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Rectal stump management in inflammatory bowel disease: a cohort study, systematic review and proportional analysis of perioperative complications

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Abstract

Background

The aim of this study was to analyse local single-institution data and perform a systematic review of the literature to calculate precise risk estimates of rectal stump-related morbidity and mortality following subtotal colectomy in patients with inflammatory bowel disease (IBD), including Crohn’s colitis, ulcerative colitis and indeterminate colitis.

Methods

Institutional information systems were interrogated to obtain local patient data. A systematic review of MEDLINE and EMBASE was performed to identify relevant articles. Fixed-effects or random-effects meta-analysis of proportions was performed to calculate pooled incidence estimates, including local data.

Results

Sixty-one patients were included locally and all had their rectal stump closed intra-abdominally. Four patients (8.3%) had a rectal stump perforation and 30-day mortality was 0. Fourteen papers were included in our review alongside local data, with a total of 1330 patients included. Pooled mortality was 1.7% (95% confidence interval, CI 1.0–2.8), pooled incidence of pelvic abscess/sepsis, stump leak and wound infection was 5.7% (95% CI 4.4–7.3), 4.9% (95% CI 3.7–6.6) and 11.3% (95% CI 7.8–16), respectively. Subcutaneous placement of the stump was associated with the highest incidence of stump leak (12.6%, 95% CI 8.3–18.6), and closure of the stump with both staples and suture was associated with the highest incidence of pelvic abscess (11.1%, 95% CI 5.8–20.3). Mortality and the incidence of wound infection were similar across stump closure techniques. There was evidence suggesting considerable heterogeneity and publication bias among studies.

Conclusions

This study provides estimates of morbidity associated with the rectal stump after subtotal colectomy for IBD. A closed intra-abdominal stump seems to be associated with the highest rate of pelvic abscess/sepsis. Further work in form of an international collaborative project would allow individual patient data analysis and identification of risk factors for complications.

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Authors and Affiliations

  1. Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK

    S. Lawday, M. Leaning, O. Flannery, S. Summers, R. Bethune & S. A. Antoniou

  2. Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK

    G. A. Antoniou

  3. Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK

    G. A. Antoniou

  4. Department of Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK

    J. Goodhand

  5. Medical School, European University Cyprus, Nicosia, Cyprus

    S. A. Antoniou

  6. Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus

    S. A. Antoniou

Authors
  1. S. Lawday
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  2. M. Leaning
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  3. O. Flannery
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Corresponding author

Correspondence to S. Lawday.

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Conflict of interest

The authors declare no conflicts of interest.

Ethical approval

Retrospective audit of local data was registered with the local hospital audit and governance department. No ethical approval was necessary for the systematic review.

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For this type of study, formal consent is not required.

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Appendices

Appendix 1

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Fig. 2
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Search strategy

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2.

Appendix 2

See Table 4.

Table 4 The risks of bias tool (iROBINS) results of all included papers from the review are presented
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Appendix 3

See Figs. 

Fig. 3
figure 3

Mortality forest plot and funnel plot

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3,

Fig. 4
figure 4

Pelvic sepsis forest plot and funnel plot

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Fig. 5
figure 5

Rectal stump leak forest plot and funnel plot

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5 and

Fig. 6
figure 6

Wound infection forest plot and funnel plot

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6.

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Lawday, S., Leaning, M., Flannery, O. et al. Rectal stump management in inflammatory bowel disease: a cohort study, systematic review and proportional analysis of perioperative complications. Tech Coloproctol 24, 671–684 (2020). https://doi.org/10.1007/s10151-020-02188-8

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  • DOI: https://doi.org/10.1007/s10151-020-02188-8

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