A new approach to extraperitoneal rectal injuries: laparoscopy and diverting loop sigmoid colostomy

BACKGROUND: Current management of extraperitoneal rectal injuries involves a laparotomy and diversion of the fecal stream. In this study, we review our experience with laparoscopy and diverting loop sigmoid colostomy without laparotomy in the management of these injuries. METHODS: All patients admitted to the trauma unit at Groote Schuur Hospital between January 1995 and May 2000 with a rectal injury were evaluated. The presence of a rectal injury was confirmed by rectal examination and proctosigmoidoscopy. Intraperitoneal injuries were excluded by laparoscopy. Only patients who did not have intraperitoneal injuries were included in the study. The patients were then managed with a diverting loop sigmoid colostomy created through an abdominal wall trephine without laparotomy. RESULTS: Ten patients were included in the study. In eight patients, laparoscopy excluded intraperitoneal injuries. All 10 patients had a diverting loop sigmoid colostomy fashioned. There were no complications related to either the rectal injury or colostomy. Nine stomas have since been closed. CONCLUSION: In patients with isolated extraperitoneal rectal injuries, laparoscopic exclusion of intraperitoneal injuries, followed by a diverting loop sigmoid colostomy, is a feasible option.     

Long-term results of surgically treated traumatic rectourethral fistulas

OBJECTIVE: Rectourethral fistulas are uncommon, usually iatrogenic injuries that are demanding to treat. We present the challenging problems involving the treatment of rectourethral fistulas caused by war wounds. MATERIALS AND METHODS: In the period 1991-1996, during the war in Croatia and Bosnia, six patients with rectourethral fistulas caused by war injuries were operated in our institution by the same surgeon. All patients were young males with a mean age of 24.6 years. In all patients, double diversion (diversion colostomy and cystostomy) was performed at the time of the injury in military hospitals. In three patients, multiple unsuccessful operations were performed in other institutions to close rectourethral fistula. We found urethrocystography and proctoscopy as the most reliable diagnostic studies and performed them in all patients. In first three patients, we performed transanal repair with anterior rectal wall advancement flap. Because it failed in all three patients, we performed York-Mason trans-sphincteric approach and anterior rectal wall advancement flap after which rectourethral fistula closed in all patients. Because of the satisfactory results, we performed the same procedure in other three patients. RESULTS: In all patients rectourethral fistula healed 2 months after the operation. Closure of diverting colostomy was performed after urethrocystography and proctoscopy proved that the rectourethral fistula has healed. There were no operative deaths and no major complications. Urethral stenosis developed in one patient and was successfully managed by dilatation. CONCLUSION: We believe that York-Mason trans-sphincteric approach offers straightforward access through healthy tissues and good fistula visualization. Anterior rectal wall advancement flap can easily be performed and offer good chances for definitive closure of the rectourethral fistula.     

Operative Management of Civilian Rectal Gunshot Wounds: Simpler Is Better

Extraperitoneal rectal gunshot wounds have been managed with a variety of methods from simple diverting colostomy to combinations of rectal repair, proximal diversion, transperitoneal or presacral drainage, and distal bowel irrigation techniques. Treatment methodology is chosen based on anecdotal experience, and there is no clear evidence that any technique is superior to the others. The objective of this study was to compare 3 methods of managing civilian extraperitoneal gunshot wounds. Retrospective analysis of 30 consecutive patients with extraperitoneal rectal gunshot wounds was undertaken. Patients were treated with 1 of these 3 techniques: (1) simple diverting colostomy without rectal repair (group A, 12 patients); (2) diverting colostomy and rectal repair (group B, 12 patients); and (3) diverting colostomy and presacral drainage without repair (group C, 6 patients). Injury, hospital course, and outcome data were compared. The 3 groups were similar in age, injury severity, admission hemodynamics, preoperative and intraoperative time, blood loss, fecal contamination, and associated injuries. The overall incidence of complications was 27% (8/27): 25% (3/12) in group A, 33% (4/12) in group B, and 17% (1/6) in group C (p= NS). Complications directly associated with the rectal injury were found in 2 cases (7%): 1 group A patient developed a vesicorectal fistula and 1 group B patient developed a rectocutaneous fistula. For 10 patients with both rectal and bladder injuries, the complication rates for groups A, B, and C were 50%, 20%, and 0%, respectively (p= NS). No patient died. In conclusion, diverting colostomy without rectal repair or drainage appears to be safe for the management of most civilian retroperitoneal rectal gunshot wounds. Additional surgical maneuvers may be required for combined rectal and urinary trauma or other complex rectal injuries. Sound surgical principles, tailored to the individual case, should overrule any unproven dogmas.     

