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Choice of Operation for the Toxic Megacolon Phase of Nonspecific Ulcerative Colitis
Choice of Operation for the Toxic Megacolon Phase of Nonspecific Ulcerative Colitis RUPERT B. TURNBULL, JR., M.D., F.A.C.S.* FRANKL. WEAKLEY, M.D., F.A.C.S.** WILLIAM A. HAWK, M.D.*** PHILIP SCHOFIELD, M.D., F.R.C.S. ****
Radical removal of the colon during the toxic megacolon phase of ulcerative colitis is dangerous and is attended by a high mortality rate, ranging from 14 to 30 per cent. 4 • 8 Disruption of the bowel readily occurs during mobilization of the colon, despite cautious manipulation. The resultant uncontrolled fecal soiling of the peritoneal cavity and ensuing mortality are well known. Rupture of the colon occurs during its removal because the walled-off perforations are disturbed by the surgeon. Klein and associates 7 describe the problem succinctly: " ... adherence of the colon in the lumbar gutters or to the anterior abdominal wall may also be present to add to the difficulties encountered by the surgeon. Thus, an impending or a walled-off perforation may give way, causing uncontrollable gross fecal soiling of the peritoneal cavity and subsequent serious postoperative morbidity." Any _;:uljacent viscus or structure that is adherent to the colon (Figs. 4 and 7) is immediately suggestive that perforation has already occurred, and we believe that colectomy should then be abandoned in favor of a lesser procedure. The question to be answered, however, is whether or not any surgical procedure less than colectomy, during the toxic dilatation phase From the Department of Colon and Rectal Surgery and The Division of Laboratory Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio *Head, Department of Colon and Rectal Surgery, The Cleveland Clinic Foundation **Department of Colon and Rectal Surgery, The Cleveland Clinic Foundation ***Head, Department of Pathology, The Cleveland Clinic Foundation *''**Consultant Surgeon, Ashton General Hospital, Lancashire, England Supported by the Noah Butkin Fund, the Rawlins Fund, The Kay Williams Memorial Fund, and the Timken Fund for Surgical Research. Surgical Clinics of North America- Vol. 50, No. 5, October, 1970
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of ulcerative colitis, will arrest the disease or at least transform a critical situation to one more favorable for removal of the colon. Current surgical thought is directed toward removal of the colon during the toxic dilatation phase. The classic contributions of Gardner and Miller, 3 Crile and Thomas, 2 Ripstein, Miller, and Gardner, 11 and Ripstein10 are responsible for this attitude. These surgeons were the first to remove the colon and to establish ileostomy, with a mortality more acceptable than 50 per cent 2 which followed ileostomy alone (without colectomy) in toxic fulminating ulcerative colitis. Increasing experience with primary colectomy in surgical centers since 1955 indicates that the operative mortality rate is not so low as was anticipated. We agree with Goligher and associates 4 who state, "Some of the more recent statistics relating to the results of primary colectomy or proctocolectomy for severe acute attacks of colitis have been much less impressive and have underlined that these operations carry grave risks." We are convinced that ileostomy alone for toxic dilatation of the colon was inadequate and dangerous because the ileostomy did not decompress the obstructed dilated colon. Subsequent perforation with fecal soilage was most often the cause of death of patients operated upon in this manner in the 1930's. In 1955, it occurred to us that the combined operative procedure of ileostomy and colostomy might reduce the high mortality of colectomy in toxic dilatation of the colon whenever it was obvious at laparotomy that walled-off perforations were present. A definitive ileostomy would divert the fecal stream and offer immediate sociophysical rehabilitation; PERFORATIONS
IN
MUCOSA
SUBMUCOSA
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A Figure 1. A, Schematic view of penetrating ulcers of the colon. Arrow indicates a walled-off perforation. B, Radiograph of descending colon showing penetrating ulceration (arrow) similar to that depicted in A .
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Figure 2. Plam radiograph of abdomen showing megacolon with gas escaping from a splenic flexure perforation.
the skin-level transverse colostomy would immediately decompress the dilated transverse colon (Fig. 3) and prevent the free perforation that inevitably occurred (Fig. 2). As we gained experience, it was obvious that the sigmoid colon was occasionally as dilated as the transverse colon (Fig. 4) and would need immediate decompression as well. Thus, ileostomy, transversostomy, and sigmoidostomy (Fig. 5) would be indicated.
HISTORICAL NOTE Surgical decompression of the dilated colon of fulminant ulcerative colitis has been performed intermittently in the past. On November 6, 1946, Colp performed cecostomy instead of colectomy. 6 Klein,S at the suggestion of Abraham Penner, performed cecostomy on a patient with toxic megacolon on April 1, 1957. Williams and Robinson13 performed cecostomy in September 1960 and again in January 1961 for toxic megacolon, with a favorable outcome each time. Klein and his associates7 reported their favorable experience with emergency cecostomy for three patients with ulcerative colitis with acute toxic dilatation of the colon. They recognized walled-off perforations in two of the patients and performed cecostomy instead of colectomy to avert disruption of the colon.
COLECTOMY AND ILEOSTOMY Colectomy with ileostomy is the most effective treatment for toxic megacolon, provided that there are no walled-off perforations of the
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Figure 3. A, Toxic megacolon. View of patient on operating table (head to the left) showing dilated transverse colon (arrow) across epigastrium. B, Same patient (head to the right) immediately after ileostomy (long arrow) and decompression transverse colostomy (short arrow) for toxic megacolon. Note scaphoid abdomen.
colon that might be disrupted during colectomy. With the patient under endotracheal anesthesia and in the left lateral position, a sigmoidoscope is introduced, and the rectum is examined and aspirated. Care is taken not to perforate the rectum, because the walls are unusually soft and friable. A No. 30 French rectal tube is introduced through the sigmoidoscope and left in the rectum as the scope is withdrawn. Another rectal tube is eased into the infundibular end of the first tube and taped so that the tubes are in tandem. A glassY-tube is put in the end of the rectal tube for intermittent suction in order to empty the colon after the abdomen has been opened.
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Figure 4. Toxic megacolon. The open abdomen is viewed from the left side (pubis to the left). The omentum is adherent to perforations of the dilated transverse colon (large arrow) and sigmoid colon (small arrows).
ILEOSTOMY AND COLOSTOMIES FOR TOXIC MEGACOLON
Figure 5. Schematic overview of ileostomy and colostomies for toxic megacolon.
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Figure 6. The ileostomy site is marked and a left paramedian incision is utilized.
Figure 7. Toxic megacolon-walled-off perforation. Open abdomen (pubis to the left) shows bladder (large arrow) with perforated dilated sigmoid colon (small arrows) adherent to it. Epiploica are large. Free perforation has not occurred.
