ISPUB.com / IJTWM/6/2/9170
  • Author/Editor Login
  • Registration
  • Facebook
  • Google Plus

ISPUB.com

Internet
Scientific
Publications

  • Home
  • Journals
  • Latest Articles
  • Disclaimers
  • Article Submissions
  • Contact
  • Help
  • The Internet Journal of Third World Medicine
  • Volume 6
  • Number 2

Original Article

Is a Diverting Colostomy Required After Repair of Obstetric Ano-rectal Injuries?

S Cawich, I Bambury, D Mitchell, J Plummer, M Newnham, L Christie

Keywords

colostomy, fecal diversion, obstetric anal sphincter injury, severe perineal laceration

Citation

S Cawich, I Bambury, D Mitchell, J Plummer, M Newnham, L Christie. Is a Diverting Colostomy Required After Repair of Obstetric Ano-rectal Injuries?. The Internet Journal of Third World Medicine. 2007 Volume 6 Number 2.

Abstract

Injuries to the ano-rectum may occur during vaginal deliveries. Occasionally, colostomies are created in these patients in order to prevent contamination of the perineal repair. We explore the factors that assist in making the decision for a colostomy.

 

Introduction

Injuries to the ano-rectum may occur during vaginal deliveries. Occasionally, colostomies are created in these patients in order to prevent contamination of the perineal repair. We explore the factors that assist in making the decision for a colostomy.

Discussion

Between 0.2% 1 and 6% 2 of women sustain injury to the ano-rectum during vaginal delivery. These injuries are classified as third degree lacerations when the external anal sphincters are lacerated, and fourth degree when the ano-rectal mucosa is breached. 3,4,5 At a recent consensus meeting, several experts supported the use of a more descriptive classification proposed by Sultan et al. 6 where third degree injuries are sub-classified according to the depth of the laceration through the anal sphincters (Table 1).

Figure 1
Table 1: Classification of Obstetric Perineal Injury

Almost 50% of the affected women will experience a complication despite early injury recognition and repair. 3,4,5,6,7 Disastrous complications may occur, including recto-vaginal fistulae in 14% of women 1 and fecal incontinence in 20-50% of cases. 1,4,7,8

Early diagnosis and anatomically correct repair by experienced surgeons are the cornerstones to minimizing the morbidity associated with these injuries. 3,4,5 Evidence continues to accumulate in favor of the overlapping technique to repair the anal sphincters. 9,10,11,12,13 A metanalysis of 279 women from three prospective randomized trials supported the use of the overlapping technique over end-to-end repair because it resulted in a lower incidence of anal incontinence and better incontinence scores at 12 months. 9

Rapidly absorbing sub-mucosal sutures should be used for mucosal repair. The latest Cochrane systematic review of 3,642 women across 8 randomized controlled trials 14,15,16,17,18 revealed that absorbable synthetic sutures result in less perineal pain and wound dehiscence while avoiding the need for suture removal. 17 Several authorities have also advocated the use of slowly absorbable monofilament suture such as Polydioxanone to repair the anal sphincters. 3,4,5

While these are all evidence-based recommendations, the need for fecal diversion after primary repair is one area in which there is still deficient evidence to guide clinical practice. Several authorities have discussed the management of obstetric ano-rectal injuries in the medical literature, but many avoid commenting on the utility of a colostomy. Defunctioning colostomies are readily described for secondary repairs 3,19,20 and when patients develop frank recto-vaginal fistulae 21 , but the decision becomes less clear for primary repair of acute injuries.

A review of the English literature over the past 20 years yielded no prospective trials evaluating the need for colostomy after repair of acute obstetric ano-rectal injuries. There were a few small case series with reports of defunctioning colostomies during repair of acute injuries, but the indications are elusive and its performance is not standard. 1,23,24,25 We encountered a single randomized trial of fecal diversion in 27 patients who had delayed anal sphincter repair. 22 There was no conclusive evidence that a defunctioning stoma conferred any benefit in wound healing or functional outcome after repair. Additionally, stoma-related complications occurred in more than 50% of the patients. 22

While there is little data on which to base clinical practice, there is a marked difference in expert opinion regarding the utility of colostomies. In a recent clinical practice survey in the United Kingdom, 910 practicing obstetricians and colorectal surgeons responded to a questionnaire. Fernando et al reported that 30% of colorectal surgeons recommended a defunctioning colostomy for third and fourth degree tears, while no obstetricians surveyed believed a colostomy was needed. 3

