The morbidity and cost of the temporary colostomy

Incidence, recurrence and risk factors of hernias following stoma reversal

BACKGROUND

To determine the incidence and risk factors for stoma site (SSH) and incisional (IH) hernias following stoma reversal as well as their recurrence following repair.

METHODS

A cohort of VA Surgical Quality Improvement Program patients undergoing stoma reversal from 2002 to 2014 were evaluated at a single institution. Variables were selected a priori and evaluated by univariate analyses.

RESULTS

Of 114 stoma reversals, 63 utilized a midline approach. The incidence of SSH and IH was 9.6% and 31.7% over a median follow-up of 5.7 (0.5-14) and 4.0 (0.1-14) years, respectively. Five SSH and 10 IH were repaired with no recurrences. Myofascial release and superficial surgical site infections (SSI) were associated with SSH while body mass index, preoperative radiotherapy, American Society of Anesthesiologists classification ≥3, operative duration ≥2.5 h and deep SSIs were associated with IH.

CONCLUSIONS

Incisional hernia incidence after stoma reversal is high for both the stoma site and midline. Risk factors differ for each hernia type. A low recurrence rate exists in short term follow-up following repair of a hernia occurrence.

Colon and rectal injuries

PURPOSE

This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature.

METHODS

Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers.

RESULTS

A total of 203 articles were considered relevant.

CONCLUSIONS

The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.

Iatrogenic injuries in gynecologic cancer surgery

Iatrogenic injury is always an unwelcome event at the time of surgery. Prior history of multiple laparatomies, radiation therapy, or a distorted pelvic anatomy caused by a malignancy are all factors that may make iatrogenic injury a likely event. In these situations, complications at times can be considered unavoidable. Injuries during benign surgical procedures also can be difficult to manage, especially if not diagnosed at the time of occurrence. Operative knowledge to manage the more commonly encountered complications must be in the repertoire of all surgeons, including those dealing with abdominopelvic malignancies. This article reviews the more common genitourinary, gastrointestinal, and neural injuries encountered during gynecological surgical procedures and discusses basic management strategies.

Complications of abdominal stoma surgery

PURPOSE

This study was undertaken to review and summarize the complications of ileostomy and colostomy creation and subsequent closure.

METHODS

The English-language medical literature for at least the past 15 years was reviewed comprehensively.

RESULTS

Complications of surgery for the creation of end, loop, and "end loop" stomas are presented. Technical factors, which might influence complication rates, are discussed. Optimal management of ostomy complications is presented, especially for peristomal hernias. Similarly, techniques and complications for stoma closure are analyzed.

CONCLUSIONS

Stoma creation is not a trivial undertaking; careful surgical technique minimizes complications (which are relatively frequent), and promotes good ostomy function. Peristomal hernias are difficult to cure permanently. The morbidity of ileostomy and colostomy closure is also appreciable.

Primary repair of colon injuries: a prospective randomized study

Due to the results of a 6-year experience with civilian penetrating colon injuries at Mount Carmel/Grace Hospital, in Detroit, Michigan, which had favored primary repair of colon injuries, a prospective randomized study was performed. Seventy-one patients with penetrating colon injuries were entered in a prospective randomized study. Forty-three patients were treated with primary repair or resection and anastomosis, and 28 patients were treated with diversion. The average Penetrating Abdominal Trauma Index score was 25.5 for the primary repair and 23.4 for the diversion groups. The majority of injuries as assessed by the Colon Injury Score (CIS) for the primary repair group were grades 2 (58%) and 3 (28%). The diversion group predominantly had grades 2 (64%) and 3 (25%). There was no significant difference between the two groups. There were 8 (19%) patients with colon and noncolon-related complications in the primary repair group, and 10 (36%) patients with colon, noncolon, and colostomy-related complications in the diversion group. In addition, there were 2 (7%) patients with complications following colostomy reversal. Independent risk factors for adverse outcomes were compared and used to calculate the probability for adverse outcomes with respect to the mode of treatment. The probability for adverse outcomes was statistically greater in the diversion group. An analysis was also made within the primary repair group comparing the subgroups of primary repair with, and without, resection of colon. It appears that the primary repair with resection of colon may have fewer complications; however, this conclusion is based on a statistically insufficient sample size. The authors contend that primary repair or resection with anastomosis is the method of choice for treatment of all penetrating colon injuries in the civilian population despite any associated risk factors for adverse outcomes.

