Loop Colostomy Research Articles

A comparative study of stoma-related complications from diverting loop ileostomy or colostomy after colorectal surgery.

Even though minor, stoma-related complications significantly impact quality of life, they are often excluded from clinical analyses that compare short-term postoperative outcomes of loop ileostomy and loop colostomy. This study compares stoma-related complications between loop ileostomy and loop colostomy after rectal resection, including minor complications, and discusses the characteristics of diverting stoma types. A retrospective review was conducted in patients who underwent diverting stoma construction after rectal resection. Data on patient background and postoperative short-term outcomes, including stoma-related complications and morbidity after stoma closure, were collected and compared between loop ileostomy and loop colostomy groups. Morbidities of all severity grades were targeted for analysis. A total of 47 patients (27 loop ileostomy, 20 loop colostomy) underwent diverting stoma construction following rectal resection. Overall stoma-related complications, incidence of skin irritation, high-output stoma, and outlet obstruction were significantly higher in the loop ileostomy group but high-output stoma and outlet obstruction were absent in the loop colostomy group. Regarding morbidity after stoma closure, operation times and surgical site infections were significantly higher in the loop colostomy group while anastomotic leakage after diverting stoma closure occurred (2 cases; 15%) in the loop colostomy group but not the loop ileostomy group. Because stoma-related complications were significantly higher in the loop ileostomy group, and even these minor complications may impair QOL, early loop ileostomy closure is recommended. For loop colostomy, stoma-related morbidities are lower but post-closure leakage is a calculated risk.

V08-12 PERINEAL APPROACH IN THE MANAGEMENT OF URORECTAL FISTULA

You have accessJournal of UrologyCME1 Apr 2023V08-12 PERINEAL APPROACH IN THE MANAGEMENT OF URORECTAL FISTULA Agusti Marfany, Anastasia Frost, Nicola Jeffery, Mariya Dragova, Angelica Lomiteng, Daniela Andrich, and Anthony Mundy Agusti MarfanyAgusti Marfany More articles by this author , Anastasia FrostAnastasia Frost More articles by this author , Nicola JefferyNicola Jeffery More articles by this author , Mariya DragovaMariya Dragova More articles by this author , Angelica LomitengAngelica Lomiteng More articles by this author , Daniela AndrichDaniela Andrich More articles by this author , and Anthony MundyAnthony Mundy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003306.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The current increase in radical prostatectomies has raised the incidence of urorectal fistulas. When the conservative management fails, a surgical solution should be considered. Urorectal fistulas are one of the most difficult problems a urologist can face. There is no standard surgical approach to treat such fistulas as few surgeons have enough large experience to deal with them. Several approaches have been described: transabdominal, posterior-sagittal (Kraske), posterior trans-sphincteric (York-Mason), transanal and perineal. The perineal approach grants a greater exposure of the rectum and the inferior urinary tract and allows the interposition of flaps if needed. But it is a surgical challenge since it is a narrow space surrounded by relevant structures. The objective of this video is to present the perineal approach of urorectal fistula repair. METHODS: A 72-year-old patient is derived to a quaternary care urology center for a reconstructive solution. He had a radical assisted laparoscopic prostatectomy (RALP) performed one year ago due to a high-risk prostate cancer, complicated with a urorectal fistula. He was initially treated with a urethral catheter and a defunctioning loop colostomy. Patient was fit and well in our first assessment. A cystoscopy is performed to assess the location and size of the fistula, its relation to the ureter orifices and bladder neck, as well as the presence of visible health tissue near the fistula. An MRI gives information about the fistula tract and its relation to surrounding organs. The patient was put in for surgery. RESULTS: An inversed U-shaped perianal incision is performed. A deepen dissection through the perineal body, levators ani and the anterior rectal wall leads to the fistula tract. Precaution is taken to follow the right directions of the dissection until the rectovesical pouch is reached. Bladder and rectal defects are closed separately with two layers of sutures. Levators ani are interposed, and dead space is obliterated with sutures. Urethral catheter is removed 4 weeks after the operation with confirmed leak tightness on the peri-catheter urethrogram. CONCLUSIONS: Urorectal fistulas are manageable through a perineal approach, which is part of the armamentarium of the urology reconstructive surgeon. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e752 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Agusti Marfany More articles by this author Anastasia Frost More articles by this author Nicola Jeffery More articles by this author Mariya Dragova More articles by this author Angelica Lomiteng More articles by this author Daniela Andrich More articles by this author Anthony Mundy More articles by this author Expand All Advertisement PDF downloadLoading ...

