- Email: [email protected]
Complications Following Surgery of the Colon
Complications Following Surgery of the Colon From the Departments of Surgery, Massachusetts general Hospital and Harvard Medical School
STEPHEN E. HEDBERG, M.D. Assistant in Surgery
CLAUDE E. WELCH, M.D., F.A.C.S. Visiting Surgeon; Associate Clinical Professor of Surgery
COMPLICATIONS following surgery on the colon are common and often very serious. Their importance is accentuated by the fact that many of them can be prevented; some attention in this paper therefore must be directed toward prophylaxis. In many instances complications occur despite the most scrupulous technique, particularly when extensive operative procedures have destroyed anatomic barriers or structures required for normal functions. Complications vary according to the type of surgery performed; thus intraperitoneal anastomosis, ileostomy and colostomy each evokes specific problems. Complications also vary according to underlying pathologic process; ulcerative colitis, for example, is a much more serious underlying disease than diverticulitis. Table 1.
Complications Following Surgery of the Colon RIGHT
LEFT
SIGMOID
COLECTOMY (CANCER)
COLECTOMY (CANCER)
RESECTION (CANCER)
Total patients .................. Patients with fatal complications ............ Patients with nonfatal complications. Total complications ...... Complications per patient with fatal complications .... Complications per patient with nonfatal complications.
MILES'
SIGMOID
RESECTION RESECTION (CANCER) (DIVERTICULITIS)
100
100
100
100
8
9
9
7
100 2
30
30
56
26 46
65
43 69
21 21
1.8
2.0
2.5
1.7
1.4
1.1
1.4
1.3
1.8
775
776
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
A careful reVIew has been made of 500 resections of the colon or rectum performed in the Massachusetts General Hospital during the past five years (Table 1.). The incidence of complications was found to be considerably higher than expected and their distribution likewise was surprising. For the analysis, 100 consecutive resections of the right colon for cancer, 100 of the left colon for cancer, 100 of the sigmoid for cancer, 100 of the sigmoid for diverticulitis, and 100 of the rectum for cancer were studied. In this discussion, the complications common to all operations on the colon will be considered first, after which those pertaining to particular operations will be described. PROPHYLAXIS OF COMPLICATIONS
Several features included in the preparation of patients for operation deserve emphasis. They include: 1. Complete mechanical cleansing of the colon. This may be impossible if intestinal obstruction, perforation, active inflammatory disease or hemorrhage is present, but in nearly all elective operations the colon can be emptied completely. Daily administration of saline laxatives (such as 180 cc. of magnesium citrate for three or four days), and daily enemas together with a low roughage diet will create optimum operative conditions. 2. Adequate restoration of blood, plasma and electrolytes. Preoperative transfusions, given over a period of several days, are far superior to a large volume of blood given on the day of operation. 3. Preparation of the colon by antibiotics. So much has been written on this subject that it would be redundant to recapitulate. It must be emphasized, however, the more perfect the preoperative preparation the greater is the chance of postoperative enterocolitis. We prefer four or five days' preparation with Sulfathalidine, given in doses of 2 grams every six hours. In other instances, when less time is available, neomycin is given orally in doses of 2 grams every six hours for four doses. Longer preparation with neomycin or the use of broad-spectrum antibiotics has been proved to be dangerous. Parenteral antibiotics are avoided except in certain instances of perforation. 4. Preoperative administration of cortisone will be necessary if the patient has been receiving adrenal replacement therapy within the last three months, and possibly within the previous year. One hundred milligrams of hydrocortisone are given intravenously just prior to operation, and another 100 mg. continued during the procedure. The dose is maintained for several days, and then reduced gradually so that it usually is eliminated entirely within two weeks. 5. Gastrointestinal decompression is maintained during and after operation. Several methods are available; some surgeons use none at all. We continue to use the Levin tube routinely, believing that it accomplishes nearly all that can be gained from long intestinal tubes, and is
Complications Following Surgery of the Colon
777
safer than a gastrostomy catheter. Decompression of low anastomoses by a rectal tube drawn up through the anastomosis has been advocated by Waugh, while some surgeons continue to use a proximal colostomy or cecostomy after resections of the left colon; we use these methods only in special instances such as an anastomosis below the peritoneal floor, or one that is unusually narrow or has been technically imperfect. 6. Postoperatively pulmonary function is aided by early ambulation, attention to coughing, avoidance of compressive binders, and by physiotherapy. Elastic stockings are used in the belief that they, as well as early ambulation, reduce the incidence of thromboembolism. Utmost care is taken to be certain the stomach remains empty until intestinal peristalsis has resumed, and gas has been passed by rectum. Meanwhile careful attention is given to blood volume, plasma and electrolyte levels. 7. Prophylactic measures, that, in our belief, are not indicated as a routine but should be used on indication, are drainage of the operative site at the time of laparotomy, and the use of postoperative antibiotics. COMPLICATIONS COMMON TO ALL COLON OPERATIONS
Sepsis, ileus, hemorrhage and fistula are the important complications that may follow any operation on the colon. Actually two or more of them frequently co-exist, and dehiscence of an anastomosis may lead to all of them simultaneously. They will be discussed in order. Sepsis
Sepsis may be manifested as peritonitis either local or generalized, as an intraperitoneal abscess, as wound infection, or as enterocolitis. PERITONITIS. Some instances of postoperative peritonitis are due to activation and spread of a previously established pathologic process (such as a perforated ulcerative colitis), to unrecognized damage to the bowel or urinary tract, to retraction of a colostomy, or to glove powder peritonitis that develops about three weeks after operation. Generally, however, peritonitis following resection and anastomosis of the colon is due to an anastomotic leak. Such a leak may be apparent shortly after operation but usually is not recognized for five to eight days. Abdominal pain and tenderness, shock, free air in the abdomen, ileus, and the signs of sepsis will be present in variable degree. Some of these patients, despite the best possible care, will not survive; others, treated rapidly and vigorously, will recover. Treatment includes massive antibiotic therapy, prompt replacement of blood, electrolytes and plasma, complete withdrawal of oral intake, Levin tube suction, prevention of hyperthermia, vasopressors and, in most instances, laparotomy. The antibiotics to be employed may be determined from culture and sensitivity tests, but in the absence of a positive culture either intravenous chloramphenicol (in doses of 2 grams daily) or a combination of intravenous penicillin and intramuscular
778
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
streptomycin (in doses of 10 million units and 2 grams, respectively) are started. The purposes of an operation are, insofar as possible, to empty the peritoneal cavity of fecal material and pus, and to control the source of contamination either by exteriorization of the anastomosis or by a completely diverting proximal colostomy or ileostomy. The decision to operate is usually more difficult than the operation itself. Fecal matter or pus is removed by suction. Peritoneal lavage may be used with caution not to spread infection. If a topical antibiotic is used, kanamycin is the safest according to Cohn, though even it has led to respiratory arrest. The value of topical administration of antibiotics is still in question and it is not clear that this method offers any advantage over the systemic route. If it is impossible because of mesenteric shortening or induration to withdraw the anastomosis from the abdominal cavity, the region of the anastomosis should be exteriorized by drains that do not touch the anastomotic line. Occasionally an anastomotic leak can be closed by suture, but a diverting colostomy or ileostomy is always necessary to prevent further soiling. Operative decompression of distended gut will reduce the severity of postoperative ileus and facilitate wound closure. The postoperative care of these patients is usually very trying. Many problems are similar to those encountered in the early treatment of thermal burns. The numerous complications that may ensue also run the gamut of abdominal, vascular, renal and pulmonary disasters. If each is met in turn with appropriate measures, it is surprising how often these desperately ill patients can be restored to health. INTRAPERITONEAL ABSCESSES. An intraperitoneal abscess usually develops in close proximity to an anastomosis. Most of these abscesses will resolve or drain spontaneously through the abdominal incision or into the bowel. Simple incision and drainage is not as simple to carry out as it might seem since a loop of adherent intestine may be entered and a high intestinal fistula result. Spontaneous drainage on the other hand may be followed by a fecal fistula from the anastomotic line. Pelvic or subdiaphragmatic abscesses are less likely to respond to conservative measures, and nearly always require surgery. Pelvic abscesses usually can be drained by an incision through the anterior wall of the rectum. Subdiaphragmatic abscesses on the left are evacuated through subcostal incisions; on the right a similar approach is used for the anterior abscesses, while Ochsner's incision through the bed of the twelfth rib is made for the posterior. WOUND INFECTIONS. In this series incisional sepsis was seen in 9.6 per cent of 500 cases. This is an incidence appreciably higher than the 3 to 5 per cent reported for "clean operations" in our institution by Barnes et al.2 Preventive measures are almost entirely technical. Effective isolation of contaminated gloves, instruments, and drapes from contact with the abdominal wound, expeditious surgery, and the use of
