Ileotransverse Colostomy Research Articles

ABCL-310 Triple Metachronous Malignancies in Primary Diagnosed Diffuse Large B-Cell Lymphoma Patient: A Case Report

Diffuse large B-cell lymphoma (DLBCL), the most common type of non-Hodgkin lymphoma (NHL), is known to be associated with increased risk of second primary malignancies (SPM). The occurrence of more than one type of cancer in a single patient is considered a rare finding, either appearing at the same time (synchronous) or subsequently (metachronous). This study is to present this interesting case of a male patient diagnosed with DLBCL, basal cell carcinoma (BCC), and adenocarcinoma of colon metachronously. A case report from May 2012 to January 2022. Oncology Unit/Oncology Center Mansoura University, Egypt. A 43-year-old male patient, HCV positive, diagnosed from splenectomy with DLBCL, Stage IV. In 2012, the patient received 8 cycles of CHOP protocol and achieved complete remission. In 2016, he presented with a face ulcer, which was excised with adequate safety margins, and histopathological examination revealed BCC. In 2017, he presented with acute abdomen. Computed tomography (CT) showed a well-defined soft tissue mass at the distal part of the ascending colon and hepatic flexure with signs of intestinal obstruction. The patient underwent right hemicolectomy and double barrel ileotransverse colostomy, and the histopathological examination revealed grade II adenocarcinoma, Stage IIa. Then, he received 6 cycles of adjuvant de Gramont regimen. After that, CT and colonoscopy were free. In 2019, he presented with B symptoms and right axillary lymphadenopathy; biopsy revealed NHL of large-cell type in favor of high-grade follicular lymphoma. After receiving 4 cycles of DHAP protocol, PET/CT was negative. Yet, he refused autologous stem cell transplantation. In 2021, he presented with cervical lymphadenopathy and tumor lysis syndrome. Biopsy showed DLBCL. The patient is 43 years old, male, HCV positive, underwent splenectomy, was diagnosed with DLBCL, and received chemotherapy. All of these are considered risk factors for SPM. The patient received supportive treatment, and 3 sessions of hemodialysis were done. He has been lost to follow-up since January 16th, 2022. DLBCL increases the risk of SPM mostly due to immune dysfunction, immunosuppression, and the mutagenic effects of chemotherapy. Hence, regular screening of DLBCL patients and survivors is recommended.

A comparative study between right hemicolectomy with ileotransverse anastomosis and primary repair with or without ileostomy/Colostomy in the management of Caecal perforation

Background: Study was conducted in the Department of General Surgery, Index Medical College and Hospital, Indore from May 2013 to April 2016 (Three Years), 100 patients admitted to surgical emergency with acute abdomen were selected for the study. Method: Comparative study was done between group A (right hemicolectomy with ileotransverse anastomosis) and group B (primary repair with omental patch, primary repair with defunctioning loop ileostomy, Right hemicolectomy with double barrel ileo-transverse colostomy). There was no selection criteria for patients. Result: We found (76%) males and the females (24%) in our study, there was statistical significance in wound infection/serous discharge between group A and group B with p value=0.047, there was statistical insignificance found in between group A and group B with p value=0.043 in anastomotic leak/ fistula, There was statistical significance found in outcome between group A and group B with p value=0.028 Conclusion: Right hemicolectomy with ileotransverse anastomosis in cases of traumatic caecal perforation plays an important role in reducing the incidence of complications like wound infection, wound dehiscenes, ileostomy and colostomy related complications like weight loss and electrolyte imbalance. We recommend that Right hemicolectomy with ileotransverse anastomosis should be preferred over other surgical options, primary repair with omental patch, primary repair with defunctioning loop ileostomy, Right hemicolectomy with double barrel ileo-transverse colostomy in cases of caecal perforations in randomised study.

