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The Surgical Management of Regional Enteritis and Ulcerative Colitis
THE SURGICAL MANAGEMENT OF REGIONAL ENTERITIS AND ULCERATIVE COLITIS ALFRED S. FROBESE, M.D. * USUALLY, when the etiology of a condition is obscure, the therapeutic attack remains a challenge to the physician. Such is the case in chronic stenosing regional enteritis, enterocolitis and ulcerative colitis. Our knowledge of the cause and pathogenesis of these inflammatory bowel lesions is meager. It is questionable whether the surgical management of these lesions should be discussed in a single paper. While, in some respects, regional enteritis, enterocolitis and ulcerative colitis appear related, we do not feel that they are manifestations of only one disease at different levels of the alimentary tract. From clinical behavior, pathologic manifestations and therapeutic results, we would group regional enteritis and enterocolitis together; ulcerative colitis is a separate entity. No attempt to discuss the diagnosis or medical therapy of these disorders will be made. Instead, our ideas as to the surgical management will be reviewed. CHRONIC STENOSING REGIONAL ENTERITIS AND ENTEROCOLITIS
Our earliest approach to the therapy of this disease was to remove large amounts of bowel in order to get well away from grossly involved gut. It was felt that the disease was primarily one of the bowel wall, and that wide excision would eradicate it. In several instances of enterocolitis the entire ileum and the proximal half of the colon were resected. These operations were staged. The first stage consisted of a lateral anastomosis of the jejunum or ileum to the distal transverse colon. Later, a resection of the sidetracked bowel was accomplished. The mortality in these cases was disproportionately high. In recent years we have done a one-stage resection of the diseased bowel and mesentery with a primary anastomosis. Owing to better preoperative preparation of patients with blood transfusions, parenteral alimentation and antibiotic agents, as well as improved surgical technics, the mortality has been lowered. No patient has been lost within the past three years. . Although the operative death rate is now low, the recurrence rate still seems high. Our cases have been closely followed up by the Departments of Gastroenterology and Radiology at the Graduate Hospital. From their studies we previously reported that 73 per cent of the cases followed up from one to fourteen years showed clinical or roentgenographic recurFrom the Department of Surgery, Graduate School of Medicine, University of Pennsylvania, and the Surgical Service of Dr. Herbert R. Hawthorne, Graduate Hospital of University of Pennsylvania, Philadelphia. * Associate in Surgery, Graduate School of Medicine, University of Pennsylvania; Assistant Surgeon, Graduate Hospital of University of Pennsylvania, Philadelphia.
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rences. l In the past three years the results have shown some improvement. Of nineteen patients that have been unoer surveillance from two to seventeen years, eleven have had clinical or roentgen evidence of recurrence-a recurrence rate of 58 per cent. This corresponds to a recurrence rate of 57 per cent reported by Sala and Ferguson. 2 It should be pointed out that a follow-up of one year or less is not adequate, since seven of our patients turned up with recurrence after a year had elapsed (Tables 1 and 2). TABLE
1
RESULTS OF RADICAL RESECTION
Total number of resections... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Operative deaths. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2 Cases lost for follow-up ....................................... 3 Cases closely followed 2-17 years. . . . . . . . . . . . . . . . . . . . . . 19 Number of proved recurrences...... . . . . . . . . . . . . . . . . . . .......... 11
24
Recurrence rate ............................................... . 58 per cent TABLE
2
TIME ELAPSE BETWEEN RESECTION AND RECURRENCE
Number of Cases One year or less .............................................. . 1-2 years ..................................................... . 2-3 years................. . ................ .
~=~l;:~~~:::::::::::::::::::::::::::::::: .... :::::::::::::::: :
4 3 1 1 2
Total. ....................................................... 1----11----
The aim of radical surgery is to remove all the diseased tissue. When one inspects the mesentery adjacent to the involved bowel in enteritis, the lymph gland involvement is striking. These nodes are enlarged, congested and edematous. It is not known whether the lymphatic lesion in this condition is primary or secondary, but histologic examination readily reveals that a chronic inflammatory process is present in the regional lymphatics. These glands are widely scattered and extend to the root of the mesentery. Complete eradication of these nodes is often impossible without impairing the circulation of the remaining gut. Therefore, we wonder if radical resection really accomplishes its aim. In considering the surgical treatment of this disease, it is necessary to define the stage of the pathologic process present; that is, the acute or the chronic, with or without complications. ACUTE STAGE OF ENTERITIS
Acute, uncomplicated cases are better handled by rigorous medical treatment as outlined by Bockus. 3 A remission often can be obtained. Furthermore, regression of the acute phase is not always followed by
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complications. It is true that the condition may recur, but operation certainly offers no guarantee against recurrence. In the acute cases that simulate acute appendicitis, exploration is done for appendectomy. If, after the abdomen has been opened and the appendix found to be normal, an uncomplicated enteritis is present, it is best to terminate the procedure without appendectomy. Because of actual involvement of the cecal wall by the inflammatory process, postoperative fistula may result. Furthermore, resection of the diseased bowel at this time is not wise. The serosa is usually fiery red; there is some free, turbid peritoneal fluid; and the diseased loops are often adherent to each other with a fibrinous exudate. Resection and anastomosis in the presence of such marked peritoneal inflammation are foolhardy. Lack of preparation of the patient and a likelihood of remission of the process add support to this conclusion. Garlock states that most of these acute cases will regress. 4 CHRONIC STAGE OF ENTERITIS
When the chronic stage is reached, the complications which require surgical intervention are apt to arise: obstruction, intra-abdominal abscess, and fistulas. Peritonitis of the spreading type does not seem to occur from the perforations. These leaks usually occur late in the course of the disease and burrow slowly through the extremely thick submucosa and mesentery. They become walled-off as localized abscesses, or penetrate into other viscera or the abdominal wall (Fig. 506). Obstruction results from stenosis of the bowel lumen following repeated inflammation, ulceration, and then cicatrization. Most of our patients were operated on for this complication (Fig. 507). The most marked changes are more often encountered in the terminal ileum, or the terminal ileum, cecum and ascending colon. Here we use a radical resection of the bowel. The ileum is transected about 18 inches proximal to the level of the gross involvement. On the colonic side, a gross appraisal of the limit of the lesion is not accurate; so we usually resect the cecum and ascending colon well past the hepatic flexure (Fig. 508). The mesentery is resected as widely as is safe, with preservation of vessels to the remaining gut. Then intestinal continuity is restored with an end-to-end or end-to-side ileocolostomy. We routinely use an open method of anastomosis without clamps. Another feature of this disease which may have to be dealt with is the presence of so-called "skip areas" (Fig. 509). These are segmental areas of involvement proximal or distal to the main lesion. Whether they occur simultaneously or result from progression of the disease is controversial. It is our feeling that all the areas are stricken at the same time. One case had five distinct areas of disease, each separated from the other by normalappearing bowel. Isolated "skip" lesions may be resected, but when there are many involving the length of the small gut, multiple resections of segments or one resection of the entire jejuno-ileum seems untenable. In the case with five such lesions we terminated the operation with exploration.
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In cases complicated by abscesses or fistulas there may be large inflammatory masses densely adherent to the underlying iliac vessels and the ureter. Adjacent bowel loops may be matted together, or the mass may extend into the base of the mesentery. In such instances we elect to do an ileotransverse colostomy with exclusion (Fig. 510, left). In this procedure the ileum is transected 18 inches proximal to the gross limit of the lesion. The proximal end is anastomosed end-to-side to the proximal transverse colon, or to the more distal colon, depending on the degree of extension of the process down the bowel. The distal stump of
Fig. 506. Roentgenogram of a case of regional enteritis with ileosigmoid fistula. A small bowel barium enema was administered through the Miller-Abbott tube. Barium passed readily from the ileum into the sigmoid colon.
ileum is inverted and closed and dropped back into the abdomen. If any significant amount of stenosis is present in the lesion, this distal stump should not be closed, because, if obstruction ensues, it would blowout and cause peritonitis. Instead, it can be brought out through a stab wound in the abdominal wall to act as a mucous fistula. This is the operation Garlock4 and Colp5 would use in all cases of enteritis in preference to resection. Their results from this type of operation have been good and the surgical hazard minimal. Indeed, in the instances in which we have used this procedure the results 'have been most satisfactory.
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Fig. 507. Roentgenogram of a case of regional enteritis with obstruction. The stenotic,loops are evident. A markedly dilated loop proximal to the obstruction is noted in the midabdomen.
Fig. 508. Diagram of usual resection procedure employed for regional enterocolitis. Shaded area represents the diseased bowel. (A) Level of transection of ileum. (B) Transection site of transverse colon. Colon stump (B') inverted and closed and ileum (A') anastomosed end-to-side to transverse colon.
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We have had the opportunity to reoperate on several of these cases, and have been surprised to find that all the gross evidences of disease in the sidetracked loop had disappeared, and the bowel appeared entirely normal. This has been reported by other surgeons interested in this condition. Unfortunately, we have had no microscopic confirmation of complete healing, since no sections were taken. We are not aware of any attempts to restore bowel continuity through these apparently quiescent loops, and we would be most hesitant to do so, for it is well known that this disease may become active after long periods of arrest.
;
Fig. 509. Roentgen appearance of "skip lesions" in regional enterocolitis.
It should be stressed that, when one elects to use the exclusion operation, a complete transection of, the bowel proximal to the involved area should be done. Some surgeons apparently anastomose the ileum to the transverse colon in continuity (Fig. 510, right). This is mentioned only to condemn it. We have reoperated on several patients who had this type of procedure and who had progression or continuation of their disease. At exploration the lesion in the so-called "sidetracked" loop was still active. Another indication for operation is medical intractability. These patients do not have any of the aforementioned complications to a marked degree, but, because of continued pain, severe anemia or poor nutritional status, they are invalids.
