Strategy for the surgical management of patients with idiopathic megarectum and megacolon

Background: Several surgical procedures have been used to treat idiopathic megabowel. A structured approach to the surgical management of megarectum/c olon is reported. Methods: Twenty-eight consecutive patients with megabowel referred for surg ery were reviewed. All patients had conservative treatment for 6 months. Th ose failing to improve underwent full-thickness biopsy of the anorectal jun ction, anorectal physiology studies, colonic transit studies and evacuation proctography. Surgery involved excision of the abnormal large bowel and fo rmation of an anastomosis (coloanal or ileoanal) using 'normal' bowel ident ified either by a defunctioning stoma or colonic motility studies. Results. Eight patients responded to conservative management. Two patients were lost to follow-up and one died from unrelated causes. Two of the 17 pa tients who underwent full-thickness biopsy were cured by the procedure. Ano rectal physiology, colonic transit and evacuation studies did not aid selec tion of the surgical procedure performed in 15 patients: proctectomy and co loanal anastomosis (six), restorative proctocolectomy (three), panproctocol ectomy (one) and defunctioning stoma (five). At a median follow-up of 3.6 y ears, 13 of 15 evaluable patients had a satisfactory outcome. Conclusion: Approximately 40 per cent of patients with megaboweI referred f or surgery responded to conservative treatment. The remaining patients may be treated successfully by surgery. The use of either a 'diagnostic' defunc tioning stoma or colonic motility studies may aid in the choice of surgical procedure.