Surgical Treatment of Severe Attacks of Ulcerative Colitis, with Special Reference to the Advantages of Early Operation

Abstract

Roughly half the attacks underwent spontaneous remission during the two periods, but the medical mortality was 4-8% in the former and 0-7% in the latter, the operative mortality 20-0 and 7.0%, and the overall mortality 11.3 and 4.5% respectively. The lowering of the mortality was particularly striking in severe first attacks and in severe attacks in-patients over 60 years of age.Perforation of the colon was found in 21 cases, or nearly 20% of 112 patients coming to operation during attacks, being commoner in the first period (32-5%) than in the second (11-1%).°The immediate mortality of all such operations was 11.6%; in cases with perforation it was 28-6%.Acute colonic dilatation was observed in 28 cases. All but one were treated by emergency colectomy, at which the colon was noted to be perforated in 11. The mortality of these operations was 18.5%.Follow-up of the 140 patients who survived without coming to operation during their attacks shows that 52 (37-1%) subsequently underwent surgical treatment either during further attacks or electively.Though all 258 attacks were thought at the time to be due to ordinary ulcerative colitis, subsequent pathological examination of operative specimens derived from 98 patients who came to urgent or subsequent operation during the 1964-9 period revealed that the lesion in the large bowel was Crohn's disease in 17 instances. IsitroductionThe dangers to life posed by ulcerative colitis are largely concentrated in the phases of acute exacerbations or relapse which so frequently characterize the course of this disease. Fortunately these severe attacks often show a considerable tendency towards spontaneous remission, which can be to some extent encouraged by corticosteroid therapy and possibly other medical measures. In quite a proportion of cases, however, the attacks fail to remit on conservative management, and surgical treatment is urgently required if a fatal outcome is to be avoided, though surgery itself undertaken in these circumstances has often carried considerable risks. There has been much controversy among physicians and surgeons about the frequency with which operative intervention is really needed in these acute conditions and regarding its optimal timing.

Early Surgery for the Treatment of Toxic Megacolon

“…Since the mortality rate in patients with perforation is high, several investigators have proposed that surgery must be performed as soon as possible [1, 11]. In our experience, early surgery resulted in the intra-operative finding of 2 cases of early perforation (13%), both having an optimal outcome.…”

Restorative Proctocolectomy for Emergency Cases of Ulcerative Colitis

“…That complication developed in 3 (12%) patients after Hartmann's colectomy as a minor pelvis abscess in 2 patients or multiple intra-abdominal abscesses in 1 patient. Similar infection occurred in 5 (14%) patients after pouch-anal anastomosis as a minor pelvis abscess in 3 patients, diffuse peritonitis in 1 patient, and procedure consisted of primary IPAA with diverting loop ileostomy (4)(5)(6)(7)(8)(9)(10). Since the threestaged procedure makes enormous demands on the patient, adds another laparotomy to the management and prolongs the treatment time, there was an attempt to introduce primary pouch anal anastomosis for urgent indications in selected cases.…”

“…Similar management is also indicated for patients who developed toxic megacolon and those in septic shock with systemic inflammatory response syndrome (4)(5)(6)(7)(8). However, there is a significant group of patients operated on for acute UC who could undergo primary restorative proctocolectomy with loop-ileostomy, that is, a two-step treatment, who might profit from such management and thus avoid another large abdominal operation and potential serious complications.…”

Toxic megacolon in ulcerative colitis: a continuing challenge

“…Even when a policy decision has been made, there is reluctance to undertake such dangerous surgery while hope remains of improving the patient's pre-operative state. The decision can be eased by strict adherence to a predetermined timetable, but the exact timing of such a programme is still debatable (Goligher et al, 1970;Truelove and Jewell, 1974). A second problem is in assessing lack of progress in the first few days, when the clinical picture has been modified by high-dose steroid therapy, intravenous rehydration and transfusions.…”

“…The prognosis of severe ulcerative colitis (UC) has improved in recent years, owing to increasing awareness of the value of prompt and intensive medical treatment in fulminating cases, with early recourse to surgery if improvement is not rapidly achieved or maintained (Lennard-Jones and Vivian, 1960;Goligher, Hoffman and de Dombal, 1970;Truelove and Jewell, 1974;Barany and Lindholmer, 1974). However, the predictive features, timing and long-term justification for emergency surgery are still debatable.…”