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Blowhole colostomy for the urgent management of distal large bowel obstruction

Published:January 13, 2014DOI:https://doi.org/10.1016/j.jss.2014.01.007

      Abstract

      Background

      Complete obstruction of the distal colon or rectum often presents as a surgical emergency. This study evaluated the efficacy of blowhole colostomy versus transverse loop colostomy for the emergent management of distal large intestinal obstruction.

      Methods

      Retrospective chart review of all colostomy procedures (CPT 44320) performed for complete distal large bowel obstruction during the past 6 y in a university hospital practice was undertaken. Blowhole was compared with loop colostomy with a primary endpoint of successful colonic decompression.

      Results

      One hundred forty-one patients underwent colostomy creation during the study period. Of these, 61 were completed for acute obstruction of the distal colon or rectum (19 blowhole versus 42 loop colostomy). No differences between study groups were seen in age, gender, body mass index, malnutrition, American Society of Anesthesiology class, time to liquid or regular diet, 30-d or inhospital mortality, or rates of complications. Patients undergoing blowhole colostomy had significantly higher cecal diameters at diagnosis (9.14 versus 7.31 cm, P = 0.0035). Operative time was shorter in blowhole procedures (43 versus 51 min, P = 0.017). Postoperative length of stay was significantly shorter for blowhole colostomy (6 versus 8 d, P = 0.014). The primary endpoint of successful colonic decompression was met in all colostomy patients.

      Conclusions

      Diverting blowhole colostomy is a safe, quick, and effective procedure for the urgent management of distal colonic obstruction associated with obstipation and massive distention.

      Keywords

      1. Introduction

      Complete obstruction of the distal colon or rectum is a surgical emergency, with 60%–70% of all emergent cases caused by rectosigmoid, rectal, or anal malignancy [
      • Deans G.T.
      • Krukowski Z.H.
      • Irwin S.T.
      Malignant obstruction of the left colon.
      ,
      • Law W.L.
      • Chan W.F.
      • Lee Y.M.
      • Chu K.W.
      Non-curative surgery for colorectal cancer: critical appraisal of outcomes.
      ,
      • Kahi C.J.
      • Rex D.K.
      Bowel obstruction and pseudo-obstruction.
      ]. The remaining 30% of large bowel obstructions (LBO) are attributable to diverticular disease, volvulus, inflammatory bowel disease, pelvic malignancies, and pseudo-obstruction. The emergent management of LBO has advanced significantly during the past 40 y. Traditional surgical options include colectomy with primary anastomosis, subtotal colectomy with ileorectal anastomosis, or Hartmann procedure. However, these procedures may prove technical difficulty in emergent situations when patients are too ill to tolerate, resulting in worsened outcomes [
      • Serpell J.W.
      • McDermott F.T.
      • Katrivessis H.
      • Hughes E.S.
      Obstructing carcinomas of the colon.
      ,
      • Runkel N.S.
      • Schlag P.
      • Schwarz V.
      • Herfarth C.
      Outcome after emergency surgery for cancer of the large intestine.
      ]. Transverse loop colostomy achieves colonic decompression while simultaneously serving as a bridge to definitive management. Unfortunately, severe colonic distention can increase the difficulty of maturing a loop or end colostomy, at times being precluded by massive distention. More recently, endoscopic colonic stenting has challenged the need for emergent surgical intervention before definitive resection [
      • Tan C.J.
      • Dasari B.V.
      • Gardiner K.
      Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction.
      ]. Unfortunately, not all centers are capable of colonic stenting, some lesions are not amenable to stenting, and significant risks include stent migration and colon perforation. Regardless of underlying etiology, emergent management of LBO is often associated with high morbidity and mortality [
      • Witzig J.A.
      • Morel P.
      • Erne M.
      • Egeli R.
      • Borst F.
      • Rohner A.
      [Surgery of digestive system cancers in patients over 80 years of age].
      ].
      Blowhole colostomy, first formally described by Turnbull [
      • Turnbull Jr., R.B.
      • Hawk W.A.
      • Weakley F.L.
      Surgical treatment of toxic megacolon. Ileostomy and colostomy to prepare patients for colectomy.
      ,
      • Weakley F.L.
      • Turnbull Jr., R.B.
      Exclusion and decompression for toxic dilatation of the colon in ulcerative colitis. Proceedings of the Royal Society of Medicine.
      ], represents a minimally invasive form of colonic decompression once used for the emergent management of toxic megacolon. Transmural fixation of the anterior colonic wall to the rectus sheath, followed by maturation of colon wall to the dermis, is performed with minimal anesthesia and operative time (Fig. 1). We hypothesized that blowhole colostomy is noninferior to loop colostomy with a primary endpoint of successful colonic decompression in patients requiring emergent or urgent operative intervention.
      Figure thumbnail gr1
      Fig. 1Schematic view of decompressive blowhole colostomy. Adapted from Turnbull et al. “Surgical Treatment of Toxic Megacolon. Ileostomy and Colostomy to Prepare Patients for Colectomy.” American Journal of Surgery, 1971; 122: 325–331. With permission from Elsevier Science.

