Colostomy Closure
A Simple Procedure?*
ERIC ANDERSON, M.D., LARRY C. CAREY, M.D., MARC COOPERMAN, M.D.
From the Department of Surgeu, The Ohio State University Hospitals, Coh~mbus, Ohio
CREATION OF A TEMPORARY COLOSTOMY has b e e n a
useful and necessary part of the surgical treatment of colonic carcinoma, diverticulitis, and colonic and rectal injuries for several decades. Thus, colostomy closure is now a common procedure. While much has been written regarding the indications, technical aspects, and management of a colostomy, only recently has attention been directed toward closure of the colostomy and its attendant complications. Frequently, colostomy closure is regarded as a minor operative procedure. Thomson and Hawley * reported 139 patients who underwent closure of loop colostomies with very few complications and no deaths. However, not only is there considerable disagreement concerning.the incidence of complications following this procedure, -~-s but there is evidence to support a disquieting frequency of complications. Knox et al. 6 and others r-~ report that colostomy closure is frequently associated with complications of wound infection, leakage of feces, and anastomotic breakdown, and may have significant mortality. This review was undertaken to evaluate our experience with colostomy closure, as well as to identify and analyze factors which apparently influence the occurrence of complications. Materials and M e t h o d s
The records of 69 patients undergoing colostomy closure from 1972 to 1976 at the Ohio State University Hospital were reviewed. There were 43 men (62 per cent) and 26 women (38 per cent) ranging in age from 18 to 74 years, with the mean age of 56 years. The colostomy was in the transverse colon in 43 patients (62 per cent), the left colon in 23 (33 per cent), and the right colon in three (4 per cent). Loop colostomies were closed in 52 patients (75 per cent). Sixteen patients (23 per cent) underwent closure of an end colostomy. The distal segment had been brought to the skin as a mucous fistula in 12 patients, and had been left intra-abdominally as a
Hartmann pouch in four. One patient had a tube cecostomy. Twenty-two of the 69 colostomies (31.9 per cent) were created after either blunt or penetrating abdominal trauma. Complications of diverticulitis in 20 patients (28.9 per cent) and obstructing colonic cancer in nine patients (13 per cent) were other frequent indications. Thirteen patients (18.9 per cent) had a temporary colostomy constructed to protect a difficult distal colonic anastomosis (Table 1). Prior to colostomy closure, all patients received a thorough mechanical bowel preparation consisting of clear liquid diet, oral cathartics, and cleansing enemas. In 41 patients (59 per cent), either kanamycin sulfate or a neomycin-erythromycin base combination was used as an oral, nonabsorbable antibiotic preparation. Factors analyzed to determine potential influences on the occurrence of complications included 1) location of the colostomy (right, transverse, or left colon), 2) type of colostomy (loop or end colostomy), 3) the initial disease process for which the colostomy was created, 4) the timing of colostomy closure, 5) the administration of antibiotics and, 6) the method of wound closure. Each factor and complication was subjected to chi-square tests to determine significant differences in morbidity.
