Medico-Surgical Teamwork in the Treatment of Ulcerative Colitis

Medico-Surgical Teamwork in the Treatment of Ulcerative Colitis 'VILEY F. BARKER" M.D., F.A.C.S.* SHF~Rl\tlAN

M. MELLINKOFF, M.D.**

FORTUNATE is the individual who requires but a single physician! All of his questions are answered by one man, whose advice is not subject to the erosion and warping that deform the simplest assertion when it is made by two different doctors to an anxious patient. Many patients with ulcerative colitis require the services of two or more doctors, often an internist or general practitioner and a surgeon, and sometimes a psychiatrist. Not uncommonly such patients attempt to provoke dissension among their doctors, much as a child seeking attention or affection complains to one parent about the pronouncements of the other. This uneasy situation, when it appears in an illness whose cause and treatment are still matters of medical controversy, may greatly hinder whatever therapy is undertaken. On the other hand, when the responsible physicians recognize the emotional hazards they face and are able to convince the patient, by word, gesture and facial expression, that they both have confidence in the therapeutic plan and in the abilities of each other, the patient's probing for disagreement and confusion ends by bringing him the reassurance and confidence that he really needs and seeks. Sometimes this teamwork is the difference between life and death. To be effective, each member of the team must be familiar with the problems that confront his colleagues and the principles that guide their therapeutic efforts. It should never appear that a patient is being sent to a surgeon or to an internist as one sends a student to an alien land. Rather it should be clear that the surgeon or the internist is joining the group and brings to it special skills in a common and congenial effort.

From the Departments of Surgery and Medicine, University of California (Los Angeles) School of Medicine.

* Assistant Professor of Surgery, University of California (Los Angeles) School oj Medt"cine; Attending Surgeon, lTeterans Administration Hospital at Los Angeles.

** Associate Professor of Medicine, University of California (Los Angeles) School of Medicine. 1155

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This paper is an attempt to illuminate the ground that is common to the physician and to the surgeon in nonspecific ulcerative colitis. The problems that surgical and nonsurgical colleagues must face together are emphasized. No attempt is made to include the details of nonsurgical medical treatment nor the intricacies of surgical technique, apart from factors in medical and surgical therapy that are intimately dependent upon one another. INDICATIONS FOR SURGICAL TREATMENT

Rupture of the Colon

Free rupture of the colon into the peritoneal cavity is a medical catastrophe. Death from overwhelming sepsis occurs, even in the era of antibiotics so numerous that many of them come and go before most of us have learned to pronounce their names. Short of death, the patient may face months of a withering illness. Peritonitis, treacherous abscesses that are difficult to find and impossible to heal until they are drained, pylephlebitis, septic pulmonary emboli, anemia, hypoalbuminemia, peripheral neuritis, myocarditis or pericarditis, wound dehiscence, bed sores, helpless immobile limbs and stiffening joints-these are some of the ravages of a perforated colon. To have seen a body thus in ruins, and the mind reduced to a fractious, whimpering helplessness, is to be persuaded that colectomy, no matter how vigorously rejected, is preferable to perforation. How soon to operate once perforation has occurred depends upon how soon the patient is seen after the perforation, whether or not it appears that the rupture has been sealed or walled off, and what one may expect to gain from a limited period of antibiotics, restitution of fluid and electrolyte balance, and infusions of whole blood or serum albumin. Unless it is clear that the infection has been localized, surgical intervention should be delayed only long enough to insure a reasonable operative risk-usually a matter of hours or less. Rupture of the colon is often easy to diagnose. Pain that was previously intermittent and related to the urge to defecate becomes steady and is aggravated by movement of the trunk, coughing or breathing. Peristalsis diminishes or disappears. Fever and leukocytosis mount. Tympanites is enormous, whether or not free peritoneal air can be demonstrated by x-ray, and there are localized or generalized signs of peritoneal irritation. Sometimes, however, the perforation is not so obvious, and any ill patient with ulcerative colitis must be scrutinized repeatedly for subtle degrees and fragments of the gross picture. Three factors are particularly prone to camouflage the advent of peritonitis: they are (1) ACTH or adrenal steroids, (2) a toxic psychosis or some other serious psychiatric aberration, and (3) narcotics. ACTH and steroids minimize or conceal the signs of inflammation, and may also produce euphoria or a type

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of psychosis. Mental disturbances vitiate the utility of symptoms and tend to confuse or even antagonize the observers, doctor and nurse. As in other acute abdominal conditions, narcotics may temporarily obscure peritonitis. It is therefore important to recognize these additional hazards and to redouble one's vigilance whenever they are present. An even more trying task is to recognize the imminence of perforation. Rupture may come with little or no warning, especially under cover of steroid therapy, if it happens that in one place ulceration or secondary infection has burrowed nearly through the bowel while elsewhere the colitis is mild, or if the systemic reaction to inflammation is suppressed. More often, however, perforation is apt to follow certain warnings, which may subside quite innocently or announce a rupture. Perhaps the most important of these signals are (1) unremitting abdominal distention and (2) persistently localized pain or tenderness, suggesting inflammation of the serosal surface of some portion of the colon. Other fellow-travelers are protracted high fever, nutritional deterioration, excessive leukocytosis, deep or burrowing ulcerations visualized by barium enema, and the abrupt disappearance of diarrhea while other signs of the disease become more marked. Perforation of the colon is almost always an absolute indication for surgical intervention in ulcerative colitis. Impending perforation is a less certain diagnosis and does not so surely portend disaster. Hence it does not make surgery mandatory, but the likelihood of perforation and the gravity of its consequences must be weighed against the chances of ultimate healing without operation and against the psychological and physical hazards of colectomy at that particular time. It should be recognized that fulminant, protracted ulcerative colitis in a desperately ill patient seldom eventuates in a healed and useful colon, even after subsidence of the acute and dire stages of inflammation. 6 In this situation. when a decision for or against operation is in the balance, it is usually wise for the attending physician to confer with the surgeon, to allow the problem to ripen in both minds simultaneously, and to avoid thrusting a new personality upon the patient suddenly and urgently immediately before any operation that is ultimately undertaken. Sometimes, when it seems best to postpone a decision, both members of the medical team may wish to decompress the bowel with Wangensteen suction, lessening a mechanical factor favoring perforation, and to administer neomycin by mouth, thus speedily reducing the intestinal flora in anticipation of a quick determination to operate and also to diminish peritoneal contamination if rupture should occur. Electrolyte imbalance, especially hypokalemia, should be treated if present, since it may aggravate or cause abdominal distention. Massive Hemorrhage

