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Treatment of Toxic Megacolon
Symposium on Surgical Practice at the University of Chicago Clinics
Treatment of Toxic Megacolon
James E. Mungas, M.D.,* A. Rahim Moossa,M.B., Ch. B.,t and George E. Block, M.D., M.s. (Surg.) t
Toxic megacolon is generally considered to be a lethal complication of ulcerative colitis; it may also arise as a complication of granulomatous colitis,2 pseudomembranous colitis,5 or bacterial or amebic colitis. Spiro 6 states that 25 per cent of patients with toxic megacolon treated medically will die. From his review of the recent literature, Glotzer reports that the operative mortality rate of toxic megacolon is 8. 7 per cent in the absence of perforation; once perforation occurs, the rate rises to 51.2 per cent. We have come to regard toxic megacolon as a surgical emergency and consider medical treatment to be resuscitative and preparatory to operation. During the period of 1970 to mid-1975, we have operated on 25 patients suffering from toxic dilatation of the colon and have had no postoperative deaths. This report outlines our principles in the surgical management of toxic megacolon.
DEFINITION AND DIAGNOSIS Toxic megacolon or, more appropriately, toxic dilatation of the colon, is an acute dilatation of the colon accompanied by signs of sepsis and catabolism and occurs in patients suffering from an underlying inflammatory disease of the colon. Many of the classic signs of toxic megacolon may be absent when the patient is first seen. The diagnosis 9f toxic megacolon should, therefore, rest on a high index of suspicion in patients with worsening colitis. When toxic dilatation of the colon is present, perforation of the bowel is imminent. The clinical features which may be present are those of local or diffuse peritonitis. Peristaltic sounds may be feeble or absent; crampy' abdominal pain, abdominal distention, mental confusion, fever, tachycar-
From the Department of Surgery, The University of Chicago Pritzker School of Medicine, Chicago, Illinois * Chief Resident in Surgery t Associate Professor of Surgery ! Professor of Surgery
Surgical Clinics of North America- Vol. 56, No.1, February 1976
95
96
JAMES
E.
MUNGAS,
A.
RAHIM MOOSSA, AND GEORGE
E. BLOCK
Figure 1. Abdominal roentgenogram in a patient with toxic megacolon, showing dilatation of colon, distention of small bowel secondary to ileus, and signs of fluid between loops of bowel.
dia, hypotension, and signs of dehydration are often prominent. Rectal examination may reveal some irregularity and nodularity in the rectal mucosa, with the presence of blood and/or mucus in the stool. A roentgenogram of the abdomen is diagnostic: marked segmental colonic dilatation as well as distention of the small bowel secondary to ileus are seen accompanied by signs of fluid between loops of small bowel (Fig. 1). Deep undermining ulceration of the colon wall may often be seen silhouetted against the colon gas. Chest roentgenograms may reveal elevation of the diaphragms, with or without basal atelectasis and pleural effusion. If perforation has already occurred, free air will usually be present beneath the diaphragms. The white blood count is generally elevated with a shift to the left; the hemoglobin concentration may be low, normal, or high, depending on the degree of previous acute or chronic blood loss, anemia, and degree of dehydration. Hypoalbuminemia and elevated blood urea ni-
TOXIC MEGACOLON
97
trogen are usually present, indicating a chronic catabolic state. Arterial blood gases often confirm a metabolic acidosis.
FURTHER DIAGNOSTIC STUDIES AND RESUSCITATION We emphasize that diagnostic and resuscitative measures should be carried out simultaneously and as rapidly as possible. These patients are extremely ill· and the majority will require operation on the day of admission after preoperative resuscitation. Large bore intravenous catheters, including a central venous pressure line, are inserted for fluid administration and monitoring of right atrial pressure. Blood is drawn for type and cross-match, as well as routine laboratory studies. Concurrently, a nasogastric tube (in preference to a long intestinal tube) and urinary catheter are inserted. A significant extracellular fluid volume deficit invariably exists in these patients accompanied by hypoalbumineInia and a decreased oncotic pressure. Infusion of electrolyte solution with salt-free albumin, supplementary potassium, and blood is therefore indicated. The goal of fluid administration is to replace the volume deficit and restore oncotic pressure. Restoration of volume is heralded by a rising right atrial pressure, slowing of pulse, rise of blood pressure, and achievement of a urine output of at least 40 ml per hour. Frequent monitoring of vital signs is essential in order to restore volume adequately without danger of fluid overload. Sodium bicarbonate may be given if there is a significant metabolic acidosis. Mild to moderate acidosis will usually respond to volume replacement alone; a severe and persistent metabolic acidosis usually indicates that perforation has already occurred. Many of these patients have already received steroid therapy. We prefer to administer 100 mg of hydrocortisone (Solu-cortef) intravenously initially and to repeat this dose every 4 hours. Blood cultures are drawn prior to starting broad spectrum antibiotics. We recommend Penicillin-G 5,000,000 units and chloramphenicol (Chloromycetin) 1 gm every 6 hours. Factors which are known to precipitate toxic dilatation of the colon are avoided. Anticholinergic drugs, morphine derivatives, and barium enema are notorious offenders. Proctoscopy is performed as soon as the patient can tolerate the procedure. Biopsy with frozen section is occasionally helpful in differentiating between ulcerative, granulomatous, and pseudomembranous colitis. The majority of the patients will prove to suffer from ulcerative colitis. Stool cultures and gram stains are obtained at the time of proctoscopy. Following these resuscitative measures, an improvement is generally noted in the patient's condition within 3 or 4 hours. The physician should not be lulled into a false sense of security at this time. The improvement in the patient's condition is a result of resuscitation; however, the diseased colon still has the propensity to perforate at any time, and morbidity and mortality increase following perforation. Even prior
98
JAMES
E.