* Received for publication May 21, 1979. Address reprint requests to Dr. Cooperman: Department of Surgery, Ohio State University Hospitals, 410 W Tenth Avenue, Columbus, Ohio 43210
Results
The postoperative course of 47 patients (68 per cent) was uncomplicated. A single complication occurred in 20 patients (29 per cent), and two patients had more than one complication (Table 2). Total morbidity was 31.8%. There were no deaths. The most common complication was superficial w o u n d infection in ten patients. Small-intestinal obstruction occurred in four patients. In each case, obstruction was partial or occurred in the early postoperative course and was resolved with long-tube decompression. Fecal fistula occurred in three patients, and transient obstruction at the site of the colostomy in three patients. All complications resolved without
0012-3706/79/1000/0466/$00.65 9 American Societyof Colon and Rectal Surgeons
466
\ olume 22 Number 7
COLOSTOMY
requiring operation other than drainage of superficial wound infections. No significant differences in the incidence of complications were observed between the sexes or between age groups. Table 3 shows that the underlying pathologic process had no statistically significant influence, on the occurrence of either local or systemic complications. T h e r e was no significant difference in the complication rate between patients operated u p o n for carcinoma and those for diverticular disease. However, there was a decided decrease in morbidity in colostomies p e r f o r m e d electively to protect a distal anastomosis, in contrast to those constructed as an e m e r g e n c y p r o c e d u r e (colonic p e r f o r a t i o n or obstruction). Closure of an end colostomy always requires resection and reanastomosis, and is associated with a significantly higher rate of complications than is closure of a loop colostomy (P < .004) (Table 4). T h e highest morbidity was seen in patients who u n d e r w e n t closure of an end colostomy with a H a r t m a n n pouch. T h e incidence of complications was higher following closure of left-sided colostomies than after those in either the right or transverse colon. T e n of 23 patients (43 per cent) with left-sided colostomies developed complications after closure, compared to 12 of 46 patients (26 per cent) with right-sided or transverse colostomies. T h e administration preoperatively of oral nonabsorbable antibiotics in 41 patients (59 per cent) demonstrated a moderate decrease in the occurrence of both local and total complications, but the difference was not statistically significant (Table 5). T h e administration of parenteral antibiotics also made no difference in the occurrence of wound infection or other complications. T h e method of wound m a n a g e m e n t had no apparent effect on the incidence of w o u n d infection. W o u n d infection developed in two of 12 patients (17 per cent) who had the skin or subcutaneous tissue left open at the time of operation, compared to eight of 57 patients (14 per cent) in whom the incision was closed primarily. T h e timing of colostomy closure, i.e., the length of time from construction of the colostomy to closure, had no apparent bearing on the incidence of complications (Table 6).
467
CLOSURE
TABLE 1.
Number of Patients
Per C e n t
Trauma
22
31.9
Diverticulitis Obstruction Perforation
5 15
7.2 21.7
Carcinoma Obstruction
9
Indications
Difficult distal a n a s t o m o s i s
TOTALS
13
13
18.9
5
7.3
Other
69
TABLE 2.
TABLE 3.
100
Complications Number of Patients
Per Cent
10 3 4 3 1 1 1
14.5 4.3 5.8 4.3 i .4 1.4 1.4
W o u n d infection Fecal fistula Small-bowel obstruction A n a s t o m o t i c obstruction Pneumonia Hemorrhage U r i n a r y tract infection
Relationship of Complications to Underlying Disease Complications Number of Patients
Number
Per C e n t
Trauma
22
6
27
Diverticulitis
20
6
30
9
2
22
13
1
8
O b s t r u c t i n g distal cancer Difficult a n a s t o m o s i s
TABLE 4.
Relationship of Complications to Type of Colosto'my Complications Number of Patients
Number
Per Cent
Loop
52
12
23
E n d (Mucous fistula)
Discussion
T h e position that closure of a colostomy is an innocuous procedure is no longer tenable. T h e hazards of this operation have become increasingly apparent. Some authors report minimal morbidity, which may be related to several factors including patient selec-
Indicationsfor Colostomy
12
5
42
E n d ( H a r t m a n n pouch)
4
4
100
Cecostomy
1
1
100
468
ANDERSON
-I'aBt.z 5.
Relation,#@ of Complications to Oral A ntibiotics
Complications Preoperative Oral Autibiodc
Number of Patients
Number
Per Cent
Yes No
41 97
10 11
-94 41
tion, meticulous surgical technique, and m e t h o d s of closure. Others r e p o r t a distressingly high rate o f complications. Yajko et al. n even suggest that alternative techniques o f m a n a g i n g colonic injuries, such as p r i m a r y closure or e x t e r i o r i z a t i o n o f a r e p a i r e d colon, should be considered in selected instances to avoid the morbidity o f later colostomy closure. Possible indications f o r this m o d e o f m a n a g e m e n t included right colonic injuries and limited p e n e t r a t i n g colonic injuries with minimal peritoneal contamination. Closure o f an e n d colostomy and closure o f colostomies o f the left colon are associated with m u c h higher complication rates than closure o f right-sided or loop colostomies. This may be related to several factors. Bacterial counts in the left colon are higher, increasing the potential for contamination, leakage, and w o u n d infection. Closure o f an end colostomy always requires resection and reanastomosis and thus requires a m o r e extensive operative dissection. Only one complication was seen in the loop colostomies created to protect difficult distal colonic anastomoses, and this lends credence to the concept that loop colostomy is p r e f e r r e d unless complete diversion o f the fecal stream is m a n d a t o r y . Knox, Birkett, and Collins 6 and other authors 10 report that the time interval between the initial operation and colostomy closure has a significant impact on the incidence o f complications. It has also been rep o r t e d that complications, specifically fecal fistulas,
TABLE 6. lntem, al Between Creation of Colostomy and Closure Complications
Complications Number of Patients
Number
Per Cent
8
3
38
More than 1 month 9 months or less
61 -91
19 6
3I 29
More than .9 months
48
16
33
Time I month or less
ET
AL.