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Figure 8. Toxic megacolon of mucosal ulcerative colitis. The glistening serosa and the mobility of the colon indicate lack of penetrating ulceration. The cecum (large arrow) and descending colon (small arrow) are not adherent. Colectomy was performed safely.
Figure 9. Construction of ileostomy. A loop of ileum near the cecum is picked up with a tape and the proximal side is marked with a suture.
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The ileostomy site is carefully marked (Fig. 6) and the abdomen is opened through a left paramedian incision from pubis to just above the umbilicus. If there is no odor or escape of gas, and if the peritoneal fluid is clear, there is no free perforation. The surgeon must now avoid exploration of the abdomen manually, because any part of the dilated colon may be lying against the anterior abdominal wall or the liver, or in the gutters, masking walled-off perforations. The in-lying rectal tube can now be advanced through the rectum up into the sigmoid colon, being carefully guided by the operator. Intermittent suction on the Ytube (managed by a nurse) and gentle pressure on the left colon will empty it of gas and liquid. With collapse of the left colon it is possible to visualize all the colon. Adherent loops of small bowel, omentum, or bladder indicate that walled-off perforations (Figs. 4 and 7) are present and must not be disturbed. When the colon is free of all other structures and is mobile (Fig. 8), and when it is not adherent in the gutters, it may be safely removed after gentle suction-decompression of the entire colon. In these critically ill patients, we believe subtotal colectomy with ileostomy12 is preferable to total proctocolectomy. The former is a safer procedure with less blood loss. With retention of the rectum, consideration can be given to preservation of sex function in the young male, and later, ileorectal anastomosis is possible in those patients having the mucosaP form of colitis.
COLOSTOMY AND ILEOSTOMY When walled-off perforations of the colon are detected at laparotomy, further steps toward colectomy should be abandoned in favor of a combined diverting-decompression operation (Fig. 5). Exploration of the abdomen is discouraged because of the possibility of disrupting walled-off perforations.
Figure 10. The loop is drawn through the abdominal wall at the predetermined ileostomy site and is rotated so that the inferior limb is proximal ileum.
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Figure 11. The loop of ileum is supported on the abdominal wall by a slim glass rod. Note suture marking the proximal limb of the ileostomy.
Operative Technique A loop of terminal ileum, 3 inches proximal to the ileocecal junction or at least a few inches proximal to disease of the terminal ileum which may be present, is selected (Fig. 9). The loop is pulled through the abdominal wall at the site selected (Fig. 10). The loop is rotated so that the functioning limb is inferior (caudad) and the nonfunctioning limb is superior (cephalad). A slim glass rod is thrust through the mesentery to support the loop on the abdominal wall (Fig. 11). Attention is now directed toward the dilated transverse colon. It is our objective to cut the right rectus muscle high in the right epigastrium and enter the abdomen exactly over the dilated proximal
Figure 12. Construction of transverse colostomy. The dilated transverse colon (arrow) is seen pressing against the right transverse rectus incision. (The abdomen has been closed.)
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transverse colon. To locate the incision over the colon, the surgeon who is standing on the patient's left side inserts his left hand through the laparotomy incision until it is palm-down over the proximal transverse colon. A transverse incision at least 2 inches long is made through the skin, fascia, right rectus muscle, and peritoneum, so that the dilated transverse colon is visible, as shown in Figure 12. The left paramedian abdominal incision is now closed with interrupted No. 30 stainless steel wire sutures through peritoneum, rectus muscle, and fascia. The skin edges are closed at intervals, and folded wicks of Telfa gauze are inserted down to the fascia between the skin sutures (Fig. 9) to provide a blood-and-serum outlet. EXTERNAL CONSTRUCTION OF LOOP ILEOSTOMY The diverting loop ileostomy12 is constructed as shown in Figure 10. It is important to open the superior (distal) limb of the loop transversely across the antimesenteric border at the level of the skin. A little more than half the circumference of the bowel is to be opened, to ensure that the functioning (inferior) limb of the stoma is dominant and will deliver dejecta away from the skin. The glass rod may be left in place for 5 days, and the postoperative ileostomy pouch may be put on over it. EXTERNAL CONSTRUCTION OF CUTANEOUS TRANSVERSE COLOSTOMY. After the abdomen is closed and the ileostomy completed, the dilated transverse colon can be seen pressing up against the undersurface of the transrectus incision in the right portion of the epigastrium (Fig. 12). The objective now is to decompress the remarkably dilated transverse colon yet leave it within the abdomen (Fig. 13). The surgical steps are depicted in Figures 14 through 18, as seen from the right side of the patient. The anterior rectus sheath is sutured to the seromuscular layers of the transverse colon with a continuous 0000 intestinal chromic suture (Fig. 14). A layer of abdominal wall fat sutured to the seromuscular layers (Fig. 15) ensures peritoneal cavity quarantine from contamination. Colonic gas will escape through the small suture needle punctures; this should cause no alarm, since no serious sepsis has ensued from this. The completion of the transverse colostomy is shown in Figure 18.
TO
co co are Ar pla
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Seromusculo r to rectus sheath or to fat
Opened colon to fat or skin
Figure 13. Schematic drawing of decompression colostomy. Seromuscular suture to rectus sheath or to fat. Opened colon to fat or skin.
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Figure 14. Epigastric transverse colostomy for decompression of megacolon. Seromuscular layers of colon are sutured to rectus sheath incision. Arrow indicates first suture being placed.
Figure 15. Suture fixation of transverse rectus incision fascia to seromuscular layers of dilated colon completed. Arrows indicate suture line.
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Figure 16. Subcutaneous fat has been sutured to the seromuscular layers of the dilated colon as a second layer. The colon is aspirated of gas to allow it to rise in the incision.
Figure 17. Transverse colon is opened for suturing to the skin edges. Note mobility after release of gas.
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Figure 18. Decompression transverse colostomy completed by colocutaneous suture.
It is not absolutely necessary to suture the colon to the skin, because the colostomy functions well in the bottom of the incision. CoNSTRUCTION OF SIGMOIDOSTOMY. Whenever the sigmoid colon is as remarkably dilated as the transverse colon, and if there are walled-off perforations (Fig. 4), cutaneous sigmoidostomy ought to be performed to prevent postoperative free perforation of this part of the colon. The procedure is accomplished by closing the lower end of the left paramedian incision around the dilated sigmoid flexure, and finally placing a layer of sutures (Fig. 15) to wall off the rest of the abdominal wound before opening the bowel for decompression. When the transverse or sigmoid colon is opened, there is a rush of gas and decompression is immediate (Fig. 3) and permanent (Fig. 19). To date, in our patients there has been no postoperative free perforation and leakage of the decompressed colon. There have been no complications from the skinlevel colostomy.
