Surgical treatment of ulcerative colitis

Surgical

Treatment

A COMPARISON

of Ulcerative

Colitis

OF SINGLE-STAGE COLOPROCTECTOMY WITH OTHER PROCEDURES

CHARLES W. MCLENATHEN, M.D. AND

JOSEPH A. WEINBERG, M.D., Long Beach, California total resection and iIeostomy in one stage [z]. The ages of the patients in this study correspond to the ages generaIIy reported for the onset of the disease and the time of operation. The youngest at the time of the onset of symptoms was nineteen years of age, and the oIdest fifty-three. The youngest patient at the time of the primary operation was twentythree years of age, and the oldest sixty-one. Most of the patients had received prolonged intensive medica therapy prior to surgical treatment. The exceptions were patients operated upon because of uncontroIIed hemorrhage The interva1 between the or perforation. recognized onset of the disease and surgica1 therapy varied from one month to fifteen years, with a mean interval of six years. The degree of debilitation at the time of operation was usuaIIy proportiona to the duration of the disease, but there were notabIe exceptions in which fulminating attacks occurred at the outset. The prior medical therapy consisted of programs in which antibiotics and corticoid drugs pIayed a dominant role. The seventeen patients (40.5 per cent) who received either cortisone or adrenocorticotropic hormone therapy showed varying responses to these agents. Cortisone therapy gave relief for no more than a few weeks. In genera1 th ere was progressiveIy poorer response with repeated courses. Psychotherapy was used in several of the patients without apparent success, but its use was too infrequent and of too short duration to afford an opportunity to assess its value fairly. The indication for surgica1 treatment in a11 the patients was the presence of disease of the coIon which was severeIy debihtating and couId not be controIled by medical means. (Table I.) Severe intractable diarrhea was present in 79 per cent, recurring bouts of hemorrhage in

From the Surgical Service, Long Beach Veterans Administration Hospital, and tbe Department of Surgery, University of Calijornia at Los Angeles, CaliJornia.

(3)

HRONICuIcerative colitis becomes a surgica1 problem once it has reached the stage when it no longer responds to medical therapy. Irreversible degenerative and ulcerative changes with associated toxic absorption, severe intractable diarrhea, dehydration, mamutrition, repeated severe hemorrhages, perforation, incontinence and obstruction are among the conditions which carI for surgica1 intervention. The possibility of the deveIopment of cancer is aIso to be considered if the disease remains active for a period of years. Hickey and Tidrick [I] found in their study that cancer of the coIon deveIoped in zg per cent of patients known to have had uIcerative colitis for ten years or longer. Although surgica1 therapy has gained genera1 acceptance for the treatment of advanced forms of the disease, there is stir1 a difference of opinion as to the merits of the various types of operations which have been devised for its treatment. Controversy centers principaIIy on whether the operation should aIways be tota coloproctectomy or whether lesser procedures such as coIectomy with ileoproctostomy are sometimes justified. In order to assess the merits of the severa methods in our own experience, we have reviewed the results in the forty-two patients operated upon in the Veterans Administration Hospital, Long Beach, in the seven-year period from January, rg5z to January, 1959. The operations performed were of three genera1 types: (I) less than total resection of the coIon, rectum and anus, (2) total resection and ileostomy in pIanned multipIe stages, and

C

165

American

Journal

of Surgery,,

Volume

98,

August.

,959

McLenathen TABLE I INDICATIONS FOR SURGICAL Indications

Some patients

TABLE II PRIMARY SURGICAL PROCEDURES

No. of Patients

No. of Patients

Procedures

Group

I : Less radical than tota coIectomy: SubtotaI colectomy with iIeostomy or coIostomy CoIectomy with iIeoproctostomy Anterior resection. CoIostomy Group 2: PIanned muItipIe-stage tota coIectomy Group 3: One-stage total coIectomy

33 27 r3 3 2

I I

had severa

Weinberg

TREATMENT*

Diarrhea........................ BIeeding........................ Weight loss. Obstruction AbdominaI mass. Perforation. Sepsis........................... *

and

indications.

64.5 per cent, extreme Ioss of weight and genera1 sepsis in 31 per cent, and obstruction in An anaI fistuIa with single or 7 per cent. multiple tracts was present in seven patients. Three patients had duodenaI uIcers with histories indicating that the onset of duodena1 uIcer folIowed the onset of the disease of the coIon. Less frequent compIications and sequeIae were perforation, malignant degeneration and arthritis. Roentgenographic examination and sigmoidoscopy were the principa1 objective means of demonstrating the gross pathoIogic changes. The roentgenographic examination was accurate in establishing the presence of the disease, but it faiIed to show the extent in half the cases. It was not infaIIibIe in determining the presence of polypoid changes. The changes commonIy seen with sigmoidoscopy were uIcerations, congestion, edema and poIypoid changes. Bleeding with contact of the instrument against the mucosa was a usual occurrence. AI1 the excised specimens of coIon showed Iarge areas of uIceration with various degrees of fibrosis, thickening, congestion and edema. Ninety-three per cent of the specimens showed mucosal poIypoid changes. The rectum showed edema, congestion, uIceration and fibrosis in a11 the cases of tota coIoproctectomy and was more seriousIy affected by the disease than other portions of the excised tract. Cancer was demonstrated by microscopic examination in five of the specimens (12 per cent). The cancerous changes were confined to the cecum and ascending coIon in two cases, to the sigmoid area in one case and to the rectum in two cases. Four of the five cases of cancer were in young patients between the ages of twenty-seven and thirty-five years.