Surgical treatment of stomal prolapse: A systematic review and meta-analysis of the literature.

This study aimed to assess success, recurrence, and overall complication rates among different surgical procedures for stomal prolapse. This study was a PRISMA-compliant systematic review. PubMed, Scopus, and Google Scholar were searched until March 2022. Studies that assessed surgical treatments of stomal prolapse in adults were included. The primary outcome was recurrence of stomal prolapse and the secondary outcome was 30-day complications. A random-effect meta-analysis was used to estimate the weighted mean rates of recurrence. Six studies published (111 patients; 103 males) were included. 52 (46.8%) patients had end colostomies, 35 (31.5%) had loop colostomies. Seven procedures were assessed and included local stoma reconstruction (40%), stapled local repair (27%), modified Altemeier technique (10%), mesh strip repair (9%), stoma relocation (6%) redo laparotomy repair (5%), and colectomy and end ileostomy (3%). The weighted mean recurrence rate after local stoma reconstruction was 37.2% (95% CI: -1.8 to 76.3), higher than that after the stapled local repair technique (14.9%; 95% CI: 1.7-28.2). The crude recurrence rate of the modified Altemeier technique was 20%, and of stoma relocation was 66.6%. No recurrence was detected after the mesh strip technique (n=10). The median follow-up ranged between 7 months and 2.5 years. Several surgical techniques are available to treat stomal prolapse. Local stoma reconstruction may be associated with high rates of recurrence while the stapled local repair and modified Altemeier procedure has relatively low recurrence. Further larger studies are needed to compare the efficacy of these techniques.

Outcome of Divided and Loop Sigmoid Colostomy for the Management of Anorectal Malformation (ARM): A Comparative Study

Background: Anorectal Malformation (ARM) is one of the common congenital anomalies in the world. There are various surgical options for management of ARM. Colostomy is usually performed as a first stage in a new born with high and intermediate variety of anorectal malformations. The aim of the study was to compare the clinical outcomes between divided and loop sigmoid colostomy for the management of anorectal malformations. Material and Methods: This prospective comparative study was conducted on 130 pediatric patients at the Faculty of Pediatric Surgery, Bangladesh Shishu Hospital and Institute, who were admitted with anorectal malformations (ARM) up to 7 days of age, from March 2018 to February 2021. Informed consent was obtained after proper counselling with the guardian. They were randomly assigned to the divided sigmoid colostomy group (group 1=65 neonates) and loop sigmoid colostomy group (group 2=65 neonates). The comparative parameters between two groups were the operation time, post-operative complications such as wound infection, skin excoriation, prolapse of colostomy, retraction of colostomy and parastomal hernia. All patients were followed up for 2 months post-operatively. Results: The mean age of the patients was 2.43±1.39days in group 1 and in group 2, the mean age was 2.61±1.73 days where majority of the patients were male. The statistical difference between the two groups regarding operation time was highly significant (0.0001). After operation, 26.15% patients developed skin excoriation in group 1 where in group 2, 29.23% patients developed skin excoriation. In group 1, 6.15% patients developed wound infection but none of them developed prolapse, retraction of colostomy and parastomal hernia. On the other hand, in group 2, 1.54% patient developed wound infection, 15.38% patients developed prolapse and 6.15% patients developed retraction of colostomy and no patient experienced parastomal hernia. The statistical difference between the two groups regarding prolapse of colostomy was significant (p=0.042). Conclusion: In our study, the frequency of different stoma-related problems was greater in the loop colostomy group, although being statistically insignificant. In the divided group, there was significantly less stoma prolapse. In light of these results, divided stoma should be suggested for newborns with ARM.

