Urgent subtotal colectomy for severe inflammatory bowel disease.

PURPOSE: The purpose of this study was to assess the safety of subtotal colectomy and outcomes after this procedure in the modern era of immunosuppressive agents and primary pelvic pouch surgery.
METHODS: All patients undergoing subtotal colectomy with ileostomy for ulcerative colitis or Crohn's colitis from July 1, 1990 to June 30, 2003 were identified from a prospective database. Only patients who were operated on while hospitalized for disease exacerbation were included in the analysis. Age at colectomy, preoperative days in the hospital, postoperative length of stay, and complications were recorded. The medical records were then reviewed for duration of disease, preoperative diagnosis, use of steroids and immunomodulators, parenteral nutrition, endoscopy findings, albumin level, postoperative diagnosis, and ultimate disposition.
RESULTS: One hundred one patients underwent subtotal colectomy for inflammatory bowel disease during the study period. Seventy-four patients met all the inclusion criteria. The mean age was 35.9 (range, 18-86) years. Median duration of disease was 36 (0-240) months, but 28 patients had colitis for less than 1 year, whereas 10 patients had disease of greater than 10 years duration at the time of colectomy. Median preoperative hospital stay was 7 (range, 0-43) days and median postoperative length of stay was 6.5 (range, 4-37) days. Sixty-six patients underwent surgery for refractory exacerbation, 5 for free perforation, 2 for abscess, and 1 patient for hemorrhage. Twenty-seven patients (36.5 percent) had a change in diagnosis after surgery. Complications occurred in 17 patients (23 percent), including 8 cases of central venous catheter-associated thrombosis; 7 of these occurred in patients who had been hospitalized for more than a week before surgery. In the ulcerative colitis patients, 31 of 52 ultimately underwent ileal pouch-anal anastomosis, but 20 (39 percent) chose either completion proctectomy or no further surgery.
CONCLUSIONS: Subtotal colectomy with ileostomy remains a safe and effective treatment for patients requiring urgent surgery for severe inflammatory bowel disease. Because of the substantial incidence of change in diagnosis and satisfaction in many patients with an ileostomy, subtotal colectomy with ileostomy may be preferable to primary ileal pouch-anal anastomosis, even when a pouch is considered safe.