      2. Materials and methods

      2.1 Patient chart review and data collection

      A retrospective chart review of all patients undergoing colostomy creation (CPT 44320) from March 2007 through March 2013 in our academic surgical practice was completed. Patients undergoing blowhole or loop colostomy for the decompression of complete distal LBO were identified for inclusion. Complete distal LBO was diagnosed by history of obstipation, massive abdominal distention on clinical examination, and severe colonic distention due to distal obstruction noted on appropriate imaging studies. Excluded from analysis were patients with nonobstructing colorectal masses and patients undergoing colostomy creation for diversion after trauma. The indication for each procedure was recorded. The primary endpoint was successful colonic decompression defined as resolution of obstructive symptoms before discharge without further surgical or endoscopic intervention. Secondary endpoints included operative time, time to liquid diet, time to regular diet, postoperative length of stay, postoperative morbidity, successful bridge to definitive therapy, 30-d mortality, and inhospital mortality. Operative time was defined as minutes from the first incision to the completion of last suture. This study was approved by our institution's Internal Review Board.

      2.2 Blowhole and loop colostomy surgical technique

      Our blowhole colostomy surgical technique was as previously described [
      • Turnbull Jr., R.B.
      • Hawk W.A.
      • Weakley F.L.
      Surgical treatment of toxic megacolon. Ileostomy and colostomy to prepare patients for colectomy.
      ,
      • Weakley F.L.
      • Turnbull Jr., R.B.
      Exclusion and decompression for toxic dilatation of the colon in ulcerative colitis. Proceedings of the Royal Society of Medicine.
      ], (Fig. 1). Briefly, the patient was taken to the operating room and anesthesia achieved by general (n = 17) or local means (n = 2) after discussion between the attending surgeon and anesthesiologist. After review of imaging studies, the abdomen was marked in the midline over the transverse colon. A 3-cm incision was carried down to the fascia. On entry into the abdomen, the transverse colon was identified and secured to the posterior fascia with fixation sutures to create a seal, thus preventing spillage of enteric contents into the abdomen. A transverse colotomy was created sharply, and the colon was decompressed with suction. The blowhole colostomy was then matured to the deep dermis with interrupted sutures. A colostomy appliance was secured, and the patient was transported to the recovery room.
      Our loop colostomy surgical technique involved general anesthesia for all patients (n = 42). After review of imaging studies, an upper abdominal incision was carried down to the fascia at the location of maximal transverse colon dilation. On entry into the abdomen, the transverse colon was identified and elevated into the wound. An ostomy rod was placed through the mesentery in a standard fashion before maturation of the colostomy. Maturation of the colostomy was by standard means. A colostomy appliance was secured, and the patient was transported to the recovery room.

      2.3 Statistical analyses

      Stata version 12.1 (Stata, College Station, TX) was used for statistical analysis. Categorical variables were compared using χ2 or Fisher exact test when appropriate. Median values of continuous variables were compared with the Wilcoxon rank-sum test. All P values were two-tailed. A value of P ≤ 0.05 was considered statistically significant.

