Improving Transverse Colostomy Function Hastings K. Wright, MD, New Haven, Connecticut
sumed a regular hospital diet adjusted to contain 170 mEq
Patients and ostomy nurses report that the function of transverse colostomies is notoriously poor, usually producing almost 1 liter of diarrhea a day on a normal diet and requiring a water-tight appliance even several months after construction. In fact, we have found that most transverse colostomies function little better than ileostomies, a surprising finding in view of the fact that such colostomies are distal to more than half the colon’s normal absorptive capacity [I]. Such poor function would be of little concern if transverse colostomies were only temporary vents. Yet, even in the surgical treatment of perforated left colon diverticulitis, more than two thirds of transverse colostomies are still intact six months after construction [2]. We therefore studied function of the different types of transverse colostomies over the six to twelve month period during which most patients have to contend with them, relating function to sodium intake, which is known to be a primary determinant of colostomy excretory volume.
sodium/day or 70 mEq sodium/day for four days, including a final 24 hour study period. The 170 mEq and 70 mEq sodium diets were selected because they represented the average amounts of sodium contained in a “normal” diet and the average amount lost from matured transverse colostomies on a I70 mElq sodium diet, respectively. Intake and output were recorded in the usual manner by nursing personnel; the amount of oral water intake was shown to bear no relationship to the 24 hour colostomy output. Each colostomy bag was collected at the end of the 24 hour period, and the 24 hour wet weight of excreta was determined by subtracting the previously measured weight of the empty bag from the weight of the bag plus the contents. The excreta were diluted with distilled water, homogenized, and an aliquot frozen until analysis. Solid content was measured by placing a 2 ml aliquot into a weighed bottle and drying the bottle and its contents to constant weight at 110°C. An aliquot of the homogenized excreta was digested with nitric acid, and the filtrate analyzed for sodium by flame photometry in the studies on 70 mEq sodium intakes.
Material and Methods
Results
Studies were performed in ten patients with loop transverse colostomies and ten patients with double-barreled end transverse colostomies approximately one month after colostomy construction for initial treatment of left colon perforated diverticulitis, and again nine to twelve months later when the patients were readmitted for colostomy closure. Informed consent was obtained from all patients after the protocol had been approved by the Yale Human Studies Committee. The loop colostomies had all healed by secondary intention, while the end colostomies
Approximately one month after colostomy construction, with all loop colostomies secondarily healed, loop colostomy patients excreted 910 f 160 gm of wet stool daily on a 170 mEq sodium diet. Patients with primarily matured end colostomies excreted 750 f 240 gm/day, an amount not significantly less than that excreted by loop colostomy patients. The dry weight of the excreta was similar in both groups. The amount and diarrhea1 nature of the excreta confirmed the clinical impression of patients and ostomy nurses that both types of transverse colostomies produce almost 1 liter of diarrhea1 stool one month after construction. Results at one month are summarized in Table I. However, at nine to twelve months after colostomy construction, end colostomy patients had significantly improved function compared with loop colostomy patients, excreting a mean of 560 f 174 gm/day of loose but not liquid stool on a 170 mEq sodium diet. In contrast, the loop colostomy patients
had had primary closure of the mucocutaneous junction. None showed clinical signs of obstruction. All patients were ambulatory during the study period, took no oral medication, took fluids ad libitum, and conFrom the Department of Surgery, Yale University School of Medicine and the Yale-New Haven Hospital, New Haven, Connecticut. This work was supported by USPHS grants AM14459 and CA16359. Reprint requests should be addressed to Hastings K. Wright, MD. Department of Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510. Presented at the Fifty-Ninth Annual Meeting of the New England Surgical Society, Dixville Notch, New Hampshire, September 29-October 1. 1976.
Volume 137, April 1979
475
Wright
TABLE I
Transverse Colostomy Function (mean f SD) in Patients on a 170 mEq Sodium Diet
Type of Transverse Colostomy
24 Hr Stool Weight (gm)
At 1 Month Loop colostomy End colostomy At 9 to 12 Months Loop colostomy End colostomy
Dry Weight (gm)
Consistency of stool
9 10 f 160 750 f 240’
41 f 10 45 f 6
Liquid Liquid
660 f 220 560 f 174+
45f 10 45 f 3
Liquid Loose
Weight not significantly different from loop colostomies at 1 month. + Compared with loop colostomies at 9 to 12 months (p < 0.01).
