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Preoperative and Postoperative Management of Patients with Lesions of the Colon and Rectum
Preoperative and Postoperative Management of Patients with Lesions of the Colon and Rectum ROBERT A. SCARBOROUGH, M.D., F.A.C.S. *
THE experienced surgeon of today has attained a high degree of proficiency in the technical surgical procedures applicable to diseases of the colon and rectum. Since no part of the large intestine is essential to life and health, any segment or all of this organ may be sacrificed for the elimination of disease which threatens the health or life of the patient. Modern anesthesia and the ability to combat the bacterial flora of the large intestine by chemotherapeutic and antibiotic agents have played a significant role in reducing the operative mortality of major colonic surgery to well below 5 per cent. It may be said that direct fatality from operation itself is a rarity, with morbidity and mortality nearly always the result of some complicating condition or associated disease. In large part, therefore, the surgeon's success is dependent upon preoperative evaluation and preparation, and postoperative care. PREOPERATIVE EVALUATION AND PLAN FOR SURGERY
The preoperative phase of surgical care must begin with competent evaluation of the existing disease, so that the appropriate technical procedure may be planned and the specific preparation for operation be started. Neoplastic Disease
The most frequent indication for colonic surgery is neoplasm. The high incidence of carcinoma and of premalignant adenomatous polyps in the colon and rectum is well known. The relatively favorable prognosis for cure by appropriate surgical procedure is also common knowledge. There is much less appreciation of the fact that the presence of one mucosal tumor of the large intestine is indicative of a predisposition to the * Clinical Professor of Surgery, Stanford University School of Medicine, San Francisco, California. 14-19
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development of other similar tumors. In our experience, 25 per cent of patients with carcinoma have had other associated adenomatous polyps, and 10 per cent of these patients have had at the time, or later developed, other primary carcinomas of the colon or rectum. It is important, therefore, when one neoplasm has been discovered, to investigate the entire colon and rectum for other possible tumors. The finding of a single small adenomatous polyp by sigmoidoscopy is an indication for roentgenologic examination of the rest of the colon with barium-air contrast enema. Conversely, sigmoidoscopy should always be done when roentgenologic examination has revealed a neoplasm higher in the colon. The utter inadequacy of roentgenologic diagnosis of neoplasms of the rectum demands emphasis. Preoperative evaluation, then, begins with thorough investigation of the entire colon and rectum for any and all lesions that may be present. The appropriate surgical procedure may then be planned. The surgeon must be prepared to revise the plan of procedure at the time of laparotomy, if exploration reveals evidence of neoplastic disease not found by preoperative study. Diverticulitis
In recent years a profound change has occurred in the attitude toward surgical approach to the problems of diverticulitis. Numerous convincing reports have shown that a radical definitive attack, by resection of the diseased segment of the colon, can result in a highly satisfactory proportion of permanent cures, with an operative mortality of 2 to 5 per cent. Proximal diversionary colostomy is not a satisfactory surgical procedure for the cure of diverticulitis, nor should it be merely a palliative operation. Colostomy should be considered an essential emergency procedure for the purpose of control of severe infection or for the relief of obstruction. At the same time it should be planned and executed as a preliminary operation, with the expectation that surgical resection of the diseased bowel will be carried out before the colostomy is closed. The interval between colostomy and resection is variable, but should not be protracted. We consider a period of 3 to 6 weeks sufficient in the majority of cases for control of acute infection. Further delay does not significantly diminish the technical problems of resection or the surgical risks. Following resection, the patency of the anastomosis should be tested by roentgenologic examination with barium enema before the colostomy is closed. This can be done usually within 2 weeks. When proximal colostomy has not been done as an emergency procedure, the elective operation of resection may be carried out in three stages or in one stage. Although a three stage operation is usually considered a safer procedure, one stage operations may be employed safely and satisfactorily in many instances. The choice between a single or
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multiple stage operation requires careful individual evaluation and sound surgical judgment. The preoperative plan of procedure should be tentative, and determined on the basis of the following factors: (1) general condition of the patient, (2) evidence of acute infection, (3) evidence of extensive diffuse chronic infection or complicating fistula, (4) presence or absence of a degree of obstruction sufficient to impede adequate mechanical and antibacterial preparation of the bowel, and (5) evidence by proctoscopic examination of an adequate length of normal rectum for good primary anastomosis. At the time of laparotomy, final evaluation and choice of procedure should be determined. Not infrequently the symptom of gross blood with bowel movements is attributed to diverticulitis or to diverticulosis. It is unquestionably true that bleeding can occur with diverticulitis. However, in our experience, repeated episodes of gross blood in the bowel movements have been found, in the great majority of cases, to have been due to a co-existing neoplasm. In a series of 81 patients, where previous diagnosis of diverticulosis or diverticulitis had been considered the explanation of rectal bleeding, removal of an adenomatous polyp or a carcinoma was followed by cessation of bleeding. The identification of a polyp or even a carcinoma in a colon with diverticula, with or without diverticulitis, is frequently difficult and sometimes impossible. Specific search for a possible polypoid tumor is always indicated when there is blood in the stool. Persistent bleeding, even though repeated roentgenologic study fails to reveal evidence of a polyp or carcinoma, should be considered an indication for surgical exploration and wide resection. Chronic Ulcerative Colitis
The indications for surgery in the treatment of chronic idiopathic ulcerative colitis are beyond the scope of this discussion. There is still no satisfactory specific medical (or psychiatric) cure for this disease. Surgical treatment has progressed far since 20 years ago, when ileostomy, with an operative mortality of 25 to 50 per cent, was the usual surgical procedure of last resort. Today the accepted principle of surgical treatment is resection of the diseased bowel, with permanent ileostomy. Permanent cure is possible by such radical treatment, with an operative mortality of less than 5 per cent. Two maj or questions arise in preoperative evaluation and determination of a plan for procedure: (1) how much bowel should be removed, and (2) should the operation be planned as a one, two or three stage procedure. Proctoscopy and barium enema examination aid in the determination of how much bowel is to be removed, but require qualification. The rectum is always involved in the typical case of chronic idiopathic ulcerative colitis, and this involvement is determinable by proctoscopy. In
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an occasional patient the rectal wall appears entirely normal by proctoscopy, despite evidence of extensive disease of the abdominal colon by roentgenologic examination with barium enema. We have reason to believe that such instances are not "atypical" idiopathic ulcerative colitis, but represent a segmental colitis comparable with regional enteritis. Whether or not this is so, it is only in the occasional patient in whom the rectal mucosa is perfectly normal that preservation of rectal function by anastomosis is justified. Barium enema examination is not a reliable means of determining the proximal limit of the disease. Not infrequently, the apperance of the cecum and ascending colon suggests that this segment of the bowel may not be involved. Even at exploration the proximal colon may appear grossly normal. Experience has shown that in most instances this part of the colon is actually involved by disease, and, as a rule, the predetermined plan of procedure should be to include the entire proximal colon in the zone of resection, even though roentgenologic examination does not prove involvement of this area. Consideration should also be given to the possibility of extension of disease into the distal ileum. Evidence of such involvement should be looked for in the films of barium enema examination. This should be re-evaluated at the time of exploration, so that resection will include several inches of normal ileum proximal to the zone of disease. The second major question for evaluation is whether the operation should be planned as a one, two or three stage procedure. Initial ileostomy, later followed by resection of the diseased bowel in one or two stages, has been until recently the usual method of attack. There is accumulating evidence to show that in most instances a single stage complete colectomy, including abdominoperineal resection of the rectum with simultaneous ileostomy, has a lower morbidity and mortality rate than any program of mUltiple-stage procedures. We have done 15 such one stage procedures with no mortality, in the last 15 patients operated upon for chronic ulcerative colitis. It has been quite evident that simultaneous removal of the diseased bowel greatly facilitates the control of electrolyte and fluid balance during the period of adjustment to ileostomy, and accelerates restoration of normal health. PREOPERATIVE PREPARATION
It is axiomatic that in preparation for any major surgical procedure there should be appropriate evaluation of the patient's general condition. This discussion will be limited to certain specific problems in the preparation for large bowel surgery. Mental Preparation of The Patient
This is the first important step in preparation of the patient for major colonic surgery. There is surprising disagreement as to how much to tell
