Surgical Treatment of Inflammatory Bowel Disease of the Colon Ulcerative Colitis and Granulomatous
(Crohn’s) Colitis
Jerome S. Abrams, MD, Burlington, Vermont
“Ulcerative Colitis: Puzzles Within Puzzles” was the title of an editorial by Kirsner [1] in 1970. Despite a wealth of new information, clinical reviews and experiments, national studies, and the like, that title may be even more appropriate in 1975. Zetzel [2] in his review of the “other” form of inflammatory bowel disease of the colon-what he termed granulomatous colitis (although less than one half of these patients have granulomas)noted that, although characteristic cases had been described as early as 1806, recognition and knowledge of the pathologic features, clinical course, and response to therapy actually began with the reports by Morson and Lockhart-Mummery in 1959. Table I represents a traditional but now outdated of reported clinical and pathologic “composite” differences between the two forms of colitis. Data from newer studies emphasize two salient points: (1) The ratio of patients with ulcerative colitis to those with the “other” colitis varies from 2O:l to l:l, depending on the author. (2) The clinical and pathologic differences noted in Table I get progressively fuzzier. Ninety-five patients treated by colectomy and ileostomy were reviewed by Glotzer [3], fifty-three (56 per cent) of whom were diagnosed as having ulcerative colitis and forty-two (44 per cent) as having granulomatous colitis. Ileostomy dysfunction occurred equally in both groups. Koralitz et al [4] at the Mount Sinai Hospital in New York reFrom the Department of Surgery. University of Vermont College of Wi tine, Burlington, Vermont. Reprint requests should be addressed to Jerome S. Abrams, MD, Department of Surgery, University of Vermont College of Medicine, Burling ton, Vermont 0540 1.
528
ported contradictory results. During the period 1940 to 1970, they managed 602 patients with inflammatory bowel disease by colectomy and ileostomy; only sixty-seven (11 per cent) of these were signed out as having granulomatous colitis. Thirty-one (46 per cent) of those patients with granulomatous colitis had recurrence at the ileostomy site; x-ray examination showed typical regional enteritis in twenty-four, and twenty-two required at least one small bowel resection. This high recurrence rate is comparable to that after ileocolectomy for regional enteritis. A similar conclusion was reached by Ritchie and LockhartMummery [5] who reported on sixty-four patients with Crohn’s disease of the large bowel treated by total colectomy and ileostomy, with a recurrence rate of approximately 50 per cent. Recently, Steinberg et al [6] reported on seventy-three patients undergoing operation for Crohn’s colitis between 1950 and 1972. Forty-five of the seventy patients available for follow-up examination (64 per cent) required subsequent admission and a total of one third of the original group had recurrence at the ileostomy site, the majority of whom required further resection. Fourteen patients had recurrence during the first five years; one had recurrence nineteen years later. Steinberg et al [6] suggest there is a recurrence rate of 10 per cent the first year with an annual 5 per cent risk in each subsequent year; all patients followed for more than fifteen years had at least one recurrence. During the five year period from 1969 through 1973, 192 patients with inflammatory bowel disease (including regional enteritis) were seen at the Medical Center Hospital of Vermont, a 500 bed
The Amerkan Journal 01 Surgery
Inflammatory