Results From January 1961 through December 1968 we examined 910 patients who had nonspecific inflammatory disease of the colon. Fifty-six of those patients had toxic megacolon and were admitted to the Cleveland Clinic Hospital and operated upon either immediately or after a brief period of medical treatment. Thirty of the patients with toxic megacolon underwent one-stage subtotal colectomy and ileostomy with preservation of the rectum. Twenty-six patients underwent emergency ileostomy and colostomy, instead of colectomy, because of walled-off perforations of the colon. In each instance, it was the opinion of the surgeon that manipulation of the dilated colon would result in disruption of the colon and fecal spillage.
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Figure 19. Roentgenogram after barium enema 3 weeks after ileostomy, sigmoidostomy, and transversostomy for perforated toxic megacolon. Barium extrudes from transversostomy (large arrow) and from sigmoidostomy (small arrow). Decompression of the colon is complete.
OPERATIVE MoRTALITY. Of 26 patients who underwent ileostomy and colostomy instead of colectomy, one died from diffuse necrotizing vasculitis, thrombosis of major abdominal veins, and duodenal stress ulcer with hemorrhage. HISTOPATHOLOGIC CLASSIFICATION OF ULCERATIVE COLITIS IN PATIENTS WHO UNDERWENT ILEOSTOMY-COLOSTOMY. Sixteen patients had ulcerative colitis of the mucosal type. Nine patients had transmural colitis (Crohn's disease of the colon), and one patient had ulcerative colitis that could not be histopathologically classified. In general the pathologic changes of acute toxic megacolon are superimposed on the basic underlying chronic colonic disease. The inflammatory process is fulminant and affects all layers of the colon, often obscuring the hallmarks of the antecedent ulcerative colitis. Serositis is usually present. In some instances the serosa is covered by patches of fibrinous exudate associated with an intense submucosal vascular display. If perforation has occurred or is impending, there are various amounts of purulent exudate present. Fibrinous and delicate fibrous adhesions to adjacent viscera and the abdominal wall are additional features. Most impressive is the thinness of the colonic wall and its extreme friability. Mucosal damage is severe. In mucosal colitis, pseudopolyposis may be extreme. Histologic examination of these colons reveals, in addition to extensive mucosal ulceration, transmural inflammation. The infiltrate is formed predominantly of neutrophils in areas of greatest dilatation, often dissecting the interstitial spaces of the muscularis propria, so that the individual muscle cells appear separated. Moreover, a curious hyaline degeneration of the muscle cells may have occurred. Ganglioni-
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tis, patchy or diffuse in distribution, affects the myenteric plexuses. The entire histologic structure suggests extreme friability. Granulomas, irregular areas of fibrosis, undermining ulcers, fissures, and pseudopolyps may also be present; these belong to the basic disease. The changes in the ganglia and the muscularis, complicated by the impaired vascular supply caused by the overdistention, are part of the toxic megacolon phase of the disease. Persistent or Recrudescent Ulcerative Colitis After Ileostomy and Colostomy The objection to performing any operative procedure less than colectomy for toxic ulcerative colitis with megacolon is that the patient fails to get well. This valid objection is demonstrated by the fact that of the 25 patients who underwent the operation we described as "less than colectomy," four did not detoxify at all, although the colon in each patient became decompressed. The patients were continuously febrile with tachycardia. One patient began to hemorrhage from the rectum on the sixth postoperative day. Nevertheless, these four patients were returned to surgery between the twelfth and eighteenth postoperative days and colectomy was safely performed after thorough preoperative rectocolonic saline lavage of the colon was performed while the patient was on the operating table under anesthesia. There were eight other patients who returned for colectomy within 6 months because of recrudescent toxic colitis. We wish to point out that in all the patients who underwent subsequent colectomy, the colon was completely decompressed (Fig. 19) and empty. There was no serious postoperative sepsis and no deaths; mortality would have been expected if primary colectomy had been performed. Thirteen patients returned to the hospital after a 6-month postoperative interval because of reactivated disease. However, toxic dilatation of the colon was not possible because of the presence of the cutaneous transverse colostomy. The symptoms and signs of recrudescent ulcerative colitis are important for the patient to recognize so that he can seek hospitalization and colectomy before he is too ill; that is, a purulent watery flux from the rectum and from the cutaneous transverse colostomy herald the onset of the toxic state. There is low-grade fever and lassitude, a loss of interest in usual daily activities, and an increased sleep requirement. The purulent watery flux may come principally from the cutaneous transverse colostomy and assume considerable proportions. One patient had worn bath towels as epigastric dressings, saturating several daily. A few patients had sudden hemorrhage from the rectum or cutaneous transverse colostomy. In summary, of 26 patients who underwent ileostomy and cutaneous transverse colostomy, four continued to have toxic colitis although the colon in each was thoroughly decompressed. An additional eight patients were re-admitted to the hospital to undergo colectomy within 6 months of the first operation because of reactivated toxic ulcerative colitis. Twelve patients underwent elective colectomy after 6 months,
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and one patient has not yet undergone colectomy. At the time of colectomy in each instance, there were few adhesions encountered because the primary operative procedure was minimal. Each of the 24 patients would have been a potential operative mortality if colectomy had been performed when they were first diagnosed.
DEFINITIVE COLECTOMY AFTER EMERGENCY ILEOSTOMY AND TRANSVERSE COLOSTOMY We would emphasize that any operative procedure less than colectomy is a temporary expedient to convert a potentially fatal situation to one less dangerous to life. Accordingly, of the 25 surviving patients who underwent emergency ileostomy-colostomy, 24 have subsequently undergone colectomy. One patient, because of continued good health during the last 4 years, has refused to undergo colectomy. Among the . 24 patients who subsequently underwent colectomy, 8 had ileorectal anastomoses, 9 underwent total proctocolectomy, and 7 underwent subtotal colectomy with preservation of the rectum. All the patients are alive and well.
Operating Room Preparation of the Colon for Colectomy After Ileostomy and Colostomy Two of the important advantages of the ileostomy-colostomy operation for toxic megacolon are that the decompressed and collapsed colon
Figure 20. External construction of loop ileostomy. A, The loop is opened over a hemostat, more than halfway through the distal limb. B, With eversion, the inferior functioning limb becomes dominant. C, The open ileum is sutured to the subcuticular fascia. The superior limb (distal) is recessive.
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Figure 21. Completed ileostomy and transverse colostomy for perforating toxic megacolon. The loop ileostomy in the right lower quadrant is at a considerable distance from the decompressive transverse colostomy.
is technically easy to remove and it can be thoroughly prepared for removal by lavage in the operating room. Under anesthesia a large Pezzer catheter is put into the rectum and connected to a gallon reservoir of saline at body temperature. Polyethylene ileostomy pouches are put on each abdominal orifice to funnel off the colonic lavage water. The saline is turned on and soon runs from the sigmoidostomy and transverse colostomy. After the returns are clear, these two stomas are occluded digitally to allow lavage water to emerge from the recessive superior (distal) ileostomy opening (Fig. 2D and E) lavaging the right side of the colon. After several gallons of saline have been lavaged through the colon, an antibiotic solution may be introduced.