Same admission colostomy closure (SACC). A new approach to rectal wounds: a prospective study

OBJECTIVE

The purposes of this project were to study the healing of protected rectal wounds (RWs) using contrast enemas (CEs) and to establish the safety of same admission colostomy closure (SACC) in terms of colostomy closure (CC) and rectal wound-related outcomes, for selected patients with radiologically healed RWs.

SUMMARY BACKGROUND DATA

Traditional treatment of RWs has included a diverting colostomy that is closed 2 or more months later during a readmission.

METHODS

All patients admitted with a rectal injury were entered into this prospective study, treated with a diverting colostomy and presacral drainage, and managed according to a postoperative protocol that included a CE per anus to detect healing of the RW. Patients with no leaking on their first CE, no infection, and anal continence underwent SACC.

RESULTS

From 1990 to 1993, 30 consecutive patients had rectal injuries, 90% of which resulted from gunshot wounds. The first CE was performed in 29 patients 5 to 10 days after injury. In this group, 21 patients did not and 8 did have leakage from their RWs. The proportions of RWs radiologically healed at 7 and 10 days after injury were 55.2% and 75%, respectively. Sixteen patients with a normal CE underwent SACC 9 to 19 days after injury (mean, 12.4 days). There were two fecal fistulas (2 of 7; 28.6%) after simple suture closure, none (0 of 9) after resection of the stoma with end-to-end anastomosis, and no RW-related complications after SACC. The mean hospitalization time was 17.4 days.

CONCLUSIONS

The following conclusions were drawn: (1) CE confirmed healing of RWs in 75% of patients by 10 days after injury; (2) 60% of patients with RWs were candidates for SACC, and 53% were discharged with their colostomies closed; (3) SACC was performed without complications in 87.5% of patients with radiologically healed RWs; and (4) there were no RW-related complications after SACC.

Laser therapy of colorectal carcinoma

A plethora of literature is available demonstrating the efficacy of Nd:YAG laser therapy for obstructing or bleeding colorectal cancers. The in-hospital mortality and morbidity rates can be reduced when Nd:YAG laser therapy is used to avoid operative diversion prior to resection and anastomosis. The Nd:YAG laser used to control bleeding or obstruction in those patients with either widely metastatic or unresectable locoregional disease has been successful in the majority of patients and has been associated with minimal morbidity and mortality rates. This laser may be the only treatment modality that may substitute for operative diversion in hopeless clinical situations such as hemorrhage or obstruction in patients with advanced disease. The utility of photodynamic therapy for colorectal cancer will require definition in further controlled trials.

Endoscopic Nd:YAG laser in the palliative treatment of advanced low rectal carcinoma in Singapore

We used the Nd:YAG laser to palliate symptoms of bleeding and obstruction in 27 cases of rectal carcinoma. Twenty of these patients had advanced inoperable rectal carcinoma, three were at high surgical risk, and four refused surgery. Obstructive symptoms were the main complaint in 10 cases, while 17 patients presented with bleeding. Good palliation of obstructive symptoms was achieved in all obstructive cases with one laser treatment session. However, bleeding tumors required an average of two sessions for complete hemostasis. There were no major complications; minor complications of bleeding after treatment occurred in two patients. Good symptomatic relief was achieved in all cases. The mean survival for all patients was five months. Nd:YAG laser therapy is a safe and efficacious means for palliation of obstructive symptoms and bleeding in advanced rectal carcinoma.

Protective colostomy closure: the hazards of a "minor" operation

A retrospective study of 87 patients, subjected to colostomy closure between 1976 and 1987, was conducted in order to evaluate the role of 8 potential risk factors on morbidity and mortality. Possible risk factors were age greater than 65 years, presence of hypoalbuminaemia (less than 3.0 gr%), anaemia (Hb less than 10 gr%), operative technique, duration of colostomy, site of colostomy, underlying disease and presence of subcutaneous drainage. Apart from hypoalbuminaemia, no clear risk factor was identified, although an interval of more than 90 days between construction and closure of colostomy appears to be safer than shorter intervals. A comparison was also made between two different periods from 1976 to 1982 and from 1983 to 1987 which resulted in important changes in patient management in the second period including: type of antibiotic prophylaxis, type of anastomosis and suture material, site of colostomy and mean duration of colostomy. Four post-operative deaths (4.6%) (two for myocardial insufficiency and two for sepsis), 11 major (13%) and 25 (29%) minor complications were recorded. The analysis of the two different periods showed a strong reduction in both mortality and morbidity in the second period, which could be related to a better management of this type of patient. In conclusion, the incidence of mortality and morbidity in colostomy closure cannot be underestimated and therefore the same skill and meticulous approach are required for this operation as for any major surgical procedure on the colon.

