Stoma Construction Research Articles

Prolyl Hydroxylase Inhibition Mitigates Pouchitis.

Pouchitis is the most common long-term complication after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or familial adenomatous polyposis (FAP), which can eventually progress to pouch failure, necessitating permanent stoma construction. Hypoxia-inducible transcription factor prolyl hydroxylase-containing enzymes (PHD1, PHD2, and PHD3) are molecular oxygen sensors that control adaptive gene expression through hypoxia-inducible factor (HIF). Emerging evidence supports PHDs as being therapeutic targets in intestinal inflammation. However, pharmacological inhibition of PHDs has not been validated as a treatment strategy in pouchitis. PHD1-3 mRNA and protein expression were analyzed in mucosal pouch and prepouch ileal patient biopsies. After establishment of a preclinical IPAA model in rats, the impact of the pan-PHD small-molecule inhibitor dimethyloxalylglycine (DMOG) on dextran sulfate sodium (DSS)-induced pouchitis was studied. Clinical and molecular parameters were investigated. PHD1, but not PHD2 or PHD3, was overexpressed in pouchitis in biopsies of patients with IPAA for UC but not FAP. In addition, PHD1 expression correlated with disease activity. DMOG treatment profoundly mitigated DSS-induced pouchitis in a rodent IPAA model. Mechanistically, DMOG restored intestinal epithelial barrier function by induction of tight junction proteins zona occludens-1 and claudin-1 and alleviation of intestinal epithelial cell apoptosis, thus attenuating pouch inflammation. Together, these results establish a strong therapeutic rationale for targeting PHD1 with small-molecule inhibitors in pouchitis after IPAA for UC.

1624 Metal Stent Insertion for Malignant Obstruction of a Colostomy

INTRODUCTION: Malignant obstruction of a colostomy is a rare occurrence that is traditionally treated with surgical intervention; however, there are no clear recommendations for management when surgery is not feasible. Here we report a case of successful placement of a colonic stent for malignant stomal obstruction due to metastatic cervical cancer. CASE DESCRIPTION/METHODS: A 47-year-old female with a history of metastatic cervical cancer presented with abdominal distention and minimal stool output from her colostomy for 2 weeks duration. She was diagnosed with cervical cancer three years prior. Her disease progressed rapidly despite treatment and was complicated by rectovaginal fistula for which she underwent laparoscopic diverting colostomy. The patient noticed an enlarging mass near the ostomy site which was biopsied and showed metastatic adenocarcinoma of endocervical origin. Examination revealed a benign abdomen with palpable peristomal subcutaneous masses. A CT scan showed a large heterogenous abdominal mass causing compression and obstruction at the level of the colostomy with significant proximal colonic dilation, measuring up to 8 cm. As a temporizing measure a rubber catheter was passed through the stoma for decompression. Given the extensive metastatic disease she was not a candidate for any operative intervention, and subsequently endoscopic stent placement was pursued. Colonoscopy was performed showing a severe stenosis 4 cm in length at the surgical stoma. A 25 mm × 6 cm self-expandable covered metal stent (SEMS) was successfully placed with the distal edge visible externally but not protruding beyond skin level. Her obstructive symptoms resolved shortly after the procedure. Two months later, a CT scan showed a patent stent still in place without recurrent colonic obstruction. DISCUSSION: Stenosis and malignant colostomy obstruction are among the complications of stoma construction. Surgery is usually the traditional treatment of these complications, but data is limited concerning the management of patients that are not good surgical candidates. There are very few case reports describing the use of either covered or uncovered SEMS for colostomy obstruction, all of which remained patent until the patients’ death 1.5 – 6 months later. In conclusion, metal stent insertion for malignant obstruction of colostomy could be a viable palliative treatment option in patients who are not operative candidates.

MON-PO487: Impact in Nutritional Status and Diet Progression of a Nutritional Consultation After Stoma Construction

MON-PO487: Impact in Nutritional Status and Diet Progression of a Nutritional Consultation After Stoma Construction

Patients with Crohn's disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications' rate.

