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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

13 Fulminant Ulcerative Colitis 1

13 FULMINANT ULCERATIVE COLITIS


Roger D. Hurst, M.D., F.A.C.S., F.R.C.S.Ed., and Fabrizio Michelassi, M.D., F.A.C.S.

Fulminant ulcerative colitis is a potentially life-threatening disorder that must be expertly managed if optimal outcomes are
to be achieved. This condition was once associated with a very
high mortality,1 but medical and surgical treatments have improved dramatically, to the point where the mortality associated with fulminant ulcerative colitis is now lower than 3%.2,3
Optimal management depends on close coordination between
medical and surgical therapy, and multidisciplinary strategies
are essential.
Classification

The most commonly applied system of classifying the severity


of ulcerative colitis has been the one devised by Truelove and
Witts, who identified clinical parameters by which colitis could be
categorized as mild, moderate, or severe.4 The Truelove-Witts classification does not, however, specify a unique category for fulminant disease. Accordingly, Hanauer modified this classification
scheme to include a category for fulminant colitis [see Table 1].5
Unfortunately, there is no universally agreed upon distinction between severe ulcerative colitis and fulminant ulcerative colitis.6
Some authors use the terms severe and fulminant interchangeably,
whereas others, concerned about the lack of a clear distinction between the two, recommend that the term fulminant ulcerative colitis be avoided altogether.7 This latter recommendation has not
been widely followed: the term fulminant ulcerative colitis remains
an established component of the medical vernacular, the absence
of a clear definition notwithstanding.8-10
Fulminant ulcerative colitis is certainly a severe condition that is
associated with systemic deterioration related to progressive ulcerative colitis. Most authorities would agree that a flare of ulcerative colitis can be considered fulminant if it is associated with one or more
of the following: high fever, tachycardia, profound anemia necessitating blood transfusion, dehydration, low urine output, abdominal
tenderness with distention, profound leukocytosis with a left shift,
severe malaise, or prostration. Patients with these symptoms should

be hospitalized for aggressive resuscitation while clinical assessment


and treatment are being initiated.11
Clinical Evaluation

When a patient is admitted with


severe or fulminant ulcerative colitis, a
complete history and a thorough physical examination are required. The
abdominal examination should focus
on signs of peritoneal irritation that
may suggest perforation or abscess formation. Any patient admitted with severe
ulcerative colitis may have already received substantial doses of corticosteroids, which can mask the physical findings of peritonitis.
Investigative Studies
LABORATORY TESTS

Initial laboratory studies should include a complete blood count


with differential, a coagulation profile, and a complete metabolic
profile with assessment of nutritional parameters (e.g., serum albumin concentration). Multiple stool specimens should be sent to be
tested for Clostridium difficile, cytomegalovirus, and Escherichia coli
0157:H7.12,13 It is important to rule out the presence of opportunistic infections, particularly with C. difficile, even in patients with
an established diagnosis of ulcerative colitis; superinfection with
C. difficile is common in such patients.
IMAGING

Abdominal films and an upright chest x-ray should be obtained


to look for colonic distention (indicative of toxic megacolon) and
free intraperitoneal air (indicative of perforation).
Endoscopic evaluation of the colon and rectum in the presence

Table 1Criteria for Evaluating Severity of Ulcerative Colitis


Mild Disease

Severe Disease

Fulminant Disease

< 4/day

> 6/day

> 10/day

Blood in stool

Intermittent

Frequent

Continuous

Temperature

Normal

> 37.5 C

> 37.5 C

Pulse

Normal

> 90 beats/min

> 90 beats/min

Hemoglobin

Normal

< 75% of normal

Transfusion required

30 mm/hr

> 30 mm/hr

> 30 mm/hr

Colonic features on radiography

__

Air, edematous wall, thumbprinting

Dilatation

Clinical signs

__

Abdominal tenderness

Abdominal distention and tenderness

Variable
Stools

Erythrocyte sedimentation rate

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

13 Fulminant Ulcerative Colitis 2

Management of Fulminant Ulcerative Colitis


Patient has severe or fulminant ulcerative colitis
Perform history and physical examination.
Abdominal examination focuses on peritoneal
signs (sometimes masked by corticosteroid therapy).
Order investigative studies:
Laboratory tests: CBC with differential, coagulation
profile, metabolic profile, stool testing (for C. difficile,
CMV, E. coli)
Imaging: abdominal films, chest x-ray, colonoscopy
(for minimum necessary distance)

Hospitalize patient.
Give blood products to treat anemia or coagulopathy.
Correct metabolic derangements.
Optimize nutritional status (e.g., via bowel rest and TPN).

