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Colostomy
Colostomy NEIL W. SWINTON, M.D. BENJAMIN H. SCHATMAN, M.D.
Colostomy is defined as the operation of forming an artificial opening into the colon. The mortality and morbidity associated with both benign and malignant diseases of the colon have been markedly reduced by a better understanding of the indications for, the techniques of, and the management of colostomy and the artificial anus. Prior to the advent of antibiotics, Lahey achieved excellent results in this clinic in the treatment of diseases of the colon, in part because of his emphasis on the use of colostomy and staged procedures.
HISTORY
Although Littre is credited with first proposing colostomy in 1710, the procedure had been practiced by veterinarians in Biblical times. 2 Littre, in examining the body of an infant who died of rectal atresia shortly after birth, suggested that the condition could be treated by anastomosing the segments above and below the obstruction or by bringing the proximal bowel out as an artificial anus. Although he never performed the operation, his name has been used as an eponym for the sigmoid colostomy.5 Dubois performed the first colostomy in 1783 on a three day old child with imperforate anus. The child died within ten days. It remained for Duret, of Lyon, to perform the first successful Littre colostomy on an infant in 1793. The obstruction was caused by an imperforate anus. The patient lived for 43 years with an abdominal stoma. Amussat, in 1839, first suggested the use of colostomy for the palliation of obstructing rectal carcinoma. He stated "an artificial anus, it is true, is a grave infirmity but it is not insupportable." Miles, at the turn of this century, described and popularized the procedure which bears his name for the treatment of rectal cancer. It is as part of the Miles proctosigmoidectomy that colostomy is most often performed today.
821
822
NEIL
Table 1.
W.
SWINTON, BENJAMIN
H.
SCHATMAN
Classification
1. Colostomy in Continuity (Loop Colostomy)
A. Permanent 1. Diverting 2. Decompressing B. Temporary 1. Diverting 2. Decompressing 3. Traumatic II. End Colostomy A. After resection of rectum (Miles) B. Divided loop 1. Lesion not resectable 2. Lesion exteriorized and resected (Mikulicz) III. Cecostomy
Many classifications of colostomy have been based on the abdominal area in which the stoma is placed, the segment of bowel used, and the purpose of colostomy. The simple classification (Table 1) which we use covers the types of colostomy performed at this clinic. The colostomy in continuity, or loop colostomy, is indicated (1) in acute obstruction of the distal colon, (2) to protect a tenuous anastomosis in the distal bowel, or (3) to divert the fecal stream in the presence of inflammatory lesions of the lower bowel. Although the majority of obstructions in the sigmoid are secondary to diverticulitis, acute obstruction of the colon caused by carcinoma of the left part of the colon or the rectum is encountered not infrequently. The treatment of choice in either case is a colostomy performed in the right transverse colon. This procedure leaves the entire left half of the colon and splenic flexure free for definitive surgical intervention in the future. After the patient has recovered from the acute episode, sigmoidoscopy and x-ray studies of the colon are performed. If the lesion is malignant, definitive operation may be done within ten to 14 days of the first procedure. If benign disease is the cause of obstruction, definitive surgery is deferred for a minimum of six weeks. Occasionally, it may not be possible to distinguish between a cancer and a diverticulitis causing an obstruction in the sigmoid without further observation. The stoma can be closed two to three weeks after the definitive procedure. Temporary loop colostomy has proved a useful diagnostic tool in cases of massive bleeding of undetermined origin. The performance of the colostomy allows the surgeon to determine whether the hemorrhage arises in the left or the right half of the colon. Occasionally, if the hemorrhage is the result of inflammatory disease in the left colon, the bleeding will cease after diversion of the fecal stream, allowing the patient to be adequately prepared for the definitive procedure. The colostomy is then closed as a third procedure.