general hospital that serves as a teaching hospital for the University of Vermont College of Medicine. As shown in Table II, thirty-six patients underwent colectomy for disease that was limited to the colon. Pathologic diagnosis on the resected specimens showed a ratio of ulcerative colitis to Crohn’s colitis of 17:l. Only one patient, managed with a one-stage total colectomy and ileostomy for ulcerative colitis, had recurrence and required revision. Of two patients with a diagnosis of Crohn’s colitis, both treated by less than total colectomy with primary anastomosis, one had recurrence. Since recurrence has been reported as late as nineteen years after definitive surgery, the records at the Medical Center Hospital of Vermont were reviewed back to 1958, during which time sixty-eight patients had colectomy for inflammatory bowel disease [7]. Prior to 1969, there had been a great deal of interest at this hospital in partial colectomy for ulcerative colitis with preservation of the ascending colon and permanent colostomy [8]. Nine of the sixty-eight patients had recurrent disease; five patients had recurrence after operation for a lesion diagnosed as ulcerative colitis and four were signed out as having Crohn’s colitis. Eight of the nine patients had been managed by partial colectomy without ileostomy. The recurrence rate for the entire group was still only 13 per cent, a figure well below that reported by others [4-61. How can these contrasting data be explained? It seems apparent that a major factor must be the validity of the clinical and pathologic diagnosis: is ulcerative colitis at one institution classified as Crohn’s colitis at another? Cook and Dixon [9] analyzed the pathologic material from fifty patients independently, using ninety-five separate pathologic criteria; twentyfive cases had been classified as Crohn’s colitis and twenty-five as ulcerative colitis. These authors concluded that many features felt to be specific for one diagnosis or the other were seen frequently enough in both diseases as to make them of little significance, for example cobblestoning, mast cells, and particularly crypt abscesses, lymphangiectasia, submucosal edema, and changes in the glandular reticulum pattern. Granulomas were never observed in patients with ulcerative colitis and therefore were a highly significant feature in patients with Crohn’s colitis in addition to confluent linear ulcerations, macroscopic deep fissures, and an aggregated pattern of inflammation. In patients with ulcerative colitis, significant features were a healed granular mucosa, the absence of fissures, and a continuous inflammatory pattern. Despite
Volume 130, November 1975
TABLE
I
Traditional
Bowel Disease
But Outdated
Criteria
Ulcerative
Colitis from
Differsntiate Granulomatous
(Crohn’s)
of Colon
to
Colitis
Criteria
Ulcerative Colitis
“Other” Colitis
Toxic megacolon Cancer Rectal involvement
10 per cent 10 per cent 95 per cent
Good response to steroids and/or azulfidine Skip areas Cobblestoning Crypt abscesses Granulomas
75 per cent
Response to proctocolectomy and ileostomy Recurrence at site of ileostomy
Excellent
Never Never 50 per cent 25 per cent Common Common Unusual < 50 per cent Poor to good Common
TABLE
II
Incidence
Never Uncommon Usual Never
Rare
and Recurrence
36 Patients
Undergoing
Inflammatory the Medical
Bowel Center
Rate in
Operation
for
Disease of the Colon at
Hospital
of Vermont
(1969-1973) Ulcerative Colitis
Operation One-stage total colectomy and ileostomy Two-stage total colectomy and ileostomy Partial colectomy Total
Number of Patients
Recurrence
“Other” Number of Patients
Colitis
Recurrence
28
l(4per cent)
. . .
. .
6
...
...
...
...
...