Management of rectal injuries. Dogma versus practice

The current treatment of civilian rectal injuries stems from military practice. Five principles have evolved: 1) complete fecal diversion, 2) debridement and closure, 3) rectal stump irrigation, 4) presacral drainage, and 5) broad spectrum antibiotics. To assess our practice results, the records of 52 consecutive patients with rectal injury seen at Detroit Receiving Hospital from 1980-88 were reviewed. Etiologies were gunshot (40), shotgun (9), anal assault (2), and stab (1). There were no blunt injuries and no deaths. Treatment consisted of celiotomy (52), diverting colostomy (51), presacral drains (35), rectal stump irrigation (26), and primary closure (1). Broad spectrum antibiotics were administered in all patients. Despite lack of universal application of the "standard" principles, only five patients had postoperative complications and none were related to the rectal injury. Our results demonstrate that a single approach may not be justified, as excellent outcome was achieved with low morbidity and no mortality despite selective management. The universal application of colostomy, repair, irrigation, drainage, and antibiotics cannot be supported.     

The influence of injury severity on complication rates after primary closure or colostomy for penetrating colon trauma.

The management of penetrating colon injury has been frequently debated in the literature, yet few reports have evaluated primary closure versus diverting colostomy in similarly injured patients. Diverting colostomy is the standard of care when mucosal penetration is present, but primary closure in civilian practice has generally had excellent results, although it has been restricted to less severely injured patients. Because the degree of injury may influence choice of treatment in modern practice, various indices of injury severity have been proposed for assessment of patients with penetrating colon trauma. As yet, however, there has been no cross-comparison of repair type versus injury severity. A retrospective study 76 patients who sustained penetrating colon trauma between January 1, 1979 and December 31, 1985 and who survived for at least 24 hours was conducted. Different preferences among attending surgeons and a more aggressive approach to the use of primary closure during the years of study led to an essentially random use of primary closure and diverting colostomy for moderate levels of colon injury, with mandatory colostomy reserved for the most serious injuries. Primary closure was performed in 37 patients (three having resection and anastomosis), and colostomy was performed in 39 patients. Severity of injury was evaluated by the Injury Severity Score (ISS), Penetrating Abdominal Trauma Index (PATI), and the Flint Colon Injury Score. Complications and outcome were evaluated as a function of severity of injury, and primary closure and colostomy were compared. Demographic profiles of the two groups did not differ regarding age, sex, mechanism of injury, shock, or delay between injury and operation. The mortality rate was 2.6% for each group. Major morbidity, including septic complications, occurred in 11% of the patients of the primary closure group and in 49% of those of the colostomy group. When PATI was less than 25, the Flint score was less than or equal to 2, or when the ISS was less than 25, primary closure resulted in fewer complications than did colostomy. Of the injury severity indices examined, the PATI most reliably predicted complications and specifically identified patients who whose outcome would be good with primary repair. These results suggest that the use of primary closure should be expanded in civilian penetrating colon trauma and that, even with moderate degrees of colon injury, primary closure provides an outcome equivalent to that provided by colostomy. In addition, the predictive value of the PATI suggests that it should be included along with other injury severity indices in trauma data bases.     

Diagnostic laparoscopy and diverting sigmoid loop colostomy in the management of civilian extraperitoneal rectal gunshot injuries