823
COLOSTOMY
Fecal fistulas that occur after primary anastomosis will usually close following a proximal diverting colostomy and this procedure should be considered early if the patient does not tolerate the fistula well. It is poor judgment to try to avoid a colostomy in the poor-risk patient with a fecal fistula. The procedure is quickly and safely performed and rapidly leads to improvement in the status of the critically ill patient who has leakage at the anastomosis. A final indication for colostomy in continuity is the traumatic laceration of the colon. Although the recent trend has been to suture the laceration and avoid colostomy, a transverse colostomy in addition to closure of the laceration is an added safety factor in most cases. This is especially important when the laceration is large or when it involves the extraperitoneal rectum. Terminal colostomy is performed almost exclusively after the Miles abdominoperineal resection. It may be indicated for patients with benign strictures of the rectum when resection and anastomosis or repair is impossible. We have been compelled to perform this type of colostomy for radiation proctitis following radiation for uterine cancer. The need for the Lahey two-stage abdominoperineal resection seldom arises today, but occasionally when the resectability of a lesion is questionable, it becomes readily resectable after a colostomy is formed. The Mikulicz type of exteriorization resection which leaves a double-barreled colostomy is rarely indicated at the present time.
TECHNIQUE No matter what technique is used in performing a colostomy, a substitute for the rectum, possessing sphincteric control, cannot be provided surgically.6 Reasonable control of the artificial anus can, however, be obtained by most patients. Although many surgeons believe that 2 inches of bowel should protrude from the abdominal wall, in recent years we have constructed skin level stomas with resultant significant reduction in the number of strictures, fistulas and paracolostomy hernias. The method now employed at this clinic was described in 1951 by Campbell and Schaerrerl in this country and by Patey 7 in Great Britain. The technique was popularized by Donald3 and Turnbull 8 with minor modifications and is now finding favor in most centers. A protruding stoma is easily traumatized and the serositis and infection which follow the spontaneous eversion of the protruding colostomy lead to stenosis. Patey 7 pointed out that healing is best obtained when epithelial surfaces are accurately approximated. With the use of the following technique, the mucous membrane of the bowel is sutured to the skin with absorbable sutures, leading to primary healing with minimal fibrosis and almost no subcutaneous infection and scarring. The colon is brought out through the chosen site (we prefer to
824
W.
NEIL
SWINTON, BENJAMIN
H.
SCHATMAN
Figure 1. Stoma following end colostomy. Absorbable sutures unite the mucosa of the bowel wall and subcutaneous margin of the skin.
use the lower portion of the left rectus incision in the Miles resection) over a clamp. After the wound is closed loosely around the bowel, the crushed margin of the bowel is resected. An ellipse of skin on both sides of the opening is removed. Then the full thickness of the free margin of the bowel is sutured to the subcutis with catgut sutures (Fig. 1). The bowel must not be under any tension and the blood supply must be adequate. The same procedure is used when a loop colostomy is performed (Fig. 2). If complete diversion of the fecal stream is desired, this may be obtained by elevating the posterior wall of the bowel over glass rods in the fashion described by Wangensteen. 10 At the completion of the suturing of the mucosa to the skin, Vaseline dressings are applied over the colostomy and left in place
c
r
0.-,
J J
J
I
I
,
\ \
\
\
,, I
,,
, I
Figure 2. Transverse loop colostomy. Bowel is anchored to fascia (A) and then is sutured to the subcutaneous margin of the skin.
825
COLOSTOMY
for 48 hours or until bowel function begins. In the obstructed bowel, decompression is immediate but the seal formed between the skin and mucosa prevents soiling of the subcutaneous tissue. This avoids the scarring and stricture formation which was so common after the conventional colostomy. The site of the colonic stoma following a proctosigmoidectomy also is important since the stoma should be visible to the patient while sitting and should not be at the belt line where the stoma is likely to be traumatized. The stoma should be located in the line of incision below the umbilicus where it will not be traumatized and will allow the patient to use a disk comfortably during irrigations. An equally satisfactory procedure is to bring the colostomy out through the umbilicus after resecting the full thickness of the abdominal wall in this area. So long as the stoma is brought out near the midline, closure of the lateral gutter is not necessary. We have not seen any instance of obstruction resulting from small bowel herniating around these colostomies. If the stoma is brought out lateral to the incision, it is essential to obliterate the lateral space carefully by suturing the mesentery of the colon to the parietal peritoneum. Colcock2 stated that this closure must not occlude any of the vessels in the mesentery and that no spaces should remain open between sutures. Incomplete closure is worse than leaving the gutter wide open. Closure of the temporary colonic stoma performed in this manner is facilitated by the lack of scarring and infection. The visible bowel wall is separated from the skin by sharp dissection and the remainder of the bowel can be easily freed from the deeper layer of the abdominal wall because there is little reaction around the bowel. There is no edematous infected margin requiring resection. The intestine is pliable and holds sutures well, so that simple transverse closure is all that is needed.