Ultrasound-Guided Enteropexy for Repair of Ostomy Prolapse.

Background: Enterostomies provide fecal diversion for numerous conditions, but anatomical complications-prolapse, stricture, and retraction-occur in up to 25%. Given up to 76% of these complications require surgical intervention, effective minimally invasive repair techniques for their management are needed. This article describes a new technique for prolapse repair utilizing image-guided surgery for incisionless repair of ostomy prolapse. Methods: To perform the procedure, the prolapsed bowel is reduced and evaluated for feasibility for ultrasound repair. Under direct ultrasound guidance sutures are used to pexy the bowel loop to the overlying fascia. Sutures are tied with knots and sutures buried below the skin to securely tack the bowel to the abdominal wall. Results: Four patients aged 2-10 years underwent ultrasound-guided enteropexy for repair of major prolapse of an end ileostomy (2 patients), loop colostomy, and end colostomy. All patients remained free of major prolapse for 3-10 months after the procedure, 2 of whom have progressed to ostomy takedown without complications. Conclusions: Ultrasound-guided enteropexy is a noninvasive effective way to manage ostomy prolapse.

Closure of Transverse Loop Colostomy.

Caiado, André M.D.1; Cabral, Francisco X. M.D.1; Barroca, Rita M.D.2 Author Information

Simultaneous Treatment of Complex Incisional Hernia and Stoma Reversal.

Purpose: The simultaneous repair of incisional hernias (IH) and the reconstruction of the intestinal transit may pose a challenge for many surgeons. Collaboration between units specialized in abdominal wall and colorectal surgery can favor simultaneous treatment. Methods: Descriptive study of patients undergoing simultaneous surgery of complex IH repair and intestinal transit reconstruction from the start of treatment in a joint team. All interventions were performed electively and with the collaboration of surgeons experts in abdominal wall and colorectal surgery. Results: 23 patients are included. 11 end colostomies, 1 loop colostomy, 6 end ileostomies and 5 loop ileostomies. Seven (30%) patients presented with a medial laparotomy incisional hernia, 3 (13%) with a parastomal incisional hernia, and 13 (56%) with a medial and parastomal incisional hernia. Closure of the hernial defect was achieved in 100% of cases, and reconstruction of the intestinal tract was achieved in 22 (95%). Component separation was required in 17 patients (74%), which were 11 (48%) posterior and 6 (26%) anterior. In-hospital morbidity was 9%, and only two patients presented Clavien-Dindo morbidity > III when requiring reoperation, one due to hemorrhage of the surgical bed and another due to dehiscence of the coloproctostomy. The mean follow-up was 11months, with 20 (87%) patients having no complications. Mesh had to be removed in one patient with anastomotic dehiscence, no mesh had to be removed due to surgical site infection.

Protective loop ileostomy or colostomy? a risk evaluation of all common complications.

Protective ileostomy and colostomy are performed in patients undergoing low anterior resection with a high leakage risk. We aimed to compare surgical, medical, and daily care complications between these 2 ostomies in order to make individual choice. Patients who underwent low anterior resection for rectal tumors with protective stomas between January 2011 and September 2018 were enrolled. Stoma-related complications were prospectively recorded by wound, ostomy, and continence nurses. The cancer stage and treatment data were obtained from the Taiwan Cancer Database of our Big Data Center. Other demographic data were collected retrospectively from medical notes. The complications after stoma creation and after the stoma reversal were compared. There were 176 patients with protective colostomy and 234 with protective ileostomy. Protective ileostomy had higher proportions of high output from the stoma for 2 consecutive days than protective colostomy (11.1% vs. 0%, P<0.001). Protective colostomy resulted in more stoma retraction than protective ileostomy (21.6% vs. 9.4%, P=0.001). Female sex, open operation, ileostomy, and carrying stoma more than 4 months were also significantly associated with a higher risk of stoma-related complications during diversion. The incidence of complication after stoma reversal did not differ between colostomy group and ileostomy group (24.3% vs. 20.9%, P=0.542). We suggest avoiding colostomy in patients who are female and potential prolong diversion when stoma retraction is a concern. Otherwise, ileostomy should be avoided for patients with impaired renal function. Wise selection and flexibility are more important than using one type of stoma routinely.

