Double-barrel Ileostomy Research Articles

Case Report: A small bowel occlusion revealed by a strangulated transomental hernia

Introduction Transomental hernias are a rare type of internal hernia, accounting for less than 1% of all internal hernias. They occur when abdominal contents protrude through a defect in the omentum, leading to bowel obstruction and potential strangulation. We report the case of a young male admitted for the management of an acute bowel obstruction. Case report A 38-year-old male patient with no significant medical or surgical history presented with a proximal bowel obstruction syndrome. Upon physical examination, he exhibited mild abdominal distension, tenderness in the right iliac fossa, and tympanism. Laboratory tests indicated elevated inflammatory markers. An emergency computed tomography (CT) scan suggested the presence of a congenital band or an internal hernia. A laparoscopic procedure was performed, which identified a transomental hernia with a segment of the ileum protruding through an omental defect adjacent to the transverse colon. The herniated loop of small intestine was found to be compromised and gangrenous. Due to the severity of the condition, a midline incision was made to convert the procedure, allowing for resection of the affected segment of the small intestine while preserving 2.5 meters of viable bowel distal to the duodenojejunal junction. The remaining small intestine was exteriorized as a double-barrel ileostomy, and the transomental defect was subsequently repaired. The postoperative recovery was uneventful. Conclusion Although internal hernias account for a relatively small percentage of cases, they are frequently overlooked as a cause of bowel obstruction. Diagnosis this condition is challenging, both clinically and radiologically. Facilitating prompt surgical intervention to mitigate high mortality is essential.

Abstract P3013: Rare Case Of Catheter-related Right Atrial Thrombosis In A Pediatric Multi-visceral Transplant Patient

Introduction: There has been a recent increase in the use of intraoperative transesophageal echocardiography (TEE) in liver transplant surgeries to identify intracardiac thrombi and pulmonary embolism (PE). These are rare but serious complications of transplant surgery that carry a high mortality risk. However, there is a lack of literature supporting the use of TEE during liver transplants, especially in pediatric cases. Case Presentation: We present a rare case of intraoperative catheter-related right atrial thrombus (CRAT) in a nine-year-old multi-visceral transplant (MVT) patient. This patient’s medical history was notable for preterm birth and gastroschisis complicated by neonatal necrotizing enterocolitis resulting in short-gut syndrome. He had a significant surgical history, including intestinal resection, Hartmann Procedure, and cholecystectomy, after which he developed non-cholestatic liver disease. He was admitted for MVT for intestinal failure associated with ESLD. The procedure was complicated by massive hemorrhage during the dissection phase, significant coagulopathy after engrafting the donor liver, profound hemodynamic instability requiring inotropic drug support, and multiple instances of intraoperative CPR. Intraoperative TEE identified right atrial thrombi around the central venous line. The patient developed RV dysfunction and PEA secondary to PE on two occasions and received a total of 4 mg tissue plasminogen activator (tPA). In both cases, ROSC was achieved after thrombolysis. Due to profound coagulopathy and massive blood loss (70 liters), the completion of the surgery was postponed, and the patient left the operating room with an open abdomen. The patient’s postoperative course was complicated by hemodiafiltration, ureteral resection with reimplantation to bladder, pyloroplasty, appendectomy, small bowel resection, end colostomy and double-barrel ileostomy. The patient eventually developed a subarachnoid hemorrhage on POD3 and expired. Conclusion: This case highlights the importance of utilizing intraoperative TEE in pediatric liver transplant surgeries to diagnose intracardiac thrombi and PE.

