The Morbidity and Mortality of Colostomy Closure*
FAROUQSAMHOURI,M.D., CARLOS GRODSINSKY, M.D. T o o OFTEN COLOSTOMY CLOSURE is r e g a r d e d as m i n o r s u r g e r y . H o w e v e r review o f the l i t e r a t u r e shows that it can lead to significant complications. In addition to r e p o r t e d complication rates ranging f r o m 10 to 49 per cent, 2,a'4"r'9"l~ the mortality rate has been r e p o r t e d up to 4.2 per cent? "*e W h e n this p r o c e d u r e is considered for what it really is, a colonic resection, those rates can be considerably lowered. Previous e x p e r i e n c e f r o m H e n r y Ford Hospital was r e p o r t e d by Fallis and B a r t o n in 1958. ~ In this retrospective analysis o f o u r e x p e r i e n c e with colostomy closure at this institution f r o m 1967 to 1977, we have reviewed certain points we believe are i m p o r t a n t in o r d e r to lower the mortality and morbidity rates.
Materials and Methods T h e indications for colostorny in 304 patients, who u n d e r w e n t closure o f colostomy at the H e n r y Ford Hospital f r o m 1967 to 1977, are summarized in Table 1. T h e 206 male and 98 female patients r a n g e d in age f r o m six months to 89 years (Table 2). O f the loop colostomies constructed, 214 were in the transverse colon; 43, in the left colon; and 47, in the right colon (Table 3). Drains were used in 184 patients (39 intraperitoneal, 145 subcutaneous). Spinal anesthesia was used in 186 patients, general endotracheal in 106, and local anesthesia in 12 patients. All p a t i e n t s h a d m e c h a n i c a l c l e a n s i n g o f the bowel preoperatively and received oral nonabsorbable antibiotics. Systemic antibiotics were used in selected cases. All patients u n d e r w e n t b a r i u m - e n e m a examination before closure to rule out distal obstruction.
Technique We used the i n t r a p e r i t o n e a l closure t e c h n i q u e . After the skin was p r e p a r e d with p H i s o H e x | solution, the stoma was closed with a purse string o f r o p e silk; the skin was then p r e p a r e d again with Betadine | solution. An ellipse o f skin s u r r o u n d i n g the colostomy was excised and dissection carried down to the fascia, a f t e r w h i c h the c o l o n was c l e a r e d f r o m peritoneal and omental attachments. T h e terminal everted edges o f the colostomy were then excised,
From Department of Surgery, Henry Ford Hospital, L)etroit, Michigan
and anastomosis was c o m p l e t e d in a two-layer closure. T h e n the bowel was d r o p p e d into the p e r i t o n e a l cavity. I f an intraperitoneal drain is used, it was b r o u g h t t h r o u g h a separate stab w o u n d , followed by closure o f the p e r i t o n e u m with absorbable sutures and of the fascia with n o n a b s o r b a b l e sutures. S u b c u t a n e o u s drains in wicks were inserted in 145 patients; 17 dev e l o p e d w o u n d infections. O f the 120 patients in whom no drains were used, 12 developed w o u n d infections (Table 4). Seven patients d e v e l o p e d fecal fistulas (an incidence o f 2.3 per cent), f o u r o f whom had drains and three o f whom did not (Table 4). T h e s e fistulas closed spontaneously without f u r t h e r surgery.
Results T h e average interval before colostomy closure in o u r series was 3.6 m o n t h s in 296 patients. O f the remaining eight patients, the operation was d o n e at two years in four patients, three years in one patient, f o u r years in two patients, and after five years in one patient. Hence, in these patients we cannot correlate the complication rate to the time o f closure. In 266 patients the average follow up was 42.5 months. T h e r e m a i n i n g 38 patients were lost to follow-up (Table 5). T h e average hospital stay was 15 days. T h e overall complication rate was 14 per cent, with 71 complications in 43 patients: 29 patients had w o u n d infection, two patients had w o u n d seromas, and seven patients d e v e l o p e d fecal fistula that later closed spontaneously (Table 6). O n e patient was c o n s i d e r e d an operative mortality, an incidence of 0.3 per cent. H e was a 37-year-old man who u n d e r w e n t colostomy for Crohn's disease with closure a t t e m p t e d t h r e e weeks later. Anastomotic dehiscence was succeeded by peritonitis and death quickly followed.