2
34
I(3 per cent)
2
l(50 per cent) l(50 per cent)
these criteria, however, the two pathologists disagreed on the diagnosis of eight of the fifty patients (16 per cent). Gross and microscopic material from fifty of our own patients were reviewed [7]. Forty-seven had been classified by the pathologist as ulcerative colitis and only three as granulomatous colitis. Three classic characteristic features of Crohn’s disease (granulomas, transmural involvement, and skip lesions) were sought in each of the fifty specimens. Study of material from twelve patients with two or more of these features resulted in a revised diagnosis of probable Crohn’s colitis, whereas material from seventeen patients met none of the three cri-
529
Abrams
teria and was diagnosed as ulcerative colitis. Each of the remaining twenty-one patients had one, and only one, of the characteristic features sought and could not be classified into either category. If these indeterminate cases were added to the list of those signed out as having ulcerative colitis, the final ratio of ulcerative colitis to Crohn’s colitis would be 3812 or 3:l. It was evident that our pathologists relied heavily on such features as crypt abscess (any specimen showing crypt abscesses was considered ulcerative colitis until proved otherwise) and, conversely, that a diagnosis of granulomatous colitis could only be made when granulomas were present, despite the fact that most studies report the presence of granulomas in less than 50 per cent of patients with granulomatous colitis. No matter which criteria are used, final diagnosis in inflammatory bowel disease of the colon generally requires a specimen. Clinical diagnosis before operation is, at best, speculative and often hinges on the presence or absence of specific criteria, namely skip lesions, involvement of the rectum, pseudopolyps, and the like or, all too frequently, on the findings of a mucosal biopsy that is useless. The classic indications for operation in inflammatory bowel disease of the colon are (1) inadequate response to nonoperative therapy, (2) major hemorrhage, (3) concern regarding the development of carcinoma, (4) stunting of growth in children, or (5) toxic megacolon. Although some surgeons continue to perform partial colectomy, particularly for Crohn’s colitis, the standard operation performed in most centers includes total removal of the colon and rectum and construction of a permanent ileostomy. One-stage total proctocolectomy and ileostomy has become fairly standardized. When performed electively, operative mortality should be well below 5 per cent and comparable to that for elective partial colectomy. We utilize a simultaneous surgical approach similar to that described by Goligher [IO]. Ileostomy dysfunction in the postoperative period, so common in the past, rarely occurs utilizing the turnback method [II]. Exit of the ileostomy through the rectus abdominus muscle and careful fixation of the ileal mesentery prevent prolapse and pseudohernia. Preoperative preparation has been vastly improved by intravenous hyperalimentation or elemental diets to correct nutritional defects. Healing of the perineal wound and avoidance of perineal and pelvic sepsis, although still more common than after abdominoperineal resection for cancer, is accomplished in the majority of
530
patients by primary perineal closure utilizing catheter or sump drainage. As noted by Silen and Glotzer [12], however, problems due to perineal wound remain a significant complication after proctocolectomy for Crohn’s colitis. The improved quality of ileostomy appliances and the availability and expertise of an enterostomal therapist has markedly improved patient acceptance and management of the ileostomy. Bone and Sorensen [13] have recently reported that of fifty-two patients evaluated for a mean period of eight years, fortynine had adjusted well to the ileostomy and experienced no significant difficulty in leading a normal life. Two major alternatives to proctocolectomy and ileostomy are currently being performed: rectal preservation operations and construction of an ileoreservoir. Abdominal colectomy with ileoproctostomy has been championed by Aylett [14] who has performed this procedure in 369 patients during an eighteen year period, with nineteen deaths (5 per cent). Cancer developed in only 7, “full health” resulted in 309 (84 per cent), and only 24 were considered failures. More