Colorectal anastomotic healing and intracolonic bypass procedure

Intestinal anastomoses continue to be complicated by leakages even in the best of hands despite the development of new surgical techniques, suture materials, devices, and stapling instruments. One may explain such persistence of anastomotic leakage on the basis of the dynamic effect that multiple factors have on the healing of an anastomosis. Awareness of these factors and proper precautions by the surgeon can make a high-risk anastomosis less prone to leakage. The intracolonic bypass procedure is an alternative to a temporary colostomy. It does not prevent an anastomotic dehiscence but can prevent anastomotic leakage with its associated complications in those situations where dehiscence is most likely to occur.

Analysis of the morbidity, mortality, and cost of colostomy closure in traumatic compared with nontraumatic colorectal diseases

One hundred sixteen patients with acute colorectal diseases, operated upon emergently and needing an intestinal stoma, were reviewed to determine the cost and morbidity of treatment of patients with colorectal trauma compared to other surgical illnesses. The first group (57 patients) perforating colonic or rectal trauma, the second (30 patients) perforated colonic disease, the third (24 patients) nonperforated colonic disease, and the fourth (five patients) a colonic injury, unrecognized initially but requiring subsequent treatment with a stoma. For the initial operation, hospital stay, complications, mortality, and costs were less for patients in group 1 (colonic injury) than in groups 2 and 3 (inflammatory or neoplastic diseases). Colostomy closure, whatever the antecedent disease or injury, required an average ten-day hospitalization, had no mortality, a complication rate of 0 to 6 percent, and an average hospital cost of $6,500. The hospital stay and costs for the total treatment were slightly higher for nontraumatic illnesses, although the rate of colostomy closure was significantly less (68 and 77 percent versus 86 percent, P = .05).

Indications for endoscopic neodymium-YAG laser treatment in the gastrointestinal tract. Twelve years' experience

Application of clinical endoscopic Nd:YAG laser (lambda = 1.06 micron) therapy has been introduced in 1975. It is suitable to stop all kinds of gastrointestinal bleeding with a primary success rate of 94% (1144/1212). Compared to surgical results a reduction in mortality rate has been achieved. These results have been confirmed worldwide in routine clinical application and in controlled trials with selected patients. Potential bleeding lesions such as Osler haemangiomas and angiodysplasias can be sealed. Recanalization of inoperable obstructed oesophageal and gastric carcinoma by laser vaporization to relieve dysphagia and subsequently endoscopic iridium after loading irradiation show a medium survival time of 7.4 months. Preoperative recanalization of obstructed colorectal carcinoma to relieve ileus or subileus allows preoperative peroral bowel lavage and total colonoscopy to find synchronous cancers and polyps and to perform primary resections without intraoperative colon lavage. Sessile benign neoplastic polyps can be resected curatively by Nd:YAG laser vaporization. Recanalization of peptic stenosis and anastomotic scar stenosis can be performed.

Raising a colostomy--results of a prospective surgical audit

A prospective surgical audit of all colostomies fashioned over a 1-year period in one hospital was conducted. Of one hundred and ten colostomies there were 56 loop and 52 end stomas. Following the formation of the colostomy a proforma was completed and the surgeon interviewed to document the precise surgical technique employed. Whilst in hospital the patients were regularly reviewed and the colostomies assessed by a surgeon and stomatherapist using a scoring system. Follow up was continued until closure of the colostomy or for a minimum period of 1 year. Only 53 (48%) of patients saw a stomatherapist preoperatively. This rate was higher in elective (86%) than in urgent cases (15%). The surgial technique used did not appear to influence the outcome of any given colostomy. However, failure to cruciate the posterior rectus sheath may predispose to stomal stenosis and the use of a subcutaneous polyethylene rod to support a loop colostomy often led to infection. Tension of the colostomy led to complications in 29 cases (26%), this was often the precipitating event to other complications and led to the only colostomy-related death. Registrars with experience of fewer than 5 colostomies received their training largely from other registrars rather than consultants. This prospective surgical audit has disclosed that fashioning a colostomy carries significant stoma related morbidity, most of which is potentially avoidable. Appropriate audit can contribute to the maintenance and improvement of surgical standards.