TABLE II
Colostomy Function of Four End Colostomy Patients on 70 mEq Sodium/Day Diets at 9 to 12 Months
Measurement
Average/Day
Wet stool weight Dry stool weight Sodium loss in stool Consistency
360 gm 43 gm (12%) 60 mEq Semisolid
l
showed no significant adaptation at all after nine to twelve months, excreting 880 f 220 gmfday of wet excreta compared to 910 f 160 gm one month after construction. The results at nine to twelve months are summarized in Table I. In four end colostomy patients placed on a 70 mEq sodium diet estimated to approximate mean sodium loss by transverse colostomy patients on a normal 170 mEq sodium intake, the wet weight of excreta was further reduced to a mean of 360 f 112 gm/day. More importantly, for the first time the excreta became semisolid. While continence could not be maintained similar to that possible after irrigations of sigmoid colostomies, the patients reported that transverse colostomy care was much improved at this low rate of semisolid excretion. Sodium loss on this 70 mEq sodium/day intake averaged 60 mEq in the stool, suggesting that chronic negative sodium balance would not be a consequence of this low sodium intake. However, further, more exact external sodium balance studies, including studies of urinary sodium losses conducted on a metabolic ward instead of on an open ward as in these studies, will be necessary to determine the exact ratio of sodium intake and output on this relatively low sodium diet. The results in the four end colostomy patients on 70 mEq sodium intakes are summarized in Table II. Comments
Surgeons generally have ignored the poor function of transverse colostomies, which is well known to patients and ostomy nurses, who consider them only temporary fecal diversions required in the emergency treatment of left colon obstruction or perforation. However, in our experience two-thirds of these “temporary” colostomies are still functioning six months later, and one-fourth one year later-and
476
functioning little better than ileostomies [2]. The present study indicates that the worst offenders are secondarily matured loop colostomies performed as emergencies without primary mucocutaneous suture. While such colostomies apparently have no mechanical obstruction on physical examination, they fail to adapt over nine to twelve months and continue to produce almost 1 liter/day of diarrhea1 fluid. Observation of these secondarily matured loop colostomies shows that many of them discharge effluent in “bursts” rather than continuously, as do end colostomies, suggesting that the nature of the loop itself or the long secondary healing process after colostomy construction produces a mild functional obstruction. The failure of these colostomies to mature reminds one of the partial obstruction noted by Brooke (31 and by Warren and McKittrick [4] in studying ileostomies not matured immediately by mucocutaneous anastomosis. In contrast to the continued poor function of loop transverse colostomies nine to twelve months after construction, primarily matured end colostomies demonstrated marked improvement in function, reducing the mean weight of excreta from 705 to 560 gm/day on a 170 mEq sodium diet over this period of time. The weight of effluent was further reduced to a mean of 360 gmlday when sodium intake was reduced to 70 mEq/day, a response akin to that demonstrated by Kramer [5] when he reduced average matured ileostomy output from approximately 600 to 500 gm/day on a similar low sodium diet. The data of Levitan ]I] suggest that half of the normal intact colon’s water absorptive capacity lies in the right colon. Debongnie and Phillips [6] also calculated that the normal intact colon absorbs approximately 1,500 cc/day on a normal sodium intake. Extrapolating from these two sets of data, it can be predicted that volume output from the midtransverse colon on a 170 mEq sodium diet should be in the range of 600 cc/day, a finding corroborated by our data showing an average of 560 gm output/day by matured end transverse colostomies on a normal (170 mEq sodium/day) intake. The further reduction
The American Journal of Surgery
Transverse
to an average of 360 gm/day on an experimental low sodium intake of 70 mEq/day is probably the lowest possible output achievable by a transverse colostomy patient, since further reductions in sodium intake may produce negative sodium balance due to obligatory sodium losses in excreta at the transverse colon level. While the crude balance data obtained in a hospital ward setting in this study suggest that a 70 mEq sodium diet will not produce negative sodium balance in patients with matured, well adapted end transverse colostomies, further external balance studies should be done under controlled conditions before recommending such low sodium diets to patients. The volume losses approaching 900 cc/day in patients on 170 mEq sodium diets up to a year after loop transverse colostomy strongly suggest that such
