The surgical rehabilitation of patients with chronic ulcerative colitis

The Surgical Rehabilitation with Chronic Ulcerative JOHN VAN PROHASKA,M.D.

Chicago,

Chicago,

of

NORMANJ. SIDERIUS, M.D., Chicago, Illinois

Tbe University of Tbis study was aided by a grant from tbe U. S. Public Healtb Service. From

tbe Department

AND

supervised over a period of seven years, an interval from rg5o to 1957. They presented several statistical observations related to the problem of rehabilitation. It would be useful to summarize these particuIar observations in tabular form for comparison with surgical results. (Table I.) The present report of surgical results is based on retrospective study of eighty-five patients who were referred to surgery during the period of 1955 to May 1961. All the surgica1 patients came from the large reservoir of 400 patients treated with corticosteroids from rgso to 1961. Corticosteroids were administered for intervals ranging from two months to six years. The surgical group consisted of forty-five maIes and forty femaIes. Their ages ranged from 12 to 66 years. Twenty children between the ages of 12 and 16 years were included. The surgical group was almost identical in sex and age distribution with the medical series reported by Kirsner [I]. Differences were found only in the two extremes of age distribution; the medical group included two children beIow the age of ten years and two patients over seventy years old. (Table II.)

Surgery,

Illinois.

HE appraisal of a successful management of chronic, idiopathic ulcerative colitis and ileocohtis rests on a critical analysis of the problem of rehabilitation of the patient. The surgical as well as the medical managements inflict certain risks upon the patient with ulcerative colitis such as a degree of mortality, unpleasant sequelae, side effects and vulnerability to complications. It seems, therefore, plausible to subject a large series of surgically managed patients to a critical analysis from the point of view of rehabilitation. Such an analysis should not only compare surgical achievements to those obtained in patients not operated on, but aIso should point out areas in which improvements in surgica1 therapy and technics are desirable. In order to establish a basis of comparison let us present a brief review of results pertaining to rehabilitation obtained in medically managed patients. The medical management of a11 patients with ulcerative colitis treated by the Gastroenterology Section of The University of Chicago CIinics consists of at least one hospitalization and specific therapy including rest, sedation, correction of anemia, restoration of electrolytes and plasma proteins, as well as supervision of nutrition and help in the soIution of emotional problems. Patients who do not respond to treatment are given corticosteroids in addition to the basic medical management. The details of the medical management and the therapeutic achievements obtained have been admirably described by Kirsner, Palmer, Spencer, Bicks and Johnson [I]. They surveyed a group of 240 patients carefuIIy managed and

T

American

Journal

of Surgery,

Volume

103, January

1961

of Patients Colitis

TABLE OBSERVATIONS

ON MEDICALLY

ULCERATIVE

N”.Sofi$gFcnts (

DISEASE

ResuIts

OF

THE

PATIENTS

WITH

BOWEL

( No. of

Patients

I

I

‘95

/ %

I-

240

FavorabIe

101 240

Remissions Deaths

::

101

Recurrences

38

38

101

UsefuI lives Incapacitated

89 I2

89 I2

IO1

42

I MANAGED

81

6:

SurgicaI

Rehabihtation

in UIcerative

CoIitis TABLE

TABLE II AGE DISTRIBUTION

DURATION

OF ULCERATlVE

BEFORE

Age

No.

(yr.)

SURGICAL

OR

ILEOCOLITIS

INTERVEKTION

Patients No.

Age hr.1 12-16 17-2 j

III COLITIS

Patients

,’ ’ .‘

20

I2 18

26-35

o-

I3 18

36.-45 46-5 5 56~65 66

3

I

I The fact that 66 per cent of patients toIerated the disease for four to twenty years before surgica1 intervention (TabIe III) suggests the importance of primary medica management as we11 as the sporadic remissions and exacerbations of ulcerative disease of the bowe1. These facts have definite bearing on rehabiIitation if we recaI1 that 89 per cent of medicaIIy treated patients reported by Kirsner [I] lived usefu1 Iives. In the tota appraisa1 of medica rehabiIitation it must be noted that patients managed on corticosteroids are amicted with side effects incident to the tota action of the drug. (TabIe IV.) These side effects bIunt somewhat the absolute peak of rehabiIitation if drugs inducing them have to be used for sustained periods of time. These facts are mentioned in the spirit of critica assessment of the patient with ulcernot as an inditement against ative colitis, medical therapy. In the same spirit, the surgeon must reaIize that his therapy often inflicts a permanent ileostomy without stipulation of its function and without contract for perpetua1 invulnerability to intestinal obstruction. The nature of ulcerative disease of the bowe1 is such that even the best medica management cannot set the patient free from severe compIications. SIDE EFFECTS OF TREATMENT

