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Endoscopy.
Contrast studies: road map.
CT/MRI: herniation, abscess, etc?
Specific Ostomies
END COLOSTOMY
Example: Hartmann resection anus/rectal stump maintained. APR closed perineum. (Special situation: perineal
colostomy—see below.)
Purpose: result of resection where (immediate) restoration of intestinal continuity not possible or not desired. If distal
anatomy still preserved
elective takedown possible.
Target location (unless adjusted): LLQ, through rectus muscle.
Appearance: relatively flat rose, < 2–4 mm elevation, 3–4 cm diameter (Figure 4–21B).
Output: formed; while most patients carry an external appliance, this stoma may be trained with scheduled enemas,
etc, to obtain planned/controlled evacuation once per day only
no need for external appliance in-between.
Advantage: fluid balance unaffected, avoidance of anastomosis under suboptimal conditions.
Disadvantage: potentially challenging operation for reversal. Odor.
LOOP COLOSTOMY
Example: sigmoid loop colostomy, transverse loop colostomy.
Technical variations: (1) true loop with afferent and efferent limb both afferent and efferent limb decompressed
but potentially incomplete diversion; (2) Prasad-type loop: open afferent limb, efferent limb closed off/attached to
afferent limb or fascia or matured into ostomy as mucous fistula
complete diversion, to be avoided in case of
(pending) distal obstruction. Temporary bridge for 10–14 days.
Purpose: colonic decompression, fecal diversion (complete, incomplete). Ostomy of choice in emergency case of acute
distal problem (anastomotic leak, obstructing tumor, pelvic sepsis, etc).
Target location (unless adjusted): (1) LLQ, through rectus muscle; (2) RUQ/LUQ, not too close to costal margin.
Caveat: double-check actual colonic vascularization post previous resection and plan ostomy proximal to feeding
vascular pedicle to avoid creation of avascular segment!
Appearance: relatively flat (2–4 mm) rose; efferent limb clearly visible (true loop), or mucous fistula only (Prasad
type).
Output: left side of colon formed stool; right side liquid stool.
Advantage: allows access to colon; both afferent and efferent limb may be decompressed/washed out, no risk of
closed loop. Reduced risk of electrolyte imbalances (compared with ileostomy). If needed, surgery can even be
performed in local anesthesia. In morbidly obese patients, colostomy may better reach than ileostomy.
Disadvantage: incomplete diversion for true loop, prolapse, peristomal hernia formation, odor (compared with
ileostomy).
DOUBLE- BARREL COLOSTOMY
Same as loop but two separate exits.
Advantage: efferent end can be removed during subsequent surgery without disturbing otherwise healed afferent
ostomy.
END-ILEOSTOMY (BROOKE ILEOSTOMY)
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Example: total abdominal colectomy (anus/rectal stump maintained), total proctocolectomy (closed perineum).
Purpose: result of resection where (immediate) restoration of intestinal continuity not possible or not desired. If distal
anatomy still preserved
elective takedown vs possible further resection/restoration (eg, ileoanal pull-through
procedure) possible.
Target location (unless adjusted): RLQ, through rectus muscle.
Appearance: symmetric nipple (2.5–3.5 cm, Figure 4–21A).
Output: oatmeal-like, opaque, 600–1000 mL/24 hours.
Advantage: predictability, avoid anastomosis, allow for physical and nutritional recuperation. Less odor.
Disadvantage: high output, risk of electrolyte imbalances, difficulty in obese patients.
LOOP ILEOSTOMY
Example: elective proximal diversion, eg, after LAR or PC/IPAA.
Technical variations: (1) true loop with afferent and efferent limb; (2) Prasad-type loop: open afferent limb, efferent
limb closed off/attached to afferent limb or fascia or matured into ostomy as mucous fistula. Occasionally temporary
bridge for 10–14 days.
Purpose: fecal diversion (complete, incomplete). Ostomy of choice in elective cases with risk of distal problem
(anastomotic leak, pelvic sepsis, etc).
Target location (unless adjusted): RLQ, through rectus muscle.
Appearance: symmetric nipple (2.5–3.5 cm).
Output: oatmeal-like, opaque, 600–1000 mL/24 hours.
Advantage: easier takedown (compared with colostomy or Hartmann), less odor, does not tether the colon or
compromise its blood supply
permits full colonic mobilization if needed.
