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Outcome in all 167 patients treated by radical local excision for rectal carcinoma between 1948 and 1984 at St Mark's Hospital was assessed in terms of the original tumour differentiation except for 15 patients with incomplete follow-up or ungraded tumours. Fifty-six of the 152 patients had low-grade tumours, with one death from carcinoma in this group. Of 81 patients with average-grade tumours, ten died from carcinoma of the rectum: two after early reoperation and eight following recurrence. Six of 15 patients with high-grade tumours underwent early reoperation and three of these died from carcinoma. Among the nine patients who did not undergo early reoperation there were three related deaths (two from carcinoma, one after rectal excision for recurrence). Local excision remains a valid therapy for suitable patients with low-grade tumours but is not recommended for those with average-grade lesions. The necessity for early reoperation in patients with high-grade tumours is questioned.

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.

This study describes the clinical features and management of 80 patients with Crohn's disease affecting initially only the rectum with or without involvement of the sigmoid colon. Most patients were treated medically, and the various measures used are considered; the cumulative probability of completing five years under conservative management was 60% among survivors. The related mortality was very low and confined to patients treated surgically; with 655.24 patient-years of follow-up the number of observed deaths was lower than the number expected from all causes. Since this distribution of the disease is usually seen in older patients and carries a favourable prognosis, it it suggested that it should be considered as a well-defined variant of the condition.

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.

There is doubt about the timing of surgery for patients with internal fistulas in Crohn's disease. Although immediate operative intervention for all patients has been advocated, such a policy has not always been followed at St. Mark's Hospital. Between 1971 and 1982, 83 internal fistulas were identified in 59 patients with Crohn's disease. Fifty-nine fistulas arose primarily from the small intestine and involved another segment of the bowel, five were between large bowel and duodenum, and three between areas of large bowel. Sixteen fistulas (ten from ileum and six from large bowel) involved the bladder. Thirty-six patients with 54 fistulas underwent immediate surgical treatment. Fifteen patients with 20 fistulas required surgery later. There was one postoperative death among the 51 patients treated surgically and one late death unrelated to the treatment of the fistula. Of the remaining 49 surgically treated patients, 46 were traced and remain well, six after further surgery. Eight patients with nine fistulas (four involving the bladder) were treated at St. Mark's without operation. One later required surgery elsewhere for an enterocutaneous fistula, but the remaining seven patients are well. This study suggests that the presence of an internal fistula, even if it involves the bladder, is not an absolute indication for immediate surgery and that the severity of the symptoms should dictate the treatment policy.

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.

The technique of intersphincteric excision of the rectum in patients with inflammatory bowel disease was introduced with the aim of avoiding postoperative sexual dysfunction and, combined with primary perineal suture, should decrease morbidity from delayed perineal wound healing. In a series of 98 patients so treated at St. Mark's Hospital, permanent sexual dysfunction from sympathetic nerve damage occurred in one male patient among 23 aged 60 years or less assessed postoperatively. No patient exhibited evidence of permanent parasympathetic nerve damage. Primary healing of the perineal wound was successful in 50 per cent of the cases and in 69 per cent the wound healed within three months of operation. It is suggested that this combination of operative techniques significantly decreases morbidity from rectal excision compared with more extensive procedures and should be more widely adopted.

Case records have been studied for the results of surgery in 294 patients operated on for inflammatory bowel disease during 1967-72 at 34 non-teaching hospitals within the North-east Metropolitan Hospital Region. All patients treated surgically for acute colitis and those treated for chronic disease by total colectomy were included. The postoperative mortality of the primary surgery was 23·7%. The mortality was 2·1% in patients treated by elective operation, 37·6% in patients coming to urgent operation, and 60·9% in patients treated by emergency operation. The three most important factors affecting the mortality were considered to be: increasing age of the patient, the presence of established colonic dilatation, and preoperative perforation of the colon.

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 (

There is little information on the natural history of anal fissure in Crohn's disease. The case notes of all new patients with Crohn's disease attending one hospital between 1977 and 1983 were reviewed: there were 61 patients with this diagnosis and an unhealed anal fissure as the only anal lesion. of these 61 patients the fissure healed in 42 (69 per cent) during medical treatment of the intestinal disease. Ten patients (16 per cent) developed other anal lesions and in the remaining nine patients the fissure remained unhealed at the time of rectal excision (six) or last out-patient attendance (three). Activity of the fissure did not reflect disease activity elsewhere in 11 cases in whom healing of the fissure occurred despite progressive intestinal disease subsequently requiring resection. This study validates the policy of conservative management of anal fissure in Crohn's disease with anal surgery (required in 9.8 per cent of patients in this series) being reserved for the development of other anal disease.