2

3

20

i

3 5

I

h

I

The eighty-five surgica1 patients were able to Iive usefu1 lives for periods ranging from one to twenty years before operative procedures were indicated. The compIications developing in the medicaIIy controIIed state of the disease were often sudden, usuaIIy severe and occasionaIIy threatened the patient’s Iives. These complications were the deciding factors for surgical intervention in 41 per cent of the surgical patients. (Table v.) The great differences in the severity and nature of compIications presented an uneven base from which to evaluate resuIts of surgica1 therapy. The patients were, therefore, divided into three groups. Group A consisted of thirty-two good risk patients. They were referred to surgery because of continua1 activity of the disease with work disabiIity; others had pseudopolyposis and three patients had carcinoma of the coIon. Group B incIuded eighteen patients acuteIy ill with active colitis marked by hemorrhages, TABLE

w WITH

7 ‘7

‘4-15 16-17 18-19

INCIDENCE

TABLE

17 ‘4 21 8

I

2- 3 4- 5 6- 7 8- 9 IO-11 12-13

OF

MEDICALLY

CORTICOSTEROIDS

V

COMPLICATIONS MANAGED

IPI‘ EIGHTY-FIVE

PATIEWTS

RECEIVING

CORTICOSTEROIDS I

CompIication

Effects

Hypercortisonism

80

Hemorrhage

IHyperglycemia. Diabetes. Hypertension EIectrolyte disturbance.. Osteoporosis. DuodenaI, gastric ulcers.

9 5 9 15 6

MegacoIon Perforations. Inanition Pseudopolyposis. Carcinoma. AnorectaI fistulas.

3

43

/ No.

I

I

Patients;

‘,‘(,

31 ‘3 ‘3 IO

36.5 16.0 16.0 II .5

32 3

37.0 3-5 17.0

15

Van Prohaska

and Siderius TABLE ~11 IMMEDIATE SURGICAL COMPLICATIONS

TABLE VI TYPES OF OPERATIONS

Operation

Complication

%

TotaI coIectomy, rectum resected. TotaI coIectomy, rectum not resected. TotaI coIectomy, iIeoproctostomy SubtotaI coIectomy.. .

.

Shock...................... Venous thrombosis.. Wound infection.. Wound disruption..

53 9 19 19

45 8 16 16

TABLE

1

I 0

%

I.2 0 10.0

9 4

4.5

patients were no different and, in fact, fewer than those observed in a simultaneous group of patients undergoing surgery for peptic ulcer, carcinoma of the bowel or gaIIbIadder disease. The assumed Iowered resistance to infection was not noted in our series of surgica1 patients. There were no instances of venous thrombosis. OnIy one instance of circuIatory coIIapse was observed. The wound healing was deIayed several days and the fina healing of the abdomina1 incisions was foIlowed by moderate keloid formation. It was not possible to concIude whether these observed deviations were due to hypercortisonism or to nutritiona depIetion common to patients with uIcerative colitis. The deIayed healing was associated with a greater incidence of wound disruption than observed in the genera1 surgica1 patients. (TabIe VII.) The mortality of patients with uIcerative coIitis on sustained corticosteroid therapy is surprisingIy Iow if one considers the magnitude of the operation and the state of depIetion. There was no surgica1 or hospita1 mortaIity in twenty chiIdren. This is not unusua1 as simiIar

nutritiona depIetion and reversa1 of aIbumin: gIobuIin ratios. Most of these patients were hospitaIized and managed medicaIIy for proIonged periods without sustained improvement in their condition on corticosteroid therapy. Group C was composed of thirty-five desperateIy III patients with acute compIications such as severe hemorrhage, toxic megacolon, perforations and severe inanition. This group incIuded patients requiring emergency surgery. The operations devised were modified according to the conditions of the patient and the extent of the disease. (TabIe VI.) It has often been mentioned that the administration of corticosteroids as a part of the tota scheme of medica management of patients with uIcerative coIitis infIicts additiona hazards on the surgica1 patient. These additiona1 hazards are stated to be Iowered resistance to infections [2], susceptibiIity to venous thrombosis [J] and circuIatory coIIapse [4]. This criticism may be valid for patients whose hypoadrena1 state incident to steroid therapy is not properIy corrected in the preand postoperative period. Immediate postoperative compIications in this series of