      3. Results

      3.1 Patient demographics and distal obstruction etiology

      A total of 141 patients undergoing colostomy creation (CPT 44320) from March 2007 through March 2013 were reviewed. Of these 141 patients, 61 underwent blowhole or loop colostomy creation for distal LBO. We identified cohorts of 19 blowhole (31.1%) and 42 loop colostomy patients (68.9%). Although no differences in age, gender, body mass index, malnutrition, or American Society of Anesthesiology class were observed, patients undergoing blowhole colostomy demonstrated significantly larger cecal diameter compared with loop colostomy patients (9.14 versus 7.31 cm, P = 0.0035; Table 1). Interestingly, 80% and 63.6% of the blowhole and loop colostomy groups, respectively, were at least minimally malnourished based on a preoperative albumin <3.5 g/dL or prealbumin <18 mg/L, levels at which patients demonstrate increased risk for postoperative complications. Evaluation of underlying distal obstruction etiology demonstrated no difference between patients undergoing blowhole versus loop colostomy (Fig. 2). Approximately 75% of colostomies were performed for malignancy (73.7%, blowhole; 80.9% loop), whereas the remainder were for benign diseases, which is consistent with current literature describing emergent management of distal LBO.
      Table 1Demographics and outcomes in blowhole and loop colostomy for distal bowel obstruction.
      Blowhole (n = 19)Loop (n = 42)P value
      Age (y)65 (42–73)63 (56–74)0.84
      Gender (%, male)31.2%45.2%0.31
      BMI26.3250.62
      Maximum colon diameter (cm)9.147.310.0035
      Malnutrition (%)8063.60.28
      Operative time (min)43 (23–55)51 (43–88)0.017
      ASA class1
       210.50%12.20%
       357.90%56.10%
       431.60%31.70%
      Time to liquid diet (d)1 (1–3)1 (1–2)0.53
      Time to regular diet (d)2.5 (1–4)3 (2–4)0.23
      Postoperative length of stay (d)6 (4–7)8 (6–10)0.014
      30-d mortality (%)5.2616.670.214
      Inhospital mortality (%)04.900.46
      Complications (%)10.5019.000.33
      ASA = American Society of Anesthesiology; BMI = body mass index.
      Figure thumbnail gr2
      Fig. 2Etiologies of distal colonic obstruction. Distal colonic obstruction etiologies in patients requiring blowhole (n = 19) and loop colostomy (n = 42) creation.

      3.2 Shorter operative time and postoperative length of stay after blowhole colostomy

      Given a significant risk of complications in patients with higher American Society of Anesthesiology status undergoing urgent or emergent operation [
      • Alvarez J.A.
      • Baldonedo R.F.
      • Bear I.G.
      • Truan N.
      • Pire G.
      • Alvarez P.
      Presentation, treatment, and multivariate analysis of risk factors for obstructive and perforative colorectal carcinoma.
      ,
      • Aslar A.K.
      • Ozdemir S.
      • Mahmoudi H.
      • Kuzu M.A.
      Analysis of 230 cases of emergent surgery for obstructing colon cancer–lessons learned.
      ,
      • Biondo S.
      • Pares D.
      • Frago R.
      • et al.
      Large bowel obstruction: predictive factors for postoperative mortality.
      ], we evaluated operative time, time to diet progression, postoperative length of stay, inhospital mortality, 30-d mortality, and rates of complication for each group (Table 1). All patients undergoing colostomy for distal obstruction had successful decompression with either blowhole or loop colostomy (P = 1.0). Furthermore, 100% of study patients eligible for definitive treatment after decompression (n = 32, 52.5%) were effectively bridged to therapy by blowhole or loop colostomy. In 29 of 61 patients (47.5%), ostomy creation was definitive management for distal LBO, as the ultimate goal of the procedure was symptom palliation. Colorectal surgeons performed blowhole colostomy in 41.4% of distal colonic obstruction cases versus general surgeons who performed blowhole colostomy in 23.3% of cases (P = 0.1). The 43-min median operative time (interquartile range = 22–53 min) for blowhole colostomy creation was significantly lower than the 51-min median operative time (interquartile range = 43–88 min, P < 0.017) for loop colostomy (Table 1). Postoperatively, no difference in time to clear liquid (1 versus 1 d, P = 0.53) or goal diet (2.5 versus 3 d, P = 0.23) progression was demonstrated. Despite comparable time to diet advancement between groups, a significantly shorter median postoperative hospital length of stay was observed in patients undergoing blowhole colostomy (6 versus 8 d, P = 0.014). Evaluation of inhospital mortality yielded no significant difference between blowhole (0%) and loop colostomy (4.9%, P = 0.46). Furthermore, we found no significant difference in 30-d mortality between groups (5.26% versus 16.67%, P = 0.214). No difference was observed in the percent of patients with postoperative complication (10.5% versus 19.1%, P = 0.33; Table 1). Of those patients with a complication, no significant differences were seen between study groups (Table 2). There were no reported mechanical complications related to ostomy creation in either group.
      Table 2Complications of colostomy creation. Percentage of patients per group with indicated complication.
      Blowhole (n = 19, %)Loop (n = 42, %)P value
      Delayed ostomy function07.100.32
      Sepsis04.800.47
      Respiratory failure5.202.400.53
      UTI5.202.400.53
      Clostridium difficile infection02.400.69
      Total10.419.10.33
      UTI = urinary tract infection.

