Operation in Inflammatoiy Bowel Disease: Indications and Type

Management of the rectal stump after emergency sub-total colectomy: which surgical option is associated with the lowest morbidity?

OBJECTIVE

To identify the preferred surgical management of the rectal stump after emergency subtotal colectomy (ESC) for acute severe colitis by assessing the morbidity associated with each option.

PATIENTS AND METHODS

Consecutive patients undergoing ESC at a district general hospital between 1999 and 2004 were retrospectively audited for pathology, rectal stump complications and length of postoperative hospital stay (POS).

RESULTS

Thirty-seven ESCs were performed, 34 were undertaken for disease refractory to medical treatment, 2 for toxic mega colon and 1 for perforation. Thirty-four cases were for ulcerative colitis, 2 Crohn's colitis and 1 infective colitis. Twenty-seven had an intraperitoneal and 10 a subcutaneously placed closed rectal stump. The median POS for patients with a subcutaneously placed stump was shorter than for those with an intraperitoneal stump, 8 and 15 days, respectively (P = 0.04). Two patients had leakage from an intraperitoneal stump, prolonging POS (33 and 193 days). Three of the subcutaneous stumps leaked causing wound infection but not prolonging the POS (6, 7 and 16 days).

CONCLUSION

Avoiding a second stoma by closing the rectal stump after ESC has been confirmed as acceptable practice by studies over the last 15 years, reporting no overall increase in complications. The location of a closed rectal stump appears to influence the incidence of pelvic sepsis. The lowest pelvic sepsis rate is associated with subcutaneous placement; despite a higher wound infection rate this option appears to be associated with a lower total morbidity reflected in a shorter POS.

Closure of rectal stump after colectomy for acute colitis

In a retrospective study complications, mortality and morbidity following acute colectomy for severe colitis with intra-abdominal closure of the rectal stump were reviewed in 147 consecutive patients (71 women and 76 men, median age of 40 years, range 18-95 years). Five patients (3%) died within 30 days postoperatively; none of the deaths were related to the rectal stump. Three patients (2%) had a pelvic abscess due to leakage of the rectal closure, all were treated successfully with percutaneous drainage, guided by ultrasonography. No difficulties in locating the rectal stump or performing intended subsequent surgery were reported. The overall complications and mortality rate in this study are low and comparable to the best results reported from centers using the mucous fistula. Closure of the rectal stump is a safe procedure, and has the advantage of not leaving the patient with a second stoma.

Clinical relapse of Crohn's disease under standardized conservative treatment and after excisional surgery

The course of 205 patients with Crohn's disease at one gastroenterological center was studied in patients with conservative drug treatment or with operative management of their disease. The decision for one or the other treatment regimen was made by an interdisciplinary team of gastroenterologists and surgeons. Using life-table analysis the 205 patients showed a clinical relapse rate of 27% after two years and 38% after four years. Clinical relapse was defined by a Crohn's disease activity index (CDAI) over 150. We used a standardized drug regimen of salazosulfapyridin and prednisone; the indication for excisional surgery was limited strictly to life-threatening situations, absolute nonresponse to drug treatment, and severe intervisceral fistulae. The operated patients (N = 93) had a lower relapse rate than the patients treated conservatively (N = 112), 20% and 51%, respectively, after four years. There were considerably fewer relapses in Crohn's colitis patients who were operated upon than in conservatively treated patients (18% versus 67% after four years); the same was found for ileocolitis (20% vs 49% after four years), but there was no difference between the treatment groups in ileitis (25-30% relapses for both after four years). In addition the patients with Crohn's disease of the colon had a more favorable course after resection with respect to symptoms, clinical and laboratory findings, and CDAI in remission. This paper gives data only for surgery in severe clinical situations and does not give a rationale for earlier surgery. This problem should now be studied in a randomized trial.

Recurrence rate after surgical treatment of Crohn's disease

In an unselected series of 207 consecutive patients with Crohn's disease diagnosed between 1958 and 1974, 170 underwent a resection of all the macroscopically involved bowel ('radically' resected). Two patients died during the first postoperative month. The crude recurrence rate for the surviving 168 patients was 49%. The cumulative recurrence rate, calculated by the actuarial method, was 53% at 15 years. Age, sex, length of preoperative disease history, localization of the lesions in the bowel, and primary surgical procedures performed had no influence on the recurrence rate. However, the histopathological appearance of the resection margins seemed to influence the prognosis, since the presence of ulcers and/or granulomas was correlated with a significantly increased recurrence rate.