Operative Technique The descending limb of the splenic flexure of the colon is the commonest site of walled-off perforations and may be densely adherent in the upper gutter and splenic area. The descending and sigmoid colons are often fixed in the gutter for the same reason. The right side of the colon and the transverse portion of the colon are seldom perforated. The perforated segments should be isolated by umbilical tape ties to occlude the lumen on either side of the perforated site and prevent the escape of any quantity of lavage fluid during mobilization of the colon. Attention is now turned to the cutaneous colostomy sites. Working through the laparotomy incision, the surgeon should ligate the colon with double stout catgut on the peritoneal side of each stoma so that lavage fluid will not be spilled. A circumferential incision in the skin around each colostomy and mobilization of the stoma down into the peritoneal cavity are easily accomplished. A second occluding ligature around the neck of the stoma is useful.
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The distal limb of the loop ileostomy is cut across and turned in with interrupted catgut sutures 2 inches inside the peritoneal cavity. The inferior peritoneal attachments of the cecum are divided in the right lower quadrant and, working between the ileostomy and liver, the surgeon pulls the cecum up into the right gutter, and further mobilizes it. The ileum is cut from its mesentery at the mesenteric border to spare the blood supply of the established loop ileostomy. The right and transverse colons are now mobilized and the mesenteric vessels are divided over to the distal transverse colon. It is a good plan to mobilize all of the free colon first, and the walled-off perforated areas last, to avoid dissemination of lavage fluid that may escape from the perforated areas. The sigmoid colon and descending colon are mobilized next, and finally the splenic flexure, by cutting the peritoneal attachments directly against the lateral border of the muscularis of the entire flexure while applying traction to it. A decision is now made as to whether the rectum is to be removed or is to be saved for later anastomosis, or whether ileorectal anastomosis is to be performed at this time. The mesentery of the terminal ileum is now sutured to the anterior abdominal wall peritoneum, from the ileostomy exit point to the duodenum, to prevent volvulus. This technique has been described in great detailP Use of Abdominal Drains Soft 7/s-inch rubber drains (Mikulicz) must be sutured in the areas of the gutters wherever a walled-off perforation of the colon has been observed, since abscesses inevitably form at these sites. Two 7/s-inch drains are sutured in the left gutter colonic bed with interrupted 0000 chromic catgut so that it is literally lined with rubber. If the walled-off perforated area is extensive, four drains are placed. They are brought out through an opening in the flank which will admit three fingers, and are sutured to the skin securely with polyethylene sutures. Silk sutures are to be avoided because of the danger of infection. The most important factor in this type of drainage is time. The drains must remain in the patient for 21 days, the patient returning home from the hospital with them in place. Suppuration occurs in the gutter during the first 10 days, and is seen coming through the drains on the twelfth day. The drainage is foul, chocolate-brown, and copious. Before the abdomen is closed, the colostomy sites are closed from within the abdomen with interrupted No. 1 chromic catgut sutures; a single 7/s-inch soft rubber drain (Mikulicz) is brought from the peritoneal level through the wound and is sutured to the skin with polyethylene sutures. These drains are also left in place for 3 weeks. In the past, failure to drain has allowed an intraabdominal abscess to form at the colostomy site.
SUMMARY AND CONCLUSIONS The postoperative mortality of colectomy for toxic megacolon is forbidding and is due to iatrogenic disruption of walled-off perforations, with fecal soiling, resulting in fatal sepsis.
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Colectomy for toxic megacolon is reasonably safe and effective when no walled-off colonic perforations are present. The operation of ileostomy-colostomy for toxic megacolon is proposed as the operation of choice when walled-off perforations of the colon are discovered at laparotomy. A series of 26 patients who underwent this operation under these conditions is reported. There was one postoperative death. Twenty-five patients are well and rehabilitated, although one of these has not yet undergone colectomy. Attention is directed to some points in technique for removal of the colon after the ileostomy-colostomy operation. In particular, the sites of colonic perforation in the gutters must be drained for as long as 21 days to avoid postoperative gutter abscesses. ADDENDUM. Since December 1968 the authors have performed an additional ten operations as described for toxic megacolon with localized perforations. All the patients are alive and well.
REFERENCES 1. Brooke, B. N., and Sampson, P. A.: An indication for surgery in acute ulcerative colitis. Lancet, 2:1272-1273 (Dec. 12) 1964. 2. Crile, G., Jr., and Thomas, C. Y., Jr.: The treatment of acute toxic ulcerative colitis by ileostomy and simultaneous colectomy. Gastroenterology, 19:58-68 (Sept.) 1951. 3. Gardner, C., and Miller, G. G.: Total colectomy for ulcerative colitis. A.M.A. Arch Surg. (Chicago), 63:370-372 (Sept.) 1951. 4. Goligher, J. C., Duthrie, H. L., and Nixon, H. H.: Surgery of the Anus, Rectum and Colon. London, England, Bailliere, Tindall, and Cassell, 2nd ed., 1967, p. 884. 5. Hawk, W. A., Turnbull, R. B., Jr., and Schofield, P. F.: Nonspecific ulcerative colitis. Surgery, 66:953-964 (Nov.) 1969. 6: Klein, S. H.: Personal communication, June 1968. 7. Klein, S. H., Edelman, S., Kirschner, P. A., Lyons, A. S., and Baronofsky, I. D.: Emergency cecostomy in ulcerative colitis with acute toxic dilatation. Surgery, 47:399-407 (March) 1960. 8. Lennard-Jones, J. E., and Vivian, A. B.: Fulminating ulcerative colitis; recent experience in management. Brit Med. J., 2:96-102 (July 9) 1960. 9. Marshak, R. H., Lester, L. J., and Friedman, A. I.: Megacolon, a complication of ulcerative colitis. Gastroenterology, 16:768-772 (Dec.) 1950. 10. Ripstein, C. B.: Primary resection of colon in fulminating ulcerative colitis. Surg. Forum (1952):117-123, 1953. 11. Ripstein, C. B., Miller, G. G., and Gardner, C. MeG.: Results of the surgical treatment of ulcerative colitis. Ann. Surg., 135:14-21 (Jan.) 1952. 12. Turnbull, R. B., Jr., and Weakley, F. L.: Atlas of Intestinal Stomas. St. Louis, C. V. Mosby Company, 1967. 13. Williams, C. L., and Robinson, D. W.: Toxic megacolon syndrome of ulcerative colitis. Ann. Surg., 155:233-237 (Feb.) 1962. The Cleveland Clinic Foundation Cleveland, Ohio 44106