These recommendations rely on the existing staging systems to stratify the need for diversion. But the available staging systems are under-equipped to address this problem because they view the injuries as a two-dimensional construct by neglecting the depth that the laceration extends into the ano-rectum. Recently we encountered a patient with a severe laceration that extended through the entire thickness of the perineum, allowing free communication between the vagina and ano-rectum and extending 9cm proximally into the rectum (Fig. 1). Surely this type of laceration is more likely to dehisce than a laceration that only transects the mucosa over the anal sphincters. Yet, both lacerations would be classified as fourth degree by the current staging systems. This makes it difficult to stratify the need for diversion using these staging systems.

Figure 2
Figure 1: A severe perineal laceration sustained during vaginal delivery is seen from the lithotomy position. There is now wide communication between rectum and vagina. The laceration extends 9cm proximally into the pelvis.

There is a considerable amount of data on diversion after repair of acute non-obstetric injuries. There has been a notable shift away from mandatory colostomy for penetrating ano-rectal trauma. 26,27,28,29,30,31,32,33 There is now consensus that once extra-peritoneal injuries can be identified, they should be primarily repaired 26,27,28,29,,30,31 , with diversion being reserved for blunt injury mechanism 32 or destructive injuries with severe anatomic disruption and marked contamination. 27,28,29,31,33

Morken et al proposed the use of the Rectal Injury Severity Score of the American Association for Surgery in Trauma (Table 2) to assist in the decision for diversion. 33,34 Their small retrospective study of 45 patients with rectal trauma, demonstrated that there was greater morbidity with diversion for low-grade injuries. They recommended limiting fecal diversion to patients with Rectal Injury Severity Scores >II. The injury previously described (fig. 1) qualifies as a Grade IV injury according to the Rectal Injury Severity Score.

Figure 3
Table 2: Rectum Injury Severity Scale

We recognize that the management of penetrating ano-rectal trauma may not equate well with the management of obstetric injuries. This is exactly why obstetric ano-rectal injuries more amenable to repair without diversion. Obstetric lacerations are low energy injuries with minimal tissue loss and the areas are well supplied with blood immediately post delivery. Furthermore, the trans-anal approach affords excellent exposure in obstetric injuries, abolishing the problem of difficult exposure in the pelvis at laparotomy.

Colostomies come at a price to the patients. There is reduced collagen metabolism and altered mucosal defense in the de-functionalized rectum, thereby impairing healing. 37,38 Diversion also attenuates mucosal integrity, promotes microbial translocation and increases infectious morbidity. 39,40 There is added morbidity in 25-29% of patients accompanying colostomy creation and closure. 41,42,43 Additionally, up to 23% of patients with colostomies for ano-rectal trauma do not have their colostomies closed for up to two years after creation. 44

Conclusion

Although several advances have been made in the treatment of ano-rectal obstetric injuries, there is still little evidence upon which to base the decision for fecal diversion. The current staging systems seem under-equipped to address this problem.

In the absence of evidence that a colostomy confers any benefit after repair of acute obstetric ano-rectal injuries, we believe that diversion is seldom warranted. More research needs to be done for there to be data on which to make evidence based decisions.

