What are the considerations and management for a colectomy?

Colectomy: Key Considerations and Management

Indications for Colectomy

For inflammatory bowel disease (IBD), colectomy should be performed for disease not responding to intensive medical therapy, with the decision made jointly by gastroenterologist and colorectal surgeon in consultation with the patient. 1

Emergency Indications

• Fulminant colitis with hemorrhage, perforation, toxic megacolon, or sepsis 2
• Massive colorectal bleeding unresponsive to medical treatment 1
• Acute severe refractory colitis after 7 days of maximal medical therapy 1, 3
• Free perforation with peritonitis (mortality up to 50% if delayed) 3

Elective Indications

• Persistent symptoms despite maximal medical therapy 2
• Dysplasia or carcinoma 1
• Medication side-effects or steroid-dependency 2
• Synchronous tumors or hereditary cancer syndromes (FAP, HNPCC) 1, 4

Surgical Approach Selection

Emergency Setting

In hemodynamically unstable patients with perforation, severe peritonitis, or massive bleeding, perform open laparotomy with damage control principles. 1

In hemodynamically stable patients, laparoscopic approach should be utilized when local expertise allows, as it reduces length of stay and infectious complications. 1, 5

Procedure of Choice by Clinical Scenario

For acute fulminant ulcerative colitis or Crohn's colitis: subtotal colectomy with end ileostomy is the emergency operation of choice, leaving a long rectal stump to facilitate later reconstruction and minimize intraperitoneal dehiscence risk. 1, 2

For Crohn's disease: resections should be limited to macroscopic disease only (conservative resection). 1

Critical Risk Stratification for Complications

High-Risk Factors Mandating Staged Procedures

• High-dose corticosteroids (≥20 mg prednisolone daily for >6 weeks) 3
• Weight loss >10% 2
• Albumin <3.0 g/dL 2
• Multiple preoperative blood transfusions 2
• Anti-TNF therapy within 12 weeks 3
• Emergency presentation 3, 2

When 2 or more risk factors for anastomotic complications are present, form a stoma following resection rather than performing primary anastomosis. 1

Anastomotic Decision-Making

Primary anastomosis should NOT be performed in the presence of sepsis, malnutrition, hemodynamic instability, or diffuse contamination. 1

If hemodynamic stability exists with only localized contamination and no other risk factors, anastomosis may be considered. 1

In severe sepsis/septic shock, perform damage control surgery with resection, stapled-off bowel ends, and temporary closure (laparostomy) with return to theater in 24-48 hours for second look. 1

When anastomosis is performed, stapled versus hand-sewn technique shows no difference in complication rates or recurrence—surgeon preference dictates choice. 1

Perioperative Management Essentials

Preoperative Optimization

• Preoperative stoma counseling and marking by clinical colorectal nurse specialist in stoma therapy 1
• Nutritional assessment and optimization in malnourished patients 5
• Steroid tapering to <20 mg prednisolone before elective surgery when possible 3

Intraoperative Principles

• Midline incisions for laparotomy in IBD patients 1
• Maintain normothermia >36°C with warming devices and warmed IV fluids 5
• Flow-guided fluid management to optimize cardiac output 5

Postoperative Care

• Implement Enhanced Recovery Protocols (ERP) for all patients 5
• Early oral feeding on postoperative day 1-2 5
• Remove nasogastric tubes before reversal of anesthesia; do not use routinely 5
• Early mobilization as soon as possible 5
• Thromboprophylaxis with compression stockings, pneumatic compression, and low molecular weight heparin 5
• Remove urethral catheter within 1-2 days 5

Major Complications and Prevention

Early Complications (Incidence and Prevention)

• Anastomotic leak: 9-11.5% (higher with delayed surgery, poor nutrition) 5, 3

  • CT scan with contrast is first-line diagnostic (91% sensitivity) 5
  • Prevented by staged procedures in high-risk patients 3

• Surgical site infections: 11-22% (higher in emergency and immunocompromised) 3

  • Reduced by laparoscopic approach 5, 3

• Pelvic sepsis: 9.5% (particularly with anti-TNF exposure) 3

  • Prevented by covering loop ileostomy with IPAA 3

• Overall mortality: 10-27% for emergency colectomy (12.9% in patients >89 years) 3

Late Complications

• Pouchitis: 48% within 2 years, up to 80% within 30 years 3

  • 64-68% in patients with primary sclerosing cholangitis 3

• Pouch failure: 7% at 3 years, 9% at 5 years 3

• Small bowel obstruction: up to 13.1% 5

• Anastomotic stricture: 9.2% 3

Critical Pitfalls to Avoid

Never delay surgery beyond 7 days of maximal medical therapy in acute severe colitis—this dramatically increases mortality and morbidity. 3, 2

Never perform ileal pouch-anal anastomosis (IPAA) in the acute setting—staged procedures are mandatory. 3, 2

Never leave >2 cm of rectal mucosa above the dentate line—this increases cuffitis and dysplasia risk. 3

Never perform colonoscopy in acute severe colitis—this risks perforation with 50% mortality. 3

Metabolic Consequences

Patients lose 400-1000 mL of isotonic ileostomy fluid daily, causing chronic salt and water depletion with compensatory renin-angiotensin-aldosterone activation. 6

Energy loss from malabsorbed substrate occurs in ileostomy patients due to loss of colonic fermentation and short-chain fatty acid absorption. 6

Monitor for vitamin B12 and bile acid malabsorption, which increases biliary cholesterol stone risk. 6