John Alexander-Williams

Natural history of perianal Crohn's disease: Ten year follow-up: A plea for conservatism

A 10 year follow-up of 109 patients with histologic Crohns disease and anal lesions is reported. Fourteen patients (13 percent) have died, 7 from unrelated disorders. Ten required excision of the rectum, but only 5 for perianal disease (4.5 percent). Of the remaining 85 patients, 61 have been followed up to proctoscopy and rectal biopsy. Anal skin tags were still evident in 25 of 37 patients (68 percent), but new tags have appeared in only 2 patients. Ten of 53 fissures (19 percent) were still present at 10 years, and there were no new fissures. Seven of 21 patients (33 percent) still had fistulas but were asymptomatic; the remainder of the fistulas had healed spontaneously (8) or after operation (6). New fistulas have appeared in five patients. None of the patients have been in continent. These results indicate that perianal manifestations of Crohns disease pursue a relatively benign course and are rarely an indication for proctectomy.

Comparison between systemic and oral antimicrobial prophylaxis in colorectal surgery.

In a prospective randomised trial in which 93 patients undergoing elective colorectal operations were given a short prophylactic course of metronidazole and kanamycin orally or systemically, postoperative sepsis occurred in only 3 (6.5%) of those given antimicrobials systemically, compared with 17 (36%) of those given oral prophylaxis (P less than 0.01). 15 of the 17 infections in patients who received antimicrobials orally were due to kanamycin-resistant bacteria present in the colon at operation. Bacterial overgrowth of Staphylococcus aureus was recorded in 6 of the patients who received oral therapy. Antibiotic-associated pseudomembranous colitis occurred in 7 patients, 6 of whom had received prophylaxis orally. These results indicate that oral administration of prophylactic antimicrobials in colon surgery should be avoided because of the risks of bacterial resistance, superinfection, and antibiotic-associated pseudomembranous colitis. Systemic per-operative antimicrobial prophylaxis is safer and more effective.

Carcinoma in a rectovaginal fistula in a patient with Crohn's disease.

A patient with Crohns disease underwent resection for internal fistulas. Later a rectovaginal fistula developed that persisted with minimal symptoms for 10 years before causing pain and induration in the posterior vaginal wall, due to carcinoma developing within the fistula.

Comparison of three methods of whole bowel irrigation

Sixty-two patients undergoing colorectal surgery or colonoscopy were prepared by three methods of whole bowel irrigation: nasogastric saline solution alone, nasogastric saline irrigation with oral mannitol, and oral mannitol solution without saline. The additional of mannitol to saline irrigation reduced the risk of sodium and water retention, which was eliminated by oral mannitol alone. The best mechanical preparation was achieved by adding mannitol to saline irrigation, but oral mannitol alone was judged more acceptable by the patients and less demanding by the nursing staff and was the preparation of choice for colonoscopy.

DIARRHŒA AND PSEUDOMEMBRANOUS COLITIS AFTER GASTROINTESTINAL OPERATIONS: A Prospective Study

241 patients who had gastrointestinal operations were studied prospectively. Postoperative diarrhoea occurred in 58 patients (24%) and was significantly more common after exposure to antibiotics. 9 patients (4%) had high titres of a neutralisable faecal toxin characteristic of pseudomembranous colitis. Toxigenic Clostridium difficile strains were isolated from the stools of all patients with neutralisable faecal toxin. If pseudomembranous colitis is defined as the presence of neutralisable faecal toxin, then the diagnosis is often missed by sigmoidoscopy and rectal biopsy.

Postoperative Gastric Retention and Delayed Gastric Emptying

Since the beginning of the era of gastric operations, surgeons have been aware of the complication of delay in emptying of the stomach. There is no absolute criterion of diagnosis of delayed gastric emptying but we suggest the arbitrary definition of failure to establish adequate emptying of fluids through the pylorus or stoma by the fifth postoperative day.