S ilv ia C ris tin e S O /d e i,A rm a n d o A n g e lo C a s a ro li
O s to m y o r in te s tin a l a n a s to m o s is in c a s e s o f p e rito n itis
Emergency
Service Of the Surgery Department,
Santa Casa de Sao Paulo School of Medicine - Sao Paulo, Brazil
T w e n t y - s ix p a t ie n t s s h o w in g p e r it o n it is d u e t o n o n t r a u m a t ic a c u t e a b d o m e n w e r e s u b m it t e d t o o s t o m y . M e a n a g e w a s 5 1 y e a r s ( r a n g e 2 5 - 8 3 ) , b e in g 1 3 m a le s a n d 1 3 f e m a le s . B o w e l o b s t r u c t io n ( B O ) w a s t h e m o s t f r e q u e n t c a u s e o f p e r it o n it is ( 1 1 c a s e s ) , f o llo w e d b y in t e s t in a l p e r f o r a t io n ( I P ) ( 8 c a s e s ) , a c u t e m e s e n t e r ic in f a r c t io n ( A M I ) ( 5 c a s e s ) , a n d a c u t e a b d o m e n o f in f la m m a t o r y / in f e c t io u s o r ig in ( A A J O ) ( 2 c a s e s ) . B r o o k 's ile o s t o m y w a s p e r f o r m e d o n 6 5 % o f t h e p a t ie n t s . J e ju n o s t o m y w a s p e r f o r m e d o n ly in 4 p a t ie n t s , le a d in g t o a b a d e v o lu t io n . O v e r a ll m o r t a lit y w a s 5 4 % . P r im a r y o s t o m y o r a n a s t o m o s is in c a s e s o f p e r it o n it is c o n s t it u t e a h ig h ly c o n t r o v e r s ia l t h e m e . I n d ic a t io n s a n d p r o b le m s in v o lv in g t h e in t e s t in a l e x t e r io r iz a t io n in e m e r g e n c y s u r g e r y u r g e n c y a r e h e r e in d is -c u s s e d .
U N I T E R M S : O s t o m y . I n t e s t in a l a n a s t o m o s is . A c u t e a b d o m e n . P e r it o n it is
I N T R O D U C T I O N
T
h e p e r f o r m a n c ei n c a s e s o f p e r i t o n i t i so f o s t o m yi s a c o n t r o v e r s i a lo r i n t e s t i n a l a n a s t o m o s i st h e m e i n e m e r g e n c y s u r g e r y . O n o n e h a n d t h e r e a r e r i s k s o f d e h i s c e n c e , a n d o n t h e o t h e r h a n d , t h e i n c o n v e n i e n c e s o f s m a l l b o w e l e x t e r i o r i z a t i o n , p a r t i c u l a r l y i n i t s m o s t p r o x i m a l p o r t i o n .T h e c o n t r o v e r s y i n c r e a s e s w h e n s m a l l b o w e l i s i n v o l v e d , w h e r e i n t h e c o l o s t o m y t o p r o t e c t a s u t u r e o r a n a s t o m o s i s w h e n t r e a t i n g a w o u n d i s w e l l d e f i n e d .
I l e o s t o m y , w h i c h r e p r e s e n t s a p e r f e c t l y t o l e r a b l e o s t o m y w i t h o u t i n t e r c u r r e n c e s , h a s a l w a y s b e e n a n o b j e c t o f r e s t r i c t i o n f o r s u r g e o n s , p a r t i c u l a r l y i n e m e r g e n c y
A d d re s s fo r c o rre s p o n d e n c e :
S a m ir R a s s la n
R u a M a rq u e s d e Itu 8 3 7 / S a la 1 3 S a o P a u lo /S P - B ra s il- C E P 0 1 2 2 3 -0 0 1
s u r g e r y , a l t h o u g h i n p e r i t o n i t i s i t h a s b e e n p r a c t i c e d s i n c e t h e b e g i n n i n g o f t h e c e n t u r y ( 8 ) . M o r e s e r i o u s i s t h e e x t e r i o r i z a t i o n o f t h e m o r e p r o x i m a l s e g m e n t s , d u e t o s e v e r e m e t a b o l i c s p o l i a t i o n , w i t h l o s s o f g r e a t v o l u m e s o f i n t e s t i n a l 'l i q u i d .