SURGICAL

18 4 2 2 4 I2

TREATMENT

Group I. Twenty-six patients had initia1 procedures Iess radical than total coIoproctectomy. The procedures used in these operations were simpIe iIeostomy, iIeoproctostomy, iIeostomy and partiaI coIectomy with estabIish&ent of a sigmoid fistuIa, coIectomy and iIeoproctostomy, and hemicolectomy with or without coIostomy. (TabIe II.) Eighteen of the twenty-six patients had additiona1 surgical procedures because of unsatisfactory resuIts with the primary operations. One patient died of cancer of the coIon one month after a secondary operation. The primary operation in this case, anterior resection of the sigmoid coIon, had been performed two years earIier. It is probable that this cancer death would have been averted if tota coloproctectomy had been performed initiaIIy. One patient, a young woman, had a massive hemorrhage one year folIowing simple iIeostomy. She faiIed to survive emergency resection of the coIon performed to arrest the hemorrhage. The other sixteen were we11 after the secondary procedures. Of the eight patients who did not have secondary operations, three died of the disease. One of the deaths was due to perforation of the Iarge bowe1 with generaIized peritonitis. Another death occurred as the result of cancer which became evident one and a half years after right hemicoIectomy. The third death was from puImonary emboIism which occurred three days after subtota1 resection of the coIon with establishment of an iIeostomy and a sigmoid fistula. This patient, a severe diabetic, was in

166

Ukerative

Colitis TABLE III

extreme1.y poor condition at the time of operation and the outcome was probabIy not inffuenced by the Iimited type of procedure. The five surviving patients in the group with operations Iess radicaI than total colectomy and without secondary procedures have not fared AI1 were having severe we11 postoperatively. diffkuItics when Iast seen after two or more years of foIIow-up. The principa1 disturbances were severe diarrhea, maInutrition, bleeding and ana fistuIa formation. AI1 were advised to have secondary operations for removal of the remaining diseased bowe1 but they refused or were Iost to foIIow-up. Group z. Four patients underwent pIanned two-stage tota coIoproctectomy with ileostomy. The eventual results were satisfactory in a11 the patients, aIthough disabiIity was proIonged for severa months in each case because of the division of the operation into stages. Group 3. TweIve patients underwent onestage tota coIoproctectomy and iIeostomy. There was one surgical death which occurred three days after an emergency operation for massive bIeeding. The immediate cause of death was coronary vessel disease. With the exception of this case, the results were uniformIy satisfactory. There was earIy restoration of heaIth and return to the former status of activity. AI1 recovered from the severe state of malnutrition and debilitation from which they had previously suffered. The onIy significant postsurgica1 complications were severa ileostomy disturbances in the earIy cases which required revision. The type of ileostomy has had an important bearing on the postoperative course. A protruding type of iIeostomy was made in the earIy cases. (TabIe III.) This resuIted in compIications of proIapse, stricture and fktuIas which made surgica1 revision of the ileostomies necessary. In the past severa years we have used the flush type of iIeostomy 131. There have been few compIications and most have required no more than minor procedures for their correction. CASE

ILEOSTOMY

COMPLICATIONS

Type of IIeostomy* CompIications FIush

Revisions. ProIapse. Stricture. Fistula.

3 I o

Protruding

4

2

7

3 2 I

* Twenty-five flush-type and nine protruding-type iIeostomies were carried out.

Group I: Planned Operations Less Radical than Total Coloproctectomy J. I*., a thirty-two year oId miIk salesman, was admitted on July IO, 1957, with the complaint of diarrhea and bleeding. The diagnosis of chronic uIcerative colitis had been estabIished five years previously, and the patient had been treated with various programs of medication incIuding steroids, Banthine,@ SuIfathaIidineO and special diets during the two years prior to admission. X-ray examination showed typica changes of uIcerative colitis in the descending and sigmoid coIon. Sigmoidoscopic examination showed uIceration of the mucosa. TotaI coIectomy was advised but was not accepted. Therefore, a less extensive operation consisting of ileostomy and partial coIectomy with establishment of a sigmoid fistuIa was performed on September 30. The rectum and dista1 part of the sigmoid mere not removed. The patient continued to have bloody puruIent discharge from the rectum and there was no improvement in his genera1 condition. He returned to the hospital seven months Iater because of severe rectal bIeeding. Proctoscopic examination showed persistence of the ulcerations and pseudopoIyposis with muItipIe sites of bleeding. Emergency operation consisting of removal of the remaining portion of the large bowel was performed on ApriI 30, 1958, to arrest the bleeding. There was immediate reIief folIowing the second operation with gain in weight, and the patient returned to his former employment one month Iater.

