Acute colectomywhat should you do with the rectal stump - PowerPoint PPT Presentation
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Acute colectomywhat should you do with the rectal stump
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Difficult to do a midline mucous fistula/subcutaneous closure ... A mucous fistula is rarely necessary. Subcutaneous/intra-peritoneal position is appropriate ... – PowerPoint PPT presentation
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Title: Acute colectomywhat should you do with the rectal stump
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Acute colectomywhat should you do with the
rectal stump
- SR Brown
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Objectives
- What to do with the rectal stump
- At the time of surgery.
- After the acute surgery.
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What to do with the rectal stump at the time of
surgery
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Controversies
- Fistula/close stump?
- Long/short stump?
- Suture/staple?
- Rectal catheter?
- Emergency IPAA?
- What about Pregnancy
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The perfect procedure
- Low risk of sepsis
- Wound infection
- Rectal dehiscence
- Pelvic sepsis
- Minimal residual inflammation
- Ease of subsequent surgery
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Options
- Mucous fistula
- Subcutaneous closure
- Intraperitoneal closure
- Infrapelvic closure
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Mucous fistula
- Advantages
- Safe
- No risk of dehiscence
- ?reduced pelvic sepsis
- Allows irrigation
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Mucous fistula
- Disadvantages
- Wound infection
- At time
- Subsequent surgery
- Patient dissatisfaction
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Mucous fistula
- Lower end of midline wound
- Lateral
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Subcutaneous closure
- Disadvantages
- Long stump for persistent inflammation
- Wound infection
- (mucous fistula) (35 spontaneously open)
- (necrotizing fasciitis)
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Intraperitoneal
- Advantages
- Easy
- No additional stoma
- Reduced wound infection rate
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Intraperitoneal
- Disadvantages
- ?increased complications related to dehiscence
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Infraperitoneal resection
- Advantages
- Short segment of diseased bowel (less symptoms)
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Infraperitoneal resection
- Disadvantages
- ?higher sepsis rate
- Difficult subsequent surgery
- Persistent rectal symptoms
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Risk of dehiscence
pgt0.05 for all pelvic sepsis comparisons
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Risk of stump related wound infection
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Choice of technique
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Risk of persistent rectal symptoms
Pgt0.05 for all comparisons
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Staple or suture?
Pgt0.05 for all comparisons
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Blown rectal stump
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(No Transcript)
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Rectal catheter
p0.05
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Need for a rectal catheter
- RCT comparison
- 5 significance
- 80 power
- 1153 patients in each group!
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What about emergency IPAA?
- 3 papers from 1990s
- 2 selective mild fulminant colitis
- 32 patients
- Sepsis lt5
- Leaklt5
- Harms et al. DCR 1994, Ziv et al. DCR 1995
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What about emergency IPAA?
- Comparison elective vs emergency IPAA
- 30 patients
- Morbidity 27 vs 66
- Leak 11 vs 41
- Sepsis 6 vs 25
Hayvaert et al., Int J Colorect Dis 1994
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Atypical situationsPregnancy
- Difficult to do a midline mucous
fistula/subcutaneous closure - Apparent high risk of pelvic sepsis (up to 32)
- Difficult to radiologically treat any abscess
- ?LIF fistula/closure
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Summary
- A mucous fistula is rarely necessary.
- Subcutaneous/intra-peritoneal position is
appropriate - Keep a long stump
- Close with whatever.
- Use a rectal catheter
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What to do with the rectal stump after surgery
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What to do with the rectal stump after surgery
- Approx 25 patients undergoing subtotal colectomy
for colitis will not undergo IPAA - About 3 will develop cancer
- Up to 40 have persistent rectal symptoms
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Options
- Retain stump
- Survey
- Medical therapy
- Proctectomy
- Mucosal ablation
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Proctectomy
- big operation
- Risk of nerve damage
- ?close rectal dissection
- Pelvic dead space
- ?close rectal dissection
- Omental mobilisation
- Perineal wound problems
- ?intersphincteric dissection
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Intersphincteric dissection
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Mucosal ablation
- Surgical mucosectomy
- Ultrasound fragmentation
- Chemical ablation
- Endoscopic transanal resection
