|Year : 2018 | Volume
| Issue : 4 | Page : 249-253
Left transverse loop colostomy versus high sigmoid loop colostomy for high-type anorectal malformations: Early outcome analysis
Sharanabasappa Gubbi, Rahul Gupta, Arun K Gupta, Arvind K Shukla
Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
|Date of Web Publication||10-Jan-2019|
Dr. Rahul Gupta
Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: High sigmoid (divided) colostomy has been recommended by various studies for the management of high-type anorectal malformation (ARM). It is postulated to be associated with fewer complications.
Aims: To compare the complications related to left transverse loop colostomy and high sigmoid loop colostomy done in male patients with high-type ARM and share our experience.
Materials and Methods: A prospective study on all male neonates admitted with high-type ARM at our high-volume tertiary care institute from January 2014 to March 2016 was carried out. The patients were randomized and divided into two groups (group A: left transverse loop colostomy and group B: high sigmoid loop colostomy). The patient's clinical presentation, operative course, and complications were recorded.
Results: Of 158 male neonates who were subjected to loop colostomy, 93 (58.9%) were in group A and 65 (41.1%) in group B. Mortality was higher in group B (16.9%) than group A (8.6%), but none directly related to the type of colostomy. Intraoperative complications (technical difficulties) such as difficulty in approaching the sigmoid colon with dilated small bowel loops and identifying the proximal and distal parts of sigmoid colon along with handling of the bowel (including serosal tears) were significantly more in group B (20%) than group A (1.07%) where transverse colon was easily exteriorized. The average time taken for the procedure, pericolostomy excoriation, and bowel obstruction was more in group B when compared with group A.
Conclusion: Left transverse loop colostomy works well to relieve the obstruction and is less time-consuming, particularly with late presentation. We recommend left transverse loop colostomy in cases of high-type male ARM because of the ease of procedure and comparatively low complication rates.
Keywords: Anorectal malformation, colostomy, high-type, loop, male, sigmoid, transverse
|How to cite this article:|
Gubbi S, Gupta R, Gupta AK, Shukla AK. Left transverse loop colostomy versus high sigmoid loop colostomy for high-type anorectal malformations: Early outcome analysis. J NTR Univ Health Sci 2018;7:249-53
|How to cite this URL:|
Gubbi S, Gupta R, Gupta AK, Shukla AK. Left transverse loop colostomy versus high sigmoid loop colostomy for high-type anorectal malformations: Early outcome analysis. J NTR Univ Health Sci [serial online] 2018 [cited 2019 Oct 13];7:249-53. Available from: http://www.jdrntruhs.org/text.asp?2018/7/4/249/249833
| Introduction|| |
Colostomy is performed as a temporary procedure soon after birth in high-type male anorectal malformation (ARM).,, The divided high sigmoid (descending) colostomy has been recommended by various studies for the management of high-type ARM. This type of colostomy is believed to reduce the risk of mechanical complications and urinary tract infections.,,, Other authors commonly perform loop colostomy.,,, Also, different types (split or loop) and colonic locations are propagated in the literature.,,,,,,, We aimed to compare the complications related to left transverse loop colostomy and high sigmoid loop colostomy in management of male patients with high-type ARM and share our experience.
| Materials and Methods|| |
This prospective study was conducted on all male neonates admitted with high-type ARM at our high-volume tertiary care institute from January 2014 to March 2016. ARMs were classified using Krickenbeck's classification. A detailed history and physical examination were completed. An invertogram was performed in whom the examination did not reveal the type of ARM.
Exclusion criteria included the following:
- All patients female with ARM (vestibular fistula, which is the most common type – single-stage correction was done),
- Males with congenital pouch colon (end colostomy was done), and
- Low-type ARM (primary anoplasty was done).
In all the cases, either left transverse or high sigmoid loop colostomy was performed. The patients were randomized and were divided into two groups (group A: left transverse loop colostomy and group B: high sigmoid loop colostomy). The patient's clinical presentation, operative course, and complications were recorded in proforma, and charts were prepared. Mortality and morbidity between the two groups were analyzed. Urinary tract infection was diagnosed on the basis of clinical symptoms of urinary tract infection in association with a positive urine culture (colony count > 105). Patients with colostomy still in place have been included in the study. We used simple statistics for calculation of results in our study.
