MINNEAPOLIS SURGICA SURGERY IN RELATION TO CHRONIC NON- SPECIFIC ULCERATIVE COLITIS Experience at the University of Minnesota Hospitals CLARENCE DENNIS, M.D. Saint Paul. Minnesota Chronic nonspecific ulcerative colitis is not a common disease, but the misery and mortality of the patients suffering from it the satisfaction to Te derived from the proper mnanagenient of it draw more attention than frequency alone would allow, The cause of the disease is open to debate. ” Bargen points out properly that one must ditferentiate the dis- and ease under discussion from tuberculous colitis, colitis die to lymphopathia venereum, colitis duc to amebic or bacillary. dysentery, and other forms. He beheves most chronic ulcerative colitis to be due toa a diplostrep- tococcus. His view is not universally accepted, and a large portion of authors group the majority of these cases as “idiopathic” or “non-specific” chronic ulcera- tive colitis. Other authors have offer pimations for the disease. R.A. Jensen of our Psychiatric Clinic tor Children, has studied eight cases in children rather carefully fram the psy- chiatric angie. He found that these “children all had: rigid personalities, an unyielding character, set exact standards for themselves, were not irce and spontane- ous in type, and usually were more intelligent than the average. He feels that in each of these set of diarrhea has been related to some unusual cir- cumstance in the family relationship. As a rule, no consideration had been given to the psychiatric aspects of these cases until the patients came here. Jensen was ed various ¢x Some siress the functional factor. cases the on- able to find special circumstances in the individual ex-- periences of the children underlying each exacerbation of the disease, and in each case there had been smoul- dering suppressed resentinent against the family. He felt that in diarrhea ina cidld in whom no specific diagnosis cun two ia weeks, the psychiatric aspects of the problem should be considered. In many of the adult cases coming to the surgical service, some of us have felt that. far too little attention has been paid to these considerations. The importance of allergic reactions to a variety of fGodstitts lias been stressed by numerous writets, An- dresen is particularly impressed ty tne frequency of sensitivity to milk. Rowe has reported a simail series of cases in which exacerbations of the disease were conclusively traced to inhalants such as ragweed and thistle pollen. , Various vitamin deficiencies have been incriminated, particularly those of the B-complex. Studies have been undertaken to determine the importance of varia- tions in activity of the various digestive enzymes. Tt is apparent that no single cause has been positive- any case of be made in three Irom the Department of Surgery, University of Minnesota Hospitals & School of Medicine. Supported by a research wrant from the Graduate School of the University of Minne- sata, 228 1. SOFT ETY ly, established, and it scems likely that in each case a multiplicity of factors is at work. . Pathology-—The congested mucosa early becomes in- flamed, bleeds easily on contact, and small hemorrhagic areas appear. Tiny abscesses form in these areas, and coalesce to form ulcers varying in size from pin-point to 2 or 3 em. | in diameter, with shaggy, undermined edges. As the 'process advances, more mucosa is de- stroyed, until in some cases only islands of mucosa remain, leaving’ a pseudopolyposis. All the layers of the bowel become involved in the inflammatory proc- ess, with marked thickening and fibrosis. The walls of the colon become thickened and rigid, and as the lumen becomes smaller, actual obstruction occasionally oceurs, Perforation with abscess formation or peri- ionitis is an important cause of death while hemorrhage from vascular erosion is the second important cause of death, Fistulae and abscesses about the anal canai are frequently seen. When pseudopolyposis is present, taalignant degeneration not infrequently occurs; pseudo- polyposis is therefore regarded as a strong indica- tion for colectomy. The pathology of the disease may vary considerably from case to case. At the Cleveland Clinic, Jones re- poried 93 per cent of the cases started with discase in the reetum, and ihen spread to upper segments with successive attacks. Others report a higher incidence of this type, and give the impression that widespread in- volvement, even to the cecum, or occasionally into the terminal ileum, is an early result of the disease. Lo- calized segmental involvement occurs in about 5 per cent of the cases. , ‘ Symptoms and Course.—Ulcerative colitis may he classified under three general headings (Table I). TABLE I. TYPES OF NONSPECIFIC ULCERS ATIVE COLITIS he fulminating type. The very mild type. The more common type-—marked persistently by sufficient disease to prevent near-normal activity or by frequent exacerbations of such severity. wie 1. Ulcerative colitis may be ushered in as an over- whelming disease characterized by profuse stools ot blood, mucus, and pus passed fifteen to thirty times 4 day with high or spiking fever, prostration, abdominal cramps and pain plus signs of peritoneal irritation. It may subside in the course of a few days or weeks o7 it may progress to a rapidly fatal outcome on tie basis of inanition, peritonitis, or massive hem: orrhage. 