Dis. Col & Rect. October 1979
are m u c h m o r e c o m m o n in the patient with diverticular disease, regardless o f the site o f the colostomy. 6 O u r data fail to s u p p o r t either o f these concepts. T h e q u e s t i o n , " W h e n s h o u l d a c o l o s t o m y be closed?" is a difficult one, a n d an exact time period c a n n o t be decreed. This decision becomes one o f clinical j u d g m e n t , and the safety o f the patient should not be c o m p r o m i s e d by a desire to restore fecal continuity rapidly. A c o l o s t o m y , o f course, s h o u l d n e v e r be closed until all i n f l a m m a t o r y e d e m a has subsided. In addition, the patient should be allowed a d e q u a t e time to convalesce f r o m his earlier operation and injuries. All distal anastomoses must be patent, and any distal !njuries must be healed and show no evidence o f leakage prior to closure. B a r i u m studies o f the distal colonic s e g m e n t as well as the "water flow test" advocated by Weinstein n are e x t r e m e l y useful in this regard. Superficial w o u n d infection is the most f r e q u e n t complication. Mechanical p r e p a r a t i o n o f the colon is always required. A suggestion o f lower infection rates was o b s e r v e d in t h o s e p a t i e n t s w h o r e c e i v e d preoperative oral n o n a b s o r b a b l e antibiotics, but these data are not conclusive. W o u n d s closed primarily at the time o f operation did not show any increase in the incidence o f w o u n d infection. T h e r e f o r e , delayed closure with its a c c o m p a n y i n g extra b u r d e n o f nursing a n d w o u n d care is not warranted. T h e t e m p o r a r y colostomy has become an essential c o m p o n e n t in the surgical treatment o f colonic injuries and disease. T h u s , closure o f colostomy has become an i m p o r t a n t and c o m m o n p r o c e d u r e , but one that harbors significant morbidity. This p r o c e d u r e can be d o n e safely, but requires the same skill and meticulous technique d e m a n d e d by any m a j o r surgical p r o c e d u r e on the colon.
References 1. Thomson JP, Hawley PR: Results of closure of loop transverse colostomies. Br MedJ 3: 459, 1979 2. Beck PH, Conklin HB: Closure of colostomy. Ann Surg 181: 795, 1975 3. Garnjobst W, Leaverton GH, Sullivan ES: Safety of colostomy closure. Am J Surg 136: 85, 1978 4. Wheeler/vii-t, BarkerJ: Colostomy closure--a safe procedure? Dis Colon Rectum 20: 29, 1977 5. Yakimets WW: Compticati'~ns of closure of loop colostomy. Can J Surg 18: 366, 1975 6. Knox AJ, Birkett FD, Collins CD: Closure of colostomy. Br J Surg 58: 669, 1971 7. Bell CA: Closure ofcolostomy--a review. AmJ Proctol -95:77 (Aug) 1974 8. Dolan PA, Caldwell FT, Thompson CH, et al: Problems of colostomy closure. AmJ Surg 137: 188, 1979 9. Yajko RD, Norton LW, Bloemendal L, et al: Morbidity of colostomy closure. Am J Surg 13.9: 304, 1976 10. Finch DR: The results ofcolostomy closure. BrJ Surg 63: 397, 1976 11. Weinstein M: Water-flow test prior to colostomy closure. Dis Colon Rectum 14: 237, 1971
A Simple Procedure?*
ERIC ANDERSON, M.D., LARRY C. CAREY, M.D., MARC COOPERMAN, M.D.