AFTERCARE After the patient has recovered from the immediate problems of the operation, he must learn to care for the colonic stoma. The transverse colostomy, which is temporary in most cases, cannot be well controlled because of the liquid or semisolid nature of the feces at this level. We instruct the patient to take a low residue diet and wear a disposable receptacle such as the Fazio bag (Fig. 3). It can be changed daily with minimal skin irritation and is not noticeable under most garments. If dietary indiscretion or gastroenteritis produces diarrhea, paregoric, 5 cc. hourly, is administered until the diarrhea is controlled. Boiled milk may be helpful. Skin irritation, if present, is treated by cleansing the skin frequently with pHisoHex and applying karaya paste on the irritated areas. Bleeding from'the stoma, although rare with this procedure, can be controlled by coating the bleeding area with petrolatum.
826
NEIL
W.
SWINTON, BENJAMIN
H.
SCHATMAN
Figure 3. Temporary plastic receptacle used with transverse colostomy.
The sigmoid or end colostomy is much less of a problem and well over 90 per cent of our patients are able to resume full activity after a Miles resection. The use of colonic irrigations at two day intervals affords the patient freedom from constant soiling and allows him to return to his preoperative activities with the least fear of accidental movements. On the seventh postoperative day, after the wound sutures have been removed, the patient is instructed in the technique of irrigation. A plastic dome receptacle, such as the Carhart or Binkley irrigating dome, is fitted loosely over the stoma. A well lubricated, number 22 F. catheter is inserted into the stoma for a distance of 4 to 6 inches through the opening in the dome. Two pints of tap water are run slowly into the colon while the catheter is slid in and out a distance of 2 inches. The return of formed stool plus irrigating fluid runs into the toilet through a plastic conduit attached to the dome. The procedure need take only a half hour. We are presently studying the effect of cool water for irrigations to stimulate peristalsis and thereby decrease the time required for the procedure. This has been suggested by Marino et al. 6 and appears physiologically sound. Our experience with laxative powders such as Lavema has been liInited, although Turnbull 9 found them useful in selected cases. In a small number of patients a rhythmicity in bowel function develops and they have one evacuation daily after their heaviest meal, with no difficulty between meals. In this fortunate group, irrigations are unnecessary. After a satisfactory irrigation, the stoma is lightly coated with petrolatum and covered with flat absorbent dressings held in place by a girdle or elastic belt. Rubber pouches retain odors, and so their use is not advisable. A disposable plastic receptacle can be used when diarrhea occurs and when the patient is traveling. As the patient becomes able to tolerate solid food, he is placed on a
827
COLOSTOMY
strict constipating diet. When the colon is controlled by diet and irrigations, the diet is liberalized so that eventually most patients are able to resume a full diet with few restrictions. We advise patients that, whenever diarrhea or loose stools occur, they should immediately resume the original strict, constipating regimen and remain on it until control is regained.
COMPLICATIONS
Prolapse of the colon through the colonic stoma is rare, but can be a terrifying sight to the patient. It is best avoided at the time of operation by careful wound closure and by resecting any redundant bowel, leaving sufficient bowel to protrude only 1 inch above the skin level. If prolapse does occur, simple measures, such as taping or trusses, are of no value. Operation with reduction of the prolapse and resection of the redundant bowel will be curative. Herniation at the site of the stoma frequently occurred when musclesplitting incisions were used. Since paramedian or muscle-retracting incisions have been employed, herniation after colostomy has been rare. Herniation around the colostomy will occur with equal frequency whether the bowel is brought out through the major incision or through a separate stab wound. 4 These hernias are actually produced by small bowel pushing up through the defect. As the small bowel enters the defect, the opening is stretched, often massively. Most of these hernias are asymptomatic and can be controlled by a girdle or supporting belt. Difficulty in inserting the irrigating catheter, or intestinal obstruction are indications for surgical intervention. We have found that hernia repair alone is followed by a high recurrence rate. Excellent results will be obtained if the colostomy is moved to another area and the hernia repaired by closing the defect in toto. Perforation of the colon by forcing the irrigating catheter farther is a surgical emergency. Patients should be told never to use a rigid tube and never to pass the tube forcefully. They should be advised concerning the pain and collapse associated with perforation and told to obtain medical aid immediately if they suspect perforation has occurred. Immediate laparotomy with resection of the perforated area and formation of a colostomy located proximal to the former stoma is indicated. If seen early, the condition can be managed with a low mortality rate.