Group 2: Planned Multiple-Stage Total Coloproctectomy with Ileostomy

REPORTS

H. G., a twenty-eight year old newspaper manager, was admitted on ApriI 7, 1953, with exacerbation of symptoms of chronic ulcerative coIitis. The disease had been present for years. Treatment with specia1 diets, antibiotics, corticotropin and cortisone was associated with short periods of remission. At the time of the current

Representative cases have been selected from each of the three groups to iIIustrate the preoperative condition of the patients, the operative course and the resuIts of the severa methods empIoyed. 167

McLenathen

and

admission he was suffering from severe diarrhea, bleeding and fever. There had been a 35 pound weight Ioss in the previous six months. X-ray examination showed a short tubular coIon. Proctoscopic examination discIosed an ulcerated, friable, bleeding mucosa with pseudopoiyposis. The patient was cachectic and anemic. SubtotaI coIectomy and iIeostomy was performed on May 4 as the first stage of a pIanned two-stage total coIoproctectomy. The manifestations of the disease remained unchanged foIIowing the first-stage procedure. The tota resection was completed on October 20, four and a haIf months after the first stage. FolIowing this the patient rapidly regained his health and he returned to his former occupation in four weeks.

Group 3: One-Stage Total Coloproctectomy Ileostomy

Weinberg COMMENTS

Our resuIts Iead us to the opinion that when surgica1 therapy is required for the treatment of ukerative coIitis the procedure shouId be tota coIoproctectomy with iIeostomy. AI1 the cases of tota resection in this series have had successfu1 outcomes except the one surgica1 death in an emergency operation for hemorrhage, whiIe the resuIts of Iesser procedures incIuding iIeostomy, partia1 resection of the coIon with end-to-end anastomosis of the iIeum to the rectum, and partia1 coIectomy with iIeostomy or coIostomy have been poor without exception. We had hoped that resection with iIeoproctostomy wouId contro1 the disease but this hope has not been reaIized. The four patients who underwent this procedure required Iater excision of the remaining anorecta1 segment because of postsurgica1 occurrences of ana fistuIas, bIeeding, puruIent discharge and incontinence. The faiIure of the anastomotic procedure is not surprising in view of the fact that the recta1 segment is more vuInerabIe to the disease than any other part of the Iarge bowe1. Other procedures less radical than total excision were equaIIy unsatisfactory. Two deaths occurred in patients with partia1 coIectomy, one from hemorrhage and the other from cancer. These deaths wouId probabIy have been averted if a11 the diseased tract had been resected at the initia1 operation. Most of the other patients with procedures Iess radica1 than tota resection had subsequent conversions to total coloproctectomy. Others refused further resection or were Iost to foIIow-up. Our experience convinces us that tota COIOproctectomy with iIeostomy shouId be done in one stage rather than in multipIe stages. The advantage of the one-stage procedure is that it is accompIished with Iess postoperative morbidity and an earIier return of the patient to norma activities. This is probabIy expIained by the fact that the source of the toxic absorption is removed at once. The one-stage operation has been we11 toIerated except in the one instance of emergency operation for massive bIeeding cited previousIy. The surgeon need not be committed to compIetion of the operation in one stage. If the patient’s condition is such that the operation shouId be discontinued, this can be done at any stage and the operation can be compIeted Iater. The permanent iIeostomy feature of tota

with

J. J., a twenty-six year old restaurant cook, was admitted on November 17, 1958, with abdomina1 pain, weakness, diarrhea and recurrent fist.uIa in ano. His disease had existed for six years. Treatment with special diets, antibiotics and cortisone had faiIed to arrest the progress of the disease. The patient was having ten to twelve bIoody bowe1 movements daiIy at the time of admission. X-ray studies showed a shortening of the coIon and pseudopoIyposis. Proctoscopic examination to 25 cm. showed a friabIe, uIcerated mucosa which bIed easiIy with contact of the instrument. The hemogIobin was 12 gr. per cent. SingIe-stage tota coIoproctectomy with iIeostomy was performed on December I I. The specimen showed inffammatory changes of the terminal 15 cm. of the iIeum, and uIcerations and pseudopoIyposis of the coIon. The patient made a good postoperative recovery with a weight gain of IO pounds in the first six weeks. He returned to his former occupation five weeks after the operation.

Group 3: Emergency One-Stage Total Coloproctectomy witb Ileostomy H. M., a twenty-three year old Iaborer, was admitted on May 30, 1956, with a history of fever, diarrhea, bIoody mucous stools and a loss of weight of approximateIy IOO pounds over a period of a year. BIood transfusions were given a week before admission and on the day of admission because of severe Ioss of bIood. The hemogIobin readings remained Iow foIIowing the transfusions. Proctoscopic examination discIosed uIcerations, edema and congestion of the rectum. TotaI coloproctectomy with iIeostomy was performed on May 31 as an emergency procedure. There was rapid restoration of heaIth and a gain in weight of 40 pounds in the weeks foIIowing the operation. He returned to work severa weeks Iater. 168

Ulcerative coIoproctectomy has been we11 accepted by the patients. (TabIe III.) After years of suffering and invalidism from the unremitting disease, they look upon iIeostomy as a smaI1 price to pay for the relief which they obtain from their distressing symptoms of genera1 toxicity, discharge of bloody purulent material, ana fistuIas and periana1 skin excoriation. It is our opinion that steriIity, which occurs commonly folIowing adequate abdominoperinea1 resections for carcinoma, is not as IikeIy to occur in resections for removal of the rectum in chronic ulcerative coJitis. In the Iatter, the dissection is made cIose to the recta1 waI1 and is not likely to disturb the nerve eIements of the sacral plexus.