- In case of left transverse colostomy, a transverse incision was made in the left upper abdomen slightly above the mid-point between the umbilicus and costal margin. Transverse colon was recognized by the presence of greater omentum and delivered out
- In case of high sigmoid colostomy, a left oblique incision was made in the left lower abdomen midway between the umbilicus and anterior superior iliac spine. Small bowel loops were retracted; sigmoid colon was recognized by the presence of its mesentery (sigmoid mesocolon) and presence of tinea coli, and subsequent delivery of sigmoid colon.
Colon was elevated using a nontraumatic rubber anchoring tube which was passed through a window in the mesentery (beneath the mesenteric border of the bowel). This prevented the loop from receding intraoperatively. One or two seromuscular sutures were applied between the proximal and distal ends at the base of the loop. Meticulous fixing of the loop with fascia and formation of good bridge between the two loops was performed [Figure 1]. After fixation, the loop was opened with the diathermy and the edges of the stoma were stitched with the skin. Distal loop wash with normal saline was done at the end of the procedure to remove the meconium from the distal loop. Breastfeeding was started after colostomy started functioning. Colostomy care was explained to the mother. Distal loop wash was also performed during the postoperative period (before discharging the patient from the hospital) and during follow-up visits to prevent fecaloma formation. The patients were followed up for 3 months and complications were recorded.
|Figure 1: Left transverse loop colostomy with good bridge between proximal and distal loops|
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| Results|| |
The results of the study are summarized in [Table 1] and [Table 2]. A total of 158 patients were operated and all were subjected to loop colostomy. There were 93 (58.9%) patients in group A and 65 (41.1%) in group B. The average age at presentation was 1.92 days (range 1–5 days), and the average birth weight was 2.3 kg (range 700 g–3.3 kg).
|Table 2: Comparison between Postoperative Complications Related to Site of Colostomy|
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Mortality was higher in group B (16.9%) than group A (8.6%), but none of them was directly related to the type of colostomy. Of 19 deaths, 2 patients had presented with colonic perforation and septic shock, whereas the other 17 patients expired due to severe septicemia, late presentation, and associated cardiac malformations. Intraoperative complications (technical difficulties) such as (a) difficulty in approaching the sigmoid colon due to hugely dilated small bowel and (b) identifying the proximal and distal parts of sigmoid colon along with handling of the bowel (including serosal tears) were significantly more in group B (20%) than group A (1.07%) where transverse colon was easily exteriorized. Intraoperative blood transfusion was required in 7 (10.7%) patients in group B, with none in group A.
The average size of the incision was smaller in group A (2.5 cm) than group B (3.5 cm). In one patient from group A, there was difficulty in exteriorizing the loop as incision was placed too inferior. The average time taken for the procedure was considerably more in group B (54 min) when compared with group A (38 min).
Minor bleeding from the colostomy site in the immediate postoperative period was seen in three (3.22%) patients of group A and five (7.69%) patients of group B, which was managed conservatively. Excoriation of the skin around the stoma and the ipsilateral thigh was very high (35.38%) in group B, during the follow-up period. It was due to frequent rubbing of the thigh against the stoma by the babies and also resulting in frequent bleeding from the colostomy and anemia. Excoriation in group A was found to be minimal (2.15%). The mothers of patients of group B found it difficult to maintain hygiene of the stoma site with frequent visits to the clinic.