To evaluate role of various clinical and diagnostics procedures in diagnosis of caecal perforation

Study includes hundred patients admitted to surgical emergency with acute abdomen were selected for the study. There was not any preoperative selection criteria; the cases which were proven to be cases of perforation peritonitis on the basis of investigations and clinical examination were taken for study and considered for comparative study if laparotomy diagnosed to be case of caecal perforation. Inflammatory cause 22 cases (22%) which include caecal perforation secondary to ruptured liver abscess 14 cases, appendicular base with caecal wall perforation 4 cases. Obstructive cause 06 cases (06 %) include obstructed inguinal hernia 02 case, obstructive band 02 case and caecal volvulus 03 case. 04 cases (04%) of caecal perforation secondary to neoplastic etiology were studied. The common etiologies in descending order were Traumatic 68 cases (68%) which include multiple stab injury 40 cases (40%), blunt trauma abdomen 12 cases (12%), iatrogenic 10 cases (10%), caecal perforation secondary to arrow injury 1 case (2%), and blast injury 2 case (4%). Chi Square Test of statistical significance was applied between group A (right hemicolectomy with ileo transverse anastomosis) and group B (primary repair with omental patch, primary repair with proximal ileostomy and right hemicolectomy with ileo transverse colostomy) for testing association between between group A and group B. From total Nine parameters chi square test was found to be significant in seven parameters with p value 0.05. Reducing mortality in patients undergoing surgery for caecal perforations. Ileostomy-specific complications, however, increase the postoperative stay of the patient. These complications can be reduced, if not outright eliminated, by proper fashioning of the stoma and provision of adequate nursing care of the stoma. It should be recommended that ileostomy in these cases is only temporary and the extra cost and cost of management are burden to life of poor community.

SUCCESSFUL SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANTATION WITH DONORS LESS THAN 10 YEARS OLD

82 Most transplant programs are reluctant to use small pediatric donors for simultaneous pancreas and kidney transplants (SPKs) for fear of inadequate islet cell mass and technical complications. The purpose of this study is to review the results with pediatric donors less than or equal to 10 years of age. Methods: From 1986 to 1997, 17 pts with a mean age of 36 (range 21-53) yrs received SPKs from donors with a mean age of 8 (range 4-10) yrs, weight of 30 (18-50) kg, and donor to recipient weight ratio of 0.46 (.26-.92). The mean cold ischemia time was 16 (range 3-29) hrs. All pancreas grafts were anastomosed to the iliac vessels utilizing a same donor iliac Y graft. The duodenal segment was drained to the bladder in 12 and to the ileum in 5 pts. One pt received a double en bloc kidney. All vascular anastomosis were performed with running 6-0 or 7-0 prolene. The ureter was reconstructed using a Liche technique over a stent. All patients received induction with OKT3 or ATG, and maintenance immunosuppression with azathioprine or mycophenolate mofetil, cyclosporine or FK 506, and prednisone. Results: All pts were normoglycemic without insulin immediately post transplant and had a mean discharge fasting blood sugar of 90 (range 66-117) mg/dL. The 12 pts with bladder drainage had a mean urinary amylase of 15230 (1530-32385) U/L one week post transplant. Two pts required enteric conversion for urethritis and one pt underwent ileo-transverse colostomy diversion for a leak after primary enteric drainage. All pts had good early renal function with a mean creatinine 1.4 (range 0.6-2.4) mg/dL on POD#7, and 1.4 (0.7-2.0) at discharge. One patient underwent ureteropyelostomy for ureteral stenosis. There were no vascular complications. One patient lost both the kidney and pancreas grafts to acute cellular rejection 3 months after transplant. The remaining 16 (94%) patients have good kidney and pancreas graft function with a mean follow up of 4 (range 0.2-11) yrs. Conclusion: We conclude that excellent SPK results can be achieved with pediatric donors 5 years of age or older and a donor to recipient weight ratio greater than 0.25.

EMERGENCY TREATMENT OF OBSTRUCTING LARGE BOWEL CANCER

Thirty cases of obstructing large bowel cancer were treated by emergency procedures like proximal colostomy (55%), caecostomy (3%), appendicostomy (2%), ileotransverse colostomy (6%), right hemicolectomy (14%), anterior resection (14%), Hartmann's procedure (3%) and Lahey's procedure (3%). Primary resection for tumours of the right colon and staged procedures for tumours of the left colon and rectum and are safe procedures in the management of obstructing large bowel cancer.