From the Department of Surgeu, The Ohio State University Hospitals, Coh~mbus, Ohio
CREATION OF A TEMPORARY COLOSTOMY has b e e n a
useful and necessary part of the surgical treatment of colonic carcinoma, diverticulitis, and colonic and rectal injuries for several decades. Thus, colostomy closure is now a common procedure. While much has been written regarding the indications, technical aspects, and management of a colostomy, only recently has attention been directed toward closure of the colostomy and its attendant complications. Frequently, colostomy closure is regarded as a minor operative procedure. Thomson and Hawley * reported 139 patients who underwent closure of loop colostomies with very few complications and no deaths. However, not only is there considerable disagreement concerning.the incidence of complications following this procedure, -~-s but there is evidence to support a disquieting frequency of complications. Knox et al. 6 and others r-~ report that colostomy closure is frequently associated with complications of wound infection, leakage of feces, and anastomotic breakdown, and may have significant mortality. This review was undertaken to evaluate our experience with colostomy closure, as well as to identify and analyze factors which apparently influence the occurrence of complications. Materials and M e t h o d s
The records of 69 patients undergoing colostomy closure from 1972 to 1976 at the Ohio State University Hospital were reviewed. There were 43 men (62 per cent) and 26 women (38 per cent) ranging in age from 18 to 74 years, with the mean age of 56 years. The colostomy was in the transverse colon in 43 patients (62 per cent), the left colon in 23 (33 per cent), and the right colon in three (4 per cent). Loop colostomies were closed in 52 patients (75 per cent). Sixteen patients (23 per cent) underwent closure of an end colostomy. The distal segment had been brought to the skin as a mucous fistula in 12 patients, and had been left intra-abdominally as a
Hartmann pouch in four. One patient had a tube cecostomy. Twenty-two of the 69 colostomies (31.9 per cent) were created after either blunt or penetrating abdominal trauma. Complications of diverticulitis in 20 patients (28.9 per cent) and obstructing colonic cancer in nine patients (13 per cent) were other frequent indications. Thirteen patients (18.9 per cent) had a temporary colostomy constructed to protect a difficult distal colonic anastomosis (Table 1). Prior to colostomy closure, all patients received a thorough mechanical bowel preparation consisting of clear liquid diet, oral cathartics, and cleansing enemas. In 41 patients (59 per cent), either kanamycin sulfate or a neomycin-erythromycin base combination was used as an oral, nonabsorbable antibiotic preparation. Factors analyzed to determine potential influences on the occurrence of complications included 1) location of the colostomy (right, transverse, or left colon), 2) type of colostomy (loop or end colostomy), 3) the initial disease process for which the colostomy was created, 4) the timing of colostomy closure, 5) the administration of antibiotics and, 6) the method of wound closure. Each factor and complication was subjected to chi-square tests to determine significant differences in morbidity.