Complications Following Surgery of the Colon
779
delayed primary closure in severely contaminated wounds are far more important than antibiotics in the avoidance of infection. POSTOPERATIVE ENTEROCOLITIS. The exact relationship of pseudomembranous enterocolitis and staphylococcal enteritis is still not clear. Though preparation of the bowel with broad-spectrum antibiotics has been the usual precursor, both diseases were seen prior to the use of antibiotics. Hypotension has been recognized as an etiologic agent, and vasopressors may contribute to necrosis of intestinal villi. Because of the usual postoperative ileus, diagnosis frequently is delayed; and in the absence of diarrhea it may be almost impossible to differentiate enterocolitis from ileus due to other causes. Though a profuse watery diarrhea is usually the first symptom, reduction in the urine volume may be the first sign of fluid loss into the gut. Fecal smears should be made at once; if numerous staphylococci are found by gram stain, vigorous treatment with chloramphenicol and erythromycin, or with Staphcillin is begun. Antibiotic therapy frequently must be started before positive smears are obtained or sensitivity tests can be completed. Fluid losses may reach 16 liters a day and must be replaced accurately with plasma and electrolyte solutions. Prohaska 7 believes that ACTH (in doses of 120 mg. daily by the intramuscular or intravenous route) is almost specific in its beneficial effect, and that it is far more effective than hydrocortisone. Certainly there is a theoretical disadvantage in the use of vasopressors in these cases. The administration of lactic acid by mouth, or of fecal suspensions from normal patients (introduced by enema or Levin tube) is of doubtful value. Ileus
Though ileus always occurs after abdominal surgery, it is apt to be more serious after operations on the colon. Colonic function usually resumes on the third or fourth day after operation, but may vary from two to 16 days so that a definition of ileus cannot be clear-cut. While postoperative ileus usually is described as paralytic or mechanical, in practice these types may be difficult to distinguish. Paralytic ileus results from a variety of causes, some of them extraperitoneal. For example lobar pneumonia, ureteral colic, septicemia and severe skeletal injury are commonly associated with absent peristalsis. Electrolyte imbalance (particularly hypokalemic alkalosis), anemia, vitamin deficiency and malnutrition are important predisposing factors. The recommended methods of treatment are as varied as the causes of ileus. Warm abdominal packs, poultices, hot drinks and enemas, parasympathomimetic drugs, sympatholytic drugs, vitamins such as Ilopan, and various electrolyte solutions have all been tried with prolonged ileus. However, none of these measures is specific, and the bowel finally regains function in most cases. Of greater importance are situations in which paralytic ileus has
780
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
become complicated by intestinal distention through forced insufflation of anesthetic gases, aerophagia, early oral feeding, or malfunction of an intestinal suction tube. Here distention itself leads to mechanical obstruction by kinking and intensified paralysis owing to decompensation of the overstretched smooth muscle. Gastrointestinal decompression by nasogastric or long tube suction should be instituted immediately and the patient allowed nothing by mouth. X-rays are helpful to document daily changes. If x-ray should show distention of small intestine only, or if the entire intestinal tract is dilated down to the anastomosis, mechanical obstruction should be suspected. Persistence of distention beyond five to seven days usually is an indication for operation because function ordinarily is not resumed in such cases until the bowel is decompressed. Furthermore, if conservative therapy is unsuccessful after a week, many patients thought initially to have paralytic ileus will be found at operation to have some mechanical cause for their obstruction. Ileus due to peritonitis is distinguished from simple ileus by fever, leukocytosis, tachycardia, and the presence of peritoneal signs on examination. The signs may be most confusing on the fourth or fifth postoperative day as sluggish gut just proximal to an anastomosis becomes distended with gas and tender. Usually the important decision whether or not to reoperate is made after judicious delay and on clinical grounds. Mechanical ileus in the postoperative phase may be due to narrowing at an anastomosis or it may be due to angulation, compression or torsion of the bowel elsewhere. Anastomotic edema usually is blamed for mechanical obstruction that is relieved spontaneously or with simple supportive measures. If intestinal intubation is still unsuccessful after a week's trial, operation is indicated. Small bowel obstruction is treated by appropriate measures, and obstruction of the colon by tube cecostomy or transverse colostomy. About 50 per cent of postoperative mechanical obstructions appear within the first two weeks. In these cases nearly 80 per cent are due to adhesions.!! Other causes of obstruction are wound dehiscence with a complete or Richter's hernia of the bowel, intraperitoneal abscesses, internal hernia, volvulus, dehiscence of a peritoneal floor, or parastomal hernia. The surgeon must be particularly wary of mechanical obstruction in patients who have had total colectomy for ulcerative colitis, or a combined abdominoperineal resection for cancer of the rectum. The vast majority of these cases require reoperation at the earliest time the diagnosis is established beyond reasonable doubt. Late obstruction after operations on the colon may also be due to the causes just mentioned. Late stricture of an anastomosis or of a colostomy or ileostomy is another cause. Operative correction is indicated. Hemorrhage
Hemorrhage following colon surgery may arise from gastroduodenal
Complications Following Surgery of the Colon
781
lesions aggravated by stress, from within the colon, or from the area of resection. Bleeding into a gutter is particularly serious since such collections readily become infected. Bleeding from within the colon either from the anastomotic line or from lesions left behind is rarely a problem except after subtotal colectomy for ulcerative colitis, where hemorrhage from a retained rectum may be severe enough to require emergency proctectomy. During abdominoperineal resection, bleeding from sacral veins may require packing with gauze or Gelfoam. Bilateral ligation of the hypogastric arteries will aid in the control of pelvic hemorrhage. Fistula
Fecal fistulas formerly were very common when drains were placed in close proximity to an anastomosis. They also may follow spontaneous anastomotic failure if the patient survives. Fistulas following colon resections occurred in 3 per cent of 400 resections with anastomosis. Fifty-six of 157 gastrointestinal fistulas collected by Edmunds et al. from the Massachusetts General Hospital were of colonic origin. 3 Twentyfive were due to complications of surgery; 20 of these arose from leakage of an anastomosis and five from surgical injury. If not associated with persistent inflammation or distal obstruction, these fistulas tend to close spontaneously. Large fistulas (greater thani cm. in diameter) are subject to eversion of the mucous membrane and epithelization of the fistulous tract. so that they are much less apt to heal. Death from large bowel fistula results primarily from peritonitis. If the external fistulous opening is inadequate in the early phase, treatment should include defunctioning colostomy, drainage of the abscess, and, if it can be done easily, suture of the perforation. Most lower bowel fistulas form an adequate tract. If closure has not occurred in six weeks operative intervention must be considered, though it must be remembered that spontaneous closure can still take place after a much longer interval. Staged operations are safer, and frequently the diverting colostomy done as the first stage results in cure. If further procedures are necessary, resection and re-anastomosis are much more likely to succeed than simple suture. COMPLICATIONS OF SPECIFIC OPERATIONS ON THE COLON
Ileostomy with Total or Subtotal Colectomy
Loop ileostomy formerly was performed as a preliminary operation before colectomy for ulcerative colitis, and is still used occasionally for this and other purposes, such as diversion above a leaking anastomosis after subtotal colectomy. Terminal ileostomy is, of course, much more common than loop ileostomy now that colectomies are usually done in one stage. Continued experience with these operations has lowered the mortality, though complications are still numerous.
