Management of the rectum following colectomy for acute colitis.

During a 6 year period, 31 consecutive patients under the care of one surgeon had emergency colectomies for complicated colitis. A selective policy of closing the rectum intraperitoneally to minimize the length of retained diseased bowel and to avoid a mucus fistula was used during the study period. One patient underwent proctocolectomy, 7 subtotal colectomy with mucus fistula and 23 total colectomies with intraperitoneal closure of the rectum. Two patients (8.9%) developed pelvic sepsis. Both had intraperitoneal closure of the rectal stump and were readily managed by drainage into the stump. Subsequent surgery in the 18 patients having rectal excision has been uncomplicated. Intraperitoneal closure of the rectal stump in emergency surgery for complicated colitis can be performed safely in most of these patients.

Mesenteric fibromatosis preventing restorative proctectomy.

A case is reported illustrating the dilemma of encountering mesenteric fibromatosis during restorative proctectomy for familial adenomatous polyposis.

Day case anorectal surgery.

All patients referred to the University Department of Surgery, Wellington Hospital, Wellington, New Zealand, with minor anorectal conditions requiring surgery were considered for day case surgery. Eighty-three per cent of the patients were found suitable for day surgery. One hundred patients underwent 103 procedures under general anaesthesia. Admission to hospital from the day care facility was required for four patients; two for bleeding, one for pain and one for drowsiness. One patient required readmission due to inability to cope at home. Twenty-six per cent reported severe pain. Eighty-nine per cent found day surgery to be convenient and preferable to inpatient surgery. Eleven per cent found day surgery inconvenient and would prefer inpatient surgery in future. It is suggested that many anorectal procedures can be performed on a day case basis in selected patients, with safety and convenience. It is well tolerated and accepted.

Bechet's colitis: a differential diagnosis in inflammations of the large intestine.

A previously well 39 year old woman presented with severe localized and painful anorectal ulceration. There were no other associated symptoms apart from arthritis of the hips and fingers. In the absence of definitive tissue diagnosis, a presumptive diagnosis of Crohn's disease was made. After a period of progression, the inflammation and ulceration subsided with conservative therapy. Following a relatively symptom-free period of 7 years, painful ulceration recurred in the same segment of bowel, which was refractory to steroid therapy but responded to defunctioning of the rectum. Upon excision of the defunctioned rectum, multiple discrete ulcers developed in the remaining colon, with a fistula from the distal sigmoid colon to the midline wound. The patient simultaneously developed painful apthous ulceration of the mouth and throat, and pustules appeared on the perianal skin and trunk for the first time. A colectomy was performed, with good results. The pathology of the colonic lesions is described. The characteristic appearance of these lesions, together with associated 'major' and 'minor' clinical criteria, enabled a diagnosis of Bechet's disease to be made. Although there is some overlap, particularly in the distribution of this condition with Crohn's colitis, the pathologic appearances in Bechet's colitis are relatively distinct. A diagnosis of Bechet's colitis should not be excluded in a patient presenting with atypical inflammatory bowel disease, even if associated clinical criteria are not simultaneously present.

Presentation, duration of symptoms and staging of colorectal carcinoma.

A prospectively recorded, consecutive series of 155 colorectal carcinoma specimens clinically and pathologically staged according to the Australian Clinico-pathological System (ACPS) between April 1987 and May 1989 at Wellington and Kenepuru Hospitals is reviewed. Clinical records were available for retrospective review for 146 of the 155 patients. Change in bowel habit, rectal bleeding and abdominal pain were the most common presenting symptoms. Thirty-five patients presented as emergencies, twenty-six with obstruction and nine with perforation. Abdominal pain resulted in the earliest surgical intervention. The median duration of symptoms prior to diagnosis was 3 months. No correlation existed between tumour stage and duration of symptoms. Earlier diagnosis during the symptomatic phase of colorectal carcinoma is unlikely to contribute significantly to improved overall survival.