colostomies do not function efficiently. defect in function can be remedied maturing loop transverse colostomies construction, as advocated by Turnbull
Whether this by primarily at the time of and Weakley
[7], will require further study. Until such evidence is available, it is recommended that only primarily matured end transverse colostomies be performed in patients expected to require a colostomy for more than two to three weeks. Summary Loop transverse colostomies as usually constructed without immediate mucocutaneous anastomosis function poorly even a year later, with diarrheal fluid output approaching 1 liter/day on a regular diet. In
contrast, primarily matured end transverse colostomies produce an average of 750 cc/day at one month and 560 cc/day at nine to twelve months on a similar diet. A further reduction to 360 cc/day was achieved on an experimental 70 mEq sodium diet. It is suggested that end transverse colostomies with immediate maturation should be performed in all patients requiring a transverse colostomy for more than a very short time to markedly improve colostomy function. References 1. Levitan R, Fordtran JS, Burrows BA. et al: Water and salt absorption in the human colon. J C/in West 41: 1754, 1962. 2. Wright HK: Recent trends in surgery for diverticulitis. Corm Med 41: 647, 1978. 3. Brooke BN: The surgery of ulcerative colitis. Ann R Coil Surg Engl a: 440, 1951. 4. Warren R, McKittrick LS: lleostomy for ulcerative colitis. Surg Gynecol Obstet 93: 555, 1951. 5. Kramer P: The effect of varying sodium loads on the ileal excreta of human ileostomized subjects. J C/in /west 45: 1710,
Volume 137, April 1979
Colostomy
1966. 6. Debongnie JC, Phillips SF: Capacity of the human colon to absoct, fluid. Gestroenterology 74: 698, 1978. 7. Turnbull RB, Weakley FL: Atlas of Intestinal Stomas. St. Louis, C. V. Mosby, 1967.
Discussion
Claude E. Welch (Boston, MA),: Dr. Wright has suggested that maturation of the stoma may be the important feature that leads to lowered colostomy output. I am inclined to believe that another mechanism ought to be considered. With loop colostomies the colon wall is not divided completely. In many instances there is some fecal overflow, and there are retained feces in the distal part of the colon. It is quite possible that there is a reflex mediated through the intact colon wall that is initiated in the distal colon and then leads to a mass evacuation of the right side and increased output through the transverse colostomy. Dr. Wright’s observations are original. His method could be employed to answer other questions. For example, assuming that the left colon is intact, will a suppository in the rectum produce a similar or different fecal output from the transverse colon in patients with loop and divided colostomies? Perhaps, the condition of the left colon is more important in the determination of colostomy output than whether or not the colonic stoma has been matured. Malcolm C. Veidenheimer (Boston, MA): The major focus of this presentation has been the technic of transverse colostomy. As pointed out by Dr. Wright, these patients often undergo colostomy as an emergency procedure. In these circumstances the colostomy is frequently performed by less experienced surgeons under conditions of urgency and stress. The stoma may be opened later on the ward, often again under trying circumstances. The effluent from a transverse colostomy is liquid, like that from an ileostomy. Therefore, it, is vital that the stoma be fashioned in such a way that the liquid effluent can be collected without spillage and leakage. We believe that primary maturation of the colostomy, using the technic expounded by Dr. Rupert Turnbull, accomplishes a neat stoma and permits excellent appliance fitting. With this type of primary maturation, and utilizing an antimesocolic incision on the loop of at least 3 inches in length, an excellent spur develops between the afferent and efferent limbs of the stoma. Barium studies have demonstrated that spillage from the proximal to the distal limb in stomas made in this fashion does not occur. Several commercial appliances are available for use in such loop colostomies; those made by Hollister, Marson, and Coloplast all work very well. Hastings K. Wright (closing): As surgeons, we construct numerous ostomies, but we do not look at their function thereafter very much. Patients do, and find that they do not always work well. Consequently, as in the present studies, patients are very eager to cooperate in any possible studies that one might wish to do.
