Colostomy lntraperitoneal
or Extraperitoneal
Adebayo Adeyemo, MD, Washington,
DC
Wendell E. Galllard, Jr, MD, Washington, Subhi D. Ali, MD, Washington,
Closure?
DC
DC
Thomas Calhoun, MD, FACS, Washington, DC Lewis H. Kurtt, MD, FACS, Washington, DC
In 1973, a retrospective study was undertaken on the Howard University Surgical Service at the District of Columbia General Hospital to determine the results of colostomy closure utilizing the intraperitoneal approach. Previously reported series by others reveal a fairly high rate of infection and other complications with extraperitoneal closure. This report presents our complication rate and describes our technic of closure. Material and Methods In a ten year period, 1963 to 1973, forty-three patients on our service had colostomy with subsequent closure. Table I lists the reasons for colostomy and their relative incidence. The interval between initial operation and closure of the colostomy is shown in Table I. This interval varied from three weeks to three years, depending on the underlying disease process and demonstration of a patent distal limb. Preoperative management consisted of routine bowel preparation utilizing mechanical cleansing of both limbs of colon, nonabsorbable antibiotics (Sulfathalidine and neomycin or kanamycin alone), low-residue diet, and administration of vitamin K, 10 mg daily for five days. Prior to preparation of the bowel, all patients had barium enema examination of p_roximal and distal limbs. If demonstrable disease or compromise of the bowel lumen was noted, closure was delayed. Laboratory data were obtained as indicated with appropriate correction of abnormal values when necessary. Prior to preparation of the abdomen, the colostomy stomas are closed separately with a running 3-O chromic suture. This minimizes spillage of bowel contents during and after preparation. Routine ten minute surgical scrub is carried out using either phisoHex@’ and Zephiran@ or Betadine@ scrub and solution. An elliptical incision is made around the colostomy, usually in a transverse direction, down to the fascial layer. (Figure
From the Howard University Surgical Service, District of Columbia General Hospital, Washington, DC. Reprint requests should be addressed to Subhi D. Ali, MD, Howard University Surgical Service, District of Columbia General Hospital, Washington, DC 20003.
Vohme 130, member
1975,
1.) By careful dissection, the two limbs of the colostomy are freed from surrounding subcutaneous tissue and fascia. (Figure 2.) Bleeding is controlled with Bovie or chromic catgut or Dexon@ sutures. Adhesions between the bowel wall and peritoneum are carefully freed and the bowel is mobilized. The mesenteric rent is repaired (Figure 3), the loop colostomy is resected, and an open two-layer anastomosis is made (Figure 4). The abdomen is closed in a single layer with number 28 monofilament wire without drainage. The subcutaneous tissue is irrigated with copious amounts of normal saline and the skin is left open. Postoperatively, the dressing is changed and the wound cleansed daily. After five to seven days the skin may be approximated. TABLE
I Underlying Pathologic Factors and Interval before Closure of Colostomy
Pathologic Factor Trauma Gunshot wound (21) Blunt injury (1) Other injuries (2) Chicken bone Pencil Stab wound (1) latrogenic injury Surgery (1) Self instrumentation (1) Gastrointestinal inflammatory disease (diverticulitis) Gastrointestinal obstruction secondary to malignant disease Anorectal venereal disease with fistulas due to lymphopathia venereum
-
Number
-
Per Cent
25
55.6
2
4.4
Interval before Closure of Colostomy 4-6
weeks
6 weeks 3 years
7
15.5
3-5
months
8
17.78
3-4
weeks
1
2.2
15 months
273
Adeyemo
et al
Figure 1. The proximal and distal stomas are closed with running catgut suture prkr to preparatkn of the abdominal skin. An eiiiptkai incision is made around the coiostomy down to the fascia. Figure 2. By careful dissection, ail adhesions between the colon and peritoneum are freed, with attention to any adherent small bowel. An appropriate site for anastomosis of the proximal and dktai limbs of the ioop is selected and cross-clamped with Kocher clamps.
Figure 3. The mesenteric rent is closed with fine chromic catgut suture prkr to anastomosis. Figure 4. An open two-layer anastomosis is made intraperitoneaiiy with assurance of an adequate blood supply.
Results Wound infection developed in two patients, an incidence of 4.6 per cent. One patient had approximation of the subcutaneous tissue, and the other, a fecal fistula. Anastomotic obstruction occurred in one patient (2.3 per cent) after the development of a hematoma at the suture line. An incisional hernia (2.3 per cent) developed in one of the infected wounds and a suture sinus (2.3 per cent) developed after delayed closure of the skin with silk. Two fecal fistulas (4.6 per cent) occurred but closed spontaneously with conservative therapy.
