End Sigmoid Colostomy Research Articles

The use of diverting colostomies in paediatric peri-anal burns

Over a 3 yr period we performed colostomies in 13 paediatric perineal burn patients out of a total of 1544 patients admitted to our Burns Unit during that period. The mean total body surface area (TBSA) burn was 34% (14–65%); ten patients sustained fire burns and the remaining three hot water burns. We performed prophylactic colostomies in seven children, therapeutic colostomies (to counteract deep wound infection and septicaemia with gut-derived organisms) in five patients and one colostomy in a cerebral palsy child with a left hemiparesis. A sigmoid end-colostomy with Hartmann's closure of the distal segment was the preferred method of choice. In all children but one (died from multi-organ failure 13 days after admission) there was a marked improvement in the clinical appearance of the burn wounds and subsequent graft-take and healing. There was a change in the bacterial profile away from predominantly gut-derived Gram negative organisms to either Pseudomonas aeruginosa or no pathological organisms grown. Complications were few — two children suffered prolapse of their colostomy requiring manual reduction. We advocate diverting colostomies in a highly select group of paediatric burn patients in whom continual faecal soiling is threatening to both graft and life.

MESENTERIC PANNICULITIS-REPORT OF TWO CASES-

Mesenteric panniculitis is a rare inflammatory process of mesenteric fat tissue with unknown etiology. Two patients with mesenteric panniculitis are presented. The first patient developed ischemic colitis and mesenteric panniculitis 5 months after descending colectomy and required a sigmoid end-colostomy after several times of non-operative therapies. The second patient presented with small intestinal obstruction with per-sistent leukocytosis resulting in endotoxin septic shock. Despite the benign clinical course and favorable outcome of this disease, careful observation is necessary, because some complications such as ischemic enteritis and septicemia can be critical. Ninety cases of meseoteric panniculitis collected from the Japanese literature. together with two cases from the author's source, are reviewed.

Stoma creation for fecal diversion: is the laparoscopic technique appropriate?

This study assessed the results of laparoscopic stoma creation for fecal diversion. All patients who underwent elective laparoscopic stoma creation as the sole procedure were evaluated prospectively. Univariate analysis was performed to determine whether previous abdominal surgery, age, gender, body mass index, indication, or surgeons' experience has an effect on the outcome. Between November 1992 and May 1998, 42 patients (17 males, 25 females) with a mean age of 62.1 years (range 17-91) underwent laparoscopic stoma formation. Fecal diversion included loop ileostomy (n = 7), loop sigmoid colostomy (n = 32), and end-sigmoid colostomy (n = 3). Most common indications were unresectable rectal cancer, rectal obstruction caused by advanced pelvic tumors and benign disorders such as perianal Crohn's disease, and fecal incontinence. Of the 42 procedures 41 were completed laparoscopically (97.6%). Complications occurred in four patients (9.5%) requiring reoperation in two (4.8%). Mean length of surgery was 74.4 min (range 30-200). First bowel movements resumed on the 3rd day (range 2nd-7th) after surgery and patients were discharged from hospital after 13 days (range 6-47). Short-term results (> 30 days-1 year) indicated that no further stoma-related complications occurred. Analyzing factors potentially predictive of outcome, no statistically significant differences were documented in relation to previous abdominal surgery, age, gender, body mass index, indication, or surgeons' experience (P > 0.05). Laparoscopic stoma creation is appropriate to achieve fecal diversion because it is technically feasible and can be performed with low morbidity. In addition to the benefits of the minimally invasive technique for the patients, laparoscopic stoma formation can be ideal for the surgeon as basic and initial step to perform laparoscopic colorectal procedures.

Experience with 30 Posttraumatic Rectourethral Fistulas: Presentation of Posterior Transsphincteric Anterior Rectal Wall Advancement

