Ostomy Closure Research Articles

The Success of the Bishop-Koop Surgery in Newborns with Meconium Ileus and Congenital Intestinal Atresia When Compared to Divided Stomas

Objective: The purpose of this study is to compare the Bishop-Koop procedure (BK) to the divided stoma in newborns with meconium ileus (MI) and congenital intestinal atresia. Study Design: Retrospective study Place and Duration: Children Hospital PIMS.Dec-2021-Jun 2022 Methods: There were seventy six neonates were presented in this study. Included neonates had meconium ileus (MI) and congenital intestinal atresia (CIA) and admitted to Hospital for surgery. Pateints were equally divided in two groups. Group I received divided stoma (DS) among 38 neonates and group II received Bishop-Koop procedure (BK) in 38 cases. Outcomes among both groups were compared in terms of surgery time, complications, and hospital stay. Mean standard deviation was used for data presentation. Results: There were 42 males (21 in each group) and 34 female (17 in each group) neonates among all cases. Mean age of the neonates in group I was 8.5 ± 4.16 days. Meconium ileus was found in 21(55.3%) in group I and 20 (52.6%) in group II and the rest of the neonates among both groups had congenital intestinal atresia. Mean operative time in group I was higher 180.7 ±9. 34 minutes as compared to group II 110.3 ± 7.26 minutes. We found that hospitalization in group II was lower 3.11 ±5. 40 days as compared to group I 10.2± 9.17 days. Frequency of complications in group I was higher found in 8 (21.5%) cases as compared to group II in 4 (10.5%) cases. Conclusion: In comparison to DS ostomies, we came to the conclusion that the BK approach is a safe, dependable, and acceptable technique for newborn surgery with a low risk of complications and shorter operating time and duration of hospital stay after ostomy closure. Keywords: Divided Stoma, Bishop-Koop, Meconium ileus , Congenital Intestinal Atresia, Complications

Diverting Ileostomy in Children With Functional Constipation: A Study Evaluating the Utility of Colon Manometry.

Pediatric functional constipation (FC) may require invasive evaluations [like colon manometry (CM)] and surgical interventions [including diverting ostomy (DO)]. We evaluated the utility of CM in guiding surgery after DO. Children with medically refractory FC undergoing an ostomy were included. Institutional Review Board approval was obtained for this retrospective study. Demographics and CM variables [high amplitude propagating contractions (HAPCs)] were recorded. Outcome measures: response to ostomy closure defined as successful if no need for further surgery after ostomy closure, and improvement on baseline CM after ostomy. A CM-guided ostomy closure algorithm was developed based on previous studies. We evaluated the association between response to ostomy closure and demographics, ostomy indication and CM improvement, and evaluated the role of CM predicting response using algorithm. A total of 60 children underwent ostomy for FC (median age: 7.1 years, range 0.15-23.6 years, 50% female). Ostomy was closed in 30 patients and deemed successful in 23 of 30. CM was performed in 42 of 60 patients before ostomy and in 29 of 30 before ostomy closure. We found no association between ostomy outcome and age, gender, weight, imaging studies, follow-up time, time with ostomy, HAPCs, and CM improvement. We found an association between failed response and ostomy indication of antegrade colonic enemas (ACE) failure ( P = 0.026) and successful response when ostomy closure was guided by algorithm ( P = 0.03). DO is a useful intervention in selected children with medically refractory FC, improving colon motility in most. CM can successfully guide the timing and type of ostomy closure. Larger studies are needed to further validate our findings.

