When is surgery indicated in the treatment of proctitis and anusitis?

Updated: Mar 27, 2020
  • Author: David E Stein, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Many factors come into play in deciding when to operate and which operation to perform. For most cases of proctitis, medical treatment should suffice. However, for certain disease processes, surgical treatment is more likely.

Choice of procedure

For patients with ulcerative colitis requiring surgical therapy, a total proctocolectomy should be performed because of the risk of cancer in the remaining rectal stump. [19] Ileostomy or reconstruction with an ileal pouch may be offered after total proctocolectomy. In patients with severe Crohn colitis or proctitis, options range from fecal diversion to proctectomy to total proctocolectomy, depending on the extent of the disease process.

In the infectious causes of proctitis, surgical treatment is rarely required. In cases of severe C difficile colitis, a subtotal colectomy may be warranted.

For patients with radiation proctitis complicated by refractory bleeding, endoscopic therapy seems to be more effective than medical therapy; it also results in less morbidity than surgical therapy. Specifically, argon plasma coagulation (APC) [16, 20, 21] has proved to be superior to formalin and endoscopic laser treatments. Other endoscopic therapies include endoscopic thermal methods, such as heater probes and lasers, which destroy telangiectasias to stop bleeding.

If, despite medical and endoscopic measures, significant hemorrhage still occurs, a laparoscopic fecal diversion (ileostomy or colostomy) should be performed. Although fecal diversion alleviates patients' symptoms, it rarely eliminates them entirely; it should be reserved for truly refractory cases. Fewer than 10% of patients do not respond to some form of medical management and require surgical intervention.

Rarely, radiation proctitis can be so severe that it ulcerates, potentially leading to the formation of a rectourethral fistula. In these cases, temporary fecal and urinary diversion should be performed until the inflammation subsides. Definitive therapy may then be provided. The procedure of choice is a perineal approach with repair of the defect with muscle and mucosal flaps.

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