Colostomy Perforation:

Report of Four Cases*

A. W. MARTIN MARINO, JR., M.D., A. W. MARTIN MARINO, M.D.

From the Department of Surgery, Division of Colon and Rectal Surgery, The Brooklyn-Cunzberland Medical Center, Brooklyn, New York

IN 1952 AND 1954, the authors repor ted their technic of colostomy managemen t . 3, 4

Briefly it is based on admin i s t e r ing irriga-

tions at periodic intervals , u t i l iz ing simple, inexpensive and readi ly avai lable equip-

merit. Since the or ig ina l report, wi th tile i n t roduc t i on of disposable plastic devices,

the authors have modif ied the technic. I n addi t ion , the newly-described bulb-syr inge method of colostomy i r r iga t ion has proved

to have mer i t in cer ta in instances. 5 Usual ly,

there has been no need for r ou t i ne irriga- t ion in the fo r tuna te mino r i t y of pa t ients who enjoyed a regular bowel hab i t p r ior

to colostomy. I n E n g l a n d colostomy m a n a g e m e n t with-

out i r r igat ions has been the ru le ra ther

than the except ion2 At St. Mark 's Hos- pital, i r r igat ions are no t r ecommended ; i t is bel ieved that their a t t endan t disadvan- tages and dangers outweigh the advantages.I

Per fora t ion of the s toma by the i r r iga t ing tube occurs so rarely that it should be considered a m i n o r de te r ren t to i r r igat ion, despite the fact that when it does occur, it can be a serious compl ica t ion which is sometimes fatal. Perforat ions can be avoided when proper precaut ions are taken

and, in our experience, this accident has been qui te rare. Al though , previously, we had no t encounte red a single perforat ion, we have seen four cases in the past six years.

D u r i n g this t ime we have followed more than 300 pat ients who irrigate the i r colos-

tomies regularly. A review of medical liter-

a ture discloses that there have been fewer than 50 ident ical instances. Perfora t ions

* Read at the meeting of the American Procto- logic Society, Cleveland, Ohio, June 20 to 22, 1966.

TABLE 1. Types of Perforation of Colostomy by Irrigating Tube

A. Extraperitoneal 1. Without fistulization (two cases) 2. With fistulization (one case)

B. Intraperitoneal (one case)

may be ex t raper i tonea l or in t raper i tonea l . T a b l e 1 shows examples of bo th types

among our four cases, T h e former may be subdiv ided in to perfora t ions which even-

tuate in fistulization and ,those that do not. I n t r ape r i t onea l perfora t ions are very seri- ous compl ica t ions wi th a h igh mor ta l i ty

rate. T h e fol lowing case reports describe the

perforat ions observed in the four pat ients unde r study and the cl inical course and

t r ea tment of each.

R e p o r t of Cases

Case 1: A man, 85 years of age, had undergone an abdominoperineal resection for adenocarcinoma of the rectum on November 18, 1963. He had been trained in the use of irrigations, and he was doing well when he was discharged on February 4, 1964. On the evening of February I3, t964, he noted painless bleeding from the stoma after an irrigation. When he was seen the next day, a mucosal lacera- tion, 0.5 cm in length, was discovered at approxi- mately the skin level of the stoma. There were no symptoms. Examinations on February 18 and 20 indicated nothing of significance. However, on February 21, a zone of erythema, 9 cm in diameter, had appeared in the abdominal wall adjacent to the perforation. The next day, purulent material was discharged spontaneously from the middle of the area of erythema. Small amounts of purulent drainage continued during the next nine days. The site of drainage was lined with granulation tissue and a tract about 5 cm in length could be traced wfth a probe to the wall of the colostomy, but not into its lumen. Despite the development of an

103

1 0 4 M A R I N O A N D M A R I N O

FIG. 1. (Case 8) E ry thema of skin and e d e m a of abdomina l wall to left of and infer ior to colostomy, 48 h o u r s after perforat ion.

FiG. 2. (Case 3). Appearance cf area adjacent to colostomy shortly after r u p t u r e of abscess in ab- domiaaal wall. P u r u l e n t d ra inage is present .

appa ren t fistula, the condi t ion subs ided rapidly a n d active t r ea tment was no longer requi red . I t appeared tha t an abscess adjacent to the colostomy h a d r u p t u r e d and was resolved spontaneous ly . W h e n the pa t ien t was seen on May 21, 1964, a n d February 4, 1965, there was no evidence of res idual t rouble . He h a d been advised to d i scont inue irri- gations, b u t he has chosen to cont inue t h e m and has exper ienced no fu r the r difficulty.

