Wound management after trauma to the colon

The records of 62 patients with injury of the colon were reviewed to ascertain the contribution of technics in wound care to morbidity. Primarily closed wounds had a very high frequency of infection (56%). Wounds treated by delayed primary closure or secondary intention developed infection in 19% of patients. Infection in an open wound was associated with intraperitoneal abscess in 73% of cases.     

Is colostomy always necessary in the treatment of open pelvic fractures?

BACKGROUND: Wound management in open pelvic fractures has used fecal diversion, debridement, and closure by secondary intention to prevent pelvic sepsis. Colostomy care and takedown adds to the morbidity and resource utilization of this approach. We reviewed our experience to determine if a selective approach to fecal diversion based on wound location was possible. METHODS: Retrospective analysis of patients admitted to a Level I trauma center during an 8-year period. Fractures were classified as open if the fracture was in continuity with the wound. Wounds were classified as perineal if they involved the rectum, ischiorectal fossa, or genitalia, and as nonperineal if they involved the pubis anteriorly, iliac crest, or anterior thigh. Pelvic sepsis was defined as cellulitis, fasciitis, or infection of a pelvic hematoma. Diversion consisted of loop or end colostomy. RESULTS: Eighteen patients with open fractures were identified. Four died from closed head injury and blood loss. The remaining 14 were treated as follows. Five patients with perineal wounds had diversion of their fecal stream. Their Injury Severity Score was 34 +/- 8.3 and their Revised Trauma Score was 7.69 +/- 0.15. No patient developed pelvic sepsis. Nine patients with nonperineal wounds did not undergo diversion. Their Injury Severity Score was 28.6 +/- 5.3 and their Revised Trauma Score was 7.36 +/- 0.45. No patients developed pelvic sepsis in the nondiverted group. CONCLUSION: No patients with anterior wounds and an intact fecal stream developed pelvic sepsis. Colostomy may not be necessary in all patients with open pelvic fracture. Protocols using fecal diversion based on wound location appear to be safe and may decrease resource utilization and subsequent morbidity related to colostomy closure.     

Primary anastomosis in the treatment of acute disease of the unprepared left colon

Between June 1, 1990 and December 31, 1996, 58 consecutive patients with unprepared colons were urgently explored for nontraumatic disease with intent to proceed with primary left-sided colonic anastomosis. Unprotected anastomoses were not attempted in 15 patients. The causes of exclusion included preoperative and intraoperative shock in three patients, and three patients were on long-term high-dose steroids, four had gross fecal contamination of the peritoneal cavity, four had large pelvic abscesses, and one had ischemic colitis. All 43 patients undergoing anastomosis without protective colostomy had stapled anastomoses. Indications included complicated diverticular disease in 32 cases. There were nine cases of obstruction from colorectal carcinoma and one obstruction due to sigmoid volvulus. There was one case of perforation from pseudomembranous enterocolitis. The most common complications were: atelectasis in nine cases, wound infection in two cases, and prolonged ileus in two cases. Pelvic abscess occurred in one case. There was one wound dehiscence. There was one anastomotic dehiscence, and there was no mortality. Operative time averaged 85 minutes and hospital length of stay 9.7 days. Primary anastomosis of the unprepared left colon is safe in most urgent and emergent situations, thus avoiding the significant morbidity and cost of colostomy closure.     

Reversal of Hartmann's colostomy

From January 1980 to December 1992, sixty-two Hartmann's procedures were performed for septic complications of sigmoid diverticular disease, in the Professorial Unit at Aberdeen Royal Infirmary. Colorectal continuity was subsequently restored in 53% of the fifty-three surviving patients. The overall morbidity and mortality was 34% and 0% respectively. There were two anastomotic leaks (7%) while two patients (7%) developed anastomotic stenoses requiring multiple dilations. Closure of Hartmann's colostomy was carried out by consultants (48%), senior registrars (38%) and registrars with consultant supervision (14%). Fifteen anastomoses were hand sewn and fourteen were stapled. Twenty-one per cent of patients had closure of colostomy in less than 3 months, 48% between 3 and 6 months and 31% of reversals were carried out more than 6 months following their formation. The grade of surgeon had no influence on the outcome of reversal. Although the numbers were small, the morbidity was found to be highest in those patients in whom colostomy closure was carried out within 3 months of colostomy formation. Also, there was an increased incidence (7%) of anastomotic stenoses in the stapled anastomosis group.     