CoIitis DISCUSSION WILLIAM P. MIKKELSEN (Los AngeIes, CaIif.): Drs. McLenathen and Weinberg have made an important contribution to the growing amount of evidence supporting the contention that any procedure short of total coloproctectomy with ileostomy for chronic ulcerative colitis is insufficient. Furthermore, they present convincing evidence to justify their opinion that in the majority of cases the operation should be conducted in a one-stage maneuver. Even in the severely debiIitated patient, total resection of the coIon is frequently weII tolerated. In certain of these instances it is perhaps unwise to terminate the operation short of this. Nevertheless, good judgment would dictate in certain instances that proctectomy be deferred to a second operation. This phase of the tota operation, I believe, is the more traumatic, time-consuming and sanguineous, and occasionaIIy is better deferred. In contrast, extreme operative conservatism, as exemplified by simple iIeostomy, is probabIy never justified in the light of current knowIedge. The addition to ileostomy of subtotal colectomy with establishment of a sigmoid mucous IistuIa can be carried out with aiacrity and is minimaIIy traumatic. Furthermore, this exhumes the major portion of a fetid, diseased structure that contributes to genera1 toxicity. The recommendation is frequentIy made that proctectomy be deferred in a young man because of fear that sexuai impotence or sterility may occur. This premise is probably no longer tenable according to information to the contrary supplied by Stahlgren and Ferguson. Finally, aIthough not emphasized by the authors, it is germaine to consider briefly the association of coIonic and recta1 carcinoma in chronic uIcerative Fear of deveIopment of this important coIitis.

SUMMARY

We wouid sum up our attitude as favoring total coloproctectomy when uIcerative colitis becomes intolerable and is no longer responsive to medica management. Medical management shouId be continued as Iong as the patient is able to adjust himseIf to the disease. We favor one stage over pIanned multipIe stages for tota resection with iIeostomy because it brings immediate relief to the patient without a proIonged convalescence in which complications may arise and in which the patient suffers mortality does not economic 10s~. Surgical appear to be a factor against the one-stage procedure. The immediate postoperative convaIescence is more satisfactory than with multipIe-stage procedures probabIy because of the immediate and total remova of the source of the toxic absorption. WhiIe muItipIe stages may give the patient an opportunity to adjust to the acceptance of permanent iIeostomy during the weeks or months between stages, we do not beIieve this is an important enough consideration to weigh against the use of the one-stage procedure.

complication is one of the indications for surgery in this disease. Perhaps this is not a justihed indication if it is true, as has been commonIy quoted, that in but 5 per cent or so of such cases carcinoma develops. On the other hand, the almost uniform failure to cure such patients Iends this tigure more signihcance. Of major importance, thus, is the necessity for data that wouId permit a more accurate seIection of those patients in whom carcinoma is 1ikeIy to deveiop. In this connection, of the important features, two deserve a greater degree of recognition than has formerly been given. The first is the duration of the disease process. AIthough rather wide discrepancy exists in reported series, it is IikeIy that an incidence of carcinoma of greater than IO per cent after ten years and greater than 20 per cent after twenty years of disease are conservative estimates. Furthermore, quiescence of chronic uIcerative coIitis does not guarantee freedom from carcinoma. The second important

REFERENCES I. HICKEX-, R. L. and TIDRICK, R. T. Cancer in patients

with chronic ukerative coLtis. Cancer, I I : 35-39, 1958. 2. RAVITCH, M. D. and MANDELBAUM, I. Evolution of surgica1 approach to the treatment of idiopathic uIcerative coIitis. S. Clin. Nortb America, 35: rq.oI-rq.og, ‘955. 3. JOHNSTON, P. W. and Movrus, H. J. CoIostomy and ileostomy, a simplified technique. Am. J. Surg., 92: 208-213, 1956.

