- Email: [email protected]
Safety of colostomy closure
Safety of Colostomy Closure William Garnjobst, MD, Portland, Oregon Gary t-t. Leaverton, MD, Portland, Oregon Eugene S. Sullivan, MD, Portland, Oregon
Recent reports dealing with closure of colostomies have described a disquieting frequency of complications after the operation [l-5]. In some series nearly half of all patients met with some type of complication. Postoperative wound infections have been reported in up to 38 per cent of patients, and anastomotic breakdowns and fistulas have occurred in up to 23 per cent. A tabulation of selected series and their complications is shown in Table I. As a result there has arisen a question of the relative safety of temporary colostomy and its attendant closure [4], leading some to seek alternative methods [6] and possibly influencing others to avoid employment of colostomy. Because of our continuing belief in the safety provided by colostomy, we were stimulated to review our own cases. The rates of complication reported in these recent series were found to be at such a variance with our own results that we have felt constrained to report our experienl:e. Material and Methods Yhe review concerns 125 consecutive colostomy closures performed during the period 1962 to the present. The beginning year of 1962 was selected because it was the initial year in which the present technic of preliminary inversion of the stomas was practiced in all cases. Average age of the sixty-seven men and fifty-eight women in the series was 62.4 years, with ages ranging from fifteen to eighty-eight years and 106 of the patients more than fifty years old. All had either a loop colostomy or stomas placed in juxtaposition as a result of primary colone resection without anastomosis. Closures following the Hartmann type of resections were not included for review since such closures require a more extensive operation and From the Department of Surgery, Providence Medical Center, Portland, Oregon. Reprint requests should be addressed to William Garnjobst. MD, 511 Southwest IOth, Portland, Oregon 97205. Presented at the Forty-Ninth Annual Meeting of the Pacific Coast Surgical Association, Newport Beach. California, February 19-22, 1978.
Volume 136, July 1978
therefore are not comparable with ordinary closures. The types of colostomy, their indications, and methods of closure are listed in Table II. All closures were intraperitoneal and all were personally performed by us. Operative Technic
Mechanical cleansing by means of a clear liquid diet and a phosphate cathartic began on the day before operation, and washout irrigations proximally and distally were administered a few hours before operation. Preparation with nonabsorbable sulfonamide, neomycin, or the combination was utilized in most cases until 1972. The last forty-eight closures in the series were performed without antibiotic bowel preparation and without prophylactic systemic antibiotic. An important technical aspect of the closures was the preliminary inversion of the stoma by a running mattress suture of heavy chromic, drawn tightly to make a waterproof seal. (Figure 1.) Prior to inversion, the surgeon carefully cleansed the stoma and accessible lumens of the proximal and distal limbs with liberal quantities of povidone-iodine (Betadine@) solution. After inversion, the abdomen was rescrubbed, drapes were placed, and the sealed stoma was mobilized within a narrow ellipse of skin, freeing the bowel from the abdominal layers by sharp knife dissection. After severing the peritoneal attachments, wound surfaces were carefully protected with moist lap pads which, in turn, were covered by dry lap pads before the colon was opened. Stomas were either resected or, if incompletely divided, often closed by simple stoma1 suture after excision of the adherent rim of skin. All anastomoses were intraperitoneal and were performed by open technic, using one-layer silk or by a two-layer method with chromic and silk. Upon completion of the anastomosis, “change-over” with new gloves and fresh drapes and instruments was practiced as a ritual in all instances. After peritoneal closure with running chromic catgut suture, the wounds were cleansed with a balanced salt solution and, in the last forty-eight cases, irrigated with a neomycin-lincomycin (Lincocinm) solution during the remainder of the closure. All wounds were closed primarily, using interrupted fine plain sutures in the subcutaneous layer and loosely tied, interrupted silk
85
Garnjobst, Leaverton, and Sullivan
TABLE I
Complications in Selected Recent Series
Authors
No. of Cases
Knox et al [ I] 1971 Yakimets [ 21 1975 Finch [3] 1976 Wheeler and Barker [ 41 1977 Mirelman et al [ 51 1977
179 71 213 73 118
33 % (local) 49% 44% 37.8% 49%
or nylon sutures in the skin. Small, vertical subcutaneous drains were placed between the skin sutures and left undisturbed until the fifth or sixth day, when they were loosened and thereafter gradually withdrawn. Results
Average hospital stay after operation was 8.7 days, with 80 per cent of the patients having been discharged by the tenth day. Lengths of stay decreased somewhat during the period, the average for the last twenty-five patients being 7.8 days. Complications were relatively few. (Table III.) There were no deaths and no anastomotic breakdowns or fistulas. Most of the early local complications were associated with early closure of colostomy, a finding which has been commented on by previous authors [3,4,7]. Both of the wound infections and the partial anastomotic obstruction occurred among the twenty-eight patients who underwent closure within six weeks or less after creation of colostomy, while only one local complication arose among the remaining patients. The latter was a wound dehiscence in a patient with chronic obstructive pulmonary disease who underwent closure eighteen months after reestablishment of his transverse colostomy had been necessitated by leak of a distal anastomosis at another hospital. In this case, and in others in which closures had been delayed more than a few months, we noted that the
