Closure of Colostomy PHILLIP H. BECK, M.D., HARVEY B. CONKLIN, M.D. We analyzed the records of 77 cases of loop colostomy closure in Vietnam War Casualties. All records were complete from the date of injury to discharge following colostomy closure. Simple closure of the loop colostomy was performed in 44 patients and resection of the stoma and reanastomosis of bowel segments was performed in 33 patients. Average operating time for simple closure of the loop was 70 minutes compared to 115 minutes for resection and anastomosis. Nasogastric suction was used less frequently and for a shorter time with simple loop closure. The total postoperative complication rate was 9%o with simple loop closure as compared to 24% for resection and anastomosis. Simple closure of the loop described in this report is technically easier and as safe as resection of the stoma and reanastomosis.

From the General Surgery Service, Department of Surgery, Letterman Army Medical Center, Presidio of San Francisco, California

Methods In a retrospective study, the records of 77 cases of loop colostomy closure performed at Valley Forge General Hospital, Phoenixville, Pennsylvania, Silas B. Hays Army Hospital, Fort Ord, California, and Letterman Army Medical Center, Presidio of San Francisco, California, were reviewed. Colostomies were performed for injuries sustained in combat in Vietnam during the years 1966 to 1971. Cases without complete records from ¶¶HE FIRST COLOSTOMY was successfully performed for initial injury to closure of the colostomy were not in1trauma in 1795.3 However, it was not until World War cluded in the study. II that colostomy became the cornerstone of therapy for Colostomy closure was not performed until the patient injuries to the colon and rectum.2-8'1517'18 While much had recovered from his initial injuries and had regained to attention in the literature has been directed towards the within 10% of his pre-injury weight. Physical examinaindications for colostomy, relatively little can be found tion, standard laboratory evaluations, sigmoidoscopy, on colostomy closure. and barium enema were performed in all patients before Two anatomic and functional types of colostomy have surgery. well known and widely accepted indications, i.e. the loop All patients underwent preoperative mechanical bowel colostomy for exteriorization or decompression, and the preparation for 24 to 72 hours. All but a few patients double barrel colostomy for complete diversion. Closure received both oral and irrigation antibiotics. of both types of colostomies is generally accomplished by Techniques of Closure resection of the stoma and end-to-end anastomosis, although some have had success with simple loop cloIn this series the two methods of colostomy closure sure.1,5'7'9"12-14 We also have found that simple closure of were 1) simple closure of the loop, and 2) resection of the the loop colostomy can be done effectively and safely. stoma with anastomosis. Simple closure of the loop colostomy is performed by making an elliptical skin inciSubmitted for publication January 3, 1975. sion around the colostomy and dissecting the bowel from Reprint requests: Technical Publications Editor, Letterman Army its fascial attachments and intraperitoneal adhesions. A Medical Center, Presidio of San Francisco, California 94129. The opinions or assertions contained herein are the private views of free loop of colon is created so that the closure can be the authors and are not to be construed as official or as reflecting the performed outside the abdominal cavity. The stomal edge views of the Department of the Army or the Department of Defense. is trimmed and hemostasis is achieved (Fig. la). A Con-

795

796

. ~ ~ ~. j':~ ;"i. :,'. . 2', . :,_t BECK AND CONKLIN

Ann. Surg. June 1975 -

TABLE 2. Associated Extra-abdominal Injuries

Injury Major fractures Chest wounds

Genito-urinary injuries Amputations Vascular injuries Ophthalmic injuries Neck wounds