Discussion * Received for publication April 5, 1979. Address reprint requests to Dr. Grodsinsky, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, Michigan 48202.
T h e essentials o f the colostomy closure were described as early as 1917 by L o c k h a r t - M u m m e r y , 8 who
0012-3706/79/0700/0312/$00.65 9 American Society of Colon and Rectal Surgeons 312
Volume 2'2
313
MORBIDITY AND MORTALITY OF COLOSTOMY CLOSURE
Number 5
TABLE 1. Indications for Colostomy
TABLE 5. Follow Up Number of Patients 119 74 48 17
Trauma
Complicated diverticulitis Obstructing colonic carcinoma Genitourinary Miscellaneous (ischemic colitis volvulus, iatrogenic* perforated appendicitis)
Period of Follow Up 3-6 months 1-2 years 2-3 years 3-4 years 5-10 years Lost to follow up
Number of Patients 21 63 79 27 76 266 38
46 TOTAL
TOTAL
304
304
* Treated with diverting colostom~.
TABLE 6. Postoperative Complications in 43 Patie'nts*
TABLE 2. Distribution According to Sex and Age
Sex
Number of Patients
Age (Years)
Number of Patients
Male Female
206 98
0-10 11-20
4 15
304
20-29 30-39 40-49 50-59 60-69 70-79 80-89
59 41 34 53 51 43 4
TOTAL
304
~'OTAL
Number of Complications Wound infections Prolonged ileus Urinary tract infection Fecal fistula Pneumonia Wound seroma Wound dehiscence Pulmonary embolism Acute tubular necrosis Septicemia TOTAL
29 16 10 7 3 2 1 1 1 1 71
* Average hospital stay was 15 days. TABLE 3.
Type of Colostomy Number of Patients
Transverse Left sided Right sided
214 43 47
TOTAL
304
TABLE 4. Incidence of Wound Infection and Fecal Fistulas Related to Use of Drains Number of Points Drains Intraperitoneal Subcutaneous No Drains TOTALS
Wound Infections
Fecal Fistulas
17
4
120
12
3
304
29
7
184 39 145
p r a c t i c e d s u t u r e o f the s t o m a , i n t r a p e r i t o n e a l placem e n t o f the a n a s t o m o s i s , a n d d r a i n a g e o f t h e w o u n d . Since t h e n , t h e r e h a v e b e e n m a n y r e p o r t s o f a dist u r b i n g l y h i g h c o m p l i c a t i o n rate ( T a b l e 7). I n 1958, B a r t o n a n d Fallis, 1 f r o m H e n r y F o r d H o s p i t a l , rep o r t e d m o r e t h a n 200 i n t r a p e r i t o n e a l c o l o s t o m y clos u r e s with n o d e a t h s a n d o n l y o n e a n a s t o m o t i c leak with a t e m p o r a r y fistula. S i m i l a r results have b e e n r e p o r t e d by T h o m s o n a n d H a w l e y 11 a n d o t h e r s . I n o u r p r e s e n t series, we h a d o n e d e a t h (a m o r t a l i t y rate o f less t h a n 0.3 p e r cent) a n d a c o m p l i c a t i o n rate o f 14 p e r cent. Classically, c o m p l i c a t i o n s a r i s i n g f r o m c l o s u r e o f c o l o s t o m y are r e l a t e d to b a c t e r i a l w o u n d i n f e c t i o n , l e a k a g e at the a n a s t o m o t i c line, b o w e l o b s t r u c t i o n , o r incisional hernia. Wound Infection: An open colostomy introduces bacterial organisms into the w o u n d which may overwhelm the body's defense mechanisms. However, m e c h a n i c a l a n d a n t i b i o t i c b o w e l p r e p a r a t i o n with a m e t i c u l o u s s u r g i c a l t e c h n i q u e will r e d u c e the n u m b e r o f these o r g a n i s m s so t h a t the p a t i e n t ' s h u m o r a l a n d
3 14
Dis. Col. & Rect.