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At present we are in agreement with the internists that only those cases deemed complicated or completely intractable to a rigorous medical program should come to operation. We are still inclined to regard resection of bowel as the procedure of ehoice, and we perform it whenever possible in spite of its obvious high percentage of failures. We have felt that as much bowel could be resected as could be sidetracked, and that the patient was better off with the diseased bowel out. However, much consideration
Fig. 510. Diagram (left) of ileotransverse colostomy with exclusion. Shaded area represents diseased bowel: A, distal stump of transected ileum, which is inverted and closed; B, proximal stump of ileum, which is anastomosed end-to-side to the transverse colon. Diagram (right) of ileotransverse colostomy without exclusion. Shaded area represents diseased segment: A, side-to-side ileotransverse colostomy in continuity. This procedure is contraindicated in this disease.
must be given to the exclusion operation, for it may be that longer follow-' up reports from clinics using it will show a superior result. MANAGEMENT OF ULCERATIVE COLITIS
Surgeons with considerable experience in the treatment of ulcerative colitis generally agree that only 25 per cent of patients so afflicted come to operation. The progress of the process in the remaining percentage is arrested or controlled by intensive medical and psychiatric programs. We are called upon to treat the patient when the disease becomes complicated or when failure to respond to medical measures results in invalidism. In recent years there has been improvement in medical therapy of ulcerative colitis through the use of antibiotic agents, parenteral nutrition, so-called "medical ileostomy," and ACTH. This has been matched by an even greater improvement of surgical technic in the making of ileostomies and the resection of diseased bowel. This has resulted in a closer understanding between the internist and the surgeon as to the indications for operation. Operation is no longer withheld until the patient is in such an
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advanced state of intoxication and malnutrition that surgical fatality is certain. The reluctance of the internist to sentence his patient to an ileostomy and of the surgeon to carry it out was once understandable. Standardization of ileostomy technic and the use of fitted bags, such as the Koenig-Rutzen bag, have altered this picture. A patient with an ileostomy can live a normal, useful life. Our present assumption is that, once this disease has ravaged the bowel, the bowel never reverts to a normal state. Therefore the surgical aim is to interrupt the fecal stream and eradicate the diseased bowel. This is carried out in stages. In the recent past the first stage was that of interruption of the fecal stream by ileostomy. This allowed the process in the colon to quiet down; the patient improved, and subsequent colon resection was done with greater safety. The resection of the colon and rectum required an additional two or three stages. Each operative procedure had its attendant complications, and the patient morbidity and mortality were too great. Most of the difficulty arose with the performance of simple ileostomy. The Lahey Clinic cited mortality figures of 22 per cent for ileostomy alone. 6 Now a decision as to the need of operation is reached much earlier. The patients are better prepared for operation with strict dietary programs containing easily assimilated protein hydrolysates in large amounts; large doses of oral and parenteral polyvitamin preparations; the use of the antibiotic agents (penicillin, aureomycin and Chloromycetin) to combat sepsis; and the restoration of blood volume with repeated infusions of whole blood. This last adjunct is most important and has resulted in a patient better able to withstand definitive surgery, even if prolonged. Therefore the number of staged operations has been decreased. In most of our cases we now accomplish ileostomy and total extirpation of the colon and rectum in two stages. INDICATIONS FOR OPERATION
Hemorrhage. Chronic blood loss from the ulcerated mucosa is a frequent complication. This may be intermittent and result in an anemia refractory to treatment. It may be severe and persistent, and thus become an indicationfor operation. Profuse bleeding may occur and threaten the patient with exsanguination. Here, operation is imperative. Ileostomy with defunctionalization of the colon should be done. The bleeding may cease temporarily. We have had two cases that had massive hemorrhages from the colon one and two years after ileostomy. If bleeding is profuse and continues after ileostomy, the most actively bleeding segment of colon should be resected. This may mean a total colectomy in one stage if all the bowel is involved. The risk of such a procedure is considerable, but must be accepted in such an emergency. To allow the patient to bleed to death is folly. We have had no success in the use of local medicaments in the colon for stopping profuse hemorrhage. Our policy is to give whole blood by rapid transfusion until the patient is out of shock and his red blood cell count has been raised to 4,000,000
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per cubic millimeter. We then operate. Blood is administered during operation, of course. Obstruction. Late in the course of this disease, marked fibrosis and shortening of the bowel occur. The periods of exacerbation with ulceration and infection, followed by periods of quiesence and cicatrization, result in a stenotic fibrous tube.The narrowing is most marked in the rectal area. The stenosis is usually not severe enough to obstruct the gut completely; however, this fibrosis is irreversible. Further healing only leads to further narrowing, and no normal colonic function is possible. Ileostomy and colectomy are indicated (Figs. 511, 512).
Fig. 511. Roentgenogram of a case of ulcerative colitis with areas of marked stenosis (arrows) and partial obstruction .
.
Perforation. Acute free perforation of the bowel is infrequently seen. Miller states that it occurs in 1 per cent of cases. 7 If it does occur, a virulent peritonitis ensues, which is likely to terminate fatally. If such a patient does survive the initial insult, ileostomy and partial colectomy should be done as soon as the patient can withstand surgical intervention. Closure of the perforation would be difficult because of the friable nature of the bowel wall and the adjacent peritoneal infection. Ileostomy plus exteriorization or drainage might be the only possible measures in extreme cases. The type of perforation most frequently seen is subacute or, chronic.
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By the time the mucosal ulcer has extended through all the thickened coats of the bowel, adhesion of other loops, mesentery or peritoneum to the leaking site has taken place. A localized abscess or fistula is produced. These are particularly common around the rectum and anus, and local surgery here is to no avail. The fecal stream must be diverted by ileostomy. Though temporary drainage of abscesses should be done, eventually the diseased bowel must be resected (Fig. 513).
Fig. 512. Roentgenogram of a case of ulcerative colitis with marked stenosis and obstruction in the proximal sigmoid colon. Compression paddle separates the upper limb of transverse colon (A) from the lower sigmoid limb (B). Note marked shortening of the bowel.
Arthritis. With the appearance of the symptoms and signs of joint involvement, medical management should be terminated and the patient prepared for ileostomy and colectomy. It is unwise to persist in conservative measures until destruction of joint surfaces 'occurs and the patient is permanently crippled. This happened to one of our patients who refused to have his colon removed until four years had elapsed after ileostomy. It is striking to note the complete disappearance of joint symptoms and the restoration of walking activity after ileostomy and colectomy. Carcinoma. There is increasing evidence that the incidence of carcinoma of the colon is greater in patients suffering with long-standing ulcerative colitis. 8 It is understandable that the repeated bouts of mucosal destruction and healing with attendant metaplasia could easily merge into neoplasia.
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Cattell has noted an incidence of malignant degeneration between 25 and 30 per cent in patients who have harbored the disease for eight or more years. 9 Furthermore, when carcinoma is superimposed on ulcerative colitis, cure is unlikely. The symptoms of the colitis may mask those of the carcinoma, which might be overlooked. The presence of the active colon inflammation appears to hasten the spread of the tumor. Of eighteen patients
Fig. 513. Roentgenogram of a case of ulcerative colitis with perforation and fistulas: A, fistula from proximal transverse colon; B, fistula from sigmoid to skin.
with colonic carcinoma complicating ulcerative colitis resected by Lahey, only two survived without recurrence. 10 We have not encountered carcinoma of the colon or rectum with ulcerative colitis, and have wondered why it has not appeared. With the evidence from other clinics, we feel that this complication must be a real danger, particularly if pseudopolyp formation is present. It is our practice to insist that total extirpation of the colon and rectum be done when ileostomy is necessary for complicated distal ulcerative colitis and pseudopolyp formation in the colon is noted. Pseudopolyposis carries not only the danger of malignant degeneration, but also the hazard of recurrent hemorrhage (Fig. 514). Acute Fulminating Cases. This type of case still remains the most difficult to manage. These patients are extremely toxic, have high temperature,
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and pass many liquid stools filled with pus and blood daily. Surgical intervention under these circumstances is risky. Every effort should be made to obtain a remission by medical means. The use of ACTH here may hold promise. 1o In any event, close cooperation between the surgeon and the internist is necessary to decide when medical therapy should be terminated and surgery instituted. Such a decision should be made early in the course of the bout before the patient is moribund. The procedure of choice is the simplest that will suffice. The object is to by-pass the fecal stream from the acutely inflamed colon in the quickest
Fig. 514. Roentgenogram of a case of ulcerative colitis with polypoid mucosal changes. These are most marked in the transverse colon.
way. This may be by simple loop ileostomy. In cases in slightly better condition an end ileostomy may be possible, but no colon resection can be considered. Intravascular thrombus formation is not uncommon in this phase of colitis and may complicate the picture. In one of our cases ileofemoral venous thrombosis was present and produced a pseudoembolic ischemia of the leg. It was necessary to ligate the inferior vena cava at the time the ileostomy was made. Medical Intractability. This indication covers an ill-defined group of cases which, despite adequate medical care, pursue a downhill course, or the acute exacerbations occur too frequently. The patients, because of their disease, are unable to lead a normal life socially or economically.
