Editing Severe colitis (section)

=== '''Surgical''' ===

** Timing is crucial - delay can lead to perforation or ACS
*** Don't be fooled by a benign abdo exam - by the time they develop peritoneal signs it is usually too late to avoid perforation
*** Severe/fulminant colitis operation can be done the next day, while if operating because toxic and unwell, should do it overnight
** Absolute indications
*** Toxic megacolon with progressive dilatation (see separate section below)
*** Uncontrolled haemorrhage
*** Development of complications such as free perforation
*** General clinical deterioration
*** Lack of improvement in 48-72 hours
** The surgery is '''subtotal colectomy with end ileostomy''', or sometimes Hartmann procedure, depending on regions involved
*** Divide distal sigmoid - probably ok to leave a bit of length above the true peritoneal reflection, to both make it easier to reverse in future and allow the stump to be sutured up to anterior abdominal wall
*** Probably take greater omentum along with the transverse colon to make the dissection easier
*** No need to do an oncologic resection
*** Be very gentle with the colon to avoid perforation
*** Can sometimes be done laparoscopically apparently, but this is hard if the bowel is dilated, not recommended
*** Do not resect rectum, no matter how inflamed it looks - it usually responds to medical therapy after the colectomy
*** Commonly complicated by rectal stump blow-out, resulting in pelvic abscess. Traditionally, can be avoided by leaving a very long rectal stump and incorporating this into the fascial closure of the midline laparotomy wound, to cause a controlled mucous fistula rather than a deep pelvic infection. Modern teaching is that this is unnecessary, but the risk of blowout is real, so oversew the staple line with PDS and leave a rectal catheter in situ for several days. If the rectal stump is so friable that it cannot be stapled at all, bring it out to skin as a true mucus fistula.
*** Restoration of intestinal continuity can take place after 3 months and after the patient is back onto maintenance therapy and preferably off immunosuppressants. Do not do a primary anastomosis.
** Post-op
*** ICU
*** Leave rectal tube to about day 5
*** Clear fluids as tolerated, light diet day 1
*** IV steroids until diet is re-established, if they are on it, then weaning dose orally
*** Many biologics can be stopped immediately post-op
*** Consider extended VTE prophylaxis for IBD