[Toxic megacolon: surgical timing important!]

Toxic megacolon is defined as a fulminant attack of colitis with total or segmental 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 dilatation of the colon is a sign of transmural acute inflammation in which perforation of the colon is impending or may already have occurred. Free perforation means a fourfold increase in the mortality of a fulminant attack of colitis. Dilatation of the colon is not by itself an indication for immediate operation. The dilatation may increase, fluctuate or even disappear, leaving the patient still severely ill with toxic colitis requiring immediate surgery. The indication and optimal timing of surgical intervention require optimal interdisciplinary collaboration between surgeons and gastroenterologists. 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 therapy and perioperative patient management has relegated simple decompression by diverting loop ileostomy and skin-level colostomy as advocated by Turnbull et al nearly 30 years ago to the role of an obsolete procedure which seems hardly ever preferable to resection of the diseased bowel.