What is subtotal colectomy in ulcerative colitis and what are its indications?

Subtotal Colectomy in Ulcerative Colitis: Definition and Indications

Subtotal colectomy with ileostomy is the surgical treatment of choice for patients with acute severe ulcerative colitis presenting with massive colorectal hemorrhage or non-response to medical treatment. 1

Definition and Procedure

Subtotal colectomy (STC) in ulcerative colitis is a surgical procedure that involves:

• Removal of most of the colon while preserving the rectum 1
• Creation of an end ileostomy to divert the fecal stream 2
• Management of the rectal remnant, which can be:
  • Divided at the rectosigmoid junction (promontory level) 1
  • Closed and left in the subcutaneous tissue 1, 3
  • Brought out as a mucous fistula 1

Indications for Subtotal Colectomy

Acute Severe Ulcerative Colitis

• Failure to respond to medical therapy within 48-72 hours of initiation 1, 4
• No improvement with second-line therapy 1
• Patients taking ≥20 mg prednisolone daily for more than 6 weeks 1
• Patients treated with anti-TNF agents 1

Life-Threatening Complications

• Free perforation of the colon 1, 4
• Massive colorectal hemorrhage with hemodynamic instability 1, 2
• Generalized peritonitis 1
• Toxic megacolon with:
  • Clinical deterioration and signs of shock 1
  • No improvement and biological deterioration after 24-48 hours of medical treatment 1

Benefits of Subtotal Colectomy

• Allows patients to regain general health and normalize nutrition 1
• Provides time for careful consideration of future options (IPAA or permanent ileostomy) 1
• Allows for clarification of pathology, definitively excluding Crohn's disease 1
• Relatively safe procedure even in critically ill patients 1
• Facilitates subsequent pelvic pouch construction 5

Surgical Approach

• Laparoscopic approach is preferred when appropriate skills are available 1
• Benefits of laparoscopic vs. open STC include:
  • Fewer complications (32% vs. 62%) 6
  • Shorter hospital stay (by 6.9 days) 6
  • Earlier hospital discharge 5
• Open approach may be necessary for hemodynamically unstable patients 2

Management of the Rectal Remnant

• Dividing the rectum at the promontory level (rectosigmoid junction) is recommended 1
• Dividing the middle rectum within the pelvis should be avoided as it creates difficulties during subsequent proctectomy 1
• Options for the rectal stump:
  • Closure and placement in subcutaneous tissue (allows secondary healing) 1, 3
  • Creation of a mucous fistula (results in an extra stoma) 1
  • Subcutaneous rectal stump closure (simple and safe alternative to open mucus fistula) 3

Subsequent Procedures

• After STC, patients may undergo:
  • Completion proctectomy with ileal pouch-anal anastomosis (IPAA) 7
  • Ileorectal anastomosis (in selected cases) 8
• Restoration of bowel continuity typically considered after 2-3 months when complete resolution of colonic inflammation is achieved 2
• Patients undergoing laparoscopic STC are more likely to undergo restorative second-stage procedures than those having open STC (75% vs. 50%) 6

Common Pitfalls and Caveats

• Delaying surgical intervention in critically ill patients with toxic megacolon can increase morbidity and mortality 4
• Attempting primary anastomosis in patients with multiple risk factors for anastomotic complications should be avoided 2
• Prolonged maintenance of a diverting ileostomy without a clear plan for restoration of continuity should be avoided 2
• Risk of carcinoma development in the rectal remnant if left for prolonged periods 8
• Careful monitoring of the rectal remnant is essential due to ongoing inflammation and potential for malignant transformation 8