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This may be due to malnutrition and weakness, abdominal pain, rectal fistulas and incontinence, or a persistent diarrhea which forbids the patient more than momentary freedom from the bedpan. Here, ileostomy and colectomy can restore the patient to a state of health compatible with a useful and possibly happy life. In the strict sense, all the aforementioned complications should be regarded as results of medical intractability. OPERATIVE PROCEDURES USED
Double.Barreled Ileostomy. This is used only in the acute fulminating case that can withstand a minimal amount of operation. A small incision is made in the right lower rectus muscle, and, without exploration, a loop of distal ileum is picked up and exteriorized. The two limbs of the loop are brought out through the incision. They are separated by closing the peritoneum, fascia and skin between them. The bowel is then divided between clamps. This type of ileostomy cannot be fitted with a good bag, but it is only a temporary, life-sparing effort. To spend time performing a divided ileostomy carries a prohibitive risk. Mter the patient improves, this ileostomy can be revised and colon resection carried out. End Ileostomy. Many surgeons still feel that most cases should only have interruption of the fecal stream by ileostomy as the first stage. While this may appear to be a simple, quick procedure, ample time should be spent on the technical details of its performance. The possibilities for postoperative complications from a simple ileostomy are far too numerous. Furthermore, the ileostomy will probably be permanent, and its proper function will govern the future comfort and health of the patient. Our first step is to. decide where the ileal stoma is to be placed. This is most important, since its success depends on the proper application of a Koenig-Rutzen bag or similar device. These appliances consist of a disk with a hole in the center through which the ileum protrudes; attached to the disk is a bag for collection of the discharged intestinal material. The disk surface is cemented to the skin surface, and a close fit must be secured to prevent leakage and skin erosion. Therefore the stoma must be placed away from the bony prominences, such as the anterior superior iliac spine or symphysis pubis, and also away from other variations in contour, such as the umbilicus. It is well to remember that operative incisions will be flat scars at the present, but, as the patient improves and gains weight, will represent dimpled or furrowed defects in the smooth skin surface. A tight fit over them will be impossible; therefore the stoma should be placed away from the operative incision. For the same reason we do not bring the ileum out through the incision as described by Colcock.H We prefer to make a circular stab wound in the abdominal wall. The site of this wound is usually 2 inches below and 2 inches to the right of the umbilicus. The operative incision is a lower midline or right paramedian one. No exploration of the peritoneal cavity is done, and the colon is not handled. This acutely inflamed bowel is friable, and its manipulation may cause some leakage of bacteria through its wall. Peritonitis would result.
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The terminal ileum is identified and delivered. A point for transection about 10 to 15 inches proximal to the ileocecal valve is selected. This is important because the terminal 3 or 4 inches of ileum are often involved by the disease,!l and the ileostomy must be made above the level of involvement. Lately we have obtained immediate histologic examination of the ileum at the level of transeotion by frozen section technic. This can be done while the ileostomy is being prepared. If disease is found at that level, a higher resection is performed. The mesentery is then divided perpendicular to the long axis of the bowel for a distance of several inches. In order to gain additional length without kinking, it may be necessary to cut along the mesentery in the direction of the long axis of the bowel. This should be done between the secondary and tertiary vascular arcades. Care must be taken not to devascularize the ileal stump. A circular section of skin, the size of the ileum, is excised at the stab wound site, and the proximal ileum is brought out through it so that several inches of bowel protrude upon the abdominal wall. It should be stressed that the size of the opening should be made to conform closely to the size of the ileum. The ileum is fixed to the anterior abdominal wall by suturing the free edge of its mesentery to the peritoneum. As the ileum is pulled through the abdominal wall, this free mesenteric edge will lie against the parietal peritoneum, and is easily fixed there with several interrupted sutures. One must be careful not to puncture a mesenteric vessel when placing these sutures. A defect is present between the cut mesenteric edges of the two limbs of the ileum, and omentum should be sutured into the gap to prevent subsequent herniation of small bowel through the aperture. No sutures are placed through the serosa or wall of the ileum. The distal limb of the ileum, which is still in the clamp, is brought out through the incisional wound, which is then closed about the bowel. This will serve as a mucous fistula and will also be situated where it is easily accessible for removal when colectomy is done. Inversion and closure of this stump, with return to the peritoneal cavity, are contraindicated. Stenosis of the bowel distal to the closure may occur and cause a perforation of the defunctionalized bowel, or the stump itself may blowout. After the incision is closed, petrolatum gauze strips are loosely inserted between the ileostomy and the skin edges down to the anterior rectus sheath. Dressings are applied to the incisional wound and to the ileostomy. The ileostomy is then opened, and a Penrose type of rubber tubular drain (1 inch in diameter and about 3 feet long) is sutured to the end of the bowel. The bowel is invaginated slightly into the tube to prevent leakage. The tube is secured to the dressings and is allowed to hang over the edge of the bed into a drainage bottle. This simple maneuver serves to carry the ileal drainage away from the abdomen for two or three days. Because of the light weight of this tube, there is no tension on the bowel. We have given up the insertion of a catheter into the lumen of the ileum for drainage. We have seen this catheter erode through the bowel and cause a fistula at the level of the parietal peritoneum. Furthermore, the lumen
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of a catheter is often inadequate to carry away the thick small bowel contents, and blockage occurs (Fig. 515). Ileostomy Plus Colectomy. For the past three years, in the majority of patients, we have coupled ileostomy with partial colectomy as the first stage. Since we now feel that all cases which require ileostomy will require colectomy, and since preoperative preparation is more intensive than before, we elect to remove as much colon as can safely be removed with ileostomy. This has not caused an increase in mortality. Morbidity has been lowered as one stage of this multiple stage procedure is eliminated. It appears to us that these patients actually respond more quickly than those in whom only ileostomy is done. Perhaps this is because a large area of absorptive surface has been removed and toxicity is diminished.
Fig. 515. Photograph of ileal stoma with Penrose drain sutured to it for drainage of ileal contents away from the abdomen.
Technically, the performance of the ileostomy is the same as described previously. However, the distal ileum, cecum and ascending and proximal transverse colon are resected. Right colectomy here is simpler than that for carcinoma of the colon, since it is not necessary to resect the mesocolon radically. Because of fibrosis and contracture, the bowel is shortened and the hepatic flexure is easily reached. After the ileostomy has been prepared and the mesocolon divided, the right peritoneal gutter is closed. The retroperitoneal space is drained through a small stab wound in the flank. The colon is then transected between clamps, and the distal stump is brought out through the superior angle of the incision as a mucous fistula. Here it is accessible for subsequent left colectomy. In those patients who are tolerating the procedure well, as evidenced
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by slow pulse rate and lack of shock, we continue to resect the colon beyond the splenic flexure to the proximal sigmoid colon at this stage. Then the proximal sigmoid is brought out through a stab wound in the left flank as a mucous fistula. The splenic flexure is also contracted and easily managed in these cases. This is done only when the surgeon and the anesthesiologist agree that the patient is withstanding operation well. Routinely 1 or 2 liters of blood are given during an operation of this magnitude. Abdominoperineal Resection. The final stage in the surgical management of this disease is abdominoperineal resection of the remaining colon and rectum. This is carried out about six months after the first stage, provided the patient has been restored to a good condition and can withstand major surgery. This operation is similar to the Miles resection of this' area for carcinoma, except that it is not necessary to radically remove the mesosigmoid or large amounts of pararectal tissues. The abdomen is opened through a left paramedian incision, and the mucous fistula is taken down. The ileostomy is not disturbed. The left mesocolon is divided, and the inferior mesenteric vessels are ligated and divided. Mter identification of the ureter, the rectum is mobilized down to the coccyx by blunt dissection. The bowel is then pressed down into the presacral space, and the pelvic peritoneal floor reconstructed. We use the two-team technic; as the abdominal incision is being closed by one group, the anus and rectum are freed from the perineum by an operator below. This shortens operating time, an important feature in this condition. The presence of anal fistulas with marked pararectal fibrosis adds slightly to the difficulty. The presence of the infected pararectal tissues contraindicates tight closure of the perineal wound. We partially close the wound around a soft rubber drain. In our opinion almost all cases that require colectomy for ulcerative colitis should have a total extirpation of ·the rectum. In 95 per cent of cases this is the most severely diseased segment of bowel,12 and it is unlikely that the rectum will revert to normal. It is subject to the same complications that occur in the rest of the colon. To rid the patient completely of his disease, one must remove the rectum. Also, it has been noted by many observers that, after total removal of the large bowel, the ileal contents become more semisolid and easier to manage. We do not agree that a small stump of distal rectum may be allowed to remain with the hope that at some future date the ileostomy can be taken down and anastomosed to it. We have yet to perform such an anastomosis. Reactivation of the disease may occur after several years of apparent quiescence. Colcock has reported that in half of a small group of patients in whom bowel continuity was restored, it was necessary to re-establish the ileostomy because of reactivation. 13 POSTOPERATIVE CARE
The problems that arise in the' postoperative state in these disorders are certainly more numerous and more troublesome than those which arise from any other type of surgery. One has to combat the complications common to any abdominal operation, plus those common to ileostomy.
