The lumen of the resected bowel revealed longitu­dinal scars of healed ulceration, more marked in the region of the strictures. Two ileo-ileal fistulae were present with adjacent areas of inflammation. Histological examination confirmed the diagnosis of Crohn’s disease. In the distal part of the resected small bowel there was a long pedunculated polyp 15mm, which was inflammatory.

There has been no further recurrence of Crohn’s disease in 7 years. The patient’s bowel frequency is 1–2 per 24 hours. His principal health problem has been the onset of Parkinson’s disease.

At the time of this patient’s first 2 admissions, he suffered acute toxic megacolon and should have been assessed by a surgeon. The importance of com­bined physician and surgeon management had been ignored.1The patient was fortunate that free perfo­ration of the colon and fecal peritonitis did not occur. Turnbull et al. were the first to emphasize the pathology of large penetrating ulcers in acute toxic megacolon sealed off by the omentum, viscera, or parietes.2This patient’s incomplete recovery from the acute phase of the illness left the colon chroni­cally dilated and malfunctioning as an adynamic obstruction. At the time of his elective operation, he was fit enough for an abdominal colectomy to be performed. The Turnbull “blowhole” ileostomy– colostomy procedure was not considered. Prelimi­nary colon irrigation via an ileotomy substantially reduced the risk of fecal contamination when the large defects in the bowel wall were exposed by mobilization. The technique of irrigation was similar to that advised by Khoo et al, who propose the method as a technique to facilitate resection for toxic megacolon.3The Cleveland Clinic experience of the “blowhole” operation has been significantly reduced. In the 18 year period, 1983–2001, it has been employed in only 6/328 (1.9%) of patients with toxic colitis due to inflammatory bowel disease

This patient underwent urgent laparotomy (Febru­ary 1989) for toxic megacolon that was initially interpreted as mechanical large bowel obstruction. The surgeon performed a loop colostomy in the transverse colon. The true nature of the disease was revealed with a subsequent colonoscopy, which demonstrated severe colitis from the rectosigmoid to the cecum. The patient made a satisfactory re­covery and was referred for further management 6 months after the urgent operation. Colonoscopy revealed an active colitis commencing at the rec­tosigmoid, with extensive polyposis extending to the transverse colon. The colon proximal to the colostomy was diffusely inflamed without obvious ulceration or polypoid lesions. The mucosa of a large prolapsed transverse colostomy was relatively normal.

Operation (10.16.89) Adhesions involving an otherwise normal small bowel were dissected. There were vascular changes on the serosal surface of the colon consistent with an underlying inflammatory process. The colon was resected from the cecum to the rectosigmoid junc­tion, and an end-to-end anastomosis between ter­minal ileum and rectosigmoid was completed with a single-layer interrupted suture of 3/0 polyglactin 910 (vicryl).

Postoperative Course/Follow-Up (2005) Recovery from operation was satisfactory. Two months after operation, his bowel frequency was Day/Night: 4/1. On flexible sigmoidoscopy, the mucosa of the rectum appeared normal, the anastomosis was at the 18cm level. These features remained unchanged throughout a follow up period of 5 years which included regular sigmoidoscopy examinations. The patient reports that he is well for his 84 years, more than 15 years since the operation.