Temporary colostomy--an outmoded procedure? A report on the intracolonic bypass

The intracolonic bypass is a procedure preventing the gastrointestinal secretions and fecal contents from coming into contact with an anastomotic closure site without interrupting the intraluminal continuity of fecal flow from proximal to distal colon. Experimental and clinical data have indicated that the intracolonic bypass can protect such an anastomosis, in the presence of maximal colonic loadings, dehiscences, and fecal peritonitis. This single stage procedure obviates the necessity for construction and subsequent closure of a temporary colostomy in situations where it is currently indicated; the morbidity, mortality, psychologic problems, and economic costs associated with these multiple procedures are avoided. Sufficient experience now has been gained to recommend the intracolonic bypass as a viable alternate to temporary colostomy.

Complications of colostomy closure

A series of 126 colostomy closures was analyzed to evaluate factors contributing to morbidity. There were no deaths, but there was a 33 percent complication rate. Patients with penetrating abdominal trauma and foreign-body rectal perforations had fewer serious complications following colostomy closures than patients with diverticulitis or cancer. No significant difference was found in the anastomotic leak rate, length of surgery or length of hospitalization in patients with sutured or stapled anastomoses. Most patients in this series had end colostomies that required limited resection and anastomoses. Complication rates were comparable with previous series, which consisted predominantly of loop colostomy closures. The incidence of surgical complications was not related to the time interval between colostomy formation and closure. Timing of closure, however, significantly influenced the complication rate in two specific patient groups: patients with intraperitoneal colon perforation at the initial procedure when closure was performed within four weeks, and patients with surgical complications at the time of colostomy creation if they underwent closure within eight weeks. Early closures in patients still recovering from colostomy complications were associated with the highest incidence of anastomotic leak. Wound infections at stoma sites were decreased by leaving the skin open. The average hospitalization was 11.1 days for patients without complications, 15.5 days for those with wound infection, 18.5 days for patients with ileus, and 20.4 days for patients with anastomotic leaks. This study illustrates that the optimal time for colostomy closure must be determined on an individual basis. The morbidity can be minimized by delaying closure in specific groups of patients for one to two months. Delaying closure for an arbitrary time interval in all patients, however, is not warranted.

Changing patterns in colostomy closure: the Bristol experience 1975-1982

The results of colostomy closure in 113 patients (1975-1982) were examined to determine whether the identification of risk factors or improvements in surgical management had made this procedure safer. Overall mortality was low (0.9 per cent), but faecal fistulas occurred in 16.5 per cent and the incidence of wound infection was high (34 per cent). Comparison of the first and second 4 year periods shows recent improvements in the rates of wound infection (24 versus 51 per cent: P less than 0.01) and anastomotic leakage (10 versus 30 per cent: P less than 0.05). A long delay (greater than 6 months) between creation and closure of the colostomy was associated with an increased incidence of postoperative diarrhoea compared with shorter periods of defunction (38 versus 14 per cent: P less than 0.01). The morbidity of colostomy closure is decreasing but remains an important clinical problem.

Prevention and treatment of intestinal dehiscence by an intraluminal bypass graft

The most important cause of morbidity and mortality in the surgery of the colon, rectum and oesophagus is dehiscence. An experimental study to investigate a method of protecting intestinal anastomoses/dehiscences by an intraluminal bypass graft was carried out. This was accomplished by the implantation of a soft tube (graft) in the proximal intestine above the proposed anastomosis/dehiscence, which conducts the salivary, gastrointestinal secretion, food and faecal stream past the anastomosis/dehiscence into the distal intestine; these contents are thereby prevented from coming in contact with the anastomosis/dehiscence. Intestinal continuity is then completed. The graft is expelled spontaneously after a varying time. In the face of gross anastomotic dehiscences, faecal peritonitis and mediastinitis, primary healing without leakage occurs. A clinical study has been instituted.

Intracolonic bypass by an intraluminal tube. An experimental study

The most important cause of morbidity and mortality in colonic resection remains anastomotic leakage and, to this end, temporary stomas, with their own incidence of mortality or morbidity, are often created. Problems associated with both anastomosis and stoma can be prevented with the use of an internal bypass tube. This tube is implanted in the proximal colon above the proposed anastomotic site, then passed distally to the rectal ampulla, following which, the proximal and distal colonic segments are anastomosed. The fecal stream and gastrointestinal secretions are there by prevented from coming in contact with the anastomotic site. The tube is expelled spontaneously after a varying time. The anastomoses in the experimental animals were subjected to maximal stress. Additionally, large dehiscences and induced fecal peritonitis were purposefully created in some animals. Results demonstrated that the intracolonic bypass tube prevents leakage even from gross dehiscences and that these dehiscences progress to complete healing. The experimental study leading to its clinical adaptation is presented.

