Factors influencing the morbidity of colostomy closure

In a series of 80 colostomy closures, a total complication rate of 26 per cent was found, with a wound infection rate of 14 per cent and an anastomotic leak rate of four per cent. Patients having preoperative systemic antibiotics had fewer wound infections than those who did not (eight per cent versus 19 per cent). Delayed primary skin closure or closure by secondary intention was associated with less wound morbidity than was primary closure (ten per cent versus 17 per cent). However, the use of preoperative systemic antibiotics decreased the incidence of wound infection in those having primary skin closure (five per cent versus 27 per cent). Patients having diverticular disease had more wound infections (40 per cent) and greater overall morbidity (70 per cent). Older patients had a higher incidence of complications (24 per cent if less than 40 years and 45 per cent if greater than 50 years). Closure of left-sided colostomies was associated with a higher infectious complication rate (26 per cent versus 13 per cent). The time interval to colostomy closure was found to alter subsequent morbidity with a waiting period of one to two months associated with zero complications.     

Early local complications following colostomy closure in cancer patients

Early surgical complications following colostomy closure in 65 cancer patients operated on at the Istituto Nazionale Tumori of Milan were evaluated retrospectively. The overall complication rate was 24.6 per cent, including infections (13.8 per cent), fistulas (6.1 per cent), wound dehiscence (3.0 per cent), and distal stenosis (1.5 per cent). Type and rate of complications were analyzed to find a correlation with type, site, and location of colostomy, technique of closure, presence or absence of drains, or time interval between construction and closure of colostomy. No statistically significant association between the aforementioned factors and occurrence and rate of complications was found. The authors think, therefore, that surgical attention, including meticulous manipulation of the stoma, avoidance of contamination of the wound, tension of sutures, dead spaces, and collection of blood in the wound, and use of antibiotics and antiseptics are the most important principles to minimize postoperative complications.     

Colostomies—indications and contraindications: Lehey clinic experience, 1963–1974

Summary and Conclusions Over a 12-year period, 276 temporary colostomies were performed on 271 patients. During this interval 118 colostomies were closed. The morbidity rate of colostomy construction was 21 per cent, and for closure it was 49.1 per cent. No definite factor could be identified as contributing to this high rate of complications for colostomy construction. With respect to colostomy closure, predisposing factors that seemed to increase morbidity were shorter interval between creation and closure of the stoma and resection of colostomy (as opposed to closure without resection). Intra-abdominal drains were associated with a prohibitively high rate of wound infection, although subcutaneous drainage was not successful in reducing the incidence of infection significantly. Read at the annual meeting of the Americal Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 12, 1977.     

Closure of colostomy—A safe procedure?

Summary A retrospective survey of a series of 73 patients undergoing closure of colostomy has been carried out. Closure was complicated in 37.8 per cent of cases, and fecal fistulas occurred in 17.6 per cent. The overall mortality rate of the procedure was 2.7 per cent. The underlying disease (carcinoma or diverticulitis) did not influence the complication rate. Furthermore, intraperitoneal and extraperitoneal methods of closure appeared equally satisfactory. Closure of colostomy within a month of construction was associated with an unacceptably high incidence of fecal fistula of 33 per cent.     

A method and the results of loop colostomy

A technique of loop colostomy which avoids a sutured skin wound, employs a deep tension suture with retained polythene sleeve as a bridge, and permits routine use of standard terminal colostomy appliances is described. The clinical results in 51 patients are reported and the advantages of this method of construction discussed. All patients were able to use standard, terminal colostomy appliances routinely from the time of construction. There were no immediate postoperative complications. Delayed complications occurred in 5 (10 per cent) patients. Intraperitoneal closure was performed in 43 patients and was complicated by 1 (2.3 per cent) transient fecal leak and 4 (9.3 per cent) would infections. The absence of a sutured skin wound, the small bridge size, and the circular shape of the stoma facilitate use of accurately fitting, standard terminal colostomy appliances rather than the usual loop colostomy apparatus. This results in an improved skin seal, reduced fecal leakage, easier nursing and stoma care, and better patient morale.     

Rectal-tube decompression in left colectomy

Summary A series of 392 patients undergoing anterior resection, in each of whom an indwelling rectal tube was used for anastomotic decompression, was reviewed. Anastomotic complications occurred in 3.8 per cent. Five patients (1.3 per cent) died postoperatively, but only one death resulted from anastomotic leak and sepsis. The need for concomitant colostomy was reduced to 3.8 per cent, obviating the morbidity and potential mortality associated with a colostomy and its subsequent closure. Use of a rectal tube facilitated colostomy closure at the time of resection in five of seven patients who had obstruction, making later colostomy closure unnecessary. The low incidence of anastomotic recurrence (1 per cent) and suture line stenosis (0.5 per cent) demonstrates that an indwelling rectal tube does not predispose to these two complications. Anastomotic dehiscence is the primary cause of morbidity and mortality associated with surgical procedures involving the left colon. To minimize anastomotic complications, the surgeon must obtain a water-tight anastomosis, without tension, using healthy bowel with a good vascular supply. The use of an indwelling rectal tube is no substitute for fulfillment of basic surgical requirements, but it assures an adequate lumen, reduces suture-line tension, protects blood supply, and provides a means for local antibiotic irrigation. Read at the meeting of the American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 12, 1977.     

