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Papers on ulcerative colitis
Papers
on Ulcerative
QUESTION
AND
ANSWER
Colitis PERIOD
WILEY F. BARKER, M.D., Moderator
DR. WILEY F. BARKER (Los Angeles, California): We have quite a few questions here. Dr. Van Prohaska, wilI you expIain the high percentage of restoration of continuity. I beheve that there was a reIativeIy Iarge number of cases in which you were abIe to perform an iIeorecta1 anastomosis. DR. JOHN VAN PROHASKA(Chicago, Illinois): I do not think it was so high. In 43 per cent of the patients we performed a tota coIectomy with proctectomy. In 8 per cent of the patients we performed a subtotal coIectomy, Ieaving the recta1 stump because they were too acuteIy iI for the compIete colectomy. The remainder of the patients (and I think the question reaIIy refers to these patients) definiteIy had some form of iIeocoIostomy or iIeorecta1 sigmoidostomy primariIy because they had a segmental disease. DR. JAMES D. HARDY (Jackson, Mississippi): May I ask just one question? DR. BARKER: Yes, Dr. Hardy. DR. HARDY: It has been said, Dr. Van Prohaska, and it may we11 be true, that removal of the rectum after the iIeostomy wiI1 diminish the fluidity or the profuse drainage from the ileostomy more quickly; is that so? DR. VAN PROHASKA: I did not notice that. I wouId not be abIe to answer that. DR. BARKER: Dr. LeVeen, do you have any answer to that? DR. HARRY LEVEEN (New York, New York): No, I have not noticed it either. DR. BARKER: I know that a few instances have been described in which the patient just did not stop Iosing blood unti1 the IocaI perineal remova1 of the recta1 segment had been carried out. I have seen it occasionally; and I have aIso seen it faiI to alter the consistency of the iIeostomy. I do not reaIly think that that AmericanJoutnol
of Strrgery,
Volume
103. Janmary
1q.h
is a good observation; there may be some other factor invoIved. Dr. Lyons, wiI1 you discuss the choice of patients and the conditions under which some kind of ileorecta1 anastomosis may be performed? DR. ALBERT S. LYONS (New York, New York): First, we have to dea1 with severa types of ulcerative colitis. As Dr. Van Prohaska mentioned, when it is segmenta colitis and the rectum is normal, an anastomosis of the iIeum to the norma rectum with subtota1 coIectomy is in order. Even then, I must admit that, in making a Iong-term study, in at Ieast one-third of such cases recurrences occurred in the rectum. The second type is the diffuse uIcerative colitis in which we leave the rectum intact and then in subsequent years, after we think it has returned to normal, perform the anastomosis. There are just as many peopIe who beIieve that the entire rectum should be removed as there are those who beIieve that a11 the rectum should be saved. From my own experience in our hospita1 I wouId say that onIy thirteen such reanastomoses have been performed, three of which failed; the others have been successfu1, one for as Iong as eighteen years; a few are onIy a few years oId. The third type is the diffuse universa1 ulcerative colitis in which the colon is removed and a primary anastomosis of smaI1 bowe1 to diseased rectum is made deIiberately. This is the procedure advocated by Mr. AyIett in London, EngIand. It is incomprehensibIe, I know, and yet the figures that he has reported are extraordinary. I have seen him perform this procedure; I have also seen the patients in foIIow-up and 66
Papers on UIcerative
Colitis
for surgica1 management,
the coions that were removed with the Iine of transection right through the diseased bowel. I have seen these patients a few years later and have examined them sigmoidoscopicaIIy myself. In some the rectal mucosa had been friabIe, in others it had returned to aImost normal. I do not advocate this procedure; I just mention it only for your consideration and discussion. These are the three different reasons for performing an anastomosis to the rectum and I wouid say that at the present time the choice depends on the surgeon’s philosophy more than it does on the facts at hand. DR. BARKER: Dr. Lyons, I would suggest that the success of that procedure depends on some factor that we know nothing about. We have performed very few. Seven or eight, I believe, have been undertaken at U. C. L. A. and the V. A. HospitaI; two in which the anastomosis was made to histoIogicaIly norma rectums, not just normal-appearing rectums, faiIed promptIy by deveIoping flagrant, severe recurrence of colitis. SeveraI patients in whom the anastomosis was made to shghtly- discased bowel