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Boldovjakova D, El-Abbassy I, Alarcon I, El-Saify M, Chan JH, Harley M, Parnaby C, Watson A, Ramsay G. Management of the Rectal Stump after Subtotal Colectomy Operations for Inflammatory Bowel Disease in the Era of Immunologic Therapy: A Two-Centre Cohort Study. Dig Dis 2023; 41:872-878. [PMID: 37690444 DOI: 10.1159/000533267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/25/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Inflammatory bowel disease (IBD) often requires surgical resection, such as subtotal colectomy operations to alleviate symptoms. However, IBD also has an inherently increased risk of colorectal dysplasia and cancer. Despite the well-accepted surveillance guidelines for IBD patients with an intact colon, contemporaneous decision-making models on rectal stump surveillance is sparse. This study looks at the fate of rectal stumps in IBD patients following subtotal colectomy. METHODS This is a two-centre retrospective observational cohort study. Patients were identified from NHS Grampian and NHS Highland surgical IBD databases. Patients that had subtotal colectomy between January 01, 2010 and December 31, 2017 were included with the follow-up end date on April 1, 2021. Socio-demographics, diagnosis, medical and surgical management data were collected from electronic records. RESULTS Of 250 patients who had subtotal colectomy procedures, only one developed a cancer in their rectal stump (0.4%) over a median follow-up of 80 months. A higher than expected 72% of patients had ongoing symptoms from their rectal stumps. Surveillance was varied and inconsistent. However, no surveillance, flexible sigmoidoscopy, or MRI identified dysplastic or neoplastic disease. CONCLUSION Based on our results, we estimate that the prevalence of rectal cancer is lower than previously reported. Surveillance strategy of rectal stump varied as no current guidelines exist and hence is an important area for future study. Given the relatively low frequency of rectal cancer in these patients, and the low level of evidence available in this field, we would propose a registry-based approach to answering this important clinical question.
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Affiliation(s)
| | - Islam El-Abbassy
- General Surgery Department, Faculty of Medicine, Ain Shams University, Abbassia, Cairo, Egypt
- Department of General Surgery, Raigmore Hospital, Inverness, UK
| | - Inari Alarcon
- Department of General Surgery, Raigmore Hospital, Inverness, UK
| | - Mamoun El-Saify
- Department of General Surgery, Raigmore Hospital, Inverness, UK
| | - Juen Hao Chan
- Department of General Surgery, Raigmore Hospital, Inverness, UK
| | - Morag Harley
- Department of General Surgery, Raigmore Hospital, Inverness, UK
| | - Craig Parnaby
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Angus Watson
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
- Department of General Surgery, Raigmore Hospital, Inverness, UK
| | - George Ramsay
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
- Institute of Medical Sciences, University of Aberdeen, King's College, Aberdeen, UK
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Is Hartmann’s Pouch an Option in the Management of Acute Severe Ulcerative Colitis? J Clin Med 2022; 11:jcm11133857. [PMID: 35807142 PMCID: PMC9267214 DOI: 10.3390/jcm11133857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/01/2022] [Accepted: 07/01/2022] [Indexed: 12/04/2022] Open
Abstract
Background: The surgical management of remnant rectosigmoid after subtotal colectomy with end ileostomy for acute severe ulcerative colitis remains controversial with respect to the need to perform sigmoidostomy or Hartmann’s pouch. The aim of this retrospective study was to investigate whether Hartmann’s pouch may be a safe option. Methods: Thirty-eight Hartmann’s pouches were performed between January 2003 and December 2015. We looked at morbidity (with a focus on the occurrence of pelvic sepsis and leakage of the rectal stump) and the rate of restored intestinal continuity. Results: Nineteen patients had surgical complications. Seven had an intra-abdominal collection, only one of which was in the pelvis, and the patient had to be reoperated. Only one patient had a reopening of the rectal stump, which was revealed by rectal bleeding. Twenty-six patients (68.4%) underwent further proctectomy with ileal J-pouch anal anastomosis with no difficulty in localizing or mobilizing the rectal stump and no major surgical complications. Conclusions: Hartmann’s pouch may be considered in patients with acute severe ulcerative colitis, with low rates of morbidity and pelvic sepsis. The restoration of intestinal continuity is possible after this procedure without any special difficulty.