MUNGAS,
A.
RAHIM MOOSSA, AND GEORGE
E.
BLOCK
to gross perforation, there is transudation of bacteria across the diseased thinned-out wall of the colon into the peritoneal cavity. The majority of these patients, therefore, have peritoneal sepsis, and this renders the signs of gross perforation subtle and difficult to appreciate. Operative management is mandatory at this stage; absolute indications for emergency colectomy are an increase in abdominal tenderness and distention, persistence or worsening of signs of volume deficit, rising temperature and/or white cell count, and persistence or worsening of metabolic acidosis on the basis of arterial blood gas measurements.
OPERATIVE MANAGEMENT We utilize a transverse abdominal incision in these malnourished patients, many of whom have been on long-term steroid therapy. In addition to safety, this incision affords excellent intra-abdominal exposure. Our preference in these poor risk patients is for total abdominal colectomy with ileostomy. The rectosigmoid is brought out as a mucous fistula. These extremely ill, toxic, malnourished, and anemic patients can ill afford the additional stress, operating time, and blood loss of a proctectomy. Only if the toxic megacolon is accompanied by hemorrhage do we advocate concomitant proctectomy; hemorrhage necessitates a one-stage proctocolectomy, as many of these patients will continue to bleed from the diseased rectum. Another reason for limiting the operation to total abdominal colectomy without protectomy is that a small percentage of these patients will prove to have granulomatous or pseudomembranous colitis. In this group of patients, ileosigmoid anastomosis may be accomplished at a later date. The patient is placed in the supine position on the operating table, unless proctectomy is deemed necessary, in which case the lithotomy position is employed. The transverse incision is placed 1 cm beneath the umbilicus~ Care is taken when entering the peritoneal cavity to avoid iatrogenic perforation of the greatly dilated colon. Specimens of the peritoneal exudate are taken for aerobic and anaerobic cultures; even without gross perforation coliform organisms are frequently present within this peritoneal fluid. The colon is handled with extreme care and gentleness, particularly when mobilizing the splenic and hepatic flexures. Garnjobst and Hardwick3 emphasize the increased morbidity associated with iatrogenic perforation of the distended colon; unlike them, however, we do not recommend colotomy or intraoperative decompression of the colon prior to colectomy, as fecal spillage is inevitable and suture of the colotomy is unsafe. We do not perform ileostomy and colostomy for patients with toxic megacolon as recommended by TurnbulF This decompression is an inadequate operation for the colitis and makes subsequent operation extremely difficult. After mobilizing the colon, its mesentery is divided close to the bowel wall between suture ligatures. The ileocolic vessels are divided last in order to decrease the risk of perforation of the cecum as a result of infarction superimposed on the disease state.
99
TOXIC MEGACOLON
The terminal ileum is then divided flush at the ileocecal valve to preserve as much of the ileum as possible (unless Crohn's disease with ileal involvement is present and necessitates resection of a portion of ileum). The rectosigmoid is divided as low as possible at a point which will allow exit of the sigmoid mucous fistula from the abdomen onto the left lower quadrant without tension. We do not close the distal end of the sigmoid and return it to the pelvis as a Hartmann's procedure; when disease is present at this site, nonhealing frequently occurs following closure of the stump and leads to perforation or abscess formation. The mucous fistula is matured in the left lower quadrant using interrupted chromic catgut sutures between full-thickness bowel wall and skin. We do not recommend leaving a Demartel clamp applied to the mucous fistula as the rate of healing is unpredictable. A standard Brooke type ileostomy is then constructed in the right lower quadrant after the terminal ileum is brought out extraperitoneally according to Goligher's4 method. This prevents any herniation or volvulus around the terminal ileum. Figure 2 illustrates the position of the ileostomy and the mucous fistula, as well as the abdominal incision. The mesenteric defects in the left and right gutters are then fully obliterated using interrupted suture technique.