      4. Discussion

      In this study, blowhole colostomy was found to be noninferior to loop colostomy for emergent decompression of distal LBO as defined by resolution of obstructive symptoms before discharge without further surgical or endoscopic intervention. In addition, blowhole colostomy provided noninferior bridging to definitive therapy in eligible candidates, along with effective palliation for patients unable to undergo further therapy. In demographically similar patient populations, blowhole colostomy was associated with significantly shorter operative time and shorter postoperative length of stay (6 versus 8 d). There were no significant differences in other secondary endpoints. Inhouse mortality did not occur in any patient after blowhole colostomy, whereas both deaths after loop colostomy occurred in patients presenting preoperatively with abdominal sepsis. For the urgent and emergent management of acute distal LBO, the easier to perform blowhole colostomy was an effective surgical option easily used by colorectal and general surgeons.
      Historically, surgical management of complete distal LBO involved a major resection such as segmental colectomy with primary anastomosis or subtotal colectomy with ileorectal anastomosis [
      • Gainant A.
      Emergency management of acute colonic cancer obstruction.
      ,
      • Cuffy M.
      • Abir F.
      • Audisio R.A.
      • Longo W.E.
      Colorectal cancer presenting as surgical emergencies.
      ]. Although appropriate in carefully selected patients, severe malnutrition and massive colonic distention may render a primary anastomosis unadvisable, with many ill patients receiving a Hartmann procedure as a surgical bailout. Although this gets the patient out of the operating room, an edematous stoma often results in postoperative dysfunction and complications. In addition, many Hartmann procedures are never resected and closed, leading to long-term complications [
      • Deans G.T.
      • Krukowski Z.H.
      • Irwin S.T.
      Malignant obstruction of the left colon.
      ,
      • Charbonnet P.
      • Gervaz P.
      • Andres A.
      • Bucher P.
      • Konrad B.
      • Morel P.
      Results of emergency Hartmann's operation for obstructive or perforated left-sided colorectal cancer.
      ]. Altogether, single stage management of emergent distal bowel obstruction is not always possible, nor indicated, because of possibly worsened surgical outcomes in emergent management of distal LBO [
      • Buechter K.J.
      • Boustany C.
      • Caillouette R.
      • Cohn Jr., I.
      Surgical management of the acutely obstructed colon. A review of 127 cases.
      ,
      • Lee Y.M.
      • Law W.L.
      • Chu K.W.
      • Poon R.T.
      Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions.
      ,
      • McArdle C.S.
      • Hole D.J.
      Emergency presentation of colorectal cancer is associated with poor 5-year survival.
      ,
      • Paulson E.C.
      • Mahmoud N.N.
      • Wirtalla C.
      • Armstrong K.
      Acuity and survival in colon cancer surgery.
      ]. Thus, discussion of alternative strategies such as decompressive colostomy or colonic stenting is warranted.
      Tekkis et al. [
      • Tekkis P.P.
      • Kinsman R.
      • Thompson M.R.
      • Stamatakis J.D.
      Association of Coloproctology of Great Britain, Ireland
      The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer.
      ] demonstrated a benefit of staged operative procedures for malignant distal obstruction when risk stratification of sicker patients was performed. In this setting, the most commonly described options for bridging of these patients are diverting colostomy and endoluminal stent [
      • Gianotti L.
      • Tamini N.
      • Nespoli L.
      • et al.
      A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction.
      ,
      • Kavanagh D.O.
      • Nolan B.
      • Judge C.
      • et al.
      A comparative study of short- and medium-term outcomes comparing emergent surgery and stenting as a bridge to surgery in patients with acute malignant colonic obstruction.
      ,
      • Cirocchi R.
      • Farinella E.
      • Trastulli S.
      • et al.
      Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: a systematic review and meta-analysis.
      ]. Four randomized controlled trials have compared endoluminal stents with emergency surgery for the management of distal LBO [
      • Alcantara M.
      • Serra-Aracil X.
      • Falco J.
      • Mora L.
      • Bombardo J.
      • Navarro S.
      Prospective, controlled, randomized study of intraoperative colonic lavage versus stent placement in obstructive left-sided colonic cancer.
      ,
      • Cheung H.Y.
      • Chung C.C.
      • Tsang W.W.
      • Wong J.C.
      • Yau K.K.
      • Li M.K.
      Endolaparoscopic approach vs conventional open surgery in the treatment of obstructing left-sided colon cancer: a randomized controlled trial.
      ,
      • Pirlet I.A.
      • Slim K.
      • Kwiatkowski F.
      • Michot F.
      • Millat B.L.
      Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial.
      ,
      • van Hooft J.E.
      • Bemelman W.A.
      • Oldenburg B.
      • et al.
      Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial.
      ]. Alcantara et al. [
      • Alcantara M.
      • Serra-Aracil X.
      • Falco J.
      • Mora L.
      • Bombardo J.
      • Navarro S.
      Prospective, controlled, randomized study of intraoperative colonic lavage versus stent placement in obstructive left-sided colonic cancer.
