Colonic mucosal-submucosal blood flow and the incidence of faecal fistula formation following colostomy closure

Early Versus Routine Stoma Closure in Patients With Colorectal Resection: A Meta-Analysis of 7 Randomized Controlled Trials

Background. A substantial proportion of patients undergoing colorectal surgery receive a temporary stoma, and the timing for stoma closure remains unclear. The aim of this study was to evaluate the safety and feasibility of early stoma closure (ESC) compared with routine stoma closure (RSC) after colorectal surgery. Methods. We comprehensively searched PubMed, Embase, and the Cochrane Library for randomized controlled trials that compared ESC and RSC after colorectal surgery. Results. A total of 7 randomized controlled trials with 814 enrolled patients were identified for this meta-analysis. There were no significant differences between the ESC and RSC groups regarding the complications of stoma closure (26.8% and 16.6%, respectively; odds ratio [OR]: 1.30; 95% confidence interval [CI]: 0.89-1.90; P = .17). A subgroup analysis was conducted by Clavien-Dindo grade of complication, and no significant difference was observed in any subgroup ( P > .05). However, the ESC group had a significantly higher risk of wound complications than the RSC group (17.6% and 7.8%, respectively; OR: 2.61; 95% CI: 1.43-4.76; P = .002), and the RSC group had more cases of small bowel obstruction than the ESC group (3.1% and 8.4%, respectively; OR: 0.37; 95% CI: 0.15-0.87; P = .02). Conclusions. ESC is a safe and effective therapeutic approach in patients who have undergone colorectal surgery; it is associated with a reduced risk of bowel obstruction but a higher risk of wound complications.

Colostomy Blood Flow Measurement by Laser Doppler Velocimetry — A Preliminary Report

Laser Doppler velocimetry has been used to study colostomy blood flow. Eight patients were studied one week after fashioning of a colostomy and a further ten patients were studied at least nine weeks post-operatively. There was a significant difference in the blood flow between the two groups (p < 0.002). We conclude that laser Doppler velocimetry may be a useful technique for measuring colostomy blood flow.

How to assess intestinal viability during surgery: A review of techniques

Objective and quantitative intraoperative methods of bowel viability assessment are essential in gastrointestinal surgery. Exact determination of the borderline of the viable bowel with the help of an objective test could result in a decrease of postoperative ischemic complications. An accurate, reproducible and cost effective method is desirable in every operating theater dealing with abdominal operations. Numerous techniques assessing various parameters of intestinal viability are described by the studies. However, there is no consensus about their clinical use. To evaluate the available methods, a systematic search of the English literature was performed. Virtues and drawbacks of the techniques and possibilities of clinical application are reviewed. Valuable parameters related to postoperative intestinal anastomotic or stoma complications are analyzed. Important issues in the measurement and interpretation of bowel viability are discussed. To date, only a few methods are applicable in surgical practice. Further studies are needed to determine the limiting values of intestinal tissue oxygenation and flow indicative of ischemic complications and to standardize the methods.

Same admission colostomy closure: a prospective, randomised study in selected patient groups

BACKGROUND

Despite a recent trend towards primary repair, colostomy still has an important place in the management of different colorectal pathologies. Timing of colostomy closure is a debatable issue among general surgeons. We carried out a prospective, randomised study to compare the outcome after same admission colostomy closure (SACC) and conventional delayed colostomy closure (CDCC) in patients with predominantly traumatic injury of the large bowel.

METHODS

Sixty patients, the majority with traumatic colorectal pathologies, were prospectively randomised to SACC [30 patients, 23 men, mean age 27.9 +/- 9.7 (range, 18-65) years] or (CDCC) [30 patients, 24 men, mean age 28.6 +/- 10.6 (range, 18-63) years]. All colostomies were closed using an intraperitoneal closure technique. Pre-operative data and post-operative outcomes were collected and analysed.

RESULTS

A total of seven patients (23.3%) with SACC developed complications compared with eight patients (26.6%) having CDCC (p = 0.83). The mean hospital stay (p < 0.01), as well as the overall cost (p < 0.001), were significantly less in the SACC group.

CONCLUSIONS

Same admission colostomy closure is a safe and cost-effective technique for colostomy closure in selected groups of patients.

Same admission colostomy closure (SACC). A new approach to rectal wounds: a prospective study

OBJECTIVE

The purposes of this project were to study the healing of protected rectal wounds (RWs) using contrast enemas (CEs) and to establish the safety of same admission colostomy closure (SACC) in terms of colostomy closure (CC) and rectal wound-related outcomes, for selected patients with radiologically healed RWs.