Dissecting microscope versus magnifying loupes with transillumination in the preparation of follicular unit grafts. A bilateral controlled study

OBJECTIVE: To review the morbidity and mortality among 68 premature infants treated with enterostomy for necrotizing enterocolitis. DESIGN: Data were collected retrospectively from hospital medical records to include the period between January 1, 1987, and September 30, 1997. SETTING: Tertiary care children's hospital. PATIENTS: A group of 68 infants aged 2 to 35 days (mean age, 12.5 days), weighing 1500 g or less, with necrotizing enterocolitis necessitating surgical enterostomy for treatment. INTERVENTIONS: Creation of any enterostomy during exploratory laparotomy for necrotizing enterocolitis and subsequent closure. MAIN OUTCOME MEASURES: Morbidity and mortality associated with infant enterostomy and its closure. RESULTS: Thirty-nine infants underwent ileostomy with mucous fistula, 16 underwent ileostomy with a Hartmann pouch, 7 had jejunostomy with mucous fistula, 2 had colostomy with mucous fistula, and 4 had colostomy with a Hartmann pouch. Eighteen (26%) of the 68 infants died in the postoperative period of sepsis (n = 10), continuing necrotizing enterocolitis (n = 5), or respiratory distress (n = 3). Of the remaining 50 infants, complications developed in 34 (68%). These complications included strictures requiring further resection at the time of enterostomy closure in 20 infants; stricture of the enterostomy requiring surgical revision in 6; incisional hernia in 3; parastomal hernia in 4; enterostomal prolapse or intussusception in 6 and 1, respectively; wound dehiscence in 4; wound infection in 8; small-bowel obstruction requiring laparotomy in 2; and anastomotic complications in 2. Only 16 enterostomies were closed uneventfully, with 3 of these infants subsequently dying of sudden infant death syndrome between 6 and 8 months after the operation. Of the surviving infants, 3 (6%) continue to require home hyperalimentation. CONCLUSIONS: Although enterostomy in infants with low birth weight with necrotizing enterocolitis may be lifesaving, it is also a major cause of morbidity. These data suggest the feasibility of a prospective study comparing resection and primary anastomosis with resection and enterostomy.     

Intellectual level (IQ) in heterozygotes for phenylketonuria (PKU). Is the PKU gene also acting by means other than phenylalanine-blood level elevation?

Wound infection in 239 patients who underwent cholecystectomy were analyzed retrospectively. Seventeen per cent of the patients with acute cholecystitis had wound infection compared with 8.9 per cent of patients with chronic cholecystitis. Bacteriology of wound infections revealed Staphylococcus aureus in 76.4 per cent of the chronic cholecystitis group and in 12.5 per cent of the acute cholecystitis group. Wound infection in the acute cholecystitis group involved gram-negative rods predominantly. Organisms were isolated from bile culture in 71.4 per cent of acute cholecystitis patients compared with 59.6 per cent of chronic cholecystitis patients. Of patients with positive bile cultures 11.3 per cent had wound infections compared with 6.8 per cent of patients with negative bile cultures. The most common organisms isolated from bile cultures with resultant wound infections were S epidermis, S aureus, and Klebsiella sp. Wound infection after cholecystectomy for chronic cholecystitis arises from external sources and not contaminated bile. Antibiotic therapy should be directed accordingly.     

Colostomy complications in children. An analysis of 146 cases

This report analyzes the course of 146 pediatric patients with colostomies in reference to problems with colostomy formation, management, and subsequent closure. Colostomy was performed predominantly for Hirschsprung's disease (70 cases) and imperforate anus (46 cases). A transverse colostomy was done in 120 patients (82%), and a sigmoid colostomy in the remaining patients. Loop colostomies were five times more frequent than divided colostomies. Early major complications occurred in 24 patients (16%). Stomal complications occurred in 69 patients and were more frequent after loop colostomies. Colostomy revision was required in 24 cases. Sigmoid colostomy had a significantly lower complication rate (P less than .01). One hundred nine patients underwent colostomy closure. Major complications occurred in 16 cases (15%). There were no deaths related to colostomy closure. The use of a sigmoid colostomy when possible and close attention to technical details, principles of stomal care, and proper parental instruction should minimize morbidity.     

