|Year : 2020 | Volume
| Issue : 3 | Page : 118-124
Technique, timing, and wound management of closure colostomy
Aamer Qais Kamil1, Raafat Ahmed Al-Turfi2, Sinan Shawkat Hamid2
1 Department of Surgery, Al-Yarmook Teaching Hospital, Baghdad, Iraq
2 Department of Surgery, Gastroenterology and Hepatology Teaching Hospital, Baghdad, Iraq
|Date of Submission||26-Feb-2021|
|Date of Acceptance||22-Jun-2021|
|Date of Web Publication||19-Jul-2021|
Dr. Raafat Ahmed Al-Turfi
Department of Digestive Surgery, Gastroenterology and Hepatology Teaching Hospital, Baghdad
Source of Support: None, Conflict of Interest: None
Introduction: Colostomy closure is an operation frequently performed in surgical practice, despite its benefits, it can produce significant morbidity and mortality. We have focused on the complications related to this surgery in regard to the closure technique and the optimal time for stoma closure and on the proper wound management in the postoperative period.
Patients and Methods: Ninety-six patients were male between 17 and 53 years (median 35), they have been subjected to colostomy closure surgery in single-layer (52 cases) and double-layer (44 cases) closure techniques according to the surgeon preference. The interval time for colostomy closure was more than 3 months in 56 cases, while the interval time was <3 months in 40 cases, and a primary wound closure for 87 cases and delayed (after few days) wound closure for 9 cases. The colostomies were created following penetrating abdominal trauma at Al-Yarmouk Teaching Hospital in a period between October 2003 and October 2007.
Results: The total number of complications was 26 (27.08%), as fecal fistula 10 cases and wound infection 16 cases. Colostomy closure more than 3 months interval had 12.5% postoperative complications versus 47.5% if <3 months interval. Regarding single-layer anastomosis, 3.84% developed fecal fistula and (11.53%) developed wound infection versus 18.18% and 22.72%, respectively, in double-layer anastomosis group. No case developed wound infection with delayed wound closure versus 16 cases (18.39%) in primary wound closure.
Discussion: The incidence of complications was more in double-layer (continuous) technique of closure colostomy versus single layer. While if the interval time for stoma closure is 3 months and more, it would give good results. Regarding wound management, delayed primary wound closure resulted in a better wound healing than the conventional skin closure technique.
Conclusion: Based on this experience, we believe that colostomy closure can be performed with minimal morbidity and would result in a successful surgical outcome. Providing a meticulous technique used by a single layer (continuous seromuscular sutures plus stay sutures) anastomosis, more than three months interval time and a delayed wound closure the outcome will be much better.
Keywords: Bowel anastomosis, colostomy, colostomy closure, fecal fistula, wound closure, wound infection
|How to cite this article:|
Kamil AQ, Al-Turfi RA, Hamid SS. Technique, timing, and wound management of closure colostomy. Saudi Surg J 2020;8:118-24
| Introduction|| |
Between the years 2003 and 2005, there was an increase in the number of cases admitted to our department at Al-Yarmouk Teaching Hospital due to penetrating injuries that needed colostomy to be performed for severe colonic injuries.
As the intestines are the most commonly affected organ by penetrating and blunt trauma, it is interesting to focus on colostomy and the method of colostomy closure and the possible complications related to this surgery, and what are the proper steps to avoid these complications in such patients.
In 1710, a French surgeon Alexis Littre described the death of 6-day-old infant with an imperforated anus as a result of rectal atresia and suggested the formation of an intestinal stoma as a method of treating this birth defect. In France in 1776, following his plan rather than relying on the long arm coincidence, H. Pillore was able to perform the first-ever colostomy. It was only in 1793 when a newborn with a proctatresia was successfully operated on for the first time. C. Duret created a colostomy in the left iliac region of a 4-day-old infant, who went on to live with colostomy for 45 years.
An ongoing increase in studies regarding anastomotic healing can be found in literatures, and despite extensive observational and experimental research in animal models and in humans, the incidence of anastomotic leak has remained unchanged. We believe that this is largely because causal factors leading to colorectal anastomotic leak are still not recognized.
Historically, two-layer anastomosis has been the conventional method for most surgical situations, but it is tedious, time-consuming and there is a potential risk of anastomotic stricture formation. Recently, single-layer continuous anastomosis using monofilament suture has been adopted by many surgeons due to reports describing its cost-effectiveness, less time consumption, and no increase in rates of leakage as compared to double-layer method.
