A Simple Method of Dividing the Posterior JAMES BARRON, M . D .

Detroit, Michigan

Colostomy Wall*"

COLOSTOMIES have been known to man for a long time. Al though the method of performing them has been pretty standard for years, refinements in technic continue. This presentation deals with a simple tech- nic for division of the posterior wall of a loop colostomy by the use of simple rubber bands.

The usual reason for dividing the wall o[ a loop colostomy completely is to pre- vent the fecal current from passing into the distal stoma. "vVith the adoption of the intraperi toneal method of closing the colostomy, crushing clamps for applica- tion to colostomy spurs have fallen into disuse. 2 I t is no longer necessary to leave the posterior wall intact solely to facilitate closure of the colostomy. Division of the posterior wall of a colostomy is accom- pished usually with scissors or the cautery, after a crushing clamp .has been applied. Often these procedures are performed by a resident or intern, without assistance, in the patient 's bedroom, where there are few facilities and the lighting is poor. Bleeding and discomfort may be encountered; this upsets a pat ient who is disturbed about an already uncomfortable situation. Often su- tures are required to control bleeding. Dur- ing applicat ion of the cl ushing c lamp or the making of incisions, some patients experi- ence pain and even nausea and vomiting, probably caused by traction and consequent disturbance of the sympathetic and p a r > sympathetic nervous system. A1! of this adds up to an experience which, if possible, should be avoided, and it can be avoided

~ Read at the mee t ing of the Amer ican Procto- logic Society, New Orleans, Louis iana, Apri l 17 to 19, 1967.

A

P " . i ; " "

FiG. 1. Technic for division of posterior colostomy wall. A. Anter ior wall of colon previously divided; glass rod in place. B. Rod removed and r u b b e r bands passed th rough opening . C. R u b b e r bands tied. D. O-rings used on h e m o r r h o i d l igator are appl ied to obta in and hold tension on r u b b e r bands to p roduce necrosis of poster ior wall of colon.

by a method that I have employed during recent years. I t has proved very satisfactory and does not expose the pat ient to such an unpleasant experience.

Customarily, the glass rod is removed on the 12th day after operat ion (Fig. l d ) . Or- dinary rubber bands are passed through the opening and tied moderately snug with sev- eral square knots (Fig. 1B and C). "The knots are not tied so tight that they cause bleeding or discomfort. "The knots are then

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B A R R O N

grasped wi th h e m o r r h o i d - g r a s p i n g f o r c e p ¢ and a h e m o r r h o i d l i ga to r is used to pass smal l r u b b e r h e m o r r h o i d - l i g a t i n g b a n d s on rhe r u b b e r bands above the p rev ious ly t ied knots (Fig. 1D). T h e s e smal l l i ga t ing bands

not on ly serve to p lace the tens ion on the r u b b e r bands so they wil l cut slowly

t h r o u g h the pos t e r io r wal l of the colon, b u t they also tend to keep the knots f rom be- coming un t ied . I f the tens ion is insuffi- c ient to p r o d u c e the des i red effect, more bands can be a p p l i e d easily. T h i s proce-

du re can be done in the p a t i e n t ' s r o o m wi th no risk of b l e e d i n g o r d i s comfor t to

the pa t ien t . By this m e t h o d the pos t e r io r wal l of a co los tomy u s u a l l y wi l l be t ran- sected wi th in three to seven days . T h e tech- nic is s imple and no anes thes i a is r equ i r ed .

Re fe r e nc e s

1. Barron, J.: Office ligation treatment of hemor- rhoids. Dis. Colon ~: Rectum. 6: 109, 1963.

2. Barron, J. and L. S. Fallis: Colostomy closure by the intraperitoneal method. Dis. Colon & Rectum. 1:466, 1958.

A Simple Diagnostic Test? e

HAR~Y A. FEmENBaUM, M.D.

Jamaica, New gorl~

The following brief account of an interesting experience is published to stimulate the interest of others. Dr. Harry A. Feigenbaum, who related his story to the Editor of DxsEasv.s oF THE COLON ~ RECTUM, believes the method he describes may be a simple diagnostic test to detect "nonspecific" ulcerative proctitis. Why not give it a trial and report results?

MANY PATIENTS seek consu l t a t i on because of s l ight rec ta l b leed ing , d ischarge of mucus on defeca t ion , m i n o r d i scomfor t af ter evacua t ion , and occas ional tenesmus ac- c o m p a n i e d by d ischarge of mucus and

b l o o d i n d e p e n d e n t of defeca t ion . T h e r e may be no c o m p l a i n t of a b d o m i n a l c ramps or o t h e r d e p a r t u r e f rom n o r m a l bowel

habi ts .

Usua l ly l~hysical e x a m i n a t i o n is negat ive ,

b u t e x a m i n a t i o n of the t e r m i n a l p o r t i o n of

the coion may reveal tha t the rec ta l mucosa

is edematous , h y p e r p l a s t i c and pa le or, at

t imes, it may be conges ted and covered by

* Received for publication May 25, 1967.

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mucus or pus. Of ten the re m a y be no mucus or pus and a b l e e d i n g p o i n t may no t be discernible . However , on s t r o k i n g the mucosa l ight ly wi th a co t t on app l i ca to r , a p ink i sh stain m a y a p p e a r on the surface of the cotton.

A p p l i c a t i o n of a so lu t ion of 5 % tann ic acid in 95% alco,hol to the mucosa causes p r e c i p i t a t i o n of mucus , b l a n c h i n g of the mucosa and def in i te discrete , b r i g h t red, o u n c t a t e ulcers which b leed .

T h i s p h e n o m e n o n has been observed in more than 30 p roved cases of nonspecif ic u lcera t ive proct i t i s , and i t has no t been poss ible to p r o d u c e it in a con t ro l series of pa t ients .