\"
/
~
'.
:1J
jj
\ ......~
1 I
I
~/
Figure 2. Diagrammatic illustration of location of abdominal incision, ileostomy, and mucous fistula in a patient undergoing total abdominal colectomy for toxic megacolon.
100
JAMES
E.
MUNGAS,
A.
RAHIM MOOSSA, AND GEORGE
E.
BLOCK
The peritoneal cavity is irrigated copiously with warm saline solution. All irrigation solution must be recovered prior to closure of the ab~ domen because of the risk of fluid overload following absorption of this fluid. No drain is left in the abdomen even if perforation has occurred. The posterior and anterior fascial layers of the abdominal wall are approximated with interrupted monofilament wire sutures. The subcutaneous layer and skin mayor may not be closed depending on the judgment of the surgeons regarding the degree of wound contamination. If left open, the wound is irrigated and dressed several times daily and is closed secondarily a few days later. The postoperative course is usually unremarkable. Intravenous fluids, including albumin and blood (if necessary), are continued until the patient is eating normally. The patients are given a full course of parenteral antibiotics postoperatively. The patient is ambulated on the 1st postoperative day. The Foley catheter is removed when the patient's volume status is stable, usually on the 2nd or 3rd postoperative day. Upon resumption of bowel sounds and passage of stool per ileostomy, the nasogastric tube is removed and oral alimentation is begun and slowly advanced. Steroids are tapered from 300 mg hydrocortisone in three divided doses on the 1st postoperative day. If disease is present in the rectum the steroids are not totally withdrawn; most patients in this category require a maintenance dose of at least 35 mg of hydrocortisone per day. The patient is instructed on methods of ileostomy care and ileostomy appliances; we prefer Hollister karaya seal stoma bags in the immediate postoperative period. It is important that the ileostomy appliance fit snugly about the ileostomy in order to prevent skin breakdown from spillage of small bowel contents. The patient is fitted with a permanent ileostomy appliance following maturation of the ileostomy. The majority of our patients are discharged in the 3rd postoperative week, and followed closely in the outpatient clinic. A decision is made on the basis of pathologic findings and repeated proctoscopic examination as to whether or not an ileosigmoid anastomosis is advisable. If the underlying process is not ulcerative colitis and if the rectum is spared or healed, anastomosis is performed as an elective procedure 3 to 6 months following the emergency abdominal colectomy. Those patients with ulcerative proctocolitis undergo proctectomy some 3 to 6 months following abdominal colectomy. However, if carcinoma were discovered, the proctectomy would be performed earlier.
RESULTS The University of Chicago Hospitals and Clinics serve as a major referral center for patients with inflammatory bowel disease, and we believe that our success is due, in large part, to the approach taken by the members of both the medical service, to whom most of these patients are initially referred, and the surgical service, to whom consultations from the medical staff are readily available at all times. Over the years a close spirit of cooperation, a high degree of suspicion for the diagnosis of toxic megacolon in patients with colitis, and an aggressive
TOXIC MEGACOLON
101
diagnostic and therapeutic approach have evolved at this· hospital. Such cooperation between medical and surgical teams is essential when dealing with this disease, as delay in appropriate treatment can only be detrimental to the patient. Between the years 1970 and 1975 we have performed the primary operations on 25 patients with the diagnosis of toxic megacolon, following the principles outlined above, with no mortality. Of these 25 patients, 17 were male and 8 were female; the youngest patient was 16 years old and the oldest 60 years; the average age was 30.33 years, and 15 patients were between the ages of 20 and 40. The average duration of colitis in this group of patients was 49 months. The longest duration of colitis was 12 years; 12 patients had colitis for less than 4 years and 8 patients had colitis for less than 1 year. The shortest duration of colitis prior to the development of toxic megacolon was 3 weeks (in two patients). Twenty-two of these patients were found to have ulcerative colitis, one 47-year~0Id male had drug-induced pseudomembranous colitis, and two patien~s had granulomatous colitis. None of the patients with ulcerative colitis was found to have a co-existing carcinoma of the colon. All of these patients were taking steroids at the time of development of