No abstract
Success depends upon attention to detail.Joseph Lister.
Mr Peter Jones was asked by the BMJ to present the case for treating patients with ulcerative colitis warranting colectomy by ileorectal anastomosis rather than by ileostomy. His article, published below, was then sent to two other surgeons and all three met to discuss the topic with one of the BMJ medical editors, Dr Tony Smith, acting as chairman. Working paperWhen the patient with colitis requires surgical treatment panproctocolectomy is the operation which is generally performed, and most patients make a satisfactory adjustment to ileostomy, greatly helped by recent advances in stoma care. Nevertheless, an operation which leaves a permanent ileostomy must be regarded as a less than ideal solution, the more so when so many of the patients are young and on the threshold of marriage, higher education, or the start of a career. The alternative operation, ileorectal anastomosis after excision of the whole colon, has not yet received any general approval, probably because experts have expressed such widely differing views about its results. A close study of a personal series assembled over 20 years, and a review of the published reports, has led me to the opinion that, while there are a number of patients for whom preservation of the rectum is impossible or ill-advised, there is another group who can obtain a very good long-term result from ileorectal anastomosis. Personal seriesThis now consists of 94 consecutive patients who have undergone total colectomy for inflammatory disease of the colon. A provisional choice between excision or retention of the rectum was made preoperatively: whenever the anal canal appeared normal, and the rectum appeared normal or only mildly inflamed and capable of distension, then the patient was considered to be a candidate for ileorectal anastomosis. In a borderline case conservation of the rectum tended to be chosen if the patient was aged under 25. The level of division of the rectum was decided at operation, after direct inspection of the mucosa, but commonly 12-15 cm of rectum was retained.Forty patients (42%) had an ileorectal anastomosis performed, 38 at total colectomy and two as a second-stage procedure after emergency total colectomy and ileostomy. At the time of operation all these patients were believed to have ulcerative colitis but a review of histology has shown that four of the earlier patients in fact had Crohn's colitis. A direct end-to-end anastomosis of ileum to rectum was always used and in no case was a covering ileostomy created. ResultsThirty-eight patients made a good initial recovery from operation and two died; one patient had an emergency colectomy and anastomosis which leaked, and the patient died from uncontrolled sepsis two weeks later. (It was a serious error of judgment to attempt an anastomosis at emergency colectomy and this has never been done again. This was the only patient to develop an anastomotic leak). The other patient, who was gravely ill and taking corticosteroids, died two weeks after operation from uncontrolled sepsis.Four patients have ...
THE problem of pulmonary collapse and consolidation following abdominal operations is a persistent one and seems to have improved to only a small extent in recent times. The advent of relaxant anaesthesia may even have made the problem worse, in so much as the cough reflex is often suppressed or minimized during the first critical hours of the post-operative period, when the seeds of collapse and consolidation are sown.In order to assess the extent of the problem at the present time, measurements of respiratory capacity have been made throughout the operative period on a series of patients undergoing a variety of operations.( 2 ) By pressure-volume measurements recording lung compliance (Attinger, Goldstein, and Segal, 1956);(3) By analysing the gaseous exchanges in the lung from blood and ventilatory samples. The first group of tests is the simplest and the most widely used (Brit. med. J . , 1958), and was considered to be adequate for the needs of the present investigation. TECHNIQUEThe forced expiratory volume, which is the volume of gas expired as rapidly and as forcibly as possible over a stated time period (Gandevia and Hugh-Jones,
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