T h e r e f o r e , t h e s u t u r e o r a n a s t o m o s i s i n c a s e s o f p e r i t o n i t i s r a i s e s o m e f u n d a m e n t a l q u e s t i o n s s u c h a s : a . D o e s i t p r e s e n t a h i g h e r i n c i d e n c e o f d e h i s c e n c e ? b . W h a t l o c a l c h a n g e s l e a d t o t h e s u t u r e f a i l u r e ? c . I s i t d i f f e r e n t a c c o r d i n g t o t h e c o m p r o m i s e d v i s c e r a ? d . W h a t i s t h e i n c o n v e n i e n c e o f o s t o m y ?
T h e a n s w e r s t o t h e s e q u e s t i o n s a r e n o t e a s y a n d n o t a l w a y s s u p p o r t e d b y s c i e n t i f i c d a t a , a s c o m p a r a t i v e s t u d i e s o f t h e d i s e a s e d p o p u l a t i o n a r e n o t f e a s i b l e . T h e y r e f l e c t , t h e r e f o r e , m o s t l y t h e e x p e r i e n c e o f s u r g e o n s . N e v e r t h e l e s s , s t u d i e s h a v e d e m o n s t r a t e d h i g h i n c i d e n c e o f a n a s t o m o s i s d e h i s c e n c e i n c a s e s o f p e r i t o n i t i s o r s e p s i s ( 6 ,1 3 ,1 4 ) .
I n v i e w o f t h e i n t e r e s t t h i s t h e m e r a i s e s a n d i t ~ c o n t r o v e r s i e s , o u r r e p o r t a i m s t o a n a l y z e t h e u s e o f o s t o m i e s i n c a s e s o f p e r i t o n e a l i n f e c t i o n , e v a l u a t i n g t h e p a r a m e t e r s t h a t m a y d i r e c t t h e s u r g e o n 's d e c i s i o n .
R A S S L A N , S . ; F O N O F F , A . M . ; S O lD A , S . C . ; C A S A R O L l, A . A . - O s t o m y o r in t e s t in a l a n a s t o m o s is inc a s e s o f p e r it o n it is
M o r ta lity in th e im m e d ia te a n d e a r ly p o s to p e r a tiv e
p e r io d ( m e a n o f 2 0 d a y s , r a n g in g f r o m I to 1 2 2 c la y s )
M A T E R I A L A N D M E T H O D
F r o m F e b r u a r y 1 9 9 0 to F e b r u a r y 1 9 9 3 , 2 6 p a tie n ts
u n d e r w e n t o s to m y d u e to n o n tr a u m a tic a c u te a b d o m e n
c o m p lic a te d w ith p e r ito n itis a t th e E m e r g e n c y S e r v ic e o f
th e S a n ta C a s a d e S a o P a u lo S c h o o l o f M e d ic in e .
M e a n a g e w a s 5 1 y e a r s , ( r a n g e 2 5 - 8 3 ) , b e in g 1 3 m a le
'a n d 1 3 f e m a le . F o r ty - tw o p e r c e n t o f th e p a tie n ts s h o w e d
b o w e l o b s tr u c tio n f r o m d if f e r e n t e tio lo g ie s , r e q u ir in g
r e s e c tio n o f th e in te s tin a l s e g m e n t a n d e x te r io r iz a tio n d u e
to v a s c u la r a c u te a b d o m e n . I n th e r e m a in in g c a s e s
ile o s to m y w a s p e r f o r m e d .
E x te r io r iz a tio n o f B r o o k e 's te r m in a l ty p e o c c u r r e d
in 1 7 p a tie n ts ( 6 5 % ) , tw o " s to m a s " in s ix p a tie n ts ( 2 3 % )
a n d lo o p o s to m y in th r e e p a tie n ts ( 1 2 % ) - ( T a b le 3 ) .
, T w e n ty - th r e e o f th e s e p a tie n ts w e r e s u b m itte d to o s to m y
d u r in g th e f ir s t p r o c e d u r e a n d th r e e d u r in g r e - o p e r a tio n
f o r tr e a tm e n t o f c o m p lic a tio n s .