toxic megacolon. The average white blood count was 11,600 (all had a shift to the left in differential); average hematocrit was 33, and all of the patients were hypoalbuminemic (average serum albumen was 2.4 7 gm per cent). Average serum potassium level was 3.66 mg per cent, although obviously riot reflecting the total body stores of potassium. All of the patients showed signs of hypovolemia and sepsis. Dilatation of the colon (at least 8 cm) was noted radiographically and/or at the time of operation in each patient . . Following diagnostic studies and resuscitation as outlined above, 20 patients underwent total abdominal colectomy with ileostomy and mucous fistula; 5 patients underwent total proctocolectomy (3 of these patients had massive hemorrhage immediately preceding operation in addition to toxic megacolon). The average delay between diagnosis of toxic megacolon and operation, during which time resuscitation was being carried out, was 1.9 days; 13 patients were operated within less than 24 hours, 20 patients within less than 48 hours, and all of the patients within less than 96 hours. Perforation of the colon occurred in 5 of the 25 patients; perforation was spontaneous and preceded operation in 4, and was iatrogenic and occurred during operation in one. None of these patients had generalized peritonitis. There have been no deaths among this group of 25 patients. Fourteen compljcations occurred in 11 patients. These included a "shock lung" syndrome, a wound dehiscence, a postoperative bowel obstruction, impotency in a male following proctectomy, and, in addition, a postoperative seizure disorder in two patients, serum hepatitis in two patients, wound infections in four patients (in each of whom the skin incision had been closed primarily), and postoperative bleeding requiring reoperation in two patients. One of the latter two patients had undergone total abdominal colectomy for toxic megacolon accompanied by
102
JAMES
E.
MUNGAS,
A.
RAHIM MOOSSA, AND GEORGE
E.
BLOCK
hemorrhage, and 11 days later underwent emergency proctectomy for continuing hemorrhage. The average length of hospital stay following operation was 21 days; the shortest hospital stay following operation was 13 days, and the longest was 39 days (a 25-year-old male who required several operative procedures for a previously existing thigh abscess). Of the 20 patients undergoing total abdominal colectomy with ileostomy and mucous fistula, nine have subsequently undergone elective proctectomy for ulcerative colitis in the rectosigmoid, at an average of 4.9 months following the initial operation. As mentioned above, one patient required emergency proctectomy because of hemorrhage from a diseased rectum. One patient with pseudomembranous colitis who underwent total abdominal colectomy has subsequently demonstrated complete heali.ng of the rectum, and ileosigmoid anastomosis was performed at 8 months. Of the remaining nine patients undergoing total abdominal colectomy for toxic megacolon complicating ulcerative colitis, eight have evidence of disease in the rectum and are awaiting proctectomy. Seven of these patients are not yet 6 months post abdominal colectomy, and one prefers to wait until after graduating from college before undergoing proctectomy. The remaining patient with ulcerative colitis has demonstrated complete healing of the rectum, and proctectomy has been deferred for the present time.
SUMMARY From 1970 to mid-1975, we have operated on 25 consecutive patients with toxic dilatation of the colon with no mortality. This report deals with the principles of management which we follow; primary emphasis is given to aggressive diagnosis and resuscitation, followed by early operative intervention. We prefer total abdominal colectomy with ileostomy and sigmoid mucous fistula for cases of toxic megacolon not complicated by hemorrhage.
REFERENCES 1. Binder, S. D., Patterson, J. F., and Glotzer, D. J.: Toxic megacolon in ulcerative colitis. Gastroenterology, 66:909, 1974. 2. Foley, W. J., Weaver, D. K., and Coon, W. W.: Toxic megacolon and granulomatous colitis: Report of two cases. Am. Surg., 37:67-72,1971. 3. Garnjobst, W., and Hardwick, C. E.: Toxic dilatation in ulcerative colitis: Hazard of intraoperative contamination. Am. Surg., 34:519, 1968. 4. Goligher, J. C.: Extraperitoneal colostomy or ileostomy. Br. J. Surg., 46:7, 1958. 5. Ripstein, C. B., and Wiener, E. A.: Toxic megacolon. Dis. Colon Rectum, 16:402, 1973. 6. Spiro, H. M.: Complications of colitis. In Clinical Gastroenterology. London, Collier-MacMillan Ltd., 1970, p. 646. 7. Turnbull, R. B., Haek, W. A., and Weakley, F. L.: Surgical treatment of toxic megacolon: Ileostomy and colostomy to prepare patients for colectomy. Am. J. Surg., 122:325, 197i.
