Background: Today, there is no consensus about the best management of the remaining rectum following subtotal colectomy for acute colitis complicating inflammatory bowel disease. There are three options: intra-peritoneal rectal stump closure (Hartmann's pouch with closed stapled rectal stump), creation of a mucous fistula by exteriorizing the recto-sigmoid remnant in the left iliac fossa, suprapubic or in the same opening as the ileostomy (stoma rectal stump) or to position the closed recto-sigmoid remnant in the subcutaneous tissue. Results from retrospective studies are conflicting. The objective was thus to evaluate the impact of rectal stump management during laparoscopic subtotal colectomy for acute colitis.
Methods: All the patients who underwent laparoscopic subtotal colectomy for inflammatory bowel disease in 2 expert centres were included and divided into 2 groups: Hartman's with stapled rectal stump (Group A) and sigmoidostomy at the same site than ileostomy, in the right iliac fossa (Group B). Comparisons were performed between groups for the following findings: demographic features, inflammatory bowel disease characteristics, preoperative treatment in the three last months, intraoperative features, postoperative outcomes, characteristics of completion proctectomy with IPAA, and long-term results.
Results: From 2005 to 2015, 129 patients (71 males, median age =37 [13–78] years) were divided into Groups A (n=52) and B (n=77). Patients in Gr. A were more frequently under steroids before subtotal colectomy (83% vs 58%, p=0.004), but less frequently under antiTNF (38% vs 74%, p=0.0001) than those from Gr. B. Operative time for subtotal colectomy was longer in Gr. A than Gr. B (210 [139–396] vs 180 [150–310] minutes, p=0.002). Overall, surgical, medical and major morbidity was similar between groups. Completion proctectomy with ileal pouch-anal anastomosis (IPAA) was more frequently performed through an open approach in Gr. A than in Gr. B (88 vs 0%, p<0.0001). Postoperative and long-term results after the second surgical stage were similar between groups.
Conclusions: This study suggests that the management of the remaining rectum after subtotal colectomy has no impact on operative and long-term results. Thus, the choice of the most appropriate option can depend on surgeon's discretion.