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the patient, particularly when a diagnosis of carcinoma has been made. Some believe that every effort should be made to avoid telling the patient the truth, with evasion and even falsification of the known facts. This is a serious mistake. The intelligence of the patient should never be underestimated. He knows that the recommendation for operation on the intestine denotes serious disease, and he usually suspects cancer, regardless of any denial by the surgeon. Frank discussion of the patient's problem, with justifiable optimism, does much to instill a spirit of hope and determination in the mind of the patient that will be a real factor in postoperative recovery. A definite diagnosis of malignancy cannot be established for lesions above reach of a sigmoidoscope until the time of laparotomy. It is neither necessary nor justifiable, in such an instance, to state flatly that the patient has cancer. He should be told, when he asks, that his illness may be due to a malignant tumor. The favorable prognosis for such a lesion, in comparison with malignant disease in other abdominal organs, should be emphasized. For example, the patient can be told that the possibility for cure of a malignant tumor of the intestine is ten times as great as for a similar tumor of the stomach. It is of particular importance to prepare mentally the patient who requires colostomy and resection of the rectum. Any patient of reasonable intelligence knows that such an operation is indicated only for serious disease. He needs to know the reason why such an operation is necessary if he is to accept it. Proof of the diagnosis should be established by biopsy examination to avoid any possible mistake by the surgeon, and to satisfy any doubt in the mind of the patient as to the diagnosis. The patient must be made to understand that there is but one known method of cure, which is radical surgical extirpation. Quite often the patient is more concerned about colostomy than about the primary diagnosis. It is the surgeon's responsibility to convince him that colostomy is not too great a price to pay for cure of a malignant rectal tumor. He must be convinced than he can continue to lead a normal life, that he will be able to work and play like anyone else. He should be assured that he will have regular bowel habits and satisfactory bowel control, with a simple routine of enema irrigation everyone or two days. Not infrequently, more time is necessary for the mental preparation of the patient than for the operation itself. A true understanding of the facts about colostomy before operation is of real value in postoperative recovery. There is no justification for withholding any knowledge of the necessity for colostomy until the operation is an accomplished fact. A persistent feeling of "resentment and distrust frequently then will delay the patient's acceptance of and adjustment to colostomy, and may seriously retard both physical and mental recovery. Mental preparation of the patient with chronic ulcerative colitis for ileostomy is usually much easier than for colostomy in the treatment of rectal carcinoma. The patient with rectal malignancy has usually felt
Robert A. Scarborough that he was in excellent health except for symptoms that he has attributed to hemorrhoids. The patient with ulcerative colitis has been critically or chronically ill for a considerable period of time. He has long been aware of the nature of his disease during a variable perIod of medical treatment, and he usually looks forward to restoration of health by surgery. Usually, however, the explanation of ileostomy has been left to the surgeon. The necessity for ileostomy and its function should"be carefully explained. The patient must be convinced that there will~be no limitation of physical or social activities because of ileostomy. He should be given an adequate understanding of the efficiency of a modern ileostomy bag, which may be cemented firmly to the skin so that there is no possibility of fecal soiling or escaping odor. He should know that there will be no voluntary control of the passage of fecal material into the bag, but that even he will be insensitive to the functioning of the ileostomy. It should be explained that when the bag is full it can be readily emptied in any toilet, and that the bag need be removed and cleaned only once every two or three days. There are no particular problems of mental preparation for surgical treatment of diverticulitis, when a single stage resection with immediate restoration of bowel continuity by anastomosis is to be done. When treatment is to be by multiple stage procedure, with initial colostomy, the function of a colostomy should be explained, with definite reassurance that this is a temporary necessity which will be eliminated subsequently. Preparation of the Colon
The satisfactory results of present day surgical procedures for colonic disease depend in good part on our ability to control the complications of infection. Suitable antibacterial preparation of the bowel is a prime prerequisite for every such elective operation. Mechanical Cleansing of the Bowel. This is important for several reasons: (1) to reduce mechanically the number of bacteria within the bowel, (2) to increase the effectiveness of chemotherapeutic or antibiotic agents on the intestinal organisms, (3) to permit more satisfactory exploration of an empty colon at laparotomy, and (4) to minimize fecal spillage at operation. In the absence of obstruction, mechanical preparation is best initiated by the administration of 2 ounces of castor oil. During the subsequent period of preparation a nonresidual, high caloric, high vitamin diet should be given. Continued use of laxatives is undesirable and usually unnecessary, since the administration of antibacterial agents causes an adequate degree of peristaltic progression of the fecal content through the bowel. A single tap water enema may be used 12 hours prior to surgery to assure an empty bowel at operation. In the presence of partial obstruction, cautious and gradual mechanical
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decompression should be attempted by the use of enemas and small divided doses of some mild saline laxative. More forceful catharsis may precipitate complete obstruction. The period for adequate preoperative preparation may need to be extended by several days. Acute or complete obstruction prohibits any effective bowel preparation. Prompt decompression by external diversion of the fecal stream proximal to the obstruction is indicated. Subsequently, both mechanical and antibacterial preparation may be effected through the colostomy stoma and per rectum before definitive surgery is done. Intestinal Antisepsis. This should be started immediately after initial catharsis. The value and the limitations of various chemotherapeutic and antibiotic agents have been the subject of extensive investigation and numerous reports in the past few years. Pioneers and outstanding contributors in this field are Poth, and Pulasky. Poth6 has recently contributed an excellent review of modern concepts of intestinal antisepsis, with a comprehensive report on the relative value of the more commonly used chemotherapeutic agents (Sulfasuxidine, Sulfathalidine) and antibiotics (streptomycin, Aureomycin, Terramycin, neomycin). Our own experience confirms the choice of neomycin as the most effective agent in antiseptic preparation of the bowel. Maximum bacterial effect may be obtained in 48 hours by administration of 1 gram of neomycin every 6 hours. Poth has advocated more rapid preparation by giving 1 gram of neomycin every hour for 4 hours beginning 1 hour after the administration of 2 ounces of castor oil. He also recommends the use of 1.5 grams of Sulfathalidine with each gram of neomycin, for more effective control of Shigella organisms, and particularly Aerobacter aerogenes. Dearing and Needham1 recommend neomycin as the antibiotic of choice, but advise simultaneous administration of Terramycin for more effective control of anaerobic organisms. Two possible unfavorable side effects of antibacterial preparation of the bowel deserve mention. Opinions regarding the effect of antibiotics on the prothrombin time are conflicting. Alterations of the clotting mechanism may conceivably occur when the bacterial flora of the intestine has been greatly reduced or eliminated. Poth has been unable to show any evidence of vitamin K deficiency following the prolonged administration of Sulfasuxidine, Sulfathalidine or neomycin. Nor have we experienced any complications of possible vitamin K deficiency. Routine administration of vitamin K would not appear to be necessary, but perhaps might be considered a useful precaution. Recently, considerable attention has been directed to the possible relationship of intestinal antisepsis and the development of acute fulminating pseudomembranous enterocolitis as a· most serious postoperative complication. Evidence of such relationship is not conclusive to date, but strong suspicion has been directed toward a pathogenetic over-
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growth of Micrococcus pyogenes when other organisms have been eliminated. Further investigation of this problem is needed. Other Preoperative Procedures
Cystoscopy and Indwelling Catheterization of Ureters. Under certain circumstances, preoperative cystoscopy and placement of indwelling ureteral catheters is advisable. Cystoscopy should be performed whenever there is any suspicion of possible bladder involvement by carcinoma or by extension of infection in diverticulitis. Preoperative catheterization of the ureters may be of considerable benefit at the time of resection for severe chronic inflammatory disease or for an extensive carcinoma of the upper rectum or sigmoid. Pyelography and determination of individual kidney function may be a wise precaution in the event that one or the other ureter may need to be sacrificed because of involvement by a carcinoma that is otherwise resectable. Preoperative Gastric Suction. Continuous suction through a Levin tube placed into the stomach for a period of 12 hours before operation effectively collapses the small intestine, thereby facilitating easy exposure for extensive resection of the abdominal colon. This is unnecessary in conjunction with abdominoperineal resection of the rectum. Suction should be continued during induction of anesthesia and during the operation, to avoid rapid distention of the small bowel by swallowed air. Continuation of gastric suction after operation is not necessary. In addition to the discomfort this causes the patient, it may increase the hazard of upper respiratory complications and may produce significant depletion of fluids and electrolytes. Transfusion. Preoperative transfusions are indicated when the hemoglobin is below the limits of normal range for the individual patient. It is not our practice to give transfusions to a patient with a hemoglobin of 80 per cent (12 grams) or better. Compatible blood should always be available for immediate use during operation. As a general rule, blood replacement requirements during operation average 500 cc. for segmental resection of the abdominal colon, 1000 cc. for combined abdominoperineal resection of the rectum, and 1500 cc. for complete one stage colectomy. Whenever there is unusual blood loss during operation, there should be prompt, adequate replacement. Laboratory Tests. The emphasis of this discussion has been directed deliberately toward the problems of clinical evaluation of the patient and his disease, mental preparation of the patient, and specific preparation of the bowel. There is often the inclination to order routinely a long list of laboratory tests, many of which are of dubious value in the management of the patient or his surgical problem. Urinalysis and blood count are always indicated. The clinical findings of history and physical examination should determine the indications for other laboratory pro-
