Part III
COLOSTOMY
CHAPTERXXX
The Management of Colostomies
DavidHenry Poer, M. D.
HISTORICAL NOTE
Althoughcolostomy was a well-established procedure in civilian surgical practice at thebeginning of World War I, military surgeons of all armies were slow to employit.1 The chief reason wasthat during the early months of this war, as in all previous wars,nonintervention was the general rule in abdominal injuries. This was partlybecause of the poor results which had attended previous efforts at interventionand partly because the majority of surgeons did not regard major surgery aspractical near the front. Since abdominal surgery, to have any hope of success,had to be performed within a reasonably short time after injury, thispessimistic point of view automatically excluded the surgical management ofthese injuries.
Manysurgeons, even in 1914,did not accept thesepremises, and as the war progressed the concept became more and more generalthat recovery could be expected in abdominal injuries if operation wasperformed. Asmobile hospital facilities, equipped and staffed for surgery, were set up near thefront, the practice of prompt surgery for these injuries became increasinglyfrequent, and in 1917 and1918 operation became the general rule in both the British andthe American Armies.
Colostomy,however, was never adopted as a routine technique in wounds of the large bowel.Instead, it was usually reserved for the most seriously wounded patients, withextensive wounds of the colon. These casualties formed a distinctly unfavorablegroup, and the high case fatality rate which attended the use of colostomy wasno more than might have been expected.
Wallace, who wrote the section onabdominal injuries for the official British medical history of World War I,2did not mention colostomy as a method of dealingwith wounds of the cecum. He considered suture preferable whenever it was feasible in wounds of thetransverse and vertical colons, and he also stressed the importance of drainage. Colostomy, he indicated, was anundesirable alternative, which was mostlikely to be necessary in injuries of the splenic flexure. Its widest application, in his opinion, was in left-sided wounds of the
1(1) History of the Great War Based on Official Documents. Medical Services Surgery of the War. London: His Majesty's StationeryOffice, 1922, vol. I, pp. 476-579. (2) The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing Office,1927, vol. XI, pt. 1, pp. 443-490.
2Wallace, C. S.: Wounds of theAbdominal Viscera. InHistory of the Great War Based on Official Documents. See footnote 1 (1).
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loin, in which sepsis tends to develop late, and in rectal injuries. Colostomy was employed only 53 times in the 155 injuries of the large bowel upon which Wallace based his discussion. It was, however, widely used in base hospitals in the management of fecal fistulas which developed after failure of suture repair.
The results whichWallace cited explain why colostomy was not a popular procedure among Britishsurgeons in World War I. The case fatality rate in wounds of the colon, hepointed out, was higher when it was employed; 73.5 percent as compared with just over 50percent in casesmanaged by suture. These figures, Wallace added, must not be taken to indicatethat colostomy is a necessarily dangerous procedure. They merely indicated that fatal sepsis was likely to occur whencolostomy was employed, because infection was already present when the operationwas performed.
Lee,who wrote the section on abdominal injuries in the official United States medical history of World WarI,3 set down the following general principles for themanagement of wounds of the colon:
1. Suture should be performed whenever it is possible, inorder to secure a satisfactory closure.
2. Colostomy should always be employed in preference toresection.
3.Colostomy ispreferable in all injuries with large, ragged openings, particularly injuries ofthe cecum, descending colon, and sigmoid.
4.Drainage should be used routinely in proved or suspected retroperitonealinjuries. It should always be used when there is any doubt of the integrity ofthe suture line.
5.Colostomy may berequired in extensive lacerations of the lower rectum and in rectal injuriesdeep in the pelvis, in which suture is not possible. According to Lee, theresults of suture repair were better than those of colostomy, in which the casefatality rate was 70 percent.
Jolly's4 extensive personal experience as a field surgeon inthe Spanish Civil War included 970 abdominal injuries. In his book on fieldsurgery in total war5 hedescribed invaginating suture and resection as alternative methods of treatmentin wounds of the colon. He emphasized the importance of drainage but did not mention colostomy.
COLOSTOMY IN OVERSEAS HOSPITALS
The attitude ofsurgeons toward colostomy in World War II is an interesting contrast to theopinion held of it early in World War I and in the Spanish Civil War, whichended only about 3 years before the United States entered World War II. Its lifesaving properties were recognized almost at once, and, togetherwith exteriorization of the damaged segment of bowel, it became the routinemethod of management for injuries of the large bowel. This policy,
3Lee, Burton, J.: Wounds of the Abdomen. In the Medical Department of the United States Army in the World War. See footnote 1 (2), p. 337.
4Jolly, Douglas W.: FieldSurgery in Total War. New York: Paul B. Hoeber, Inc., 1941.
5Ibid.
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which saved many thousands of lives, can fairly be regardedas one of the most important advances ever made in the treatment ofbattle-incurred injuries of the colon.
Colostomy, with and withoutexteriorization of the damaged bowel, was first used by British surgeons duringthe air bombardment of London in 1940 and 1941, at therepeated suggestion of Ogilvie.6
The newpolicy was apparently dictated by two considerations. The first was the successof this method of management of intestinal tumors in civilian practice. Theaffected segment of bowel was brought outside the abdomen at the first operationand resected later at a second-stage operation. The second consideration was theprohibitively high case fatality rate associated with immediate repair ofinjuries of the colon and replacement of the bowel into the abdominal cavity. AsOgilvie remarked later, in a report of the British experience with abdominalinjuries in the Western Desert,7 it would be rash to claimthat any of the patients who died after colostomy could have
6In a personal communication to the author of this chapter, dated 24 May 1955, Sir Heneage Ogilvie pointed out that much of this teaching was informal. He had first publicly advocated the use of colostomy for wounds of the large bowel at a lecture given at the Postgraduate Hospital in Hammersmith, England, late in 1939. This lecture was one of a series prepared for the emergency and dealing with the surgical treatment of wounds of warfare. How to manage wounds of the colon was vigorously discussed by the numerous surgeons present, and at this meeting, as well as at later meetings, a certain amount of opposition to the policy of colostomy was expressed.
A lecture given by Sir Heneage in Kenya, when he was consulting surgeon to the East African Force which was conducting the attack on Abyssinia from the south, was reproduced in the June 1941 issue of the East African Medical Journal. The substance of the recommendations concerning the management of wounds of the colon was as follows:
"Holes in the free portions of the colon may be closed by a purse-string suture if the bowel wall round them is perfectly healthy, but in most cases a local repair is unsafe and resection is wise. A free mobilisation is often required before the resected ends can be brought together without tension. Nearly all writers on military surgery advise end-to-end suture after resection, with or without caecostomy, but this advice is unsound in the light of modern teaching and practice, and the high mortality in colon wounds in all published statistics suggests that it is not good treatment. After mobilisation sufficient to allow the colon above and below the injury to be approximated without tension, the injured segment should be removed and the cut ends above and below it, closed with crushing clamps, should be brought to the surface at one end of the incision or wound. The clamps are removed after 24 hours, and the continuity of the bowel is restored later by crushing the spur between the openings.
