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In a prospective double-blind randomised trial, 200 patients undergoing elective colorectal surgery received ceftizoxime 2g with either placebo or a single dose of metronidazole 500mg followed by a single dose of ceftizoxime 2g two hours later in both treatment groups. There was no difference in the rate of wound infection (9 of 85 vs 7 of 89), distal site infection (16 of 85 vs 18 of 89) or noninfective complications between the 2 treatment groups. Duration of hospital stay was also similar for the 2 groups (mean 11.3 vs 12.3 days). The low incidence of wound infection in this study is particularly impressive, as 13 of 16 wound infections were delayed, minor superficial discharges occurring after the patient left hospital. These results suggest that intravenous ceftizoxime offers effective prophylaxis in colorectal surgery and may be used without metronidazole.

The results of revisional surgery for ileostomy complications in a referral centre have been reviewed. 34 of 129 (26%) of patients who had their primary surgery in our unit have required revisional su

We report an audit of outcome on 24 patients (16 females) who had a strictureplasty to treat ileo-colic anastomotic strictures. All except one patient had their original resection for Crohn's disease, and required reoperation because of symptoms of recurrent intestinal obstruction for a mean 9.3 months (range 1-36); the remaining patient was discovered to have ileo-colic anastomotic stricture before he underwent laparotomy for closure of loop ileostomy. At operation, four patients needed additional small bowel strictureplasties, two of whom also underwent small bowel resection for separate areas of phlegmonous disease. There was no post-operative mortality, three patients developed wound infection and one had a pelvic abscess, which settled on antibiotic therapy. Two patients have since died of unrelated disease. Five patients have since needed reoperation for recurrence; only one had a stricture at the site of previous strictureplasty. Over a mean follow-up of 70.8 months (range 18-393) all 22 living patients now have complete relief of symptoms.

The perineal wound is a frequent source of morbidity following proctocolectomy for inflammatory bowel disease. In 8 patients low transection of the anorectum or conservative proctocolectomy has been performed as an alternative to proctocolectomy in order to avoid a perineal wound. All patients passed copious mucoid discharge per anum post-operatively. Five patients required a proctectomy, 2 remain symptomatic and 1 patient has undergone a restorative proctocolectomy. This small series suggests conservative proctocolectomy does not seem to offer any advantage over conventional proctocolectomy in the surgical management of inflammatory bowel disease.

Two treatment policies for rectal prolapse were prospectively assessed between April 1986 and January 1989. Sixteen patients had a Marlex® mesh posterior rectopexy alone and 13 underwent a sigmoidectomy combined with a sutured posterior rectopexy. Preoperative and post-operative assessment included manometry, a saline infusion test and video-proctography. Hospital stay, control of prolapse and complications were comparable in both groups. Restoration of continence occurred in nine of the 12 incontinent patients after Marlex rectopexy, compared with six of nine after sutured rectopexy and sigmoidectomy. Constipation persisted in three patients who were constipated before operation and in four of 13 who had previously normal bowel habits became constipated after Marlex rectopexy; constipation persisted in one of five previously constipated patients while none with previously normal bowel habits became constipated after sutured rectopexy and sigmoidectomy. Sigmoidectomy combined with sutured rectopexy was safe and as efficient as Marlex rectopexy in prolapse control and improvement of continence; significantly fewer patients were constipated (one of 13) after sigmoidectomy than following rectopexy alone (seven of 16). A randomized trial now seems justified.

The conventional maximum time for oral presentation of a scientific paper is 8 to 10 minutes. Anything longer than that can be defined as “a longer talk.” A longer talk is usually by invitation and is a review. It may be an eponymous lecture or designated by such terms as state of the art or quadrennial review.

Although Hirschsprung's disease is diagnosed most commonly during infancy and childhood, some cases are seen in adults, when clinical features are usually similar to those described in younger patients. We report a case whose unusual clinical presentation led to an initial diagnosis and subsequent treatment of colonic Crohn's disease. The correct diagnosis was made only after motility measurements suggested the possibility of adult Hirschsprung's disease and prompted the histological examination of the myoenteric plexus, which led to the establishment of the correct diagnosis.

This paper is a distillate of mistakes made and lessons learned from 40 years of lecturing. The message is: Planning, preparation and presentation make for perfection.

