Influence of proximal colostomy on the healing of a left colon anastomosis: an experimental study in the rat

The healing of an experimental left colon anastomosis protected by a proximal diverting colostomy was studied in the rat. Collagen synthesis in the anastomotic area was measured by incorporation of [3H]proline. With a defunctioning proximal colostomy, the synthesis and accumulation of collagen in the anastomosis was diminished, and the anastomotic strength development delayed and reduced. The development of anastomotic strength seems to proceed according to the level of strain from intraluminal bulk. As the healing of the anastomosis protected by a diverting colostomy was uncomplicated, these findings should not contra-indicate the use of diverting colostomy.     

The effect of relative bowel rest on healing of colonic anastomoses. Breaking strength and collagen in the colonic wall following left colon resection and anastomosis in the rat

The breaking strength of anastomoses in the left colon in the early phase of healing was studied in rats fed low residue diet (Biosorbin MCT) and the results were compared to those from rats fed standard laboratory diet. Further, eventual correlation between mechanical strength development and collagen content in the colonic wall around the anastomosis was evaluated. The anastomotic strength with sutures in place decreased by approximately 30% of the immediate postoperative value during the first two days in both groups of animals. There was no correlation between changes in anastomotic strength and collagen content at that time. After the second day there was a gradual increase of anastomotic strength, reaching the strength at day 0 after 7 days. The regain of strength was mainly due to collagen deposition in the anastomosis. Despite more collagen deposition in animals on standard laboratory diet the anastomoses had comparable strength development in the two groups. It was concluded that low residue diet does not impair the suture holding capacity or the anastomotic strength. Instead there was some evidence for a more uncomplicated healing when the bowel content was diminished.     

Effects of pneumoperitoneum with or without colostomy on rat colonic anastomotic healing

Background: Elevated intra‐abdominal pressure and colostomy have adverse effects on colonic anastomoses. The aim of the present study was to investigate the effects of laparoscopic colon surgery with and without diverting colostomy on healing of colonic anastomoses in an experimental model. Methods: Thirty‐six male rats were divided into three equal groups: group 1, control (colonic anastomosis and anaesthesia for 180 min only); group 2, 180 min pneumoperitoneum and colonic anastomosis; and group 3, similar to group 2 with a proximal colostomy. On day 7, bursting pressures, tissue hydroxyproline and nitric oxide concentrations and histopathological inflammation scores were determined and compared. Results: Mean bursting pressures were higher in the control group than the two pneumoperitoneum groups (P = 0.0003). Mean tissue hydroxyproline concentrations showed no difference (P > 0.05). Mean tissue nitric oxide concentrations were significantly increased in the control group (P = 0.0013). Histopathological scores demonstrated increased inflammatory response in group 3 compared to the controls (P = 0.0009). Conclusion: Pneumoperitoneum delays collagen maturation and impairs anastomotic strength in the colon. Following pneumoperitoneum, performance of a diverting loop colostomy to protect the anastomosis will not have additional detrimental effects on anastomotic healing.     

Influence of intraperitoneal Escherichia coli with septicemia on the healing of colonic anastomoses and skin wounds. An experimental study in the rat

In rats a standardized left colonic resection was performed and colonic continuity restored by an end-to-end anastomosis in one layer. The rats were subjected to an LD50 septic challenge by intraperitoneal injection of live Escherichia coli pre- or postoperatively. Controls received saline in a corresponding manner. Groups of animals were sacrificed on the 3rd or 7th postoperative day. The breaking strengths of the anastomosis and of the skin wound were measured. The collagen content of the anastomotic segments was analyzed. There were no differences in anastomotic or skin wound strength between septic animals and controls. Collagen content was unaffected. Wound healing was not influenced by sepsis in this model.     

Healing of experimental colonic anastomoses. II. Breaking strength of the colon after left colon resection and anastomosis.