Morbidity reduction employing a semi-standardized protocol

To evaluate a semi-standardized protocol for colostomy closure, the cases of 166 consecutive patients from 1974 through 1981 were analyzed retrospectively. There were 17 complications (17/166); overall morbidity rate was 2.4 per cent. A significantly increased incidence of major morbidity and septic complications was associated with colostomies closed at an interval of less than 8.5 weeks from formation (P≤0.001). Simple transverse closure of colostomy versus resection and end-to-end anastomosis did not result in increased morbidity (P≤0.1). The wound infection rate was 1.2 per cent (2/166) with 135/166 wounds closed primarily, or primarily over a subcutaneous drain, thus rendering primary wound closure safe and desirable Read at the annual meeting of the Southern Medical Association, Atlanta, Georgia, October 30, 1982.     

Transverse colostomy in the management of cancer of the colon

Summary The indications, time factors, results and complications of the transverse colostomy when used at some time in the course of management of 45 patients with cancer of the large bowel are reviewed. The transverse colostomy is safe and effective for decompression, but when it was needed to alleviate acute obstruction only approximately half of the patients subsequently completed the three staged procedures. An average of 94 days was required for completion of the staged operations. Significant complications are associated with closure of the transverse colostomy. The survival rate in 45 patients with cancer of the colon who had transverse colostomies was extremely poor—8.8 per cent survived five years. Colostomy closure was not achieved in 42 per cent of the patients. It is suggested that when possible, reconsideration be given to Mikulicz resection for management of obstructing lesions of the proximal colon. When a transverse colostomy has been established to alleviate obstruction closure at the time of resection would be desirable, in view of the poor prognosis for these patients and in order to decrease hospitalization and the need for a further major surgical procedure, with its attendant risks and expense.     

The morbidity and mortality of colostomy closure

Summary Retrospective analysis was done of 304 patients who underwent colostomy closure at Henry Ford Hospital between 1967 and 1977. A mortality of less than 0.3 per cent and a morbidity rate of 14 per cent, with an average hospital stay of 15 days, is hereby reported. Wound infection was the most common complication with an incidence of 9.5 per cent. Late complications during the study period were less than 3 per cent. In our experience, if the intraperitoneal closure technique with resection and anastomosis is used, colostomy closure can be a safe procedure with minimal mortality and morbidity. We believe colostomy closure should be considered as nothing less than a major colonic resection.     

Healing of the perineal wound after proctectomy for nonmalignant conditions

A series of 62 patients was studied as regards healing of the perineal wound after proctectomy; 23 patients suffered from ulcerative colitis, 25 from Crohn's colitis, and 14 from polyposis coli. The overall results were in keeping with data from the literature: 73.9 per cent of wounds in patients with ulcerative colitis and 60 per cent of wounds in patients with Crohn's colitis were healed at six months. The worst results were obtained with packing of the perineal wound, especially in inflammatory bowel disease: 61 per cent of those wounds were not healed at six months. Superior results were obtained with conservative surgery, consisting of perirectal excision and intersphincteric resection. With this technique perineal wounds were not healed at six months in 13.6 per cent of patients with inflammatory bowel disease. In the treatment of persistent sinuses after proctectomy, curettage proved disappointing. Better results were obtained with excision of the sinus tract and primary closure of the resulting wound.     

Proximal fecal diversion: Review of ten years' experience

In a retrospective study, the clinical course of 250 patients subjected to 257 transverse colostomies was reviewed in an effort to evaluate the problems associated with proximal fecal diversion. Morbidity following stomal construction was 28 per cent, with a significant increase when performed in infants or as an emergency. Two-thirds of the colostomies were emergencies, chiefly due to obstruction and free perforation which was associated with a mortality rate of 12 and 48 per cent respectively. In 102 patients undergoing definite colorectal resection with a previous or simultaneous transverse colostomy, the overall morbidity rate was 58 per cent including a leakage rate of 22.5 per cent. Despite a proximal defunctioning colostomy, surgical intervention was required in 12.7 per cent with a fatal outcome due to peritonitis in 3.9 per cent. Colostomy closure was associated with a morbidity rate of 57 per cent, comprising a leakage rate of 10 per cent and a mortality rate of 1.7 per cent. Apart from incurable cancer and deaths prior to closure every third patient kept the transverse colostomy permanently. Advanced age and poor condition of patients not proceeding to a definite treatment, or an underlying benign lesion were the three most determining factors. The present results indicate a too extensive use of transverse colostomy, emphasizing the need for a circumspect initial selection of patients for diversionary procedures.     