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cedures such as electrocardiogram; liver function tests; determination of urea nitrogen, serum protein and albumin-globulin ratio, serum sodium, potassium, chloride, or carbon dioxide combining power. Potential Adrenal Insufficiency
The administration of adrenal cortical hormones (cortisone, hydrocortone) has been shown to suppress adrenal function and induce adrenal atrophy. The use of adrenocorticotropic hormone (ACTH) has been shown to induce atrophy of the anterior pituitary gland, with resultant suppressed adrenal function after ACTH is discontinued. The extent, duration and potential seriousness of this hazard in medical and surgical practice are only now becoming apparent (Salassa6). It is now recognized that acute adrenal insufficiency may be a cause of irreversible postoperative shock and death. More careful evaluation of the integrity of the pituitary adrenocortical mechanism prior to operation is now required (Hayes4). At the present time it may be said that there is no completely satisfactory test of adrenocortical function. The circulating blood level of adrenocortical steroids is reflected by the number of eosinophils circulating in the blood stream (Thorne test). Hayes states that failure to demonstrate eosinopenia following administration of adrenocorticotropic hormone should be considered evidence of adrenocortical insufficiency. The possibility of potential adrenal insufficiency should be particularly suspected in patients who have been treated previously with either cortisone or ACTH, even though such treatment was terminated several months prior to surgery. It should also be considered in any patient who haa had prolonged infection, or who has already had other recent surgical procedures. Salassa advises that any patient who has received adrenocortical or corticotropic therapy within 6 months, or who has had hypercortisonism within 18 monthi, be treated prophylactically to supply sufficient deposit of adrenal steroids in muscle to insure adequate cortisone supply at critical times during and after operation. He recommends administration of 200 mg. of cortisone intramuscularly, 48, 24 and 1 hour preoperatively, with continuance of cortisone in diminishing amounts for 3 or 4 days postoperatively. Selection of Anesthesia
Selection of the most appropriate type of anesthesia for the particular operation and the individual patient is important in the preoperative planning of procedure. This should be a matter for consultation and agreement between the surgeon and the anesthetist. There appears to be an increasing tendency for the anesthesiologist to assume the prerogative of selection of the mode of anesthesia. The surgeon is chiefly concerned about the level and duration of anesthesia and the adequacy of
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relaxation. The anesthetist is concerned about the relative safety of the type of anesthesia to be used and at times is influenced by his personal preference, with insufficient consideration of the requirements of the surgeon. Neither the surgeon nor the anesthetist should decide arbitrarily upon the type of anesthesia to be used. Decision should be reached by mutual consultation. The responsibility, professionally and legally, rests upon the surgeon. For many years we have preferred spinal anesthesia for surgical procedures on any part of the colon. More recently we have been favorably impressed with the efficiency, safety, and durability of epidural block anesthesia. POSTOPERATIVE CARE
At the completion of a major surgical procedure the average surgeon welcomes a brief period of rest and relaxation. The responsibility for immediate postoperative care and nursing instructions may be left to a more or "less inexperienced intern. It should not be forgotten that the first few minutes and the first few hours following operation are the most critical period in recovery. In many hospitals now there is a surgical recovery room, staffed and equipped for close observation of the patient and immediate institution of any indicated emergency procedure. The most important item of immediate postoperative care is the continuous maintenance of an adequate blood pressure. A good portion of the postoperative complications and the majority of postoperative deaths after colonic surgery today are due to cardiovascular complications. These are usually directly or indirectly related to abnormal fluctuations of blood pressure for a transient or more prolonged period of time. It behooves the surgeon, therefore, to institute an immediate, precise program of postoperative observation with frequent recording of blood pressure and pulse rate, and to be prepared to utilize appropriate methods of treatment to correct any degree of postoperative shock. Treatment of Postoperative Shock
In most instances minor depressions of blood pressure are quickly corrected by restoration of fluid volume by adequate replacement of blood loss and intravenous infusion of solutions of glucose and electrolytes. Any significant reduction of blood pressure, with associated reduction of the effective circulating blood volume, denotes shock and portends insufficient delivery of nutrient blood to vital organs. Initially such shock is usually reversible, but progressive circulatory impairment eventually may terminate in a state of irreversible circulatory failure. The occurrence of shock during and after surgery is usually due to hemorrhage, anesthesia or the traumatic effect of the operation. The effect of hemorrhage must be counteracted by prompt and adequate
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blood replacement. Because of the vasodepressor action of many anesthetic agents, vasopressor drugs such as phenylephrine are frequently employed by anesthesiologists. Epinephrine has been found of limited value, producing transient increase of systolic blood pressure mainly by stimulating the heart rate and the strength of systolic ejection. Since the first report by Goldenberg and his associates,3 intense interest has been stimulated in the value of norepinephrine (arterenol, Levophed) in the treatment of shock. These authors demonstrated that norepinephrine causes a rise in blood pressure, both systolic and diastolic, by effecting an over-all increase in peripheral resistance without any direct cardiodynamic action. They showed that the action of norepinephrine is short-lived and easily controlled when the drug is used in constant intravenous infusion. Fremont and his associates 2 have reported arterenol (norepinephrine) of distinct value in the treatment of operative and postoperative shock, when added to fluid replacement therapy which in itself had been ineffective. In our own limited experience with the use of norepinephrine, it has proved efficacious in controlling blood pressure in patients showing evidence of shock attributable to the vasodepressor action of anesthesia or the surgical shock of extensive visceral trauma. The possibility of postoperative hemorrhage as the cause of shock should never be overlooked. Pressor drugs are no substitute for the recognition and treatment of hemorrhage. The ill-advised use of norepinephnne could temporarily mask the signs of significant blood loss, and might accelerate hemorrhage by increasing systolic blood pressure. Fremont and his associates state that the dangers of the use of arterenol (norepinephrine) are inherent in the potent effect upon the peripheral resistance regardless of the cause of shock. They warn against being lulled into a false sense of security by the promptness of the clinical response and emphasize that lost blood must be replaced and continued bleeding must be stopped. These authors describe the method of administration of arterenol. They consider the response of the blood ipressure and of the pulse rate the best guides to the efficacy of the drug. Attention has already been called to the fact that acute adrenal insufficiency may be a cause of refractory postoperative shock. Such a possibility must be considered in any patient with persistent signs of shock unresponsive to the usual methods of treatment. Shock due to this cause may begin in the operating room or may develop suddenly several hours after operation. Other causes of shock should be excluded, i.e., hemorrhage, atelectasis, pulmonary embolism, cardiovascular accident, cerebrovascular accident, etc. Failure to demonstrate eosinopenia following operation may be considered evidence of adrenocortical insufficiency. Taylor and Essig7 list 15 diagnostic signs, including (1) delayed shock unrelated to depleted blood volume and unresponsive to blood replaceI
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ment, (2) marked hypotension, (3) rapid pulse, (4) cyanosis of fingers, toes, neck and face, (5) marked thirst, (6) anuria or oliguria, (7) mental confusion, disorientation or coma. When acute adrenal insufficiency is suspected, immediate treatment should be instituted to supply adrenal cortical substance. For rapid effect, aqueous adrenocortical extract should be given by intravenous infusion and intramuscularly. At the same time cortisone should be administered intramuscularly. Since up to 24 hours may be required for optimum effect of cortisone, aqueous extract should be continued or repeated as indicated. Mter equilibrium has been established, cortisone should be continued in diminishing doses for several days. Prompt response to hormone therapy in shock is ample evidence of the accuracy of diagnosis. Thomes states that no beneficial effect of hormone therapy in shock has been evident in patients with adequate adrenocortical function. General Considerations in Postoperative Care
