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Surgical treatment of ulcerative colitis
Surgical
Treatment WILEY
F. BARKER,
of Ulcerative M.D.,
From tbe Department of Surgery, University of California Medica 1 Center, and tbe Surgical Service, Wadswortb General Hospital, Veterans Administration Center, Los Angeles, California.
HERE is considerabIe reIuctance on the part of many physicians to utiIize the surgeon in the care of uIcerative coIitis. The hesitancy dates back to the time prior to the introduction of satisfactory coIIecting devices and prior to present advances in technic and in supportive therapy. This report wiI1 be an accounting of the results of surgica1 management of eightyfour patients who were treated for utcerative colitis at The University of California MedicaI Center, Los AngeIes and the Veterans Administration HospitaI, West Los Angeles during the past ten years. The cases presented are those in which the author pIayed a persona1 roIe in surgical management and procedure, aIthough resident staffs performed the actua1 operation in about haIf the cases. The age range was from fourteen to fifty-six years. There was a sex distribution of thirty-four women and fifty men. For purposes of evaIuation the tables wiI1 show the cases in two groups: patients originaIIy operated upon between 1950 and 1954 are in group I, and those operated upon between 1955 and 1960 are in group II.
T
SURGICAL
TECHNIC
ConsiderabIe attention has been given eIsewhere to the important phases of preparation of the patient for operation [2]. It is our preference not to operate upon a patient receiving steroid therapy but operation is performed if necessary and proper SuppIementation is added to other forms of preparation. SuIfasuxidine,@ supplemented with a twenty-four hour course of neomycin, is the choice for intestina1 antisepsis. Purgatives and enemas are avoided. Nasogastric intubation is usuaIIy employed. The type of anesthesia is Ieft to the discretion of a American
Journal
of Surgery.
Volume
102, Aupusf
1061
176
Colitis
Los Angeles, Calijornia competent anesthesioIogist: genera1 anesthesia with endotrachea1 intubation is commonly administered. The site of the iIeostomy is carefuIIy seIected with regard for cutaneous scars, the umbilicus, bony Iandmarks and parieta1 ffexion creases; the stoma1 incision is prepared through a11 Iayers prior to opening the abdomen. The major abdomina1 incision is usuaIIy a long Ieft paramedian incision. DetaiIed expIoration is performed. The right colon is mobiIized first; the terminal iIeum is then divided as far distahy as possibIe with due regard for avoiding division in areas of iIeac invoIvement by true uIcerative disease. Traces of edema and diIatation secondary to more dista1 obstruction may be disregarded. Preservation of as much termina1 iIeum as possibIe is important because of the water resorbing abilities of this organ. A generous segment of ileum proxima1 to the line of division is then prepared by dividing the ,mesentery about I to 2 cm. from the bowe1. (Fig. I.) This maneuver assures viabiIity of the dista1 tip. At such a point as to nourish the dista1 tip of bowe1 by a major arcade of vesseIs, the incision in the mesentery doubIes back on itseIf. At this apex, a nonabsorbabIe suture is pIaced in the mesentery, next to the bowe1 wal1, avoiding injury to the blood supply to the dista1 portion. This suture serves for IateraI attachment to the peritonea1 ring at the point of emergence of the bowe1. The mesenteric incision is now carried cephaIad in a convex curve IateraIIy, ending at the posterior parieta1 attachments of the 3eocoIic mesentery. This curved edge of mesentery will fit into the IateraI gutter and cIose it without distortion of the prestoma bowe1. The future stoma should now be drawn through the tunne1 in the abdomina1 wail previousIy prepared for it. The mesentery is attached to the parietal peritoneum so that it lies Iateral to the stoma, thus continuing the plane of the mesenteric curtain into its natural
Surgical
Treatment
intersection with the nIxlomin:J wall. To secure this mesentery and to reduce the risk of proIapse, it is advisable to suture the cut edge 01 the mesentery with interrupted nonabsorbable sutures to the parietal peritoneum, beginning at the stoma with the suture previously placed there. In order to assure permanent adherence, an incision may be made in the parietal peritoneum to accept the mesenteric edge. Once this stage of construction of the ileostomy has been reached, one may proceed with the remainder of the colectomy with the comfortable feeling that the procedure can be terminated quickly at any time if necessary by exteriorization of as much colon as has been mobilized. In general terms it is preferred to perform a total colectomy in one stage except as follows: (I) where rectal innocence of disease implies possible ileorectal anastomosis, now or later; (2,~ where extensive anorectal sepsis might seriously contaminate the abdominal wound and peritoneal cavity; (3) in maIes whose sexual potency might be affected by a bloody dissection in a narrow pelvis in the presence of acute inflammation; (4) in any patient whose general condition does not warrant further operating by the time dissection has come around to the rectosigmoid colon. Removal of all the colon proxima1 to the rectosigmoid is urged in the presence of free perforation. Total one stage coIectomy may be the only means of controlling bleeding when this has been the indication for operation. If a two stage procedure is chosen, it is preferaMe to leave an open mucous fistula to assure external drainage of any active septic process in the distal segment. During the actual rectal dissection, care is taken to keep the pIane of dissection as &se to the bowel as possible, especially in the male, to avoid the genitourinary complications of impotence and bladder dysfunction. It is neither desirable nor necessary to remove any portion of the levator ani muscles. 1fan ileorectal anastomosis is to be performed Turnbull’s technic [4] is followed in detail. Closure of the wound is usuaIIy performed in layers, with the use of nonabsorbabIe sutures; and in all but the best risk patients retention sutures are used for extra support. If serious contamination has been encountered, as in free perforation, the fascial and peritoneal Iayers are closed with wire or catgut and the skin and
of Ulcerati\:e
Colitis
rl/y/-
FIG. 1. This drawing shows the level at which the distal ileum is divided, the long vascularized loop of ileum to be brought through the abdominal wall, and the curved incision in the ileocolic mesentery. The suture placed at the angle will be used to attach the ileum to the peritoneum as the bowel emerges from thr pcritoncal cavity.
fat are left open for a delayed closure in four or five days. The ileostomy is matured immediately by a technic similar to that of Turnbull [?I. Several longitudinal incisions are placed in the distal two thirds of the exteriorized ileum, through serosa and muscularis. This renders the distal portion patulous without devitalizing it, anti assures adherence of the everted and scarified layer to the proximal inner layer. A carefully fitted transparent, disposable pIastic ileostomy bag is placed on the wound immediatelv. The majority of complications encountered in the second half of this series can be directly traced to failure to follow meticulously the principles described above. OPERATIONS
PERFORMED
Table I presents a summation of the eightyfour cases. Approximately fifteen other patients were seen during this period. They had received surgical treatment for ulcerative colitis elsewhere and their probIem was not currently of a surgical nature. The one stage total colectomy was the most common initial operation. It was performed in twenty-three of the sixty-six patients operated upon ‘in the last five years. There were three deaths among the thirty-one patients in whom this operation was used in the total period. The t\vo stage total colectomy appears to carrl
Barker TABLE SUMMARY
OF
SURGICAL
TREATMENT
OF
I
EIGHTY-FOUR
PATIENTS
WITH
ULCERATIVE
COLITIS
1955-196* Emergency
No.
of Cases
Late
Postc,perative I kath
Ileostomy only.. . later colectomy Ileostomy, (partial) . One stage ikostomy and total colectomy
Ileostomy and staged total colectomy. Ileostomy and partial colectomy. AnsI ileostomy.. Ikorectal anastomosis, complementary ileostomy.. Transverse colostomy.. Revision only, original operation elsewhere. Colectomy only. origina operat,o” elsewhere.,
Late Death from
1Death
from Any ,zause
_-
Any
Late of CaS25
from Any
Calls‘2
I
0
0
0
0
0
0
0
0
0
0
0
8
I
*
0
20
I
4
0
0
0
5
0
4 I
0 0
2 0
0 0
lot 0
I 0
o 2*
0 0
0 0
0 0
1 2*
0 0
I
0
0
0
5*
0
0
0
0
0
I
0 -
-
TABLE FOR
-
for Operation
and right colectomy
AND
ResuIts
RESULTS
ResuIts
rgso-1954.
