Rescue Diverting Loop Ileostomy: An Alternative to Emergent Colectomy in the Setting of Severe Acute Refractory IBD-Colitis.

BACKGROUND

Severe acute refractory colitis has traditionally been an indication for emergent colectomy in IBD, yet under these circumstances patients are at elevated risk for complications because of their heightened inflammatory state, nutritional deficiencies, and immunocompromised state.

OBJECTIVE

We hypothesized that rescue diverting loop ileostomy may be a viable alternative to emergent colectomy, providing the opportunity for colonic healing and patient optimization before more definitive surgery.

DESIGN

This was a retrospective case series.

SETTINGS

The study was conducted at a single academic center.

PATIENTS

Patients with severe acute medically refractory IBD-related colitis were included.

INTERVENTION

Rescue diverting loop ileostomy was the intervening procedure.

MAIN OUTCOME MEASURES

The primary outcome was avoidance of urgent/emergent colectomy. The secondary outcome was efficacy, defined by 3 clinical aims: 1) reduced steroid dependence or opportunity for bridge to medical rescue, 2) improved nutritional status, and 3) ability to undergo an elective laparoscopic definitive procedure or ileostomy reversal with colon salvage.

RESULTS

Among 33 patients, 14 had Crohn's disease and 19 had ulcerative colitis. Three patients required urgent/emergent colectomy, 2 with ulcerative colitis and 1 with Crohn's disease. Across both disease cohorts, >80% of patients achieved each clinical aim for efficacy: 88% reduced their steroid dependence or were able to bridge to medical rescue, 87% improved their nutritional status, and 82% underwent an elective laparoscopic definitive procedure or ileostomy reversal. A total of 4 patients (11.7%) experienced a postoperative complication following diversion, including 3 surgical site infections and 1 episode of acute kidney injury.

LIMITATIONS

The study was limited by being a single-center, retrospective series.

CONCLUSIONS

Rescue diverting loop ileostomy in the setting of severe, refractory IBD-colitis is a safe and effective alternative to emergent colectomy. This procedure has acceptably low complication rates and affords patients time for medical and nutritional optimization before definitive surgical intervention. See Video Abstract at http://links.lww.com/DCR/A520.