Following any type of surgical procedure on the colon it is best to keep the intestinal tract at complete rest for a period of 48 hours, with neither food nor fluids by mouth. Morphine is the ideal drug for postoperative pain, since this also has the specific effects of stimulating intestinal tonus and diminishing peristalsis. During this period an adequate fluid intake should be administered intravenously. Usually 750 cc. of glucose in water each morning and 750 cc. of glucose in saline each evening, given slowly, is entirely adequate for body requirements. Any unusual loss of fluids and electrolytes due to vomiting or gastric suction, or to loss from an ileostomy must be replaced. There is often a tendency to give an excessive amount of intravenous fluid following operation. This is hazardous, particularly in elderly patients, and may place a dangerous burden on the cardiovascular system. A patient literally may be drowned by overzealous use of intravenous fluids. This error is usually made because of the surgeon's anxiety to maintain "normal" urinary output. It has been our observation that the latter normally totals not over 500 cc. daily for the first 2 days following operation, and that even doubling the amount of fluids given intravenously causes no appreciable increase in the urinary flow during that period. If for any reason a patient is continued more than 2 days on a constant intravenous fluid intake of 1500 cc. daily, the urine output usually doubles on the third and fourth days. We consider this relative diminution in kidney excretion in the immediate postoperative period a normal physiologic response, and we are quite satisfied with a daily urine output of 400 to 500 cc. for the first 2 days. Subsequently, a daily output of 1000 cc. or better is desirable and should be maintained by adequate fluid intake. Early ambulation of surgical patients has been popularized in recent
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years as a panacea for many postoperative complications. There is no desire to criticize here the recognized value of early ambulation. However, we believe that emphasis should be placed upon early physical activity by the patient rather than on early ambulation. To get the patient out of bed for 15 minutes once or twice in 24 hours, and then allow him to lie motionless in bed the rest of the time is of dubious value. It is much better to encourage and insist upon active, physical exercise in bed at frequent intervals during the day and when awake at night. The patient himself should frequently turn from side to side, he should move and exercise his arms and legs, and then as soon as he is sitting himself up in bed he is ready for ambulation. Bladder Dysfunction Following Resection of the RectuIll
There is a fairly high incidence of postoperative bladder dysfunction following rectal resection, principally in elderly male patients. This has been attributed by some authorities to neurogenic disturbance due to surgical trauma. We have been unable to demonstrate evidence of neurogenic bladder dysfunction following abdominoperineal resection of the rectum. Not infrequently urinary retention has occurred, due to bladder neck obstruction as the result of prostatic hypertrophy or angulation of the bladder neck following operation. Such diagnosis has been confirmed by the fact that treatment by transurethral resection consistently has been followed by normal micturition with complete emptying of the bladder. It is our custom to maintain constant bladder drainage by use of a retention catheter from the time of operation until the patient is out of bed. The catheter is then removed and bladder function checked by measurement of residual urine after voiding. If the patient is unable to void or has more than 100 cc. of residual urine, a retention catheter is again employed for another 2 to 3 days. If then there is persistent inability of the bladder to empty adequately, cystoscopy is performed and any demonstrable bladder neck obstruction is subsequently corrected by transurethral resection. Care of Patients with Intestinal AnastoIllosis
Continuation of antibacterial medication for several days after operation minimizes edema and promotes more rapid primary healing at the site of ana5tomosis. Neomycin or Sulfathalidine is the agent of choice. After fluids are being taken well by mouth, a nonresidual diet is advisable until spontaneous bowel movements are resumed. After satisfactory function at the level of anastomosis is evident diet may be liberal and antibacterial medication may be discontinued.
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Care of Patients with EnterostOlnies
Care of Colostomy. The surgeon has a continuing responsibility for supervision of the patient during the period of mental adjustment to an abnormal fecal stoma, and for the establishment of satisfactory colostomy control. Until the patient is able to be out of bed for an hour at a time, there is no reason to begin irrigation of the colostomy. The patient should be assured that a colostomy will function adequately without irrigation, and he should be prepared to experience spontaneous evacuation prior to establishment of bowel control by daily irrigation. A suitable apparatus for irrigation should be obtained and explained to the patient before the time for its use. Experienced nursing supervision during irrigation is invaluable for the first few days, but as quickly as possible the patient must be encouraged to take the entire responsibility for the procedure, so that when he leaves the hospital he will have no feeling of dependence on others for his bowel care. Colostomy bags are unnecessary and inadvisable. As soon as the patient has confidence in his bowel control, the colostomy stoma may be covered with a piece of absorbent tissue held in place by a broad elastic-webbing belt. The patient should be instructed in the daily insertion of a gloved finger into the stoma until healing of mucosa to skin takes place, to counteract the development of a stricture at the skin level. Care of Ileostomy Patients. The major immediate problem after ileostomy is that of control of fluid and electrolyte balance until physiologic readjustment takes place. A special chart should be started on the day of operation to show the quantity and quality of all fluids and electrolytes administered and to show the quantity and quality of fluid output in the urine, from the stomach, and from the ileostomy. Insensihle fluid loss also should be calculated in computing the daily fluid balance. Positive fluid balance should be calculated and maintained daily, and there should be adequate replacement of lost electrolytes, with particular attention to potassium. Not infrequently satisfactory balance is easily maintained for 3 or 4 days, but then may be suddenly and seriously disturbed by voluminous excretion through the ileostomy. Determinations of serum potassium, sodium and chloride, and carbon dioxide combining power will frequently be necessary as a guide for appropriate replacement therapy. To minimize excessive fluid and electrolyte loss per ileostomy, the patient should receive a high residue diet as soon as it can be tolerated. Care of Ileostomy. It was once our practice to insert a soft rubber catheter through the ileostomy stoma and close the end of the ileum with a purse-string suture of chromic catgut around the tubing, so that for several days all ileostomy drainage could be diverted into a receptacle beneath the bed, thereby protecting the surrounding skin from the digestive action of the fecal discharge. More recently this procedure has
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been abandoned in favor of immediate application of a transparent polyethelene bag (ordinary ice-box bag), with a hole cut in the side to fit over the ileostomy stoma, cementing the bag to the surrounding skin with Paget dermatome glue. The open end of the bag is tied around rubber tubing which empties into a receptacle beneath the bed. This apparatus is usually effective in protecting the skin and preventing fecal spillage for several days. Before the patient is out of bed, a Rutzen type bag of appropriate size is cemented in place, and is changed and reapplied only as often as the cement seal is broken, usually every 2 or 3 days. Ileostomy Dysfunction and Obstruction. A recent article by Turnbull9 offers an excellent treatise on the problem of ileostomy care and ileostomy dysfunction. Our own experience has confirmed his statement that the newly made ileostomy does not function properly in the majority of instances. His explanation of such dysfunction is entirely reasonable and now seems perfectly obvious. Dysfunction is not due to organic obstruction to ileal flow, but rather is due to functional obstruction of the protruding segment of ileum caused by the inevitable development of serosal peritonitis, with accompanying induration and cessation of peristalsis through the exposed segment. When obstruction develops because of such dysfunction, simple insertion of a retention tube through the ileostomy effects adequate decompression and relief of symptoms. Turnbull proposes a secondary surgical procedure to hasten "maturation" of the ileostomy by trimming the stoma on the seventh day in such a way as to leave the mucosa long enough to evert part of the way down the side of the ileostomy. We have long been concerned about the problem of ileostomy dysfunction and obstruction, and during recent months have successfully employed a technique of ileostomy that permits primary union of mucosa to skin. To date this appears to eliminate serosal peritonitis and subsequent functional obstruction. Further experience and longer observation are necessary before the use of this procedure can be recommended. SUMMARY
The emphasis of this discussion has been upon general principles in the over-all management of patients requiring abdominal surgery for disease of the colon or rectum. Statistical tabulation of morbidity and mortality figures, and discussion of operative techniques have been deliberately omitted. ~ REFERENCES 1. Dearing, W. H. and Needham, G. M.: Effect of Oral Administration of Neomycin and Terramycin on the Intestinal Bacterial Flora of Man. Proc. Staff Meet., Mayo Clin. 28: 507-512, 1953. 2. Fremont, R. E., Luger, N. M., Surks, S. N. and Kleinman, A.: Treatment of Surgical Shock with Arterenol, A. M. A. Arch. Surg. 68: 44-56, 1954.