Retraction was observed in one (1.53%) patient of group B. Stenosis followed by loop obstruction was seen in five (7.69%) patients of group B, of which three (4.61%) patients had to be reoperated. On the contrary, prolapse was seen more in group A (12.9%) than group B (1.53%) with only one patient requiring colostomy revision due to major prolapse. Urinary tract infection in group A (9.67%) was higher and was managed with antibiotics.
| Discussion|| |
ARM (1 out of every 5000 live births) comprises wide spectrum of diseases, affects both sex (slightly more common in males), and involves the anus and rectum as well as urinary and genital tracts.,, The most common defect in males is imperforate anus with a rectourethral fistula (high-type ARM) and in females is vestibular fistula. A newborn male with a trace of meconium at the urethral meatus strongly suggests the presence of rectourinary fistula (high-type ARM), while meconuria is confirmatory. In 80%–90% of male neonates, clinical evaluation and urinalysis will provide enough information for the surgeon to decide whether the baby requires a colostomy.,,, If none of the clinical signs reveals the type of ARM by 24 h, an invertogram (as in our study) or a cross-table lateral film with the baby in prone position with the pelvis elevated is performed. Patients with ARM are classified radiologically into high and low types using two imaginary lines, the pubococcygeal line and M line. Rectal pouches terminating above the M line are high-type, whereas those below it are low-type anomaly. Male neonates with low-type anomaly do not need a colostomy. They undergo a posterior sagittal anoplasty.
Even though a new trend of primary repair without colostomy in high-type ARM has been reported, most pediatric surgeons prefer a protective colostomy before the definitive surgery.,,,, Presence of associated anomalies, level of fistula, and creation of colostomy (to prevent inadvertent injury to urinary tract, pelvic sling, and persistence of fistula and also protection of the operated site when corrective procedure has been performed) are an essential determinant of final outcome.,,,
Two varieties of colostomy are generally performed, either loop or divided colostomy. In the former, the colon is sutured into the abdominal wall and is not completely divided, whereas in the latter, both the ends must be placed separately. The divided colostomy has the advantage of preventing overflow of stool into the mucous fistula and its complications, but it is technically more difficult and time-consuming when compared with a loop colostomy, especially when the bowel is dilated (patient presents late) as seen in our study. In our institution, colostomy formations are of loop type, either left transverse or high sigmoid colon, but with formation of good bridge which prevents overflow of stool into the distal loop.
High sigmoid (descending) colostomy has been recommended by various studies for the management of high-type ARM and has been considered an ideal procedure with advantages over transverse colostomy which are enumerated as follows: there is relatively short segment of defunctionalized distal colon; in case of large rectourethral fistula, the patient may pass urine into the colon, whereas more distal colostomy allows urine to escape through the distal stoma without significant obstruction resulting in low rates of hyperchloremic acidosis; mechanical cleansing of the distal colon prior to the definitive repair is less difficult when colostomy is located in the descending colon and enough length for distal limb to reach the perineum.,,,,
There were multiple problems while performing sigmoid colostomy. In our center, patients present late with delayed diagnosis (some are breastfed) with presence of markedly dilated small bowel loops and hugely distended abdomen. There were difficulties in approaching the dilated sigmoid colon and identifying its proximal and distal parts along with excessive handling of the bowel resulting in serosal tears (colostomy is usually performed by residents in our institute, under supervision). We had to decompress the colon before doing colostomy. The other disadvantages with sigmoid colostomy seen in our study are the larger average size of the incision and considerably more time for the procedure. The excessive handling of the intestines could be the cause of postoperative adhesions and intestinal obstruction seen with sigmoid colostomy. Postoperatively with sigmoid colostomy, there was more excoriation of the skin around the stoma and the ipsilateral thigh, bleeding from the colostomy site, difficulty in maintaining hygiene of the stoma site, and obstruction due to retraction and stenosis. Most of these complications have been mentioned in other studies also.,,,,,,,,
The indications of left transverse colostomy are suspicion of wide bladder neck fistula (presence of both meconuria and pneumaturia) and type 4 Congenital Pouch Colon (CPC). The advantages with transverse colostomy seen in our study are lesser intraoperative time and intraoperative complications, smaller average size of the incision, lesser duration of the hospital stay, and hygiene of the stoma site.