Obstructing carcinoma of the cecum

Carcinoma of the cecum, the third most common location for malignancy of the large bowel, was examined with attention centered upon cecal cancers producing obstruction. Reviewing 136 patients revealed 11 obstructing lesions (8.1%) presenting as distal small bowel obstructions. The mean age of the patients was 74 years. All but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy. There was no operative mortality or significant morbidity. Bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment.

Typhoid Perforation: Further Experience with End-To-Side Ileotransverse Colostomy

Typhoid Perforation: Further Experience with End-To-Side Ileotransverse Colostomy

Obstructing Malignant Lesions of the Colon

Evidence has been presented to suggest that the patient with an obstructed carcinoma of the colon may have a more malignant form of the disease independent of lymph node status or tumor encirclement of the bowel. Rate of tumor growth is never consistent in patients with this disease. Patients who develop colon obstruction early in the course of the disease seem to have more aggressive tumors with rapid growth and a much poorer long-term prognosis. Perforations frequently accompany obstructions of the colon. Patients in this group have a dismal prognosis. Individuals with obstructed carcinoma of the colon have a higher operative mortality and morbidity and a shorter long-term survival. The higher operative mortality and morbidity may depend entirely on the choice of operative procedures. Tumor location affects prognosis. Obstructing tumors in the left colon have a more favorable prognosis than those in the right colon. Obstructing right colon tumors have a much poorer survival (three times worse) than nonobstructing carcinomas of the right colon. Obstructing tumors in the rectum have a very poor prognosis. Evidence exists that resection of the tumor without preliminary proximal decompression may reduce hospital mortality and morbidity and increase long-term survival. In selected cases, primary resection can be done as safely as staged operative procedures. Primary anastomosis with resection of the left colon carries a higher operative mortality because of anastomotic leaks. Resection without anastomosis is much safer. Primary resection with anastomosis is the procedure of choice in obstructing lesions of the right colon. This has a lower operative mortality and morbidity than a staged procedure. This primary resection with anastomosis is certainly as safe as an ileotransverse colostomy. It is important not to abandon the time-honored surgical principle of never suturing obstructed bowel. Primary resection without anastomosis confirms this surgical principle. Meticulous preoperative and postoperative care employing physiological monitoring, multiple antibiotics, total parenteral hyperalimentation, and respiratory and circulatory support will further reduce the hospital mortality and morbidity. Patients who initially appear to be obstructed on barium enema, but who in truth are only partially obstructed, can be properly managed so that an elective primary resection with anastomosis can be done with the same operative mortality and morbidity as in other elective colon cancer patients.

Pseudolymphoma masquerading as colonic malignancy

The case of a patient with a constricting lesion of the hepatic flexure is presented. Radiographic and endoscopic findings in this patient could not conclusively distinguish a benign from a malignant process. The patient eventually underwent operation, at which time hemicolectomy and ileotransverse colostomy were performed. The final pathologic diagnosis of the resected lesion was pseudolymphoma. The definition and significance of this diagnosis are discussed.

Management of cecal volvulus in debilitated patients.

We retrospectively evaluated ten cases of cecal volvulus. The average age of these patients was 57 years. Five patients were more more than 60 years old and three were over 70. All patients had significant delays in coming to the hospital, and all had concomitant medical problems that made them poor operative risks. Our data and data in the recent literature support a conservative approach in debilitated patients with acute cecal volvulus. We do not recommend resection of the cecum if it is viable at the time of operation. Resection remains the treatment of choice when gangrene is present, but primary ileotransverse colostomy is contraindicated in this population of patients.

Diverticulitis of the right colon.