Exceltent
--
Dead ( 4ny Car
Fai
Excel lent
8
3
2
I
I
2
I 2
3
Fair
=
14
28 I
36 : 1*
5
21
2
3 2
7
- I
eIsewhere for this indication.
Igsq--I960
No.
No.
p= Elective Chronicity (faiIure to respond to medica care, distant complications, muItipIe recurrences) BIeeding Sepsis (incIuding rectal infection). Perforations, PoIyposis. Stricture (or suspicion of carcinoma).
in one case and iieocolos-
II
SURGERY
I
* Initial operation
Death
Lstc 3eath from Any Jause
-_
INDICATIONS
Totat..............................
operative
,Cause
* One patient in each of these groups has had proximal recurrence requiring ileostomy tomy in the other. t Three of these patients were ultimately treated by ileorectal anastomosis.
TotaI.............................. Emergency Perforations Acute fuIminant disease.. Hemorrhage.......................... Sepsis.
Post-
IDeath
io.
_
-
Indication
I
Elective
Emergency
Elective Type of Operation
Operation I78
-
at UCLA MedicaI Center for stricture.
Dead of 4ny Cause
Episodes
of Complications
Stoma1 complications Retraction and/or necrosis Prolapse. FistuIa Stricture. Proximal perforation 2 degrees to stricture., Prestomal twist.. IntestinaI obstruction due to bands or internal adhesions. Dehiscence Peptic ulceration. Intra-abdominal abscesses. Recurrent enteritis.. Neoplasm of colon. tlepatitis Spontaneous ileac perforation. Septicemia (gram-negative). Enteritic (staDhvkxoccal)_ . Perineal a&Ass”(maior) .‘. Wound infection (major). Spontaneous rupture of spleen. Seotic abortion. Delvic Deritonitis Severe electrolyte imbalance. Total gastric erosion.. hfaln bsorption, severe Potassium loss nephritis.. Transfusion reaction, renal shutdown .. II
Total.
.
T> pc of Surgery
I
Lapnrotomy (for obstruction, volvulus bands, etc.). Closure, drhiscencc. hlajor local revision. hlinor local revision. Incision and drainage, intra-abdominal abscess. Gastric resection for ulcer.
6 2 0
5 / 0
0
Total
7 5
..
2
3 4
considered important. There were only two deaths among the Iast forty-four patients who underwent elective operation. Many of these “elective” operations were performed as urgent operations without optimal preparation, but they could not be pIaced in a class of true emergencies.
0 I 2
3 2 0 4 I I
INDICATIONS
I I
FOR
OPERATION
The indications for operation reviewed in Table II are related to the results. The general term, chronicity, describes the chief indication for operation. Herein are lumped those patients whose chronic debility or whose recurring episodes of colitis make the compromise of ileostomy and colectomy attractive. Included with this group are a few patients whose distant complications, such as arthritis, were an important factor in bringing them to operation. The next most common indications are much more imperative: perforation and the acute fulminating form of the disease. There was no clear impression that the results are related to the reason for which the operation was performed.
2 0
52
the lowest mortality risk (no deaths among sixteen patients) amongst the major types of operation. This may be an illusion because of the fact that several of the patients who were subjected only to ileostomy and partial coIectomy died before being subjected to the second stage and their mortality is debited to the first operation. Four patients with what appeared to be left sided colitis were treated initially by transverse colostomy. In two of these patients there has been no proxima1 recurrence; a third has undergone iIeostomy and right coIectomy and the fourth has had a resection of terminal ileum with an ileocohc anastomosis. The over-al1 mortality risk improved during the second period. There were four deaths among the first t.wenty-eight patients and four in the second group of sixty-six patients. This gain may be ascribed to many factors but experience and technical improvement must be
COMPLICATIONS
The number and type of complications are detailed in Table III. The number of surgical procedures needed to correct the more critical of these compIications are described in Table IV. It would seem unlikely that any surgical operation that is followed by such a cataIogue of problems shouId be widely accepted. Several points should be made regarding these compIications to dispel this impression. ‘79
Barker consiclerable
improvement in frcetlorn from in the lirst series only one fil’th of the patients were free of complicat’ions, while in the second series two fifths were free of al1 complications. This improvement is in part due to selection of more favorabIe cases for referral by the internist to the surgeon but is also due in part to the surgeon learning to provide better surgical management. Furthermore, only six patients experienced complications after three years from the date of the original operation, and all these had suffered continuing problems since operation. One might put this differently: after three years have elapsed from time of operation one need anticipate few further problems.