BACKGROUNDRight hemicolectomy or ileocecal resection are used to treat benign conditions like Crohn’s disease (CD) and malignant ones like colon cancer (CC).AIMTo investigate differences in pre- and peri-operative factors and their impact on post-operative outcome in patients with CC and CD.METHODSThis is a sub-group analysis of the European Society of Coloproctology’s prospective, multi-centre snapshot audit. Adult patients with CC and CD undergoing right hemicolectomy or ileocecal resection were included. Primary outcome measure was 30-d post-operative complications. Secondary outcome measures were post-operative length of stay (LOS) at and readmission.RESULTSThree hundred and seventy-five patients with CD and 2,515 patients with CC were included. Patients with CD were younger (median = 37 years for CD and 71 years for CC (P < 0.01), had lower American Society of Anesthesiology score (ASA) grade (P < 0.01) and less comorbidity (P < 0.01), but were more likely to be current smokers (P < 0.01). Patients with CD were more frequently operated on by colorectal surgeons (P < 0.01) and frequently underwent ileocecal resection (P < 0.01) with higher rate of de-functioning/primary stoma construction (P < 0.01). Thirty-day post-operative mortality occurred exclusively in the CC group (66/2515, 2.3%). In multivariate analyses, the risk of post-operative complications was similar in the two groups (OR 0.80, 95%CI: 0.54-1.17; P = 0.25). Patients with CD had a significantly longer LOS (Geometric mean 0.87, 95%CI: 0.79-0.95; P < 0.01). There was no difference in re-admission rates. The audit did not collect data on post-operative enhanced recovery protocols that are implemented in the different participating centers.CONCLUSIONPatients with CD were younger, with lower ASA grade, less comorbidity, operated on by experienced surgeons and underwent less radical resection but had a longer LOS than patients with CC although complications' rate was not different between the two groups.

Loop Transverse Colostomy - A Modified Technique.

Transverse colostomy is commonly performed to create temporary stoma in rectal cancer patients after neoadjuvant chemoradiotherapy. Conventional methods are either difficult to implement or to care for. To resolve these problems, we herein describe a modified transverse colostomy method. Two sutures of peritoneum were made as "bridges" to support the stoma. Absorbable sutures were utilized to reinforce the stoma. Once the stoma was created, the stoma bag was immediately placed on the skin. 120 patients who received conventional or modified transverse colostomy between 2008 and 2014 were selected. Then, the two groups of patients were compared for stoma-related complications. The operation time of stoma construction was 34±10 minutes for the conventional method and 28±7 minutes for the modified method (P= 0.009). There were no significant differences between the two groups with respect to postoperative bleeding, bowel obstruction or stoma retraction. Patients with conventional transverse colostomy were remarkably more likely to experience parastoma hernia (P= 0.048) and stoma prolapse (P= 0.038). In comparison with conventional methods, the modified transverse colostomy is a safe and effective diverting technique. It can be readily performed by all kinds of surgeons, especially those in underdeveloped areas. The technique represents a preferred method for constructing temporary stoma in rectal cancer patients treated with neoadjuvant chemoradiotherapy.

Standardization of surgical care for malignant colonic obstruction

To standardize surgical care for malignant colonic obstruction. There were 572 patients with malignant colonic obstruction: 247 of them were hospitalized in 2011-2013 (I group); 325 - in 2014-2017 (group II). Forty-six patients underwent medication; 302 - acute resection; 141 - stoma construction; 83 - stent deployment. Elective surgery and radiation or chemotherapy was performed after 0.5-6 months in 110 patients of group II. Acute resection was more common in I group, elective resection - in group II. Early and long-term results including Kaplan-Meier 3-year overall survival were compared in both groups. Complications occurred in 46.69% (group I) and 21% (group II). Postoperative mortality was significantly higher in group I compared with II group: 26.11 and 10.33%, respectively. Three-year overall survival was higher in group I compared with group II: 0.82 and 0.69, respectively. Advisability of new two-stage surgical standard is confirmed for malignant colonic obstruction. Stoma formation and stenting may be a valid alternative in some patients with malignant colonic obstruction due to significantly lower postoperative mortality.

Systematic review of the applications of three-dimensional printing in colorectal surgery.

