End Sigmoid Research Articles

End Sigmoid Colostomy Reconstruction Using Purse-string Subcutaneous Suture via Extraperitoneal Route at the Site of a Previous Transperitoneal Loop Stoma.

We previously experienced two cases of end sigmoid colostomy reconstruction via the extraperitoneal route at the same site as the transperitoneal loop stoma. For an anterior rectus fascia, the transperitoneal route used closed intraperitoneal interrupted sutures and continuous sutures with barbed sutures. A new extraperitoneal route was established through the sutured anterior rectus sheath. Before reconstructing the end stoma, a subcutaneous purse-string with monofilament absorbable sutures tied to create an approximately 2.5 cm diameter was used. There were no early complications associated with the stoma. One year after surgery, a parastomal hernia was not defined. Using the presented technique, two cases were successfully recreated extraperitoneally at the same site's end stoma.

Sacral chordoma with incidental rectal adenocarcinoma: a case report

BackgroundWe report a unique case of synchronous sacrococcygeal chordoma in association with rectal invasive adenocarcinoma. Retrorectal tumors are a rare disease caused by a variety of pathologies. To our knowledge, no prior cases of such a coincidental finding of both cancers have been reported in the literature.Case presentationThis is the case of a 74-year-old white middle eastern man, with known hypertension under treatment, who presented with complaints of progressive lower back pain associated with urinary incontinence over the past 12 months. Magnetic resonance imaging (MRI) of the pelvis showed a large midline, well-defined, oval-shaped lesion replacing the sacrococcygeal portion of the spine, with extension to the presacral region. Computed tomography (CT)-guided Tru-Cut biopsy revealed features suggestive of chordoma. At surgery, we performed excision of the entire mass en bloc, sacrectomy with rectus abdominis myocutaneous flap reconstruction and end sigmoid colostomy. Surgical histopathology proved it to be sacral dedifferentiated chordoma and rectal invasive adenocarcinoma. Overall, the patient recovered well postoperatively, was discharged home with functional stoma and on permanent Foley catheter use.ConclusionTo the best of our knowledge, this is the only reported case of such a presentation, and sheds light on the approach and management. We hope that reporting such a case will add value to the medical literature.

The Application of Extraperitoneal Ostomy Combined with Pelvic Peritoneal Reconstruction in Laparoscopic Abdominoperineal Resection for Rectal Cancer.

Background Due to the technical difficulty, it is not common to close the pelvic peritoneum in laparoscopic abdominoperineal resection (LAPR) in China, which increases the risk of related complications. Permanent sigmoid colostomy is performed through the transperitoneal route conventionally in LAPR. This leads to the high occurrence of parastomal hernias and bowel obstructions. To prevent the complications and reduce surgical costs of LAPR, we performed some modifications for it. Methods 38 patients diagnosed with low rectal cancer during July 2014 to July 2016 received LAPR with our modifications. First, the mobilization of the rectum and lymphadenectomy were identical to the classical routine method. Second, two sutures were performed on the pelvic peritoneum with the first to reduce the tension, followed by the second continuous suture to close the pelvic floor. Third, a tunnel was made between the parietal peritoneum and abdominal wall for the end sigmoid to pass through to finish the colostomy. Results LAPR was performed on totally 38 patients successfully with no case transferring to open surgery. The follow-up period was from 1 month to 1 year. The mean operative time was 142.2 ± 16.5 min ranging from 100 min to 175 min. The mean hospital stay was 12.0 ± 1.5 days. No case underwent the reconstruction of stoma. There was not a single complication of LAPR with these two techniques that occurred to all 38 patients. Conclusion We consider LAPR with our two techniques feasible and safe, which can be accepted quickly to improve the life quality of patients. Therefore, we suggest our procedures as the first choice during LAPR surgery. This trial is registered with trial registration number 2014028.