Purpose We present the challenging problems involving the treatment of rectourethral fistulas, especially those caused by war wounds. Various existing techniques used by a single surgeon are compared in this study. The method of posterior transsphincteric anterior rectal wall advancement is described as the treatment of choice. We emphasize the importance of fecal and urinary diversion. To our knowledge this series is the largest in the literature. Materials and Methods From 1981 to 1994 we treated 30 men 18 to 50 years old (mean age 34) with posttraumatic rectourethral fistulas, including 23 (76.5%) caused by missiles. Urethroscopy with digital examination under anesthesia was the most reliable diagnostic study. End sigmoid colostomy and suprapubic cystostomy were performed in all patients. Results In 14 patients (46.5%) the fistula healed after double diversion but 16 (53.5%) required reconstruction for repair. Of the 6 procedures using established techniques in 5 patients 3 (50%) failed and 3 were successful but a urethral stricture developed after 2 (66%). On the other hand, in all patients (100%) who underwent repair via posterior transsphincteric anterior rectal wall advancement the fistula resolved and a stricture developed in 3 (27%). Fistula size and extent of fibrosis affected treatment, while etiology did not. Urethral obstruction complicated only the missile wounds. Conclusions Double diversion has resulted in resolution of approximately half of the small, less fibrous fistulas. Early repair is recommended for large fibrous fistulas. Anterior rectal wall advancement through a posterior transsphincteric incision offers a new option that has proved to be successful and safe, and causes fewer urethral complications. It also provided good visualization with minimal bleeding and was less painful. Double diversion is a prerequisite to reconstruction.

Gluteus maximus augmentation for the treatment of fecal incontinence

Fecal incontinence is a devastating problem for schoolaged children and adults. Medical and biofeedback therapies are unsuccessful in most patients who have severely defective internal and external sphincters. Continued fecal incontinence frequently leads to social isolation and withdrawal. Gluteus maximus augmentation of the sphincter mechanism is one surgical method for treating fecal incontinence. The authors present their results with gluteus maximus augmentation of the anal sphincter and describe patient selection criteria. From 1992 through 1996, seven patients underwent gluteus maximus augmentation of the anal sphincter for fecal incontinence. Six of these patients were children 5 to 6 years of age who had major deficiencies of their anorectal sphincter demonstrated by manometry. One patient was a 56-year-old adult woman who had acquired idiopathic fecal incontinence. Four of the six children (67%) had imperforate anus and two had cloacal anomalies (33%). The augmentation was performed in three stages. A sigmoid-end colostomy with a Hartman's pouch was followed 1 month later by rotation of a portion of the gluteus maximus for anorectal sphincter augmentation. A colostomy take down was performed 2 to 4 months later. All patients underwent dilatation after sphincter augmentation and were taught muscle exercises for using their neosphincter during the period before colostomy take down. Four of six children and the adult are continent postoperatively (71%). Both patients who remain incontinent are unable to sense rectal distention clinically or on anal manometric analysis but have excellent voluntary sphincter tone. Fecal incontinence can be successfully treated with gluteus maximus augmentation in carefully selected patients. Patients unable to sense rectal distension are unlikely to benefit from this procedure. The presence of a rectal reservoir and a skin-lined anal canal also appear to be important in attaining fecal continence.

Metabolic and nutritional management of a patient with multiple enterocutaneous fistulas

The patient is a 26-y-old male who sustained a close-range shotgun wound to the perineum. Following resuscitation at a community hospital in which an exploratory laparotomy with sigmoid loop colostomy was performed, he was transferred to a tertiary referral trauma center. Upon re-exploration, there was no evidence of viable rectum, and the wound was approximately lo- 14 cm in depth and extended from the base of the scrotum to the sacrum. Following several debridements, he was left with an end sigmoid colostomy with the open perineal and abdominal wounds to heal by secondary intention. Postoperatively, the patient’s stay was complicated by the development of multiple enterocutaneous fistulas all confined to the right lower quadrant. Initially these were treated conservatively with control of drainage, octreotide acetate, non per OS (NPO), and total parenteral nutrition (TPN) for nutritional support. Once stable he underwent split-thickness skin graft to his abdominal wounds following a brief course of human recombinant growth hormone (GH) in hopes of enhancing development of granulation tissue of the grafting bed.

Basic Considerations for End Sigmoid Colostomy in Conjunctive with the Miles Operation for Cancer of the Rectum.

Basic Considerations for End Sigmoid Colostomy in Conjunctive with the Miles Operation for Cancer of the Rectum.