782
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
Examples of complications that have nearly been eliminated in recent years are intestinal obstruction due to ileostomy dysfunction and paraileostomy volvulus of the small intestine. Dysfunction of the ileostomy is prevented by Brooke's technique whereby mucosa is sewed to skin at the time of the ileostomy. From an historical point of view, it is interesting to note that Warren and McKittrick, before the introduction of this method, found an incidence of dysfunction in 62 per cent of 210 patients with ileostomy.9 When the right colon is removed at the time of ileostomy, it is possible to suture mesentery of terminal ileum accurately to lateral peritoneal wall, so that herniation of intestine lateral to the loop is prevented. Severe electrolyte and fluid derangements are the rule after ileostomy and require utmost care to tide the patient over the critical postoperative period until the ileum begins to absorb fluid. Relatively large amounts of water, salt and potassium are needed, in addition to the plasma that is required particularly in depleted patients. The most frequent serious complication that occurs after total colectomy, however, is intestinal obstruction. In the most recent analysis from the Massachusetts General Hospital, Warren and Wheelock found, in an analysis of 139 patients subjected to total or subtotal colectomy, 23 admissions for small bowel obstruction occurring in 18 patients. 12 All but one had the first attack within a year of operation. Eight patients were obstructed because of volvulus of small bowel about the terminal ileum, 11 because of adhesions, and in 4 the cause of obstruction was not determined. Complications due to dehiscence of the peritoneal floor were not seen, presumably because ample peritoneum and mesosigmoid had been preserved to allow strong closure. Similarly, ureteral complications were not observed in contrast to sigmoidal and rectal resections for carcinoma where dissection is carried much more widely, with proportionate increase of risk to retroperitoneal structures. Other complications of ileostomy include fistula, prolapse, paraileostomy hernia and dermatitis. Fistulas were found in 7 per cent of patients. When they are superficial and arise from the stoma, they are treated by an incision which connects and unifies the major and minor stomas. Revision of the stoma with elevation of the ileum may be required with deeper fistulas. When the fistula originates from a still higher level, resection of the involved segment may be necessary. Para-ileostomy hernia is not common; major revision was required in only one case. Prolapse of the stoma was observed in 13 per cent of the patients. It is now less common because terminal ileum is sutured to the lateral peritoneal wall. Minor prolapse can be managed by a compressive belt, similar to a truss, worn over the appliance to maintain reduction of the bowel. A new appliance, just being developed at Massachusetts Institute of Technology by Dr. Egon Orwan, has been very effective in preventing or reducing prolapse; it consists of an inflatable rubber doughnut that
Complications Following Surgery of the Colon
783
is held against the stoma with slight pressure. 6 Operative correction may be secured by transplantation of the ileostomy to the upper abdomen, which tightens the elongated mesentery seen in these cases, or by plication of a loop or two of the terminal ileum as suggested by Garlock. 4 Dermatitis occurs with less frequency now that a closely fitted appliance is used immediately. We apply a self-adhering plastic bag cut to fit the stoma while the patient is still on the operating table. A fitted permanent appliance is attached within a few weeks. Dermatitis results when ileal content leaks under the appliance ring at the site of irregularities in the skin surface. Poor contact is not uncommon early because of malnutrition, but it may also be caused by proximity of the iliac crest, pubis or umbilicus, or by the presence of depressed scars near the stoma. A custom-made disk may suffice to prevent leakage, but transplantation of the stoma to a more favorable location is sometimes required. For dermatitis so severe that application of a bag is not possible, the quickest results are obtained if the patient is kept prone on a special mattress that allows collection of ileal discharge as it falls away from the patient without touching the skin. Karaya gum powder has been the most satisfactory local application that we have found to prevent or relieve dermatitis. Cecostomy
Cecostomy by the Gibson tube technique now is an uncommon operation. It is followed regularly by an elevation of temperature implying some local contamination of the peritoneal cavity. Inadequate decompression is the most common early complication; this can be avoided by the use of a tube of adequate size that projects well into the lumen of the colon. Retention of such a tube for too long a time may lead to erosion and perforation of the bowel. Late complications include persistent fistula (which required closure in 6 per cent of a series of 240 cases reported by Allen and Welch) and incisional hernia (which nearly always follows the operation but which is rarely large enough to require repair).1 Colostomy
Colostomy is performed for the purpose of decompressing and defunctioning the colon; Failure to achieve this objective is a mishap so serious that its inclusion simply as a complication may be questioned. It must be re-emphasized, however, that cecostomy does not defunction the colon and may not decompress it adequately, that a loop colostomy sometimes does not defunction, and that a loop colostomy in the transverse or distal colon may not decompress the cecum and right colon rapidly enough to prevent perforation from overdistention unless the proximal colon is evacuated in some fashion at the time of operation. Of the complications that follow colostomy, the most important are obstruction at the colostomy, prolapse of a loop of intestine adjacent to the stoma, prolapse of the colon, and paracolostomy hernia. Some of
784
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
these problems are due to the great distention of the colon that exists at the time of colostomy. It is our impression that these complications are more frequent after loop colostomy than after one in which the colon has been divided and a bridge of fascia and skin sutured between the loops. With loop colostomies there is occasionally a massive evisceration in which distended small bowel pushes the colon in front of it; in such a case early conversion of the loop to a divided colostomy will be necessary. Extensive prolapse of the colon may occur with either type of colostomy. If reduction is not secured rapidly, resection will be necessary. This complication occurs most frequently in the transverse colon because of its long mobile mesentery. Permanent colostomies, usually of the single lumen variety that follow resection for cancer of the rectum, are also subject to many complications. In the immediate postoperative period stomal gangrene and retraction usually require reoperation unless it can be ascertained that viable bowel extends high enough to assure extraperitoneal discharge of its contents. Gangrene of the stoma should be recognized before the clamp is removed from the stoma on the first or second postoperative day when the colon may be elevated to a proper level before the field is contaminated with feces. Internal herniation about a colonic stoma is prevented by suture of mesocolon to lateral abdominal wall, so that the trap is eliminated. Intestinal obstruction resulting from parastomal herniation should be treated by obliteration of the hernial sac or trap; occasionally it is necessary to resect bowel and construct a new stoma to achieve this end. Goligher has shown that a great reduction in the incidence of hernias through these traps has been achieved by the use of a lateral rather than a midline stoma, presumably because closure of the trap can be made more secure./; Late stricture of the stoma may require plastic revision. Some surgeons apply the Brooke ileostomy technique to colostomies in order to prevent this complication. Stricture is not, however, of much significance, and can be made even less common if the patient will dilate the stoma regularly for a few months after the original operation. Perforatipn of the colon by a catheter used for colostomy enemas is an unfortunate late complication. It is less likely to occur if patients are instructed to use relatively large catheters (No. 22) and to insert them for a distance of only 3 or 4 inches. Perforation should be suspected if severe pain and local peritoneal signs occur during or just after an enema. Immediate operation is essential; while it is sometimes possible to close the perforation it is usually best to resect the colon distal to the point of perforation and make a new stoma. Ileotransverse Colostomy
Ileotransverse colostomy now is seldom the operation of choice either
Complications Following Surgery of the Colon
785
for cancer of the right colon or for terminal ileitis. It generally represents a compromise when resection appears too formidable. Complications include persistently active disease, failure to decompress the right colon when the ileocecal valve is incompetent, and rarely the blind-loop syndrome. Internal herniation of small bowel through the trap behind the ileocolostomy may occur. Resection of terminal ileum and right colon as the second stage of a two-stage procedure is the preferred treatment for these complications, though it may be possible only to reviEe the side-to-side anastomosis, converting it to an end-to-side. If obstruction is present the distal ileum should be brought to the abdominal wall as a mucous fistula. Segmental Resections of the Colon
The incidence of complications following various segmental resections may be seen from Table 2. Besides those common to all colon surgery, each segment also has specific neighboring organs that may be injured. Thus, with the right colon, the ureter and duodenum are the most important and particular care must be taken to maintain the integrity of the superior mesenteric vessels when radical resections are done. In the transverse colon, high ligation of the mid colic vessels may damage the pancreas. The spleen may be injured when the splenic flexure is resected. With resection of the left colon and rectum the ureters and bladder require special attention. Of all segmental resections, those of the right colon are least subject to complications (Table 2). Surprisingly, sigmoid resection for carcinoma carried a higher risk of complication than left colectomy. We were unprepared for this finding which is at variance with our general impression that anastomotic failure is less frequent after conservative resection. A detailed analysis of the factors responsible is not yet accomplished, but it is reasonable to suppose that the complete lack of tension possible in anastomosis after left colectomy has a favorable influence which outweighs the potential risks of wider dissection. Furthermore when transverse colon is used for anastomosis there is less chance of injury to blood supply than when the sigmoidal vessels are taken near their origin. Complications referable to the anastomosis tend to be more common if the suture line lies below the peritoneal floor. Resection of the pelvic colon with anastomosis to the distal inch or two of rectum carries a high risk of anastomotic failure in addition to all the dangers of hemorrhage encountered in Miles' resection. Drainage of the area anteriorly with suction catheters and complementary colostomy are advisable in most cases. An inlying rectal tube has practical and theoretical advantages which probably outweigh certain potential drawbacks. If separation of the suture line occurs, treatment depends on the extent of the defect. Colostomy, if not done at the initial operation, should be done now. A drain may be inserted in the paracoccygeal area. The mo.rtality is high.
