Original Article

Same admission colostomy closure: A prospective,

randomised study in selected patient groups

M. S. Khalid S. Moeen A. W. Khan R. Arshad A. F. A. Khan

Department of Surgery, Lahore General Hospital, Lahore, Pakistan

Correspondence to: M. S. Khalid, 25 Hawthorne Close Creagh Portiuncula Hospital, Ballinasloe, Co Galway, Ireland Email: sufian999@hotmail.com

Introduction Materials and Methods Results Discussion References

Keywords: Colostomy, conventional, trauma, large bowel, stoma Surgeon, 1 February 2005, 11-14

INTRODUCTION

Temporary diverting colostomy is the standard of care for a variety of traumatic and nontraumatic colorectal pathologies. However, it is associated with a well-recognised morbidity, cost and unproven need for a long delay until closure.¹ Colostomy closure is a frequently performed procedure for temporary colostomies in surgical practice. Timing of colostomy closure is a controversial issue among general surgeons. In the absence of severe intra-abdominal sepsis, malnutrition or major wound problems, early colostomy closure can be safely undertaken in a vast majority of patients.^2,3 Same admission colostomy closure is a technique of early colostomy closure which is undertaken in the very first admission in which the colostomy was constructed. The concept of SACC appears highly attractive and is likely to be accepted by the patient.⁴ Early colostomy closure, however, is technically more difficult and associated with greater blood loss.⁵

In a developing country like Pakistan, colostomies are ill-managed by the patients due to poor education, poverty and unreliable supply of collecting appliances.⁶ Keeping these considerations in view we undertook this prospective, randomised study to compare the safety and cost-effectiveness of SACC.

MATERIALS AND METHODS

Patient Selection

Over a 24-month period (July 2001 to June 2003), 60 patients from a total population of 123 patients with colostomy, predominantly for traumatic causes, were randomised (Table 1). A majority of the randomised patients had colorectal trauma as the primary pathology. They underwent colostomy closure for the first time under the supervision of a single consultant. On the basis of their eligibility for colostomy closure, half of these 60 patients underwent SACC [30 patients, 23 men, mean age 27.9 ± 9.7 (range, 18-65) years] and the other half CDCC [30 patients, 24 men, mean age 28.6 ± 10.6 (range, 18-63) years]. The randomisation sequence was obtained by card allocation and strictly followed. This was a simple procedure and the patient picked up one of two envelopes. Each envelope contained one card that had written either an SACC or CDCC operation on it.

Exclusion criteria included patients who needed a permanent colostomy, patients with inflammatory bowel disease, patients in whom primary operation was complicated by intra-abdominal sepsis or wound infection, patients with a poor general condition, such as severe malnutrition, anaemia or systemic diseases and those patients with polytrauma.

The study was approved by the Institutional Medical Ethics Committee, and all patients gave informed consent.

Operative Technique

Same admission colostomy closure was performed between the first and second week following stoma formation. Conventional delayed colostomy closure was performed six to twelve weeks after the primary operation. Prior to colostomy closure a contrast enema was performed to exclude leaks and perforations in the distal gut as well as concomittant pathology. The bowel was prepared as follows: 72 hours before surgery, only clear fluids were given to the patient; 48 hours before surgery, a cathartic was given eight hourly for 24 hours and 24 hours before surgery, an enema, one at 8am and the other at 2pm, was administered.

The patient was kept fasting overnight with maintenance of an intravenous line with Ringer lactate solution. Serum electrolytes were monitored throughout this period. The abdomen was opened through the previous laparotomy incision. An incision was made around the edge of the colostomy taking a small fringe of skin approximately 2mm wide. The gut was completely freed from adhesions. After obtaining an adequate length, resection of both ends of the colostomy was done ensuring that the cut ends were not oedematous and were viable. Thereafter, intraperitoneal closure was performed with polyglactin (vicryl 3/0, Ethicon) interrupted stitches in double layer. The laparotomy wound was closed en masse. Colostomy wound was closed in layers. Controlled anal stretch was performed at the end of the operation in all cases to counteract increased internal anal sphincter tone, which may develop due to prolonged disuse. All patients received the same antibiotic regimen (cephradine 500mg intravenously six hourly, gentamycin 80mg intravenously six hourly, metronidazole 500 mg intravenously eight hourly) for 72 hours. This regimen, however, was continued for a week if septic complications developed

Follow-up

All patients were followed-up fortnightly for three months for measurable and comparable parameters including complications and quality of life.