"There has been a marked tendency in recent years to look on the large intestine with increasing respect or even fear. Its walls are thin, their blood-supply is poor, and the peritoneal coat is interrupted by a broad mesentery and distorted by fat blisters, the contents are highly infective and mechanically traumatic, its luminal pressure alters with explosive suddenness. No sutures can be placed accurately in its wall, and what are thought to be lemberts often pass through all coats and carry infection. All surgeons have experienced trouble with leakage and sepsis at the suture line after resection and many feel today that no stitch should ever be put through a colon that is not both empty and sterile. A colostomy or a resected loop should not be stitched to the skin, but the skin opening should be made to fit the colostomy; a segment of bowel should not be excised and the ends sutured unless the contents have been diverted above by an excluding colostomy for at least 2 weeks. Devine has shown the way to success in cancer of the colon by his operation of exclusion and Lahey has made resection of the colon for ulcerative colitis and of the rectum for cancer safe by stage operations in which the bowel is brought to the surface. In war injuries, the way to safety is the same, for caecostomy provides only partial relief of tension at the injured site and proximal colostomy is no better unless it is done some weeks before."
The same advice was repeated in various memorandums circulated in the British East African Force in 1941 and in the British Middle East Force in 1942 and 1943, as well as in a field manual published for the use of British troops during the invasion of the Continent in June 1944. Meantime, Ogilvie had published his comprehensive report Abdominal Wounds in the Western Desert (March 1944, see footnote 7).
The personal communication from Sir Heneage Ogilvie from which the information in this footnote has been taken concludes with the following paragraph:
"Under the influence of these antiseptics [the effective intestinal antiseptics which were later developed], with improved surgical conditions and with the development of skilled surgery in the forward units, the policy was somewhat modified in that closure of small perforations in the proximal colon was countenanced if the surgeon was a man of considerable experience and if the case could be retained for the first 10 days for observation. However, as far as I know, up to the end of the war it was considered that exteriorisation of all colon wounds was the safest policy and the one to be recommended to all surgeons undertaking the abdominal surgery of warfare for the first time."
7Ogilvie, W. H.: Abdominal Wounds in the Western Desert. Surg., Gynec. Obst. & Obst. 78: 225-238, March 1944.
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beensaved by suture alone, but there was no doubt that certain of the deaths whichoccurred after suture of the injured bowel could have been avoided by colostomy. In his opinion, the exteriorization of the damaged colon was one of sevendecisive points in the management of abdominal injuries. By this time (1943) the British experience had been sufficiently largefor him to be able to analyze the conditions which made closure of a colostomystoma difficult and to suggest improved techniques.
The American experience.-Colostomy was extensively employed ininjuries of the colon during the North African campaign in 1942-43, at first, itwould seem, without knowledge of the earlier British experience. Circular LetterNo. 20, 22 June 1943, Office of the Surgeon, North African Theater ofOperations, consisted chiefly of comments from hospitals of the CommunicationsZone, North African Theater of Operations, United States Army, on the managementof battle casualties in forward areas during the fighting in Tunisia. One of the criticisms hadto do with failure to perform immediate colostomy in retroperitoneal injuries ofthe rectum.
Colostomy became officialpractice for injuries of the large bowel when Circular Letter No. 178, dated 23October 1943, was issued from the Officeof The Surgeon General of the Army. The instructions were that-
* * * in large bowel injuries, the damaged segment will beexteriorized by drawing it out through a separate incision, preferably in theflank. In order to facilitate subsequent closure the two limbs of the loopshould be approximated by suture for a distance of about 2? inches and thenreturned to the abdomen, leaving the apex exteriorized with a short length ofrubber tubing or other suitable material beneath it. If the segment cannot bemobilized, the injury should be repaired and a proximal colostomy done.
Thereafter in World War II,surgery of the colon in the United States Army was based on three generalprinciples: (1) Exteriorization of the wounded portions of the bowel (fig.31), to avoid intraperitoneal contamination; (2) complete diversion of the fecalstream away from distal wounds of the colon and rectum; and (3) colostomy toeffect incomplete diversion of the fecal stream for purposes of gaseousdecompression as well as possible future complete diversion.
Soldiers with wounds of the colon were for the most part treated in field hospitals, located near division clearing stations. They were brought to them and were prepared for surgery by resuscitative measures within a remarkably short time. Figures of the 2d Auxiliary Surgical Group (p. 256) show that the average timelag between wounding and operation in 1,222 wounds of the colon and rectum was 10.9 hours. The speed with which treatment was instituted in itself saved many lives. Strict adherence to the policy of exteriorization of the bowel and colostomy shortened the time necessary to care for wounds of the colon and saved additional lives by making earlier treatment possible for other wounded men.
During the early Americanparticipation in the war, revision of the colostomy stoma was undertaken, whenit was indicated, in fixed hospitals overseas, after which the casualties werereturned to the Zone of Interior for reconstructive surgery and closure of theopening in the bowel. As experience
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increased and additional trained surgeons were sentoverseas, closure of the colostomy was frequently effected in numbered generalhospitals in the communications zone. This was a common British practice.Ogilvie related that men who had been wounded in the abdomen at El Alamein marched with the BritishEighth Army into Tunis. Similarly, many United States soldiers who had sustainedwounds of the colon and had been treated by colostomy were able to return toactive military duty in the theaters in which they had been wounded.
For many reasons, however, it was more expedient toclose most colostomies in general hospitals in the Zone of Interior, and thegreater part of the data upon which this chapter is based concern thatexperience.
COLOSTOMY IN ZONE OF INTERIOR HOSPITALS
BasicData
Duringthe winter of 1945-46,questionnaires dealingwith various aspects of colostomy were sent to all general hospitals in the United States. Although
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many hospitals had been closed by this time and their records had been forwarded to a general collection center, the replies received furnished information on 2,378 soldiers with wounds of the colon who had been treated by colostomy in forward hospitals overseas. As might have been expected, since a large majority of these patients had already undergone disposition proceedings, numerous details were missing on many of the records.
Forconvenience, and because of the deficits in the data just mentioned, these 2,378cases are discussed in the followinggroupings:
1. Two thousand one hundred and two cases in which closurehad been done in Zone of Interior hospitals and on which information had beensecured when the final analysis of cases was begun.
2. Four hundred and sixty-four cases included in the two thousand one hundredand two cases just mentioned and reported from ten general hospitals in theFifth and Sixth Service Commands and from McCloskey General Hospital in theEighth Service Command (series A). These data were unusually complete and, for that reason, are frequentlydiscussed separately.
3. One hundred and eighty cases in which the colostomy had been closed ineight overseas hospitals (series B).
4. Ninety-six cases from Rhodes General Hospital in the Second Service Command (series C) . These data werereceived after the rest of the material had been analyzed but are discussedseparately at appropriate places.
Techniques of Colostomy
As might be expected, when so many surgeons had operated onso many patients and under such widely different circumstances, the 2,378colostomies which make up this compositeseries represented every known technique. In approximately 300 cases, nodetails were stated. Loop colostomy with a single opening was performed in 40percent of the remaining cases, the Paul-Mikuliczcolostomy with spur in 30 percent, theDevine technique or some modification thereof and mucous fistulas with single ormultiple openings in 10 percent each, and the tube or tangential colostomy andthe loop colostomy with double openings in 5 percent each. The colostomy waslocated on the left side in 50 percent of the stated cases, in the transversecolon in 30 percent, and on the rightside in 17 percent. The remaining operations were in the sacral region.