A multiparametric computer analysis of carcinoma of the colon

From 1957 to 1973, 656 patients with carcinoma of the entire colon, excluding those with carcinoma of the rectum, were reviewed with the aid of a computer. Of 457 patients, 69.7 per cent were observed for a minimum of five years. Sixty-five per cent of the lesions were located in the cecum or sigmoid colon. In patients with type A lesion, the five year plus survival rate was 71.15 per cent while, in patients with type D lesions, the five year plus survival rate was zero per cent. Patients who presented with intestinal obstruction had a significantly lower five year survival rate. Roentgenographic visualization of the cecum was significantly less accurate in demonstrating carcinoma when compared with that of the sigmoid colon. An emergency surgical procedure had a significantly higher operative mortality than did elective procedures. In both groups of patients undergoing emergency and elective operations, primary resection and anastomosis led to similar operative mortality rates, although staged procedures resulted in the lowest operative mortality in both groups. In the group of patients who had elective operations, resection an primary anastomosis led to a significantly lower wound infection and fistula rate when compared with the group of patients who had emergency procedures. In comparison with other series, no improvement in survival was illustrated in patients with carcinoma of the colon. The use of new modalities of adjuvant therapy, such as radiotherapy or chemotherapy, or both, actually should be evaluated.     

Reversible colostomy--what is the outcome?

PURPOSE: The trend toward avoidance of a colostomy at both elective and emergency large-bowel surgery is partly driven by the perceived morbidity and low closure rates of temporary stomas. The aim of this study was to examine whether significant colostomy-related morbidity remains persistently high. METHODS: To examine this, we reviewed 120 patients with a potentially reversible colostomy performed during either elective or emergency large-bowel surgery during a seven-year period. RESULTS: Forty-seven patients underwent elective and 73 patients underwent emergency colonic or colorectal resection. Fifty-eight patients had colorectal carcinoma (48.3 percent), diverticular disease accounted for 39 patients (32.5 percent), and a miscellaneous group of 23 patients (19.2 percent) made-up the remainder. Seven patients died, all in the emergency group (9.6 percent). Colostomy-related morbidity, which included stenosis, retraction, prolapse, and hernia formation, occurred in 19.2 percent of patients, with no difference between the elective (14.9 percent) and emergency (21.9 percent) groups or underlying pathologic condition. Colostomy closure was performed initially in 71 patients (59.2 percent). Highest closure rates occurred in the diverticular group (84.6 percent), followed by the colorectal carcinoma group (48.3 percent), and then the miscellaneous group (43.5 percent). One patient died undergoing colostomy closure, and complications occurred in 25 patients (35.2 percent), requiring fashioning of a second colostomy in eight patients, two of whom were closed. Final colostomy closure rate was 54.2 percent. CONCLUSIONS: This study confirms the contention that both formation and closure of defunctioning colostomies are associated with significant complications; furthermore, approximately one-half of patients will not have their colostomy closed.     

Endoscopic treatment of postoperative hemorrhage from a stapled colorectal anastomosis

We present the sixth reported case of endoscopic electrocoagulation to successfully treat postoperative hemorrhage from a stapled colorectal anastomosis. A literature review revealed 17 patients with postoperative hemorrhage from a combined total of 775 patients (1.8 per cent) after stapled colorectal anastomosis requiring blood transfusion and/or emergency surgery. Twelve of the 17 cases involved a circular stapler (71 per cent) used during an anastomosis to the rectum (69 per cent). Nonoperative therapy was successful in 14 of the 17 patients (82 per cent), using endoscopic electrocoagulation in six patients (43 per cent) and blood transfusion alone in another six patients (43 per cent). In follow-up there was one death (cardiac) and two anastomotic fistulas (one requiring temporary colostomy) in the nonoperative group. Both anastomotic fistulas occurred following hemorrhage from an anastomosis to the rectum using the circular stapler, one after endoscopic electrocoagulation and the second after blood transfusion alone. In summary, postoperative hemorrhage from a stapled colorectal anastomosis, although rare, is most likely to occur in a colorectal anastomosis constructed with the circular stapler. Nonoperative treatment is usually successful. Endoscopic electrocoagulation may be safely and effectively used in the early postoperative period to cease unremitting anastomotic hemorrhage.     

A study of perineal wound healing after abdominoperineal resection

A comparative study of 53 cases has revealed that a technique of complete primary closure of the perineal wound after abdominoperineal resection of the rectum and anal canal appears to be a superior, more rational approach than other orthodox techniques. (It is unsuitable for any case contaminated with pus or faeces during operation.) Redivac apparatus used through a separate route for continuous drainage from the sacral cavity has made the postoperative care easier for nurses and surgeons and this period more comfortable for the patient. It provides a simple method compared with other suction apparatus used for the same purpose. Of the 53 cases, 12 were operated on using a traditional technique involving the closure of the perineal wound around a tube drain connected to an underwater seal, while in the remaining 41 the approach described here was used. Primary healing of the perineal wound with the later approach was obtained in about 88 per cent. With the other technique the figures were 34 and 66 per cent respectively for early healing within 3 weeks and delayed healing between 3-8 weeks. Primary healing of the perineal wound reduces the total stay in hospital and the morbidity.     

