The surgical management of chronic ulcerative colitis

Abstract

1. 1. The surgical treatment of chronic ulcerative colitis, in selected cases, may now be streamlined safely to one-stage total colectomy with removal of the rectum and ileostomy in one operation. 2. 2. The advantages of this procedure are: (1) it is technically feasible; (2) it avoids multiple operative procedures with the attendant risks; (3) it is performed when the patient is usually in better general condition, at the beginning of his illness, not after he has had two or three operations; (4) it avoids the difficulty of building up the patient while he still has a diseased colon; (5) there is an excellent psychic effect in that the patient is cured in one operation. Many patients will not submit to staged procedures. 3. 3. Complications are avoided, such as later foci of infection in the remaining colon, perforation, peritonitis, hemorrhage, rectal stricture, fistula, abscess and segmental ulceration, and pseudopolyposis and malignant degeneration. 4. 4. The danger of malignant degeneration in ulcerative colitis is emphasized. 5. 5. To obtain a good result, both the colon and rectum must be sacrificed and permanent ileostomy performed. 6. 6. Indications for ileostomy and total colectomy are: chronic invalidism, perforation, hemorrhage, toxicity, arthritis and dermatitis, stricture and malignant degeneration. 7. 7. The preoperative preparation of the patient should place him in optimum fluid and electrolyte balance, with adequate hemoglobin and serum protein, plus control of infection with antibiotics. Above all the patient should be conditioned psychologically to his operation and the ileostomy care that is to follow. 8. 8. The operative procedure is described with the conservative removal of the rectum to retain the nervi erigentes and normal sexual potency as well as the anal sphincter for its beneficial psychic effects. 9. 9. The all-important 2 inch area of the ileostomy is emphatically stressed, and adequate time and extreme care should be taken in fashioning the ileostomy, for the success of this entire major procedure is dependent upon how this stoma functions. 10. 10. Methods of ileostomy drainage and tips on operative technic are offered. 11. 11. Postoperative care is primarily designed to anticipate rather than to combat complications, especially fluid and electrolyte loss and to understand the physiology of the ileostomy. 12. 12. The ileostomy patient does not see the end of life with his operation. Actually, he begins a new life, slightly altered. Weight gain, new mental outlook and new vistas of life are possible, as shown by the many ileostomy patients who have adjusted to normal lives once more. As we stated at the outset, this is but one way to handle the surgical management of chronic ulcerative colitis, not the answer to the condition. Let us all hope that some original research as to the true nature of this illness may soon be discovered. Until then, one-stage total proctocolectomy and ileostomy are preferable to the multi-stage operations surgeons were forced to use in the past.