Role of Laparoscopy in Radiation Proctitis: Case Report and Review of Literature

Introduction: The radiation proctitis is a known complication following the pelvic radiation therapy. Radiation proctitis is categorized as acute and chronic. Most of the cases are managed conservatively except in grade four chronic radiation proctitis, which active surgical management is needed. Previously these surgeries were done by conventional open technique. With the evolution of minimal access surgery it has now possible to do these surgeries by laparoscopic methods. Case Presentation: We here by present a case of 75 year old male patient presented with passage of dark colored blood mixed stools with tenesmus, pain and diarrhea. Patient had surgical history of transurethral resection of the prostrate (TURP) done for Benign Prostatic Hypertrophy. The tissue diagnosis of specimen was adenocarcinoma of prostate. Patient had received radiotherapy 9 months back for that prostatic carcinoma. The colonoscopy was suggestive of severe distal rectal proctitis, which was managed by laparoscopic proctectomy with partial sigmoidectomy and permanent end sigmoid colostomy. Conclusions: Laparoscopy has definitive role in management of chronic radiation proctitis, blessing the patient with benefits of minimal access surgery.

Predictors of morbidity in patients undergoing diverting colostomy for non-healing sacral, perineal or ischial wounds

Abstract Background The treatment of non-healing sacral, perineal, or ischial wounds often requires fecal diversion to promote wound healing. The purpose of this study was to identify risk factors for morbidity, rates of colostomy reversal and complications related to type of colostomy. A retrospective chart review was conducted on all patients with non-healing wounds who underwent diverting colostomies. Results Sixty six patients met criteria for inclusion in the study. Complication rates and revision rates were studied. 27% of all stomas required revision. Stoma revision was required in a higher proportion (33%) of all loop colostomies as compared to all end colostomies (10%). During the study period, 26% of diverted patients went on to have a myocutaneous flap. The stoma reversal rate was 5% (3/66). Complications occurred in 32% of patients. The most common complication was parastomal hernia (20%). Other complications included: small bowel obstruction, 8%; stoma prolapse, 6%; stoma bleeding 5%; and stoma retraction, 5%. Patients with loop colostomies had a higher rate of overall complications as compared to end colostomies (37% vs.10%) Conclusions Based on the findings of this study, consideration should be given to fashioning end sigmoid colostomies for fecal diversion in patients with non-healing wounds.

Spinal epidural abscess as a complication of Crohn's disease

A 39-year-old woman with a history of Crohn’s disease presented with complaints of fever, low back pain, and right leg weakness. C-reactive protein was 91 mg/L and erythrocyte sedimentation rate was 140 mm/h. Pelvic computed tomography revealed wall thickening of the ileal loops and a gas-containing abscess in the presacral space characteristic of Crohn’s disease (Fig. 1). Computed tomography and magnetic resonance imaging of the lumbar spine demonstrated fistulae between distal ileum, sigmoid colon, and intraspinal extradural space, causing epidural abscess with air and lumbosacral spondylitis (Fig. 2). Following 10 days of medical treatment, surgery including a diverting end sigmoid colostomy and presacral abscess drainage was performed. This treatment with appropriate antibiotics conveyed recovery, without requiring spinal surgery. Spinal epidural abscess is a serious and rare complication of Crohn’s disease. It must be kept in mind along with caudal neurologic symptoms and leg pain in Crohn’s disease [1].

Physiological and Functional Evaluation of the Transposed Human Pylorus as a Distal Sphincter

Background/AimsStudies evaluating the human pylorus as a sphincter are scanty and contradictory. Recently, we have shown technical feasibility of transposing the human pylorus for end-stage fecal incontinence. This unique cohort of patients provided us an opportunity to study the sphincter properties of the pylorus in its ectopic position.MethodsAntro-pylorus transposition on end sigmoid colostomies (n = 3) and in the perineum (n = 15) was performed for various indications. Antro-pylorus was assessed functionally (digital examination, high resolution spatiotemporal manometry, barium retention studies and colonoscopy) and by imaging (doppler ultrasound, MRI and CT angiography) in its ectopic position.ResultsThe median resting pressure of pylorus on colostomy was 30 mmHg (range 28-38). In benign group, median resting pressure in perineum was 12.5 mmHg (range 6-44) that increased to 21.5 mmHg (range 12-29) (P = 0.481) and 31 mmHg (range 16-77) (P = 0.034) on first and second follow-up, respectively. In malignant group, median post-operative pressures were 20 mmHg (range 14-36) and 21 mmHg (range 18-44) on first and second follow-up, respectively. A definite tone and gripping sensation were felt in all the patients on digital examination. On distal loopogram, performed through the diverting colostomies, barium was retained proximal to the neo-pyloric valve. Both perineal ultrasound and MRI showed viable transposed graft. CT angiography and color doppler studies confirmed vascular flow in the transposed position.ConclusionsThe human pyloric valve can function as a tonic sphincter when removed from the gastroduodenal continuity.