Similarities between pleuropulmonary blastoma and Askin tumor

AIM: The purpose of the study was to determine the risk of postoperative complications and the functional outcome after a hand-sewn ileal pouch-anal anastomosis (IPAA) for ulcerative colitis using a single J-shaped pouch design. METHODS: Preoperative function, operative morbidity and long-term functional outcome were assessed prospectively in 1310 patients who underwent IPAA between 1981 and 1994 for ulcerative colitis. RESULTS: Three patients died after operation. Postoperative pelvic sepsis rates decreased from 7 per cent in 1981-1985 to 3 per cent in 1991-1994 (P = 0.02). After mean follow-up of 6.5 (range 2-15) years, the mean number of stools was 5 per day and 1 per night. Frequent daytime and nighttime incontinence occurred in 7 and 12 per cent of patients respectively, and did not change over a 10-year period. The cumulative probability of suffering at least one episode of 'clinical' pouchitis was 18 and 48 per cent at 1 and 10 years and the cumulative probability of pouch failure at 1 and 10 years was 2 and 9 per cent respectively. CONCLUSION: These results indicate that increased experience decreases the risk of pouch-related complications and that with time the functional results remain stable, but the failure rate increases.     

The role of barium enema in colostomy closure in trauma patients

Recently, the routine use of barium enema preceding colostomy closure in trauma patients has been challenged. It has been argued that the nature of the injury should be apparent from the initial laparotomy and that the likelihood of finding an unsuspected colonic lesion in the young, previously healthy patients who constitute the majority of trauma patients is very small. We retrospectively reviewed 124 consecutive cases of patients who received colostomy takedowns for trauma. One hundred six of the patients had preoperative barium enema evaluation. 87.1 per cent of the examinations were negative, with a subsequent stoma closure complication rate of 20.4 per cent. Of the 13 positive barium enemas, 9 were falsely positive. These patients had a higher stoma closure complication rate of 39 per cent, a fact that could not be explained on the basis of their abnormal studies. The 18 patients who did not have barium enema performed did not have an increase in complications (17.6%). Barium enema failed to uncover unsuspected pertinent diagnoses, often added unnecessary delays and expense, and in no case changed the operative management. Contrast studies were found to be useful in defining anatomy in cases of known fistulas and when the takedowns were performed without the benefit of operative reports from the previous surgery.     

Five-year audit of the acute complications of diverticular disease

BACKGROUND: The objective of this study was to audit the presentation and outcome for patients admitted with an acute complication of diverticular disease. METHODS: This study was a retrospective review of 418 admissions with an acute complication of diverticular disease over a 5-year interval. RESULTS: Of the 418 admissions, 15 patients were eventually found to have an alternative diagnosis. Some 403 patients were studied further. The overall mortality rate in this group was 5.7 per cent. A total of 113 patients (28.0 per cent) required an operation and in this group the mortality rate was 17.7 per cent. All deaths occurred in patients who had surgery for septic complications or bowel obstruction. Of the patients who had surgery, 90.2 per cent had a resection of the involved colon. One-third of these had a primary anastomosis; the remainder underwent Hartmann's procedure. Some 83 patients had a stoma fashioned and of these 72 went on to have the stoma closed. The median age of those who died after operation was 80 years. An American Society of Anesthesiologists (ASA) score of 3 or more, concurrent medical disease and shock on admission were all associated with a high mortality rate (P < 0.001). Some 30 per cent of patients were readmitted during this study with a further complication of diverticular disease. CONCLUSION: The mortality rate after surgery for acute diverticular disease remains excessive and a high-risk group can be identified before operation. A policy of resection and anastomosis appears justified for selected patients. Adopting a practice of interval elective sigmoid colectomy after admission with acute diverticulitis might prevent readmission with further complications.     

Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis

BACKGROUND: Anal sphincter function is increasingly preserved following rectal excision for cancer and provides a better quality of life for patients than does a permanent colostomy. However, anastomotic complications may cause considerable morbidity and mortality. This retrospective study examined the incidence of anastomotic complications following two forms of reconstruction after resection for mid-rectal cancer: colonic pouch-anal anastomosis (CPAA) and low colorectal anastomosis (LCRA). METHODS: Some 258 consecutive patients with mid-rectal cancers between 6 and 11 cm from the anal verge underwent proctectomy with mesorectal excision and either CPAA or LCRA. The incidence of clinical and radiological leaks was determined in these patients who were considered in three groups: LCRA (defunctioning stoma), LCRA (no defunctioning stoma) and CPAA (all defunctioned). RESULTS: In the LCRA group without a defunctioning stoma, a clinical leak occurred in 17.0 per cent, compared with two of 30 in the LCRA group with a defunctioning stoma. In the CPAA group a clinical leak occurred in 4.9 per cent of patients, which was not significantly different from the rate in those with a defunctioned LCRA. Patients with a non-defunctioned LCRA were more likely to suffer a clinical anastomotic leak (P=0.01), peritonitis (P=0.001) and require unscheduled reoperation (P=0.006) than those with a defunctioned LCRA and/or CPAA. CONCLUSION: The use of a protective defunctioning stoma is advocated in conjunction with LCRAs.     