SUMMARY BACKGROUND DATA

Traditional treatment of RWs has included a diverting colostomy that is closed 2 or more months later during a readmission.

METHODS

All patients admitted with a rectal injury were entered into this prospective study, treated with a diverting colostomy and presacral drainage, and managed according to a postoperative protocol that included a CE per anus to detect healing of the RW. Patients with no leaking on their first CE, no infection, and anal continence underwent SACC.

RESULTS

From 1990 to 1993, 30 consecutive patients had rectal injuries, 90% of which resulted from gunshot wounds. The first CE was performed in 29 patients 5 to 10 days after injury. In this group, 21 patients did not and 8 did have leakage from their RWs. The proportions of RWs radiologically healed at 7 and 10 days after injury were 55.2% and 75%, respectively. Sixteen patients with a normal CE underwent SACC 9 to 19 days after injury (mean, 12.4 days). There were two fecal fistulas (2 of 7; 28.6%) after simple suture closure, none (0 of 9) after resection of the stoma with end-to-end anastomosis, and no RW-related complications after SACC. The mean hospitalization time was 17.4 days.

CONCLUSIONS

The following conclusions were drawn: (1) CE confirmed healing of RWs in 75% of patients by 10 days after injury; (2) 60% of patients with RWs were candidates for SACC, and 53% were discharged with their colostomies closed; (3) SACC was performed without complications in 87.5% of patients with radiologically healed RWs; and (4) there were no RW-related complications after SACC.

Angiogenesis in wound healing

Angiogenesis is an essential component of wound healing. Vessel growth is controlled by the local actions of chemical mediators, the extracellular matrix, metabolic gradients, and physical forces. Manipulation of some of these factors can improve healing in experimental wounds. The clinical potential and specific application of 'angiomodulatory' strategies are discussed.

Laser Doppler velocimetry and the measurement of colostomy blood flow

Early colostomy closure leads to a high rate of fecal fistula formation which may be due to a poor blood supply. Laser Doppler flowmetry is a new method of measuring colonic blood flow. Blood flow in 17 colostomies has been measured at one week, median flux 28 units (range, 13 to 43) and in 12 colostomies more than eight weeks after formation, median flux 46 units (range, 35-56; P less than 0.002). Nine of the "mature" colostomies have been closed without a fecal fistula or other signs of anastomotic failure. Serial readings of colostomy blood flow were made at weekly intervals in another ten stomas over a period of two months. Blood flow increased over this time from a median of 19 units (range, 17 to 22) at one week to a median of 44 units (range, 39 to 48; P less than 0.002) at eight weeks. Laser Doppler flowmetry is a simple, noninvasive method of measuring colostomy blood flow and the findings support a clinical policy for delayed colostomy closure.

Endoscopic measurements of canine colonic mucosal blood flow using hydrogen gas clearance

We have examined the feasibility of hydrogen (H2) clearance for endoscopic measurements of colonic mucosal blood flow in anesthetized dogs. In 6 animals, measurements of H2 clearance did not differ significantly in different regions of the sigmoid colon and they were highly reproducible (p less than 0.001) on different days. In a total of 12 dogs, measurements of H2 clearance correlated closely with those obtained using radioactive microspheres under resting conditions and, in 4 dogs, during infusion of vasopressin (slope = 0.94, p less than 0.001). In 8 dogs, ligation of the major arteries supplying the sigmoid colon resulted in an acute 60% decrease in sigmoid mucosal blood flow (p less than 0.001); however, in 5 animals that survived the procedure, mucosal blood flow returned nearly to control levels as early as 3 days after operation. Endoscopic H2 clearance thus appears to be feasible for measuring mucosal blood flow in the colon. Serial measurements of H2 clearance may prove useful in characterizing the role of mucosal blood flow in the pathogenesis of various forms of human colonic disease.