The authors' experience with right-sided diverticulitis is reviewed. The symptoms among 18 patients were continuous right lower quadrant abdominal pain and periumbilical pain radiating to the right lower quadrant. Only three patients had nausea and vomiting. Twelve patients (67 per cent) had an abnormally high white blood cell count; three had granulocytosis. Barium enema examination was not a helpful diagnostic aid; and in only two patients was the preoperative diagnosis correct. The operative procedures undertaken were right colectomy with ileotransverse colostomy (15 patients), partial right colectomy with ileoascending colostomy (two patients), and diverticulectomy and appendectomy (one patient). There were no deaths; the average hospital stay was 14.2 days (range 5 to 30 days). The authors conclude that there is no characteristic clinical pattern pointing to this diagnosis; diagnostic maneuvers are usually unrewarding; right hemicolectomy is a safe and expeditious procedure; and open cecotomy is not favored, as recommended in the medical literature, to establish the diagnosis.

Congenital colonic atresia

Nineteen cases of congenital colon atresia are presented with two deaths resulting in a mortality rate of 10.5%. The authors conclude that operative management of atresias proximal to the splenic flexure should include resection of the dilated proximal colon with primary ileotransverse colostomy or ileosigmoidostomy. Atresias distal to the splenic flexure should be managed with a colostomy with later establishment of gastrointestinal continuity.

Typhoid perforation of the ileum in children

Since 1974, 59 children with typhoid perforation of the ileum were studied prospectively using two protocols. In the first 36 cases a temporary total bypass of the terminal ileum was done (end-to-side ileotransverse colostomy) and several weeks later the intestinal continuity was restored (end-to-end ileoileostomy). The second protocol consisted, in 23 cases, of a partial bypass of the terminal ileum (one stage lateral tube ileostomy). Of the first group 10 died (27.7%). There was no reperforations or fistulae in this group. Of the 26 lateral tube ileostomies 8 died (34.8%). There was one reperforation and 4 fistula in this group. The combined mortality was 30.5%. Complications are presented as well as different methods of treatment. The author believes that a bypass operation with good medical supportive treatment, including total parenteral alimentation, will improve results.

Typhoid perforation of the bowel. Experiences in 78 cases.

Seventy-eight patients ranging from four to 65 years of age were treated for typhoid perforation of the bowel. Sixty-one patients (78%) were males. The average time from perforation to admission was 56 hours. The mortality rate was 32% and was adversely influenced by the duration of illness, duration of perforation, shock, uremia, encephalopathy and fecal peritonitis. Forty-nine patients were treated by closure of the perforation, resection or miscellaneous procedures; the other 29 by closure of the perforation combined with an end-to-end ileotransverse colostomy. Although mortality was the same in both groups, those undergoing bypass had a significantly smoother postoperative course.

Ileostomy of the distal end of the bypassed intestine in a patient with jejunoileal bypass for obesity

Ileostomy of the distal end of the bypassed segment of small intestine was done twenty-three months after a 28 to 20 cm (12 to 8 inch) end-to-end jejunoileal bypass for obesity (Scott operation) in a forty-eight year old white female, thus creating a Thiry fistula. Weight prior to jejunoileal bypass was 130 kg (287 pounds). Before ileostomy it had stabilized at 80.3 kg (177 pounds). Indications for ileostomy were three episodes of blind loop syndrome and three episodes of severe bleeding from the ileotransverse colostomy anastomotic site. Culture of the bypassed segment at laparotomy revealed bacteroides, clostridia, and other anaerobes as well as the usual aerobic large bowel flora. After ileostomy the bypassed segment contained no anaerobic bacteria. Daily fluid output from the ileostomy has decreased with time, averaging 436 ml per day for the first postileostomy month and 50 ml per day for the ninth month. Beneficial effects of the ileostomy include: (1) better sense of well being; (2) no further episodes of blind loop syndrome or intestinal bleeding; and (3) cessation of anal itching. Nine months after ileostomy, hyperoxaluria and acquired megacolon were present. Weight was 5.9 kg (13 pounds) greater than before ileostomy.