Patient is stable and has no


indications for emergency surgery
Initiate I.V. corticosteroid therapy
(e.g., methylprednisolone, 4060
mg/day I.V.)

Colitis responds to I.V. corticosteroid therapy

Patient is unstable or has indication


for emergency surgery (e.g., findings
suggestive of perforation, massive
GI bleeding, or toxic megacolon)

Colitis does not respond to I.V.


corticosteroid therapy within 57 days

Switch to oral regimen, then gradually wean


patient from steroids.
Initiate maintenance therapy with purine analogues
or immunosalicylates.

Cyclosporine therapy is not contraindicated


Initiate I.V. cyclosporine therapy, initially 4 (or 2)
mg/kg/day I.V., adjusted as necessary.

Colitis responds to I.V.


cyclosporine therapy
Initiate maintenance therapy with
6-MP or azathioprine.

Cyclosporine therapy is
contraindicated (e.g., because
of renal insufficiency,
hypocholesterolemia, sepsis,
or patient refusal)

Colitis does not respond to I.V.


cyclosporine therapy within 45 days
or complete remission is not achieved
within 1014 days

Initiate surgical treatment. Consider laparoscopic-assisted


approach as an option (except in cases of toxic megacolon).

Patient is healthy enough to


undergo full procedure at once

Patient has perforation, peritonitis,


or sepsis

Perform proctocolectomy with


ileoanal anastomosis.

Perform a staged procedure


(abdominal colectomy with ileostomy,
followed later by proctectomy with
ileoanal anastomosis).

Patient does not have obvious perforation,


peritonitis, or sepsis but may not be healthy
enough to undergo full procedure at once
Choose all-at-once or staged approach on the
basis of experience and clinical judgment. Most
patients who do not respond to maximal medical
therapy are probably best treated with a
staged procedure.

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen


of fulminant ulcerative colitis is a controversial measure.14-16 Undoubtedly, colonoscopy with biopsy can provide useful diagnostic
information in this setting, and numerous reports indicate that in
experienced hands, colonoscopy poses little risk to patients with
severe colitis.14,15 In general, however, it is recommended that endoscopic examination proceed no further than the minimum distance necessary to confirm severe colitis. If an endoscopic examination is to be performed, insufflation of air must be minimized;
overdistention of the colon may lead to perforation or the development of megacolon. In addition to diagnostic information, endoscopy can provide useful prognostic information. In one study,
the presence of deep, extensive colonic ulcerations indicated a low
probability for successful medical treatment of fulminant ulcerative colitis: fewer than 10% of patients with such ulcerations responded to medical measures.14 Thus, an endoscopic finding of
deep ulcers [see Figure 1] may facilitate the decision to proceed
with early operative treatment if medical therapy does not lead to
rapid and significant improvement.
Management
GENERAL CARE

All patients with fulminant ulcerative


colitis should be hospitalized. Blood
products should be administered to
treat significant anemia or coagulopathy. Metabolic derangements should be
corrected.17 Patients with a perforation
or massive lower GI hemorrhage are
taken to the operating room for emergency surgical treatment;
more stable patients are initially managed with medical therapy.
Narcotics, antidiarrheal agents, and other anticholinergic medications should be avoided because they can precipitate toxic dilation
of the colon.
Bowel rest typically reduces the volume of diarrhea, but
whether it affects the clinical course of the fulminant colitis
remains to be established.18,19 One study of patients with acute

Figure 1 Sigmoidoscopy demonstrates deep ulcerations


in a patient with fulminant ulcerative colitis.

