eP615 - Management of the Remnant Rectal Stump in Total Colectomy for Acute Colitis

Purpose/Background: Severe acute colitis requires surgery in approximately 30% of cases which are refractory to medical therapy. Whilst subtotal colectomy (STC) with ileostomy is universally agreed as the standard procedure, there is no universal consensus regarding management of the rectal stump. There are three common approaches-1. Rectal stump closed intraperitoneally (IP)2. Closed mucus fistula - subcutaneously placed staple line (SC-C)3. Mucus fistula exteriorised (MF)Patients undergoing STC can often be unwell and nutritionally deficient. We present consecutive cases from three centres in the United Kingdom, specifically assessing the rectal stump and associated complications.Methods/Interventions: A multicentre retrospective case series of all consecutive patients undergoing STC for refractory severe acute colitis over a 15-year period. Demographic data, ASA, surgical approach, rectal stump management, complications, post-operative stay and death were recorded.Results/Outcomes: A total of 167 cases were identified (M:F 1.04:1). The mean age of presentation was 44-years (19-78). Indications for STC were ulcerative colitis (54.4%), Crohn’s (16.8%), indeterminate colitis (4.8%), drug induced (1.8%), infective (4.2%), other causes (1.2%) and unknown/no data (16.8%). The surgical approach in 52.1% cases was open, 43.1% laparoscopic assisted and 4.8% laparoscopic converted to open procedures.With regard to management of the rectal stump in 28.7% cases the stump was oversewn and left within the peritoneum (IP-O) , 4.2% were stapled but not oversewn and left within the peritoneum (IP-S), 37.1% were closed within the subcutaneous space (SC-C), 3.0% were brought out as a mucocutaneous fistula (MF) , 5.9% were managed by a non-standard technique, and in 25.7% the data was not available or documented clearly.The mean post-operative stay was 16.2 days (range 0-85 days). In the majority, 157 (94%) patients no stump complications were demonstrated. Whereas in ten patients (6%) had confirmed stump related complications. Of these, three patients had a stump collection requiring antibiotics (IP-O n=1, SC-C n=1, Unknown n=1), 3 patients required radiological drainage (IP-O n=1, SC-C n=1, unknown n=1), two patients required further surgery to treat the stump related collection (SC-C n=1, unknown n=1) and two patients required formal conversion into a mucocuteneous fistula (SC-C n=2). In hospital mortality was 6%. However, no deaths were related to stump related complications. No data was available on the use of a rectal stump catheter.Conclusion/

Discussion: High quality data and literature for rectal stump management for subtotal/total colectomy in severe colitis is sparse. This retrospective review highlights a need for prospective trial data to establish a comprehensive decision matrix algorithm on optimum management of the rectal stump for these cases.