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14 Intestinal Stomas 11 5
The Hole in the Abdominal Wall
The hole in the abdominal wall is made after completing the abdominal
part of the operation and before closing the abdomen. A disk of skin (average
diameter of 2 cm), including some subcutaneous fat, is resected at the chosen
location; through a cruciate incision in the anterior rectus sheath, the fibers of
the rectus muscle are split; the posterior fascia (if present) and peritoneum are
generously incised, allowing the passage of two fingers. Beware of any bleeding
that may result from an injury to the epigastric artery.
Exteriorization of the Bowel
Tension-free exteriorization of a well-perfused bowel segment is essential.
If necessary, you have to return your attention to the abdominal cavity to liberate or mobilize the bowel further to prevent an ischemic and retracted stoma,
which otherwise will be a nightmare for the patient, the surgeon, and the stoma
therapist.
Primary Maturation
Primary maturation of the stoma, suturing the bowel wall to the surrounding skin or to the subcuticular layer with absorbable sutures, is performed only
after closing the abdominal incision, including the skin, and covering it to prevent contamination from the stoma. Leaving the closed exteriorized bowel hanging out and maturing it a day or two later (“delayed maturation”) is still practiced
by some “antique” surgeons but no longer has a role.
Respect for these principles is fundamental in achieving a satisfactory stoma,
whatever its type and location. But, the various types and locations have different
indications and require technical refinements, which are addressed next.
Small Bowel Stomas
The small bowel stomas are almost always ileostomies. Proximal small
bowel stomas (jejunostomies) are indicated only in desperate cases and most are
end stomas after resections for massive mesenteric ischemia (> Chap. 23) or for
proximal “diversion” for complex leaking small bowel anastomoses (> Ch ap. 50).
Although difficult to manage because of their high output, they are preferred to
an anastomosis that is doomed to fail or intractable intra-abdominal infection.
116 Luis Carriquiry
End ileostomies may be indicated in the following situations:
After right hemicolectomy or subtotal colectomy, when the surgeon decides not
to anastomose the ileum to the colon or rectum (> Chaps. 24, 25, and 27)
After dismantling a leaking ileocolic or ileorectal anastomosis (
The end ileostomy has to be located in the right side, exiting through the
rectus abdominis muscle. If you have liberal access to mechanical suturing devices, you can use them to cut the bowel, sealing its open end to prevent contamination; otherwise, occlude the cut end with a clamp. When the operation is
“primary” on a virginal abdomen, the ileum is easily exteriorized; however, in
the postoperative setting, with an engorged bowel and an edematous, shortened
mesentery, exteriorization is more difficult and sometimes requires further resection or construction of an end-loop ileostomy, in which the apex of the loop
reaches the skin with less tension than the end because of mesenteric retraction
(the end of the loop is sutured or stapled, and its side is opened and matured).
There is no need to fix the loop of bowel to the peritoneum or the fascia; simple
proper exteriorization and primary maturation are enough to prevent retraction.
But, in the case of the end ileostomy, exteriorization should be generous enough (5
cm) to allow eversion of the stoma, thus creating a spout that will be fundamental
for future management of the effluent. Eversion is achieved by a few sutures, placed
in the antemesenteric border and both sides of the mesentery, which go from the
skin (or subcuticula) to the intestinal serosa and then to the cut end of the bowel.
What do you do with the distal end of divided small bowel (or colon—after
right hemicolectomy)? To facilitate future closure of the stoma (surgeons tend to
be chronic optimists) through the actual site of the stoma, the distal end should
be situated near the stoma itself. Simply attach the sutured, or stapled, distal end
with a few sutures (end to side) to the serosa of the proximal loop at the point
where it exits the abdominal wall. Obviously, when the bowel or mesentery are
distended, inflamed, and shortened, this is impossible. In such situations, try to
bring out the distal end of bowel elsewhere as mucous fistula; otherwise, close it
the best you can and drop it back into the peritoneal cavity. Naturally, such patients will need a formal laparotomy to reverse their stomas.
>
Chap. 51)
Loop ileostomies are seldom done emergently. We have used them quite
rarely:
To divert—“protect” risky distal colonic anastomoses after emergency re-
sections—sort of a compromise measure between primary anastomosis and
Hartmann’s procedure, having the advantage of an easier and less-risky re-
construction if everything goes well.
To divert early recognized leaks in ileocolic anastomoses, when there is no ad-
vanced peritonitis. This is frequently combined with resuturing of the leak.