Three-dimensional (3D) printing has been recognized as a revolutionary technological innovation that has benefitted numerous disciplines, including medicine. The present systematic review aimed to demonstrate the current applications of 3D printing in colorectal surgery along with the limitations and potential future applications of this innovation. A PRISMA-compliant systematic literature search of studies that applied 3D printing in colorectal surgery in the period from January 1990 to July 2018 was conducted. Electronic databases including PubMed/Medline, Scopus and the Cochrane Library were searched. All full-text original articles were eligible for inclusion. Nine studies including 58 patients with a median age of 60.7 years were reviewed. The studies assessed 3D printing in patients with planned stoma construction, colon cancer with liver metastasis, right colon cancer, rectal cancer, intractable constipation and anal fistula. The applications of 3D printing were classified into three categories: patient education, preoperative planning and evaluation of response of colorectal liver metastasis to chemotherapy. 3D printed models aided in planning resection of colorectal liver metastasis, facilitating D3 lymphadenectomy in complete mesocolic excision, improving the understanding of pelvic anatomy in laparoscopic rectal cancer treatment, guiding electrode implantation in sacral neuromodulation for intractable constipation, and elucidating the morphology of anal fistula tract and anal sphincter muscles. Colorectal surgery may benefit from 3D printing in enhancing patient education before stoma construction, preoperative planning and evaluation of the response of liver metastasis to chemotherapy using 3D ultrasonography.

Incidence and risk factors influencing morbidity and mortality in cases of burst abdomen after emergency and elective midline laparotomies

Background: Burst abdomen is a serious postoperative complication faced by surgeons and of greatest concern because of risk of evisceration, the need for immediate intervention and the possibility of repeat dehiscence. Wound dehiscence carries with it a substantial morbidity and mortality. In addition, there is an increase in the cost, increased hospital stays, nursing and manpower cost in managing its complications.Methods: In this study a total 202 patients enrolled who underwent emergency and elective midline laparotomies. Patients clinically presenting as gaping of abdominal wound were included in study. Diagnosis was established by clinical examination. In all cases gentle probing of the wound with gloved finger done to confirm defect.Results: In this study incidence of burst abdomen was seen in 80 patients (39.6%) and was common in patients who underwent emergency surgeries. Patients who had stoma construction had maximum number of burst abdomen. 150 (74%) cases underwent emergency laparotomies in which 64 (42%) cases developed burst abdomen. In 60 cases closure done with re-suturing of fascia and remaining cases by skin closure only due to sepsis, poor general condition of patients. Mortality was seen in (22.5%) patients due to postoperative complicationsConclusions: Burst abdomen is more common in emergency surgeries than elective surgeries. Wound infection and stoma construction increase the rate of burst abdomen. Mid-mid line incisions have increased incidence of wound dehiscence. Mortality is high despite early treatment due to complications.

A study of complications of temporary ileostomy in cases of acute abdomen with ileal perforation and obstruction

Background: Construction of a gastrointestinal stoma is a frequently performed surgical procedure. Although formation of defunctioning loop ileostomy is usually a straightforward procedure, there is an appreciable complication rate. The purpose of the research was to study the complications, outcome associated with temporary ileostomy and to study the complications related to its closure.Methods: Institutional based observational study using prospective data collection large ileal perforations covering more than one third of the circumference, or gangrenous change or severe adhesions and old perforations with presence of peritoneal contamination were included in the study. 50 patients were included in the study. Clinical, intra-operative, biochemical parameters with stomal and peristomal complications and tissue histopathology were assessed in the study.Results: The commonest aetiology for which stoma was performed enteric perforation (44%) whereas perforation was the commonest aetiology for which stoma was performed (64%) apart from gangrene and other aetiologies. The commonest post-operative complication encountered was skin excoriation (64%). Most of the the complications encountered post operatively were statistically significant when correlated with aetiology and duration of presentation.Conclusions: Although being bothersome, loop ileostomy is still a live saving procedure. Complications of stoma could be managed conservatively with the application of proper user-friendly stoma appliances and it is of paramount importance that ileostomies are properly sited. Before closure of ileostomy it is essential to be careful of operative biopsy report showing non-specific inflammation. Preference of surgeons in the present day to perform ileostomy in emergency setting is increasing.

Interpretation of 2017 European Hernia Society Guidelines for The Prevention and Treatment of Parastomal Hernias

European Hernia Society issued a guideline for the prevention and treatment of parastomal hernias in 2017, which is the first international guideline for the parastomal hernia. This guideline proposed 12 problems about incidence, diagnosis and treatment, and discussed these problems in depth. The main contents of this guideline are summarized as follows: (1) End colostomy is associated with a higher incidence of parastomal hernia compared to other types of stomas. (2) Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. (3) The use of the European Hernia Society classification for uniform research reporting is recommended. (4) There is insufficient evidence on the policy in watchful waiting. (5) There is insufficient evidence on the route and location of stoma construction, and the size of the aperture. (6) The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present.(7) It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. (8) So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, most data in this guideline were retrospective without high level evidence. A lot of questions remain controversial and more high-level evidence are expected to solve these problems.