13 Fulminant Ulcerative Colitis 3


flares of ulcerative colitis reported no significant difference in outcome between those who were managed with total parenteral
nutrition (TPN) and bowel rest and those who received enteral
nutrition. This study, however, included patients with colitis of
varying degrees of severity, and apparently, only a small number
of them had fulminant ulcerative colitis.19 A subsequent study
found that bowel rest and TPN did have a potential clinical
advantage in patients with fulminant ulcerative colitis.18 The most
common approach to nutritional management of these patients is
first to place them on bowel rest with hyperalimentation, then to
initiate oral feeding once the symptoms of the fulminant attack
begin to be alleviated. Whether patients are being maintained on
bowel rest or are receiving oral feedings, adequate nutritional
support must always be ensured. Hence, TPN, if employed,
should be maintained until the patient is receiving and tolerating
full enteral feedings.
MEDICAL THERAPY

The standard medical approach to


fulminant ulcerative colitis involves
induction of remission by means of
I.V. corticosteroid therapy, followed
by long-term maintenance treatment
(in the form of purine analogues) once
remission has been achieved. If treatment with steroids fails to induce
remission, I.V. cyclosporine therapy is
considered.
Steroids
For decades, steroid treatment has been the frontline therapy
for acute flares of ulcerative colitis. Response rates in cases of fulminant ulcerative colitis range from 50% to 60% when the
steroids are given over a period of 5 to 10 days.20,21 Methylprednisolone, 40 to 60 mg/day in a continuous I.V. infusion, is a
common regimen.5,22-24
The length of time that should be allowed for patients to
respond to I.V. steroid therapy has been a subject of debate. In
1974,Truelove and Jewell recommended urgent operative treatment after 5 days if there is no response to I.V. steroid therapy.25
This 5-day rule has been widely adopted, but more recent experience suggests that steroids can be safely administered for as
long as 7 to 10 days to allow patients more time to respond.12
Patients who respond to I.V. steroid therapy are switched to
an oral steroid regimen (typically prednisone). It is important,
however, to stress that corticosteroids should never be employed as long-term maintenance therapy.5,26 The toxic effects of
corticosteroids are related to not only the dosage but also the
duration of treatment. Severe complications are common with
extended use of even modest doses of steroids. Accordingly,
patients should be slowly but completely weaned from steroid
therapy. Because symptomatic colitis recurs in 40% to 50% of
patients who initially respond to I.V. therapy, maintenance therapy with either purine analogues or immunosalicylates should
be instituted.5,20
Unfortunately, corticosteroid dependency is frequently encountered in patients with ulcerative colitis. Often, the steroid dosage
cannot be tapered without an increase in disease activity and exacerbation of symptoms. In such cases, if the patient cannot be
weaned from steroids and switched to purine analogues within 3 to
6 months, surgical consultation is indicated. In addition, if complications related to ulcerative colitis or to corticosteroid therapy
develop, the colitis must be treated surgically.

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5 Gastrointestinal Tract and Abdomen

13 Fulminant Ulcerative Colitis 4

Cyclosporine
At one time, patients who did not respond to I.V. steroid treatment were invariably referred for surgical treatment.
Currently, such patients are most often
treated with I.V. cyclosporine therapy.
Cyclosporine is an immunosuppressant
macrolide that suppresses the production
of interleukin-2 by activated T cells
through a calcineurin-dependent pathway.27 Originally employed to prevent tissue rejection after transplantation, cyclosporine has become the standard treatment of
steroid-refractory severe ulcerative colitis.
The first report of the use of cyclosporine to treat ulcerative colitis was published in 1984.28 It was not until 10 years later, however, that a randomized, placebo-controlled trial of cyclosporine
therapy for steroid-refractory ulcerative colitis convincingly
demonstrated the effectiveness of cyclosporine in this setting.29 In
this trial, patients with steroid-refractory ulcerative colitis who
received cyclosporine (4 mg/kg) had an 82% response rate, compared with a 0% response rate in those treated with continued I.V.
steroid therapy alone. Since this initial report, response rates ranging from 56% to 91% have been reported in the medical literature,
confirming cyclosporine as a major advance in the treatment of
severe and fulminant ulcerative colitis.30-32
The beneficial effects of cyclosporine therapy are not always
durable: as many as 60% of patients experience recurrence of disease
after initial cyclosporine-induced remission.33 Fortunately, recurrence rates can be substantially lowered by means of maintenance
therapy with 6-mercaptopurine (6-MP) or azathioprine.With appropriate maintenance therapy, the rate of early recurrence of symptoms
after successful I.V. cyclosporine treatment may be reduced to levels
as low as 22%.31,34 Even if the disease does recur, the initial success
of cyclosporine therapy in aborting the acute phase of the ulcerative
colitis allows patients to recover from the acute illness, so that they
are in better condition to undergo elective surgical treatment at a later date if such treatment ultimately proves necessary.This is a major
benefit, in that operative management of ulcerative colitis carries a
much higher risk of complications when carried out on an urgent basis than when carried out in an elective setting.18,35,36
The major side effects of cyclosporine treatment are renal insufficiency, opportunistic infections, and seizures.The risk of seizures
appears to be highest in patients with hypocholesterolemia. Consequently, cyclosporine should not be given to patients with significant hypocholesterolemia (serum cholesterol concentration
< 100 mg/dl). Hypomagnesemia is commonly seen in patients with
fulminant ulcerative colitis who undergo cyclosporine treatment;
accordingly, serum magnesium levels should be closely followed.
Dosing regimens for cyclosporine vary. The typical starting
dosage is 4 mg/kg/day I.V., which is then adjusted to achieve a
whole-blood level between 150 and 400 ng/ml, as measured by
high-power liquid chromatography or radioimmunoassay.37,38
Whole-blood levels as high as 800 ng/ml are considered acceptable
by some investigators.29 If the patient shows no improvement within 4 to 5 days or if complete remission is not achieved by 10 to 14
days, surgical treatment is advised.12 Most of the side effects of
cyclosporine therapy are dose dependent. Several studies have
shown that an initial dosage of 2 mg/kg/day I.V. can also be effective in achieving remission.39-41 Some physicians prefer to begin at
this lower dosage and then increase it as necessary on the basis of
the measured cyclosporine levels.
Concerns have been raised about the possibility that prolonging
medical therapy in patients with severe colitis who have already