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3. Goldenberg, M. and others: The Hemodynamic Response of Man to Norepinephrine and Epinephrine and Its Relation to the Problem of Hypotension. Am. J. Med. 5: 792,1948. 4. Hayes, M. A.: Shock and the Adrenocortex. Surgery 35: 174-190, 1954. 5. Poth, E. J.: Intestinal Antisepsis in Surgery. J.A.M.A. 153: 1516-1521,1953. 6. Salassa, R. M., Bennett, W. A., Keating, F. R., Jr., and Sprague, R. G.: Postoperative Adrenal Cortical Insufficiency. Occurrence in Patients Previously Tnlated with Cortisone. J.A.M.A. 152: 1509-1515, 1953. 7. Taylor, E. S. and Essig, L. L.: Acute Adrenal Cortical Failure as a Cause of Shock and Death. Am. J. Obst. & Gynec. 65: 720-732,1953. 8. Thorne, G. W. and others: Pharmacologic Aspects of Adrenocortical Steroids and ACTH in Man. New England J. Med. 248: 232, 284, 323, 369, 414, 588, 632, 1953. 9. Turnbull, R. B.: Management of the Ileostomy. Am. J. Surg. 86: 617-624,1953. 490 Post Street San Francisco 2, California
THE experienced surgeon of today has attained a high degree of proficiency in the technical surgical procedures applicable to diseases of the colon and rectum. Since no part of the large intestine is essential to life and health, any segment or all of this organ may be sacrificed for the elimination of disease which threatens the health or life of the patient. Modern anesthesia and the ability to combat the bacterial flora of the large intestine by chemotherapeutic and antibiotic agents have played a significant role in reducing the operative mortality of major colonic surgery to well below 5 per cent. It may be said that direct fatality from operation itself is a rarity, with morbidity and mortality nearly always the result of some complicating condition or associated disease. In large part, therefore, the surgeon's success is dependent upon preoperative evaluation and preparation, and postoperative care. PREOPERATIVE EVALUATION AND PLAN FOR SURGERY
The preoperative phase of surgical care must begin with competent evaluation of the existing disease, so that the appropriate technical procedure may be planned and the specific preparation for operation be started. Neoplastic Disease
The most frequent indication for colonic surgery is neoplasm. The high incidence of carcinoma and of premalignant adenomatous polyps in the colon and rectum is well known. The relatively favorable prognosis for cure by appropriate surgical procedure is also common knowledge. There is much less appreciation of the fact that the presence of one mucosal tumor of the large intestine is indicative of a predisposition to the * Clinical Professor of Surgery, Stanford University School of Medicine, San Francisco, California. 14-19
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Robert A. Scarborough
development of other similar tumors. In our experience, 25 per cent of patients with carcinoma have had other associated adenomatous polyps, and 10 per cent of these patients have had at the time, or later developed, other primary carcinomas of the colon or rectum. It is important, therefore, when one neoplasm has been discovered, to investigate the entire colon and rectum for other possible tumors. The finding of a single small adenomatous polyp by sigmoidoscopy is an indication for roentgenologic examination of the rest of the colon with barium-air contrast enema. Conversely, sigmoidoscopy should always be done when roentgenologic examination has revealed a neoplasm higher in the colon. The utter inadequacy of roentgenologic diagnosis of neoplasms of the rectum demands emphasis. Preoperative evaluation, then, begins with thorough investigation of the entire colon and rectum for any and all lesions that may be present. The appropriate surgical procedure may then be planned. The surgeon must be prepared to revise the plan of procedure at the time of laparotomy, if exploration reveals evidence of neoplastic disease not found by preoperative study. Diverticulitis
In recent years a profound change has occurred in the attitude toward surgical approach to the problems of diverticulitis. Numerous convincing reports have shown that a radical definitive attack, by resection of the diseased segment of the colon, can result in a highly satisfactory proportion of permanent cures, with an operative mortality of 2 to 5 per cent. Proximal diversionary colostomy is not a satisfactory surgical procedure for the cure of diverticulitis, nor should it be merely a palliative operation. Colostomy should be considered an essential emergency procedure for the purpose of control of severe infection or for the relief of obstruction. At the same time it should be planned and executed as a preliminary operation, with the expectation that surgical resection of the diseased bowel will be carried out before the colostomy is closed. The interval between colostomy and resection is variable, but should not be protracted. We consider a period of 3 to 6 weeks sufficient in the majority of cases for control of acute infection. Further delay does not significantly diminish the technical problems of resection or the surgical risks. Following resection, the patency of the anastomosis should be tested by roentgenologic examination with barium enema before the colostomy is closed. This can be done usually within 2 weeks. When proximal colostomy has not been done as an emergency procedure, the elective operation of resection may be carried out in three stages or in one stage. Although a three stage operation is usually considered a safer procedure, one stage operations may be employed safely and satisfactorily in many instances. The choice between a single or
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multiple stage operation requires careful individual evaluation and sound surgical judgment. The preoperative plan of procedure should be tentative, and determined on the basis of the following factors: (1) general condition of the patient, (2) evidence of acute infection, (3) evidence of extensive diffuse chronic infection or complicating fistula, (4) presence or absence of a degree of obstruction sufficient to impede adequate mechanical and antibacterial preparation of the bowel, and (5) evidence by proctoscopic examination of an adequate length of normal rectum for good primary anastomosis. At the time of laparotomy, final evaluation and choice of procedure should be determined. Not infrequently the symptom of gross blood with bowel movements is attributed to diverticulitis or to diverticulosis. It is unquestionably true that bleeding can occur with diverticulitis. However, in our experience, repeated episodes of gross blood in the bowel movements have been found, in the great majority of cases, to have been due to a co-existing neoplasm. In a series of 81 patients, where previous diagnosis of diverticulosis or diverticulitis had been considered the explanation of rectal bleeding, removal of an adenomatous polyp or a carcinoma was followed by cessation of bleeding. The identification of a polyp or even a carcinoma in a colon with diverticula, with or without diverticulitis, is frequently difficult and sometimes impossible. Specific search for a possible polypoid tumor is always indicated when there is blood in the stool. Persistent bleeding, even though repeated roentgenologic study fails to reveal evidence of a polyp or carcinoma, should be considered an indication for surgical exploration and wide resection. Chronic Ulcerative Colitis
The indications for surgery in the treatment of chronic idiopathic ulcerative colitis are beyond the scope of this discussion. There is still no satisfactory specific medical (or psychiatric) cure for this disease. Surgical treatment has progressed far since 20 years ago, when ileostomy, with an operative mortality of 25 to 50 per cent, was the usual surgical procedure of last resort. Today the accepted principle of surgical treatment is resection of the diseased bowel, with permanent ileostomy. Permanent cure is possible by such radical treatment, with an operative mortality of less than 5 per cent. Two maj or questions arise in preoperative evaluation and determination of a plan for procedure: (1) how much bowel should be removed, and (2) should the operation be planned as a one, two or three stage procedure. Proctoscopy and barium enema examination aid in the determination of how much bowel is to be removed, but require qualification. The rectum is always involved in the typical case of chronic idiopathic ulcerative colitis, and this involvement is determinable by proctoscopy. In
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an occasional patient the rectal wall appears entirely normal by proctoscopy, despite evidence of extensive disease of the abdominal colon by roentgenologic examination with barium enema. We have reason to believe that such instances are not "atypical" idiopathic ulcerative colitis, but represent a segmental colitis comparable with regional enteritis. Whether or not this is so, it is only in the occasional patient in whom the rectal mucosa is perfectly normal that preservation of rectal function by anastomosis is justified. Barium enema examination is not a reliable means of determining the proximal limit of the disease. Not infrequently, the apperance of the cecum and ascending colon suggests that this segment of the bowel may not be involved. Even at exploration the proximal colon may appear grossly normal. Experience has shown that in most instances this part of the colon is actually involved by disease, and, as a rule, the predetermined plan of procedure should be to include the entire proximal colon in the zone of resection, even though roentgenologic examination does not prove involvement of this area. Consideration should also be given to the possibility of extension of disease into the distal ileum. Evidence of such involvement should be looked for in the films of barium enema examination. This should be re-evaluated at the time of exploration, so that resection will include several inches of normal ileum proximal to the zone of disease. The second major question for evaluation is whether the operation should be planned as a one, two or three stage procedure. Initial ileostomy, later followed by resection of the diseased bowel in one or two stages, has been until recently the usual method of attack. There is accumulating evidence to show that in most instances a single stage complete colectomy, including abdominoperineal resection of the rectum with simultaneous ileostomy, has a lower morbidity and mortality rate than any program of mUltiple-stage procedures. We have done 15 such one stage procedures with no mortality, in the last 15 patients operated upon for chronic ulcerative colitis. It has been quite evident that simultaneous removal of the diseased bowel greatly facilitates the control of electrolyte and fluid balance during the period of adjustment to ileostomy, and accelerates restoration of normal health. PREOPERATIVE PREPARATION
It is axiomatic that in preparation for any major surgical procedure there should be appropriate evaluation of the patient's general condition. This discussion will be limited to certain specific problems in the preparation for large bowel surgery. Mental Preparation of The Patient
This is the first important step in preparation of the patient for major colonic surgery. There is surprising disagreement as to how much to tell