Data Collection and Statistical Analysis

Data were prospectively collected in a locally maintained database (Microsoft^® Access). Data were expressed as mean ± standard deviation or number (percentage) of patients. Continuous data were analysed by the Mann-Whitney test. Categoric data comparison was made by the chi square (X 2) test. Statistical significance was confirmed with a probability error of less than 5%( p<0.05). All calculations were performed with GraphPad Instat Version 3.00(GraphPad Software San Diego, CA, USA).

RESULTS

The two groups were similar with respect to pre-operative demographics as shown in Table 1. The majority of patients (28/30=93.3%) in both groups had a colostomy for traumatic colorectal pathologies. There were no deaths in either group. The incidence of complications in the two cohorts of patients was similar and presented in Table 2. The patients in the SAAC group had a significantly shorter hospital stay, 16.4 ± 2.6 days (range 14 to 19) versus 21.3 ± 2.9 days (range 19 to 24 days), p<0.01; reduced cost, $32.022 versus $84.645, p<0.001 and a better quality of life and early return to work, compared with the CDCC group. Table 3 provides a comparison of the 60 patients in the study group with the 63 patients who were excluded.

DISCUSSION

Boyden (1950), after retrospectively reviewing the outcome of patients with diverticulitis-related colostomies, who underwent colostomy closure at a mean of nine weeks, was the first to question the rationale behind colostomy closure after three to twelve months of primary surgery.⁷ Same admission colostomy closure is not a revolutionary new technique. In 1938, Powers and O’Meara reported the first case of SACC for rectal trauma in a patient who had a transanal rectal impalement.⁸ In 1952, Powers reported another case of sigmoidoscopic perforation of the distal sigmoid colon that underwent SACC 17 days after injury without any complication and was noted to be doing well five years later.⁹ This is the only case of SACC in the literature with a longterm follow-up.⁹ Thereafter, the concept of SACC has been discussed by various authors.^2,4,10-12

To the best of our knowledge, this is the first ever prospective, randomised comparison of SACC and CDCC techniques. Our study confirms the findings of Renz et al (1993) that SACC can be safely performed in a carefully selected group of patients.⁴ However, in our study the incidence of faecal fistula formation was only 3.3% in the SACC group and 6.66% in the CDCC group, which is much less than that reported by Renz et al (1993).⁴ We attribute this difference to our technique of colostomy closure. As we resect the stoma prior to colostomy closure, therefore, removal of oedematous and possibly infected tissue aids better healing of the suture line. Furthermore, the overall morbidity and mortality rates of our study are comparable with those previously published in the literature.^13-15 The majority of colostomies in the two study groups (SACC=86.6% and CDCC=90%) were loop colostomies. This reflects the underlying major colorectal pathology i.e. trauma. Loop colostomies enabled exteriorisation of most proximal injury after repair of distal injuries thereby ensuring protection of the distal repairs. In the SACC group, 60% (18/30) of the loop colostomies compared with 66.6% (20/30) in the CDCC group, were in the transverse colon.

Same admission colostomy closure is based upon sound principles. Collagen synthesis and content of colostomy wound are optimal seven to eleven days after colostomy construction.¹⁶ Closure of colostomies during this proliferative phase of wound healing will ensure better anastomotic healing and strength. Hence, after radiological confirmation of the healing of the primary injury or process distal to the colostomy, SACC can be safely undertaken between the first and second week after colostomy construction. Delayed colostomy closure has been practiced to date to ensure repletion of lean body mass, resolution of peritonitis, sepsis, and inflammation in the region of the primary pathology, and healing of anastomoses or injuries distal to the colostomy.⁴ In our opinion, in otherwise fit and healthy patients with normal wound healing SACC is an attractive option. Not only does it reduce hospital stay but also ensures early return to work. Even more important, in developing countries where healthcare systems are not well-established and poverty is rife, SACC ensures that patients never have to learn colostomy care, purchase appliances or deal with colostomy-associated chores. The limitation of this study is probably the small size of cohorts. However, a large multicentre trial needs to be undertaken to further confirm the findings of our study. In conclusion, the results of this study suggest that same admission colostomy closure is a safe and cost-effective technique in carefully selected patients with colostomy, predominantly traumatic causes.

Copyright 13 December 2004

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