Department of Surgery University of Chicago Pritzker School of Medicine 950 East Fifty-Ninth Street Chicago, Illinois 60637
Treatment of Toxic Megacolon
James E. Mungas, M.D.,* A. Rahim Moossa,M.B., Ch. B.,t and George E. Block, M.D., M.s. (Surg.) t
Toxic megacolon is generally considered to be a lethal complication of ulcerative colitis; it may also arise as a complication of granulomatous colitis,2 pseudomembranous colitis,5 or bacterial or amebic colitis. Spiro 6 states that 25 per cent of patients with toxic megacolon treated medically will die. From his review of the recent literature, Glotzer reports that the operative mortality rate of toxic megacolon is 8. 7 per cent in the absence of perforation; once perforation occurs, the rate rises to 51.2 per cent. We have come to regard toxic megacolon as a surgical emergency and consider medical treatment to be resuscitative and preparatory to operation. During the period of 1970 to mid-1975, we have operated on 25 patients suffering from toxic dilatation of the colon and have had no postoperative deaths. This report outlines our principles in the surgical management of toxic megacolon.
DEFINITION AND DIAGNOSIS Toxic megacolon or, more appropriately, toxic dilatation of the colon, is an acute dilatation of the colon accompanied by signs of sepsis and catabolism and occurs in patients suffering from an underlying inflammatory disease of the colon. Many of the classic signs of toxic megacolon may be absent when the patient is first seen. The diagnosis 9f toxic megacolon should, therefore, rest on a high index of suspicion in patients with worsening colitis. When toxic dilatation of the colon is present, perforation of the bowel is imminent. The clinical features which may be present are those of local or diffuse peritonitis. Peristaltic sounds may be feeble or absent; crampy' abdominal pain, abdominal distention, mental confusion, fever, tachycar-
From the Department of Surgery, The University of Chicago Pritzker School of Medicine, Chicago, Illinois * Chief Resident in Surgery t Associate Professor of Surgery ! Professor of Surgery
Surgical Clinics of North America- Vol. 56, No.1, February 1976
95
96
JAMES
E.
MUNGAS,
A.
RAHIM MOOSSA, AND GEORGE
E. BLOCK
Figure 1. Abdominal roentgenogram in a patient with toxic megacolon, showing dilatation of colon, distention of small bowel secondary to ileus, and signs of fluid between loops of bowel.
dia, hypotension, and signs of dehydration are often prominent. Rectal examination may reveal some irregularity and nodularity in the rectal mucosa, with the presence of blood and/or mucus in the stool. A roentgenogram of the abdomen is diagnostic: marked segmental colonic dilatation as well as distention of the small bowel secondary to ileus are seen accompanied by signs of fluid between loops of small bowel (Fig. 1). Deep undermining ulceration of the colon wall may often be seen silhouetted against the colon gas. Chest roentgenograms may reveal elevation of the diaphragms, with or without basal atelectasis and pleural effusion. If perforation has already occurred, free air will usually be present beneath the diaphragms. The white blood count is generally elevated with a shift to the left; the hemoglobin concentration may be low, normal, or high, depending on the degree of previous acute or chronic blood loss, anemia, and degree of dehydration. Hypoalbuminemia and elevated blood urea ni-
TOXIC MEGACOLON
97
trogen are usually present, indicating a chronic catabolic state. Arterial blood gases often confirm a metabolic acidosis.
FURTHER DIAGNOSTIC STUDIES AND RESUSCITATION We emphasize that diagnostic and resuscitative measures should be carried out simultaneously and as rapidly as possible. These patients are extremely ill· and the majority will require operation on the day of admission after preoperative resuscitation. Large bore intravenous catheters, including a central venous pressure line, are inserted for fluid administration and monitoring of right atrial pressure. Blood is drawn for type and cross-match, as well as routine laboratory studies. Concurrently, a nasogastric tube (in preference to a long intestinal tube) and urinary catheter are inserted. A significant extracellular fluid volume deficit invariably exists in these patients accompanied by hypoalbumineInia and a decreased oncotic pressure. Infusion of electrolyte solution with salt-free albumin, supplementary potassium, and blood is therefore indicated. The goal of fluid administration is to replace the volume deficit and restore oncotic pressure. Restoration of volume is heralded by a rising right atrial pressure, slowing of pulse, rise of blood pressure, and achievement of a urine output of at least 40 ml per hour. Frequent monitoring of vital signs is essential in order to restore volume adequately without danger of fluid overload. Sodium bicarbonate may be given if there is a significant metabolic acidosis. Mild to moderate acidosis will usually respond to volume replacement alone; a severe and persistent metabolic acidosis usually indicates that perforation has already occurred. Many of these patients have already received steroid therapy. We prefer to administer 100 mg of hydrocortisone (Solu-cortef) intravenously initially and to repeat this dose every 4 hours. Blood cultures are drawn prior to starting broad spectrum antibiotics. We recommend Penicillin-G 5,000,000 units and chloramphenicol (Chloromycetin) 1 gm every 6 hours. Factors which are known to precipitate toxic dilatation of the colon are avoided. Anticholinergic drugs, morphine derivatives, and barium enema are notorious offenders. Proctoscopy is performed as soon as the patient can tolerate the procedure. Biopsy with frozen section is occasionally helpful in differentiating between ulcerative, granulomatous, and pseudomembranous colitis. The majority of the patients will prove to suffer from ulcerative colitis. Stool cultures and gram stains are obtained at the time of proctoscopy. Following these resuscitative measures, an improvement is generally noted in the patient's condition within 3 or 4 hours. The physician should not be lulled into a false sense of security at this time. The improvement in the patient's condition is a result of resuscitation; however, the diseased colon still has the propensity to perforate at any time, and morbidity and mortality increase following perforation. Even prior
98
JAMES
E.