Closed-wound negative pressure therapy dressing after loop ostomy closure: a retrospective comparative study

Closed-wound negative pressure wound therapy (NPWT) dressings were recently introduced with the purpose to reduce incisional surgical site infections (iSSI) in high-risk wounds. The aim of this study was to compare iSSI rates in patients after ostomy closure with and without additional application of a closed-wound NPWT dressing. Single-center retrospective analysis of consecutive patients undergoing ileo- or colostomy closure over an 8-year period (January 2013—January 2021). Intradermal non-purse string technique with absorbable sutures were used in all patients. Since November 2018, all patients (study group) received a NPWT device for a maximum of 5 days postoperatively (PICO, SMITH AND NEPHEW). Primary outcome was iSSI rate within 30 days of surgery. SSI was defined in accordance with the Center of Disease Control (CDC) classification and included superficial and deep incisional SSI. Data was retrieved from the institutional enhanced recovery after surgery (ERAS) database, with standardized complication assessment by trained abstractors. In total, 85 patients (25%) in the study group were comparable with 252 (75%) patients in the control group regarding demographics (age, gender, body mass index, ASA score), ostomy type and anastomotic technique (all p > 0.05), but not wound contamination class (class III: 5% vs 0%, p < 0.001). Median time to NPWT removal was 4 (IQR 3–5) days. Incisional SSI were observed in 4 patients (4.7%) in the study group and in 27 patients (10.7%) in the control group (p = 0.097). These preliminary results suggest a potential benefit of systematic application of the NPWT device after loop ostomy closure. A randomized controlled study is needed.

Applying a Silver-containing Dressing to the Incision Site and Its Effect on the Development of Surgical Site Infection After Ostomy Closure: A Prospective Randomized Clinical Pilot Study

BACKGROUND: Surgical site infections (SSIs) can occur after colorectal surgery. Ionic silver has been used to prevent the development of SSIs. New-generation dressings, defined as total occlusive ionic silver–containing dressings, have been shown to reduce bacterial colonization in SSIs. PURPOSE: To evalute the effect of a silver hydrofiber dressing on the development of SSIs at the abdominal incision after ostomy closure. METHODS: There was a total of 37 eligible patients who underwent temporary ostomy closure. Five patients required an associated intervention during ostomy closure and were excluded. One patient was lost to follow-up. Hence, 32 patients were included in the study. Silver-containing occlusive dressings and conventional dressings were used in patients who underwent ostomy closure. In the control group (n = 16), the wound area was covered with a standard sterile gauze dressing for 24 to 48 hours, and then wound cleansing was performed with 10% povidone iodine, followed by daily dressing replacement with sterile gauze for 5 days. The patients in the study group (n = 16) were treated with a silver-containing hydrofiber dressing, which was not changed for 5 days following application in the operating room. RESULTS: At the end of the 30-day follow-up period, no SSIs were observed in the study group. When the dressing methods applied to the patient groups with and without SSIs were compared, SSIs developed at a higher rate in the control group (n = 4; 26.7%) compared with the study group (n = 0); this result was statistically significant (P = .043). CONCLUSIONS: In this study, the use of a wound care product containing ionic silver reduced the rate of SSIs related to ostomy closure. Multicenter, randomized, clinical studies involving a larger number of patients are needed. In addition, occlusive wound dressings with and without silver should be investigated in further studies.

Ostomy closure rate during COVID-19 pandemic: an Italian multicentre observational study.

During the corona virus disease 2019 (COVID-19) pandemic, most of the surgical procedures were performed for emergencies or oncologic reasons to the detriment of the remaining elective procedures for benign conditions. Ileostomy or colostomy creation are sequelae of oncologic or emergency colorectal surgery, but their closure does not fall within the definition of oncologic or emergency surgery. The aim of this retrospective multicentre observational study is to report the impact of COVID-19 pandemic on the ostomy closure rate in Italy. Data regarding ileostomy and colostomy creation and closure from 24 Italian centres, during the study period (March 2020–February 2021) and during the control period (March 2019–February 2020) were collected. Three hospitals (12.5%) were COVID free. The number of colostomies and ileostomies created and closed in the same period was lower ( -18.8% and -30%, respectively) in the study period in comparison to the control period (p = 0.1915 and p = 0.0001, respectively), such as the ostomies closed in the analysed periods but created before (colostomy -36.2% and ileostomy -7.4%, p = 0.2211 and p = 0.1319, respectively). Overall, a 19.5% reduction in ostomies closed occurred in the study period. Based on the present study, a reduction in ostomy closure rate occurred in Italy between March 2020 and February 2021. During the pandemic, the need to change the clinical practice probably prolonged deterioration of quality of life in patients with ostomies, increasing number of stomas that will never be closed, and related management costs, even if these issues have not been investigated in this study.