Table 2.
Complications Following 500 Resections of Colon and Rectum (100 in Each Category) o = 1 CASE FATAL ~ NON-FATAL
'-l
00
0;,
RIGHT COLECTOMYI LEFT COLECTOMY ISIGMOID RESECTION I MILES RESECTION ISIGMOID RESECTlO~ (CANCER) AN4"'TnunTIC FAILURE WOUND INFECTION ...... ....... SEPSIS
PERITONITiS·····················
~
PERFORATED DIVERTICULUM· SUBHEPATIC ABSCESS· ...... . RETROPERITONEAL ABSCESS·
''':::::"i.~',,~''.:::::::::::~
(CANC~fl)
(CANCER)
(CANCER)
(DIVERpl"lIl
~
~
·~I ~~ ~ ~ ;
~
=:
1m-
~
MECHANiCAL····················· PARALyTIC························
FIS~~~tL BOWEL................... ~ll
IS'"
m~ •
IT
, J
I
z
tr1
................. ~
PULE~~~~~~M"""""""""""'!' Am PNEUMONIA..... ·•·•·· .. ··· .. ·· ..
~
~' .....-----:.•
'~tl;I'1 --,-,I
~
~
~._ II
~ _
:~~~~~~~~.~.~~~~:::::. . . .:: ~~~===========l~~~==========j~··=============fr============~D============~ ASTHMATIC BRONCHITIS ..... " ATELECTASIS ....•........•.•...
~
CARDIAC (FAILUREorM.I.)······15If
URI~:JRJ~~g~ .••••••••••••••••.. ~ INFECTION .......................
•
FiSTULA .... ·• .... · .. ···•• .. ·....
~
~
E
::
CO~:~TlON ••••••••.•.••.•••••• II-------+-------+--------I.i------+-------1 OBSTRUCTION .................... NECROSIS ... , .................. .
I-------+-------+--------Rb-------f--------I
::c: t'=j t? t:C
t'=j ~
~Q
o ~
§ t'=j
tr1
~
t'
(":l
CEREBRO-VASCULAR ACCIDENT· MiSCELLANEOUS···················
.;] t'=j
~t'=j
~
LARGE BOWEL .. · ......•.........
WOUND
U2
~ ~
~
Complications Following Surgery of the Colon
787
If pelvic hemorrhage is uncontrolled by suction catheters and transfusion, then the pelvis must be packed. Waugh states that effective packing almost always requires taking down the anastomosis and making an end colostomy, but we have not encountered this problem. In addition to the other complications, pull-through operations yield a somewhat higher incidence of anastomotic stenosis if healing is by secondary rather than primary intention. Repeated dilatations usually produce a satisfactory lumen. The incidence of incontinence is also high after pullthrough resection. In one of the largest series studied, Waugh found that fecal control was good or excellent in over half of his patients. 1o After resections of the rectum for cancer, colostomy complications replace anastomotic failure as a source of trouble. Other problems peculiar to abdominoperineal resections include hemorrhage, dehiscence of the peritoneal floor, ileus, urinary tract injury or dysfunction, and posteri9r wound complications. According to a study made by Ulfelder and Quinby in the Massachusetts General Hospital several years ago, half of the postoperative deaths were due to intestinal obstruction. 8 Cardiopulmonary and urinary complications often occurred in the patients who died. Urinary tract problems are very common and will be discussed in another article. Extensive and often crude dissection in the pelvis, where it is difficult to ligate vessels accurately, accounts for the increased risk of hemorrhage in Miles' resections. Fortunately, the narrow confines of the pelvic outlet can be packed effectively with gauze. A certain amount of persistent ooze always necessitates drainage of this space; if there is doubt that drainage will suffice, however, it is better to pack at the initial procedure than to return the patient to the operating room later under circumstances that may be less than ideal. Wide resection of peritoneum in cancer surgery sometimes leaves little with which to reconstruct a pelvic floor even after extensive mobilization of lateral flaps. As with closures of the gutters lateral to colostomies, no closure at all is better than a weak one. In questionable cases a pack covered with rubber tissue is inserted to provide support for seven to ten days. Prolapse of small bowel through a tear in the reconstructed floor is very serious, leading rapidly to strangulation obstruction. This possibility, as well as that of pericolostomy hernia, must be kept uppermost in mind in the differential diagnosis of ileus following combined resection. Persistent drainage from the posterior wound is surprisingly infrequent considering the size of the space nature must obliterate, and this complication is often the result of a residual carcinoma. An exception is after resection for ulcerative colitis, where delayed healing is the rule. Irrigation of the sinus with 50'per cent Dakin's solution and occasional curettage of exuberant granulations may speed closure. Pain in the healed posterior wound is usually due to residual or recurrent tumor that is sometimes amenable to secondary resection.
788
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
Late hernias in the perineum are not uncommon and rarely are bothersome. In one of the recent cases treated in the Massachusetts General Hospital, however, a violent fit of coughing led to evisceration through a perineal hernia several years after a Miles' resection. Segmental resections of the colon by exteriorization procedures now are done so rarely that no statistical material is available on the incidence of complications. When they are done, however, the colostomy is closed by resection and anastomosis rather than by crushing of the spur because of the danger of crushing an adherent loop of the intestine by the clamp. MORTALITY
This formidable list of complications might lead the reader to suspect that the mortality rates following operations on the colon are excessively high. Actually, colectomy for inflammatory disease such as diverticulitis or ulcerative colitis now is done with a mortality of about 2 per cent, while the corresponding rate for cancer is about 8 per cent. The latter figure is higher because of the very extensive resections that are carried out in the hope of cure or significant palliation. These relatively low rates do not, however, reflect the fact that many of these patients have had a harrowing convalescence. It is only by continuous attention to prophylaxis and care of the complications of operation that such rates may be maintained or improved. REFERENCES 1. Allen, A. W. and Welch, C. E.: Cecostomy. Surg. Gynec. & Obst: 73: 549, 1941. 2. Barnes, B. A., Behringer, G. E., Wheelock, F. C., Wilkins, E. W. and Cope, 0.: Surgical sepsis: Report on subtotal gastrectomies. New England J. Med. 173: 1068, 1960. 3. Edmunds, L. H., Jr., Williams, G. M. and Welch, C. E.: External fistulas arising from gastro-intestinal tract. Ann. Surg. 152: 445, 1960. 4. Garlock, J. H. and Kirschner, P. A.: Prevention of ileostomy dysfunction. Surgery 40: 678, 1956. 5. Goligher, J. C., Lloyd-Davies, O. V. and Robertson, C. T.: Small gut obstruction following combined excision of rectum. Brit. J. Surg. 38: 467, 1951. 6. Orwan, Egon: Personal communication. 7. Prohaska, J. V., Farrell, M., Baker, W. and Collins, R.: Pseudomembranous (staphylococcal) enterocolitis. Internat. Abstr. Surg. 112: 103, 1961. 8. Ulfelder, H. and Quinby, W. C., Jr.: Small bowel obstruction following abdominoperineal resection of rectum. Surgery 30: 174, 1951. 9. Warren, R. and McKittrick, J,. S.: Ileostomy for ulcerative colitis: Technique, complications and management. Surg. Gynec. & Obst. 93: 555,1951. 10. Waugh, J. M., Block, M. A. and Gage, R. P.: Three and five-year survivals following combined abdominoperineal resection: Abdominoperineal resection with sphincter preservation and anterior resection for carcinoma of the rectum and lower part of the sigmoid colon. Ann. Surg. 142: 752, 1955. 11. Welch, C. E.: Intestinal Obstruction. Chicago, Year Book Publishers, 1958. 12. Wheelock, F. C., Jr. and Warren, R.: Ulcerative colitis: Follow-up studies. New England J. Med. 252: 421, 1955. 275 Charles Street Boston 14, Massachusetts
STEPHEN E. HEDBERG, M.D. Assistant in Surgery
CLAUDE E. WELCH, M.D., F.A.C.S. Visiting Surgeon; Associate Clinical Professor of Surgery
COMPLICATIONS following surgery on the colon are common and often very serious. Their importance is accentuated by the fact that many of them can be prevented; some attention in this paper therefore must be directed toward prophylaxis. In many instances complications occur despite the most scrupulous technique, particularly when extensive operative procedures have destroyed anatomic barriers or structures required for normal functions. Complications vary according to the type of surgery performed; thus intraperitoneal anastomosis, ileostomy and colostomy each evokes specific problems. Complications also vary according to underlying pathologic process; ulcerative colitis, for example, is a much more serious underlying disease than diverticulitis. Table 1.
