Br. J. Surg. Vol. 63 (1976) 799-800
Is colostomy closure a hazardous procedure? A comparison of elemental diet and routine bowel preparation R. J. R. T O M L I N S O N , B. M. N E W M A N A N D P. F. S C H O F I E L D * SUMMARY
Morbidity after closure of a colostomy is low i f a simple antiseptic technique of intraperitoneal closure is used. In 26 patients there was no example of major wound sepsis and only 2 faecal fistulas both of which rapidly closed spontaneously. A randomized study of preoperative bowel preparation incorporating an elemental diet showed no apparent advantage for this method using our criteria for assessment. THEmarked morbidity and mortality associated with colostomy closure reported by Knox et al. (1971) stimulated this investigation. We felt that any morbidity after adequate closure of a colostomy was uncommon. The study was of sepsis rate and faecal leakage after colostomy closure of the intraperitoneal type. The suggestion that an elemental diet may be a good bowel preparation was investigated.
Patients and methods Twenty-six consecutive patients with loop stomas were studied. They were admitted 5 days prior to operation and randomly allocated, by the spin of a coin, to one of two types of bowel preparation. The first group received an orthodox preparation by repeated wash-outs of the distal lumen, a low residue diet for 48 hours followed by a fluid diet for 24 hours before operation. The second group received similar bowel wash-outs combined with an elemental diet (Vivonex) with flavouring for 5 days pre- and postoperatively. No patient received antibiotic preparation. In our regime Vivonex provided 1800 cal of glucose, 36g of essential amino acids and the normal daily requirements of fats, minerals and vitamins. Each group contained 13 patients of similar average age. The siting of the colostomy and the incidence of carcinoma and diverticular disease in the two groups were similar. Closure was by a standard technique. The colostomy was fully mobilized from the abdominal wall and all fibrous tissue excised to produce a ‘fresh’ colonic edge. Antiseptics (0.5 per cent Hibitane in spirit) were liberally used during the dissection. The colostomy was closed with seromuscular continuous 2/0 chromic catgut and interrupted thread reinforcing serosal sutures and then returned to the abdomen. The abdominal wall was closed with two layers of Dexon and interrupted silk skin sutures with simple drainage of the wound for 48 hours. The wound was inspected daily and the presence of sepsis or faecal fistula noted. Sepsis was classified simply into ‘wound abscess’, ‘persisting purulent discharge’, ‘transient
non-purulent discharge’ and ‘no discharge’. Changes in the patients’ weight and plasma proteins were noted as was the first day of passage of a formed motion.
Results There was no difference between the groups in the incidence of macroscopically clean bowel at operation, and no gross difference in wound sepsis. The routine group had 8 clean wounds, 4 with transient discharge and 1 faecal fistula. The elemental diet group had 10 clean wounds, 2 with transient discharge and 1 fistula. The day of first bowel action, loss of weight, drop in plasma proteins and length of postoperative stay were similar in both groups (Table I ) . Table I: FINDINGS AFTER COLOSTOMY CLOSURE Elemental diet Routine Albumin fall (g) Weight loss (kg) Function (d) Postoperative stay (d)
0.39 1.37 3.6 10.4
0.5 1.5 3.9 11.5
Discussion The operation of colostomy closure has long had a bad, and probably undeserved, reputation for breakdown and subsequent leakage of faeces. Knox et al. (1971) reported a faecal fistula rate of 23 per cent and a mortality of 2.2 per cent in 179 patients, and a subsequent Leading Article (1971) in the British Medical Journal further emphasized these apparent hazards. We felt that with adequate bowel preparation producing a clean gut, adequate mobilization and removal of fibrous tissue to obtain a pliable colon to suture, use of an antiseptic technique and careful intraperitoneal closure, the incidence of leakage, sepsis and morbidity from colostomy closure is low. Our figures show no major sepsis, no reoperation and a clinical leakage rate of 7.6 per cent. Thomson and Hawley (1972) reported even better figures in 139 patients, with an incidence of anastomotic breakdown of 2.9 per cent. We feel, therefore, that the hazards of colostomy closure may have been over-emphasized, and it should be regarded as a relatively safe practical procedure.