169

McLenathen

and Weinberg

feature to be considered is the age of the patient at the onset of the disease. The onset of chronic uIcerative colitis in a patient under the age of twenty renders this patient 500 times more likely to deveIop coIonic carcinoma than a non-diseased person of similar age. This figure is in contrast to the patient who contracts the disease after the age of forty-five; he is but five times more vuInerable to carcinoma than a non-diseased person. Thus, application of these facts wouId seem to make it aImost imperative that colectomy be recommended in a patient thirty-five years of age who has had symptoms of chronic uIcerative colitis for twenty years, and increasingIy strong consideration for coIectomy shouId be given to those patients with Iess imperative surgical indications. ERIC R. SANDERSON (Seattle, Wash.): I think it should be pointed out that uIcerative colitis is not always a generaIized disease. We do occasionaIly see patients who have IocaIized uIcerative coIitis and on whom it is not necessary to perform surgery as extensive as tota coIectomy. I wouId like to present three cases in support of this thought. The Iirst patient, a woman in her Iate thirties, had a history dating back to 1937. At that time she started to have diarrhea and bIoody stooIs recurrentIy to the point where she was debihtated and sociaIIy embarrassed. Repeated x-ray IiIms showed onIy a 6 inch segment of sigmoid coIon, interpreted as uIcerative colitis. Therefore, in March, 1954 segmenta resection of a smaII piece of the sigmoid was performed. After excision the patient was in reasonabIy good condition for six months and she was quite happy. At the end of six months, because of inadequate resection, she began to have recurrence of her symptoms. I observed her for a year after her primary surgery, and then feeling what had been done was correct in theory but incorrect in practice, I performed resection a second time. At the time of the second operation excision was performed from the middIe of the transverse coIon to the upper portion of the rectum, and end-to-end anastomosis was carried out at that point. The pathologist assured me repeatedly that this was typical mcerative colitis. Since March, 1955 (the time of re-resection) she has been without symptoms. The next patient, a sixty-five-year oId man from the tropics, had had a seven-year history of recurrent diarrhea with bIeeding. He had been assured by his physician that everyone in the tropics had this sort of thing and it was to be expected. However, barium enema examinations showed a 6 inch segment of sigmoid with one polyp and what was thought to be a poorIy prepared bowe1 above it. Therefore, sigmoidoscopy was performed with the thought that the poIyp couId be removed. It was apparent at the time of sigmoidoscopy that he had 170

many pseudopoIyps typical of advanced uIcerative colitis. At Iaparotomy he was found to have a segment of IOO or more tiny pseudopolyps. This is typica of chronic ulcerative cohtis. He was operated upon onIy recentIy so aIthough he is asymptomatic at the present time I cannot give you a Iong term evaIuation. An incidenta finding of interest in this case was an aneurysm of the splenic artery, which was excised one month after operation for colitis. The fIna patient, a woman in her sixties, had had her appendix removed about three years previously. For the preceding six months to the time I saw her she had had right-sided abdomina1 pain. After study, we conchrded that the right coIon was the site of disease, which we interpreted as carcinoma. In October, 1955, surgery was performed. UIcerative cohtis invoIved the termina1 iIeum and the right colon. Right coIectomy was performed with end-to-end iIeotransverse colostomy. No symptoms referabIe to recurrent ulcerative cohtis have deveIoped so far. I think one aspect of uIcerative cohtis is IocaIized segmenta uIcerative cohtis for which Iimited resection is adequate treatment. I do not think this is discussed as frequentIy as it might be and that is why I brought it up now. I am sure that there must be many other patients similar to the three I have presented. CLARENCE J. BERNE (Los AngeIes, CaIif.): I wouId Iike to change the subject from the surgicaI management of chronic uIcerative coIitis to the probIem of the ileostomy. In Los Angeles we have had some experience with a rather active iIeostomy cIub. There are two pubhcations avaiIabIe to surgeons and their pa“The Ileostomy QuarterIy” and a newstients: Ietter of the Ileostomy Association of Great Britain. One can get both of these sent to his offrce reguIarly; they have much vaIuabIe information for the surgeon and many aids for the patient. I think this is worthy of emphasis because after successfu1 recovery from coIectomy these patients have their iIeostomies for the rest of their lives, and after a few years this total experience actualIy is judged in terms of their satisfaction with the iIeostomy. I would like to refer to a point in the paper of Drs. McLenathen and Weinberg, that of a Aush iIeostomy. This operation has been presented before by Dr. Weinberg’s group. I am of the opinion that a flush iIeostomy is Iess satisfactory than a protruding ileostomy. Much can be said about technics for this, and a11 of them are the same in principIe if the iIeostomy has some Iength, an outside epitheIia1 (mucosa1) cover and no granuIation tissue. It does not matter much with which one of the standard technics this is obtained. I prefer the AIIan Brooke.