Radiation enteropathy: prevention and treatment

Surgical considerations in the management of radiation-induced injury of the gastrointestinal tract include the prevention of future radiation injury and treatment of the complications of established chronic radiation enteropathy. At the time of operation for abdominal or pelvic malignancy, the surgeon must be aware of the indications for and techniques of postoperative radiation therapy. Careful preoperative staging and close cooperation between the surgeon and the radiation therapist should allow for the planning of measured designes to position the small bowel intraoperatively such that it will receive the minimal possible radiation exposure during the course of postoperative radiotherapy. Surgical management of chronic radiation enteropathy is concerned with treatment of the complications of obstruction, fistulization, infection and bleeding. The distal small intestine and the rectum are the areas involve most frequently. Partial obstructive symptoms are best treated nonoperatively until complete obstruction ensues on until the symptoms are incapacitating. These operations can be extremely difficult. Principles of operative management include resection (whenever feasible and safe) with primary anastomosis between healthy, nonirradiated segments of bowel. Radiation proctitis is also best managed conservatively with laser therapy of rectal bleeding and supportive care of symptomatic tenesmus. When symptoms are sufficiently severe to warrant surgical intervention, protectomy with a permanent end-sigmoid colostomy is the treatment of choice. Fistula formation and pelvic sepsis are the most challenging complications associated with radiation enteropathy and may require staged procedures for management.

Radiation-Induced Vesicosacral Fistula: Treatment with Continent Urinary Diversion

This is the first Case Report of a vesicosacral fistula related to prior radiation therapy. This patient developed recurrent adenosquamous carcinoma of the cervix 1 year after radical hysterectomy. She received 5000 cGy to the whole pelvis and a 1500-cGy boost to the area of recurrence in the right pelvic sidewall. The patient had significant toxicity with recurrent pelvic fistula formation ultimately requiring an end sigmoid colostomy. In addition, the patient required urethral catheterization due to urinary incontinence secondary to a hypertonic bladder. Approximately 14 years after radiation therapy the patient developed a vesicosacral fistula. With a nonfunctional bladder, the decision was made to proceed with a continent urinary diversion procedure. Despite a prior ileocecal resection due to radiation injury, a Miami pouch reservoir was created. Postoperatively, the patient remained continent using intermittent catheterization of the pouch.

Colostomy tube: new device for a continent colostomy.

This study describes a new device (the colostomy tubus) for potentially establishing continence in patients with a diverted bowel. The device was used in an animal experiment on dogs. The period of wearing the device was from one day to an uninterrupted insertion period of eight months. The device was used on an end sigmoid colostomy (4 dogs) and on a specifically shaped pouch stoma (2 dogs), in which the results proved most favorable. There were no complications caused by the device itself. The colostomy tubus seems to be a safe method of creating a continent colostomy and causes no tissue lesions. It proved reliable to wear. The device seems reasonable for human use, and a trial is currently under way.

Laparoscopic Sigmoid Colostomy for Perianal Crohn??s Disease

Fecal stream diversion is not an uncommonly used procedure in the treatment of symptomatic Crohn's disease of the rectum. We present a case report of a patient with documented Crohn's proctitis with multiple rectovaginal and perianal fistulas; an end sigmoid colostomy was performed as part of the management of her disease.

Colostomy closure.

One hundred and forty-seven colostomies were closed in 146 patients at Wellington Hospital between 1 January 1978 and 1 January 1987. The majority of stomata were formed in patients with colorectal cancer. At least one additional significant procedure was undertaken at the time of stoma closure in 10 patients. The overall complication rate was highest in those patients undergoing closure of a sigmoid end-colostomy (50%). Three complications resulted in death (2%). Twenty-four patients (16.3%) developed wound infections. Five patients developed 'leaks' (3.4%). The use of prophylactic antibiotics appeared to reduce the rate of infection significantly. The highest rates of wound infection and leakage occurred in patients in whom drains were used. Wound infections increased hospital stay. Thirty-one non-bowel or wound-related complications occurred in 25 patients.

A simple method for preventing retraction of an end colostomy.

A simple technique for performing a functional end sigmoid colostomy is reported. This procedure can help to prevent retraction of an end stoma in an obese patient or any patient with a shortened mesentery.

An assessment of colostomy irrigation

One hundred patients with permanent sigmoid colostomies were surveyed to determine their satisfaction and success with the "irrigation" technique of colostomy management. Most patients who irrigate their colostomies achieve continence. Odors and skin irritation are minimized. The irrigation method is economical, time efficient, and allows a reasonably liberal diet. It avoids bulky appliances and is safe. In appropriately selected patients, the irrigation technique is the method of choice for management of an end-sigmoid colostomy.

