Friday, December 14, 2007
I've done four colostomy takedowns in the past 10 days. One of those weird streaks. All of them had had Hartmann's procedures done. Three had perforated diverticulitis and peritonitis and the fourth presented with an incarcerated inguinal hernia (gangrenous sigmoid colon.) The Hartmann's procedure involves doing a sigmoid colectomy and then bringing out the descending colon as an end colostomy. Patients who are sick or have a lot of fecal contamination of the peritoneal cavity are more safely treated with diversion because primary anastomoses in the pelvis are almost doomed to fail (leak) in such situations. The treatment plan is two-staged. Divert, recover from sepsis, and then bring them back in a few months for colostomy takedown. Patients are always disappointed to wake up and find they have the dreaded "bag" attached to their belly. It's understandable, of course, and you just try to reassure them that once they heal, re-establishing intestinal continuity is possible. They like to hear the word "temporary".
The problem is, not all colostomies are temporary. After Hartmann's procedures, only about 75-80% of patients are able to have the bowel reconnected. The long term effect of fecal contamination of the peritoneal cavity is severe scarring, disruption of normal tissue planes, and, often, transformation of pelvic anatomy into something unrecognizable. Colostomy takedowns are fraught with hazard. You spend over an hour sometimes just lysing adhesions and identifying what exactly the anatomy is. It's a major abdominal operation. Few cases make me as nervous. There's a disconnect between patient expectation and the reality. No matter how many times you tell the patient that the procedure is risky and could potentially make things worse, they want the "bag" to go away, no matter what. Luckily, none of the four leaked and are doing quite well......