recently, Yudin et al [15] reported their own results in sixty-three patients, with four operative deaths for a mortality of 6 per cent. One fourth of their patients were children or adolescents. All had significant difficulty during the first postoperative year, with frequent electrolyte imbalance, diarrhea, and repeated hospitalization. One in five were considered to have excellent results, although these patients still showed moderate proctitis with hyperemia, edema, and surface erosions. In 25 per cent of the patients, the operation was either a complete failure or the patient had severe diarrhea and electrolyte imbalance or required construction of an ileostomy. The functional results were directly related to the extent of rectal inflammation before anastomosis: the greater the inflammation, the poorer the result. A technic worthy of further study is the instillation of 15 to 20 ml of liquid ileostomy content into the rectum two or three times a day for a period of five to six days [15]. If there is no significant increase in the degree of inflammation of the rectum, ileoproctostomy should be considered. It is evident that this would only work in staged operations. Absolute contraindications to rectal preservation were (1) excessive, persistent rectal ulceration that did not improve after subtotal colectomy, (2) endoscopic or x-ray evidence of rectal stenosis, (3) increased motor activity of the rectum and ileum, (4) retrograde ileitis, (5) intolerance of the rectal
The American Journal of Surgery
Inflammatory
effluent, and (6) poor general condition. Despite these rigid criteria, only about one half of their patients had good to excellent results and even those with good results had up to seven bowel movements a day. Despite the reported excellent results after conventional ileostomy, surgeons continue to search for procedures that will, in essence, create a new or artificial anus. Beahrs et al [16] reported a series of twenty patients in whom an ileoreservoir was constructed using the method of Kock. Eighteen of the twenty were less than forty years of age and seventeen had undergone colectomy for ulcerative colitis. One patient had intestinal obstruction that required an ileostomy and four patients required reexploration with revision of the reservoir. Approximately one half of the patients had some initial difficulty intubating the reservoir and a similar number had to wear an appliance part or all of the time. In a group of five patients that had the modified procedure in which a “nipple” was constructed, three were totally continent for gas and fluid and did not use an appliance. This brief review indicates that we are still far from solving Kirsner’s “puzzles within puzzles,” a conclusion emphasized by the knowledge that two experienced colon pathologists, supplied with clinical and radiologic information, a gross specimen, and microsocpic sections from that specimen could not agree on the diagnosis in 16 per cent of the patients examined and that the surgical services of two major hospitals with vast experience in inflammatory bowel disease, both serving large urban eastern American populations, report such marked difference in the incidence of each form of colitis and the recurrence after operation. Did, in fact, patients who had recurrence at the site of ileostomy after colectomy for ulcerative colitis really have Crohn’s colitis? The proposed alternative procedures to total proctocolectomy and ileostomy must be considered seriously and with some degree of trepidation. Twenty or thirty years may elapse before carcinomas occur in a preserved rectal stump [17]. Cancer has been reported in patients with Crohn’s colitis [IS], and diagnosis is possibly unreliable. Until the problem of cancer and recurrence are resolved, rectal preservation cannot be recommended as a standard procedure for inflammatory bowel disease of the colon. The ileoreservoir procedure, with the sacrifice of 40 cm of distal ileum to construct the reservoir, offers so little in exchange for the potential risk of recurrence, obstruction, necessity mucosa
to ileostomy
Volume 130, November 1975
Bowel Disease of Colon
for revision, and so on that it must be considered an experimental procedure until a large series of patients have been followed for a prolonged period of time.