TABLE II
Colostomy Closure In 125 Patients No. of Patients
Indications Three-stage resections Protective (complementary) colostomies Therapeutic for surgical complications Resections without anastomosis (Mikulicz)
50 59 13 3
Types of Colostomy Transverse loop Sigmoid loop Juxtaposition
118 4 3
Methods of Closure Simple stoma1 closure Resection-anastomosis
88
Total Complications
63 62
Wound Infections 10% 38% 21% 23% 19%
Anastomotic Fistulas, Breakdowns 23% 2.8% 9.3% 17% 13%
No. of Deaths 4 2 1 2 0
fascial openings tended to become larger and somewhat circular, making for difficult closures. In one obese woman, an impossible gap was bridged by an implant of polypropylene mesh. We believe the low rate of wound infection to be partly attributable to preliminary inversion of the stomas. This is at least strongly suggested by comparison of the series with an earlier group of thirtyeight patients who underwent closure without inversion. In the latter group, there were four wound infections and one fecal fistula. The usefulness of preoperative sulfonamide preparation of the intestine was not apparent. The two patients who developed early wound infections had been prepared with succinylsulfathiazole (Sulfasuxidinee), and one of the two had also been given systemic antibiotics prophylactically. In the last forty-eight closures, in an ongoing study, neither enteric nor systemic antibiotic was given, reliance being placed upon basic aseptic technic, local cleansing of the stomas, and irrigation of the wound during closure with a neomycin-lincomycin solution. Close scrutiny of the wounds in these forty-eight cases revealed no perceptible infection. An early complication of complete obstruction distal to closure of a transverse colostomy resulted from a stricture in a recent sigmoid anastomosis and required reoperation for revision of the anastomosis. This predicament adequately reemphasized the need for examination of the distal colon in all cases before colostomy closure. Because follow-up of patients was incomplete, the late complications listed in Table III must be considered only tentative. Comments
The present series demonstrates that closure of a colostomy can be accomplished with a low incidence of complications, a point made in 1958 by Barron and Fallis [8] who reported more than 200 intraperitoneal closures with no deaths and but one anastomotic leak with a temporary fistula. Creditable results have also been attained by Thomson and Hawley [ 71 and oth-
The American Journal of Surgery
Colostomy Closure
Figure 1. A, preliminary inversion of stoma; B, mobilization within narrow, elliptical skin incision; C, scalpel dissection aided by traction; D, muitip/e subcutaneous drains.
L;:”
er6 [9]. The essentials of technic had already been perceived as early as 1917 by Lockhart-Mummery (101, who practiced suture of the stoma, intraperitoneal placement of the anastomosis, and drainage of the wound. It seems contradictory, then, that the lesser operation of colostomy closure should, in the present day, be followed by complications as frequently as is the more extensive operation of major colonic resection [ 111. We suspect the unfortunate difficulties with colostomy closure as reported in the recent literature arise from its being regarded as a rather simple operation, and as a result, it is too often approached with insufficient forethought and experience. As Wheeler and Barker [4] observed, “It is all too easy to regard the operation. . . as a simple procedure that is relatively free of complications and can be entrusted to the junior surgeon in training.” We agree with their conclusion that the most important factor determining the success or failure is likely to be the careful technic of the surgeon. The lack of local complications in our last forty-eight closures which were performed without antibiotic bowel preparation and without systemic antibiotics further emphasizes this point. Preliminary suture of the stoma may be likened to Kocher’s purse-string suture of the anus which so greatly lessened the complications of rectal resection at that time. Its greatest virtue probably lies in keeping the operator’s fingers out of the lumen dur-
Volume 136, July 1978
ing dissection and thereby decreasing contamination of the wound. While it is tempting to perform early closure to shorten the period of disability, experience has shown that this is followed by unacceptably frequent wound and anastomotic complications. It is far safer to wait until the colostomy has completely healed to the skin and all inflammatory edema has subsided. Also, the patient should have recovered sufficiently to withstand another operation. In our experience, these conditions require at least six weeks, and it is safer to wait until seven or eight weeks. Early in the series most loop colostomies were completely divided and were, therefore, closed by resection and anastomosis. More recently we have
TABLE III
Postoperative Complications No. of Patients
Early Wound infection Partial obstruction Wound dehiscence Minor upper gastrointestinal bleeding Enterocolitis Obstruction at distal anastomosis Total
2 1 1 1 1 1 7 (5.6%)
Late Incisional hernia Deep stitch abscess Total
4
Total early and late
9.6%
: (4.0%)
a7
Garnjobst, Leaverton,
and Sullivan
