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Early Colostomy Reversal: Not A Good Idea

I have already spoken about the hazards of doing favours, but recently I was reminded of another example when I was still a registrar where I only just escaped the proverbial falling anvil.

It was not an unusual case but still fairly challenging for a registrar like myself. The old man presented with an acutely tender abdomen and free air revealed on x-rays. If you ignore the outside horses for a while, this is either a perforated peptic ulcer or complicated diverticulitis (some people would throw complicated appendicitis into the mix, but I’m going to leave it in the stable with the outside horses if there are no objections). The patient needed an operation and soon. So with the sun shining happily over Australia somewhere, I took him to theater.

It turned out to be diverticulitis, but what a mess. The entire abdomen was full of pus and there was a big inflammatory mass in the region of the sigmoid colon. I knew what to do. I whipped out the offending sigmoid colon and, because the risk of reattaching the bowel in that level of sepsis was too high and because the patient couldn’t afford a further complication, I pulled out a colostomy.  After the surgery the patient started recovering at an acceptable rate. the plan was to reverse the colostomy in the future.

Now usually, this sort of colostomy would be left in place for quite a while (in the order of six months) to give the abdomen time to recover fully from the severe inflammation that accompanies free pus throughout the abdomen. Inflamed bowel is very friable and difficult to work with. Thereafter it would be closed in a second operation. However there was a private consultant with sessions at the university who strongly advocated for what he called early closure of colostomy. He said that as soon as the sepsis had cleared up, long before the inflammation had settled, you could re-operate and reverse the colostomy. He advised that the second operation be done before the patient even leaves the hospital, even within a week of the first procedure. he actually approached me about this patient specifically and told me I should try it. I started contemplating the idea.

Then something happened that I should have seen as a big warning sign: an old friend asked me for a favour.

You see this friend was related to my patient in some way. Apparently he had visited him in hospital and discovered I was the one who had done the operation. As can be expected from someone who wakes up from surgery with an unexpected colostomy, the patient was bemoaning his lot in life. In the end he asked my friend to ask me for a favour. The friend asked me to close the colostomy, sooner rather than later. I should have seen warning lights. I didn’t.

So I decided this would be the case where I listen to the often contentious advice of this specific private surgeon. I took the patient back to theater to close the colostomy about a week after the first operation.

Quite soon I was in trouble. Everything was adhered to everything. Over and above this, because the inflammation was far from resolved, everything was oozing blood at somewhat more than an acceptable rate.  But it was too late. I was elbow deep in the abdomen. I had no choice but to continue. The other catch was that I was doing the operation at the advice of the outside consultant and not with the consent of my own consultant. This essentially meant I would experience a severe loss of cool if I asked my consultant to come in to help me *read bail me out*.

The details need not be dwelled upon (truth be told I have filed them deep in the forget folder in the darkest archives of my mind) but suffice to say it was an almost impossible dissection to get the two ends of the colon together to reattach them. Finally, almost miraculously, I approximated the two ends in a somewhat acceptable manner and attached them.

During the postoperative period I almost expected a leak. Day after day I’d check the patient out and be surprised to see there was no leak. Finally I discharged him in good health. But not before I swore to myself never ever to attempt an early closure of colostomy again. Also I reminded myself of the dangers of doing favours.

P.S. Many years later I ran into this friend and was pleasantly surprised to hear the old man was still going strong.

*This blog post was originally published at other things amanzi*

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One Response to “Early Colostomy Reversal: Not A Good Idea”

  1. Laura says:

    My infant son has been in quite a predicament due to an early ostomy closure (reversed at 12 days). He’s been in hospital for 7 months due to a leak that went undetected for 2 weeks after the closure. The result was septic shock, from which he very nearly died. In the damage control laparotomy, they failed to pull out a stoma. He first developed a fecal fisula in the superficially open wound at 1 week post laparotomy. His belly fell apart about a week after that, revealing initially 5 holes in matted mass of small intestine. He was treated with an open abdomen for 4.5 months, during which time the hole count rose to a final total count of 13. He has finally had a bowel resection and closure, and miraculously lost only about a third of his small intestine. Honestly, I think we are bound to pursue legal action for this very poor decision by the initial surgeon. It was a reckless move.

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“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

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Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

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Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

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