Ulcerative An ileostomy about I to 1>5 inches in Iength is better than one that is too Iong. If one investigates these matters with a number of patients in an ileostomy club, the first basic principIe the patients want is to have the ileostomy as near the midhne as possible. The surgeon, of course, wants it as far Iaterai as possibIe because the gutter closure problem is thereby minimized on the inside. Many patients find that their iIeostomies are either too high or too low. There is a problem in w h ere they should be. However, if one deciding studies his own body, whiIe seated upright in a straight back chair, and bends forward sharpIy, he will find that his abdomen deveIops a primary and secondary flexion crease. A major flexion crease usually exists at the line of the umbiIicus so that the plate must have room between the stoma and the primary llexion crease. If the stoma is too high, the pIate wiI1 lie over the flexion crease and aIso constantly annoy the patient at his beIt or her waistline. More important, it wiI1 be drawn into probIems with the primary llexion crease. If it is too Iow the disc will strike the thigh. Therefore, the vertical and transverse positions in the fronta plane are both of great importance to the patient. I think that the surgeon shouId study the problem by sitting erect and putting the uInar side of his own right hand against his Iower abdomen, sIiding it downward against his groin with his thigh flexed at right angles, and then putting his thumb at his primary llexion crease. When he bends over sharpIy he will ascertain that he has outlined an area of abdomen, the center of which is the best site for the ileostomy. 1 know most of these points are controversia1 but I wiIl summarize by saying that the iIeostomy itself is tremendousIy important to the patient. The patients with whom I have had contact through the club are much happier if they have an iIeostomy with Iength rather than a flush iIeostomy, and it is very important to them how high or low it is and where it is in reIation to the midline. ALLEN M. BOYDEN (PortIand, Ore.): Our treatment of tota ulcerative cohtis, eliminating such fortunate patients as Dr. Sanderson mentioned, has changed markedly. I am sure the surgical answer to this disease today is infiniteIy better than it was in 1945, for example. We have Iearned that most of these patients can be operated upon in one stage consisting of total colectomy and an adequate iIeostomy which wiI1 function almost immediateIy. For about live years we have performed onIy one-stage coIectomies upon patients who have tota invoIvement of their colon. I have been using the flush type of iIeostomy ever since Dr. Weinberg’s group reported on it to this Association severa years ago. I have found myself revising the oId type of iIeostomy in patients who have trouble to a flush-type iIeostomy, and most of

CoIitis these patients are better satisfied. I hnd that most of the flush-type ileostomies do not remain hush with the skin but have a smal1 protrusion. They wiI1 accept the bag without leak and without dilhculty cquaIIy as we11 as the protruding type of iIcostomy. In the Iast severa years I have developed what I believe to be a minor improvement in the technic of making such an iIeostomy. I have been disturbed by the smaI1 listulas or stitch sinuses that occur when one sutures the skin to the mucosa of the smaI1 bowe1. These sutures also produce a distortion of the circuIar aspect of the iIeostomy. I prepare this ileostomy in the same manner as a subcuticular suture of a superficial wound or an abdominal operative wound. By using very line catgut on “swedged” needles and taking a subcuticular stitch through the sero-muscular Iayer at the cut edge of the iIeostomy and the subcuticular Iayer of the skin, and dividing the bowe1 into segments (quarters, eighths and then sixteenths), one can produce a seaIed wound almost immediately. In one case, the suture Iine was completely healed on the seventh day. There was no evidence of granuiation and no sinus where the sutures were placed. This procedure takes a IittIe more time but has been very rewarding to me. CHARLES E. MACMAHON (Seattle, Wash.): I wouId Iike to support Drs. Weinberg and McLenathen’s approach to this particuIar probIem in one specific group of cases within the large group of patients with uIcerative colitis, emphasizing a point that Dr. MikkeIsen made in his discussion. The patients who die of this disease usualIy faI1 into the category of those with acute florid fulminating progressive uIcerative coIitis with peritonitis. These are the patients who are critically ill with temperatures of 104 and IOS'F., and who have usuaIIy worn out three or four internists whiIe they are making up their minds whether intervention is indicated. I think the procedure can more safriy be performed in one stage than in two or more stages. This was we11 pointed out by Dr. Scarborough before this Association a few years ago. His mortahty rate was, as I recaII, not much greater than I per cent in a rather Iarge series. The point that Dr. MikkeIscn made was that the most traumatic part of the procedure is the posterior dissection, lvhich ordinariIy comes at the. end of this operation. I have used a minor variation in five cases of acute progressive uIcerative colitis and reported it to the North Pacific Surgical Society last November. It mereIy amounts to doing the procedure wrong end-to. This consists of placing the patient in the Buie position and performing the posterior dissection initiaIIy. Approximately hftecn to twenty minutes are needed to mobilize the rectum beIow the pcIvic floor. Then, reversing the patient

171

McLenathen

and Weinberg

into the supine position, you progress from Ieft to right. The tota length of operating time in my experience has never been in excess of three hours. 1 think the patient, separated from this acute inflammatory process that is about to kiII him, is in a safer situation than with a staged procedure. My experience with these five patients has been most gratifying, without mortaIity and with minima1 morbidity. ROBERT A. SCARBOROUGH(San Francisco, CaIif.) : I think it is quite obvious from this extensive discussion that surgeons have developed much more enthusiasm for surgery in chronic uIcerative colitis than they had ten years ago. When Dr. Emmett AIIen was an invited guest in San Francisco at a genera1 meeting of the county society, he gave as the only indication for surgery in uIcerative coIitis the internist and the patient coming to the surgeon and begging for operation. We have certainIy advanced a long way since then. I would Iike to comment on a few points in this paper. First, the primary definitive operation for this disease is coIectomy, aIthough peopIe stiI1 speak of ileostomy as the primary procedure. We a11 reaIize now that that is the secondary but necessary procedure, unfortunateIy, in deaIing with the disease surgicaIIy. We are aIso coming to Iearn that we have a Iower operative mortaIity, fewer postoperative complications and a we11 patient in a much shorter period of time if we perform the entire procedure as a singlestage operation. IIeostomy aIone Ieaves behind the diseased bowe1 with its toxic manifestations, its impending or prior or subsequent compIications, and we must remove the diseased bowel. At the present time, of course, there is considerabIe enthusiasm, initiated, I think, principaIIy by Mr. AyIett of London, to perform resection and save the rectum and anastomose, at the same time or at a Iater date, the iIeum to the rectum. This idea is sweeping the country in certain areas with an enthusiasm I fee1 is going to end in great disappointment. Three patients have been mentioned in whom the rectum couId be saved and resection performed with re-anastomosis. There are occasiona cases which encourage us to perform a re-anastomosis in chronic coIitis. We have actuaIIy had tweIve such patients but we do not consider them as patients who had chronic idiopathic uIcerative coIitis. They have had segmenta coIitis, and certainly in those cases in which the rectum is not invoIved at a11 such resection and anastomosis can be performed. However, in the typica disease the rectum is the most severeIy and usuaIIy the first portion of the coIon to be involved, and that portion of the coIon must be sacrificed. 172

