In Reply.—Dr Braslow raises the question of postcolectomy colonization of the distal part of the small bowel with colonic bacteria that might limit the effectiveness of colectomy in ameliorating the severity of chronic portal-systemic encephalopathy. Such colonization does occur, but the benefits of colectomy persisted during the follow-up period in our patients. The encephalopathy that recurred was more amenable to standard medical therapy, including oral antibiotics. The reasons are theoretic but include the following: elimination of the reservoir function of the colon, more rapid transit time through the ileum and distal colon, quantitative decrease in total mass of urea-splitting organisms in the small bowel as compared with the colon, and more effective reduction of bacteria with oral antibiotics.
The role and efficacy of antireflux ileal valves in the long-term prevention of reflux or bacterial colonization of the small bowel remain to be proved.