References

1. Cawich SO, Mitchell DIG, Martin A, Newnham MS, Dacosta VE, Lewis T, et al. Can we Improve Therapeutic Outcomes after Obstetric Anal Sphincter Injury at the University Hospital in Jamaica? West Ind Med J. 2007;56(1):53(A).
2. Carroll TG, Engelken T, Mosier MC, Nazir N. Epidural Analgesia and Severe Perineal Laceration in a Community-based Obstetric Practice. J Am Board Fam Pract. 2003; 16(1): 1-6.
3. Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal sphincter injury: Systematic review and national practice survey. BMC Health Ser Res. 2002;2(9):1472-6963.
4. Leeman L, Spearman M, Rogers R. Repair of Obstetric Perineal Lacerations. Am Fam Physician 2003; 68:1585-90.
5. Fernando RJ, Williams AA, Adams EJ. RCOG Green Top Guidelines: Management of third and fourth degree perineal tears following vaginal delivery. RCOG Green Top Guidelines. 2007;29.
6. Sultan AH. Perineal injury and fecal incontinence after childbirth: Obstetrical perineal injury and anal incontinence. Clinical Risk. 1999;5:193-196.
7. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ. 1994;308:887-891.
8. Fitzpatrick M, Fynes M, Cassidy M, Behan M, O'Connell PR, O'Herilhy C. Prospective study of the influence of parity and operative technique on the outcome of primary anal sphincter repair following obstetrical injury. Eu J Obstet Gynecol Reprod Biol. 2000;89:159-163.
9. Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal sphincter injury. Cochrane Database of Systematic Reviews 2006;3:CD002866.
10. Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O'Brien PMS. Repair Techniques for Obstetric Anal Sphincter Injuries: A Randomized Controlled Trial. Obstet Gyn. 2006;107(6):1261-1269.
11. Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair of obstetric anal sphincter rupture using the overlap technique. Br J Obstet Gynaecol. 1999;106 (4):318-323.
12. Fitzpatrick M, Fynes M, Cassidy M, Behan M, O'Connell PR, O'Herlihy C. A randomised controlled trial of primary repair of third degree perineal tears, comparing overlap and approximation techniques. Am J Obstet Gynecol. 2000;183:1220-1224.
13. Kairaluoma MV, Raivio P, Aarnio MT, Kellokumpu IH. Immediate repair of obstetric anal sphincter rupture: medium-term outcome of the overlap technique. Dis Colon Rectum. 2004;47(8):1358-63.
14. Mahomed K, Grant A, Ashurst H, James D. The Southmead perineal suture study. A randomized comparison of suture materials and suturing techniques for repair of perineal trauma. Br J Obstet Gynaecol. 1989;96:1272-80.
15. Mackrodt C, Gordon B, Fern E, Ayers S, Truesdale A, Grant A. The Ipswich Childbirth Study 2. A randomised comparison of polyglactin with chromic catgut for postpartum perineal repair. Br J Obstet Gynaecol. 1998;105:441-5.
16. Grant A. The choice of suture and techniques for repair of perineal trauma: an overview of evidence from controlled trials. Br J Obstet Gynaecol 1989;96:1281-9.
17. Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair. Cochrane Database Syst Rev 2003; (1):CD000006.
18. Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet 2002;359:2217-23.
19. Browning GPB, Motson RW. Anal Sphincter Injury: Management and Results of Parks Sphincter Repair. Ann Surg. 1984;199(3):351-357.
20. Rothbarth J, Bemelman WA, Meijerink WJ, Buyze-Westerweel ME, van-Dijk JG, Delemarre JBV. Long-Term Results of Anterior Anal Sphincter Repair for Fecal Incontinence due to Obstetric Injury. Digest Surg. 2000;17(4):390-394.
21. Lavery IC. Surgical Management of Gastrointesinal fistulas. Surg Clin North Am. 1996;76(5):1183-90.
22. Hasegawa H, Yoshioka K, Keighley MR. Randomized trial of fecal diversion for sphincter repair. Dis Colon Rectum. 2000;43(7):961-5.
23. Young CW, Mathur MN, Evers AA, Solomon MJ. Successful overlapping anal sphincter repair: relationship to patient age, neuropathy, and colostomy formation. Dis Colon Rectum. 1998;41(3):344-9.
24. Engel AF, Kamm MA, Sultan AH, Bartram CI, Nicholls RJ. Anterior anal sphincter repair in patients with obstetric trauma. Br J Surg. 1994;81(8):1231-4.
25. Cook TA, Deane D, Mortenson NJM: Is there a role for a colorectal team in the management of severe third degree vaginal tears. Colorectal Dis. 1999;1:263-266.