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Operative blood loss has usually been replaced by transfusion during operation, and shock should not occur in an adequately prepared patient. Blood is used postoperatively in those patients with a low blood volume or those with hypoproteinemia with an insufficient oral food intake. Infection is a likely possibility, owing to the contaminated and infected bowel that is handled. This may result in peritonitis, incisional wound infection, perineal wound infection, or abscesses in the retroperitoneal gutters. This should be anticipated, and an attempt should be made to prevent it with antibiotic therapy. Twice daily 300,000 units of procaine penicillin are administered, and 0.5 gm. of dihydrostreptomycin is given every six hours, starting at operation. In the more toxic patients, or in those in whom considerable intraperitoneal soilage occurred at operation, aureomycin is given by the intravenous route in amounts of 500 mg. twice daily. If allergenic manifestations to antibiotic therapy arise, parenteral sulfadiazine therapy can be used. Fluid balance and electrolyte derangements are prone to occur; and a carefully planned replacement program starting at operation is essential. When a smooth course ensues, the problem is only one of administering sufficient parenteral fluid to cover the insensible loss and guarantee adequate renal output. This is identical with the program followed after any abdominal or intestinal procedure. However, ileostomies may temporarily obstruct at the abdominal wall, or they may discharge tremendous amounts of material at first. Certainly, one fourth of the cases take one of these two courses. If they obstruct, nausea and vomiting rapidly ensue, and the fluid and electrolyte loss can be alarming. Dehydration, hypochloremia and alkalosis will result. In the hyperfunctioning ileostomy great volumes of fluid with a 'high content of fixed base may be discharged. The sodium and potassium levels are depleted, and acidosis results. Intelligent therapy of either of these is guided by a careful record of the fluid lost and by chemical anaiysis of the blood serum. Here the amount of fluid given must be sufficient to replace that lost by vomiting or ileostomy, the insensible loss, and the amount needed for proper renal function. Electrolytes should also be replaced as lost. Hyponatremia can be corrected by the administration of 0.8 per ceni sodium chloride solution. Hypokalemia may be marked. This is determined by blood serum analysis or electrocardiographic tracing. Administration of potassium by parenteral route will be just as important as the use of sodium chloride and water. In some cases, hypochloremia and hyponatremia will not respond to therapy unless the potassium level is also corrected. We give a 1.14 per cent solution of potassium chloride; in many patients this causes discomfort and must be diluted. We have seen two ileostomy patients with hypokalemia suffer a refractory alkalosis and an adynamic ileus which responded only to the replacement of the potassium ion. Normal peristaltic activity resumed and vomiting ceased. Nutrition assumes paramount importance, since most of these patients are on a subnormal nutritional level before operation. As soon as oral feedings are tolerated, we give formulas fortified with protein hydrolysates, dextrimaltose and vitamins.
1742
ALFHED S. FHOBESE
Care of the Ileostomy. After the patient is returned to the ward, the tube from the ileostomy is connected to a drainage bottle. Lahey has emphasized the importance of frequent inspection of the ileostomy.6 If it becomes nonviable, it can be revised before gangrene, leakage and peritonitis occur. The intestinal material will be carried away by the tube for seventy-two to ninety-six hours. As soon as this system begins to leak, meticulous care of the skin is instituted. It is much easier to prevent skin erosion by the digestive ferments than to treat it once it has occurred. This erosion is painful, and the measures used to treat it cause added discomfort. As soon as the intestinal contents begin to soil the wall, the skin is protected by frequent, liberal applications of compound tincture of benzoin. After each passage and soilage of dressings, the ileostomy should be dressed. The skin is cleansed with soap and water and thoroughly dried, and benzoin is reapplied. It is a common practice for the attendants to use many dressings and change them infrequently. It is far better to use a small amount of gauze and remove it as soon as it is soiled. We have used kaolin, aluminum hydroxide paste, aluminum paste, absorptive resins and other protective agents to prevent digestion. None has worked as well as the constant mechanical removal of ileal material. The skin will adhere to the bowel wall in seven to ten days, and a widemouthed ileostomy or colostomy bag may be utilized temporarily. The ileostomy will shrink enough in six weeks to enable the patient to be measured for a snug-fitting Koenig-Rutzen bag. Once this bag has been applied, the major problem is solved. The bag face is cemented to the skin surface around the circumference of the ileostomy, and no leakage or erosion can take place. Many patients show some evidence of partial obstruction in the ileum just as it passes through the abdominal wall. Presumably, this is· due to edema. In the average case this causes little difficulty. A few "cramplike" pains will be noted just before the ileostomy discharges; after several days, this subsides. In some cases it is more serious, and the picture of mechanical ileus with nausea and vomiting arises. The decision as to the management of this problem is always a difficult one. Often intubation with a Miller-Abbott tube and decompression of the ileostomy with a catheter will suffice; in one or two days the ileostomy will begin to function. Occasionally, this may occur several times before the patient is discharged from the hospital. In cases in which the ileus persists and "cramplike" pain is severe, one must be alert not to overlook a kink or volvulus with embarrassment of bowel vascularity. We have been forced to reoperate upon several of our cases to lyse adhesive bands or release kinks. These kinks have been found just proximal to the ileostomy and were of the type usually seen in low grade peritonitis. We now feel that these eases might have subsided without reoperation. Our tendency now is toward long tube decompression and watchful waiting. Ileostomies are also prone to prolapse or retract. Retraction can be minimized by bringing sufficient ileum out on the abdominal wall and
REGIONAL ENTERITIS AND ULCERATIVE COLITIS
1743
fastening the mesentery to the wall. We exteriorize about 2 inches of ileum. When shrinkage occurs, a bud of ileum will protrude about ! inch above the level of the skin. The ileum should not be sutured to the abdomen or the wound. When sutures are placed in the bowel wall, the mucosa may be penetrated and a fistula might result. This will destroy the efficiency of the ileostomy. For this reason we have not used the technic advocated by Dennis,14 although he does report favorable results. We prefer to fix the ileostomy by suturing the cut edge of the divided mesentery to the abdominal wall for a distance of 2 or 3 inches. Prolapse of the ileum through the ileostomy may be most troublesome and severe enough to cause partial obstruction. One patient had a marked prolapsus of about 1 foot of bowel; it became eroded from constant contact with the bag, and a profuse hemorrhage occurred. We know of no good method to prevent this complication. It can be minimized by careful fixation of the mesentery and by making the stab wound just large enough to accommodate the ileum. Skin grafting of the ileal appendage, as advocated by Dragstedt,15 has been tried. Contracture of the graft caused stenosis of the ileostomy, and the graft had to be split. We can see no particular advantage to this method with the modern ileostomy bags available. In an occasional case the disease process in the remaining colon may flare up after ileostomy, and bleed or perforate. This unhappy situation calls for further surgery. SUMMARY
1. Surgical intervention in chronic stenosing regional enteritis should be confined to those cases complicated by obstruction, abscess or fistulas, and those in which a most thorough medical regimen has failed. 2. Radical excision of the diseased bowel has been practised whenever possible. The results of this surgery have been disappointing. Recurrence after radical resection was noted in 58 per cent of a closely followed up group of cases. This is in line with reports on the results of resection from other clinics. . 3. Ileostransverse colostomy with exclusion has been used and has given good results in the few cases in which we have used it. This procedure is less hazardous,_and longer follow-up studies from clinics using it may show that it gives superior results. 4. Improvement in preparation of patients and of surgical technic, plus the use of fitted bags, such as the Koenig-Rutzen bag, have materially altered the results of surgery in ulcerative colitis. These patients can be converted from invalids to well persons. 5. The indications for surgery in ulcerative colitis are hemorrhage, obstruction, perforation, arthritis, danger of malignant degeneration, and medical intractability. 6. The surgical aim is interruption of the fecal stream by ileostomy and resection of the diseased bowel. 7 . We no longer believe that ileostomy alone should be performed for
1744
ALF:allln S. FROnlllSlll
ulcerative colitis; if ileostomy is necessary, the diseased colon must be removed also. 8. In most cases we perform an ileostomy and partial colectomy as the first stage. The remaining colon and rectum are removed at the second stage. This has not increased our mortality, and the morbidity has been decreased. 9. Once ileostomy and colectomy are necessary for ulcerative colitis, we believe that the rectum should be resected. 10. Operative technic and postoperative care are discussed. REFERENCES 1. Hawthorne, H. R., and Frobese, A. S.: Chronic Stenosing Regional Enteritis; Surgical Pathology and Experience in Surgical Treatment. Ann. Surg., 103: 233, 1949. 2. Sala, L. F., and Ferguson, L. K.: Surgical Treatment of Regional Enteritis. J. Philadelphia General Hospital, 2:23, 1950. 3. Bockus, H. L.: Present Status of Chronic Regional or Cicatrizing Enteritis. J.A.M.A., 127:449, 1945. 4. Garlock, J. H.: The Present Status of the Problem of Regional Ileitis. Am. J. Surg., 72:875, 1946. . 5. Colp, R.: Proximal Extension and Progression following Operations for Regional Ileitis. S. CLIN. NORTH AMERICA, 27:333, 1947. 6. Lahey, F.: Complications of Ileostomy. S. CLIN. NORTH AMERICA, 30:893,1950. 7. Miller, G. G., Ripstein, C. B., and Tabah, E. J.: The Surgical Management of Ulcerative Colitis. Surg., Gynec. & Obst., 88:351, 1949. 8. Welch, C. E., and Giddings, W. P.: Carcinoma of Colon and Rectum. New England J. Med., 244:859, 1951. 9. Cattell, R. B., and Boehme, E. J.: Chronic Ulcerative Colitis Complicated by Carcinoma of Colon and Rectum. S. CLIN. NORTH AMERICA, 26:641, 1946. 10. Lahey, F.: Indications for Surgical Intervention in Ulcerative Colitis. Ann. Surg., 133:726, 1951. 11. Colcock, B.: Technic of Ileostomy. S. CLIN. NORTH AMERICA, 31:775,1951. 12. Rankin, F. W., Bargen, J. A., and Buie, L. A.: The Colon, Rectum and Anus. Philadelphia, W. B. Saunders Company, 1932. 13. Colceck, B.: The Surgical Treatment of Ulcerative Colitis. New England J. Med., 242:320, 1950. 14. Dennis, C.: Ileostomy and Colectomy in Chronic Ulcerative Colitis. Surgery, 18:435, 1945. 15. Dragstedt, L. R., Dack, G. M., and Kirsner, J. B.: Chronic Ulcerative Colitis; Summary of Evidence Implicating Bacterium necrophorum· as Etiologic Agent. Ann. Surg., 114:653, 1941.
