Mucous Fistula Research Articles

Acute Intestinal Obstruction Due to an Anomalous Ileosigmoid Band – A Case Report

We report a case of a 30-year-old female who presented with symptoms and signs of intestinal obstruction. The patient reported no previous history of abdominal surgery or trauma while clinical and radiographic examinations were not diagnostic. Patient planned for exploratory laparotomy in view of complete intestinal obstruction. Exploratory laparotomy with limited resection of gangrenous segment with primary closure of abnormal ileosigmoid communication with proximal ileostomy with distal mucous fistula. Intraoperatively distal 60cm of ileum, caecum and part of ascending colon was gangrenous there was a fibrous band extending from parities to ileum approximately 60 cm proximal to IC junction. Congenital bands are extremely rare. Their exact incidence is still unknown and usually observed in childhood. This case, therefore, represents an unusual surgical problem in an older individual in which the diagnosis was clinically unexpected. Small bowel obstruction is the most common surgical disorder of the small intestine. Adhesions are by far the most frequent causes followed by hernias, tumors, intussusception, foreign bodies, gallstones, and inflammatory bowel disease. Obstruction by a congenital band is extremely rare and usually observed in childhood. This report presents a 30-year-old female with symptoms of intestinal obstruction, subsequently treated by ligation and division of a congenital band.

Clinical and microbiological characteristics of Chryseobacterium indologenes bacteremia: A case report and review of literature

Chryseobacterium indologenes is an uncommon human pathogen that is aerobic, non-fermentative, and oxidase and indole positive. Its clinical relevance has yet to be fully determined. An increase in deadly infectious cases has been recorded in recent years, mostly in patients of older age group and immunocompromised states as a result of C. indologenes infection of medical equipment involving fluids and implanted devices. Because C. indologenes is resistant to the majority of antibiotics, therapy is challenging and this bacterium is thought to be an emerging cause of high mortality in critically ill patients. In our study, we describe a case of C. indologenes producing bacteremia in an elderly female patient with a history of ovarian cancer and hepatitis B infection who had underwent a right hemicolectomy with end ileostomy and a distal mucus fistula and was effectively treated with levofloxacin.

Emergency intestinal stomas incidence and early complications

Background: An intestinal stoma is a frequently performed procedure with a high percentage of complications. Even though creating an intestinal stoma is a procedure that can save lives while treating various gastrointestinal conditions, its accompanying morbidity and mortality have been the topic of many studies. This study was carried out in order to better understand a variety of complications in various types of intestinal stomas. Methods: A total of 60 patients with intestinal stoma construction in the general surgery emergency department at Kasr Al-Ainy emergency hospital Cairo, Egypt as an emergency procedure from December 2019 to May 2020 were included in this prospective cohort analysis. The inclusion criteria were all emergency cases undergoing intestinal stomas for treatment of either traumatic bowel injuries or acute abdominal surgical emergencies. Results: With a mean age of 45.18 years, 60 patients in all were evaluated. Males were 65% and females were 35%. End ileostomy with mucous fistula (33.3%) and loop transverse colostomy (18.30%) were the two stomas that were constructed most frequently. Intestinal obstruction (41.7%) was the most often reported indication of stoma formation. Complications of the peristomal skin made up the majority of cases (61.90%). Conclusions: This work significantly advances our understanding of stoma problems and their prevention to some extent through pre-operative soma site marking, good surgical technique, an experienced surgeon, a stoma therapy nurse, and patient education to enhance the care and quality of life for those who have stomas.

Postoperative Distal Enteral Tube Refeeding in Stoma Patients: A Comparative Analysis of Clinical Outcomes.