Is colostomy closure a hazardous procedure? A comparison of elemental diet and routine bowel preparation

Morbidity after closure of a colostomy is low if a simple antiseptic technique of intraperitoneal closure is used. In 26 patients there was no example of major wound sepsis and only 2 faecal fistulas both of which rapidly closed spontaneously. A randomized study of preoperative bowel preparation incorporating an elemental diet showed no apparent advantage for this method using our criteria for assessment.     

Expenditure and loss of income incurred by tuberculosis patients before reaching effective treatment in Bangladesh

Fistulae arising from the intestinal tract are associated with significant morbidity and mortality rates. Most contemporary studies of fistulae report mortality rates between 6 and 20 per cent. The major causes of death in these patients are sepsis, electrolyte imbalance, and malnutrition. A total of 48 patients with either external or internal intestinal fistulae were reviewed in this study over a 5-year period at the Louisiana State University Medical Center at Shreveport. Intestinal fistulae were classified into three types, anatomic site, physiologic type, and etiology, to evaluate morbidity and mortality rates. We also attempted to evaluate the role of parenteral nutrition in this patient population, but our data were inconclusive because of the limited number of patients. There was no difference in mortality rates associated with anatomical sites. High-output fistulae were associated with a higher mortality rate compared to low-output fistulae. Fifty-six per cent of the patients achieved closure. The overall mortality rate was 21 per cent. Spontaneous closure rates were lower when compared to those in other studies. This was attributed to sepsis, malignancy, and history of previous radiation therapy. Management of intestinal fistulae includes control of sepsis, correction of electrolyte disturbances, nutritional support, and operative intervention if necessary.     

Audit of colorectal cancer surgery by non-specialist surgeons

BACKGROUND: Some authorities recommend that colorectal cancer should be treated in specialist units but evidence that non-specialist units demonstrate comparatively poor results may be lacking. METHODS: Between 1987 and 1991, 267 patients were operated on by four general surgeons, none of whom was a specialist in colorectal surgery. Procedure-related complications, postoperative mortality and disease-related survival rates were analysed. RESULTS: There were four cases of intraperitoneal sepsis (1 per cent) and five of 189 patients (3 per cent) had clinical anastomotic dehiscence; there was no case of wound dehiscence. The postoperative mortality rate after elective and emergency surgery was 2 and 13 per cent respectively. The 5-year disease-related survival rate for curative and palliative surgery was 67 and 9 per cent respectively. There were no significant differences between the surgeons. CONCLUSION: Disease-related variables such as early-stage disease and fewer patients presenting as emergencies may have a greater favourable influence on ultimate survival than surgeon-related variables.     

Subtotal colectomy with primary ileocolonic anastomosis for obstructing carcinoma of the left colon: valid option for elderly high risk patients

During a period of 4 years, 20 patients with obstructing carcinoma of the left colon were treated by subtotal colectomy with primary ileocolonic anastomosis. Thirteen patients (65%) were 65 years of age or older. All patients presented to the emergency room with large bowel obstruction. Twelve patients (age > 65) suffered other systemic diseases (chronic obstructive pulmonary disease, ischemic heart disease, morbid obesity), placing them in a high risk category. The mortality rate was 5% (1/20), 7.6% if only high risk patients are considered. The one-stage procedure in the treatment of obstructing carcinoma of the left colon offers the patient a number of advantages over stage intervention elimination of colostomy, namely removal of occult lesions in the resected colon, shorter hospitalization and low morbidity and mortality. We found this procedure to be a valid option also in the elderly (> 65) high risk patient. Metastatic disease in our view is not a contraindication, since the elimination of colostomy will improve the quality of life of these patients.     

Protective transverse loop colostomy associated with low colo-rectal anastomoses

A transverse loop colostomy to protect a low colorectal anastomosis should be carried out with minimal morbidity and mortality related to its creation and closure. A modification of the conventional technique is described.