The disadvantages with left transverse loop colostomy seen were more cases of prolapse and urinary tract infection in our series. The presence and incidence of associated urinary tract abnormalities is being studied and would be dealt separately. The high incidence of prolapse (due to its relative mobility) with transverse colostomy has also been observed in other studies also. Most of the prolapses were minor and reducible; not associated with other complications, except one necessitating colostomy revision due to major prolapse. No case of microcolon with mega-rectosigmoid and metabolic acidosis was seen on follow up.
| Conclusion|| |
Formation of colostomy is a major procedure for a newborn patient with ARM as it is associated with high incidence of complications. Left transverse loop colostomy with meticulous anchoring technique and formation of good bridge between the two loops works well to relieve the obstruction and is less time-consuming, particularly with late presentation, although prolapse was more commonly seen. We found sigmoid colostomy to be a cumbersome technique, as most of the babies present late and there is difficulty in approaching the sigmoid colon due to hugely dilated small bowel and identifying the proximal and distal parts of sigmoid colon along with handling of the bowel. Also, excoriation of the skin around the stoma and the ipsilateral thigh was very high with sigmoid colostomy. We recommend left transverse loop colostomy to be performed in cases of high-type male ARM because of the ease of procedure and comparatively low (both intra- and postoperative) complication rates.
The authors are sincerely thankful to faculty, residents, and nursing staff of the Department of Paediatric Surgery, SMS Medical College, Jaipur, for helping in their endeavour. Dr. Sharanabasappa Gubbi and Dr. Rahul Gupta contributed equally to this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brenner EC. Congenital defects of the anus and rectum. Surg Gynecol Obstet 1915;20:579-88.
Tusler GA, Wilkinson RH. Imperforate anus: A review of17 cases. J Surg 1962;5:169-77.
Levitt MA, Pena A. Anorectal malformations. Orphanet J Rare Dis 2007;2:33.
Pena A, Krieger M, Levtt MA. Colostomy in anorectal malformations: A procedure with serious but preventable complications. J Pediatr Surg 2005;41:748-56.
Wilkins S, Pena A. The role of colostomy in the management of anorectal malformations. Pediatr Surg Int 1988;3:105-9.
Patwardhan N, Kiely EM, Drake DP, Spitz L, Pierro A. Colostomy for anorectal malformation: High incidence of complications. J Pediatr Surg 2001;36:795-8.
Gupta R, Sharma SB, Dagla R. Nonfluoroscopic well-tempered pressure augmented distal colostogram in high-type anorectal malformation: Our experience. Arch Int Surg 2015;5:88-95. [Full text]
Oda O, Davies D, Colapinto K, Gerstle JT. Loop versus divided colostomy for the management of anorectal malformations. J Pediatr Surg 2014;49:87-90.
Chowdhary SK, Chalapathi G, Narashima KL, Samajh R, Mahajan JK, Menon P, et al.
An audit of neonatal colostomy for high anorectal malformation: The developing world perspective. Pediatr Surg Int 2004;20:111-3.
Gangopadhyay AN, Gopal SC, Sharma S, Gupta DK, Sharma SP, Mohan TV. Management of anorectal malformations in Varanasi, India: A long-term review of single and three stage procedures. Pediatr Surg Int 2006;22:169-72.
Holschneider A, Hutson J, Pena A, Beket E, Chatterjee S, Coran A, et al.
Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations. J Pediatr Surg 2005;40:1521-6.
Peña A, Levitt MA. Anorectal malformations. In: Grosfeld JL, O'Neill JA, Fonkalsrud EW, Coran AG, editors. Pediatric Surgery. 6th
ed. Philadelphia: Mosby Elsevier; 2006. p. 1566-89.
Bellman BA, King LR. Urinary tract abnormalities associated with imperforate anus. J Urol 1972;108:823-4.
Boemers TM, de Jong TP, van Gool JD, Bax KM. Urologic problems in anorectal malformations. Part 2: Functional urologic sequelae. J Pediatr Surg 1996;31:634-7.
Stoll C, Alembik Y, Dott B. Associated malformations in patients with anorectal anomalies. Eur J Med Genet 2007;50:281-90.
Liu G, Yuan J, Geng J, Wang C, Li T. The treatment of high and intermediate anorectal malformations: One stage or three procedures? J Pediatr Surg 2004;39:1466-71.
Nour S, Beck J, Stringer MD. Colostomy complications in infants and children. Ann R Coll Surg Engl 1996;78:526-30.
[Table 1], [Table 2]