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A retrospective study of colostomy closures was prompted by recent reports detailing frequent postoperative complications. In a series of 125 intraperitoneal colostomy closures there was a low incidence of complications. There were no anastomotic breakdowns, fistulas, or deaths. We conclude that closure of a well healed colostomy is a safe operation, the success of which is determined by the careful technic with which it is performed.
Twenty-five patients underwent a colostomy that came to closure. There were eight blunt, 15 penetrating and two impaling injuries. Colostomy-related complications occurred in four patients; two wound infections, one stoma prolapse, one loop obstruction. Closure was performed during a second hospital stay after a standard mechanical bowel preparation and enteral and parenteral broad-spectrum antibiotics perioperatively. The procedure performed by board certified/eligible surgeons, lasted an average of 2.5-3h. Incisional hernias occurred as the only complication in two patients. For certain injuries of the colon, rectum and perineum, diverting colostomy is still the procedure of choice. It can be performed without significant additional morbidity. Subsequent closure in experienced hands does not carry a significant complication rate.
Recent advances in colostomy care are described. A colostomy is a surgically created opening of the large bowel through the abdominal wall. Three kinds of stoma care are presented, paying particular attention to several advances and setbacks. The special conditions of colostomy care in China are described.
AIM: This prospective study was designed to evaluate functional results of a pseudocontinent perineal colostomy (PCPC) using Schmidt's technique. METHODS: Functional results in eight patients whose rectum were resected due to cancer or anal epidermoid carcinoma and reconstructed by PCPC between January 1995 and July 2002 in our institution were evaluated. Surgical technique and post-operative care were described. Morbidity, functional results and degree of patient satisfaction were reported. Median follow-up was 40 months (18-70 months) and was completed in 100% of patients. RESULTS: There were no operative deaths. Four patients had post-operative complications, whose two patients had partial disunion of sutures, and two patients had urinary infection that was treated by adequate antibiotherapy. No conversion to a definitive abdominal colostomy was performed. On a functional level, one patient has normal continence, six had gas incontinence, and one has occasional minimal soiling. Seventy-five percent of patients were either highly satisfied with their continence. DISCUSSION: PCPC is a reliable technique, which can be proposed as an alternative to a left iliac colostomy following amputation of the rectum due to cancer, provided that certain requirements are met: careful selection of patients, informed consent, flawless surgical technique and lifetime daily colic irrigation.
We report our findings and results on treating a patient with Fournier's gangrene by using colostomy along with open drainage. A 39-year-old male had noticed a swelling and experienced pain in the scrotal sac approximately 1 week before his admission. On admission, his symptoms aggravated and he experienced constipation and difficulty in urination. Local examination of the scrotum circumference revealed a remarkable swelling, and redness and sloughing that had extended to the perianal area. In an emergency operation, incision and drainage of the scrotum, double-barrelled colostomy at the transverse colon, and reconstruction of the percutaneous cystotomy were performed. Postoperative open wound was cleaned twice a day and intravenous infusions of 1g imipenem/cilastatin sodium and 1.2g clindamycin phosphate were administered daily. The patient was discharged 61 days after the operation. Fournier's gangrene has a high mortality rate, and in severe cases that are complicated with infection protracted from defecation, dyschezia and difficulty in urination, we believe that it would be most effective to perform an open drainage and a colostomy simultaneously.
A series consisting of 110 patients who had colostomy closure was studied in an attempt to define the role of various factors in causing colon-related morbidity. The overall complication rate was 14.5 percent (wound sepsis 11.8 percent and anastomotic leak 2.7 percent). Patient age, the underlying pathologic abnormality (trauma versus nontrauma), the type of colostomy (loop versus end colostomy), the site of the stoma (right side, left side, or transverse), whether a drain was inserted or not, and the timing of the operation did not influence morbidity. Oral preoperative antibiotics appeared to be associated with less morbidity than parenteral antibiotics (p less than 0.01), and experienced surgeons had less complications than junior surgeons (p less than 0.05).
BACKGROUND: Percutaneous endoscopic colostomy was used successfully to treat 3 patients with chronic intestinal pseudo-obstruction whose symptoms were not controlled by conservative measures. METHODS: Percutaneous endoscopic colostomy tubes were placed to allow intermittent decompression of the colon in response to the occurrence of symptoms. The technique and the equipment are the same as for PEG and are described herein. OBSERVATIONS: Symptom improvement was observed in 3 patients, and, to date, surgery has been avoided for all. CONCLUSIONS: Percutaneous endoscopic colostomy is a safe and effective management option for selected patients with chronic intestinal pseudo-obstruction.