have proceeded to do beautifuIIy, an d one of the most unstable people in the whoIe group, in whom I thought the procedure wouId fail, has had a perfect resuIt. Therefore I am sure that there is another factor on which none of us has put our finger at all. Now, Dr. Cushing, is there an increased incidence of coIon cancer in segmenta uIcerative coIitis? DR. WILLIAM J. CUSHINC (I+hshington, D. C.): In our very smal1 group we did not observe this complication. In the literature, five or six cases of carcinoma of the coIon arising in areas of segmental colitis have been recorded. It is reported as a rare complication of segmental cohtis. DR. BARKER: I have a few questions here Ivhich I will try to answer: (I) Do you beIieve that uIcerative coIitis is due to heredity or environment? I do not know. I do not have the least idea. (2) Was the famiIy history of uIcerative colitis in children significant? It was not of particuIar significance in our group because it was comprised aimost. wholly of ad&s; a Iarge number of our patients came from the V. A. Hospital. Our Pediatric Service has referred very few children with ulcerative colitis to us
hence this group was
not surveyed. I should note that the patients who had a family history of uIcerative colitis were younger than the group in general. I wouId like to point out also that there were two patients with a definite family history of ulcerative colitis, both were girls fourteen, fifteen or sixteen years oId. Now, what is the best type of iIeostomy bag? Dr. LeVeen, do you have any particular favorite? DR. LEVEEN: I think it depends upon the individual. ILlost of the patients we have seen in the large metropoIitan area, belong to iIeostomy clubs, at Ieast in the beginning, and they see prncticaIIy aIl the types of appIiances that are available; they usuaIly choose the most comfortabIe one. It is a highIy individual situation. DR. BARKER: This is aIso my opinion. Dr. Lyons, do you want to comment on this? DR. LYONS: I wiI1 agree with that. I wiI1 say that most peopIe have chosen the flat rubber bags, white rubber bags or those with the bIaek rubber addition. But an engineer told me that, when he had to get an ileostomy bag for a friend of his, he was horrified at what he considered the poor engineering principIes invoIved that we, as doctors, an d the patients have finaIl? hit upon. He has some ideas which, I hope, wrI1 be a great improvement over what is currently available. DR. BARKER: Dr. Van Prohaska, what is your opinion? DR. VAN PROHASKA: I do not know lvhich is the best bag. DR. BARKER: There is another question reIating very closely to this: What can be done for the patient with pain but no erosion or IistuIas beneath the “doughnut” of the ileostomy appliance? Dr. Lyons? DR. LYONS: There have been a few patients who have had such pain and we have been unabIe to explain the reason for it. One of these patients had a reanastomosis performed to what we had considered a normal rectum. Of course, the pain disappeared but that was because wc removed the ileostomy. In the other, we transposed the ileostomy to the left side, and the pain subsequently disappeared, but I never found the reason for the pain before. DR. BARKER: I recently found a neuroma in 67
Question
and Answer
the subcutaneous tissue, I am sure you have seen these IittIe excrescences of granuIation tissue and macerated epithelium which become tender, but I do not think this shouId be incIuded in this question. Here is a question I can answer for you. ShouId not the mortaIity that you presented in the “poor risk” patients reaIIy be considered more of a medica mortality than a surgica1 mortaIity because of the deIay in surgica1 therapy? I think that it is up to us to persuade the gastroenteroIogists that the figures presented by Dr. Van Prohaska are representative of good surgica1 resuIts in patients with uIcerative colitis and indicative of the effective rehabilitation which can be achieved; we must make them see that the deIays in referring the patient for treatment increase the risk of death. The mortaIity of such patients shouId not be charged to us but to the delay of transfer to surgica1 care. Dr. Van Prohaska, in view of your operative resuIts in chiIdren, wouId you recommend earIy surgery in children with uIcerative coIitis? DR. VAN PROHASKA: I do not know how to decide it. If I were so arrogant as to be abIe to say that I can aIways teI1 when uIcerative colitis in a child wiI1 terminate spontaneousIy under medica management, then I wouId never operate on them. If I couId aIways say