Disadvantage: incomplete diversion for true loop, high output, risk of electrolyte imbalances, does not decompress
colon if competent ileocecal valve, difficulty in obese patients.
DOUBLE- BARREL ILEOSTOMY
Same as loop but two separate exits.
CONTINENT ILEOSTOMY (KOCK POUCH, BARNETT POUCH/BCIR, T -POUCH)
Example: post–proctocolectomy (IBD, FAP), inability to reconstruct, failure of J-pouch.
Purpose: ileostomy continent for feces and gas (valve mechanism), storage area, no need for external appliance.
Target location (unless adjusted): as low as possible, ideally hiding in underwear.
Appearance: skin-level, symmetric, 1 cm diameter (Figure 4–21C).
Output: Only upon intubation (3–5x per day): oatmeal-like, opaque, 600–1000 mL/24 hours.
Advantage: avoidance of appliance (covered with bandaid only), elimination of ileoanal dysfunction, permitting active
physical lifestyle, improved body image.
Disadvantage: need for patient selection, increased perioperative morbidity, long-term dysfunction, pouchitis,
concept and management familiar to only limited number of physicians.
Figure 4–21C.
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Skin-level stoma of continent ileostomy, covered with bandaid.
PERINEAL COLOSTOMY
Example: status post colonic pull-through procedure for imperforate anus or secondary abdominoperineal
reconstruction post APR.
Purpose: restoration of anatomy, for functionality may need implantation of artificial bowel sphincter.
Target location: center of perineum (sufficient tissue coverage toward coccyx and vagina).
Appearance: flat, no anal verge, no anal canal.
Output: stool.
Advantage: body image. Up to 60–70% acceptable control despite lack of sphincter muscle.
Disadvantage: lack of or insufficient spontaneous control, lack of blood supply from distance, development of mucosal
ectropion.
TUBE CECOSTOMY
Example: cecal volvulus, colonic pseudoobstruction (Ogilvie syndrome).
Purpose: venting of colon, colopexy. Caveat: tube cecostomy is not a fecal diversion!
Target location: RLQ.
Appearance: large-diameter Foley catheter.
Output: air, some stool (needs daily irrigation with fluid).
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Advantage: spontaneous closure once catheter removed.
Disadvantage: does not allow fecal diversion, need for irrigation.
TUBE GASTROSTOMY
Example: carcinomatosis or massive adhesions with expected recurrent/progressive SBO.
Purpose: decompression of stomach, ability to insert tube feeding.
Target location: LUQ.
Appearance: large-diameter Foley catheter or percutaneous endoscopic gastrostomy (PEG).
Output: stomach retention.
Advantage: avoidance of NGT. Spontaneous closure once catheter removed.
Disadvantage: leakage, need for irrigation.
TUBE JEJUNOSTOMY
Same as tube gastrostomy, but tube placed more distally (jejunum), used for enteral feeding.
APPENDICOSTOMY FOR MACE (MALONE ANTEGRADE COLONIC ENEMA)
Example: fecal incontinence, cases of severe constipation (eg, in cystic fibrosis).
Purpose: maturation of appendix into umbilicus to allow insertion of tube irrigation of colon with > 2 L of fluid every
day.
Target location: umbilicus.
Appearance: as little visible as possible.
Output: None.
Advantage: lavaging and/or liquefaction of stool in colon.
Disadvantage: time-consuming: after completion continuation of liquid discharge for up to 2 hours.
UROSTOMY
Urinary conduit.
BLOWHOLES (TURNBULL)
Example: historically used in fulminant colitis; today mostly obsolete except under very unusual circumstances.
Technical variations: flat suturing of (friable) bowel to the fascia.
Purpose: venting/decompression of toxic intestines while avoiding emergency resection.
Target location (unless adjusted): loop ileostomy, 3–5 colonic locations.
Appearance: skin-level, no maturation.
Advantage: avoidance of risky emergency resection (rarely a true advantage).
Disadvantage: diseased colon left in place ( continued sepsis), need for secondary resection.