<b><br>Introduction:</b> Stoma surgery, which involves creating a diversion of the small intestine through an abdominal wall opening, poses challenges in managing fluid and electrolyte imbalances. Patients with high proximal stoma often rely on costly and risky parenteral nutrition (PN). Distal enteral tube feeding, a method of delivering nutrition to the small intestine, is intended to improve clinical outcomes and reduce complications. This study presents a comparative analysis of clinical outcomes between postoperative distal enteral tube refeeding and traditional enteral and PN approaches in stoma patients with distal mucous fistula.</br> <b><br>Aim:</b> To evaluate the effectiveness of distal enteral tube refeeding in improving postoperative outcomes after stoma surgery and to examine the impact of distal enteral tube refeeding on total hospitalization stay, ICU length of stay, TPN duration, and time to closure of the stoma.</br> <b><br>Material and methods:</b> The study is a retrospective, single-center trial involving 84 patients who had undergone stoma surgery. The patients were divided into two groups: those receiving postoperative distal enteral tube refeeding (n = 42) and the control group (n = 42), with standard mucous fistula creation. The data was collected retrospectively from January 2012 to January 2022 and the statistical analysis was performed using descriptive statistics, the chi-square test, and the t-test.</br> <b><br>Results:</b> The results of our study show that the patients who had undergone postoperative distal enteral tube refeeding had a significantly shorter total hospitalization stay (p = 0.0002), a significantly shorter ICU length of stay (p = 0.0006), a significantly shorter TPN duration (p= 0.0004), and a significantly faster time to closure (p = 0.0002).</br&gt.

Five Years’ Single-center Experience of a Modified Approach to Divided Sigmoid Colostomy for Anorectal Malformation

BackgroundIn patients with anorectal malformation (ARM), a divided descending colostomy is associated with high complication rates, including wound infection, dehiscence, and prolapse, and it places a significant burden on caregivers. To decrease the chances of such complications, we modified our approach for colostomy fashioning by keeping an intact skin bridge between the colostomy and mucous fistula. The objective was to compare the rate of complications among patients diagnosed with ARM who underwent a modified divided descending colostomy and classical descending colostomy. MethodsWe included all the patients diagnosed with ARM who underwent a divided colostomy with modified (group A) or classical technique (group B) in the last 5 years. The type of approach used to fashion the stoma was based on the surgeon's preference than on patients' selection criteria. All patients were followed and monitored for postoperative complications. SPSS version 26 was used to analyze the data. ResultsA total of 62 patients with ARM underwent the colostomy creation; 27 in group A and 35 in group B. Males were more in both groups and other demographic variables were comparable. The most common associated anomalies were cardiac (58%). The mean duration of surgery was 72.2 ± 18.26 min in group A while 91.25 ± 21.43 min in group B (P = 0.000). The mean hospital stay was 4.28 ± 3.63 days in group A while 7.97 ± 6.12 days in group B (P = 0.007). The overall complication rate was 14.8% in group A and 34.2% in group B (P = 0.082). ConclusionThe modified approach to fashioning a divided colostomy is easily reproducible and carries a low risk of postoperative complications. Level of EvidenceIV.

Efficacy and safety of mucous fistula refeeding in preterm infants: an exploratory randomized controlled trial

BackgroundThis study aimed to evaluate whether mucous fistula refeeding (MFR) is safe and beneficial for the growth and intestinal adaptation of preterm infants with enterostomies.MethodsThis exploratory randomized controlled trial enrolled infants born before 35 weeks’ gestation with enterostomy. If the stomal output was ≥ 40 mL/kg/day, infants were assigned to the high-output MFR group and received MFR. If the stoma output was < 40 mL/kg/day, infants were randomized to the normal-output MFR group or the control group. Growth, serum citrulline levels, and bowel diameter in loopograms were compared. The safety of MFR was evaluated.ResultsTwenty infants were included. The growth rate increased considerably, and the colon diameter was significantly larger after MFR. However, the citrulline levels did not significantly differ between the normal-output MFR and the control group. One case of bowel perforation occurred during the manual reduction for stoma prolapse. Although the association with MFR was unclear, two cases of culture-proven sepsis during MFR were noted.ConclusionsMFR benefits the growth and intestinal adaptation of preterm infants with enterostomy and can be safely implemented with a standardized protocol. However, infectious complications need to be investigated further.Trial registrationclinicaltrials.gov NCT02812095, retrospectively registered on June 6, 2016.