that it wiI1 not terminate, then I would aIways operate on them. I stiI1 prefer to have a good medica survey made of a11 patients with uIcerative colitis; I prefer to follow them as Iong as they are doing weI1, are abIe to attend schoo1 and are not disabIed, unless they have symptoms, which fit into the group of indications common to uIcerative coIitis and by which many of us are guided, or a severe sudden complication. For fuIminating universa1 colitis, the child shouId be operated upon. The chiId wilt do better foIIowing surgery and, although growth will not be arrested by the removal of the coIon, it wiI1 be arrested by the persistence of the disease. DR. BARKER: This begins to border on another question which I wanted to ask. Excluding the cases in which we are forced to operate because of the absotute indications of hemorrhage or perforation or some such compIication, what are the criteria that you would like to see used in selecting a patient for eIective iIeostomy? How far wouid you Iet the
Period
patient go medicaIIy before you wouId have him operated upon? Dr. LeVeen? DR. LEVEEN: I Iike to take the patient into consideration; I Iike to have the patient heIp in determining what is going to happen to him. Whether to operate or not to operate must be decided on the basis of the severity of the disease, the severity of symptoms, incIuding toxicity. It is pretty much of an individua1 probIem and requires consuItation and judgment on our part as to how the patient will do with and without his or her coIon. DR. BARKER: It certainIy revoIves around the three variabIes of the surgeon, the patient and how soon the gastroenteroIogist is willing to refer the patient back to the surgeon. DR. LEVEEN: That is right. DR. BARKER: At what stage would you like to have the patient referred to you for operation? To what degree must uIcerative coIitis be present before you operate? DR. VAN PROHASKA:Working with a group that is reIativeIy conservative in the approach to surgica1 management, I think this is a most important question and diffIcuIt to define. Let us say that we are deaIing with a patient who has ulcerative coIitis but has none of the usual indications or comp1ication.s. I wouId decide to operate upon this patient on the basis of the persistence of the disease. If the disease under good medica management continued to persist as demonstrated by x-ray and proctoscopic findings, for a sustained period of time, I wouId say that the patient was never going to get weI1, that he was just marking time; I would discuss the probIem with him personaIIy and recommend operation at that moment. Dr. BARKER: I think that is as nearly a concrete an answer as one couId get. SPEAKER FROM THE FLOOR: ExactIy how Iong is that? DR. VAN PROHASKA:I was hoping you would not ask that question because I do not reaIIy know. I wouId say that if the disease persists for a year or two, then the patient shouId be operated upon. I think that criteria of time is important. DR. BARKER: Dr. Waugh, do you have an answer to that? DR. JOHN M. WAUGH: No, they are all individua1 probIems. DR. BARKER: I beIieve that I have been working with enteroIogists or gastroenteroIo68
Papers
on UIcerative
CoIitis
DR. VAN PROHASKA: We close it. DR. BARKER: I think most of us do. I wonder if this question arose from Dr. Turnbull’s recommendation that the ileorectal anastomosis not be peritonealized but be Ieft to drain freely back into the pelvic cavity so that there is no contaminated hematoma secluded below the tissue plain. SPEAKER FROM THE FLOOR: W’hat is the reIationship between cancer and ulcerative colitis? DR. BARKER: I think it is dificult to establish an exact reIationship between cancer and ulcerative colitis, some people have even declined to admit that there is a link between cancer and ulcerative colitis. SPEAKER FROM THE FLOOR: There is one more question that I would like to ask. In a certain number of cases sigmoidoscopic examination may reveal a bad looking coIon but the patient may not have many symptoms. Would you urge surgery in such cases? DR. BARKER: I would be incIined to if the condition was proved to be ulcerative colitis of chronic idiopathic nature. You are referring now to a patient who has not just the architectural destruction but. the actual mucosal changes and who has gotten along with it pretty weI1. I think that such a patient is sitting on a powder keg and is in danger of acute Hare-ups, such as perforations, hemorrhage and cancer. I also think that such a patient would most likely be among those with best surgica1 result.