2. On-the other hand, it may begin in an_ insidious fashion, with mild cramps or diarrhea, later presentins mucus in the stools. As the process advances and u- ceration develops, the stools may occasionally beconie frequent, purulent, and bloody. It may remain a mild Giscase which responds at once to medical management. Apparently, a somewhat more common course, how: ever, is a prolonged one characterized by exacerbation: and remissions. Usually the patient never - become entirely but gets along well enough to continu work except during the exacerbations. There is jus- sepsis, well, MINNESOTA MEbICINE MINNEAPOLIS SU tification for medical management of some such ciasces. 3. Between the fulminating cases on the and the mild ones on the other, th pa- tients with ulcerative colitis will fall. The disease is constantly severe enough or marked by exacerbations of suihcient severity to prevent continuance at work or even at restricted activin. Chronic bleeding and loss of plasma, as demonstrated by Welch, Iead to marked or moderate inanition and anemia, and these pa- tients are difficult to nandle because of loss of Strength, impaired resistance to surgical procedures, and lack of ability to take an adequate diet without diarrhea. The degree of weight-loss in patients in the severe phases of the discase is greater than that seen in any other group of surgical patients at the University of Minnesota Hospitals. We have had several who have lost 35 per cent of the body weight, and one lost almost 50 per cent. The complications of perforation, hemorrhage, and sinus formation have already been mentioned. Poly- posis occurs only in the chronic cases, and carcinoma is a complication in this group. Arthritis, thromho- phlebitis, achlorhydric gastritis, endocarditis, and other lesions sccm to be late. complications. one hand, of Made e increasing the iritis, Diagnosis —Diagnosis of ulcerative colitis is not usu- ally difficult to establish, but to differentiate the chron- i¢ nonspecific type from other types is less siniple. The patient usually looks chronically i! and apprehensive. The abdomen is moderately to mark- edly tender to palpation. The chief complaint is usu- ally of diarrhea, but may be of ischiorectal aliscess, fistula, or other complication. The diagnosis of colitis is largely settled by examination of the stool for pus, blood, and mucus, proctoseapy, and barium enema x- ray examination. The proctoscopic appearance is one of a swollen, con- gested mucosa with a granular appearance, which bleeds easily on contact, usually with myriads of small ulcers, and sometimes larger ones. There are usuaily no areas which look entirely normal. , underweight, Barium enema x-ray examination is usually fairly typical. Early in the disease there rpay be a fine featherlike irregularity of the mucosal pattern. Later the haustrations are partly lost; they are totally lost still later in the disease. Because of spasm and scarring the lumen is decreased markedly and the bowel is shortened. The caliber is fairly uniform. All these changes give rise to the “lead pipe” appearance con- sidered so typical of the disease. Ladd and Gross fee! the wide distribution of these chanyes is characteristic, and that it serves to differentiate nonspecific from ame- bic colitis, which usually involves chicily or solely the right colon. Mention of the important conditions which must he differentiated is necessary. Tuberculous enteritis ‘may be recognized by careful general study of the pa- tient and ileac barium injection through a Miller-Ab- bott tube. The bacillary dysenteries should be ex- cluded by tlood agglutination studies. Amebiasis can usually be recognized by repeated examinations of the Marcu, 1945 RGICAL SOCIETY fresh stowl, but it is customary to give a diagnostic trial ot emetine nevertheless, Medival Therapy—The number of different. meas- ures employed in the medical management of ulcera- tive colitis is testimony of the lack of specificity of any form of therapy. Certain measures are generally ac- cept nied as of definite value. Strict bed rest and a low residue or bland diet are usually effective measures for tiding aver exacerbations, The use of the vitamin B complex, especially thiamine, ard of liver extract seems he widely accepted. Brewer's yeast, cevitamic acid, and a host of other vitamin, preparations have been added to the pot. Mackie has summarized present miccical management and favors, in addition to the measures already mentioned, use of hydrochloric acid by mouth in those with achlorhydria, mild sedation, as with phenobarbital, and adequate mineral intake, bearing in mind that the involved colon is normally the site of absorption of most minerals. Andresen has called par- ucular attention to the importance of allergic reactions to the devclopment and perpetuation of ulcerative coli- tis, and favors climination diets and a thorough allergic study on each patier