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.
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