Morbidity and mortality following intraperitoneal closure of transverse loop colostomy

A retrospective analysis of 153 patients having intraperitoneal closure of transverse loop colostomies was performed. The mortality was 1.4 per cent. The morbidity rate was 15 per cent, including 7 per cent wound infections and 5.2 per cent fecal fistulas. The incidence of wound infection was not significantly improved by the use of systemic or nonabsorbable intestinal antibiotics. Intraperitoneal drainage alone or in combination with subcutaneous drainage resulted in the highest rate of wound infection. However, the use of intraperitoneal drains seems justified for the control of fecal fistula if it should occur. The lowest incidence of complication was noted when colostomies were closed in 2–4 months. Particular attention must be given to cases with diverticulitis as these have a greater morbidity. Factors which reduce morbidity appear to be directly related to clean and careful dissection of the bowel with a sound technique of anastomosis.     

Survival in acute obstructing colorectal carcinoma

Acute intestinal obstruction was the presenting feature in 124 (19 per cent) of 646 patients with colorectal carcinoma seen over a six-year period. Forty-two per cent of tumors were incurable at presentation. Obstruction was complicated by perforation in 22 patients (18 per cent). Only 15 per cent of tumors occurred in the rectum. Although the postoperative mortality rate was higher in patients with coincidental perforation than in those without (52 vs. 26 per cent:P=0.03), five-year survival rates were the same: 18 per cent overall, rising to 29 to 34 per cent after “curative” resection. Five-year survival rates were best for right colon tumors and worst for rectal tumors (36 vs. 5 per cent:P=0.01). The overall hospital mortality rates for colostomy and delayed resection, resection with colostomy, and resection with anastomosis were equivalent (18 to 22 per cent), but following “curative” resection the hospital mortality rate was higher for resection with colostomy than with other treatments (29 vs. 15 per cent), since two patients died following early colosure of colostomy. Five-year survival was better following resection with anastomosis (48 per cent) than staged procedures (18 per cent:P=0.01), since two patients died following late closure of colostomy.     

Management of perineal wounds after proctocolectomy: A retrospective study of 50 cases in which treatment by the open technique was used

Conclusion A series of 50 patients with proctectomy had the perineal wound treated by the open technique following closure of the pelvic peritoneum. Sound wound healing was achieved in 78 per cent of patients within four months and in 96 per cent of patients within six months after operation. The open technique is especially advisable in cases of large, low-lying or squamous tumors, and in the presence of fecal contamination or extensive involvement of the perineum by inflammatory disease. Read at the meeting of the American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 12, 1977.     

Sexual function and perineal wound healing after intersphincteric excision of the rectum for inflammatory bowel disease

The technique of intersphincteric excision of the rectum in patients with inflammatory bowel disease was introduced with the aim of avoiding postoperative sexual dysfunction and, combined with primary perineal suture, should decrease morbidity from delayed perineal wound healing. In a series of 98 patients so treated at St. Mark's Hospital, permanent sexual dysfunction from sympathetic nerve damage occurred in one male patient among 23 aged 60 years or less assessed postoperatively. No patient exhibited evidence of permanent parasympathetic nerve damage. Primary healing of the perineal wound was successful in 50 per cent of the cases and in 69 per cent the wound healed within three months of operation. It is suggested that this combination of operative techniques significantly decreases morbidity from rectal excision compared with more extensive procedures and should be more widely adopted.     

Colostomy closure promotes cell proliferation and dimethylhydrazine-induced carcinogenesis in rat distal colon

The influence of adaptive cell proliferation on colonic carcinogenesis was studied in male Fischer rats with a defunctioning transverse colostomy that was closed 4 wk later. Control observations were made in other rats after colonic transection, repeated at 4 wk, after laparotomy alone, or after permanent colostomy. Tumors were induced by 1,2-dimethylhydrazine (total dose, 300 mg/kg) over 11 wk, starting 2 days after the second operation. After creation of the colostomy, amounts of protein, RNA, and DNA in the distal colon halved in 4 wk (p less than 0.001), but returned to normal 7 days after restoration of colonic continuity. This reactive hyperplasia promoted the development of distal colonic carcinomas, as compared with rats having repeated transection of the bowel (incidence 32% vs. 6%; p less than 0.03). Although the amounts of protein and nucleic acid in the proximal colon were unchanged by transverse colostomy, values increased by 18%-59% 4 wk after colostomy closure (p = 0.05-0.002); nonetheless, the yield of tumors in this segment was unaltered. Suture-line cancers were commoner after repeat transection than after colostomy closure (76% vs. 39%; p less than 0.01). These data confirm the promotional effect of increased cell proliferation on intestinal carcinogenesis.     