Certainly obstruction of the small bowel due to adhesive bands has been one of the most common complications but one which was treated surgicaIly with minima1 morbidity. The number and severity of adhesions could in no way be related to the type of operation, the degree of peritoneal contamination or the use of steroid therapy. It had been our clinica impression that the presence of concurrent therapy with steroids greatly added to the hazards of late complications. This cannot be substantiated statistically, but certainly the majority of compIications detailed above are derived from only haIf a dozen patients, whose complications seemed aggravated by high dosages of steroids. Most specificaIly reIated to steroid therapy were three episodes of completely unexplained small bowe1 perforations in smaI1 bowe1 free of adhesions, trauma or previous apparent disease. Another less clearly defined relationship exists in the enlargement in the stoma1 hiatus and deveIopment of a combination of prolapse, (alternating with retraction) and peristomal herniation, seen most commonIy in those patients operated upon under large doses of steroids. This enIargement of the parieta1 opening has been observed even in those patients in whom care was taken to try to keep the tunne1 narrow. Another serious complicating factor has been the recurrence of enteritis in proximal bowel. This has not always been presaged by at recognizable specific ileac involvement operation. The presence of true Iocal disease of the small bowel, however, has been impIicated in several instances of local ileostomy problems, especiaIly those of stricture and fistula. The early diagnosis of stenosis of the stoma, as indicated by cramps and paradoxical diarrhea, and its ease of correction by a minor surgica1 Iysis of the constricting scar has been described elsewhere [I]. Prolapse, a much more difficult condition to treat successfully, has occurred much less frequently in the more recent series. Major revision, including reattachment of the ileac mesentery to the parietes, shortening of the mesentery and reduction of a peristomal hernia, if present, are the important factors in its treatment. In this rehearsal of compIications one can easily lose sight of severa profitable aspects. First, between the two periods there has been
complications;
REHABILITATION
With the background of frequent complications of varying severity beclouding the advisability of surgical treatment of ulcerative colitis, it seemed proper to evaIuate the results in terms of rehabilitation. The extent of relief that can be given to a patient can be appreciated by answers from the two patients whose resuIts were to the author most discouraging from the point of view of multipIe complications and operations. Their case reports are presented briefly below: CASE I. M. F. was operated upon in 1954 because of tweIve years of incapacitating bloody diarrhea. His course had been compIicated by a transfusion reaction and temporary acute renaI failure. Later complications of stricture, prolapse and peristomal herniation folIowing trauma have necessitated a tota of eIeven minor or major operations. Nevertheless he is actively empIoyed, weighs more than at any other time in his Iife and avers that he is better abIe to handIe the affairs of his Iife than at any time since the onset of the coIitis. CASE II. M. S. was operated upon in 1950 because of hemorrhage and recta1 sepsis. His course has simiIarIy been complicated by proIapses and strictures and a recurrence of an enteritis involving the full extent of his smaI1 bowel. MuItipIe stoma1 revisions and proxima1 bowe1 resections have been necessary, but the patient is presentIy empIoyed as an electrician, weighs about twenty-five pounds more than at the origina operation and states that in spite of the compIicated course of his disease he would not hesitate to choose iIeostomy again, and indeed wishes it had been undertaken earlier. 180
SurgicaI
Treatment
This thcmc of satisfaction was repeated o\‘er and over again in questioning the forty-three patients with lvhom direct contact could be made at the present time. The results of the survev of these forty-three patients, representing two thirds of the living patients, are presented as follows: 1Veight Gain. The average weight gain since operation has been twenty-nine pounds, with a spread of from minus twelve to more than eighty pounds. The present weights average one pound greater than the previousIy recorded highest weights prior to operation. Occupation. Forty patients denied that their present occupation was compromised by the ileostomy. One patient who was a cook bec.arne a salesman; one fashion model bought the dress shop; one woman whose job required lifting heavy bundles of newspapers could not be re-employed. Seven young women have married. There have been at Ieast four children born to the female patients since operation. Satisfactory adaptation to sexual activity has been reported by most patients of both sexes and in both married and single estate. Impotence has not been encountered in the male patient since our adoption of the technics of rectal dissection described under TECHNIC. Only five patients admitted any social restrictions. The most common source of complaint \vas the noisiness of the stomal activity and a limitation of vigorous physical activity by distodgement of the appliance. AImost a11 patients, however, have been able to continue swimming, bowling, tennis, dancing and similar activities without inhibition. Only one patient felt he was Iess well able to cope with the affairs of his life now than prior nine felt equally well able and to operation; thirty-three felt they were much better able. Indeed, fourteen patients felt better able to manage their affairs than ever before; eighteen felt equally well able; only eleven did not return an answer or stated that they were less able to deal with life. It is recognized that most of these are highly subjective responses. Replies from the fourteen patients n-ho later died and which one would expect to be unfavorable have not been included in this tabulation. Psychologic rehabilitation is another benetit derived from adequate surgica1 treatment. The so-called “ ulcerative colitis personality” does not persist after extirpation of the organic
of Ulcerati\-e
Colitis
problem. It is clear that in this group tients there ~~1s far more somatopsychic obser\,ed than psychosomatic.
of paeffect
SUMMAR\
In reviewing the experience with eighty-four patients who had ulcerative colitis and who were treated by ileostomy and colectomy, it is apparent that this operative procedure is fraught with many complications and a signiticant mortality and morbidit,v. These unfavorable aspects can be minimized by careful attention to detail and meticulous adherence to the surgical principles that have been established during the acquisition of this experience. In spite of these complications, the end result is an excelIent one with regard to rehabilitation. Ileostomy and colectomy can restore a near normal life to the patient with ulcerative whatever handicaps m:ty exist arc colitis; gratefully accepted by the patient as a most desirable exchange for the emotional and physical misery and disability lvhich often foIlow the prolonged conservative, nonoperative approach. REFERENCES I. BARKEK, W. F. Factors contributing to ilcostomy dysfunction. West. J. Surg., 64: 235, 19~6. 2. BAKKEK, W. F. and MEILI~KOFI:, S. W. hledicosurgical teamwork in the trcatmcnt of ulccrativc colitis. M. C&n. North America, 43: I I 55, 1959. 3. TURNB~~.LL, R. B., JR. Management of the iieostomy. Am. J. Surg., 86: 617, 1953. A. TURNBULL.
R. B.. JR. Surnical treatment
of ulcera-
tive coliks: early results after colectomy and IOU ilcorrcta1 nnastomosis. Dis. Colon P Rectum, 2:
260, 1959. DISCUSSION R0BER.r A. SCARBOROUGH (San Francisco, Calif.) : Dr. Barker has presented a comprehensive report on his considerabIe experience in the surgical treatment of ulcerative colitis. I-It has not minimized the complications of surgery, but he has demonstrated that improved technics have greatly reduced their incidence. And he has concluded, rightly I believe, that surgical treatment can curt this discasc, with most satisfactory physical and psychologic rehabilitation of the patient. The significant reduction in morbidity and mortality resulting from surgical treatment during the past ten years can be largely attributed to: (I) removal of the diseased colon as the primary procedure; (2) improved methods of ileostomy stoma construction for prevention of ilcostom~ dysfunction; (3) improved “collecting devices
181