gists who are about as progressive surgicalIy as you wiI1 find. In looking over the records of patients who have been seen at U. C. L. A. in its scant five years of existence, we have discovered that three-fourths of those admitted with ulcerative colitis have come to colectomy. This is a rather alarming figure, yet it is a little misIeading in that many such patients are seen as outpatients and not admitted; nevertheless, it indicates a trend quite different from that in many parts of the country. I have two more questions. First, what is the importance of liver disease in chronic ulcerative colitis? Dr. LeVeen? DR. LEVEES: I know that Dr. Clarence Dennis beIieves rather strongIy that cirrhosis is a complication of ulcerative colitis. As a matter of fact, we have studied two or three patients who have had cirrhosis with ulcerative colitis and, following colectomy, it was our impression that the cirrhosis was Iess severe. There is no question in my mind that the continued insuIts of the Iiver by paracolon baciIIus toxin and other products are injurious to the liver and that cirrhosis is a definite compIication of ulcerative colitis. DK. BARKER: The second question is strictly technical: Do you close the pelvic peritoneum when performing an abdominoperineal resection of the rectum for uIcerative colitis? I cIose it up tight. Dr. LeVeen? DR. LEVEEN: We close it tight too. DR. LYONS: We close it tight aIso.
69
on Ulcerative
QUESTION
AND
ANSWER
Colitis PERIOD
WILEY F. BARKER, M.D., Moderator
DR. WILEY F. BARKER (Los Angeles, California): We have quite a few questions here. Dr. Van Prohaska, wilI you expIain the high percentage of restoration of continuity. I beheve that there was a reIativeIy Iarge number of cases in which you were abIe to perform an iIeorecta1 anastomosis. DR. JOHN VAN PROHASKA(Chicago, Illinois): I do not think it was so high. In 43 per cent of the patients we performed a tota coIectomy with proctectomy. In 8 per cent of the patients we performed a subtotal coIectomy, Ieaving the recta1 stump because they were too acuteIy iI for the compIete colectomy. The remainder of the patients (and I think the question reaIIy refers to these patients) definiteIy had some form of iIeocoIostomy or iIeorecta1 sigmoidostomy primariIy because they had a segmental disease. DR. JAMES D. HARDY (Jackson, Mississippi): May I ask just one question? DR. BARKER: Yes, Dr. Hardy. DR. HARDY: It has been said, Dr. Van Prohaska, and it may we11 be true, that removal of the rectum after the iIeostomy wiI1 diminish the fluidity or the profuse drainage from the ileostomy more quickly; is that so? DR. VAN PROHASKA: I did not notice that. I wouId not be abIe to answer that. DR. BARKER: Dr. LeVeen, do you have any answer to that? DR. HARRY LEVEEN (New York, New York): No, I have not noticed it either. DR. BARKER: I know that a few instances have been described in which the patient just did not stop Iosing blood unti1 the IocaI perineal remova1 of the recta1 segment had been carried out. I have seen it occasionally; and I have aIso seen it faiI to alter the consistency of the iIeostomy. I do not reaIly think that that AmericanJoutnol
of Strrgery,
Volume
103. Janmary
1q.h
is a good observation; there may be some other factor invoIved. Dr. Lyons, wiI1 you discuss the choice of patients and the conditions under which some kind of ileorecta1 anastomosis may be performed? DR. ALBERT S. LYONS (New York, New York): First, we have to dea1 with severa types of ulcerative colitis. As Dr. Van Prohaska mentioned, when it is segmenta colitis and the rectum is normal, an anastomosis of the iIeum to the norma rectum with subtota1 coIectomy is in order. Even then, I must admit that, in making a Iong-term study, in at Ieast one-third of such cases recurrences occurred in the rectum. The second type is the diffuse uIcerative colitis in which we leave the rectum intact and then in subsequent years, after we think it has returned to normal, perform the anastomosis. There are just as many peopIe who beIieve that the entire rectum should be removed as there are those who beIieve that a11 the rectum