Management of the rectal stump after emergency sub-total colectomy: which surgical option is associated with the lowest morbidity?

Abstract

Objective: To identify the preferred surgical management of the rectal stump after emergency subtotal colectomy (ESC) for acute severe colitis by assessing the morbidity associated with each option.

Patients and methods: Consecutive patients undergoing ESC at a district general hospital between 1999 and 2004 were retrospectively audited for pathology, rectal stump complications and length of postoperative hospital stay (POS).

Results: Thirty-seven ESCs were performed, 34 were undertaken for disease refractory to medical treatment, 2 for toxic mega colon and 1 for perforation. Thirty-four cases were for ulcerative colitis, 2 Crohn's colitis and 1 infective colitis. Twenty-seven had an intraperitoneal and 10 a subcutaneously placed closed rectal stump. The median POS for patients with a subcutaneously placed stump was shorter than for those with an intraperitoneal stump, 8 and 15 days, respectively (P = 0.04). Two patients had leakage from an intraperitoneal stump, prolonging POS (33 and 193 days). Three of the subcutaneous stumps leaked causing wound infection but not prolonging the POS (6, 7 and 16 days).

Conclusion: Avoiding a second stoma by closing the rectal stump after ESC has been confirmed as acceptable practice by studies over the last 15 years, reporting no overall increase in complications. The location of a closed rectal stump appears to influence the incidence of pelvic sepsis. The lowest pelvic sepsis rate is associated with subcutaneous placement; despite a higher wound infection rate this option appears to be associated with a lower total morbidity reflected in a shorter POS.