Complications Following Surgery of the Colon RIGHT
LEFT
SIGMOID
COLECTOMY (CANCER)
COLECTOMY (CANCER)
RESECTION (CANCER)
Total patients .................. Patients with fatal complications ............ Patients with nonfatal complications. Total complications ...... Complications per patient with fatal complications .... Complications per patient with nonfatal complications.
MILES'
SIGMOID
RESECTION RESECTION (CANCER) (DIVERTICULITIS)
100
100
100
100
8
9
9
7
100 2
30
30
56
26 46
65
43 69
21 21
1.8
2.0
2.5
1.7
1.4
1.1
1.4
1.3
1.8
775
776
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
A careful reVIew has been made of 500 resections of the colon or rectum performed in the Massachusetts General Hospital during the past five years (Table 1.). The incidence of complications was found to be considerably higher than expected and their distribution likewise was surprising. For the analysis, 100 consecutive resections of the right colon for cancer, 100 of the left colon for cancer, 100 of the sigmoid for cancer, 100 of the sigmoid for diverticulitis, and 100 of the rectum for cancer were studied. In this discussion, the complications common to all operations on the colon will be considered first, after which those pertaining to particular operations will be described. PROPHYLAXIS OF COMPLICATIONS
Several features included in the preparation of patients for operation deserve emphasis. They include: 1. Complete mechanical cleansing of the colon. This may be impossible if intestinal obstruction, perforation, active inflammatory disease or hemorrhage is present, but in nearly all elective operations the colon can be emptied completely. Daily administration of saline laxatives (such as 180 cc. of magnesium citrate for three or four days), and daily enemas together with a low roughage diet will create optimum operative conditions. 2. Adequate restoration of blood, plasma and electrolytes. Preoperative transfusions, given over a period of several days, are far superior to a large volume of blood given on the day of operation. 3. Preparation of the colon by antibiotics. So much has been written on this subject that it would be redundant to recapitulate. It must be emphasized, however, the more perfect the preoperative preparation the greater is the chance of postoperative enterocolitis. We prefer four or five days' preparation with Sulfathalidine, given in doses of 2 grams every six hours. In other instances, when less time is available, neomycin is given orally in doses of 2 grams every six hours for four doses. Longer preparation with neomycin or the use of broad-spectrum antibiotics has been proved to be dangerous. Parenteral antibiotics are avoided except in certain instances of perforation. 4. Preoperative administration of cortisone will be necessary if the patient has been receiving adrenal replacement therapy within the last three months, and possibly within the previous year. One hundred milligrams of hydrocortisone are given intravenously just prior to operation, and another 100 mg. continued during the procedure. The dose is maintained for several days, and then reduced gradually so that it usually is eliminated entirely within two weeks. 5. Gastrointestinal decompression is maintained during and after operation. Several methods are available; some surgeons use none at all. We continue to use the Levin tube routinely, believing that it accomplishes nearly all that can be gained from long intestinal tubes, and is
Complications Following Surgery of the Colon
777
safer than a gastrostomy catheter. Decompression of low anastomoses by a rectal tube drawn up through the anastomosis has been advocated by Waugh, while some surgeons continue to use a proximal colostomy or cecostomy after resections of the left colon; we use these methods only in special instances such as an anastomosis below the peritoneal floor, or one that is unusually narrow or has been technically imperfect. 6. Postoperatively pulmonary function is aided by early ambulation, attention to coughing, avoidance of compressive binders, and by physiotherapy. Elastic stockings are used in the belief that they, as well as early ambulation, reduce the incidence of thromboembolism. Utmost care is taken to be certain the stomach remains empty until intestinal peristalsis has resumed, and gas has been passed by rectum. Meanwhile careful attention is given to blood volume, plasma and electrolyte levels. 7. Prophylactic measures, that, in our belief, are not indicated as a routine but should be used on indication, are drainage of the operative site at the time of laparotomy, and the use of postoperative antibiotics. COMPLICATIONS COMMON TO ALL COLON OPERATIONS
Sepsis, ileus, hemorrhage and fistula are the important complications that may follow any operation on the colon. Actually two or more of them frequently co-exist, and dehiscence of an anastomosis may lead to all of them simultaneously. They will be discussed in order. Sepsis
Sepsis may be manifested as peritonitis either local or generalized, as an intraperitoneal abscess, as wound infection, or as enterocolitis. PERITONITIS. Some instances of postoperative peritonitis are due to activation and spread of a previously established pathologic process (such as a perforated ulcerative colitis), to unrecognized damage to the bowel or urinary tract, to retraction of a colostomy, or to glove powder peritonitis that develops about three weeks after operation. Generally, however, peritonitis following resection and anastomosis of the colon is due to an anastomotic leak. Such a leak may be apparent shortly after operation but usually is not recognized for five to eight days. Abdominal pain and tenderness, shock, free air in the abdomen, ileus, and the signs of sepsis will be present in variable degree. Some of these patients, despite the best possible care, will not survive; others, treated rapidly and vigorously, will recover. Treatment includes massive antibiotic therapy, prompt replacement of blood, electrolytes and plasma, complete withdrawal of oral intake, Levin tube suction, prevention of hyperthermia, vasopressors and, in most instances, laparotomy. The antibiotics to be employed may be determined from culture and sensitivity tests, but in the absence of a positive culture either intravenous chloramphenicol (in doses of 2 grams daily) or a combination of intravenous penicillin and intramuscular
778
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
streptomycin (in doses of 10 million units and 2 grams, respectively) are started. The purposes of an operation are, insofar as possible, to empty the peritoneal cavity of fecal material and pus, and to control the source of contamination either by exteriorization of the anastomosis or by a completely diverting proximal colostomy or ileostomy. The decision to operate is usually more difficult than the operation itself. Fecal matter or pus is removed by suction. Peritoneal lavage may be used with caution not to spread infection. If a topical antibiotic is used, kanamycin is the safest according to Cohn, though even it has led to respiratory arrest. The value of topical administration of antibiotics is still in question and it is not clear that this method offers any advantage over the systemic route. If it is impossible because of mesenteric shortening or induration to withdraw the anastomosis from the abdominal cavity, the region of the anastomosis should be exteriorized by drains that do not touch the anastomotic line. Occasionally an anastomotic leak can be closed by suture, but a diverting colostomy or ileostomy is always necessary to prevent further soiling. Operative decompression of distended gut will reduce the severity of postoperative ileus and facilitate wound closure. The postoperative care of these patients is usually very trying. Many problems are similar to those encountered in the early treatment of thermal burns. The numerous complications that may ensue also run the gamut of abdominal, vascular, renal and pulmonary disasters. If each is met in turn with appropriate measures, it is surprising how often these desperately ill patients can be restored to health. INTRAPERITONEAL ABSCESSES. An intraperitoneal abscess usually develops in close proximity to an anastomosis. Most of these abscesses will resolve or drain spontaneously through the abdominal incision or into the bowel. Simple incision and drainage is not as simple to carry out as it might seem since a loop of adherent intestine may be entered and a high intestinal fistula result. Spontaneous drainage on the other hand may be followed by a fecal fistula from the anastomotic line. Pelvic or subdiaphragmatic abscesses are less likely to respond to conservative measures, and nearly always require surgery. Pelvic abscesses usually can be drained by an incision through the anterior wall of the rectum. Subdiaphragmatic abscesses on the left are evacuated through subcostal incisions; on the right a similar approach is used for the anterior abscesses, while Ochsner's incision through the bed of the twelfth rib is made for the posterior. WOUND INFECTIONS. In this series incisional sepsis was seen in 9.6 per cent of 500 cases. This is an incidence appreciably higher than the 3 to 5 per cent reported for "clean operations" in our institution by Barnes et al.2 Preventive measures are almost entirely technical. Effective isolation of contaminated gloves, instruments, and drapes from contact with the abdominal wound, expeditious surgery, and the use of