Thomson and Hawley [3] noted postoperative complications in 21.5 per cent of their patients, with 17.2 per cent having wound infection. Their method of closure was intraperitoneal but the skin and subcutaneous space were not left open. Hubbard, Nonco, and Harris [4] had a wound infection rate of 11.1 per cent. Intraperitoneal colostomy closure seems to have a much more favorable overall complication rate than does extraperitoneal closure. When our results are compared with those of other investigators, our overall complication rate of 15.4 per cent, with only two wound infections (4.6 per cent) and two fecal fistulas (4.6 per cent), is considerably lower. The major factors that lower the incidence of wound infection are closing the colostomy stoma prior to preparation of the abdomen and leaving the skin open postoperatively. Of 200 patients reported on by Barron and Fallis [5], only one had a fecal fistula after intraperitoneal closure. In the absence of contraindications for colostomy closure, it appears that the intraperitoneal approach has a much lower complication rate than does the extraperitoneal approach. Closing the colostomy stoma before preparing the abdomen and leaving the skin and subcutaneous tissue open postoperatively significantly decrease the incidence of wound infection and shorten hospital stay. A two-layer open anastomosis with careful attention to hemostasis diminishes anastomotic complications and does not require drainage of the peritoneal cavity.
Summary Forty-three patients who underwent intraperitoneal closure of colostomy are reported on. Complication rates of 4.6 per cent for wound infection and 4.6 per cent for fecal fistulas appear significantly lower than the 10 to 21 per cent complication rates reported for colostomy closure using other technics. References
Comments In 1944 Dixon and Benson 111 reported the development of fecal fistulas in 18 per cent of their patients after colostomy closure. Knox, Birkett, and Collins [2] reported an incidence of fecal fistulas of 16 per cent and a rate of wound infection of 10 per cent. They advocated extraperitoneal closure.
274
1. Dixon CF, Benson RE: Closure of colonic stoma. Improved results with combined succinylsulfathiazole and sulfathiazole therapy. Ann Surg 120: 56i, 1944. 2. Knox AJS,. Birkett FDH, Collins CD: Closure of colostomy. f?r J Surg58: 669, 1971. 3. Thomson JP, Hawley RR: Results of closure of transverse loop colostomies. Br A&d J 3: 459. 1972. 4. Hubbard TB, Nonco A, Harris RA: Two stage resection of colon. Sura Gvneco/ Cbstet 124: 1081. 1967. 5. Barron J, Fallis LS: Dis Co/on Rectum 1: 466, 1958.
The Arnerkan Journal of Suqery
or Extraperitoneal
Adebayo Adeyemo, MD, Washington,
DC
Wendell E. Galllard, Jr, MD, Washington, Subhi D. Ali, MD, Washington,
Closure?
DC
DC
Thomas Calhoun, MD, FACS, Washington, DC Lewis H. Kurtt, MD, FACS, Washington, DC
In 1973, a retrospective study was undertaken on the Howard University Surgical Service at the District of Columbia General Hospital to determine the results of colostomy closure utilizing the intraperitoneal approach. Previously reported series by others reveal a fairly high rate of infection and other complications with extraperitoneal closure. This report presents our complication rate and describes our technic of closure. Material and Methods In a ten year period, 1963 to 1973, forty-three patients on our service had colostomy with subsequent closure. Table I lists the reasons for colostomy and their relative incidence. The interval between initial operation and closure of the colostomy is shown in Table I. This interval varied from three weeks to three years, depending on the underlying disease process and demonstration of a patent distal limb. Preoperative management consisted of routine bowel preparation utilizing mechanical cleansing of both limbs of colon, nonabsorbable antibiotics (Sulfathalidine and neomycin or kanamycin alone), low-residue diet, and administration of vitamin K, 10 mg daily for five days. Prior to preparation of the bowel, all patients had barium enema examination of p_roximal and distal limbs. If demonstrable disease or compromise of the bowel lumen was noted, closure was delayed. Laboratory data were obtained as indicated with appropriate correction of abnormal values when necessary. Prior to preparation of the abdomen, the colostomy stomas are closed separately with a running 3-O chromic suture. This minimizes spillage of bowel contents during and after preparation. Routine ten minute surgical scrub is carried out using either phisoHex@’ and Zephiran@ or Betadine@ scrub and solution. An elliptical incision is made around the colostomy, usually in a transverse direction, down to the fascial layer. (Figure
From the Howard University Surgical Service, District of Columbia General Hospital, Washington, DC. Reprint requests should be addressed to Subhi D. Ali, MD, Howard University Surgical Service, District of Columbia General Hospital, Washington, DC 20003.