nt, As already indicated, more attention should be paid to the psychiatric study of these patients than has been the custom here in the past. The advent of the sulfonamides brought new hope. Some enthusiastic, but the general concensus of Opimion scems to be that, although the bacterial count of the feces may be decreased by such drugs as sulfa- nylyuanidine and succinyl sulfathiazole, yet no change in the course of the disease has been demonstrated con- sistently to occur.2.22,26,80, 238 Various other procedures, popular some years ago, such as irrigation of the colon with Dakin’s solution, have heen abandoned. are Medical Versus Surgical Management—An extreme- ly wide difference of opinion exists about the part which surgical intervention should play in the management of patients witih nonspecific ulcerative colitis. Most of the publications up to a few years ago indicated the internist’s horror of the plight of the patient left with permanent Heosiomy. It has been appreciated that this is a disease in which more or less prolonged re- missions are the rule! and therefore the temptation has constantiy been to delay active treatment in the sicker patients in the hope that such a remission might occur. : a Examples of the diversity of opinion on the choice of procedure are illustrated by the following. Mackie advises a thorough trial of conservative management for several months preferably, and avoids surgical measures to divert the fecal stream from the colon until proctoscopic examination and barium enema study show that irreversible changes are ‘occurring. Willard and associates are almost bitterly opposed to surgery in this disease, basing their contentions on the finding .. of a high death rate in those referred tor surgery late. in the disease. The general concensus of Opinion among the surgical authors, however, seems to be that the 229 MINNEAPOLIS SURGICAL SOCIETY high-mortality following surgical intervention has oc- curred in patients who have reached a terminal status before reference by the internist.71625 Certain sur- geons have suggested the performance of ileostomy in the first few weeks of the disease, for a fair portion of these recover and can successfully have the ileostomy: closed.8.17,15,29 A fair comparison of figures has been presented by _Elsom and Ferguson, internist and surgeon, respectively, of the Hospital of the University of Pennsylvania. They sclected two groups of patients with disease of comparable severity and treated approximately half by surgical procedures, and the remainder by the more conventional medical management. he findings in- dicated that in all respects, survival, weight gain, abiliiy to return to work, and present health, those treated surgically did better than did those in the other group. Surgical Therapy, Neostomy—Indications —The indications for surgical intervention are as diverse as the opinions of the value of surgery. ‘Those listed recently in the surgical lit- erature are fairly uniform, and include the following indications : 1. Emergency indications: (a} Uncontroilable hemorrhage . (b) Acute ulcerative colitis with profound toxemia (iulminating cases) (c) Tinpending perforation (d) Obstruction 2. Elective indications: (a) Chronic ulcerative colitis resisting all forms of medical treatment. (b) Segmental ulcerative colitis. (c) Very early ulcerative colitis. (d) Polyposis including those cases with possible malignancy. An impression of the variation in indications is gath- ered from the fact that at the Mayo Clinic the pro- portion of cases treated surgically has progressively declined from 20 per cent in. the period from 1919 to 1923 to 14 per cent in the period trom 1932 to 19365, while in the same period at the Massachusetts General Hospital 65 per cent of cases were treated surgicaily.?* In a discussion published with McNittrick’s report of these figures, Dr. Daniel Jones of Boston questioned whether the classification of cases as ulcerative colitis was uniform in all clinics, also the criteria of cure. Prior to about 1936, surgical treatment consisted of appendicostomy, cecastamy, and occasionally colostomy. Garlock states, “The purpose of these procedures was to permit irrigation of the diseased bowel with med- icated solutions in the hope of restoring the mucosa to normal. Experience in recent years has shown that this therapy was based upon fallacious reasoning. It is important to emphasize that the first requisite Of suc- cessful surgical treatment is complete diversion of the fecal stream from the diseased bowel segment.” This can be accomplished only by terminal ileostomy. The general indications for major surgical interven- 230 tion, aside from drainage of abscesses, have been dis- cussed. The procedure to be done in any of these cir- cumstances is ileostomy. Attempts to close perfora- tions have all been reported unsuccessful. Attempts to do primary large or small resections with primary anastomosis have all proved too risky save in a few cases of segmental disease in which the process was too quiescent to reveal the true nature of the ailment until examination of the specimen by the pathologist. In