Complications Following Surgery of the Colon
779
delayed primary closure in severely contaminated wounds are far more important than antibiotics in the avoidance of infection. POSTOPERATIVE ENTEROCOLITIS. The exact relationship of pseudomembranous enterocolitis and staphylococcal enteritis is still not clear. Though preparation of the bowel with broad-spectrum antibiotics has been the usual precursor, both diseases were seen prior to the use of antibiotics. Hypotension has been recognized as an etiologic agent, and vasopressors may contribute to necrosis of intestinal villi. Because of the usual postoperative ileus, diagnosis frequently is delayed; and in the absence of diarrhea it may be almost impossible to differentiate enterocolitis from ileus due to other causes. Though a profuse watery diarrhea is usually the first symptom, reduction in the urine volume may be the first sign of fluid loss into the gut. Fecal smears should be made at once; if numerous staphylococci are found by gram stain, vigorous treatment with chloramphenicol and erythromycin, or with Staphcillin is begun. Antibiotic therapy frequently must be started before positive smears are obtained or sensitivity tests can be completed. Fluid losses may reach 16 liters a day and must be replaced accurately with plasma and electrolyte solutions. Prohaska 7 believes that ACTH (in doses of 120 mg. daily by the intramuscular or intravenous route) is almost specific in its beneficial effect, and that it is far more effective than hydrocortisone. Certainly there is a theoretical disadvantage in the use of vasopressors in these cases. The administration of lactic acid by mouth, or of fecal suspensions from normal patients (introduced by enema or Levin tube) is of doubtful value. Ileus
Though ileus always occurs after abdominal surgery, it is apt to be more serious after operations on the colon. Colonic function usually resumes on the third or fourth day after operation, but may vary from two to 16 days so that a definition of ileus cannot be clear-cut. While postoperative ileus usually is described as paralytic or mechanical, in practice these types may be difficult to distinguish. Paralytic ileus results from a variety of causes, some of them extraperitoneal. For example lobar pneumonia, ureteral colic, septicemia and severe skeletal injury are commonly associated with absent peristalsis. Electrolyte imbalance (particularly hypokalemic alkalosis), anemia, vitamin deficiency and malnutrition are important predisposing factors. The recommended methods of treatment are as varied as the causes of ileus. Warm abdominal packs, poultices, hot drinks and enemas, parasympathomimetic drugs, sympatholytic drugs, vitamins such as Ilopan, and various electrolyte solutions have all been tried with prolonged ileus. However, none of these measures is specific, and the bowel finally regains function in most cases. Of greater importance are situations in which paralytic ileus has
780
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
become complicated by intestinal distention through forced insufflation of anesthetic gases, aerophagia, early oral feeding, or malfunction of an intestinal suction tube. Here distention itself leads to mechanical obstruction by kinking and intensified paralysis owing to decompensation of the overstretched smooth muscle. Gastrointestinal decompression by nasogastric or long tube suction should be instituted immediately and the patient allowed nothing by mouth. X-rays are helpful to document daily changes. If x-ray should show distention of small intestine only, or if the entire intestinal tract is dilated down to the anastomosis, mechanical obstruction should be suspected. Persistence of distention beyond five to seven days usually is an indication for operation because function ordinarily is not resumed in such cases until the bowel is decompressed. Furthermore, if conservative therapy is unsuccessful after a week, many patients thought initially to have paralytic ileus will be found at operation to have some mechanical cause for their obstruction. Ileus due to peritonitis is distinguished from simple ileus by fever, leukocytosis, tachycardia, and the presence of peritoneal signs on examination. The signs may be most confusing on the fourth or fifth postoperative day as sluggish gut just proximal to an anastomosis becomes distended with gas and tender. Usually the important decision whether or not to reoperate is made after judicious delay and on clinical grounds. Mechanical ileus in the postoperative phase may be due to narrowing at an anastomosis or it may be due to angulation, compression or torsion of the bowel elsewhere. Anastomotic edema usually is blamed for mechanical obstruction that is relieved spontaneously or with simple supportive measures. If intestinal intubation is still unsuccessful after a week's trial, operation is indicated. Small bowel obstruction is treated by appropriate measures, and obstruction of the colon by tube cecostomy or transverse colostomy. About 50 per cent of postoperative mechanical obstructions appear within the first two weeks. In these cases nearly 80 per cent are due to adhesions.!! Other causes of obstruction are wound dehiscence with a complete or Richter's hernia of the bowel, intraperitoneal abscesses, internal hernia, volvulus, dehiscence of a peritoneal floor, or parastomal hernia. The surgeon must be particularly wary of mechanical obstruction in patients who have had total colectomy for ulcerative colitis, or a combined abdominoperineal resection for cancer of the rectum. The vast majority of these cases require reoperation at the earliest time the diagnosis is established beyond reasonable doubt. Late obstruction after operations on the colon may also be due to the causes just mentioned. Late stricture of an anastomosis or of a colostomy or ileostomy is another cause. Operative correction is indicated. Hemorrhage
Hemorrhage following colon surgery may arise from gastroduodenal
Complications Following Surgery of the Colon
781
lesions aggravated by stress, from within the colon, or from the area of resection. Bleeding into a gutter is particularly serious since such collections readily become infected. Bleeding from within the colon either from the anastomotic line or from lesions left behind is rarely a problem except after subtotal colectomy for ulcerative colitis, where hemorrhage from a retained rectum may be severe enough to require emergency proctectomy. During abdominoperineal resection, bleeding from sacral veins may require packing with gauze or Gelfoam. Bilateral ligation of the hypogastric arteries will aid in the control of pelvic hemorrhage. Fistula
Fecal fistulas formerly were very common when drains were placed in close proximity to an anastomosis. They also may follow spontaneous anastomotic failure if the patient survives. Fistulas following colon resections occurred in 3 per cent of 400 resections with anastomosis. Fifty-six of 157 gastrointestinal fistulas collected by Edmunds et al. from the Massachusetts General Hospital were of colonic origin. 3 Twentyfive were due to complications of surgery; 20 of these arose from leakage of an anastomosis and five from surgical injury. If not associated with persistent inflammation or distal obstruction, these fistulas tend to close spontaneously. Large fistulas (greater thani cm. in diameter) are subject to eversion of the mucous membrane and epithelization of the fistulous tract. so that they are much less apt to heal. Death from large bowel fistula results primarily from peritonitis. If the external fistulous opening is inadequate in the early phase, treatment should include defunctioning colostomy, drainage of the abscess, and, if it can be done easily, suture of the perforation. Most lower bowel fistulas form an adequate tract. If closure has not occurred in six weeks operative intervention must be considered, though it must be remembered that spontaneous closure can still take place after a much longer interval. Staged operations are safer, and frequently the diverting colostomy done as the first stage results in cure. If further procedures are necessary, resection and re-anastomosis are much more likely to succeed than simple suture. COMPLICATIONS OF SPECIFIC OPERATIONS ON THE COLON
Ileostomy with Total or Subtotal Colectomy
Loop ileostomy formerly was performed as a preliminary operation before colectomy for ulcerative colitis, and is still used occasionally for this and other purposes, such as diversion above a leaking anastomosis after subtotal colectomy. Terminal ileostomy is, of course, much more common than loop ileostomy now that colectomies are usually done in one stage. Continued experience with these operations has lowered the mortality, though complications are still numerous.
