EP.TU.688The fate of the rectal stump following subtotal colectomy for acute colitis

Abstract

Abstract Aims Acute severe colitis requires surgery in approximately thirty percent of cases. Subtotal colectomy with end ileostomy is the standard procedure with distinct advantages to a laparoscopic approach. 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 this patient cohort. Methods Analysis of prospective data of patients who underwent emergency subtotal colectomy for severe acute colitis between 2010 and 2020 in a tertiary referral centre. Results Sixty-six patients underwent subtotal colectomy (median age, 40years; M:F, 1.3:1). Subtotal colectomy was performed for failure of medical therapy during an acute episode of severe colitis (56%), for fulminant colitis (40%), or for colonic strictures (4%). In 98% percent of patients the rectal stump was closed at the level of the recto-sigmoid junction and in 2% a mucous fistula was formed. 73% of patients opted for no further surgery, but 27% underwent a completion proctectomy, most commonly performed because of rectal stump bleeding. The median follow-up was 6.25years, during which 17% of those with a completion proctectomy underwent an ileo-pouch anal anastomosis (IPAA). Conclusions 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, this procedure should be abandoned. Pelvic dissection should not be performed at the time of the emergency subtotal colectomy given the risk of morbidity.