S Y N D R O M E
B O
I P
A M I
A A I O
T O T A L
R E S U L T S
T A B L E 1
C a u s e s o f A c u t e A b d o m e n
N o . O F C A S E S ( % )
1 1 ( 4 2 % )
8 ( 3 1 % )
5 ( 1 9 % )
2 ( 8 % )
2 6 ( 1 0 0 % )
B 0
I P
A M I
A A I O
T A B L E 2
E t io lo g y o f A c u t e A b d o m e n w it h P e r it o n it is
I n c a r c e r a t e d h e r n ia 4
A d h e s io n s 3
T r a n s v e r s e C o lo n t u m o r 1 ( c o m p lic a t e d w it h is c h e m ia a s f a r a s ile u m )
R e c t a l s t e n o s is 1 ( D u h a m e l- H a d d a d p . o . w it h is c h e m ia a s f a r a s ile u m )
I le a l S t e n o s is 1
I le a l p e r f o r a t io n b y t u b e r c u lo s is 2
I le a l p e r f o r a t io n in H I V + 2
I le a l T u m o r 2
I le a l p e r f o r a t io n b y C r o h n 's D ia s e 1
C e c a l p e r f o r a t io n 1
T h r o m b o s is o f m e s e n t e r ic a r t e r y 1
T h r o m b o s is o f m e s e n t e r ic v e in 1
N o n - o c lu s iv e m e s e n t e r ic in s u f f ic ie n c y 2
T e r m in a l ile a l t u m o r 1
E n t e r ic f is t u la ( a n a s t o m o s is d e h is c e n c e ) 1
B 0 = B o w e l o b s t r u c t io n
I P
=
I n t e s t in a l p e r f o r a t io nA M I = A c u t e m e s e n t e r ic in f a r c t io n
A A I O = A c u t e A b d o m e n o f in f la m m a t o r y o r in f e c t io u s o r ig in
occurred in 14 patients (54% ), all directly related to the
acute illness.
T he rate w as 80% for' the patients w ith
AMI
(4 in 5),45% w ith
no
(5 in 11),50% w ithIP
(4 in 8) and of 50%w ith
AAIO
( I in 2). T here w ere no survivors in the groupsubm itted to jejunostom y (T able 4).
T ransit reconstruction w as perform ed on 6 of the 12
survivors. A m ong the patients not subm itted to
reconstruction, 2 had A ID S (A cquired Im m unodeficiency
S yndrom e) and w ere referred to specific hospitals, 2 are
expecting re-hospitalization and abandoned the follow
-u p .
T olerance to ostom y w as satisfactory, w ith no
significant m etabolic effects, repercussions or local
changes in the abdom inal w all. R econstruction w as alw ays
perform ed three m onths after the postoperative period.
D I S C U S S I O N
A nastom otic dehiscence is the m aIn cause of m orbidity and m ortality in intestinal resections, especially
colorectal, w ith rates of up to 30% (2,7,12).
O ur analysis excludes the infections from large bow el
lesions in w hich there are few doubts as to the use of
ostom ies. P rim ary colon anastom osis is an uncom m on
procedure (w hich can only be applied in selected cases), and colostom y does not raise inconveniences from the
m etabolic point of view .
O n the other hand, ileum exteriorization is perform ed w ith caution, and term inal jejunostom y is rarely
considered. M ost of the tim e the risk of a high jejunal
anastom osis dehiscence is preferred to the m etabolic disturbances raised by ostom y. In this w ay, , surgeons often
try intestinal sutures or anstom osis in patients w ith poor
TABLE 3
Types of intestinal exteriorization
general conditions, or in re-operations w ith dehiscence and
severe peritoneal contam ination (4).
In peritoneal infection, even w hen the theoretical
aspects and principles are respected by the surgeon, such
as good irrigation, adequate border coaptation, and tension
and the absence of disease, dehiscence m ay occur due to
other system ic or local factors (2).
T he role played by the intra-cavity infection has been
studied experim entally and seem s to determ ine
biochem ical disturbances explained by a collagen synthesis
and acti vity reduction (6, I,9). It is generally accepted that
infection or bacteri al con tam i nation determ i nes the
collagen lysis increase by stim ulating the colon subm ucosa
collagenasis. (6,12). D unphy (I )dem onstrated in ani m als
that the bacterial grow th in the anastom osis stim ulates the
collagen lithic activity, giving rise to changes in the suture
tension, w ith failure of the anastom osis.