Our earliest approach to the therapy of this disease was to remove large amounts of bowel in order to get well away from grossly involved gut. It was felt that the disease was primarily one of the bowel wall, and that wide excision would eradicate it. In several instances of enterocolitis the entire ileum and the proximal half of the colon were resected. These operations were staged. The first stage consisted of a lateral anastomosis of the jejunum or ileum to the distal transverse colon. Later, a resection of the sidetracked bowel was accomplished. The mortality in these cases was disproportionately high. In recent years we have done a one-stage resection of the diseased bowel and mesentery with a primary anastomosis. Owing to better preoperative preparation of patients with blood transfusions, parenteral alimentation and antibiotic agents, as well as improved surgical technics, the mortality has been lowered. No patient has been lost within the past three years. . Although the operative death rate is now low, the recurrence rate still seems high. Our cases have been closely followed up by the Departments of Gastroenterology and Radiology at the Graduate Hospital. From their studies we previously reported that 73 per cent of the cases followed up from one to fourteen years showed clinical or roentgenographic recurFrom the Department of Surgery, Graduate School of Medicine, University of Pennsylvania, and the Surgical Service of Dr. Herbert R. Hawthorne, Graduate Hospital of University of Pennsylvania, Philadelphia. * Associate in Surgery, Graduate School of Medicine, University of Pennsylvania; Assistant Surgeon, Graduate Hospital of University of Pennsylvania, Philadelphia.
1725
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ALFRED S. FROBESE
rences. l In the past three years the results have shown some improvement. Of nineteen patients that have been unoer surveillance from two to seventeen years, eleven have had clinical or roentgen evidence of recurrence-a recurrence rate of 58 per cent. This corresponds to a recurrence rate of 57 per cent reported by Sala and Ferguson. 2 It should be pointed out that a follow-up of one year or less is not adequate, since seven of our patients turned up with recurrence after a year had elapsed (Tables 1 and 2). TABLE
1
RESULTS OF RADICAL RESECTION
Total number of resections... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Operative deaths. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2 Cases lost for follow-up ....................................... 3 Cases closely followed 2-17 years. . . . . . . . . . . . . . . . . . . . . . 19 Number of proved recurrences...... . . . . . . . . . . . . . . . . . . .......... 11
24
Recurrence rate ............................................... . 58 per cent TABLE
2
TIME ELAPSE BETWEEN RESECTION AND RECURRENCE
Number of Cases One year or less .............................................. . 1-2 years ..................................................... . 2-3 years................. . ................ .
~=~l;:~~~:::::::::::::::::::::::::::::::: .... :::::::::::::::: :
4 3 1 1 2
Total. ....................................................... 1----11----
The aim of radical surgery is to remove all the diseased tissue. When one inspects the mesentery adjacent to the involved bowel in enteritis, the lymph gland involvement is striking. These nodes are enlarged, congested and edematous. It is not known whether the lymphatic lesion in this condition is primary or secondary, but histologic examination readily reveals that a chronic inflammatory process is present in the regional lymphatics. These glands are widely scattered and extend to the root of the mesentery. Complete eradication of these nodes is often impossible without impairing the circulation of the remaining gut. Therefore, we wonder if radical resection really accomplishes its aim. In considering the surgical treatment of this disease, it is necessary to define the stage of the pathologic process present; that is, the acute or the chronic, with or without complications. ACUTE STAGE OF ENTERITIS
Acute, uncomplicated cases are better handled by rigorous medical treatment as outlined by Bockus. 3 A remission often can be obtained. Furthermore, regression of the acute phase is not always followed by
REGIONAL ENTERITIS AND ULCERATIVE COLITIS
1727
complications. It is true that the condition may recur, but operation certainly offers no guarantee against recurrence. In the acute cases that simulate acute appendicitis, exploration is done for appendectomy. If, after the abdomen has been opened and the appendix found to be normal, an uncomplicated enteritis is present, it is best to terminate the procedure without appendectomy. Because of actual involvement of the cecal wall by the inflammatory process, postoperative fistula may result. Furthermore, resection of the diseased bowel at this time is not wise. The serosa is usually fiery red; there is some free, turbid peritoneal fluid; and the diseased loops are often adherent to each other with a fibrinous exudate. Resection and anastomosis in the presence of such marked peritoneal inflammation are foolhardy. Lack of preparation of the patient and a likelihood of remission of the process add support to this conclusion. Garlock states that most of these acute cases will regress. 4 CHRONIC STAGE OF ENTERITIS
When the chronic stage is reached, the complications which require surgical intervention are apt to arise: obstruction, intra-abdominal abscess, and fistulas. Peritonitis of the spreading type does not seem to occur from the perforations. These leaks usually occur late in the course of the disease and burrow slowly through the extremely thick submucosa and mesentery. They become walled-off as localized abscesses, or penetrate into other viscera or the abdominal wall (Fig. 506). Obstruction results from stenosis of the bowel lumen following repeated inflammation, ulceration, and then cicatrization. Most of our patients were operated on for this complication (Fig. 507). The most marked changes are more often encountered in the terminal ileum, or the terminal ileum, cecum and ascending colon. Here we use a radical resection of the bowel. The ileum is transected about 18 inches proximal to the level of the gross involvement. On the colonic side, a gross appraisal of the limit of the lesion is not accurate; so we usually resect the cecum and ascending colon well past the hepatic flexure (Fig. 508). The mesentery is resected as widely as is safe, with preservation of vessels to the remaining gut. Then intestinal continuity is restored with an end-to-end or end-to-side ileocolostomy. We routinely use an open method of anastomosis without clamps. Another feature of this disease which may have to be dealt with is the presence of so-called "skip areas" (Fig. 509). These are segmental areas of involvement proximal or distal to the main lesion. Whether they occur simultaneously or result from progression of the disease is controversial. It is our feeling that all the areas are stricken at the same time. One case had five distinct areas of disease, each separated from the other by normalappearing bowel. Isolated "skip" lesions may be resected, but when there are many involving the length of the small gut, multiple resections of segments or one resection of the entire jejuno-ileum seems untenable. In the case with five such lesions we terminated the operation with exploration.
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ALFRED S. FROBESE
In cases complicated by abscesses or fistulas there may be large inflammatory masses densely adherent to the underlying iliac vessels and the ureter. Adjacent bowel loops may be matted together, or the mass may extend into the base of the mesentery. In such instances we elect to do an ileotransverse colostomy with exclusion (Fig. 510, left). In this procedure the ileum is transected 18 inches proximal to the gross limit of the lesion. The proximal end is anastomosed end-to-side to the proximal transverse colon, or to the more distal colon, depending on the degree of extension of the process down the bowel. The distal stump of
Fig. 506. Roentgenogram of a case of regional enteritis with ileosigmoid fistula. A small bowel barium enema was administered through the Miller-Abbott tube. Barium passed readily from the ileum into the sigmoid colon.
ileum is inverted and closed and dropped back into the abdomen. If any significant amount of stenosis is present in the lesion, this distal stump should not be closed, because, if obstruction ensues, it would blowout and cause peritonitis. Instead, it can be brought out through a stab wound in the abdominal wall to act as a mucous fistula. This is the operation Garlock4 and Colp5 would use in all cases of enteritis in preference to resection. Their results from this type of operation have been good and the surgical hazard minimal. Indeed, in the instances in which we have used this procedure the results 'have been most satisfactory.
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1729
Fig. 507. Roentgenogram of a case of regional enteritis with obstruction. The stenotic,loops are evident. A markedly dilated loop proximal to the obstruction is noted in the midabdomen.
Fig. 508. Diagram of usual resection procedure employed for regional enterocolitis. Shaded area represents the diseased bowel. (A) Level of transection of ileum. (B) Transection site of transverse colon. Colon stump (B') inverted and closed and ileum (A') anastomosed end-to-side to transverse colon.
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ALFRED S. FROB ESE
We have had the opportunity to reoperate on several of these cases, and have been surprised to find that all the gross evidences of disease in the sidetracked loop had disappeared, and the bowel appeared entirely normal. This has been reported by other surgeons interested in this condition. Unfortunately, we have had no microscopic confirmation of complete healing, since no sections were taken. We are not aware of any attempts to restore bowel continuity through these apparently quiescent loops, and we would be most hesitant to do so, for it is well known that this disease may become active after long periods of arrest.
;
Fig. 509. Roentgen appearance of "skip lesions" in regional enterocolitis.
It should be stressed that, when one elects to use the exclusion operation, a complete transection of, the bowel proximal to the involved area should be done. Some surgeons apparently anastomose the ileum to the transverse colon in continuity (Fig. 510, right). This is mentioned only to condemn it. We have reoperated on several patients who had this type of procedure and who had progression or continuation of their disease. At exploration the lesion in the so-called "sidetracked" loop was still active. Another indication for operation is medical intractability. These patients do not have any of the aforementioned complications to a marked degree, but, because of continued pain, severe anemia or poor nutritional status, they are invalids.