The location of the stoma is as mentioned, and the most distal segment of
the ileum must be chosen to afford easy exteriorization. We prefer to pass
14 Intestinal Stomas 117
a vessel loop through the mesentery without damaging the marginal vascular
arcades and pull the bowel delicately through the (generous) hole in the abdominal wall. After closing the main abdominal incision, a transverse incision is
placed on the antimesenteric surface of exteriorized loop (incise about half of the
circumference), and the distal end is sutured flush to the skin; the proximal end
is everted (see discussion for end ileostomy) to achieve a 2- to 3-cm spout. Be
careful to identify properly what is proximal and distal; I have seen some cases
of proximal flush limbs and distal everted ones. We do not use any type of rod to
maintain the stoma in place, and we have never seen retraction of a well-mobilized and matured loop ileostomy.
If you think about a colostomy, you should (probably) do a colostomy. (Leo A.
Gordon)
Colostomies
End colostomy has a few variants:
When only the proximal limb of the bowel is exteriorized and the distal one
is closed and left in the abdominal cavity—the Hartmann procedure.
When both limbs are exteriorized through the same hole: “double-barrel
colostomy” (the distal end could be closed and attached to the serosa of the
emerging proximal end).
When both limbs are exteriorized through separate abdominal wall holes,
the proximal one as an end colostomy, the distal one as a “mucous fistula.”
All these procedures usually follow a transverse or a left-sided colectomy
when an anastomosis is not performed. Bringing out both limbs of the remaining colon through one hole in the abdominal wall (as is usually feasible after
segmental resections of the splenic flexure, descending or sigmoid colon for
obstruction, perforation, or sigmoid volvulus) allows easier reconstruction
with no need to reopen the general abdominal cavity. When the two limbs cannot be brought together in one abdominal wall opening, it is necessary to bring
out the two loops through separate holes. Hartmann’s procedure (end left colostomy + closure of the rectal stump) shou ld be the last choice but sadly is still
frequently used because of the high incidence of low tumors and diverticular
complications affecting the sigmoid, in which resection includes the rectosigmoid junction with no possibility of bringing out the remaining rectum as a
mucous fistula. And, I say the “last choice” because “take down” of colostomy
after the Hartmann procedure is a major operation that cannot always be accomplished, often more due to adhesions than to difficulties with the new
anastomosis.
118 Luis Carriquiry
Some technical advice:
Make a bigger hole than for ileostomy (a future paracolostomy hernia is
better than a colostomy that is too tight).
Always be sure you are exteriorizing a well-perfused colon (watch for arte-
rial bleeding from the divided end of the bowel and the marginal artery);
necrosis of the colostomy is a serious complication even if it does not reach
the peritoneal cavity because it will lead to stenosis.
If necessary, free more proximal colon: free the bowel from its lateral peri-
toneal attachments; when more length of left colon is needed, do not hesitate to divide the inferior mesenteric artery or vein.
If you do a divided colostomy, closing the end of the distal bowel, make
sure—again and again—that the end colostomy is created in the proximal
loop and not the distal one. (It can happen to anyone.)
There is no need for any fixation of the bowel loop to the peritoneum or the fascia.
Some surgeons close—but many believe this is unnecessary—with a few sutures,
the lateral space between the emerging loop and the abdominal wall to prevent
internal hernia leading to postoperative small bowel obstruction (> Chap. 48).
Primary maturation of the stoma, after abdominal closure, should be done
flush to the skin, with no need for eversion.
In the case of double-barrel colostomy, suture the exteriorized limbs where they
are in contact with one another as well as suture the remaining edges to the skin.
Loop Colostomies
Loop colostomies are used to divert the fecal stream after anorectal trauma
or necrotizing infection of the perineum (> Chaps. 29 and 39.2). The most common locations are the transverse colon and the sigmoid, but they can be done in
any segment of the large bowel that can be exteriorized without tension (e.g., cecum). A loop of colon is pulled outward through the abdominal wall hole using the
same technique described for loop ileostomies, but here we prefer using a rod to
prevent retraction and ensure proper diversion of feces. Many types of rods have
been described. We prefer a segment of latex tubing longitudinally cut and everted
(with the aid of sutures) at both ends, a maneuver that prevents sliding of the rod
and allows proper placement of the colostomy bag. Primary maturation should be
the rule; the practice of delayed opening of the colostomy has no current role. A
longitudinal incision is done on the surface of the loop, and absorbable sutures are
passed between the edges of the colostomy and the skin or its subcuticular layer.