MUNGAS,
A.
RAHIM MOOSSA, AND GEORGE
E.
BLOCK
to gross perforation, there is transudation of bacteria across the diseased thinned-out wall of the colon into the peritoneal cavity. The majority of these patients, therefore, have peritoneal sepsis, and this renders the signs of gross perforation subtle and difficult to appreciate. Operative management is mandatory at this stage; absolute indications for emergency colectomy are an increase in abdominal tenderness and distention, persistence or worsening of signs of volume deficit, rising temperature and/or white cell count, and persistence or worsening of metabolic acidosis on the basis of arterial blood gas measurements.
OPERATIVE MANAGEMENT We utilize a transverse abdominal incision in these malnourished patients, many of whom have been on long-term steroid therapy. In addition to safety, this incision affords excellent intra-abdominal exposure. Our preference in these poor risk patients is for total abdominal colectomy with ileostomy. The rectosigmoid is brought out as a mucous fistula. These extremely ill, toxic, malnourished, and anemic patients can ill afford the additional stress, operating time, and blood loss of a proctectomy. Only if the toxic megacolon is accompanied by hemorrhage do we advocate concomitant proctectomy; hemorrhage necessitates a one-stage proctocolectomy, as many of these patients will continue to bleed from the diseased rectum. Another reason for limiting the operation to total abdominal colectomy without protectomy is that a small percentage of these patients will prove to have granulomatous or pseudomembranous colitis. In this group of patients, ileosigmoid anastomosis may be accomplished at a later date. The patient is placed in the supine position on the operating table, unless proctectomy is deemed necessary, in which case the lithotomy position is employed. The transverse incision is placed 1 cm beneath the umbilicus~ Care is taken when entering the peritoneal cavity to avoid iatrogenic perforation of the greatly dilated colon. Specimens of the peritoneal exudate are taken for aerobic and anaerobic cultures; even without gross perforation coliform organisms are frequently present within this peritoneal fluid. The colon is handled with extreme care and gentleness, particularly when mobilizing the splenic and hepatic flexures. Garnjobst and Hardwick3 emphasize the increased morbidity associated with iatrogenic perforation of the distended colon; unlike them, however, we do not recommend colotomy or intraoperative decompression of the colon prior to colectomy, as fecal spillage is inevitable and suture of the colotomy is unsafe. We do not perform ileostomy and colostomy for patients with toxic megacolon as recommended by TurnbulF This decompression is an inadequate operation for the colitis and makes subsequent operation extremely difficult. After mobilizing the colon, its mesentery is divided close to the bowel wall between suture ligatures. The ileocolic vessels are divided last in order to decrease the risk of perforation of the cecum as a result of infarction superimposed on the disease state.
99
TOXIC MEGACOLON
The terminal ileum is then divided flush at the ileocecal valve to preserve as much of the ileum as possible (unless Crohn's disease with ileal involvement is present and necessitates resection of a portion of ileum). The rectosigmoid is divided as low as possible at a point which will allow exit of the sigmoid mucous fistula from the abdomen onto the left lower quadrant without tension. We do not close the distal end of the sigmoid and return it to the pelvis as a Hartmann's procedure; when disease is present at this site, nonhealing frequently occurs following closure of the stump and leads to perforation or abscess formation. The mucous fistula is matured in the left lower quadrant using interrupted chromic catgut sutures between full-thickness bowel wall and skin. We do not recommend leaving a Demartel clamp applied to the mucous fistula as the rate of healing is unpredictable. A standard Brooke type ileostomy is then constructed in the right lower quadrant after the terminal ileum is brought out extraperitoneally according to Goligher's4 method. This prevents any herniation or volvulus around the terminal ileum. Figure 2 illustrates the position of the ileostomy and the mucous fistula, as well as the abdominal incision. The mesenteric defects in the left and right gutters are then fully obliterated using interrupted suture technique.