Radical removal of the colon during the toxic megacolon phase of ulcerative colitis is dangerous and is attended by a high mortality rate, ranging from 14 to 30 per cent. 4 • 8 Disruption of the bowel readily occurs during mobilization of the colon, despite cautious manipulation. The resultant uncontrolled fecal soiling of the peritoneal cavity and ensuing mortality are well known. Rupture of the colon occurs during its removal because the walled-off perforations are disturbed by the surgeon. Klein and associates 7 describe the problem succinctly: " ... adherence of the colon in the lumbar gutters or to the anterior abdominal wall may also be present to add to the difficulties encountered by the surgeon. Thus, an impending or a walled-off perforation may give way, causing uncontrollable gross fecal soiling of the peritoneal cavity and subsequent serious postoperative morbidity." Any _;:uljacent viscus or structure that is adherent to the colon (Figs. 4 and 7) is immediately suggestive that perforation has already occurred, and we believe that colectomy should then be abandoned in favor of a lesser procedure. The question to be answered, however, is whether or not any surgical procedure less than colectomy, during the toxic dilatation phase From the Department of Colon and Rectal Surgery and The Division of Laboratory Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio *Head, Department of Colon and Rectal Surgery, The Cleveland Clinic Foundation **Department of Colon and Rectal Surgery, The Cleveland Clinic Foundation ***Head, Department of Pathology, The Cleveland Clinic Foundation *''**Consultant Surgeon, Ashton General Hospital, Lancashire, England Supported by the Noah Butkin Fund, the Rawlins Fund, The Kay Williams Memorial Fund, and the Timken Fund for Surgical Research. Surgical Clinics of North America- Vol. 50, No. 5, October, 1970
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of ulcerative colitis, will arrest the disease or at least transform a critical situation to one more favorable for removal of the colon. Current surgical thought is directed toward removal of the colon during the toxic dilatation phase. The classic contributions of Gardner and Miller, 3 Crile and Thomas, 2 Ripstein, Miller, and Gardner, 11 and Ripstein10 are responsible for this attitude. These surgeons were the first to remove the colon and to establish ileostomy, with a mortality more acceptable than 50 per cent 2 which followed ileostomy alone (without colectomy) in toxic fulminating ulcerative colitis. Increasing experience with primary colectomy in surgical centers since 1955 indicates that the operative mortality rate is not so low as was anticipated. We agree with Goligher and associates 4 who state, "Some of the more recent statistics relating to the results of primary colectomy or proctocolectomy for severe acute attacks of colitis have been much less impressive and have underlined that these operations carry grave risks." We are convinced that ileostomy alone for toxic dilatation of the colon was inadequate and dangerous because the ileostomy did not decompress the obstructed dilated colon. Subsequent perforation with fecal soilage was most often the cause of death of patients operated upon in this manner in the 1930's. In 1955, it occurred to us that the combined operative procedure of ileostomy and colostomy might reduce the high mortality of colectomy in toxic dilatation of the colon whenever it was obvious at laparotomy that walled-off perforations were present. A definitive ileostomy would divert the fecal stream and offer immediate sociophysical rehabilitation; PERFORATIONS
IN
MUCOSA
SUBMUCOSA
CIRCULAR MUSCLE
LONGITUDINAL MUSCLE
A Figure 1. A, Schematic view of penetrating ulcers of the colon. Arrow indicates a walled-off perforation. B, Radiograph of descending colon showing penetrating ulceration (arrow) similar to that depicted in A .
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Figure 2. Plam radiograph of abdomen showing megacolon with gas escaping from a splenic flexure perforation.
the skin-level transverse colostomy would immediately decompress the dilated transverse colon (Fig. 3) and prevent the free perforation that inevitably occurred (Fig. 2). As we gained experience, it was obvious that the sigmoid colon was occasionally as dilated as the transverse colon (Fig. 4) and would need immediate decompression as well. Thus, ileostomy, transversostomy, and sigmoidostomy (Fig. 5) would be indicated.
HISTORICAL NOTE Surgical decompression of the dilated colon of fulminant ulcerative colitis has been performed intermittently in the past. On November 6, 1946, Colp performed cecostomy instead of colectomy. 6 Klein,S at the suggestion of Abraham Penner, performed cecostomy on a patient with toxic megacolon on April 1, 1957. Williams and Robinson13 performed cecostomy in September 1960 and again in January 1961 for toxic megacolon, with a favorable outcome each time. Klein and his associates7 reported their favorable experience with emergency cecostomy for three patients with ulcerative colitis with acute toxic dilatation of the colon. They recognized walled-off perforations in two of the patients and performed cecostomy instead of colectomy to avert disruption of the colon.
COLECTOMY AND ILEOSTOMY Colectomy with ileostomy is the most effective treatment for toxic megacolon, provided that there are no walled-off perforations of the
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Figure 3. A, Toxic megacolon. View of patient on operating table (head to the left) showing dilated transverse colon (arrow) across epigastrium. B, Same patient (head to the right) immediately after ileostomy (long arrow) and decompression transverse colostomy (short arrow) for toxic megacolon. Note scaphoid abdomen.
colon that might be disrupted during colectomy. With the patient under endotracheal anesthesia and in the left lateral position, a sigmoidoscope is introduced, and the rectum is examined and aspirated. Care is taken not to perforate the rectum, because the walls are unusually soft and friable. A No. 30 French rectal tube is introduced through the sigmoidoscope and left in the rectum as the scope is withdrawn. Another rectal tube is eased into the infundibular end of the first tube and taped so that the tubes are in tandem. A glassY-tube is put in the end of the rectal tube for intermittent suction in order to empty the colon after the abdomen has been opened.
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Figure 4. Toxic megacolon. The open abdomen is viewed from the left side (pubis to the left). The omentum is adherent to perforations of the dilated transverse colon (large arrow) and sigmoid colon (small arrows).
ILEOSTOMY AND COLOSTOMIES FOR TOXIC MEGACOLON
Figure 5. Schematic overview of ileostomy and colostomies for toxic megacolon.
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Figure 6. The ileostomy site is marked and a left paramedian incision is utilized.
Figure 7. Toxic megacolon-walled-off perforation. Open abdomen (pubis to the left) shows bladder (large arrow) with perforated dilated sigmoid colon (small arrows) adherent to it. Epiploica are large. Free perforation has not occurred.
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Figure 8. Toxic megacolon of mucosal ulcerative colitis. The glistening serosa and the mobility of the colon indicate lack of penetrating ulceration. The cecum (large arrow) and descending colon (small arrow) are not adherent. Colectomy was performed safely.