BACKGROUND/PURPOSE: The aim of this study was to determine the benefits and adverse effects of protocolized early postoperative enteral feeding in pediatric patients undergoing a closure of colostomy. METHODS: Pediatric patients, completely treated for anorectal malformation, who underwent a closure of colostomy during September 2000 and May 2002 received early postoperative feeding according to the authors' protocol (EF group). Retrospective data of consecutive patients operated on from March 1998 to August 2000 who received traditional feeding practice were used as a control (TF group). The protocol began with a small volume of formula or breast feeding within the first postoperative day. Volume allowance was advanced every 4 hours up to the daily maintenance volume. Full feeding was defined as when the patient was able to tolerate at least 80% of daily maintenance volume. TF group received nothing by mouth until documentation of bowel function. The groups were compared with regard to postoperative stay, postoperative hour of full feeding, first bowel movement, and adverse effects. Statistical analyses were performed with chi2 test, Student's t test, and Mann-Whitney U test. RESULTS: There were 34 and 30 patients in EF and TF groups, respectively. Median age of the patients was 13 months, and median weight was 8.39 kg. Except for the associated anomalies, which were found more in the EF group, there were no differences in the demographic characteristics of the 2 groups. On average, feeding was initiated at 19.7 (16 to 24) hours in the EF group and 51.7 (18 to 92) hours in the TF group (P <.01). Median full feeding hours were 45.5 and 70.5 hours in the EF and TF group, respectively (P <.01). First bowel movement in the EF group was recorded at the average of 4.14 postoperative nurse shifts, compared with 5.96 shifts in the TF group (P <.01). Postoperative stay was significantly reduced from the average of 6.1 days to 4.5 days (P <.01). The overall hospital expenses were not significantly different between the 2 groups. (203.95 dollars US in TF group and 198.50 dollars US in EF group; P =.75) There was 1 vomiting case in the EF group that was temporary and resolved spontaneously. Septic complications were noted in 8 patients in the EF group and 6 patients in the TF group (P =.27). The majority were uncomplicated urinary tract infections. CONCLUSIONS: Early feeding after a closure of colostomy in pediatric patients stimulated early bowel movement and reduced hospital stay with no increased adverse effects.
In the management of cloacal exstrophy, controversy exists regarding use of the rudimentary hindgut as a terminal colostomy v salvage of the hindgut for urinary or genital tract reconstruction. Over the past 26 years, 19 patients with cloacal exstrophy have undergone surgical reconstruction at our institution. Ten were managed by terminal ileostomy with an average follow-up of 9 years; nine were managed by permanent colostomy with an average follow-up of 8 years. The number of in-hospital days required due to gastrointestinal (GI) complications and the number of days required for supplemental parenteral hyperalimentation were significantly higher in patients managed by terminal ileostomy than by colostomy (P less than .05 and P less than .03, respectively). All patients have had continued long-term follow-up evaluations in regard to their weight and growth velocities. There is essentially no difference in regard to these characteristics within the two patient population groups. In summary, patients with terminal ileostomies require more frequent hospitalization and prolonged intravenous nutrition during their initial management phase. However, as the child matures and adaptation of the intestine develops, it appears that there are no substantial differences between the growth characteristics of the two patient populations.
We describe our experience with a technique for simultaneous urinary and fecal diversion using a single abdominal stoma. The procedure requires the construction of a diverting loop colostomy with division of the colon approximately 15 cm. distal to the stoma. This distal segment of colon acts as a urinary conduit, and allows internal separation of the urine and fecal streams. The procedure has been used in patients without a prior stoma as well as those with existing loop and end colostomies. Unlike the watery diarrhea associated with the wet colostomy described previously, these patients experience a continuous urine output and intermittent semiformed bowel movements. Complications have been minimal: there have been no episodes of clinical pyelonephritis, no new electrolyte problems and no significant stomal complications. In 1 patient late radiographic evidence of hydronephrosis developed associated with advancing metastatic disease, while in another late bilateral ureterocolonic strictures developed. The majority of patients died of the underlying cancer but 1 died of a myocardial infarction 2 weeks postoperatively. This procedure has now been performed in 11 patients with followup from 0.5 to 80 months. The results are gratifying for a group of highly complex cases.