* Received for publication May 21, 1979. Address reprint requests to Dr. Cooperman: Department of Surgery, Ohio State University Hospitals, 410 W Tenth Avenue, Columbus, Ohio 43210
Results
The postoperative course of 47 patients (68 per cent) was uncomplicated. A single complication occurred in 20 patients (29 per cent), and two patients had more than one complication (Table 2). Total morbidity was 31.8%. There were no deaths. The most common complication was superficial w o u n d infection in ten patients. Small-intestinal obstruction occurred in four patients. In each case, obstruction was partial or occurred in the early postoperative course and was resolved with long-tube decompression. Fecal fistula occurred in three patients, and transient obstruction at the site of the colostomy in three patients. All complications resolved without
0012-3706/79/1000/0466/$00.65 9 American Societyof Colon and Rectal Surgeons
466
\ olume 22 Number 7
COLOSTOMY
requiring operation other than drainage of superficial wound infections. No significant differences in the incidence of complications were observed between the sexes or between age groups. Table 3 shows that the underlying pathologic process had no statistically significant influence, on the occurrence of either local or systemic complications. T h e r e was no significant difference in the complication rate between patients operated u p o n for carcinoma and those for diverticular disease. However, there was a decided decrease in morbidity in colostomies p e r f o r m e d electively to protect a distal anastomosis, in contrast to those constructed as an e m e r g e n c y p r o c e d u r e (colonic p e r f o r a t i o n or obstruction). Closure of an end colostomy always requires resection and reanastomosis, and is associated with a significantly higher rate of complications than is closure of a loop colostomy (P < .004) (Table 4). T h e highest morbidity was seen in patients who u n d e r w e n t closure of an end colostomy with a H a r t m a n n pouch. T h e incidence of complications was higher following closure of left-sided colostomies than after those in either the right or transverse colon. T e n of 23 patients (43 per cent) with left-sided colostomies developed complications after closure, compared to 12 of 46 patients (26 per cent) with right-sided or transverse colostomies. T h e administration preoperatively of oral nonabsorbable antibiotics in 41 patients (59 per cent) demonstrated a moderate decrease in the occurrence of both local and total complications, but the difference was not statistically significant (Table 5). T h e administration of parenteral antibiotics also made no difference in the occurrence of wound infection or other complications. T h e method of wound m a n a g e m e n t had no apparent effect on the incidence of w o u n d infection. W o u n d infection developed in two of 12 patients (17 per cent) who had the skin or subcutaneous tissue left open at the time of operation, compared to eight of 57 patients (14 per cent) in whom the incision was closed primarily. T h e timing of colostomy closure, i.e., the length of time from construction of the colostomy to closure, had no apparent bearing on the incidence of complications (Table 6).
467
CLOSURE
TABLE 1.
Number of Patients
Per C e n t
Trauma
22
31.9
Diverticulitis Obstruction Perforation
5 15
7.2 21.7
Carcinoma Obstruction
9
Indications
Difficult distal a n a s t o m o s i s
TOTALS
13
13
18.9
5
7.3
Other
69
TABLE 2.
TABLE 3.
100
Complications Number of Patients
Per Cent
10 3 4 3 1 1 1
14.5 4.3 5.8 4.3 i .4 1.4 1.4
W o u n d infection Fecal fistula Small-bowel obstruction A n a s t o m o t i c obstruction Pneumonia Hemorrhage U r i n a r y tract infection
Relationship of Complications to Underlying Disease Complications Number of Patients
Number
Per C e n t
Trauma
22
6
27
Diverticulitis
20
6
30
9
2
22
13
1
8
O b s t r u c t i n g distal cancer Difficult a n a s t o m o s i s
TABLE 4.
Relationship of Complications to Type of Colosto'my Complications Number of Patients
Number
Per Cent
Loop
52
12
23
E n d (Mucous fistula)
Discussion
T h e position that closure of a colostomy is an innocuous procedure is no longer tenable. T h e hazards of this operation have become increasingly apparent. Some authors report minimal morbidity, which may be related to several factors including patient selec-
Indicationsfor Colostomy
12
5
42
E n d ( H a r t m a n n pouch)
4
4
100
Cecostomy
1
1
100
468
ANDERSON
-I'aBt.z 5.
Relation,#@ of Complications to Oral A ntibiotics
Complications Preoperative Oral Autibiodc
Number of Patients
Number
Per Cent
Yes No
41 97
10 11
-94 41
tion, meticulous surgical technique, and m e t h o d s of closure. Others r e p o r t a distressingly high rate o f complications. Yajko et al. n even suggest that alternative techniques o f m a n a g i n g colonic injuries, such as p r i m a r y closure or e x t e r i o r i z a t i o n o f a r e p a i r e d colon, should be considered in selected instances to avoid the morbidity o f later colostomy closure. Possible indications f o r this m o d e o f m a n a g e m e n t included right colonic injuries and limited p e n e t r a t i n g colonic injuries with minimal peritoneal contamination. Closure o f an e n d colostomy and closure o f colostomies o f the left colon are associated with m u c h higher complication rates than closure o f right-sided or loop colostomies. This may be related to several factors. Bacterial counts in the left colon are higher, increasing the potential for contamination, leakage, and w o u n d infection. Closure o f an end colostomy always requires resection and reanastomosis and thus requires a m o r e extensive operative dissection. Only one complication was seen in the loop colostomies created to protect difficult distal colonic anastomoses, and this lends credence to the concept that loop colostomy is p r e f e r r e d unless complete diversion o f the fecal stream is m a n d a t o r y . Knox, Birkett, and Collins 6 and other authors 10 report that the time interval between the initial operation and colostomy closure has a significant impact on the incidence o f complications. It has also been rep o r t e d that complications, specifically fecal fistulas,
TABLE 6. lntem, al Between Creation of Colostomy and Closure Complications
Complications Number of Patients
Number
Per Cent
8
3
38
More than 1 month 9 months or less
61 -91
19 6
3I 29
More than .9 months
48
16
33
Time I month or less
ET
AL.