Helzer et al. (1984) have reported a 56% incidence of psychiatric disorders in patients with Crohn’s disease compared with a 30% incidence in a group of medically ill controls without Crohn’s disease. However, there was no evidence that the two disease syndromes have any consistent relationship to each other. Other studies have suggested an increased prevalence in depression in patients with Crohn’s disease (Gerbert 1980). Nevertheless, psychiatric illnesses are even more prevalent in patients with functional gastrointestinal disorders than they are in Crohn’s disease. Alpers and Clouse (1986) stress that the detection of psychiatric disease in a patient who also has inflammatory bowel disease will not resolve all the symptoms that cannot be attributed directly to the inflammatory bowel disease. However, it will clarify many difficulties. They felt that physicians treating patients with Crohn’s disease should learn to seek and recognise symptoms of psychiatric disorder and that it was well worthwhile to treat active psychiatric symptoms; especially affective and anxiety disorders (Alpers and Clouse 1986). There seems to be little firm evidence to suggest that psychiatric disease can have an adverse effect on the natural history of Crohn’s disease, but it is not surprising that, with the onset of recrudescence of symptoms in a chronic bowel disease, there is likely to be worsening of any inherent psychiatric illness.

Surgical emergencies are life-saving operations that have to be performed within a matter of hours, without time for comprehensive resuscitation. These are rare. More frequently in Crohn’s disease an urgent operation is required after 12 to 24 hours of resuscitation to assure optimum operative conditions.

Because the place of surgery in the management of Crohn’s disease is so different from that in the management of ulcerative colitis, these two diseases are described separately; therefore there will be a certain overlap between these two sections of the book. Many of the factors in the aetiology and epidemiology are so similar in the two diseases that many people consider that Crohn’s disease and ulcerative colitis are different manifestations of the same disease. In many monographs on inflammatory bowel disease there is a tendency to consider the diseases under the one heading of idiopathic inflammatory bowel disease. However, we make no apology for separating them in this surgical textbook for reasons that will be obvious from reading the sections on the surgical treatment of the two diseases. Of the two, Crohn’s disease is by far the more protean in its manifestations as will be seen; not only can it occur anywhere throughout the alimentary tract but also it can apparently affect the liver, skin, the eyes and joints.

Although small and large bowel disease often coincide in patients with Crohn’s disease, the surgical management of colonic disease has many different indications and so is described separately. Colonic Crohn’s disease is more likely to be associated with perianal lesions than is small bowel disease. Colonic disease less often obstructs and fistulates, although it may often have a fistula entering the sigmoid colon from associated ileal disease. Compared with small bowel Crohn’s disease colonic disease is more likely to present with acute and chronic bleeding and, occasionally, it is subject to acute exacerbations, closely resembling acute attacks of ulcerative colitis.

Bypass overcomes obstruction and may allow inflammatory oedema to settle. The traumatic aspect of the disease process that is being provoked by intestinal contents being forced under pressure through the stitches is relieved if the narrow area is bypassed. The effect of the bypass on the local disease is similar to that produced by total parenteral nutrition, when there is little apart from intestinal secretion passing through the area. However, bypass does not cure the disease or necessarily overcome the complication of stenosis.

The majority of patients who have had operations for the complications of Crohn’s disease have a satisfactory and rapid recovery. They have resumption of normal oral feeding during the first post-operative week and are discharged home during the second week. However, in the early days after operation 10%–20% of patients experience some complication (Irving 1990). These complications can be categorised as fever, ileus, or peritonitis.

The patient is operated on in the prone position. The bladder is drained with a (16F) catheter and a large balloon catheter (24F) is placed in the rectum and connected by drainage tubing so that the sigmoid colon can be inflated with carbon dioxide if necessary. An adhesive unipolar diathermy pad is fixed to a shaved patch on the thigh. The right-handed surgeon usually stands on the patient’s left. The most difficult access usually involves the freeing of the gut from the right side of the abdomen and pelvis as the ileocaecal junction is mobilised and delivered into the wound. The assistant and the scrub nurse stand on the opposite side of the table. Only one assistant is usually required.

An intestinal fistula is a granulation tissuelined tract between the gut and an epithelial surface. An intestinal fistula should be expected to heal by the normal process of healing of granulation tissue. To understand the principles governing fistula healing and the management of a fistula it is useful first to understand the physiological mechanisms involved.