A clinical and experimental study of colostomy blood flow and healing after closure

Colostomy blood flow and healing have been studied in both man and rat. Laser Doppler velocimetry (LDV) was used to measure flow and showed a significant difference between colostomy blood flow measured at 1 week and at more than 8 weeks after fashioning (p less than 0.002). Hartmann colostomies were constructed in rats and closed at 3 or 6 weeks later. There was a correlation between distal colonic (stump) blood flow and anastomotic bursting pressures 3 days after closure in the 3-week group (r = 0.080; p less than 0.01). Colostomies closed at 6 weeks were significantly stronger than those closed at 3 weeks (p less than 0.02). Collagen concentration in proximal (stoma) colon was higher in the 6-week group compared with the 3-week group prior to anastomosis. There was also a fall in the proximal collagen after anastomosis in both 3- (p less than 0.01) and 6-week groups (p less than 0.01). Poor blood flow measured by LDV and colonic collagen concentration may predict poor healing after colostomy closure. LDV is a non-invasive technique with clinical application in this field.

Construction and closure of the transverse loop colostomy

The clinical courses of 211 patients having transverse loop colostomies performed during the years 1969 to 1980 in the Stockholm region were examined to evaluate problems connected with construction and closure. Forty-seven percent of these stomas became permanent. The morbidity rate for colostomy construction and closure seemed to be independent of the operative techniques used, the underlying disease, and the timing of closure. Thus, early closure (within six to eight weeks after construction) did not affect the local complication rate from the stoma. A meticulous surgical technique is of great importance, and stoma construction and closure is therefore not to be considered a minor operative procedure.

First experimental results with the oxygen electrode as a local blood flow sensor in canine colon

A modified oxygen electrode was tested against the electromagnetic flowmeter to see if its reading indicated blood flow to the canine colon. Although gross inflow was compared with local flow, the correlation was good in each of seven individuals (r ranged from 0.86 to 0.97). The closeness of the relative values gives the instrument potential for cheap, fast, repeatable and non-invasive estimation of regional blood flow, in colon and other exposed tissues.

Evaluation of laser Doppler flowmetry in the assessment of intestinal blood flow in cat

Laser Doppler flowmetry with a differential detector system has been used in the assessment of blood flow in the feline small intestine. Simultaneous mucosal and serosal laser Doppler flowmeter recordings were compared with total blood flow of a bowel segment measured by an optical drop-recorder unit in 6 cats. Blood flow through the muscularis layer was estimated using the 85Kr washout technique. A correlation coefficient of r = 0.96 (mucosal recordings = 90, serosal recordings = 80, p less than 0.001) was obtained between laser Doppler flowmeter output signals and total blood flow at different levels of vascular tone, regardless of whether the flowmeter recordings were made from the mucosal or the serosal side of the bowel wall. At intense vasodilation, the flowmeters showed a tendency to underestimate blood flow. The flowmeter signals were at variance with the muscularis blood flow but were clearly correlated to the calculated mucosal-submucosal blood flow. The uneven blood flow distribution in the intestinal wall did not affect the ability of the flowmeters to reflect total blood flow from either side of the bowel wall. A calibration curve could be constructed for approximate interpretation of the laser Doppler signals in absolute flow units. However, further experiments in humans and further development of the technique must be performed to elucidate clinical applications of the method.

EEA stapler for mid-rectum carcinoma. Review of recent literature and own initial experience

Over a three-year period, 1980-82, 79 per cent of our patients with rectal cancer were treated with the intention of cure, and sphincter-saving procedures were performed in 62 per cent of these cases. This report concerns 21 patients with mid-rectum cancer operated on with low anterior resection and extraperitoneal EEA-stapled anastomosis. Nine patients had Dukes' stage A tumors, seven had stage B, and five had stage C tumors. An 86-year-old woman died in the sixth postoperative week, and a 74-year-old man died after 20 months with a probable recurrence. Nineteen patients are currently alive 4 to 40 months post-operatively, with no overt signs of recurrence. We cannot confirm recent alarming reports on a significant incidence of early local recurrence. Routine Gastrografin enemas were performed and offered very little in terms of clinical guidance. Significant anastomotic leakage occurred in four patients, although without clinical symptoms or the need for fecal diversion. Despite initially intact anastomoses in 13 patients, pelvic sepsis with late dehiscence developed in three, all of whom required fecal diversion. The clinical leak rate was thus 3 of 21, 14 per cent, and the total incidence of leakage 7 of 21, 33 per cent. We performed routine colostomy on the first three patients but, in retrospect, believe this was unneccessary. Only one of the 19 survivors still has a colostomy, due to a benign anastomotic stricture. We consider anterior resection of mid-rectum carcinoma with EEA-stapled anastomosis a highly feasible procedure, the curative potential of which, however, can be established only by long-term follow-up studies.