What are the considerations and management strategies for a patient undergoing proctectomy with ileostomy?

Management of Proctectomy with Ileostomy: Considerations and Strategies

A staged approach with initial subtotal colectomy and ileostomy is the recommended surgical strategy for patients requiring proctectomy, especially in acute severe colitis, as it reduces surgical complications and mortality while allowing for patient stabilization before definitive surgery. 1

Indications for Proctectomy with Ileostomy

• Acute severe colitis refractory to medical therapy
• Toxic megacolon or perforation
• Massive colorectal bleeding unresponsive to medical treatment
• Colorectal cancer or high-grade dysplasia in inflammatory bowel disease
• Failed restorative procedures (e.g., failed ileal pouch-anal anastomosis)
• Poor anal sphincter function or incontinence
• Elderly patients (>60-65 years) with higher risk of pouch failure 2

Preoperative Considerations

Patient Assessment

• Evaluate nutritional status - correct malnutrition if possible
• Assess medication history - particularly steroids and immunosuppressants
• Evaluate hemodynamic stability - determines surgical approach
• Consider comorbidities - higher risk with multiple comorbidities

Timing of Surgery

• For acute severe colitis: Avoid delay beyond 7 days of rescue therapy
• Prolonged preoperative hospitalization increases postoperative complications 1
• Mortality increases with delayed surgery (>3 days from admission) 1

Surgical Planning

• Staged approach is preferred for acute presentations:
  • First stage: Subtotal colectomy with ileostomy and rectal stump
  • Second stage: Completion proctectomy with permanent ileostomy or pouch creation

Surgical Technique

First Stage (Subtotal Colectomy)

• Laparoscopic approach is preferred when patient is hemodynamically stable 1
  • Reduces wound infections and length of hospital stay
• Open approach is appropriate for hemodynamically unstable patients 1
• When dividing the rectum:
  • Divide at the rectosigmoid junction (promontory level)
  • Avoid dividing too low in the pelvis (complicates subsequent proctectomy)
  • Consider transanal rectal drainage to prevent rectal stump blowout 1

Rectal Stump Management

• Options include:
  • Hartmann's pouch (closed rectal stump within abdomen)
  • Mucous fistula (bringing distal colon to skin)
  • Subcutaneous placement of closed stump 1

Second Stage (Completion Proctectomy)

• Performed after patient recovery and optimization
• Options after proctectomy:
  • Permanent end ileostomy - simpler with fewer complications 3
  • Ileal pouch-anal anastomosis (IPAA) - preserves anal route of defecation 1

Postoperative Management

Immediate Care

• Monitor for signs of:
  • Intra-abdominal sepsis
  • Bleeding
  • Fluid and electrolyte imbalances
  • Stoma complications

Stoma Care

• Early involvement of stoma nurse specialist
• Patient education on stoma management
• Regular assessment of stoma viability and function
• Monitoring for high output and dehydration

Considerations for Ileostomy Closure

• If IPAA is performed, consider timing of ileostomy closure:
  • Traditional approach: 8-12 weeks after pouch creation
  • Early ileostomy closure (within 2 weeks) may be considered in selected cases 4

Special Considerations

Elderly Patients

• Higher risk of permanent ileostomy after attempted IPAA (>25% in patients >60 years) 2
• Consider primary permanent ileostomy rather than restorative procedures

Patients on Immunosuppression

• Higher risk of complications with:
  • Steroids ≥20 mg daily for >6 weeks
  • Anti-TNF therapy 1
• Staged procedure strongly recommended in these patients

Patients with Cancer Risk

• Total proctocolectomy with permanent ileostomy may be preferred for:
  • Rectal cancer requiring radiation
  • Lynch syndrome with rectal cancer (high risk of metachronous cancer) 1

Potential Complications and Management

Early Complications

• Bleeding - may require reoperation
• Intra-abdominal sepsis - drainage and antibiotics
• Stoma complications - necrosis, retraction, high output
• Rectal stump blowout - drainage and antibiotics

Late Complications

• Small bowel obstruction - adhesiolysis may be required
• Parastomal hernia - repair if symptomatic
• Peristomal skin complications - stoma care and topical treatments
• Phantom rectum syndrome - reassurance and pain management

Follow-up Recommendations

• Regular stoma assessment
• If rectal stump remains:
  • Surveillance for inflammation or dysplasia
  • Consider completion proctectomy if symptomatic or dysplastic
• Monitor for nutritional deficiencies
• Quality of life assessment

Conclusion

Proctectomy with ileostomy remains an important surgical option for selected patients with inflammatory bowel disease, colorectal cancer, and failed restorative procedures. While restorative options like IPAA offer improved body image and quality of life for many patients, proctectomy with permanent ileostomy provides a reliable solution with fewer complications in appropriate candidates, particularly elderly patients and those with poor sphincter function.