BACKGROUND: This prospective study reviews the management of isolated civilian extraperitoneal rectal gunshot injuries using a protocol of diagnostic laparoscopy and abdominal wall trephine diverting loop colostomy, without laparotomy, distal rectal washout and presacral drainage. METHODS: Patients admitted to the trauma unit at Groote Schuur Hospital between January 2000 and December 2002 with a rectal injury were evaluated. A rectal injury was confirmed by digital rectal examination and proctosigmoidoscopy. Missile peritoneal violation was excluded by diagnostic laparoscopy. Normal laparoscopy was followed by creation of a diverting sigmoid loop colostomy through an abdominal wall trephine, without a laparotomy. No distal rectal washout or presacral drainage was performed. RESULTS: Of the 104 patients admitted with 106 rectal injuries, 20 (19.2 per cent) qualified for inclusion in the study. All had sustained low-velocity gunshot injuries of which 18 exhibited a transpelvic trajectory. Diagnostic laparoscopy was normal and a trephine diverting loop sigmoid colostomy was performed in all 20 patients. No pelvic sepsis occurred. Two patients developed rectocutaneous fistulas, both of which resolved without surgical treatment. Nineteen stomas have since been closed. CONCLUSION: Low-velocity gunshot injuries isolated to the extraperitoneal rectum can be managed safely by laparoscopic exclusion of intraperitoneal missile penetration and diverting sigmoid loop colostomy, without laparotomy, distal rectal washout or presacral drainage     

Rectal perforations. Personal experience and literature review

BACKGROUND: Rectal perforation presents high morbidity and mortality and its treatment is still not standardized, it is still rather based on the surgeon's personal experience. This retrospective trial, with a literature review, aims to define these types of lesions, and tries to identify the diagnostic and therapeutic options able to reduce related morbidity and mortality. METHODS: On 1175 operations conducted for colo-rectal emergency, over a ten-year period at our institution, fourteen consecutive patients (1.2%) were seen and treated for rectal perforation. In 43% of cases the treatment consisted in Hartmann's procedure, in the 28.5% ones in rectal wound repair with diverting colostomy and in 28.5% left in diverting colostomy alone. RESULTS: There were no postoperative complications in 86% of patients, and no deaths from sepsis. In 28.5% of cases intestinal continuity was restored at our institution. CONCLUSIONS: Our results demonstrate that a standardized protocol which is based on patients' conditions, type and degree of rectal injury and of peritonitis, must be followed in order to determine the type of surgical option and consequently to reduce the morbidity and mortality related to rectal perforation.     

Laparoscopic [correction of laproscopic] management of rectal injury during laparoscopic [correction of laproscopic] radical prostatectomy

PURPOSE: Rectal injury is a potential complication of radical prostatectomy. Because laparoscopic radical prostatectomy is still a challenging procedure, we review the incidence and management of rectal injury in 1,000 cases of consecutive laparoscopic radical prostatectomy performed at our institution. MATERIALS AND METHODS: Of the first 1,000 laparoscopic transperitoneal radical prostatectomies performed between January 1998 and April 2002, 13 (1.3%) were complicated by rectal injury. Mean patient age was 66.5 years (range 58 to 76) and mean prostate specific antigen was 12.9 ng./ml. (range 2.9 to 26). Clinical stage was T1c, T2a and T2b in 5, 7 and 1 patient, respectively. Mean preoperative Gleason score was 5.8 (range 3 to 8). Once recognized the rectal defect was closed laparoscopically in 2 layers and tested for the absence of leakage. Broad-spectrum intravenous antibiotics were given for 7 days. Oral liquids were started the day after surgery with a low residue diet, and a regular diet was started on postoperative day 5. Healing of the vesicourethral anastomosis was confirmed by voiding cystourethrogram on postoperative day 5. RESULTS: All patients underwent a non-nerve sparing procedure except 1 in whom unilateral neurovascular bundle preservation was done. Of 13 injuries 11 were diagnosed and repaired intraoperatively, and 2 were diagnosed postoperatively. Of the 11 cases of intraoperative diagnosis and repair 9 healed primarily without colostomy and peritonitis was diagnosed in the remaining 2 on days 3 and 4, respectively. Of the latter 2 patients 1 required repair of a small rectal defect without colostomy while the other required colostomy. Colostomy was performed in the 2 patients with delayed diagnosis on days 3 and 4 but even then a rectourethral fistula developed in 1, necessitating secondary repair. Average urethral catheterization time was 8.6 days for the 9 patients with an uneventful immediate postoperative course and mean hospital stay was 6.8 days. For the remaining 4 patients urethral catheterization duration was 12, 13, 15 and 120 days, and hospital stay was 7, 16, 21 and 27 days, respectively. There was no perioperative mortality. CONCLUSIONS: Rectal injury during laparoscopic radical prostatectomy requires meticulous intraoperative repair in 2 layers, which allows primary healing without diversion colostomy. For injury prevention scrupulous attention is required during non-nerve sparing radical prostatectomy, particularly at the posterior surface of the prostatic apex.     

