Problems of Colostomy Closure Patrick A. Dolan, MD, Little Rock, Arkansas Fred T. Caldwell, MD, Little Rock, Arkansas Carolyn H. Thompson, MS, Little Rock, Arkansas Kent C. Westbrook, MD, Little Rock, Arkansas
The liberal use of the colostomy, beginning in World War II, was the greatest single factor in reducing the mortality of colon and rectal injuries [I]. From such experience, temporary colostomy has become an essential part of the treatment of many emergent and some elective colon conditions. Thus, colostomy closure is now a common procedure. Despite this universal adoption and the seemingly low risk of the procedure, colostomy closure results in a significant morbidity (10 to 50 per cent) and occasional mortality (0.5 to 1 per cent). Initially, problems associated with colostomies and their closure were accepted as a matter of course. Recently, the surgical literature has included recommendations designed to reduce the morbidity of colostomy closure. Some authors have suggested that colostomy be avoided under certain conditions when it would normally be done [z]. To identify factors that contribute to the high morbidity of colostomy closure, a retrospective study of our experience was performed. Specific aims of the study included: (1) identification of problems related to colostomy closure; (2) correlation of complications with factors related to the colostomy and its management; and (3) formulation of an approach to the handling of colostomy closure. Material and Methods A chart review of 118 patients undergoing colostomy closure at the University of Arkansas Medical Center from 1970 to 1977 was performed. The study population included seventy-eight males and forty females, ranging in age from one to seventy-eight years (mean, 38 years). Sixty-eight of the 118 colostomies (58 per cent) were created after penetrating abdominal trauma. There was associated injury in approximately three fourths of these patients. It usually involved the small intestine. Other From the Department of Surgery. University of Arkansas for Medical Sciences, Little Rock, Arkansas. Reprint requests should be addressed to Kent C. Westbrook, MD, Department of Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72201. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
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common primary indicators for colostomy were obstructing carcinoma (13 per cent) and diverticulitis (12 per cent). The transverse colon was the site of colostomy in 49 per cent of patients, whereas in the others either the right (16 per cent) or left (35 per cent) colon was involved. All types of colostomy were performed in this group. Sixty per cent of patients had loop colostomies, 17 per cent end colostomies with mucous fistula, 13 per cent end colostomies with Hartmann’s pouch, and 10 per cent Mikulicz type resections. Approximately half the loop colostomies were either elevated over a glass rod or brought out at skin level over a fascial bridge. Most colostomies were matured (sutured to the skin) either at the time of creation or in three to four days. The duration of the colostomy ranged from one to twenty-four months (mean, 4.6 months). In the preclosure management, 75 per cent of the patients had a barium enema; 96 per cent of the proximal colon limbs and 84 per cent of the distal limbs were normal. The abnormalities included diverticulosis in several patients and an unsuspected carcinoma in one. Proctoscopy was performed in most of the patients. Mechanical bowel preparation consisting of oral cathartics (castor oil or magnesium sulfate), cleansing enemas, and a low residue diet was administered to 91 per cent of the patients. Systemic antibiotics were administered to 91 per cent of the patients. In addition, 46.6 per cent of these patients received an oral antibiotic prep, most commonly neomycin and erythromycin base [3]. The colostomies were closed by resident surgeons with staff supervision. All closures were intraperitoneal. The vast majority were handled by resection and anastomosis. The type of anastomosis was determined by the operating surgeon and was single layer in 52 per cent, double layer in 42 per cent, and done with staples in 6 per cent. The fascia was closed with nonabsorbable suture, Poly-deke (52 per cent) and steel wire (35 per cent) being the most commonly used. The skin was usually left open (76 per cent) but was closed primarily in some patients (24 per cent). Drains were rarely used (4 per cent). (Table I.) Hospital stays ranged from seven to forty-five days (mean, 14.5 days). Patient follow-up was available in 90 per cent of the cases, ranging from 1 to 364 weeks (mean, 31 weeks). In the analysis of the data chi-square tests were used to determine significant morbidity difference. Mann-Whitney tests were used for statistical comparison involving ordinal data.