The location of the wound andof the colostomy was not stated in a large proportion of the records. In seriesA, the wound was on the left side in about a third of the 416 stated cases, andthe colostomy was on this side in about 58percent of the 338 stated cases.
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Preclosure Problems in Zoneof Interior Hospitals
The eventual medical policyin the management of wounds of the colon was, as already stated, to close thestoma in almost all instances in Zone of Interior hospitals. Closure, however,involved considerably more than the actual operative act. It required verycareful preoperative preparation, the routine of which was based upon theproblems presented in the special case. Among these problems the following werethe most important:
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Associated wounds.-Well over half of the patients received in Zone of Interior hospitals with unclosed colostomies had other major injuries, which in many instances were multiple (see following tabulation of associated visceral injuries in 179 patients in series A). Wounds of the small intestine were particularly frequent; series A, in which they made up considerably over half of all associated wounds, is typical. Fractures of the long bones represented as much as 40 percent of associated injuries in many hospitals. A few patients in each hospital were paraplegic.
Organ | Cases |
Esophagus | 1 |
Stomach | 31 |
Small intestine: | |
| Duodenum | 6 |
| Jejunum | 80 |
| Ileum | 126 |
| Not stated | 29 |
241 | |
241 | |
Appendix | 1 |
Gallbladder | 8 |
Liver | 32 |
Spleen | 16 |
Diaphragm | 17 |
Urinary tract | 64 |
Spinal cord | 9 |
| Total | 420 |
The majority of the associated injuries were well on the way to healingwhen the patients reached the United States, but the associated injuriessometimes required attention more urgently than did the colostomy. Iffractures, for instance, had to be treated by balanced suspension skeletaltraction, closure of the colostomy stoma was not feasible immediately; it wasdesirable that the patient be ambulatory before abdominal surgery wasundertaken. Nerve suture and plastic surgery, on the other hand, were usuallypostponed until after the colostomy had been closed.
Organic disease was not usualin young, sturdy soldiers, but three patients at McCloskey General Hospital had pulmonary tuberculosis.There were also occasional instances of this and other diseases at otherhospitals.
Nutritional status.-Almost all of the patients whoarrived in the Zone of Interior with unclosed colostomies had lost weight (fig. 32).At one typical hospital, the weight loss ranged from 10 to80 pounds and averaged 36pounds. In numerousinstances, the patients were at least partly responsible for their own poornutritional status. They deliberately restricted their food intake in order todecrease the number of daily dressings required. Hypoproteinemia was found inabout 10 percent of the serum-protein determinations, but other-
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FIGURE 32.-Right-sided colostomy. The cecum and ascending colon wereresected at the first operation after wounding, and the ends were implanted intothe incisions. After resection, the ends were brought out, and an ileostomy andcolostomy were created. Note the extreme emaciation which accompaniesright-sided colostomy. This patient also had a fecal fistula in the buttocks. After a long period of careful preparation,intestinal continuity wasrestored by ileotransverse colostomy. Full recovery followed.
wise there was littleevidence of serious alteration in the basic constituents of the blood except inpatients with wounds on the right side, complicated by drainage from the smallintestine.
Complicationsrelated to the colostomy.-The series A statistics may be taken as typical of thecollected series in respect to complications related to the colostomy. In 275 of the 464 cases, herniationof various degrees had occurred; in some instances the bowel actually protrudedthrough itself (that is, through the colostomy stoma). Fecal fistulas werepresent in 70 patients, wound infection ofsome degree in 38, obstruction of some degree in 34, fistulasinto the buttocks in 31, osteomyelitis in 25, wounddehiscence in 10, and peritonitis in 7. Complications of wounding unrelated tothe colostomy included urinary fistula in 7 cases, empyema in 2,thrombophlebitis in 2, and a fistula of the biliary tract in 1.
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In a small number of cases,the colostomy was not functioning satisfactorily when the patients werereceived in Zone of Interior hospitals, and prompt revision or relocation wasrequired. A colostomy placed posteriorly in the sacral region, for instance, wasrelocated anteriorly, in the descending or sigmoid colon. When there waspersistent contamination of the buttocks or a persistent perineal fistula (fig. 33), secondary colostomy was necessary to accomplishdefunctionalization of the lower rectal segment. The secondary opening waspreferably placed proximally in the transverse colon (fig. 34), a site which many surgeons preferred for primary colostomyin injuries of the pelvic colon.
Colostomies performed bysurgeons working under the stress of field conditions were sometimes notperformed with the care and precision possible in civilian hospitals. Holder andLewison,8 who had a large experience in the closure of colostomyoverseas, listed the conditions which made reconstructive surgery difficult asfollows:
1. Thecolostomy had been placed so near the costal margins or the iliac crest thatosteomyelitis was an almost inevitable complication (fig. 35).
8Holder, H. G.; and Lewison, E. F.: Managementof Colostomies Performed for War Injuries. Ann. Surg. 126: 253-261, September 1947.
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2. The colostomy had been placed too close to a coexisting cystostomy.
3. Thecolostomy had been created through the exploratory incision, without adequatemobilization of the bowel. This error, which was most often evident incolostomies of the transverse colon, was likely to be followed by retraction ofthe stoma, infection of the abdominal wall, intraperitoneal infection, sinusformation, and wound dehiscence. Wound infection, in fact, was almost inevitablebecause of the practice in military surgery of removing the clamps from thebowel immediately. This was necessary precaution, for, in the rush of work, theycould easily be overlooked, and obstruction could occur as a result; but when itwas carried out in a colostomy created through the exploratory incision, fecespromptly spilled over the fresh wound.
4. The colostomy was createdthrough the wound of entry or exit (fig. 36). Thistechnique was almost invariably followed by infection, which frequently went onto spreading cellulitis.
5. The spur in a Mikuliczcolostomy was sometimes too short because the loops had been insufficientlymobilized. As a result, the bowel retracted, and the loops became rotated orpartially obstructed.
6. Edema or necrosis sometimes complicated loop colostomiesbecause glass rods or heavy rubber tubing had been used to support aninadequately mobilized
FIGURE 34.-Double stoma intransverse colon, with complete division of bowel. The mucous membranes,however, are still in contact, and the distal segment of the colon remainscontaminated. Note the extensive abdominal incisions, the result of multiplesurgery.
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FIGURE 36.-Lumbar colostomy following exteriorization of cecum and ascending colon inwound of flank. The lumbar region is not a location of choice for colostomy, but in thisinstance function was satisfactory. Closure was effected at an extensiveintra-abdominal operation, byileotransverse colostomy.
loop. If the incision through which the bowel had been brought out was tooshort, constriction of the bowel, with partial dysfunction of the colostomy, wasa likely result.
7. The openings in loopcolostomies were sometimes unnecessarily large (fig. 37). Oftenthey had been created in the transverse axis of the bowel rather than thelongitudinal axis.
8. Completediversion of the fecal stream had sometimes not been accomplished (fig. 38). This was essential in wounds of the rectum and extensivewounds of the rectosigmoid, with associated injury to the bladder, urethra, andbony pelvis.