Results of the double stapling procedure in colorectal surgery

In this report we review our results with the double stapling technique (DST) in 162 patients with colorectal diseases in an attempt to identify some of the potential pitfalls of this new technique. Among these 162 patients, there were 125 patients with colorectal cancer, 25 with chronic ulcerative colitis (UC), 9 with familial adenomatous polyposis (FAP), 2 with adult Hirschsprung's disease, and 1 with sigmoid colon fistula. A total of 46 anastomoses (28 for rectal cancer, 13 for UC, 3 for FAP, and 2 for adult Hirschsprung's disease) were performed at or near the dentate line. Of these, 10 had protective diverting colostomy or ileostomy. The results showed that 6 patients with rectal cancer had anastomotic leakage (3.7%); however, 4 of the 6 patients had also received preoperative irradiation. All the leaks healed after the patients had undergone diverting colostomy, but 7 patients with rectal cancer suffered from neurogenic bladder postoperatively (4.3%). Wound infection occurred in 4 patients (2.5%), anastomotic bleeding in 3 (1.9%), and anal pain in 1 (0.6%), respectively. One patient with rectal cancer and multiple liver metastases died of disseminated intravascular coagulation (DIC). These results thus suggest that the double stapling technique provides a safe anastomosis at or near the dentate line not only for rectal cancer but also for UC, FAP, and adult Hirschsprung's disease.     

Primary Anastomosis and Diverting Colostomy in Diffuse Diverticular Peritonitis

Background: Despite the well documented morbidity associated with its reversal, Hartmann’s procedure remains the favoured option in patients with complicated diverticular disease in the presence of diffuse peritonitis. A prospective study was conducted to determine whether primary anastomosis with diverting colostomy constitutes a valid alternative to the Hartmann procedure.

Methods: Between 1994 and 1998, all patients with diffuse peritonitis due to perforated diverticulitis of sigmoid origin underwent resection and primary anastomosis with diverting colostomy. Restoration of colonic continuity was programmed six weeks later, after verification of the anastomose by gastrograffin enema. The group included 5 men and 15 women with a mean age of 72 years (32-97 years). The ASA classification of the patients was as follows: ASA II (n = 2), ASA III (n = 12), ASA IV (n = 3), ASA V (n = 3). The mean delay between onset of symptoms and surgery was 74 hours (8–215 hours).

Results: Operative mortality and morbidity was 15% (n = 3) and 50% respectively. No patients showed signs of suture disruption and this was confirmed by routine radiological controls of the anastomoses. Mean length of hospitalization was 20 ± 10 days (SD; median: 18 days). Closure of the colostomy using a small peristomal incision was performed in all surviving patients after a mean delay of 45 ±9 days (range 28-67 days). Mean length of hospitalization for colostomy closure was 7 ±3 days (range 3-18 days) without mortality.

Conclusions: Applied systematically to all patients with diffuse peritonitis due to perforated diverticular disease, primary anastomosis was found to be as safe as the Hartmann procedure but appears to be superior in terms of total length of hospital stay, interval to stoma closure and rates of stoma closure. Primary anastomosis with diverting colostomy could constitute a valid alternative to the Hartmann procedure in selected patients with complicated diverticular disease, even in the presence of diffuse peritonitis.     

Loop Ileostomy versus Loop Colostomy for Defunctioning Low Anastomoses during Rectal Cancer Surgery

Several studies have compared loop ileostomy with loop colostomy to defunction colorectal anastomoses. The discordant results may be due to the heterogeneity of the indications. We therefore performed a retrospective study to compare the two procedures in a homogeneous group of patients operated on electively for rectal cancer. Among 462 consecutive patients undergoing rectal resection for cancer during 1986–1998, 60 had a loop colostomy and 107 a loop ileostomy to defunction a low anastomosis. The two groups were similar with respect to age, gender, obesity, tumor stage, and duration before closure (109 vs. 104 days; p= 0.28). All the stoma-related complications that occurred after construction and after closure of the stoma were recorded. There were no stoma-related deaths in the two groups. After stoma construction, the morbidity rate was significantly higher following loop colostomy than after loop ileostomy (35% vs. 19%; p= 0.02). After stoma closure the complication rate was significantly higher in the colostomy group than in the ileostomy group (34% vs. 12%; p= 0.004). The risk of surgical reintervention related to the morbidity of both construction and closure of the stoma was twice as high after loop colostomy than after loop ileostomy (22% vs. 9%; p= 0.03). The results of this study showed that, in our experience, the overall stoma-related morbidity and risk of reoperation were significantly lower after loop ileostomy than after loop colostomy. This suggests that loop ileostomy is the best procedure for defunctioning colorectal anastomoses electively. We therefore recommend using a loop ileostomy during rectal cancer surgery.     