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1731
At present we are in agreement with the internists that only those cases deemed complicated or completely intractable to a rigorous medical program should come to operation. We are still inclined to regard resection of bowel as the procedure of ehoice, and we perform it whenever possible in spite of its obvious high percentage of failures. We have felt that as much bowel could be resected as could be sidetracked, and that the patient was better off with the diseased bowel out. However, much consideration
Fig. 510. Diagram (left) of ileotransverse colostomy with exclusion. Shaded area represents diseased bowel: A, distal stump of transected ileum, which is inverted and closed; B, proximal stump of ileum, which is anastomosed end-to-side to the transverse colon. Diagram (right) of ileotransverse colostomy without exclusion. Shaded area represents diseased segment: A, side-to-side ileotransverse colostomy in continuity. This procedure is contraindicated in this disease.
must be given to the exclusion operation, for it may be that longer follow-' up reports from clinics using it will show a superior result. MANAGEMENT OF ULCERATIVE COLITIS
Surgeons with considerable experience in the treatment of ulcerative colitis generally agree that only 25 per cent of patients so afflicted come to operation. The progress of the process in the remaining percentage is arrested or controlled by intensive medical and psychiatric programs. We are called upon to treat the patient when the disease becomes complicated or when failure to respond to medical measures results in invalidism. In recent years there has been improvement in medical therapy of ulcerative colitis through the use of antibiotic agents, parenteral nutrition, so-called "medical ileostomy," and ACTH. This has been matched by an even greater improvement of surgical technic in the making of ileostomies and the resection of diseased bowel. This has resulted in a closer understanding between the internist and the surgeon as to the indications for operation. Operation is no longer withheld until the patient is in such an
1732
ALFRED S. FROBESE
advanced state of intoxication and malnutrition that surgical fatality is certain. The reluctance of the internist to sentence his patient to an ileostomy and of the surgeon to carry it out was once understandable. Standardization of ileostomy technic and the use of fitted bags, such as the Koenig-Rutzen bag, have altered this picture. A patient with an ileostomy can live a normal, useful life. Our present assumption is that, once this disease has ravaged the bowel, the bowel never reverts to a normal state. Therefore the surgical aim is to interrupt the fecal stream and eradicate the diseased bowel. This is carried out in stages. In the recent past the first stage was that of interruption of the fecal stream by ileostomy. This allowed the process in the colon to quiet down; the patient improved, and subsequent colon resection was done with greater safety. The resection of the colon and rectum required an additional two or three stages. Each operative procedure had its attendant complications, and the patient morbidity and mortality were too great. Most of the difficulty arose with the performance of simple ileostomy. The Lahey Clinic cited mortality figures of 22 per cent for ileostomy alone. 6 Now a decision as to the need of operation is reached much earlier. The patients are better prepared for operation with strict dietary programs containing easily assimilated protein hydrolysates in large amounts; large doses of oral and parenteral polyvitamin preparations; the use of the antibiotic agents (penicillin, aureomycin and Chloromycetin) to combat sepsis; and the restoration of blood volume with repeated infusions of whole blood. This last adjunct is most important and has resulted in a patient better able to withstand definitive surgery, even if prolonged. Therefore the number of staged operations has been decreased. In most of our cases we now accomplish ileostomy and total extirpation of the colon and rectum in two stages. INDICATIONS FOR OPERATION
Hemorrhage. Chronic blood loss from the ulcerated mucosa is a frequent complication. This may be intermittent and result in an anemia refractory to treatment. It may be severe and persistent, and thus become an indicationfor operation. Profuse bleeding may occur and threaten the patient with exsanguination. Here, operation is imperative. Ileostomy with defunctionalization of the colon should be done. The bleeding may cease temporarily. We have had two cases that had massive hemorrhages from the colon one and two years after ileostomy. If bleeding is profuse and continues after ileostomy, the most actively bleeding segment of colon should be resected. This may mean a total colectomy in one stage if all the bowel is involved. The risk of such a procedure is considerable, but must be accepted in such an emergency. To allow the patient to bleed to death is folly. We have had no success in the use of local medicaments in the colon for stopping profuse hemorrhage. Our policy is to give whole blood by rapid transfusion until the patient is out of shock and his red blood cell count has been raised to 4,000,000
REGIONAL ENTERITIS AND ULCERATIVE COLITIS
1733
per cubic millimeter. We then operate. Blood is administered during operation, of course. Obstruction. Late in the course of this disease, marked fibrosis and shortening of the bowel occur. The periods of exacerbation with ulceration and infection, followed by periods of quiesence and cicatrization, result in a stenotic fibrous tube.The narrowing is most marked in the rectal area. The stenosis is usually not severe enough to obstruct the gut completely; however, this fibrosis is irreversible. Further healing only leads to further narrowing, and no normal colonic function is possible. Ileostomy and colectomy are indicated (Figs. 511, 512).
Fig. 511. Roentgenogram of a case of ulcerative colitis with areas of marked stenosis (arrows) and partial obstruction .
.
Perforation. Acute free perforation of the bowel is infrequently seen. Miller states that it occurs in 1 per cent of cases. 7 If it does occur, a virulent peritonitis ensues, which is likely to terminate fatally. If such a patient does survive the initial insult, ileostomy and partial colectomy should be done as soon as the patient can withstand surgical intervention. Closure of the perforation would be difficult because of the friable nature of the bowel wall and the adjacent peritoneal infection. Ileostomy plus exteriorization or drainage might be the only possible measures in extreme cases. The type of perforation most frequently seen is subacute or, chronic.
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ALFRED S. FROBESE
By the time the mucosal ulcer has extended through all the thickened coats of the bowel, adhesion of other loops, mesentery or peritoneum to the leaking site has taken place. A localized abscess or fistula is produced. These are particularly common around the rectum and anus, and local surgery here is to no avail. The fecal stream must be diverted by ileostomy. Though temporary drainage of abscesses should be done, eventually the diseased bowel must be resected (Fig. 513).
Fig. 512. Roentgenogram of a case of ulcerative colitis with marked stenosis and obstruction in the proximal sigmoid colon. Compression paddle separates the upper limb of transverse colon (A) from the lower sigmoid limb (B). Note marked shortening of the bowel.
Arthritis. With the appearance of the symptoms and signs of joint involvement, medical management should be terminated and the patient prepared for ileostomy and colectomy. It is unwise to persist in conservative measures until destruction of joint surfaces 'occurs and the patient is permanently crippled. This happened to one of our patients who refused to have his colon removed until four years had elapsed after ileostomy. It is striking to note the complete disappearance of joint symptoms and the restoration of walking activity after ileostomy and colectomy. Carcinoma. There is increasing evidence that the incidence of carcinoma of the colon is greater in patients suffering with long-standing ulcerative colitis. 8 It is understandable that the repeated bouts of mucosal destruction and healing with attendant metaplasia could easily merge into neoplasia.
REGIONAL ENTERITIS AND ULCERATIVE COLITIS
1735
Cattell has noted an incidence of malignant degeneration between 25 and 30 per cent in patients who have harbored the disease for eight or more years. 9 Furthermore, when carcinoma is superimposed on ulcerative colitis, cure is unlikely. The symptoms of the colitis may mask those of the carcinoma, which might be overlooked. The presence of the active colon inflammation appears to hasten the spread of the tumor. Of eighteen patients
Fig. 513. Roentgenogram of a case of ulcerative colitis with perforation and fistulas: A, fistula from proximal transverse colon; B, fistula from sigmoid to skin.
with colonic carcinoma complicating ulcerative colitis resected by Lahey, only two survived without recurrence. 10 We have not encountered carcinoma of the colon or rectum with ulcerative colitis, and have wondered why it has not appeared. With the evidence from other clinics, we feel that this complication must be a real danger, particularly if pseudopolyp formation is present. It is our practice to insist that total extirpation of the colon and rectum be done when ileostomy is necessary for complicated distal ulcerative colitis and pseudopolyp formation in the colon is noted. Pseudopolyposis carries not only the danger of malignant degeneration, but also the hazard of recurrent hemorrhage (Fig. 514). Acute Fulminating Cases. This type of case still remains the most difficult to manage. These patients are extremely toxic, have high temperature,
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ALFRED S. FROBESE
and pass many liquid stools filled with pus and blood daily. Surgical intervention under these circumstances is risky. Every effort should be made to obtain a remission by medical means. The use of ACTH here may hold promise. 1o In any event, close cooperation between the surgeon and the internist is necessary to decide when medical therapy should be terminated and surgery instituted. Such a decision should be made early in the course of the bout before the patient is moribund. The procedure of choice is the simplest that will suffice. The object is to by-pass the fecal stream from the acutely inflamed colon in the quickest
Fig. 514. Roentgenogram of a case of ulcerative colitis with polypoid mucosal changes. These are most marked in the transverse colon.
way. This may be by simple loop ileostomy. In cases in slightly better condition an end ileostomy may be possible, but no colon resection can be considered. Intravascular thrombus formation is not uncommon in this phase of colitis and may complicate the picture. In one of our cases ileofemoral venous thrombosis was present and produced a pseudoembolic ischemia of the leg. It was necessary to ligate the inferior vena cava at the time the ileostomy was made. Medical Intractability. This indication covers an ill-defined group of cases which, despite adequate medical care, pursue a downhill course, or the acute exacerbations occur too frequently. The patients, because of their disease, are unable to lead a normal life socially or economically.