Early local complications following colostomy closure in cancer patients

Early surgical complications following colostomy closure in 65 cancer patients operated on at the Istituto Nazionale Tumori of Milan were evaluated retrospectively. The overall complication rate was 24.6 per cent, including infections (13.8 per cent), fistulas (6.1 per cent), wound dehiscence (3.0 per cent), and distal stenosis (1.5 per cent). Type and rate of complications were analyzed to find a correlation with type, site, and location of colostomy, technique of closure, presence or absence of drains, or time interval between construction and closure of colostomy. No statistically significant association between the aforementioned factors and occurrence and rate of complications was found. The authors think, therefore, that surgical attention, including meticulous manipulation of the stoma, avoidance of contamination of the wound, tension of sutures, dead spaces, and collection of blood in the wound, and use of antibiotics and antiseptics are the most important principles to minimize postoperative complications.

Factors affecting the morbidity of colostomy closure: a retrospective study

The use of a temporary colostomy is essential in the management of trauma, carcinoma, iatrogenic perforations, diverticulitis, and a number of congenital anomalies of the colon. Closure of a colostomy can be associated with a significant complication rate and even mortality and should not be considered a minor procedure. This is a retrospective study of 114 patients undergoing closure of colostomy, in which an attempt was made to investigate and single out the factors determining complications of colostomy closure. The results point toward timing and technique of closure as the two main factors determining complications associated with colostomy closure.

[Morbidity and mortality following intraperitoneal closure of transverse loop colostomy (author's transl)]

The postoperative course of 104 patients, who underwent closure of a transverse loop colostomy at the Surgical Department of the Teaching Hospital Herford between 1974 and 1980 after distal resection and anastomosis of the large bowel for neoplastic or diverticular disease has been reviewed in detail. The mortality was 0.9% and the morbidity rate was 25%, including 25% wound infections and 4.8% fecal fistulas. The highest complication rate was noted, when colostomies were closed during the first 6 weeks. Wound infections and fecal fistulae did not occur more frequently than in patients with diverticulitis. The intraperitoneal procedure of transverse loop colostomy closure can be recommended as to be straightforward and safe.

Proximal fecal diversion: review of ten years' experience

In a retrospective study, the clinical course of 250 patients subjected to 257 transverse colostomies was reviewed in an effort to evaluate the problems associated with proximal fecal diversion. Morbidity following stomal construction was 28 per cent, with a significant increase when performed in infants or as an emergency. Two-thirds of the colostomies were emergencies, chiefly due to obstruction and free perforation which was associated with a mortality rate of 12 and 48 per cent respectively. In 102 patients undergoing definite colorectal resection with a previous or simultaneous transverse colostomy, the overall morbidity rate was 58 per cent including a leakage rate of 22.5 per cent. Despite a proximal defunctioning colostomy, surgical intervention was required in 12.7 per cent with a fatal outcome due to peritonitis in 3.9 per cent. Colostomy closure was associated with a morbidity rate of 57 per cent, comprising a leakage rate of 10 per cent and a mortality rate of 1.7 per cent. Apart from incurable cancer and deaths prior to closure every third patient kept the transverse colostomy permanently. Advanced age and poor condition of patients not proceeding to a definite treatment, or an underlying benign lesion were the three most determining factors. The present results indicate a too extensive use of transverse colostomy, emphasizing the need for a circumspect initial selection of patients for diversionary procedures.

Morbidity and mortality following intraperitoneal closure of transverse loop colostomy

A retrospective analysis of 153 patients having intraperitoneal closure of transverse loop colostomies was performed. The mortality was 1.4 per cent. The morbidity rate was 15 per cent, including 7 per cent wound infection was not significantly improved by the use of systemic or nonabsorbable intestinal antibiotics. Intraperitoneal drainage resulted in the highest rate of wound infection. However, the use of intraperitoneal drains seems justified for the control of fecal fistula if it should occur. The lowest incidence of complication was noted when colostomies were closed in 2--4 months. Particular attention must be given to cases with diverticulitis as these have a greater morbidity. Factors which reduce morbidity appear to be directly related to clean and careful dissection of the bowel with a sound technique of anastomosis.