Next to perforation of the colon the most dramatic imperative in ulcerative colitis is uncontrolled bleeding. Massive hemorrhage may also

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foreshadow a perforation. In most patients with ulcerative colitis blood loss is so slow that severe anemia and hypovolemia can be prevented by the ingestion or injection of iron, provided that food intake is quantitatively and qualitatively adequate to meet the metabolic demands of the illness. In some patients, however, transfusion is necessary, and in a few hemorrhage is massive, requiring quick multiple infusions of quarts or gallons of blood to avoid death. Bleeding of this type is usually seen in an irreversibly diseased bowel, but it may occur, suddenly and without warning, when most of the colon is neither grossly rotten nor badly scarred. Apart from surgical measures there is little that can be done to arrest the bleeding. Any correctable bleeding diathesis should, of course, be treated, but the only ones likely to play an important role in the absence of associated liver disease are those induced by massive blood replacement itself. 13 , 14 Transfusion-induced deficiencies are best treated by the administration of fresh whole blood collected in silicone-coated containers. Steroid therapy, which frequently effects a dramatic abatement of fever and toxemia, is seldom helpful in arresting major hemorrhage in ulcerative colitis. Even surgical intervention is far from an ideal solution to the problem of acute bleeding. The continuing hemorrhage during a long and arduous operation adds to the surgical risk and sometimes dictates a shorter and less complete procedure than would otherwise be desirable. Thus the patient with severe intractable bleeding is caught between hazardous surgery and relatively impotent medical therapy, a dilemma that provokes carping negativism in the patient and captious questions from the relatives. It is usually wise to observe the consequences of rest, adequate sedation, and a reasonable number of blood transfusions. Often nature will do what the physician cannot, and a temporary cessation of bleeding restores conditions more conducive to unanimous decisions and effective surgery. Sometimes, however, the hemorrhage seems interminable, and emergency operation becomes the only choice. If such a crisis is passed without operation, it is usually best to perform elective colectomy soon, before another hemorrhage, which is more likely to occur in a patient who has revealed himself to be "a bleeder." The dangers of multiple blood transfusions are considerable, including anuria, anaphylactoid reactions, and viral hepatitis. The mortality rate from a single pint of transfused blood approximates the mortality rate for an appendectomy. The latter, to be sure, seems harmless enough, but who would not prefer a colectomy to the hazard of 50 appendectomies, especially when the latter risk, even when surmounted, leaves one as vulnerable as ever? Overwhelming Toxemia

There is a fulminant form of ulcerative colitis, or a stage in the disease, sometimes called malignant ulcerative colitis. This type of illness is

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characterized by high septic fever, extreme prostration, nearly total anorexia, poor capacity to retain ingested fluids, and almost continuous bloody diarrhea. Such a patient often raises the question of impending perforation, discussed above, but even apart from perforation the situation is precarious. The body's protoplasm is, consumed by combustion at a profligate rate and ebbed away as blood and pus. Electrolyte and fluid loss are challenging defects, but with diligence can ordinarily be corrected. As long as the inflammatory storm persists, however, the replacement of proteins essential to life is an uphill battle. It, is difficult to persuade the patient to eat; in some cases one is lucky to avoid vomiting on a low-calorie diet. Each meal is apt to be followed-if not interrupted -by a demoralizing, weakening bowel movement. Calories may be supplied as intravenous glucose, or even as fat,llt 12 and infusions of whole blood and serum albumin help to restore proteins. Many other measures, such as elimination diets and various chemotherapeutic agents including azulfidine, are said by some to be curative in ulcerative colitis. In our experience, however, in these severe forms of colitis, no therapy is likely to be effective other than the meticulous general support briefly mentioned above, good nursing care, nurturing the will to live and to cooperate, adrenal steroids, and surgery. Of the nonsurgical measures the only one frequently followed by dramatic improvement is steroid therapy.21 Cortisone or one of the newer adrenocortical anti-inflammatory hormones may be given by mouth, but for reasons as yet unknown, and in contrast to the therapeutic comparison in many other diseases, AC1'H in the treatment of ulcerative colitis appears to be a more powerful agent than any of the presently tested individual adrenal hormones. The requisite dose of ACTH is often in the neighborhood of 40 units by slow intravenous drip or two to three times that amount of depot-ACTH in two divided intramuscular injections daily. Advantages and Disadvantages of ACTH. Whether or not to begin ACTH therapy in a patient acutely and desperately ill with ulcerative colitis is a question that deserves carefully individualized thought. Many excellent physicians regard this crisis as a clear and obvious indication for hormone therapy. In favor of this vie\v is the seemingly miraculous improvement that ordinarily follows the initiation of adequate ACTH therapy within 24 to 72 hours. On the other hand, prolonged observation of such patients lessens the zeal of the steroid therapist.A~b~st, ACrlI does not "cure"the.colitis, but only provides ~re~p~t~. The respite comes as a benison, but time and ag[1in'disheartening relapses appear in the wake of hormone withdrawal. One is then sometimes surprised to find that during an interval in which the patient and the doctor have been convinced from outward signs that the colon was healing, the lesions were, in fact, becoming more marked, as judged by x-ray or by direct inspection at laparotomy. It is as though

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the warning flames were smothered while a steadily destructive smoldering fire burned more deeply and silently. Permanent cure occasionally follows the so-called malignant stage of ulcerative colitis, but much more often, barring death or operation, chronic invalidism of some degree is the eventual reward for temporizing. This ultimate prognosis should be considered in deciding whether or not to use .ACTH, especially since this therapy, for all its dramatic benefits, introduces hazards of its own and impediments to definitive surgical treatment. ACTH may cause or aggravate peptic ulceration or a toxic psychosis. Either of these complications is among the last things the very sick patient with ulcerative colitis can afford to have. ACTH therapy, as mentioned above, may dangerously delay the recognition of a ruptured colon. Prolonged hormone therapy may open the door to bacterial infection. Too often Cushing's syndrome, with its fragile bones and papery skin, is insidiously produced by the doctor, goaded into a slow but inexorable iatrogenic disaster by the patient's refusal to accept surgery on the one hand or post-ACTH relapse on the other. A kind of addiction to ACTH or the corticosteroids may appear before the patient can be persuaded to undergo colectomy, and by this time recovery from the operation is jeopardized by the critical need to manipulate exogenously the corticosteroid requirements of surgery and by the liability to infection and wound dehiscence. In some cases the natural and necessary responsiveness of the adrenal glands to stress is not fully regained for as long as six months or more after steroid administration has been discontinued. All things considered, ·to·begin~CTH therapy in ulcerative colitis is sometimes to open)?andora's box. it is best, therefore, to decide whether or not to give ACTH in each particular case in the light of the above considerations. Certainly one can minimize the hazards of ACTH by an awareness of all of its potentialities, good and bad, and by avoiding the stubborn adherence to a course of action that is empirically a failure. An occasional patient with ulcerative colitis does not improve substantially even at the outset of steroid treatment and despite maximal dosage. Such a patient should undergo an early colectomy; to persist in ACTH therapy without surgery is very risky. If hormone therapy is decided upon and is initially successful, ,the following rules seem to us generally profitable: (1) Every effort should be made to' capitalize upon the return of appetite by improving nutrition, and upon the euphoria by establishing the kind' of rapport that will permit the physician to direct subsequent therapy with the patient's and the family's enthusiastic cooperation. (2) Prophylactic antacids should be given. (3) Edema should be carefully sought, not only in the feet but also in the back and by using the scale, and should be treated or prevented by sodium restriction appropriate to the circumstances, by giving potassium chloride in an absorbable form, and, if necessary, with