Clinical efficacy of different approaches for laparoscopic intersphincteric resection of low rectal cancer: a comparison study

BackgroundThe operative results of different approaches for the laparoscopic intersphincteric resection (LAISR) of low rectal cancer vary, and the patient characteristics associated with the best outcomes for each procedure have not been reported. We compared the efficacy of different approaches for LAISR of low rectal cancer and discussed the surgical indications for each approach.MethodsWe retrospectively reviewed data from 235 patients with low rectal cancer treated via LAISR from October 2010 to September 2016. Patients underwent either the transabdominal approach for ISR (TAISR, n = 142), the transabdominal perineal approach for ISR (TPAISR, n = 57), or the transanal pull-through approach for ISR (PAISR, n = 36).ResultsThe PAISR and TAISR groups exhibited shorter operation times and less intraoperative blood loss than the TPAISR group. The anastomotic distance was shorter in the PAISR and TPAISR groups than in the TAISR group. No differences in the ability to perform radical resection, overall complications, postoperative recovery, Wexner score recorded 12 months after ostomy closure, 3-year disease-free survival, local recurrence-free survival, distant metastasis-free survival, or overall survival (OS) were observed among the three groups.ConclusionsTAISR, TPAISR, and PAISR have unique advantages and do not differ in terms of operation safety, patient outcomes, or anal function. TPAISR requires a longer time to complete and is associated with more bleeding and a slower recovery of anal function. PAISR should be considered when TAISR cannot ensure a negative distal margin and the tumor and BMI are relatively small; otherwise, TPAISR is required.

Psychological and sexual distress in rectal cancer patients and partners.

Rectal cancer (RC) patients experience unique sources of distress, including sexual dysfunction and body image concerns, which can also cause distress among partners. This preliminary study investigated patterns of psychological distress, sexual functioning, sexual distress, and relationship satisfaction among RC patient-partner couples at pivotal points during cancer treatment. Twenty couples participated (N=40). Patients and partners completed a series of validated measures of psychological distress (ET), sexual functioning (FSFI; IIEF), sexual distress (GMSEX; Sexual Distress Scale) and relationship satisfaction (GMREL) at time of diagnosis, 3weeks after radiation, 4weeks post-surgery, and after chemotherapy and surgery for ostomy closure. Descriptive statistics, t-tests, and repeated-measures ANOVA were used to analyze scores over time, first for patients and partners, and then by sex. Relationship satisfaction remained elevated over time. In this sample, 55% of patients and 78.9% of partners reported clinically significant rates of psychological distress at diagnosis, which decreased to 23% and 46% respectively at the last assessment. Sexual satisfaction and distress worsened for patients and partners between baseline and surgery for ostomy closure. Both male and female participants reported statistically significant declines in sexual function from baseline to end of treatment (p<0.05). Relative to relationship satisfaction, psychological and sexual health outcomes seem more vulnerable to the effects of RC treatment during the first year after diagnosis, both for patients and partners and for men and women. Results support the need for psychosocial care and sexual education/counseling for couples coping with RC.

COMPARAÇÃO ENTRE O FECHAMENTO DE OSTOMIA EM BOLSA VS. GRAMPEAMENTO LINEAR EM CRIANÇAS

Type of ostomy closure has connection with some complications and also cosmetic effects. This study aimed to compare result of colostomy closure using purse-string method versus linear method in terms of surgical site infection, surgical time, and patient satisfaction. In this study, 50 patients who underwent purse-string ostomy closure and 50 patients who underwent linear closure were included. Two groups were compared for surgical time, wound infection, patient satisfaction, scar length. A p-value <0.05 was considered significant. Wound infection was not reported among purse-string group compared to 10% in linear group (p=0.022). Scar length was 24.09±0.1 mm in purse string and 52.15±1.0 mm in linear group (p=0.033). Duration of hospital admission was significantly shorter in purse-string group (6.4±1.1 days) compared to linear (15.5±4.6 days, p=0.0001). The Patient and Observer Scar Assessment Scale scale for observer (p=0.038) and parents (p=0.045) was more favorable among purse-string group compared to linear. Purse-string technique has the less frequent surgical site infection, shorter duration of hospital admission, less scar length, and more favorable cosmetic outcome, compared to linear technique.