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FIGURE 37.-Excessive protrusion of transverse colon and eventration of mucous membrane withincomplete division of bowel. The opening in the abdominal wall is alsounnecessarilylarge. This patient sustained an injury of the perineum, with loss of urinarycontrol. Afterreduction of the internal herniation of the mucosa, the colostomy was closed byprimary anastomosis without too much difficulty.
9. Drainage of theretroperitoneal and pelvic spaces had been omitted in some cases and was notadequate in others. Drainage through the track created by the missile was almostnever adequate.
In addition to the technicalerrors just listed, other errors were observed. The use of sutures which weretoo tight and the inclusion of the mesenteric artery in the suture of the spurcould cause tension, torsion, and constriction of the bowel, with resultingimpairment of the circulation. Thrombosis wasalso a possible complication. Hernia might develop when too large a segment of the bowel was used forthe colostomy. Partial obstruction could follow too tight closure. Eventration of theileocecal area was a possibility in wounds of the cecum.
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Infection.-Infection always introduced serious preoperative difficulties. It could arise, as just observed, in dysfunction of the colostomy. It could also originate in a number of other ways. Sometimes abscesses in the chest or the abdomen failed to resolve completely. Infection frequently occurred along persistent fistulous tracts, particularly when osteomyelitis was a complication or a foreign body had not been removed. Fistulas which had healed spontaneously or which had been closed in overseas hospitals sometimes broke down and became infected because the fecal stream had been incompletely diverted and the tract had become contaminated. In cases of persistent infection, the cause had to be sought for and eliminated and adequate drainage established. This often required an extensive surgical procedure (pp. 352, 353).
Fecal fistulas.-Fecal fistulas were always troublesome andwere sometimes the cause of serious preoperative difficulties. This wasparticularly true of fistulas of the small bowel and fistulas in the sacralregion. Urinaryfistulas could also be very troublesome.
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In some instances, because of a surgical error, the artificial anus had been constructed in the terminal ileum or the ileum had been used to form the colostomy in combination with the large bowel. The spur might consist of colon and ileum, or a single or a double mucous fistula might be created following end-to-end or side-to-side anastomosis between the ileum and the colon. Fistulas of the jejunum or the duodenum were usually the result of the original injury or of surgical attempts to repair it.
Fistulas of the small bowelproduced irritation or actual digestion of the skin. Sometimes the process wasextensive. All methods used to protect the contaminated areas were likely to beunsatisfactory. Moreover, because of continuous drainage and the loss ofessential elements from the gastrointestinal tract, patients with fistulas wereoften gravely emaciated. Immediate closure of the fistula was thereforeindicated.
Small, uncomplicated fistulascould be eliminated by inversion of the intestine into the lumen. In somecomplicated cases, a shunting or sidetracking procedure had to be employed,with anastomosis of the ileum to the descending or transverse colon proximal tothe fistula, by either the side-to-side or the end-to-end technique. Later, thecolostomy could be closed by some one of the methods shortly to be described,or, if it was indicated, resection of the intervening ileum and colon could becarried out. Improvement following closure of a fistula in the small bowel wasusually prompt and was often dramatic.
Patients with fistulas in thesacral region usually arrived in the Zone of Interior in poor condition, as theresult of chronic sepsis. In perhaps half of all wounds of the rectum, the bonystructure of the pelvis had been damaged also, and osteomyelitis was a frequentcomplication. As a rule, it was extensive, involving the sacrum, the coccyx, the wingsof the ilium, or the upper portion of the femur. The joint cavities were alsooften involved in the infection. The fistula was persistently contaminatedbecause the distal segment of the intestine had not been completelydefunctionated, and the fecal drainage enhanced the bone infection. Finally,foreign bodies, which in this location are difficult to localize accurately andwhich were therefore often left in situ, frequently served as foci of infection.The complete removal of all foreign bodies, while extremely important at thefirst operation, was by no means assimple as it may sound. Pieces of clothing and gauze and bits of equipment which were notradiopaque were extremely difficult to visualize and identify. If all extraneousmaterial was not removed, persistence of infection in fistulous tracts wasinevitable. The vicious circle thus set up was extremely difficult to interrupt.
If a foreign body was notpresent or if osteomyelitis was not a complication, a fistula in the sacralregion occasionally healed spontaneously, even when there was persistentcontamination of the distal segment of bowel. Morefrequently, prolonged treatment was necessary. It includeddaily irrigations of the fistula with physiologic salt solution or some othersolution, the admin-
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istration of a sulfonamide, and measures directed toward improvement of the general condition. These measures, although they were occasionally successful, were not desirable definitive treatment for a fecal fistula. For one thing, it was impossible to determine in which cases they would succeed. For another, even an apparently successful result of expectant treatment was not always permanent. The fistula was likely to reopen, the mucous membrane of the bowel tended to evert into the fistulous tract, and other undesirable consequences could ensue.
Experience soon showed thateven a short and direct fistulous tract which traversed bone would not healuntil three conditions had been fulfilled: (1) The fecal stream had to becompletely diverted; (2) all dead bone, including the coccyx and parts of thesacrum, had to be removed; and (3) all scar tissue which prevented obliterationof dead spaces also had to be removed. Paradoxically, healing of long, tortuousfistulous tracts which traversed bone sometimes occurred when only expectantmeasures were used, but the course of treatment was long and tedious and theresults were so uncertain that surgery was always the preferred method.
The first step in thetreatment of a fecal fistula was diversion of the fecal stream, either byrevision of the colostomy or by creation of a secondary colostomy placedproximally in the transverse colon. Revision was best accomplished by some modification of the Devinetechnique (fig. 39), in which the openings would be separated by a bridge ofskin. The next steps were removal of any foreign bodies in the region of thefistula and adequate unroofing of the entire tract from its external openingdown to the rectum. Unroofing was often difficult and hazardous because of the extensivethickening and resulting rigidity of the rectal wall and the adjacent tissues. Incisions into the peritoneum lateralto the rectosigmoid helped to free the rectum. Eversion of the rectal mucosa into the fistula, which had usuallyoccurred, was corrected by excision of the involved mucosa or by inverting itinto the rectal lumen. The final step of the operation was excision of scar tissue and of thecoccyx and parts of the sacrum, together with removal of all foreign materialsuch as metal, bits of clothing or equipment, and surgical gauze, which wassometimes still present since it had been applied as a first-aid measure.
The extensive surgeryrequired for the repair of sacral fistulas, in addition to the tissue lostbecause of the ravages of infection, usually caused serious losses of softtissue. Plastic repair was therefore frequently necessary. The preferred technique was to perform a staged operation, swingingmuscle flaps across the debrided tract and then using full-thickness skingrafts.
Fistulous communicationsbetween the intestine and urinary tract were fairly frequent and had to be dealtwith by various measures before closure of the colostomy could be attempted.They were sometimes kept open by obstruction caused by urinary calculi or byadhesions. The proctoscopic and cystoscopic studies which were essential had tobe carried out with great care because of the induration and scar tissue presentin both rectum and
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FIGURE 39.-Revision of sigmoidcolostomy by modified Devine technique to provide complete diversion of fecalstream from fistula in buttocks. The colostomy was closed by direct anastomosiswithin the abdominal cavity.
bladder. Barium enemas and the injection of the fistulawith radiopaque substances were useful in determining the limits of extension ofthe lesions.