Radio-contrast imaging of the rectum prior to colostomy closure for rectal trauma--is routine use still justified?

This retrospective study was undertaken to assess the yield of radio-contrast imaging of the rectum before closure of colostomy following extraperitoneal rectal trauma. Sixty-nine patients (63 males) underwent colostomy closure in 36 months. All radio-contrast studies (colograms) performed before closure of colostomy were normal, and there were no deaths following closure. This study demonstrated that the yield from pre-closure radio-contrast imaging of the rectum after rectal trauma was negligible and did not influence colostomy closure. We conclude that while it may be appealing to suggest abandonment of its routine use, this investigation needs to be further evaluated prospectively with special attention given to injury to associated structures such as bone, bladder and vagina.     

Diverting colostomy increases anastomotic leakage in the rat colon

In the present study, we examined the effect of a diverting colostomy on the intestinal healing of colonic anastomosis in the rat. For this purpose, we created a colonic stenosis 2 days prior to the formation of a distal one-layer end-to-end anastomosis with or without a proximal double-barreled deviation colostomy in the rats. Radiological examination of anastomotic leakage was performed daily for 4 days and on day 7 after the operation. We found that anastomotic leakage was markedly increased in rats with a diverting colostomy compared to control animals; i.e. the leakage index (percentage of days with leakage during the experimental period) in colostomy rats was 29%, whereas in animals with no colostomy, the leakage index was only 7%. Interestingly, it was observed that anastomosis formation was associated with a higher mortality rate in rats with colostomy diversion (36%) compared to control animals (7%). However, there was no difference in suture holding capacity on day 7. Moreover, body weight decreased significantly in the colostomy group compared to rats without surgical defunctioning when followed for up to 7 days after surgery. Taken together, our novel findings suggest that a diverting colostomy may increase intestinal leakage after anastomosis formation in the rat colon. Thus, the role of proximal colostomy in the protection of colorectal anastomosis needs to be reevaluated and further investigations are required to resolve the influence of surgical defunctioning on intestinal healing.     

Perforating wounds of the colon and rectum

In summary, in this last group of ninety-five cases there were thirty-six double barrel spur colostomies, fifty-five loop colostomies and four cecostomies. No instance of spreading peritonitis was seen after closure of the loop colostomy even though all were replaced in the free peritoneal cavity. No complications were associated with the clamping of the spur in the thirty-six double barrel spur colostomies. No patient required a secondary cecostomy following the closure of his colostomy, although in several patients with a loop colostomy on the left side, it was four to five days following closure before they were able to pass gas by rectum.Eleven patients in this group were evacuated to the United States with their colostomies not closed. Seven of these patients had rectal wounds which were not healed five to six weeks following their injury. The other four were evacuated early because of an especial need for hospital beds at the time, and each had associated injuries or complications which made closure of their colostomies a secondary matter.There were no fatalities in the first group of patients. In the second group there were four fatalities. One patient died suddenly shortly after admission from an exsanguinating hemorrhage due to a divided gastroduodenal artery which had been overlooked at the time the perforation in his duodenum had been repaired and the perforation in his hepatic flexure of the colon exteriorized. A second died seven weeks following his original injury from generalized peritonitis arising from a series of abscesses secondary to a retracted cecostomy. Two large abscesses in the right lumbar gutter were drained but a third gave rise to peritonitis from which he failed to recover. The third patient died from a pulmonary embolus following laparotomy for an intestinal obstruction ten days after his colostomy had been closed. The fourth patient died several weeks after his original injury from persistent suppuration in the retroperitoneal tissues. He failed to respond to penicillin, chemotherapy and drainage of the infected area.     

