CHICAGO – Diverting loop ileostomy may be a better option than urgent colectomy as the first surgical step for medically refractory severe ulcerative colitis and Crohn’s disease.
Investigators from the University of California, Los Angeles, have found that ileostomy gives patients a chance to recover from their acute illness – and their colons a chance to heal – so they’re in better shape for definitive surgery further down the road, if it’s even needed (J Am Coll Surg. 2015 Oct;221:S37-S38).
“Urgent colectomy is standard practice for medically refractory severe ulcerative and Crohn’s colitis. However, immunosuppression and malnutrition can result in significant morbidity. This change in management strategy does not eliminate the potential need for definitive surgery, but it does allow for the more extensive procedure to be performed in an elective setting under optimized conditions, thereby improving clinical outcomes,” said the investigators, led by Dr. Amy Lightner, formerly of UCLA but now a colorectal surgery fellow at the Mayo Clinic in Rochester, Minn.
There were just eight patients in the series, so the results are tentative. Six had ulcerative colitis (UC) and two had Crohn’s disease (CD). On presentation, the patients were tachycardic, febrile, malnourished, and anemic, with severe mucosal disease confirmed by endoscopy. Steroids, immunomodulators, and biologics no longer helped. Overall, the patients were too sick to go home, but not quite sick enough for the ICU. Their average age was 29 years.
They underwent a single-incision, laparoscopic diverting loop ileostomy, which took about 45 minutes. The technique, and perhaps the thinking behind it, are similar to one gaining popularity for Clostridium difficile colitis, but without the colonic lavage.
Within 24-48 hours postop, tachycardia and fevers resolved, and patients tolerated oral intake. Narcotic use dropped, and bloody stools became less frequent, and then ceased in all but one patient. Within a month, the average hemoglobin level had climbed from a baseline of 9 g/dL to 11.5 g/dL, and average albumin from 2.5 g/dL to 4 g/dL. Within 2 months, patients’ bowels looked pink and healthy on repeat endoscopy.
“It was a remarkable turnaround. Within 48 hours, they looked markedly different. We are having very good results with this, and it’s much better for patients” than is colectomy during acute illness. “It’s a good change in management,” Dr. Lightner said.
After months of follow-up, two patients, one with UC and one with CD, haven’t needed a colectomy and are maintained on biologics. The other UC patients have had ileal pouch-anal anastomosis. The other CD patient had a subsequent ileorectal anastomosis. Patients were able to undergo those procedures laparoscopically and “have done really well,” Dr. Lightner said.
It’s unclear why loop ileostomy seems so helpful. Perhaps it has something to do with shifts in bacterial populations or decompression of the colon. Maybe it’s just about giving the colon a rest, she said.
The investigators will continue to study the approach. Since the initial report, 8 more patients have joined the series, for a current total of 16. “We are still seeing good results,” Dr. Lightner said.
Dr. Lightner has no disclosures, and there was no outside funding for the work.