Summary Ulcerative colitis and Crohn’s colitis may be separate diseases or simply different manifestations of the same disease. New technics will be developed that help differentiate these lesions and permit better interpretation of postoperative complications and response to therapy. Until more information is available, one-stage total proctocolectomy with ileostomy remains the treatment of choice for inflammatory bowel disease of the colon that is refractory to nonoperative management. References 1. Kirsner JB: Editorial-ulcerative 2. 3. 4.
5.
6.
7. 8.
9.
10. 11. 12. 13. 14. 15.
16.
17.
18.
colitis: puzzles within puzzles. N Engl J Med 282: 625, 1970. Zetzel L: Granulomatous (ileo) colitis. N Engl J Med 262: 600, 1970. Glotzer DJ: Crohn’s disease of the colon-homogenous or diverse entity? Gastroenterology 64: 1185, 1973. Koralitz BI, Prescott DH, Alpert L, Marshak, R, Janowitz HD: Recurrent regional ileitis after ileostomy and colectomy for granulomatous colitis. N Engl J Med 287: 110, 1972. Ritchie JK, Lockhart-Mummery HE: Non-restorative surgery in the treatment of Crohn’s disease of the large bowel. Gut 14: 263, 1973. Steinberg DM, Allen RN, Thompson H, Brooke BN, Alexander-Williams J. Cooke WT: Excisional surgery with ileostomy for Crohn’s colitis with particular reference to factors affecting recurrence. Gut 15: 845, 1974. Abrams JS, DeBoer JL. Feldman SL: Unpublished data. Topuzlu C, Andrews A, Gladstone A, Mackay AG: Preservation of the ascending colon in the surgical treatment of ulcerative colitis. Surg Gynecol Obstet 127: 836. 1968. Cook MG, Dixon MF: An analysis of the reliability of detection and diagnostic value of various pathological features in Crohn’s disease and ulcerative colitis. Gut 14: 225, 1973. Goligher JC: Surgery of the Anus, Rectum and Colon, 2nd ed. London, Bailliere, Tindall and Cassell, 1970, p 639. Turnbull RB, Weakley FC: Atlas of Intestinal Stomas. St. Louis, CV Mosby, 1967. p 23. Silen W, Glotzer DJ: The prevention and treatment of the persistent perineal sinus. Surgery 75: 535, 1974. Bone J, Sorensen FH: Life with a conventional ileostomy. Dis Colon Rectum 17: 194, 1974. Aylett SO: Ulcerative colitis. Proc R Sot A&d 64: 967, 1971. Yudin IY, Sergevnin VV, Krasmora Al, Ginsburg SA: The feasibility of ileorectal anastomosis for nonspecific ulcerative colitis. Contemp Surg 6: 75. 1975. Beahrs OH, Kelly KA, Adson MA, Chong CG: lleostomy with ileoreservoir rather than ileostomy alone. Ann Surg 179: 634, 1974. Devroede DJ, Taylor WF, Sauer WG, Jackman RT, Strikler GB: Ulcerative colitis and colonic cancer. N Engl J Med 285: 17, 1971. Darke SD, Parks AG, Grogono JL, Pollock DJ: Adenocarcinoma and Crohn’s disease: a report of 2 cases and analysis of the literature. Br J Surg 60: 169, 1973.
531
(Crohn’s) Colitis
Jerome S. Abrams, MD, Burlington, Vermont
“Ulcerative Colitis: Puzzles Within Puzzles” was the title of an editorial by Kirsner [1] in 1970. Despite a wealth of new information, clinical reviews and experiments, national studies, and the like, that title may be even more appropriate in 1975. Zetzel [2] in his review of the “other” form of inflammatory bowel disease of the colon-what he termed granulomatous colitis (although less than one half of these patients have granulomas)noted that, although characteristic cases had been described as early as 1806, recognition and knowledge of the pathologic features, clinical course, and response to therapy actually began with the reports by Morson and Lockhart-Mummery in 1959. Table I represents a traditional but now outdated of reported clinical and pathologic “composite” differences between the two forms of colitis. Data from newer studies emphasize two salient points: (1) The ratio of patients with ulcerative colitis to those with the “other” colitis varies from 2O:l to l:l, depending on the author. (2) The clinical and pathologic differences noted in Table I get progressively fuzzier. Ninety-five patients treated by colectomy and ileostomy were reviewed by Glotzer [3], fifty-three (56 per cent) of whom were diagnosed as having ulcerative colitis and forty-two (44 per cent) as having granulomatous colitis. Ileostomy dysfunction occurred equally in both groups. Koralitz et al [4] at the Mount Sinai Hospital in New York reFrom the Department of Surgery. University of Vermont College of Wi tine, Burlington, Vermont. Reprint requests should be addressed to Jerome S. Abrams, MD, Department of Surgery, University of Vermont College of Medicine, Burling ton, Vermont 0540 1.
