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SUMMARY We report a patient with severe Crohn's disease and the short bowel syndrome on parenteral feeding who was not responding to conventional therapy and underwent treatment with cyclosporin (CyA) given initially intravenously and subsequently orally in each of two courses. Plasma drug concentrations were largely kept within the therapeutic range but wide variability was observed on oral therapy. Improvement both clinically and by objective assessment, was observed on intravenous CyA therapy, but was not sustained when the drug was given orally for several months. None of the side effects observed resisted treatment or was severe enough to warrant discontinuation of therapy. These findings suggest that there may be a place for intravenous CyA therapy in patients with severe Crohn's disease who do not respond to conventional therapy or to oral treatment with CyA.

CASE REPORTS 305 progressreport on the treatment of 157 patients with advanced cancer usinglymphokine-activated killer cellsand interleukin-2 or high dose interleukin-2 alone. N. Engl. J. Med.. 316,889- 897.West, W. H., Tauer, K. W., Yanelli, J. R. e t d . (1988). Constant infusion recombinant interleukin-2 in adoptive immunotherapy of advanced cancer. N. Engl. J . Med., 316,898-905.

SirOf two reports concerning intraoperative testing of colorectal anastomoses, Beard et al. (Br .I Surg 1990; 77: 1095-7) described the effectiveness of air testing using a sigmoidoscope, while Pitchard et al. (Br J Surg 1990; 77: 1105) did air testing using a bladder syringe which might be misleading for low colorectal anastomoses using the double stapler techniques. An intraoperative leak test is performed to determine whether or not the anastomosis is air tight. However, airtight anastomoses d o not guarantee complete prevention of the postoperative leak.Recently, we have employed the urological cather with quadrant large holes (Malecot Model Drain, C. R. Bard Incorporated, Conington, Georgia, USA) for intraoperative air testing after colorectal anastomoses. A Foley catheter balloon may disrupt low anastomoses, but the procedure has the advantage of simplicity compared to the use of a sigmoidoscope. The advantage of sigmoidoscopy is the ability to observe the anastomoses directly. A Malecot catheter equipped with large holes has been useful and easy for not only air testing but also draining the residual faeces and for rectal washout. Furthermore, we positioned the catheter above the anal sphincter and connected it to a closed drainage system to decrease the intrarectal pressure in the first 5 days after operation. Anorectal manometry showed an increase of intrarectal pressure when flatus was passed'. Then, catheter drainage of flatus and faeces decompressed the anastomosed neorectum. Also we can perform a limited water-soluble contrast enema through the Malecot catheter before withdrawing it.Seventy-eight consecutive patients who underwent colorectal anastomoses with air testing by using the Malecot catheter have been evaluated. Six patients were found to have an air leak, added reinforcing sutures or a covering stoma. Two of them developed postoperative leakage. Three patients whose anastomoses were air tight developed postoperative leakage. We reduced the postoperative leak rate from 18 to 7 per cent by an introduction of a Malecot catheter.As Dr Pitchard described, leakage must be the result of factors other than the construction of structurally sound staple lines. We choose a Malecot catheter not only to make a sound anastomosis but also to minimize postoperative anastomotic hazard caused from intraluminal problems. It is an important concept that the surgeon should give special attention to the anastomosis.

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