Case 2: A woman, 70 years of age, h a d unde r - gone a n abdominoper inea l resection elsewhere, seven years before she was seen by us in J a n u a r y of 1960, comp' .aining of colostomy m a l f u n c t i o n a n d inabi l i ty to use the closed m e t h o d of i r r iga t ion which h a d been advised. T h e s toma wou ld no t admi t the tip of the smal l finger. A plast ic opera- t ion was per formed on February l, 1960, establish- ing a funct ional ly adequate colostomy wi th a gen- erous lumen . Despite this, the pa t ien t con t inued to hav e difficulty with irr igations. Previously she had h a d an obstruct ive type of "d iar rhea ," but , after s toma-plasty, she was t roubled wi th "const ipa- tion." O n Augus t 7, 1960, while i r r iga t ing the colostomy, she exper ienced sudden p a i n in its vicinity. T h i s was followed, in a few days, by sweIIing of the a b d o m i n a l wail ad jacent to the stoma. T h r e e days later, she appeared at our office, a n d it was evident tha t she had an abscess of the abdomina l wall. Colonoscopy was p e r f o r m e d and no mucosal in jury was seen, bu t the bowel mucosa adjacent to the abscess was edematous . She was admi t t ed to the hospi ta l and an incision, 5 cm long, was made over the most p r o m i n e n t par t of the swelling, 5 cm lateral to the s toma. T e n cc of p u r u l e n t ma te r i a l with a fecal odor were evacuated. T h e incision was enlarged a n d

necrotic fat and muscle were removed. T h e abscess h ad ex tended to the r ight and cepha lad to the cotostomy, and a counter- incis ion was m a d e in this area. Analysis of the r emoved tissue disclosed "acute cellulitis and focal s u p p u r a t i o n , " and E. coli were identif ied in cul tures of the pus. Daily dress- ings were admin is te red and the wounds healed in abou t five weeks. I t was obvious tha t there h a d been a perfora t ion of the bowel at the onset, b u t there was no fistula af ter the w o u n d healed.

Case 3: A 60-year-old m a n h a d u n d e r g o n e an abdominoper inea l resection and p e r m a n e n t end colostomy on J u n e 10, 1964. His postoperat ive course was complicated by prosta t ic hype r t rophy which requi red a t r ansure th ra l resect ion on October 30, 1964. Despite the fact tha t he h a d a modera te- sized paracolostomy hern ia , his abil i ty to use a closed-system'* i r r igator was so good tha t he was used to demons t ra te the procedure in a film on colostomy irr igation, p repa red by the au thors in December 1964.

On March 28, 1965, while i r r iga t ing his colos- tomy, the pa t i en t , exper ienced sudden abdomina l pain, accompanied by chills and fever, which lasted all day. Examina t i on pe r fo rmed abou t 12 hour s after the inc ident revealed local a b d o m i n a l tender- ness to the left of the s toma (Fig. 1). Digital e x a m i n a t i o n of the colostomy disclosed an area of mucosal roughness , 7.5 cm from the s toma on the left side. On coIonoscopy, a perfora t ion , 1.25 cm

* I r r iga t ing device wi th a plastic condui t which directs the fecal discharge into a toilet. T h e cath- eter is in t roduced into the colostomy t h r o u g h a hole in the conduit .

C O L O S T O M Y P E R F O R A T I O N 1 0 5

Fro. 3. (Case 3). Appearance two weeks after perforat ion. W o u n d is g r anu la t i ng and there is no sign of fecal drainage.

Fro. 4. (Case 3). Appearance four weeks after perforat ion. Fecal d ra inage has appeared . Metal probe revealed colocutaneous fistula.

in length, was discovered 7.5 cm f rom the s toma and there was some mucosa l edema ad jacent to the perforat ion.

In view of the fact tha t the in jury appea red to be localized and the bowels were func t ion ing nor- mally, expec tan t t r ea tmen t was observed. T h e pat ient ' s t empera tu re was 102 F in the beginning , bu t it subsided rapidly. Forty-eight h o u r s la ter , i ndu ra t i on appeared in the abdorninal wail to the left of the colostomy stoma. T h e r e was no evidence of f luctuat ion, bu t five days after the in jury foul- smel l ing pus was discharged spontaneously f rom an o p e n i n g s i tuated to the left of the colostomy (Fig. 2) . Cul tures revealed E. coli, Proteus and B. pyocyane.t,s. T h e externa l opening of the ab- scess was enlarged and the wound was irr igated daily (Fig. 3). T h e result was very gratifying; there was no difficulty unt i l fecal discharges on the 21st day indicated the presence of a fistula (Fig. 4) . A r ight transverse colostomy was establ ished on April 25, 1965, and on Ju ly 5, 1965, definitive sur- gery was performed. At tha t operation, the coto- cu taneous fistula and the left colon, f rom the colostomy in the descending colon to and includ- ing the transverse colon, were removed, leaving an end colostomy of the r ight transverse colon (Fig. 5). T h e gal lb ladder was also removed because of symptomat ic cholelithiasis and the left abdomina l incisional he rn i a was repaired. Recovery was un- eventful . T h e pa t ien t has had no difficuIty since his discharge.