Colostomy in Anorectal Malformation and Hirschsprung’s Disease in Infants and Children

Background: There are numerous and frequent common complications following construction of large bowel stomas, which may lead to significant morbidity and mortality. The overall morbidity from colostomy has been reported to be as high as 42-75%. Aims of the study: •To study the complications of colostomy (immediate, early &amp; late) taking into consideration the site and types of the colostomy. •To determine the types and sites of colostomy in anorectal malformation and Hirschsprung’s disease. •To study some associated risk factors in colostomy with anorectal malformation and Hirschsprung’s Disease. •To estimate the rate of death for performed colostomies in anorectal malformation and Hirschsprung’s disease. Patients and methods: A cross-sectional prospective study included a total number of (160) temporary colostomies were performed for neonates, infants and children in the pediatric surgical department of Children Welfare Teaching Hospital in Baghdad over a period of three years from January 2008 to January 2011. A standardized data sheets were prepared for collecting the information including age, sex, associated congenital anomalies and colostomy data (type, site, indication, and complication). Results: Most of the colostomies were done in the neonatal period (69.4%) and mainly for imperforate anus (46.9%) while colostomies that were performed in infancy (26.2%) were done mainly for Hirschsprung’s disease (18.1%). The most common type of stoma was right loop transverse colostomy for Hirschsprung’s disease (31.2%) and pelvic loop for imperforate anus (42.5%). 107 different complications developed in 71 patients as a result of colostomy formation and the most common complications were stomal prolapse, skin excoriation, wound sepsis, stomal stenosis, retraction, and bleeding. The mortality rate was 7.5% (12 patients); 4 patients had Hirschsprung’s disease and 8 patients had an imperforate anus.Conclusion: Hirschsprung’s disease and imperforate anus were the most common indications of stoma formation in pediatric age group. The right transverse loop and pelvic loop colostomy were the commonest stoma that was performed with a high rate of complications.

Achievements in colorectal cancer care during 8 years of auditing in The Netherlands

IntroductionThe efficacy of auditing is still a subject of debate and concerns exist whether auditing promotes risk averse behaviour of physicians. This study evaluates the achievements made in colorectal cancer surgery since the start of a national clinical audit and assesses potential signs of risk averse behaviour. MethodsData were extracted from the Dutch ColoRectal Audit (2009–2016). Trends in outcomes were evaluated by uni and multivariable analyses. Patients were stratified according to operative risks and changes in outcomes were expressed as absolute (ARR) and relative risk reduction (RRR). To assess signs of risk averse behaviour, trends in stoma construction in rectal cancer were analysed. ResultsPostoperative mortality decreased from 3.4% to 1.8% in colon cancer and from 2.3% to 1% in rectal cancer. Surgical and non-surgical complications increased, but with less reintervention. For colon cancer, the high-risk elderly patients had the largest ARR for complicated postoperative course (6.4%) and mortality (5.9%). The proportion of patients receiving a diverting stoma or end colostomy after a (L)AR decreased 11% and 7%, respectively. In low rectal cancer, patients increasingly received a non-diverted primary anastomosis (5.4% in 2011 and 14.4% in 2016). ConclusionsNo signs of risk averse behaviour was found since the start of the audit. Especially the high-risk elderly patients seem to have benefitted from improvements made in colon cancer treatment in the past 8 years. For rectal cancer, trends towards the construction of more primary anastomoses are seen. Future quality improvement measures should focus on reducing surgical and non-surgical complications.

Non-operative treatment as a strategy for patients with parastomal hernia: a multicentre, retrospective cohort study.