Barker for ileostomy discharge; (4) improved technic of rectal resection for preservation of normal sexual function; and (5) elimination of an open perineal wound by preservation of the external anal sphincter and completion of rectal excision through the ana cana1. Efficient function of the iIeostomy stoma is a prime requisite to the success of surgica1 treatment. There is genera1 agreement that this depends upon the avoidance of both physioIogic and mechanica obstruction. Primary union of iIea1 mucosa and skin is an accepted objective, aIthough there are a number of variations of technic employed. There are members of this Association who advocate a stoma flush with the surrounding skin and other members who believe that the stoma should protrude for 2 cm. or more above the IeveI of the abdomina1 waI1. Dr. Barker empIoys a modihcation of the technic of mucosa1 graft originally described by TurnbuII. We have now abandoned this as an unnecessary procedure, and accompIish a moderate eversion by fixation of the mesentery so that there is a 2 cm. slack in the emerging ileum, with simple interrupted suture of the open end of the ileum to skin. In preparation for the ileostomy, we excise a square of skin and of anterior rectus sheath to minimize any obstructive compression of the ileum as it emerges through the abdominal wall. Our technic for ileostomy is aIso at variance with the generally accepted practice of closure of the IateraI gutter. We do not close this space, and assure ourselves of a wide open area by fixation of the mesentery to the anterior peritoneum in a cephaIad direction with siIk sutures. I wouId like to point out that the author’s tabIe of indications for operation does not refIect the rea1 danger of development of carcinoma in disease of long standing. Dr. Barker has made onIy brief comment upon the recent rebirth of some tempered enthusiasm for preservation of the rectum and ultimate restoration of bowel continuity. Further elaboration on this subject is therefore not warranted in discussion of this paper. LEON GOLDMAN (San Francisco, Cahf.): I am sure that many of you have been concerned in recent years, as we have, about the apparent increase in the incidence of perforation and massive hemorrhage in patients with ulcerative colitis who have received steroid therapy, Dr. Barker, in referring to this phenomenon, mentioned that from his observations it was impossibIe to prove that a connection existed between perforation and steroid therapy. As we know, the use of steroids, particuIarIy in patients with acute uIcerative cohtis, is becoming more common. In many patients the dosage is increased if they fail to respond initiahy; therefore, I82
they may receive Iargc doses of steroids often for long periods of time. We are particularly concerned about the increase in the incidence of perforation because it is difficult to make an earIy diagnosis of a free or walled-off perforation in patients with uIcerative colitis since steroid therapy masks symptoms. We reviewed our cases of ulcerative coIitis to try to determine whether there was any difference in the incidence of complications in patients who were receiving steroid therapy as compared to those who were not. In this thirteen year period, although these statistics may be interpreted in various ways, the number of patients in both groups is approximately the same. Yet eight patients in the steroid group deveIoped massive hemorrhage as compared to only two in the nonsteroid group. Perforation occurred in eight patients in the group receiving steroids as compared to only one patient in the nonsteroid group. Ten patients deveIoped hypokalemia in the steroid group but no patients did so in the nonsteroid group. Six patients who received steroids deveIoped psychoses, but none did in the nonsteroid group. Four patients developed peptic uIcer in the group which received steroids as compared to only one patient with peptic uIcer in the nonsteroid group. These statistics seem to indicate that more compIications deveIop in patients who have received steroid therapy for ulcerative colitis. LUCIUS D. HILL, III (Seattle, Wash.): Dr. Barker has given a timely and forthright coverage of large experience with a disease which has interested most of us. I wouId like not only to agree with what he has said about the iIeostomy, but to emphasize that we, too, fee1 that suture of the mucosa of the iIeostomy to the skin has been one of the great advances in surgery for ulcerative colitis. But we, like Dr. Scarborough, have abandoned the technic that was originaIIy described by Turnbuli in favor of the technic that was described by Brook, nameIy, simpIy everting the end of the ileostomy and suturing it to the skin. We believe that without incising the serosa of the termina1 iIeum we have had fewer instances of stricture of the ileostomy. As far as the operative technic is concerned, we have preferred to use a singIe stage, tota coIectomy and iIeostomy whenever feasibIe. In this technic we are aided by inserting into the rectum a pack which is soaked in Zephiran.@ We tie a tape proximal to this pack. An additiona tape is tied to it SO that the circuIating nurse can remove this from beIow during the operation. This heIps us to define the Iocation of the anus; it aIso heIps in doing the things that Dr. Barker has so aptIy pointed out, nameIy avoiding denervation of the bIadder, and also staying close to the rectum to avoid impotence in the maIe.
Surgicd
Treatment
After the rectal dissection is complctc, the pack is withdrawn from below; the rectal ampulla, a rclatively sterile and empty organ, can be opened; the dentate line can be visualized and the entire rectum removed through the abdomen. This saves turning the patient during the operation and performing an abdominal perineal resection, which we believe is a more traumatic proccdurc. WC ha\-e used this procedure in twenty-three instances over the past six years with one death. \Vc have utilized it in some patients on whom we operated as an emergency, and believe that it is only the i-are individual who has either extensive pathologic condition of the pelvis, such as endomctriosis, or pelvic inflammatory disease, who is not a candidate for this procedure. The only innovations we have been forced to add during the past five years have been those aimed at corrrccting complications in the posterior wound. Careful drainage of the posterior wound, scrupulous attention to the posterior wound and digital examination of the posterior wound under sterile conditions insure that there are no locufated pockets of fluid left behind. WII-LIAM II. SKYDEK, JR. (Los Angeles, Calif.): In Doctor Barker’s extensive series I was interested to note that the youngest patient was fourteen years oId. I think this disease usuaIly occurs in older patients. In the November rg, rg6o issue 01 I he J. A. ,%I. A. Dr. Kenneth Sawyer reported on several patients having ulcerative colitis, the youngest of whom was seven years old. Within the last two months we have had two patients in our Chilclrcns’ Hospital under the age of live years. In one of these the symptoms began at the age of one and one-half years. At the time we saw the patient, therefore, he had been subject to intermittent bleeding with the usua1 symptoms of ulcerative colitis for about three years so that it was necessary, because of hemorrhage, to perform a colectomy at this tirne. We believe, without a large series to back it up, that in this younger age group we should leave the rectum on the possibility of this condition clearing. WC do not know the ultimate outcome regarding this younger age group, but I make this suggestion because the problem may be presented to you at any time. WILEY F. BAH~FR (Los Angeles, Calif.): I want to thank all of my discussants for their kind remarks. Let me say quickly that I don’t believe the slight differences in technic \vhich have been discussed are significant. I think that the point is that, as has been said in another context, there are many ways
of Ulcerati\.e
Colitis
01‘ skinning a cat, and if you kno\v hc,bv to handle this procedure and know in your own mind ho\v to avoid the pitfalls \vhich your particular technic may expose you to, you will undoubtedly have good results with it. I might say that in our abstract the comment was made that three fourths of the patients admitted to U.C.L.A.‘s hospital ended up having colectomy. This sounds like a dramatically high incidence ol surgical attack. This is partly because only the more seriously ill patients have been admittcd to the medical services for study. This biases the sclrction immediately. But beyond that, we have internists at the U.C.L.A. Hospital as well as at the Veterans Administration Hospital who are surgically minded with regard to this disease. Perhaps the early selection of cases in these last few years has been one of the reasons for there being almost no mention ol carcinoma in this series. In the last five vears I do not befieve we have had a single patient with ulcerative colitis and carcinoma; whereas, in the first five years I believe we had seen several such patients not included in this series because thcit initial operation had been at another hospital. W’c are tending more and more, as Dr. Hill suggested, to do the total colectomy in one stapc, with the exceptions that I mentioned for you. And I am perfectly certain that there arc several patients who had serious complications but in whom \ve cautiously chose the subtotal procedure. T\vo I can think of immediately suffered major blerding from the distal segment after the initial partial colectomy and probably would have been spared serious morbidity by having had a total procedure performed at the first stage. The problem of ileorectal anastomosis is a fascinating enc. 1 don’t know where we stand on it at this point. I do not think Dr. Turnbull, who is the main advocate of ileorectal anastomosis in this country, is quite willing to come out flatly and say what the role of this operation is. We, with Dr. Clarke at the Veterans Hospital, have had experience with perhaps eight cases of ilcorcctal anastomosis, and that is a subject for another day’s discussion. I think it is something which should be considered further, but I am not willing to accept it wholeheartedly yet. Regarding Dr. Snyder’s comment about our youngest patient being fourteen; this is almost chance Of course there are no veterans under fourteen, but the exclusion of pediatric patients has been an almost chance occurrence rather than resulting from any other kind of selection.