Case 4: A 70-year-old m a n had unde rgone an abdominoper inea l resection sev:en years previously. D u r i n g the entire period since the operat ion, he h a d been ut i l izing irr igat ions every 48 hours , with

excellent results. On November 15, 1964, he was hospital ized because of swelling in the area of the r ight clavicle. He repor ted tha t on November 16, 1964, while i r r igat ing his colostomy wi th a solution of soapsuds (which he had been advised to avoid) he exper ienced difficulty in ob ta in ing a r e tu rn of the i r r iga t ing fluid and h a d sudden severe abdom- inal pain. Vomi t ing ensued and it became appa ren t

FIG. 5. (Case 3). Appearance immedia te ly pr ior to definitive surgery when end colostomy of descend- ing colon, fistula, mucous fistuIa of left transverse colon and all colon between these s tomas were removed. Note end colostomy in r ight transverse colon.

106 M A R I N O AND M A R I N O

FIG. 6. (Case 4) . I n this necropsy, specimen, colostomy s toma and in t ra -abdomina l por t ion of colostomy can be seen. O m e n t u m and smal l bowel are adheren t to large bowel. Defect in intra- abdomina l por t ion of colostomy is appa ren t (cath- eter has been in t roduced into s toma) . Note necrosis and acute infection.

tha t he h a d an "acute abdomen ." Digi tal examina- tion of the colostomy and colonoscopy disclosed a lacerat ion in the infer ior and media l aspect of the bowel about 7.5 cm. in te rna l to the s toma. T h e mucosa in the vicinity of the lacerat ion was edem- atous. T h e pat ient ' s condi t ion deter iorated rapidly. W i t h i n three hours , his t empera tu re was 104 F and a state of shock developed. Exploratory laparo tomy was pe r fo rmed t h r o u g h a r igh t p a r a m e d i a n incision. T w o h u n d r e d cc of tu rb id f l u i d were evacuated from the pelvis; it was obvious tha t there was severe generalized peri tonit is . T h e o m e n t u m a n d small bowel were ma t t ed and adheren t to the t e rmina l por t ion of large bowel. T h e area in the region of the perfora t ion was explored, a r igh t transverse colostolny was per formed, a n d tubes were inserted for the purpose of pe r fus ing the per i toneal cavity with ant ibiot ic agents. Despite these measures , the pa t ien t never recovered from the ini t ial shock and died two and one-hal f days after the opera t ion (Fig. 6) .

Summary and Conclusions

A simple, satisfactory method of admin-

istering irrigation of colostomies period- ically has been reported previously. Four instances of perforation of colostomies have been mentioned, and extra-abdominal and intra-abdominal types of perforation have been described.

Owing to our experience, we have been impressed by the need for detailed instruc- tions to colostomized patients, stressing that extreme caution and gentleness must be exercised while introducing the irrigating tube. Furthermore, the importance of these precautions should be repeated periodically and emphasized.

Early colonoscopy is strongly advocated as the single most valuable diagnostic method in instances when perforation of a colostomy is suspected.

Although periodic irrigation of colos- tomies has been utilized in the United States for many years, it is not free of dan- ger. Nevertheless, the authors believe that judicious use of the method is of value in management of colostomies.

R e f e r e n c e s

1. Gabriel, ~vV. B.: T h e Principles and Practice of Rectal Surgery. Ed. 5, Springfield, Charles C T h o m a s , 1963, p. 647.

2. Grier, W. R. N., A. H. Postel, A. Syarse, and S. A. Localio: A n eva lua t ion of colonic s toma m a n a g e m e n t w i thou t i rr igat ions. Surg., Gynec. g: Obst. 118: 1234, 1964.

3. Marino, A. ~g. M., A. J. Caliendo, and M. Marino, Jr.: M a n a g e m e n t of colostomy. Proc- tology. 17: 6I, 1952.

4. Marino, A. ~g. M., A. J. Caliendo, and M. Marino, Jr.: T h e m o d e r n m a n a g e m e n t of colostomy. South. M. J. 47: 1173, 1954.

5. Postel, A. H., }V. R. N. Grier, a n d S. A. Localio: T r a i n i n g the pa t i en t in the bu lb syringe m e t h o d of colostomy irr igat ion: A m a n u a l for nurses. Ins t i tu t e of Physical Medicine g: Re- habi l i ta t ion , New York Univers i ty Medical Center. Rehab i l i t a t ion M o n o g r a p h XXVI, 1965.