Mechanical strength of the left colon with anastomosis and the intact transverse colon was studied by breaking strength tests performed from four to twenty-eight days after standardized left colon resection in the rat. Two different single layer inverting suture technics were used, continuous and interrupted.Breaking strength of the colon in unoperated rats paralleled to a certain extent the collagen concentration of the colonic wall, with highest values of strength in the left colon where collagen concentration is highest.Both types of anastomoses showed a rapid and equal gain in strength between days 4 and 10, after which time the increase in strength occurred at a much slower rate. After ten days the anastomosis had gained approximately 50 per cent of the strength of the left colon in unoperated control rats. Four weeks after the operation the anastomoses made of continuous suture had reached 75 per cent of normal breaking strength and were significantly stronger than those made of interrupted sutures, which had gained only about 55 per cent of normal strength.Breaking strength test measured the strength of the anastomosis throughout the four week period of investigation, since the rupture always occurred in the anastomotic line.Breaking strength determinations of the intact transverse colon did not show any alterations from normal during the healing course as did determinations of bursting strength reported in a previous study.In skin wounds breaking strength showed a constant development of strength during the four week investigation period, while the gain in strength of the anastomosis slowed down after ten days, although it had only reached 50 per cent of normal.     

Healing of experimental colonic anastomoses. The effect of suture technic on collagen concentration in the colonic wall.

The present experimental study in rats has demonstrated a marked difference in the healing process of anastomoses in the left colon following two different suture technics: continuous and interrupted sutures. Rats having anastomoses constructed of continuous suture showed a high incidence of complications and a marked decrease of collagen concentration in the anastomosis and in the colonic wall proximal to the anastomosis during the first week of healing. In animals with anastomoses made of interrupted sutures there were fewer complications, the decrease in collagen concentration was confined to the anastomotic region, and the recovery of collagen concentration occurred earlier. The findings indicate that the interrupted suture technic is preferable for anastomosis in the left colon.     

Colonic resection in trauma: colostomy versus anastomosis

OBJECTIVES: The management of colonic trauma is well established for simple injuries with primary repair, and ileocolostomy for right-sided injuries that undergo colonic resection. Segmental colon resection for injuries to the left colon can be managed with either an end colostomy or primary anastomosis. A retrospective review was performed to evaluate the outcome and complications associated with colonic resection for trauma to determine the risk factors associated with anastomotic leakage. METHODS: A retrospective review included patients undergoing colonic resection for trauma. The patients were stratified into colostomy, ileocolostomy, and colocolostomy groups. Patient demographics and colon-related complications were collected. Comparison between the colostomy and colocolostomy groups was performed to determine the difference in outcome. The outcome of right-sided colon injuries managed by either an ileocolonic or colocolonic anastomosis was compared. Analysis was performed to identify the factors associated with an increased risk of anastomotic leakage. RESULTS: One hundred forty patients over a 66-month period were included in the analysis. Overall, 41% (57 of 140) of patients developed a colon-related complication; 28% (39 of 140) of patients developed an abscess. Overall, the anastomotic leak rate was 13% (7 of 56) in the colocolostomy group, 4% (2 of 56) in the ileocolostomy group. Right-sided colon injuries managed with a colocolonic anastomosis had a higher incidence of anastomotic leakage than ileocolonic anastomosis, i.e., 14 versus 4% respectively. Of the seven patients who developed a leak from a colocolonic anastomosis, two patients died (29%). Univariate analysis identified an Abdominal Trauma Index Score > or = 25 (p = 0.03) or hypotension in the emergency department (p = 0.001) to be associated with increased risk of developing an anastomotic leak from a colocolonic anastomosis. CONCLUSION: Colonic injuries that are managed with resection are associated with a high complication rate regardless of whether an anastomosis or colostomy is performed. Colonic resection and anastomosis can be performed safely in the majority of patients with severe colonic injury, including injuries to the left colon. For injuries of the right colon, an ileocolostomy has a lower incidence of leakage than a colocolonic anastomosis. For injuries to the left colon, there remains a role for colostomy specifically in the subgroups of patients with a high ATI or hypotension, because these patients are at greater risk for an anastomotic leak. The role of resection and primary anastomosis versus colostomy in colonic trauma requires further investigation.     