Cross-Reference
Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
Kock pouch dysfunction (Ch. 4)
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Creation of end-ileostomy or -colostomy (Ch. 5)
Ileostomy takedown (Ch. 5)
Loop colostomy takedown (Ch. 5)
Hartmann reversal (laparoscopic vs open) (Ch. 5)
TRAUMA (863.X)
Overview
Colorectal trauma is a major cause of morbidity and often involves patients of younger age. Number of injury patterns is
unlimited, but four main mechanisms include:
1. Penetrating trauma, ie, focal impact through body surface:
a. Direct internal injury limited to path: eg, stab wound, impalement.
b. Combined injury from trajectory as such and the much more serious cavitation effect: gunshot wounds,
particularly if high-velocity projectiles.
2. Blunt abdominal and/or pelvic trauma, ie, broad impact to body surface which causes indirect internal injury.
3. Internal trauma, ie, direct impact onto anorectum or intestines:
a. Inside-out: eg, endoscopic perforation, enema perforation, foreign body insertion/ingestion, sexual assault,
internal overpressure (eg, air or water jet), fall straddling, jumping, bouncing, suction.
b. Outside-in: eg, intraoperative laceration, obstetric injury.
4. Devascularization: mesenteric avulsion, aortic dissection, retroperitoneal hemorrhage, compartment syndrome.
Management depends on the severity and location of colorectal and associated injuries. Circumstances (war vs civilian) are
major factor affecting outcome for major injuries of comparable severity: delay to therapy, recognition and treatment of
associated injuries, overall condition (shock, blood loss, contamination).
Surgical options include diversion, local debridement, and/or primary repair—by suturing or resection/anastomosis.
Exteriorization of repaired bowel segments largely abandoned (obstruction).
Classical contraindications for primary colon repair (as opposed to fecal diversion):
> 1000 mL of blood in peritoneum (or transfusion of > 6 units of blood).
More than just minimal fecal contamination.
Delay in surgical intervention > 6–8 hours.
Hemodynamic instability (or preoperative blood pressure < 80/60).
> 2 other organs injured (or penetrating abdominal trauma index > 25).
Peritonitis.
Current contraindications for primary repair: delayed presentation (> 24 hours), gross fecal contamination, need for damage
control.
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Epidemiology
Colon injury (frequently not isolated): 30% of all penetrating injuries, 5% of all blunt abdominal traumas. Vice versa: 90% of
colorectal injuries caused by gunshot or stab wounds, 5% by motor vehicle crashes.
Rectal injury: 95% due to penetrating trauma, blunt rectal trauma and pelvic fractures, endorectal trauma. Penetrating rectal
injuries: gunshot 80–90%, impalement (rare); blunt rectal trauma (eg, deceleration: crashes, falls).
Symptoms
All traumata: possibly more serious symptoms in other organ systems (eg, cardiovascular, pulmonary, cerebral, etc).
Anorectal trauma: visible wound(s) or marks, rectal bleeding (
at least mucosal injury), "rectal pain," abdominal pain
(ominous sign peritonitis), symptoms of associated injury.
Abdominal trauma: visible wound(s) or marks, bleeding (external/internal), hemodynamic instability, abdominal wall pain vs
peritoneal pain, nausea, vomiting, fever, abdominal distention, compartment syndrome.
Differential Diagnosis
Based on the history of trauma, the diagnosis is not typically in question, more the extent of damage.
Pathology
Depending on trauma mechanism, location, secondary underperfusion (shock, hemorrhage, etc).
Evaluation
REQUIRED MINIMAL STANDARD
All Traumas
History: trauma mechanism? Coherence of the story (involvement of others, possible crime?), current symptoms (hematuria,
bleeding per rectum, pain etc)? Injury causing object still in patient? Pregnancy?
Inspection of whole body: locations of primary and secondary wounds/marks (consistent with reported trauma type?),
suspected wound extent and path (entry and exit sites
possible photographic documentation)!
Whole body examination.
Anorectal Trauma
Clinical examination: careful palpation of the perineum (urethral injury? sphincter avulsion or lacerations?), digital rectal
exam (rectal wall integrity/defect? sphincter tone? position of prostate? Sacrum/coccyx not palpable presacral hematoma?
), vaginal exam (vaginal/uterine injury, extent of the anorectal injury). Associated neurologic deficits from spine/pelvic
injuries?
Anoscopy/rigid sigmoidoscopy evaluation: careful to avoid aggravation of injury.
Urinalysis: micro-/macrohematuria.