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Abdulrahman GO, Das N, Chandrasekaran TV, Khot U, Drew PJ, Bose P, Vet JN, Tofazzal N, Roberts S, Lutchman Singh K. Pelvic Exenteration for the Treatment of Locally Advanced Vulvar Cancer in South West Wales. Cancers (Basel) 2022; 14:cancers14071767. [PMID: 35406539 PMCID: PMC8997009 DOI: 10.3390/cancers14071767] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022] Open
Abstract
The treatment of locally advanced vulvar carcinoma (LAVC) represents a major challenge. We investigated the role of pelvic exenteration as a treatment of LAVC. Women who underwent pelvic exenteration for primary and recurrent LAVC in our centre between 2001 and 2019 were included. Among the 19 women included during the study period, 14 women (73.7%) had primary LAVC while 5 women (26.3%) had recurrent disease. Surgical resection margins were microscopically clear (R0) in 94.7% of patients—14/14 undergoing primary treatment and 4/5 undergoing treatment for recurrent disease. Complete closure of the wound was achieved in 100% of women, with no wound left to heal by secondary intention. Tumour size was a predictor of requiring myocutaneous flap reconstruction, with all tumours less than 40 mm undergoing primary closure, while almost all tumours 40 mm diameter or greater (14/15 women) required flap reconstruction (p = 0.001). The 30-day major morbidity rate was 42% and there was no perioperative death. The mean overall survival was 144.8 months (2–206 months), with 1-, 2- and 5-year survival rates of 89.5%, 75.1% and 66.7%, respectively. In our centre, a primary surgical approach to the management of LAVC has resulted in good survival outcomes with acceptable morbidity rates.
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Affiliation(s)
- Ganiy Opeyemi Abdulrahman
- Swansea Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (G.O.A.); (N.D.); (J.N.V.)
- Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK
| | - Nagindra Das
- Swansea Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (G.O.A.); (N.D.); (J.N.V.)
| | - Thipparajapura V. Chandrasekaran
- Department of Gastrointestinal and Colorectal Surgery, Swansea Bay University Health Board, Swansea SA6 6NL, UK; (T.V.C.); (U.K.)
| | - Umesh Khot
- Department of Gastrointestinal and Colorectal Surgery, Swansea Bay University Health Board, Swansea SA6 6NL, UK; (T.V.C.); (U.K.)
| | - Peter J. Drew
- Welsh Centre for Burns and Plastic Surgery, Swansea Bay University Health Board, Swansea SA6 6NL, UK;
| | - Pradeep Bose
- Department of Urology, Swansea Bay University Health Board, Swansea SA6 6NL, UK;
| | - Jessica N. Vet
- Swansea Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (G.O.A.); (N.D.); (J.N.V.)
| | - Nasima Tofazzal
- Department of Cellular Pathology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (N.T.); (S.R.)
| | - Shaun Roberts
- Department of Cellular Pathology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (N.T.); (S.R.)
| | - Kerryn Lutchman Singh
- Swansea Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (G.O.A.); (N.D.); (J.N.V.)
- Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK
- Correspondence:
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Hennessy O, Egan L, Joyce M. Subtotal colectomy in ulcerative colitis—long term considerations for the rectal stump. World J Gastrointest Surg 2021; 13:198-209. [PMID: 33643539 PMCID: PMC7898189 DOI: 10.4240/wjgs.v13.i2.198] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy. A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis.
AIM To review the existing literature in relation to the significant long-term complic-ations associated with the rectal stump, to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort.
METHODS A systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis. A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum.