Vohme 130, member
1975,
1.) By careful dissection, the two limbs of the colostomy are freed from surrounding subcutaneous tissue and fascia. (Figure 2.) Bleeding is controlled with Bovie or chromic catgut or Dexon@ sutures. Adhesions between the bowel wall and peritoneum are carefully freed and the bowel is mobilized. The mesenteric rent is repaired (Figure 3), the loop colostomy is resected, and an open two-layer anastomosis is made (Figure 4). The abdomen is closed in a single layer with number 28 monofilament wire without drainage. The subcutaneous tissue is irrigated with copious amounts of normal saline and the skin is left open. Postoperatively, the dressing is changed and the wound cleansed daily. After five to seven days the skin may be approximated. TABLE
I Underlying Pathologic Factors and Interval before Closure of Colostomy
Pathologic Factor Trauma Gunshot wound (21) Blunt injury (1) Other injuries (2) Chicken bone Pencil Stab wound (1) latrogenic injury Surgery (1) Self instrumentation (1) Gastrointestinal inflammatory disease (diverticulitis) Gastrointestinal obstruction secondary to malignant disease Anorectal venereal disease with fistulas due to lymphopathia venereum
-
Number
-
Per Cent
25
55.6
2
4.4
Interval before Closure of Colostomy 4-6
weeks
6 weeks 3 years
7
15.5
3-5
months
8
17.78
3-4
weeks
1
2.2
15 months
273
Adeyemo
et al
Figure 1. The proximal and distal stomas are closed with running catgut suture prkr to preparatkn of the abdominal skin. An eiiiptkai incision is made around the coiostomy down to the fascia. Figure 2. By careful dissection, ail adhesions between the colon and peritoneum are freed, with attention to any adherent small bowel. An appropriate site for anastomosis of the proximal and dktai limbs of the ioop is selected and cross-clamped with Kocher clamps.
Figure 3. The mesenteric rent is closed with fine chromic catgut suture prkr to anastomosis. Figure 4. An open two-layer anastomosis is made intraperitoneaiiy with assurance of an adequate blood supply.
Results Wound infection developed in two patients, an incidence of 4.6 per cent. One patient had approximation of the subcutaneous tissue, and the other, a fecal fistula. Anastomotic obstruction occurred in one patient (2.3 per cent) after the development of a hematoma at the suture line. An incisional hernia (2.3 per cent) developed in one of the infected wounds and a suture sinus (2.3 per cent) developed after delayed closure of the skin with silk. Two fecal fistulas (4.6 per cent) occurred but closed spontaneously with conservative therapy.
Thomson and Hawley [3] noted postoperative complications in 21.5 per cent of their patients, with 17.2 per cent having wound infection. Their method of closure was intraperitoneal but the skin and subcutaneous space were not left open. Hubbard, Nonco, and Harris [4] had a wound infection rate of 11.1 per cent. Intraperitoneal colostomy closure seems to have a much more favorable overall complication rate than does extraperitoneal closure. When our results are compared with those of other investigators, our overall complication rate of 15.4 per cent, with only two wound infections (4.6 per cent) and two fecal fistulas (4.6 per cent), is considerably lower. The major factors that lower the incidence of wound infection are closing the colostomy stoma prior to preparation of the abdomen and leaving the skin open postoperatively. Of 200 patients reported on by Barron and Fallis [5], only one had a fecal fistula after intraperitoneal closure. In the absence of contraindications for colostomy closure, it appears that the intraperitoneal approach has a much lower complication rate than does the extraperitoneal approach. Closing the colostomy stoma before preparing the abdomen and leaving the skin and subcutaneous tissue open postoperatively significantly decrease the incidence of wound infection and shorten hospital stay. A two-layer open anastomosis with careful attention to hemostasis diminishes anastomotic complications and does not require drainage of the peritoneal cavity.
Summary Forty-three patients who underwent intraperitoneal closure of colostomy are reported on. Complication rates of 4.6 per cent for wound infection and 4.6 per cent for fecal fistulas appear significantly lower than the 10 to 21 per cent complication rates reported for colostomy closure using other technics. References
Comments In 1944 Dixon and Benson 111 reported the development of fecal fistulas in 18 per cent of their patients after colostomy closure. Knox, Birkett, and Collins [2] reported an incidence of fecal fistulas of 16 per cent and a rate of wound infection of 10 per cent. They advocated extraperitoneal closure.
274
1. Dixon CF, Benson RE: Closure of colonic stoma. Improved results with combined succinylsulfathiazole and sulfathiazole therapy. Ann Surg 120: 56i, 1944. 2. Knox AJS,. Birkett FDH, Collins CD: Closure of colostomy. f?r J Surg58: 669, 1971. 3. Thomson JP, Hawley RR: Results of closure of transverse loop colostomies. Br A&d J 3: 459. 1972. 4. Hubbard TB, Nonco A, Harris RA: Two stage resection of colon. Sura Gvneco/ Cbstet 124: 1081. 1967. 5. Barron J, Fallis LS: Dis Co/on Rectum 1: 466, 1958.
The Arnerkan Journal of Suqery