Postoperative Care
Before leaving the operating room, the surgeon should supervise proper
placement of the stoma appliance. The bag should be transparent to allow
14 Intestinal Stomas 11 9
inspection of the stoma in the first postoperative days and properly fitted to the
base to allow distension with gases—a finding that makes the surgeon happy.
Early postoperative complications of stomas are not rare and have the po-
tential of wrecking the result of the operation.
Ileostomies: with necrosis and retraction being rare, the main complication is the high output of the stoma, which could lead to dehydration and electrolyte imbalance, more frequently in older patients. Careful measurement of the
output is important, especially when the ileostomy has been done after intestinal
obstruction or is situated in the proximal ileum. If high output develops, intravenous rehydration, dietary adjustments, and even medications to slow intestinal transit may be indicated.
Colostomies: here, high output is never a problem, but the surgeon should
be aware of the risk of early necrosis. Starting on the first operative day, inspec-
tion of the bowel through the transparent bag, or directly, is a must. If a dark or
black mucosa is seen, it is important to evaluate, under good light, or even an
anoscope, the depth of the ischemia. That is, how far does the “blackness” extend
down the lumen of the stoma? If it is superficial (involving only the “end of the
stoma”), one does not have to worry too much, although it may lead to some retraction and subsequent stenosis. But, if it is “deep” and goes beyond the level of
the fascia, intervention is mandatory and implies a re-laparotomy and better
mobilization of the exteriorized colon to achieve a new, well-perfused colostomy.
Trying simply to pull the colon outward through the hole can be dangerous.
Another infrequent early complication is the paracolostomy abscess (one
wonders why such a complication is so rare), which should be drained through
the mucocutaneous suture line, leaving the new hole within the colostomy bag.
Some of these infections may be resistant to local care, occasionally requiring
change of the site of the colostomy.
The patient should be educated about stoma function and its management
with the invaluable aid of the stoma therapist.
This book is about emergency treatment, so I will not bore you with late
complications or the “take down” of the stoma. But here are warnings by some
wise men:
Failure of a colostomy closure is more due to the youth of the colostomy than the
youth of the surgeon. (Ivor Lewis, 1895–1982)
There is no law that says that a colostomy must be closed. (Leo A. Gordon)
Esophageal Emergencies
Thomas Anthony Hor an
“If thou examinest a man having a gaping wound piercing through to his gullet; if
he drinks water he chokes (and) it come out of the mouth of his wound; it is greatly
inflamed, so that he develops fever from it; thou shouldst draw together that
wound with stitching. Thou shouldst bind it with fresh meat the first day. Thou
shouldst treat it afterward with grease, honey, (and) lint every day, until he
recovers. If, however, thou findst him continuing to have fever from that wound
thou shouldst apply for him dry lint in the mouth of his wound, (and) moor (him)
at his mooring stakes until he recovers.” (From the Edwin Smith papyrus,
written in Egypt roughly 3,000 years ago)
The esophagus gives no pleasure, but senses all forms of pain. Its job is
simple: relax and let the bolus in, push it with gravity assistance, relax again to
let it into the stomach. Despite this simplicity, it is prone to obstructive problems.
As there is no serosa, the submucosa is its one layer of strength; thus, it is relatively weak. The stomach can generate two to three times the force necessary to
rupture it during vomiting. Almost all neoplastic or inflammatory lesions of the
esophagus rapidly affect this one layer of strength, as may vigorous endoscopic
manipulation. When something disrupts its integrity, the esophagus delivers a
cocktail of mouth anaerobes directly into the mediastinum, which is one of the
body’s least-resistant areas.
As a general surgeon, the two esophageal emergencies you are most likely
to be called to solve are obstruction and perforation.
15
Foreign Body Ingestion: Obstruction
The night nursing matron ate her tuna sandwich as always at 2 a.m. but felt something sharp in her throat. The X-rays in the morning were normal. Discomfort persisted
for the next 3 weeks; barium swallow suggested cervical esophageal cancer. On September
10, I slipped out her dentures and passed the flexible scope for biopsy. The bread bag clip,
deeply embedded in the esophageal wall, read “best before August 13.” How true.
Swallowed foreign bodies (FBs) are the most frequent cause of acute dysphagia.