Table 2Indications for Operation in Patients


with Fulminant Ulcerative Colitis
Inability to tolerate medical treatment
Failure to respond to medical treatment
Inability to be weaned from corticosteroids
Presence of complications of ulcerative colitis (e.g., perforation, peritonitis,
progressive signs of sepsis, hemorrhage, and toxic megacolon)
Development of complications related to medical treatment

received large amounts of corticosteroids may increase the risk of


perioperative morbidity and mortality in those who respond to
neither steroids nor cyclosporine therapy and thus require operative management. At present, however, there is no evidence that
patients who do not respond to cyclosporine therapy are at
increased risk for perioperative complications; such therapy does
not appear to compromise surgical results.42
SURGICAL THERAPY

Indications
Indications for surgical treatment of
fulminant ulcerative colitis have been
established [see Table 2]. One such indication, of course, is the exhaustion of
options for appropriate medical treatment. Because most patients with fulminant ulcerative colitis respond to aggressive medical therapy, such treatment is
warranted in almost all cases. Care must be exercised, however, not
to overtreat patients with fulminant ulcerative colitis who are otherwise stable. The immunosuppressive effects of high-dose corticosteroids and I.V. cyclosporine, along with the debilitation induced by
prolonged severe disease, can place patients at high risk for perioperative complications. Patients who do not show significant improvement in response to I.V. steroid therapy within 5 to 7 days should be
started on I.V. cyclosporine therapy or referred for operative treatment.12 Those who do not respond to cyclosporine therapy within 4
days or in whom remission of major symptoms is not achieved within 2 weeks should be treated surgically. Patients whose symptoms
progress during the course of I.V. therapy or who show no sign of
improvement at all should be considered for early surgery. Patients
known to have deep longitudinal ulcerations are less likely to
respond to I.V. medical therapy and thus may also be referred for
early surgery. The decision regarding when to abandon medical
therapy for fulminant ulcerative colitis in favor of surgical therapy is
difficult and requires considerable experience and special expertise.
Accordingly, patients with fulminant ulcerative colitis are best managed in a center specializing in inflammatory bowel disease.
Patients with perforation or severe GI bleeding require urgent
surgical treatment.43 The debilitation resulting from the disease,
coupled with the immunosuppression resulting from intensive
medical therapy, can mask the signs and symptoms of sepsis and
peritonitis associated with perforation. Perioperative mortality in
cases of fulminant colitis is as much as 10 times higher when perforation occurs than when it does not.44 For this reason, patients
with high fever, marked leukocytosis, and persistent tachycardia
should be referred for early surgery, regardless of whether other
indications of perforation or peritonitis are noted.
Toxic megacolon, though an uncommon complication of severe
ulcerative colitis, is important in that it is associated with impend-