short, any patient with severe enough ulcerative colitis to require surgery needs an ileostomy first, and a period of months or even years should pass before further procedures are undertaken. Technique of Heostoniy—The manner of perform- ance of ileostomy has received too little attention. Tt is probably true that most patients with ileostomy will heal the operative wound satisfactorily without special precaution, but it is virtually impossible to tell which of the patients seen will have more than usually irri- tating ileac drainage and will therefore develop break- down of the wound. The procedures recommended in the literature uniformly involve bringing a single- barrel or a double-barrel ileostomy out through the wound, and closure of the wound about the bowel. This type of procedure has heen abandoned at this clinic. . These patients are regularly in extremely poor con- dition, and shock is easily induced. McNHittrick’s con- clusions are in agreement with our own, that spinal anesthesia certaiuly should not be used for ileostomy, and general anesthesia also is better avoided. He fa- vors the use of local anesthesia insofar as possible, a choice we also have adopted. Response to Ileostomy.—Following performance of ileostomy, all are agreed that the majority of patients improve rapidly. The temperature frequently returns to normal in one or two days, the appetite returns, the rectal discharges diminish quickly, and thereafter the weight gain is marked and fast. One of our patients gained 56 pounds in two months after ileostomy. Those for whom the ileostomy is done as an emergency ior bleeding have generally been observed to cease to suifer hemorrhage within a few days. Other Faclors in the Performance of Ileostomy— The most trying’ complication of ileostomy is digestion of the wound by the unspent ferments of the ileac se- retions. If the wound is not carefully protected early, the line of closure in the wound adjacent to the ileostomy is likely to break down and suppurate. Heal- ing of such defects is slow and painful, for the wounc is constantly soaked with intestinal discharge, and the ultimate results are not satisfactory. A wound so healed is ever subject to fresh digestion and can make the patient miserable indefinitely. Most satisfactory elimination of this problem has been accomplished by bringing the proximal end of the ileum out through a stab wound apart from the main incision. The distal end is closed and returned to the abdomen. The bowel MINNESOTA MEDICINE MINNEAPOLIS S$ heals to the skin readily, and this process seems seldom to be delayed by secretions.+ Digestion of the skin about the sleostomy is equally trying. Apparently somewhat more than half of these patients have litde difficulty regardless of the care given, but the others suffer from obstinate erosion of the skin. There are repeated references in the lit- erature to the belict that this erosion subsides as scon as the i+ © Sved colon has been removed. This has not been «oir experience here. Various methods have been proposed to treat this skin erosion, but all are agreed that prevention of it in the first place is far simpler than management after it has developed. Most authors say little of this trouble, but earcful reading of their reports indicates that the pay tients must have been made miscrahble by this compli- cation, Numerous pastes and ointments have had their day, but in the experience of the Clinic here, that of Ladd and Gross is the only satisfactory one. They recommend a combination of zine oxide oint- ment, castor oil, and aristol, made up into a_ thick paste. Others have favored yeast paste or alumium paste. Pressman suggested use of a vinylite resin prep- aration which can be coated onto the skin, but this layer is quickly freed from. the skin by the ileac secre- tions, and therefore gives Httle protection. John R. Paine called our attention here to the use of the Koenig ileostomy bag, a description of which was published by Baker.* This bag has a rubber ing which is fixed with rubber cement to the skin about the ileostomy stoma. The hag facing has an opening made to order to fit about 2 mm. around ihe slightly projecting bowel. In my experience, the use of rubber cement and rubber dam to protect the skin in the first few postoperative days, until a bag can be fitted, offers an cxcellent means of prevention of ulcerations and erosions. This may also be accom- plished with Ladd and Gross’ paste. The bag in my opinion offers the only satisfactory way to care for the ileostomies in these patients after they have be- come ambulatory. fac- Further Surgical Management.—In general, the opin- ion of those dealing wit should be done if two bouls of acute colitis occur after ileostomy. drainage conthiucs for more than a few months after ileostomy. Pseudopolyposis is precancerous and should dictate both ileostomy and calectomy, but thé fast as em. of *fectufh, Which Gar be watched with the tescope, may be saved in the hope that later heal will permit ileoprectostomy. . In performing colectomies, McNittrick, Lalicy, and Cave have ‘recommended staged operations, utilizing as many as four procedures to compicte removal of colon and rectum, and they all suggest the upper end of the segment left after each operation be brought through the abdominal wall as a mucous fistula, for secure closure cannot be assured in the involved colon. h this disease is that coigetomy tThe details of the technique employed at the present time are -published elsewhere. (Surgeyy—in press). *This is now obtained from HI. W. Rutzen, Road, Chicago. > - Marcu, 1945 t should also be done if pronounced. 