Massive rectal bleeding caused by diversion colitis

A 74-year-old male patient presented to the emergency department with hematochezia and dizziness. Seven years ago, the patient had a colonoscopy at another hospital, during which a perforation in the sigmoid colon was found; consequently, he underwent a loop colostomy. He was pale, with a blood pressure of 70/40 mmHg and a pulse of 130 beats per minute

Retrospective analysis of surgical and oncological results of laparoscopic surgeries performed by residents of coloproctology.

with the improvement and wide acceptance of laparoscopy in colorectal operations, there was a need for specific training of surgeons in training. There are few studies evaluating the postoperative results of laparoscopic colectomies performed by resident physicians and their impact on patient safety. to analyze the surgical and oncological results of laparoscopic colectomies performed by coloproctology residents and compare them with data in the literature. this is a retrospective analysis of patients undergoing laparoscopic colorectal surgery performed by resident physicians at the Hospital das Clínicas de Ribeirão Preto, between 2014 and 2018. The clinical characteristics of the patients were studied, as well as the main surgical and oncological aspects in a period of one year. we analyzed 191 operations, whose main surgical indication was adenocarcinoma, most of them stage III. The mean duration of surgeries was 210±58 minutes. There was a need for a stoma in 21.5% of the patients, mainly loop colostomy. The conversion rate was 23%, with 79.5% due to technical difficulties, and the main predictors of conversion were obesity and intraoperative accidents. The median length of stay was 6 days. Preoperative anemia was associated with a higher rate of complications (11.5%) and reoperations (12%). Surgical resection margins were compromised in 8.6% of cases. The one-year recurrence rate was 3.2% and the mortality rate was 6.3%. videolaparoscopic colorectal surgery performed by residents showed efficacy and safety similar to data found in the literature.

Gastric Outlet Obstruction Secondary to Incarcerated Stomach in Parastomal Hernia

Gastric outlet obstruction due to an incarcerated stomach in a parastomal hernia is extremely rare. Here, we present the management of such a case with a review of the literature. A 79-year-old woman presented with a 3-week history of postprandial vomiting and associated parastomal and epigastric pain. She had a loop colostomy created for severe fecal incontinence secondary to anal stenosis. Imaging revealed a large parastomal hernia with an incarcerated gastric antrum. She was initially managed nonoperatively with a nasogastric tube. She underwent a semi-elective open Sugarbaker mesh repair of the parastomal hernia with good results. Gastric outlet obstruction secondary to incarceration of the stomach in a parastomal hernia is uncommon. A conservative approach with nasogastric tube decompression is a reasonable initial approach in a patient who is not critically unwell, which allows time for consideration of different parastomal hernia repair techniques.

SJLA_2024_A1: Appendix and Ascending Colon Intussusception through a Prolapsed Transverse Colostomy: A Case Report with Literature Review

Background: Stoma creation is one of the most common performed surgical procedures. For both benign and malignant conditions, in elective and emergency settings. Like any surgical procedure, it is associated with complications. One of the most frequently encountered is prolapse, with the incidence rate reaching 26%. On the other hand, intussusception of the bowel through the ostomy is a rare complication, with few cases being reported in the literature. Methods: The study was a case report. Results: We reported a case of a 52-year-old female with a proximal limb transverse loop colostomy prolapse noted 1 day before her presentation. Intraoperatively, cecal intussusception through the ostomy is encountered with unsalvageable right colon. The patient ended up with right hemicolectomy, end ileostomy, and mucus fistula. Discussion: Although stoma prolapse is a common late complication with an impact on quality of life in terms of difficulty with appliance fitting, it can be an early sign of a serious condition like intussusception. This necessitates a differentiation between intussusception through a prolapsed colostomy from simple prolapse. Based on literature, reduced stoma output along with significant irreducible prolapsed segment are the frequent clinical characteristics. Yet, it should be noted that the intussuscepted segment is only evident upon surgical exploration. Conclusion: Caution during stoma creation must be attempted, with the avoidance of underestimating a significant irreducible prolapse. As it may be lead to intussusception and subsequent bowel perforation.