Figure 9. Construction of ileostomy. A loop of ileum near the cecum is picked up with a tape and the proximal side is marked with a suture.
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The ileostomy site is carefully marked (Fig. 6) and the abdomen is opened through a left paramedian incision from pubis to just above the umbilicus. If there is no odor or escape of gas, and if the peritoneal fluid is clear, there is no free perforation. The surgeon must now avoid exploration of the abdomen manually, because any part of the dilated colon may be lying against the anterior abdominal wall or the liver, or in the gutters, masking walled-off perforations. The in-lying rectal tube can now be advanced through the rectum up into the sigmoid colon, being carefully guided by the operator. Intermittent suction on the Ytube (managed by a nurse) and gentle pressure on the left colon will empty it of gas and liquid. With collapse of the left colon it is possible to visualize all the colon. Adherent loops of small bowel, omentum, or bladder indicate that walled-off perforations (Figs. 4 and 7) are present and must not be disturbed. When the colon is free of all other structures and is mobile (Fig. 8), and when it is not adherent in the gutters, it may be safely removed after gentle suction-decompression of the entire colon. In these critically ill patients, we believe subtotal colectomy with ileostomy12 is preferable to total proctocolectomy. The former is a safer procedure with less blood loss. With retention of the rectum, consideration can be given to preservation of sex function in the young male, and later, ileorectal anastomosis is possible in those patients having the mucosaP form of colitis.
COLOSTOMY AND ILEOSTOMY When walled-off perforations of the colon are detected at laparotomy, further steps toward colectomy should be abandoned in favor of a combined diverting-decompression operation (Fig. 5). Exploration of the abdomen is discouraged because of the possibility of disrupting walled-off perforations.
Figure 10. The loop is drawn through the abdominal wall at the predetermined ileostomy site and is rotated so that the inferior limb is proximal ileum.
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Figure 11. The loop of ileum is supported on the abdominal wall by a slim glass rod. Note suture marking the proximal limb of the ileostomy.
Operative Technique A loop of terminal ileum, 3 inches proximal to the ileocecal junction or at least a few inches proximal to disease of the terminal ileum which may be present, is selected (Fig. 9). The loop is pulled through the abdominal wall at the site selected (Fig. 10). The loop is rotated so that the functioning limb is inferior (caudad) and the nonfunctioning limb is superior (cephalad). A slim glass rod is thrust through the mesentery to support the loop on the abdominal wall (Fig. 11). Attention is now directed toward the dilated transverse colon. It is our objective to cut the right rectus muscle high in the right epigastrium and enter the abdomen exactly over the dilated proximal
Figure 12. Construction of transverse colostomy. The dilated transverse colon (arrow) is seen pressing against the right transverse rectus incision. (The abdomen has been closed.)
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transverse colon. To locate the incision over the colon, the surgeon who is standing on the patient's left side inserts his left hand through the laparotomy incision until it is palm-down over the proximal transverse colon. A transverse incision at least 2 inches long is made through the skin, fascia, right rectus muscle, and peritoneum, so that the dilated transverse colon is visible, as shown in Figure 12. The left paramedian abdominal incision is now closed with interrupted No. 30 stainless steel wire sutures through peritoneum, rectus muscle, and fascia. The skin edges are closed at intervals, and folded wicks of Telfa gauze are inserted down to the fascia between the skin sutures (Fig. 9) to provide a blood-and-serum outlet. EXTERNAL CONSTRUCTION OF LOOP ILEOSTOMY The diverting loop ileostomy12 is constructed as shown in Figure 10. It is important to open the superior (distal) limb of the loop transversely across the antimesenteric border at the level of the skin. A little more than half the circumference of the bowel is to be opened, to ensure that the functioning (inferior) limb of the stoma is dominant and will deliver dejecta away from the skin. The glass rod may be left in place for 5 days, and the postoperative ileostomy pouch may be put on over it. EXTERNAL CONSTRUCTION OF CUTANEOUS TRANSVERSE COLOSTOMY. After the abdomen is closed and the ileostomy completed, the dilated transverse colon can be seen pressing up against the undersurface of the transrectus incision in the right portion of the epigastrium (Fig. 12). The objective now is to decompress the remarkably dilated transverse colon yet leave it within the abdomen (Fig. 13). The surgical steps are depicted in Figures 14 through 18, as seen from the right side of the patient. The anterior rectus sheath is sutured to the seromuscular layers of the transverse colon with a continuous 0000 intestinal chromic suture (Fig. 14). A layer of abdominal wall fat sutured to the seromuscular layers (Fig. 15) ensures peritoneal cavity quarantine from contamination. Colonic gas will escape through the small suture needle punctures; this should cause no alarm, since no serious sepsis has ensued from this. The completion of the transverse colostomy is shown in Figure 18.
TO
co co are Ar pla
tra ser com
Seromusculo r to rectus sheath or to fat
Opened colon to fat or skin
Figure 13. Schematic drawing of decompression colostomy. Seromuscular suture to rectus sheath or to fat. Opened colon to fat or skin.
Toxic MEGACOLON PHASE OF NoNSPECIFIC ULCERATIVE CoLITIS
Figure 14. Epigastric transverse colostomy for decompression of megacolon. Seromuscular layers of colon are sutured to rectus sheath incision. Arrow indicates first suture being placed.
Figure 15. Suture fixation of transverse rectus incision fascia to seromuscular layers of dilated colon completed. Arrows indicate suture line.
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Figure 16. Subcutaneous fat has been sutured to the seromuscular layers of the dilated colon as a second layer. The colon is aspirated of gas to allow it to rise in the incision.
Figure 17. Transverse colon is opened for suturing to the skin edges. Note mobility after release of gas.
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Figure 18. Decompression transverse colostomy completed by colocutaneous suture.
It is not absolutely necessary to suture the colon to the skin, because the colostomy functions well in the bottom of the incision. CoNSTRUCTION OF SIGMOIDOSTOMY. Whenever the sigmoid colon is as remarkably dilated as the transverse colon, and if there are walled-off perforations (Fig. 4), cutaneous sigmoidostomy ought to be performed to prevent postoperative free perforation of this part of the colon. The procedure is accomplished by closing the lower end of the left paramedian incision around the dilated sigmoid flexure, and finally placing a layer of sutures (Fig. 15) to wall off the rest of the abdominal wound before opening the bowel for decompression. When the transverse or sigmoid colon is opened, there is a rush of gas and decompression is immediate (Fig. 3) and permanent (Fig. 19). To date, in our patients there has been no postoperative free perforation and leakage of the decompressed colon. There have been no complications from the skinlevel colostomy.
