The effect of 32 split ileostomies on 29 patients with severe symptomatic perianal Crohn's disease is reported. The perianal disease improved or healed after 23 (72 per cent) split ileostomies, although it relapsed in 2 patients while diverted and in 6 after closure of split ileostomy. Seven of 12 rectovaginal fistulas healed initially but only remained healed in those patients without rectal involvement with disease. At the time of review 6 patients have normal bowel continuity, 8 have had proctocolectomies and 15 are still defunctioned. Split ileostomy should be considered as an initial step in the management of intractable perianal disease.

The incidence of abnormalities of micturition and sexual function after removal of the rectum is discussed. It is thought that surgical damage to the autonomic nerves in the pelvis is the main cause of disability in young patients with benign disease. The various modifications of the standard abdominoperineal dissection of the rectum which have been introduced to prevent injury during the operation are described. None has proved entirely successful. A new technique of rectal dissection, in which two surgeons concentrate on opposite sides of the bowel and carry out the dissection under direct vision in a bloodless field, is described. The results of its use in 24 patients are recorded.

One hundred and fifteen patients who were treated by a proctocolectomy in Oxford between 1972 and 1984 for inflammatory bowel disease have been studied. All the patients had the rectum removed by the technique of perimuscular dissection which was introduced in 1972 in an attempt to overcome the problems associated with the previous types of proctectomy. The method has been shown to be safe; the operative mortality was 1.7 per cent. The most worrying potential complications due to permanent autonomic nerve damage (i.e. impotence and urinary incontinence), which previously have been recorded as occurring in a significant percentage of patients, were completely prevented by the method of dissection. One man suffered transient impotence which responded to psychiatric treatment. There were no long term urinary tract or sexual problems. Postoperative complications occurred in 37 per cent of patients, perineal wound infections being the most common (25.7 per cent). Perineal healing, however, was achieved in 75 per cent of patients by the time of their discharge from hospital. The mean length of postoperative hospital stay was 19 days in patients with ulcerative colitis and 15 days in patients with Crohn's disease. Our rate of perineal healing is better than has been recorded using other operative techniques.

Strictureplasty is controversial in the management of obstructive Crohn's disease. Only a small proportion of patients undergoing surgery for obstructive Crohn's disease are suitable for strictureplasty. Lesions which are most amenable for this procedure are short, fibrous strictures. Over a 10-year period 24 patients have undergone 30 operations at which 86 strictureplasties were performed. The median follow-up has been 40 (range 4-112) months. No leaks or fistulae arose from the strictureplasties. The median weight gain 3 months postoperatively was +4.0 kg. Four patients subsequently required a further 13 strictureplasty procedures, between 12 and 36 (median 18) months after the initial operation; all but one of the previous strictureplasties were patent. Thirteen patients have been symptom free following surgery, four have required further medical therapy for recurrent Crohn's disease and three have sustained episodes of self-limiting intestinal colic. Strictureplasty is a safe and effective procedure in selected patients undergoing surgery for obstructive Crohn's disease.

Patients attending a breast clinic in two different periods were studied. In the first period fine needle aspiration cytology (FNAC) was not available and in the second it was used on all discrete solid breast lumps and reported immediately in the clinic. With the use of FNAC the overall surgical excision rate for discrete solid lumps was reduced from 83 per cent to 41 per cent and the excision rate in patients with benign disease was reduced from 74 per cent to 23 per cent (P less than 0.001). All patients with breast cancer in the second period had malignant cytology and no patient with benign or acellular cytology has been shown, after a minimum follow-up period of 18 months, to have breast cancer. Using FNAC with immediate reporting, the number of operations performed in patients with benign breast disease can be safely reduced.

Local excision of rectal tumours SirWe read with interest your recent article by C . W. Mann (Br J Surg 1985; 72(Suppl.): S57-8), in which the importance of patient selection is stressed. It is stated that only tumours of favourable cytological differentiation ('well' or 'average' histological grade) are suitable for these local radical techniques.It is important to draw attention to the fact that it is not possible to exclude accurately all poorly differentiated tumours pre-operatively based on the results of rectal biopsies. In a recent study' we found that 70 per cent of poorly differentiated growths had been thought to be of only average grade when the rectal biopsy was examined. These findings were confirmed by Elliott et a/.' who found that only 17 of 42 poorly differentiated tumours were correctly identified as being of unfavourable histological grade on rectal biopsy, a 60 per cent error.The discovery of unfavourable histology after local excision may result in a medically unfit patient being subjected to further surgery. lnaccuracy in the histological grading of rectal biopsies means that it cannot be certain that selection is completely correct when advocating local excision.

Five hundred and thirty-five polyps were found in 200 patients over 6 years at a regional teaching hospital. Eighty-five per cent of the patients were from the hospital area yet the presentation of the patients, the complications of polypectomy, the size, distribution and histological features of the polyps were similar to large series reported from metropolitan specialist centres of referral both in this country and the USA. However, a smaller proportion of our polyps were over 1 cm diameter. Between 25 and 53 per cent of patients had recurrent or residual polyps on the second and third colonoscopy. Patients with two or more polyps at the first endoscopy were significantly more likely (P less than 0.01) to have further polyps at follow-up. We therefore recommend that patients with colonic polyps are colonoscoped annually until free from polyps for 2 years, before being placed on colonoscopic review at 5-year intervals.

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