782
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
Examples of complications that have nearly been eliminated in recent years are intestinal obstruction due to ileostomy dysfunction and paraileostomy volvulus of the small intestine. Dysfunction of the ileostomy is prevented by Brooke's technique whereby mucosa is sewed to skin at the time of the ileostomy. From an historical point of view, it is interesting to note that Warren and McKittrick, before the introduction of this method, found an incidence of dysfunction in 62 per cent of 210 patients with ileostomy.9 When the right colon is removed at the time of ileostomy, it is possible to suture mesentery of terminal ileum accurately to lateral peritoneal wall, so that herniation of intestine lateral to the loop is prevented. Severe electrolyte and fluid derangements are the rule after ileostomy and require utmost care to tide the patient over the critical postoperative period until the ileum begins to absorb fluid. Relatively large amounts of water, salt and potassium are needed, in addition to the plasma that is required particularly in depleted patients. The most frequent serious complication that occurs after total colectomy, however, is intestinal obstruction. In the most recent analysis from the Massachusetts General Hospital, Warren and Wheelock found, in an analysis of 139 patients subjected to total or subtotal colectomy, 23 admissions for small bowel obstruction occurring in 18 patients. 12 All but one had the first attack within a year of operation. Eight patients were obstructed because of volvulus of small bowel about the terminal ileum, 11 because of adhesions, and in 4 the cause of obstruction was not determined. Complications due to dehiscence of the peritoneal floor were not seen, presumably because ample peritoneum and mesosigmoid had been preserved to allow strong closure. Similarly, ureteral complications were not observed in contrast to sigmoidal and rectal resections for carcinoma where dissection is carried much more widely, with proportionate increase of risk to retroperitoneal structures. Other complications of ileostomy include fistula, prolapse, paraileostomy hernia and dermatitis. Fistulas were found in 7 per cent of patients. When they are superficial and arise from the stoma, they are treated by an incision which connects and unifies the major and minor stomas. Revision of the stoma with elevation of the ileum may be required with deeper fistulas. When the fistula originates from a still higher level, resection of the involved segment may be necessary. Para-ileostomy hernia is not common; major revision was required in only one case. Prolapse of the stoma was observed in 13 per cent of the patients. It is now less common because terminal ileum is sutured to the lateral peritoneal wall. Minor prolapse can be managed by a compressive belt, similar to a truss, worn over the appliance to maintain reduction of the bowel. A new appliance, just being developed at Massachusetts Institute of Technology by Dr. Egon Orwan, has been very effective in preventing or reducing prolapse; it consists of an inflatable rubber doughnut that
Complications Following Surgery of the Colon
783
is held against the stoma with slight pressure. 6 Operative correction may be secured by transplantation of the ileostomy to the upper abdomen, which tightens the elongated mesentery seen in these cases, or by plication of a loop or two of the terminal ileum as suggested by Garlock. 4 Dermatitis occurs with less frequency now that a closely fitted appliance is used immediately. We apply a self-adhering plastic bag cut to fit the stoma while the patient is still on the operating table. A fitted permanent appliance is attached within a few weeks. Dermatitis results when ileal content leaks under the appliance ring at the site of irregularities in the skin surface. Poor contact is not uncommon early because of malnutrition, but it may also be caused by proximity of the iliac crest, pubis or umbilicus, or by the presence of depressed scars near the stoma. A custom-made disk may suffice to prevent leakage, but transplantation of the stoma to a more favorable location is sometimes required. For dermatitis so severe that application of a bag is not possible, the quickest results are obtained if the patient is kept prone on a special mattress that allows collection of ileal discharge as it falls away from the patient without touching the skin. Karaya gum powder has been the most satisfactory local application that we have found to prevent or relieve dermatitis. Cecostomy
Cecostomy by the Gibson tube technique now is an uncommon operation. It is followed regularly by an elevation of temperature implying some local contamination of the peritoneal cavity. Inadequate decompression is the most common early complication; this can be avoided by the use of a tube of adequate size that projects well into the lumen of the colon. Retention of such a tube for too long a time may lead to erosion and perforation of the bowel. Late complications include persistent fistula (which required closure in 6 per cent of a series of 240 cases reported by Allen and Welch) and incisional hernia (which nearly always follows the operation but which is rarely large enough to require repair).1 Colostomy
Colostomy is performed for the purpose of decompressing and defunctioning the colon; Failure to achieve this objective is a mishap so serious that its inclusion simply as a complication may be questioned. It must be re-emphasized, however, that cecostomy does not defunction the colon and may not decompress it adequately, that a loop colostomy sometimes does not defunction, and that a loop colostomy in the transverse or distal colon may not decompress the cecum and right colon rapidly enough to prevent perforation from overdistention unless the proximal colon is evacuated in some fashion at the time of operation. Of the complications that follow colostomy, the most important are obstruction at the colostomy, prolapse of a loop of intestine adjacent to the stoma, prolapse of the colon, and paracolostomy hernia. Some of
784
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
these problems are due to the great distention of the colon that exists at the time of colostomy. It is our impression that these complications are more frequent after loop colostomy than after one in which the colon has been divided and a bridge of fascia and skin sutured between the loops. With loop colostomies there is occasionally a massive evisceration in which distended small bowel pushes the colon in front of it; in such a case early conversion of the loop to a divided colostomy will be necessary. Extensive prolapse of the colon may occur with either type of colostomy. If reduction is not secured rapidly, resection will be necessary. This complication occurs most frequently in the transverse colon because of its long mobile mesentery. Permanent colostomies, usually of the single lumen variety that follow resection for cancer of the rectum, are also subject to many complications. In the immediate postoperative period stomal gangrene and retraction usually require reoperation unless it can be ascertained that viable bowel extends high enough to assure extraperitoneal discharge of its contents. Gangrene of the stoma should be recognized before the clamp is removed from the stoma on the first or second postoperative day when the colon may be elevated to a proper level before the field is contaminated with feces. Internal herniation about a colonic stoma is prevented by suture of mesocolon to lateral abdominal wall, so that the trap is eliminated. Intestinal obstruction resulting from parastomal herniation should be treated by obliteration of the hernial sac or trap; occasionally it is necessary to resect bowel and construct a new stoma to achieve this end. Goligher has shown that a great reduction in the incidence of hernias through these traps has been achieved by the use of a lateral rather than a midline stoma, presumably because closure of the trap can be made more secure./; Late stricture of the stoma may require plastic revision. Some surgeons apply the Brooke ileostomy technique to colostomies in order to prevent this complication. Stricture is not, however, of much significance, and can be made even less common if the patient will dilate the stoma regularly for a few months after the original operation. Perforatipn of the colon by a catheter used for colostomy enemas is an unfortunate late complication. It is less likely to occur if patients are instructed to use relatively large catheters (No. 22) and to insert them for a distance of only 3 or 4 inches. Perforation should be suspected if severe pain and local peritoneal signs occur during or just after an enema. Immediate operation is essential; while it is sometimes possible to close the perforation it is usually best to resect the colon distal to the point of perforation and make a new stoma. Ileotransverse Colostomy
Ileotransverse colostomy now is seldom the operation of choice either
Complications Following Surgery of the Colon
785
for cancer of the right colon or for terminal ileitis. It generally represents a compromise when resection appears too formidable. Complications include persistently active disease, failure to decompress the right colon when the ileocecal valve is incompetent, and rarely the blind-loop syndrome. Internal herniation of small bowel through the trap behind the ileocolostomy may occur. Resection of terminal ileum and right colon as the second stage of a two-stage procedure is the preferred treatment for these complications, though it may be possible only to reviEe the side-to-side anastomosis, converting it to an end-to-side. If obstruction is present the distal ileum should be brought to the abdominal wall as a mucous fistula. Segmental Resections of the Colon
The incidence of complications following various segmental resections may be seen from Table 2. Besides those common to all colon surgery, each segment also has specific neighboring organs that may be injured. Thus, with the right colon, the ureter and duodenum are the most important and particular care must be taken to maintain the integrity of the superior mesenteric vessels when radical resections are done. In the transverse colon, high ligation of the mid colic vessels may damage the pancreas. The spleen may be injured when the splenic flexure is resected. With resection of the left colon and rectum the ureters and bladder require special attention. Of all segmental resections, those of the right colon are least subject to complications (Table 2). Surprisingly, sigmoid resection for carcinoma carried a higher risk of complication than left colectomy. We were unprepared for this finding which is at variance with our general impression that anastomotic failure is less frequent after conservative resection. A detailed analysis of the factors responsible is not yet accomplished, but it is reasonable to suppose that the complete lack of tension possible in anastomosis after left colectomy has a favorable influence which outweighs the potential risks of wider dissection. Furthermore when transverse colon is used for anastomosis there is less chance of injury to blood supply than when the sigmoidal vessels are taken near their origin. Complications referable to the anastomosis tend to be more common if the suture line lies below the peritoneal floor. Resection of the pelvic colon with anastomosis to the distal inch or two of rectum carries a high risk of anastomotic failure in addition to all the dangers of hemorrhage encountered in Miles' resection. Drainage of the area anteriorly with suction catheters and complementary colostomy are advisable in most cases. An inlying rectal tube has practical and theoretical advantages which probably outweigh certain potential drawbacks. If separation of the suture line occurs, treatment depends on the extent of the defect. Colostomy, if not done at the initial operation, should be done now. A drain may be inserted in the paracoccygeal area. The mo.rtality is high.