The indications for urinary and fecal diversion often mirror each other and at times overlap. Between 1980 and 1990 we encountered 14 patients with preexisting or newly diagnosed rectosigmoid disease who required diverting colostomy and urinary diversion. We describe a simple method for managing urinary diversion in these patients, which avoids a bowel anastomosis. The preexisting or newly created colostomy is used as the urinary stoma for a colon conduit, while a proximal colostomy is created for fecal diversion. This technique has proved to be beneficial and should be considered for high risk patients who require urinary and fecal diversion, and for whom an abbreviated operation would be desired.
PURPOSE: To assess pelvic chemoradiotherapy (CXRT) without colostomy as a component of the multidisciplinary management of patients presenting with metastatic rectal cancer. METHODS AND MATERIALS: Eighty patients with synchronous distant metastases from rectal cancer were treated with initial CXRT. Hypofractionated radiotherapy was administered usually with concurrent 5-FU (92%, 300 mg/m(2)/day, M-F). Three-field belly-board technique was used in 89%. Group 1 had CXRT alone (n = 55). Group 2 (n = 25) patients were selected for primary disease resection, and sometimes HAI chemotherapy (n = 10) or hepatic resection (n = 5). Subsequently, 78% received systemic chemotherapy. RESULTS: Symptoms from primary tumor resolved in 94%. Endoscopic complete clinical response rate was 36%. Two-year survival (11% vs. 46%, p < 0.0001) and symptomatic pelvic control (PC, 81% vs. 91%, p = 0.111) were higher in Group 2, but colostomy-free rate (CFR) was lower (79% vs. 51% p = 0.02). CFR was 87% in Group 1 patients managed initially without fecal diversion (n = 50). Examining all patients using multivariate analysis, pelvic pain at presentation (p < 0.00001), BED (biologic equivalent dose at 2 Gy/fraction) < 35 Gy (p = 0.077), and poor differentiation (0.079) predicted worse PC. Poor differentiation (p = 0.017) and selection for CXRT alone (p < 0.0001) predicted worse survival. There were 4 RTOG of Grade 3 or greater acute complications, 5 severe perioperative complications, and no significant late treatment-related complications. CONCLUSION: Durable PC can be safely achieved without colostomy in most patients presenting with primary rectal cancer and synchronous systemic metastases using hypofractionated pelvic chemoradiation. A BED greater than 35 Gy is recommended. Selected patients appear to benefit from resection of primary disease. Higher doses should be investigated in patients with pelvic pain.
INTRODUCTION: Fecal continence with a perineal colostomy performed after abdominoperineal resection (APR) is not always satisfactory despite retrograde colonic enemas. Functional improvement is currently examined using artificial sphincters. Preliminary results are disclosed. PATIENTS: In 3 female patients, 45, 59 and 68 years old, curative APR and perineal colostomy were performed after radiotherapy in 2, for T1-2N0 cancer of the lower rectum. Due to occasional leaks, need for strict diet and fear of incontinence, an Acticon Neosphincter (AMS) was implanted consecutively at a mean 4.5 years after APR. RESULTS: Device implantation was feasible and uneventful. In one case, a superficial hematoma was drained and healed by second intention. Devices were activated 3 months after implantation. At a mean 2.5 years follow-up, the 3 patients had an activated and functional artificial sphincter. Leaks and fecal urgency significantly decreased but colonic enemas were maintained. Dietary restrictions were less and quality of life improved. All 3 considered the device as a useful adjunct. CONCLUSION: In this limited experience, implantation of artificial sphincter around a perineal colostomy following APR for rectal cancer appeared feasible and safe even in case of previous radiotherapy. Mid-term tolerance was satisfactory. Continence and quality of life significantly improved.
The purpose of this study was to determine the efficacy of twice weekly hypo-fractionated radiation therapy (RT) plus continuous infusion 5-fluorouracil for unresectable or locally advanced colorectal cancer with synchronous metastases. Palliative radiation consisting of 30 Gy/6 fractions/3 weeks was administered to 87 patients from 1982-1995 with 3 field belly board technique. Diverting colostomy was required for obstruction in 14 (16%) prior to radiation; 47 patients (54%) had recurrent disease following prior resection and 58 (66%) had distant metastases on presentation. Median follow-up was 12 months (1-104 months). Stabilization/regression of pelvic disease was accomplished in 65 patients (75%). Complete resection of the pelvic disease was accomplished in 5 patients (6%), all of whom had synchronous metastases. Diverting colostomy was required in only 11 patients after chemoradiation because of progressive pelvic tumor; 2 of these 11 patients (18%) had isolated progression of pelvic disease. Overall, colostomy was not required in 48 of the 72 patients (67%) who did not present with a stoma. Median survival was 11 months if metastatic disease was present and only 6 months when disease was limited to the pelvis. Grade 3 acute radiation toxicities occurred in <10% and no grade 4 acute toxicities were observed. No significant late radiation effects were noted. Twice weekly hypofractionated RT is well tolerated and provides durable palliation of symptoms related to locally advanced primary or recurrent colorectal cancer with metastatic disease.