Civilian Extraperitoneal Rectal Gunshot Wounds: Surgical Management Made Simpler

Background Rectal injuries are associated with significant morbidity and mortality. Controversy persists regarding routine presacral drainage, distal rectal washout (DRW), and primary repair of extraperitoneal rectal injuries. This retrospective review was performed to determine the outcome of rectal injuries in an urban trauma center with a high incidence of penetrating trauma where a non-aggressive surgical approach to these injuries is practiced. Methods The records of all patients with a full-thickness penetrating rectal injury admitted to the Trauma Center at Groote Schuur Hospital over a 4-year period were reviewed. These were reviewed for demographics, injury mechanism and perioperative management, anatomical site of the rectal injury, associated intra-abdominal injuries and their management. Infectious complications and mortality were noted. Intraperitoneal rectal injuries were primarily repaired, with or without fecal diversion. Extraperitoneal rectal injuries were generally left untouched and a diverting colostomy was done. Presacral drainage and DRW were not routinely performed. Results Ninety-two patients with 118 rectal injuries [intraperitoneal (7), extraperitoneal (59), combined (26)] were identified. Only two extraperitoneal rectal injuries were repaired. None had presacral drainage. Eighty-six sigmoid loop colostomies were done. Two (2.2%) fistula, one rectocutaneous, and one rectovesical, were recorded. There were nine (9.9%) infectious complications: surgical site infection (4), buttock abscess (1), buttock necrosis (1), pubic ramus osteitis (1), septic arthritis (2). No perirectal sepsis occurred. Conclusions Extraperitoneal rectal injuries due to low-velocity trauma can be safely managed by fecal diversion alone.     

Colostomy and drainage for civilian rectal injuries: is that all?

One hundred consecutive patients with injuries to the extraperitoneal rectum were treated over a ten-year period at an urban trauma center. The mechanisms of injury included firearms in 82 patients, stab wounds in 3 patients, a variety of other penetrating injuries in 10 patients, and in 5 patients the injuries resulted from blunt trauma. Treatment of the rectal injury was determined by the bias of the operating surgeon, the condition of the patient, and the magnitude of the rectal injury. Proximal loop colostomies were performed in 44 patients, diverting colostomies in 51 patients, Hartmann's procedure in 4 patients, and an abdominoperineal resection in 1 patient. Extraperitoneal rectal perforations were closed in 21 patients and the rectum was irrigated free of feces in 46 patients. Transperineal, presacral drainage was used in 93 patients. Infectious complications potentially related to the management of the rectal wound occurred in 11 patients (11%) and included abdominal or pelvic abscesses (4 patients), wound infections (6 patients), rectocutaneous fistulas (3 patients), and missile tract infections (2 patients). Four patients (4%) died as a result of their injuries. Of the therapeutic options available, statistical analysis revealed that only the failure to drain the presacral space increased the likelihood of infectious complications (p = 0.03); however, as it could not be determined with certainty that the use of, or failure to use, any particular therapeutic option had an effect on the risk of death. It is concluded that colostomy and drainage are the foundations of the successful treatment of civilian injuries to the extraperitoneal rectum. The use of adjuncts such as diverting colostomies, repair of the rectal wound, and irrigation of the rectum has little effect on mortality and morbidity.     

Follow-up abdominal computed tomography after splenic trauma in children may not be necessary

Nonoperative management of splenic injuries in children is well accepted. However, the need for follow-up abdominal CT to document splenic healing has not been well studied. We retrospectively reviewed initial and follow-up abdominal CT examinations of pediatric patients admitted to our institution with documented splenic trauma who were managed nonoperatively. Eighty-four patients were admitted to our pediatric surgical service with splenic injury documented by CT from 1994 through 1998. The standard approach for splenic injury was bedrest for 5 to 21 days and limited activity for up to 90 days at the discretion of the attending surgeon. Thirty-five of the 84 had follow-up CTs during outpatient follow-up to evaluate and document splenic healing by CT criteria. The initial and follow-up studies were randomized and read blindly by pediatric radiologists using a modified American Association for the Surgery of Trauma grading system (I-V). The age range of the patients was 6 months to 17 years (mean +/- SE; 11 +/- 1 years). Nineteen (54%) were male and 16 (46%) were female. Causes of splenic trauma included motor vehicle accident (22), fall (seven), assault (four), pedestrian versus vehicle (one), and sports injury (one). Eight children (23%) had grade II injuries, 14 (40%) had grade III injuries, and 13 children (37%) had grade IV injuries on initial CT scan. Seven (88%) of the grade II splenic injuries were healed by 64 +/- 11 days. The remaining grade II injury had healed by 210 days. Thirteen (93%) of the grade III splenic injuries were healed by 76 +/- 7 days. The remaining grade III injury was healed by 140 days. Spleens in 10 (77%) of the 13 patients with grade IV injuries were healed by 81 +/- 8 days. Of the three remaining grade IV injuries two were healed by 173 +/- 14 days. The remaining patient's spleen was radiologically considered to have a grade III defect 91 days from the time of injury, and no further CTs were obtained. Of the 34 patients who underwent follow-up CT imaging until splenic healing was demonstrated the mean time to complete healing was 87 +/- 8 days postinjury (range 11-217 days). These data suggest that routine follow-up abdominal CTs may not be necessary to allow children to resume their normal activities after an appropriate time of restricted activity.     