Mucous fistula refeeding in neonates: a systematic review and meta-analysis

Background and objectiveMucous fistula refeeding (MFR) aims to maximise bowel function when an ostomy is active after abdominal surgery, by introducing the proximal ostomy effluent into the distal mucous fistula...

Patient with suspected severe acute respiratory syndrome coronavirus 2 infection with successful emergency surgery for ulcerative colitis-associated toxic megacolon

BackgroundIn patients with acute severe ulcerative colitis with concomitant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the treatment strategy should consider the presence of pneumonia, respiratory status, and the severity of the ulcerative colitis (UC). We report a case of a 59-year-old man with SARS-CoV-2 infection who was diagnosed with toxic megacolon caused by UC.Case presentationPreoperative computed tomography scanning of the chest showed ground-glass opacities. The patient was treated conservatively until the pneumonia improved, but developed bleeding and liver dysfunction associated with UC. As the patient’s condition worsened, emergency surgery with subtotal colorectal resection, ileostomy, and rectal mucous fistula creation was performed while undertaking adequate infection control measures. Intraoperatively, contaminated ascites was observed, and the intestinal tract was markedly dilated and fragile. Nevertheless, the postoperative outcome was positive, with no pulmonary complications. The patient was discharged on postoperative day 77.ConclusionsThe COVID-19 pandemic presented challenges in surgical scheduling. Patients with SARS-CoV-2 infection required close monitoring for postoperative pulmonary complications.

MUC-FIRE: Study protocol for a randomized multicenter open-label controlled trial to show that MUCous FIstula REfeeding reduces the time from enterostomy closure to full enteral feeds

BackgroundAfter enterostomy creation, the distal bowel to the ostomy is excluded from the physiologic passage of stool, nutrient uptake, and growth of this intestinal section. Those infants frequently require long-term parenteral nutrition, continued after enterostomy reversal due to the notable diameter discrepancy of the proximal and distal bowel. Previous studies have shown that mucous fistula refeeding (MFR) results in faster weight gain in infants. The aim of the randomized multicenter open-label controlled MUCous FIstula REfeeding (“MUC-FIRE”) trial is to demonstrate that MFR between enterostomy creation and reversal reduces the time to full enteral feeds after enterostomy closure compared to controls, resulting in shorter hospital stay and less adverse effects of parenteral nutrition.Methods/Design: A total of 120 infants will be included in the MUC-FIRE trial. Following enterostomy creation, infants will be randomized to either an intervention or a non-intervention group.In the intervention group, perioperative MFR between enterostomy creation and reversal will be performed. The control group receives standard care without MFR.The primary efficacy endpoint of the study is the time to full enteral feeds. Secondary endpoints include first postoperative bowel movement after stoma reversal, postoperative weight gain, and days of postoperative parenteral nutrition. In addition adverse events will be analyzed. DiscussionThe MUC-FIRE trial will be the first prospective randomized trial to investigate the benefits and disadvantages of MFR in infants. The results of the trial are expected to provide an evidence-based foundation for guidelines in pediatric surgical centers worldwide. Trial registrationThe trial has been registered at clinicaltrials.gov (number: NCT03469609, date of registration: March 19, 2018; last update: January 20, 2023, https://clinicaltrials.gov/ct2/show/NCT03469609?term=NCT03469609&draw=2&rank=1).

431 - Feasibility, safety, and short-term outcomes of mucous fistula refeeding in infants with intestinal failure and stoma

431 - Feasibility, safety, and short-term outcomes of mucous fistula refeeding in infants with intestinal failure and stoma

SJLA_2024_A1: Appendix and Ascending Colon Intussusception through a Prolapsed Transverse Colostomy: A Case Report with Literature Review