Combined side-to-end anastomosis with temporary end colostomy for the management of selected left-sided colonic emergencies

Management of surgical emergencies of the left colon commonly requires excision of the colonic segment bearing the lesion, creation of an end colostomy, and closure of the rectosigmoid stump. Closure of the end stoma may be technically challenging. During this study, we used a new surgical technique involving the creation of an end-to-side anastomosis of the rectosigmoid stump to the base of the proximal colonic segment in association with an end colostomy. During a 15-year period, 23 patients were offered this type of surgery. Mortality was zero. Complications were observed in seven patients (morbidity, 7/23). Mean hospitalization time was 12.3 days. Closure of the colostomy was performed approximately 1 month after initial surgery and was easily performed using a mechanical stapler, either intraperitoneally or even extraperitoneally. No complications were observed after closure of the colostomy. The described technique is a useful alternative for the management of selected patients with left-sided colonic surgical emergencies. Its main advantage is that it greatly facilitates colostomy closure, which is performed earlier compared with the colostomy closure after a typical Hartmann's procedure.     

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.     

Healing of experimental colonic anastomoses. I. Bursting strength of the colon after left colon resection and anastomosis.

Mechanical strength of the left colon with anastomosis and the intact transverse colon was studied by the bursting strength technic from four to fourteen days after standardized left colon resection in the rat. Two different single layer inverting suture technics were used, continuous suture and interrupted sutures. Bursting strength was tested by determinations of both bursting pressure and bursting wall tension, both of which provided the same information concerning mechanical strength of the colon. The bursting strength test measures the anastomotic strength only during the early stages of healing, since more than 90 per cent of the left colon segments ruptured outside the anastomosis as early as day 7. The two different suture technics resulted in the same bursting strength of the left colon segment with anastomosis. Both types of anastomoses showed a moderate narrowing at the anastomotic line upon inflation. This was due to the fact that the anastomosis constituted a relatively firm fibrotic ring from day 7, and both types of anastomoses had an equal inner diameter at that time. By supporting the colonic wall above and below the anastomosis, it could be calculated that the anastomosis on day 7 withstood at least 50 per cent higher circular wall tension than the surrounding colonic wall.There was no correlation between collagen concentration of the colonic wall and bursting strength of the colon either in unoperated controls or after resection and anastomosis. When interrupted sutures were used for anastomosis of the left colon, bursting strength of the intact transverse colon was significantly higher on day 7 than when continuous suture was used. It actually exceeded that of the transverse colon in unoperated controls by almost 50 per cent on the seventh postoperative day, although the collagen concentration in the transverse colon was within normal range. This finding indicated changes in the proximal colonic wall after left colon resection, which are probably related to changes in the structure or arrangement of collagen.     

The effect of relative bowel rest on healing of colonic anastomoses. Collagen synthesis and content in the colonic wall after left colon resection and anastomosis in the rat

Collagen metabolism was studied in the colonic wall of rats after standardized resection and anastomosis. Diminished faecal loading was obtained by feeding rats low-residue diet (Bisorbin MCT). The postoperative increase of collagen synthesis and collagen content was on a lower level in these rats than in rats on standard laboratory diet. The increase was confined to the immediate anastomotic region and presumably represented changes in collagen caused by the operative trauma per se. It was concluded that the intraluminal content is an important factor in stimulating collagen turnover. The findings of lower collagen turnover in the anastomotic area in animals on low-residue diet may have positive significance, but could also imply impairment of healing. For elucidation of this question, studies on mechanical strength of the anastomosis are necessary.     