Childhood colostomies: patterns, indications and outcomes in a Nigerian University Teaching Hospital.

Most childhood colostomies are done for decompression or diversion in gastrointestinal tract congenital anomalies. Colostomy may be sited in the transverse or sigmoid colon as loop or defunctioning (divided) colostomies. Current pattern seems towards construction of more sigmoid and defunctioning colostomies. To evaluate the patterns, indications and outcomes of childhood colostomies. Patients and Methods: Retrospective chart review of all colostomies performed in children below 15 years from September 2010 to August 2020. There were 104 colostomies (55males; 49females; 65 sigmoid; 39 transverse colostomies; 3 loop; 101 defunctioning colostomies. Anorecatal Malformation (ARM)was indication in 32 males and 41 females; age range 2 days to 13 years. Hirschsprung's Disease (HD) was indication in 18 males and 4 females; age range 6 weeks to 15 years.In HD there were three loop colostomies (3/22) in transverse colon and 19 defunctioning colostomies (8 sigmoid, 11 transverse) while in ARM all 73 were defunctioning colostomies(P=0.01)In HD there were 14/22 transverse colostomies and 8/22 sigmoid colostomies while ARM had 24/73 transverse and 49/73 sigmoid colostomies (P =0.013)In HD 91% colostomies were done beyond infancy while in ARM 93% were before one year(P<0.0001). Mortalities were noted in 1.9% patients. Commonest indication for colostomy is ARM. There are more defunctioning than loop colostomies, and more sigmoid than transverse colostomies. of most colostomies in ARM were during infancy while mostly beyond infancy in HD.

Adaptation to the Resource Available in Construction of Stoma in Pediatric Stoma Care in Bangladesh: A Descriptive Analytical Study

Background: Stoma construction is a routine operation in the field of pediatric surgery. Commercially accessible resources, such as ostomy bags (either disposable or with extended lifespans), are often employed to care for these stomas. These may be rather pricey, especially in places like Bangladesh, and it might be difficult to get ones in the right size. Objective: In this study our main objective is to evaluate the efficacy of resource available in construction of stoma in Pediatric stoma care in Bangladesh. Method: From January 2014 through December 2015, a total of 60 patients were included in a prospective research done by the pediatric surgery department at Dhaka Medical College and Hospital. The research group consisted of patients less than 12 years old who had temporary loop colostomy or ileostomy in the pediatric surgical units at Dhaka Medical College &amp; Hospital throughout the study period. Zinc oxide paste was first administered to the Peristomal skin after stoma formation. The stoma was covered with a betel leaf, which had a glossy, smooth outside surface and a rough inner surface. The size of the hole in the betel leaf was adjusted to accommodate the stoma. The stoma is protected by an additional leaf that is still fully intact. When nature calls, one must remove the undamaged leaf above it and wipe away the feces before moving on. The cleaned leaves were put to further use. Ostomy bags (like those made by Convatec) and adhesive paste (Stomahesive) are used to seal the bag to the Peristomal skin. Results: During the study, both the stoma bag and betel leaf groups had a wide range of ages, from one day to 4,320 days. In addition, both group anorectal malformations found as common indication 70% vs 73.33% (stoma bag vs betel leaf) followed by in stoma bag group 23.33% had Hirschsprung’s disease and 6.67% had Colonic atresia. Where as in betel leaf group 20% had Hirschsprung’s disease and 6.67% had Colonic atresia? In stoma bag group majority had ......