REFERENCES 1. Campbell, F. B. and Schaerrer, W. C.: Colostomy; its reconstruction and care. J.A.M.A. 146: 93-96 (May 12) 1951. 2. Colcock, B. P.: Colostomy: Historical role in the surgery of the colon and rectum. Surgery 31: 794-804 (May) 1952.
828
NEIL
W.
SWINTON, BENJAMIN
H.
SCHATMAN
3. Donald, D. C.: Revised technique for construction of single barreled colostomy. Surg. Gynec. & Obst. 191: 642-646 (Nov.) 1955. 4. Donaldson, G. A.: Current concepts in therapy. Management of ileostomy and colostomy. New England J. Med. 268: 827-830 (April 11) 1963. 5. Lichtenstein, M. E.: Colostomy; classification of types based on anatomy and function-with historical notes. Quart. Bull. Northwestern Univ. M. School 27: 44-53, 1953. 6. Marino, A. W. M., Caliendo, A. J. and Marino, M., Jr.: Modern management of colostomy. South. M. J. 47: 1173-1180 (Dec.) 1954. 7. Patey, D. H.: Primary epithelial apposition in colostomy. Proc. Roy. Soc. Med. 44: 423-424 (June) 1951. 8. Turnbull, R. B., Jr.: Intestinal stomas. S. CLIN. NORTH AMERICA 38: 1361-1372 (Oct.) 1958. 9. Turnbull, R. B., Jr.: Instructions to the colostomy patient. Management of the colostomy. Cleveland Clin. Quart. 28: 134-140 (April) 1961. 10. Wangensteen, O. H.: Personal communication.
Colostomy is defined as the operation of forming an artificial opening into the colon. The mortality and morbidity associated with both benign and malignant diseases of the colon have been markedly reduced by a better understanding of the indications for, the techniques of, and the management of colostomy and the artificial anus. Prior to the advent of antibiotics, Lahey achieved excellent results in this clinic in the treatment of diseases of the colon, in part because of his emphasis on the use of colostomy and staged procedures.
HISTORY
Although Littre is credited with first proposing colostomy in 1710, the procedure had been practiced by veterinarians in Biblical times. 2 Littre, in examining the body of an infant who died of rectal atresia shortly after birth, suggested that the condition could be treated by anastomosing the segments above and below the obstruction or by bringing the proximal bowel out as an artificial anus. Although he never performed the operation, his name has been used as an eponym for the sigmoid colostomy.5 Dubois performed the first colostomy in 1783 on a three day old child with imperforate anus. The child died within ten days. It remained for Duret, of Lyon, to perform the first successful Littre colostomy on an infant in 1793. The obstruction was caused by an imperforate anus. The patient lived for 43 years with an abdominal stoma. Amussat, in 1839, first suggested the use of colostomy for the palliation of obstructing rectal carcinoma. He stated "an artificial anus, it is true, is a grave infirmity but it is not insupportable." Miles, at the turn of this century, described and popularized the procedure which bears his name for the treatment of rectal cancer. It is as part of the Miles proctosigmoidectomy that colostomy is most often performed today.
821
822
NEIL
Table 1.
W.
SWINTON, BENJAMIN
H.