Role of protective colostomy in colorectal surgery. Apropos of 68 cases

A retrospective study was made from the records of 68 patients who had temporary loop colostomy with left colectomy between 1975 and 1985. Six fecal fistula occurred. Two of these patients died in spite of the colostomy. The colostomy closure was complicated by six leakages and four wound infections. The results are compared with those from literature. Finally loop colostomy for protecting an anastomosis keeps good indications with sub-obstructions and acute obstructions without large colectasia, infections without abscess, bowels no or bad prepared, and some low colo-rectal anastomosis. Large bowel obstruction with megacolon, and peritonitis avoid all kind of anastomosis. The colostomy closure is a high colonic surgery procedure. It must occur three months after its formation. A barium enema is necessary before loop colostomy closure.     

Emergency surgical treatment of complicated acute diverticulitis

Twenty-five percent of patients undergoing surgery for acute complicated diverticulitis represent emergencies. This condition is currently treated by colonic resection with primary anastomosis with or without colostomy, or by a Hartmann operation. We report on our experience with 52 consecutive patients with generalized peritonitis (8 cases), peri- and paracolonic abscesses (19 cases), severe pelvic abscesses (12 cases) and multiple abscesses with visceral fistulas (13 cases). All patients had emergency surgery. In 50/52 patients (96.2%) we performed a colonic resection with primary anastomosis using a mechanical stapler and in 2/52 a Hartmann operation. The overall mortality rate was 5.8%. The morbidity rate was 22% with 9 anastomotic leakages. A diverting colostomy was constructed in 16 patients and opened in only 8 patients. In 4 cases a parastomal hernia occurred after late closure and reduction of the colostomy. This data suggest that colonic resection with primary anastomosis, even without colostomy, is a safe procedure for the emergency treatment of acute complicated diverticulitis.     

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.     

大鼠左半结肠与右半结肠吻合愈合能力的对比研究

目的 比较大鼠左半结肠和右半结肠吻合愈合的能力,为临床行结肠手术方式的选择提供理论依据.方法 将40只雄性Wistar大鼠随机分为A、B两组,每组20只.A组行右半结肠端端吻合,B组行左半结肠端端吻合.分别于术后第4天和第7天处死两组各10只动物,用免疫组化法测量吻合口组织中基质金属蛋白酶1(MMP-1)、MMP-13以及Ⅰ型胶原的表达,并同时进行组织病理学检查.结果 术后第4天,两组大鼠的左半结肠和右半结肠吻合口组织中MMP-1的表达分别为(1226±506)μm2和(732±376)μm2,两组之间比较差异有统计学意义(t=-2.54,P<0.05);两组MMP-13的表达分别为(1726±509)μm2和(1161±753)μm2,两组之间比较差异有统计学意义(t=-2.47,P<0.05);两组Ⅰ型胶原的表达分别为(199±90)μm2和(314±135)μm2,两组之间比较差异有统计学意义(t=2.30,P<0.05).术后第7天,两组大鼠的左半结肠和右半结肠吻合口组织中MMP-1的表达分别为(1264±508)μm2和(869±378)μm2,两组之间比较差异有统计学意义(t=-3.19,P<0.05);两组Ⅰ型胶原的表达分别为(228±79)μm2和(374±130)μm2,两组之间比较差异有统计学意义(t=2.61,P<0.05).结论 在结肠吻合术后,大鼠右半结肠吻合口组织中MMP-1和MMP-13的表达明显低于左半结肠,Ⅰ型胶原的表达明显高于左半结肠,提示右半结肠吻合愈合能力明显强于左半结肠.     

Intra-operative colonic irrigation in the management of left-sided large bowel emergencies

In a consecutive series of 93 patients who required emergency surgery for distal colonic lesions, 61 had primary bowel resection with immediate anastomosis after intra-operative antegrade colonic irrigation. The operative mortality was 8 per cent, anastomotic leakage rate 7 per cent and superficial wound infection occurred in 3 per cent of patients. The mean hospital stay was 13 days. Of the remaining 32 patients, 3 did not have a resection and 29 had a primary resection and end colostomy without anastomosis: bowel continuity was later restored in 17 of 28 survivors (61 per cent) but 11 (39 per cent) were left with a permanent colostomy. The hospital mortality in this group was 6 per cent, superficial wound infection rate 14 per cent and the mean hospital stay 26 days. The results of this study suggest that intra-operative colonic irrigation is an effective method enabling the surgeon to perform a primary anastomosis with reasonable safety after emergency resection of selected distal colonic lesions.     