REGIONAL ENTERITIS AND ULCERATIVE COLITIS
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This may be due to malnutrition and weakness, abdominal pain, rectal fistulas and incontinence, or a persistent diarrhea which forbids the patient more than momentary freedom from the bedpan. Here, ileostomy and colectomy can restore the patient to a state of health compatible with a useful and possibly happy life. In the strict sense, all the aforementioned complications should be regarded as results of medical intractability. OPERATIVE PROCEDURES USED
Double.Barreled Ileostomy. This is used only in the acute fulminating case that can withstand a minimal amount of operation. A small incision is made in the right lower rectus muscle, and, without exploration, a loop of distal ileum is picked up and exteriorized. The two limbs of the loop are brought out through the incision. They are separated by closing the peritoneum, fascia and skin between them. The bowel is then divided between clamps. This type of ileostomy cannot be fitted with a good bag, but it is only a temporary, life-sparing effort. To spend time performing a divided ileostomy carries a prohibitive risk. Mter the patient improves, this ileostomy can be revised and colon resection carried out. End Ileostomy. Many surgeons still feel that most cases should only have interruption of the fecal stream by ileostomy as the first stage. While this may appear to be a simple, quick procedure, ample time should be spent on the technical details of its performance. The possibilities for postoperative complications from a simple ileostomy are far too numerous. Furthermore, the ileostomy will probably be permanent, and its proper function will govern the future comfort and health of the patient. Our first step is to. decide where the ileal stoma is to be placed. This is most important, since its success depends on the proper application of a Koenig-Rutzen bag or similar device. These appliances consist of a disk with a hole in the center through which the ileum protrudes; attached to the disk is a bag for collection of the discharged intestinal material. The disk surface is cemented to the skin surface, and a close fit must be secured to prevent leakage and skin erosion. Therefore the stoma must be placed away from the bony prominences, such as the anterior superior iliac spine or symphysis pubis, and also away from other variations in contour, such as the umbilicus. It is well to remember that operative incisions will be flat scars at the present, but, as the patient improves and gains weight, will represent dimpled or furrowed defects in the smooth skin surface. A tight fit over them will be impossible; therefore the stoma should be placed away from the operative incision. For the same reason we do not bring the ileum out through the incision as described by Colcock.H We prefer to make a circular stab wound in the abdominal wall. The site of this wound is usually 2 inches below and 2 inches to the right of the umbilicus. The operative incision is a lower midline or right paramedian one. No exploration of the peritoneal cavity is done, and the colon is not handled. This acutely inflamed bowel is friable, and its manipulation may cause some leakage of bacteria through its wall. Peritonitis would result.
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The terminal ileum is identified and delivered. A point for transection about 10 to 15 inches proximal to the ileocecal valve is selected. This is important because the terminal 3 or 4 inches of ileum are often involved by the disease,!l and the ileostomy must be made above the level of involvement. Lately we have obtained immediate histologic examination of the ileum at the level of transeotion by frozen section technic. This can be done while the ileostomy is being prepared. If disease is found at that level, a higher resection is performed. The mesentery is then divided perpendicular to the long axis of the bowel for a distance of several inches. In order to gain additional length without kinking, it may be necessary to cut along the mesentery in the direction of the long axis of the bowel. This should be done between the secondary and tertiary vascular arcades. Care must be taken not to devascularize the ileal stump. A circular section of skin, the size of the ileum, is excised at the stab wound site, and the proximal ileum is brought out through it so that several inches of bowel protrude upon the abdominal wall. It should be stressed that the size of the opening should be made to conform closely to the size of the ileum. The ileum is fixed to the anterior abdominal wall by suturing the free edge of its mesentery to the peritoneum. As the ileum is pulled through the abdominal wall, this free mesenteric edge will lie against the parietal peritoneum, and is easily fixed there with several interrupted sutures. One must be careful not to puncture a mesenteric vessel when placing these sutures. A defect is present between the cut mesenteric edges of the two limbs of the ileum, and omentum should be sutured into the gap to prevent subsequent herniation of small bowel through the aperture. No sutures are placed through the serosa or wall of the ileum. The distal limb of the ileum, which is still in the clamp, is brought out through the incisional wound, which is then closed about the bowel. This will serve as a mucous fistula and will also be situated where it is easily accessible for removal when colectomy is done. Inversion and closure of this stump, with return to the peritoneal cavity, are contraindicated. Stenosis of the bowel distal to the closure may occur and cause a perforation of the defunctionalized bowel, or the stump itself may blowout. After the incision is closed, petrolatum gauze strips are loosely inserted between the ileostomy and the skin edges down to the anterior rectus sheath. Dressings are applied to the incisional wound and to the ileostomy. The ileostomy is then opened, and a Penrose type of rubber tubular drain (1 inch in diameter and about 3 feet long) is sutured to the end of the bowel. The bowel is invaginated slightly into the tube to prevent leakage. The tube is secured to the dressings and is allowed to hang over the edge of the bed into a drainage bottle. This simple maneuver serves to carry the ileal drainage away from the abdomen for two or three days. Because of the light weight of this tube, there is no tension on the bowel. We have given up the insertion of a catheter into the lumen of the ileum for drainage. We have seen this catheter erode through the bowel and cause a fistula at the level of the parietal peritoneum. Furthermore, the lumen
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of a catheter is often inadequate to carry away the thick small bowel contents, and blockage occurs (Fig. 515). Ileostomy Plus Colectomy. For the past three years, in the majority of patients, we have coupled ileostomy with partial colectomy as the first stage. Since we now feel that all cases which require ileostomy will require colectomy, and since preoperative preparation is more intensive than before, we elect to remove as much colon as can safely be removed with ileostomy. This has not caused an increase in mortality. Morbidity has been lowered as one stage of this multiple stage procedure is eliminated. It appears to us that these patients actually respond more quickly than those in whom only ileostomy is done. Perhaps this is because a large area of absorptive surface has been removed and toxicity is diminished.
Fig. 515. Photograph of ileal stoma with Penrose drain sutured to it for drainage of ileal contents away from the abdomen.
Technically, the performance of the ileostomy is the same as described previously. However, the distal ileum, cecum and ascending and proximal transverse colon are resected. Right colectomy here is simpler than that for carcinoma of the colon, since it is not necessary to resect the mesocolon radically. Because of fibrosis and contracture, the bowel is shortened and the hepatic flexure is easily reached. After the ileostomy has been prepared and the mesocolon divided, the right peritoneal gutter is closed. The retroperitoneal space is drained through a small stab wound in the flank. The colon is then transected between clamps, and the distal stump is brought out through the superior angle of the incision as a mucous fistula. Here it is accessible for subsequent left colectomy. In those patients who are tolerating the procedure well, as evidenced
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ALFRElD S. FROBElSEl
by slow pulse rate and lack of shock, we continue to resect the colon beyond the splenic flexure to the proximal sigmoid colon at this stage. Then the proximal sigmoid is brought out through a stab wound in the left flank as a mucous fistula. The splenic flexure is also contracted and easily managed in these cases. This is done only when the surgeon and the anesthesiologist agree that the patient is withstanding operation well. Routinely 1 or 2 liters of blood are given during an operation of this magnitude. Abdominoperineal Resection. The final stage in the surgical management of this disease is abdominoperineal resection of the remaining colon and rectum. This is carried out about six months after the first stage, provided the patient has been restored to a good condition and can withstand major surgery. This operation is similar to the Miles resection of this' area for carcinoma, except that it is not necessary to radically remove the mesosigmoid or large amounts of pararectal tissues. The abdomen is opened through a left paramedian incision, and the mucous fistula is taken down. The ileostomy is not disturbed. The left mesocolon is divided, and the inferior mesenteric vessels are ligated and divided. Mter identification of the ureter, the rectum is mobilized down to the coccyx by blunt dissection. The bowel is then pressed down into the presacral space, and the pelvic peritoneal floor reconstructed. We use the two-team technic; as the abdominal incision is being closed by one group, the anus and rectum are freed from the perineum by an operator below. This shortens operating time, an important feature in this condition. The presence of anal fistulas with marked pararectal fibrosis adds slightly to the difficulty. The presence of the infected pararectal tissues contraindicates tight closure of the perineal wound. We partially close the wound around a soft rubber drain. In our opinion almost all cases that require colectomy for ulcerative colitis should have a total extirpation of ·the rectum. In 95 per cent of cases this is the most severely diseased segment of bowel,12 and it is unlikely that the rectum will revert to normal. It is subject to the same complications that occur in the rest of the colon. To rid the patient completely of his disease, one must remove the rectum. Also, it has been noted by many observers that, after total removal of the large bowel, the ileal contents become more semisolid and easier to manage. We do not agree that a small stump of distal rectum may be allowed to remain with the hope that at some future date the ileostomy can be taken down and anastomosed to it. We have yet to perform such an anastomosis. Reactivation of the disease may occur after several years of apparent quiescence. Colcock has reported that in half of a small group of patients in whom bowel continuity was restored, it was necessary to re-establish the ileostomy because of reactivation. 13 POSTOPERATIVE CARE
The problems that arise in the' postoperative state in these disorders are certainly more numerous and more troublesome than those which arise from any other type of surgery. One has to combat the complications common to any abdominal operation, plus those common to ileostomy.