Hartmans' Pouch Mucocele Misdiagnosed as an Ovarian Tumor in an 86 Year Old Nursing Home Resident

Introduction/Objective: An end sigmoid colostomy resulting in a Hartmann's pouch is the procedure of choice when permanent fecal diversion is required. The distal portion of the rectosigmoid colon is exteriorized resulting in a mucinous fistula. This procedure can lead to the development of a mucocele which may be misdiagnosed unless a complete evaluation is done.

What Is the Risk for a Permanent Stoma After Low Anterior Resection of the Rectum for Cancer? A Six-Year Follow-Up of a Multicenter Trial

The aim of this study was to assess the risk for permanent stoma after low anterior resection of the rectum for cancer. In a nationwide multicenter trial 234 patients undergoing low anterior resection of the rectum were randomly assigned to a group with defunctioning stomas (n = 116) or a group with no defunctioning stomas (n = 118). The median age was 68 years, 45% of the patients were women, 79% had preoperative radiotherapy, and 4% had International Union Against Cancer cancer stage IV. The patients were analyzed with regard to the presence of a permanent stoma, the type of stoma, the time point at which the stoma was constructed or considered as permanent, and the reasons for obtaining a permanent stoma. Median follow-up was 72 months (42-108). One patient with a defunctioning stoma who died within 30 days after the rectal resection was excluded from the analysis. During the study period 19% (45/233) of the patients obtained a permanent stoma: 25 received an end sigmoid stoma and 20 received a loop ileostomy. The end sigmoid stomas were constructed at a median of 22 months (1-71) after the low anterior resection of the rectum, and the loop ileostomies were considered as permanent at a median of 12.5 months (1-47) after the initial rectal resection. The reasons for loop ileostomy were metastatic disease (n = 6), unsatisfactory anorectal function (n = 6), deteriorated general medical condition (n = 3), new noncolorectal cancer (n = 2), patient refusal of further surgery (n = 2), and chronic constipation (n = 1). Reasons for end sigmoid stoma were unsatisfactory anorectal function (n = 22) and urgent surgery owing to anastomotic leakage (n = 3). The risk for permanent stomas in patients with symptomatic anastomotic leakage was 56% (25/45) compared with 11% (20/188) in those without symptomatic anastomotic leakage (P < .001). One patient of 5 ended up with a permanent stoma after low anterior resection of the rectum for cancer, and half of the patients with a permanent stoma had previous symptomatic anastomotic leakage.

Individualized management of upper rectal atresia

Background/Purpose Congenital colonic atresia (CA) or stenosis is an infrequent cause of low intestinal obstruction in the neonate. Atresias can occur at any level, and the management of CA is determined by the atretic site and by the presence or absence of associated anomalies. We report our experience dealing with upper rectal atresia during a 5-year period. Methods Between January 2004 and December 2008, 3 female newborns with upper rectal atresia with or without associated anomalies were treated. Modes of clinical presentation, methods of diagnosis, associated anomalies, alternative management techniques, and clinical outcome were retrospectively analyzed. Results All 3 patients had progressive abdominal distension, bilious vomiting, and failure to pass meconium. Contrast enema showed an atresia at the upper rectum in 2 patients. At laparotomy, case 1 was found to have type III atresia of the upper rectum. Resection of the dilated portion of the proximal colon with end sigmoid colostomy was accomplished in the neonatal period followed by a transanal mucosectomy with takedown of the colostomy and a pull-through procedure at age 3 months. Case 3 had multiple jejunoileal atresias and an upper rectal atresia. The initial management was multiple resections of atretic bowel and anastomoses and an end sigmoid colostomy. The secondary procedure was a takedown of the colostomy and transanal mucosectomy with a pull-through procedure. Case 2 had type I upper rectal atresia in association with imperforate anus complicated by colon perforation during performance of a distal colostogram leading to a complicated and protracted clinical course. All the patients are currently well with voluntary bowel movements, and one has occasional soiling with follow-up of 9 months to 3 years. Conclusions Colon atresia, especially at the level of the upper rectum, is uncommon. Whether to proceed with an ostomy or to individualize the operative procedure according to the location of the atresia is still controversial. Transanal mucosectomy was a useful technique at the time of the definitive pull-through for the treatment of upper rectal atresia. In cases of upper CA associated with imperforate anus, delay in diagnosis and potential complications may result if the diagnosis of upper rectal atresia is missed.

