Surgical treatment of toxic megacolon

Toxic megacolon is defined as a fulminant attack of colitis with total or s egmental dilatation of the colon. Toxic megacolon is mostly a complication of nonspecific ulcerative colitis or Crohn's colitis but it may also occur in pseudomembranous colitis and other forms of infectious colitis. Toxic di latation of the colon is a sign of transmural acute inflammation in which p erforation of the colon is impending or may already have occurred. Free per foration means a fourfold increase in the mortality of a fulminant attack o f colitis. Dilatation of the colon is not by itself an indication for immed iate operation. The dilatation may increase, fluctuate or even disappear, l eaving the patient still severely ill with toxic colitis requiring immediat e surgery. The indication and optimal timing of surgical intervention requi re optimal interdisciplinary collaboration between surgeons and gastroenter ologists. The procedure of choice for surgical treatment of toxic megacolon is colectomy and ileostomy. The mortality and morbidity of urgent surgery have been decreased by avoiding rectal excision. The rectal stump is either closed as a pelvic Hartmann's pouch or the sigmoid remnant is exteriorized as a mucous fistula or closed subcutaneously. Progress in intensive therap y and perioperative patient management has relegated simple decompression b y diverting loop ileostomy and skin-level colostomy as advocated by Turnbul l et al nearly 30 years ago to the role of an obsolete procedure which seem s hardly ever preferable to resection of the diseased bowel.