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diuretics. (4) Progress of the disease and the advent of complications should be watched carefully as, following a week or two of high dosages, an attempt is made to withdraw the hormones very slowly and cautiously. In this fashion it is usually possible to weigh surgical treatment and prolonged medical therapy and, depending upon the circumstances, at each step, before great harm is done, to choose the lesser risk. Chronic Invalidism.

Surgical intervention in ulcerative colitis, as noted above, is sometimes a life-saving emergency measure. Much more often, however, surgery is not necessary to save life, but rather to make life less onerous and more productive. Here one considers no single aspect of the disease alone, but the degree to which the patient is handicapped by his illness and the likelihood of surmounting various complications as compared with the operative mortality, postoperative disabilities, and the patient's reluctance to accept colectomy. Some of the components of chronic invalidism in ulcerative colitis are considered briefly in the following paragraphs. Diarrhea. There is great variability in the frequency of bowel movements in ulcerative colitis. Constipation may be habitual. Sometimes diarrhea is so severe, even in the absence of grave illness as judged by other signs, that the patient is made miserable, kept from gainful labor, and embarrassed by explosive incontinence if he sleeps soundly or ventures far from a toilet. Such diarrhea is partially due to the colonic inflammation and scarring, often accompanied by chronic inflammatory damage to the anal sphincters, and influenced to a degree by emotional tensions. The more chronic the condition, the less likely is ACTH to be helpful. Codeine or other narcotics are likely to provide great relief, but only for a very limited period of time. Other drugs are usually disappointing. Malnutrition. The chronic inflammatory process constantly adds to the patient's ordinary nutritional requirements. Depending upon the severity of the disease and the patient's determination to eat, and often also upon such natural metabolic burdens as growth, adolescence and pregnancy, various degrees of malnutrition may appear, including hypoalbuminemia, hypogonadism, anemia, low resistance to intercurrent infections and the ordinary vicissitudes of life, and a chronic state of weakness and apathy. A high-calorie, high-protein diet with added vitamins and iron are the major nonsurgical weapons in this long war of attrition. Electrolyte Imbalance. Any chronic diarrheal state, especially one complicated by malnutrition, may create a variety of electrolyte disorders. Most of them are impermanent and correctable. Prolonged unrecognized potassium deficiency, however, may cause a type of nephropathy whose reversibility depends upon the alacrity with which treatment is begun. 2o Liver Disease. Ulcerative colitis may be accompanied by cirrhosis of the liver and other hepatic lesions,24 and in a given case it is difficult to

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say what factors are responsible. Malnutrition, chronic infection, viral hepatitis, and perhaps hypersensitivity phenomena may play a role. The treatment of this type of liver disease is the treatment of ulcerative colitis plus any special problems, such as portal hypertension, that may complicate cirrhosis. Perianal Infections. With severe diarrhea, the perianal skin often becomes macerated and raw, and hemorrhoids and fissures are frequently troublesome. These difficulties are often helped by hot sitz baths, gentle drying of the tender area and coating it with zinc oxide or a similar protective ointment. Often, however, perianal or perirectal abscesses appear, pointing with great pain and tenderness in one of the buttocks. Antibiotics are seldom of much help in treating such abscesses, and they may aggravate the diarrhea and thereby irritate and enlarge the region of cellulitis by causing it to be bathed in a constant fecal stream. Application of heat, usually by means of sitz baths, and, when the abscess is ripe, incision and drainage remain the best conservative forms of therapy. More radical procedures are seldom rewarding, other than definitive colectomy. In fact, local Burgery sometimes stirs up the colitis, and the wound may fail to heal. Usually the perirectal abscess is actually one end of a fistulous tract that connects the skin ,vith the rectum. The proximal opening, often difficult or impossible to visualize through a sigmoidoscope, may nevertheless arise in 11 badly infected rectal crypt. Such a fistula sometimes improves temporarily, but its permanent cure is intimately dependent upon the status of the ulcerative colitis itself. If the rectal wall (or any other part of the colon) is robbed of its integrity by chronic infection and burrowing abscesses, some sort of fistula or sinus is very likely to appear, short of the swifter and far more perilous colonic perforation. Repeated anal infections sometimes destroy or seriously damage the anal sphincter and make control of the diarrhea virtually impossible. Scarring. The bowel is narrowed and shortened by scarring in ulcerative colitis; the severity of the scarring and the dimensions of the lumen depend upon the depth, location and chronicity of the inflammation. After many years the entire large bowel Inay be reduced to a short Ilpipestem" colon, no longer capable of absorbing water and salts and now a nuisance rather than a useful reservoir. Sometimes the major scarring is localized to a particular region of the bowel, often high in the rectum, and a partially obstructing stricture develops. Such strictures may require repeated dilatation and cause various degrees of disability, sometimes a dangerous degree of obstruction. Focal Lesions Associated with Ulcerative Coliti8. A number of organs apart from the colon are sometimes diseased in patients with ulcerative colitis. 4 , 10,22,28 Since no one knows what causes ulcerative colitis, it is impossible to s"ay with certainty how these focal lesions are related to the pathogenesis of the bowel disease. Opinions are circumscribed by em-