If the ostium was not too large, conservative therapy wasusually given a trial in urinary fistulas, in an attempt to promote healing atthe point of origin. If urinary calculi or adhesions were responsible forfailure of healing, conservative measures were useless, and surgery wasindicated. If the fistula communicated with the rectum in the lower segment ornear the anus, a plastic procedure (the Stone operation) was almost alwaysrequired. The patients in this group were transferred to Walter Reed General Hospital for the necessary surgery.
In addition to the more usual types of fistulas, bizarre types were notuncommon. They included fistulas extending through the vertebral column, throughthe diaphragm and chest, into the acetabulum, and into the urethra. The lattertype was easily diagnosed by the passage of gas through the penis.
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PreoperativeRegimen
The time interval betweenreception of the patient in a Zone of Interior hospital and closure of thecolostomy varied widely, sometimes because of the patient's own status andsometimes, particularly during periods of intense activity, because of crowdedhospital conditions. Thecategoric statement can be made, however, that in no instance was any harmcaused by the delay. In fact, one of the strongest points in favor of handlingwounds of the colon by exteriorization and colostomy was the ability of patientsthus treated to travel long distances without harm and to wait indefinitely forclosure of the stoma without deterioration of their status.
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The relatively few patientswho were received in Zone of Interior hospitals without associated injuries,free from infection, and with colostomies which were functioning satisfactorilywere prepared for operation at once and were operated on as soon as possible. These patients were the exceptions.The great majority presented preoperative problems of one sort or another(p. 343) and required a more extensive preparatory regimen in addition tospecial measures suitable to their individual difficulties.
As soon as patients werereceived in Zone of Interior hospitals, they were taught to take care of theirown dressings. Those who were able to be ambulatory were required to be.Associated injuries were treated as necessary. Whenever it was practical,arrangements for furloughs were made. The psychologic stimulus of a return totheir homes and families amply compensated for any delay in closure of thecolostomy.
Operation was not undertakenin any case until the colostomy was functioning satisfactorily (fig. 40) andcertain other criteria had been met:
1. The nutritional statusmust be restored to a level at which surgery would not be attended with anyundue risk. A completely normal status was desirable but was not regarded asessential.
2. The healing of associatedinjuries must have advanced to a stage at which ambulation was possible.
3. Fecal fistulas must have been healed for at least 8 to 12 weeks.
4. The skin about the colostomy must be in optimum condition.
Special measures.-The first essential of the generalpreoperative regimen was attention to the colostomy. Many patients, after tripsfrom overseas which sometimes occupied a considerable time, were received withlarge amounts of inspissated fecal material in the distal loop. Theseaccumulations were removed by irrigations of distilled water, physiologic saltsolution, or solutions containing acriflavine, potassium permanganate, orpenicillin. After the distal loop had been completely cleaned out by thesemeans, irrigations were carried out three to five times weekly, with twoobjectives, to restore the tone of the loop and to increase the size of theopening, which had often become much smaller in the weeks or months since thecolostomy had been created.
The second essential ofpreoperative preparation was the protection of the skin from fecal discharges.This was particularly important if irritation was already present. The bestresults were accomplished with dressings of kaolin or aluminum paste.
The third essential of thegeneral regimen was restoration of the nutritional status to a levelapproaching normal. The caloric content ofthe diet was maintained between 3,500 and 5,000 calories daily. There was special emphasis on the protein component, which ranged between125 and 175 gm.daily. Transfusions of plasma and whole blood were given as indicated.Supplementaryvitamins, iron, and liver extract were also given as necessary.
Immediate preoperative preparation.-Special preparationsfor surgery were begun several days in advance of operation. The routine varied in details
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from hospital to hospital but was always based upon the following general policies:
l.Routine laboratory tests were conducted, and operation was postponed if thechlorides, protein, and vitamin-C levels of the blood were not approximatelynormal. Theprothrombin time was determined the day before operation, and closure of thecolostomy was deferred if it was not satisfactory. Roentgenograms of the abdomenwere made to demonstrate possible retained foreign bodies, and barium-enemastudies were made to exclude possible intestinal obstruction.
2. A sulfonamide drug(usually Sulfasuxidine (succinylsulfathiazole), phthalylsulfathiazole, orsulfaguanidine) was given for 5 daysbefore operation in doses of 1 gm. six times daily. If local irritation wasevident on the skin during the course of treatment, kaolin or aluminum paste wasapplied.
3.Vitamin K was usually given the day before, and the day of,operation. Paregoric was ordered just before the patient was taken to theoperating room.
4. The ample diet previously provided was discontinued 3 daysbefore operation and was replaced by a low-residue diet, which was, however,equally high in protein content. Only clear fluids were permitted during the 24 hours immediately beforeoperation.
5. Irrigation of both loops ofbowel was continued up to the day of operation. On the morning of operation,irrigations of sterile physiologic salt solution were continued until theyreturned perfectly clear.
Anesthesia
Practically all methods ofanesthesia were used to close the colostomies in this series, but fractionalinstillation of an anesthetic drug into the spinal canal was perhaps the mostfavored technique. Pentothal Sodium was sometimes used for induction but wasnever used for the entire procedure. Local anesthetic agents were avoided,because of the risk of spreading infection.
Technical Considerations
Official directives did notspecify any standard procedure for the closure of a colostomy. This left thesurgeons at the various general hospitals free to develop their own methods,under the general supervision of consultants. Since 106 surgeons are known tohave closed the 2,198 colostomies managed in the general hospitals in the United States, the range of detailedtechniques was correspondingly wide, although only a few basic techniques wereemployed.
During the early months ofAmerican participation in the war, the tendency was to employ extraperitonealmethods of closure. Later, intraperitoneal techniques became increasinglypopular, for two reasons:
1. In spite of careful efforts to avoid opening theperitoneal cavity, it was frequently entered during extraperitoneal operations.
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2. It was found that undesirable consequences did not follow deliberate or accidental invasion of the peritoneal cavity during the closure of a colostomy.
In the 1,813 cases in which the techniqueemployed in closing colostomies in the Zone of Interior hospitals was stated,the intraperitoneal approach was used 1,055 times (58.2 percent) and theextraperitoneal approach 758 times. At Rhodes General Hospital (series C), all 96 patients were treated by the intraperitoneal technique. Inthe 437 cases in which thisinformation was available in series A, the intraperitoneal approach was used 186times and the extraperitoneal 251 times.
Informationconcerning the precise technique of closure was available in only 1,331 of the 2,198 operationsperformed in Zone of Interior hospitals. End-to-end anastomosis was employed in 642 cases (48.2 percent).The Pauchet type of anastomosis was employed in 22 cases,all at the same hospital, and other measures, including spur crushing followedby closure, were employed in the remaining 667 cases.At Rhodes General Hospital, simple closure wasperformed in 60 cases, end-to-end anastomosis in 42, and ileocolostomy in 6. Therewere 12 multiple operations in this series. Theprocedures used in the special group of hospitals which make up series A arepresented in the following table.