Perforated diverticulitis of the terminal ileum

The clinical course of a patient with perforated diverticulitis of the terminal ileum is described and six other reports in the literature are reviewed. The acute symptoms and signs simulate those of acute appendicitis, although two patients were seen with a less acute stage of disease; one had an enterovesical fistula and one (our patient) a walled-off abscess. Primary resection with ileotransverse colostomy is probably the preferred treatment, but mortality and morbidity have been significant.

Delayed hemorrhage from a gastrointestinal anastomotic suture line: report of a case.

The unusual occurrence of bleeding from a gastrointestinal anastomosis 29 days after right colectomy and ileotransverse colostomy is described. Diagnosis and prompt treatment were facilitated by the use of selective superior mesenteric arteriography.

Delayed Suture-Line Hemorrhage

To the Editor.— Hemorrhage from the suture-line following gastrointestinal anastomoses is a well known phenomenon. Suture-line hemorrhage has been most frequently reported following gastrectomy, with a reported incidence of 3.4%. 1 This hemorrhage is most often secondary to technical failure to control vessels at the site of the anastomosis and usually manifests itself in the immediate postoperative period. Occasionally, this hemorrhage may occur on the sixth to tenth postoperative day, presumably due to sloughing of the inner layer of the anastomotic suture line. 2 This report describes a case of delayed sutureline hemorrhage 29 days following right colectomy and ileotransverse colostomy for carcinoma of the cecum. Report of a Case.— An 83-year-old woman underwent right colectomy and ileotransverse colostomy for carcinoma of the cecum (Duke's B classification) on Aug 7, 1970. The anastomosis was performed using a two-layer open technique. There were no intraoperative complications, and the procedure was accomplished

Metastatic ovarian carcinoid tumor

Case report The patient was a multiparous, unmarried female, age 66 years. She presented with a history of sudden onset of varicose veins some months previously, followed by oedema of the ankles for 6 weeks. Eight years previously she was investigated extensively for post-menopausal vaginal bleeding, no cause being found at that time. At the same time a duodenal ulcer was discovered, and treated successfully with a medical regimen. Five years later, a severe attack of diarrhoea was diagnosed clinically and radiologically as due to diverticulitis, and controlled with adequate doses of 'Lomotil'. On examination the patient was fit, and abdominal examination was essentially negative. Rectal examination revealed a large, firm mass in the pouch of Douglas. This was confirmed vaginally, but the mass appeared separate from the uterus, right-sided, and fixed to the lateral pelvic wall. Both legs showed marked varicosity of the long saphenous systems, together with minimal oedema of the ankle to midcalf regions. Operation. A laparotomy was performed through a lower, right paramedian incision. The terminal ileum was obstructed due to an extensive tumour. There was a large mass of glands along the right ovarian vein, particularly at the junction of the vein with the vena cava. Both lobes of the liver contained numerous metastatic tumour deposits. The pelvis contained a large, incarcerated, solid tumour of the right ovary, with involvement of the uterus medially, and the pelvic wall laterally. A total hysterectomy, bilateral salpingo-oophorectomy and radical excision of the right ovarian vessels, and lymph nodes as far as the vena cava, were performed. An ileo-transverse colostomy was also necessary to bypass the obstruction in the small bowel. Following operation she made a complete clincal recovery, the ankle oedema subsiding and the varicose veins completely resolving. The diarrhoea temporarily cleared, only to return after 4 months. At the same time, she began to develop more symptoms and signs of the malignant carcinoid syndrome, namely flushing attacks, facial cyanosis and attacks of breathlessness. The diarrhoea became uncontrollable. One year after operation, the liver has enlarged to fill approximately the upper half of the abdomen, and contains palpable secondary deposits of tumour. Despite all these problems she manages to lead a reasonably active life. Post-operatively, the 24-hr urinary excretion of 5-hydroxyindole acetic acid was 45 mg (upper limit

Control of diarrhea by cholestyramine administration.

Troublesome diarrhea with abdominal cramping, urgency to stool and tenesmus occurred in four subjects with ileal bypass, and one with an ileotransverse colostomy and ileal resection. There is reason to believe that this may have been due to failure of ileal absorption of bile salts so that they ente