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pirical observations alone, and the data are often too meager to allow more than a guess. The problem has been mentioned above in connection with liver disease. Iritis is another complication of colitis; it may be mild and transient, painful and recurrent, manageable with cortisone eyedrops, or intractable and blinding. It usually heals after a colectomy, but sometimes it does not. The same range of severity and capricious outcome characterizes the type of 1'heumatoid arthritis or spondylitis that may accompany ulcerative colitis. A great variety of skin lesions, usually of the erythema multiforme or erythema nodosum type or the putrid undermining ulcers of pyoderma gangrenosum, are in the same general category as the arthritis so far as the course and prognosis are concerned. Even less is kno\vn about a complicating type of nephritis, characterized by painless hematuria and sometimes eventual uremia, or about odd types of pericarditis, myocarditis, focal arteritis, thrombophlebitis, pancreatitis and endocarditis (baterial or nonbacterial) sometimes seen with chronic ulcerative colitis. Such widespread and diverse manifestations of this disease and some of its histological features have led some to propose that ulcerative colitis is a collagen disease. 16 The question remains sub judice. Certainly there are rare patients \vith unquestioned lupus erythematosus whose clinical picture simulates ulcerative colitis. 9 'rhe vast majority of patients with ulcerative colitis, however, are not pathologically identical with those suffering from lupus, nor are "L.E. cells" found in such cases. The important therapeutic consideration is that in most but not all cases the focal lesions will heal if the colitis itself can be made to disappear. Unhappily, complete and permanent disappearance of the colitis is often accomplished only by extirpation. Thus persistence of the focal lesions mentioned above is sometimes a relative indication for surgical intervention even \vhen the colitis itself is not intolerable. The indication is relative rather than absolute because colectomy does not guarantee the healing of the focal lesions. Colectomy, however, remains in our present stage of ignorance the measure most likely to cure ulcerative colitis permanently, and permanent cure of the colitis remains the surest means to heal the associated focal lesions. Amyloidosis. Ulcerative colitis, like most chronic inflammatory diseases, is one cause of secondary amyloid disease. Peculiarly, however, chronic active ulcerative colitis does not result in amyloidosis nearly as often as do many other diseases, such as bronchiectasis and tuberculosis.1 7 As with other forms of secondary amyloidosis, the cure depends upon healing the primary disease, or by removing it surgically. Ulcerative Colitis Elsewhere in the Gastrointestinal Tract. While it would appear that Mrs. Malaprop herself had begun to study medicine, it is nevertheless true that the illness known as ulcerative colitis may affect any part of the small intestine and perhaps rarely even the esophagus. 1 , 18 Usually ulcerative colitis beyond the colon advances no further than the

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terminal ileuIll, but before or after colectomy the disease infrequently attacks the entire small bowel. In such weird and unusual forms of ulcerative colitis treatment must be extemporaneous, since large series of cases are difficult to find. Generally it would appear best to use whatever combination of medical and surgical procedures seem in a given patient most likely to improve nutrition. Sometimes no surgical measure is feasible because the lesions are too widespread to remove and not so much more critical in a localized area that segmental resection is apt to bring about improvement. In other cases segmental resection is advisable despite involvement of the entire small bowel, because one area of the intestine is the major impediment to systemic rehabilitation, due either to severe localized infection or to mechanical obstruction. Then the catabolic insult of the operation must be weighed against the possible advantages. Care must be taken to avoid doing about as much harm as good with a long succession of self-perpetuating surgical procedures, a syndrome reminiscent of Br'er Fox's fist-fight with the Tar-Baby. Cancer of the Colon. Ulcerative colitis does not usually end in 'canc~r of the colon, but the latter disease is about eight times as common in patients with ulcerative colitis as it is in other individuals of the same age and sex. 7 When it does appear in ulcerative colitis, cancer of the colon is usually very difficult to diagnose except by surgical removal. The differentiation of chronic inflammatory distortion and neoplasia is a difficult task for the best radiologist, and the colonic carcinomas that complicate ulcerative colitis are often multicentric or of the linitis plastica variety.8 They are usually Jncur~bl~. Cancers may arise in the hyperplastic stages of ulcerative colitis, when the x-rays show pseudopolyps, or they may appear in atrophic, burned-out residues of the inflammatory process. The longer the duration of the colitis, the higher the incidence of cancer; the average time of appearance after the onset of the colitis is about 17 years. All of these considerations taken together do not, of course, dictate colectomy in every case of chronic ulcerative colitis. They do, however, tend to favor the surgical approach to any patient who has suffered from ulcerative colitis, even in a smoldering form, for many years. When other factors bearing upon colectomy are evenly balanced, the possibility of an ultimately fatal carcinoma shifts the fulcrum upon which the scales rest. PREPARATION OF THE PATIENT FOR OPERATION

The Problem of Acceptance

Many of the factors, pro and con, that the physician considers in deciding whether or not to recommend surgical treatment of ulcerative colitis are considered in the first sections of this paper. Chiefly these factors involve matters of life or death and chronic invalidism. Whatever the physician may decide on the basis of the facts as he sees them, equal

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importance is what the patient considers in making his own decision. Reluctance to undergo major surgery per se is uncommon and usually irrational. The major obstacle is an aversion to having one's anus, as it were, on the abdomen instead of between the buttocks. It is sometimes possible to choose an operation that avoids the question of ileostomy, at least temporarily, but usually the patient must even then be told, in all honesty, that no one can guarantee the indefinite success of such a procedure. Modern ileostomy care can satisfactorily eliminate the physical objections to an abdominal anus, i.e., the odor, the uncontrollability, and the mess. Explanation of these matters helps but does not of itself obliterate the aesthetic barrier involved. The crucial factor in aesthetic acceptance of an ileostomy is usually inseparable from the patient's sexual outlook. In married patients the attitude of the spouse is all-important. In unwed individuals the problem is often more difficult to define, and the only brief comment that covers the various complexities is that many patients have ileostomies in early life and are subsequently happily married. The help of a psychiatrist is sometimes required, but usually an empathic and patient physician can accomplish as much if he takes the time to do so. The physician should avoid two opposite pitfalls. One is to expect the patient to respond quickly and rationally to a highly emotional situation; the doctor is then likely to react with alienating anger or sullen hostility when this expectation is not fulfilled. The opposite pitfall is for the doctor to allow his own emotions, including disgust with ileostomy problems, to create a false and futile sympathy that makes him shrink from frank explanation of the patient's best hope. The anxiety thus generated produces a type of medical myopia, robbing the physician of his ability to read the handwriting on the wall. Of inestimable help in this multifaceted problem of patient-acceptance is the Ileostomy Club. Members of this dedicated organization are to be found in nearly every large city in the United States. They need only to be notified of the problem to begin at once the intelligent, technically expert, friendly educational program of which only the patient who has had an ileostomy is capable. In some cases the Ileostomy Club so opens the heart of the new member that he achieves a happiness apparently impossible before his illness, thus confirming Francis Bacon's observation that "adversity is not without comforts and hopes." The OptilllUIll Physical Condition