SAMHOURI AND GRODSINSKY
july-August 1979
TABLE 7. Colostomy Closure Complications
Reference Barron and Fallis (1958) 1 Knox et al. (1971) v Thomson and Hawley (1972) x~ Yakimets (1975) ~a Beck and Conklin (1975) 2 Finch (1976) a Wheeler and Barker (1976) ~a Hines and Harris (1977) 5 Mitchell et al. (1977) 10 Garnjobst et al. (1978) 4 Mirehnan et al. (1978) 9 Present report
Number of Patients
Complications (per cent)
Fecal Fistulas (per cent)
Mortality (per cent)
900 179 191 71 213 213 73 100 89 125 118 304
0.5 35.7 21.5 49 15.5 44.0 37.8 17 33 9.6 49.1 14
0.5 23.0 2.9 2.8 2.6 9.0 17.6 1 5.6 0 9.3 2.3
0 2.2 0 2.8 0 0.4 2.7 1 2.2 0 4.2 0.3
cellular defense mechanisms can handle them. P r e o p e r a t i v e l y we rarely use p r o p h y l a c t i c systemic antibiotics. It is i m p o r t a n t to e m p h a s i z e the n e e d o f closing the s t o m a a n d r e p r e p a r i n g b e f o r e the o p e r a t i o n b e g i n s in o r d e r to r e d u c e c o n t a m i n a t i o n . It is o f interest that the use o f s u b c u t a n e o u s drains did n o t s e e m to a f f e c t t h e i n c i d e n c e o f w o u n d i n f e c t i o n significantly. Timing: A n y c o l o s t o m y closure less t h a n t h r e e weeks old, we believe, is still a fresh w o u n d . A six- to e i g h t - w e e k delay allows the c o l o s t o m y w o u n d to mature and provides for nutritional and lean-body-mass repletion, so that the patient has a better cellular a n d h u m o r a l r e s p o n s e . I n o u r series, the a v e r a g e time was 3.6 m o n t h s in 296 patients. I n the r e m a i n i n g eight patients, closure was a c c o m p l i s h e d after two to five years. T h e o n l y mortality in o u r series was that o f a 3 7 - y e a r - o l d p a t i e n t in w h o m closure at t h r e e weeks was f o l l o w e d by a n a s t o m o t i c d e h i s c e n c e a n d fatal peritonitis. Fecal Fistulas: Seven patients d e v e l o p e d fecal fistulas (an i n c i d e n c e o f 2.3 p e r cent) which did not s e e m to be i n f l u e n c e d by the use o f drains, a l t h o u g h t h e y m a y h a v e p r e v e n t e d the o c c u r r e n c e o f fatal peritonitis. T h i s i n c i d e n c e is c o n s i d e r a b l y lower t h a n m o s t r e p o r t e d series. All fistulas closed s p o n t a n e o u s l y without additional surgery. Late Complications: O f 276 patients, nine dev e l o p e d c o m p l i c a t i o n s d u r i n g the follow-up p e r i o d , f o r a 3.26 p e r c e n t i n c i d e n c e . F o u r p a t i e n t s h a d s m a l l - b o w e l o b s t r u c t i o n , two o f w h o m h a d to be treated surgically. Two patients had large-bowel obstruction, o n e necessitating cecostomy. T h r e e patients u n d e r w e n t r e p a i r o f incisional hernias. We believe t h a t the t e c h n i q u e o f resection a n d o p e n anastomosis is p r e f e r a b l e to simple closure. C a r e f u l a t t e n t i o n to technical details w o u l d also result in lower mortality a n d m o r b i d i t y rates. F u r t h e r m o r e , this ope r a t i o n takes no l o n g e r t h a n a simple closure.