Thrombophilia in a patient with short bowel syndrome

This article presents a clinical case of thrombophilia in a patient with short bowel syndrome. Thrombophilia is characterized by a disorder of the blood clotting system, in which the risk of thrombosis increases. Thrombophilia, local vascular insufficiency, intestinal obstruction with fistula formation requiring intestinal resection play a significant role in the pathogenesis of short bowel syndrome. The patient was admitted with the diagnosis “thrombophilia, resection of the small intestine (residual small intestine 17 cm), ileostoma”. Condition after multiple surgical interventions on the abdominal cavity. Surgeries performed: atypical gastric resection, resection of the greater omentum, jejunostomy, resection of the cardial and antral parts of the stomach, derivation of duodenostomy, esophagostomy, derivation of loop jejunostomy, Braun enteroanastomosis, perforation of the colon, suturing, derivation of colostomy, cholecystectomy, GI reconstruction, Roux esophagoenteroanastomosis, resection of the sigmoid colon, small intestine, bearing intestinal fistulas, removal of double-barrel ileostomy, abdominal cavity drainage, relaparotomy, closure of ileal perforation, retrograde intubation of the small intestine, determination of indications for intestinal transplantation. The following tests were performed: CT-enterography, colonoscopy with subsequent morphological examination, abdominal ultrasound, enterogastroscopy, clinical and biochemical blood tests, PCR, coagulogram, urinalysis, percussion and auscultation of the chest. Morphological examination showed fragments of the wall of the colon – with erosion, fragments of fatty tissue – with immature granulation tissue, fragment of stroma covered with multilayer flat keratinized epithelium with the focus of epithelized slit-like ulcer. Clexane was administered as part of the treatment complex, nutritional support additionally included Micrazyme capsules 25000 units, teduglutide, remabipid. Rebamipid and Teduglutide allowed to stabilize the patient's condition and improve the condition of the perioperative area tissues. In case of ineffectiveness of the therapy used the indications for liver transplantation are determined.

Preservation of the left colic artery in modified laparoscopic anterior rectal resections without auxiliary abdominal incisions for transanal specimen retrieval

BackgroundLaparoscopic low anterior rectal resection is the most widely used surgical procedure for middle and low rectal cancer. The aim of this study was to investigate the feasibility and safety of the extracorporeal placement of the anvil in preserving the left colic artery in laparoscopic low anterior rectal resection without auxiliary incisions for transanal specimen retrieval in this research.MethodsClinical data and follow-up data of patients undergoing laparoscopic low anterior rectal resection from January 2017 to October 2020 were collected. The resections were modified such that the resisting nail holder was extracorporeally placed for the transanal exenteration of the specimen without using auxiliary abdominal incisions while preserving the left colic artery. By analyzing the data of anastomotic stenosis, anastomotic bleeding and anastomotic fistulas after surgery, the advantages and disadvantages of this surgical method for patients were clarified.ResultsA total of 22 patients were enrolled. Five of 22 patients simultaneously underwent double-barrel terminal ileostomy. The postoperative exhaust time was 2–7 (median, 3) days. Postoperative anastomotic bleeding occurred in one patient, postoperative anastomotic fistula occurred in four patients, and postoperative anastomotic stenosis occurred in six patients. There were four patients with postoperative distant metastasis, of which three had concomitant local recurrence. Seventeen patients had no obvious symptoms or signs of recurrent metastases during follow-up appointments, and one died of liver failure.ConclusionsModified laparoscopic low anterior rectal resection, which resects the specimen through anus eversion by inserting the anvil extracorporeally while preserving the left colic artery, is safe and feasible for patients with low rectal cancer.

Challenge in diagnosis of late onset necrotizing enterocolitis in a term infant: a case report

BackgroundNecrotizing enterocolitis (NEC) is a common devastating inflammatory gastrointestinal disease and frequently occurs in premature infants. Here, we reported a case of late-onset NEC in a term neonate with good outcome after surgery for long-term follow-up.Case presentationTen-week-old male came to emergency unit due to prolonged diarrhea and abdominal distention. He was born at gestational age of 40 weeks with birth weight and Apgar score of 2800 g and 7/8, respectively. He had no history of formula feeding. Two weeks before admitted to the hospital, the patient had frequent diarrhea with fever. He was found lethargic with abdominal distention, absence of bowel sounds and abdominal tenderness. Plain abdominal x-ray and CT scan showed gastric and intestinal dilatation and gasless colon, suggesting a small bowel obstruction, and bowel wall thickening indicating peritonitis, without any free subdiaphragmatic air (pneumoperitoneum). Moreover, the patient did not have a congenital heart disease. While in intensive medical treatment, he showed a continuous clinical deterioration. All findings were suggestive of intestinal inflammation with clinical deterioration, and we decided to perform an emergency exploratory laparotomy and found an ischemia along the jejunoileal with a perforation at 25 cm above the ileocecal valve. Subsequently, we performed a double-barrel ileostomy through a separate incision from the laparotomy. Histopathological findings confirmed the diagnosis of NEC. We closed the stoma at postoperative day 43. The patient was discharged uneventfully a month after stoma closure.ConclusionAbdominal CT scan might be useful to establish an early recognition of late-onset NEC; thus, immediate surgical intervention might be performed to decrease its morbidity and mortality. Moreover, late-onset NEC in term neonates might occur without any risk factors or significant co-morbidities.

