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Editor,—Mr Phillips (Gut1998;43:303–4) enjoys stirring the pot, but we cannot support all of his views on ileo-anal pouch surgery for Crohn’s disease. Firstly, we do not think ulcerative colitis and Crohn’s disease are necessarily “apples and oranges” (though familial adenomatous polyposis is). We believe that there is often a spectrum of disease and that in some cases only the long term natural history enables clinicians to know whether they are dealing with one or other disorder.
Also, we do not think it is appropriate to compare the outcome of Kock pouch surgery against pelvic pouch surgery for Crohn’s disease. If there is a stricture in or above a pouch which is out of the pelvis, the chances of successful reconstruction without pouch excision is much greater than for pouches in the pelvis (as our own experience confirms).
To confuse matters further, Mr Phillips compares colectomy and ileo-rectal anastomosis with pouch-anal anastomosis for Crohn’s disease. This certainly introduces an “apples and oranges” scenario as ileo-rectal anastomosis is selective because of rectal sparing and, furthermore, even quiescent perianal disease or ileal involvement is not generally a contraindication. By contrast, ileo-anal pouches are not advised if there is perianal or small bowel disease.
Much of today’s literature highlights a 10% change in diagnosis from ulcerative colitis to Crohn’s disease over 10 years.1 In some cases, as in our earlier experience,2 the initial pathological scrutiny was not sufficiently rigorous and the patient had Crohn’s disease from the start, whereas in others, small bowel disease develops after pouch construction and the diagnosis has to be revised. To advise pouch construction for known Crohn’s proctocolitis when there is no anal or small bowel disease was heretical in the past and, still, is rarely advised. If a patient does not want a stoma a lot of counselling is needed if a surgeon proceeds with the patient’s wishes. Admittedly, in our experience, just under half have a reasonable functional result over 10 years. However, for those that fail, morbidity is high with many more hospital admissions, a much greater length of small bowel sacrificed and a far higher risk of perineal sinus than in patients having proctectomy after a failed ileo-rectal anastomosis.
Editor,—I think the readership will need to decide whether “apples and oranges” have been compared in the past. The leading article simply tried to point out the huge differences between ulcerative colitis and Crohn’s disease and queried whether comparisons were fair, or even reasonable. After all, ulcerative colitis is curable by surgery, it has a reasonably low surgical morbidity and good prospects. Conversely, Crohn’s disease is not cured by surgery, there is a recognised high surgical morbidity, all anastomoses are prone to recurrent disease, and reoperation is frequent.
As far as disease spectrum is concerned, Keighleyet al may be right, although another possibility, partly supported by their own final paragraph, is that Crohn’s disease may arise in patients with ulcerative colitis just as arthritis, heart disease or asthma may arise in these patients.
The rationale of alluding to Kock pouches was not to indicate that they are exactly equivalent to an ileo-anal pouch, but rather to show that when Kock pouches were made in Crohn’s disease, the results were nothing like as bad as many people currently assume.
The purpose of introducing colectomy and ileo-rectal anastomosis (IRA) was to make the point that, by comparison with proctocolectomy and ileostomy, reoperation is frequent, lengths of bowel are lost and short bowel syndrome is rare and yet it is an acceptable treatment modality. Keighley et al assist this comparison by indicating that, despite rectal sparing, patients undergoing IRA still do badly when compared with patients undergoing total excision and an ileostomy, the latter generally having worse disease. Obviously the issue here is that all anastomoses in Crohn’s disease are prone to recurrence and yet the medical community accepts the recurrences as a reasonable trade off when the alternative is a permanent stoma.
In the leading article I tried to indicate that excluding ileo-anal pouch construction as one choice in carefully selected and counselled patients with Crohn’s disease who have neither anal nor small bowel disease was neither logical nor consistent with the published results of pouches made, usually inadvertently, in Crohn’s disease.