No. Patients

Per cent

20 14 9 6 4 4 4

33 23 15 10 6 6 6

caused by high velocity missiles and two-thirds by relatively low velocity missiles such as Claymore mines, rockets, and grenades. The patients had a variety of associated abdominal injuries (Table 1) and extra............ . . ._!115~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~..... abdominal injuries (Table 2). In the majority of cases, definitive surgical care was initiated within one hour of injury after helicopter evacuation from the combat site. Severe complications occurred in 63% of the cases wounded by high velocity missiles and in 39o wounded by fragmentation weapons (Table 3). Intraperitoneal abscesses and enteric fistulas occurred frequently. Bowel obstruction requiring lysis FIG. I. Simple loop closure. A free loop is created so that closure can be performed outside the abdominal cavity. A, The stomal edge is trimmed. of adhesions was also common. B, A Connell suture is started at both ends with the first stitch placed well The indications for colostomy are listed in Table 4. behind the corner and tied on the inside. C, Both sutures are brought to There were 77 loop colostomies performed. The average midpoint and tied. D, Lembert sutures are placed and the bowel is returned to abdomen. interval from injury to closure was 16 weeks. Rectal injuries generally were treated with closure of the perforation and proximal colostomy. In Vietnam, nell suture is started at both ends with the first stitch Lavenson and Cohen10 instituted thorough operative recplaced well behind the corner and tied on the inside. (Fig. tal washout and noted a significant decrease in mortality. 1B). Both sutures are brought to the mid point and tied Adequate presacral drainage, with or without coccygec(Fig. IC). Lembert seromuscular sutures of 3-0 silk are tomy, has been established as an important adjunct in the placed as illustrated (Fig. ID). The bowel is returned to treatment of rectal perforation.8'0'"'16 It was not perthe abdomen and the fascia is closed. The skin and sub- formed consistently in our series until 1970. Loop coloscutaneous tissues may be (a) closed primarily, (b) closed tomies with incomplete diversion of the fecal stream over a drain, or (c) closed 4 to 5 days later. were performed in 15 of 42 of our patients with rectal, perineal or buttock wounds, where complete diversion Clinical Data was required (Table 4). Seventy-three per cent of these The average age of the group was 22 years (70% were 21 or younger). Approximately one-third of the injuries were

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....

..

TABLE 3. Postinjury Complications

Complication* TABLE 1. Associated Abdominal Injuries

Injury Small bowel Stomach Liver Spleen Pancreas

Kidney Gallbladder

No. Patients

Per cent

26 14 13 8 2 2 1

39 21 20 12 3 3 1.5

Intra-abdominal abscess or empyema Bowel obstruction Stress ulcer bleed Enterocutaneous fistula Pancreatitis Pneumonia Malaria Thrombophlebitis, lower extremity

No. Patients

Per cent

16 10 5 5 2 2 2 2

35 22 11 11 4 4 4 4

*The postinjury course of patients with one or more complications is considered "stormy."

VOl. 181 NO. 6

CLOSURE OF COLOSTOMY

TABLE 4. Indications for Colostomy

Indication

TABLE 6.

No. Loop Colostomies

Colon Injury Exteriorization Proximal decompression Rectal injury Buttock and/or perineal injury

797

Complications Associated with Loop (Simple) Closure Versus Resection and Anastomosis

Loop Closure (44 cases)

62 51 11 9 6

Resection and Anastomosis (33 cases)

Superficial wound infection (2) Superficial wound infection (1) Suture line leak and obstruction (1) Deep wound infection, abscess (3) Urinary tract infection (1) Subdiaphragmatic abscess (1) Anastomotic leak (1) Urinary tract infection (1) Ureteral Calculus (1) Total 4 (9o) Total 8 (24%)

patients experienced a "stormy" post-injury course (i.e., with one or more of the complications listed in Table 3), whereas, 41% of those with complete diversion had a stormy course. This experience again re-affirms the dictum that a completely diverting double barrel colostomy is mandatory in the management of perforating rectal injuries.4'6'10,11,16,18

blood supply to the bowel edges is theoretically enhanced by maintaining continuity of the mesentric wall. It could be argued that simple loop closure, when feasible, is a safer procedure than end-to-end anastomosis.

Results Simple loop closure was performed in 44 cases and resection with anastomosis was performed in 33 cases (Table 5). The indications for loop colostomy and the number of associated injuries were comparable for the two groups. Fifty per cent of those who had simple loop closure had had a stormy initial post-injury course while only 39% of those who had resection and anastomosis had had significant complications following their initial surgery. Choice of the loop closure procedure was left to the surgeon's discretion. Two attempts at simple loop closure were aborted in favor of resection and anastomosis because of edema of the bowel wall. Both of these patients had suffered multiple severe injuries. The average operating time for simple loop closure was 70 minutes compared to 115 minutes for resection and anastomosis. In 13 of the 44 simple loop closures, no nasogastric tube was used postoperatively, and in the other 31 patients, nasogastric suction was used an average of 2.8 days. Nasogastric intubation was used an average of 3.4 days in 28 of the 33 patients who had resection and anastomosis. The complication rate following simple loop closure was 9o. It was 24% following resection and anastomosis (Table 6). With simple loop closure the

Discussion The overall complication rate for the 77 cases of colostomy closure was 15.5%. Major complications involving the anastomosis occurred in 3.9o (Table 7). Although 87% of the wounds were closed primarily, the incidence of postoperative wound infection was only 7.6%. Patient age, and demonstrated ability to survive many severe injuries which were frequently complicated by sepsis, may have contributed to this low rate of infection. Another consideration is that colostomy closure was delayed until the patient had regained his lost weight and was considered to be in excellent condition. There were no deaths. Our experience with simple closure of the loop colostomy compares favorably with the report by Thomson and Hawley14 who performed simple closure of transverse loop colostomies on 130 older patients with carcinoma or diverticulitis. They reported an incidence of 2.9o leakage and 17.2% wound infection. We had one significant complication in 44 single loop closures. The patient suffered a suture line breakdown which required a proximal diverting colostomy. The other three minor complications consisted of two wound infections and one