1819 Irving Park. ° URGICAL SOCIETY \ In the experience here this procedure has proved nearly disastrous, and we fcel that if the entire colon is to come out, it should be removed with the rectum, if the rectum is to be removed, in one stage, for this itas given excellent results. The leaving of a mucous fistula has led in at least one instance to marked per- sistent pyoderma arcl deterioration of the. patient, com- promising subsequent management, Rankin recommends removal of the colon to below the peritoneal reflection with inversion end and closure of ‘the peritoneum above the The rectum can sutticient healing a point of the closure. then be observed at intervals, and, occurs, ileaproctostomy may subse- quently be done. Adequate inversion has been diffi- cult to obtain, for the walls are thickened and infect ed, and the lumen is small: pelvic abscess was a fre- quent complication until methods of sccure closure were developed. These are to be reported elsewhere.f This is nevertheless the procedure of choice, particularly in in whom impotence is the usual sequel of proctectomy, : A final type of procedure should be mentioned, name- reconstitution of the normal fecal pathway, either by simple closure of the ileostomy or by anastomosis, at some time after ileostomy, of the end of the ileum to the lower sigmoid or upper rectum with removal of the intervening bowel. Either of these procedures is pred- icated on prior complete healing of the bowel from the. proposed anastomosis to the anus, niales, ¥, cm ost tone, Ladd and Gross, and Cattell have all report- ec series of cases of successfully closed ileostomies. They all stress that ileostomy must be done very early in the disease if subsequent closure is to be tolerated without recurrence of symptoms of colitis. Experience with Chronic Ulcerative Colitis at University of Minnesota Hospitals 1934 to 1944 In the ten years from January 1, 1934, to January 1, 1944, eighty-two patients with chronic or acute non- specific ulcerative colitis have been seen at the Uni- versity of Minnesota Hospitals. Fifty-seven of these have been treated solely by nonoperative means as far ulcerative colitis is concerned, although some had drainage of perineal abscesses or other incidental surgery performed. Three patients are in- ciuded in this group who were treated by conserva- tive means until death was inevitable, and then were ou bjecte Untmproved .. nS Worse 2... 4h 1, Two of these refused iieostumy Complications: Large poychiatric Poly posis Others ... and left. COM PONeENnte Service has been. excellent, at least throughout the pen riod when I have observed it. Twenty-five individuals were treated surgically for ulcerative colitis.* These cases have excited the interest of various members of the surgical staff and have therefore been carefully followed, while there has been no one particularily interested in those treated conserva- tively, and the follow-up in a large proportion of those Cases is nonexistent or only of a few weeks. A comparison of the overall mortality Agures of con- servalive as against surgical management is offered in Table II. The medical therapy is not the subject of this review. An analysis of the causes of death in the conservative group is given in Table TIT. It should he mind that the follow-up was poor and that those listed as surviving have probably since died. The status of those surviving on conservative manage- ment is given in Table IV, borne in many GF The indications under which surgery was undertaken and the results thereof are indicated in Table V. As has already been stated, a great deal of trouble was encountered in the healing of ileostomy wounds until the adoption of the method of ileostomy indicated — *The author wishes to stress that the care of these patients was a joint effort. First Dr. O. He Wansensteen, Drs. W. OT. Peyton, W. TT. Avanson, aad nh been active in the fu patients, a : clusions presented and many successful Cases, come from the eHorts of this group as a svhole rather than from the writer aione. 232 SUI RGICAL SOCIETY TABLE V. INDICATIONS FOR SURGERY IN ULCERATIVE COLITIS 1934 to 1944 University of Minnesota Hospitals 2 & x ot z : at 22 § ve gk Es Es a xg Ls a S 3.e fos mh ts 3 3 ao = aS raw oe a lleostamy 7 I 10% 1 i 20 Colostany . 7 t Seynrental Reseciion 1 1 Primary Colectoiny and Leoproctostomy 2 2 Primary Total Co! ectomy and “Pull-through”™ 1 1 Total 8 i 14 i 1 25 I. One death due to improper surgery. 