477
sumed a regular hospital diet adjusted to contain 170 mEq
Patients and ostomy nurses report that the function of transverse colostomies is notoriously poor, usually producing almost 1 liter of diarrhea a day on a normal diet and requiring a water-tight appliance even several months after construction. In fact, we have found that most transverse colostomies function little better than ileostomies, a surprising finding in view of the fact that such colostomies are distal to more than half the colon’s normal absorptive capacity [I]. Such poor function would be of little concern if transverse colostomies were only temporary vents. Yet, even in the surgical treatment of perforated left colon diverticulitis, more than two thirds of transverse colostomies are still intact six months after construction [2]. We therefore studied function of the different types of transverse colostomies over the six to twelve month period during which most patients have to contend with them, relating function to sodium intake, which is known to be a primary determinant of colostomy excretory volume.
sodium/day or 70 mEq sodium/day for four days, including a final 24 hour study period. The 170 mEq and 70 mEq sodium diets were selected because they represented the average amounts of sodium contained in a “normal” diet and the average amount lost from matured transverse colostomies on a I70 mElq sodium diet, respectively. Intake and output were recorded in the usual manner by nursing personnel; the amount of oral water intake was shown to bear no relationship to the 24 hour colostomy output. Each colostomy bag was collected at the end of the 24 hour period, and the 24 hour wet weight of excreta was determined by subtracting the previously measured weight of the empty bag from the weight of the bag plus the contents. The excreta were diluted with distilled water, homogenized, and an aliquot frozen until analysis. Solid content was measured by placing a 2 ml aliquot into a weighed bottle and drying the bottle and its contents to constant weight at 110°C. An aliquot of the homogenized excreta was digested with nitric acid, and the filtrate analyzed for sodium by flame photometry in the studies on 70 mEq sodium intakes.
Material and Methods
Results
Studies were performed in ten patients with loop transverse colostomies and ten patients with double-barreled end transverse colostomies approximately one month after colostomy construction for initial treatment of left colon perforated diverticulitis, and again nine to twelve months later when the patients were readmitted for colostomy closure. Informed consent was obtained from all patients after the protocol had been approved by the Yale Human Studies Committee. The loop colostomies had all healed by secondary intention, while the end colostomies
Approximately one month after colostomy construction, with all loop colostomies secondarily healed, loop colostomy patients excreted 910 f 160 gm of wet stool daily on a 170 mEq sodium diet. Patients with primarily matured end colostomies excreted 750 f 240 gm/day, an amount not significantly less than that excreted by loop colostomy patients. The dry weight of the excreta was similar in both groups. The amount and diarrhea1 nature of the excreta confirmed the clinical impression of patients and ostomy nurses that both types of transverse colostomies produce almost 1 liter of diarrhea1 stool one month after construction. Results at one month are summarized in Table I. However, at nine to twelve months after colostomy construction, end colostomy patients had significantly improved function compared with loop colostomy patients, excreting a mean of 560 f 174 gm/day of loose but not liquid stool on a 170 mEq sodium diet. In contrast, the loop colostomy patients
had had primary closure of the mucocutaneous junction. None showed clinical signs of obstruction. All patients were ambulatory during the study period, took no oral medication, took fluids ad libitum, and conFrom the Department of Surgery, Yale University School of Medicine and the Yale-New Haven Hospital, New Haven, Connecticut. This work was supported by USPHS grants AM14459 and CA16359. Reprint requests should be addressed to Hastings K. Wright, MD. Department of Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510. Presented at the Fifty-Ninth Annual Meeting of the New England Surgical Society, Dixville Notch, New Hampshire, September 29-October 1. 1976.
Volume 137, April 1979
475
Wright
TABLE I
Transverse Colostomy Function (mean f SD) in Patients on a 170 mEq Sodium Diet
Type of Transverse Colostomy
24 Hr Stool Weight (gm)
At 1 Month Loop colostomy End colostomy At 9 to 12 Months Loop colostomy End colostomy
Dry Weight (gm)
Consistency of stool
9 10 f 160 750 f 240’
41 f 10 45 f 6
Liquid Liquid
660 f 220 560 f 174+
45f 10 45 f 3
Liquid Loose
Weight not significantly different from loop colostomies at 1 month. + Compared with loop colostomies at 9 to 12 months (p < 0.01).