Procedure | Cases | Procedure | Cases |
Simple closure | 119 | Ileocolostomy | 11 |
End-to-end anastomosis | 316 | Anal reconstruction | 10 |
End-to-side anastomosis | 3 | Closure distal loop | 3 |
Side-to-side anastomosis | 9 | Crushing of spur | 167 |
Pauchet anastomosis | 22 | Reconstruction of spur | 3 |
Resection | 11 | Coccygectomy | 10 |
1This information is not available in 17 cases.
Information concerning thetechnique of closure employed in the 180 cases(series B) in which closure was accomplished overseas was available in only 76 cases. Some method of anastomosis was used in 5 cases, and spur crushing and closure were employed in theother 71.
Extraperitoneal operations.-Simple closure of the colostomy wasemployed in approximately 60 percent of the cases in whichthe approach was extraperitoneal. This was an entirely adequate operation whenthe stoma was small. In such cases, the technique used at the original operationhad been tube or tangential colostomy or loop colostomy without division of theposterior wall of the colon. The preferred suture material was catgut of smallsize. The
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suture line was inverted at least once. If spur crushing had been necessary, closure of the anterior wall of the colon was the final step of the operation.
End-to-end anastomosis was usedin about 30 percent of the cases managedby extraperitoneal operation. Side-to-side or end-to-side anastomosis wasemployed in the other 10 percent. These techniques all proved satisfactory in thecases-which were not too numerous-in which it was possible to mobilize the loops of bowel adequatelyoutside of the abdomen, and they had the great advantage of eliminating all riskof postoperative intestinal obstruction at the suture line.
Intraperitoneal operations.-When intraperitoneal closure of a colostomy was contemplated, no attempt was ever made to crush anexisting spur. Instead, the limbs were dissected free, and sufficient spacewas thus provided for any type of anastomosis. When the peritoneal cavity was tobe entered, special efforts were also made to free the area of adhesions. Thesedense adhesions, which often bound the bowel intimately to the anteriorabdominal wall, many times had to be treated by sharp dissection. The objectiveof these maneuvers was to leave the repaired intestine entirely free in itsnormal location.
Simple closure of theanterior wall of the bowel was a satisfactory technique if the posterior wall ofthe colon remained intact. If it was not intact, end-to?end anastomosis was thepreferred technique, though a number of surgeons had good results withside-to-side and end-to-side anastomoses. The Pauchet technique producedexcellent results in the single hospital in which it was used. In thistechnique, longitudinal slits are made in the proximal and distal loops afterthey have been fixed with a posterior suture, and side-to-side anastomosis, asin a Finney pyloroplasty, is used to reconstruct the bowel. The large stoma thuscreated at the line of anastomosis serves as a safeguard against possible futureobstruction at this point.
Ileotransverse colostomy wasused in a small number of cases in which damage to the right half of the colonand the small intestine had been followed by infection and massive destructionof soft tissues and in which sidetracking of the fecal current had beennecessary. The operation was performed by joining the ileum, above the injury,to the transverse or descending colon. Closure of the original colostomy byend-to-end anastomosis was then possible. Leakage of irritating material seldomoccurred, and failure was unusual. In most cases, because of the multipleopenings, resection of some portion of the intestine was necessary. Usually theportion resected was in the ascending, transverse, or descending colon. Ifextensive damage had made two or more colostomies necessary, it was frequentlysimpler, when closure was undertaken, to resect the middle segment of theintestine and restore intestinal continuity by an end-to-end anastomosis.
Adjunct procedures.-Herniationsin the fascia (p. 345)varied from slight weakening of the tissues, whichpermitted insignificant protrusions of the peritoneal contents, to extensiveopenings which required plastic repair. Unless there was some good reason forterminating the operation after
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closure has been accomplished, the repair was performed at the same time the stoma was closed. Catgut, silk, or cotton was used for sutures, depending upon the preference of the individual surgeon. The results of these operations were generally good.
Drainage was seldom necessary when the stoma was closed,and instances were on record in which it was clearly harmful. The risk ofplacing drains between layers of fascia was typified by the slough whichoccurred in two cases in a hospital in which this technique was popular.
Ina few hospitals, it was the custom to close the wound through the fascial layerat the first operation and complete the closure 2 or3 days later.
PostoperativeRegimen
Although practices varied from hospital to hospital, thepostoperative regimen after closure of a colostomy was deliberately kept assimple as possible. In some hospitals, nothing was given by mouth for from 24 to 48 hours.In others, fluids were given promptly and soft food shortly afterward.
The fluid balance and nutritional status were maintained bythe parenteral administration of dextrose solution, physiologic salt solution,casein hydrolysate, plasma, and whole blood, according to the necessities of theindividual case.
Constant intestinal decompression by the Wangensteentechnique or by means of the Miller-Abbott tube was instituted in all cases inwhich distention was considered a possibility. These methods were mostfrequently employed after operations on the right half of the colon.
The sulfonamide which had been employed before operationwas continued for 5 to 7 days afterward. When penicillin became available, itwas used by the intramuscular route in all cases in which infection seemed apossibility. The dose was 100,000 units every 4 hours. Towardthe end of the war, when streptomycin became available, it was used withapparently good results in gram-negative infections.
When vitamin K had been used before operation, it wasusually continued for 3 days or more after operation.
Anal dilatation was carried out daily for 5 days afteroperation.
Earlyambulation was not practiced uniformly, but there were no untoward results inany of the hospitals in which it was permitted.
Before the patient wasdischarged, all the laboratory determinations which had been carried out beforeoperation were repeated. Roentgenologic studies were also carried out, toestablish the patency of the anastomosis and as a final check against overlookedforeign bodies.
PostoperativeComplications
The discussionof postoperative complications is confined to the 464 cases(series A) from the group of hospitals which supplied especially full details on
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the questionnaires from which the data on closure of colostomy were secured. They are typical of the complications which occurred in all hospitals.
In these 464 operations,leakage occurred at the site of closure in 70 cases (about 15 percent). It was usually insignificant, and healing occurred promptly underconservative management. In 23 cases, however, secondary closure was necessary,and, in a few instances, multiple operations were necessary before theintestinal wall was securely closed. One patient required seven operations.
Local infection occurred in 39 cases (8.4 percent). It varied from slight exudation to extensive abscess formation, and in afew cases was associated with wound dehiscence. Clostridial myositis occurred in1 case, and in 2 others the infection was apparently the result of amebicinfection.
Hemorrhage occurred in sixcases. It was usually manifested by local bleeding. In one case, the formationof a large hematoma was followed by abscess formation. In two instances,bleeding occurred in patients who had received Sulfasuxidine. Although thebleeding was controlled without difficulty in all six cases in which itoccurred, the potential seriousness of this complication was obvious.
Paralytic ileus occurred onlytwice, but in one instance it was associated with massive distention; secondarysurgery was eventually required. The negligible incidence of ileus in thisseries as well as in the larger total series can be attributed to theprophylactic institution of constant intestinal decompression in so manycases.