Parastomal hernia is the most common complication following stoma construction. Surgical treatment is usually chosen over non-operative treatment, but a clear rationale for the choice of management is often lacking. This study aims to investigate the reasons for non-operative treatment, cross-over rates and postoperative complications. A multicentre, retrospective cohort study was conducted. Patients diagnosed with a parastomal hernia between January 2007 and December 2012 were included. Data on baseline characteristics, primary surgery and hernias were collected. For non-operative treatment, reasons for this treatment and cross-over rates were evaluated. For all patients undergoing surgery (surgical treatment and cross-overs), complication and recurrence rates were analysed. Of the 80 patients included, 42 (53%) were in the surgical treatment group and 38 (48%) in the non-operative treatment group. Median follow-up was 46months (interquartile range 24-72). The reasons for non-operative treatment were absence of symptoms in 12 patients (32%), comorbidities in nine (24%) and patient preference in three (7.9%). In 14 patients (37%) reasons were not documented. Eight patients (21%) crossed over from non-operative treatment to surgical treatment, of whom one needed emergency surgery. In 23 patients (55%), parastomal hernia recurred after the original surgical treatment, of whom 21 (91%) underwent additional repair. Parastomal hernia repair is associated with high recurrence and additional repair rates. Non-operative treatment has a relatively low cross-over and emergency surgery rate. Given these data, non-operative treatment might be a better choice for patients without complaints or with comorbidities.

Loop transverse colostomy versus loop ileostomy after low and ultralow anterior resection

Background: Since the introduction of sphincter saving procedures for low and mid-rectal carcinoma and the associated high anastomotic leakage rate is a matter of troublesome. There is a consensus between surgeons that diverting proximal stoma decreases the incidence of clinical leakage. But the choice between loop transverse colostomy (LTC) and loop ileostomy (LI) still a matter of debate. In this study we tried to compare both methods and evaluate the outcome of each.Methods: This is a prospective observational study included 28 patients suffering from mid- or low-rectal cancer who underwent elective low anterior resection (LARs), admitted to Sohag University Hospital between July 2013 to July 2017. Patients were randomly allocated into two groups; group (A) included 15 patients and managed with LTC, and group (B) included 13 patients and managed with LI. The data of the patients were collected, tabulated and analyzed, with special consideration of the general outcome measures related to stoma construction, special outcome measures related to stoma construction, and the outcome measures related to stoma closure. All of the patients were followed up for 6 months.Results: Author found a significantly higher incidence rate of skin excoriation (p&lt;0.001), leaks from the appliance (p&lt;0.005), in the LI group than in the LTC group and higher incidence of parastomal hernia (p=0.042) in the LTC than in the LI. Also, author found a significantly higher incidence rate of intestinal obstruction in the LI group (p&lt;0.001), also we found a significantly higher incidence of wound infection after stoma closure (p=0.006) in the LTC group than in the LI group. The mean time to first bowel movement (days) was earlier in the LI than LTC group and showing also a significant value (p&lt;0.001). The mean cumulative total hospital stay was significantly longer in the LTC group than in the LI group (p&lt;0.001).Conclusions: LTC and LI; both have advantages and disadvantages and the use of any for fecal diversion after low and mid-rectal carcinoma should be considered for every patient individually according to his circumstances.

An appraisal of intestinal stomas at a tertiary hospital in South Western, Nigeria

Background: Intestinal stomas are frequently constructed as part of abdominal surgeries in our center especially for colorectal cancer (CRC). There has been no previous documentation of the experience at our tertiary center. Objective: The objective of this study is to document the indications, types, and complications of intestinal stomas in our center to make necessary recommendations. Patients and Methods: This was a retrospective descriptive study of all patients who had intestinal stomas constructed during a 4-year period. The demographic data of patients, the information on indications, types, and complications of intestinal stomas were obtained from theatre records, and case notes. Data were analyzed using SPSS version 23. Results: A total of 85 intestinal stomas were constructed during the study period. Forty-four (51.8%) were males and 41 (48.2%) females with a male-female ratio of 1.07 to 1. The common indications were large bowel obstruction due to CRC (21.2%), anastomotic dehiscence (15.3%), and rectal/sigmoid injuries (12.7%). The intestinal stomas constructed in patients included defunctioning stomas (61.2%), decompression stomas (31.8%), permanent end colostomy following abdominoperineal resection of rectum for cancer (3.5%), and palliative sigmoid colostomy (3.5%) in patients with anal cancer. Sigmoid loop was the commonest stoma, constructed in 26 patients (30.6%). The common complications were peristoma skin excoriation (53.5%), retraction (11.6%) pouch leakage (9.3%), and prolapse (9.3%). Conclusion: Malignant intestinal obstruction due to CRC was the most common indication for stoma construction at our institution. Consequently, massive health education campaign to ensure early presentation of CRC is needed to reduce the need for stoma creation.