T his has also been noticed by other authors (5).
T he follow ing param eters should be taken into
consideration before a decision for prim ary ostom y or
anastom osis is taken: portion of the digestive tract, severity
of peritonitis, patient's general condition, etiology of
infection, and others. O f all these, the m ost difficult to
evaluate is the severity of peritonitis, w hich cannot be
m athem atically assessed, being subjective, and related to
the surgeon's experience. .
W hen the large bow el is involved, independently of
the degree of peritonitis, the etiology of the infection and
the patient's condition, the option for alm ost all cases is
colostom y. P rim ary colon anastom osis is rarely perform ed
in peritonitis cases. T he surgeon m ay regret or even be
criticized for having perform ed anastom osis, but this w ill never happen in the case of exteriorization. N ot that
anastom osis is a forbidden procedure, but it should be
avoided, being reserved for special cases only if and w hen
infection is not so severe. O ur 26 patients w ere subm itted to the sm all bow el exteriorization, term i nal jejunostom y
TABLE 4 Postoperative Mortality
E X T E R I O R I Z A T I O N
B r o o k e 's T e r m in a l
T w o S t o m a s
L o o p
J e ju n o s t o m y
I le o s t o m y
N o . o f C a s e s
1 7 ( 6 5 % )
6 ( 2 3 % )
3 ( 1 2 % )
4 ( 1 5 % )
2 2 ( 8 5 % )
B O
I P
A M I
A A I O
T O T A L
5 ( 4 5 % )
4 ( 5 0 % )
4 ( 8 0 % )
1 ( 5 0 % )
1 4 ( 5 4 % )
R A S S L A N , S . ; F O N O F F , A . M . ; S O L D A , s . C . ; C A S A R O L l, A A - O s t o m y o r in t e s t in a l a n a s t o m o s is in c a s e s o f p e r it o n it is
CHART 1
Parameters for the performance of primary anastomosis or ostomy
S E V E R I T Y O F E T I O L O G Y O F P A T I E N T 'S
P E R I T O N I T I S I N F E C T I O N C O N D I T I O N
O S T O M Y S E V E R E V A S C U L A R
P U R U L E N T I N T E S T I N A L
S T E R C O R A L D I A S E
B A D
I N F L A M A T O R Y
D I A S E
R E O P E R A T I O N
P R I M A R Y N O T S E V E R E T R A U M A
A N A S T O M O S I S
C H E M I C A L G O O D
M E C H A N I C A L
F I B R I N O U S O B S T R U C T I O N
being performed only in four and ileostomy in the
remaining.
Although there are no specific rules for the small
bowel, it is possible to define them based on different
parameters. The performance of ostomy is usually the rule, even in the small intestine, in patients with poor general
conditions and severe compromising of the peritoneal
cavity.
The etiology of the infection injection or the primary
disease contribute to this decision. W hen the peritonitis is
due to a primary vascular cause, which determines
intestinal infarctions or necrosis, the decision should be
taken towards exteriorization due to the risk of post
operati ve - which cannot be characterized during the
operation - resulting in a high rate of fistulas ( I I ) . In the
presence of intestinal inflammatory disease with
perforation and peritonitis, the option should also be
ostomy (10), as the suture or anastomosis can be done in an affected area which, many times, the surgeon has no
ability to assess macroscopically. Chart I is a suggestion
to systematize the procedure adopted in our Emergency
Service.
A correct evaluation of the intestine during the
operation procedure is very difficult.
In spite of adequate irrigation, the edema and trophic changes of the intestinal wall, which are not visible,
interfere with healing, contributing to the failure.
Another situation is when re-operation is indicatecl
due to infection and anastomosis dehiscence. It is important
to stress that if the suture was not effecti ve in the fi rst
operation, when .the patients conclittons were more
favorable, it is not likely to be effective in the second trial.
The attempt to resuture depending on local conditions,
can even worsen the dehiscence. In special situations, such
as a gastroenteroanastomosis dehiscence, the surgeon can
try to approximate the layers, being aware of the high
probability of postoperative failure.
M ortality in our cases was extremely high (54% ),
but in accordance with the population analyzed. No patient
with proximal terminal jejunostomy survived, niostly in
consequence of the primary disease - intestinal infarction
- and probably not due to the enteric ostomy.
