Overview
Definition:
Subtotal colectomy with end ileostomy is a surgical procedure involving the removal of a significant portion of the colon, leaving the rectum and anus intact, and creating a stoma (ileostomy) from the ileum to the abdominal wall
This operation is typically performed when extensive colon pathology necessitates removal but rectal preservation is desired or feasible.
Epidemiology:
Incidence varies based on the underlying pathology
It is a common procedure for inflammatory bowel disease (IBD) affecting the colon, such as severe ulcerative colitis or Crohn's disease involving most of the colon, and for large bowel obstruction or malignancy where rectal involvement is minimal or absent.
Clinical Significance:
This procedure is crucial for managing severe, diffuse colonic diseases that do not respond to medical therapy, and for patients with obstructive lesions in the proximal colon where rectal preservation is a surgical goal
It allows for diversion of fecal stream and relief of symptoms, while preserving the option for future restorative proctocolectomy in select cases
Understanding its indications, technique, and management of complications is vital for surgical residents preparing for DNB and NEET SS.
Indications
Absolute Indications:
Severe, refractory ulcerative colitis or Crohn's disease involving the entire colon but sparing the rectum
Malignancy of the colon with no involvement of the distal rectum
Acute toxic megacolon refractory to medical management and perforation risk
Obstructing colonic lesions where distal resection is not feasible or desirable.
Relative Indications:
Recurrent C
difficile colitis unresponsive to multiple treatment courses
Familial adenomatous polyposis (FAP) or hereditary non-polyposis colorectal cancer (HNPCC) with extensive colonic polyposis and minimal rectal involvement
Infectious colitis with complications like perforation or severe bleeding.
Contraindications:
Active sepsis or severe systemic illness precluding surgery
Uncontrolled coagulopathy
Extensive rectal involvement by malignancy or severe inflammation
Patient refusal or inability to manage a stoma.
Preoperative Preparation
Patient Assessment:
Comprehensive history and physical examination focusing on bowel habits, symptoms, and comorbidities
Nutritional status assessment and optimization are critical, especially in IBD patients
Cardiac, pulmonary, and renal function assessment.
Bowel Preparation:
Mechanical bowel preparation with clear liquid diet and laxatives
Antibiotic prophylaxis is essential, typically covering gram-negative bacilli and anaerobes (e.g., neomycin and erythromycin, or oral ciprofloxacin and metronidazole).
Stoma Counseling:
Preoperative stoma site marking by an enterostomal therapy nurse is essential to identify an optimal location on the abdomen, avoiding creases, scars, or bony prominences
Patient and family education regarding stoma care, diet, and lifestyle adjustments is crucial.
Imaging And Labs:
Complete blood count, electrolytes, renal and liver function tests
Coagulation profile
Imaging may include CT abdomen/pelvis for extent of disease, obstruction, or malignancy
Colonoscopy if feasible and safe, to assess extent of disease and rule out rectal pathology.
Procedure Steps
Surgical Approach:
Can be performed via open laparotomy or laparoscopy
Laparoscopy offers faster recovery, reduced pain, and smaller scars but requires appropriate expertise and patient selection.
Bowel Mobilization And Resection:
Mobilization of the entire colon from the splenic flexure to the rectosigmoid junction
Identification and preservation of vital structures like the ureters and gonadal vessels
Division of the colon at an appropriate level proximal to the intended stoma site and distally at the rectosigmoid junction.
Creation Of End Ileostomy:
The distal end of the ileum is brought out through a carefully created opening in the anterior abdominal wall (usually in the left or right lower quadrant, depending on surgeon preference and stoma nurse marking)
The serosal layer of the ileum is often sutured to the peritoneum to prevent retraction
The bowel is divided and matured at the skin level.
Rectal Management:
The rectal stump is typically closed with staplers or sutures, creating a blind pouch
In some cases, a mucus fistula may be created if distal colonic resection is extensive and rectal closure is challenging
Drainage may be placed depending on intra-abdominal contamination or surgical concerns.
Closure Of Abdominal Wall:
Peritoneal closure if necessary, followed by layered closure of the abdominal wall muscles, fascia, and skin
Placement of drains as indicated.
Postoperative Care
Pain Management:
Multimodal analgesia including patient-controlled analgesia (PCA), epidural analgesia, and oral pain medications is essential
Early mobilization is encouraged to prevent VTE and respiratory complications.
Fluid And Electrolyte Balance:
Intravenous fluids are administered until bowel function returns
Close monitoring of fluid intake and output
Electrolyte levels (sodium, potassium, chloride) should be checked regularly, especially given the ileostomy, which can lead to fluid and electrolyte losses.
Stoma Care And Monitoring:
Regular inspection of the stoma for viability, edema, and bleeding
Application of a well-fitting ostomy appliance
Education on stoma emptying and skin care
Monitoring for stoma-related complications.
Dietary Advancement:
Gradual advancement from clear liquids to a low-residue diet as bowel sounds return and flatus is passed
Patients with ileostomies often require advice on avoiding high-fiber foods initially to prevent obstruction
Adequate hydration is paramount.
Monitoring For Complications:
Close observation for signs of infection, bleeding, ileus, anastomotic leak (if applicable in other configurations), and stoma complications.
Complications
Early Complications:
Ileus
wound infection
intra-abdominal abscess
bleeding
stoma ischemia/necrosis
stoma retraction
urinary tract infection
pneumonia
deep vein thrombosis (DVT) and pulmonary embolism (PE).
Late Complications:
Stoma stenosis
stoma prolapse
parastomal hernia
adhesive small bowel obstruction
incisional hernia
nutritional deficiencies (e.g., vitamin B12, vitamin D)
dehydration
electrolyte imbalances
peristomal skin irritation or breakdown
potential for future pouchitis if restorative surgery is considered and not performed properly.
Prevention Strategies:
Meticulous surgical technique, appropriate patient selection, aggressive pain management and early mobilization, aggressive fluid and electrolyte management, careful stoma site selection and construction, and adequate stoma care education are key preventive measures.
Prognosis
Factors Affecting Prognosis:
The underlying pathology (e.g., malignancy vs
IBD), patient's overall health status, presence of comorbidities, surgical technique, and prompt management of complications significantly influence prognosis.
Outcomes:
For benign conditions, the prognosis is generally good with relief of symptoms and improved quality of life, although requiring lifelong stoma management
For malignancy, prognosis depends on the stage of the disease at diagnosis and the success of the resection.
Follow Up:
Regular follow-up appointments are necessary to monitor stoma function, manage stoma-related issues, assess for nutritional deficiencies, and, in cases of malignancy, monitor for recurrence
Frequency of follow-up is determined by the underlying condition and individual patient needs.
Key Points
Exam Focus:
Indications for subtotal colectomy vs
total colectomy
Stoma site selection and maturation techniques
Management of early and late stoma complications
Fluid and electrolyte management in ileostomy patients
Nutritional considerations with ileostomies.
Clinical Pearls:
Always involve an enterostomal therapy nurse preoperatively
Ensure adequate bowel length for stoma creation to prevent tension and retraction
Educate patients extensively on stoma care, diet modification, and hydration
Recognize and manage electrolyte disturbances promptly.
Common Mistakes:
Inadequate bowel preparation
Poor stoma site selection leading to complications
Insufficient patient education on stoma care
Failure to recognize and treat electrolyte imbalances
Overlooking potential for stoma retraction or ischemia in the immediate postoperative period.