Summary R e t r o s p e c t i v e analysis was d o n e o f 304 patients who u n d e r w e n t c o l o s t o m y closure at H e n r y F o r d H o s p i t a l b e t w e e n 1967 a n d 1977. A mortality o f less t h a n 0.3 p e r cent a n d a m o r b i d i t y rate o f 14 p e r cent, with an a v e r a g e hospital stay o f 15 days, is h e r e b y r e p o r t e d . W o u n d infection was the m o s t c o m m o n c o m p l i c a t i o n with an i n c i d e n c e o f 9.5 p e r cent. Late c o m p l i c a t i o n s d u r i n g the s t u d y p e r i o d w e r e less t h a n 3 p e r cent. I n o u r e x p e r i e n c e , if the i n t r a p e r i t o n e a l closure t e c h n i q u e with resection a n d a n a s t o m o s i s is used, col o s t o m y closure can be a safe p r o c e d u r e with m i n i m a l mortality a n d m o r b i d i t y . W e believe c o l o s t o m y clos u r e s h o u l d be c o n s i d e r e d as n o t h i n g less t h a n a m a j o r colonic resection.
References 1. Barron J, Fallis LS: Colostomy closure by the intraperitoneaI method. Dis Colon Rectum 1: 466, 1958 2. Beck PH, Conklin MB: Closure of colostomy. Ann Surg 181: 795, 1975 3. Finch DR: The results of colostomy closure. Br] Surg 63: 397, 1976 4. Garnjobst W, Leaverton GH, Sullivan ES: Safety of colostomy closure. Am J Surg 136: 85, 1978 5. Hines JR, Harris GD: Colostomy and colostomy closure. Surg Clin North Am 57:1379 (DEC) 1977 6. Irvin TT, Goligher JC: Aetiology of disruption of intestinal anastomoses. BrJ Surg 60: 461, 1973 7. Knox AJ, Birkett FD, Collins CD: Closure of colostomy. Br J Surg 58: 669, 1971 8. Lockhart-Mummery P: Making and closing ofcolostomy openings. Br MedJ 1: 685, 1917 9. Mirelman D, Corman ML, Veidenheimer MC, et al: Colostomies--indications and contradictions: Lahey Clinic experience, 1963-1974. Dis Colon Rectum 21: 172, 1978 10. Mitchell WH, Kovalcik PJ, Cross GH: Complications of colostomy closure. Dis Colon Rectum 21: 180, 1978 11. Thomson JP, Hawley PR: Results of closure of loop transverse colostomies. Br Med J 3: 459, 1972 12. Wheeler MH, Barker J: Closure of colosmmy--a safe procedure? Dis Colon Rectum 20: 29, 1977 13. Yakimets WW: Complications of closure of loop colostomy. CanJ Surg 18: 366, 1975
FAROUQSAMHOURI,M.D., CARLOS GRODSINSKY, M.D. T o o OFTEN COLOSTOMY CLOSURE is r e g a r d e d as m i n o r s u r g e r y . H o w e v e r review o f the l i t e r a t u r e shows that it can lead to significant complications. In addition to r e p o r t e d complication rates ranging f r o m 10 to 49 per cent, 2,a'4"r'9"l~ the mortality rate has been r e p o r t e d up to 4.2 per cent? "*e W h e n this p r o c e d u r e is considered for what it really is, a colonic resection, those rates can be considerably lowered. Previous e x p e r i e n c e f r o m H e n r y Ford Hospital was r e p o r t e d by Fallis and B a r t o n in 1958. ~ In this retrospective analysis o f o u r e x p e r i e n c e with colostomy closure at this institution f r o m 1967 to 1977, we have reviewed certain points we believe are i m p o r t a n t in o r d e r to lower the mortality and morbidity rates.