Intestinal obstruction ofsome degree was apparent clinically in about 10 percent of all cases. It wasusually slight and transient and subsided spontaneously; in such cases, thecause was assumed to be edema at the anastomosis or the suture line. Adhesions were usually responsible formechanical intestinal obstruction, though in a small number of cases it occurredbecause so much of the bowel wall had been infolded that an actual diaphragm hadbeen created across the intestinal lumen. Although the 10-percent incidence ofpostoperative intestinalobstruction was undesirably high, only 3 of the 11 deaths which occurred in Zoneof Interior hospitals after closure of colostomy could be attributed to it.Advocates of the open abdominal approach contended that the risk of obstructionwas less when this technique was used.
Peritonitis occurred in 8cases, 1.8 percent of the total number in series A. In 1 or 2 instances, theinfection was mild and localized. In the other cases, peritoneal involvement wasgeneralized, and five deaths were attributed to it. In 2 of the 3 survivingpatients, abscess formation subsequently occurred, in the pelvis and thesubphrenic space, respectively, and surgical drainage was necessary.
There was only one instanceof thrombophlebitis. The infrequent occurrence of this complication wasattributed by many surgeons to the emphasis placed upon movement about the bedimmediately after operation, as well as to the practice, in many hospitals, ofearly ambulation.
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Fatalities
Eleven deaths are known to have followed closure of the colostomy stoma in the 2,198 cases cared for in Zone of Interior hospitals (0.5 percent). They were about equally distributed between the intraperitoneal and extraperitoneal techniques. Five, as just noted, were caused by peritonitis and three by intestinal obstruction. Liver failure, mesenteric vascular occlusion with gangrene of the bowel, and inanition accounted for the three remaining deaths.
Twoother deaths occurred before operation, in patients who were being prepared forsurgery. In each instance, the cause was an intractably poor nutritional statusand the resulting inanition. Thecause of the single death which occurred in the 180 colostomies closed inoverseas hospitals is not known.
The 12 deaths which followed surgery in these 2,378closures thus represented acase fatality rate of 0.5 percent.
COMMENT
A studyof the 2,378 patients who underwent closure of colostomy in this compositeseries indicates that, from the standpoint of the initial phase of managementoverseas, casualties with wounds of the colon fared better in World War II thanin any previous war for which records are available. They wereremoved from the battlefield with remarkable speed. They were prepared foroperation with efficient resuscitative measures and without loss of time.Finally, the routine practice of colostomy in wounds of the colon savedinnumerable lives which would undoubtedly have been lost in any previous war.The principle of exteriorization of the damaged colon was so firmly establishedin World War II that no further controversy can possibly arise concerning itsuse in any case in which the bowel can be sufficiently mobilized to permit it.It is a simple procedure, which can be carried out safely and promptly bysurgeons of limited experience. It entirely obviates the need for difficultsurgical decisions and for extensive resections and anastomoses in patientswhose status is poor and who must be operated on under field conditions. Certain aspects of the operation deserving special comment are given insucceeding paragraphs.
Diversionof the fecal stream.-One of theitems on the questionnaire circulated in general hospitals of the Zone ofInterior concerned the possibility of accomplishing total diversion of the fecalstream with an ordinary colostomy. There was not complete agreement in the 19replies received. Four surgeons did notthink that it could be accomplished with a tube or tangential colostomy. Fourthought that it could not be, or probably could not be, accomplished with a loopcolostomy, one thought that it could be, and one other thought that it probablycould be. Four thought that it could be accomplished by spur colostomy orprobably could be, and one thought that it could not be. The four remaining surgeonsthought that total diversion ofthefecal stream could be accomplished with a Devine colostomy. The infer-
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ence, therefore, is that only by the use of the Devine technique (fig. 39, p. 354) or some other special technique (fig. 41) in which there is actual separation of the stoma could one be absolutely certain of complete diversion of the fecal stream. Some surgeons regarded the creation of a second colostomy of the spur type, proximal to the sigmoid colostomy, as the better method of preventing contamination of the distal segment. The transverse colon was the preferred location for the second colostomy.
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There was also some difference of opinion concerning the absolute necessity for diversion of the fecal stream in the event that a fistula existed distal to the colostomy, particularly in the sacral region or the buttocks. The majority of the 62 surgeons who replied to this question considered it absolutely essential, or advisable, or desirable. The others did not consider it necessary. There was general agreement that a short, direct fistulous tract would not heal if fecal contamination continued, particularly if the tract traversed bone which was the site of an osteomyelitis. There was also general agreement that even if long, tortuous tracts healed under conservative management, sometimes without complete diversion of the fecal current, expectant treatment was not justified. The healing process could be expected to cover many months, and healing was unlikely until dead bone and foreign bodies had been removed. The consensus was that under these circumstances there were three courses of action: (1) Complete decontamination of the fistulous tract by revision of the colostomy into a modified Devine colostomy; (2) creation of a proximal colostomy in the transverse colon; or (3) closure and inversion of the fistula into the rectum, with complete unroofing of the tract, excision of everted rectal mucosa, and removal of all foreign bodies and of the coccyx or part of the sacrum.
Technical considerations.-The trend,as the war progressed, to substitute intraperitoneal for extraperitonealtechniques of closure has already been mentioned. The untoward results which sometimes followed crushing of the spur hadmuch to do with the change in practice. Incivilian surgery, the management of the spur presents no problem, for thesurgeon who creates the colostomy crushes it himself. In military practice, the surgeon who constructs thecolostomy almostnever crushes the spur. The hundreds of patients admitted to general hospitals in the Zone ofInterior with unclosed colostomies were operated on by surgeons who, howeverexperienced they might be, had no knowledge of the initial surgery in any casebeyond what was contained on the field medical record. These data were often entirely inadequate. Even when the records were reasonably complete, the conditions were notat all the same as if the surgeon who was to crush the spur had been responsiblefor the creation of the colostomy or had at least observed its creation.Furthermore, the unavoidable haste with which many operations were necessarilyperformed in forward hospitals, combined with the limited experience of some ofthe operating surgeons, militated against the construction of an ideal spur,especially when it was known that a simple loop colostomy would suffice.
Inaddition to these fundamental considerations, unfortunate experiences in dealingwith poorly constructed spurs played a large part in the substitution of theintraperitoneal for the extraperitoneal technique. The application of a clamp or an enterotome oftenproduced severe pain, nausea, and vomiting. Peritonitis sometimes followed theaccidental crushing of large mesenteric vessels. Other complications includedinfection, fistula formation into the ileum or jejunum, paralytic ileus,intestinal obstruction, and prolonged edema
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and cyanosis of the intestinal mucosa. In two instances in this series, benign neoplasms occurred at the site of the spur.
Most serious of all, rotationof the loops had taken place in nearly a hundred cases in the total series, andthe existing relationships could not be determined before the enterotome wasapplied. As a result of this combined experience, more and more surgeons abandonedattempts to crush the spur and resorted, instead, to intraperitoneal closure ofthe colostomy.
The data available in thisanalysis do not supply adequate statistical proof concerning the relativefrequency of postoperative complications after extraperitoneal versusintraperitoneal colostomy closure. The clinical impression was, however, thatcomplications were fewer when the intraperitoneal technique was used. There was considerable logic in this point of view:
1. The peritoneal surfaceshad been vaccinated before operation, because the colostomy had practicallyalways existed for months before closure was attempted.
