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OF ARTIFICIAL ANUS OF EIGHT YEARS' DURATION, CLOSURE WITH SOME REMARKS ON THE QUESTION OF INTESTINAL ANASTOMOSIS* BY ELLSWORTH ELIOT, JR., M.D. OF NEW YORK, N. Y. INSTANCES of the closure of an artificial anus of more than one years' duration are obviously rare. During that interval no material depreciation in the function of the intestine below the abnormal orifice has taken place. The closure of the opening leads immediately to the complete restoration of colonic action. On the other hand, in cases of long standing, in which the entire bowel contents are discharged through the artificial anus, it is quite reason- al)le to infer that, owing to the disuse extending over a period of years, the motor, vascular, secretory and nervous apparatus of the intestinal wall may have become so atrophied or otherwise changed that even a partial restoration of their several functions may not take place when the abnormal orifice is closed. In 1913, the writer was asked to see a patient who had developed an artificial anus following an operation for the relief of an infected appendix. As a fecal fistula, espe- cially where the appendix at the junction with the cwecum happens to be gangrenous, is not a rare post-operative complication and as these fistul< usually close spontaneously in the course of ten days to several weeks, conservative measures were advised not- withstanding that the entire bowel contents passed through the artificial opening. As the condition remained unchanged at the end of a year, a second consultation was held to discuss the propriety of operation. The patient, about sixty years of age, had for many years been an incurable paranoiac and required the constant attention of two nurses whose testimony, together with that of the attending physician, conclusively showed that the occasional fecal discharge through the abnormal opening did not cause the slightest perceptible annoyance or discomfort and that the usual prophylaxis prevented any irritation of the adjacent skin. Furthermore, the relatively low position of the opening precluded any deterioration in the patient's general condition. WVhile closure would unquestionably have been attempted in an otherwise normal subject, the fact that such a procedure, if successful, would, in the case of an incurable paranoiac, have neither added to her comfort nor have removed the need of constant nursing, seemed to justify a laissez-faire policy. This conclusion was still further strengthened by the surmise that a marked decrease in reparative power, due to the long-continued mental derange- ment, would, if present, unfavorably affect the chance of successful closure if it did not actually predispose to a fatal post-operative peritonitis. and easily controlled After several years prolapse appeared. This at first was slight the by an overlying pad, although it gradually increased in size. After a time, however, the prolapse, always reducible, became more complete until finally, seven years after original operation, it formed a voluminous mass, balloon-shaped, bulging over the side of the patient for a distance of at least I2 inches, consisting evidently of the entire ascending colon. When reduced every contrivance failed to prevent its spontaneous return. In this condition it became both a source of annoyance and irritation and its resection seemed justifiable provided that the capacity of the distal gut to function could * Read before the American Surgical Association, April I7, I924. 478 OF ARTIFICIAL ANUS CLOSURE Le established with reasonable certainty. Would the delicate nervous, secretory, vascular and muscular mechanisms of the wall of the large intestine, after so many years of inactivity respond to the stimulus of intestinal contents and conduct them by their successful co6rdination through the entire length of the large intestine to and through the rectal outlet? Digital examination disclosed a tonic rectal sphincter. Enemata were expelled, the first with a considerable discharge of mucus and feces, the first in seven years. A small quantity of an analine dye, administered under low pressure in a colon irrigation, appeared at the artificial anus. The operation, as suggested, was therefore performed, the terminal ileum, the entire ascending and several inches of the transverse colon being resected through an incision inclosing the former operative scar and the artificial anus, followed by a lateral anastomosis. The wound was closed in layers around a protrud- ing drain. The patient stood the operation well. The temperature, never above ioo, was normal on the fourth day. There was no distention at any time. Peristalsis was quickly reestablished, gas being passed per rectum at the end of the first 24 hours. The bowels moved naturally on the second day without enema or drip. For the first week the bowel movement were fluid and occurred on an average of once every four hours. The buttocks became considerably excoriated, necessitating constalnt watching. A small occasional dose of morphine lessened the frequency. The first formed movement occurred one week after operation and afterward the consistency varied. The patient took fluids and soft nourishmnent with relish. The superficial wound became infected with some sloughing of the aponcurosis. A persistent sinus remained. During the past four years the patient's condition has been satisfactory, although the post-operative sloughing of the aponeurosis was followed by some bulging in the scar. The function of the bowels is normal. The type of anastomosis after intestinal excision, presents a most inter- esting question and a fruitful theme for discussion. In the small intestine, end-to-end anastomosis by suture, the abdomen being closed without drainage, gives excellent results. In the large intestine, a similar procedure may be followed in the sigmoid, of which the mesentery insures proper peritoneal adaptation and protection. Furthermore in this location, a flexible rubber tube inserted into the rectum by an assistant and directed by the operator's hand through the site of anastomosis into the bowel above it, serves to conduct gas and the colon contents through the sutured segment, thereby averting the danger of possible local distention and leakage. In other parts of the large intestine where proper peritoneal covering cannot be secured, the writer prefers a side-to-side anastomosis after closure of the divided intestinal lumina. This seems to afford the greatest protection against subsequent leak- age with the formation of a fistula, of which the successful closure is fre- quently extremely difficult. The writer has had little or no experience with end-to-side anastomosis. Theoretically, after excision of the ileocaecal junc- tion, this method of anastomosis is supposed to restore more satisfactorily than a side-to-side anastomosis the normal condition of this part of the intestine. In informal discussion, however, with those experienced in this method of anastomosis, the writer has gained the impression that both leakage and post-operative obstruction from undue angulation or adhesions are more common than after other methods of anastomosis.. Perhaps the standardiza- tion of the most desirable method of anastomosis is impossible. The per- - 479 ELIOT, JR. ELLSWORTH sonal equation may prove, after all, the determining factor, the choice of method depending upon the individual skill and preference of each surgeon. The writer advocates drainage with a small flexible rubber tube, inclosing a wick of gauze in all cases of anastomosis involving the large intestine. Frequently the wound remains free from infection and the drain is perma- nently withdrawn at the end of 24 to 72 hours. Occasionally infection appears in the abdominal incision while the intestinal repair is prompt and satisfactory, In a few instances, a small fecal fistula forms, a possibility that fully justifies the use of precautionary drainage. It is scarcely necessary to add that all contact of the drain with the site of anastomosis should be carefully avoided. While it is both impossible and undesirable to urge any special method of treatment from the experience of a single case, the result, in the present instance at least, has proved sufficiently encouraging to justify an attempt to close an artificial anus even though it be of long standing and complicated by conditions indicative of impaired reparative power. To Contributors and Subscribers: and should be AUcontributions for Publication, Books for Review, Exchanges sent to the Editorial Office, 145 Gates Ave., Brooklyn, N. Y. Remittances for Subscriptions and Advertising and all business communications should be addressed to the ANNALS ef SURGERY 227-23I S. 6th Street Penna. Philadelphia, 480
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