TABLE 5. Loop Colostomy Closure: Initial Indication for Colostomy

Simple Closure

Resection and Anastomosis

(44 cases)

(33 cases)

Exterionization Decompression Diversion (Rectal, buttock or penneal injury)

27 (61%) 8 (18%) 9 (21%)

24 (73%) 3 ( 9o) 6 (18%)

Total

44

(00%o)

33 (100%o)

urinary tract infection. Goligher'5 stated in reference to simple loop closure: "This operation has a notorious reputation for sub-

sequent breakdown and leakage of faeces, but with a TABLE 7. Complications of Colostomy Closure in 77 Cases

Complication

Leakage and/or obstruction* Wound infection Urinary tract infection Ureteral Calculus *One required new colostomy.

Number

Rate (per cent)

3 6 2 1

3.9 7.6 2.6 1.3

798

BECK AND CONKLIN

well-conducted closure this should seldom occur." Our results would bear out his optimism and establish this procedure as a safe and simple means of closure for the loop colostomy. References

Ann. surg. June 1975

8. Imes, P. R.: War Surgery of the Abdomen. Surg. Gynecol. Obstet., 81:608, 1945. 9. Knox, A. J. S., Birckett, F. D. H. and Collins, C. D.: Closure of Colostomy. Br. J. Surg., 58:669, 1971. 10. Lavenson, G. S., Jr. and Cohen, A.: Management of Rectal Injuries. Am. J. Surg., 122:226, 1971. 11. Lung, J. A., Turk, R. P., Miller, R. E. and Eiseman, B.: Wounds of 1. Aldrete, I., Hendricks, D. E. and Dimond, F. C.: Reconstructive the Rectum. Ann. Surg., 172:985, 1970. Surgery of the Colon in Soldiers Injured in Vietnam. Ann. Surg., 12. Madden, J. L.: Atlas of Techniques in Surgery, 2nd ed., Vol. 1. 72:1007, 1970 New York, Appleton-Century-Crofts, 1958. 2. Beall, A. C., Jr., Bricker, D. L., Alessi, F. J., et al.: Surgical 13. Sullivan, W. G., Miller, R. E. and Eiseman, B.: Closure of Colonic Considerations in the Management of Civilian Colon Injuries. Stomas in Patients Injured in Combat. Surg. Gynecol. Obstet., Ann. Surg., 173:971, 1971. 131:1045, 1970. 3. Cromar, C. D. L.: The Evolution of Colostomy. Dis. Colon Rectum, 14. Thomson, J. P. S. and Hawley, P. R.: Results of Closure of Loop 11:256, 1966. Transverse Colostomies. Br. Med. J., 3:459, 1972. 4. Ganchrow, M. I., Lavenson, G. S., Jr. and McNamara, J. J.: 15. Tucker, J. W. and Fey, W. P.: The Management of Perforating Surgical Management of Traumatic Injuries of the Colon and Injuries of the Colon and Rectum in Civilian Practice. Surgery, Rectum. Arch. Surg., 100:515, 1970. 35:213, 1954. 5. Goligher, J. C.: Surgery of the Anus, Rectum, and Colon, 2nd ed. 16. Wanebo, H. J., Hunt, T. K. and Mathewson, C.: Rectal Injuries. J. London, Bailliere, Tindall, and Cassell, 1967. Trauma, 9:712, 1969. 6. Heaton, L. D., Hughes, C. W., Rosegay, H., et al.: Military Surgi- 17. Woodhall, J. P. and Ochsner, A.: The Management of Perforating cal Practices of the United States Army in Vietnam. Curr. Probl. Injuries of the Colon and Rectum in Civilian Practice. Surgery, Surg., November, 1966. 29:305, 1951. 7. Horsley, G. W. and Michaux, R. A.: Surgery of Colon as seen in an 18. Ziperman, H. H.: The Management of Large Bowel Injuries in the Korean Campaign. U.S. Armed Forces Med. J., 7:85, 1956. Overseas General Hospital. Surgery, 19:845, 1946.

Closure of colostomy.

We analyzed the records of 77 cases of loop colostomy closure in Vietnam War Casualties. All records were complete from the date of injury to discharg...
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