2. Patient died, TABLE Vi. INCIDENCE OF WOUND BREAKDOWN IN ILEOSTOMIES 1934 to 1944 University of Minnesota Hospitals . Late Primary Disruption Hernia or Late Healing of Wound Prolapse Stenosis Lteostumy, made . in incision 4 71 3 1 Leostomy made as described 6 0 1 0 1, Three healed after 1 to 12 months. | } Three were redone after o 3 montis ta 3 years. One died from massive wound breakdowa and. skin excoriation. Total ileostomies ......, tee eeeeee pevenee OF Total ileostomy pationts.....cccececeae eens 22 above. The results with ileostomy are indicated in Table VI. Evaluation of the factors contributing to erosion of the skin is impossible because there are inadequate notes in the charts concerning care of the skin, but in several of the earlier cases in which the measures outlined were not used, extreme erosion occurred. One case required transplantation of the ileostomy because of erosion alone, and another died of erosion and wound breakdown. In “the cases in the past one and a half years, which is the time in which the ileostomy has been made as described and in addition carefully protected by rubber dam and cement, there has been none but the most insignificant erosion. Fourteen patients have been subjected to colectomy of one type or another, and there have been no deaths in association with these operations, all patients being alive at the end of the study period. The present status of these patients as well as that of those not yet hav- ing undergone colectomy is indicated in Table VII. Cominent—One rightly concludes from Tables V and VIL that we have ample evidence in our own series of cases that when operation is necessary in the man- agement of ulcerative colitis, the procedure should be ileostomy and nothing else, for no other procedure has left us with a good result without subsequent operation. Tn other words, “shortcut” operations made in an effort to spare the patient one operation and the inconvenience, even if temporary, of an ileostomy have not been suc- cess{ul, Tt is my impression, therefore, that the colon should be pur at rest for a period of months or years and untit _complete subsidence of the inflammatory process in the MINNESOTA“MEDICINE MIN TABLE VII. SUBMITTING TO OPERATION FOR CHRONIC ULCERATIVE COLITIS 1934 to 1944 University of Minnescta Hespt tals Good Fay i "oor Dead Heoustomy only 3t 3 2 Heustomy, later colectomy in- cluding rectum 4+ Og 16 Qo leastormmy, later colectomy Jeaving rectum 2 0 6 . 0 Heostomy, later colveromy and anastomosis to sigmoid or . rectum 1 0 0 Primary colectomy and “pull. through ”’-—subsequent ileus. tomy i* 0 0 6 Primary colectomy and ileo- proctostomy . Qa J j 0 Segmental colectomy 0 1 0 0 Colostomy 0 Qo a "4 Total il 3 . (45.890) (20.3% ©) (16. 704 c) (8.3%) 1. One of these is now seriously Hl (May 1444) after effort at resection and anastomosis to invalved rectum, Recovered. 2. One still has some rectal discharge, one has Sinmmond’s Disease and one had skin eresion Jast scen, Wii. 3. One refused colectomy for pols and has carcinomatosis now. One has cancer, presumably, 4. One died of cancer of rectum; one of improperly doue ileostoniy, » Had only mucosa of rectum removed—still d 6. Vias ventral hernia and poor healing of peri 7. Has small (3 cm.) ve veral, nernia, 8. Very poor contre! aft rst operation; ion af of perineum and buttocks, w cvecht loss, pain. Later improperly done, Later properly revised, now well. NLRB. 4 cases of polyposis—2 of these develaned c sibly a third. skin had ileostomy cancer, Pos- rectum or lower sigmoid before attempts are made to remove the colon in these paticnts and anastomose the ilerm to the pelvic colon. Tn the majority of patients with advanced disease, this reanastomosis will never become feasible. Ta those given ileostomy very early it may become the rule. Conclusions 1. Careful surgical management seems to offer patients with nonspecific ulcerative colitis better hope of sur- vival and good health than the medical therapy em- ployed today. 2. Heavier emphasis should probably be placed on the psychiatric aspects carly im the disease. Tr is possible t arly ileostomy will { this and more effective therapy than we huve had in che past. that combination of offer 3. When surgery is necessary, ileostomy 15 the proce- dure of choice. If it is done properly, the artific: causes most patients little dificulty. 4.° Colectomy is indicated for bouts after Heostomy, of It should be dune in one stare. 5. Very early ileostomy should be conmtempla series of cases to test the promising suggest closure with good results will later be possible. References 1. Andresen, A. F. Ro: Gastro-intestinal allergy; its present satus. South, A. Jo. S4s41R, 1941, . 2. Baker, Joel W. Tleostomy preliminary to ocean of gastrey- tjejunocolic. fistula. Northwest Mea., 39:398, 19 3% Bargen, J. Arnoids The management of vicerative oontis. Gasiroenterol., 1:449, 1943. . 