Colonic Stoma Creation as the First Stage of Surgical Correction of Total Colonic Aganglionosis in Children

Abstract. The use of a staged approach in surgical treatment of total colonic aganglionosis is controversial. The creation of a protective colonic stoma as the first stage of surgical correction of total colonic aganglionosis rather than one-stage correction has become an alternative in treatment of such patients. This approach contributes to better survival, reduces the incidence of ileoanal anastomotic failure and improves functional outcomes.
 The objective of the research was to study and evaluate the need for colonic stoma creation as the first stage of surgical correction of total colonic aganglionosis in children.
 Materials and Methods. The analysis of surgical treatment of 41 children with total colonic aganglionosis over the period 1980-2020 was conducted. Protective colonic stoma was created in all the patients, namely 36 children with isolated colonic aganglionosis and 5 children with the involvement of the entire colon and a segment of the small bowel.
 Results. Twenty-four (58.54%) patients were diagnosed and underwent the first stage of treatment in National Specialized Children’s Hospital “Okhmatdyt”. There were 17 (41.46%) patients who were transferred from other clinics after being diagnosed with a pathology and undergoing colonic stoma creation. During staged treatment of children with total colonic aganglionosis, a single-barrel ileostomy (n=10, 24.40%), a double-barrel ileostomy (n=5, 12.19%), or a loop colonic ileostomy (n=26, 63.41%) were created. The periods between creating the protective colonic stoma and performing radical surgery ranged from 4 to 14 months. The colonic stomas were closed 2-4 months after radical surgery. The third stage of surgical correction of total colonic aganglionosis in children was carried out after the state of the neorectum formed and ileoanal anastomosis were assessed for readiness of inclusion in the passage. There were no complications after protective stoma closure. Within the first 3 months, the frequency of bowel movement ranged from 10 to 15 times a day, and, in a year, it was 2-4 times a day. All the children survived. Functional outcomes of treatment were found to be good. Bowel function was satisfactory. The X-ray images demonstrated the rectal reservoir of sufficient size with pronounced colonization.
 Conclusions. Surgical correction of total colonic aganglionosis in children involves the three-stage approach consisting in the creation of the protective small bowel stoma (the first stage), radical surgery, namely colectomy with reconstructive plastic formation of functionally advantageous reservoir version of the neorectum (the second stage) and ileostomy closure after adaptation of the small bowel reservoir (the third stage). The creation of the protective small bowel stoma as the first stage of surgical correction of total colonic aganglionosis in children is emergency surgery. The creation of the loop small bowel stoma at 12 cm above aganglionosis level is the most rational type of the first stage of correcting total colonic aganglionosis in children.

Comparison of outcomes following three surgical techniques for patients with severe jejunoileal atresia.