preferred to leave the stomas incompletely divided so that only simple stoma1 suture, as advocated by Thomson and Hawley [ 71, is necessary. This appears to be the safer and simpler method [12]. There were no local complications among the sixty-three patients who underwent this type of closure. Summary
A retrospective study of colostomy closures was prompted by recent reports detailing frequent postoperative complications. In a series of 125 intraperitoneal colostomy closures there was a low incidence of complications. There were no anastomotic breakdowns, fistulas, or deaths. We conclude that closure of a well healed colostomy is a safe operation, the success of which is determined by the careful technic with which it is performed. References 1. Knox AJS, Birkett FDH, Collins CD: Closure of colostomy. Br J Surg 58: 669, 197 1. 2. Yakimets WW: Complications of closure of loop colostomy. Can J Surg 18: 366, 1975. 3. Finch DRA: The results of colostomy closure. 8r J Surg 63: 397, 1976. 4. Wheeler MH, Barker J: Closure of colostomy-a safe procedure? Dis Colon Rectum 20: 29, 1977. 5. Mirelman D, Corman ML, Caller JA, Veidenheimer MD: Colostomies, indications and complications; the Lahey Clinic experience. Presented at the 76th Annual Meeting of the American Society of Colon and Rectal Surgeons, Orlando, Florida, May 6-12, 1977. 6. Hubbard TB Jr, Norico A, Harris RA: Two stage resection of the colon. Surg Gynecol Obstet 124: 1061, 1967. 7. Thomson JPS,.Hawley PR: Results of closure of loop transverse colostomies. Br Med J 3: 459, 1972. 8. Barron J, Fallis LS: Colostomy closure by the intraperitoneal method. Dis Co/on Rectum 1: 466, 1958. 9. Sullivan WG, Miller RE, Eiseman B: Closure of colonic stomas in patients injured in combat. Surg Gynecol Obstet 131: 1045, 1970. 10. Lockhart-Mummery P: Making and closing of colostomy openings. Br A-fedJ 1: 685, 1917. 11. Yajko RD, Norton LW, Bloemendal L, Eiseman B: Morbidity of colostomy closure. Am J Surg 132: 304, 1976. 12. Beck PH, Conklin HB: Closure of colostomy. AnnSurg 181: 795, 1975.
Discussion Allen M. Boyden (Portland, OR): The excitement of the many new advances in surgery in recent years rightfully has held our attention and particularly the interest of our students and residents. Heart surgery, vascular surgery, joint replacement, and transplantation have been on the front burner while the more mundane problems of the general surgeon have lost attractiveness. The authors are to be congratulated for reminding us that great care and fine surgical principles must continue to be applied in whatever area of surgery one deals.
88
It is startling to realize that in recent reviews of colostomy closure, an operation that most general surgeons would consider relatively simple, the complications of fistula, anastomotic breakdown, and wound infection have been so distressingly high. This review of cases from the recent literature, showing complications ranging from 33 to 49 per cent, can only mean that mature judgment and attention to sound surgical principles have been lacking in the care of these patients. In contrast, in the present series there were no fistulas, no anastomotic failures, and less than 2 per cent wound infections. This record will be hard to duplicate. Delaying closure until maturation of the colostomy, planning preoperative bowel preparations, avoiding contamination of the wound, meticulous closure of the carefully prepared stoma or the anastomosis when resection of the limbs is required, avoidance of wound dead space, and thorough irrigation and adequate drainage of the wound have yielded these excellent results and prove the importance of seasoned experience. It has been our practice, in contrast to that of the authors, to use not only mechanical preparation of the bowel and irrigations of both proximal and distal limbs but also oral antibiotics to reduce colonic pathogens to a minimum. We prefer to use neomycin and erythromycin base, following the regimen suggested by Nichols et al (Ann Surg 178: 453,1973). There have been two other recent randomized doubleblind series of cases utilizing oral antibiotics which have corroborated the results of Nyhus and his associates showing significant reduction of wound infections after colon operations. Similarly, the statistically significant effectiveness of parenteral broad spectrum antibiotic administration begun in the immediate preoperative period in reducing wound infections has been demonstrated by a similar randomized series. Therefore, we have added both short-term oral and parenteral antibiotics preoperatively in all colon operations. It has been our practice at The Portland Clinic when protective colostomy is elected to open the loop longitudinally rather than to divide it. This permits simple transverse closure after removing the skin edge and freshening the margins of the stoma and avoids anastomosis which must inevitably carry greater risk. I have not used preliminary inversion of the stoma suggested by the authors, but I do use great care in protecting and irrigating the wound. Intraperitoneal placement of the bowel after closure is most important. Dead space anterior to the fascia may be unavoidable and requires drainage. We use suction tube drains or, when fecal contamination occurs, secondary closure of the skin. We have had no fecal fistulas while following this program. Barium enema of the distal limb must be done routinely prior to closure to prove the integrity of the anastomosis and the absence of distal obstruction. Finally, I would ask the authors to comment on the thirteen patients requiring diverting colostomy because of complications related to prior colonic resection. I must
The American Journal of Sqery
Golostomy