RESULTS For rectal stump surveillance guidelines, 20% recommended an interval of 6 mo to a year, 50% recommended yearly surveillance 10% recommended 2 yearly surveillance and the remaining 30% recommended risk stratification of patients and different screening intervals based on this. All studies agreed surveillance should be carried out via endoscopy and biopsy. Increased vigilance is needed in endoscopy in these patients. Literature review revealed a number of options for surgical management of the remnant rectum.
CONCLUSION The retained rectal stump needs to be surveyed endoscopically according to risk stratification. Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy. If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique.
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Affiliation(s)
- Orla Hennessy
- Department of Colorectal Surgery, Galway University Hospital, Galway H91RR2N, Ireland
| | - Laurence Egan
- Department of Gastroenterology, Galway University Hospital, Galway H91RR2N, Ireland
| | - Myles Joyce
- Department of Gastroenterology, Galway University Hospital, Galway H91RR2N, Ireland
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Bedrikovetski S, Liu J, Dudi-Venkata NN, Kroon HM, Lewis M, Lawrence M, Andrews JM, Sammour T. Rectal Stump Management After Subtotal Colectomy for Severe Colitis, In or Out? A Retrospective Cohort Study. Indian J Surg 2020. [DOI: 10.1007/s12262-019-02004-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Lawday S, Leaning M, Flannery O, Summers S, Antoniou GA, Goodhand J, Bethune R, Antoniou SA. Rectal stump management in inflammatory bowel disease: a cohort study, systematic review and proportional analysis of perioperative complications. Tech Coloproctol 2020; 24:671-684. [PMID: 32236745 DOI: 10.1007/s10151-020-02188-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of this study was to analyse local single-institution data and perform a systematic review of the literature to calculate precise risk estimates of rectal stump-related morbidity and mortality following subtotal colectomy in patients with inflammatory bowel disease (IBD), including Crohn's colitis, ulcerative colitis and indeterminate colitis. METHODS Institutional information systems were interrogated to obtain local patient data. A systematic review of MEDLINE and EMBASE was performed to identify relevant articles. Fixed-effects or random-effects meta-analysis of proportions was performed to calculate pooled incidence estimates, including local data. RESULTS Sixty-one patients were included locally and all had their rectal stump closed intra-abdominally. Four patients (8.3%) had a rectal stump perforation and 30-day mortality was 0. Fourteen papers were included in our review alongside local data, with a total of 1330 patients included. Pooled mortality was 1.7% (95% confidence interval, CI 1.0-2.8), pooled incidence of pelvic abscess/sepsis, stump leak and wound infection was 5.7% (95% CI 4.4-7.3), 4.9% (95% CI 3.7-6.6) and 11.3% (95% CI 7.8-16), respectively. Subcutaneous placement of the stump was associated with the highest incidence of stump leak (12.6%, 95% CI 8.3-18.6), and closure of the stump with both staples and suture was associated with the highest incidence of pelvic abscess (11.1%, 95% CI 5.8-20.3). Mortality and the incidence of wound infection were similar across stump closure techniques. There was evidence suggesting considerable heterogeneity and publication bias among studies. CONCLUSIONS This study provides estimates of morbidity associated with the rectal stump after subtotal colectomy for IBD. A closed intra-abdominal stump seems to be associated with the highest rate of pelvic abscess/sepsis. Further work in form of an international collaborative project would allow individual patient data analysis and identification of risk factors for complications.