The development of an enterocutaneous fistula has frequently been reported as being attended by a high morbidity and mortality, particularly in patients with inflammatory bowel disease who have high output, small bowel fistulas. We report a series of 114 patients who required treatment for 132 fistulas during the period 1976–1981. Fifty-one fistulas originated in the jejunum and ileum, and forty-eight patients had Crohn's disease. The majority of patients required surgical intervention and parenteral nutrition was required in forty-eight cases. Using an integrated programme of nursing, medical and surgical care, the overall healing rate was 90.9 per cent and the mortality 5.3 per cent. With the therapeutic methods currently available, an unacceptably high mortality rate in these patients can be avoided.

Between 1957 and 1985, 886 women with Crohn's disease and an intact distal large bowel were seen at St. Mark's Hospital. Ninety of these patients developed a fistula between the vagina and anus or rectum at an average age of 34 years. The track of the fistula was clearly documented in 80 patients and was extrasphincteric or suprasphincteric in 36, transsphincteric in 42 (high 13, low 29), and superficial in two. Of the 90 patients, 12 (13 percent) were managed throughout without recourse to surgery. Twelve (13 percent) had the fistula laid open or drainage of an abscess as the only surgery. Twelve (13 percent) underwent repair of the fistula and, of these, eight remain symptomatically cured. One has had further symptoms but no surgery while three later underwent proctectomy for rectal disease. In eight patients the colon was removed and the rectum defunctioned and in 34 the rectum was excised as the initial surgery after development of the fistula. The remaining 12 (13 percent) underwent later proctectomy for rectal disease or failed conservative management of the fistula. Extensive colonic involvement, rectal disease, or associated anal lesions were the main reasons for rectal excision in 38 patients. In only ten was the rectovaginal fistula a prominent indication for proctectomy. As medical treatment, repair, or other local surgery were successful in one third of the patients, these options should always be considered in the first instance.

Resection and peranal suture is now an accepted technique for low rectal carcinoma; however, long-term results of large numbers are not known. Eighty-four patients who had this procedure at a specialist institution between 1972 and 1985 are reviewed. There was a low operative mortality (2.4 percent), but a high complication rate with pelvic sepsis in 34 (40.5 percent) and anastomotic dehiscence (either partial or complete) in 40 (47.6 percent). The crude five-year survival rate was 56 percent. Isolated local recurrence occurred in seven patients (9.2 percent) and in a further seven patients it was associated with systemic recurrence. The functional results were satisfactory with 92 percent of assessed patients having three or less bowel actions per day. Subsequent incontinence occurred in 8 of the 60 patients assessed and 5 of these needed proximal diversion. For patients in whom the only alternative is abdominoperineal excision of the rectum, these results confirm that there is no disadvantage in terms of potential cure and that the functional results are acceptable.

Elective surgery for ulcerative colitis usually involves the removal of the entire large bowel with either a conventional ileostomy or the formation of an ileoanal pouch anastomosis. Seventy patients undergoing a one stage elective total proctocolectomy and ileostomy between 1976 (the first year an ileoanal pouch was carried out in this hospital) and 1986 have been studied. We have confirmed that proctocolectomy and ileostomy for ulcerative colitis is not the trouble free operation many presume it to be when considering the alternative of an ileoanal pouch.

A statistical analysis of the correlations between a number of factors, including age, tumour pathology and surgical management, and the results of primary suture of the perineum after excision of the rectum for adenocarcinoma in 63 males is presented. An unsuccessful outcome was related to the extent of the dissection either necessitated by advanced tumour or resulting from excision of the coccyx. A successful result was associated with small tumours and preoperative antibacterial treatment. Topical antibacterial treatments, topical mercuric perchloride and the drainage route did not appear to affect the outcome.

Most patients with ulcerative colitis respond well to medical treatment, however surgical treatment may be required in cases with severe clinical symptoms. We treated eight patients with distal ulcerative colitis (DUC), limited to the rectum and distal sigmoid colon, who were treated at St. Mark's Hospital by excision of the rectum and sigmoid colon with permanent colostomy. Four who did not respond to medical treatment and had severe and intermittent symptoms of long-standing, three with no control of the distressing diarrhea with a shorter history, and those with a severe dysplasia evidenced by rectal biopsy were surgically treated. Two of eight had a recurrence at the proximal colon within 6 and 10 years respectively but responded well to conservative management. From these observations it concluded that the procedure for patients with DUC may be one of adequate operations. Histological features of the resected specimens did not relate to the postoperative outcome of these patients.

Summary Anal fistulas were recorded in 112 patients out of a series of 329 patients with Crohn's disease admitted to St Mark's Hospital for the first time between 1965 and 1974. Only 13 of the 112 patients had small bowel disease alone. The remainder all had involvement of some part of the large bowel. There were 125 fistulas in the 112 patients. No treatment was attempted for 47 fistulas (38 per cent). Most patients had low fistulas which were treated by conventional techniques and healed successfully. Limited surgery was often successful in curing the symptoms of patients with more difficult fistulas. Anal lesions were the major reason for surgery in only a third of the patients who finally underwent excision of the rectum.