TOXIC MEGACOLON

Toxic megacolon is characterized by nonobstructive segmental or total colonic dilation with

resultant abdominal distension and pain accompanied by signs of systemic toxicity usually
including tachycardia, fever, and leukocytosis. Depending on the acuity and severity of the
colitis, hypoalbuminemia, anemia, and electrolyte imbalance may be observed. Mental
status changes and hypotension progressing to shock are ominous signs of impending death
from underlying sepsis.

Etiology
Today, toxic megacolon is more often seen in patients at their initial presentation of ulcerative
or Crohn colitis or in patients with other forms of colitis including pseudomembranous
colitis, cytomegalovirus colitis, colitis associated with salmonellosis, Campylobacter jejuni and
other bacteria, ischemic colitis, or drug-induced colitis including chemotherapy.

Initial Evaluation and Resuscitation

stabilization of the patient by vigorous fluid resuscitation and prompt correction of electrolyte
abnormalities. bowel rest and nasogastric suction. If the patient has been on corticosteroids,
stress-dose intravenous steroids are administered.

Indications for Emergency Surgery

Free air, diffuse peritonitis, localized peritonitis with associated increasing abdominal pain and/or
acute distension of the colon greater than 10 cm, major hemorrhage, and uncontrolled sepsis
are the primary indications for emergency laparotomy.

Advocates of aggressive medical therapy note that over half of patients with flares of acute
colitis from inflammatory bowel disease respond to high-dose corticosteroids, cyclosporine,
and other drugs and can be spared the need for emergency colectomy. Conversely, advocates
for early surgical intervention point out that mortality from operations for toxic megacolon or
toxic colitis is usually the result of delays in operative intervention. This is especially tragic, they
say, since most patients with toxic megacolon who initially improve without surgery
eventually require colectomy.

Initial Nonoperative Management

Supportive measures including hyperalimentation are instituted.

If the patient has known ulcerative colitis or Crohn colitis, it is generally assumed that toxic
colitis or toxic megacolon is related to an acute flare. Corticosteroids, cyclosporine, and other
agents may be used to control the disease process.

Patients with probable pseudomembranous toxic megacolon are also given vancomycin orally or
per the nasogastric tube and by gentle enemas.

A particularly difficult diagnostic dilemma is posed by the patient who presents with acute
toxic megacolon and no known history of ulcerative colitis or Crohn disease and no
history suggestive of infectious colitis such as recent use of antibiotics or foreign travel.
Such patients may benefit from additional diagnostic workup including stool for Gram stain
and cultures for pathogens as well as a limited proctoscopy examination. If performed gently
and without air insufflation, such an examination can provide useful information to guide
medical therapy without iatrogenic injury. The rectal mucosa is visualized and biopsied for
histology. Diffuse mucosal granularity with friability may suggest a diagnosis of ulcerative
colitis. Aphthous ulcers, rake ulcers, or skip areas of diseased mucosa with intervening
normal mucosa may suggest Crohn disease. Pseudomembranes suggest the diagnosis of
infectious colitis from Clostridium difficile.

Thus, frequent (two to four times per day) clinical evaluations coupled with serial monitoring of
hemoglobin, white blood cell counts, and abdominal radiographs are essential to determine the
patient's response to medical therapy. The response to medical therapy determines the need for
operative intervention and is categorized as an improvement, a plateau, or a deterioration.

Improvement
Medical management is continued if the patient's condition is clearly improving as denoted
by reversal of signs of toxicity including fever, tachycardia, leukocytosis, abdominal pain, and
colonic distention. Return of bowel function and cessation of hematochezia are favorable signs.
As improvement continues, treatment of the underlying cause of the colitis is maximized, oral
intake is begun, and intravenous therapy is changed to oral agents. If tolerated, the patient
is discharged and followed closely in the outpatient setting.

Plateau
Patients may reach a plateau after institution of medical therapy. This clinical scenario
is characterized by initial reversal of some of the signs of toxicity but failure to resolve
other parameters. For instance, the colonic distension may decrease, but tachycardia may
persist despite adequate fluid resuscitation. Often a fluctuating clinical picture of
possible improvement is followed by laboratory or clinical examinations suggesting worsening of
the patient's condition. When this pattern is observed, the decision to operate is difficult.
Patients are sometimes reluctant to consent to a major operation on an urgent basis, but
surgeons bear the responsibility of intervening before a life-threatening complication such
as perforation occurs. In our experience, illusory improvement really is no improvement and is
an important indication for urgent surgery. Our rule of thumb is to operate if the response to
medical therapy has reached a plateau persisting more than 24 to 48 hours.