SCHATMAN
Classification
1. Colostomy in Continuity (Loop Colostomy)
A. Permanent 1. Diverting 2. Decompressing B. Temporary 1. Diverting 2. Decompressing 3. Traumatic II. End Colostomy A. After resection of rectum (Miles) B. Divided loop 1. Lesion not resectable 2. Lesion exteriorized and resected (Mikulicz) III. Cecostomy
Many classifications of colostomy have been based on the abdominal area in which the stoma is placed, the segment of bowel used, and the purpose of colostomy. The simple classification (Table 1) which we use covers the types of colostomy performed at this clinic. The colostomy in continuity, or loop colostomy, is indicated (1) in acute obstruction of the distal colon, (2) to protect a tenuous anastomosis in the distal bowel, or (3) to divert the fecal stream in the presence of inflammatory lesions of the lower bowel. Although the majority of obstructions in the sigmoid are secondary to diverticulitis, acute obstruction of the colon caused by carcinoma of the left part of the colon or the rectum is encountered not infrequently. The treatment of choice in either case is a colostomy performed in the right transverse colon. This procedure leaves the entire left half of the colon and splenic flexure free for definitive surgical intervention in the future. After the patient has recovered from the acute episode, sigmoidoscopy and x-ray studies of the colon are performed. If the lesion is malignant, definitive operation may be done within ten to 14 days of the first procedure. If benign disease is the cause of obstruction, definitive surgery is deferred for a minimum of six weeks. Occasionally, it may not be possible to distinguish between a cancer and a diverticulitis causing an obstruction in the sigmoid without further observation. The stoma can be closed two to three weeks after the definitive procedure. Temporary loop colostomy has proved a useful diagnostic tool in cases of massive bleeding of undetermined origin. The performance of the colostomy allows the surgeon to determine whether the hemorrhage arises in the left or the right half of the colon. Occasionally, if the hemorrhage is the result of inflammatory disease in the left colon, the bleeding will cease after diversion of the fecal stream, allowing the patient to be adequately prepared for the definitive procedure. The colostomy is then closed as a third procedure.
823
COLOSTOMY
Fecal fistulas that occur after primary anastomosis will usually close following a proximal diverting colostomy and this procedure should be considered early if the patient does not tolerate the fistula well. It is poor judgment to try to avoid a colostomy in the poor-risk patient with a fecal fistula. The procedure is quickly and safely performed and rapidly leads to improvement in the status of the critically ill patient who has leakage at the anastomosis. A final indication for colostomy in continuity is the traumatic laceration of the colon. Although the recent trend has been to suture the laceration and avoid colostomy, a transverse colostomy in addition to closure of the laceration is an added safety factor in most cases. This is especially important when the laceration is large or when it involves the extraperitoneal rectum. Terminal colostomy is performed almost exclusively after the Miles abdominoperineal resection. It may be indicated for patients with benign strictures of the rectum when resection and anastomosis or repair is impossible. We have been compelled to perform this type of colostomy for radiation proctitis following radiation for uterine cancer. The need for the Lahey two-stage abdominoperineal resection seldom arises today, but occasionally when the resectability of a lesion is questionable, it becomes readily resectable after a colostomy is formed. The Mikulicz type of exteriorization resection which leaves a double-barreled colostomy is rarely indicated at the present time.
TECHNIQUE No matter what technique is used in performing a colostomy, a substitute for the rectum, possessing sphincteric control, cannot be provided surgically.6 Reasonable control of the artificial anus can, however, be obtained by most patients. Although many surgeons believe that 2 inches of bowel should protrude from the abdominal wall, in recent years we have constructed skin level stomas with resultant significant reduction in the number of strictures, fistulas and paracolostomy hernias. The method now employed at this clinic was described in 1951 by Campbell and Schaerrerl in this country and by Patey 7 in Great Britain. The technique was popularized by Donald3 and Turnbull 8 with minor modifications and is now finding favor in most centers. A protruding stoma is easily traumatized and the serositis and infection which follow the spontaneous eversion of the protruding colostomy lead to stenosis. Patey 7 pointed out that healing is best obtained when epithelial surfaces are accurately approximated. With the use of the following technique, the mucous membrane of the bowel is sutured to the skin with absorbable sutures, leading to primary healing with minimal fibrosis and almost no subcutaneous infection and scarring. The colon is brought out through the chosen site (we prefer to
824
W.
NEIL
SWINTON, BENJAMIN
H.