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5 Gastrointestinal Tract and Abdomen
ing colonic perforation and therefore must be watched for and
aggressively managed if present. Two specific conditions must be
satisfied to establish the diagnosis of toxic megacolon.45 First,
there must be colonic dilatation; second, the patient must be in a
toxic state. Patients with mild symptoms of ulcerative colitis may
experience a degree of colonic dilatation, perhaps in conjunction
with colonic ileus. This condition is distinctly different from and
considerably less worrisome than toxic megacolon. Patients admitted to the hospital with fulminant ulcerative colitis will, by definition, exhibit some degree of toxicity. Colonic dilatation in these
patients is a very worrisome phenomenon, in that it completes the
picture of toxic megacolon. Accordingly, in all patients with fulminant ulcerative colitis, an abdominal x-ray should be obtained to
look for colonic dilatation. Those in whom abdominal distention
develops or who experience a sudden decrease in the number of
bowel movements without signs of significant clinical improvement
should also be assessed for colonic dilatation and toxic megacolon.
In patients with toxic megacolon who are otherwise stable, conservative management, consisting of elimination of narcotics and anticholinergic agents, may be briefly tried. Changes in patient position
may be tried as well: moving the patient from side to side, from
supine to prone, and into the knee-elbow prone position is thought
to facilitate expulsion of colonic gas.46 Patients with toxic megacolon
should be kept on a nihil per os (NPO) regimen, and broad-spectrum I.V. antibiotics should be given. Endoscopic decompression is
to be avoided. Blind placement of rectal tubes is ineffective and may
be harmful. Patients who do not rapidly respond to conservative
management and those who show signs of peritonitis or are otherwise unstable require urgent surgical treatment.47
Preparation for Operation
With patients who are stable but are not responding to medical therapy, there may be time for preoperative preparation.
Patients who are not on NPO status should be maintained on
clear liquids, then kept on an NPO regimen for 6 to 8 hours
before operation. On occasion, a patient may be able to tolerate
mild bowel preparation with either polyethylene glycol or Fleet
Phospho-soda (Fleet Pharmaceuticals, Lynchburg, Virginia).
Any bowel preparations that are used need be employed only
until bowel movements are free of residue. If time allows, the
patient should be counseled by an experienced enterostomal
therapist, and an optimal site for the ostomy should be marked
on the abdomen. Prophylactic antibiotics should be given before
the the surgical incision is made, and appropriate stress-dose
steroids should be administered.
Surgical Strategies
The operative strategies for treating
fulminant ulcerative colitis are controversial. Ultimately, almost all patients
end up undergoing a restorative proctocolectomy with ileoanal anastomosis [see
5:33 Procedures for Ulcerative Colitis]. In
most cases, however, the final surgical
goal is achieved in multiple steps. Performing an extensive resection in conjunction with a prolonged and delicate reconstruction in an acutely ill patient is a procedure of questionable safety. Accordingly,
many surgeons elect first to perform a total abdominal colectomy
with an ileostomy, leaving the rectal stump as either a Hartmann
pouch or a mucous fistula,43,44 then to perform a restorative proctectomy with ileoanal anastomosis at a later date. This staged approach allows the patient to recover from the acute illness, to be