528
ported contradictory results. During the period 1940 to 1970, they managed 602 patients with inflammatory bowel disease by colectomy and ileostomy; only sixty-seven (11 per cent) of these were signed out as having granulomatous colitis. Thirty-one (46 per cent) of those patients with granulomatous colitis had recurrence at the ileostomy site; x-ray examination showed typical regional enteritis in twenty-four, and twenty-two required at least one small bowel resection. This high recurrence rate is comparable to that after ileocolectomy for regional enteritis. A similar conclusion was reached by Ritchie and LockhartMummery [5] who reported on sixty-four patients with Crohn’s disease of the large bowel treated by total colectomy and ileostomy, with a recurrence rate of approximately 50 per cent. Recently, Steinberg et al [6] reported on seventy-three patients undergoing operation for Crohn’s colitis between 1950 and 1972. Forty-five of the seventy patients available for follow-up examination (64 per cent) required subsequent admission and a total of one third of the original group had recurrence at the ileostomy site, the majority of whom required further resection. Fourteen patients had recurrence during the first five years; one had recurrence nineteen years later. Steinberg et al [6] suggest there is a recurrence rate of 10 per cent the first year with an annual 5 per cent risk in each subsequent year; all patients followed for more than fifteen years had at least one recurrence. During the five year period from 1969 through 1973, 192 patients with inflammatory bowel disease (including regional enteritis) were seen at the Medical Center Hospital of Vermont, a 500 bed
The Amerkan Journal 01 Surgery
Inflammatory
general hospital that serves as a teaching hospital for the University of Vermont College of Medicine. As shown in Table II, thirty-six patients underwent colectomy for disease that was limited to the colon. Pathologic diagnosis on the resected specimens showed a ratio of ulcerative colitis to Crohn’s colitis of 17:l. Only one patient, managed with a one-stage total colectomy and ileostomy for ulcerative colitis, had recurrence and required revision. Of two patients with a diagnosis of Crohn’s colitis, both treated by less than total colectomy with primary anastomosis, one had recurrence. Since recurrence has been reported as late as nineteen years after definitive surgery, the records at the Medical Center Hospital of Vermont were reviewed back to 1958, during which time sixty-eight patients had colectomy for inflammatory bowel disease [7]. Prior to 1969, there had been a great deal of interest at this hospital in partial colectomy for ulcerative colitis with preservation of the ascending colon and permanent colostomy [8]. Nine of the sixty-eight patients had recurrent disease; five patients had recurrence after operation for a lesion diagnosed as ulcerative colitis and four were signed out as having Crohn’s colitis. Eight of the nine patients had been managed by partial colectomy without ileostomy. The recurrence rate for the entire group was still only 13 per cent, a figure well below that reported by others [4-61. How can these contrasting data be explained? It seems apparent that a major factor must be the validity of the clinical and pathologic diagnosis: is ulcerative colitis at one institution classified as Crohn’s colitis at another? Cook and Dixon [9] analyzed the pathologic material from fifty patients independently, using ninety-five separate pathologic criteria; twentyfive cases had been classified as Crohn’s colitis and twenty-five as ulcerative colitis. These authors concluded that many features felt to be specific for one diagnosis or the other were seen frequently enough in both diseases as to make them of little significance, for example cobblestoning, mast cells, and particularly crypt abscesses, lymphangiectasia, submucosal edema, and changes in the glandular reticulum pattern. Granulomas were never observed in patients with ulcerative colitis and therefore were a highly significant feature in patients with Crohn’s colitis in addition to confluent linear ulcerations, macroscopic deep fissures, and an aggregated pattern of inflammation. In patients with ulcerative colitis, significant features were a healed granular mucosa, the absence of fissures, and a continuous inflammatory pattern. Despite
Volume 130, November 1975
TABLE
I
Traditional
Bowel Disease
But Outdated
Criteria
Ulcerative
Colitis from
Differsntiate Granulomatous
(Crohn’s)
of Colon
to
Colitis
Criteria
Ulcerative Colitis
“Other” Colitis
Toxic megacolon Cancer Rectal involvement
10 per cent 10 per cent 95 per cent
Good response to steroids and/or azulfidine Skip areas Cobblestoning Crypt abscesses Granulomas
75 per cent
Response to proctocolectomy and ileostomy Recurrence at site of ileostomy
Excellent
Never Never 50 per cent 25 per cent Common Common Unusual < 50 per cent Poor to good Common
TABLE
II
Incidence
Never Uncommon Usual Never
Rare
and Recurrence
36 Patients
Undergoing
Inflammatory the Medical
Bowel Center
Rate in
Operation
for
Disease of the Colon at
Hospital
of Vermont
(1969-1973) Ulcerative Colitis
Operation One-stage total colectomy and ileostomy Two-stage total colectomy and ileostomy Partial colectomy Total
Number of Patients
Recurrence
“Other” Number of Patients
Colitis
Recurrence
28
l(4per cent)
. . .
