Colostomy closure: how to avoid complications

Abstract

PurposeColostomy is an operation frequently performed in pediatric surgery. Despite its benefits, it can produce significant morbidity. In a previous publication we presented our experience with the errors and complications that occurred during cases of colostomy creation. We now have focused in the morbidity related to the colostomy closure. The technical details that might have contributed to the minimal morbidity we experienced are described.MethodsThe medical records of 649 patients who underwent colostomy closure over a 28-year period were retrospectively reviewed looking for complications following these procedures. Our perioperative protocol for colostomy closure consisted in: clear fluids by mouth and repeated proximal stoma irrigations 24 h prior to the operation. Administration of IV antibiotics during anesthesia induction and continued for 48 h. Meticulous surgical technique that included: packing of the proximal stoma, plastic drape to immobilize the surgical field, careful hemostasis, emphasis in avoiding contamination, cleaning the edge of the stomas to allow a good 2-layer, end-to-end anastomosis with separated long-term absorbable sutures, generous irrigation of the peritoneal cavity and subsequent layers with saline solution, closure by layers to avoid dead space, and avoidance of hematomas. No drains and no nasogastric tubes were used. Oral fluids were started the day after surgery and patients were discharged 48–72 h after the operation.ResultsThe original diagnoses of the patients were: anorectal malformation (583), Hirschsprung’s disease (53), and others (13). 10 patients (1.5%) had complications: 6 had intestinal obstruction (5 due to small bowel adhesions, 1 had temporary delay of the function of the anastomosis due to a severe size discrepancy between proximal and distal stoma with a distal microcolon) and 4 incisional hernias. There were no anastomotic dehiscences or wound infection. There was no bleeding, no anastomotic stricture and no mortality.ConclusionBased on this experience we believe that colostomy closure can be performed with minimal morbidity provided a meticulous technique is observed.

Ostomy Closures in Children: Variations in Perioperative Care Do Not Change the Outcome

“…Our SSI rate was 9.2 %. Rates of SSI due to ostomy closure vary between 0 and 36 % in the literature [4, <0.001 5,14,15]. The mean SSI rate was 14 % (17/118) in a similar study where the incisions were primarily closed after ostomy closure in children, and SSI rates did not differ according to bowel cleansing and preoperative and postoperative antibiotic regimens, which supports our own findings [10].…”

“…Although there are surgeons who prefer secondary closure to prevent SSI as colostomy closure is a contaminated procedure, primary skin closure can be performed safely [13,14]. All our incisions were closed primarily, and no subcutaneous drain was placed.…”

“…Closing the layers one by one also prevents the creation of a dead space. Mass or secondary closure that produces aesthetically worse results and more pain should be avoided [14].…”

“…Early feeding after ostomy closure in children has similarly been shown to stimulate bowel movements without increasing complications [3]. Children can be given clear liquids on the first day if there is no distension or vomiting [14].…”

Rates and burden of surgical site infections associated with pediatric colorectal surgery: insight from the National Surgery Quality Improvement Program

“…In a larger, multicenter retrospective review of colostomy closure in pediatric patients, where the most common indication for colostomy was ARM or HD, wound infection rates were 5.8% in patients who did not receive a mechanical bowel preparation and as high as 14.4% in those who did receive a bowel preparation [24]. Because of the known risk of complications following this procedure, Bischoff et al reported on efforts to minimize such risk, including packing of the proximal stoma, avoiding contamination, cleaning the edge of the stoma, and closure by layers, among other recommendations [25]. While these studies all report various rates of wound infection or anastomotic leaks, these outcome definitions were not standardized across studies.…”