Food with bones and other embedded sharp objects take the unaware—children,
Thomas Anthony Horan
Hospital Sarah Kubitschek, SMHS, Quadra 501, Brasilia-DF, Brazil
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_15, © Springer-Verlag Berlin Heidelberg 2010
121
122 Thomas Anthony Horan
patients with dentures, the intoxicated—and their doctors by surprise. Children
will swallow just about anything that fits in the mouth, coins and safety pins predominating. Psychiatric patients swallow the most interesting things. Most of the
rest of FB-related esophageal obstruction is superimposed on underlying esophageal diseases such as motility disorder, hiatus hernia, stricture, diverticula, and cance r. Even the notorious steak house syndrome is more common in patients with
underlying esophageal pathology. Therefore, after the FB is evacuated, all patients
deserve evaluation of their esophagus. Delay in treatment vies with ill-conceived
efforts at retrieval as the cause for most perforations from FBs.
How to Manage Esophageal Foreign Bodies?
The average transit time from cricopharyngeus to stomach is between 3
and 5 s. Thus, if the FB is still in the esophagus when the patient gets to the hospital, it is by definition stuck. A stuck FB may cause the patient to gag, cough,
drool, hurt, bleed, and aspirate while it tries to move down, up, or through the
esophagus. So, you have to assist it out through an anatomical passage before it
describes a nonanatomical one by itself.
Fi rst , fi nd i t. Fre qu en tl y, t he pa ti ent k now s r ig ht w he re it i s, wh at i t i s, an d w hy
and how it got there. So ask the patient. Insistence on anteroposterior and lateral
neck, chest, and abdomen X-rays seems a bit old fashioned, but these are cheap and
efficient and may quickly define the problem. If they do not, there is always contrast
or computed tomography (CT) to help. Sometimes a wisp of contrast-soaked cotton
baton will hang up on it. The X-rays help you plan, choose your equipment, and
warn you about possible risks of perforation. Because of false-negative radiology
and associated conditions, every symptomatic patient should get endoscopy.
Methods of FB removal are based on visualization for safe removal (see near
disaster). No matter how sophisticated your snares and flexible equipment, you must
know how to use the good-old rigid scope for the removal of sharp objects. Blind
methods or pushing impacted boluses into the stomach are risky and can lead to
iatrogenic perforation. Judging when the risk of endoscopic removal outweighs risk
of open surgery is aided by a history of bleeding, pus, and buried sharp objects next
to the aortic indentation. A large number of exculpatory reports testify to the role for
operative removal in selected high-risk cases. We note, for example, a recent report
of poor planning, which led to pneumomediastinum and bilateral pneumothorax
while attempting to remove a knitting needle incarcerated in a hiatus hernia.
There is controversy about asymptomatic patients with smooth small FBs,
like coins, since left alone most pass into the stomach and then go down the whole
distance without further trouble. Some caution needs to be exercised, but if you are
sure the FB is not chemically active (button batteries and zinc-containing coins),
how long should you wait? Many suggest “up to 3 days,” but this sounds suspiciously
15 Esophageal Emergencies 12 3
like it is based on the length of the weekend. In the absence of a fail-safe rule, any
symptom or failure to reach the stomach by the time of the X-ray in the morning
should urge you do endoscopic removal.
Summary
Investigate all symptomatic patients
Remove all FBs not in the stomach within 24 hrs
Get help from someone who can use a rigid scope
Consider surgery in selected cases
Esophageal Perforation
The admiral had eaten a heavy meal. During the next few hours, he had taken small
cups of a mild emetic, as was usual when he was feeling heavy. Four times he had about
28 g of olive oil and later drank about 180 g of beer. When this did not have the desired
effect, he took another four cups. He tried to throw up but suddenly screamed because of
an excruciating pain in the chest. He immediately declared himself dying and started praying. It was a very sick patient, though free of fever, who met Boerhaave. The house physician,
Dr. de Bye, had tried bleeding. There were no symptoms of any known disease or poisoning,
and the two physicians ordered another bleeding, something nonalcoholic to drink and
warm compresses. But, in vain, the baron succumbed the next day. Herman Boerhaave conducted an autopsy that revealed the rent in the esophagus and the contents of a previous
meal, gas, and fluid in the chest.
Esophageal perforations continue to increase in number, with the “traditional” FB and vomiting etiologies remaining constant but instrumental or iatrogenic perforations having a fourfold increase. These are likely to increase even
further with the current enthusiasm for laparoscopic Nissen fundoplication and
the plethora of new gimmicks for the endoluminal treatment of gastroesophageal
reflux. Prior to World War II, the mortality of esophageal perforations was horrendous. Today, the emphasis on early diagnosis and treatment, and perhaps effective antibiotic treatment of the associated mediastinitis, have greatly improved
results. The improvement in survival seems correlated with the large number of
endoscopic instrumental perforations, which make early diagnosis correspondingly easier.