BackgroundSevere jejunoileal atresia is associated with prolonged parenteral nutrition, higher mortality and secondary surgery. However, the ideal surgical management of this condition remains controversial. This study aimed to compare the outcomes of patients with severe jejunoileal atresia treated by three different procedures.MethodsFrom January 2007 to December 2016, 105 neonates with severe jejunoileal atresia were retrospectively reviewed. Of these, 42 patients (40.0%) underwent the Bishop–Koop procedure (BK group), 49 (46.7%) underwent primary anastomosis (PA group) and 14 (13.3%) underwent Mikulicz double-barreled ileostomy (DB group). Demographics, treatment and outcomes including mortality, morbidity and nutrition status were reviewed and were compared among the three groups.ResultsThe total mortality rate was 6.7%, showing no statistical difference among the three groups (P = 0.164). The BK group had the lowest post-operative complication rate (33.3% vs 65.3% for the PA group and 71.4% for the DB group, P = 0.003) and re-operation rate (4.8% vs 38.8% for the PA group and 14.3% for the DB group, P < 0.001). Compared with the BK group, the PA group showed a positive correlation with the complication rate and re-operation rate, with an odds ratio of 4.15 [95% confidence interval (CI): 1.57, 10.96] and 12.78 (95% CI: 2.58, 63.29), respectively. The DB group showed a positive correlation with the complication rate when compared with the BK group, with an odds ratio of 7.73 (95% CI: 1.67, 35.72). The weight-for-age Z-score at stoma closure was –1.22 (95% CI: –1.91, –0.54) in the BK group and –2.84 (95% CI: –4.28, –1.40) in the DB group (P = 0.039). ConclusionsThe Bishop–Koop procedure for severe jejunoileal atresia had a low complication rate and re-operation rate, and the nutrition status at stoma closure was superior to double-barreled enterostomy. The Bishop–Koop procedure seems to be an appropriate choice for severe jejunoileal atresia.

Выбор метода формирования превентивной кишечной стомы после резекции прямой кишки: протокол проспективного многоцентрового рандомизированного клинического исследования

Aim of review. To justify and present the protocol of the prospective, multicenter randomized clinical trial for evaluation of the choice of preventive intestinal stoma formation method after rectectomy. Summary. Modern surgery for the rectal cancer is featured by preferential sphincter-preserving operations. It is established that colorectal anastomosis incompetence is severe and in some cases lethal complication that reduce quality of life of patients and an increase the risk of disease relapses, which rate reaches 15 to 20% at low colorectal anastomosis. Formation of preventive stoma is an effective way to avoid this complication that is why it’s inclusion to treatment protocols for the middle and low ampullary rectal cancers is undisputed by the most of surgeons. However the choice of preventive stoma formation method is under discussion yet and remains to be an urgent issue. In the western countries the preferred method is double barreled ileostomy due to more rapid formation and closure, as well as due to lower rate of stoma-related morbidity. In Russia and CIS countries application of double-barreled transverse colostoma is preferred traditionally due to lower rate of electrolytic disorders and related repetitive hospital admissions in conditions of imperfect stoma care system, along with series of unproven advantages, usually defined as hospital tradition. Conclusion. Presented study will allow to reveal the early and late postoperative morbidity rate and the related repeated hospital admissions in real-life clinical practice of Russia from the standpoints of evidencebased medicine, to define indications and contraindications for each method of «low» colorectal anastomosis protection with the least risk for the patient.

A NEW METHOD OF DECOMPRESSION BY MALIGNANT LARGE BOWEL OBSTRUCTION

Purpose: improve the immediate results of treatment of patients with acute colonic obstruction of tumor genesis through the use of a new method of colon decompression. Materials and methods: the study included 35 patients who were divided into 2 groups. The control group consisted of 9 patients who were formed from a double-barreled colostomy minimal access without removing the contents of the large intestine and the rehabilitation of its lumen.The main group consisted of 26 patients,which after the application of double-barreled loop ileostomy through minimal access for the removal of intestinal contents was used a new method of colon decompression. Results: in the main group was noted more rapid normalization of basic clinical and laboratory parameters, as well as indicators of abdominal pressure. Complications were found in the main group in 1 (3.8%) patient, in the control group in 3 (33.3%) patients. Summary: а new method reduces the number of complications and deaths compared with conventional double-barreled ileostomy,due to forced removal of colon content and readjustment of its lumen, leading to a more rapid normalization of the major clinical and laboratory parameters as well as parameters of intraabdominal pressure.

Is stoma care effective in terms of morbidity in complicated ileostomies?