The study of morphofunctional changes in the gastrointestinal tract after various operations on the colon (an experiment in rats)

Objective : modeling various types of surgical procedure in an experiment in rats, assessing the effect of surgery on the motility of the gastrointestinal tract (GIT). Materials and methods : the study was carried out on 30 female Wistar rats weighing 200–250 grams, comparable in age, divided into 3 groups (10 animals each) in random order. group 1 — rats underwented to laparotomy (LT), group 2 — laparotomy, creation of a loop colostomy (LT + C), group 3 — laparotomy, a colonic single-row anastomosis (LT + A). Gastrointestinal motility was assessed using the gastrointestinal transit index (GTI), calculated by the formula: (length of the stained area of the intestine / total length of the intestine) x100, as well as by the results of a morphological study. Results : surgery has a depressing effect on the motility of the gastrointestinal tract, while the maximum decrease in IHT was noted in the Colostomy group: 1.08±1.4% versus 2.3±3.3% in the Laparotomy group and versus 3.8±1.8% in the Anastomosis group. Comparison of the groups “Colostomy” and “Anastomosis” showed a significant difference in this feature — p=0.002. Conclusion : modeling of various surgical procedure in rats made it possible to prove the relationship between the formation of a stoma and the inhibition of gastrointestinal motility, further study of this pattern will allow us to develop ways to prevent the development of postoperative ileus.

Types and Levels of Colostomy in Children with Anorectal Malformation

Objective: Divided colostomy for anorectal management is often recommended due to reports of higher complications associated with loop colostomy. This study was conducted to compare outcomes and complications in colostomies in children with anorectal malformations according to type and level of colostomy.&#x0D; Materials and Methods: A retrospective study was performed in children with anorectal malformations who underwent a colostomy at Siriraj Hospital between December 2003 and June 2018.&#x0D; Results: Out of 167 patients, 159 had a loop colostomy while 8 had a divided colostomy. Overall complication rates were 33.3% for loop colostomy and 62.5% for divided colostomy (p = 0.100). Urinary tract infection was the most frequently encountered complication in both loop and divided colostomies, at 23.7% and 50%, respectively (p = 0.094). The prolapse rate in the loop colostomy group was 8.8 % and 0% in the divided colostomy group (p = 0.376). Overall complication rates with respect to location of stoma also did not differ (p = 0.706). Prolapse rates were 15.8 % in transverse colostomy and 7.1 % in sigmoid colostomy (p = 0.231). Overall complications rates of colostomy closure in loop and divided colostomy was 7.5% and 12.5%, respectively (p = 0.672). Non-inferiority was demonstrated by the differences in overall complications of loop and divided colostomy (p = 0.008).&#x0D; Conclusion: There was no difference in incidence of complications between type or location of colostomy performed in children with anorectal malformations. Loop colostomy was non-inferior to divided colostomy in respect to overall complications.

S2049 Important Considerations for Gastroenterologists to Take into Account in an Adult Patient With Anorectoplasty Secondary to Anorectal Malformation