Posterior Sagittal Anorectoplasty for Congenital Rectovaginal Malformations in the Adult

Posterior sagittal anorectoplasty is a well accepted procedure utilized for repair of congenital imperforate anus. This procedure allows acceptable function and quality of life in these unfortunate children. However, for obvious reasons it is seldom performed in the adult patient. In this video, we demonstrate a unique case of a congenital imperforate anus in an adult patient who presented initially with fecal incontinence at 42 years of age. Inspection of her perineum revealed the typical appearance of a congenital imperforate anus with rectovestibular fistula. Intraoperative localization of the external sphincter with a Pena nerve/muscle stimulator (Integra, Plainsboro, NJ) revealed its presence in the appropriate posterior midline location. A two-staged procedure is utilized. This begins with a laparoscopic end sigmoid colostomy followed by the anorectoplasty three weeks later. We demonstrate the technique of posterior sagittal anorectoplasty with the patient in the prone jackknife position. Postoperative function one year after colostomy reversal demonstrates good continence with peak manometric resting and squeeze pressures of 26 mm and 42 mm respectively. Though not usually pertinent in the adult setting, posterior sagittal anorectoplasty should be considered an acceptable option for adults with anorectal malformations.

Stoma formation for fecal diversion: a plea for the laparoscopic approach

The aim of this study was to assess the results of laparoscopic stoma creation for fecal diversion, specifically focussing on feasibility, safety, and efficacy, as well as indications and techniques. Within a 10-year-period, all patients requiring laparoscopic stoma creation were evaluated prospectively. Patients' profiles and indications, procedures and results of operation, conversion, morbidity, mortality and short-term complications (stoma-related, laparoscopy-associated) were analyzed. A total of 80 patients (39 males, 41 females) with a mean age of 55.5 years (range, 17-91) underwent laparoscopic stoma creation. Most common indications were unresectable advanced colorectal cancer (n=20), pelvic malignant cancer (e. g. ovarian, cervix and prostate cancer, n=16), and perianal Crohn's disease with complex fistulas (n=16). Only in one female patient with pelvic malignant disease was the procedure converted to laparotomy due to obesity (conversion rate, 1.3%). 79 patients underwent laparoscopic stoma creation (completion rate, 98.7%) including loop ileostomy (n=30), loop sigmoid colostomy (n=40) and end sigmoid colostomy (n=9). Postoperative complications were documented in 9 patients (overall morbidity rate, 11.4%), including 4 minor complications treated conservatively (2 cases of prolonged atonia and 1 case each of pneumonia and urinary tract infection) and 5 major complications requiring reoperation (reoperation rate, 6.3%): one parastomal abscess (drainage), one stoma retraction following rod dislocation (laparoscopic stoma recreation), small bowel obstruction in two patients (small bowel resection), one port-site hernia (fascial closure), and hemorrhage (managed by re-laparoscopy). Mean operation time was 74 min (range, 30-245 min). Mean blood loss volume was 80 ml (range, 30-400 ml). Patients were discharged from hospital after a mean of 10.3 days (range, 3-47). Within a 1-year follow-up, no further stoma complications were documented. The advantages of laparoscopic stoma creation are low morbidity and reoperation rates, and no procedure-related mortality; our results suggest that laparoscopic stoma creation for fecal diversion is safe, feasible and effective. Therefore, at our institution, laparoscopic stoma creation is the method of choice for fecal diversion.