Materials and Methods T h e indications for colostorny in 304 patients, who u n d e r w e n t closure o f colostomy at the H e n r y Ford Hospital f r o m 1967 to 1977, are summarized in Table 1. T h e 206 male and 98 female patients r a n g e d in age f r o m six months to 89 years (Table 2). O f the loop colostomies constructed, 214 were in the transverse colon; 43, in the left colon; and 47, in the right colon (Table 3). Drains were used in 184 patients (39 intraperitoneal, 145 subcutaneous). Spinal anesthesia was used in 186 patients, general endotracheal in 106, and local anesthesia in 12 patients. All p a t i e n t s h a d m e c h a n i c a l c l e a n s i n g o f the bowel preoperatively and received oral nonabsorbable antibiotics. Systemic antibiotics were used in selected cases. All patients u n d e r w e n t b a r i u m - e n e m a examination before closure to rule out distal obstruction.
Technique We used the i n t r a p e r i t o n e a l closure t e c h n i q u e . After the skin was p r e p a r e d with p H i s o H e x | solution, the stoma was closed with a purse string o f r o p e silk; the skin was then p r e p a r e d again with Betadine | solution. An ellipse o f skin s u r r o u n d i n g the colostomy was excised and dissection carried down to the fascia, a f t e r w h i c h the c o l o n was c l e a r e d f r o m peritoneal and omental attachments. T h e terminal everted edges o f the colostomy were then excised,
From Department of Surgery, Henry Ford Hospital, L)etroit, Michigan
and anastomosis was c o m p l e t e d in a two-layer closure. T h e n the bowel was d r o p p e d into the p e r i t o n e a l cavity. I f an intraperitoneal drain is used, it was b r o u g h t t h r o u g h a separate stab w o u n d , followed by closure o f the p e r i t o n e u m with absorbable sutures and of the fascia with n o n a b s o r b a b l e sutures. S u b c u t a n e o u s drains in wicks were inserted in 145 patients; 17 dev e l o p e d w o u n d infections. O f the 120 patients in whom no drains were used, 12 developed w o u n d infections (Table 4). Seven patients d e v e l o p e d fecal fistulas (an incidence o f 2.3 per cent), f o u r o f whom had drains and three o f whom did not (Table 4). T h e s e fistulas closed spontaneously without f u r t h e r surgery.
Results T h e average interval before colostomy closure in o u r series was 3.6 m o n t h s in 296 patients. O f the remaining eight patients, the operation was d o n e at two years in four patients, three years in one patient, f o u r years in two patients, and after five years in one patient. Hence, in these patients we cannot correlate the complication rate to the time o f closure. In 266 patients the average follow up was 42.5 months. T h e r e m a i n i n g 38 patients were lost to follow-up (Table 5). T h e average hospital stay was 15 days. T h e overall complication rate was 14 per cent, with 71 complications in 43 patients: 29 patients had w o u n d infection, two patients had w o u n d seromas, and seven patients d e v e l o p e d fecal fistula that later closed spontaneously (Table 6). O n e patient was c o n s i d e r e d an operative mortality, an incidence of 0.3 per cent. H e was a 37-year-old man who u n d e r w e n t colostomy for Crohn's disease with closure a t t e m p t e d t h r e e weeks later. Anastomotic dehiscence was succeeded by peritonitis and death quickly followed.
Discussion * Received for publication April 5, 1979. Address reprint requests to Dr. Grodsinsky, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, Michigan 48202.
T h e essentials o f the colostomy closure were described as early as 1917 by L o c k h a r t - M u m m e r y , 8 who
0012-3706/79/0700/0312/$00.65 9 American Society of Colon and Rectal Surgeons 312
Volume 2'2
313
MORBIDITY AND MORTALITY OF COLOSTOMY CLOSURE
Number 5
TABLE 1. Indications for Colostomy
TABLE 5. Follow Up Number of Patients 119 74 48 17
Trauma
Complicated diverticulitis Obstructing colonic carcinoma Genitourinary Miscellaneous (ischemic colitis volvulus, iatrogenic* perforated appendicitis)
Period of Follow Up 3-6 months 1-2 years 2-3 years 3-4 years 5-10 years Lost to follow up
Number of Patients 21 63 79 27 76 266 38
46 TOTAL
TOTAL
304
304
* Treated with diverting colostom~.