Background: Stoma creation is one of the most common performed surgical procedures. For both benign and malignant conditions, in elective and emergency settings. Like any surgical procedure, it is associated with complications. One of the most frequently encountered is prolapse, with the incidence rate reaching 26%. On the other hand, intussusception of the bowel through the ostomy is a rare complication, with few cases being reported in the literature. Methods: The study was a case report. Results: We reported a case of a 52-year-old female with a proximal limb transverse loop colostomy prolapse noted 1 day before her presentation. Intraoperatively, cecal intussusception through the ostomy is encountered with unsalvageable right colon. The patient ended up with right hemicolectomy, end ileostomy, and mucus fistula. Discussion: Although stoma prolapse is a common late complication with an impact on quality of life in terms of difficulty with appliance fitting, it can be an early sign of a serious condition like intussusception. This necessitates a differentiation between intussusception through a prolapsed colostomy from simple prolapse. Based on literature, reduced stoma output along with significant irreducible prolapsed segment are the frequent clinical characteristics. Yet, it should be noted that the intussuscepted segment is only evident upon surgical exploration. Conclusion: Caution during stoma creation must be attempted, with the avoidance of underestimating a significant irreducible prolapse. As it may be lead to intussusception and subsequent bowel perforation.

Successful management of clostridium difficile colitis with antegrade Vancomycin through a mu-cous fistula eliminating the need for subtotal colectomy

Clostridium difficile (CD) is the most common cause of healthcare-associated infections and can have devastating morbidity and mortality. A 40-year-old diabetic patient who was recently treated for wound sepsis, subsequently developed CD colitis. This patient failed the standard medical therapy for CD colitis, decompensated and required surgical exploration, partial colectomy and mucous fistula creation. Following surgery, her clinical condition improved and her colitis resolved with the antegrade administration of vancomycin through mucous fistula. Traditional treatment algorithms involve oral metronidazole or vancomycin. Our case study report describes the index case of topical vancomycin through a mucous fistula may have reduced the need for total colectomy in the treatment of fulminant CD colitis.

3D Fluoroscopic imaging facilitates reconstruction of common urogenital sinus and cloacal anomalies

Cloacal anomalies and common urogenital sinus are rare structural abnormalities in hindgut and urogenital development. Surgical correction in childhood is often indicated to create normal external genital anatomy, allow for adequate bladder and vaginal drainage, and create the appropriate anorectal opening in patients with persistent cloaca. Understanding the anatomy and relationships between the pelvic organs is critical as there is a drastic variation in potential surgical approaches to the repair. Traditional imaging modalities such as pelvic ultrasound, magnetic resonance imaging, and two-dimensional fluoroscopic imaging have been utilized to delineate the pelvic anatomy for facilitation of surgical planning. Limitations to these modalities include the inability to adequately dilate structures and the difficulty in identifying the common confluence, or where the structures ultimately coalesce within the pelvis. In this article we describe the utilization of three-dimensional rotational fluorosco- py in combination with examination under anesthesia to provide optimal clarity of anatomy. Examination under anesthesia, specifically cystoscopy and vaginoscopy, helps the surgeon to visualize the anatomy and to place catheters in the correct lumens. Contrast material can then be injected into the catheters to dilate the bladder, vagina, and mucous fistula for fluoroscopic imaging. The rotational images can then be reconstructed in three dimensions to create a roadmap for the surgeons, providing accurate description of the location of the confluence, distance to the introitus and other critical measurements. We believe that three-dimensional rotation fluoroscopy is an underutilized diagnostic modality in the evaluation and surgical planning in patients with urogenital sinus and cloacal anomalies and should be considered by surgeons prior to proceeding with corrective surgery.

A Case Report Baby Born with Multiple Congenital Anomalies Including Ruptured Omphalocele at a Primary Healthcare

A baby was born at a primary healthcare with multiple congenital anomalies, which included ruptured omphalocele, cloacal exstrophy, and congenital talipes equinovarus. IV line was obtained, and the baby was stabilized. The baby was referred to a tertiary health care and underwent surgery to close the defect, ileostomy, and mucous fistula. He survived the surgery but is currently in intensive care.&#x0D;

Baby Born with Multiple Congenital Anomalies Including Ruptured Omphalocele at a Primary Healthcare

A baby was born at a primary healthcare with multiple congenital anomalies, which included ruptured omphalocele, cloacal exstrophy, and congenital talipes equinovarus. Intra Venous line was obtained, and the baby was stabilized. The baby was referred to a tertiary health care and underwent surgery to close the defect, ileostomy, and mucous fistula. He survived the surgery but is currently in intensive care.