ACS Surgery: Principles and Practice


13 Fulminant Ulcerative Colitis 5
weaned from immunosuppressive agents, and to achieve improved
nutritional status. Although the remaining rectal stump continues
to be affected by ulcerative colitis, the fecal diversion greatly diminishes disease activity, so that almost all patients can be completely
weaned from steroids and other immunosuppressive medications.
It is then possible to perform the proctectomy with ileoanal anastomosis in more controlled conditions.
The exact circumstances in which it is best to follow a staged approach have not been clearly defined. It is universally accepted that a
staged procedure is mandatory in patients with perforation, peritonitis, or sepsis, but beyond this point, there is no clear consensus.The
studies published to date have been inconclusive on this issue: either
they included only a small number of patients, they did not clearly
define what constituted fulminant colitis, or they did not directly
compare the results of the two alternative strategies (i.e., staged
colectomy and immediate ileoanal anastomosis). A 1995 study reported excellent long-term results and acceptable short-term morbidity in 12 patients undergoing immediate restorative proctocolectomy with ileal pouchanal anastomosis (IPAA) for fulminant
colitis.48 These 12 patients, however, represented an extraordinarily
small percentage of the total number of ileoanal procedures performed by the authors. In addition, this study used a somewhat liberal definition of fulminant colitis and thus might have included a
number of cases that would not have qualified as fulminant colitis
or, possibly, even as severe colitisaccording to the criteria cited earlier [see Table 1]. Finally, the study provided no data on the experience of patients undergoing a staged procedure for the management
of severe or fulminant colitis.
A 1994 study also reported excellent long-term results and exceptionally low perioperative morbidity in 20 patients undergoing
restorative proctocolectomy with IPAA for urgent treatment of ulcerative colitis.49 Another study from the same year, however, reported a 41% anastomotic leakage rate in 12 patients also undergoing an urgent ileoanal procedure for ulcerative colitis, compared
with an 11% leakage rate in patients undergoing ileoanal anastomosis under more controlled conditions.50 On the basis of these
results, the authors counseled against ileoanal anastomosis in the
urgent setting. A later study also noted a higher incidence of anastomotic leakage (36%) in patients undergoing urgent ileoanal
anastomosis.51 These authors likewise advised against ileoanal
anastomosis in the urgent setting.
The fact of the matter is that the distinction between severe and
fulminant ulcerative colitis may be little more than an academic exercise. At one end of the disease spectrum, there is a small subset of
patients who have symptoms severe enough to necessitate hospitalization yet are healthy enough to undergo a primary ileoanal anastomosis without undue risk. At the other end of the spectrum, there is
a subset of severely ill patients with fulminant colitis for whom a
staged procedure is mandatory.The middle of the spectrum remains
something of a gray area. Because specific criteria for quantifying the
risk have not been defined, the decision whether to follow a staged
operative approach ultimately is made on the basis of the experienced surgeons clinical judgment. It has been our experience, however, that the majority of patients who fit the criteria of fulminant colitis [see Table 1] and who do not respond to maximal medical therapy
are best managed with a staged approach.
Technical Considerations
Surgical exploration is performed via either a midline or a transverse incision.The abdomen is carefully examined, with particular
attention paid to the small intestine in an effort to detect any signs of
Crohn disease.The colon often shows the changes typical of colitis:
serosal hyperemia, corkscrew vessels, and edema [see Figure 2].

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5 Gastrointestinal Tract and Abdomen

ACS Surgery: Principles and Practice


13 Fulminant Ulcerative Colitis 6

Figure 2 In a colon affected by fulminant ulcerative colitis,


changes on the serosal aspect are typically subtle. Serosal
hyperemia with small corkscrew vessels is present.

Figure 3 Shown is a Hartmann pouch constructed at the


level of the sacral promontory. TA staple line is reinforced
with interrupted silk Lembert sutures.

Figure 4 Surgical specimen from a patient with fulminant


ulcerative colitis shows severe ulceration and inflammation.

Figure 5 Shown is mobilization of splenic flexure during


laparoscopic colectomy for fulminant ulcerative colitis.

Colectomy may be performed in the standard fashion, with


mesenteric division occurring at a convenient distance from the
bowel; wide mesenteric resection is not necessary. If a staged
colectomy is to be performed, the colon is removed, and the rectum is left either as a Hartmann pouch or as a mucous fistula. In
most cases, a Hartmann pouch can safely be created. In the construction of a Hartmann pouch, it is important that the stump be
of the appropriate length. If the stump is too short, the proctectomy to be performed in the second stage may prove very difficult; if
it is too long, there is an increased risk of complications related to
persistent disease in the rectum (e.g., bleeding, discharge, and
tenesmus). Ideally, the Hartmann pouch should be made at the
level of the sacral promontory [see Figure 3]. During the colectomy, the sigmoid branches of the inferior mesenteric artery should
be divided and the terminal branches of the inferior mesenteric
artery preserved.This measure ensures a good blood supply to the
remaining rectal stump and helps the Hartmann closure to heal.
Preservation of the terminal branches of the inferior mesenteric
artery and the superior rectal artery also simplifies the subsequent
proctectomy by keeping the pelvic sympathetic nerves free of surrounding scar tissue and by providing a key anatomic landmark