WOCN Society Clinical Guideline: Management of the Adult Patient With a Fecal or Urinary Ostomy-An Executive Summary.

This article provides an executive summary of the recommendations from the Clinical Guideline: Management of the Adult Patient With a Fecal or Urinary Ostomy, published by the Wound, Ostomy and Continence Nurses Society (WOCN Society). It presents an overview of the process used to update and develop the guideline and lists specific recommendations from the guideline. We provide recommendations that include the following topics: stoma construction, preoperative education, stoma site marking, selection of an ostomy pouching system, postoperative education, postoperative management issues, follow-up care after discharge from the acute care setting, health-related quality of life, and stomal and peristomal complications. The intent of the guideline is to provide information that will assist healthcare providers to manage adult patients with ostomies, prevent or decrease complications, and improve patient outcomes. The full text of the published guideline, which includes available evidence supporting the recommendations and a complete reference list, is available in print and as a mobile application from the WOCN Society's online bookstore (http://www.wocn.org). Refer to Supplemental Digital Content 1 (available at: http://links.lww.com/JWOCN/A40) associated with this article for a complete reference list for the guideline.

Impact of suturing of stoma edges directly to skin without peritoneal fixation

Introduction: Enterostomies are one of the common surgical procedures performed in a general surgery unit. Enterostomies are fixed to the peritoneum/abdominal wall, before being sutured to the skin. This results in prolongation of operative time and dense adhesions between the bowel wall and the abdomen at the site of stoma. This is a comparative study between the commonly followed methods of maturation with our method of direct suturing of the stoma to the skin. Materials and Methods: A prospective randomized study to compare the traditional method of maturation of stoma with direct suturing of the stoma edges to the skin without a peritoneal fixation was carried out in a tertiary health-care hospital. Results: Skin complications and stomal prolapse were the most common type of complication seen. Most of the stoma-related complications were managed conservatively. There was no difference in stoma-related complications between the two methods of stoma construction in our study. However, during stoma closure, dense adhesions were seen in 90% of cases in Group A (peritoneal hitch) as compared to 7% in Group B (direct skin fixation). There was a significantly high 16.7% incidence of iatrogenic perforation of bowel in Group A during stoma closure. Conclusions: Thus, additional rectus and/or peritoneum fixation does not add any benefit in preventing stoma-related complications over intestinal stomas, which are constructed with fixation only to skin. In the group, where the stoma was fixed to abdominal wall, the higher incidence of dense adhesions between the stoma and the abdominal wall resulted in longer operative time during stoma closure and increased risk of iatrogenic bowel trauma.

進行大腸癌に対する緩和的単孔式腹腔鏡下人工肛門造設術の検討

進行大腸癌に対する緩和的単孔式腹腔鏡下人工肛門造設術の検討

European Hernia Society guidelines on prevention and treatment of parastomal hernias.

International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project. The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants. End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed. An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

Use of a Modified Continent Ileovesicostomy in Adults with Prior Enterocystoplasty

Background/Aims: To describe our initial experience with a novel modification of the Mitrofanoff conduit technique utilizing the Yang-Monti ileovesicostomy and the serosa lined extramural tunnel of the T-pouch to create a continent catheterizable stoma in patients with a prior enterocystoplasty. Methods: A 14 cm segment of bowel was harvested, and the distal 4 cm was divided and reconfigured utilizing the Yang-Monti technique. The remaining segment was folded into a U and secured with a serosal basting stitch. Half of the Yang-Monti tube is laid in the trough of the U-shaped segment and secured. Next, the U-shaped segment was incised along the anti-mesenteric border for the length of the tube. The newly created flaps adjacent to the tube was then laid over the tube and sutured together completing the serosa lined tunnel. The entire patch was anastomosed to a cystostomy through the previous enterocystoplasty. Finally, the proximal end of the tube was brought through the umbilicus and matured as a stoma. Results: Two patients with prior enterocystoplasties underwent the procedure described above. At follow-up of 18 and 24 months, both patients reported excellent continence. To date, there have been no revisions or significant complications. Conclusion: The construction of continent catheterizable stoma in adults with prior history of enterocystoplasty presents many technical challenges. The combination of the Yang-Monti ileovesicostomy and the extramural tunnel of the T-pouch provides an effective option for creating a continent catheterizable stoma in adults with prior history of enterocystoplasty.