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the patient, particularly when a diagnosis of carcinoma has been made. Some believe that every effort should be made to avoid telling the patient the truth, with evasion and even falsification of the known facts. This is a serious mistake. The intelligence of the patient should never be underestimated. He knows that the recommendation for operation on the intestine denotes serious disease, and he usually suspects cancer, regardless of any denial by the surgeon. Frank discussion of the patient's problem, with justifiable optimism, does much to instill a spirit of hope and determination in the mind of the patient that will be a real factor in postoperative recovery. A definite diagnosis of malignancy cannot be established for lesions above reach of a sigmoidoscope until the time of laparotomy. It is neither necessary nor justifiable, in such an instance, to state flatly that the patient has cancer. He should be told, when he asks, that his illness may be due to a malignant tumor. The favorable prognosis for such a lesion, in comparison with malignant disease in other abdominal organs, should be emphasized. For example, the patient can be told that the possibility for cure of a malignant tumor of the intestine is ten times as great as for a similar tumor of the stomach. It is of particular importance to prepare mentally the patient who requires colostomy and resection of the rectum. Any patient of reasonable intelligence knows that such an operation is indicated only for serious disease. He needs to know the reason why such an operation is necessary if he is to accept it. Proof of the diagnosis should be established by biopsy examination to avoid any possible mistake by the surgeon, and to satisfy any doubt in the mind of the patient as to the diagnosis. The patient must be made to understand that there is but one known method of cure, which is radical surgical extirpation. Quite often the patient is more concerned about colostomy than about the primary diagnosis. It is the surgeon's responsibility to convince him that colostomy is not too great a price to pay for cure of a malignant rectal tumor. He must be convinced than he can continue to lead a normal life, that he will be able to work and play like anyone else. He should be assured that he will have regular bowel habits and satisfactory bowel control, with a simple routine of enema irrigation everyone or two days. Not infrequently, more time is necessary for the mental preparation of the patient than for the operation itself. A true understanding of the facts about colostomy before operation is of real value in postoperative recovery. There is no justification for withholding any knowledge of the necessity for colostomy until the operation is an accomplished fact. A persistent feeling of "resentment and distrust frequently then will delay the patient's acceptance of and adjustment to colostomy, and may seriously retard both physical and mental recovery. Mental preparation of the patient with chronic ulcerative colitis for ileostomy is usually much easier than for colostomy in the treatment of rectal carcinoma. The patient with rectal malignancy has usually felt
Robert A. Scarborough that he was in excellent health except for symptoms that he has attributed to hemorrhoids. The patient with ulcerative colitis has been critically or chronically ill for a considerable period of time. He has long been aware of the nature of his disease during a variable perIod of medical treatment, and he usually looks forward to restoration of health by surgery. Usually, however, the explanation of ileostomy has been left to the surgeon. The necessity for ileostomy and its function should"be carefully explained. The patient must be convinced that there will~be no limitation of physical or social activities because of ileostomy. He should be given an adequate understanding of the efficiency of a modern ileostomy bag, which may be cemented firmly to the skin so that there is no possibility of fecal soiling or escaping odor. He should know that there will be no voluntary control of the passage of fecal material into the bag, but that even he will be insensitive to the functioning of the ileostomy. It should be explained that when the bag is full it can be readily emptied in any toilet, and that the bag need be removed and cleaned only once every two or three days. There are no particular problems of mental preparation for surgical treatment of diverticulitis, when a single stage resection with immediate restoration of bowel continuity by anastomosis is to be done. When treatment is to be by multiple stage procedure, with initial colostomy, the function of a colostomy should be explained, with definite reassurance that this is a temporary necessity which will be eliminated subsequently. Preparation of the Colon
The satisfactory results of present day surgical procedures for colonic disease depend in good part on our ability to control the complications of infection. Suitable antibacterial preparation of the bowel is a prime prerequisite for every such elective operation. Mechanical Cleansing of the Bowel. This is important for several reasons: (1) to reduce mechanically the number of bacteria within the bowel, (2) to increase the effectiveness of chemotherapeutic or antibiotic agents on the intestinal organisms, (3) to permit more satisfactory exploration of an empty colon at laparotomy, and (4) to minimize fecal spillage at operation. In the absence of obstruction, mechanical preparation is best initiated by the administration of 2 ounces of castor oil. During the subsequent period of preparation a nonresidual, high caloric, high vitamin diet should be given. Continued use of laxatives is undesirable and usually unnecessary, since the administration of antibacterial agents causes an adequate degree of peristaltic progression of the fecal content through the bowel. A single tap water enema may be used 12 hours prior to surgery to assure an empty bowel at operation. In the presence of partial obstruction, cautious and gradual mechanical
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decompression should be attempted by the use of enemas and small divided doses of some mild saline laxative. More forceful catharsis may precipitate complete obstruction. The period for adequate preoperative preparation may need to be extended by several days. Acute or complete obstruction prohibits any effective bowel preparation. Prompt decompression by external diversion of the fecal stream proximal to the obstruction is indicated. Subsequently, both mechanical and antibacterial preparation may be effected through the colostomy stoma and per rectum before definitive surgery is done. Intestinal Antisepsis. This should be started immediately after initial catharsis. The value and the limitations of various chemotherapeutic and antibiotic agents have been the subject of extensive investigation and numerous reports in the past few years. Pioneers and outstanding contributors in this field are Poth, and Pulasky. Poth6 has recently contributed an excellent review of modern concepts of intestinal antisepsis, with a comprehensive report on the relative value of the more commonly used chemotherapeutic agents (Sulfasuxidine, Sulfathalidine) and antibiotics (streptomycin, Aureomycin, Terramycin, neomycin). Our own experience confirms the choice of neomycin as the most effective agent in antiseptic preparation of the bowel. Maximum bacterial effect may be obtained in 48 hours by administration of 1 gram of neomycin every 6 hours. Poth has advocated more rapid preparation by giving 1 gram of neomycin every hour for 4 hours beginning 1 hour after the administration of 2 ounces of castor oil. He also recommends the use of 1.5 grams of Sulfathalidine with each gram of neomycin, for more effective control of Shigella organisms, and particularly Aerobacter aerogenes. Dearing and Needham1 recommend neomycin as the antibiotic of choice, but advise simultaneous administration of Terramycin for more effective control of anaerobic organisms. Two possible unfavorable side effects of antibacterial preparation of the bowel deserve mention. Opinions regarding the effect of antibiotics on the prothrombin time are conflicting. Alterations of the clotting mechanism may conceivably occur when the bacterial flora of the intestine has been greatly reduced or eliminated. Poth has been unable to show any evidence of vitamin K deficiency following the prolonged administration of Sulfasuxidine, Sulfathalidine or neomycin. Nor have we experienced any complications of possible vitamin K deficiency. Routine administration of vitamin K would not appear to be necessary, but perhaps might be considered a useful precaution. Recently, considerable attention has been directed to the possible relationship of intestinal antisepsis and the development of acute fulminating pseudomembranous enterocolitis as a· most serious postoperative complication. Evidence of such relationship is not conclusive to date, but strong suspicion has been directed toward a pathogenetic over-
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growth of Micrococcus pyogenes when other organisms have been eliminated. Further investigation of this problem is needed. Other Preoperative Procedures
Cystoscopy and Indwelling Catheterization of Ureters. Under certain circumstances, preoperative cystoscopy and placement of indwelling ureteral catheters is advisable. Cystoscopy should be performed whenever there is any suspicion of possible bladder involvement by carcinoma or by extension of infection in diverticulitis. Preoperative catheterization of the ureters may be of considerable benefit at the time of resection for severe chronic inflammatory disease or for an extensive carcinoma of the upper rectum or sigmoid. Pyelography and determination of individual kidney function may be a wise precaution in the event that one or the other ureter may need to be sacrificed because of involvement by a carcinoma that is otherwise resectable. Preoperative Gastric Suction. Continuous suction through a Levin tube placed into the stomach for a period of 12 hours before operation effectively collapses the small intestine, thereby facilitating easy exposure for extensive resection of the abdominal colon. This is unnecessary in conjunction with abdominoperineal resection of the rectum. Suction should be continued during induction of anesthesia and during the operation, to avoid rapid distention of the small bowel by swallowed air. Continuation of gastric suction after operation is not necessary. In addition to the discomfort this causes the patient, it may increase the hazard of upper respiratory complications and may produce significant depletion of fluids and electrolytes. Transfusion. Preoperative transfusions are indicated when the hemoglobin is below the limits of normal range for the individual patient. It is not our practice to give transfusions to a patient with a hemoglobin of 80 per cent (12 grams) or better. Compatible blood should always be available for immediate use during operation. As a general rule, blood replacement requirements during operation average 500 cc. for segmental resection of the abdominal colon, 1000 cc. for combined abdominoperineal resection of the rectum, and 1500 cc. for complete one stage colectomy. Whenever there is unusual blood loss during operation, there should be prompt, adequate replacement. Laboratory Tests. The emphasis of this discussion has been directed deliberately toward the problems of clinical evaluation of the patient and his disease, mental preparation of the patient, and specific preparation of the bowel. There is often the inclination to order routinely a long list of laboratory tests, many of which are of dubious value in the management of the patient or his surgical problem. Urinalysis and blood count are always indicated. The clinical findings of history and physical examination should determine the indications for other laboratory pro-
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cedures such as electrocardiogram; liver function tests; determination of urea nitrogen, serum protein and albumin-globulin ratio, serum sodium, potassium, chloride, or carbon dioxide combining power. Potential Adrenal Insufficiency
The administration of adrenal cortical hormones (cortisone, hydrocortone) has been shown to suppress adrenal function and induce adrenal atrophy. The use of adrenocorticotropic hormone (ACTH) has been shown to induce atrophy of the anterior pituitary gland, with resultant suppressed adrenal function after ACTH is discontinued. The extent, duration and potential seriousness of this hazard in medical and surgical practice are only now becoming apparent (Salassa6). It is now recognized that acute adrenal insufficiency may be a cause of irreversible postoperative shock and death. More careful evaluation of the integrity of the pituitary adrenocortical mechanism prior to operation is now required (Hayes4). At the present time it may be said that there is no completely satisfactory test of adrenocortical function. The circulating blood level of adrenocortical steroids is reflected by the number of eosinophils circulating in the blood stream (Thorne test). Hayes states that failure to demonstrate eosinopenia following administration of adrenocorticotropic hormone should be considered evidence of adrenocortical insufficiency. The possibility of potential adrenal insufficiency should be particularly suspected in patients who have been treated previously with either cortisone or ACTH, even though such treatment was terminated several months prior to surgery. It should also be considered in any patient who haa had prolonged infection, or who has already had other recent surgical procedures. Salassa advises that any patient who has received adrenocortical or corticotropic therapy within 6 months, or who has had hypercortisonism within 18 monthi, be treated prophylactically to supply sufficient deposit of adrenal steroids in muscle to insure adequate cortisone supply at critical times during and after operation. He recommends administration of 200 mg. of cortisone intramuscularly, 48, 24 and 1 hour preoperatively, with continuance of cortisone in diminishing amounts for 3 or 4 days postoperatively. Selection of Anesthesia