Pre-operative preparation is to make sure that the patient is in the best attainable health with as good as possible nutrition. The patient should have the local conditions in the most favourable state and be able to mount an inflammatory response. It is obviously desirable not to have the bowel distended or full of indigestible material or faeces. The application of these principles has been discussed already in Chapter 8.

On admission the patient has blood taken for measurement of haemoglobin, haematocrit, serum urea and electrolytes and usually also of the serum proteins. The serum is also used for the cross-matching of two units of blood. A final psychological counselling session ensures that the patient knows precisely what is to be done and the reasons for doing so. The stomatherapist discusses with the patient the possibility of there being a temporary diverting stoma and marks the stoma site.

As patients with Crohn’s disease are likely to need many operations during the course of their life, it is important that the surgeon should make surgery as safe as possible. Our goal is that no patient should die as the result of an operation for Crohn’s disease. This ideal depends, partly, on the patients being referred for surgery before they become too ill and partly on the acceptance that surgeons should tailor their operative intervention to the fitness of the patient presented to them. They should always try to operate with the patient in optimum condition and, when they do operate, they should try to consider and avoid all possible complications.

Five surgical teams in two operating suites were studied for three months with random allocation to receive either A or B operating gloves. The gloves were identified as used by the surgeon, the assistant and the scrub nurse. At the end of each day the gloves were tested by standard air insufflation and immersion under water. Surgeons experienced significantly more punctures 174:884 (19.7%) [17%-23%] than the scrub nurses or assistants 161:1770 (9.4%) [8.6%-10.2%]. Surgeons were particularly prone to experience punctures of the tip of the index or little finger of the left hand whereas nurses were more likely to experience punctures of the index finger and thumb of the left hand. There was a wide variation between the five surgical teams varying between 5.7% [2%-11%] and 37.5% [24%-52%] wearing B and 11.4% and 28.4% wearing A. There were significantly more punctures when wearing A gloves (23.0%) [20%-26%] than when wearing B gloves (15.8%) [13%-19%] for surgeons but no significant difference for surgical assistants or scrub nurses. Contrary to our expectation there were no significant differences between the two types in the tearing of cuffs (1% in each).

SUMMARY Culture studies have suggested that Mycobacterium paratuherculosis may play a role in the aetiology of Crohn's disease. However, evidence of sensilizalion to mycobactcrial antigens amongst patients with Crohn's disease has not yet been adequately demonstrated. Previous studies of cell-mediated immunity (CMI) in Crohn's disease were restricted to responses of peripheral blood mononuclcar cells (PBMC) to mycobacterial antigens. In this study we have investigated the proliferativc responses of both PBMC and mesenteric lymph node mononuclcar cells (MLNMC) to a range of mycobacterial and non-mycobactcrial antigens. There was no evidence of specific sensitization in the responses of MLNMC and PBMC from patients with inflammatory bowel disease (IBD) to the mycobacterial antigens. However, anergy to M. paratuherculosis could not be excluded. IBD MLNMC responses to most antigens were generally greater than those of PBMC. which were often undetectable. When compared with controls, there was evidence of increased CM 1 to a range of non-mycobactcrial antigens, especially Yersinia enterocolitica. amongst both MLNMC and PBMC from patients with Crohn's disease and ulcerative colitis (UC). These results do not provide support to the proposed role of mycobacteria in the pathogcnesis of Crohn's disease, but indicate that further investigation may determine a role for bacterial-specific T cell-mediated responses in the palhogcncsis of IBD.

Crohn's disease is a panintestinal disease of unknown aetiology and a tendency to recrudescence throughout the patient's life. It is therefore impossible to cure Crohn's disease by medical therapy or surgical excision. In spite of this, the majority of patients can be managed through their disease and maintained in a good state of health by a combination of medical and surgical treatment. Early attempts at surgical management of Crohn's disease in the 1930's and 1940's involved bypass procedures which were marred with serious complications of sepsis, development of cancer and increased rate of recurrence. By the 1950's resection became the preferred operation but there soon arose a controversy about the amount of bowel that should be removed. There were some who advocated radical excision; removing all diseased bowel with a large margin of apparently normal tissue on each side of the resection. Others found less radical resection safer as it preserved gut and also had no apparent effect on the rate of recurrence of the disease. Although this argument continued, the balance gradually shifted towards less radical surgery. Furthermore, the wave of conservatism led to the evolution of the concept of minimal surgery.