COVID-19 infection and large intestinal perforation: A case series.

IntroductionCOVID-19 is a viral illness characterized primarily by respiratory symptoms. However, patients with COVID-19 infection may also present with gastrointestinal symptoms. Subsequent complications can be associated with high morbidity and mortality.MethodsThis is a retrospective observational study of three COVID-19 positive patients who developed large intestinal perforations and an analysis of their clinical characteristics, diagnosis, surgical treatment and outcomes. Three patients aged 45, 51 and 82 years old presented to our institution between November 2021 and March 2022 and were diagnosed with COVID-19 pneumonia requiring admission to the intensive care unit (ICU). All three patients received steroids and underwent surgery during their admission. None of our patients had prior history of bowel perforation or risks factors justifying their presentation.Presentation of casesOur first patient was found to have an ascending colon perforation and underwent right colon resection and end ileostomy. Our second patient was found to have a cecal perforation and underwent ileocecectomy with end ileostomy and mucus fistula creation. Our third patient was found to have a large cecal perforation and underwent right hemicolectomy and was left in discontinuity during the index operation.DiscussionGI perforation is a less common but serious extra-pulmonary complication of COVID-19. The cases in the present study involve ascending colon perforations in the setting of active COVID-19 infection that occurred within two to five weeks after initial COVID-19 diagnosis. Given viral replication in GI cells, the local inflammatory effect of viral infection in the GI may play a role in bowel perforation. Providers should additionally be aware of the risk of perforation with steroids and immunomodulators. Immunosuppressive effects of these therapies may mask the classical signs of abdominal sepsis and lead to possible missed diagnoses.ConclusionGastrointestinal perforation is a rare but serious complication of COVID-19 infection. A high degree of clinical suspicion is necessary for timely diagnosis and management.

A rare presentation of OEIS variant with a recto-bladder neck fistula: A case report and literature review.

IntroductionOmphalocele, bladder extrophy, imperforate anus and spinal defect (known as OEIS) is a very rare congenital anomaly with an unknown etiology. In this report we describe a case of an OEIS variant associated with a wide pubic diastasis, bladder extrophy with a recto-bladder neck fistula and a high ano-rectal malformation. This work has been reported in line with the SCARE 2020 criteria.Presentation of the caseA 30-year-old mother delivered a male baby at 39 weeks through a normal vaginal delivery. Examination revealed multiple congenital anomalies in the form of an Omphalocele, extrophied bladder, imperforate anus, ambiguous genitalia and a large pelvic diastasis. Fecal matter was noted at the most inferior point of the extrophied bladder, raising the suspicion of a recto- vesical fistula.An exploratory laparotomy showed a fistula between the rectum and the neck of the extrophied bladder. A sigmoid colostomy was carried out in addition to a mucous fistula. The fascial defect of the Omphalocele was approximated to the upper border of the extrophied bladder.At the age of 2 years, the baby underwent a bladder extrophy repair, a posterior sagittal anorectoplasty and bilateral osteotomies.DiscussionOEIS complex has been reported to occur with a wide variety of associated anomalies, and this necessitates a thorough investigation in order to formulate an appropriate treatment plan. A prenatal diagnosis of OEIS complex can be made by ultrasound stressing the importance of antenatal follow up and a multidisciplinary approach in management.ConclusionWe described a rare variant of an OEIS complex and management of such anomalies requires a multidisciplinary input.