SCHATMAN
Figure 1. Stoma following end colostomy. Absorbable sutures unite the mucosa of the bowel wall and subcutaneous margin of the skin.
use the lower portion of the left rectus incision in the Miles resection) over a clamp. After the wound is closed loosely around the bowel, the crushed margin of the bowel is resected. An ellipse of skin on both sides of the opening is removed. Then the full thickness of the free margin of the bowel is sutured to the subcutis with catgut sutures (Fig. 1). The bowel must not be under any tension and the blood supply must be adequate. The same procedure is used when a loop colostomy is performed (Fig. 2). If complete diversion of the fecal stream is desired, this may be obtained by elevating the posterior wall of the bowel over glass rods in the fashion described by Wangensteen. 10 At the completion of the suturing of the mucosa to the skin, Vaseline dressings are applied over the colostomy and left in place
c
r
0.-,
J J
J
I
I
,
\ \
\
\
,, I
,,
, I
Figure 2. Transverse loop colostomy. Bowel is anchored to fascia (A) and then is sutured to the subcutaneous margin of the skin.
825
COLOSTOMY
for 48 hours or until bowel function begins. In the obstructed bowel, decompression is immediate but the seal formed between the skin and mucosa prevents soiling of the subcutaneous tissue. This avoids the scarring and stricture formation which was so common after the conventional colostomy. The site of the colonic stoma following a proctosigmoidectomy also is important since the stoma should be visible to the patient while sitting and should not be at the belt line where the stoma is likely to be traumatized. The stoma should be located in the line of incision below the umbilicus where it will not be traumatized and will allow the patient to use a disk comfortably during irrigations. An equally satisfactory procedure is to bring the colostomy out through the umbilicus after resecting the full thickness of the abdominal wall in this area. So long as the stoma is brought out near the midline, closure of the lateral gutter is not necessary. We have not seen any instance of obstruction resulting from small bowel herniating around these colostomies. If the stoma is brought out lateral to the incision, it is essential to obliterate the lateral space carefully by suturing the mesentery of the colon to the parietal peritoneum. Colcock2 stated that this closure must not occlude any of the vessels in the mesentery and that no spaces should remain open between sutures. Incomplete closure is worse than leaving the gutter wide open. Closure of the temporary colonic stoma performed in this manner is facilitated by the lack of scarring and infection. The visible bowel wall is separated from the skin by sharp dissection and the remainder of the bowel can be easily freed from the deeper layer of the abdominal wall because there is little reaction around the bowel. There is no edematous infected margin requiring resection. The intestine is pliable and holds sutures well, so that simple transverse closure is all that is needed.
AFTERCARE After the patient has recovered from the immediate problems of the operation, he must learn to care for the colonic stoma. The transverse colostomy, which is temporary in most cases, cannot be well controlled because of the liquid or semisolid nature of the feces at this level. We instruct the patient to take a low residue diet and wear a disposable receptacle such as the Fazio bag (Fig. 3). It can be changed daily with minimal skin irritation and is not noticeable under most garments. If dietary indiscretion or gastroenteritis produces diarrhea, paregoric, 5 cc. hourly, is administered until the diarrhea is controlled. Boiled milk may be helpful. Skin irritation, if present, is treated by cleansing the skin frequently with pHisoHex and applying karaya paste on the irritated areas. Bleeding from'the stoma, although rare with this procedure, can be controlled by coating the bleeding area with petrolatum.
826
NEIL
W.
SWINTON, BENJAMIN
H.
SCHATMAN
Figure 3. Temporary plastic receptacle used with transverse colostomy.