The American Journal of Surgery
Colostomy Closure
TABLE I
Closure Management
Bowel management
TABLE II
Resection and anastomosis (8 1%
)
Simple closure (19%)
Type of anastomosis
Single layer (52%)
Double layer (6%)
Stapler (42%)
Fascia closure
Poly-dek (52%)
Wire (35%)
Other (13%)
Skin -
Open (76%)
Closed (24%)
Results
There was no mortality associated with colostomy closure. Complications were divided into those seen in the early postoperative period (Table II) and those observed during the follow-up period (Table III). In the early postoperative course, the complication rate was 22 per cent. Wound complications occurred in 13 per cent and colon complications in 5 per cent. Two of the colon complications, that of fistula and anastomotic leak with peritonitis, required reoperation. The other colon complications (3.4 per cent) were obstructive symptoms which resolved on conservative management. Patients older than forty years had a 29.6 per cent complication rate, compared to 15.6 per cent for those less than forty. This difference was not statistically significant (p 10.1) but is suggestive of increased complications in older patients. Underlying disease showed no relationship to the complication rate. There were more complications in handling the right and transverse colon (16.2 per cent) than in handling the left colon (12 per cent), but this difference was not statistically significant (p 10.25). There were fewer complications in handling loop colostomies compared with end colostomies (10 per cent versus 22.9 per cent, p 50.1). The time of closure did not affect the complication rate. (Table IV.) In the preclosure management of the patient, a barium enema was rarely helpful. In no patient did the barium enema delay the colostomy closure because of an abnormality. Early in the series, patients underwent a mechanical prep plus receiving systemic antibiotics, while in more recent years, oral antibiotics were used as well. The addition of oral antibiotics to the colon prep decreased the incidence of wound complications from 19.7 to 10.9 per cent, which is not statistically significant (p 10.25). Sixteen patients (13.6 per cent) had simple closure of a loop colostomy with no complications. In fact, all colon and wound complications occurred in the resection and anastomosis group, this differing significantly from simple closure (p 10.05). There was
Volume 137, February 1979
Early Complications
None Colon
78.0 %,,I’ 2.5%
Colon + wound Wound Other
2.5% 10.5%\ 6.5%
Obstruction Fistula
3.4% 0.8%
Peritonitis
0.8%
5.0%
TABLE Ill
Late Complications
Lost to follow-up No complications Hernia Suture sinus Functional colon symptoms
13.5% 68.0% 4.5% 10.2% 5.0%
no correlation between colon complications and the type of anastomosis or between wound complications and the type of suture material. However, the wound infection rate was significantly increased with primary skin closure compared with delayed closure (14 per cent versus 27.3 per cent, p -< 0.05). Any complication increased the length of hospital stay by an average of six days. (Table V.) In the follow-up period the complication rate was 19 per cent. Complications consisted of suture sinus formation (10.2 per cent), colon problems (5 per cent), and hernia (4.5 per cent). The colon problems reported were subjective complaints with no diarrhea present, as has been previously reported [4]. Comments
Colostomy closure remains a major operation, with complication rates ranging from 10 to 50 per cent. Our early complication rate of 22 per cent is about average for reports in the literature. Based on the present study and a review of the literature, reasonable answers to the following questions are possible. (1) When Should a Colostomy Be Closed? Selection of the proper timing for colostomy closure depends upon the technic of colostomy construction, completeness of healing of the colostomy and colon, and the underlying reason for the colostomy. Currently, we mature all colostomies either at the time of construction or after a delay of three to four days. This means that colon mucosa is sewn to the skin and that healing without serositis occurs. If infection develops around the colostomy site, closure should be delayed. In general, patients in whom the abnormal colon is exteriorized as a colostomy can be closed earlier than those in whom the colostomy is proximal to an injury or anastomosis. Although we determined no relationship between closure time and complication rate, most authors have reported more compli-
189
Dolan et al
TABLE IV
Patient and Colostomy Factors Affecting the Complications Complication Rate
Race (black