P018 COLLABORATIVE APPROACH FOR SIMULTANEOUS REPAIR OF COMPLEX INCISIONAL HERNIA AND STOMA REVERSAL

Abstract Aim 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. We present our experience in the collaboration between specialized units for the simultaneous treatment of complex incisional hernias and ostomy closure. Material and Methods Descriptive study of patients undergoing simultaneous surgery of complex IH repair and intestinal transit reconstruction in the period 2018.2021. All interventions were performed electively and with the collaboration of surgeons experts in abdominal wall and colorectal surgery. Demographic variables, hernias characteristics, surgical techniques, postoperative evolution, morbidity and mortality are recorded Results 16 patients are included. 8 with ileostomy, 3 lateral colostomies and 5 end colostomies . All the patients presented IH of the middle laparotomy and 12 had stomal hernias associated. The mean diameters of the IH were 16.2cm longitudinal and 11cm transverse. Intestinal transit was reconstructed in 15 cases (94%) and incisional hernia repair in 100%. Component separation was required in 75% of cases (8 posterior and 4 anterior). Morbidity in the first postoperative month was 18%, requiring 2 reoperations (12%). At the end of the mean follow-up of 10.8 months, 81% of the cases did not present complications. Conclusions The collaboration between specialist allows the use of advanced techniques in the simultaneous reconstruction of the abdominal wall and intestinal transit, with good clinical results and patient quality of life.

Incisional hernia following ileostomy closure: who's at risk? The Gold Coast experience.

Diverting ileostomy is utilized to protect high-risk anastomoses, though it is not shown to reduce the leak rate it may reduce the severe consequences of an anastamotic leak. In recent years mesh development has advanced to allow placement of meshes into potentially contaminated fields, such as an ostomy closure site. A retrospective review of all ileostomy closure procedures in Gold Coast from 1st January 2011 until 31st December 2018 were included. Patient demographics and surgical outcomes and follow up reviewed to identify any cases of incisional hernia relating to ostomy closure. A total of 193 patients were identified, after exclusions 171 were suitable for analysis within the study, a total of 25 incisional hernia detected radiologically or clinically. Two independent risk factors were identified BMI >30 and ASA 3-4. Both had significant association with development of incisional hernia with a 3- and 2-fold RR increase, respectively. This was also reflected in a subset analysis of BMI ranges demonstrating increased risk in the obese and severely obese group. The high-risk group in our population was elevated BMI and ASA, these are the patients we would expect to benefit the most from targeted therapy to reduce the incidence of incisional hernia. Future studies to look at whether reducing BMI or prophylactic mesh placement are effective.

Management of colorectal anastomotic leakage using endoscopic negative pressure therapy with or without protective ostomy: a retrospective study

PurposeManagement of colorectal anastomotic leakage (AL) is patient-oriented and requires an interdisciplinary approach. We analyzed the management of AL according to its severity and presence of ostomy and proposed a therapy algorithm.MethodsWe identified all patients who underwent colorectal surgery and developed an AL in our clinic between 2012 and 2017. The management of AL was retrospectively analyzed according to the severity grade: asymptomatic (A), requesting interventional or antibiotic therapy (B), undergoing re-operation (C). The groups were compared according to the leakage characteristics, presence of ostomy, and patient clinical conditions.ResultsWe identified 784 consecutive patients meeting the inclusion criteria. Of these, 10.8% experienced an AL (A = 18%, B = 48%, and C = 34%). The rate of successful ostomy closure was 100% (A), 68% (B), and 62% (C), respectively. Within group B, 91% of the patients were treated solely by endoscopic negative pressure therapy (ENPT), whereas 37% of the patients within group C required ENPT in addition to surgery. Seven cases within group B (17%) required no protective ostomy (nOB) during ENPT which was itself shorter and required less cycles in comparison to group B with ostomy (OB) (p = 0.017 and 0.111, respectively). Moreover, the leakage distance to anal verge was higher in the OB subgroup (p < 0.001).ConclusionENPT for the treatment of colorectal AL is efficient in combination with operative revision or protective ostomy. In selected patients, it is feasible also in the absence of a protective ostomy.