SURGICAL

/ No. patients

TABLE

IX

LATE COMPLICATIONS INCIDENT TO SURGICAL PROCEDURES IN SEVENTY-NINE SURVIVING PATIENTS

VIII

MORTALITY I

MortaIity

NO.

No.

Patients

Deaths

%

Comphcation

IntestinaI obstruction.. Released spontaneously.. . Released by division of adhesions. ReIeased by resection of gangrenous bowe1, . Beostomy revisions (fifty-two iIeostomy patients). Neurogenic urinary bIadder. SexuaI impotence. Incisiona hernias.. .

---Entire series. Group A (good risk). Group B (poor risk). Group C (with critica cations). By compIications Toxic megacoIon. Perforations. Emergencies. In chiIdren. . . .

85 32 18

6 0 0

7 0 0

35

6

17

13 13 8 20

4 4 4

31 31 50

compli-

o/o

44

IO

12.5

3 5

3.8 6.3

2

2.5 13 0 0 0

25.0 0 0 0

SurgicaI

RehabiIitation

in UIcerative

CoIitis

used in tying strangulated over ligatures mesenteric blood vessels. Ileostomies had to be revised in z$ per cent of patients. The iIeostomies performed in 1955 and 1956 were poorl,v constructed. Their subsequent reoperations increased abnormally the totaI percentage of revisions. Since 1956 the ileostomies are made by excising a 3 cm. seromuscular cuff of the terminal ileum, exerting it and suturing the stoma to the cutaneous round outIet of the abdominal wall channe1. This type of ileostomy seldom needs revision. The space between the emerging terminal ileum and the parietal peritoneum is obliterated by suturing the meso of the terminal iIeum to the parietal peritoneum. The proper execution of this maneuver fixes the terminal ileum so that pIication of the termina1 loops of ileum is not for preventing herniation of the necessary intestine. There are two additional Jate complications which may detract from the ideal state of surgical rehabilitation of the patient with ulcerative colitis. Failure of closure of the perineal wound left after resection of the rectum occurred in six patients out of fortyfive. Al1 of the six patients had multiple perianal fistulas preoperatively. Studies are 110~ being conducted to correct and to prevent this relatively minor defect. In the final assessment of surgical rehabilitation one must include recurrence of the disease. Recurrences were noted in fifteen out of seventy-nine surviving patients, an incidence of Ig per cent. nlost of the recurrences appeared in thirty-two patients with ileocofitis. The incidence calculated on this basis gives a recurrence rate of 47 per cent. The recurrences were reIatively benign as most of the patients were able to live useful, active lives on medica management. Five reoperations were necessary for recurrent disease.

good resuIts were reported by others [T]. Postoperative deaths occurred only in the patients in group C consisting of acutely iII patients with critica presurgical complications. The major pathoIogic disorder found in the six patients n-ho died foIIowing surgery was generalized peritonitis. The total surgicai mortality was 7 per cent, exactly the same as the mortality of medicaIIy managed patients with coIitis who never had surgery for ulcerative disease of the bowel. The complications found at Iaparotomy in the six patients who died postoperatively were such that it is doubtfu1 they wouId have survived had they not been operated on. The fear of mortality, therefore, shouId not be the deterring factor which keeps the patients with ulcerative colitis from surgery when events in the course of the disease so indicate. (Table VIII.) Late compIications incident to curative surgica1 procedures are the important factors in the evaluation of rehabilitation of the patient \\ith ulcerative coIitis. If radical surgery, however curative it may be, becomes a basis for subsequent episodes of intestina1 obstruction and ileostomy- revisions, surgery must then seek refinements to avoid these complications. Let us now anaIyze Iate postoperative complications in tabular form. (Table IX.) COMMENTS

