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