Biomedical subjects
Publications and source records attributed to J K Ritchie.
Four patients with ulcerative colitis apparently limited to the rectum and distal sigmoid colon were treated by excision of the distal large bowel only, during the years 1964-1975 at St Mark's Hospital. Two patients have remained well since with no further treatment and the other two have had symptoms of colonic disease and have responded to medical measures.
Among 10 hospitals of the North East Thames Region, 84 patients were operated on for inflammatory bowel disease in the years 1977-81. There was one death in the 51 patients treated electively. The postoperative mortality was 24% in 33 patients coming to urgent surgery. The factors leading to this continuing high mortality are analysed as a contribution to an improvement in management.
In the years 1966-80, 303 patients with radiologically extensive ulcerative colitis were followed up regularly, both by clinical assessment and by mucosal biopsies, to detect dysplastic (precancerous) change. Moderate or severe dysplasia (but no carcinoma) was found in the specimen in 8 patients treated surgically. Despite regular surveillance, carcinoma developed in 13 of the 186 patients with a history of disease for ten years or more. Of the total sixteen carcinomas in these 13 patients, eleven were Dukes stage A, three stage B, one stage C, and one was inoperable. There has been 1 death from carcinoma in this series over the fifteen year observation period. The method of follow-up has probably prevented the development of carcinoma in 8 patients and permitted diagnosis of carcinoma at a stage when cure is likely in 11. The incidence of moderate or severe dysplasia and carcinoma in these patients with mild or symptomless extensive colitis shows that either proctocolectomy or careful follow-up should be advised once the duration of symptoms reaches ten years.
Visible changes associated with dysplasia or carcinoma have been assessed in 62 colectomy specimens from patients with ulcerative colitis. In 34 colectomy specimens with one or more carcinomas, there were 51 visible carcinomas and 65 macroscopic dysplastic lesions; only one carcinoma was found in flat mucosa. Among 28 specimens with microscopic dysplasia but no carcinoma, eight contained no visible dysplastic lesion, and the remaining 20 contained a total of 40 polypoid or elevated dysplastic areas. In 32 operative specimens removed for long-standing chronic colitis without dysplasia or carcinoma, nine contained visible inflammatory polypoid lesions. On radiological or endoscopic examination of the colon in long-standing colitis close attention should be given to the identification and biopsy of polyps, elevated nodular areas or plaques, strictures, and isolated ulcers. It is likely that colectomy specimens with visible polypoid or elevated dysplastic lesions will contain a carcinoma more often than those removed for dysplasia in flat mucosa.
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 1976. Only 13 of 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 return.
Between 1947 and 1980, 67 patients with carcinoma complicating ulcerative colitis were treated at St Mark's Hospital. The tumours in these patients were compared with those in 4817 patients without colitis seen over the same period. There was a higher proportion of inoperable and high grade tumours in the colitic group but the prognosis was found to be very similar in patients with and without colitis.
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.
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269 patients with ulcerative colitis and a history of less than 6 months when first seen at St. Mark's Hospital in the decade 1966--75 have been followed for up to 11 years. The outcome has been correlated with the maximum extent of the disease observed within 3 months of presentation. 75 patients required hospital admission, 56 within a year of presentation. Extensive colitis developed in 60 patients. The cumulative probability of the disease being extensive was 21% +/- 3% at 5 years and 29% +/- 4% at 10 years. 25 patients required surgical treatment. The cumulative probability of operation was 8% +/- 2% at 5 years and 15% +/- 4% at 10 years. 19 patients are known to have died. The expected number of deaths was 19.2.
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.
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 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.
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A retrospective review of outcome was undertaken in forty-two patients with ulcerative colitis and twenty patients with Crohn's disease who were treated for haemorrhoids and the inflammatory bowel disease between 1935 and 1975. Both surgical and conservative treatment of haemorrhoids in patients with ulcerative colitis had low complication-rates (4 complications after 58 courses of treatment). In Crohn's disease the complication-rate was high (11 complications after 26 courses of treatment). One of the forty-two patients with ulcerative colitis and six of the twenty with Crohn's disease required rectal excision for complications apparently dating from the treatment of haemorrhoids. These results suggest that treatment of symptomatic haemorrhoids is usually safe in patients with ulcerative colitis but is contraindicated in those with Crohn's disease.
This paper presents the application of a classification of anal fistulas to an unselected consecutive series of 793 patients treated for this condition at St Mark's Hospital from 1968 to 1973 inclusive. The fistulas were divided into five categories on their anatomical relationships: superficial (16 per cent), intersphincteric (54 per cent), trans-sphincteric (21 per cent), suprasphincteric (3 per cent) and extrasphincteric (3 per cent), with the remaining cases multiple or unclassified (3 per cent). There was good correlation between the categories and presentation, physical signs and treatment of the fistulas. Two hundred and forty-nine patients had potentially difficult fistulas. Follow-up of these patients revealed healing of almost all the fistulas, but the functional results were less satisfactory (incontinence of loose stool in 17 per cent and of flatus in 25 per cent, soiling in 31 per cent).
Follow-up studies of 2 groups of patients with idiopathic proctitis show that the survival rate is little affected by the disease. The cumulative probability of extension of the inflammation to the descending colon above the left iliac crest was about 5% at 5 years and 12% at 10 years. Corresponding figures for extension to the hepatic flexure were about 4% at 5 years and 6% at 10 years. The probability of radical surgical treatment was 3--5%.
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