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The aim of a defunctioning ileotomy after restorative proctocolectomy is to mitigate the consequences of pelvic sepsis, should it occur. However, there are complications related to the ileostomy itself. Of 310 patients (174 male and 136 female; mean age 33.2 years) who underwent restorative proctocolectomy between 1976 and 1990, 296 had a covering ileostomy and 14 did not. The stoma has been closed in 263 (88.9 per cent) at a median interval from formation of 12.0 weeks. Ileostomy-related complications before closure occurred in 17 patients (5.7 per cent). Laparotomy for obstruction due to the ileostomy was required in seven patients (2.4 per cent). Retraction requiring revision occurred in three patients (1.0 per cent), an abscess behind the stoma in one (0.3 per cent) and miscellaneous appliance problems in seven (2.4 per cent). Following closure, 59 patients overall (22.4 per cent) developed an ileostomy-related complication. There were 30 cases of small bowel obstruction, treated conservatively in 19 (7.2 per cent) and by laparotomy in 11 (4.2 per cent). Peritonitis requiring laparotomy occurred in three patients (1.1 per cent) and two (0.8 per cent) developed an enterocutaneous fistula. There were 14 (5.3 per cent) wound infections and 16 (6.1 per cent) other miscellaneous problems. Significant complications associated with a temporary ileostomy were less frequent in this series than in some other reports. Obstruction was the most common complication and fistula was rare.

Since 1954, 34 patients have attended St. Mark's Hospital with pyoderma gangrenosum in association either with ulcerative colitis (22 patients) or Crohn's disease (12 patients). Lesions were multiple in 71 per cent and over half were situated below the knees. Ulcerative colitis was active in 11 patients (50 per cent) and Crohn's disease was active in nine (75 per cent) when pyoderma gangrenosum was diagnosed. Associated illnesses - most commonly a seronegative arthritis affecting large joints - were present in 55 per cent and 92 per cent of cases respectively. A diffuse pustular rash appeared in six patients, synchronously with pyoderma in five. In a further seven patients (two with ulcerative colitis, five with Crohn's disease) the onset or course of pyoderma might have been linked to the presence of non-dermatological suppuration. Pyoderma resolved without intestinal resection in two-thirds of patients. When present at the time of surgical resection (15 procedures in 13 patients), pyoderma healed promptly in six cases, only with additional therapy in four cases and very slowly or not at all in five cases. Pyoderma gangrenosum occurs in both ulcerative colitis and Crohn's disease. Healing after intestinal resection is unpredictable both with respect to timing and extent of resection.

The case notes of all patients treated for ulcerative colitis by colectomy and ileorectal anastomosis at the Gordon Hospital under the care of Mr S. O. Aylett from 1952 to 1976 have been reviewed. Three hundred and seventy-four patients left hospital with an ileorectal anastomosis and have been followed for periods up to 23 years. Twenty-two patients are known to have developed a carcinoma of the rectum. Within 10 years of the onset of the disease, no rectal carcinoma was found in 3534 patient-years. The risk was 1 in 185 patient-years between the tenth and twentieth years and 1 in 115 patient-years between the twentieth and thirtieth years. The cumulative risk was 6 per cent (± 2 per cent) at 20 years and 15 per cent (± 4 per cent) at 30 years. The need for meticulous follow-up is emphasized. The finding of dysplasia in rectal mucosal biopsies will, it is hoped. identify the patient at particularly high risk and enable rectal excision to be undertaken before carcinoma develops.

Delay in healing of the perineal wound is a major cause of disability in patients after excision of the rectum. The outcome of primary suture in 76 patients treated at St Mark's Hospital between 1967 and 1976 was correlated with a number of factors describing the patients, their preparation for surgery and details of surgical technique and management. The perineal wound healed by first intention in 33 patients. The remaining 43 patients regarded as failures included 7 with delayed breakdown after initial healing. The results showed that women fared better than men. Excision of the rectum following colectomy and ileostomy was associated with failure of the perineal wound to heal in 9 out of 10 patients. Treatments with peroperative ampicillin and topical antibacterial agents were both correlated significantly with success. Preoperative sepsis and operative contamination were followed by perineal sepsis and wound breakdown on 16 out of 21 occasions. Discriminant analysis showed that topical and peroperative antibacterial treatments, sex, preoperative sepsis and finally ACTH were the most important variables in descending order of importance. The prediction of success and failure by this procedure was 72.4 per cent correct.

The complications of synchronous combined excision of the rectum for adenocarcinoma in 227 patients were analysed. Urinary retention with infection occurred in 78 patients (34-4 per cent) and was the commonest complication. There was a significant correlation between tumours involving the anterior quadrants of the rectum and urinary complications. Primary suture of the perineal wound with closed drainage was associated with a higher incidence of complications than open drainage. The cumulative risk of a paracolostomy hernia in the sixth postoperative year was approximately 33 per cent. Extraperitoneal colostomy gave some protection against paracolostomy herniation.

