Indexing Title:

RJOSON’s Medical Anecdotal Report [05-6]

MAR Title:

Colostomy – An Inconvenient But Life-Saving Procedure Which Nobody Likes

Date of Medical Observation: July, 2005

Narration:

A 89-year-old female was admitted because of hematochezia secondary to a rectosigmoid adenocarcinoma.  The options preoperatively was a low anterior resection with end-to-end anastomosis or a Hartmann’s procedure.  Intraoperatively, with the lesion being 3 cm above the peritoneal reflection, the preop options remained to be the same.  In the end, I decided to do the Hartmann’s procedure.   Postoperatively, the course was a little stormy with the patient developing abdominal distention and dyspnea.  However, in the end, after 10 days of hospitalization, with supportive treatment, the patient was discharged improved.

Insights (Discovery, Stimulus, REINFORCEMENT) / (Physical, PSYCHOSOCIAL, Ethical):

Intraoperatively, before I finally decided to do the Hartmann’s procedure, I tried to compare the benefit-risk considerations of the two options.  At one point, the balance was tilting towards end-to-end anastomosis as I was using the patient’s psychosocial perspective and quality of life as a justification.  I was thinking why still let an elderly patient suffer the inconvenience of a colostomy.  She might feel depressed when she sees feces coming out through her abdomen.  She might prefer dying.  She might regret being operated.  I finally decided to do the Hartmann’s procedure because I thought it was safer in terms of risk of anastomotic leak  – first, there was marked discrepancy in the diameters of the proximal and distal segment of intestines that were to be anastomosed and second, an extensive dissection and resection was done in the pelvis as the rectosigmoid mass had infiltrated the right pelvic wall and adherent to the right ureter. 

No person likes to have a colostomy because it is inconvenient and it distorts the body image.  As a surgeon, despite knowing it is often a life-saving procedure, I always think twice before finally doing it.  I placed all the data needed in the benefit-risk balance.  I considered not only the physical aspect and consequence but also the psychosocial impact on the patient in the balance sheet.  Whenever I have to do it, I do it with a heavy heart and with an informed consent from the patient and relatives.