How surgical training in Switzerland affects outcomes and new predictors for teaching

Abstract Objective Teaching in the operating room represents the cornerstone of surgical education. Residents need to perform a sufficient number of basic procedures in order to gain independence. However, it is still debated what impact surgical teaching has on outcomes. With this study, we provide recent data of a large national cohort and identify new factors that are associated with increased teaching. Methods We studied common procedures that are essential for surgical training: Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), ostomy closure (OC), laparoscopic (LH) and Open Inguinal Hernia Repair (OH). The national database of the Swiss association for quality management in surgery was screened, and 72072 patients were identified from 2009 to 2019. Teaching was defined as a procedure mainly performed by a surgeon in training under supervision. Results A minority of basic surgical procedures were used for teaching (LA 28.1%, LC 22.3%, OC 21.5%, OH 31.8%, LH 6.3%), even in teaching hospitals of &amp;gt; 200 beds (LA 33.0%, LC 32.9%, OC 27%, OH 51.5%, LH 6.5%). During the study period, there was also generally a trend towards less teaching, exemplified by the two most frequent procedures: LA 35.6 to 26.7% (-25.0%, p = &amp;lt;0.001), LC 27.6 to 18.9% (-31.5%, p = &amp;lt;0.001). Operating time was significantly longer for procedures that were used for teaching with a more pronounced effect for inguinal hernia repairs: LA 63.4 vs 57.5min (+10.3%, p = &amp;lt;0.001), LC 84.0 vs 74.9min (+12.1%, p = &amp;lt;0.001), OC 88.6 vs 81.6min (+8.6%, p = &amp;lt;0.001), OH 81.5 vs 68.3min (+19.3%, p = &amp;lt;0.001), LH 97.9 vs 73.8min (+32.7%, p = &amp;lt;0.001). The overall complication rate for LA (2.6 vs 1.8%, p = &amp;lt;0.001) and LC (3.6 vs 2.8%, p = &amp;lt;0.001) were slightly higher in the no-teaching group and without a significant difference between the groups for OC, LH and OH. We identified the following parameters associated with increased teaching: A hospital size above 200 beds (OR = 2.48, p = &amp;lt;0.001), an operation during office hours (OR = 1.27, p = &amp;lt;0.001), the summer months (OR = 1.11, p = &amp;lt;0.001) and weekdays (OR = 1.10, p = 0.003). Conclusion The teaching of basic surgical procedures appears safe. Even if associated with longer operating times, it should be promoted as teaching is currently only performed in a minority of procedures (10-33%).

Pull-Through in Patients after Pelvic Anastomosis Leak Following Proctectomy: A Cross-Sectional Study

Abstract Introduction Colorectal cancer is the second most common type of cancer and the third leading cause of mortality due to cancers. Anastomosis leak after proctectomy is a dangerous complication that must be managed carefully. The aim of the present study was to assess the procedure of resection and pull-through of the new rectum after anastomosis leak in patients after proctectomy. Methods and Materials This was a cross-sectional study. Patients who visited the Firoozgar Hospital between 2015 and 2018 for rectal cancer surgery and had anastomosis leak entered the study. All patients underwent resection of the residue of rectum and pull-through of colon. Results In the present study, out of the 110 cases who underwent proctectomy, 12 patients with postoperative anastomosis leak were reported. Five (41.7%) were male and 7 (58.3%) were female. The mean age of the patients was 41.5 ± 4.3 years (33–51). Resection of the new rectum and pull-through anastomosis were performed for these 12 patients. No major intraoperative complication occurred. Postoperative course was uneventful in all patients. Discussion Resection of residue of rectum and pull-through in patients with anastomosis leak can be done after rectal cancer surgery. This method is superior to abdominopelvic resection in many aspects, especially regarding accessibility to the new rectum by rectal exam or endosonography to assess recurrence or a relative continence after closure of ostomy.

