Rectosigmoid stump washout as an alternative to permanent mucous fistula in patients undergoing subtotal colectomy for ulcerative colitis in emergency settings

Abstract

BackgroundRestorative 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.MethodsIPAA 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.ResultsThirty-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.ConclusionsRectal 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.

Systematic review of rectal stump management during and after emergency total colectomy for acute severe ulcerative colitis

“…Five retrospective case series (including 144 patients) reported on a subcutaneous placement of the rectal stump (Table ). This technique was associated with the lowest rate of pelvic sepsis (2%) followed by a low mortality rate (0%) comparable to mucous fistula placement (Table ) . Overall complications occurred in 27% of patients, with a 14.5% of wound infection rate.…”

“…However, the rates of pelvic sepsis (3.1%) and wound infection (9.4%) are higher when compared with an intraperitoneal placement. The overall mortality rate following a mucous fistula was 0% (Table ) …”

“…The current literature may suggest that subcutaneous placement of the closed rectal stump is the least morbid, with a pelvic sepsis rate of 2%, and a mortality rate of 0% . Although intraperitoneal placement of the rectal stump was associated with the lowest wound infection rate (7.9%), this was counteracted by higher rates of pelvic sepsis (5.3%), overall complications (25%) and mortality (1.5%) .…”

“…This technique was associated with the lowest rate of pelvic sepsis (2%) followed by a low mortality rate (0%) comparable to mucous fistula placement ( Table 2). 17,21,25,27 Overall complications occurred in 27% of patients, with a 14.5% of wound infection rate.…”

Thyroid Surgery in the Elderly: A Comparative Experience of 400 Patients From an Italian University Hospital

“…[14][15][16][17][18] This has been possible due to technical 19,20 and technological advancements 5,6,17,20,21 in perioperative management of frail patients, who have some peculiarities.…”