assume that these were necessary because of anastomotic breakdown Or fistulas with or without abscess or peritonitis. If 30, it is again a reminder that colonic anastomoses may be hazardous and should be protected by complementary colostomy at the original operation whenever there is any doubt about the integrity of the suture line. My indications fo:- such protection have included some very low anastoml,ses, uncontrollable oozing in the pelvis near an anastomosis, anastomoses of small caliber due to spasm of the bcwel, or perhaps when resection is required when the bc.wel is unprepared. The side-to-end anastomosis described by Dr. Joel Baker (Arch Surg 61: 143,195O) has proved of great value in improving security of low anastomoses, and with its use I have found complementary colostomy to be required less frequently. Philip R. Westdahl (San Francisco, CA): I want to commend the authors on the success of their colostomy ckrsures. Their technic is well designed and their attention to details rewarding. However, I question the need for colo3tomy as opposed to cecostomy as a decompressing procedure in acute obstruction of the colon. Colostomy always requires operative closure whereas cecostomy rarely does. In 1957 I presented a paper before this association comparing cecostomy and colostomy in the management of’ acute obstruction of the colon at the San Francisco General Hospital. In 1969 I updated our experience to include ninety-three emergency cecostomies for acute obstruction. I would like at this time to read my conclusions in that paper to emphasize my point: “( 1) Tube cecostomy is a safe and simple procedure and is particularly desirable in markedly distended cecum and colon. (2) Direct exposure of the cecum has the advantage of visualizing the most common site of perforation of a markedly dilated large bowel. (3) The risk of peritonitis from spillage at cecostomy is h;.ghly overemphasized. Peritonitis did not occur in any of those 93 cases. (4) Tube cecostomy will effectively decompress and prepare the colon for subsequent resection. (5) The incidence of significant complications after tube cecostomy is no higher than after colostomy. (6) The mortality for acute obstruction of the colon in elderly poor risk patients is abnormally high, but death is rarely due to the cecostomy itself. (7) Tube cecostomy will almost always close spontaneously if given adequate time. The advantage of this feature over colostomy is obvious.” Leon Morgenstern (Los Angeles, CA): We too have been practicing this method of colostomy closure for the past twenty years, performing preliminary closure of the stoma with an interlocking 2-O silk suture. This permits complete mobilization of the stoma with no contamination and also facilitates the peristomal dissection, allowing Allis
Volume 136,July 1979
Closure
clamp “tractors” to be used on the closed stoma. (Slide) ‘One instance in which this technic was not possible was in a patient with a colostomy and with severe portal hypertension due to advanced cirrhosis. The peristomal varices would periodically erupt in spout-like bleeding. Obviously, this method of preliminary closure could not be used because of the bleeding problem. I commend this method of closure as practical, simple, and conducive to minimal contamination and negligible wound infection. John A. Schilling (Seattle, WA): I rise to emphasize the importance of what was stressed in the present study, namely matters of surgical technic in the reduction of wound complications. In view of the remarkable surgical results of our cardiothoracic colleagues, and our own morbidity and mortality statistics that are not nearly as good in certain general gastrointestinal areas, we have to analyze critically what we do in the operating room. Most important is the reduction of organisms. A colostomy that is unsealed introduces organisms (10s to lOs/ml) into the wound. More than lo5 organisms/ml exceeds and overwhelms the body’s defense mechanisms. Thus, irrigation and antibiotics serve to reduce these organisms to fewer than 105/ml so that the patient’s cellular and humoral defense mechanisms can handle them. I would like to emphasize the importance of timing. Any colostomy closure less than three weeks old is still a fresh wound with the flora of a fresh and open wound. We cancel a hernia operation because of a scratch made the night before, and yet we may close a contaminated wound too early. Further, a six week delay provides the opportunity for nutritional and lean body mass repletion so that the patient can mount a better cellular and humoral response. William Garnjobst (closing): Dr. Boyden alluded to the fact that colostomy closure has a reputation for being a simple operation, and I think this is often the cause of its downfall. Dr. Boyden, of the thirteen therapeutic colostomies, at least four were necessitated by instrumental perforations of the colon. The others were mainly for anastomotic complications, including two for distal necrosis after pull-through procedures. Preliminary suture of the stoma has been advocated by others and I was pleased to see Dr. Morgenstern’s nice example of how he does it. Another reason for waiting more than six weeks is the difficulty encountered in preliminary inversion of the stoma prior to’that time due to edema and thickening. Dr. Schilling mentioned the desirability of reducing the concentrations of bacteria within the colon. We do not believe it is necessary to reduce the concentrations of the entire intestine. By cleansing the interior of the stoma, a nearly sterile local condition is obtained. Once the anastomotic line becomes sealed, it does not seem to matter how many bacteria pass through the lumen.