BackgroundPerforming transient or permanent ileostomy is one of the common procedures involved in colorectal surgery. Complication rates up to 40% have been reported in ileostomies. In this report, the effect of specific stoma care unit on ileostomy and its complications were investigated.MethodsA total of 141 patients, who were operated and underwent ileostomy, due to different causes, at Department of General Surgery, Uludağ University, Bursa, Turkey, between 2003 and 2006, were examined, retrospectively. Patient records were examined in terms of age, sex, surgery indications, urgent/elective state, benign/malign origin, ileostomy type, complications and stoma care, and education. χ2 test was used to compare the categorical data.ResultsAmong the patients, 95 (67%) were male and 46 (33%) were female. The mean age was 47 years (17–67). Some of the subjects (49%) were operated urgently and some (51%) were under elective conditions. The ileostomy types used included the following: end ileostomy (43%), loop ileostomy (46%), and double-barrel ileostomy (11%). Permanent ileostomy was performed in 23 patients and transient ileostomy was performed in 118 patients. The patients were operated because of either benign (48%) or malign (52%) causes. Complications developed in 37 (26%) patients. The rate of development of complication was markedly higher in ileostomies performed under urgent conditions (61% vs 39%) (P<0.001). The complications included mucocutaneous separation (12 patients), maceration in the peristomal skin (ten patients), retraction (five patients), necrosis (three patients), prolapsus (three patients), and other metabolic complications (four patients). The complications were treated with care (68%) and surgical revision (32%).ConclusionThe rate of ileostomy was found to be higher in the male patients compared to female patients. The risk of development of complications was found to be higher in ileostomies performed under urgent conditions. The most common complication observed was mucocutaneous separation. Ileostomy complications can be treated conservatively with professional care and education.

A Case of Prolapsed of Double Barreled Ileostomy Caused by a Homemade Brace of the Stoma

A Case of Prolapsed of Double Barreled Ileostomy Caused by a Homemade Brace of the Stoma

Metastatic small bowel adenocarcinoma in a 10-year-old Chinese girl

Small bowel adenocarcinoma is a rare entity in both adult and paediatric populations. Diagnosis is usually delayed due to vague symptoms. We report a case of ileal adenocarcinoma presented with multiple metastases. A 10-year-old Chinese girl presented with recurrent right lower quadrant pain developed intestinal obstruction. Computerized tomography showed terminal ileum wall thickening, a pelvic mass and suspicious pulmonary metastases. Laparotomy showed a terminal ileal tumour causing mechanical obstruction with metastases to the left ovarian and mesenteric lymph nodes. Palliative right hemi-colectomy with double-barrel ileostomy was performed. The pathology was reported to be ileocaecal adenocarcinoma with extensive lymphovascular permeation. She was the started on palliative chemotherapy with static disease. Diagnosis of small bowel adenocarcinoma remains a challenge to surgeons as the clinical presentation is subtle in spite of the advanced clinical course. Surgery plays a role in symptomatic treatment for patients with intestinal obstruction in advanced stage.

Diagnostic program and tactical approaches to treatment of patients with obturative colonic obstruction of tumor genesis

Aim. To determine the value of ultrasound investigations, colonoscopy and laparoscopy in the complex diagnosis of acute obturative colonic obstruction of tumor genesis and in selecting the optimal treatment strategy. Methods. Conducted was an anlysis of results of treatment of 112 patients with obturative colonic obstruction of tumor genesis. A set of diagnostic procedures was carried out for every admitted patient: digital rectal examination, radiography of the abdomen, ultrasound examination, fiber colonoscopy, and laboratory studies. Results. Based on the clinical and radiographic the diagnosis of obturative colonic obstruction was established in 64.3%, ultrasound investigation revealed the presence of bowel obstruction without specifying its location in 92% of the cases. Emergency colonoscopy was informative only in 55.5% of cases due to inadequate prior preparation of the colon. Using the developed methodology of preparing the colon, it was possible to perform colonoscopy up to the level of the tumor in 26 patients (92.9%) out of 28 patients. In the 32 cases minimal surgical intervention were performed by way of formation of an ileotransverse anastomosis by-pass, double-barreled ileostomy or colostomy. 80 patients underwent resection of the bowel with the tumor, including operations with the formation of a primary anastomosis, which were performed in 20 patients when the tumor was located in the right segments of the colon. In 22 patients an intraoperative colonic lavage was performed. Postoperative complications were recorded in 30 (26.8%) patients. Postoperative mortality was 24.1% (27 patients). Conclusion. Based on the radiographic and ultrasound investigations of the abdominal cavity it is possible to establish the presence of bowel obstruction without specifying the localization of the obstruction zone; in order to determine the cause of the obturative colonic obstruction it is necessary to perform an emergency colonoscopy with rigorous preparation of the colon according to the developed technique, while the volume of surgical intervention should be determined in each case individually.

