The Out-of-Circuit Rectum in Ulcerative Colitis: The Bumpy Road Less Traveled Comment on “ Fate of Rectal Stump After Subtotal Colectomy for Ulcerative Colitis in the Era of Ileal Pouch–Anal Anastomosis” Out-of-Circuit Rectum in Ulcerative Colitis

Longo WE. — Wed, 01 May 2013 00:00:00 GMT

Historically, subtotal colectomy has been one option for patients requiring surgery for ulcerative colitis. It is performed in severely ill patients who are uncertain of their diagnosis or desire to have this procedure. At a future date, patients may undergo a completion proctectomy with an ileoanal anastomosis, a proctectomy with an end ileostomy, or, exceedingly rarely, an ileorectal anastomosis. However, a cohort of patients continue to retain their rectal stump for a significant period for a variety of reasons, including but not limited to health-related reasons, caution regarding impotence until childbearing years have passed, concerns about the functional results of a restorative procedure, or the fear of an eventually permanent stoma. On the other hand, concerns about cancer in the retained rectal stump, continued symptoms from the retained rectum, and the need for continued surveillance of the rectal stump all preoccupy both the patient and the physician in optimizing the patient's care. Decision making among patients with a retained rectum following subtotal colectomy may be problematic, and the best option may be delayed for the heretofore listed reasons as well as loss of patient follow-up.

Fate of the Rectal Stump After Subtotal Colectomy for Ulcerative Colitis in the Era of Ileal Pouch–Anal Anastomosis Fate of the Retained Rectum

Munie S, Hyman N, Osler T. — Wed, 01 May 2013 00:00:00 GMT

Importance

Total proctocolectomy with ileal pouch–anal anastomosis is considered the procedure of choice for patients requiring elective surgery for ulcerative colitis, but some patients undergoing subtotal colectomy with end ileostomy are satisfied with an ileostomy and do not choose to undergo later pelvic pouch surgery. The need and timing for completion proctectomy in this setting are uncertain.

Objective

To assess the long-term fate of the retained rectum compared with the morbidity associated with completion proctectomy in patients who underwent subtotal colectomy for ulcerative colitis.

Design and Setting

Retrospective review of a prospective database in an academic medical center.

Participants

Patients who underwent subtotal colectomy with ileostomy for ulcerative colitis from July 1, 1990, to December 31, 2010.

Main Outcomes and Measures

Proctectomy, surgical complications, and symptoms from the retained rectum.

Results

One hundred eight patients underwent subtotal colectomy for ulcerative colitis during the study period: 73 for acute disease, 18 for advanced age and/or comorbidities, and 17 to avoid the risk of sexual dysfunction or infertility. Of these patients, 71 (65.7%) underwent subsequent ileal pouch–anal anastomosis, 2 died of other causes, and 3 were lost to follow-up. Of the remaining 32 patients, 20 chose rectal stump surveillance and 12 underwent elective proctectomy. Median follow-up was 13.8 years. No difference was noted in age, sex, surgical complications, pad use, or urinary dysfunction between the 2 groups. Only 8 of 20 patients in the surveillance group were compliant with follow-up endoscopy, and 13 were able to maintain their rectum; 2 required proctectomy at 11 and 16 years, respectively, for rectal cancer; neither has developed recurrent disease. One patient in each group reported erectile dysfunction.

Conclusions and Relevance

Management of the retained rectum after subtotal colectomy remains an important issue even in the era of ileal pouch–anal anastomosis. Considering the risk of rectal cancer, the low success rate of long-term rectal preservation, and the safety of surgery, a more aggressive approach to early completion proctectomy seems justified in this situation.

JAMA Surgery: Colorectal Surgery Topic Collection

The Out-of-Circuit Rectum in Ulcerative Colitis: The Bumpy Road Less Traveled Comment on “ Fate of Rectal Stump After Subtotal Colectomy for Ulcerative Colitis in the Era of Ileal Pouch–Anal Anastomosis” Out-of-Circuit Rectum in Ulcerative Colitis

Fate of the Rectal Stump After Subtotal Colectomy for Ulcerative Colitis in the Era of Ileal Pouch–Anal Anastomosis Fate of the Retained Rectum