Introduction: Anorectal malformations (ARMs) are congenital conditions with varying clinical presentations. The approximate incidence is 1:2,500 to 1:5,000 live births. Diagnosis and treatment are usually performed in childhood; therefore, ARMs are relatively rare in adults. However, some cases can go unnoticed in underdeveloped countries due to health care barriers and errors. Globally, few cases of ARMs have been reported in adulthood, so the literature is limited. Medical debate continues about the best approach and follow-up of the patient. The objective of this case is to describe the main gastroenterological points for consideration. Case Description/Methods: A 54-year-old female patient product of a vaginal birth delivered outside of medical facilities by unqualified personnel. Throughout the patient's childhood, she consulted different clinics and public health services for infections secondary to the discharge of feces through the vagina. In 2021, she was seen at a family medicine clinic of the national university in Guatemala for osteoarthritis. In her medical history, she mentioned the ARM condition and was referred to a proctologist who diagnosed an Imperforate Anus (Figure A) and a Rectovestibular Fistula, even though she had successfully delivered 3 infants by c-section. An MRI was ordered to rule out any other associated malformations prior to surgery. Subsequently, a 2-stage surgery under spinal anesthetic block was performed: First, a loop colostomy and Peña Posterior Sagittal Anorectoplasty were done (Figure B, C), with a thinning of the elevator and anus muscles diagnosed. Three months later a colostomy closure was performed. The patient has been followed monthly for 6 months with satisfactory results with anal dilatation reserved, if necessary, but the functionality of the neo-anus has, to date, been adequate. Discussion: The main points for consideration are a) age should not be a contraindication for corrective surgery; b) the functionality of the sphincter complex must be determined in each patient; c) due to the congenital etiology of the imperforate anus, as well as physiological and the anatomical changes, there has been no developed hemorrhoidal vascular network; d) the main anticipated complication is cicatricial stenosis of the neo-anus secondary to the surgical intervention, so programmed anal dilations should be considered if needed. Given the rarity of ARMs in adults, further manometric research of the physiology of the anal complex is required to establish functionality parameters.Figure 1.: Anorectoplasty Process: (a) Imperforate anus, (b) Anorectoplasty with reconstruction of the rectovaginal septum, (c) Anoplasty.

S2610 Huge Pain in the Behind: Radiation-Induced Perforation and Bleeding Treated with Hemostatic Spray

Introduction: Prostate brachytherapy with radiation is an effective treatment for localized prostate cancer. While generally well tolerated, radiation-associated proctopathy with resultant lower gastrointestinal (GI) bleeding is a common complication of this treatment. Rarely, prostate brachytherapy can result in rectoprostatic fistulae. There is no standard endoscopic treatment for lower GI bleeding from this complication. Increasingly, hemostatic powders are used as a “bail-out” or temporizing measure to control bleeding when the source is not amenable to other endoscopic interventions. Herein we report a case of successful control of lower GI bleeding from a rectoprostatic fistula using hemostatic spray. Case Description/Methods: A 78-year-old man with stage IV rectal adenocarcinoma and history of prostate cancer treated with radiation and brachytherapy 20 years ago presented with 4 weeks of intermittent anorectal pain. A contrast-enhanced CT of the pelvis showed air-fluid collections around the prostate contiguous with the rectum. Flexible sigmoidoscopy showed a large solitary rectal ulcer covered in stool and mucous, not requiring any intervention. One month later, he presented with profuse hematochezia. Although he was hemodynamically stable, his hemoglobin decreased to 10.1 g/dL from 13 g/dL. Repeat flexible sigmoidoscopy showed a large, cratered rectal ulcer with adherent clots and active oozing. The prostate, with visible brachytherapy beads, was seen eroding into the rectal wall. Hemostatic spray was successfully deployed to control the bleeding. He ultimately underwent a diverting loop colostomy. Discussion: The incidence of rectoprostatic fistula after brachytherapy is 0.26-1%. Fistula formation tends to occur within 37 months. Our case is rare in that rectoprostatic fistula after brachytherapy has only once been reported after 37 months, with that case being at 12 years and ours at 20 years. To our knowledge, hemostatic spray has not been used to treat lower GI bleeding from rectoprostatic fistulae. Our experience demonstrates that this could be a viable temporizing measure in this situation. Definitive therapy may involve hyperbaric oxygen, where one patient with rectal perforation from radiotherapy was cured after 5 weeks of 24 sessions. Other considerations may be a diverting colostomy, which occurred in this patient, or proctectomy for more severe cases.