should be saved. From my own experience in our hospita1 I wouId say that onIy thirteen such reanastomoses have been performed, three of which failed; the others have been successfu1, one for as Iong as eighteen years; a few are onIy a few years oId. The third type is the diffuse universa1 ulcerative colitis in which the colon is removed and a primary anastomosis of smaI1 bowe1 to diseased rectum is made deIiberately. This is the procedure advocated by Mr. AyIett in London, EngIand. It is incomprehensibIe, I know, and yet the figures that he has reported are extraordinary. I have seen him perform this procedure; I have also seen the patients in foIIow-up and 66
Papers on UIcerative
Colitis
for surgica1 management,
the coions that were removed with the Iine of transection right through the diseased bowel. I have seen these patients a few years later and have examined them sigmoidoscopicaIIy myself. In some the rectal mucosa had been friabIe, in others it had returned to aImost normal. I do not advocate this procedure; I just mention it only for your consideration and discussion. These are the three different reasons for performing an anastomosis to the rectum and I wouid say that at the present time the choice depends on the surgeon’s philosophy more than it does on the facts at hand. DR. BARKER: Dr. Lyons, I would suggest that the success of that procedure depends on some factor that we know nothing about. We have performed very few. Seven or eight, I believe, have been undertaken at U. C. L. A. and the V. A. HospitaI; two in which the anastomosis was made to histoIogicaIly norma rectums, not just normal-appearing rectums, faiIed promptIy by deveIoping flagrant, severe recurrence of colitis. SeveraI patients in whom the anastomosis was made to shghtly- discased bowel have proceeded to do beautifuIIy, an d one of the most unstable people in the whoIe group, in whom I thought the procedure wouId fail, has had a perfect resuIt. Therefore I am sure that there is another factor on which none of us has put our finger at all. Now, Dr. Cushing, is there an increased incidence of coIon cancer in segmenta uIcerative coIitis? DR. WILLIAM J. CUSHINC (I+hshington, D. C.): In our very smal1 group we did not observe this complication. In the literature, five or six cases of carcinoma of the coIon arising in areas of segmental colitis have been recorded. It is reported as a rare complication of segmental cohtis. DR. BARKER: I have a few questions here Ivhich I will try to answer: (I) Do you beIieve that uIcerative coIitis is due to heredity or environment? I do not know. I do not have the least idea. (2) Was the famiIy history of uIcerative colitis in children significant? It was not of particuIar significance in our group because it was comprised aimost. wholly of ad&s; a Iarge number of our patients came from the V. A. Hospital. Our Pediatric Service has referred very few children with ulcerative colitis to us
hence this group was
not surveyed. I should note that the patients who had a family history of uIcerative colitis were younger than the group in general. I wouId like to point out also that there were two patients with a definite family history of ulcerative colitis, both were girls fourteen, fifteen or sixteen years oId. Now, what is the best type of iIeostomy bag? Dr. LeVeen, do you have any particular favorite? DR. LEVEEN: I think it depends upon the individual. ILlost of the patients we have seen in the large metropoIitan area, belong to iIeostomy clubs, at Ieast in the beginning, and they see prncticaIIy aIl the types of appIiances that are available; they usuaIly choose the most comfortabIe one. It is a highIy individual situation. DR. BARKER: This is aIso my opinion. Dr. Lyons, do you want to comment on this? DR. LYONS: I wiI1 agree with that. I wiI1 say that most peopIe have chosen the flat rubber bags, white rubber bags or those with the bIaek rubber addition. But an engineer told me that, when he had to get an ileostomy bag for a friend of his, he was horrified at what he considered the poor engineering principIes invoIved that we, as doctors, an d the