Abdominopelvic and chest x-rays: evidence for free peritoneal air? Retained foreign body? Associated skeletal injuries?
CT scan (if possible with triple water-soluble contrast, ie, oral, IV, rectal): extent of injury, perforation, etc.
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Abdominal Trauma
Clinical examination: hemodynamic, respiratory, and neurologic assessment, careful abdominal evaluation (wounds, marks,
evisceration, peritoneal signs, tension), digital rectal exam (rectal wall integrity? sphincter tone? sacrum/coccyx not palpable
presacral hematoma?).
X-rays: evidence for free peritoneal air? Involvement of other organ system (eg, traumatic diaphragmatic hernia, chest,
mediastinum, retroperitoneum), retained foreign body? Associated skeletal injuries?
Urinalysis: micro-/macrohematuria.
CT scan (if possible with triple water-soluble contrast, ie, oral, IV, rectal): extent of injury, evidence for colon perforation,
associated injuries (abdominopelvic/retroperitoneal organs, vascular and osseous structures, etc).
ADDITIONAL TESTS (OPTIONAL)
Contrast studies with water-soluble contrast:
– Urethrography/cystography vs IV urography.
– Contrast enema.
Diagnostic peritoneal lavage (DPL) vs abdominal ultrasound: intra-abdominal fluid?
CT/MRI with 3D reconstruction of skeletal and soft tissue injuries.
Cystoscopy.
Angiography with possible embolization: diagnostic and therapeutic.
Measurement of bladder pressure: abdominal compartment syndrome?
Classification
Nondestructive vs destructive intestinal trauma: colon/rectal injury score (by American Association for Surgery for
Trauma): Table 4–8.
Anorectal and sphincter trauma.
Table 4–8. AAST Score for Colorectal Injury.
Grade
a
Description of Colon/Rectal Injury
I Hematoma (contusion without devascularization)
Laceration (partial thickness, no perforation)
II Laceration < 50% circumference
III Laceration > 50% circumference without transection
IV Laceration transection of colon
V Laceration transection with segmental tissue loss
a
Grade for single injury; for multiple injuries upgraded by one to grade III.
Nonoperative Treatment
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All traumata: adequate resuscitation (fluid and electrolytes, blood products as needed), broad-spectrum antibiotics, tetanus
prophylaxis, close observation with serial assessments, Foley catheter (unless high index of suspicion for urethral
disruption!).
Blunt and penetrating abdominal trauma:
Nonoperative management in selected patients serial examinations physical examination reliable in detecting
significant injuries: minimizing rate of unnecessary laparotomies.
Patient selection: hemodynamically stable, local abdominal tenderness only, no peritoneal signs, absence of factors
making clinical examination unreliable (ie, severe head or spinal cord injury, intoxication, need for
sedation/intubation).
Operative Treatment
INDICATION
Any trauma with proven, suspected, or pending intestinal disruption/perforation, unless very favorable individual
circumstances permit a conservative approach.
Patients with (initially or in the course of serial exams):
– Hemodynamic instability.
– Diffuse abdominal tenderness after penetrating abdominal trauma.
– Unreliable clinical examination (ie, severe head injury, spinal cord injury, severe intoxication, or need for
sedation or intubation).
OPERATIVE APPROACH
Intraperitoneal Colon/Rectal Injuries
Nondestructive colon/rectal injuries: primary repair.
Destructive colon/rectal injuries:
– Resection with primary anastomosis if possible.
– Resection with ostomy if: shock, hemorrhage, comorbidities, blast wounds, crush injuries, radiated tissue,
distal obstruction, mesenteric vascular damage or otherwise impaired blood supply, massive infection.
Extraperitoneal Rectal Injuries
Nondestructive injuries: distal rectal washout, antibiotics, possible ostomy.
Destructive injuries:
– Repair with/without proximal fecal diversion.
– Presacral drainage, colostomy for fecal diversion, distal rectal washout.
– Low anterior resection with primary anastomosis (unless diffuse pelvic trauma) with or without protective
ileostomy/colostomy.
Infralevator Injuries (Minor to Moderate)
Examination under anesthesia, debridement, suture repair of essential structures (sphincter), drainage, possible fecal
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diversion.
Perineal wounds left open post-primary wound closure or healing by secondary intention.
