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

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.

Essential updates 2018/2019: Colorectal (benign)

“…Patients with i.p. placement had less wound infection but high mortality . Risk factors in patients with chronic refractory UC were an absence of clinical response and lack of mucosal healing after induction with biological therapy.…”

“…placement had less wound infection but high mortality. 27 Risk factors in patients with chronic refractory UC were an absence of clinical response and lack of mucosal healing after induction with biological therapy. Early assessment (12-16 weeks after therapy) of the clinical and endoscopic response could predict subsequent risk of colectomy.…”

Minimally Invasive and Robotic Surgery for Ulcerative Colitis

“…When performed, the rectal stump can be implanted in the lower aspect of the midline incision for open cases, or at the Pfannenstiel or lower midline extraction site for MIS cases. 28 One decision specific to MIS approaches is how to transect the rectosigmoid colon. While many surgeons use laparoscopic or robotic staplers through the right lower quadrant port to transect the specimen, some surgeons transect the specimen open through a Pfannenstiel or lower midline extraction site with a contour curved stapler (Ethicon) or thoracoabdominal (TA) stapler (Medtronic).…”

“…When performed, the rectal stump can be implanted in the lower aspect of the midline incision for open cases, or at the Pfannenstiel or lower midline extraction site for MIS cases. 28…”

Surgical Management of Hospitalized Patients with Ulcerative Colitis

“…A minimally invasive approach is preferable for the colectomy [51]. Rectal stump leakage occurs in approximately 5-10% of cases and can have significant morbidity especially if the stump is stapled and left intraperitoneal [52][53][54]. Options to decrease morbidity related to rectal stump leakage include creating a mucus fistula with the proximal end of the divided sigmoid colon.…”