vs white) Sex (male vs female)
Age
The liberal use of the colostomy, beginning in World War II, was the greatest single factor in reducing the mortality of colon and rectal injuries [I]. From such experience, temporary colostomy has become an essential part of the treatment of many emergent and some elective colon conditions. Thus, colostomy closure is now a common procedure. Despite this universal adoption and the seemingly low risk of the procedure, colostomy closure results in a significant morbidity (10 to 50 per cent) and occasional mortality (0.5 to 1 per cent). Initially, problems associated with colostomies and their closure were accepted as a matter of course. Recently, the surgical literature has included recommendations designed to reduce the morbidity of colostomy closure. Some authors have suggested that colostomy be avoided under certain conditions when it would normally be done [z]. To identify factors that contribute to the high morbidity of colostomy closure, a retrospective study of our experience was performed. Specific aims of the study included: (1) identification of problems related to colostomy closure; (2) correlation of complications with factors related to the colostomy and its management; and (3) formulation of an approach to the handling of colostomy closure. Material and Methods A chart review of 118 patients undergoing colostomy closure at the University of Arkansas Medical Center from 1970 to 1977 was performed. The study population included seventy-eight males and forty females, ranging in age from one to seventy-eight years (mean, 38 years). Sixty-eight of the 118 colostomies (58 per cent) were created after penetrating abdominal trauma. There was associated injury in approximately three fourths of these patients. It usually involved the small intestine. Other From the Department of Surgery. University of Arkansas for Medical Sciences, Little Rock, Arkansas. Reprint requests should be addressed to Kent C. Westbrook, MD, Department of Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72201. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
180
common primary indicators for colostomy were obstructing carcinoma (13 per cent) and diverticulitis (12 per cent). The transverse colon was the site of colostomy in 49 per cent of patients, whereas in the others either the right (16 per cent) or left (35 per cent) colon was involved. All types of colostomy were performed in this group. Sixty per cent of patients had loop colostomies, 17 per cent end colostomies with mucous fistula, 13 per cent end colostomies with Hartmann’s pouch, and 10 per cent Mikulicz type resections. Approximately half the loop colostomies were either elevated over a glass rod or brought out at skin level over a fascial bridge. Most colostomies were matured (sutured to the skin) either at the time of creation or in three to four days. The duration of the colostomy ranged from one to twenty-four months (mean, 4.6 months). In the preclosure management, 75 per cent of the patients had a barium enema; 96 per cent of the proximal colon limbs and 84 per cent of the distal limbs were normal. The abnormalities included diverticulosis in several patients and an unsuspected carcinoma in one. Proctoscopy was performed in most of the patients. Mechanical bowel preparation consisting of oral cathartics (castor oil or magnesium sulfate), cleansing enemas, and a low residue diet was administered to 91 per cent of the patients. Systemic antibiotics were administered to 91 per cent of the patients. In addition, 46.6 per cent of these patients received an oral antibiotic prep, most commonly neomycin and erythromycin base [3]. The colostomies were closed by resident surgeons with staff supervision. All closures were intraperitoneal. The vast majority were handled by resection and anastomosis. The type of anastomosis was determined by the operating surgeon and was single layer in 52 per cent, double layer in 42 per cent, and done with staples in 6 per cent. The fascia was closed with nonabsorbable suture, Poly-deke (52 per cent) and steel wire (35 per cent) being the most commonly used. The skin was usually left open (76 per cent) but was closed primarily in some patients (24 per cent). Drains were rarely used (4 per cent). (Table I.) Hospital stays ranged from seven to forty-five days (mean, 14.5 days). Patient follow-up was available in 90 per cent of the cases, ranging from 1 to 364 weeks (mean, 31 weeks). In the analysis of the data chi-square tests were used to determine significant morbidity difference. Mann-Whitney tests were used for statistical comparison involving ordinal data.