The morbidity after subsequent colostomy closure varies widely; there are risk factors responsible for high wound complications rate which may result from colostomy closure. It is found that adequate bowel preparation, secondary suture of the wound, and delaying of colostomy closure for 2–3 months after the initial procedure may reduce the high wound morbidity. Due to the significant difference in complication rates between intervals from formation to closure of a colostomy, all patients should have their colostomies closed only after a minimum of 90 days has elapsed. Hence, closure of colostomy should not be considered a minor procedure, it requires the same standards of surgical care as any anastomosis of the large intestine.,
There are man conditions that predispose to the leak such as poor blood supply, bad surgical techniques, impairment of general condition of the patient (anemia, diabetes, corticosteroid therapy, and hypoalbuminemia), or advance age.
Fecal fistula may heal following a conservative management and after correction of general condition of the patient, provided that the patient has positive bowel motion and the bowel distally is patent as proved by contrast enema that was done preoperatively. Continuous fecal fistula that is not responding to conservative measures requires exploration (refreshing the two edges and re-anastomosis).
The aim of our study is to focus on fecal fistula and wound infection as complications of colostomy closure, other complications such as incisional hernia, intestinal obstruction, and intra-abdominal sepsis have not come a crossed.
| Patients and Methods|| |
Patients included in this study were 96 patients, subjected to closure colostomy surgery at Al-Yarmouk Teaching Hospital, in a period of 4 years between October 2003 and October 2007, all of them are males, between the ages of 17 and 53-year-old (median = 35). The duration of hospital admission was from 6 days to 18 days (mean = 12). The time interval between the original surgery (colostomy) and colostomy closure was from 2 to 6 months (mean = 4).
Of those 96 patients who had colostomies due to penetrating injuries, the mechanism of the traumas was as follows: 58 cases due to bullet injury (60.41%), 28 cases due to shell (blast) injuries (29.16%), 8 cases due to stab wounds (8.33%), and only 2 cases due to road traffic accidents (2.08%) [Table 1].
|Table 1: Demography, duration of admission, interval of closure, and the causes of original trauma|
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Informed written consent was obtained from all the patients and their relative after explaining the operating plan and its risks. This research was approved by the ethical committee in Al-Yarmook Teaching Hospital.
Most of the patients had bowel preparation by clear fluid oral diet for 24 h before surgery and nil by mouth at the night before the surgery in addition to frequent bowel enemas (two to three times a day) including the stoma site and distally (through the anus), with the use of antimicrobial prophylaxis as metronidazole 500 mg orally (twice daily), and preoperatively intravenous third generation cephalosporine before skin incision. Contrast enema was done to all of the patients 10–14 days before the operation by injection of a contrast medium to the distal limb (per anus), followed by radiographs to detect the patency of the distal limb or the stump.
Of those 96 patients, the types of colostomies they had as follows:
Forty-two patients had loop colostomy (43.75%), 40 patients had Hartmann's colostomy (41. 66%), eight patients had mucous fistulas (8.33%), and six patients had cecostomy (6.25%) [Table 2]. The sites of the original colostomies were as follows: sigmoid colon: 42 cases, transverse colon: 32 cases, left colon: 16 cases, and 6 cases in which the cecum was involved [Table 2].
Methods of closure
Intraperitoneal colostomy closure: an elliptical skin incision is made around the stoma leaving a cuff of skin of about 1 cm, the bowel is separated from the layers of abdominal wall by sharp dissection as far as the peritoneum, while dissection continues, the bowel ends clamped. The edges of the opening in the colon, on which there is still a narrow margin of skin attached, are excised (trimmed).
The defect in the colon at its anterior wall is repaired by sutures placed in the anterior wall of the bowel (in case of blow out loop colostomy), or if we have two ends, so end-to-end anastomosis by either a single-layer seromuscular continuous + interrupted stay sutures, using a delayed absorbable sutures (braided polyglactin 2/0 or 3/0), OTHER group repair by double layer continuous full-thickness anastomosis inner and outer layers using braided polyglactin sutures 2/0 or 3/0.
Colostomy closure in single layer was done in 52 cases (54.16%) and double-layer closure was done in 44 (45.83%) [Table 3].
The wound either closed primarily in 87 (90.62%) cases and in 9 (9.37%) cases, the wounds were packed with gauze wrung with povidone iodine solution for 3–4 days before closure (delayed type of wound closure).