patients have finaIl? hit upon. He has some ideas which, I hope, wrI1 be a great improvement over what is currently available. DR. BARKER: Dr. Van Prohaska, what is your opinion? DR. VAN PROHASKA: I do not know lvhich is the best bag. DR. BARKER: There is another question reIating very closely to this: What can be done for the patient with pain but no erosion or IistuIas beneath the “doughnut” of the ileostomy appliance? Dr. Lyons? DR. LYONS: There have been a few patients who have had such pain and we have been unabIe to explain the reason for it. One of these patients had a reanastomosis performed to what we had considered a normal rectum. Of course, the pain disappeared but that was because wc removed the ileostomy. In the other, we transposed the ileostomy to the left side, and the pain subsequently disappeared, but I never found the reason for the pain before. DR. BARKER: I recently found a neuroma in 67
Question
and Answer
the subcutaneous tissue, I am sure you have seen these IittIe excrescences of granuIation tissue and macerated epithelium which become tender, but I do not think this shouId be incIuded in this question. Here is a question I can answer for you. ShouId not the mortaIity that you presented in the “poor risk” patients reaIIy be considered more of a medica mortality than a surgica1 mortaIity because of the deIay in surgica1 therapy? I think that it is up to us to persuade the gastroenteroIogists that the figures presented by Dr. Van Prohaska are representative of good surgica1 resuIts in patients with uIcerative colitis and indicative of the effective rehabilitation which can be achieved; we must make them see that the deIays in referring the patient for treatment increase the risk of death. The mortaIity of such patients shouId not be charged to us but to the delay of transfer to surgica1 care. Dr. Van Prohaska, in view of your operative resuIts in chiIdren, wouId you recommend earIy surgery in children with uIcerative coIitis? DR. VAN PROHASKA: I do not know how to decide it. If I were so arrogant as to be abIe to say that I can aIways teI1 when uIcerative colitis in a child wiI1 terminate spontaneousIy under medica management, then I wouId never operate on them. If I couId aIways say that it wiI1 not terminate, then I would aIways operate on them. I stiI1 prefer to have a good medica survey made of a11 patients with uIcerative colitis; I prefer to follow them as Iong as they are doing weI1, are abIe to attend schoo1 and are not disabIed, unless they have symptoms, which fit into the group of indications common to uIcerative coIitis and by which many of us are guided, or a severe sudden complication. For fuIminating universa1 colitis, the child shouId be operated upon. The chiId wilt do better foIIowing surgery and, although growth will not be arrested by the removal of the coIon, it wiI1 be arrested by the persistence of the disease. DR. BARKER: This begins to border on another question which I wanted to ask. Excluding the cases in which we are forced to operate because of the absotute indications of hemorrhage or perforation or some such compIication, what are the criteria that you would like to see used in selecting a patient for eIective iIeostomy? How far wouid you Iet the
Period
patient go medicaIIy before you wouId have him operated upon? Dr. LeVeen? DR. LEVEEN: I Iike to take the patient into consideration; I Iike to have the patient heIp in determining what is going to happen to him. Whether to operate or not to operate must be decided on the basis of the severity of the disease, the severity of symptoms, incIuding toxicity. It is pretty much of an individua1 probIem and requires consuItation and judgment on our part as to how the patient will do with and without his or her coIon. DR. BARKER: It certainIy revoIves around the three variabIes of the surgeon, the patient and how soon the gastroenteroIogist is willing to refer the patient back to the surgeon. DR. LEVEEN: That is right. DR. BARKER: At what stage would you like to have the patient referred to you for operation? To what degree must uIcerative coIitis be present