Intestinal Stomas and their Complications:A Descriptive Study

Summary A retrospective review of 80 consecutive patients with different types of intestinal stomas was carried out to analyze the indications, complications and the complication rate with respect to stoma type. The most common type of stoma was found to be end sigmoid colostomy (35%) followed by transverse loop colostomy (22.5%). The most common indication for stoma construction was colorectal cancer (37.5%) followed by Hirschsprung's disease and imperforate anus (12.5% for each). A total of 64 complications were reported in 49patients for a corrected complication rate of (61.25%). Peristomal skin excoriation was the most frequently recognized complication in this study (45.3%), followed by prolapse (23.4%) which was almost exclusive to infants and children. Transverse loop colostomy was associated with the highest complication rate (72.2%) followed by end sigmoid colostomy (64.28%). End ileostomy was associated with the lowest complication rate (33.3%) of all types of stoma. Emergency stomas and stomas in children were found to be associated with higher complication rates. The morbidity of stoma seems to be related to insufficient preoperative planning, technical errors of stoma construction and poor stoma care and management.

Untreatable faecal incontinence: colostomy or colostomy and proctectomy?

PURPOSE: To determine the frequency of rectal symptoms and secondary proctectomy in patients undergoing elective permanent end sigmoid colostomy for faecal incontinence and determine risk factors. METHODS: A retrospective chart review of patients undergoing elective end sigmoid colostomy for faecal incontinence at St Mark's Hospital between January 1991 and December 1998. Patients were divided into three groups: A, symptoms leading to subsequent proctectomy; B, symptomatic but avoiding proctectomy; C, asymptomatic. RESULTS: There were 44 patients (80% women, average age 57 years): Group A 12 (27%); Group B 13 (30%); Group C 19 (43%). Group A were on average younger than Group C (45 years vs 64 years, P < 0.05). No other risk factor for symptoms or proctectomy was evident, and in particular a prior history of obstructed defaecation/anal digitation was not related. Only half the patients undergoing proctectomy had histological evidence of defunctioned proctitis in the resected rectum. CONCLUSIONS: Data are insufficient presently to recommend primary proctectomy in this group of patients (even if it were to be performed laparoscopically).

Spontaneous Rupture of the Rectum with Evisceration of Omentum through the Anus: A Case Report and Review of the Literature

Spontaneous Rupture of the Rectum with Evisceration of Omentum through the Anus: A Case Report and Review of the Literature

Experience with 30 Posttraumatic Rectourethral Fistulas: Presentation of Posterior Transsphincteric Anterior Rectal Wall Advancement

Purpose We present the challenging problems involving the treatment of rectourethral fistulas, especially those caused by war wounds. Various existing techniques used by a single surgeon are compared in this study. The method of posterior transsphincteric anterior rectal wall advancement is described as the treatment of choice. We emphasize the importance of fecal and urinary diversion. To our knowledge this series is the largest in the literature. Materials and Methods From 1981 to 1994 we treated 30 men 18 to 50 years old (mean age 34) with posttraumatic rectourethral fistulas, including 23 (76.5%) caused by missiles. Urethroscopy with digital examination under anesthesia was the most reliable diagnostic study. End sigmoid colostomy and suprapubic cystostomy were performed in all patients. Results In 14 patients (46.5%) the fistula healed after double diversion but 16 (53.5%) required reconstruction for repair. Of the 6 procedures using established techniques in 5 patients 3 (50%) failed and 3 were successful but a urethral stricture developed after 2 (66%). On the other hand, in all patients (100%) who underwent repair via posterior transsphincteric anterior rectal wall advancement the fistula resolved and a stricture developed in 3 (27%). Fistula size and extent of fibrosis affected treatment, while etiology did not. Urethral obstruction complicated only the missile wounds. Conclusions Double diversion has resulted in resolution of approximately half of the small, less fibrous fistulas. Early repair is recommended for large fibrous fistulas. Anterior rectal wall advancement through a posterior transsphincteric incision offers a new option that has proved to be successful and safe, and causes fewer urethral complications. It also provided good visualization with minimal bleeding and was less painful. Double diversion is a prerequisite to reconstruction.