TABLE II
Colostomy Function of Four End Colostomy Patients on 70 mEq Sodium/Day Diets at 9 to 12 Months
Measurement
Average/Day
Wet stool weight Dry stool weight Sodium loss in stool Consistency
360 gm 43 gm (12%) 60 mEq Semisolid
l
showed no significant adaptation at all after nine to twelve months, excreting 880 f 220 gmfday of wet excreta compared to 910 f 160 gm one month after construction. The results at nine to twelve months are summarized in Table I. In four end colostomy patients placed on a 70 mEq sodium diet estimated to approximate mean sodium loss by transverse colostomy patients on a normal 170 mEq sodium intake, the wet weight of excreta was further reduced to a mean of 360 f 112 gm/day. More importantly, for the first time the excreta became semisolid. While continence could not be maintained similar to that possible after irrigations of sigmoid colostomies, the patients reported that transverse colostomy care was much improved at this low rate of semisolid excretion. Sodium loss on this 70 mEq sodium/day intake averaged 60 mEq in the stool, suggesting that chronic negative sodium balance would not be a consequence of this low sodium intake. However, further, more exact external sodium balance studies, including studies of urinary sodium losses conducted on a metabolic ward instead of on an open ward as in these studies, will be necessary to determine the exact ratio of sodium intake and output on this relatively low sodium diet. The results in the four end colostomy patients on 70 mEq sodium intakes are summarized in Table II. Comments
Surgeons generally have ignored the poor function of transverse colostomies, which is well known to patients and ostomy nurses, who consider them only temporary fecal diversions required in the emergency treatment of left colon obstruction or perforation. However, in our experience two-thirds of these “temporary” colostomies are still functioning six months later, and one-fourth one year later-and
476
functioning little better than ileostomies [2]. The present study indicates that the worst offenders are secondarily matured loop colostomies performed as emergencies without primary mucocutaneous suture. While such colostomies apparently have no mechanical obstruction on physical examination, they fail to adapt over nine to twelve months and continue to produce almost 1 liter/day of diarrhea1 fluid. Observation of these secondarily matured loop colostomies shows that many of them discharge effluent in “bursts” rather than continuously, as do end colostomies, suggesting that the nature of the loop itself or the long secondary healing process after colostomy construction produces a mild functional obstruction. The failure of these colostomies to mature reminds one of the partial obstruction noted by Brooke (31 and by Warren and McKittrick [4] in studying ileostomies not matured immediately by mucocutaneous anastomosis. In contrast to the continued poor function of loop transverse colostomies nine to twelve months after construction, primarily matured end colostomies demonstrated marked improvement in function, reducing the mean weight of excreta from 705 to 560 gm/day on a 170 mEq sodium diet over this period of time. The weight of effluent was further reduced to a mean of 360 gmlday when sodium intake was reduced to 70 mEq/day, a response akin to that demonstrated by Kramer [5] when he reduced average matured ileostomy output from approximately 600 to 500 gm/day on a similar low sodium diet. The data of Levitan ]I] suggest that half of the normal intact colon’s water absorptive capacity lies in the right colon. Debongnie and Phillips [6] also calculated that the normal intact colon absorbs approximately 1,500 cc/day on a normal sodium intake. Extrapolating from these two sets of data, it can be predicted that volume output from the midtransverse colon on a 170 mEq sodium diet should be in the range of 600 cc/day, a finding corroborated by our data showing an average of 560 gm output/day by matured end transverse colostomies on a normal (170 mEq sodium/day) intake. The further reduction
The American Journal of Surgery
Transverse
to an average of 360 gm/day on an experimental low sodium intake of 70 mEq/day is probably the lowest possible output achievable by a transverse colostomy patient, since further reductions in sodium intake may produce negative sodium balance due to obligatory sodium losses in excreta at the transverse colon level. While the crude balance data obtained in a hospital ward setting in this study suggest that a 70 mEq sodium diet will not produce negative sodium balance in patients with matured, well adapted end transverse colostomies, further external balance studies should be done under controlled conditions before recommending such low sodium diets to patients. The volume losses approaching 900 cc/day in patients on 170 mEq sodium diets up to a year after loop transverse colostomy strongly suggest that such