The surgical treatment of 3163 patients seen at St Mark's Hospital with a single adenocarcinoma of the rectum in the years 1948–72 is described and the results analysed. In 2948 patients (93·2 per cent) the primary tumour was removed. The operative mortality fell from 7·0 per cent in the years 1948–52 to 2·1 per cent in 1968–72. The proportion of restorative operations has risen steadily over the years to a level of 41·1 per cent in the years 1968–72. There were 2410 operation survivors in the years 1948–67, The crude 5-year survival rate in the whole group was 47·1 per cent (corrected figure 56·7 per cent), and 56·6 per cent (corrected figure 68·4 per cent) for the 1931 survivors of radical operations. Comparison of results for patients surviving radical synchronous combined excision and radical anterior resection shows a significant difference in the two groups: in the former the crude 5-year survival rate was 52·7 per cent (corrected figure 63·8 per cent), and in the latter group the respective figures were 66·7 and 79·4 per cent. A higher proportion of Dukes' A and B cases and of low grade tumours are shown as the pathological background to the more favourable prognosis for patients surviving radical anterior resection.

An analysis is presented of 143 patients with early colorectal carcinoma treated by local excision between 1948 and 1972 at St Mark's Hospital. The tumours are considered in three groups; colonic tumours, pedunculated rectal tumours and non-pedunculated rectal tumours. The importance of careful clinical assessment and accurate pathological examination is emphasized. Local excision of the tumours, using various operative techniques, gave good results and this method of management can be recommended in the carefully selected case.

At St Mark's Hospital survival after radical surgery for cancer of the rectum has not changed significantly over the past 30 years. The technique of extended abdomino-iliac lymphadenectomy was developed in an attempt to improve prognosis in patients considered to have particularly unfavourable tumours. Between 1960 and 1981 the technique was used in 75 patients with a single adenocarcinoma of the rectum. Two patients died postoperatively and 52 patients developed complications; a mortality and morbidity similar to those seen after conventional surgery at this hospital. Five-year survival rate showed no improvement over that achieved by conventional techniques; disappointingly this was also the case for patients with Dukes' C1 tumours. The results of this study suggest that an improvement in survival in patients with cancer of the rectum is unlikely to be achieved by any extension of conventional radical surgery.

Summary Restorative resection is being used increasingly for carcinoma of the mid rectum but it is not yet certain whether this operation is as curative as total excision. Between 1963 and 1972, 209 patients left St Mark's Hospital after a radical operation for a single rectal carcinoma situated between 8 and 12 cm from the anal verge. A total of 199 patients was followed up for 5 years. Of these, 112 had been treated by total excision of the rectum and 87 by restorative operation. Survival was correlated with the Dukes' stage, histological grade and extent of local spread in the two groups. There was no significant difference in 5-year survival after either total excision or restorative resection for Dukes' B (74 per cent, 71 per cent respectively) or average grade (61 per cent, 73 per cent respectively) tumours. Patients with Dukes' C tumours fared better when treated by restorative resection (36 per cent, 63 per cent), probably due to fewer high grade tumours in the restorative group (38 per cent, 18 per cent). Combining two variables, survival was not significantly different for patients with Dukes' B tumours of average grade (69 per cent, 62 per cent) or for Dukes' C tumours of average grade (48 per cent, 76 per cent). When the three pathological variables were combined, there was an improved survival after restorative resection for some pathological combinations. It is concluded that restorative resection for carcinoma of the mid rectum is as curative as total excision in terms of 5-year survival.

In a review of cases of colorectal cancer presenting to St. Mark's Hospital over the 16-year period 1970–85, 59 patients were found to have a synchronous carcinoma (3·4 per cent). Although 82 per cent of these synchronous tumours were distal to the splenic flexure (and hence within reach of a 60 cm flexible sigmoidoscope) only 42 per cent were detected pre-operatively: the remaining tumours were noted at surgery (24 per cent) or found incidentally on pathological examination of the resected specimen (34 per cent). Histological examination of these synchronous lesions revealed a high proportion with favourable stage (Dukes' A — 75 per cent) and grade (well or moderate differentiation - 90 per cent). Over the same 16-year period, 10 patients presented with an ‘early’ metachronous lesion (

Between 1971 and 1978 at St Mark's Hospital and St Bartholomew's Hospital, 8 patients were seen with a psoas abscess complicating Crohn's disease. All patients had a long history of disease and the diagnosis was usually obvious on clinical grounds. The abscess was drained in all patients and 5 required drainage on more than one occasion. The underlying Crohn's disease was treated surgically in all patients. Seven patients are now well, although 2 have required further excisional surgery; 1 patient died 2– years after the first drainage of the psoas abscess.