TABLE 6. Postoperative Complications in 43 Patie'nts*
TABLE 2. Distribution According to Sex and Age
Sex
Number of Patients
Age (Years)
Number of Patients
Male Female
206 98
0-10 11-20
4 15
304
20-29 30-39 40-49 50-59 60-69 70-79 80-89
59 41 34 53 51 43 4
TOTAL
304
~'OTAL
Number of Complications Wound infections Prolonged ileus Urinary tract infection Fecal fistula Pneumonia Wound seroma Wound dehiscence Pulmonary embolism Acute tubular necrosis Septicemia TOTAL
29 16 10 7 3 2 1 1 1 1 71
* Average hospital stay was 15 days. TABLE 3.
Type of Colostomy Number of Patients
Transverse Left sided Right sided
214 43 47
TOTAL
304
TABLE 4. Incidence of Wound Infection and Fecal Fistulas Related to Use of Drains Number of Points Drains Intraperitoneal Subcutaneous No Drains TOTALS
Wound Infections
Fecal Fistulas
17
4
120
12
3
304
29
7
184 39 145
p r a c t i c e d s u t u r e o f the s t o m a , i n t r a p e r i t o n e a l placem e n t o f the a n a s t o m o s i s , a n d d r a i n a g e o f t h e w o u n d . Since t h e n , t h e r e h a v e b e e n m a n y r e p o r t s o f a dist u r b i n g l y h i g h c o m p l i c a t i o n rate ( T a b l e 7). I n 1958, B a r t o n a n d Fallis, 1 f r o m H e n r y F o r d H o s p i t a l , rep o r t e d m o r e t h a n 200 i n t r a p e r i t o n e a l c o l o s t o m y clos u r e s with n o d e a t h s a n d o n l y o n e a n a s t o m o t i c leak with a t e m p o r a r y fistula. S i m i l a r results have b e e n r e p o r t e d by T h o m s o n a n d H a w l e y 11 a n d o t h e r s . I n o u r p r e s e n t series, we h a d o n e d e a t h (a m o r t a l i t y rate o f less t h a n 0.3 p e r cent) a n d a c o m p l i c a t i o n rate o f 14 p e r cent. Classically, c o m p l i c a t i o n s a r i s i n g f r o m c l o s u r e o f c o l o s t o m y are r e l a t e d to b a c t e r i a l w o u n d i n f e c t i o n , l e a k a g e at the a n a s t o m o t i c line, b o w e l o b s t r u c t i o n , o r incisional hernia. Wound Infection: An open colostomy introduces bacterial organisms into the w o u n d which may overwhelm the body's defense mechanisms. However, m e c h a n i c a l a n d a n t i b i o t i c b o w e l p r e p a r a t i o n with a m e t i c u l o u s s u r g i c a l t e c h n i q u e will r e d u c e the n u m b e r o f these o r g a n i s m s so t h a t the p a t i e n t ' s h u m o r a l a n d
3 14
Dis. Col. & Rect.