that will assist the surgeon in locating the appropriate presacral


dissection plane for any future planned proctectomy.
To create the Hartmann pouch, the mesenteric and pericolonic fat are removed from the bowel wall for a distance of approximately 2 cm. A transverse anastomosis (TA) stapler loaded
with 4.8 mm staples is placed on the prepared bowel and fired to
close the pouch.The bowel is then divided proximal to the staple
line. The staple line should be closely examined to confirm that
the staples are closed properly into two rows of well-formed Bs
and that individual staples are not cutting into the muscularis
propria of the bowel.To provide additional protection against dehiscence, the staple line may be oversewn with interrupted Lembert sutures [see Figure 3]. If sutures are employed, they should be
carefully placed so that the anterior and posterior serosal surfaces
are approximated without undue tension.With a well-constructed Hartmann pouch, pelvic drains are unnecessary and may even
be harmful, in that they can promote dehiscence if situated close
to the suture line.
In some cases, the colon at the level of the sacral promontory is
affected by deep ulcerations and severe inflammation, to the point
where closure of the Hartmann pouch at this level poses an unac-

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ACS Surgery: Principles and Practice

5 Gastrointestinal Tract and Abdomen

13 Fulminant Ulcerative Colitis 7

ceptably high risk of dehiscence [see Figure 4]. If the severity of disease precludes safe closure of the Hartmann pouch, creation of a
mucous fistula should be considered. A mucous fistula requires a
longer segment of bowel than a Hartmann pouch does and thus is
associated with a higher risk of bleeding from the retained segment. In addition, a mucous fistula is unsightly and often generates a very foul odor. As a compromise approach, some surgeons
advocate creating a Hartmann pouch of moderate length and
placing the proximal end of the stump through the fascia at the
lower edge of the midline incision; the end of the stump is then left
buried in the subcutaneous tissue. The benefit of this approach is
that if dehiscence of the staple line occurs, any ensuing infection
is limited to the subcutaneous space and does not result in an
intra-abdominal or pelvic abscess.
If attempts to fashion a secure Hartmann closure fail and the
remaining rectal stump is too short to be brought out as a mucous
fistula, the proximal rectum should be resected, and closure of the
Hartmann pouch should be performed just below the peritoneal
reflection. In this situation, closed suction drains should be placed
deep in the pelvis, and the peritoneum should be closed over the
rectal stump. Such a short Hartmann pouch, however, will be
more difficult to locate during the subsequent restorative proctectomy and ileoanal anastomosis.
With a staged colectomy, an end ileostomy is created in the
standard fashion [see 5:30 Intestinal Stomas], and the abdomen is
closed. Placing a rectal tube to drain rectal secretions may be

beneficial in reducing the risk of dehiscence of the Hartmann


pouch.
Laparoscopic Approaches
Experience has demonstrated that laparoscopic-assisted approaches to abdominal colectomy can be safely employed in patients
with ulcerative colitis.52 Mobilization of the colon and division of the
mesentery can be accomplished laparoscopically [see Figure 5], with
the specimen being removed through a small Pfannenstiel incision.
An end ileostomy can also be fashioned with the aid of inspection
through the Pfannenstiel incision. Alternatively, the Pfannenstiel incision can be made early in the procedure and used for placement of
a hand port, and the colon can be removed by means of a handassisted laparoscopic approach.
Whether a laparoscopic-assisted approach to the management of
fulminate ulcerative colitis possesses any significant clinical advantages remains to be determined. However, a growing body of experience with this approach indicates that in experienced hands, laparoscopic-assisted colectomy is a safe and reasonable alternative that may
well result in shorter hospital stays and decreased postoperative pain.
The laparoscopic-assisted approach may therefore be considered as
an option for patients with fulminant ulcerative colitis. Patients with
toxic megacolon, however, should be managed by means of an open
surgical approach; the instruments used to grasp the bowel in a laparoscopic-assisted colectomy are likely to cause perforation of the severely thinned walls of the dilated megacolon.

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14. Carbonnel F, Lavergne A, Lemann M, et al: Colonoscopy of acute colitis: a safe and reliable tool for assessment of severity. Dig Dis Sci 39:1550, 1994

2. Daperno M, Sostegni R, Rocca R, et al: Medical


treatment of severe ulcerative colitis. Aliment Pharmacol Ther 16(suppl 4):7, 2002

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