# The Rectal Stump During and After Subtotal Colectomy for Ulcerative Colitis: A Narrative Review of Surgical Strategies, Medical Management Options, and Cancer Surveillance Recommendations

## TL;DR

This review summarizes the challenges and strategies for managing the rectal stump after surgery for ulcerative colitis, including surgical techniques, treatment of complications, and cancer surveillance.

## Contribution

The paper provides a comprehensive narrative review of rectal stump management strategies and recommendations for ulcerative colitis patients post-subtotal colectomy.

## Key findings

- Intra-peritoneal closure increases pelvic sepsis risk, while subcutaneous placement increases wound infections.
- Mucous fistula placement has the lowest overall complication rate.
- Diversion proctitis is common but only a minority of patients develop symptoms.

## Abstract

Background/Objectives: There are multiple decision nodes, during and after subtotal colectomy for ulcerative colitis (UC), regarding the management of the rectal stump. Intra-operatively, the surgeon must decide on the closure technique and positioning of the retained stump, while post-operatively, clinicians often face the challenge of managing diversion proctitis, as well as determining an appropriate endoscopic surveillance strategy, given the increased risk of cancer. This narrative review aims to summarise the evidence relating to these key decision points in rectal stump management. Methods: A narrative review of the literature was performed. Relevant studies were identified through a search of Ovid Medline and Embase. Inclusion criteria were adult population and diagnosis of UC. Cohort studies, review articles, and guidelines were eligible for inclusion. The references were grouped according to the subject of interest and reported accordingly. Results: Intra-peritoneal closure has been shown to have higher pelvic sepsis rates (5–25%), whereas subcutaneous placement results in higher rates of wound infections (up to 15%). A mucous fistula has been shown to have the lowest overall complication rate. Microscopic findings compatible with diversion proctitis develop in most patients, with incidence ranging from 71.4% to 100%. However, only a minority of these patients (30–40%) develop symptoms. Suggested treatments for diversion proctitis include topical mesalamine, corticosteroids, or short-chain fatty acids. The overall risk of rectal stump neoplasia in patients with UC after subtotal colectomy is as low as 0.7%, with prior colorectal neoplasia being a major risk factor. No universal standardised guidance exists regarding endoscopic surveillance in this patient population. Conclusions: This narrative review has appraised the latest evidence on three crucial stages of rectal stump management in UC. There is still uncertainty about the optimal surgical management of the stump, with different complication profiles. Medical management of diversion proctitis remains a major unmet need, and there are no randomised trials addressing this issue. There are no universally accepted guidelines on endoscopic surveillance of the rectal stump.