\"
/
~
'.
:1J
jj
\ ......~
1 I
I
~/
Figure 2. Diagrammatic illustration of location of abdominal incision, ileostomy, and mucous fistula in a patient undergoing total abdominal colectomy for toxic megacolon.
100
JAMES
E.
MUNGAS,
A.
RAHIM MOOSSA, AND GEORGE
E.
BLOCK
The peritoneal cavity is irrigated copiously with warm saline solution. All irrigation solution must be recovered prior to closure of the ab~ domen because of the risk of fluid overload following absorption of this fluid. No drain is left in the abdomen even if perforation has occurred. The posterior and anterior fascial layers of the abdominal wall are approximated with interrupted monofilament wire sutures. The subcutaneous layer and skin mayor may not be closed depending on the judgment of the surgeons regarding the degree of wound contamination. If left open, the wound is irrigated and dressed several times daily and is closed secondarily a few days later. The postoperative course is usually unremarkable. Intravenous fluids, including albumin and blood (if necessary), are continued until the patient is eating normally. The patients are given a full course of parenteral antibiotics postoperatively. The patient is ambulated on the 1st postoperative day. The Foley catheter is removed when the patient's volume status is stable, usually on the 2nd or 3rd postoperative day. Upon resumption of bowel sounds and passage of stool per ileostomy, the nasogastric tube is removed and oral alimentation is begun and slowly advanced. Steroids are tapered from 300 mg hydrocortisone in three divided doses on the 1st postoperative day. If disease is present in the rectum the steroids are not totally withdrawn; most patients in this category require a maintenance dose of at least 35 mg of hydrocortisone per day. The patient is instructed on methods of ileostomy care and ileostomy appliances; we prefer Hollister karaya seal stoma bags in the immediate postoperative period. It is important that the ileostomy appliance fit snugly about the ileostomy in order to prevent skin breakdown from spillage of small bowel contents. The patient is fitted with a permanent ileostomy appliance following maturation of the ileostomy. The majority of our patients are discharged in the 3rd postoperative week, and followed closely in the outpatient clinic. A decision is made on the basis of pathologic findings and repeated proctoscopic examination as to whether or not an ileosigmoid anastomosis is advisable. If the underlying process is not ulcerative colitis and if the rectum is spared or healed, anastomosis is performed as an elective procedure 3 to 6 months following the emergency abdominal colectomy. Those patients with ulcerative proctocolitis undergo proctectomy some 3 to 6 months following abdominal colectomy. However, if carcinoma were discovered, the proctectomy would be performed earlier.
RESULTS The University of Chicago Hospitals and Clinics serve as a major referral center for patients with inflammatory bowel disease, and we believe that our success is due, in large part, to the approach taken by the members of both the medical service, to whom most of these patients are initially referred, and the surgical service, to whom consultations from the medical staff are readily available at all times. Over the years a close spirit of cooperation, a high degree of suspicion for the diagnosis of toxic megacolon in patients with colitis, and an aggressive
TOXIC MEGACOLON
101
diagnostic and therapeutic approach have evolved at this· hospital. Such cooperation between medical and surgical teams is essential when dealing with this disease, as delay in appropriate treatment can only be detrimental to the patient. Between the years 1970 and 1975 we have performed the primary operations on 25 patients with the diagnosis of toxic megacolon, following the principles outlined above, with no mortality. Of these 25 patients, 17 were male and 8 were female; the youngest patient was 16 years old and the oldest 60 years; the average age was 30.33 years, and 15 patients were between the ages of 20 and 40. The average duration of colitis in this group of patients was 49 months. The longest duration of colitis was 12 years; 12 patients had colitis for less than 4 years and 8 patients had colitis for less than 1 year. The shortest duration of colitis prior to the development of toxic megacolon was 3 weeks (in two patients). Twenty-two of these patients were found to have ulcerative colitis, one 47-year~0Id male had drug-induced pseudomembranous colitis, and two patien~s had granulomatous colitis. None of the patients with ulcerative colitis was found to have a co-existing carcinoma of the colon. All of these patients were taking steroids at the time of development of toxic megacolon. The average white blood count was 11,600 (all had a shift to the left