783
Treatment WILEY
F. BARKER,
of Ulcerative M.D.,
From tbe Department of Surgery, University of California Medica 1 Center, and tbe Surgical Service, Wadswortb General Hospital, Veterans Administration Center, Los Angeles, California.
HERE is considerabIe reIuctance on the part of many physicians to utiIize the surgeon in the care of uIcerative coIitis. The hesitancy dates back to the time prior to the introduction of satisfactory coIIecting devices and prior to present advances in technic and in supportive therapy. This report wiI1 be an accounting of the results of surgica1 management of eightyfour patients who were treated for utcerative colitis at The University of California MedicaI Center, Los AngeIes and the Veterans Administration HospitaI, West Los Angeles during the past ten years. The cases presented are those in which the author pIayed a persona1 roIe in surgical management and procedure, aIthough resident staffs performed the actua1 operation in about haIf the cases. The age range was from fourteen to fifty-six years. There was a sex distribution of thirty-four women and fifty men. For purposes of evaIuation the tables wiI1 show the cases in two groups: patients originaIIy operated upon between 1950 and 1954 are in group I, and those operated upon between 1955 and 1960 are in group II.
T
SURGICAL
TECHNIC
ConsiderabIe attention has been given eIsewhere to the important phases of preparation of the patient for operation [2]. It is our preference not to operate upon a patient receiving steroid therapy but operation is performed if necessary and proper SuppIementation is added to other forms of preparation. SuIfasuxidine,@ supplemented with a twenty-four hour course of neomycin, is the choice for intestina1 antisepsis. Purgatives and enemas are avoided. Nasogastric intubation is usuaIIy employed. The type of anesthesia is Ieft to the discretion of a American
Journal
of Surgery.
Volume
102, Aupusf
1061
176
Colitis
Los Angeles, Calijornia competent anesthesioIogist: genera1 anesthesia with endotrachea1 intubation is commonly administered. The site of the iIeostomy is carefuIIy seIected with regard for cutaneous scars, the umbilicus, bony Iandmarks and parieta1 ffexion creases; the stoma1 incision is prepared through a11 Iayers prior to opening the abdomen. The major abdomina1 incision is usuaIIy a long Ieft paramedian incision. DetaiIed expIoration is performed. The right colon is mobiIized first; the terminal iIeum is then divided as far distahy as possibIe with due regard for avoiding division in areas of iIeac invoIvement by true uIcerative disease. Traces of edema and diIatation secondary to more dista1 obstruction may be disregarded. Preservation of as much termina1 iIeum as possibIe is important because of the water resorbing abilities of this organ. A generous segment of ileum proxima1 to the line of division is then prepared by dividing the ,mesentery about I to 2 cm. from the bowe1. (Fig. I.) This maneuver assures viabiIity of the dista1 tip. At such a point as to nourish the dista1 tip of bowe1 by a major arcade of vesseIs, the incision in the mesentery doubIes back on itseIf. At this apex, a nonabsorbabIe suture is pIaced in the mesentery, next to the bowe1 wal1, avoiding injury to the blood supply to the dista1 portion. This suture serves for IateraI attachment to the peritonea1 ring at the point of emergence of the bowe1. The mesenteric incision is now carried cephaIad in a convex curve IateraIIy, ending at the posterior parieta1 attachments of the 3eocoIic mesentery. This curved edge of mesentery will fit into the IateraI gutter and cIose it without distortion of the prestoma bowe1. The future stoma should now be drawn through the tunne1 in the abdomina1 wail previousIy prepared for it. The mesentery is attached to the parietal peritoneum so that it lies Iateral to the stoma, thus continuing the plane of the mesenteric curtain into its natural
Surgical
Treatment
intersection with the nIxlomin:J wall. To secure this mesentery and to reduce the risk of proIapse, it is advisable to suture the cut edge 01 the mesentery with interrupted nonabsorbable sutures to the parietal peritoneum, beginning at the stoma with the suture previously placed there. In order to assure permanent adherence, an incision may be made in the parietal peritoneum to accept the mesenteric edge. Once this stage of construction of the ileostomy has been reached, one may proceed with the remainder of the colectomy with the comfortable feeling that the procedure can be terminated quickly at any time if necessary by exteriorization of as much colon as has been mobilized. In general terms it is preferred to perform a total colectomy in one stage except as follows: (I) where rectal innocence of disease implies possible ileorectal anastomosis, now or later; (2,~ where extensive anorectal sepsis might seriously contaminate the abdominal wound and peritoneal cavity; (3) in maIes whose sexual potency might be affected by a bloody dissection in a narrow pelvis in the presence of acute inflammation; (4) in any patient whose general condition does not warrant further operating by the time dissection has come around to the rectosigmoid colon. Removal of all the colon proxima1 to the rectosigmoid is urged in the presence of free perforation. Total one stage coIectomy may be the only means of controlling bleeding when this has been the indication for operation. If a two stage procedure is chosen, it is preferaMe to leave an open mucous fistula to assure external drainage of any active septic process in the distal segment. During the actual rectal dissection, care is taken to keep the pIane of dissection as &se to the bowel as possible, especially in the male, to avoid the genitourinary complications of impotence and bladder dysfunction. It is neither desirable nor necessary to remove any portion of the levator ani muscles. 1fan ileorectal anastomosis is to be performed Turnbull’s technic [4] is followed in detail. Closure of the wound is usuaIIy performed in layers, with the use of nonabsorbabIe sutures; and in all but the best risk patients retention sutures are used for extra support. If serious contamination has been encountered, as in free perforation, the fascial and peritoneal Iayers are closed with wire or catgut and the skin and
of Ulcerati\:e
Colitis
rl/y/-
FIG. 1. This drawing shows the level at which the distal ileum is divided, the long vascularized loop of ileum to be brought through the abdominal wall, and the curved incision in the ileocolic mesentery. The suture placed at the angle will be used to attach the ileum to the peritoneum as the bowel emerges from thr pcritoncal cavity.
fat are left open for a delayed closure in four or five days. The ileostomy is matured immediately by a technic similar to that of Turnbull [?I. Several longitudinal incisions are placed in the distal two thirds of the exteriorized ileum, through serosa and muscularis. This renders the distal portion patulous without devitalizing it, anti assures adherence of the everted and scarified layer to the proximal inner layer. A carefully fitted transparent, disposable pIastic ileostomy bag is placed on the wound immediatelv. The majority of complications encountered in the second half of this series can be directly traced to failure to follow meticulously the principles described above. OPERATIONS
PERFORMED
Table I presents a summation of the eightyfour cases. Approximately fifteen other patients were seen during this period. They had received surgical treatment for ulcerative colitis elsewhere and their probIem was not currently of a surgical nature. The one stage total colectomy was the most common initial operation. It was performed in twenty-three of the sixty-six patients operated upon ‘in the last five years. There were three deaths among the thirty-one patients in whom this operation was used in the total period. The t\vo stage total colectomy appears to carrl
Barker TABLE SUMMARY
OF
SURGICAL
TREATMENT
OF
I
EIGHTY-FOUR
PATIENTS
WITH
ULCERATIVE
COLITIS
1955-196* Emergency
No.
of Cases
Late
Postc,perative I kath
Ileostomy only.. . later colectomy Ileostomy, (partial) . One stage ikostomy and total colectomy
Ileostomy and staged total colectomy. Ileostomy and partial colectomy. AnsI ileostomy.. Ikorectal anastomosis, complementary ileostomy.. Transverse colostomy.. Revision only, original operation elsewhere. Colectomy only. origina operat,o” elsewhere.,
Late Death from
1Death
from Any ,zause
_-
Any
Late of CaS25
from Any
Calls‘2
I
0
0
0
0
0
0
0
0
0
0
0
8
I
*
0
20
I
4
0
0
0
5
0
4 I
0 0
2 0
0 0
lot 0
I 0
o 2*
0 0
0 0
0 0
1 2*
0 0
I
0
0
0
5*
0
0
0
0
0
I
0 -
-
TABLE FOR
-
for Operation
and right colectomy
AND
ResuIts
RESULTS
ResuIts
rgso-1954.