colostomies do not function efficiently. defect in function can be remedied maturing loop transverse colostomies construction, as advocated by Turnbull
Whether this by primarily at the time of and Weakley
[7], will require further study. Until such evidence is available, it is recommended that only primarily matured end transverse colostomies be performed in patients expected to require a colostomy for more than two to three weeks. Summary Loop transverse colostomies as usually constructed without immediate mucocutaneous anastomosis function poorly even a year later, with diarrheal fluid output approaching 1 liter/day on a regular diet. In
contrast, primarily matured end transverse colostomies produce an average of 750 cc/day at one month and 560 cc/day at nine to twelve months on a similar diet. A further reduction to 360 cc/day was achieved on an experimental 70 mEq sodium diet. It is suggested that end transverse colostomies with immediate maturation should be performed in all patients requiring a transverse colostomy for more than a very short time to markedly improve colostomy function. References 1. Levitan R, Fordtran JS, Burrows BA. et al: Water and salt absorption in the human colon. J C/in West 41: 1754, 1962. 2. Wright HK: Recent trends in surgery for diverticulitis. Corm Med 41: 647, 1978. 3. Brooke BN: The surgery of ulcerative colitis. Ann R Coil Surg Engl a: 440, 1951. 4. Warren R, McKittrick LS: lleostomy for ulcerative colitis. Surg Gynecol Obstet 93: 555, 1951. 5. Kramer P: The effect of varying sodium loads on the ileal excreta of human ileostomized subjects. J C/in /west 45: 1710,
Volume 137, April 1979
Colostomy
1966. 6. Debongnie JC, Phillips SF: Capacity of the human colon to absoct, fluid. Gestroenterology 74: 698, 1978. 7. Turnbull RB, Weakley FL: Atlas of Intestinal Stomas. St. Louis, C. V. Mosby, 1967.
Discussion
Claude E. Welch (Boston, MA),: Dr. Wright has suggested that maturation of the stoma may be the important feature that leads to lowered colostomy output. I am inclined to believe that another mechanism ought to be considered. With loop colostomies the colon wall is not divided completely. In many instances there is some fecal overflow, and there are retained feces in the distal part of the colon. It is quite possible that there is a reflex mediated through the intact colon wall that is initiated in the distal colon and then leads to a mass evacuation of the right side and increased output through the transverse colostomy. Dr. Wright’s observations are original. His method could be employed to answer other questions. For example, assuming that the left colon is intact, will a suppository in the rectum produce a similar or different fecal output from the transverse colon in patients with loop and divided colostomies? Perhaps, the condition of the left colon is more important in the determination of colostomy output than whether or not the colonic stoma has been matured. Malcolm C. Veidenheimer (Boston, MA): The major focus of this presentation has been the technic of transverse colostomy. As pointed out by Dr. Wright, these patients often undergo colostomy as an emergency procedure. In these circumstances the colostomy is frequently performed by less experienced surgeons under conditions of urgency and stress. The stoma may be opened later on the ward, often again under trying circumstances. The effluent from a transverse colostomy is liquid, like that from an ileostomy. Therefore, it, is vital that the stoma be fashioned in such a way that the liquid effluent can be collected without spillage and leakage. We believe that primary maturation of the colostomy, using the technic expounded by Dr. Rupert Turnbull, accomplishes a neat stoma and permits excellent appliance fitting. With this type of primary maturation, and utilizing an antimesocolic incision on the loop of at least 3 inches in length, an excellent spur develops between the afferent and efferent limbs of the stoma. Barium studies have demonstrated that spillage from the proximal to the distal limb in stomas made in this fashion does not occur. Several commercial appliances are available for use in such loop colostomies; those made by Hollister, Marson, and Coloplast all work very well. Hastings K. Wright (closing): As surgeons, we construct numerous ostomies, but we do not look at their function thereafter very much. Patients do, and find that they do not always work well. Consequently, as in the present studies, patients are very eager to cooperate in any possible studies that one might wish to do.
477
