Aetiology and surgical management of toxic megacolon

Objective: The purpose of this article is to review the surgical management and outcome of toxic megacolon and to update the aetiology of toxic megacolon. Patients and method: A retrospective chart review of three academic colorectal surgery units was undertaken. Over a period of 20 years, 70 patients with surgically managed toxic megacolon were identified: 32 men and 38 women, median age 63 years (range, 23-87 years). Results: In 33 (48%) patients the main cause of toxic megacolon was inflammatory bowel disease. Thirty-seven (52%) patients had toxic megacolon of different aetiology. Sixty-three patients underwent colonic resection: 49 (70%) subtotal colectomies and 14 (20%) total colectomies, including 4 (6%) proctocolectomies. Seven (10%) patients had decompression (n = 3) or faecal diversion (n = 4) only. Forty-four of the resected patients underwent a Hartmann's procedure and an ileostomy; 13 (19%) patients had primary anastomoses, 11 (16%) ileorectal anastomoses (IRA) and 2 (3%) patients had ileal pouch-anal anastomosis (IPAA). Twenty-six (37%) patients subsequently had continuity restored. Total surgical complication rate was 19% (n = 13), 8% (n = 4) in patients treated with subtotal colectomy, 21% (n = 3) in patients treated with total proctocolectomy and 86% (n = 6) in patients treated with either decompression or diversion. The total mortality rate was 16% (n = 11). Conclusions: Toxic colitis complicated by toxic megacolon can occur after various diseases of the colon and remains a life-threatening disorder associated with a significant risk of postoperative complications. Subtotal colectomy with ileostomy remains the procedure of choice. Surgical colonic decompression with faecal diversion alone is associated with a high rate of complications.