. .
6
...
...
...
...
...
2
34
I(3 per cent)
2
l(50 per cent) l(50 per cent)
these criteria, however, the two pathologists disagreed on the diagnosis of eight of the fifty patients (16 per cent). Gross and microscopic material from fifty of our own patients were reviewed [7]. Forty-seven had been classified by the pathologist as ulcerative colitis and only three as granulomatous colitis. Three classic characteristic features of Crohn’s disease (granulomas, transmural involvement, and skip lesions) were sought in each of the fifty specimens. Study of material from twelve patients with two or more of these features resulted in a revised diagnosis of probable Crohn’s colitis, whereas material from seventeen patients met none of the three cri-
529
Abrams
teria and was diagnosed as ulcerative colitis. Each of the remaining twenty-one patients had one, and only one, of the characteristic features sought and could not be classified into either category. If these indeterminate cases were added to the list of those signed out as having ulcerative colitis, the final ratio of ulcerative colitis to Crohn’s colitis would be 3812 or 3:l. It was evident that our pathologists relied heavily on such features as crypt abscess (any specimen showing crypt abscesses was considered ulcerative colitis until proved otherwise) and, conversely, that a diagnosis of granulomatous colitis could only be made when granulomas were present, despite the fact that most studies report the presence of granulomas in less than 50 per cent of patients with granulomatous colitis. No matter which criteria are used, final diagnosis in inflammatory bowel disease of the colon generally requires a specimen. Clinical diagnosis before operation is, at best, speculative and often hinges on the presence or absence of specific criteria, namely skip lesions, involvement of the rectum, pseudopolyps, and the like or, all too frequently, on the findings of a mucosal biopsy that is useless. The classic indications for operation in inflammatory bowel disease of the colon are (1) inadequate response to nonoperative therapy, (2) major hemorrhage, (3) concern regarding the development of carcinoma, (4) stunting of growth in children, or (5) toxic megacolon. Although some surgeons continue to perform partial colectomy, particularly for Crohn’s colitis, the standard operation performed in most centers includes total removal of the colon and rectum and construction of a permanent ileostomy. One-stage total proctocolectomy and ileostomy has become fairly standardized. When performed electively, operative mortality should be well below 5 per cent and comparable to that for elective partial colectomy. We utilize a simultaneous surgical approach similar to that described by Goligher [IO]. Ileostomy dysfunction in the postoperative period, so common in the past, rarely occurs utilizing the turnback method [II]. Exit of the ileostomy through the rectus abdominus muscle and careful fixation of the ileal mesentery prevent prolapse and pseudohernia. Preoperative preparation has been vastly improved by intravenous hyperalimentation or elemental diets to correct nutritional defects. Healing of the perineal wound and avoidance of perineal and pelvic sepsis, although still more common than after abdominoperineal resection for cancer, is accomplished in the majority of
530
patients by primary perineal closure utilizing catheter or sump drainage. As noted by Silen and Glotzer [12], however, problems due to perineal wound remain a significant complication after proctocolectomy for Crohn’s colitis. The improved quality of ileostomy appliances and the availability and expertise of an enterostomal therapist has markedly improved patient acceptance and management of the ileostomy. Bone and Sorensen [13] have recently reported that of fifty-two patients evaluated for a mean period of eight years, fortynine had adjusted well to the ileostomy and experienced no significant difficulty in leading a normal life. Two major alternatives to proctocolectomy and ileostomy are currently being performed: rectal preservation operations and construction of an ileoreservoir. Abdominal colectomy with ileoproctostomy has been championed by Aylett [14] who has performed this procedure in 369 patients during an eighteen year period, with nineteen deaths (5 per cent). Cancer developed in only 7, “full health” resulted in 309 (84 per cent), and only 24 were considered failures. More recently, Yudin et al [15] reported their own results in sixty-three patients, with four operative deaths for a mortality of 6 per cent. One fourth of their patients were children or adolescents. All had significant difficulty during the first postoperative