Deterioration

Immediate operative intervention is indicated for patients whose clinical condition deteriorates.
This may be denoted by increased leukocytosis, increased tachycardia, persisting fever,
inadequate urine output, confusion, progression of colonic distension, or development of
localized or generalized peritonitis.

Operative Choices

I. Total or subtotal colectomy and ileostomy with

A. Hartmann pouch
B. Mucous fistula
C. Subcutaneous exteriorization of closed distal bowel
II. Total proctocolectomy and ileostomy
III. Diversion procedures
A. Ileostomy
B. Cecostomy
C. Ileostomy with transverse decompressive colostomy (Turnbull “blowhole” procedure)
IV. Restorative procedures
A. Total colectomy and ileorectal anastomosis
B. Restorative proctocolectomy with ileal pouch–anal anastomosis

Almost always, the procedure of choice involves a subtotal or total colectomy with ileostomy.

Mucous Fistula

Mucous fistula or subcutaneous exteriorization of the bowel may be optimal in patients with
a relatively healthy sigmoid colon. The proximal end of the rectosigmoid colon is exteriorized to
decompress the remaining colon and rectum. This second stoma is placed either at the inferior
edge of the midline incision or in a separate lower abdominal site.

Advocates say this makes mucous fistula the safest and preferred option.

Subcutaneous Exteriorization of the Closed Distal Bowel

Mucous fistula or subcutaneous exteriorization of the bowel may be optimal in patients with
a relatively healthy sigmoid colon. A modification of mucous fistula in which the closed end of the
distal bowel is placed in a subcutaneous location at the site of the ileostomy, the inferior aspect
of the midline wound, or a remote site. In the event of a suture line dehiscence, the bowel opens
in a controlled, subcutaneous location, thus creating a mucous fistula.

Hartmann Pouch

Many patients requiring emergent colectomy for toxic megacolon will have severe disease
throughout the abdominal colon. It is for these reasons that we generally close the rectum
and leave it in situ as a Hartmann pouch. Neither sutured closure nor stapled closure has proven
to be superior, although, in reality, the edematous bowel is rarely amenable to stapled closure
only. We generally oversew the staple line.
Despite the presence of a high-risk suture or staple line, the risk of rectal stump leak (“stump
blowout”) remains relatively low (between 2% and 12%) and can be minimized further if a few
simple precautions are followed. Placement of the suture or staple line intraperitoneally, as
opposed to low in the pelvis, may decrease the rate of leakage and avoids a pelvic dissection.
Prior to closing the abdomen, the Hartmann pouch can be decompressed via proctoscopy and a
drain (usually a soft red rubber catheter or Foley catheter) can be placed transanally to maintain
decompression of the rectal stump. In the event of a stump leak, the resulting pelvic abscess can
often be managed by percutaneous catheter drainage.

Other Operative Choices

ileostomy with transverse decompressive colostomy, the so-called Turnbull “blowhole” operation
– rarely used as high rate of mortality and morbidity.

A total proctocolectomy and ileostomy is sometimes performed for toxic megacolon or toxic
colitis if the rectum is the source of life-threatening hemorrhage or if the rectal disease is severe
and/or there is no consideration of subsequently performing a restorative ileal pouch–anal
anastomosis procedure. This particularly applies to patients with severe rectal Crohn disease.

It is usually unwise to do a primary anastomosis when operating for toxic megacolon or toxic
colitis, especially if significant peritoneal contamination is present or if the patient is
malnourished, has required transfusions, or is in any way unstable. Thus, total colectomy
with ileorectal anastomosis or restorative proctocolectomy with ileal pouch–anal anastomosis
is rarely performed in this setting.

When planning an operation for toxic megacolon, we find it useful to focus on four specific goals:
(a) control of existing fecal contamination, (b) avoidance of iatrogenic perforation during
the operation, (c) safe and efficient resection of the severely diseased colon including all sites
of perforation so the patient can regain health status, and (d) keeping future operative options
open to restore bowel continuity with good function.

The almost certain need for an ileostomy is discussed with the patient and preoperative
consultation with an enterostomal therapy nurse is requested to educate the patient and to mark
the abdomen for potential ileostomy sites. Most often, the ideal site is marked over the right
rectus muscle to minimize the risk of parastomal hernias. On rare occasions, a patient with toxic
megacolon may present with a free perforation and diffuse peritonitis and be so
hemodynamically unstable that preoperative marking for an ileostomy is not possible. In such
cases, the surgeon should place the stoma high on the right side of the abdomen away from
scars and bony protuberances.
Laparoscopic-assisted procedures are not appropriate for cases of toxic megacolon and are
almost never appropriate for toxic colitis.