Results From January 1961 through December 1968 we examined 910 patients who had nonspecific inflammatory disease of the colon. Fifty-six of those patients had toxic megacolon and were admitted to the Cleveland Clinic Hospital and operated upon either immediately or after a brief period of medical treatment. Thirty of the patients with toxic megacolon underwent one-stage subtotal colectomy and ileostomy with preservation of the rectum. Twenty-six patients underwent emergency ileostomy and colostomy, instead of colectomy, because of walled-off perforations of the colon. In each instance, it was the opinion of the surgeon that manipulation of the dilated colon would result in disruption of the colon and fecal spillage.
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Figure 19. Roentgenogram after barium enema 3 weeks after ileostomy, sigmoidostomy, and transversostomy for perforated toxic megacolon. Barium extrudes from transversostomy (large arrow) and from sigmoidostomy (small arrow). Decompression of the colon is complete.
OPERATIVE MoRTALITY. Of 26 patients who underwent ileostomy and colostomy instead of colectomy, one died from diffuse necrotizing vasculitis, thrombosis of major abdominal veins, and duodenal stress ulcer with hemorrhage. HISTOPATHOLOGIC CLASSIFICATION OF ULCERATIVE COLITIS IN PATIENTS WHO UNDERWENT ILEOSTOMY-COLOSTOMY. Sixteen patients had ulcerative colitis of the mucosal type. Nine patients had transmural colitis (Crohn's disease of the colon), and one patient had ulcerative colitis that could not be histopathologically classified. In general the pathologic changes of acute toxic megacolon are superimposed on the basic underlying chronic colonic disease. The inflammatory process is fulminant and affects all layers of the colon, often obscuring the hallmarks of the antecedent ulcerative colitis. Serositis is usually present. In some instances the serosa is covered by patches of fibrinous exudate associated with an intense submucosal vascular display. If perforation has occurred or is impending, there are various amounts of purulent exudate present. Fibrinous and delicate fibrous adhesions to adjacent viscera and the abdominal wall are additional features. Most impressive is the thinness of the colonic wall and its extreme friability. Mucosal damage is severe. In mucosal colitis, pseudopolyposis may be extreme. Histologic examination of these colons reveals, in addition to extensive mucosal ulceration, transmural inflammation. The infiltrate is formed predominantly of neutrophils in areas of greatest dilatation, often dissecting the interstitial spaces of the muscularis propria, so that the individual muscle cells appear separated. Moreover, a curious hyaline degeneration of the muscle cells may have occurred. Ganglioni-
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tis, patchy or diffuse in distribution, affects the myenteric plexuses. The entire histologic structure suggests extreme friability. Granulomas, irregular areas of fibrosis, undermining ulcers, fissures, and pseudopolyps may also be present; these belong to the basic disease. The changes in the ganglia and the muscularis, complicated by the impaired vascular supply caused by the overdistention, are part of the toxic megacolon phase of the disease. Persistent or Recrudescent Ulcerative Colitis After Ileostomy and Colostomy The objection to performing any operative procedure less than colectomy for toxic ulcerative colitis with megacolon is that the patient fails to get well. This valid objection is demonstrated by the fact that of the 25 patients who underwent the operation we described as "less than colectomy," four did not detoxify at all, although the colon in each patient became decompressed. The patients were continuously febrile with tachycardia. One patient began to hemorrhage from the rectum on the sixth postoperative day. Nevertheless, these four patients were returned to surgery between the twelfth and eighteenth postoperative days and colectomy was safely performed after thorough preoperative rectocolonic saline lavage of the colon was performed while the patient was on the operating table under anesthesia. There were eight other patients who returned for colectomy within 6 months because of recrudescent toxic colitis. We wish to point out that in all the patients who underwent subsequent colectomy, the colon was completely decompressed (Fig. 19) and empty. There was no serious postoperative sepsis and no deaths; mortality would have been expected if primary colectomy had been performed. Thirteen patients returned to the hospital after a 6-month postoperative interval because of reactivated disease. However, toxic dilatation of the colon was not possible because of the presence of the cutaneous transverse colostomy. The symptoms and signs of recrudescent ulcerative colitis are important for the patient to recognize so that he can seek hospitalization and colectomy before he is too ill; that is, a purulent watery flux from the rectum and from the cutaneous transverse colostomy herald the onset of the toxic state. There is low-grade fever and lassitude, a loss of interest in usual daily activities, and an increased sleep requirement. The purulent watery flux may come principally from the cutaneous transverse colostomy and assume considerable proportions. One patient had worn bath towels as epigastric dressings, saturating several daily. A few patients had sudden hemorrhage from the rectum or cutaneous transverse colostomy. In summary, of 26 patients who underwent ileostomy and cutaneous transverse colostomy, four continued to have toxic colitis although the colon in each was thoroughly decompressed. An additional eight patients were re-admitted to the hospital to undergo colectomy within 6 months of the first operation because of reactivated toxic ulcerative colitis. Twelve patients underwent elective colectomy after 6 months,
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and one patient has not yet undergone colectomy. At the time of colectomy in each instance, there were few adhesions encountered because the primary operative procedure was minimal. Each of the 24 patients would have been a potential operative mortality if colectomy had been performed when they were first diagnosed.
DEFINITIVE COLECTOMY AFTER EMERGENCY ILEOSTOMY AND TRANSVERSE COLOSTOMY We would emphasize that any operative procedure less than colectomy is a temporary expedient to convert a potentially fatal situation to one less dangerous to life. Accordingly, of the 25 surviving patients who underwent emergency ileostomy-colostomy, 24 have subsequently undergone colectomy. One patient, because of continued good health during the last 4 years, has refused to undergo colectomy. Among the . 24 patients who subsequently underwent colectomy, 8 had ileorectal anastomoses, 9 underwent total proctocolectomy, and 7 underwent subtotal colectomy with preservation of the rectum. All the patients are alive and well.
Operating Room Preparation of the Colon for Colectomy After Ileostomy and Colostomy Two of the important advantages of the ileostomy-colostomy operation for toxic megacolon are that the decompressed and collapsed colon
Figure 20. External construction of loop ileostomy. A, The loop is opened over a hemostat, more than halfway through the distal limb. B, With eversion, the inferior functioning limb becomes dominant. C, The open ileum is sutured to the subcuticular fascia. The superior limb (distal) is recessive.
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Figure 21. Completed ileostomy and transverse colostomy for perforating toxic megacolon. The loop ileostomy in the right lower quadrant is at a considerable distance from the decompressive transverse colostomy.
is technically easy to remove and it can be thoroughly prepared for removal by lavage in the operating room. Under anesthesia a large Pezzer catheter is put into the rectum and connected to a gallon reservoir of saline at body temperature. Polyethylene ileostomy pouches are put on each abdominal orifice to funnel off the colonic lavage water. The saline is turned on and soon runs from the sigmoidostomy and transverse colostomy. After the returns are clear, these two stomas are occluded digitally to allow lavage water to emerge from the recessive superior (distal) ileostomy opening (Fig. 2D and E) lavaging the right side of the colon. After several gallons of saline have been lavaged through the colon, an antibiotic solution may be introduced.