4. Bargen, f. Nenold : The Modern Management of Colitis. Spriugneld, Tilisiais : Charles ec, thomas, 1o48, 5. anaes de Pidladelphia: W. 3. Saunders ¢ 6. Cave, rR W. ulcerative colitis. Marchi, 1945 gieal treativent of intractabie, chronic hn Sur, dovisaG, 193s. PRESENT STATUS (JAN, 1, 1944) Ge PATIENTS | NNEAPOLIS SURGICAL SOCIETY 7. Cave, H. W., and Thompson, Tames EL: in the surgical treatment of ulcerative colitis. Mortality factors Ann. Surg., Ligs46, Jud. 8. Cattell, Richard B.: Closure of ileostomy in ulcerative ecaiitis. Aun. Sure. 1153956, 1942, 9; Cheney, € Vitamin By and liver extract in the treatment ai nonspecific diarrhea and colitis, Am. J. Digest. Dis., Ost61, 1439, 1. Crohn, H. Be: Vhe clinical use of succinyl sulfathiazole. Gastroenterol, Je 140, 1943, Th. Danieis Geo, Ke: Payeh iatric aspects of ulcerative colitis. gland J. Med. 2202178, 19-42, 12, edt, Leste. Ro Dack, G. M., and Kirsner, J. Tes ans Chronic wiverative colitis, A summary. of evidence impti- ag Bacterium necrophorum as an etiologic agent. Aan, Surin, 1147652, Ma 13. Elsem, Rendall A., and Ferguson, L. Kracer: An appraisal of the medical versus the surgical treatment of idtopathie ulcerative Sa Follow-up data on fifty cases. Am, J. ML oSe., 202559, U4), I Garieck, John is The surgical treatment of intractable jesrative colitis, Aun. Surg, P13s2, 1941, WRAL: Persons sb commuticarion, Thomas i. The surgical treatment of ulcerative MA. 111 12076, 10238, m EF. and ‘Gross, Robert F.: Infancy and Childhood, Abdominal Philadelphia: W. 3B. Hi.: Ulcerative colitis. New York State servations on etiology of ulcerative colitis, f. Se, PG7 2841, 1934, “Troms Jos VYhe medical management of chronic . La. MOA. 21222071, 1038. land S., and’ Miller, Richard H.: Idiopathic ulcerative colitis: A review af 149° cases with particular reference to Cie value of, and indications for, surgical treat. ment, wAun: Sure. 102 :656, 1935, 22. Mills, M.A. and Mackie, ‘T. T.: The chemotherapy of chronic uicerative colitis, Am, J. Digest, Dis., 10:55, 1943. 23. Presman, David: Ao new method of skin protection for Hesstomies and colostomies, Surgery, 13:322. 1943, shin, Fred W., Bargen, J. Arnold, and Buie, Louis .A.: The Colon. Rectum, and” Anus. Philadelphia: W. 3. Saunders Co., 1932, 25, Rankin, Fred W., Weorative ealitiay os Mood... $4406, 1041 che, EF. sner, J, 2B, and Palmer, WW. oT.: t of the oral administration of sulfonamide compounds se fecal Bera of patients with nouspecifce ulcerative colitis, Gastroenterol, 1:132, 1943. 27. ‘Rowe, Albert Ho: Chronic ulcerative colitis—allergy in its euolagy, Ann. Int. Med., 17:83, 1942, 28. Spink, WI OW.: Sulfanilamide and Related Compounds in General Practice. 2nd ed., Chicago: Year Book T'ublishers, 1942, 29, Stone, Hf. Be: Chronic ulcerative colitis. J., 32:211, Glan.) 1929 30. Streicher, M. IL: Sulfonamides : clinical evaluation in in- jectious diseases of the colon. M. Clin. North America, 27 3189, 1943. 31. Welch, C. S., Adams, M., and Wakefield, E. G.: ' Metabolic studies in chronic ulcerative colitis, J. Clin, Investig., 16: lol, 1937 32. Willard, J. H., Pessel, J. F., Hundley, J. W., and Bockus, OH. Ji: Prognosis of ulcerative colitis. J.A.M.A., VL: 2078, 1938. Coleman C.: Chronic ud Johnston, . its treatment. ial cunsiderations of Pennsylvania M,. Discussion De. Harry W. Curistianson: Thromboulcerative colitis-idiopathic ulcerative colitis is a disease of mani- test fascination and intrigue, which, during twenty- -tive has occuy fed a prominent Position in medical i, if is % aineas fy the rene an. in are Ie cS tit reserung im its cment we accept an attitude of defeatism, A few go 1 firmly believed that surgery was to he years resorted | to in but a limited number of cases, namely, those with serious complications. Further, it seemed that the disease was firmly entrenched in the wall of the colon and, hence, the performance of an ileostomy al- lowed the diseased bowel to remain behind, to be dealt with at a later date. One assumed that ileostomy, there- fore, merely complicated the situation by adding a “sec- ond rectum.” {t is apparent that surgery has a greater role in the management of ulcerative colitis, Dr. Dennis advocates ileostomy early in the course of the disease, earlier than has heretoiore been gencrally suggested, In retrospect, and in revicwing the presented data, it seems that we “233. NNEAPOLIS SURGICAL SOCIETY have been tardy, if not reticent, in suggesting ileostomy in the management of this disease. At the outset it is to be understoud that we are con- sidering thromboulcerative colitis and excluding any of the other tyres of ulcerative colitis, such as tuberculosis, amebiasis, allergic colitis, colitis with av itaminosis, bacil- lary colitis, lyr nphogranuloma venereum or the unknown types 2 and 3 of fargen® These are separate and dis- tinct entities which must Le painstakingly excluded by exhaustive clinical study and laboratory procedure, in order to establish the differential diagnosis. Each re- quires separate and distinct therapy. Although ileostomy seems, at this time, to be of con- siderably more value in the management of ulcerative colitis than was formerly believed, | cannot as yet con- cur with the present siieeestion as to the exact time of its performance. To do an iicostemy in every carly cuse -which exhibits an insufficient or delayed initial response to medical or consery ative management scems too radical an approach. J] have had the oppar tunity to observe a large number of patients with this disease who responded well to conservative therapy. As T sce