Does the timing of pouch creation in 2-stage operations for pediatric patients with ulcerative colitis matter?

IntroductionChildren with fulminant ulcerative colitis(UC) traditionally undergo 2-stage operations: restorative-proctocolectomy(RP/IPAA) and ileostomy followed by ostomy closure. In the biologic era, surgeons have modified their strategy: initial subtotal-colectomy/diversion, followed by RP/IPAA without diversion. Yet, evidence on efficacy and functional outcomes with the “modified 2-stage” approach is limited in children. We sought to compare the timing of pouch creation in 2-stage operations to determine outcomes. MethodsThis is a retrospective study of children with UC undergoing either a traditional 2-stage RP/IPAA or modified 2-stage RP/IPAA between 2010 and 2019. Complications (leak, stricture, wound-infection) were recorded at 90-days and 1 year from 2nd operation. ResultsN = 57 (Traditional n = 40, Modified n = 17). Median time to surgery from consultation was shorter in the modified-group (7 vs.25 days, p = 0.01). Preoperatively, the modified-group had lower albumin(p = 0.01), higher CRP(p = 0.01), and more frequently took biologics within 90-daysp=0.001). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (59% vs.18%, p = 0.008). No difference in pouch leak (p = 0.38), bowel obstruction(p = 0.35), loperamide dose(p = 0.21), or incontinence(p = 0.38) was observed. ConclusionDelaying pouch creation to the second operation without a protective ileostomy as a modified 2-stage is safe in a sicker and more acute pediatric population.

Broad Utility of a Minimally Invasive Technique for Pediatric Wound Care: Simple and Effective.

Infected or contaminated wound sites have historically been managed with incision and drainage. Here, the authors review their experience with skin closure over vessel loops and assess the results of this technique in a variety of clinical situations, hypothesizing that minimally invasive drainage strategies are associated with a decrease in common postoperative complications. Investigators retrospectively reviewed the data of all children with infected or contaminated wound sites operated on by a single surgeon with skin closure over vessel loops from September 2016 to September 2018. Demographics, indications for surgery, complications, and follow-up were assessed. Over a 2-year period, 33 children underwent skin closure over vessel loops. The majority were female (82%), Hispanic/Latino (40%), and younger than 5 years (58%; range, 4 months to 16 years). One-third were obese. Reasons for intervention included skin and soft tissue infection (64%), trauma (15%), and ostomy closure (6%). Median postoperative length of stay was 1 day. Three-quarters (76%) of the patients returned to the clinic for follow-up and/or vessel loop removal. At 30 days after operation, no patients in this cohort returned to the ED with recurrent infection or wound dehiscence. This minimally invasive technique for contaminated wound management demonstrates no evidence of subsequent infection in standard follow-up. These results are indicative of specific advantages related to vessel loop drainage, including shorter lengths of stay and ease of wound maintenance, in a variety of challenging clinical scenarios.

Predisposing factors and clinical impact of high-output syndrome after sphincter-preserving surgery with covering ileostomy for rectal cancer: a retrospective single-center cohort study.