In general, there are four major groups of esophageal perforations, each with
differing therapy.
124 Thomas Anthony Horan
The Kind You Think You Can Get Away With
The catheter slipped beyond the impacted 4-cm beach rock. The 30-ml balloon got a
good hold. Increasing withdrawal tension released with a “thwack.” Nothing. Reinspection
revealed blood and esophageal muscle but no rock. Gastrografin swallow suggested a contained rupture and a rock packed in the posterior nose. Nasal disimpaction, NPO (nothing
by mouth [nil per os]), nasogastric suction, antibiotics, parenteral nutrition, and discharge
to the patient’s mental hospital followed over the next 2 weeks.
The nonoperative treatment of a small, contained, intramuscular, incomplete tear of the esophagus is employed when it is recognized right away and only
if there is no adverse systemic response, tachycardia, fever, or pain. The trick is
being sure that there is no residual material retained outside the esophageal wall
and no dependent pockets (by which I mean what goes in comes right back out).
The mucosal defect closes on the follow-up esophagram. If anything is not right,
treat like all ruptures (see below). Optimistic overdiagnosis of this entity leads to
delay and possible disaster.
The Kind a Surgeon Likes to Treat (If Someone Else Caused It)
This is the classic early-diagnosed perforation treated in the first 24 hrs. But,
it is surprising how frequently patients get sent home despite the obvious—“Worst
case of esophagitis I ever saw” (>Fig. 15.1). Reticence to accept the obvious costs
lives and reputations. Pain after endoscopy means a high risk of perforation,
Fig. 15.1. “Gee, this is severe esophagitis!”
15 Esophageal Emergencies 12 5
subcutaneous emphysema indicates the same, and fever means mediastinitis.
History almost always gives the cause and diagnosis and frequently the level of
injury. Positive physical findings of emphysema, pericardial crunch, pneumothorax, or hydrothorax used to be indicators of late diagnosis. Now, with the air
pumped in by endoscopes, they may be the first noted abnormality. The level of
emphysema on X-ray cor responds to t he level of inju ry: low p erfor ations typica lly
give left hydropneumothorax, midesophageal perforations are suspected in right
hydrothorax. Diagnosis is confirmed with contrast studies, with or without CT.
Do not waste time; treat with NPO, resuscitation, antibiotics, and surgery.
Perforations in the neck and upper mediastinum are repaired and drained
through the neck. Use the anterior border of the sternomastoid approach because it
is so easy to extend and lends itself to the rotation of buttressing strap muscles. See
the whole defect and close the mucosa/submucosa. Close the muscle over it, buttress with local muscles, and use a big floppy soft drain. Make a two-finger hole for
the drain. If they leak, they get better anyway as long as there is good drainage.
For perforations in the chest, follow exactly the same principles. Go to the left
side for low leaks or right side for higher leaks and get wide mediastinal exposure for
good visualization and drainage. See and close the whole mucosal defect. Then, close
the esophageal muscle over it. Cover all with good tissue, like pleural flaps or intercostal muscle flap wrapped around the esophagus and sewn on the esophageal closure,
not just laid on it. Every book written in the last 40 years shows this technique; use it
even if you do not think it is necessary because you only get one good chance. Finish
with big dependent chest drains, provisions for nutrition, and antibiotics.
Spontaneous perforation results from vomiting against a conscious attempt
to prevent it (Boerhaave syndrome). The pressure generated in the esophagus blows
out the weakest point, usually located just above the lower esophageal sphincter. It
is treated just as all the other perforations, with surgery at the earliest opportunity.
However, the risk of spontaneous rupture is higher in patients with an already
sick esophagus due to hiatus hernia, congenital or acquired connective tissue disorders, use of steroids, malnutrition, and old age. Because of a particularly high
mortality and morbidity, these special cases need to be considered in the same
category as late-diagnosed perforations (see below).
Associated lesions. Closing a perforation above an obstructing lesion does
not work. In achalasia, epiphrenic diverticula, and diffuse esophageal spasm, do the
myotomy on the opposite side of the esophagus from the perforation. Make the myotomy from the gastroesophageal junction to 8 cm above the level of the perforation.
Then, close the perforation just like above. Strictures distal to a perforation have to
be dealt with one way or another. Perforation at or just above a stricture associated
with gastroesophageal reflux may pose a special problem with full-thickness fibrosis
and shortening of the esophagus. The antireflux wrap will greatly assist the closure
in these cases provided that the fundus is able to be sutured to the perforation. Do
not simply wrap like usual but be sure to secure in place over the perforation. You
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