Exceltent
--
Dead ( 4ny Car
Fai
Excel lent
8
3
2
I
I
2
I 2
3
Fair
=
14
28 I
36 : 1*
5
21
2
3 2
7
- I
eIsewhere for this indication.
Igsq--I960
No.
No.
p= Elective Chronicity (faiIure to respond to medica care, distant complications, muItipIe recurrences) BIeeding Sepsis (incIuding rectal infection). Perforations, PoIyposis. Stricture (or suspicion of carcinoma).
in one case and iieocolos-
II
SURGERY
I
* Initial operation
Death
Lstc 3eath from Any Jause
-_
INDICATIONS
Totat..............................
operative
,Cause
* One patient in each of these groups has had proximal recurrence requiring ileostomy tomy in the other. t Three of these patients were ultimately treated by ileorectal anastomosis.
TotaI.............................. Emergency Perforations Acute fuIminant disease.. Hemorrhage.......................... Sepsis.
Post-
IDeath
io.
_
-
Indication
I
Elective
Emergency
Elective Type of Operation
Operation I78
-
at UCLA MedicaI Center for stricture.
Dead of 4ny Cause
Episodes
of Complications
Stoma1 complications Retraction and/or necrosis Prolapse. FistuIa Stricture. Proximal perforation 2 degrees to stricture., Prestomal twist.. IntestinaI obstruction due to bands or internal adhesions. Dehiscence Peptic ulceration. Intra-abdominal abscesses. Recurrent enteritis.. Neoplasm of colon. tlepatitis Spontaneous ileac perforation. Septicemia (gram-negative). Enteritic (staDhvkxoccal)_ . Perineal a&Ass”(maior) .‘. Wound infection (major). Spontaneous rupture of spleen. Seotic abortion. Delvic Deritonitis Severe electrolyte imbalance. Total gastric erosion.. hfaln bsorption, severe Potassium loss nephritis.. Transfusion reaction, renal shutdown .. II
Total.
.
T> pc of Surgery
I
Lapnrotomy (for obstruction, volvulus bands, etc.). Closure, drhiscencc. hlajor local revision. hlinor local revision. Incision and drainage, intra-abdominal abscess. Gastric resection for ulcer.
6 2 0
5 / 0
0
Total
7 5
..
2
3 4
considered important. There were only two deaths among the Iast forty-four patients who underwent elective operation. Many of these “elective” operations were performed as urgent operations without optimal preparation, but they could not be pIaced in a class of true emergencies.
0 I 2
3 2 0 4 I I
INDICATIONS
I I
FOR
OPERATION
The indications for operation reviewed in Table II are related to the results. The general term, chronicity, describes the chief indication for operation. Herein are lumped those patients whose chronic debility or whose recurring episodes of colitis make the compromise of ileostomy and colectomy attractive. Included with this group are a few patients whose distant complications, such as arthritis, were an important factor in bringing them to operation. The next most common indications are much more imperative: perforation and the acute fulminating form of the disease. There was no clear impression that the results are related to the reason for which the operation was performed.
2 0
52
the lowest mortality risk (no deaths among sixteen patients) amongst the major types of operation. This may be an illusion because of the fact that several of the patients who were subjected only to ileostomy and partial coIectomy died before being subjected to the second stage and their mortality is debited to the first operation. Four patients with what appeared to be left sided colitis were treated initially by transverse colostomy. In two of these patients there has been no proxima1 recurrence; a third has undergone iIeostomy and right coIectomy and the fourth has had a resection of terminal ileum with an ileocohc anastomosis. The over-al1 mortality risk improved during the second period. There were four deaths among the first t.wenty-eight patients and four in the second group of sixty-six patients. This gain may be ascribed to many factors but experience and technical improvement must be
COMPLICATIONS
The number and type of complications are detailed in Table III. The number of surgical procedures needed to correct the more critical of these compIications are described in Table IV. It would seem unlikely that any surgical operation that is followed by such a cataIogue of problems shouId be widely accepted. Several points should be made regarding these compIications to dispel this impression. ‘79
Barker consiclerable
improvement in frcetlorn from in the lirst series only one fil’th of the patients were free of complicat’ions, while in the second series two fifths were free of al1 complications. This improvement is in part due to selection of more favorabIe cases for referral by the internist to the surgeon but is also due in part to the surgeon learning to provide better surgical management. Furthermore, only six patients experienced complications after three years from the date of the original operation, and all these had suffered continuing problems since operation. One might put this differently: after three years have elapsed from time of operation one need anticipate few further problems.