A retrospective study long term complications and outcome of Ano rectal malformation following LAARP (Laparoscopic Assisted Ano Rectal Pull through) procedure

Background: The laparoscopic procedure has many added advantages of being less time consuming, early discharge from the hospital, less tissue damage, and better visualization of the pelvic structures. Objective: to study the complications and outcomes in ARM patients following LAARP. Methods: This study was conducted on 55 ARM patients in the Raichur Institute of Medical Sciences RIMS/ RGSSH (OPEC) Raichur Karnataka. The study period is from Dec 2016 to Dec 2020. Results: All the fifty five patients who are operated for anorectal malformation, they underwent first surgery (high sigmoid loop colostomy) within the second and third day of neonatal period, and second surgery the LAARP within the six weeks to three months of the first surgery, a Demographics, type of ARM, and age at pull-through. All LAARP surgery was done by single surgeon, there were no anaesthetic complications. Conclusion: This study emphasizes the emerging laparoscopic technique for management of anorectal malformations. Using this approach it is possible to achieve better continence rates as the extent of perineal dissection is minimal, hence inflicting minimal neural and sphincter injury.

P22 Paraneoplastic diffuse systemic sclerosis in association with ano-rectal tumour

Introduction/BackgroundRheumatic diseases can manifest as a paraneoplastic phenomenon. They can be seen during the course of neoplastic disease, precede the diagnosis, appear simultaneously or occur after the diagnosis of malignancy. Overall, paraneoplastic rheumatic syndromes are rare. It is however important to be aware of this phenomenon as the signs and symptoms of the rheumatic syndrome will usually subside with treatment of the underlying malignant disease. Furthermore, reappearance of symptoms may suggest cancer relapse.Description/Method51 year old woman with no significant past medical history was referred by her General Practicioner with 6-week history of pain and stiffness in hands, arms and legs. There was also associated 4-week history of change in bowel habit (diarrhoea and faecal incontinence). Clinical examination revealed skin thickening proximal to elbows and knees, sclerodactyly, facial telangiectasia as well as tendon friction rubs in lower limbs. There was also a mass palpable on digital rectal examination. Investigations revealed that the patient had new iron deficiency anaemia and mildly raised carcinoembryonic antigen. Anti-RNA polymerase III antibody returned positive. CT of chest, abdomen and pelvis suggested tumour involving the anus and lower rectum with metastatic lymphadenopathy. Those findings were also confirmed on subsequent MRI pelvis and PET CT. She underwent anal biopsy, examination under anaesthesia and formation of loop colostomy. Histopathology results confirmed poorly differentiated squamous carcinoma. Patient was then reviewed by oncology and discussed at multidisciplinary meeting. She was commenced on palliative chemotherapy (paclitaxel and carboplatin). After the first session she became severely anaemic and developed acute renal failure. She passed away approximately three months after initial referral to rheumatology.Discussion/ResultsThis patient was diagnosed with paraneoplastic diffuse systemic sclerosis in association with ano-rectal tumour. Unfortunately at the time of diagnosis the disease was metastatic therefore the only treatment option available was palliative rather than curative. Paraneoplastic rheumatic syndromes are rare. The signs and symptoms are secondary to the presence of malignancy. They may be induced by the substances that are secreted by the tumour or the immune system’s response to the malignant cells. Usually once patient recovers from the neoplastic disease the rheumatic disease signs/symptoms subside. In our patient’s history there were a number of features which raised the possibility of paraneoplastic aetiology. These included: sudden onset and rapid progression of clinical symptoms, late onset of disease (after 50 years of age), family history of cancer (dad had prostate cancer), new iron deficiency anaemia as well as the presence of anti-RNA polymerase III antibodies. This antibody is linked with cancer-associated systemic sclerosis. Patients who are positive have shorter cancer-scleroderma interval. Anti-RNA polymerase III antibody is unique to scleroderma and is not found in cancer patients without scleroderma.Key learning points/ConclusionThe key learning point from this case was not to forget the paraneoplastic aetiology in patients who present with rheumatic syndromes. In particular if the symptoms are of sudden onset or are progressing rapidly/responding poorly to therapy. There is only a small number of cases reported in literature of paraneoplastic systemic sclerosis. Furthermore, the importance of anti-RNA polymerase III antibody testing in scleroderma patients. If positive, it is important to be aware that those patients have >4-fold increased risk of cancer occurring within 2 years of scleroderma onset. It is therefore vital to look for any signs/symptoms during their routine follow-up appointments at rheumatology clinics.