Systematic Reviews
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Feb 27, 2021; 13(2): 198-209
Published online Feb 27, 2021. doi: 10.4240/wjgs.v13.i2.198
Subtotal colectomy in ulcerative colitis—long term considerations for the rectal stump
Orla Hennessy, Laurence Egan, Myles Joyce
Orla Hennessy, Department of Colorectal Surgery, Galway University Hospital, Galway H91RR2N, Ireland
Laurence Egan, Myles Joyce, Department of Gastroenterology, Galway University Hospital, Galway H91RR2N, Ireland
Author contributions: Hennessy O contributed data collection and main development and writing of the manuscript; Joyce M provided conceptual development, significant contributions to writing of the manuscript and supervision; Egan L provided edits to manuscript, medical expertise and supervision.
Conflict-of-interest statement: The authors have no conflict of interest to declare.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Orla Hennessy, MBChB, MSc, Surgeon, Department of Colorectal Surgery, Galway University Hospital, Newcastle Road, Galway H91RR2N, Ireland. o.hennessy95@gmail.com
Received: November 11, 2020
Peer-review started: November 11, 2020
First decision: December 4, 2020
Revised: December 23, 2020
Accepted: January 21, 2021
Article in press: January 21, 2021
Published online: February 27, 2021
Abstract
BACKGROUND

The initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy. A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis.

AIM

To review the existing literature in relation to the significant long-term complic-ations associated with the rectal stump, to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort.

METHODS

A systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis. A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum.

RESULTS

For rectal stump surveillance guidelines, 20% recommended an interval of 6 mo to a year, 50% recommended yearly surveillance 10% recommended 2 yearly surveillance and the remaining 30% recommended risk stratification of patients and different screening intervals based on this. All studies agreed surveillance should be carried out via endoscopy and biopsy. Increased vigilance is needed in endoscopy in these patients. Literature review revealed a number of options for surgical management of the remnant rectum.

CONCLUSION

The retained rectal stump needs to be surveyed endoscopically according to risk stratification. Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy. If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique.

Keywords: Stump, Ulcerative colitis, Surveillance, Endoscopy, Rectal, Screening

Core Tip: Rectal stumps require long term surveillance due to well documented risk of malignancy, the authors provide a summary of current guidance and recommendations for this. Patients may require completion proctectomy due to dysplasia, malignancy or persistent symptoms, options for completion proctectomy are explored. Endoscopic surveillance of the rectal stump poses certain challenges, potential complications and their management are explored.