* Park Hospital, Davyhulme, Manchester, and Department of Surgery, Manchester Royal Infirmary. Present address of R. J. R. Tomlinson and P. F. Schofield: Withington Hospital, West Didshury, Manchester. 799
R. J. R. Tomlinson et al. Winitz et al. (1970) have established the lowering of faecal bulk and reported decreased faecal bacterial levels on an elemental diet. This provides a rational reason for suggesting that it may be a satisfactory method of bowel preparation, especially as it provides a means of maintaining a reasonable caloric and nitrogen intake in the immediate preoperative period. Glotzer et al. (1973), however, showed no decrease in faecal bacterial levels in colonic surgery and Cooney et al. (1974) no decrease in anastomotic leakage in animal experiments. Johnson (1974), in a mixed group of colonic operations, found no difference in wound infection or enterocolitis in patients on an elemental diet. In our series we have shown no significant advantage in using an elemental diet as a bowel preparation, and we have estimated that in order to show even a marginal advantage a very large study would be needed. It appears that both an elemental diet and our routine bowel preparation are effective.
Acknowledgement We wish to thank Eaton Laboratories Ltd for the supply of Vivonex.
800
References et al. (1974) Are elemental diets useful in bowel preparation ? Arch. Surg. 109, 206-210. GLOTZER D. J., BOYLE P. L. and SILEN w. (1973) Preoperative preparation of the colon with an elemental diet. Surgery 74, 703-707. JOHNSON w. v. (1974) Oral elemental diet. Arch. Surg. 108, 32-34. KNOX A. J. s., BIRKETT F. D. H. and COLLINS c. D. (1971) Closure of colostomy. Br. J. Surg. 58, 669-672. LEADING ARTICLE (1971) Hazards of colostomy closure. Br. Med. J. 4, 380. THOMSON J. P. s. and HAWLEY P. R. (1972) Results of closure of loop transverse colostomies. Br. Med. J. 3, 459462. WINITZ M., ADAMS R. F., SEEDMAN D. A. et al. (1970) Studies in metabolic nutrition employing chemically defined diets. Am. J . Clin. Nutr. 23, 525-559. COONEY D. R., WASSNER J. D., GROSFELD J. L.
Is colostomy closure a hazardous procedure? A comparison of elemental diet and routine bowel preparation R. J. R. T O M L I N S O N , B. M. N E W M A N A N D P. F. S C H O F I E L D * SUMMARY
Morbidity after closure of a colostomy is low i f a simple antiseptic technique of intraperitoneal closure is used. In 26 patients there was no example of major wound sepsis and only 2 faecal fistulas both of which rapidly closed spontaneously. A randomized study of preoperative bowel preparation incorporating an elemental diet showed no apparent advantage for this method using our criteria for assessment. THEmarked morbidity and mortality associated with colostomy closure reported by Knox et al. (1971) stimulated this investigation. We felt that any morbidity after adequate closure of a colostomy was uncommon. The study was of sepsis rate and faecal leakage after colostomy closure of the intraperitoneal type. The suggestion that an elemental diet may be a good bowel preparation was investigated.
Patients and methods Twenty-six consecutive patients with loop stomas were studied. They were admitted 5 days prior to operation and randomly allocated, by the spin of a coin, to one of two types of bowel preparation. The first group received an orthodox preparation by repeated wash-outs of the distal lumen, a low residue diet for 48 hours followed by a fluid diet for 24 hours before operation. The second group received similar bowel wash-outs combined with an elemental diet (Vivonex) with flavouring for 5 days pre- and postoperatively. No patient received antibiotic preparation. In our regime Vivonex provided 1800 cal of glucose, 36g of essential amino acids and the normal daily requirements of fats, minerals and vitamins. Each group contained 13 patients of similar average age. The siting of the colostomy and the incidence of carcinoma and diverticular disease in the two groups were similar. Closure was by a standard technique. The colostomy was fully mobilized from the abdominal wall and all fibrous tissue excised to produce a ‘fresh’ colonic edge. Antiseptics (0.5 per cent Hibitane in spirit) were liberally used during the dissection. The colostomy was closed with seromuscular continuous 2/0 chromic catgut and interrupted thread reinforcing serosal sutures and then returned to the abdomen. The abdominal wall was closed with two layers of Dexon and interrupted silk skin sutures with simple drainage of the wound for 48 hours. The wound was inspected daily and the presence of sepsis or faecal fistula noted. Sepsis was classified simply into ‘wound abscess’, ‘persisting purulent discharge’, ‘transient
non-purulent discharge’ and ‘no discharge’. Changes in the patients’ weight and plasma proteins were noted as was the first day of passage of a formed motion.