Certainly obstruction of the small bowel due to adhesive bands has been one of the most common complications but one which was treated surgicaIly with minima1 morbidity. The number and severity of adhesions could in no way be related to the type of operation, the degree of peritoneal contamination or the use of steroid therapy. It had been our clinica impression that the presence of concurrent therapy with steroids greatly added to the hazards of late complications. This cannot be substantiated statistically, but certainly the majority of compIications detailed above are derived from only haIf a dozen patients, whose complications seemed aggravated by high dosages of steroids. Most specificaIly reIated to steroid therapy were three episodes of completely unexplained small bowe1 perforations in smaI1 bowe1 free of adhesions, trauma or previous apparent disease. Another less clearly defined relationship exists in the enlargement in the stoma1 hiatus and deveIopment of a combination of prolapse, (alternating with retraction) and peristomal herniation, seen most commonIy in those patients operated upon under large doses of steroids. This enIargement of the parieta1 opening has been observed even in those patients in whom care was taken to try to keep the tunne1 narrow. Another serious complicating factor has been the recurrence of enteritis in proximal bowel. This has not always been presaged by at recognizable specific ileac involvement operation. The presence of true Iocal disease of the small bowel, however, has been impIicated in several instances of local ileostomy problems, especiaIly those of stricture and fistula. The early diagnosis of stenosis of the stoma, as indicated by cramps and paradoxical diarrhea, and its ease of correction by a minor surgica1 Iysis of the constricting scar has been described elsewhere [I]. Prolapse, a much more difficult condition to treat successfully, has occurred much less frequently in the more recent series. Major revision, including reattachment of the ileac mesentery to the parietes, shortening of the mesentery and reduction of a peristomal hernia, if present, are the important factors in its treatment. In this rehearsal of compIications one can easily lose sight of severa profitable aspects. First, between the two periods there has been
complications;
REHABILITATION
With the background of frequent complications of varying severity beclouding the advisability of surgical treatment of ulcerative colitis, it seemed proper to evaIuate the results in terms of rehabilitation. The extent of relief that can be given to a patient can be appreciated by answers from the two patients whose resuIts were to the author most discouraging from the point of view of multipIe complications and operations. Their case reports are presented briefly below: CASE I. M. F. was operated upon in 1954 because of tweIve years of incapacitating bloody diarrhea. His course had been compIicated by a transfusion reaction and temporary acute renaI failure. Later complications of stricture, prolapse and peristomal herniation folIowing trauma have necessitated a tota of eIeven minor or major operations. Nevertheless he is actively empIoyed, weighs more than at any other time in his Iife and avers that he is better abIe to handIe the affairs of his Iife than at any time since the onset of the coIitis. CASE II. M. S. was operated upon in 1950 because of hemorrhage and recta1 sepsis. His course has simiIarIy been complicated by proIapses and strictures and a recurrence of an enteritis involving the full extent of his smaI1 bowel. MuItipIe stoma1 revisions and proxima1 bowe1 resections have been necessary, but the patient is presentIy empIoyed as an electrician, weighs about twenty-five pounds more than at the origina operation and states that in spite of the compIicated course of his disease he would not hesitate to choose iIeostomy again, and indeed wishes it had been undertaken earlier. 180
SurgicaI
Treatment
This thcmc of satisfaction was repeated o\‘er and over again in questioning the forty-three patients with lvhom direct contact could be made at the present time. The results of the survev of these forty-three patients, representing two thirds of the living patients, are presented as follows: 1Veight Gain. The average weight gain since operation has been twenty-nine pounds, with a spread of from minus twelve to more than eighty pounds. The present weights average one pound greater than the previousIy recorded highest weights prior to operation. Occupation. Forty patients denied that their present occupation was compromised by the ileostomy. One patient who was a cook bec.arne a salesman; one fashion model bought the dress shop; one woman whose job required lifting heavy bundles of newspapers could not be re-employed. Seven young women have married. There have been at Ieast four children born to the female patients since operation. Satisfactory adaptation to sexual activity has been reported by most patients of both sexes and in both married and single estate. Impotence has not been encountered in the male patient since our adoption of the technics of rectal dissection described under TECHNIC. Only five patients admitted any social restrictions. The most common source of complaint \vas the noisiness of the stomal activity and a limitation of vigorous physical activity by distodgement of the appliance. AImost a11 patients, however, have been able to continue swimming, bowling, tennis, dancing and similar activities without inhibition. Only one patient felt he was Iess well able to cope with the affairs of his life now than prior nine felt equally well able and to operation; thirty-three felt they were much better able. Indeed, fourteen patients felt better able to manage their affairs than ever before; eighteen felt equally well able; only eleven did not return an answer or stated that they were less able to deal with life. It is recognized that most of these are highly subjective responses. Replies from the fourteen patients n-ho later died and which one would expect to be unfavorable have not been included in this tabulation. Psychologic rehabilitation is another benetit derived from adequate surgica1 treatment. The so-called “ ulcerative colitis personality” does not persist after extirpation of the organic
of Ulcerati\-e
Colitis
problem. It is clear that in this group tients there ~~1s far more somatopsychic obser\,ed than psychosomatic.
of paeffect
SUMMAR\
In reviewing the experience with eighty-four patients who had ulcerative colitis and who were treated by ileostomy and colectomy, it is apparent that this operative procedure is fraught with many complications and a signiticant mortality and morbidit,v. These unfavorable aspects can be minimized by careful attention to detail and meticulous adherence to the surgical principles that have been established during the acquisition of this experience. In spite of these complications, the end result is an excelIent one with regard to rehabilitation. Ileostomy and colectomy can restore a near normal life to the patient with ulcerative whatever handicaps m:ty exist arc colitis; gratefully accepted by the patient as a most desirable exchange for the emotional and physical misery and disability lvhich often foIlow the prolonged conservative, nonoperative approach. REFERENCES I. BARKEK, W. F. Factors contributing to ilcostomy dysfunction. West. J. Surg., 64: 235, 19~6. 2. BAKKEK, W. F. and MEILI~KOFI:, S. W. hledicosurgical teamwork in the trcatmcnt of ulccrativc colitis. M. C&n. North America, 43: I I 55, 1959. 3. TURNB~~.LL, R. B., JR. Management of the iieostomy. Am. J. Surg., 86: 617, 1953. A. TURNBULL.
R. B.. JR. Surnical treatment
of ulcera-
tive coliks: early results after colectomy and IOU ilcorrcta1 nnastomosis. Dis. Colon P Rectum, 2:
260, 1959. DISCUSSION R0BER.r A. SCARBOROUGH (San Francisco, Calif.) : Dr. Barker has presented a comprehensive report on his considerabIe experience in the surgical treatment of ulcerative colitis. I-It has not minimized the complications of surgery, but he has demonstrated that improved technics have greatly reduced their incidence. And he has concluded, rightly I believe, that surgical treatment can curt this discasc, with most satisfactory physical and psychologic rehabilitation of the patient. The significant reduction in morbidity and mortality resulting from surgical treatment during the past ten years can be largely attributed to: (I) removal of the diseased colon as the primary procedure; (2) improved methods of ileostomy stoma construction for prevention of ilcostom~ dysfunction; (3) improved “collecting devices
181