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Affiliation(s)
- S Lawday
- Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - M Leaning
- Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - O Flannery
- Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - S Summers
- Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - J Goodhand
- Department of Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK
| | - R Bethune
- Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - S A Antoniou
- Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Medical School, European University Cyprus, Nicosia, Cyprus.,Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus
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Colectomy with ileostomy for severe ulcerative colitis-postoperative complications and risk factors. Int J Colorectal Dis 2020; 35:387-394. [PMID: 31865435 DOI: 10.1007/s00384-019-03494-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE In the era of biological therapy of ulcerative colitis (UC), surgical treatment frequently consists of colectomy, end ileostomy, and rectal stump closure before patients go on towards restorative proctocolectomy. We aimed to evaluate possible risk factors for the occurrence of postoperative complications and investigate those after initial colectomy in these patients. METHODS Retrospective analysis of 180 patients (76 female, 104 male) undergoing colectomy for UC with formation of a rectal stump and terminal ileostomy between March 2008 and March 2018 at Charité University Hospital Berlin, Campus Benjamin Franklin. A panel of possible postoperative complications was established, patient history was screened, and postoperative complications were analyzed using the Clavien Dindo Classification. RESULTS Postoperative complication rate was 27.7%. Mortality was 0.5%. Postoperative ileus occurred in 15.3% and rectal stump leakage in 14.8%. Complications were categorized as Clavien Dindo 3 in 80%. Risk factors for surgical complications after multivariate analysis were ASA classification (p = 0.004), preoperative anemia (Hemoglobin < 8 mg/dl) (p = 0.025), use of immunosuppressants (p = 0.003), more than two cardiovascular diseases (p = 0.016), and peritonitis (p = 0.000). Reoperation rate of patients with surgical complications was 27.7%. CONCLUSION Colectomy in high-risk UC patients is associated with significant morbidity. However, most of the surgical complications can be treated conservatively. Overall mortality is low. Patient-related risk factors are associated with postoperative complications. Optimizing these risk factors or earlier indication for surgery in the course of UC may help to reduce morbidity of this procedure.
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Bedrikovetski S, Dudi-Venkata N, Kroon HM, Liu J, Andrews JM, Lewis M, Lawrence M, Sammour T. Systematic review of rectal stump management during and after emergency total colectomy for acute severe ulcerative colitis. ANZ J Surg 2019; 89:1556-1560. [PMID: 30919553 DOI: 10.1111/ans.15075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/16/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is no consensus about the optimal management of the rectal stump after an emergency subtotal colectomy in patients with acute severe ulcerative colitis (ASUC). The aim was to perform a systematic review of the published literature on the surgical and medical management of the rectal stump after an emergency (sub) total colectomy in patients with ASUC. METHODS The following databases were searched, MEDLINE (PubMed), EMBASE and OVID SP, from January 1993 to March 2018. Studies that reported post-operative outcomes after surgical and/or medical management of the rectal stump after emergency (sub) total colectomy in adults with ASUC were included. Two independent assessors reviewed eligible articles. RESULTS A total of 11 studies met the inclusion criteria. All were case series and included 476 patients. Regarding surgical management, five studies reported on closed subcutaneous placement of the rectal stump, seven on intraperitoneal placement and two on the formation of a formal mucous fistula. The lowest reported pelvic sepsis rate was in patients with subcutaneous closure of the rectal stump (n = 144, 2%) and lowest wound infection rate was reported after intraperitoneal closure (n = 268, 7.8%). The highest rate of mortality was reported after intraperitoneal placement of the rectal stump (n = 268, 1.5%). There were insufficient data reported on medical management for any comparison. CONCLUSION Subcutaneous placement of the rectal stump was associated with the lowest morbidity and mortality rate, although data are of limited quality and insufficient to guide practice recommendations.
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Affiliation(s)
- Sergei Bedrikovetski
- Faculty of Health and Medical Science, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nagendra Dudi-Venkata
- Faculty of Health and Medical Science, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jianliang Liu
- Faculty of Health and Medical Science, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jane M Andrews
- Faculty of Health and Medical Science, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mark Lewis
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Matthew Lawrence
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Faculty of Health and Medical Science, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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The type of stoma matters-morbidity in patients with obstructing colorectal cancer. Int J Colorectal Dis 2018; 33:1773-1780. [PMID: 30225654 DOI: 10.1007/s00384-018-3164-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE A loop colostomy may reduce the risk of severe intraabdominal complications in patients with obstructing colorectal cancer compared to an end colostomy. The aim of this study was to relate complications to the type of stoma, and a secondary aim was to evaluate whether the type of colostomy had an impact on time until oncological/surgical treatment. METHODS All patients who underwent surgery and received a deviating colostomy due to obstructing colorectal cancer between January 2011 and December 2015 in five Swedish hospitals in Region Västra Götaland were included (n = 289). Patient charts were reviewed retrospectively. Patients alive in the end of 2016 were contacted and were sent a questionnaire including questions about stoma function and health-related quality of life. RESULTS Some 289 patients were included; 147 received an end colostomy and 140 a loop colostomy. Two patients were excluded from the analysis due to missing data. There was no difference in complications at 90 days between the two groups, 44% (end colostomy) and 54% (loop colostomy) (odds ratio: 0.83 (95% CI: 0.49; 1.41). Time to start of treatment was similar in both groups. Patients with a loop colostomy had significantly higher stoma-related morbidity with retraction, prolapse, leakage and bandaging problems. No differences in quality of life were found. CONCLUSION The hypothesis that a loop colostomy reduced complications could not be confirmed. An end colostomy should be the first choice in these patients particularly in patients who will have their colostomy for the remainder of their life to reduce stoma-related symptoms.
