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A 68 years old patient who had a colostomy done for an abdomino-perineal resection, started episodes of bleeding seven years later from varices at the colostomy site secondary to portal hypertension. Direct suture of the varices and distal colonic resection were ineffective to stop the bleeding. Sclerotherapy with polidocanol, however permitted the patient to remain asymptomatic during 14 months.
The authors stop onto make use of the colon smooth musculature to resolve the question of medical and surgical methods used until now to improve the continence of colostomies. Owing to the experiences and co-operating with some other research centers, the authors refer about the experiment performed on the rabbit, where a small leaf of intestine serous-muscular tissue was employed to perform a continence system on colostomy. The analysis of manometric results obtained from check animals in different post-operatory periods (3-7-14-21 days) pointed out a moderate reaction of neosphincterial function, while the histological results prove a favorable histological development without to change the muscular tunica fibrous tissue. The easy application, harmless of employed methods and undoubted comfort for the patient stand for valid indications in the development to come of this method.
The patient with carcinoma of the vulva may present with tumor involvement of the perirectal area. Traditional treatment has often involved ultraradical therapy including a radical vulvectomy with posterior or total pelvic exenteration in an effort to obtain adequate surgical margins. Five-year survival rates for these patients range from 20-50%, and major operative morbidity as well as psychological problems are associated with this extensive surgery. Five patients treated for a locally advanced vulvar carcinoma involving the perirectal area were thought to be candidates for a rectum-sparing procedure. They underwent a radical vulvectomy, bilateral inguinal lymphadenectomy, partial rectal resection, and a diverting colostomy. Four of the five patients agreed to a colostomy closure 6 months after their primary therapy; these four patients have resumed normal bowel function. All patients remain clinically free of tumor.
The author analyses the results of various methods of terminal colostomy, among which are the "column" technique, with stitching of the edges of the peritoneum to the skin and leaving the excess of the brought out intestine in 258 patients, the formation of a flat stoma by the ordinary method in 179 patients, and with retroperitoneal passing of the intestine in 752 patients in radical surgical treatment of rectal carcinoma and other diseases of the large intestine. The operations were conducted in the period from 1973 to 1987. The frequency of early paracolostomy complications (suppuration, retraction, etc.) in these groups of patients was, respectively, 31%, 22.9%, and 17.6%; that of late-term complications, 70.6%, 50.3%, and 20.3%. The article shows the results of study of the causes of these complications, which formed the basis for improving the methods and techniques of the operation the principal differences of which consisted in: (1) colostomy, except for the final formation of the opening at the level of the skin, was conducted before mobilization of the rectum; (2) retroperitoneal passing of the intestine was accomplished through the upper angle of a lyre-shaped incision of the pelvic peritoneum to the left of the sigmoid colon; (3) the use of a "closed" method of flat stoma formation by cutting the intestinal wall at the level of the skin down to the mucosa and attaching it to the skin by the musculoserous coat with interrupted catgut sutures, and only after that is the excessive mucosa cut off and the intestinal lumen opened.(ABSTRACT TRUNCATED AT 250 WORDS)
The result of 70 Colostomy Closures (1979-1988) were analysed using certain factors considered to influence morbidity and mortality. 20/70 (28.5 pc) had wound infection, two patients (2.8) suffered wound dehiscence, two anastomotic leak, two intraabdominal abscesses, two small bowel obstructions, two transient large bowel obstructions (anastomotic oedema) two incisional hernias. There were two deaths, a mortality of 2.8 pc. Only the method of bowel preparation the location of colostomy and type of closure were found to significantly affect morbidity. There was an overall morbidity of 37.7 pc.
An atraumatic, pneumatic occlusive colostomy appliance has been described which in animal experiments was well tolerated and was effective in preventing leakage. It is hoped that this may improve the unsatisfactory aspects of management in patients using conventional colostomy appliances.
After having examined different methods as to continence colostomy, the authors introduce their own control system for the stoma. The study was carried out on 6 colostomized patients. Preliminary, the intraluminal pressure in closed colostomy was recorded. Pressure waves, largely varying from patient to patient, were obtained as to frequency of waves and pressure values. The same variations were observed during meals waking and sleeping. Sometimes the patients suffered from serious disorder, but in most cases they did not feel pain. A catheter, provided with an inflatable balloon for closing the stoma, formed the system tested. It was also provided with a second intraluminal low-pressure inflated balloon, connected with an external compensating chamber. As a result of the system the pressure dropped down to about 1/6 compared with the reference values observed under the same conditions. In addition, the continence was complete and the patient did not suffer from any disorder in non-stop recordings up to 24 hours. We believe that the system may be useful for colostomized patients if carefully carried out.
Although many surgeons still perform the definitive terminal colostomy using the initial technique--pararectal incision, transperitoneal tract, secondarily retouched excess--this procedure complicates uselessly the surgical technique leading frequently to complications. These drawbacks might be avoided by using transrectal extraperitoneal extemporaneously matured colostomy that simplifies the surgical technique and prevents both precocious complications (peritonitis, occlusions, parietal abscess, necessity of a second "retouch" surgery) and also tardy complications (stomal prolapse, parastomal eventration).