Results There was no difference between the groups in the incidence of macroscopically clean bowel at operation, and no gross difference in wound sepsis. The routine group had 8 clean wounds, 4 with transient discharge and 1 faecal fistula. The elemental diet group had 10 clean wounds, 2 with transient discharge and 1 fistula. The day of first bowel action, loss of weight, drop in plasma proteins and length of postoperative stay were similar in both groups (Table I ) . Table I: FINDINGS AFTER COLOSTOMY CLOSURE Elemental diet Routine Albumin fall (g) Weight loss (kg) Function (d) Postoperative stay (d)
0.39 1.37 3.6 10.4
0.5 1.5 3.9 11.5
Discussion The operation of colostomy closure has long had a bad, and probably undeserved, reputation for breakdown and subsequent leakage of faeces. Knox et al. (1971) reported a faecal fistula rate of 23 per cent and a mortality of 2.2 per cent in 179 patients, and a subsequent Leading Article (1971) in the British Medical Journal further emphasized these apparent hazards. We felt that with adequate bowel preparation producing a clean gut, adequate mobilization and removal of fibrous tissue to obtain a pliable colon to suture, use of an antiseptic technique and careful intraperitoneal closure, the incidence of leakage, sepsis and morbidity from colostomy closure is low. Our figures show no major sepsis, no reoperation and a clinical leakage rate of 7.6 per cent. Thomson and Hawley (1972) reported even better figures in 139 patients, with an incidence of anastomotic breakdown of 2.9 per cent. We feel, therefore, that the hazards of colostomy closure may have been over-emphasized, and it should be regarded as a relatively safe practical procedure.
* Park Hospital, Davyhulme, Manchester, and Department of Surgery, Manchester Royal Infirmary. Present address of R. J. R. Tomlinson and P. F. Schofield: Withington Hospital, West Didshury, Manchester. 799
R. J. R. Tomlinson et al. Winitz et al. (1970) have established the lowering of faecal bulk and reported decreased faecal bacterial levels on an elemental diet. This provides a rational reason for suggesting that it may be a satisfactory method of bowel preparation, especially as it provides a means of maintaining a reasonable caloric and nitrogen intake in the immediate preoperative period. Glotzer et al. (1973), however, showed no decrease in faecal bacterial levels in colonic surgery and Cooney et al. (1974) no decrease in anastomotic leakage in animal experiments. Johnson (1974), in a mixed group of colonic operations, found no difference in wound infection or enterocolitis in patients on an elemental diet. In our series we have shown no significant advantage in using an elemental diet as a bowel preparation, and we have estimated that in order to show even a marginal advantage a very large study would be needed. It appears that both an elemental diet and our routine bowel preparation are effective.
Acknowledgement We wish to thank Eaton Laboratories Ltd for the supply of Vivonex.
800
References et al. (1974) Are elemental diets useful in bowel preparation ? Arch. Surg. 109, 206-210. GLOTZER D. J., BOYLE P. L. and SILEN w. (1973) Preoperative preparation of the colon with an elemental diet. Surgery 74, 703-707. JOHNSON w. v. (1974) Oral elemental diet. Arch. Surg. 108, 32-34. KNOX A. J. s., BIRKETT F. D. H. and COLLINS c. D. (1971) Closure of colostomy. Br. J. Surg. 58, 669-672. LEADING ARTICLE (1971) Hazards of colostomy closure. Br. Med. J. 4, 380. THOMSON J. P. s. and HAWLEY P. R. (1972) Results of closure of loop transverse colostomies. Br. Med. J. 3, 459462. WINITZ M., ADAMS R. F., SEEDMAN D. A. et al. (1970) Studies in metabolic nutrition employing chemically defined diets. Am. J . Clin. Nutr. 23, 525-559. COONEY D. R., WASSNER J. D., GROSFELD J. L.
