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Surgical Treatment of Inflammatory Diseases of the Large Bowel
We have reported long-term results in the cases of 42 patients following total colectomy and ileorectal anastomosis for inflammatory bowel disease. In this group, 35 patients had Crohn's disease and seven had ulcerative colitis. Five of those seven patients with ulcerative colitis had carcinoma of the colon at the time of colectomy. A diverting loop ileostomy was constructed in 14 of the 35 patients who had Crohn's colitis at the time of operation, and none of these patients had any anastomotic leakage either before or after the ileostomy was closed. However, there patients with Crohn's colitis in whom anastomotic leaks developed postoperatively; all three patients died. In the group with ulcerative colitis, one patient had an anastomotic leak but there was no operative nortality. Of the 29 patients with Crohn's disease followed for one to 18 years, 12 (41 per cent) developed recurrences in the ileum and/or rectum, and seven of these patients had to have their anastomoses taken down.
The results of excisional surgery with the eastablishment of a permanent ileostomy in 246 patients with ulcerative colitis operated on in the years 1955-69 at St. Mark's Hospital, London, are presented. The overall mortality of the primary surgery was 8.1 per cent, being 9.3 per cent in the years 1955-9, 10.6 per cent in the years 1960–4, and 5.3 per cent the years 1965–9. This mortality was 1.6 per cent in 128 patients treated electively, 10.7 per cent in 75 cases coming to urgent surgery, and 23.3 per cent in 75 cases coming to urgent surgery, and 23.3 per cent in 43 patients undergoing emergency operations. The mortality in this third group fell from 36.4 per cent in the years 1955-;9 to 25 per cent in the years 1960–9. The indcidence of major postoperative complications for patients treated by total proctolectomy or colectomy and ileostomy was also clearly related to the preoperative servertity of the disease, being 18.8 per cent in the elective cases, 31.3 per cent in the urgent cases, and 40 per cent in the emergency cases.
Late complications of surgery were, with the exception of intestinal obstruction requiring surgery, infrequent in this series and showed a marked fall in the last 5 years of the study. With the possible exception of urolithiasis, the investigation revealed no increased susceptibility to diseases or conditions of a general nature in the long-term study of these patients (average length of follow-up 7 years) and emphasized the excellent life expectancy in patients in whom radical surgery had been carried out in the absence of malignant change.
Ileostomy, excluding intestinal contents from the colon, was done in sixteen patients with chronic inflammatory disease of the large intestine. Ten patients had Crohn's disease, five had ulcerative colitis, and one could not be classified. These designations were based on histological assessment. Clinical recovery followed operation in the Crohn's disease group; the only relapse to occur was in one of the two patients who had intestinal continuity restored. In the ulcerative colitis group, on the other hand, relapse was universal; four of the five patients required total colectomy. The response to bypass ileostomy suggests that there is a fundamental difference between ulcerative colitis and Crohn's disease.
Diverting ileostomy has been performed in thirteen patients with Crohn's disease of the colon with or without ileal involvement. Immediate and persistent relief of symptoms has occurred in all patients in three to twenty-four months (mean sixteen months) without evidence of recurrence. Radiologic as well as histologic findings have shown a return towards normal. Three patients have undergone restoration of intestinal continuity after two years. A mild recurrence developed in one patient which was controlled by corticosteroids whereas the other two remain well after two and thirty-six months. The results of diverting ileostomy have been unsuccessful in cases of chronic ulcerative colitis, further serving to illuminate fundamental differences in addition to clinical and histologic differences between these two inflammatory conditions. Further experience with this mode of therapy is justified.
- H A Oberbelman
- S Kohatsu
- K Taylor
- R Kivel
Oberbelman H A, Kohatsu S, Taylor K B & Kivel R M
(1968) Amer. J. Surg. 115, 231