Intraperitoneal or subcutaneous: does location of the (colo)rectal stump influence outcomes after laparoscopic total abdominal colectomy for ulcerative colitis?

BACKGROUND: The optimal management of the closed defunctionalized large-bowel stump after laparoscopic total abdominal colectomy with end ileostomy for ulcerative colitis remains controversial. OBJECTIVE: The aim of this study is to compare postoperative outcomes after different techniques of management of the defunctionalized (colo)rectal stump. DESIGN AND PATIENTS: Patients undergoing laparoscopic total abdominal colectomy for ulcerative colitis during 1998 to 2010 were assigned to an intraperitoneal group (creation of Hartmann rectal stump) or a subcutaneous group (subcutaneous placement of rectosigmoid stump). OUTCOME MEASURE: Postoperative morbidity was defined as complications occurred within 30 days after the operation or during the same hospital stay. RESULTS: Of 204 patients, 99 were in the intraperitoneal group and 105 were in the subcutaneous group. There were no significant differences in demographics or preoperative data, with the exception of a significantly increased age-adjusted Charlson Comorbidity Index and preoperative total parental nutrition use in the intraperitoneal group. There was 1 postoperative death for myocardial infarction in the subcutaneous group. Overall postoperative morbidity, pelvic sepsis rates, and length of hospital stay were similar. Stump leaks occurred in 5 patients in the intraperitoneal group vs 10 patients in the subcutaneous group (p = 0.23). All stump leaks in the subcutaneous group only required local wound treatments without causing pelvic sepsis or need for reoperation. Pelvic sepsis in the intraperitoneal group required reoperation in 1 case, CT-guided drainage in 3, and antibiotics alone in 2 cases. Pelvic sepsis in the subcutaneous group required CT-guided drainage in 3 cases and antibiotics alone in 1 case. CONCLUSION: With the limitations of a retrospective study, postoperative outcomes were comparable after either technique of stump management, none of which could offset the risk of pelvic sepsis. Subcutaneous placement of colorectal stump was associated with more frequent but less morbid complications.