89
Recent reports dealing with closure of colostomies have described a disquieting frequency of complications after the operation [l-5]. In some series nearly half of all patients met with some type of complication. Postoperative wound infections have been reported in up to 38 per cent of patients, and anastomotic breakdowns and fistulas have occurred in up to 23 per cent. A tabulation of selected series and their complications is shown in Table I. As a result there has arisen a question of the relative safety of temporary colostomy and its attendant closure [4], leading some to seek alternative methods [6] and possibly influencing others to avoid employment of colostomy. Because of our continuing belief in the safety provided by colostomy, we were stimulated to review our own cases. The rates of complication reported in these recent series were found to be at such a variance with our own results that we have felt constrained to report our experienl:e. Material and Methods Yhe review concerns 125 consecutive colostomy closures performed during the period 1962 to the present. The beginning year of 1962 was selected because it was the initial year in which the present technic of preliminary inversion of the stomas was practiced in all cases. Average age of the sixty-seven men and fifty-eight women in the series was 62.4 years, with ages ranging from fifteen to eighty-eight years and 106 of the patients more than fifty years old. All had either a loop colostomy or stomas placed in juxtaposition as a result of primary colone resection without anastomosis. Closures following the Hartmann type of resections were not included for review since such closures require a more extensive operation and From the Department of Surgery, Providence Medical Center, Portland, Oregon. Reprint requests should be addressed to William Garnjobst. MD, 511 Southwest IOth, Portland, Oregon 97205. Presented at the Forty-Ninth Annual Meeting of the Pacific Coast Surgical Association, Newport Beach. California, February 19-22, 1978.
Volume 136, July 1978
therefore are not comparable with ordinary closures. The types of colostomy, their indications, and methods of closure are listed in Table II. All closures were intraperitoneal and all were personally performed by us. Operative Technic
Mechanical cleansing by means of a clear liquid diet and a phosphate cathartic began on the day before operation, and washout irrigations proximally and distally were administered a few hours before operation. Preparation with nonabsorbable sulfonamide, neomycin, or the combination was utilized in most cases until 1972. The last forty-eight closures in the series were performed without antibiotic bowel preparation and without prophylactic systemic antibiotic. An important technical aspect of the closures was the preliminary inversion of the stoma by a running mattress suture of heavy chromic, drawn tightly to make a waterproof seal. (Figure 1.) Prior to inversion, the surgeon carefully cleansed the stoma and accessible lumens of the proximal and distal limbs with liberal quantities of povidone-iodine (Betadine@) solution. After inversion, the abdomen was rescrubbed, drapes were placed, and the sealed stoma was mobilized within a narrow ellipse of skin, freeing the bowel from the abdominal layers by sharp knife dissection. After severing the peritoneal attachments, wound surfaces were carefully protected with moist lap pads which, in turn, were covered by dry lap pads before the colon was opened. Stomas were either resected or, if incompletely divided, often closed by simple stoma1 suture after excision of the adherent rim of skin. All anastomoses were intraperitoneal and were performed by open technic, using one-layer silk or by a two-layer method with chromic and silk. Upon completion of the anastomosis, “change-over” with new gloves and fresh drapes and instruments was practiced as a ritual in all instances. After peritoneal closure with running chromic catgut suture, the wounds were cleansed with a balanced salt solution and, in the last forty-eight cases, irrigated with a neomycin-lincomycin (Lincocinm) solution during the remainder of the closure. All wounds were closed primarily, using interrupted fine plain sutures in the subcutaneous layer and loosely tied, interrupted silk
85
Garnjobst, Leaverton, and Sullivan
TABLE I
Complications in Selected Recent Series
Authors
No. of Cases
Knox et al [ I] 1971 Yakimets [ 21 1975 Finch [3] 1976 Wheeler and Barker [ 41 1977 Mirelman et al [ 51 1977
179 71 213 73 118
33 % (local) 49% 44% 37.8% 49%
or nylon sutures in the skin. Small, vertical subcutaneous drains were placed between the skin sutures and left undisturbed until the fifth or sixth day, when they were loosened and thereafter gradually withdrawn. Results
Average hospital stay after operation was 8.7 days, with 80 per cent of the patients having been discharged by the tenth day. Lengths of stay decreased somewhat during the period, the average for the last twenty-five patients being 7.8 days. Complications were relatively few. (Table III.) There were no deaths and no anastomotic breakdowns or fistulas. Most of the early local complications were associated with early closure of colostomy, a finding which has been commented on by previous authors [3,4,7]. Both of the wound infections and the partial anastomotic obstruction occurred among the twenty-eight patients who underwent closure within six weeks or less after creation of colostomy, while only one local complication arose among the remaining patients. The latter was a wound dehiscence in a patient with chronic obstructive pulmonary disease who underwent closure eighteen months after reestablishment of his transverse colostomy had been necessitated by leak of a distal anastomosis at another hospital. In this case, and in others in which closures had been delayed more than a few months, we noted that the
