[Low ileorectal anastomosis in the surgery of ulcerative rectocolitis]

The authors report their experience of 23 patients with ulcerative colitis treated with surgery from 1991 to 1994. At admission 8 patients had a high-grade illness, 10 patients had a middle-grade illness, 5 patients had a toxic megacolon. All the patients were treated with systemic medical management (mesalazine + methylprednisolone) and topical medical management with rectal steroid (methylprednisolone) and rectal mesalazine by enema, and with nutritional support (Total Parenteral Nutrition). The 5 patients with toxic megacolon, after 48 hours of unsuccessful medical management, underwent surgery with deferred urgency; the other 18 patients underwent surgery after one-four months. The authors prefer the ileorectal anastomosis (IRA), since the rectal lesions are more susceptible to topical therapy. A single-stage IRA was performed in 17 patients. A sigmoid resection has been employed in the first stage in the 18th patient with a local development of the disease in the sigma; a following relapse of the lesions required a total colectomy with a low ileorectal anastomosis. A first-stage subtotal colectomy with ileostomy and Hartmann closure of the rectum with low ileorectal anastomosis at a later date was performed in the 5 patients with toxic megacolon. One of these, 18 years old, died after a heart failure. After surgery, as soon as the patients start moving their bowels all of these had again a systemic therapy with mesalazine for a short period and after they had a topical therapy with mesalazine + methylprednisolone by enema, for a long period. The average postoperative period of admission was 16.3 days. The functional results have been encouraging with an average of 1.6 bowel movements daily and an average of 0.4 nocturnal bowel movements. All the patients had a normal anal sphincter function with an acceptable stool frequency. In male patients there no urinary or sexual defects. In one case of these, there was a low grade of dysplasia, revealed by endoscopic biopsy. The authors conclude that today surgical treatment of ulcerative colitis is not well established.