Ileostomy-related high-output syndrome has become a major cause of postoperative morbidity after rectal cancer surgery. This study aimed to clarify the predisposing factors and clinical impact of high-output syndrome. Clinical parameters that were associated with high-output syndrome and clinical impact of high-output syndrome on nutritional status, electrolyte abnormality and renal dysfunction were retrospectively investigated in consecutive patients with rectal cancer undergoing resection with covering ileostomy during 2016-2017. High-output syndrome developed in 44/195 eligible patients (22.6%). Multivariable analysis revealed that neoadjuvant (chemo)radiotherapy [odds ratio (OR): 2.4; 95% confidence interval (CI) 1.1-5.2; P = 0.02], postoperative complications (OR: 2.2; 95% CI 1.0-4.6; P = 0.049), postoperative maximal white blood cell ≥ 10,000 cells/μl (OR: 4.0; 95% CI 1.9-8.8; P = 0.0004), and postoperative maximal C-reactive protein ≥ 10mg/dl (OR: 2.4; 95% CI 1.1-5.2; P = 0.02) were independently associated with high-output syndrome. High-output syndrome was associated with increased renal dysfunction at the time of ostomy closure (29.6% versus 11.9%, patients with high-output syndrome vs. without high-output syndrome, P = 0.008), but not with nutritional imbalance or electrolyte abnormalities. High-output syndrome (OR: 2.5; 95% CI 1.1-5.9; P = 0.03) and postoperative maximal C-reactive protein ≥ 10mg/dl (OR: 2.4; 95% CI 1.0-5.6; P = 0.04) were independently associated with renal dysfunction at ostomy closure. Preoperative (chemo)radiotherapy, postoperative inflammatory response, and postoperative complications predisposed to high-output syndrome, and it significantly impacted postoperative renal dysfunction. Active monitoring and early intervention are warranted to prevent renal dysfunction in patients with these factors.

Peritonitis Diverticular: ¿Qué Nos Enseñó Ladies Trial? Análisis Metodológico de su Diseño, Aplicación y Resultados

Contexto y Antecedentes: LADIES TRIAL es uno de los ensayos más importantes referidos a peritonitis diverticular. A pesar de este y otros ensayos publicados, aún se debate cuáles son los procedimientos adecuados para cada escenario de peritonitis diverticular, haciendo necesaria una revisión profunda de la metodología empleada en los ensayos para validar u objetar sus conclusiones.Objetivos: Analizar la metodología empleada en el diseño, aplicación, análisis de resultados y conclusiones de sus publicaciones. Secundariamente, colaborar en el mejoramiento de la investigación de la peritonitis diverticular y facilitar el análisis del tema por parte de los lectores.Métodos: Se analizaron las partes centrales de toda investigación, desde la pregunta de investigación, elaboración de hipótesis, operacionalización de variables y diseño del ensayo, análisis estadístico de resultados y conclusiones. Se buscaron errores, sesgos y debilidades que pudiesen objetar los hallazgos del estudio.Resultados: LADIES se trató de un estudio randomizado, abierto con análisis de superioridad según intención de tratar modificada en aquellos casos de incumplimiento de los criterios de inclusión y exclusión. Su diseño fue en general correcto, aunque en su aplicación se detectaron errores, debilidades y sesgos. En cuanto a resultados LOLA mostró que en Hinchey III el lavado laparoscópico tiene mayor morbimortalidad temprana que la sigmoidectomía, con un tiempo operatorio menor. Por su parte, DIVA mostró que en Hinchey III y IV la anastomosis primaria tiene mayor sobrevida libre de ostomía con menor morbilidad, combinando la cirugía inicial y cierre ostomía, respecto de la operación de Hartmann.Conclusiones: El no haber llegado al tamaño de muestra calculado hizo que solo grandes diferencias consiguieran significancia estadística. Las bajas frecuencias de eventos adversos acentuaron este problema metodológico. La especialización de los centros y cirujanos intervinientes, como la exclusión de pacientes hemodinámicamente inestables o bajo corticoterapia comprometieron su validación externa.

Efficacy of single layered intestinal anastomosis over double layered intestinal anastomosis-an open labelled, randomized controlled trial.