Operative Technique The descending limb of the splenic flexure of the colon is the commonest site of walled-off perforations and may be densely adherent in the upper gutter and splenic area. The descending and sigmoid colons are often fixed in the gutter for the same reason. The right side of the colon and the transverse portion of the colon are seldom perforated. The perforated segments should be isolated by umbilical tape ties to occlude the lumen on either side of the perforated site and prevent the escape of any quantity of lavage fluid during mobilization of the colon. Attention is now turned to the cutaneous colostomy sites. Working through the laparotomy incision, the surgeon should ligate the colon with double stout catgut on the peritoneal side of each stoma so that lavage fluid will not be spilled. A circumferential incision in the skin around each colostomy and mobilization of the stoma down into the peritoneal cavity are easily accomplished. A second occluding ligature around the neck of the stoma is useful.
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The distal limb of the loop ileostomy is cut across and turned in with interrupted catgut sutures 2 inches inside the peritoneal cavity. The inferior peritoneal attachments of the cecum are divided in the right lower quadrant and, working between the ileostomy and liver, the surgeon pulls the cecum up into the right gutter, and further mobilizes it. The ileum is cut from its mesentery at the mesenteric border to spare the blood supply of the established loop ileostomy. The right and transverse colons are now mobilized and the mesenteric vessels are divided over to the distal transverse colon. It is a good plan to mobilize all of the free colon first, and the walled-off perforated areas last, to avoid dissemination of lavage fluid that may escape from the perforated areas. The sigmoid colon and descending colon are mobilized next, and finally the splenic flexure, by cutting the peritoneal attachments directly against the lateral border of the muscularis of the entire flexure while applying traction to it. A decision is now made as to whether the rectum is to be removed or is to be saved for later anastomosis, or whether ileorectal anastomosis is to be performed at this time. The mesentery of the terminal ileum is now sutured to the anterior abdominal wall peritoneum, from the ileostomy exit point to the duodenum, to prevent volvulus. This technique has been described in great detailP Use of Abdominal Drains Soft 7/s-inch rubber drains (Mikulicz) must be sutured in the areas of the gutters wherever a walled-off perforation of the colon has been observed, since abscesses inevitably form at these sites. Two 7/s-inch drains are sutured in the left gutter colonic bed with interrupted 0000 chromic catgut so that it is literally lined with rubber. If the walled-off perforated area is extensive, four drains are placed. They are brought out through an opening in the flank which will admit three fingers, and are sutured to the skin securely with polyethylene sutures. Silk sutures are to be avoided because of the danger of infection. The most important factor in this type of drainage is time. The drains must remain in the patient for 21 days, the patient returning home from the hospital with them in place. Suppuration occurs in the gutter during the first 10 days, and is seen coming through the drains on the twelfth day. The drainage is foul, chocolate-brown, and copious. Before the abdomen is closed, the colostomy sites are closed from within the abdomen with interrupted No. 1 chromic catgut sutures; a single 7/s-inch soft rubber drain (Mikulicz) is brought from the peritoneal level through the wound and is sutured to the skin with polyethylene sutures. These drains are also left in place for 3 weeks. In the past, failure to drain has allowed an intraabdominal abscess to form at the colostomy site.
SUMMARY AND CONCLUSIONS The postoperative mortality of colectomy for toxic megacolon is forbidding and is due to iatrogenic disruption of walled-off perforations, with fecal soiling, resulting in fatal sepsis.
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Colectomy for toxic megacolon is reasonably safe and effective when no walled-off colonic perforations are present. The operation of ileostomy-colostomy for toxic megacolon is proposed as the operation of choice when walled-off perforations of the colon are discovered at laparotomy. A series of 26 patients who underwent this operation under these conditions is reported. There was one postoperative death. Twenty-five patients are well and rehabilitated, although one of these has not yet undergone colectomy. Attention is directed to some points in technique for removal of the colon after the ileostomy-colostomy operation. In particular, the sites of colonic perforation in the gutters must be drained for as long as 21 days to avoid postoperative gutter abscesses. ADDENDUM. Since December 1968 the authors have performed an additional ten operations as described for toxic megacolon with localized perforations. All the patients are alive and well.
REFERENCES 1. Brooke, B. N., and Sampson, P. A.: An indication for surgery in acute ulcerative colitis. Lancet, 2:1272-1273 (Dec. 12) 1964. 2. Crile, G., Jr., and Thomas, C. Y., Jr.: The treatment of acute toxic ulcerative colitis by ileostomy and simultaneous colectomy. Gastroenterology, 19:58-68 (Sept.) 1951. 3. Gardner, C., and Miller, G. G.: Total colectomy for ulcerative colitis. A.M.A. Arch Surg. (Chicago), 63:370-372 (Sept.) 1951. 4. Goligher, J. C., Duthrie, H. L., and Nixon, H. H.: Surgery of the Anus, Rectum and Colon. London, England, Bailliere, Tindall, and Cassell, 2nd ed., 1967, p. 884. 5. Hawk, W. A., Turnbull, R. B., Jr., and Schofield, P. F.: Nonspecific ulcerative colitis. Surgery, 66:953-964 (Nov.) 1969. 6: Klein, S. H.: Personal communication, June 1968. 7. Klein, S. H., Edelman, S., Kirschner, P. A., Lyons, A. S., and Baronofsky, I. D.: Emergency cecostomy in ulcerative colitis with acute toxic dilatation. Surgery, 47:399-407 (March) 1960. 8. Lennard-Jones, J. E., and Vivian, A. B.: Fulminating ulcerative colitis; recent experience in management. Brit Med. J., 2:96-102 (July 9) 1960. 9. Marshak, R. H., Lester, L. J., and Friedman, A. I.: Megacolon, a complication of ulcerative colitis. Gastroenterology, 16:768-772 (Dec.) 1950. 10. Ripstein, C. B.: Primary resection of colon in fulminating ulcerative colitis. Surg. Forum (1952):117-123, 1953. 11. Ripstein, C. B., Miller, G. G., and Gardner, C. MeG.: Results of the surgical treatment of ulcerative colitis. Ann. Surg., 135:14-21 (Jan.) 1952. 12. Turnbull, R. B., Jr., and Weakley, F. L.: Atlas of Intestinal Stomas. St. Louis, C. V. Mosby Company, 1967. 13. Williams, C. L., and Robinson, D. W.: Toxic megacolon syndrome of ulcerative colitis. Ann. Surg., 155:233-237 (Feb.) 1962. The Cleveland Clinic Foundation Cleveland, Ohio 44106