Ogilvie's syndrome (acute colonic pseudo-obstruction):

Four additional cases of Ogilvie's syndrome (acute colonic pseudo-obstruction), representing the first cases described in Italy, are reported. The medical literature concerning the subject is also thoroughly reviewed. Ogilvie's syndrome is an acute massive dilatation of the large bowel without organic obstruction of the distal colon. Three hundred and fifty-one cases have been described in the literature to date. Eighty-eight per cent of cases were associated with various extracolonic affections (metabolic and organ dysfunctions, postoperative and posttraumatic states, etc.). Twelve per cent of cases were not associated with known disorders and were defined as idiopathic. The pathophysiology of the syndrome is still unknown. Ogilvie, who first described the syndrome in 1948, suggested an imbalance between the sympathetic and parasym-pathetic innervation of the colon: this neurogenic hypothesis has been shared by other authors, although explanations may differ slightly. The clinical and radiologic picture closely resembles mechanical obstruction of the large bowel. The most marked dilatation usually takes place in the right colon and cecum: if the distended cecum reaches a diameter larger than 9 to 12 cm, perforation is likely to occur; if perforation occurs, the mortality rate incrases from 25 to 31 per cent to about 43 to 46 per cent. If conservative management fails to control the dilatation and cecal rupture is impending or suspected emergency surgery is indicated, the surgical procedure of choice is dictated by the general conditions of the patient as well as by the intestinal findings: operation may consist of cecostomy, colostomy, or right hemicolectomy or simply emptying the bowel.     

Treatment of diverticulitis of the large intestine and its complications

Summary and Conclusions There is no intra-abdominal surgical condition requiring more judgment concerning the indications for definitive surgery or the management of acute complications than diverticulitis. It is my feeling from observing the service cases in hospitals with which I am associated that more errors are made by doing too much than too little during the surgical procedure. This applies to the acute emergencies and also to the elective operations. Patients with free perforation or abscess formation from acute diverticulitis rarely, if ever, need a proximal colostomy. In the 27 cases in this series, there was a mortality rate of 7.5 per cent after simple closure of the performation and drainage. In patients with fistula formation or complete obstruction, it is essential that a proximal colostomy be performed before definitive surgery. In most patients needing definitive surgery for diverticulitis and in many instances in partial obstruction from acute diverticulitis, a one-stage operation can be performed without a proximal colostomy. Massive hemorrhage was a most unusual complication in this group of patients and presented no surgical problem. Read at the meeting of the American Proctologic Society, Atlantic City, New Jersey, June 15 to 17, 1959.     

Audit of sepsis in operations for inflammatory bowel disease

We report the results of a prospective audit of the rates of postoperative infection in patients having operations for inflammatory bowel disease. Apart from a single prospective controlled trial, all other groups have been studied sequentially using the original placebo control group for comparison. The rate of abdominal wound sepsis when no antibiotic was used was 37 per cent. This was reduced to 23.3 per cent with 24-hour cover using metronidazole and gentamicin. However, only after prolonged use of metronidazole and gentamicin for five days was there a significant reduction in abdominal wound infections to 13.3 per cent. Prophylaxis, using 24-hour cover with metronidazole combined with five-day therapy with mezlocillin, achieved an abdominal wound infection rate of 15.6 per cent. The most recent group of patients studied have received 24-hour cover with metronidazole and five-day exposure to latamoxef. In the last group the rate of abdominal wound infections was only 13.5 per cent and serious postoperative bleeding was recorded in eight patients (15 per cent) compared with serious bleeding in only three of the remaining 129 patients (2.3 per cent). The only patients in whom streptococcal isolates were eliminated were those receiving metronidazole and mezlocillin. The majority of infections was due to antibiotic-sensitive strains ofEscherichia coli. Proteus, andStaphylococcus species.     

Healing of a left colon anastomosis after early colostomy closure

The healing of a standardized left colon anastomosis after early (7 days) closure of a concomitant proximal diverting colostomy was studied experimentally. Early closure of the diverting colostomy could be conducted safely by an intraperitoneal technique and the healing of the primary anastomosis was uncomplicated. Colostomy closure in the proliferative phase of wound healing resulted in development of anastomotic strength similar to colonic healing without faecal diversion. The anastomotic strength had doubled after three weeks. As compared to colostomy closure in the remodelling phase of anastomotic healing development of anastomotic strength was more rapid and without serious local complications.