Outcome
Survival determined by extracolonic injuries, mortality of isolated colorectal injury low (if managed timely).
Morbidity: anastomotic leak, colostomy-related complications, presacral abscess, pelvic or abdominal abscess, fistula
formation (enterocutaneous, enterovesical, enterovaginal, perianal, pelvic plexus damage, fecal/urinary incontinence).
Follow-Up
Functional reassessment (constipation, incontinence) after convalescence.
Planning of secondary surgeries (ostomy takedown, etc).
Cross-Reference
Computed tomography (CT scan) (Ch. 2)
Foreign bodies (937, 936/938) (Ch. 4)
Spinal cord injury—associated colorectal pathology (Ch. 4)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
Creation of end-ileostomy or -colostomy (Ch. 5)
Ileostomy takedown (Ch. 5)
Loop colostomy takedown (Ch. 5)
Hartmann reversal (laparoscopic vs open) (Ch. 5)
SPINAL CORD INJURY–ASSOCIATED COLORECTAL PATHOLOGY
Overview
Severe spinal cord injury (SCI) causes multiple irreversible physical changes that require lengthy adjustments. Acute
abdominal and intestinal problems are relatively rare (eg, acute GI dilation) unless related to direct traumatic impact.
However, irreversible neurologic damage after spinal cord injury is associated with significant long-term GI and pelvic organ
management issues and morbidity. Acute management centered around damage control, chronic management on
rehabilitation and maintenance of functionality.
Extent of neurologic dysfunction primarily depending on level of trauma (cervical injury
tetraplegia; thoracic/lumbar injury
paraplegia) and completeness of motor-sensory damage.
Epidemiology
Annual incidence of SCI in the US: each year ~ 40 cases per million population or 11,000 new cases. Prevalence: estimated
225,000–300,000 persons in the US. Age at time of injury: most frequently between 16–30 years. Gender: 75% male.
Symptoms
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Acute symptoms (immediately/early after the injury):
Acute colonic dilation with risk of perforation.
Acute gastric dilation with risk of necrosis/perforation.
Direct trauma to abdominal organs.
Chronic symptoms (most common problems):
Overall patient mobility, transfers, ability to sit (eg, on toilet).
Baseline bowel function: bowel control, constipation, manual stimulation of evacuation.
Baseline urinary function: bladder emptying, need for suprapubic or Foley catheter vs intermittent catheterization,
bladder reservoir, bladder stone formation, urinary tract infections, sepsis.
Spasticity of paralyzed extremities.
Relaxation of pelvic floor with perineal descent, rectal prolapse, hemorrhoids.
Lack of protective sensory input decubitus, abscess/fistula formation.
Issues not directly related to spinal injury:
Unchanged need for colon cancer screening per guidelines.
Constipation increased risk for diverticulosis/itis (caveat: lack of abdominal pain!).
Differential Diagnosis
Depending on presenting symptomatology.
Pathology
Neurogenic colon (lack of nervous control): may lead to fecal impaction (80% of patients with spinal cord injury), bowel
distention, incontinence, discoordination of defecation.
Autonomic dysreflexia: chronic constipation with resulting risk of developing autonomic dysreflexia in spinal cord injury above
T6: potentially life-threatening condition: sudden increase in blood pressure, severe, pounding headache, profuse sweating,
goose pimples of the skin, bradycardia, cardiac arrhythmias. Dysreflexia resolves when triggering cause removed, ie,
evacuation of fecal impaction. Prophylaxis prior to manual evacuation: calcium antagonists or topical local anesthesia.
Impaired rectal sensation and sphincter function: periodic mass movements in the colon lead to rectal fullness
reflex
relaxation with incontinence.
Diverticulosis: chronic constipation with increased intraluminal pressures
overdistention of the bowel resulting in diverticula
formation.
Rectal prolapse: passage of large hard stools in combination with weakened pelvic and anorectal tonus.
Hemorrhoids: frequent problem (70–80%), result from combination of constipation, lack of pelvic floor muscle tone,
chronically high pressures in the anorectal marginal veins.
Bladder dysfunction:
Spastic (reflex) bladder: automatic triggering of bladder voiding.
Flaccid (nonreflex) bladder: decreased/absent bladder reflexes lead to urinary retention with urinary tract infections.