Diverting Ileostomy: An Alternative to Emergent Colectomy in the Setting of Acute Medically Refractory IBD-Related Colitis

Abstract

Introduction: Severe, medically refractory colitis is an indication for emergent colectomy in inflammatory bowel disease (IBD). When compared to elective colectomy, emergent surgery has higher risks of serious complications and mortality, especially with immunosuppression and malnutrition. We hypothesize that diverting laparoscopic ileostomy (DLI) can serve as a safer initial surgery for patients with acute severe colitis. The definitive colectomy can then be performed electively after patient optimization. Methods: Consecutive patients who had a DLI for severe, refractory colitis by a single colorectal surgeon at a tertiary IBD center from 10/2013-10/2016 were identified. Pre-, peri- and post-operative clinical and surgical data were abstracted from the medical record. Results: 36 patients (17 CD, 19 UC), mean age 36 yrs (range 17-81), including 21 (59%) patients who met SIRS criteria who were hospitalized with severe IBD had single incision laparoscopic DLI during the 3-yr study period. Medication use pre-operatively included 56% IV steroids use, 8% IV cyclosporine use, and 94% with anti-TNF exposure. Other notable pre-operative variables included: C-reactive protein (5.6 ± 1.0 g/dL), albumin (2.9 ± 0.1 g/dL), and hemoglobin (9.9 ± 0.3 g/dL). The median operative time was 60 minutes, and median post-operative length of stay was 5 days (range 2-20). 62% of patients had resolution of SIRS within 24 hours and 93% were tolerating oral intake on post-operative day 1. Post-operative complications occurred in 4 (11.1%) patients: 3 surgical site infections, 1 hospital acquired pneumonia, and 2 (5.6%) patients required re-operation due to acute appendicitis and disease progression within 30 days. Emergent colectomy was avoided in 94.4% (n=34) of patients with subsequent elective surgery planned at a later stage. Conclusion: DLI in the setting of severe, refractory colitis is a viable alternative to emergent colectomy with low post-operative morbidity and re-operation rates. By performing DLI, patients have time to improve their physical conditioning, nutritional status and eliminate/taper immunosuppression prior to undergoing a definitive colectomy or further medical optimization with decreased subsequent surgical complications. This strategy may be more cost-effective and safe for severe, hospitalized IBD patients, especially for persons located in community practices who are not able to have surgery by an expert colorectal surgeon.