A PROSPECTIVE INTERVENTIONAL STUDY ON EXTERIORIZATION OF INTESTINAL ANASTOMOSIS

Abstract

Colostomy was introduced in surgical practice more than 200 years ago as a simple and safe procedure. Since then, the time honored dictums “exteriorize colon injuries” and a “well prepared bowel is a pre-requisite for any colon repair”, formed the basis for sound colon surgery. In 1945, the practice of routine colostomy was challenged by a military surgeon, James Mason, who introduced the technique of primary suture of unprepared colon and exteriorizing the segment of bowel outside the peritoneal cavity. Initially, this technique did not gain much momentum in civilian practice mainly because of difculties encountered in introducing procedures which would challenge established orthodox surgical practice. Intestinal disruption is a common problem with a wide-ranging aetiology. It requires anastomosis or repair or creation of stoma with or without Total Parenteral Nutrition therapy. Failure of anastomosis leads to signicant morbidity and mortality. Creation of Stoma is associated with signicant morbidity. Stoma closure also carries signicant risk. In this study, we propose an alternative procedure in the form of exteriorisation of intestinal anastomosis (both small and large bowel), followed by delayed internalization after the anastomosis has healed. Aim: To develop a technique which could bypass or minimize the risks associated with intestinal disruption following anastomosis and also alleviate the morbidity associated with creation of stomas. Alternative proposed: Exteriorisation of anastomosis. Materials And Methods: The study has been carried out on 15 patients with clinical presentation of peritonitis in an emergency setting as well as an alternative procedure in an elective setting over a period of 4 years who were seen in general surgery outpatient department (OPD) and general surgery wards of a single teaching institution of Eastern India. The procedural steps include Exteriorisation of anastomosis, keeping the bowel moist using irrigation and internalization after the anastomosis has healed. Results: 12/19 procedures succeeded (63%). One death occurred due to convulsions despite healing of anastomosis. 7/19 procedures failed (37%). There were two deaths due to failure of anastomosis and lung complications respectively. Conclusion: Existing treatment options for gut repairs, particularly if proximal, are not wholly satisfactory. This study throws some light on the fact that the temporary exteriorisation of repaired gut is safe. Dangers of intraperitoneal anastomotic leak are avoided. Complications of stoma may be avoided. The requirement of costly, and potentially harmful Total Parenteral Nutrition therapy is lessened. Best technique is yet to be determined.