A new operation for transit reconstruction should not
be performed before 12 weeks. This period of ti me is
generally enough for the recovery, infection control ancl
improvement of the local abdominal wall condition,
negatively affected by the secretions rich in gastrintestinal
enzymes
In case of doubt regarding the performance of a
primary anastomosis, the surgeon should choose ostomy,
as experience shows that mortality is lower when it is
carried out during the first operation as compared to the
second operation (3).
RRSUMO
Sao analisados 26 doentes submetidos
a
estomia na vigencia de peritonite por abdome agudo nao traumatico. A faixa etaria variou de 25 a 83 anos, com media de idade de 51 anos. Nao houve predomfnio quanto ao sexo. 0 abdome agudo obstrutivo( A A O ) foi a causa mais frequente de peritonite (11 casos), seguido do abdome agudo perfurativo ( A A P ) em 8, abdome agudo vascular ( A A V ) em 5 e inflamat6rio ( A A I) em 2. Namaioria dos doentes (65%) foi realizada ileostomia
a
Brooke. Em apenas 4 praticou-se a jejunostomia, observando-se maevolU9aO. A mortalidade global foi de 54%. A realiza9aO de estomia ou anasto-mose primaria na presen9a de peritinite constitui um tema com muitas controversias. Neste artigo sao discutidas as indica96es e os problemas envolvendo a exterioriza9ao intestinal na ~rgencia.REFERENCES
I . DUNPHY, .T.E - The cat gut. Am
.I
Surg. 119: I . 1974. 2. GENZINI. T; D' ALBUQUERQUE, L.A.C.; MIRANDA,M.P.; SCAFURI, A.G. & SILVA. A.O. - Intestinal anastomosis. Rev Paul ]\lIed. 110: 183,1992.
3. GON<;ALVES, A..T.- A utiliza~ao das ileostomias na cirurgia
de urgencia. Disserta\3o de Mestrado. Faculdade de
Ciencias Medicas da Santa Casa de Sao Paulo, 1985.
4. GO <;ALVES, A..T.& RASSLAN, S. - I1eostomias: uma alternativa na cirurgia de urgencia. In Rasslan, S. - Aspectos
"crlticos" do doente cirlIrgico. Sao Paulo, Robe Ed. 1988.
p.247.
5. HAWLEY, P.R.; PAGEFAULK, W. & HUNT, TK. -Collagenase activity in the gastrintestinal tract. Br
.I
Surg. 57:896, 1970.6. IRVIN, TT - Collagen metabolism in infected colonic
anastomosis. Surg Gynecol Obstct. 143:220, 1976. 7. KHOURY, G.A. & WAXMAN. B.P. - Large bowel
anastomosis. The healing process and sutured anastomosis.
A review. Br
.I
Surg. 70: 1983.8. LUND, EN. - The value of enterostomy in selected cases of
peritonits . .lAMA. 41:74, 1993.
9. NIINIKOSKI, J . & GRILlS HUNT, T.K. - Respiratory gas tensions and collagen in infected wounds. Ann Surg.
175:588, 1972.
10. RASSLAN, S.; KLUG, W.A.; MANDIA NETO . .T.; FAVA.
.T.; SAAD .TR, R. & GON<;ALVES, A ...T. - Tuberculose intestinal complicada. Rev Assoc Mcd Brasil. 30:39, 1984.
I I . RASSLAN, S.; MANDIA NETO, .T.& FAVA, .T.- FIstulas intestinais ap6s ressec90es extensas de delgado. GED. 4: 17,
1985.
12. RAVO, B. - Colon'ectal anastomotic healing ancl intracolonic
bypass procedure. Surg elin orth Am. 68: 1267, 1988.
13. SCHROCK, T R ; DEVENCY, C. W. & DUNPHY, lE. -Factors contributing to leakage of colonic anastomosis. Ann
Surg. 177:513, 1973.
14. YAMAKAWA, T; PATTIN, C.S.; SOBEL, S. &
MARGENSTERN, L. - Healing of colonic anastomosis
following resections for experimental diverticulitis. Arch
Surg. 103: 17, 1971.
R A S S L A N , S .; F O N O F F , A .M .; S O L D A , S .C .; C A S A R O L l, A A - O s to m y o r in te s tin a l a n a s to m o s is in c a s e s o f p e r ito n itis
