Porter DJ*, Lucocq J and Muthukumarasamy G
Department of Emergency and Colorectal Surgery, Ninewells Hospital and Medical School, Dundee, ScotlandFulltext PDF
Objective: Acute severe colitis requires surgery in approximately thirty percent of cases. Subtotal
colectomy with end ileostomy is the standard procedure with the laparoscopic approach offering
distinct advantages. Controversy surrounds the optimal short and long-term management of the
distal rectal stump. This study reviews the clinical outcomes and the fate of the rectal stump in
patients who have had a subtotal colectomy for acute colitis.
Methods: Analysis of prospective data of patients who had an emergency subtotal colectomy for
severe acute colitis over a ten-year period in a tertiary referral centre.
Results: Sixty-six patients had a subtotal colectomy in Ninewells Hospital from January 2010
until September 2019. The average age of the patients at the time of surgery was 40.5 years. 54% of
patients were female and 56% were male. Subtotal colectomy was performed for fulminant colitis in
40% of patients, for failure of medical therapy during an acute episode of severe colitis in 56%, and
for colonic strictures in the remaining 4% of patients.
Complications included peritonitis, with return to theatre in 9% of patients; wound infection in
6%, pneumonia in 2%, ileus in 15%, conversion to open in 2%, and stoma - related problems in 6%
of patients. In 98% percent of patients the rectal stump was closed at the level of the recto-sigmoid
junction and in 2% the rectal stump was left open and brought to the skin as a mucous fistula.
73% percent of patients opted for no further surgery, but 27% percent of patients underwent a
completion proctectomy, and this was most commonly performed because of bleeding from the
rectal stump. The median follow-up of patients within this study was 6.25 years and during this time
three of the eighteen patients (17%) who had a completion proctectomy underwent an Ileo-Pouch
Anal Anastomosis (IPAA).
Conclusion: Subtotal colectomy with closed rectal intra-peritoneal stump and end ileostomy is
the procedure of choice in severe acute colitis refractory to maximal medical therapy or fulminant
colitis. Given the patient dissatisfaction and morbidity associated with mucous fistula, we believe
that this procedure should be abandoned. We suggest that pelvic dissection should not be performed
at the time of the emergency subtotal colectomy given the risk of morbidity and to reduce difficulty
for future pelvic dissection should a proctectomy or IPAA be performed.
Acute colitis; Ulcerative colitis; Colectomy; Rectal stump; Ileo-pouch anal anastomosis; Proctectomy
Porter DJ, Lucocq J, Muthukumarasamy G. The Fate of the Rectal Stump Following Subtotal Colectomy for Acute Colitis. World J Surg Surgical Res. 2021; 4: 1321..