before you operate? DR. VAN PROHASKA:Working with a group that is reIativeIy conservative in the approach to surgica1 management, I think this is a most important question and diffIcuIt to define. Let us say that we are deaIing with a patient who has ulcerative coIitis but has none of the usual indications or comp1ication.s. I wouId decide to operate upon this patient on the basis of the persistence of the disease. If the disease under good medica management continued to persist as demonstrated by x-ray and proctoscopic findings, for a sustained period of time, I wouId say that the patient was never going to get weI1, that he was just marking time; I would discuss the probIem with him personaIIy and recommend operation at that moment. Dr. BARKER: I think that is as nearly a concrete an answer as one couId get. SPEAKER FROM THE FLOOR: ExactIy how Iong is that? DR. VAN PROHASKA:I was hoping you would not ask that question because I do not reaIIy know. I wouId say that if the disease persists for a year or two, then the patient shouId be operated upon. I think that criteria of time is important. DR. BARKER: Dr. Waugh, do you have an answer to that? DR. JOHN M. WAUGH: No, they are all individua1 probIems. DR. BARKER: I beIieve that I have been working with enteroIogists or gastroenteroIo68
Papers
on UIcerative
CoIitis
DR. VAN PROHASKA: We close it. DR. BARKER: I think most of us do. I wonder if this question arose from Dr. Turnbull’s recommendation that the ileorectal anastomosis not be peritonealized but be Ieft to drain freely back into the pelvic cavity so that there is no contaminated hematoma secluded below the tissue plain. SPEAKER FROM THE FLOOR: W’hat is the reIationship between cancer and ulcerative colitis? DR. BARKER: I think it is dificult to establish an exact reIationship between cancer and ulcerative colitis, some people have even declined to admit that there is a link between cancer and ulcerative colitis. SPEAKER FROM THE FLOOR: There is one more question that I would like to ask. In a certain number of cases sigmoidoscopic examination may reveal a bad looking coIon but the patient may not have many symptoms. Would you urge surgery in such cases? DR. BARKER: I would be incIined to if the condition was proved to be ulcerative colitis of chronic idiopathic nature. You are referring now to a patient who has not just the architectural destruction but. the actual mucosal changes and who has gotten along with it pretty weI1. I think that such a patient is sitting on a powder keg and is in danger of acute Hare-ups, such as perforations, hemorrhage and cancer. I also think that such a patient would most likely be among those with best surgica1 result.
gists who are about as progressive surgicalIy as you wiI1 find. In looking over the records of patients who have been seen at U. C. L. A. in its scant five years of existence, we have discovered that three-fourths of those admitted with ulcerative colitis have come to colectomy. This is a rather alarming figure, yet it is a little misIeading in that many such patients are seen as outpatients and not admitted; nevertheless, it indicates a trend quite different from that in many parts of the country. I have two more questions. First, what is the importance of liver disease in chronic ulcerative colitis? Dr. LeVeen? DR. LEVEES: I know that Dr. Clarence Dennis beIieves rather strongIy that cirrhosis is a complication of ulcerative colitis. As a matter of fact, we have studied two or three patients who have had cirrhosis with ulcerative colitis and, following colectomy, it was our impression that the cirrhosis was Iess severe. There is no question in my mind that the continued insuIts of the Iiver by paracolon baciIIus toxin and other products are injurious to the liver and that cirrhosis is a definite compIication of ulcerative colitis. DK. BARKER: The second question is strictly technical: Do you close the pelvic peritoneum when performing an abdominoperineal resection of the rectum for uIcerative colitis? I cIose it up tight. Dr. LeVeen? DR. LEVEEN: We close it tight too. DR. LYONS: We close it tight aIso.
69