Ulcerative Colitis

Abstract

It is now widely accepted that surgery has an important role to play in the management of ulcerative colitis. Correctly applied, it can prevent much suffering and save many lives. Surgical treatment for colitis began in a small way with appendicostomy to allow regular irrigation of the colon. This was gradually displaced by simple ileostomy, which provided a total faecal diversion to the surface and away from the affected bowel. But even this operation was found to be not entirely satisfactory, for it frequently proved ineffective in arresting the course of the disease, particularly during severe attacks which had failed to remit on medical treatment. Furthermore it was discovered that in long-standing cases of colitis there was a greatly increased risk of carcinoma developing in the diseased large intestine, which was thus safer removed than merely defunctioned by ileostomy. Accordingly an accepted aim of surgical treatment became excision of the affected portion of bowel, preferably at the time of the initial intervention, and this has led to the adoption of the operation of ileostomy and proctocolectomy in one or two stages as the method of choice at the present day. An alternative operation, favoured by a few surgeons, is that of colectomy and ileorectal anastomosis. In this technique the entire colon is removed, but the rectum is retained, and the end of the ileum is anastomosed to the top of the rectal stump. No ileostomy is needed, and this is the main advantage of the procedure. If the rectum itself was frequently spared by the colitis, ileorectal dnastomosis would often be a very logical and acceptable way of treating the disease. But unfortunately the reverse is the case, and-with the exception of the excessively rare so-called segmental or right-sided forms of colitis, which nearly always turn out to be examples of Crohn's disease-the rectum is practically invariably heavily affected in ulcerative colitis. So when colectomy and ileorectal anastomosis is done, it means as a rule retaining and using a diseased rectal stump, which seems to be tantamount to an invitation to further trouble either from inflammatory complications or even the develop ment of a rectal carcinoma, as has now been recorded in a number of cases after this operation. Though Aylettl has reported excellent results with colectomy and ileorectal anasto mosis, with some 90% of satisfied patients, most surgeons who have tried it have had failure rates of from 20% to 50%. It must be admitted that it is not easy to define failure in this context, and this may account for some of the discrepancies in the reports of results. Undoubtedly most patients after colectomy and ileorectal anastomosis make an excellent recovery of general health-so much so indeed that, even if they should continue to have severe changes of proctitis in the rectal stump and to suffer quite troublesome diarrhoea with up to 10 or 12 motions a day, possibly with some bleeding and discharge of mucus, they may be very reluctant to accept a further operation involving the creation of an ileostomy. My own experience of patients referred to me after unsuccessful colectomy and ileo rectal anastomo is elsewhere is that they have been most agree ably surprised at the much f eer and more enjoyable life they ave been able to lead after conversion to ileostomy. It has bee suggested that one should try most patients coming to radical surgical treatment for ulcerative colitis on colectomy and ileorectal anastomosis in the first instance, for if it ails they can then be conv rted to ileostomy and the rectum rem ved. But, as already explained, there may be great difficulty in getting the pa ents to accept a second operation, and if they per ist indefinitely with a diseased rectal stump they are seriously exposed to the hazard of malignant change in this piece of b wel. Furthermore, conversion operations someti es ar technically qu t difficult to do, for the rectum is frequently adherent and apt to be torn in the process, with resulting contamination and a high risk of postoperative morbidity. Altogether it would be fair to say that most surgeons with extensive experience of ulcerative colitis feel that colectomy and ileorectal anastomosis is too unreliable a method for the treat ment of this disease, and that if operation is to be undertaken an integral part of it must be the establishment of an ileostomy.