The hand-sewn method of bowel anastomosis is the most common because of its affordability, familiarity and easy availability of materials. It can be done in single or double layers, with different surgeons preferring one technique over the other. Double layer intestinal anastomosis (DLIA) is time-consuming, challenging to perform, and carries possibly a higher risk of devascularisation, infection, and necrosis. Studies conducted so far do not show a significant difference between the two, but have concluded that more studies are required to determine this definitively. This study attempted to see whether the single layer intestinal anastomosis (SLIA) is non-inferior to DLIA in terms of incidence of anastomotic leak. It also compared mortality, morbidity, and length of hospitalization (LOH) between the two groups. This was a parallel arm, open labelled, non-inferiority randomized controlled trial conducted in the department of surgery in a tertiary care centre between October 2016 and March 2018. Patients who fulfilled the inclusion criteria were randomly allotted to two groups: Patients undergoing SLIA and patients undergoing DLIA. After the procedure, all patients were assessed for anastomotic leak, morbidity, mortality and LOH in the postoperative period. A 3-month follow-up period was observed for complications. A total of 106 patients were randomised, 52 in SLIA and 54 in DLIA. Baseline demographic and clinicopathological characteristics between the two groups were comparable. The most common indication for intestinal anastomosis was ostomy closure in both groups. There was no significant difference between the two groups in terms of anastomotic leak, other complications, mortality and LOH. SLIA was comparable to DLIA with respect to incidence of anastomotic leak, morbidity, mortality, and the length of hospitalization, and can be considered as a safe and feasible alternative, in elective and emergency settings.

Improved colorectal anastomotic leakage healing by transanal rinsing treatment after endoscopic vacuum therapy using a novel patient-applied rinsing catheter.

Anastomotic or stump leakage is a common and serious complication of colorectal surgery. The objective of this study was to retrospectively investigate the clinical use and potential benefit of transanal rinsing treatment (TRT) using an innovative rinsing catheter (RC) after treatment with endoscopic vacuum therapy (EVT). Patients with leakage after low colorectal surgery who had been treated with EVT were retrospectively analyzed. A subset of patients was trained to perform TRT with a specially developed RC. We investigated the rate of complete healing of the leakage, septic complications, failure of the therapy, surgical revisions, ostomy closure rate, and complications related to endoscopic therapy. Between February 2007 and January 2014, 98 patients with local complications after low colorectal surgery, treated with EVT, were identified. Eighty-nine patients were analyzed (the treatment of nine patients was stopped due to medical or technical problems): 31 patients were treated with EVT only (EVT group) and 58 patients with EVT followed by TRT (EVT/TRT group). Complete healing of the leakage was significantly better in the EVT/TRT group [84% vs. 58% (p < 0.009)], and significantly fewer septic complications needing surgical revision were detected [3% vs. 11% (p = 0.001)]. No significant differences regarding endoscopy-related complications and ostomy closure were found between EVT and EVT/TRT patients. The use of patient-administered TRT with an innovative, customized RC after EVT is technically feasible and reliable and significantly improves therapeutic results. Further prospective trials with larger patient groups are needed to validate the results of our study.

Incidence of and risk factors for delayed acute kidney injury in patients undergoing colorectal surgery

BackgroundThe risk of delayed AKI (AKI development beyond the perioperative period) in patients undergoing colorectal surgery is greater than that in patients undergoing other major operations. However, the characteristics of and risk factors for delayed AKI are unclear. MethodsWe investigated 683 patients who underwent colorectal surgery with intestinal resection at a single tertiary hospital. All patients were followed-up for a year postoperatively. The primary outcome was the development of AKI during follow-up. ResultsAKI occurred in 177 (25.9%) during the first postoperative year. Patients who developed AKI were significantly older, showed a lower body mass index, and significantly lower preoperative hemoglobin and serum albumin levels. AKI occurred most commonly during the first 3 months postoperatively. However, AKI occurred persistently even after this initial period. Older age, lower preoperative serum albumin levels, and late ostomy closure were independently associated with a higher risk of delayed AKI. ConclusionAKI commonly occurs beyond the perioperative period. Careful risk stratification and modification of risk factors may prevent delayed AKI in patients undergoing colorectal cancer surgery.