year, with frequent electrolyte imbalance, diarrhea, and repeated hospitalization. One in five were considered to have excellent results, although these patients still showed moderate proctitis with hyperemia, edema, and surface erosions. In 25 per cent of the patients, the operation was either a complete failure or the patient had severe diarrhea and electrolyte imbalance or required construction of an ileostomy. The functional results were directly related to the extent of rectal inflammation before anastomosis: the greater the inflammation, the poorer the result. A technic worthy of further study is the instillation of 15 to 20 ml of liquid ileostomy content into the rectum two or three times a day for a period of five to six days [15]. If there is no significant increase in the degree of inflammation of the rectum, ileoproctostomy should be considered. It is evident that this would only work in staged operations. Absolute contraindications to rectal preservation were (1) excessive, persistent rectal ulceration that did not improve after subtotal colectomy, (2) endoscopic or x-ray evidence of rectal stenosis, (3) increased motor activity of the rectum and ileum, (4) retrograde ileitis, (5) intolerance of the rectal
The American Journal of Surgery
Inflammatory
effluent, and (6) poor general condition. Despite these rigid criteria, only about one half of their patients had good to excellent results and even those with good results had up to seven bowel movements a day. Despite the reported excellent results after conventional ileostomy, surgeons continue to search for procedures that will, in essence, create a new or artificial anus. Beahrs et al [16] reported a series of twenty patients in whom an ileoreservoir was constructed using the method of Kock. Eighteen of the twenty were less than forty years of age and seventeen had undergone colectomy for ulcerative colitis. One patient had intestinal obstruction that required an ileostomy and four patients required reexploration with revision of the reservoir. Approximately one half of the patients had some initial difficulty intubating the reservoir and a similar number had to wear an appliance part or all of the time. In a group of five patients that had the modified procedure in which a “nipple” was constructed, three were totally continent for gas and fluid and did not use an appliance. This brief review indicates that we are still far from solving Kirsner’s “puzzles within puzzles,” a conclusion emphasized by the knowledge that two experienced colon pathologists, supplied with clinical and radiologic information, a gross specimen, and microsocpic sections from that specimen could not agree on the diagnosis in 16 per cent of the patients examined and that the surgical services of two major hospitals with vast experience in inflammatory bowel disease, both serving large urban eastern American populations, report such marked difference in the incidence of each form of colitis and the recurrence after operation. Did, in fact, patients who had recurrence at the site of ileostomy after colectomy for ulcerative colitis really have Crohn’s colitis? The proposed alternative procedures to total proctocolectomy and ileostomy must be considered seriously and with some degree of trepidation. Twenty or thirty years may elapse before carcinomas occur in a preserved rectal stump [17]. Cancer has been reported in patients with Crohn’s colitis [IS], and diagnosis is possibly unreliable. Until the problem of cancer and recurrence are resolved, rectal preservation cannot be recommended as a standard procedure for inflammatory bowel disease of the colon. The ileoreservoir procedure, with the sacrifice of 40 cm of distal ileum to construct the reservoir, offers so little in exchange for the potential risk of recurrence, obstruction, necessity mucosa
to ileostomy
Volume 130, November 1975
Bowel Disease of Colon
for revision, and so on that it must be considered an experimental procedure until a large series of patients have been followed for a prolonged period of time.
Summary Ulcerative colitis and Crohn’s colitis may be separate diseases or simply different manifestations of the same disease. New technics will be developed that help differentiate these lesions and permit better interpretation of postoperative complications and response to therapy. Until more information is available, one-stage total proctocolectomy with ileostomy remains the treatment of choice for inflammatory bowel disease of the colon that is refractory to nonoperative management. References 1. Kirsner JB: Editorial-ulcerative 2. 3. 4.
5.
6.
7. 8.
9.
10. 11. 12. 13. 14. 15.
16.
17.
18.
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