The American Journal of Surgery
Colostomy Closure
TABLE I
Closure Management
Bowel management
TABLE II
Resection and anastomosis (8 1%
)
Simple closure (19%)
Type of anastomosis
Single layer (52%)
Double layer (6%)
Stapler (42%)
Fascia closure
Poly-dek (52%)
Wire (35%)
Other (13%)
Skin -
Open (76%)
Closed (24%)
Results
There was no mortality associated with colostomy closure. Complications were divided into those seen in the early postoperative period (Table II) and those observed during the follow-up period (Table III). In the early postoperative course, the complication rate was 22 per cent. Wound complications occurred in 13 per cent and colon complications in 5 per cent. Two of the colon complications, that of fistula and anastomotic leak with peritonitis, required reoperation. The other colon complications (3.4 per cent) were obstructive symptoms which resolved on conservative management. Patients older than forty years had a 29.6 per cent complication rate, compared to 15.6 per cent for those less than forty. This difference was not statistically significant (p 10.1) but is suggestive of increased complications in older patients. Underlying disease showed no relationship to the complication rate. There were more complications in handling the right and transverse colon (16.2 per cent) than in handling the left colon (12 per cent), but this difference was not statistically significant (p 10.25). There were fewer complications in handling loop colostomies compared with end colostomies (10 per cent versus 22.9 per cent, p 50.1). The time of closure did not affect the complication rate. (Table IV.) In the preclosure management of the patient, a barium enema was rarely helpful. In no patient did the barium enema delay the colostomy closure because of an abnormality. Early in the series, patients underwent a mechanical prep plus receiving systemic antibiotics, while in more recent years, oral antibiotics were used as well. The addition of oral antibiotics to the colon prep decreased the incidence of wound complications from 19.7 to 10.9 per cent, which is not statistically significant (p 10.25). Sixteen patients (13.6 per cent) had simple closure of a loop colostomy with no complications. In fact, all colon and wound complications occurred in the resection and anastomosis group, this differing significantly from simple closure (p 10.05). There was
Volume 137, February 1979
Early Complications
None Colon
78.0 %,,I’ 2.5%
Colon + wound Wound Other
2.5% 10.5%\ 6.5%
Obstruction Fistula
3.4% 0.8%
Peritonitis
0.8%
5.0%
TABLE Ill
Late Complications
Lost to follow-up No complications Hernia Suture sinus Functional colon symptoms
13.5% 68.0% 4.5% 10.2% 5.0%
no correlation between colon complications and the type of anastomosis or between wound complications and the type of suture material. However, the wound infection rate was significantly increased with primary skin closure compared with delayed closure (14 per cent versus 27.3 per cent, p -< 0.05). Any complication increased the length of hospital stay by an average of six days. (Table V.) In the follow-up period the complication rate was 19 per cent. Complications consisted of suture sinus formation (10.2 per cent), colon problems (5 per cent), and hernia (4.5 per cent). The colon problems reported were subjective complaints with no diarrhea present, as has been previously reported [4]. Comments
Colostomy closure remains a major operation, with complication rates ranging from 10 to 50 per cent. Our early complication rate of 22 per cent is about average for reports in the literature. Based on the present study and a review of the literature, reasonable answers to the following questions are possible. (1) When Should a Colostomy Be Closed? Selection of the proper timing for colostomy closure depends upon the technic of colostomy construction, completeness of healing of the colostomy and colon, and the underlying reason for the colostomy. Currently, we mature all colostomies either at the time of construction or after a delay of three to four days. This means that colon mucosa is sewn to the skin and that healing without serositis occurs. If infection develops around the colostomy site, closure should be delayed. In general, patients in whom the abnormal colon is exteriorized as a colostomy can be closed earlier than those in whom the colostomy is proximal to an injury or anastomosis. Although we determined no relationship between closure time and complication rate, most authors have reported more compli-
189
Dolan et al
TABLE IV
Patient and Colostomy Factors Affecting the Complications Complication Rate
Race (black
vs white) Sex (male vs female)
Age
