What are the potential side effects of a colectomy?

Side Effects of Colectomy

Colectomy carries significant early and late complications affecting approximately one-third of patients, with the most common being infectious complications, pouchitis, bowel obstruction, and chronic metabolic derangements that substantially impact quality of life. 1, 2

Early Post-Operative Complications (≤30 Days)

Infectious Complications

• Anastomotic leak occurs in 9-11.5% of patients and represents the most serious early complication, with higher rates when surgery is delayed or performed emergently 1, 3, 2
• Pelvic sepsis develops in approximately 9.5% of patients following ileal pouch-anal anastomosis (IPAA), particularly in those with prior anti-TNF exposure 1, 3
• Surgical site infections occur more frequently in emergency procedures and immunocompromised patients, with overall infectious complication rates of 11-22% 3, 2
• Intra-abdominal abscesses complicate the post-operative course and may require percutaneous drainage or reoperation 1, 4

Non-Infectious Early Complications

• Paralytic ileus affects approximately 18% of patients and delays recovery 5, 2
• Small bowel obstruction occurs in up to 13.1% of patients, with some requiring surgical intervention 3, 5
• Hemorrhage can necessitate transfusion or reoperation in severe cases 1, 5
• Thromboembolism, including potentially fatal cerebral sinus thrombosis, requires aggressive prophylaxis 1

Catastrophic Complications

• Perforation carries mortality up to 50% and is associated with delayed surgery, toxic megacolon, or inappropriate colonoscopy in acute severe colitis 1
• Overall mortality for emergency colectomy ranges from 10-27%, with higher rates in elderly patients (12.9% in those >89 years) and those requiring >10 units of blood transfusion 1, 4

Late Post-Operative Complications (>30 Days)

Pouch-Specific Complications (Following IPAA)

• Pouchitis is the most common late complication, affecting 48% of patients within 2 years and up to 80% within 30 years 1
  • Acute pouchitis resolves with 2-4 weeks of antibiotics 1
  • Chronic antibiotic-dependent pouchitis affects approximately 17% of patients with frequent relapses 1
  • Chronic antibiotic-refractory pouchitis shows inadequate response to antibiotics and requires advanced therapies 1
• Cuffitis (inflammation of the retained rectal cuff) occurs when >2 cm of anorectal mucosa remains above the dentate line, causing persistent symptoms and dysplasia risk 1
• Pouch failure occurs in 7% at 3 years and 9% at 5 years, requiring pouch excision and permanent ileostomy 3
• Anastomotic stricture develops in 9.2% of patients 3
• Fistula formation (pouch-vaginal or pouch-anal) affects 5.5% of patients 3

Functional and Metabolic Consequences

• Chronic salt and water depletion results from loss of 400-1000 ml of isotonic ileostomy fluid daily, activating the renin-angiotensin-aldosterone system 6
• Kidney stones develop from reduced urine volumes and chronic dehydration 6
• Energy loss of significant calories occurs in ileostomy patients due to loss of colonic fermentation and short-chain fatty acid absorption 6
• Vitamin B12 malabsorption may occur with ileal resection or bacterial overgrowth in pouches 6
• Bile acid malabsorption increases risk of cholesterol gallstones 6
• Fecal incontinence affects 21% of patients long-term, significantly impacting quality of life 2
• Small bowel obstruction occurs in 17% of patients as a late complication 2

Quality of Life Impact

• Diarrhea, rectal bleeding, pain, and fecal urgency persist in patients with chronic pouchitis, substantially reducing quality of life 1
• Social, work, and sexual restrictions are reported by patients with end-ileostomy, though continent ileostomy (Kock's pouch) shows superior quality of life 1

Risk Factors for Increased Complications

Patient-Related Factors

• High-dose corticosteroids (≥20 mg prednisolone daily for >6 weeks) significantly increase complication rates 1, 3
• Malnutrition with albumin <3.0 g/dL or weight loss >10% increases risk 7
• Multiple blood transfusions preoperatively correlate with worse outcomes 7, 4
• Advanced age (>70 years) increases mortality from 21% to 37% 4
• Primary sclerosing cholangitis with ulcerative colitis increases pouchitis rates to 64-68%, with higher rates of chronic pouchitis and severe inflammation 1

Surgery-Related Factors

• Delayed surgery in acute severe colitis increases all complication rates 1, 3
• Emergency surgery carries substantially higher morbidity and mortality than staged procedures 1, 7
• Anti-TNF exposure within 12 weeks of surgery shows conflicting evidence, with some studies showing increased pelvic sepsis and infectious complications 1

Prevention Strategies

Surgical Approach

• Staged procedures (subtotal colectomy with ileostomy first, followed by completion proctectomy and IPAA) are strongly recommended for acute severe colitis, high-dose steroid use, or anti-TNF therapy 1, 3
• Covering loop ileostomy should be performed with IPAA to reduce clinical anastomotic leak rates and septic sequelae 1, 3
• Laparoscopic approach when appropriate skills are available reduces wound infections, intra-abdominal abscesses, and hospital stay 1

Medical Optimization

• Nutritional optimization and correction of malnutrition preoperatively 3
• Steroid tapering to <20 mg prednisolone before elective surgery 3
• Thromboprophylaxis is essential, particularly in IBD surgery 3
• Early surgical decision-making (within 7 days) for non-responders to medical therapy prevents complications 1

Critical Pitfalls to Avoid

• Delaying surgery in acute severe colitis beyond 7 days of maximal medical therapy increases mortality and morbidity 1
• Performing IPAA in the acute setting dramatically increases complication rates; staged procedures are mandatory 1, 8
• Leaving >2 cm of rectal mucosa above the dentate line increases cuffitis risk and dysplasia 1
• Blind segmental resection without localization carries rebleeding rates up to 33% and mortality up to 57% 1
• Transfusing >10 units of blood before emergency colectomy increases mortality to 45%; surgery should be performed earlier or ileostomy considered 4