The continent ileostomy--an 11 year experience.

An 11 year experience of the continent ileostomy is reported. Forty-nine patients have undergone a continent ileostomy during this period. There were 30 females and 19 males. The mean age was 35 years, the youngest 19 and the oldest 58. Forty-four patients were suffering from chronic ulcerative colitis, four from polyposis coli and one from carcinoma of the rectum and multiple colonic polyps. The majority (41) of operations were carried out as secondary procedures but eight were done as primary procedures. The follow-up varies from 11 years to three months. There were no deaths. Seventeen patients (34%) required revisional surgery for complications relating to the valve reservoir or stoma. Eleven of these were related to the valve--slipping four, prolapse five, fistula and perforation one each. Three patients had a para-ileostomy hernia and two a stricture at skin level. Four patients required excision of the reservoir with establishment of an orthodox ileostomy. Eighty-six per cent of patients are continent and never wear an appliance. The average capacity of the reservoir is 400 ml (range 150-900). Most patients catheterize three times daily (range 2-6). Eighteen per cent catheterize once at night. The average time for catheterization is 6 min. Provided the procedure is technically satisfactory the continent ileostomy is considered the operation of choice for patients requiring a permanent ileostomy.

Proctocolectomy without ileostomy: ileo-anal anastomosis with an ileal reservoir.

Six patients with polyposis coli and five with chronic ulcerative colitis underwent total colectomy and mucosal proctectomy with preservation of the anal sphincter and levator ani muscle. An ileal reservoir, constructed from the terminal ileum, is brought out through the anal sphincter for anastomosis to to the anus at the dentate line. Two patients in the series had a three-limb reservoir with anastomosis of a short efferent ileal limb to the anus (Parks technique). Nine patients had a two-limb J-shaped reservoir with the apex of the reservoir anastomosed to the anus (Utsunomiya technique). All patients had a temporary defunctioning ileostomy. There were no deaths. Two patients suffered from severe infection within the rectal muscle cuff. One resolved completely with spontaneous drainage into the reservoir; the other had continuing sepsis and eventually required excision of the anus and conversion to a continent ileostomy. All patients remain in good general condition with no disturbance of urinary or sexual function. Continence is satisfactory in all patients but two wear a pad at night. All evacuate their reservoirs spontaneously: none requires the use of a catheter. For most patients stool frequency varies from four to eight times daily but two patients have more frequent bowel motions. Colitis patients have more frequent bowel activity than those with polyposis. Three patients take Imodium tablets to lessen bowel frequency. The operation should be reserved for specialized centres and is still under trial; however, it appears likely to become the operation of choice for all patients with polyposis coli and for many patients with chronic ulcerative colitis.

Hemoccult II test: routine screening procedure for colorectal neoplasm?

In October, 1978, the Hemoccult II Test was introduced as a screening procedure by the Sydney Hospital Heath Information and Screening Service. In the first two years, 4498 people were screened and 150 positive results were obtained. These people were referred for further investigation, with 114 choosing to attend the Edward Wilson Colon and Rectum Unit outpatient clinic at Sydney Hospital. Forty-four patients were found to have 59 colorectal neoplasms of which 13 were carcinomas. This represents a cancer incidence of 0.29% and corroborates the results of similar studies conducted overseas.

Irradiation injuries of the large intestine.

A series of 15 patients suffering from irradiation injuries to the large bowel is reviewed. Ten patients required surgical intervention, initially a diverting stoma in eight; intestinal continuity was re-established in three patients. Loop ileostomy may be preferable to loop transverse colostomy for fecal diversion, as the former is easier for the patient to manage, and ensures that there is no interference with blood supply to the colon should an abdomino-anal pull-through procedure be indicated later to restore continuity. As only three of the patients developed recurrent carcinoma, the initial operation for irradiation injury to the large bowel should be carefully planned so that the patient is not ultimately cured of carcinoma but left with a permanent stoma.

Prophylactic administration of low-dose heparin in colorectal surgery.

A retrospective study of 192 patients operated on by three members of the Edward Wilson Colon and Rectum Unit, Sydney Hospital, was carried out. All operations performed involved dissection within the pelvis. Prophylactic administration of low-dose heparin was used for 71 of these patients. The incidences of clinical thromboembolic disease were 7 per cent in both the group receiving heparin and the other group. In slightly more than half of the patients, pulmonary emboli occurred in the absence of peripheral deep venous thrombosis. It is suggested that the source of these emboli was thrombosis arising in the pelvic veins.