in differential); average hematocrit was 33, and all of the patients were hypoalbuminemic (average serum albumen was 2.4 7 gm per cent). Average serum potassium level was 3.66 mg per cent, although obviously riot reflecting the total body stores of potassium. All of the patients showed signs of hypovolemia and sepsis. Dilatation of the colon (at least 8 cm) was noted radiographically and/or at the time of operation in each patient . . Following diagnostic studies and resuscitation as outlined above, 20 patients underwent total abdominal colectomy with ileostomy and mucous fistula; 5 patients underwent total proctocolectomy (3 of these patients had massive hemorrhage immediately preceding operation in addition to toxic megacolon). The average delay between diagnosis of toxic megacolon and operation, during which time resuscitation was being carried out, was 1.9 days; 13 patients were operated within less than 24 hours, 20 patients within less than 48 hours, and all of the patients within less than 96 hours. Perforation of the colon occurred in 5 of the 25 patients; perforation was spontaneous and preceded operation in 4, and was iatrogenic and occurred during operation in one. None of these patients had generalized peritonitis. There have been no deaths among this group of 25 patients. Fourteen compljcations occurred in 11 patients. These included a "shock lung" syndrome, a wound dehiscence, a postoperative bowel obstruction, impotency in a male following proctectomy, and, in addition, a postoperative seizure disorder in two patients, serum hepatitis in two patients, wound infections in four patients (in each of whom the skin incision had been closed primarily), and postoperative bleeding requiring reoperation in two patients. One of the latter two patients had undergone total abdominal colectomy for toxic megacolon accompanied by
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JAMES
E.
MUNGAS,
A.
RAHIM MOOSSA, AND GEORGE
E.
BLOCK
hemorrhage, and 11 days later underwent emergency proctectomy for continuing hemorrhage. The average length of hospital stay following operation was 21 days; the shortest hospital stay following operation was 13 days, and the longest was 39 days (a 25-year-old male who required several operative procedures for a previously existing thigh abscess). Of the 20 patients undergoing total abdominal colectomy with ileostomy and mucous fistula, nine have subsequently undergone elective proctectomy for ulcerative colitis in the rectosigmoid, at an average of 4.9 months following the initial operation. As mentioned above, one patient required emergency proctectomy because of hemorrhage from a diseased rectum. One patient with pseudomembranous colitis who underwent total abdominal colectomy has subsequently demonstrated complete heali.ng of the rectum, and ileosigmoid anastomosis was performed at 8 months. Of the remaining nine patients undergoing total abdominal colectomy for toxic megacolon complicating ulcerative colitis, eight have evidence of disease in the rectum and are awaiting proctectomy. Seven of these patients are not yet 6 months post abdominal colectomy, and one prefers to wait until after graduating from college before undergoing proctectomy. The remaining patient with ulcerative colitis has demonstrated complete healing of the rectum, and proctectomy has been deferred for the present time.
SUMMARY From 1970 to mid-1975, we have operated on 25 consecutive patients with toxic dilatation of the colon with no mortality. This report deals with the principles of management which we follow; primary emphasis is given to aggressive diagnosis and resuscitation, followed by early operative intervention. We prefer total abdominal colectomy with ileostomy and sigmoid mucous fistula for cases of toxic megacolon not complicated by hemorrhage.
REFERENCES 1. Binder, S. D., Patterson, J. F., and Glotzer, D. J.: Toxic megacolon in ulcerative colitis. Gastroenterology, 66:909, 1974. 2. Foley, W. J., Weaver, D. K., and Coon, W. W.: Toxic megacolon and granulomatous colitis: Report of two cases. Am. Surg., 37:67-72,1971. 3. Garnjobst, W., and Hardwick, C. E.: Toxic dilatation in ulcerative colitis: Hazard of intraoperative contamination. Am. Surg., 34:519, 1968. 4. Goligher, J. C.: Extraperitoneal colostomy or ileostomy. Br. J. Surg., 46:7, 1958. 5. Ripstein, C. B., and Wiener, E. A.: Toxic megacolon. Dis. Colon Rectum, 16:402, 1973. 6. Spiro, H. M.: Complications of colitis. In Clinical Gastroenterology. London, Collier-MacMillan Ltd., 1970, p. 646. 7. Turnbull, R. B., Haek, W. A., and Weakley, F. L.: Surgical treatment of toxic megacolon: Ileostomy and colostomy to prepare patients for colectomy. Am. J. Surg., 122:325, 197i.
Department of Surgery University of Chicago Pritzker School of Medicine 950 East Fifty-Ninth Street Chicago, Illinois 60637