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Dal Buono A, Carvello M, Sachar DB, Spinelli A, Danese S, Roda G. Diversion proctocolitis and the problem of the forgotten rectum in inflammatory bowel diseases: A systematic review. United European Gastroenterol J 2021; 9:1157-1167. [PMID: 34845854 PMCID: PMC8672074 DOI: 10.1002/ueg2.12175] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background and aims Diversion proctocolitis (DP) is a non‐specific mucosal inflammation arising in the defunctionalized colon and/or rectum following faecal diversion (colostomy, ileostomy). Differential diagnosis of DP from the underlying disease in patients with inflammatory bowel diseases (IBD) is often unclear. As a result, it might be difficult to undertake any specific treatment. We aimed to systematically review the literature evidence on DP in IBD patients. Methods For this qualitative systematic review, we searched PubMed, EMBASE and Scopus to identify all studies published until July 2021 including IBD patients affected by DP. Results Overall, 37 papers published between 1982 and 2021 were included. A total of 1.211 IBD patients were included: 613 UC (50.6%), 524 CD (43.3%), 66 IBD‐unclassified (IBD‐U) (5.4%), 8 unspecified patients (0.7%). Most patients with DP are asymptomatic, although inflammation is detectable in almost all patients with a rectal stump. Reduced short‐chain fatty acids and an altered microbiome, may trigger mucosal inflammation and have been proposed as causing factors. An increased risk of developing cancer on DP has been reported in patients with a history of previous dysplasia/cancer. Conclusions The etiopathogenesis of DP is still unknown. The efficacy of mesalamine, corticosteroids or short‐chain fatty acids has not been proven by randomized trials yet. Since the incidence of cancer of the rectal stump can reach 4.5 per 1.000 diverted patients‐year, IBD patients undergoing subtotal colectomy with end‐ileostomy should undergo close endoscopic surveillance, being eventually counseled for surgery with or without the restoration of the intestinal continuity.
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Affiliation(s)
- Arianna Dal Buono
- IBD Center, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Division, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - David B Sachar
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Antonino Spinelli
- Colon and Rectal Surgery Division, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Giulia Roda
- IBD Center, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
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Landerholm K, Wood C, Bloemendaal A, Buchs N, George B, Guy R. The rectal remnant after total colectomy for colitis - intra-operative,post-operative and longer-term considerations. Scand J Gastroenterol 2018; 53:1443-1452. [PMID: 30451043 DOI: 10.1080/00365521.2018.1529195] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Acute severe colitis requires surgery in around 30% of the cases. Total colectomy with ileostomy is the standard procedure with distinct advantages to a laparoscopic approach. Less agreement exists regarding the formation or configuration of the retained rectal stump and its short-term and long-term management. In this review, aspects of management of the rectal remnant, including perioperative considerations, potential complications, medical treatment, surveillance and implications for proctectomy and reconstructive surgery are explored. METHODS A thorough literature review exploring the PubMed and EMBASE databases was undertaken to clarify the evidence base surrounding areas of controversy in the surgical approach to acute severe colitis. In particular, focus was given to evidence surrounding management of the rectal remnant. RESULTS There is a paucity of high quality evidence for optimal management of the rectal stump following colectomy, and randomised trials are lacking. Establishment of laparoscopic colectomy has been associated with distinct advantages as well as the emergence of unique considerations, including those specific to rectal remnant management. CONCLUSIONS Early surgical involvement and a multidisciplinary approach to the management of acute severe colitis are advocated. Laparoscopic subtotal colectomy and ileostomy should be the operation of choice, with division of the rectum at the pelvic brim leaving a closed intraperitoneal remnant. If the rectum is severely inflamed, a mucus fistula may be useful, and an indwelling rectal catheter is probably advantageous to reduce the complications associated with stump dehiscence. Patients electing not to proceed to proctectomy should undergo surveillance for dysplasia of the rectum.
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Affiliation(s)
- Kalle Landerholm
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Christopher Wood
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Alexander Bloemendaal
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Nicolas Buchs
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Bruce George
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Richard Guy
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
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Kakizawa N, Tsujinaka S, Miyakura Y, Kikugawa R, Hasegawa F, Ishikawa H, Tamaki S, Takahashi J, Rikiyama T. The surgical treatment of acute and severe diversion colitis mimicking ulcerative colitis: a case report. Surg Case Rep 2018; 4:86. [PMID: 30073476 PMCID: PMC6081828 DOI: 10.1186/s40792-018-0490-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 07/19/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Diversion colitis (DC) is characterized by nonspecific inflammation in the remaining colon or rectum, and loss of the fecal stream plays a major role in the disease's development. Although the majority of patients are asymptomatic, medical and/or surgical treatment is required for those who are symptomatic. There is a particular interest on how to manage patients with acute and severe clinical presentations, but the pathogenesis is not fully understood. We report the rare case of a man with acute and severe DC mimicking ulcerative colitis (UC) with extra-intestinal manifestations that was successfully managed with surgical treatment. CASE PRESENTATION A 68-year-old man with a history of laparoscopic intersphincteric resection of the rectum with diverting loop ileostomy for lower rectal cancer suffered from anastomotic stenosis requiring repeated endoscopic dilatation. His loop stoma was not reversed because these treatments were unsuccessful. He denied having a history of inflammatory bowel disease. Twelve years postoperatively, he developed a perineal abscess requiring drainage. Subsequently, he developed a high-grade fever, bloody discharge per anus, and skin ulcers in the right ankle and around the stoma. Because culture tests were negative for bacteria, it was deemed that his acute illness reflected an inflammatory response rather than an infectious disease. Colonoscopy revealed anastomotic stenosis, a colonic fistula, and mucosa that hemorrhaged easily, with lacerations. A pathological examination with biopsy revealed inflammatory infiltration without malignancy. After reviewing the patient's clinical episodes and discussing the case with physicians in multiple specialties, we performed total colectomy with end ileostomy in accordance with the abdominoperineal resection. The postoperative course was uneventful. A resected specimen showed atrophic mucosa with the disappearance of haustra in the distal colon, as well as edematous and dilated mucosa in the proximal colon. The pathological diagnosis was suggestive of UC, including erosion and ulceration in edematous wall, crypt abscess, and inflammatory infiltration into the mucosa. The skin ulcers in the right ankle and around the stoma healed over time. CONCLUSIONS DC can eventuate in a long-term period after fecal diversion surgery, possibly with extra-intestinal manifestations mimicking UC. Surgical treatment seems feasible for patients with acute and severe DC.
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Affiliation(s)
- Nao Kakizawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya, Saitama-shi, Saitama, 330-8503, Japan
| | - Shingo Tsujinaka
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya, Saitama-shi, Saitama, 330-8503, Japan.
| | - Yasuyuki Miyakura
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya, Saitama-shi, Saitama, 330-8503, Japan
| | - Rina Kikugawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya, Saitama-shi, Saitama, 330-8503, Japan
| | - Fumi Hasegawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya, Saitama-shi, Saitama, 330-8503, Japan
| | - Hideki Ishikawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya, Saitama-shi, Saitama, 330-8503, Japan
| | - Sawako Tamaki
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya, Saitama-shi, Saitama, 330-8503, Japan
| | - Jun Takahashi
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya, Saitama-shi, Saitama, 330-8503, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya, Saitama-shi, Saitama, 330-8503, Japan
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