TABLE II
Colostomy Closure In 125 Patients No. of Patients
Indications Three-stage resections Protective (complementary) colostomies Therapeutic for surgical complications Resections without anastomosis (Mikulicz)
50 59 13 3
Types of Colostomy Transverse loop Sigmoid loop Juxtaposition
118 4 3
Methods of Closure Simple stoma1 closure Resection-anastomosis
88
Total Complications
63 62
Wound Infections 10% 38% 21% 23% 19%
Anastomotic Fistulas, Breakdowns 23% 2.8% 9.3% 17% 13%
No. of Deaths 4 2 1 2 0
fascial openings tended to become larger and somewhat circular, making for difficult closures. In one obese woman, an impossible gap was bridged by an implant of polypropylene mesh. We believe the low rate of wound infection to be partly attributable to preliminary inversion of the stomas. This is at least strongly suggested by comparison of the series with an earlier group of thirtyeight patients who underwent closure without inversion. In the latter group, there were four wound infections and one fecal fistula. The usefulness of preoperative sulfonamide preparation of the intestine was not apparent. The two patients who developed early wound infections had been prepared with succinylsulfathiazole (Sulfasuxidinee), and one of the two had also been given systemic antibiotics prophylactically. In the last forty-eight closures, in an ongoing study, neither enteric nor systemic antibiotic was given, reliance being placed upon basic aseptic technic, local cleansing of the stomas, and irrigation of the wound during closure with a neomycin-lincomycin solution. Close scrutiny of the wounds in these forty-eight cases revealed no perceptible infection. An early complication of complete obstruction distal to closure of a transverse colostomy resulted from a stricture in a recent sigmoid anastomosis and required reoperation for revision of the anastomosis. This predicament adequately reemphasized the need for examination of the distal colon in all cases before colostomy closure. Because follow-up of patients was incomplete, the late complications listed in Table III must be considered only tentative. Comments
The present series demonstrates that closure of a colostomy can be accomplished with a low incidence of complications, a point made in 1958 by Barron and Fallis [8] who reported more than 200 intraperitoneal closures with no deaths and but one anastomotic leak with a temporary fistula. Creditable results have also been attained by Thomson and Hawley [ 71 and oth-
The American Journal of Surgery
Colostomy Closure
Figure 1. A, preliminary inversion of stoma; B, mobilization within narrow, elliptical skin incision; C, scalpel dissection aided by traction; D, muitip/e subcutaneous drains.
L;:”
er6 [9]. The essentials of technic had already been perceived as early as 1917 by Lockhart-Mummery (101, who practiced suture of the stoma, intraperitoneal placement of the anastomosis, and drainage of the wound. It seems contradictory, then, that the lesser operation of colostomy closure should, in the present day, be followed by complications as frequently as is the more extensive operation of major colonic resection [ 111. We suspect the unfortunate difficulties with colostomy closure as reported in the recent literature arise from its being regarded as a rather simple operation, and as a result, it is too often approached with insufficient forethought and experience. As Wheeler and Barker [4] observed, “It is all too easy to regard the operation. . . as a simple procedure that is relatively free of complications and can be entrusted to the junior surgeon in training.” We agree with their conclusion that the most important factor determining the success or failure is likely to be the careful technic of the surgeon. The lack of local complications in our last forty-eight closures which were performed without antibiotic bowel preparation and without systemic antibiotics further emphasizes this point. Preliminary suture of the stoma may be likened to Kocher’s purse-string suture of the anus which so greatly lessened the complications of rectal resection at that time. Its greatest virtue probably lies in keeping the operator’s fingers out of the lumen dur-
Volume 136, July 1978
ing dissection and thereby decreasing contamination of the wound. While it is tempting to perform early closure to shorten the period of disability, experience has shown that this is followed by unacceptably frequent wound and anastomotic complications. It is far safer to wait until the colostomy has completely healed to the skin and all inflammatory edema has subsided. Also, the patient should have recovered sufficiently to withstand another operation. In our experience, these conditions require at least six weeks, and it is safer to wait until seven or eight weeks. Early in the series most loop colostomies were completely divided and were, therefore, closed by resection and anastomosis. More recently we have
TABLE III
Postoperative Complications No. of Patients
Early Wound infection Partial obstruction Wound dehiscence Minor upper gastrointestinal bleeding Enterocolitis Obstruction at distal anastomosis Total
2 1 1 1 1 1 7 (5.6%)
Late Incisional hernia Deep stitch abscess Total
4
Total early and late
9.6%
: (4.0%)
a7
Garnjobst, Leaverton,
and Sullivan