Hematometria and hematosalpinx in a duplicated uterus with congenital absence of one kidney

M.L.. 47-47-68, was born on 1 l/30/62 and passed meconium at birth. No external anal opening or tistula were seen. Examination under anesthesia revealed a rectal fistula entering the postertor wall of the vagina at the level of the cervix. A sigmoid end colostomy was performed. The distal rectum was oversewn and returned to the peritoneal cavity. During the first week of life, an intravenous pyelogram revealed congenital absence of the right kidney uith a normal-appearing left upper urinary tract. A cystourethogram performed at this time revealed a large bladder with low pressure left ureteral reflux: there was mild dilation of the ureter and calices. At 9 mo of age. an abdominoperineal pull-through procedure was carried out. At this operation it was noted that the patient had a complete duplication of the uterus. Each uterus had a single fallopian tube and a single ovary. At I I mo of age, she was readmitted to the hospital for correction of an anal stricture at the mucocutaneous junction by means of bilateral “V plastics.” The patient’s diapers were noted to be constantly wet and she had a chronic lower urinary tract infection that was treated with the approprtate antibiotics, She was watched in a conservative f;lshion for the anticipated appearance of urinary continence. By 5 yr of age, she was noted to be almost completely incontinent of urine. She underwent cystourethrogram and intravenous pyelogram annually and during thtr period of time, there was no change in her upper urinary tract. nor in the degree of retlux. Because of the persistence of the urinary incontinence and because urcthroscopy revealed a short patulous urethra, it was decided to perform a Young-Dees urethroplasty and left ureteroneocystostomy. This procedure was carried out on 3/15/67 without dihiculty. Postoperatively. the patient continued to be incontinent and displayed low pressure left ureteral reflux by cystogram. The patient was followed carefully and one year later. on 3/13/68. while still demonstrating low pressure reflux, she underwent exploration of the left ureter with the hope of performing another Young-Dees urethroplasty and ureteroneocystostomy. After dissecting out the ureter. it was obvious that the distal one-third was too scarred and fibrous to permit a successful uretero neocystostomy. She, therefore, underwent a left ureteral cutaneous anastomosis. Microscopic examination of the distal ureter revealed fibrosis and chronic inflammation, She had an uncventful postoperative recovery and was discharged. She was seen annually through April of 1973. The last intravenous pyelogram on J/26/73, revealed a normal appearing left upper urinary tract with no ureteral obstruction. It was noted at this ttmr that the patient cared for her uretcrostomy apphance herself without any difficulty. She stimulated a daily bo*rl movement by means ol a minienema using an all rubber ear syringe. At age I2 yr, she experienced menarche and each menstrual period was accompanied by such srvcre pain that she had to remain in bed and take large amounts of aspirin and codeine uith only partial relief of pain. After one year. the patient was seen by her pediatrician \nho made the diagnosis of urinary tract infection. Examination revealed a well formed left uretcrostomy that drained without obstruction into a urinary collecting bag. There was a large obvtoua right lower quadrant mass. This was easily palpable. stony-hard and projected above the level of the abdomen when the child lay flat. A No. 12 Coude catheter was passed into the bladder with ease. The bladder was found to be empty and irrigated clear. An intravenous pyelogram revealed a normally-functioning left uppet

Colitis cystica profunda: localized, segmental, and diffuse.

Colitis cystica profunda is a benign disease in which mucus-filled cysts are found beneath the submucosa of the colon. It usually is localized in the rectum, causes minimal symptoms, and is cured by local excision. A young man was debilitated by chronic mucus diarrhea and had diffuse cystic involvement of the distal colon. His symptoms were relieved by an end sigmoid colostomy, and he regained good health. The cause of this condition is apparently inflammatory in nature and seems to be reversible, as demonstrated by this patient. The successful management of the case reported, together with accumulated evidence, strongly suggests that radical excisional surgery for colitis cystica profunda is rarely necessary to effect relief of symptoms.

Resection of rectal mucosa without proctectomy as an adjunct to abdominoperineal resection for nonmalignant conditions

Summary An operative procedure consisting of excision of the rectal pouch and sigmoid end colostomy was performed in each of ten dogs to evaluate the fate of the rectal pouch. In each of the chronic survivors the lumen of the rectal pouch became obliterated within six to eight weeks, and abscess did not occur. Because of the frequent morbidity associated with abdominoperineal resection, it is believed that the described operation may warrant clinical trial in selected patients with ulcerative colitis and certain other nonmalignant conditions involving the rectum.