26. McGrath V, Fabian TC, Croce MA, Minard G, Pritchard FE. Rectal trauma: management based on anatomic distinctions. Am Surg. 1998;64:1136-1141.
27. Levy RD, Strauss P, Aladgem D, Degiannis E, Boffard KD, Saadia R. Extraperitoneal rectal gunshot injuries. J Trauma. 1995;38: 273-277.
28. Berne JD, Velmahos GC, Chan LS, Asensio JA, Demetriades D. The high morbidity of colostomy closure after trauma: Further support for the primary repair of colon injuries. Surg. 1998;123:157-164.
29. Velmahos GC, Gomez H, Falabella A, Demetriades D. Operative management of civilian rectal gunshot wounds: simpler is better. World J Surg. 2000;24:114-118.
30. Ivatury R, Licata J, Gunduz Y, Rao P, Stahl WM. Management options in penetrating rectal injuries. Am Surg. 1991;57(1):50-55.
31. Levine JH, Longo WE, Pruitt C, Mazuski JE, Shapiro MJ, Durham RM. Management of selected rectal injuries by primary repair. Am J Surg. 1996;172: 575-579.
32. Miller BJ, Schache DJ. Colorectal injury: where do we stand with repair? ANZ Journal of Surg. 1996;66:348-352.
33. Morken JJ, Kraatz JJ, Balcos EG, Hill MJ, Ney AL, West MA, et al. Civilian rectal trauma: A changing perspective. Surg. 1999;126(4):693-700.
34. Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA, et al: Organ injury scaling II: pancreas, duodenum, small bowel, colon and rectum. J Trauma. 1990;30(11)1427-1429.
35. Rombeau JL, Wilk PJ, Turnbull RB, Fazio VW. Total fecal diversion by the temporary skin level loop tansverse colostomy. Dis Colon Rectum 1987;21:223-226.
36. Morris DM, Rayburn D. Loop colostomies are totally diverting in adults. Am J Surg. 1991;161(6):668-71.
37. Alverdy J, Sang-Chi H, Sheldon G, The effect of parenteral nutrition on gastro-intestinal immunity: importance of enteral stimulation. Ann Surg. 1985;202: 681-4.
38. Border JR, Hassett J, LaDuca J, Seibel R, Steinberg S, Mills B, et al. The gut origin septic states in blunt multiple trauma in the ICU. Ann Surg. 1987 Oct;206(4):427-48.
39. Schweinberg FB, Seligman AM, Fine J. Transmural migration of intestinal bacteria: a study based on the use of radioactive E Coli. N Eng J Med. 1950;242(19):747-751.
40. Kudsk KA. Current aspects of mucosal immunology and its influence by nutrition. Am J Surg 2002; 183: 390-398.
41. Pachter HL, Hoballah JJ, Corcoran TA, Hofstetter SR. The morbidity and financial impact of colostomy closure in trauma patients. J Trauma. 1990;30(12):1510-1513.
42. Ghorra SG, Rzeczycki TP, Natarajan R, Pricolo VE. Colostomy closure: impact of preoperative risk factors on morbidity. Am Surg. 1999;65:266-269.
43. Riesener KP, Lehnen W, Hofer M, Kasperk R, Braun JC, Schumpelick V. Morbidity of ileostomy and colostomy closure: impact of surgical technique and perioperative treatment. World J Surg. 1997;21:103-108.
44. Plummer JM, McDonald AH, Newnham ME, McFarlane ME. Civilian rectal trauma: the surgical challenge. West Ind Med J. 2004;53(6):382-6.

Author Information

Shamir O. Cawich, M.B.B.S., D.M.
Department of Basic Medical Sciences, The University of the West Indies

Ian Bambury, M.B.B.S., D.M.
Department of Obstetrics and Gynaecology, The University of the West Indies

Derek I.G. Mitchell, M.B.B.S, D.M.
Department of Surgery, Radiology, Anaesthesia and Intensive Care, The University of the West Indies

Joseph Plummer, M.B.B.S, D.M.
Department of Surgery, Radiology, Anaesthesia and Intensive Care, The University of the West Indies

Mark S. Newnham, M.B.B.S, D.M.
Department of Surgery, Radiology, Anaesthesia and Intensive Care, The University of the West Indies

Loxley Christie, M.B.B.S, D.M.
Department of Obstetrics and Gynaecology, The University of the West Indies

Download PDF

Your free access to ISPUB is funded by the following advertisements:

 

 

BACK TO TOP
  • Facebook
  • Google Plus

© 2013 Internet Scientific Publications, LLC. All rights reserved.    UBM Medica Network Privacy Policy

Close

Enter the site

Login

Password

Remember me

Forgot password?

Login

SIGN IN AS A USER

Use your account on the social network Facebook, to create a profile on BusinessPress