In patients who developed fecal fistula, fistulogram was done by injecting the fistula with contrast medium followed by radiographs to prove the fistula and to find out the length and the direction of the track, while computed tomography scan and/or magnetic resonance imaging were done to detect the site and the extent of the fistula tract.
| Results|| |
The total number of complications in the study was 26 cases (27.08%). Those who had colostomy closure in double-layer anastomosis were 44, 18 cases (40.90%) of them developed postoperative complications. While of the 52 cases had single-layer anastomosis, eight cases (15.38%) had postoperative complications [Table 3] and [Figure 1].
|Figure 1: Cases of complications related to single- and double-layer closure|
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Patients who developed fecal fistula were 10, eight of them (80%) had double-layer closure (one Lt. colon loop colostomy, two sigmoid loop colostomy, and two Hartmann's of the sigmoid colon and three mucous fistulas of the transverse colon). Moreover, two cases (20%) developed fecal fistula with single-layer closure (one Hartmann's colostomy and one with sigmoid loop colostomy) [Table 3].
In those 10 cases of fecal fistulae, the interval of colostomy and colostomy closure was <3 months. Six cases ended with re-colostomy, four cases with fecal fistula needed redo surgery (by refreshing of bowel edges and re-anastomosis) after no response to conservative treatment for about 3 weeks.
Four patients with single layer of end-to-end anastomosis after Hartmann's procedure had a minimal leakage of fecal matter from the peritoneal tube drain between day 3 and day 6 postoperatively, then stopped spontaneously. Bowel action was positive between 5 and 8 days (mean = 6.5) postoperatively.
The total number of complications in closure <3 months was 19 (47.50%), and in closure time, more than 3 months was 7 (12.50%) [Figure 2].
The total numbers of cases who developed wound infection was 16, all of them in primary wound closure group, [Figure 3] of those patients three were diabetes on oral hypoglycemic drugs.
|Figure 3: Cases of wound infection related to primary wound closure and delayed primary wound closure|
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Only one patient with wound infection required wound debridement under general anesthesia and his wound left opened.
The rest of those cases of wound infection responded to conservative treatment.
Nine patients had a delayed primary wound closure after 3–4 days following the operation of closure colostomy and none of them had any wound infection [Table 3].
In those cases of wound infection, their conditions started 4–6 days (mean = 5) postoperatively as a local erythema and edema of the skin with discharge at the suture line and four patients developed abscesses plus wound disruption.
Of those 16 patients with wound infection, ten (62.50%) had double-layer method of closure colostomy, of them three had sigmoid loop, one had transverse colon loop, four had Hartmann's colostomy, and two had mucous fistula. Six patients (37.50%) had single-layer method of closure colostomy (two had sigmoid loop, one had transverse colon loop, two had Hartman's colostomy, and one had mucous fistula), also the incidence of wound infection was more if the closure interval <3 months [Table 3].
| Discussion|| |
To understand the pathogenesis of anastomotic failure, it is necessary to study the healing process. The sequences of events start as an inflammation followed by mobilization of cells (fibroblasts) which then proliferate with synthesis and extraction of collagen. Collagen synthesis and lysis are assumed to be in equilibrium and under the influence of collagenase of the mucosa. The activity of this enzyme in the intestine is increased after surgery. Regarding the colon, there is predominance of collagen break down during the first 4 postoperative days, whereas synthesis predominant at the 2nd week, the entire colon is involved by this response especially proximal to anastomosis. Thus, the healing of large bowel anastomosis starts with a lag phase of (0–5 days), in which the wound has no intrinsic strength and must be supported entirely by sutures.
After the lag phase is the fibroblast phase lasting 4–16 days in which the tissue gains strength rapidly. In the gastrointestinal tract, healing is nearly complete after 2–3 weeks.
The healing of the colonic suture lines is dependent upon many systemic and local factors which include healthy bowel, good blood supply, absence of tension, accurate placement of sutures (meticulous anastomosis), and proper bowel preparation.
Morbidity and mortality following closure colostomy are not insignificant so proper patient selection and surgical technique are essential.
Risk factors for the development of anastomotic leak are, for example, older age, male gender, malnutrition, and operative time, as demonstrated by Bakker et al.
The current hypothesis is that anastomotic leakage has a complex multifactorial pathophysiology, where at least ischemia, bacteria, and inflammation are involved.
In our study, the possibility of fecal fistula and wound infection was more frequent in those patients with double-layer (continuous) technique of anastomosis, after surgery of the left colon, and in an interval time for stoma closure of <3 months [Table 3].
In the literature, no evidence was found to demonstrate any superiority of stapled over hand-sewn techniques in colorectal anastomosis surgery, regardless of the level of anastomosis as shown by Neutzling et al., While in our study, all cases were selected by hand-sewn anastomosis to compare the different techniques used.