The four cases of iIeoproctostomy mentioned in this paper a11 resuIted in faiIure, and uItimate resection of the rectum was necessary. That has been our experience in the past. We have resumed attempts to do the same thing again because of Mr. AyIett’s experience and that of a few others. To date, no patient upon whom we have performed anastomosis of the iIeum to the rectum has been abIe to retain his rectum. AI1 have had to have subsequent resection and iIeostomy. Regarding the type of iIeostomy performed, we have spoken of the flush type and the protruding type. I think the important thing here is the improvement we have in the technic of performing primary anastomosis of the end of the ileum to the skin which prevents chronic inflammatory changes with stricture and mechanica obstructive features. The important thing is not the type of iIeostomy performed; it is important that primary anastomosis of the open end of the iIeum to the skin is effected so there wiI1 be no necessity for maturation of the ileostomy. It wiI1 hea per primam. ActuaIIy we can combine the idea1 primary anastomosis of the end of the iIeum to the skin with some protrusion. The rea1 point of this procedure is that in the formation of the iIeostomy, the mesentery of the bowel within the abdomen be attached to the anterior abdominal waI1 in such a manner that there wiI1 be a redundancy of iIeum passing through the abdominal waI1 to the outside. With that as a fixed point you can turn back the open end of the iIeum. You are not conscious that you are turning it back but it does evert. You suture the skin and then norma peristaItic activity produces a certain protrusion which is better mechanicaIIy in the subsequent care of an iIeostomy. I wouId Iike to make one point about the probIem of steriIity. There is no reason for steriIity after resection of the rectum for ulcerative coIitis. The important thing is to stay cIose to the bowe1 when you resect the rectum as you go down through the pelvis. If you do, this probIem wiI1 not arise. FinaIIy, as far as the possibiIity of cancer as an indication for surgery, I agree with the former discusser that when the disease has been present for a Iong time this is a rea1 threat; if it shouId occur before coIectomy, the chances for cure are smaI1. LESTER R. CHAUNCEY (Portland, Ore.) : I hate to proIong this discussion much Ionger, particuIarIy because my remarks must necessariIy be based upon a reIativeIy smaI1 series of cases. However, I wouId Iike to say something in support of the attempts made to save the rectum in the treatment of this disease. UsuaIIy these attempts fai1. Drs. McLenathen and Weinberg recorded four such procedures, a11 of which faiIed. In his discussion Dr. Scarborough mentioned tweIve more instances and a11 of these faiIed aIso.

UIcerative However, not alI attempts fail. About six years ago we performed two such procedures. Both patients were young women in their thirties with fmminating disease, one of whom had suffered a perforation of the cecum. In each instance, after the establishment of an ileostomy, subtotal colectomy was performed but the rectum was saved and brought out as a low-Iying colostomy. After a two-year interval the ileostomy was taken down and iIeoproctostomy performed. In one of these instances the attempt failed; because of recurrent massive hemorrhage the lower bowel was subsequently removed and a permanent ileostomy estabIishet1. However, the second case was not a failure. This young woman is quite we11 five years later. Her marriage had been threatened by divorce, the husband being unable to tolerate the ileostomy. Now, five years Iater, the wife is an active high school teacher and her marriage has been saved. The daily need of tincture of opium pIus the occasional remova of edematous poIyps from the rectum seem to be a smaI1 price to pay for her well-being. Furthermore, I think we must realize that in spite of what types of ileostomies we might establish, flush or otherwise; in spite of what journals the patient may read; in spite of what heIp he may receive from iIeostomy clubs; the basic fact stiI1 remains that no one reaIIy Iikes an iIeostomy. This is particuIarIy true of younger children. In the present state of our knowIedge of this disease, I think it is wrong to commit a young boy of fourteen or fifteen irrevocabIy to Iife with a permanent ileostomy when the lower segment could be saved without detriment to his heaIth. GORDON S~IITEI (Los AngeIes, CaIif.): I wouId like to make two points in regard to the criticaIIy iI patient who is a candidate for surgery for uIcerative colitis. One is the use of miId hypothermia in the very septic patient. On several occasions we have used this and found that the patient wiI1 toIerate the one-stage compIete operation very well. The second is the use of the two-team procedure for the operation. It decreases operating time almost 50 per cent. We believe it facilitates the perineal part of the dissection, and I recommend this to your attention. LEON GOLDMAN (San Francisco. CaIif.): I think there are two reasons for the improvement in results foIlowing the present day treatment of mcerative coIitis. First, the resuIts of surgical treatment have proved to our medica coIIeagues that we can operate upon these patients with a reasonable mortality rate and a high index of cure; hence patients are referred earlier. It was not very Iong ago that we could not offer such hope. The second factor is in good part due to the contributions of Ripstein of New York who showed that, paradoxicalIy, it was more important to remove the