Methicillin-resistant Staphylococcus aureus enterocolitis in a 16-month-old boy: a case report

BackgroundMethicillin-resistant Staphylococcus aureus enterocolitis is a rare disease that typically affects immunocompromised adults. Most cases of pediatric enterocolitis are caused by Gram-negative bacteria, Gram-positive Clostridiodes difficile, or viruses. This is the first published case report of a toddler with methicillin-resistant Staphylococcus aureus enterocolitis.Case presentationA 16-month-old non-Hispanic White boy with no past medical or psychosocial history initially presented to the emergency room with abdominal pain and emesis. Past family history was pertinent only for his father having a history of constipation. He was diagnosed with intussusception and underwent successful contrast reduction on hospital day 0. The following day, the patient had recurrent symptoms and a repeat contrast enema showed no evidence of recurrent intussusception. A computed tomography scan was obtained, which was concerning for possible recurrence with compromised bowel. He was taken to the operating room for operative reduction and underwent an ileocecetomy with primary handsewn end-to-end anastomosis. His postoperative course was complicated by an anastomotic leak on hospital day 6 necessitating reoperation and creation of an end ileostomy with mucous fistula. He received intravenous metronidazole, ceftriaxone, and ceftazidime antibiotics during his hospital course. On postoperative day 12, the patient developed a sudden increase in ileostomy output, and stool cultures were obtained. His symptoms persisted despite diet modifications, stopping antibiotics, and initiating loperamide. Three days later, stool cultures resulted negative for Escherichia coli, Salmonella, Shigella, Campylobacter species, and Clostridiodes difficile but were positive for methicillin-resistant Staphylococcus aureus. The patient was started on a 10-day course of oral vancomycin and discharged home in good condition 4 days later. After 12 weeks, the patient underwent reversal of the ostomy and is doing well at the 1 month postoperative follow-up, now 5 months from his initial surgery.ConclusionsTo our knowledge, this is the first published report of a toddler being diagnosed with methicillin-resistant Staphylococcus aureus enterocolitis. Because methicillin-resistant Staphylococcus aureus enterocolitis is rare and has overlapping symptoms with more common gastrointestinal pathologies, it is often misdiagnosed. When a patient presents with diarrhea or high ostomy output along with fecal cultures negative for Clostridiodes difficile and other common pathogenic agents, methicillin-resistant Staphylococcus aureus should be considered.

Acute superior mesenteric artery occlusion associated with COVID-19 pneumonia: a case report

BackgroundThe novel 2019 coronavirus disease (COVID-19), which is caused by infection with the severe acute respiratory syndrome coronavirus 2, has spread rapidly around the world and has caused many deaths. COVID-19 involves a systemic hypercoagulable state and arterial/venous thrombosis which induces unfavorable prognosis. Herein, we present a first case in East Asia where an acute superior mesenteric artery (SMA) occlusion associated with COVID-19 pneumonia was successfully treated by surgical intervention.Case presentationA 70-year-old man presented to his local physician with a 3-day history of cough and diarrhea. A real-time reverse transcriptase-polymerase chain reaction test showed positive for COVID-19, and he was admitted to the source hospital with the diagnosis of moderate COVID-19 pneumonia. Eight days later, acute onset of severe abdominal pain appeared with worsening respiratory condition. Contrast CT showed that bilateral lower lobe/middle lobe and lingula ground glass opacification with distribution suggestive of COVID-19 pneumonia and right renal infarction. In addition, it demonstrated SMA occlusion with intestinal ischemia suggesting extensive necrosis from the jejunum to the transverse colon. The patient underwent an emergency exploratory laparotomy with implementing institutional COVID-19 precaution guideline. Upon exploration, the intestine from jejunum at 100 cm from Treitz ligament to middle of transverse colon appeared necrotic. Necrotic bowel resection was performed with constructing jejunostomy and transverse colon mucous fistula. We performed second surgery to close the jejunostomy and transverse colon mucous fistula with end-to-end anastomosis on postoperative day 22. The postoperative course was uneventful and he moved to another hospital for rehabilitation to improve activities of daily living (ADLs) on postoperative day 45. As of 6 months after the surgery, his ADLs have completely improved and he has returned to social life without any intravenous nutritional supports.ConclusionsIntensive treatment including surgical procedures allowed the patient with SMA occlusion in COVID-19 pneumonia to return to social life with completely independent ADLs. Although treatment for COVID-19 involves many challenges, including securing medical resources and controlling the spread of infection, when severe abdominal pain occurs in patients with COVID-19, physicians should consider SMA occlusion and treat promptly for life-saving from this deadly combination.

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

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.