Metabolic and nutritional management of a patient with multiple enterocutaneous fistulas

The patient is a 26-y-old male who sustained a close-range shotgun wound to the perineum. Following resuscitation at a community hospital in which an exploratory laparotomy with sigmoid loop colostomy was performed, he was transferred to a tertiary referral trauma center. Upon re-exploration, there was no evidence of viable rectum, and the wound was approximately lo- 14 cm in depth and extended from the base of the scrotum to the sacrum. Following several debridements, he was left with an end sigmoid colostomy with the open perineal and abdominal wounds to heal by secondary intention. Postoperatively, the patient’s stay was complicated by the development of multiple enterocutaneous fistulas all confined to the right lower quadrant. Initially these were treated conservatively with control of drainage, octreotide acetate, non per OS (NPO), and total parenteral nutrition (TPN) for nutritional support. Once stable he underwent split-thickness skin graft to his abdominal wounds following a brief course of human recombinant growth hormone (GH) in hopes of enhancing development of granulation tissue of the grafting bed.

Basic Considerations for End Sigmoid Colostomy in Conjunctive with the Miles Operation for Cancer of the Rectum.

Basic Considerations for End Sigmoid Colostomy in Conjunctive with the Miles Operation for Cancer of the Rectum.

Laparoscopic techniques for fecal diversion

Although the role of laparoscopic techniques in performing major colorectal resections is unclear, laparoscopy may be well suited for fecal diversion procedures because no resection and minimal tissue dissection is required. This report reviews our initial experience with laparoscopic stoma procedures to assess safety and efficacy. Using a simple two-cannula technique, 24 such procedures (16 loop ileostomies, 6 end sigmoid colostomies, 1 transverse, and 1 sigmoid loop colostomy) were attempted. Indications for diversion were rectovaginal fistula (7), perianal sepsis (7), incontinence (4), advanced rectal or colon carcinoma (4), and complicated pelvic infection (2). There were 15 females and 9 males with a median age of 44 (range, 25-88) years. Median operative time was 60 (range, 20-120) minutes, and median blood loss was 50 (range, 0-150) ml. There were no intraoperative complications. One case was converted to a laparotomy because of dense adhesions. Median time to passage of both flatus and stool was one (range, 1-3) day for ileostomy patients, two (range, 2-4) for flatus, and 3 (range, 2-6) days for stool after colostomy. Median time to discharge was 6 (range, 2-28) days and was often delayed by the primary disease process or ostomy teaching. One major postoperative complication, a pulmonary embolism, occurred eight days after operation in a patient with near obstructing, widely metastatic colon carcinoma. This patient later died of pulmonary failure. All stomas have functioned well, with no revisions required. Laparoscopic fecal diversion procedures can be performed safely, simply, and effectively. Apparent advantages over standard techniques are avoidance of a laparotomy, while maintaining the ability to precisely identify and orient the pertinent bowel segment and rapid return of bowel function.

Radiation-Induced Vesicosacral Fistula: Treatment with Continent Urinary Diversion

This is the first Case Report of a vesicosacral fistula related to prior radiation therapy. This patient developed recurrent adenosquamous carcinoma of the cervix 1 year after radical hysterectomy. She received 5000 cGy to the whole pelvis and a 1500-cGy boost to the area of recurrence in the right pelvic sidewall. The patient had significant toxicity with recurrent pelvic fistula formation ultimately requiring an end sigmoid colostomy. In addition, the patient required urethral catheterization due to urinary incontinence secondary to a hypertonic bladder. Approximately 14 years after radiation therapy the patient developed a vesicosacral fistula. With a nonfunctional bladder, the decision was made to proceed with a continent urinary diversion procedure. Despite a prior ileocecal resection due to radiation injury, a Miami pouch reservoir was created. Postoperatively, the patient remained continent using intermittent catheterization of the pouch.