The authors were able to prevent uncontrollable discharge of intestinal contents in 70 patients with colostomy by means of a pneumo-obturator of an original design. Its advantages over magnetic obturating devices were revealed: the simple and light design, hygienic properties, short adaptation period, and no need for implantation of a foreign body into the tissues surrounding the colostomy. Sixty-four patients use the device regularly and are able to retain feces of any consistency. No complications have been noted. The pneumo-obturator may therefore be used for creating a new method for controllable evacuation of the intestine.
Some aspects of the social life and trend of work were studied in 188 patients with temporary colostomy formed after radical operation for various diseases and injury of the colon. In the group of 188 patients examined after surgery, 160 were declared invalids (group I--6 persons, group II--72, group III--82 persons). Diminished social activity, development of an asthenic personality and of familiar and social conflicts were noted in many cases. With the object of rehabilitation, patients with temporary colostomy should be trained in the methods of irrigation of the large intestine while they are still in the hospital and the question of restoration of natural continuity of the intestine should be contemplated in time.
We report an unusual complication occurring after diversion transverse loop colostomy in a patient with long-standing ulcerative colitis. The formation of a giant colonic mucocele resulted from distal stomal and rectal stenosis, with subsequent accumulation of mucus in the obstructed segment over many years. The pathophysiologic features of this case, which are similar to mucocele of the appendix, are discussed. To our knowledge, this is the first report in the literature of a giant colonic mucocele after diversion colostomy.
Complete diversion of the digestive transit requires intestinal section and terminal rather than lateral colostomy. This can now be achieved by using a mechanical stapler to obturate temporarily the distal end of the colonic segment bearing a conventional lateral colostomy, then performing an extra-mucosal anastomosis to re-establish continuity. This technique can be applied to protect low colonic anastomoses or to treat a minor anastomotic disruption. It can also be extended to ileostomy.
Seventy nine patients with closure of a loop (51 patients) or a terminal (28 patients) colostomy were reviewed retrospectively. Operative mortality was 2.5%. Wound infection in 19% and anastomotic breakdown in 7.7% were the most important postoperative complications. Restoring continuity after a Hartmann intervention, closure of left sided colostomies and early closure (before 12 weeks) all accounted for a statistically significant higher complication rate, while age and sex, the underlying disease, bowel preparation and the method of closure had no influence on the operative outcome.
A series of 32 patients operated on for rectal carcinoma is reported. A new technique by using the gracilis muscles to reconstruct a functional anal sphincter after abdominoperineal resection was performed. No operative mortality was recorded. Functionality of the new sphincter was guaranteed by electromyostimulation. Electrostimulation has been useful in both increasing the muscular trophic level and in improving the postoperative bio-feedback. Perineal infection was recorded in 9 patients being the most common complication although it did not compromise the functionality of the new sphincter. In one case acute colonic ischaemia was treated by resection and definitive left colostomy. 17 out of the 27 patients in which a functional follow-up was obtained, scored a "very good" continence to stool and flatus while in 6 patients occasional episodes of incontinence to liquid stool are referred. Local or distant metastases presented in 6 patients. The obtained results encourage in continuing the research with this technique in the attempt to reduce the number of patients that must pay the high price of a definitive abdominal colostomy for cure.
A comparative double-blind study of tinidazole vs placebo was conducted in order to assess the prophylaxis of post-surgical abdominal infections in 40 patients undergoing closure colostomy surgery. During three days the patients were kept on a low residue diet, and underwent a colon mechanical cleansing. About 10 to 12 hours prior to surgery the patients were given placebo or tinidazole in tablets of identical appearance; the dose of tinidazole was of 2 g (4 tablets) in a single oral dose. Evaluation performed after surgery showed that in the tinidazole group occurred two surgical mild infections (10%), while in placebo group occurred nine infections (45%)--four of them severe and one very severe, showing a significative difference between the two groups (p less than 0.05). In placebo group 21 bacteria were isolated, 3 of them were anaerobic; only two aerobic species were identified in the tinidazole group (p less than 0.001). No adverse reactions were reported in both groups. The authors concluded that in this study, tinidazole showed a prophylactic effect on post-surgical abdominal infections in patients who underwent closure colostomy surgery.
This study summarizes the clinical results after 61 operations including diverting stomas in 56 patients. 29 transverse colostomies and 32 loop ileostomies were constructed over a 2-year period. Two thirds of the operations were performed on acute indications. The patients were followed up with regard to closure rate and complications up until the end of 1985. Within this period there was a closure rate of 38% and a stoma-related complication rate of 21% without any significant difference between the two different groups of stomas. The complications following ileostomy appeared to be more serious than those after transverse colostomy.
Recently, although a trend for applying sphincter-saving procedures for carcinoma of the rectosigmoid and upper rectum has been increasing, the majority of patients with advanced rectal carcinoma located in the lower rectum and anal canal have been receiving Mile's operation as in the past. Consequently, these patients become permanent colostomates. In this paper, we deal with the following problems occurring in colostomates, i.e., operative procedures involved in colostomy, the management of colostomy by natural evacuation or irrigation and urogenital deficiencies, and in addition discuss the current aspects and prospects for stoma rehabilitation.
A continent colostomy was performed on 15 mongrel dogs by free transplantation of autologous smooth muscle. The myoelectrical observations of this colostomy and of a 3 years old human transplant show a vital and high active sphincter mechanism.