preferred to leave the stomas incompletely divided so that only simple stoma1 suture, as advocated by Thomson and Hawley [ 71, is necessary. This appears to be the safer and simpler method [12]. There were no local complications among the sixty-three patients who underwent this type of closure. Summary
A retrospective study of colostomy closures was prompted by recent reports detailing frequent postoperative complications. In a series of 125 intraperitoneal colostomy closures there was a low incidence of complications. There were no anastomotic breakdowns, fistulas, or deaths. We conclude that closure of a well healed colostomy is a safe operation, the success of which is determined by the careful technic with which it is performed. References 1. Knox AJS, Birkett FDH, Collins CD: Closure of colostomy. Br J Surg 58: 669, 197 1. 2. Yakimets WW: Complications of closure of loop colostomy. Can J Surg 18: 366, 1975. 3. Finch DRA: The results of colostomy closure. 8r J Surg 63: 397, 1976. 4. Wheeler MH, Barker J: Closure of colostomy-a safe procedure? Dis Colon Rectum 20: 29, 1977. 5. Mirelman D, Corman ML, Caller JA, Veidenheimer MD: Colostomies, indications and complications; the Lahey Clinic experience. Presented at the 76th Annual Meeting of the American Society of Colon and Rectal Surgeons, Orlando, Florida, May 6-12, 1977. 6. Hubbard TB Jr, Norico A, Harris RA: Two stage resection of the colon. Surg Gynecol Obstet 124: 1061, 1967. 7. Thomson JPS,.Hawley PR: Results of closure of loop transverse colostomies. Br Med J 3: 459, 1972. 8. Barron J, Fallis LS: Colostomy closure by the intraperitoneal method. Dis Co/on Rectum 1: 466, 1958. 9. Sullivan WG, Miller RE, Eiseman B: Closure of colonic stomas in patients injured in combat. Surg Gynecol Obstet 131: 1045, 1970. 10. Lockhart-Mummery P: Making and closing of colostomy openings. Br A-fedJ 1: 685, 1917. 11. Yajko RD, Norton LW, Bloemendal L, Eiseman B: Morbidity of colostomy closure. Am J Surg 132: 304, 1976. 12. Beck PH, Conklin HB: Closure of colostomy. AnnSurg 181: 795, 1975.
Discussion Allen M. Boyden (Portland, OR): The excitement of the many new advances in surgery in recent years rightfully has held our attention and particularly the interest of our students and residents. Heart surgery, vascular surgery, joint replacement, and transplantation have been on the front burner while the more mundane problems of the general surgeon have lost attractiveness. The authors are to be congratulated for reminding us that great care and fine surgical principles must continue to be applied in whatever area of surgery one deals.
88
It is startling to realize that in recent reviews of colostomy closure, an operation that most general surgeons would consider relatively simple, the complications of fistula, anastomotic breakdown, and wound infection have been so distressingly high. This review of cases from the recent literature, showing complications ranging from 33 to 49 per cent, can only mean that mature judgment and attention to sound surgical principles have been lacking in the care of these patients. In contrast, in the present series there were no fistulas, no anastomotic failures, and less than 2 per cent wound infections. This record will be hard to duplicate. Delaying closure until maturation of the colostomy, planning preoperative bowel preparations, avoiding contamination of the wound, meticulous closure of the carefully prepared stoma or the anastomosis when resection of the limbs is required, avoidance of wound dead space, and thorough irrigation and adequate drainage of the wound have yielded these excellent results and prove the importance of seasoned experience. It has been our practice, in contrast to that of the authors, to use not only mechanical preparation of the bowel and irrigations of both proximal and distal limbs but also oral antibiotics to reduce colonic pathogens to a minimum. We prefer to use neomycin and erythromycin base, following the regimen suggested by Nichols et al (Ann Surg 178: 453,1973). There have been two other recent randomized doubleblind series of cases utilizing oral antibiotics which have corroborated the results of Nyhus and his associates showing significant reduction of wound infections after colon operations. Similarly, the statistically significant effectiveness of parenteral broad spectrum antibiotic administration begun in the immediate preoperative period in reducing wound infections has been demonstrated by a similar randomized series. Therefore, we have added both short-term oral and parenteral antibiotics preoperatively in all colon operations. It has been our practice at The Portland Clinic when protective colostomy is elected to open the loop longitudinally rather than to divide it. This permits simple transverse closure after removing the skin edge and freshening the margins of the stoma and avoids anastomosis which must inevitably carry greater risk. I have not used preliminary inversion of the stoma suggested by the authors, but I do use great care in protecting and irrigating the wound. Intraperitoneal placement of the bowel after closure is most important. Dead space anterior to the fascia may be unavoidable and requires drainage. We use suction tube drains or, when fecal contamination occurs, secondary closure of the skin. We have had no fecal fistulas while following this program. Barium enema of the distal limb must be done routinely prior to closure to prove the integrity of the anastomosis and the absence of distal obstruction. Finally, I would ask the authors to comment on the thirteen patients requiring diverting colostomy because of complications related to prior colonic resection. I must
The American Journal of Sqery
Golostomy