Venous thrombosis prophylaxis is instituted and pneumatic compression devices are used. We
prefer the modified lithotomy position because it allows simultaneous access to the perineum and
abdomen and allows a second assistant to stand between the legs (Fig. 2).
 Just prior to prepping, the surgeon can gently insert a proctoscope to deflate the rectosigmoid
and assess the mucosa of the rectum. Air insufflations during this examination is avoided.

The status of the intra-abdominal rectum and sigmoid is especially important in planning the
extent of distal resection and determining whether a mucous fistula or Hartmann pouch will be
used.

Colon Mobilization

As the hepatic flexure is approached, care is taken to identify and protect the duodenum. It is
important to avoid excess traction on the colonic mesentery during mobilization of the hepatic
flexure as troublesome bleeding from a branch of the mesenteric veins in the paraduodenal area
can occur. If the omentum is free and easy to separate from the transverse colon, it can be
preserved, but in most cases of toxic megacolon, the omentum is adherent to the serosal surface
of the colon and may contain small perforations. If adherence is noted, we remove the omentum
with the colon. The dissection is continued from right to left, entering the lesser sac and
approaching the splenic flexure (Fig. 6). Because the splenic flexure can be difficult to dissect in
the presence of colonic dilation and acute colitis with possible areas of walled-off perforation, we
next mobilize the sigmoid and descending colon. The peritoneal attachments along the white line
of Toldt are divided, beginning in the pelvis and working toward the splenic flexure. As we do so,
the left ureter and gonadal vessels are identified and swept into the retroperitoneum. The risk of
splenic traction injury is minimized by avoiding downward traction on the descending colon.
Instead, we gently dissect upward in the retrocolic plane and then sweep a hand laterally to
expose and facilitate division of the remaining lateral attachments. Gentle simultaneous traction
on the mobilized portions of the transverse and descending colon allows the splenic flexure to
be taken down safely.

Colon Resection
Having mobilized the entire colon, we now divide the mesentery and proceed with the colectomy.
If the mesentery is thick or difficult to secure, we utilize suture ligatures. The ileocolic mesentery
is divided and tied. The distal ileum is transected with a linear cutter stapler near the cecum. As
the remaining mesentery is divided, the right colic, middle colic, and left colic vessels are
individually divided and ligated. At this point in the operation, the surgeon must decide how far
the resection will be carried distally—that is, will the operation be a total colectomy or a
subtotal colectomy? If the sigmoid colon appears significantly diseased from the underlying
colitis, we divide the sigmoid vessels and resect the colon to the rectum at the pelvic brim.
We proceed with a proctectomy only if there is evidence of perforation in the rectum, massive
bleeding from the rectum, or such severe rectal disease that a secure closure cannot be ensured.
If proctectomy is needed, it is usually possible to leave a short rectal stump for later ileal pouch
anastomosis. If the sigmoid appears minimally involved from the colitis, a subtotal colectomy will
restore the patient to health and the sigmoid can be safely retained. The colon is transected with
a linear cutter stapler if possible and the specimen is submitted for pathology. If the upper
rectum is too edematous to accommodate a stapler, it may be divided between bowel clamps
and closed in a hand-sewn fashion. The abdominal cavity is irrigated with saline.

Ileostomy Construction

The goal is to create a round, symmetrically protruding, matured stoma that is 2 to 2.5 cm
above the skin level at a site convenient for the patient to perform self-care. A 3.5 cm in
diameter circle of skin is excised from the marked stoma site in the right lower quadrant. The
subcutaneous fat is incised vertically and retracted to expose the anterior rectus abdominis
fascia. A cruciate 2.5- cm incision is made with electrocautery, thus exposing the underlying
muscle.
Right-angle retractors are placed more deeply and used to retract the muscle fibers to each side.
A cruciate incision large enough to accommodate passage of the distal ileum is made with
electrocautery on the posterior rectus sheath and peritoneum. Care is taken during this process
to avoid injury to the inferior epigastric artery. If injured, it must be ligated. With the ileal
mesentery oriented in a cephalad direction, the mobilized distal ileum is delivered through the
abdominal wall defect. Intra-abdominal mobilization of the ileum and its mesentery should be
done to allow the ileum to protrude 5 to 6 cm above the skin level.

For a permanent stoma, we suture the mesentery to the posterior fascia from the stoma site
toward the liver to minimize the risk of a small bowel volvulus occurring around the stoma.