Interspersed above with the indications for operative treatment are mentioned many of the principles that influence the preparation of the patient to withstand operation. This association is inevitable, because upon the urgency with which surgical treatment is undertaken depends the length of time one can afford in preoperative treatment. Besides the psychological elements discussed above, the important features of pre-

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paredness are these: (1) Fluid and electrolyte balance, which are reflected in the physical findings, the electrocardiogram, the blood urea nitrogen and electrolyte concentrations, and by the urine output. (2) Nutritional status, reflected in the physical findings and the body vveight, the hematocrit and red cell morphology, and the serunl albumin concentration. It should be remembered that the hematocrit indicates only the concentration and not the volume of the red cell mass, and that malnutrition may reduce the blood volume drastically.19 (3) Special problems peculiar to the individual patient, such as immobility of the limbs in a patient vvith active arthritis associated with his ulcerative colitis. (4) Sterilization of the bowel, which is most quickly accomplished with neomycin. The basic nutritional ingredients of preoperative treatment are fluids and electrolytes designed to meet the encountered pattern; generous administration of vitamins; if iron-deficiency is found, iron by mouth if time allows and the drug is well tolerated, or, if not, intramuscularly; as much food as the circumstances permit; and adequate blood and albumin replacement. In a crisis nothing does more than restoration of the blood volume to shield the patient from the shocks of the operative period. Steroid Therapy Before and During the Operative Period

The advantages and disadvantages of ACTH and corticosteroid therapy in severe ulcerative colitis have been discussed with the indications for operation, since many physicians and patients remain unconvinced that surgical intervention is necessary until the most potent nonsurgical therapeutic agent has been found wanting. It thus happens that a large number of the patients currently subjected to colectomy have within the period of the preceding several months been treated with AC1"'I-I, cortisone, or some similar drug for a considerable length of time. In that case it should be assumed that the patient's native adrenal response to stress is unreliable, and the physician must therefore estimate the steroid requirements. Not to do so is to risk sudden fatal vascular collapse, renal shutdown, or an electrolyte imbalance that may cause a lethal cardiac arrhythmia. One general plan of therapy, among many rational ones, is to give 50 mg. of cortisone acetate intramuscularly every six hours beginning 24 hours before operation and continuing this dosage schedule until the patient is clearly no longer in danger of postoperative shock, often a matter of two or three days. At that point it is usually wise to taper the cortisone, which can effectively be given in the same dosage by mouth or intramuscularly. The dose should be diminished slowly, perhaps 10 mg. a day for a few days and 5 mg. a day thereafter, with close observation for signs of adrenal insufficiency, including unexplained fall in blood pressure or urine output and any unusual gastrointestinal disturbance, such as vomiting, stubborn ileus, or diarrhea. Any general plan, such as

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this one, should be modified to fit the individual conditions. In sudden vascular collapse suggesting an adrenal crisis a therapeutic trial of a quick-acting intravenous adrenal steroid is safe, but the possibility of adrenal failure should not benumb the physician to the possibility of blood loss or some other ordinary cause of hypotension. CHOICE OF OPERATION

At the present time the operation of choice for ulcerative colitis is ileostomy combined with removal of most or all of the diseased colon. Ileostomy was originally the procedure of last resort in almost terminally ill patients, but the development of efficient collecting bags and improvements in general surgical and supportive techniques have enabled the surgeon to be bolder in the treatment of this disease. Those patients in whom the major part of the diseased colon can be removed at the original operation will do vastly better than those in whom simple ileostomy is performed. The remarkably benign course after colectomy and ileostomy is largely due to the removal of the diseased colon, but it is also favored by the fact that removal of the colon allows one to make a technically better ileostomy. rhe cut edge of the ileac mesentery can be more accurately secured to the lateral peritoneal wall, thus reducing the. te~g~tiQY to '-< prolapse and volvulus. ,,- Under some circumstances the rectum has been removed at the time of ileostomy and colectomy. Performance of the entire procedure in this one stage requires not only a skilled and determined surgeon, but also a well prepared patient. It should never be undertaken lightly. In males total colectomy and proctectomy should rarely be performed because the narrower pelvis of the male and the acute inflammation in the rectal segment make pelvic nerve damage a hazard; sexual potency may be lost. This operation is more often appropriate in female patients when they have such serious involvement of the lower rectum as to preclude consideration of any future anastomosis. If there is serious anal and low rectal involvement, and particularly if there is associated fistula, abscess or incompetence of the sphincter, total removal of the rectal segment will be indicated initially or at a later date. It has recently been pointed out by Aylett,2 Turnbu1l26 and others that even when very severe ulcerative colitis exists in the upper rectal segment, there actually may be an area in the lower rectum free of serious ulceration and polypoid formation. ,~Ee"inHammatory--proc~"in-.-thia.~, area seems s9Jnetimes-to-be-a __'.~drip~dGWR~'--phenomenon.. In this group of-patients, success has been achieved with the performance of an ileoproctostomy either as the initial procedure or as a secondary procedure after temporary ileostomy. Ileoproctostomy h~_E;_an llllcertain,·.bat-hopeful status)n the future; Aylett's cases have shown a very low rate of reclirre~~e. -Tnis--operation is to be distinguished from previously de-

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scribed attempts to anastomose ileum to the sigmoid colon or to the anus. In the procedure as described by Aylett the plane posterior to the rectum is dissected free, denervating this segment, and anastomosis is performed about three inches above the pectinate line. Until more clearly proved, it is wi.sest to postpone ileoproctostomy for a time and leave the anorectal segment untouched after initial subtotal colectomy and abdominal ileostomy. One of the factors contributing greatly to the improved surgical results in ulcerative colitis is the immediate maturation of the exteriorized stoma, avoiding inflammation on the exposed peritoneal surface and the secondary serositis of the bowel within the abdomen. The healing of an exteriorized piece of bowel is ordinarily accomplished by gradual scarring of the peritoneal surface so that the mucosa and skin edges are ultimately approximated. During this healing period a dense ring of scar forms under the junction of mucosa and skin. This scar is an unyielding obstructive band that accounts for much of the late ileostomy dysfunction. The present techniques of immediate maturation as advocated by Turnbu1l 26 and by Brooke6 include the immediate eversion of the mucosal surface and immediate direct suture of this everted mucosa to the skin edge. The result is prompt healing without a stubborn collar of scar tissue. Nevertheless there still remains some tendency for ileostomy stricture to form, but it is vastly less than in former years. A variety of other procedures, including vagotomy, sympathectomy and pelvic parasympathectomy, have been tried but have had but limited success. CARE OF THE PATIENT THROUGH THE OPERATIVE PERIOD

