Surgery of aggressive idiopathic proctocolitis and principles of rectal preservation.

During 1969-1985 seventy-one patients with aggressive idiopathic disease of the large intestine (i.e. ulcerative and Crohn's proctocolitis) were treated by colectomy and ileorectal anastomosis (IRA). In sixty-two of them proctitis was associated with colitis and required topical preparation of the rectum. The use of an antiphlogistic drug (6-methylprednisolone or betamethasone) in saline solution by daily enemas was followed by proctitis regression and permitted a safe IRA. After the surgical procedure the rectal treatment with the same drugs in smaller doses continued, so as to prevent long-term side effects. In some patients the steroid was replaced periodically by sulphasalazine per os or by 5-ASA per rectum in a daily maintenance dosage. This rectal care for unlimitated time has proved able to prevent recurrences of proctitis, while the epithelial recovery with regression of dysplasia gives protection against the risk of cancer.

Proximal gastric vagotomy and anterior fundoplication as complementary procedures to Heller's operation for achalasia.

While Heller's myotomy has become the accepted operation for achalasia, still, there is no agreement about the indications for and choice of complementary procedures to minimize subsequent acid esophageal reflux. In the instances described in this investigation Heller's operation was accompanied by proximal gastric, or highly selective, vagotomy and anterior fundoplication. Dysphagia was abolished and normal alimentation restored in all but one patient, who was elderly and had an advanced megaesophagus. In every patient after the operation, results of pH-manometry, acid reflux tests and endoscopy demonstrated the absence of both acid reflux and esophagitis.

[Ulcerative colitis and Crohn's colitis. Medical or surgical treatment]. / Colite ulcerosa e colite di Crohn. Terapia medica o chirurgica?

Colectomy with ileorectal anastomosis was performed in 47 patients affected by ulcerative colitis and Crohn's colitis. These two forms of "aggressive idiopathic colitis" present the same problems of therapy from both the pharmacological and the surgical point of view. The topical employment of antiphlogistic steroids and sulphasalazine by daily retention enemas caused a regression of proctitis and allowed a safe ileorectal anastomosis. After the surgical procedure a protective treatment of the rectal mucosa was prosecuted with minimal dosages of the same antiphlogistic drug by daily minienemas. Betametasone in aqueous solution have proved, among the antiphlogistic steroids, to be very suitable for a topical action without side-effects in the long time. The association of topical treatment and surgery is particularly indicated for those patients who cannot recover with medical therapy alone, as it enables them to recover and return to a normal life. The opportunity for colectomy is so much greater as it is possible, as a rule, to spare the rectum and protect the ileorectal anastomosis by means of a topical therapy without limitations of time. Therefore the surgical indication should not be delayed whenever the medical treatment by systemic administration of steroids, sulphasalazine and immunosuppressors is unable to prevent the evolution of aggressive idiopathic colitis to a chronic and seriously invalidating disease.