Barker for ileostomy discharge; (4) improved technic of rectal resection for preservation of normal sexual function; and (5) elimination of an open perineal wound by preservation of the external anal sphincter and completion of rectal excision through the ana cana1. Efficient function of the iIeostomy stoma is a prime requisite to the success of surgica1 treatment. There is genera1 agreement that this depends upon the avoidance of both physioIogic and mechanica obstruction. Primary union of iIea1 mucosa and skin is an accepted objective, aIthough there are a number of variations of technic employed. There are members of this Association who advocate a stoma flush with the surrounding skin and other members who believe that the stoma should protrude for 2 cm. or more above the IeveI of the abdomina1 waI1. Dr. Barker empIoys a modihcation of the technic of mucosa1 graft originally described by TurnbuII. We have now abandoned this as an unnecessary procedure, and accompIish a moderate eversion by fixation of the mesentery so that there is a 2 cm. slack in the emerging ileum, with simple interrupted suture of the open end of the ileum to skin. In preparation for the ileostomy, we excise a square of skin and of anterior rectus sheath to minimize any obstructive compression of the ileum as it emerges through the abdominal wall. Our technic for ileostomy is aIso at variance with the generally accepted practice of closure of the IateraI gutter. We do not close this space, and assure ourselves of a wide open area by fixation of the mesentery to the anterior peritoneum in a cephaIad direction with siIk sutures. I wouId like to point out that the author’s tabIe of indications for operation does not refIect the rea1 danger of development of carcinoma in disease of long standing. Dr. Barker has made onIy brief comment upon the recent rebirth of some tempered enthusiasm for preservation of the rectum and ultimate restoration of bowel continuity. Further elaboration on this subject is therefore not warranted in discussion of this paper. LEON GOLDMAN (San Francisco, Cahf.): I am sure that many of you have been concerned in recent years, as we have, about the apparent increase in the incidence of perforation and massive hemorrhage in patients with ulcerative colitis who have received steroid therapy, Dr. Barker, in referring to this phenomenon, mentioned that from his observations it was impossibIe to prove that a connection existed between perforation and steroid therapy. As we know, the use of steroids, particuIarIy in patients with acute uIcerative cohtis, is becoming more common. In many patients the dosage is increased if they fail to respond initiahy; therefore, I82
they may receive Iargc doses of steroids often for long periods of time. We are particularly concerned about the increase in the incidence of perforation because it is difficult to make an earIy diagnosis of a free or walled-off perforation in patients with uIcerative colitis since steroid therapy masks symptoms. We reviewed our cases of ulcerative coIitis to try to determine whether there was any difference in the incidence of complications in patients who were receiving steroid therapy as compared to those who were not. In this thirteen year period, although these statistics may be interpreted in various ways, the number of patients in both groups is approximately the same. Yet eight patients in the steroid group deveIoped massive hemorrhage as compared to only two in the nonsteroid group. Perforation occurred in eight patients in the group receiving steroids as compared to only one patient in the nonsteroid group. Ten patients deveIoped hypokalemia in the steroid group but no patients did so in the nonsteroid group. Six patients who received steroids deveIoped psychoses, but none did in the nonsteroid group. Four patients developed peptic uIcer in the group which received steroids as compared to only one patient with peptic uIcer in the nonsteroid group. These statistics seem to indicate that more compIications deveIop in patients who have received steroid therapy for ulcerative colitis. LUCIUS D. HILL, III (Seattle, Wash.): Dr. Barker has given a timely and forthright coverage of large experience with a disease which has interested most of us. I wouId like not only to agree with what he has said about the iIeostomy, but to emphasize that we, too, fee1 that suture of the mucosa of the iIeostomy to the skin has been one of the great advances in surgery for ulcerative colitis. But we, like Dr. Scarborough, have abandoned the technic that was originaIIy described by Turnbuli in favor of the technic that was described by Brook, nameIy, simpIy everting the end of the ileostomy and suturing it to the skin. We believe that without incising the serosa of the termina1 iIeum we have had fewer instances of stricture of the ileostomy. As far as the operative technic is concerned, we have preferred to use a singIe stage, tota coIectomy and iIeostomy whenever feasibIe. In this technic we are aided by inserting into the rectum a pack which is soaked in Zephiran.@ We tie a tape proximal to this pack. An additiona tape is tied to it SO that the circuIating nurse can remove this from beIow during the operation. This heIps us to define the Iocation of the anus; it aIso heIps in doing the things that Dr. Barker has so aptIy pointed out, nameIy avoiding denervation of the bIadder, and also staying close to the rectum to avoid impotence in the maIe.
Surgicd
Treatment
After the rectal dissection is complctc, the pack is withdrawn from below; the rectal ampulla, a rclatively sterile and empty organ, can be opened; the dentate line can be visualized and the entire rectum removed through the abdomen. This saves turning the patient during the operation and performing an abdominal perineal resection, which we believe is a more traumatic proccdurc. WC ha\-e used this procedure in twenty-three instances over the past six years with one death. \Vc have utilized it in some patients on whom we operated as an emergency, and believe that it is only the i-are individual who has either extensive pathologic condition of the pelvis, such as endomctriosis, or pelvic inflammatory disease, who is not a candidate for this procedure. The only innovations we have been forced to add during the past five years have been those aimed at corrrccting complications in the posterior wound. Careful drainage of the posterior wound, scrupulous attention to the posterior wound and digital examination of the posterior wound under sterile conditions insure that there are no locufated pockets of fluid left behind. WII-LIAM II. SKYDEK, JR. (Los Angeles, Calif.): In Doctor Barker’s extensive series I was interested to note that the youngest patient was fourteen years oId. I think this disease usuaIly occurs in older patients. In the November rg, rg6o issue 01 I he J. A. ,%I. A. Dr. Kenneth Sawyer reported on several patients having ulcerative colitis, the youngest of whom was seven years old. Within the last two months we have had two patients in our Chilclrcns’ Hospital under the age of live years. In one of these the symptoms began at the age of one and one-half years. At the time we saw the patient, therefore, he had been subject to intermittent bleeding with the usua1 symptoms of ulcerative colitis for about three years so that it was necessary, because of hemorrhage, to perform a colectomy at this tirne. We believe, without a large series to back it up, that in this younger age group we should leave the rectum on the possibility of this condition clearing. WC do not know the ultimate outcome regarding this younger age group, but I make this suggestion because the problem may be presented to you at any time. WILEY F. BAH~FR (Los Angeles, Calif.): I want to thank all of my discussants for their kind remarks. Let me say quickly that I don’t believe the slight differences in technic \vhich have been discussed are significant. I think that the point is that, as has been said in another context, there are many ways
of Ulcerati\.e
Colitis
01‘ skinning a cat, and if you kno\v hc,bv to handle this procedure and know in your own mind ho\v to avoid the pitfalls \vhich your particular technic may expose you to, you will undoubtedly have good results with it. I might say that in our abstract the comment was made that three fourths of the patients admitted to U.C.L.A.‘s hospital ended up having colectomy. This sounds like a dramatically high incidence ol surgical attack. This is partly because only the more seriously ill patients have been admittcd to the medical services for study. This biases the sclrction immediately. But beyond that, we have internists at the U.C.L.A. Hospital as well as at the Veterans Administration Hospital who are surgically minded with regard to this disease. Perhaps the early selection of cases in these last few years has been one of the reasons for there being almost no mention ol carcinoma in this series. In the last five vears I do not befieve we have had a single patient with ulcerative colitis and carcinoma; whereas, in the first five years I believe we had seen several such patients not included in this series because thcit initial operation had been at another hospital. W’c are tending more and more, as Dr. Hill suggested, to do the total colectomy in one stapc, with the exceptions that I mentioned for you. And I am perfectly certain that there arc several patients who had serious complications but in whom \ve cautiously chose the subtotal procedure. T\vo I can think of immediately suffered major blerding from the distal segment after the initial partial colectomy and probably would have been spared serious morbidity by having had a total procedure performed at the first stage. The problem of ileorectal anastomosis is a fascinating enc. 1 don’t know where we stand on it at this point. I do not think Dr. Turnbull, who is the main advocate of ileorectal anastomosis in this country, is quite willing to come out flatly and say what the role of this operation is. We, with Dr. Clarke at the Veterans Hospital, have had experience with perhaps eight cases of ilcorcctal anastomosis, and that is a subject for another day’s discussion. I think it is something which should be considered further, but I am not willing to accept it wholeheartedly yet. Regarding Dr. Snyder’s comment about our youngest patient being fourteen; this is almost chance Of course there are no veterans under fourteen, but the exclusion of pediatric patients has been an almost chance occurrence rather than resulting from any other kind of selection.
783