If obesity precludes the ability to create an end ileostomy that protrudes above the skin surface,
a loop ileostomy should be considered. A loop of ileum just proximal to the stapled end of the
bowel is brought through the abdominal wall defect. A rod or catheter may be placed through a
small mesenteric window created just beneath the loop and used to support the stoma above
the skin. Because a loop stoma requires mobilization of two limbs of bowel and the
associated mesentery, it is thicker than an end stoma. As a result, the tunnel in the abdominal
wall and the skin opening often have to be enlarged.
Management of the Rectum or Rectosigmoid

In most cases, a total or near-total colectomy was performed and the retained large bowel
stump is not long enough to create a mucous fistula or to leave it closed off in the subcutaneous
tissues. Instead, a Hartmann pouch is created by oversewing the previously placed staple line on
the end of the retained stump with interrupted absorbable sutures.

If the Hartmann pouch is long enough, the closed sigmoid can be sutured to the posterior fascia
at the inferior aspect of the midline wound or to the back of the uterus or pelvic peritoneum,
thus facilitating its later identification.

We take several steps to minimize the small risk of a symptomatic leak or fistula from a
“blowout” of the Hartmann pouch. An omental patch may be mobilized and placed over the
closed stump. We decompress and irrigate the Hartmann pouch via proctoscopy before closing
the abdominal wound. A soft drain may be placed into the rectum via the anus and left for 3 to 7
days postoperatively to minimize the risk of accumulations of mucus, blood, and gas that
might cause the suture line to breakdown. In cases where a rectum that is so severely diseased
that staples or sutures cut through the bowel, it is better to proceed with proctectomy than to
persist in trying to close the badly diseased rectal stump. Usually this requires a limited resection
of several centimeters at the rectosigmoid junction to identify healthy tissues amenable to
secure closure. If the entire rectum is severely diseased, a more extensive resection may be
necessary, but for patients in whom a subsequent restorative ileal pouch procedure is
appropriate, the anal canal can usually be left in situ. Subsequent removal or conversion to a
pelvic pouch is more difficult but not impossible. If the anal canal is so diseased that it cannot
be preserved, it is usually not going to be functional, and a total proctocolectomy is performed.
GOLDEN WORDS

Most of the time, the operation performed is an ileostomy and Hartmann turn-in, or sigmoid
mucous fistula, which is rare in my experience.

Every now and then, depending on the condition of the patient, I have carried out an ileal
pouch–anal anastomosis with a diverting ileostomy. This is usually not done under acute
conditions, but more often in the setting of a patient who comes in with toxic megacolon,
improves somewhat, and then hits a plateau. At this point, if consulted, I would place the
patient on parenteral nutrition; add intravenous chloramphenicol, a not-often-used drug
that can actually be added to the total parenteral nutrition (Dr. Lester Martin, a noted
pediatric surgeon, taught me this) in the dose of 3 g per 24 hours and allow the patient to
improve; use rectal steroids; and carry out the ileal pouch–anal anastomosis during that
hospitalization.

I prefer to make the incision as a lateral paramedian incision, keeping it well away from the
placement of the ileostomy.

I put in wound towels and sew them to the fascia prior to opening the peritoneum in case
there is the opportunity for perforation of the colon.

Antibiotic rather than sterile saline irrigation is most appropriate for the peritoneum, and
peritoneal debridement with sponges and other devices to rid the peritoneum of solid stool
may be necessary. I prefer kanamycin for the irrigation, or gentamicin if available. Irrigation
with antibiotic solution to the subcutaneous tissue is perfectly appropriate.

The ileostomy sutures, in my view and as according to Brooke, should not go through the
skin, which has already been mentioned, but nor should they go through the mucosa, as
mucosal cells tend to grow along the suture if they are through the mucosa, as pictured
here.

With respect to the skin closure, delayed primary closure is appropriate, provided one
understands that the infection rate for delayed primary closure is not 0%, but 5%. I prefer
to close the skin primarily after irrigation and debridement of the subcutaneous fat, and
leave closed suction drains in for 10 days, because that is when the wound suppurates.

Primary closure and closed suction drainage is less painful, and if one leaves the drains in
for a long period of time, one rarely gets a wound infection.

Taken all together, I believe that toxic megacolon should alert the surgeon that surgical
intervention is necessary. It would be best if the toxic megacolon were allowed to subside, if
the opiates and the anticholinergics were removed, and if the patient was watched carefully,
supported with parenteral nutrition, and allowed to get to a plateau where one could
prepare the rectum for rectal stripping for those who carry out ileal pouch–anal anastomosis
using that technique.