Friday, December 14, 2007

Takedown
















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......

15 comments:

Anonymous said...

How did you approach the incarcerated sigmoid inguinal hernia - ? laparotomy. Thanks - surgery resident

Buckeye Surgeon said...

Started with groin incision, converted to laparotomy when clear what was happening.

Sid Schwab said...

It's a gratifying operation in that it makes patients very happy. It's also one of those that can be pleasantly easy or maddeningly difficult.

Anonymous said...

I've been looking into Colostomy Takedowns lately since I am actually getting one on the 10th (Thursday) but I am still actually pretty nervous. Now my doctor hasnt really talked much to me about it, he's really straight forward about everything. Im still scared to be honest... I was just wondering if you might have any input as to what I should expect... my email is Dementedfiend138@aol.com, any input or advice you could give me would be greatly appreciated. My name is Russ by the way, Im a big Dead-head myself, anyway. Thanks.

Buckeye Surgeon said...

Anon-
A lot of it depends on what kind of ostomy takedown you need. Loop ileostomy and loop colostomy takedowns are generally less morbid and recovery is quicker. Colostomy takedowns that require hooking up the descending colon to the rectum usually necessitate a laparotomy and in-hsopital recovery can be 5-10 days. Expect initial bowel movements to be loose. You may have some minor incontinence at first. For major abdominal surgery, expect full recovery to take two to three months...

sierradoc said...

i have done two in the past week and just wish there was a decent CPT code to use! both cases involved nearly an hour of dissection, two short segment colon resections and closure of abdominal wall defects @ long-standing ostomy sites - and of course the 'mos! folks spend a week in the house causing usual angst and we can't even present a solid bill for services rendered.

not like this is some weird, arcane kind of procedure!

Angel F said...

howdy, my name is angel flores from el paso tx, my surgen Dr. Mc Lean is going to preform... well i might start with;
i'm an active gymnist whole does all events tumble ring pommel you name it, i've had a colostomyon my right side with a mucus fishtula on the left, i'm getting my take down surgey this tuesday, how long will it take me to recover and get back to doing my flips?
gymflip355@hotmail.com
may-20-07
i was hit with a land scaping brick standing out side my house thrown from a car going about 45 mph i had several surgeys, hemapthic repair, i had a grade 4 liver laseration, and i ended up with that colostomy. i was out for 3 weeks in ICU like out out when i woke up, i leanred how to walk again by the 2nd day, ad was out back at home by the 6th day. that just to give you more prespective. i had a total of 6 surgerys. if you could get back to me it'd be deeply appriciated. =)

Buckeye Surgeon said...

Angel-
Congratulations on your seemingly rapid recovery from a life threatening situation. The colostomy takedown operation could be a little tricky, given that you've had 6 operations so far. There's bound to be dense adhesions from all the scar tissue. If everything goes well, you ought to anticipate a 5-10 day stay in the hospital and then 4-6 weeks of recuperation at home. However, I wouldn;t expect full recovery for several months...good luck.

Anonymous said...

Dr. Buckeye - What are your thoughts on using Seprafilm to eliminate those adhesions? If it is applied at the creation of the colostomy, you'd be pleasantly surprised at the results when you perform the takedown. Just my $.02.

Buckeye Surgeon said...

Anon-
I do try to use the seprafilm on the initial colectomy but Ive had varying results. Sometimes there's no adhesions, sometimes it's like I never used anything at all....

Brigitte said...

My husband perforated during a colonoscopy and subsequently had to have a colostomy placed. Last week the surgeon decided to do a takedown. 3 days after surgery he developed drainage in his abdomen. A pigtail drain was put in place and he was sent home. It drained dark brown liquid. The surgeon then decided to to a laparotomy and found undigested pills in his abdominal cavity and decided to just leave his abdomen open with packing. It is now leaking very dark green drainage. He tells me this is bile and should stop. I am extremely worried. What could be going on?????

Buckeye Surgeon said...

Brigiitte-
Sounds like an anastomotic leak, a dreaded complication of reversing colostomies. It happens 5-8% of the time. The leak is decompressing through the midline wound suggesting an entercutaneous fistula. This is a problem. It's going to take time and patience to get him well again. Best of luck to you both.

sierradoc said...

Brigette - this is an anastomotic leak until proven otherwise.

it is unfortunate your hubby had to have a colostomy constructed for an iatrogenic perforation during lower endoscopy as many of these injuries are manageable primarily if recognized quickly enough.

good luck!

Anonymous said...

I have a 8 month old son that was born with an inperforate anus right now he has a colostomy bag and is scheduled to have colostomy take down surgery this week what are the risk that come after surgery and how long does this procedure usually take ....

nichelle said...

I had a colostomy placed jan 27, 2010 n tried getting a takedown jan 12, 2011 it went horrible, dr lost me twice on op table and during my almost 9 hr surgery I had to get an ileostomy put on due to severe leakage.. stiches staples NOTHING held. I was left with my stomack wide open n eventually got a wound vac n was in hospital for 2 weeks exactly. Any ideas what would have caused that?