Colitis coIon in the treatment of acute uIcerative colitis than it was in the treatment of the chronic disease. As Dr. Scarborough just mentioned, the patient is apt to have a rather hectic postoperative course if the coIon remains and thereby continues as a toxic focus. Another point I would like to make is that any operation for ulcerative colitis in which the diseased bowel is anastomosed invoIves considerabIe danger from such compIications as a Ieaking stoma, abscess, peritonitis or even death. As the authors have shown, patients undergoing the lesser procedures have a higher immediate mortality rate, lower cure rate and higher index of recurrence. CALEB S. STONE, JR. (Seattle, Wash.): I wouId Iike to support the authors’ contention that the one-stage procedure serves a very important purpose. Some four or five years ago Lucius Hi11 and I presented the technic of total coIectomy and proctectomy accomphshed from above. We had a fairIy smaI1 series of cases at that time. We have used this operation consistently in the treatment of uIcerative colitis and it has proved extraordinariIy satisfactory. It saves about thirty minutes or more in operating time, and avoids the necessity of turning the patient (usually in critica condition) at the end of a long operation. We have encountered no difficulty in the accomplishment of colectomy and proctectomy in this one-stage procedure, ail done from above, and I can recommend it to you very highIy. JOSEPH A. WEINBERG (cIosing) : Dr. McLenathen and I are pleased with the response to our presentation. We realize that this is due to the importance of the subject to everyone and that it is somewhat of a controversial subject. The comments of the discussers Iead us to beIieve that there is Iess difference of opinion now than there was a few years ago. We are in agreement with Dr. MikkeIsen that there may be patients who appear poorIy suited to withstand one-stage total resection. However, the more experience we have, the fewer occasions we find for multipIe stages. In regard to Dr. Sanderson’s remarks, I do not think we have serious disagreement, even though Dr. Sanderson might be understood as favoring less extensive resection. I do not consider his third case one of chronic uIcerative cohtis. I interpret it as a combination of regional iIeitis and coIitis, a disease which caIIs for less extensive resection. I know that Dr. Sanderson must have his good reasons for cIassifying it as chronic ulcerative coIitis and I may be in error in my interpretation. Regarding Dr. Berne’s remarks about the type of ileostomy, our patients with the so-caIIed flush type of ileostomy have been so we11 satisfied with the operation and our CompIications have been so

I73

McLenathen

and Weinberg successes. However, our experience was poor without exception when this procedure was resorted to and this, together with the experience cited by others, has caused us to abandon the operation of iIeoproctostomy except in specia1 instances. For exampIe, we wouId give the ileoproctostomy a trial in the case of a young person, having in mind that conversion to compIete coIoproctectomy with permanent iIeostomy might be necessary at some time in the future. We shouId give consideration to Dr. Smith’s remark about two teams working simuItaneousIy, especiaIIy when teams can be easiIy arranged for. Time is an important factor in these seriousIy III patients, and it is ceqtainIy worth giving a lot of thought to. We are happy to hear Dr. GoIdman emphasize the special need for tota coIoproctectomy in acute fuIminating exacerbation of the disease when seemingIy one wouId want to do the Ieast possibIe because of the patient’s poor condition. We agree with Dr. GoIdman that one must do the most rather than the Ieast if anything is to be accompIished. We wish to thank Dr. Stone for his vaIuabIe suggestions for improving the technic of the operation.

minima1 that we fee1 obIiged to continue advocating this type. With regard to Dr. Boyden’s comments, we appear to be in compIete agreement. We are pIeased to have some new angIes on the performance of the iIeostomy. We certainIy shaI1 Iook into it further as a way of improving the operation. Dr. MacMahon’s procedure of reversing the order of excision seems to be an exceIIent idea. His reasons for performing the anorecta1 dissection first and then turning the patient for compIetion of the resection appear to make good sense. As to Dr. Scarborough’s remark that we have advanced from the time when the indications for surgery were strong pIeas on the part of the patient and his physician that something be done surgicaIIy, we agree that one shouId not wait for exsanguination, fistula formation and other such serious complications before advising operation, but we &II Iike to have the patient insist that the operation be performed before we take the step of giving him a permanent iIeostomy. About Dr. Chauncey’s remark on anastomosing the ileum to the rectum, we had hoped earIier that this couId be satisfactoriIy accompIished. We were encouraged in this thinking by AyIett’s reports of

I74