Selection of the most appropriate type of anesthesia for the particular operation and the individual patient is important in the preoperative planning of procedure. This should be a matter for consultation and agreement between the surgeon and the anesthetist. There appears to be an increasing tendency for the anesthesiologist to assume the prerogative of selection of the mode of anesthesia. The surgeon is chiefly concerned about the level and duration of anesthesia and the adequacy of
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relaxation. The anesthetist is concerned about the relative safety of the type of anesthesia to be used and at times is influenced by his personal preference, with insufficient consideration of the requirements of the surgeon. Neither the surgeon nor the anesthetist should decide arbitrarily upon the type of anesthesia to be used. Decision should be reached by mutual consultation. The responsibility, professionally and legally, rests upon the surgeon. For many years we have preferred spinal anesthesia for surgical procedures on any part of the colon. More recently we have been favorably impressed with the efficiency, safety, and durability of epidural block anesthesia. POSTOPERATIVE CARE
At the completion of a major surgical procedure the average surgeon welcomes a brief period of rest and relaxation. The responsibility for immediate postoperative care and nursing instructions may be left to a more or "less inexperienced intern. It should not be forgotten that the first few minutes and the first few hours following operation are the most critical period in recovery. In many hospitals now there is a surgical recovery room, staffed and equipped for close observation of the patient and immediate institution of any indicated emergency procedure. The most important item of immediate postoperative care is the continuous maintenance of an adequate blood pressure. A good portion of the postoperative complications and the majority of postoperative deaths after colonic surgery today are due to cardiovascular complications. These are usually directly or indirectly related to abnormal fluctuations of blood pressure for a transient or more prolonged period of time. It behooves the surgeon, therefore, to institute an immediate, precise program of postoperative observation with frequent recording of blood pressure and pulse rate, and to be prepared to utilize appropriate methods of treatment to correct any degree of postoperative shock. Treatment of Postoperative Shock
In most instances minor depressions of blood pressure are quickly corrected by restoration of fluid volume by adequate replacement of blood loss and intravenous infusion of solutions of glucose and electrolytes. Any significant reduction of blood pressure, with associated reduction of the effective circulating blood volume, denotes shock and portends insufficient delivery of nutrient blood to vital organs. Initially such shock is usually reversible, but progressive circulatory impairment eventually may terminate in a state of irreversible circulatory failure. The occurrence of shock during and after surgery is usually due to hemorrhage, anesthesia or the traumatic effect of the operation. The effect of hemorrhage must be counteracted by prompt and adequate
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blood replacement. Because of the vasodepressor action of many anesthetic agents, vasopressor drugs such as phenylephrine are frequently employed by anesthesiologists. Epinephrine has been found of limited value, producing transient increase of systolic blood pressure mainly by stimulating the heart rate and the strength of systolic ejection. Since the first report by Goldenberg and his associates,3 intense interest has been stimulated in the value of norepinephrine (arterenol, Levophed) in the treatment of shock. These authors demonstrated that norepinephrine causes a rise in blood pressure, both systolic and diastolic, by effecting an over-all increase in peripheral resistance without any direct cardiodynamic action. They showed that the action of norepinephrine is short-lived and easily controlled when the drug is used in constant intravenous infusion. Fremont and his associates 2 have reported arterenol (norepinephrine) of distinct value in the treatment of operative and postoperative shock, when added to fluid replacement therapy which in itself had been ineffective. In our own limited experience with the use of norepinephrine, it has proved efficacious in controlling blood pressure in patients showing evidence of shock attributable to the vasodepressor action of anesthesia or the surgical shock of extensive visceral trauma. The possibility of postoperative hemorrhage as the cause of shock should never be overlooked. Pressor drugs are no substitute for the recognition and treatment of hemorrhage. The ill-advised use of norepinephnne could temporarily mask the signs of significant blood loss, and might accelerate hemorrhage by increasing systolic blood pressure. Fremont and his associates state that the dangers of the use of arterenol (norepinephrine) are inherent in the potent effect upon the peripheral resistance regardless of the cause of shock. They warn against being lulled into a false sense of security by the promptness of the clinical response and emphasize that lost blood must be replaced and continued bleeding must be stopped. These authors describe the method of administration of arterenol. They consider the response of the blood ipressure and of the pulse rate the best guides to the efficacy of the drug. Attention has already been called to the fact that acute adrenal insufficiency may be a cause of refractory postoperative shock. Such a possibility must be considered in any patient with persistent signs of shock unresponsive to the usual methods of treatment. Shock due to this cause may begin in the operating room or may develop suddenly several hours after operation. Other causes of shock should be excluded, i.e., hemorrhage, atelectasis, pulmonary embolism, cardiovascular accident, cerebrovascular accident, etc. Failure to demonstrate eosinopenia following operation may be considered evidence of adrenocortical insufficiency. Taylor and Essig7 list 15 diagnostic signs, including (1) delayed shock unrelated to depleted blood volume and unresponsive to blood replaceI
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ment, (2) marked hypotension, (3) rapid pulse, (4) cyanosis of fingers, toes, neck and face, (5) marked thirst, (6) anuria or oliguria, (7) mental confusion, disorientation or coma. When acute adrenal insufficiency is suspected, immediate treatment should be instituted to supply adrenal cortical substance. For rapid effect, aqueous adrenocortical extract should be given by intravenous infusion and intramuscularly. At the same time cortisone should be administered intramuscularly. Since up to 24 hours may be required for optimum effect of cortisone, aqueous extract should be continued or repeated as indicated. Mter equilibrium has been established, cortisone should be continued in diminishing doses for several days. Prompt response to hormone therapy in shock is ample evidence of the accuracy of diagnosis. Thomes states that no beneficial effect of hormone therapy in shock has been evident in patients with adequate adrenocortical function. General Considerations in Postoperative Care
Following any type of surgical procedure on the colon it is best to keep the intestinal tract at complete rest for a period of 48 hours, with neither food nor fluids by mouth. Morphine is the ideal drug for postoperative pain, since this also has the specific effects of stimulating intestinal tonus and diminishing peristalsis. During this period an adequate fluid intake should be administered intravenously. Usually 750 cc. of glucose in water each morning and 750 cc. of glucose in saline each evening, given slowly, is entirely adequate for body requirements. Any unusual loss of fluids and electrolytes due to vomiting or gastric suction, or to loss from an ileostomy must be replaced. There is often a tendency to give an excessive amount of intravenous fluid following operation. This is hazardous, particularly in elderly patients, and may place a dangerous burden on the cardiovascular system. A patient literally may be drowned by overzealous use of intravenous fluids. This error is usually made because of the surgeon's anxiety to maintain "normal" urinary output. It has been our observation that the latter normally totals not over 500 cc. daily for the first 2 days following operation, and that even doubling the amount of fluids given intravenously causes no appreciable increase in the urinary flow during that period. If for any reason a patient is continued more than 2 days on a constant intravenous fluid intake of 1500 cc. daily, the urine output usually doubles on the third and fourth days. We consider this relative diminution in kidney excretion in the immediate postoperative period a normal physiologic response, and we are quite satisfied with a daily urine output of 400 to 500 cc. for the first 2 days. Subsequently, a daily output of 1000 cc. or better is desirable and should be maintained by adequate fluid intake. Early ambulation of surgical patients has been popularized in recent
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years as a panacea for many postoperative complications. There is no desire to criticize here the recognized value of early ambulation. However, we believe that emphasis should be placed upon early physical activity by the patient rather than on early ambulation. To get the patient out of bed for 15 minutes once or twice in 24 hours, and then allow him to lie motionless in bed the rest of the time is of dubious value. It is much better to encourage and insist upon active, physical exercise in bed at frequent intervals during the day and when awake at night. The patient himself should frequently turn from side to side, he should move and exercise his arms and legs, and then as soon as he is sitting himself up in bed he is ready for ambulation. Bladder Dysfunction Following Resection of the RectuIll
There is a fairly high incidence of postoperative bladder dysfunction following rectal resection, principally in elderly male patients. This has been attributed by some authorities to neurogenic disturbance due to surgical trauma. We have been unable to demonstrate evidence of neurogenic bladder dysfunction following abdominoperineal resection of the rectum. Not infrequently urinary retention has occurred, due to bladder neck obstruction as the result of prostatic hypertrophy or angulation of the bladder neck following operation. Such diagnosis has been confirmed by the fact that treatment by transurethral resection consistently has been followed by normal micturition with complete emptying of the bladder. It is our custom to maintain constant bladder drainage by use of a retention catheter from the time of operation until the patient is out of bed. The catheter is then removed and bladder function checked by measurement of residual urine after voiding. If the patient is unable to void or has more than 100 cc. of residual urine, a retention catheter is again employed for another 2 to 3 days. If then there is persistent inability of the bladder to empty adequately, cystoscopy is performed and any demonstrable bladder neck obstruction is subsequently corrected by transurethral resection. Care of Patients with Intestinal AnastoIllosis
Continuation of antibacterial medication for several days after operation minimizes edema and promotes more rapid primary healing at the site of ana5tomosis. Neomycin or Sulfathalidine is the agent of choice. After fluids are being taken well by mouth, a nonresidual diet is advisable until spontaneous bowel movements are resumed. After satisfactory function at the level of anastomosis is evident diet may be liberal and antibacterial medication may be discontinued.