Surgical wounds in the depleted patient heal slowly and are prone to infections. For this reason careful judgment must be exercised in the technique of wound closure. Stay sutures are often necessary. Delayed primary closure of skin wounds frequently avoids serious infection even in the face of operative contamination. This latter technique is not rendered unnecessary by "prophylactic" antibiotics. Intubation of the intestinal tract is useful because of the prolonged ileus which may follow this operation. The presence of an indwelling nasal gastric tube for several days may prove an almost unbearable burden to some of these patients who are so thoroughly exhausted from their intestinal complaints, and if prolonged intubation appears indicated, the technique of Smith and Farris,23 which involves intubation through a temporary gastrostomy, can be used. The return of the patient to a nutritious dietary regimen should be the early goal of the surgeon. Intestinal decompression must be maintained until normal ileostomy discharge makes its appearance. A small amount of .:thin, green material may be passed more or less passively before the normal mushy brown stool appears, but does not indicate return of

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adequate intestinal activity. Once normal ileostomy output appears, the patient may quickly but cautiously be advanced to a full and palatable diet. It is to be expected that within two weeks the patient should be back to a substantially normal diet. A few unpredictable dietary idiosyncrasies may become apparent, but many patients regain the ability to take even such remarkable foods as highly spiced Mexican foods, salads, and alcoholic beverages. The physician must offer strong support to the patient during the trying postoperative days in which he has traded his colon for an assortment of tubes, catheters, needles and pain. Once these bedeviling agents go and the patient begins to eat, a most dramatic change in outlook will be seen. ILEOSTOMY APPLIANCES

The modern surgical treatment of ulcerative colitis stems from the invention of satisfactory collecting devices; a multitude of agents are now available. After the immediate maturation of the exteriorized stoma we dress the wound by placing over it one of the soft, transparent disposable bags. This allows protection of the skin so that no erosion of consequence is to be expected. The transparent bag allows the surgeon to inspect the stoma at frequent intervals and to be guided by the type of discharge issuing from it. With early maturation the stoma quickly reaches its permanent size and can very soon be fitted with a permanent bag. Our preference is for one of the hard white rubber bags built over a flat metal ring, which maintains the shape of the face plate that fits over the stoma. In certain types, this plate can be obtained in varying degrees of convexity to fit into the concavity which may develop around the stoma as the patient gains weight. Some patients, however, find that it is uncomfortable to wear these hard-faced bags. Soft-faced plates are also available. It is in the fitting of the permanent ileostomy bag and in the selection of the bag which meets the individual's requirements that the local ileostomy groups have proved most useful. The famous advertising slogan, "ask the man who owns one," is pertinent to this problem. Some member of the ileostomy group has almost invariably faced problems similar to those which arise to plague any individual. One of the greatest catastrophies that can befall a patient with an ileostomy is erosion of the skin. Within a matter of a few hours, particularly in the early postoperative period, serious destruction of the skin can occur that may literally require months to heal. Even after healing occurs, such erosions may leave irregular, thin, scarred skin that does not readily accept a snug-fitting bag and does not adhere well to any cement. It therefore behooves all in attendance on a patient with an ileostomy to take the greatest pains to recognize at the earliest moment impending erosion of the skin. This is usually manifest to the patient by

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a burning sensation in the skin around the stoma. There are many techniques available to protect the mildly eroded skin to prevent further damage. Once significant erosion occurs, of course, none of the organic base cements will adhere to the skin. Under these conditions a variety of techniques may be used, but probably the most satisfactory is the use of karaya gum powder and water to form a gelatinous paste under vvhich the skin can heal. The bag can be applied using this paste, with which it may be as effectively sealed as with the organic based cements. To protect the skin before serious erosion develops and before the skin reaches a state of continuous weeping, tincture of benzoin, plastic aerosol sprays and various other agents can be used. A properly fitted appliance is one of the best safeguards, however, against the development of such an erosion. 1-"he appliance should fit so that there is approximately 1 mm. clearance beyond the mucocutaneous margin. If it is narrower thaii·ThTs;~··iIieii""l:Ire<·Ieastswelling of the stoma may cause the opening to become so tight as to constrict and seriously damage the distal part of the stoma. Anything larger than 1 mm. exposes so much skin to the erosive intestinal juices that a thick fungating ring of scar may develop on the skin itself. POSTOPERATIVE COMPLICATIONS

Early COlllplications

There is nothing different in the recognition or management of the complications common to all surgical operations, such as atelectasis, urinary tract infection, and wound infection. Distention due to paralytic ileus or mechanical obstruction may be difficult to recognize after the bulky diseased colon has been removed from the abdominal cavity. Venous thrombosis is a common complication, having as its background not only the general debility of the patient, but also the necessity for frequent intravenous injections. Becau~e of the danger of this occurrence, the leg veins are used only in cases of utmost emergency. Late COlllplications

Perhaps the most important group of complications are those related to intestinal obstruction. Adhesive bands or attachment of a loop of bowel to the newly created pelvic floor may cause mechanical intestinal obstruction which must be distinguished carefully from the obstruction to be described below. The development of an ileostomy stricture was an almost inevitable sequel to ileostomy prior to the use of the immediate maturation. The tendency still persists, but to a lesser degree. In most patients this is of no significance. Some require a few episodes of gentle digital dilatation. In a very small group continued stricture formation will cause significant

