying that before one undertakes an anastomosis under any circumstances, I think one should be certain that the anorecta1 segment is free of pseudopolypoid changes, and that the patient has a good sphincter. If there is anything worse than an abdomina1 iIeostomy, it is an ana iIeostomy without a sphincter. Furthermore, as Dr. Hutchinson said, I would like to have some way of assuring myseIf of a IittIe bit of luck.