A study by Fonseca et al. showed that the total complications rate was 20.5% of stoma reversal cases, and that the most common adverse event was anastomotic leakage; in our study, the complications rate was 27%.
Roig et al. found that the complications occurred in 45.2%, with a 6.2% rate of anastomotic leakage, in Hartmann's reversal surgery, and that the complications were associated with age, diabetes mellitus (DM), arteriosclerosis, obesity, smoking, chemotherapy, and chronic obstructive pulmonary disease, while in our study, the majority of patients were young with negligible comorbidities.
Motoson et al. in their study mentioned that the double-layer anastomosis may interfere with the blood supply to the site of anastomosis and using nonabsorbable silk suture in close proximity to colon may predispose to micro-abscesses. In addition, they mentioned that using catgut suture alone leads to rapid loss of tensile strength and may not serve a useful purpose.
Qatia found that colostomies closed with double-layer anastomosis were associated with increased risk morbidities (51.1%) than those closed with single-layer anastomosis (35.0%), the cause might be longer operative time and increase in the narrowing of bowel lumen, her study was conducted on pediatric age group. A study conducted by Hamooddi et al. found that 22% of all patients developed complications after colostomy closure, 10% of the cases developed fecal fistula, and the incidence of wound infection was less in closure of loop colostomy in comparison with closure of end colostomy.
Moreover, about the minimum waiting time required for stoma reversal to reduce the peritoneal adhesions, so the consensus is a waiting time of an average of 3 months, as shown in a study by Roig et al. in 151 patients who underwent stoma reversal at median time of 10 months.
A study by Nelson et al., 100 patients were included, with 50 cases in each group (early closure group [at 4 weeks] and conventional time closure group [8–12 weeks]), 16 cases developed wound infection in early group versus 9, while anastomotic leak was just 2 in early group versus 4, concluded that early stoma closure is safe and feasible when patients are selected appropriately. While in our study, the fecal fistula incidence was more (the P value was significant) in early closure group (<12 weeks).
DM was the independent risk factor for surgical site infection and evisceration (P < 0.01). DM was present in 66.7% of cases who had an anastomotic leak and leak was more common compared to nondiabetics (P < 0.05), patients waiting more than 3 months before stoma reversal had experienced more anastomotic leak compared to those waiting less, as shown by Goret et al.
Over a century ago, mechanical bowel preparation (MBP) was considered, dogmatically, as a standard surgical practice. However, the gradual spread of minimally invasive surgery as laparoscopy in colorectal procedures added to enhanced recovery after surgery program promoted its abandonment. Therefore, several large retrospective studies recently questioned the abandonment of MBP suggesting that its omission was deleterious in terms of surgical sites infection and anastomotic leakage, especially when MBP was combined with oral antibiotics as in a study by Bretagnol et al.
On the basis of finding in their study (regarding wound management), Kim and Kang showed that negative pressure wound therapy reduces seroma formation in the wound and stimulates angiogenesis and granulation. Negative pressure also creates a hypoxic environment in the wound, resulting in upregulation of inflammatory cytokines which stimulates wound healing.
However, an attempt has been made to clarify the benefit of MBP with or without antibiotics on anastomotic leakage (fecal fistula), using a large retrospective cohort as shown in a study conducted by Kiran et al.
A meta-analysis conducted by Hsieh et al. included four randomized controlled trials with a total of 319 participants (162 in the purse-string wound closure group and 157 in the conventional primary closure group). Compared with the conventional primary closure group, the purse-string closure group had a significant decrease in surgical site infection.
A study conducted by Khan et al. was done on patients underwent colostomy reversal between January 2003 and December 2011, which showed that the most common complications were wound infection (19.8%) followed by incisional hernia (15.6%).
De'angelis et al. found that laparoscopic Hartmann's colostomy reversal to be a safe and feasible procedure that is associated with reduced hospital stays, complication rates, and costs compared to open Hartmann's reversal.
Lopez et al. found that with regard to wound infection rates, the circumferential subcutaneous wound approximation method was better than the conventional method of wound closure.
| Conclusion|| |
Colostomy closure is a common procedure in general surgery, it still carries the risk of postoperative complications. Single-layer closure technique with tension free was associated with less morbidity than the double-layer closure technique.
Less complications were found with colostomy closure more than 3 months (12 weeks) of the original colostomy.
Delayed primary wound closure gives better results than with primary wound closure regarding wound infections.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]