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symptoms. The tendency to stricture formation is more apt to be found in those who have had a great deal of inflammation around the stoma. Obstruction due to stricture has in the past been a difficult thing for the physician to recognize. The distal small bowel does not tolerate even slight degrees of stasis, and serious difficulties may be caused by a scar that seems to encroach only slightly upon the lumen. Serious symptoms, such as cramps and paradoxical diarrhea, may be encountered. This combination can easily n1islead an unwary physician, who assumes that because the stoma is patent and the output greater than it had been, the patient must have either a recurrence of the basic disease or a severe neurosis. The subtlety of this diagnosis was first recognized by Warren and McKittrick. 27 Early recognition of a stricture is essential for the well-being of the ileostomy patient and its treatment is exceedingly simple. Digital dilatation may in some instances be successful, but should be done very cautiously because, if a previous stricture does exist, digital dilatation may only succeed in tearing the mucosa and producing a fistula. The surgical approach is a brief one that is carried out under light general anesthesia. 8 Gentle dilatation is performed, and then with utmost care three or four radial cuts, less than a ccntimeter long, are made through the constricting mucocutaneous scar and the intact submucosa is allowed to bulge through these small incisions, much as in the technique of pyloromyotomy. The bag may be immediately replaced, and healing will follow promptly. It is important to distingiush this form of obstruction from two other situations, namely, primary recurrent enteritis and the obstruction due to adhesive bands. Obstruction due to adhesive bands is usually more sudden in its onset, whereas the obstruction due to stricture is graduaL The former is rarely associated with paradoxical diarrhea. It is more rapidly progressive. It usually cannot be relieved by passing a catheter through the stoma for a few inches as can obstruction due to stricture. It is sometimes more difficult to differentiate a recurrent primary ileitis from a strictured ileostomy. In the first place, the two may be associated. In fact, the tendency toward ileostomy stricture is in some instances due to the failure to remove all of the actively diseased bowel. Furthermore, a simple mechanical stricture with chronic stasis may produce a form of ileitis in the obstructed bowel, but this ileitis is nonspecific in form, and is consistent only with chronic intestinal obstruction. A patient with recurrent ileitis, however, is much less apt to have done well in the past, is more apt to have weight loss, fever and more signs of systemic disease. It may be necessary to relieve the stricture, whatever its cause, in order to carry out further diagnostic studies, which in general are those used in the investigation of any small bowel disease. The patients who have had ulcerative colitis and who have had an ileostomy are often susceptible to all manner of systemic stresses which

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will be reflected in an increased activity of the gastrointestinal tract. It is not uncommon, therefore, for the patient to have diarrhea following an upper respiratory infection or some other minor and unrelated illness. Such episodes are self-limited, and the patient can usually match his loss of fluids with an increased intake of fluids and salts. Prolapse of the ileostomy is one of the most difficult complications of the late surgical period. This is a form of intussusception, often coupled with a peristomal hernia. Prolapse of the stoma for a distance of a centimeter or two beyond the normal length is not unusual. However, when prolapse exceeds a few centimeters it may be progressive and lead to the protrusion of 3 or 4 feet of bowel through the abdominal ring, creating extreme pain and complete intestinal obstruction. The prolapsed bowel may become gangrenous and either perforate or require surgical resection. This situation, therefore, must be quickly recognized and jf necessary treated surgically to avoid catastrophe. The immediate supportive treatment is the application of ice, sedation of the patient and immediate bed rest. Under most circumstances the prolapse will reduce itself. Once a full scale prolapse has occurred, however, it is more apt to recur and one should consider its surgical correction. Surgical treatment of prolapse may involve making the abdominal ring slightly more snug, reattachment of the ileac mesentery to the lateral gutter right up to the peritoneal ring itself, and even plication of the mesenteric curtain. Plication of the bowel as described by Noble for intestinal obstruction, and as recently advocated by Lichtenstein,16 is another useful technique. Closely akin to prolapse is the tendency of the bowel to retract within the abdominal ring. In both of these situations, the mucosa is attached to the abdominal wall as a simple ring instead of as a cylinder. Once retraction does occur there is a very prompt tendency for the cutaneous ring to close over. Not infrequently, patients are encountered in whom retraction has occurred and in whom there is only a mound of granulation tissue to mark the stoma, which must from time to time be cannulated with some kind of a catheter to allow evacuation of the ileac contents. This situation, of course, demands full scale revision of the ileostomy. The development of any change in symptomatology in the defunctionalized bowel should alert one to the serious possibility that neoplasm has become a part of the clinical picture. 'I'he risk of neoplasm is, of course, one relative indication for removal of all of the colon which cannot be directly inspected by means of sigmoidoscopy. Another of the complications that plagues the patient with ulcerative colitis is fistula formation. It is not infrequent to have fistulas develop in the stoma itself. These are of no consequence as long as the internal aspect of the fistula does not lie below the level of the skin. The fistulasshould be laid open so that they may heal from the bottom, and the stoma trimmed to restore symmetry. The fistulas which open proximal

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to the skin line or drain out into the skin itself pose serious problems, because they prevent adherence of the ileostomy bag, and these must usually be treated by formal revision with an exteriorization of a new piece of bowel. Traumatic dilatation of the stoma may be responsible for a break in the mucosa leading to a fistula, but in some instances the fistula arises from intrinsic disease in the bowel itself. Erosion of the margin of the stoma by the plate of the ileostomy bag may also occur when the ileostomy bag slides across the surface of the skin. RESULTS

Since the opening of the University of California at Los Angeles Hospital three years ago, 26 patients with ulcerative colitis have been treated here surgically. The cases of nine of these who had previously been operated upon elsewhere are summarized in Table 1. In the remaining seventeen instances the initial ileostomy was performed at our hospital. Ten patients had a one-stage total colectomy and proctectomy. In three further cases ileostomy and partial colectomy were followed at a later stage by completion of the coloproctectomy. Four patients have been left with an anorectal segment and may be candidates for future ileorectal anastomosis. There were two deaths, both occurring in severely depleted patients who looked like Buchenwald graduates at the time of their admission to this hospital. One patient died five months postoperatively due to a combination of extensive enteritis, cholecystitis, peritonitis, pulmonary edema, iliac thrombophlebitis, cholangitis and gastric ulceration. The other death occurred in a patient who was operated Table 1 COMPL1CATIONS REQUIRING REOPERATION IN NINE PATIENTS INDICATION FOR FURTHER OPERATION

1. Stricture and

retraction 2. Stricture and retraction 3. Stricture 4. Stricture, fistulas

5. Prolapse of the ileum 6. Prolapse of the ileum 7. Chronic rectal discharge 8. Rectal bleeding 9. Perineal absce~s

PROCEDURE

Revision Revision and abdominoperineal resection Lysis (2 times) Abdominoperineal resection, temporary transplantation ileofZtomy to epigastrium, restoration to right lower quadrant Mesenteric plication Repair of perj~tomal hernia, revision of ileac attachments Abdominoperineal resection Abdominoperineal resection Incision and drainage

RESUr..T

Prolapse: ultimate Ileorectal anastomosis Good Good Good, physically (suicide, Nov. 1958 for unrelated emotional reasons) Good Good Good Good Good