Dis. Col & Rect. October 1979
are m u c h m o r e c o m m o n in the patient with diverticular disease, regardless o f the site o f the colostomy. 6 O u r data fail to s u p p o r t either o f these concepts. T h e q u e s t i o n , " W h e n s h o u l d a c o l o s t o m y be closed?" is a difficult one, a n d an exact time period c a n n o t be decreed. This decision becomes one o f clinical j u d g m e n t , and the safety o f the patient should not be c o m p r o m i s e d by a desire to restore fecal continuity rapidly. A c o l o s t o m y , o f course, s h o u l d n e v e r be closed until all i n f l a m m a t o r y e d e m a has subsided. In addition, the patient should be allowed a d e q u a t e time to convalesce f r o m his earlier operation and injuries. All distal anastomoses must be patent, and any distal !njuries must be healed and show no evidence o f leakage prior to closure. B a r i u m studies o f the distal colonic s e g m e n t as well as the "water flow test" advocated by Weinstein n are e x t r e m e l y useful in this regard. Superficial w o u n d infection is the most f r e q u e n t complication. Mechanical p r e p a r a t i o n o f the colon is always required. A suggestion o f lower infection rates was o b s e r v e d in t h o s e p a t i e n t s w h o r e c e i v e d preoperative oral n o n a b s o r b a b l e antibiotics, but these data are not conclusive. W o u n d s closed primarily at the time o f operation did not show any increase in the incidence o f w o u n d infection. T h e r e f o r e , delayed closure with its a c c o m p a n y i n g extra b u r d e n o f nursing a n d w o u n d care is not warranted. T h e t e m p o r a r y colostomy has become an essential c o m p o n e n t in the surgical treatment o f colonic injuries and disease. T h u s , closure o f colostomy has become an i m p o r t a n t and c o m m o n p r o c e d u r e , but one that harbors significant morbidity. This p r o c e d u r e can be d o n e safely, but requires the same skill and meticulous technique d e m a n d e d by any m a j o r surgical p r o c e d u r e on the colon.
References 1. Thomson JP, Hawley PR: Results of closure of loop transverse colostomies. Br MedJ 3: 459, 1979 2. Beck PH, Conklin HB: Closure of colostomy. Ann Surg 181: 795, 1975 3. Garnjobst W, Leaverton GH, Sullivan ES: Safety of colostomy closure. Am J Surg 136: 85, 1978 4. Wheeler/vii-t, BarkerJ: Colostomy closure--a safe procedure? Dis Colon Rectum 20: 29, 1977 5. Yakimets WW: Compticati'~ns of closure of loop colostomy. Can J Surg 18: 366, 1975 6. Knox AJ, Birkett FD, Collins CD: Closure of colostomy. Br J Surg 58: 669, 1971 7. Bell CA: Closure ofcolostomy--a review. AmJ Proctol -95:77 (Aug) 1974 8. Dolan PA, Caldwell FT, Thompson CH, et al: Problems of colostomy closure. AmJ Surg 137: 188, 1979 9. Yajko RD, Norton LW, Bloemendal L, et al: Morbidity of colostomy closure. Am J Surg 13.9: 304, 1976 10. Finch DR: The results ofcolostomy closure. BrJ Surg 63: 397, 1976 11. Weinstein M: Water-flow test prior to colostomy closure. Dis Colon Rectum 14: 237, 1971