The sigmoid or end colostomy is much less of a problem and well over 90 per cent of our patients are able to resume full activity after a Miles resection. The use of colonic irrigations at two day intervals affords the patient freedom from constant soiling and allows him to return to his preoperative activities with the least fear of accidental movements. On the seventh postoperative day, after the wound sutures have been removed, the patient is instructed in the technique of irrigation. A plastic dome receptacle, such as the Carhart or Binkley irrigating dome, is fitted loosely over the stoma. A well lubricated, number 22 F. catheter is inserted into the stoma for a distance of 4 to 6 inches through the opening in the dome. Two pints of tap water are run slowly into the colon while the catheter is slid in and out a distance of 2 inches. The return of formed stool plus irrigating fluid runs into the toilet through a plastic conduit attached to the dome. The procedure need take only a half hour. We are presently studying the effect of cool water for irrigations to stimulate peristalsis and thereby decrease the time required for the procedure. This has been suggested by Marino et al. 6 and appears physiologically sound. Our experience with laxative powders such as Lavema has been liInited, although Turnbull 9 found them useful in selected cases. In a small number of patients a rhythmicity in bowel function develops and they have one evacuation daily after their heaviest meal, with no difficulty between meals. In this fortunate group, irrigations are unnecessary. After a satisfactory irrigation, the stoma is lightly coated with petrolatum and covered with flat absorbent dressings held in place by a girdle or elastic belt. Rubber pouches retain odors, and so their use is not advisable. A disposable plastic receptacle can be used when diarrhea occurs and when the patient is traveling. As the patient becomes able to tolerate solid food, he is placed on a
827
COLOSTOMY
strict constipating diet. When the colon is controlled by diet and irrigations, the diet is liberalized so that eventually most patients are able to resume a full diet with few restrictions. We advise patients that, whenever diarrhea or loose stools occur, they should immediately resume the original strict, constipating regimen and remain on it until control is regained.
COMPLICATIONS
Prolapse of the colon through the colonic stoma is rare, but can be a terrifying sight to the patient. It is best avoided at the time of operation by careful wound closure and by resecting any redundant bowel, leaving sufficient bowel to protrude only 1 inch above the skin level. If prolapse does occur, simple measures, such as taping or trusses, are of no value. Operation with reduction of the prolapse and resection of the redundant bowel will be curative. Herniation at the site of the stoma frequently occurred when musclesplitting incisions were used. Since paramedian or muscle-retracting incisions have been employed, herniation after colostomy has been rare. Herniation around the colostomy will occur with equal frequency whether the bowel is brought out through the major incision or through a separate stab wound. 4 These hernias are actually produced by small bowel pushing up through the defect. As the small bowel enters the defect, the opening is stretched, often massively. Most of these hernias are asymptomatic and can be controlled by a girdle or supporting belt. Difficulty in inserting the irrigating catheter, or intestinal obstruction are indications for surgical intervention. We have found that hernia repair alone is followed by a high recurrence rate. Excellent results will be obtained if the colostomy is moved to another area and the hernia repaired by closing the defect in toto. Perforation of the colon by forcing the irrigating catheter farther is a surgical emergency. Patients should be told never to use a rigid tube and never to pass the tube forcefully. They should be advised concerning the pain and collapse associated with perforation and told to obtain medical aid immediately if they suspect perforation has occurred. Immediate laparotomy with resection of the perforated area and formation of a colostomy located proximal to the former stoma is indicated. If seen early, the condition can be managed with a low mortality rate.
REFERENCES 1. Campbell, F. B. and Schaerrer, W. C.: Colostomy; its reconstruction and care. J.A.M.A. 146: 93-96 (May 12) 1951. 2. Colcock, B. P.: Colostomy: Historical role in the surgery of the colon and rectum. Surgery 31: 794-804 (May) 1952.
828
NEIL
W.
SWINTON, BENJAMIN
H.
SCHATMAN
3. Donald, D. C.: Revised technique for construction of single barreled colostomy. Surg. Gynec. & Obst. 191: 642-646 (Nov.) 1955. 4. Donaldson, G. A.: Current concepts in therapy. Management of ileostomy and colostomy. New England J. Med. 268: 827-830 (April 11) 1963. 5. Lichtenstein, M. E.: Colostomy; classification of types based on anatomy and function-with historical notes. Quart. Bull. Northwestern Univ. M. School 27: 44-53, 1953. 6. Marino, A. W. M., Caliendo, A. J. and Marino, M., Jr.: Modern management of colostomy. South. M. J. 47: 1173-1180 (Dec.) 1954. 7. Patey, D. H.: Primary epithelial apposition in colostomy. Proc. Roy. Soc. Med. 44: 423-424 (June) 1951. 8. Turnbull, R. B., Jr.: Intestinal stomas. S. CLIN. NORTH AMERICA 38: 1361-1372 (Oct.) 1958. 9. Turnbull, R. B., Jr.: Instructions to the colostomy patient. Management of the colostomy. Cleveland Clin. Quart. 28: 134-140 (April) 1961. 10. Wangensteen, O. H.: Personal communication.