OBJECTIVE: To compare the complications of temporary diverting ileostomy with those of temporary colostomy for patients with colorectal diseases. METHODS: Two independent researchers conducted a systematic search for randomized controlled trials (RCTs) comparing temporary ileostomy with temporary colostomy in MEDLINE, the Cochrane database, evidence-based medicine reviews and the American College of Physicians journal club, as well as relevant reference lists in journal articles. Five RCTs were found and included in this meta-analysis. All complications were abstracted and compared between groups. All complications were also assessed using tests of statistical heterogeneity, pooling of risk ratios using Mantel-Haenszel fixed effects and DerSimonian and Laird random effects. Clinical heterogeneity was investigated by examining the methodology and selection of patients described in each trial. RESULTS: Temporary colostomy was significantly more likely to cause stoma complications in colorectal cancer patients undergoing elective resections, and also more likely to cause infectious and wound complications. Temporary ileostomy tended to cause more post-closure surgical complications. CONCLUSIONS: There is not yet a strong case for the superiority of one temporary diverting stoma over another for all colorectal patients. In this regard, a large, well-conducted RCT is still needed.
The nursing implications for care of colostomy patients is discussed. Colostomy surgery has more than doubled in the last 15 years, making it common to see several patients with colostomies on medical-surgical floors on a daily basis. Because enterostomal nurses are not always available, staff nurses have the responsibility to provide proper care for these patients.
AIMS: The ability of surgeons to site a colostomy is assessed in a clinical model. In addition, the tuition received by surgical trainees in stoma siting is also reviewed. MATERIALS AND METHODS: Eleven surgeons (trainees--six, colorectal subspeciality interest--two) were asked to site an end colostomy on nine patients using an adhesive disc (diameter--1cm). The position of the stoma was then measured on the 'x' and 'y' axis of a 2cm box grid, (maximum error--1cm) which was placed on the abdomen and centred on the umbilicus. The positions were then compared with that chosen by the stoma nurse who was taken as the gold standard. Results were compared using ANOVA and the Mann Whitney--U test. A telephone questionnaire was then undertaken to review the training of junior surgeons. RESULTS: There was variance present within the group of surgeons studied (p<0.01). Trainees and consultants had a similar accuracy in stoma-siting (p<0.2). Consultants with a colorectal subspeciality interest were better at placing stomas than those with a general interest (p<0.002). Badly placed stomas were three times more likely to be too low than too high (p<0.002). Thirty of 37 trainees reported receiving no undergraduate training from a specialist stoma nurse. Ninety per cent received postgraduate training from another surgeon while a specialist nurse trained only 35%. CONCLUSION: There was no difference between trainees and consultants in their ability to site a colostomy. However, surgeons with a subspeciality interest chose stoma sites that were more consistent with the specialist nurse than general surgeons. Training is haphazard and ability is frequently assumed rather than proven.
BACKGROUND: Loop ileostomy or loop transverse colostomy for temporary decompression of a left colonic anastomosis represents an important issue in abdominal surgery. METHODS: A randomized study, comparing loop ileostomy (n = 37; group 1) or loop transverse colostomy (n = 39; group 2), was conducted. Patients were followed from construction to closure of the stoma. RESULTS: Age, weight, sex and indication for surgery were similar in both groups. After stoma construction complications were reported in nine of 37 patients in group 1 and in one of 39 in group 2 (P < 0.01), leading to postoperative death in five of 37 in group 1 and one of 39 in group 2. In the period between stoma construction and closure significant differences were observed only in prolapse rate (one of 32 group 1, 16 of 38 group 2; P < 0.01), need for temporary adaptation of clothing (eight of 32 group 1, 22 of 38 group 2; P < 0.01) and dietary guidelines (23 of 32 group 1, four of 38 group 2; P < 0.01). One patient died in group 1 and four in group 2; the deaths were not stoma related. After stoma closure eight of 29 patients in group 1 had complications and there were two deaths compared with three of 32 and no deaths in group 2. CONCLUSION: Both types of stoma carry a high complication rate with a considerable associated mortality rate. The interval between stoma construction and closure has substantial impact on social and economic status. Based on all three phases studied, routine use of transverse colostomy is advised if decompression of the left colon is indicated.