assume that these were necessary because of anastomotic breakdown Or fistulas with or without abscess or peritonitis. If 30, it is again a reminder that colonic anastomoses may be hazardous and should be protected by complementary colostomy at the original operation whenever there is any doubt about the integrity of the suture line. My indications fo:- such protection have included some very low anastoml,ses, uncontrollable oozing in the pelvis near an anastomosis, anastomoses of small caliber due to spasm of the bcwel, or perhaps when resection is required when the bc.wel is unprepared. The side-to-end anastomosis described by Dr. Joel Baker (Arch Surg 61: 143,195O) has proved of great value in improving security of low anastomoses, and with its use I have found complementary colostomy to be required less frequently. Philip R. Westdahl (San Francisco, CA): I want to commend the authors on the success of their colostomy ckrsures. Their technic is well designed and their attention to details rewarding. However, I question the need for colo3tomy as opposed to cecostomy as a decompressing procedure in acute obstruction of the colon. Colostomy always requires operative closure whereas cecostomy rarely does. In 1957 I presented a paper before this association comparing cecostomy and colostomy in the management of’ acute obstruction of the colon at the San Francisco General Hospital. In 1969 I updated our experience to include ninety-three emergency cecostomies for acute obstruction. I would like at this time to read my conclusions in that paper to emphasize my point: “( 1) Tube cecostomy is a safe and simple procedure and is particularly desirable in markedly distended cecum and colon. (2) Direct exposure of the cecum has the advantage of visualizing the most common site of perforation of a markedly dilated large bowel. (3) The risk of peritonitis from spillage at cecostomy is h;.ghly overemphasized. Peritonitis did not occur in any of those 93 cases. (4) Tube cecostomy will effectively decompress and prepare the colon for subsequent resection. (5) The incidence of significant complications after tube cecostomy is no higher than after colostomy. (6) The mortality for acute obstruction of the colon in elderly poor risk patients is abnormally high, but death is rarely due to the cecostomy itself. (7) Tube cecostomy will almost always close spontaneously if given adequate time. The advantage of this feature over colostomy is obvious.” Leon Morgenstern (Los Angeles, CA): We too have been practicing this method of colostomy closure for the past twenty years, performing preliminary closure of the stoma with an interlocking 2-O silk suture. This permits complete mobilization of the stoma with no contamination and also facilitates the peristomal dissection, allowing Allis
Volume 136,July 1979
Closure
clamp “tractors” to be used on the closed stoma. (Slide) ‘One instance in which this technic was not possible was in a patient with a colostomy and with severe portal hypertension due to advanced cirrhosis. The peristomal varices would periodically erupt in spout-like bleeding. Obviously, this method of preliminary closure could not be used because of the bleeding problem. I commend this method of closure as practical, simple, and conducive to minimal contamination and negligible wound infection. John A. Schilling (Seattle, WA): I rise to emphasize the importance of what was stressed in the present study, namely matters of surgical technic in the reduction of wound complications. In view of the remarkable surgical results of our cardiothoracic colleagues, and our own morbidity and mortality statistics that are not nearly as good in certain general gastrointestinal areas, we have to analyze critically what we do in the operating room. Most important is the reduction of organisms. A colostomy that is unsealed introduces organisms (10s to lOs/ml) into the wound. More than lo5 organisms/ml exceeds and overwhelms the body’s defense mechanisms. Thus, irrigation and antibiotics serve to reduce these organisms to fewer than 105/ml so that the patient’s cellular and humoral defense mechanisms can handle them. I would like to emphasize the importance of timing. Any colostomy closure less than three weeks old is still a fresh wound with the flora of a fresh and open wound. We cancel a hernia operation because of a scratch made the night before, and yet we may close a contaminated wound too early. Further, a six week delay provides the opportunity for nutritional and lean body mass repletion so that the patient can mount a better cellular and humoral response. William Garnjobst (closing): Dr. Boyden alluded to the fact that colostomy closure has a reputation for being a simple operation, and I think this is often the cause of its downfall. Dr. Boyden, of the thirteen therapeutic colostomies, at least four were necessitated by instrumental perforations of the colon. The others were mainly for anastomotic complications, including two for distal necrosis after pull-through procedures. Preliminary suture of the stoma has been advocated by others and I was pleased to see Dr. Morgenstern’s nice example of how he does it. Another reason for waiting more than six weeks is the difficulty encountered in preliminary inversion of the stoma prior to’that time due to edema and thickening. Dr. Schilling mentioned the desirability of reducing the concentrations of bacteria within the colon. We do not believe it is necessary to reduce the concentrations of the entire intestine. By cleansing the interior of the stoma, a nearly sterile local condition is obtained. Once the anastomotic line becomes sealed, it does not seem to matter how many bacteria pass through the lumen.
89