In fiction, particularly in cinema fiction, we often see the victims of stabbing or gunshot wounds to the abdomen dying rapidly and often dramatically at the site of combat. All surgeons who have been involved in the treatment of traumatic perforations of the bowel know that this is far from the truth. Death is not the inevitable consequence of traumatic bowel perforation; it now occurs rarely and, if it does so, then only after days, weeks, or even months of a battle against infection. We also know that traumatic perforation of the bowel, even in elderly Presidents and Popes, eventually responds satisfactorily to surgical intervention. There will probably be few of us who have the worrying privilege of being on duty when Heads of State or Church are admitted with such a mishap, but in case we ever are we should be aware of current thinking lest the eyes of the world turn on us and find us unprepared. The management of such perforations has been subjected to pendulum swings of fashion almost as great as those of skirt length. Most of the major advances in the management of this once frequently fatal mishap have been the experience of war, which has provided thinking surgeons with an enormously concentrated experience. Sadly, in modem so-called ‘peacetime’ there are some parts of the world with such endemic violence from what is sometimes described as the local Knife and Gun Clubs that some hospitals have such a wealth of clinical material that even prospective randomized trials become possible. In 1979, following the presentation to the Annual Meeting of the American Surgical Association of one of the few prospective randomized studies performed on this subject (Stone and Fabian, 1979) the discussant was Dr Owen Wangensteen of Minneapolis (Wangensteen, 1979), already emeritus and steeped in surgical history. It was he who informed the audience that it was a Russian surgeon and affluent Princess, Vera Gedroitz, who was the first to operate successfully on a series of abdominal gunshot injuries in the Russo-Japanese war of 1904. Apparently her wealth enabled her to engage ambulances to send to the fighting front and evacuate the casualties rapidly to hospital. It is amazing that in those days any such patients survived. That they did was a tribute to the Princess’s surgical ability and clairvoyance in arranging early ambulance evacuation. Before the Second World War and the ready availability of antibiotics, the surgical textbooks apparently advocated primary closure more in hope than expectation. In Britain it has been customary to cite the writings of Major General (later Sir) Heneage Ogilvie who, observing a 53 per cent mortality in battle wounds associated with a perforated

Patients with inflammatory and ischaemic bowel diseases seem to tolerate narrowing of the gut lumen to a critical degree of stenosis without obstructive symptoms. To determine the physical factors involved in bowel occlusion, we created an experimental model using New Zealand rabbits in acute experiments under general anaesthesia. At operation a loop of small bowel was isolated and canulated, proximally for perfusion and pressure recording and distally to monitor flow. Having established the physiological pressure and flow conditions in a normal loop of gut, a stenosis was created using circular adjustable rings of determined widths. Pressure and flow were measured constantly and the variables studied were luminal diameter, stenosis length, and perfusate viscosity. This experimental model was reproduced using resected segments of human small bowel. We found a critical point- at 60% of the original diameter-down to which the small bowel is able to maintain normal flow. At a diameter smaller than this, the physiological parameters are rapidly altered up to the point of complete obstruction. In the rabbit model bowel rupture occurs at 30% of the initial size. Increased viscosity of the fluid and length of the stenosis alter this critical point inducing a larger critical diameter. We did not observe any cumulative effect of multiple identical stenoses.

Any symptomatic manifestation of Crohn's disease results not from the disease itself but from some complication. The first complication is stenosis, which precedes and favors the appearance of abscesses, fistulae, perforations and sometimes hemorrhages. The ideal treatment consists in identifying and treating the disease as early as the appearance of stenosis and before the other complications occur. In our series, mortality most often was caused by an infection that was not or poorly managed, even when the primary cause of death was embolism or sometimes a massive hemorrhage. In many patients, the risks of septic complications are all the higher as the subject's immunological defense is weakened by immunodepressive corticosteroid treatments and by malnutrition. All septic foci must therefore be located and drained before any extensive surgical operation. Malnutrition can be improved by parenteral nutrition, and often by enteral feeding as well. After severe surgical complications, the next operation should not be performed until 12 weeks have elapsed, in order to reduce both technical difficulties and risks.