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Uchida K, Araki T, Kusunoki M. History of and current issues affecting surgery for pediatric ulcerative colitis. Surg Today 2012. [PMID: 23203770 DOI: 10.1007/s00595-012-0434-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pediatric ulcerative colitis (UC) is reportedly more extensive and progressive in its clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent colectomies are needed. When physicians treat pediatric UC, they must consider the therapeutic outcome as well as the child's physical and psychological development. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This procedure was developed 100 years after the first surgical therapy, which treated UC by colon irrigation through a temporary inguinal colostomy. Predecessors in the colorectal and pediatric surgical fields have struggled against several postoperative complications and have long sought a surgical procedure that is optimal for children. We herein describe the history of the development of surgical procedures and the current issues regarding the surgical indications for pediatric UC. These issues differ from those in adults, including the definition of toxic megacolon on plain X-rays, the incidence of colon carcinoma, preoperative and postoperative steroid complications, and future growth. Surgeons treating children with UC should consider the historical experiences of pioneer surgeons to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.
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Affiliation(s)
- Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan,
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Pellino G, Sciaudone G, Candilio G, Canonico S, Selvaggi F. Rectosigmoid stump washout as an alternative to permanent mucous fistula in patients undergoing subtotal colectomy for ulcerative colitis in emergency settings. BMC Surg 2012; 12 Suppl 1:S31. [PMID: 23173990 PMCID: PMC3499271 DOI: 10.1186/1471-2482-12-s1-s31] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Restorative proctocolectomy with ileopouch-anal anastomosis (IPAA) is the treatment of choice for intractable or complicated ulcerative colitis(UC). Elderly patients often present with acute colitis requiring emergent subtotal colectomy(SC). Frail patients are at risk of developing septic complications related to the closed rectosigmoidal stump, often requiring formation of a second stoma to be reversed at the time of completion proctectomy. This carries nuisance to such exhausted patients. We propose a simple and inexpensive trick to avoid the need for creating a mucous fistula. Methods IPAA was performed as a 3-stage procedure in emergency settings. The rectosigmoidal stump was closed and placed subcutaneously; skin was closed over it. After SC, if patients showed signs of stump-related pelvic sepsis, a lavage of the rectal stump with povidone iodine solution and with saline was carried out as a rescue treatment aiming to avoid the need of opening the rectal stump to drain sepsis. Results Thirty-five patients underwent SC for UC between 1987 and 2012. The skin was closed over the closed stump in the 20. Seven patients out of these 20 experienced early stump-related septic complication. In five cases, we were able to avoid opening of the rectal stump, and a second stoma was unnecessary. After opening the closed stump in the remaining ones, a prompt improving of symptoms was observed. Conclusions Rectal washout was well tolerated and avoided a second stoma in five out of seven patients, with better quality of life and body perception after IPAA surgery. This is relevant when dealing with geriatric patients, needing to completely recover before undergoing completion proctectomy.
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Affiliation(s)
- Gianluca Pellino
- Department of Surgery, Unit of General and Geriatric Surgery, School of Medicine, Second University of Naples, Naples, Italy
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