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Robert A. Scarborough
Care of Patients with EnterostOlnies
Care of Colostomy. The surgeon has a continuing responsibility for supervision of the patient during the period of mental adjustment to an abnormal fecal stoma, and for the establishment of satisfactory colostomy control. Until the patient is able to be out of bed for an hour at a time, there is no reason to begin irrigation of the colostomy. The patient should be assured that a colostomy will function adequately without irrigation, and he should be prepared to experience spontaneous evacuation prior to establishment of bowel control by daily irrigation. A suitable apparatus for irrigation should be obtained and explained to the patient before the time for its use. Experienced nursing supervision during irrigation is invaluable for the first few days, but as quickly as possible the patient must be encouraged to take the entire responsibility for the procedure, so that when he leaves the hospital he will have no feeling of dependence on others for his bowel care. Colostomy bags are unnecessary and inadvisable. As soon as the patient has confidence in his bowel control, the colostomy stoma may be covered with a piece of absorbent tissue held in place by a broad elastic-webbing belt. The patient should be instructed in the daily insertion of a gloved finger into the stoma until healing of mucosa to skin takes place, to counteract the development of a stricture at the skin level. Care of Ileostomy Patients. The major immediate problem after ileostomy is that of control of fluid and electrolyte balance until physiologic readjustment takes place. A special chart should be started on the day of operation to show the quantity and quality of all fluids and electrolytes administered and to show the quantity and quality of fluid output in the urine, from the stomach, and from the ileostomy. Insensihle fluid loss also should be calculated in computing the daily fluid balance. Positive fluid balance should be calculated and maintained daily, and there should be adequate replacement of lost electrolytes, with particular attention to potassium. Not infrequently satisfactory balance is easily maintained for 3 or 4 days, but then may be suddenly and seriously disturbed by voluminous excretion through the ileostomy. Determinations of serum potassium, sodium and chloride, and carbon dioxide combining power will frequently be necessary as a guide for appropriate replacement therapy. To minimize excessive fluid and electrolyte loss per ileostomy, the patient should receive a high residue diet as soon as it can be tolerated. Care of Ileostomy. It was once our practice to insert a soft rubber catheter through the ileostomy stoma and close the end of the ileum with a purse-string suture of chromic catgut around the tubing, so that for several days all ileostomy drainage could be diverted into a receptacle beneath the bed, thereby protecting the surrounding skin from the digestive action of the fecal discharge. More recently this procedure has
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Lesions of Colon and Rectum
been abandoned in favor of immediate application of a transparent polyethelene bag (ordinary ice-box bag), with a hole cut in the side to fit over the ileostomy stoma, cementing the bag to the surrounding skin with Paget dermatome glue. The open end of the bag is tied around rubber tubing which empties into a receptacle beneath the bed. This apparatus is usually effective in protecting the skin and preventing fecal spillage for several days. Before the patient is out of bed, a Rutzen type bag of appropriate size is cemented in place, and is changed and reapplied only as often as the cement seal is broken, usually every 2 or 3 days. Ileostomy Dysfunction and Obstruction. A recent article by Turnbull9 offers an excellent treatise on the problem of ileostomy care and ileostomy dysfunction. Our own experience has confirmed his statement that the newly made ileostomy does not function properly in the majority of instances. His explanation of such dysfunction is entirely reasonable and now seems perfectly obvious. Dysfunction is not due to organic obstruction to ileal flow, but rather is due to functional obstruction of the protruding segment of ileum caused by the inevitable development of serosal peritonitis, with accompanying induration and cessation of peristalsis through the exposed segment. When obstruction develops because of such dysfunction, simple insertion of a retention tube through the ileostomy effects adequate decompression and relief of symptoms. Turnbull proposes a secondary surgical procedure to hasten "maturation" of the ileostomy by trimming the stoma on the seventh day in such a way as to leave the mucosa long enough to evert part of the way down the side of the ileostomy. We have long been concerned about the problem of ileostomy dysfunction and obstruction, and during recent months have successfully employed a technique of ileostomy that permits primary union of mucosa to skin. To date this appears to eliminate serosal peritonitis and subsequent functional obstruction. Further experience and longer observation are necessary before the use of this procedure can be recommended. SUMMARY
The emphasis of this discussion has been upon general principles in the over-all management of patients requiring abdominal surgery for disease of the colon or rectum. Statistical tabulation of morbidity and mortality figures, and discussion of operative techniques have been deliberately omitted. ~ REFERENCES 1. Dearing, W. H. and Needham, G. M.: Effect of Oral Administration of Neomycin and Terramycin on the Intestinal Bacterial Flora of Man. Proc. Staff Meet., Mayo Clin. 28: 507-512, 1953. 2. Fremont, R. E., Luger, N. M., Surks, S. N. and Kleinman, A.: Treatment of Surgical Shock with Arterenol, A. M. A. Arch. Surg. 68: 44-56, 1954.
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3. Goldenberg, M. and others: The Hemodynamic Response of Man to Norepinephrine and Epinephrine and Its Relation to the Problem of Hypotension. Am. J. Med. 5: 792,1948. 4. Hayes, M. A.: Shock and the Adrenocortex. Surgery 35: 174-190, 1954. 5. Poth, E. J.: Intestinal Antisepsis in Surgery. J.A.M.A. 153: 1516-1521,1953. 6. Salassa, R. M., Bennett, W. A., Keating, F. R., Jr., and Sprague, R. G.: Postoperative Adrenal Cortical Insufficiency. Occurrence in Patients Previously Tnlated with Cortisone. J.A.M.A. 152: 1509-1515, 1953. 7. Taylor, E. S. and Essig, L. L.: Acute Adrenal Cortical Failure as a Cause of Shock and Death. Am. J. Obst. & Gynec. 65: 720-732,1953. 8. Thorne, G. W. and others: Pharmacologic Aspects of Adrenocortical Steroids and ACTH in Man. New England J. Med. 248: 232, 284, 323, 369, 414, 588, 632, 1953. 9. Turnbull, R. B.: Management of the Ileostomy. Am. J. Surg. 86: 617-624,1953. 490 Post Street San Francisco 2, California