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Operative blood loss has usually been replaced by transfusion during operation, and shock should not occur in an adequately prepared patient. Blood is used postoperatively in those patients with a low blood volume or those with hypoproteinemia with an insufficient oral food intake. Infection is a likely possibility, owing to the contaminated and infected bowel that is handled. This may result in peritonitis, incisional wound infection, perineal wound infection, or abscesses in the retroperitoneal gutters. This should be anticipated, and an attempt should be made to prevent it with antibiotic therapy. Twice daily 300,000 units of procaine penicillin are administered, and 0.5 gm. of dihydrostreptomycin is given every six hours, starting at operation. In the more toxic patients, or in those in whom considerable intraperitoneal soilage occurred at operation, aureomycin is given by the intravenous route in amounts of 500 mg. twice daily. If allergenic manifestations to antibiotic therapy arise, parenteral sulfadiazine therapy can be used. Fluid balance and electrolyte derangements are prone to occur; and a carefully planned replacement program starting at operation is essential. When a smooth course ensues, the problem is only one of administering sufficient parenteral fluid to cover the insensible loss and guarantee adequate renal output. This is identical with the program followed after any abdominal or intestinal procedure. However, ileostomies may temporarily obstruct at the abdominal wall, or they may discharge tremendous amounts of material at first. Certainly, one fourth of the cases take one of these two courses. If they obstruct, nausea and vomiting rapidly ensue, and the fluid and electrolyte loss can be alarming. Dehydration, hypochloremia and alkalosis will result. In the hyperfunctioning ileostomy great volumes of fluid with a 'high content of fixed base may be discharged. The sodium and potassium levels are depleted, and acidosis results. Intelligent therapy of either of these is guided by a careful record of the fluid lost and by chemical anaiysis of the blood serum. Here the amount of fluid given must be sufficient to replace that lost by vomiting or ileostomy, the insensible loss, and the amount needed for proper renal function. Electrolytes should also be replaced as lost. Hyponatremia can be corrected by the administration of 0.8 per ceni sodium chloride solution. Hypokalemia may be marked. This is determined by blood serum analysis or electrocardiographic tracing. Administration of potassium by parenteral route will be just as important as the use of sodium chloride and water. In some cases, hypochloremia and hyponatremia will not respond to therapy unless the potassium level is also corrected. We give a 1.14 per cent solution of potassium chloride; in many patients this causes discomfort and must be diluted. We have seen two ileostomy patients with hypokalemia suffer a refractory alkalosis and an adynamic ileus which responded only to the replacement of the potassium ion. Normal peristaltic activity resumed and vomiting ceased. Nutrition assumes paramount importance, since most of these patients are on a subnormal nutritional level before operation. As soon as oral feedings are tolerated, we give formulas fortified with protein hydrolysates, dextrimaltose and vitamins.
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Care of the Ileostomy. After the patient is returned to the ward, the tube from the ileostomy is connected to a drainage bottle. Lahey has emphasized the importance of frequent inspection of the ileostomy.6 If it becomes nonviable, it can be revised before gangrene, leakage and peritonitis occur. The intestinal material will be carried away by the tube for seventy-two to ninety-six hours. As soon as this system begins to leak, meticulous care of the skin is instituted. It is much easier to prevent skin erosion by the digestive ferments than to treat it once it has occurred. This erosion is painful, and the measures used to treat it cause added discomfort. As soon as the intestinal contents begin to soil the wall, the skin is protected by frequent, liberal applications of compound tincture of benzoin. After each passage and soilage of dressings, the ileostomy should be dressed. The skin is cleansed with soap and water and thoroughly dried, and benzoin is reapplied. It is a common practice for the attendants to use many dressings and change them infrequently. It is far better to use a small amount of gauze and remove it as soon as it is soiled. We have used kaolin, aluminum hydroxide paste, aluminum paste, absorptive resins and other protective agents to prevent digestion. None has worked as well as the constant mechanical removal of ileal material. The skin will adhere to the bowel wall in seven to ten days, and a widemouthed ileostomy or colostomy bag may be utilized temporarily. The ileostomy will shrink enough in six weeks to enable the patient to be measured for a snug-fitting Koenig-Rutzen bag. Once this bag has been applied, the major problem is solved. The bag face is cemented to the skin surface around the circumference of the ileostomy, and no leakage or erosion can take place. Many patients show some evidence of partial obstruction in the ileum just as it passes through the abdominal wall. Presumably, this is· due to edema. In the average case this causes little difficulty. A few "cramplike" pains will be noted just before the ileostomy discharges; after several days, this subsides. In some cases it is more serious, and the picture of mechanical ileus with nausea and vomiting arises. The decision as to the management of this problem is always a difficult one. Often intubation with a Miller-Abbott tube and decompression of the ileostomy with a catheter will suffice; in one or two days the ileostomy will begin to function. Occasionally, this may occur several times before the patient is discharged from the hospital. In cases in which the ileus persists and "cramplike" pain is severe, one must be alert not to overlook a kink or volvulus with embarrassment of bowel vascularity. We have been forced to reoperate upon several of our cases to lyse adhesive bands or release kinks. These kinks have been found just proximal to the ileostomy and were of the type usually seen in low grade peritonitis. We now feel that these eases might have subsided without reoperation. Our tendency now is toward long tube decompression and watchful waiting. Ileostomies are also prone to prolapse or retract. Retraction can be minimized by bringing sufficient ileum out on the abdominal wall and
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fastening the mesentery to the wall. We exteriorize about 2 inches of ileum. When shrinkage occurs, a bud of ileum will protrude about ! inch above the level of the skin. The ileum should not be sutured to the abdomen or the wound. When sutures are placed in the bowel wall, the mucosa may be penetrated and a fistula might result. This will destroy the efficiency of the ileostomy. For this reason we have not used the technic advocated by Dennis,14 although he does report favorable results. We prefer to fix the ileostomy by suturing the cut edge of the divided mesentery to the abdominal wall for a distance of 2 or 3 inches. Prolapse of the ileum through the ileostomy may be most troublesome and severe enough to cause partial obstruction. One patient had a marked prolapsus of about 1 foot of bowel; it became eroded from constant contact with the bag, and a profuse hemorrhage occurred. We know of no good method to prevent this complication. It can be minimized by careful fixation of the mesentery and by making the stab wound just large enough to accommodate the ileum. Skin grafting of the ileal appendage, as advocated by Dragstedt,15 has been tried. Contracture of the graft caused stenosis of the ileostomy, and the graft had to be split. We can see no particular advantage to this method with the modern ileostomy bags available. In an occasional case the disease process in the remaining colon may flare up after ileostomy, and bleed or perforate. This unhappy situation calls for further surgery. SUMMARY
1. Surgical intervention in chronic stenosing regional enteritis should be confined to those cases complicated by obstruction, abscess or fistulas, and those in which a most thorough medical regimen has failed. 2. Radical excision of the diseased bowel has been practised whenever possible. The results of this surgery have been disappointing. Recurrence after radical resection was noted in 58 per cent of a closely followed up group of cases. This is in line with reports on the results of resection from other clinics. . 3. Ileostransverse colostomy with exclusion has been used and has given good results in the few cases in which we have used it. This procedure is less hazardous,_and longer follow-up studies from clinics using it may show that it gives superior results. 4. Improvement in preparation of patients and of surgical technic, plus the use of fitted bags, such as the Koenig-Rutzen bag, have materially altered the results of surgery in ulcerative colitis. These patients can be converted from invalids to well persons. 5. The indications for surgery in ulcerative colitis are hemorrhage, obstruction, perforation, arthritis, danger of malignant degeneration, and medical intractability. 6. The surgical aim is interruption of the fecal stream by ileostomy and resection of the diseased bowel. 7 . We no longer believe that ileostomy alone should be performed for
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ALF:allln S. FROnlllSlll
ulcerative colitis; if ileostomy is necessary, the diseased colon must be removed also. 8. In most cases we perform an ileostomy and partial colectomy as the first stage. The remaining colon and rectum are removed at the second stage. This has not increased our mortality, and the morbidity has been decreased. 9. Once ileostomy and colectomy are necessary for ulcerative colitis, we believe that the rectum should be resected. 10. Operative technic and postoperative care are discussed. REFERENCES 1. Hawthorne, H. R., and Frobese, A. S.: Chronic Stenosing Regional Enteritis; Surgical Pathology and Experience in Surgical Treatment. Ann. Surg., 103: 233, 1949. 2. Sala, L. F., and Ferguson, L. K.: Surgical Treatment of Regional Enteritis. J. Philadelphia General Hospital, 2:23, 1950. 3. Bockus, H. L.: Present Status of Chronic Regional or Cicatrizing Enteritis. J.A.M.A., 127:449, 1945. 4. Garlock, J. H.: The Present Status of the Problem of Regional Ileitis. Am. J. Surg., 72:875, 1946. . 5. Colp, R.: Proximal Extension and Progression following Operations for Regional Ileitis. S. CLIN. NORTH AMERICA, 27:333, 1947. 6. Lahey, F.: Complications of Ileostomy. S. CLIN. NORTH AMERICA, 30:893,1950. 7. Miller, G. G., Ripstein, C. B., and Tabah, E. J.: The Surgical Management of Ulcerative Colitis. Surg., Gynec. & Obst., 88:351, 1949. 8. Welch, C. E., and Giddings, W. P.: Carcinoma of Colon and Rectum. New England J. Med., 244:859, 1951. 9. Cattell, R. B., and Boehme, E. J.: Chronic Ulcerative Colitis Complicated by Carcinoma of Colon and Rectum. S. CLIN. NORTH AMERICA, 26:641, 1946. 10. Lahey, F.: Indications for Surgical Intervention in Ulcerative Colitis. Ann. Surg., 133:726, 1951. 11. Colcock, B.: Technic of Ileostomy. S. CLIN. NORTH AMERICA, 31:775,1951. 12. Rankin, F. W., Bargen, J. A., and Buie, L. A.: The Colon, Rectum and Anus. Philadelphia, W. B. Saunders Company, 1932. 13. Colceck, B.: The Surgical Treatment of Ulcerative Colitis. New England J. Med., 242:320, 1950. 14. Dennis, C.: Ileostomy and Colectomy in Chronic Ulcerative Colitis. Surgery, 18:435, 1945. 15. Dragstedt, L. R., Dack, G. M., and Kirsner, J. B.: Chronic Ulcerative Colitis; Summary of Evidence Implicating Bacterium necrophorum· as Etiologic Agent. Ann. Surg., 114:653, 1941.