      ] stopped their study prematurely because of an unacceptably high rate of anastomotic leak after emergent primary colonic anastomosis, suggesting a clear advantage to bridge therapy with endoluminal stenting. This agrees with reports that urgent or emergent stenting produces fewer serious adverse events, shorter hospital stay, and higher efficacy than emergent resection [
      • Watt A.M.
      • Faragher I.G.
      • Griffin T.T.
      • Rieger N.A.
      • Maddern G.J.
      Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review.
      ]. However, although Alcantara et al. reported no complications from stent placement, other studies have demonstrated upwards of 53% failure to decompress the colon, yielding an overall failure rate of 30% in one meta-analysis [
      • Tan C.J.
      • Dasari B.V.
      • Gardiner K.
      Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction.
      ]. The clinical perforation rate for all studies was 6.9%, with a silent perforation rate on pathologic review that approached 14% [
      • Tan C.J.
      • Dasari B.V.
      • Gardiner K.
      Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction.
      ]. Although colonic stenting provides a viable option for bridge to therapy in emergent distal LBO presentation, it requires expertise not found in all settings, may fail to decompress distal LBO due to technical failure, and can increase morbidity related to stent migration and perforation.
      Our study reflects a select group of very ill distal LBO patients, with nearly 50% undergoing emergent diversion that was ultimately for palliation. We demonstrate patients deemed too ill for an emergent single-stage operation are effectively bridged to definitive therapy by decompressive colostomy. Although loop colostomy as a bridge therapy is effective, a dilated and edematous colon results in difficult stoma creation and produces significant prolapse in many patients [
      • Edwards D.P.
      • Leppington-Clarke A.
      • Sexton R.
      • Heald R.J.
      • Moran B.J.
      Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial.
      ,
      • Park J.J.
      • Del Pino A.
      • Orsay C.P.
      • et al.
      Stoma complications: the Cook County Hospital experience.
      ,
      • Kim J.T.
      • Kumar R.R.
      Reoperation for stoma-related complications.
      ]. Furthermore, in patients with massive colonic distention, creation of a loop colostomy may prove technically impossible. With the blowhole technique, our primary endpoint of successful colonic decompression was met in 100% of patients. Although a decreased operative time of 7 min is not clinically significant, our data suggest maximum operative time for blowhole colostomy is less than the mean loop colostomy operative time. In critically ill patients, the ability for any surgeon to quickly perform decompressive colostomy as bridging or palliative therapy is invaluable. The 2-d decrease in postoperative hospital length of stay is certainly clinically significant. Although this study was not designed to determine the underlying factors responsible for a shorter length of stay, future work will evaluate this. In addition, evaluation of postoperative recovery, timing of definitive therapy, and blowhole colostomy versus endoluminal stenting provide future avenues of study. Overall, this study demonstrates that blowhole colostomy provides a technically simple, safe, and effective surgical option easily performed by all surgeons for the management of emergent distal colonic obstruction.
      Limitations of this study include retrospective analysis of small patient cohorts with inability to control for selection bias at the time of operation. In addition, long-term mechanical outcomes such as parastomal herniation and ostomy prolapse were not available for us to study. Since most of these stomas were closed as part of a staged management, the long-term mechanical issues are most applicable to patients who were treated with a permanent palliative diversion. Future areas of study may include prospective evaluation of blowhole colostomy versus stent for emergent decompression of critically ill patients, along with future areas stated previously.

      5. Conclusions

      When a surgeon chooses a diverting transverse colostomy for management of a complete distal LBO, blowhole colostomy is noninferior at providing effective emergent colonic decompression. In addition, a significant 2-d reduction in postoperative length of stay was shown using a procedure easily taught and performed by any surgeon in a setting of minimal or massive hospital resources. These advantages were observed without increasing patient morbidity or mortality. Diverting blowhole colostomy is a safe, quick, and effective means for the urgent management of distal colonic obstruction associated with obstipation and massive distension.

      Acknowledgment

      No grant support was used for this manuscript.
      Author contributions: K.R.K., D.R.B., R.F.J., and P.M.I. involved in conception and design of study. K.R.K., M.F.E., and P.M.I. involved in data collection. K.R.K. and P.M.I. participated in analysis and interpretation of data. R.K. participated in writing the manuscript. M.F.E., D.R.B., R.F.J, and P.M.I. were responsible for providing critical revisions. K.R.K., M.F.E., D.R.B., and R.F.S. were given approval of final revision.
      The authors have no conflict of interest.

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