SAMHOURI AND GRODSINSKY
july-August 1979
TABLE 7. Colostomy Closure Complications
Reference Barron and Fallis (1958) 1 Knox et al. (1971) v Thomson and Hawley (1972) x~ Yakimets (1975) ~a Beck and Conklin (1975) 2 Finch (1976) a Wheeler and Barker (1976) ~a Hines and Harris (1977) 5 Mitchell et al. (1977) 10 Garnjobst et al. (1978) 4 Mirehnan et al. (1978) 9 Present report
Number of Patients
Complications (per cent)
Fecal Fistulas (per cent)
Mortality (per cent)
900 179 191 71 213 213 73 100 89 125 118 304
0.5 35.7 21.5 49 15.5 44.0 37.8 17 33 9.6 49.1 14
0.5 23.0 2.9 2.8 2.6 9.0 17.6 1 5.6 0 9.3 2.3
0 2.2 0 2.8 0 0.4 2.7 1 2.2 0 4.2 0.3
cellular defense mechanisms can handle them. P r e o p e r a t i v e l y we rarely use p r o p h y l a c t i c systemic antibiotics. It is i m p o r t a n t to e m p h a s i z e the n e e d o f closing the s t o m a a n d r e p r e p a r i n g b e f o r e the o p e r a t i o n b e g i n s in o r d e r to r e d u c e c o n t a m i n a t i o n . It is o f interest that the use o f s u b c u t a n e o u s drains did n o t s e e m to a f f e c t t h e i n c i d e n c e o f w o u n d i n f e c t i o n significantly. Timing: A n y c o l o s t o m y closure less t h a n t h r e e weeks old, we believe, is still a fresh w o u n d . A six- to e i g h t - w e e k delay allows the c o l o s t o m y w o u n d to mature and provides for nutritional and lean-body-mass repletion, so that the patient has a better cellular a n d h u m o r a l r e s p o n s e . I n o u r series, the a v e r a g e time was 3.6 m o n t h s in 296 patients. I n the r e m a i n i n g eight patients, closure was a c c o m p l i s h e d after two to five years. T h e o n l y mortality in o u r series was that o f a 3 7 - y e a r - o l d p a t i e n t in w h o m closure at t h r e e weeks was f o l l o w e d by a n a s t o m o t i c d e h i s c e n c e a n d fatal peritonitis. Fecal Fistulas: Seven patients d e v e l o p e d fecal fistulas (an i n c i d e n c e o f 2.3 p e r cent) which did not s e e m to be i n f l u e n c e d by the use o f drains, a l t h o u g h t h e y m a y h a v e p r e v e n t e d the o c c u r r e n c e o f fatal peritonitis. T h i s i n c i d e n c e is c o n s i d e r a b l y lower t h a n m o s t r e p o r t e d series. All fistulas closed s p o n t a n e o u s l y without additional surgery. Late Complications: O f 276 patients, nine dev e l o p e d c o m p l i c a t i o n s d u r i n g the follow-up p e r i o d , f o r a 3.26 p e r c e n t i n c i d e n c e . F o u r p a t i e n t s h a d s m a l l - b o w e l o b s t r u c t i o n , two o f w h o m h a d to be treated surgically. Two patients had large-bowel obstruction, o n e necessitating cecostomy. T h r e e patients u n d e r w e n t r e p a i r o f incisional hernias. We believe t h a t the t e c h n i q u e o f resection a n d o p e n anastomosis is p r e f e r a b l e to simple closure. C a r e f u l a t t e n t i o n to technical details w o u l d also result in lower mortality a n d m o r b i d i t y rates. F u r t h e r m o r e , this ope r a t i o n takes no l o n g e r t h a n a simple closure.
Summary R e t r o s p e c t i v e analysis was d o n e o f 304 patients who u n d e r w e n t c o l o s t o m y closure at H e n r y F o r d H o s p i t a l b e t w e e n 1967 a n d 1977. A mortality o f less t h a n 0.3 p e r cent a n d a m o r b i d i t y rate o f 14 p e r cent, with an a v e r a g e hospital stay o f 15 days, is h e r e b y r e p o r t e d . W o u n d infection was the m o s t c o m m o n c o m p l i c a t i o n with an i n c i d e n c e o f 9.5 p e r cent. Late c o m p l i c a t i o n s d u r i n g the s t u d y p e r i o d w e r e less t h a n 3 p e r cent. I n o u r e x p e r i e n c e , if the i n t r a p e r i t o n e a l closure t e c h n i q u e with resection a n d a n a s t o m o s i s is used, col o s t o m y closure can be a safe p r o c e d u r e with m i n i m a l mortality a n d m o r b i d i t y . W e believe c o l o s t o m y clos u r e s h o u l d be c o n s i d e r e d as n o t h i n g less t h a n a m a j o r colonic resection.
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