Prospective study of primary anastomosis without colonic lavage for patients with an obstructed left colon.

BACKGROUND: Traditionally, left-sided colon obstruction is managed by a multistaged defunctioning colostomy and resection. However, there is growing acceptance of one-stage primary resection and anastomosis with on-table antegrade irrigation. This paper presents a series of patients managed prospectively by primary anastomosis without intraoperative colonic lavage. METHODS: Emergency resection of acutely obstructed left-sided colonic carcinomas was performed. This was followed by primary anastomosis without on-table lavage after bowel decompression using a new technique. RESULTS: Fifty-eight consecutive, unselected patients underwent bowel decompression, resection and primary colocolic anastomosis. Only one patient developed a leak at the anastomotic site, requiring pelvic abscess drainage and transverse loop colostomy. One death occurred 12 h following surgery. Autopsy confirmed that this was due to myocardial infarction. Mean hospital stay was 9.8 days. CONCLUSION: Emergency surgery on the obstructed left colon can be carried out safely after decompression alone, without intraoperative colonic lavage.     

Revision and closure of the colostomy

Reoperative stomal surgery includes the correction of complications and closure of a colostomy. Necrosis, retraction, and stenosis are the most frequently occurring complications and are simply corrected by straightforward techniques. Prolapse of the colostomy and parastomal hernia occur less frequently. Their repair is slightly more complex than that of the previous group of complications. Colostomy closure ranges from simple suture closure of the loop colostomy, through anastomosis of the divided colostomy, to the sometimes difficult gastrointestinal reconstruction after the Hartmann procedure. Death after closure of colostomy is infrequent, but anastomotic complications occur after all types of closure. Leak and sepsis are by far the most frequent anastomotic complications. Stenosis occurs less often. The same degree of care exercised during colectomy and anastomosis is necessary for optimal results after colostomy closure.     

Effect of diverting colostomy on breaking strength of anastomoses after resection of the left side of the colon. Studies in the rat

In the present investigation, the effect of a proximal diverting colostomy on suture holding capacity and on anastomotic strength of the excluded left colon was studied. Suture holding capacity was increased 7 days after fecal diversion. Anastomotic strength development, however, was significantly delayed. These differences were accompanied by a diminished collagen response in the anastomotic region after fecal diversion. This might suggest impairment of healing in the excluded colon. The gross appearance of the anastomoses would, however, indicate that increased collagen formation and greater strength development in animals without colostomy is a result of more complicated healing.     

Effect of Temporary Abdominal Closure on Colonic Anastomosis and Postoperative Adhesions in Experimental Secondary Peritonitis

Background The effect of relaparotomies and temporary abdominal closure on colonic anastomoses and postoperative adhesions is under debate. Methods In the experiments reported here, colonic anastomosis was constructed 24 hours after cecal ligation and puncture in rats that were divided into three groups of eight animals each. The abdomen was closed primarily in groups I and II, and a Bogota bag was used for abdominal closure in group III. At 24 hours following anastomosis, relaparotomy was performed only in group II and III rats, and the abdomen was closed directly in group II; after removal of the Bogota bag in group III animals, the abdomen was closed directly. On the fifth day of anastomotic construction, bursting pressures and tissue hydroxyproline content of the anastomoses, along with peritoneal adhesions, were assessed and compared. Results Mean anastomotic bursting pressures and hydroxyproline contents did not differ among the groups. Median adhesion scores were significantly higher in group III than the other two groups. Conclusions Relaparotomy and the type of temporary closure have no negative effect on anastomotic healing in rats with peritonitis. Temporary abdominal closure with a Bogota bag caused a significantly high rate of adhesions.