The incidence of intestina1 obstruction in our series is not too high. Tolstedt and Be11 [6] reported a much higher incidence of postoperative obstruction following total coIectomy for ulcerative colitis. Thus far, each of the patients with obstruction has suffered onIy one episode of obstruction and in each instance the complication was corrected without mortaIity. Intestinal obstructions have occurred onIy in those patients who underwent total coIectomJ with combined abdominoperinea1 resection of the rectum with iIeostomy. The principal causes of.intestinaI obstruction as noted at celiotomy were adhesions in five patients and strangulation of the intestine in the right peritonea1 gutter in two. These obstructions occurred despite routine peritoneaIization of all raw surfaces and closure of the space between the terminal ileum and the right lateral parietal peritoneum; a space created by the ileostomy. The adhesion bands appeared to have formed in areas where mesenteric fat was

SURGICAL

REHABILITATION

Surgical mortality, early and late postoperative complications and recurrences of the disease stand out as the important factors in surgica1 attempts at rehabilitation of the patient with ulcerative colitis. It has been shown that surgical mortaIity does not need to be a constraint against surgica1 therapy because the surgical mortaiity is no higher than the medical. Furthermore, postoperative deaths occur mainIy in those patients who presumably could not survive the presurgical compIication with45

Van Prohaska

taIity couId be significantIy reduced by surgica1 intervention before the onset of critical or fata complications. Further surgica1 improvement is possibIe in the direction of Iowering the incidence of postoperative intestina1 obstruction and in creating troubIe free iIeostomies. The idea1 care of patients with uIcerative colitis consist of medica management rendered by a competent gastroenteroIogist abIe to recognize surgica1 indications and wiIIing to share the ensuing responsibiIity with a quaIifIed surgeon.

TABLE x SURGICAL REHABILITATIONOF SEVENTY-NINE SURVIVING PATIENTS

I

. .

No.

Patients

73

Patients not disabIed (working) Patients partially disabled. . . Patients totaIly disabIed. TotaI..

I

I

Rehabilitation

2 ~-__-

.

4

79

I

and Siderius

%

92.3 2.7 5.0 100

out attempted saIvage by surgery. EarIy and Iate postoperative compIications are the areas in which surgeons must seek improvement. These complications are created by the surgical procedure and not necessariIy by the nature of the uIcerative disease. Improvements shouId be in the direction of minimizing postoperative adhesions and in creating troubIe free iIeostomies. Despite the existence of these shortappears comings, the surgica1 rehabiIitation statisticalIy in a favorabIe Iight. (TabIe x.)

REFERENCES I. KIRSNER, J. B., PALMER, W. L., SPENCER, J. A., BICKS, R. 0. and JOHNSON, C. F. Corticotropin (ACTH) and the adrena steroids in the management of ulcerative coIitis: observations in 240 patients. Ann. Znt. Med., 50: 891, 1959. 2. THOMAS, L. Cortisone, ACTH and infection. Bull. New York Acad. Med., 31: 485, 1955. 3. THORN, G. W., JENKINS, D., LAIDLAW, J. C., GOETZ, F. C., DINGMAN, J. F., ARONS, W. L., STREETEN, D. H. P. and MCCRACKEN, B. H. Medical Uses of Cortisone, chapt. 2. New York, F. D. W. Lukens. 4. BAYLISS, R. I. S. SurgicaI coIIapse during and after

CONCLUSIONS

corticosteroid therapy. Brit. M. J., 2: 935, 1958. 5. EHRENPREIS, T., ERICSSON, N. O., BILLING, L.,

NearIy a11 patients with uIcerative coIitis and iIeocoIitis are rehabiIitated by seIective surgery. Statistica evidence presented indicates that surgica1 mortality shouId not be considered a deterrent to proper surgica1 intervention. Mor-

LAGERCRANTZ, R. and RUDHE, U. SurgicaI treatment of uIcerative colitis in chiIdren. Acta paediat.,

49: 810, 1960. 6. TOLSTEDT, G. E. and BELL, J. W. Intestinal obstruction foIIowing totat coIectomy for uIcerative colitis.

Ann. Surg., 153: 241, 1961.

46