Passagere Kolostomieanlagen nach Eingriffen am Colon Sigmoideum und Rektum—Sind Sie Noch Gerechtfertigt?

Primary anastomosis is increasingly favored even in emergency colorectal surgery. Two-stage procedures are frequently considered obsolete. The aim of this study is to define conditions when a two-staged operative strategy with a temporary colostomy is still appropriate. We analyzed a series of 126 patients who were treated by a colostomy following resection and subsequent closure of the colostomy. In 44 cases the primary operation was a Hartmann resection, in 39 cases a resection with colostomy and mucous fistula and in 43 cases a resection with primary anastomosis and proximal loop colostomy. Complications of diverticlar or neoplastic disease were generally managed by resection without primary anastomosis. Protective loop colostomy was done after low anterior resection of the rectum or in cases of anastomotic leakage. Patients were hospitalized again after an average of 6 months for closure of the colostomy. Restoration of intestinal continuity carried no significant risk of severe intra- or postoperative complications. Disturbances of wound healing occurred in 4.5% (Hartmann resection), 17.9% (colostomy and mucous fistula) and 20.9% (loop colostomy) of patients. We found an anastomotic dehiscence rate of 2.4% after discontinuity resections and of 4.7% after closure of loop colostomies. Only one patient with anastomotic leakage required surgical reintervention. The mortality after closure of a colostomy was zero. The rate of anastomotic leakage of 2.4% was lower than in published series with more than 7.2% after primary anastomosis, thus emphasizing the beneficial effect of a two-stage operative strategy. In emergency situations of sigmoidal and rectal surgery or in cases of low anastomosis of the distal rectum, unnecessary surgical complications can be avoided by resection without primary anastomosis or by performing protective loop colostomies.     

Indications and results of endoscopic rectal stenting

Self expandable metal stents (SEMS) are a useful option to diverting colostomy for the palliation of malignant rectal obstruction. SEMS can be successfully placed in approximately 90% of cases with acceptable complication rates. Covered SEMS allow closure of malignant rectovaginal and rectovesical fistulae associated with rectal obstruction. The main drawback to these devices is the inability to palliate bleeding.     

Factors influencing perineal wound healing after proctectomy

The hospital and office records of 86 patients who underwent proctectomy for cancer of inflammatory bowel disease with primary closure of the perineal wound were reviewed. Almost one fourth of all patients suffered a significant perineal wound complication, the majority of which were infections. The incidence of postoperative perineal wound complications was comparable in both groups of patients. Urinary retention occurred in 24 percent of patients who underwent abdominoperineal resection or rectal cancer, and half of these patients required transurethral resection which indicates the need for more thorough preoperative assessment of bladder function, especially in older men. The development of leg ischemia that resulted in amputation in two elderly patients who had preoperative evidence of obstructive peripheral vascular disease suggests that a synchronous two-team abdominoperineal resection with the patient in the modified lithotomy position for a prolonged period should be avoided. One third of all patients were discharged less than 10 days after surgery and two thirds within 2 weeks. Prolonged stays were more frequent in cancer patients and appeared to be related to age rather than to the development of postoperative complications. The perineal wound after abdominoperineal resection for cancer healed more rapidly and more completely than did the wound after proctectomy for inflammatory bowel disease. Fourteen percent of the inflammatory bowel disease patients did not have a healed wound 1 year after surgery. The extent of rectal cancer as determined by Duke's classification played no role in healing of the perineal wound, but women with rectal cancer healed at a slower rate than did men. The location of the exit site for wound catheters and the use of cautery and preoperative steroid therapy appeared too have no effect on the healing of the perineal wound.