them today, fully, recovered, I would have felt guilty, in the least, had f subjected them to the hazard and discomtort of an ileostomy ; for. in the majority f hands this procedure is fraught with difiicuity and danger. The surgical skill and ingenuity manifested by the excellent results Dr. Dennis has presented, might distract us from the real dangers attendant to this procedure. He has de- veloped a meticulous technique together with -a pains- taking and exhaustive pre-operative and postoperative regime of care in the management of these pationts, Pur- ther, in this connection, it is interes ing to note that this procedure is only effected, in his hands, under local anesthesia, Certain fairly definite indications for ileostomy and probably for subsequent parual or total colectomy, seem apparent at this stage in development of our knowledge of the management of throniboulcerative co- Nitis. On the other hand, certain other situations encoun- tered in this disease seem to contraindicate these surgical procedures. Hleostomy does not seem advisable as an emergency measure; nor does it seem advisable in in- stances of perforation of ihe bowel, or of acute fui- minating thromboulcerative colitis. Stricture formation, pseudo- polyposis or dual abscesses and fistulae, regard- less of the time element, constitute indications for lieos- tomy. Early thickening of the bowel wali, because of its potentiality for forming intramural abscesses, con- stitute an absolute indication for ileostomy. he ‘devel- opment of polyposis or pseuda- polyposis in the coton of ulcerative colitis renders ileostomy mandatory, coupled with a subsequent colon resection. The occurrence ot multiple anal abscesges or fistulae dictates the almost immediate performance of an ieostomy. To withstand surgical procedure the patient ulcerative colitis must be in comparative oly satisiactory condition, Manifest starvation and exhaustion, su often noted in patients with this disease, when it has heen allowed to progress, constitutes a situation most dif Beult to adjudicate. Durcther ummpeded prot on Gi the disease leads unequivocally ito rapid exodis, while on the other hand, the additten of the surgical trauma of an ileostomy most frequently eventuates in the same conclusion. The status of this patient is already so far gone that recovery cannot be effected. The physiological pre-operative preparation of these patients, as empioyed by Dr. Dennis, considerably reduces this hazard. How- ‘ever, we are in agreement on the point that the pauent should not be allow ed to progress to this extreme status of affairs, but rather, that an ileostomy should be per- formed sufficiently early to obviate this possibility. The time for the performance of a colectomy, after preliminary ileostomy, must be ascertained in each indi- *Type 3 af Bargen ren: resents the form involving the rectum and rectos: gmoid. “Vype 2 UnVvOIves the remainder of the coien, mot the rectum and “rectosigmoid, 234 with © vidual case. IT agree that one should not be in haste, but, rather, that one should allow sufficient time to elapse in order to ensure complete subsidence of inflam- Ration of the affected bowel. In some cases the rectum can be preserved and. an ileoproctostomy effected. This procedure should he reserved for those ileostomy patients in whom the stools have become solid (all suggestion of watery or liquid stools or diarrhea has subsided). Curther, before this procedure can be contemplated all inflammation and ulceration in the rectum must have. abated. Tn conclusion, I wish to state that Dr. Dennis should be commended for his painstaking Jabors in obtaining remarkable results, Thromboulcerative colitis con- stitutes a severe and mysterious malady with which in nuiny. respects we are still unfamiliar, and, it is only with work such as that which has just been presented that progress is made. De. Dennis (closing) : IL would like to add a few words. In the first place. I am very flattered to have been asked to taik tonight. It has been a much ap- pr eciated pr iv ilege. { want to say a word about Doctor Christianson’s remarks. I am impressed with his bringing out one indication for ileostomy which I had overlooked, and that was the matter of abscess and fistula formation in the rectum. I happen to know of one case in which this was the indication for which ileostomy was per- formed. Doctor Paine did the procedure, as that was before my interest in the disease. In this matter of hemorrhage, my serics has heen Limited to but one case, so what [| say about hemorrhage should be taken with many grains of salt. In this case liecding was profuse, over a liter of blood every day before ileostomy. The conclusions in the patients we have been able to low are thar the paticnts who develop ulcerative itis are never entirely tree of trouble and are always to exacerbations of the disease. fam elad Dr. Christianson brought out the matter e type of colitis under question. My comments have been intended to- apply to nonspecific ulcerative colitis, and not to the other types. iol o} subj us oO tis ypect Ernest R. Anpverson, M.D. : / Recorder MINNESOTA MEDICINE