2. All the patients wereyoung and free from organic disease. As a rule, they were in excellent condition except for the colostomy andits complications.
3. Chemotherapy and antibiotic therapy probably played somepart in the good results, by preventing invasive infection. Streptomycin was regarded as particularly useful in this respect.
4. With the intraperitonealtechnique, the restoration of the bowel more nearly approached normal becausethe anastomosis could be performed more accurately and all adhesions could beobliterated. At the conclusion of the operation, therefore, the repaired bowellay free in its normal location, and postoperative intestinal obstruction wasless likely to occur.
Theexperience in this series showed that injuries to the right side of the colonpresented special problems, particularly if the small intestine had also beendamaged. It was not felt, however, that the use of the small bowel with the colonto create a spur colostomy offered any solution of the problem. Wounds in thisarea were best dealt with by resection of the damaged cecum or ascending colon,with direct end-to-end anastomosis between the ileum and colon. After this hadbeen done, a single-barreled external mucous fistula was created in the proximalcolon.
Injuriesof the rectum also furnished special problems. Sacral or perineal colostomy, employed in less than1 percent of thecases in this total series, was used chiefly when severe damage to the rectumwas associated with partial or total destruction of the anal sphincter. Even asa temporary expedient, however, this was not regarded as good surgery. Thenursing care in such cases was extremely difficult, irritation of the skin wasalmost unavoidable, and the patients themselves objected to this type ofcolostomy for a number of reasons, including purely esthetic reasons.
The best plan in injuries tothe fixed portions of the rectum and colon was immediate repair of the analsphincter, combined with posterior drainage and followed by proximal colostomy,preferably in the transverse or descending
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colon (fig. 42). Loop openings were separated, to avoid continued contamination of thedistal loop. This precautionwas particularly important if the pelvis or the sacrum had been injured or ifthere had been extensive damage to the rectum or bladder below the peritonealattachment (fig. 43).
When a patient was receivedwith a sacral colostomy and with damage to the anal sphincter which had not beenrepaired or the repair of which had been unsuccessful, a secondary colostomy wascreated at once, in the sigmoid or transverse colon, before plastic surgery onthe anus was undertaken. Evenif this colostomy had to become permanent, because of failure of repair of theanus, it was possible to close the sacral opening, and the unfortunate casualtywas left in much better condition than he had been in after the first operation.
A consideration of the errorsobserved in the colostomies in this series leads to the conclusion, fortified bythe entire experience of World War II, that, in injuries of the colon, thedamaged loop should always be brought out through a stab wound placed laterallyto the main incision and that it should be fixed in this location by sutureswhich do not pass through the bowel wall (fig. 44).
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Satisfactory support can be provided by a glass tube of thekind in which catgut is sterilized or by some similar blunt object placedbeneath the mesenteric border. Rubber tubing can also be used. Spur formation isnot essential. In fact, observations in Zone of Interior hospitals, and attemptsto crush spurs in which the relationship to surrounding structures had changed,suggested that any technique which required creation of a spur might be actuallyundesirable.
Therevisions and relocations of the original colostomies performed in this serieswould have been entirely unnecessary if the general principles set forth in thischapter had been followed in the creation of the original opening. Furthermore, some, at least, of the problems encountered at everyhospital, such as retraction of the loops of bowel, undue protrusion of thebowel through exces-
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sively large fascialopenings, intestinal obstruction caused by adhesions, continued contaminationof a distal fistulous tract, and retained foreign bodies, would have presentedno difficulties if these principles had been followed.
Chemotherapy and antibiotic therapy.-Although thecolon is one of the most heavily contaminated structures in the body, there wasconsiderable divergence of opinion as to the necessity for, and the value of,supplemental chemotherapy and antibiotic therapy in closure of colostomies. Oneor the other of these methods, and sometimes both, were used in most cases inthis total series, but about a third of the surgeons who performed theoperations were not convinced of the value of any of these agents, about 10percent considered them of no value, and a few regarded them as harmful.
Most of the surgeons who usedthese drugs thought that their chief value, at least as far as the then newlydeveloped preparations Sulfathalidine (phthalyl?sulfathiazole) andSulfasuxidine were concerned, was to insure a clean intestinal surface at thetime of operation. They questioned their antibacterial effect and were inclinedto attribute the striking absence of infection in these cases to the fact thatsufficient time had elapsed since the first operation to permit some degree ofautovaccination of the peritoneal surfaces. In spite of these doubts of thevalue of the routine use of these agents, it was the general practice toadminister Sulfasuxidine and Sulfathalidine orally for several days beforeoperationto all patients who had had peritonitis or intra-abdominal abscesses, as well asto those who were likely to require extensive resection of the colon.
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When penicillin and streptomycin became available, theywere used on the same indications.
Almostall of the available sulfonamides except sulfanilamide were used in this series,but Sulfasuxidine and sulfaguanidine were the most popular. Sulfathalidine wasnot available at all hospitals. All routes of administration were employed, including the localapplication of the powdered drug, which was used at operation in about 10percent of all cases. Stool examinations made in the cases in which chemotherapywas used showed that, while there was not complete destruction of allmicro-organisms, the colonies were always greatly reduced in number.
Irritation of the skin aboutthe colostomy was an annoying consequence of sulfonamide therapy (fig. 45). It could usually be controlled by the use of
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aluminum or kaolin paste. Secondary hemorrhage, another possiblecomplication, was alwayspotentially serious. Its prevention required careful prothrombin studiesbefore operation and the administration of vitamin K in the immediatepreoperative and postoperative period.
Penicillinwas used extensively after it became available in the Zone of Interior in thespring of 1944. It was thought to be of great value in the prevention ofinfections caused by gram-positive organisms. Streptomycin did not becomeavailable until later and then only in hospitals designated for special studies.It was regarded as of great value in the prevention and treatment ofgram-negative infections.
SUMMARY
The most important lesson tobe derived from the large number of colostomies upon which this chapter isbased is that the closure of the stoma created in the management of abattle-incurred injury of the colon is a safe and relatively simple procedure.In this series, almost every possible unfavorable circumstance was presentfrom the moment of wounding. Initial treatment was carried out in a forwardhospital, under field conditions. Even in fixed hospitals, treatment wasconducted under the stress and strain of military conditions. The wounds werefrequently of great gravity. Otherwounds were frequently associated. In spite of these facts, the case fatalityrate for closure of the colostomy was fractional, complications were relativelyfew, and practically every patient who survived was returned to normalactivities and, from the standpoint of his intestinal injury, was in excellentcondition on discharge.
In World War II, improvementsin the technique of intestinal surgery, the intelligent use of replacementtherapy and of chemotherapy and antibiotic therapy, and increasing experience onthe part of responsible surgeons made it possible to close colostomies withinrelatively short periods after their creation. The wartime experience suggeststhat in future wars it may be possible to accomplish closure in all but the mostcomplicated cases in overseas hospitals, without evacuating the patients to Zoneof Interior hospitals. From a military standpoint, this would be a mostimportant advance, for it would permit soldiers with wounds of the colon toreturn to full duty after relatively brief periods of disability andconvalescence.
