Early surgery in the management of severe ulcerative colitis.

During the last two decades there has been a substantial improvement in the overall outlook for patients suffering from ulcerative colitis. Nevertheless, many patients continue to experience severe attacks of this disease, and the mortality from these attacks is often very high. Thus Gallagher et al. (1962) stated that nearly two-thirds of their patients with "fulmin-ating" attacks of colitis during 1950-8 died; Edwards and Truelove (1963) reported a 26.8% fatality rate in all severe attacks treated during the previous decade; while Demole (1956) noted a 40% fatality rate in all acute attacks of colitis. Recently we also described a large series of cases with severe attacks of ulcerative colitis, the fatality rate of which was considerable, being 9.6% in severe first attacks and 13.7% in severe relapses (de Dombal et al., 1965a). In the care of these patients it had been our practice to submit practically all cases to intensive conventional medical therapy (usually including large doses of corticosteroids), for a period of 10 days or so in the first instance. Only if this regimen failed to secure a remission within that time-or if perforation or massive uncontrollable haemorrhage occurred-was surgical treatment considered. In view of the disappointing results obtained it seemed to us that a drastic change in our plan of management was justified in the hope of reducing the high mortality. Accordingly we resolved (Watts et al., 1966b) for a trial period to make surgery the sheet-anchor of our therapy in these cases and to invoke surgical aid at a very early stage of severe attacks-within a very few days of the patient entering hospital-unless there was unequivocal evidence of rapid improvement in his condition on conservative management. Since this decision was taken at the end of 1963 some 74 patients have been treated by us for severe attacks of ulcerative colitis; all have been managed according to the plan outlined above. In this paper we report the results obtained and compare them with those previously reported in a similar group of 124 patients managed during 1952-63. 74 patients were admitted to the General Infirmary at Leeds under the care of the professorial surgical unit because they were suffering from severe attacks of ulcerative colitis. Occasionally patients were admitted twice during separate severe attacks, so that the total number of such attacks during 1964-6 was 81. Table I shows the age distribution of the patients at the time …