Table 2.
Complications Following 500 Resections of Colon and Rectum (100 in Each Category) o = 1 CASE FATAL ~ NON-FATAL
'-l
00
0;,
RIGHT COLECTOMYI LEFT COLECTOMY ISIGMOID RESECTION I MILES RESECTION ISIGMOID RESECTlO~ (CANCER) AN4"'TnunTIC FAILURE WOUND INFECTION ...... ....... SEPSIS
PERITONITiS·····················
~
PERFORATED DIVERTICULUM· SUBHEPATIC ABSCESS· ...... . RETROPERITONEAL ABSCESS·
''':::::"i.~',,~''.:::::::::::~
(CANC~fl)
(CANCER)
(CANCER)
(DIVERpl"lIl
~
~
·~I ~~ ~ ~ ;
~
=:
1m-
~
MECHANiCAL····················· PARALyTIC························
FIS~~~tL BOWEL................... ~ll
IS'"
m~ •
IT
, J
I
z
tr1
................. ~
PULE~~~~~~M"""""""""""'!' Am PNEUMONIA..... ·•·•·· .. ··· .. ·· ..
~
~' .....-----:.•
'~tl;I'1 --,-,I
~
~
~._ II
~ _
:~~~~~~~~.~.~~~~:::::. . . .:: ~~~===========l~~~==========j~··=============fr============~D============~ ASTHMATIC BRONCHITIS ..... " ATELECTASIS ....•........•.•...
~
CARDIAC (FAILUREorM.I.)······15If
URI~:JRJ~~g~ .••••••••••••••••.. ~ INFECTION .......................
•
FiSTULA .... ·• .... · .. ···•• .. ·....
~
~
E
::
CO~:~TlON ••••••••.•.••.•••••• II-------+-------+--------I.i------+-------1 OBSTRUCTION .................... NECROSIS ... , .................. .
I-------+-------+--------Rb-------f--------I
::c: t'=j t? t:C
t'=j ~
~Q
o ~
§ t'=j
tr1
~
t'
(":l
CEREBRO-VASCULAR ACCIDENT· MiSCELLANEOUS···················
.;] t'=j
~t'=j
~
LARGE BOWEL .. · ......•.........
WOUND
U2
~ ~
~
Complications Following Surgery of the Colon
787
If pelvic hemorrhage is uncontrolled by suction catheters and transfusion, then the pelvis must be packed. Waugh states that effective packing almost always requires taking down the anastomosis and making an end colostomy, but we have not encountered this problem. In addition to the other complications, pull-through operations yield a somewhat higher incidence of anastomotic stenosis if healing is by secondary rather than primary intention. Repeated dilatations usually produce a satisfactory lumen. The incidence of incontinence is also high after pullthrough resection. In one of the largest series studied, Waugh found that fecal control was good or excellent in over half of his patients. 1o After resections of the rectum for cancer, colostomy complications replace anastomotic failure as a source of trouble. Other problems peculiar to abdominoperineal resections include hemorrhage, dehiscence of the peritoneal floor, ileus, urinary tract injury or dysfunction, and posteri9r wound complications. According to a study made by Ulfelder and Quinby in the Massachusetts General Hospital several years ago, half of the postoperative deaths were due to intestinal obstruction. 8 Cardiopulmonary and urinary complications often occurred in the patients who died. Urinary tract problems are very common and will be discussed in another article. Extensive and often crude dissection in the pelvis, where it is difficult to ligate vessels accurately, accounts for the increased risk of hemorrhage in Miles' resections. Fortunately, the narrow confines of the pelvic outlet can be packed effectively with gauze. A certain amount of persistent ooze always necessitates drainage of this space; if there is doubt that drainage will suffice, however, it is better to pack at the initial procedure than to return the patient to the operating room later under circumstances that may be less than ideal. Wide resection of peritoneum in cancer surgery sometimes leaves little with which to reconstruct a pelvic floor even after extensive mobilization of lateral flaps. As with closures of the gutters lateral to colostomies, no closure at all is better than a weak one. In questionable cases a pack covered with rubber tissue is inserted to provide support for seven to ten days. Prolapse of small bowel through a tear in the reconstructed floor is very serious, leading rapidly to strangulation obstruction. This possibility, as well as that of pericolostomy hernia, must be kept uppermost in mind in the differential diagnosis of ileus following combined resection. Persistent drainage from the posterior wound is surprisingly infrequent considering the size of the space nature must obliterate, and this complication is often the result of a residual carcinoma. An exception is after resection for ulcerative colitis, where delayed healing is the rule. Irrigation of the sinus with 50'per cent Dakin's solution and occasional curettage of exuberant granulations may speed closure. Pain in the healed posterior wound is usually due to residual or recurrent tumor that is sometimes amenable to secondary resection.
788
STEPHEN
E.
HEDBERG, CLAUDE
E.
WELCH
Late hernias in the perineum are not uncommon and rarely are bothersome. In one of the recent cases treated in the Massachusetts General Hospital, however, a violent fit of coughing led to evisceration through a perineal hernia several years after a Miles' resection. Segmental resections of the colon by exteriorization procedures now are done so rarely that no statistical material is available on the incidence of complications. When they are done, however, the colostomy is closed by resection and anastomosis rather than by crushing of the spur because of the danger of crushing an adherent loop of the intestine by the clamp. MORTALITY
This formidable list of complications might lead the reader to suspect that the mortality rates following operations on the colon are excessively high. Actually, colectomy for inflammatory disease such as diverticulitis or ulcerative colitis now is done with a mortality of about 2 per cent, while the corresponding rate for cancer is about 8 per cent. The latter figure is higher because of the very extensive resections that are carried out in the hope of cure or significant palliation. These relatively low rates do not, however, reflect the fact that many of these patients have had a harrowing convalescence. It is only by continuous attention to prophylaxis and care of the complications of operation that such rates may be maintained or improved. REFERENCES 1. Allen, A. W. and Welch, C. E.: Cecostomy. Surg. Gynec. & Obst: 73: 549, 1941. 2. Barnes, B. A., Behringer, G. E., Wheelock, F. C., Wilkins, E. W. and Cope, 0.: Surgical sepsis: Report on subtotal gastrectomies. New England J. Med. 173: 1068, 1960. 3. Edmunds, L. H., Jr., Williams, G. M. and Welch, C. E.: External fistulas arising from gastro-intestinal tract. Ann. Surg. 152: 445, 1960. 4. Garlock, J. H. and Kirschner, P. A.: Prevention of ileostomy dysfunction. Surgery 40: 678, 1956. 5. Goligher, J. C., Lloyd-Davies, O. V. and Robertson, C. T.: Small gut obstruction following combined excision of rectum. Brit. J. Surg. 38: 467, 1951. 6. Orwan, Egon: Personal communication. 7. Prohaska, J. V., Farrell, M., Baker, W. and Collins, R.: Pseudomembranous (staphylococcal) enterocolitis. Internat. Abstr. Surg. 112: 103, 1961. 8. Ulfelder, H. and Quinby, W. C., Jr.: Small bowel obstruction following abdominoperineal resection of rectum. Surgery 30: 174, 1951. 9. Warren, R. and McKittrick, J,. S.: Ileostomy for ulcerative colitis: Technique, complications and management. Surg. Gynec. & Obst. 93: 555,1951. 10. Waugh, J. M., Block, M. A. and Gage, R. P.: Three and five-year survivals following combined abdominoperineal resection: Abdominoperineal resection with sphincter preservation and anterior resection for carcinoma of the rectum and lower part of the sigmoid colon. Ann. Surg. 142: 752, 1955. 11. Welch, C. E.: Intestinal Obstruction. Chicago, Year Book Publishers, 1958. 12. Wheelock, F. C., Jr. and Warren, R.: Ulcerative colitis: Follow-up studies. New England J. Med. 252: 421, 1955. 275 Charles Street Boston 14, Massachusetts