Parastomal hernia incarceration due to migrated intragastric balloon

The temporary placement of intragastric balloons is a common method to achieve rapid weight loss before planned metabolic surgery. We report the case of a 48-year-old morbidly obese patient. Ten years ago the patient underwent emergency sigmoidectomy with creation of a double-barreled ileostomy for perforated diverticulitis. Over time he developed a giant parastomal hernia. For preoperative weight reduction before planned restoration of intestinal continuity, an intragastric balloon was inserted 3 years ago. The patient was admitted to our emergency department with peritonism and a septic shock. After computed tomography showing small bowel ileus, laparotomy was performed, revealing marked ischemia of incarcerated small and large intestine. Only postoperatively was the intragastric balloon found in the resected small bowel, causing a mechanical ileus with consecutive incarceration of the bowel. We review the literature on complications due to the migration of intragastric balloons. This clinical case gives a fair warning of the possible deleterious outcome of intragastric balloons, especially in hernia patients.

Double-Barreled Wet Ileostomy Following Pelvic Exenteration

Double-Barreled Wet Ileostomy Following Pelvic Exenteration

The double-barreled wet ileostomy: an alternative method for simultaneous urinary and intestinal diversion without intestinal anastomosis after total colectomy and pelvic exenteration

Although the number of cases of locally advanced colorectal cancer related to familial adenomatous polyposis (FAP) has decreased as a result of a better understanding of the disease, the condition still can offer therapeutic challenges. We report a case of a rectal tumor with prostate invasion associated with FAP, treated with neoadjuvant radiotherapy and total extended proctocolectomy with cystoprostatectomy. The reconstruction was undertaken with a double-barreled ileostomy with ureteral reimplantation on the distal segment of the ileostomy. Data including surgical aspects, post-operative complications, and outcome were evaluated. The double-barreled wet ileostomy is a technically straightforward and safe procedure that is easily executed and may be an alternative to simultaneous diversion in extreme situations. To the best of our knowledge, this is the first description of this procedure in the literature.

Colon perforation in a patient with hyperimmunoglobulin E (Job's) syndrome

A Taiwanese boy was diagnosed as having hyperimmunoglobulin E syndrome at the age of 4 years. At age 18 he was admitted to the hospital because of pneumonia in the left lower lobe. Abdominal pain developed 9 days later, and his condition progressed to peritonitis. Colon perforation, 10 cm distal to the ileocecal valve, was found. Double-barrel ileostomy was performed, and reanastomosis was done 1 1 2 months later. Afterward, he was fine, and he had no significant gastrointestinal problems after being discharged. To the authors' knowledge, this is the first reported case of hyperimmunoglobulin E syndrome complicated by colon perforation.

4-STAGE OPERATION FOR FULMINANT ULCERATIVE COLITIS

A 48 year old female with fulminant ulcerative colitis was treated by a 4 -stage operation. Initially, she was managed by conservatively. i. e. with oral sulfasal azine, predonisolone, and imuran. But her condition was not corrected, so predonisolone was given intravenously. Nevertheless her illness became worse and toxic megacolon was suspected, emergency operation was performed by double-barreled ileostomy for intracolonic decompression. In the second stage, total colon and upper rectum resection was performed, and a terminal ileostomy was made. In the third stage, mucosectomy of the residual rectum and an anastomosis between the ileal J-pouch and dented line of the anal canal was performed. At the same time, a safety ileostomy was made. Therefore in the fourth stage, this ileostomy was closed. These operative procedures are safe and give the patient of good quality of life because anal function is completely preserved.