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Table 2 COMPLICArl'IONS IN

15

PATIENTS SURVIVING SURGERY FOR

U LCERA1~IVE

COLITIS

Ileostomy retraction or necrosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Wound infection " Stenosis of ileo8tomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Intestinal obstruction due to bands or internal hernia " Thrombophlebitis " Transfusion hepatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

3

2 2

3 1 1

upon after receiving 54 pints of blood in two days prior to operation. On the eleventh day after operation the patient, who had begun to eat and to be ambulatory, died of electrolyte disturbances and hyperkalemia, probably due largely to difficulties in the withdrawal of steroid hormones. In spite of numerous complications (see Table 2) the remaining 15 patients have done well, averaging more than 15 pounds of weight gain, some gaining up to 60 pounds. All are in good nutritional condition. While such complications require vigilant care, they are in most cases relatively minor compared with the primary disease. All 15 of these patients have been restored to a useful and happy life. REFERENCES 1. Achenbach, H., Lynch, J. P. and Dwight, R. W.: Idiopathic Ulcerative Esophagitis. Report of a Case. New England J. Med. 255: 456-459 (Sept. 6) 1956. 2. Aylett, S.: Total Colectomy and Ileo-rectal Anastomosis in Diffuse Ulcerative Colitis. Brit. M. J. 1: 489, 1957. 3. Barkor, W. F.: Factors Contributing to Ileostomy Dysfunction. vVest. J. Surg., Gbst. & Gynec. 64: 235-239, 1956. 4. Ba.rgen, J. A.: Complications and Sequelae of Chronic Ulcerative Colitis. Ann. Int. Med. 3: 335-352 (Oct.) 1929. 5. Braoke, B. N.; Ulcerative Colitis and Its Surgical Treatment. Edinburgh, E. & S. Livingstone, 1954, p. 100. 6. Flood, C. A. : Symposium on l\ianagement of Ulcerative Colitis (Burrill B. Crohn, Moderator). Bull. New York Acad. lVled., June, 1958. 7. Goldgraber, 1'1. B., Humphreys, E. M., I{irsner, J. B. and Palmcr, W. L.: Carcinoma a.nd Ulcerative Colitis, A Clinical-Pathological Study. 11. Statistical Analysis. Gastroenterology 34: 840-846 (May) 1958. 8. Goldgraber, M. B., Humphreys, E. M., Kirsner, J. B. and Pahnel', W. L.: Carcinoma of the Colon, a Clinical-Pathological Study. 1. Cancer ])eaths. Gastroenterology 34: 809-839 (May) 1958. 9. Harvery, A. M. a.nd others: Systernic Lupus :Erythematosus: Review of Literature and Clinical Analysis of 138 Cases. Baltimore, Williams & Wilkins Co., 1955, 437 pages. 10. Jensen, E. J., Baggenstross, A. H. and Bargcn, J. A.: Renal Lesions Associated with Chronic Colitis. Am. J. M. Se. 21.9: 281-290, 1950. 11. Jordan, P. H . ..Jr.: Use of Intravenous Fat Emulsion in Management of Surgical Patients. Arch. Surge 76: 794-806 (l\1ay) 1958. 12. Jordan, P. H. Jr.: Symposium on Intravenous Fat Emulsions. Metabolism 6: 656-665 (Nov.) 1957. 13. Krevans, 1. R., Jackson, D. P., Conley, C. L. and Hartman, R. C.: Nature of Hemorrhagic l)isorder Accompanying I-Iemolytic Transfusion Reactions in Man. Blood 12: 834-843 (Sept.) 1957.

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14. Krevans, J. R. and Jackson, D. P.: Hemorrhagic Disorder Following Massive Whole Blood Transfusions. J.A.M.A. 159: 171-177 (Sept.) 1955. 15. Levine, M. D., Kirsner, J. B. and Klotz, A. P.: New Concept of Pa.thogenesis of Ulcerative Colitis. Science llJ,.: 552-553 (Nov. 23) 1951. 16. Lichtenstein, 1. L. and Herzekoff, S. S.: Recurrent Ileostomy Prolapse-An Old Problem. Ann. Surge lJ,.1: 95-97, 1955. 17. lVlandelbaum, J. and Bryk, D.: Idiopathic Chronic Ulcerative Colitis and Amyloidosis. J. Mt. Sinai Hosp. New York 22: 24-33 (May-June) 1955. 18. McCready, F" J., Bargen, J. A., Dockerty, M. B. and Waugh, J. M.: Involvement of Ileum in Chronic Ulcerative Colitis. New England J. Med. 2J,.0: 119-127 (Jan. 27) 1949. 19. Nelson, W., Clark, J. and Linden, M. C.: Blood Volume Studies in Depleted Surgical Patient, Clinical Applications. Surgery 28: 705-715 (Oct.) 1950. 20. Relman, A. S. and Schwartz, W. B.: Kidney in Potassium Deficiency. Am. J. Med. 24: 764 (May) 1958. 21. Rosenak, B. D. and others: Present Status of Treatment of Chronic Ulcerative Colitis with Steroid Hormones. Gastroenterology 34: 879-891 (May) 1958. 22. Samitz, M. H. and Greenberg, 1\1. S.: Skin Lesions in Association with Ulcerative Colitis. Gastroenterology 19: 476-479, 1951. 23. Smith, G. K. and Farris, J. M.: Rationale of Vagotomy and Pyloroplasty in Management of Bleeding Duodenal Ulcer. J.A.M.A. 166: 878-881 (Feb. 22) 1958. 24. Spellberg, M. A.: Diseases of Liver. New York, Grune & Stratton, 1954, 646 pages. 25. Turnbull, R. B. Jr.: Surgical Treatment of Ulcerative Colitis. Colectomy and Supra-anal Ileorectal Anastomosis. Delivered at A. M. A. Scientific Assembly, San Francisco, June 24, 1958. 26. Turnbull, R. B. Jr.: Management of Ileostomy. Am. J. Surge 86: 617-624,1953. 27. Warren, R. and McKittrick, L. S.: Ileostomy for Ulcerative Colitis. Surg., Gynec. & Obst. 98: 555-567, 1951. 28. Wasserman, F., I{rosnick, .A.. and Tumen, II.: Necrotozing Angiitis Associated with Chronic Ulcerative Colitis. Am. J. Med. 17: 736-743 (Nov.) 1954. University of California at Los Angeles Medical Center, Los Angeles 24, California