Surgical Aspects of Ulcerative Colitis

Ileostomy used to be considered the essential item of surgical treatment, but now excision of the colon and rectum is held to be equally important and as a rule colectomy – sometimes rectal excision as well – is performed simultaneously with the ileostomy. The reasons for removing the large bowel are that the presence of the colitis predisposes to the development of carcinoma, and recovery after operation is more rapid and certain if the septic colon had been excised at the primary operation. Experience in many centres has demonstrated that despite the magnitude of this operation and the frail condition of many of these patients primary colectomy or proctocolectomy can be performed with a very low operative mortality. In a series of 74 primary excision operations for colitis which the author has reported (Golígher 1954), the operative mortality was 2.7 %, the only 2 deaths having occurred in the group of 8 patients in the series for whom the operation was a life saving measure for acute fulminating colitis or very severe exacerbations of chronic relapsing colitis. This is contrasted with an immediate mortality of 21.6 % in a previous series (Counsell and Golígher 1952) of 60 cases of colitis treated by ileostomy alone in the first instance; in the group of 5 life saving operations in this latter series there were 4 deaths. Some of the difference in the results in the 2 series might have been explained by the higher standard of postoperative care in the more recent colectomy series, but it is hard to believe that this is the sole explanation, and the very considerable lowering in the mortality is held to vindicate the policy of primary excision. This operation is therefore strongly advocated and its value as an emergency measure is particularly emphasized in the treatment of more florid cases. The author distrusts cortisone for the treatment of these more acute cases, for in his experience it has frequently failed to halt the progress of the disease and an emergency colectomy has then to be 587 Congress Goligher 719 performed when the patient is in a much poorer condition to stand it. Also the fact that the patient is on cortisone therapy introduces a complication in treatment, for after urgent operation it is necessary to continue with this drug during the postoperative period. As the main danger after emergency colectomy is peritonitis due to contamination from a perforated or torn bowel, and the surgeon naturally wishes his patient’s resistance to sepsis to be at its highest, it seemed unfortunate to perform the operation under conditions which necessitate the continued use of cortisone. For these reasons he prefers to treat really urgent cases of colitis by immediate colectomy without preliminary cortisone and feels confident that an impartial survey would show that the results of this regime are better than those of cortisone treatment alone or of cortisone followed by later colectomy in the event of the cortisone failing to induce a remission. With