Report and discussion of five cases in general surgery

Abstract

Colonic dilatation during a severe acute attack of ulcerative colitis usually occurs at the initial presentation of the disease and is often referred to as toxic megacolon. Toxic dilatation of the colon may also occur in Crohn's disease and occasionally in amoebiasis, ischaemic colitis, pseudomembranous colitis, obstructing tumours and Hirschsprung's disease.Although colonic dilatation in acute colitis may respond to medical therapy, toxic megacolon requires surgical intervention. This bowel tends to fall apart with the gentlest handling at operation and even when surgery is performed prior to perforation, there is an increased risk of postoperative peritonitis and abscess.Perforation of the during severe attacks of colitis. This may be a frank opening from the bowel into the general peritoneal cavity leading to a diffuse faecal peritonitis, or alternatively it may be found that the part of the colon penetrated is firmly adherent to the anterior or lateral abdominal wall or to an adjacent viscus, so that the hole in the bowel is in effect sealed off and there is no general peritoneal contamination. With regard to open perforations, it is obvious that, whatever is done surgically at operation, post operative peritonitis will be one of the major hazards and will require management including peritoneal irrigation at the conclusion of the laparotomy and massive systemic antibiotic therapy during and after the operation. Probably the best operative plan in these patients is to press on with ileostomy and colectomy, making an effort to control further leakage of faecal material into the peritoneal cavity by the judicious use of the sucker inserted into the bowel early in the operation.In dealing with sealed perforations, however, if a colectomy is performed, this will result in unsealing the perforation with consequent contamination of the peritoneum. This can be avoided by making an ileostomy alone or caecostomy as suggested by Klein et al (1960). Truelove et al (1965) employed a double -barrelled ileostomy combined with installation of steroid solutions into the colon in 14 emergency operations for colitis and had four failures (as indicated by operative death or by need for a subsequent emergency colectomy). Turnbull et al (1970) favoured a loop ileostomy combined with a decompressing transverse (and possibly sigmoid) colostomy. In 26 patients treated by this method for severe attacks of colitis, there was only one operative death. Of the 25 survivors, 12 patients required emergency colectomy during the 6 months after operation and 13 patients proceeded to elective colectomy.Extensive peritonitis is still associated with significant morbidity and mortality rates. The concept of mechanically cleansing the peritoneal cavity using lavage is not new, being first advocated for use at the time of operation by Nolan in 1893. In 1957, Burnett et al reported the advantages of adding antibiotics to the operative lavage, and McKenna et al in 1970 halved the mortality rate with the use of continuous antibiotic lavage. Stephens and Loewenthal (1979) treated 27 patients by continuous postoperative peritoneal lavage with 6 deaths, and mention that in a former series of 68 patients treated by perioperative lavage alone, combined with a course of postoperative systemic antibiotics, there were 33 deaths.Although these new techniques have been introduced peritonitis still remains a significant cause of morbidity and mortality.