Primary Ileostomy Research Articles

Ileocecal valve-preservation ileocecostomy (IVPI) in infants with extremely short distal ileum after primary stoma.

Preserving the ileocecal valve (ICV) has shown significant benefits. We present our experience with 18 infants who underwent ileocecal valve-preservation ileocecostomy (IVPI) with an extremely short distal ileum after primary ileostomy. A retrospective analysis was conducted on IVPI cases between 2014 and 2020. Medical records were reviewed, including birth weight, age, primary diseases, length of ileus stump, surgical time and procedure, time to enteral feeding, postoperative hospital stay, and complications. Eighteen patients (male: female = 12:6, median birth weight 1305 (750-4000) g, median gestational age 29 + 5 (27 + 6-39 + 6) weeks) were included in the analysis. Causes of surgery included necrotizing enterocolitis (13), ileocecal intestinal atresia (1), ileum volvulus (2), meconium peritonitis (1), and secondary intestinal fistula (1). The median corrected age of ileostomy closure was 3.2months (2.0-8.0months). The distance from the distal ileal stoma to the ICV ranged from 0.5 to 2cm. The median length of the residual bowel was 90cm (50-130cm). ICV-plasty was performed in 3 cases due to secondary ICV occlusion or stenosis. All patients resumed feeding within 6 to 11days after surgery. The postoperative hospital stay ranged from 12 to 108days (median: 16.5days). Complications included incisional infections in 2 cases, anastomotic stricture and adhesive ileus in 1 case, nosocomial sepsis and septic shock in 1 case. All children showed normal growth and development during a 6-65month follow-up. IVPI is safe and feasible for infants with an extremely short distal ileal stump. ICV-plasty could be applicable for cases with ileocecal occlusion/stenosis.

A systematic review of primary ileostomy site malignancies.

This paper aimed to elucidate the etiologies of all primary ileostomy site malignancies published in the literature. A review of the literature was conducted following PRISMA guidelines by querying PubMed, Global Health, and Web of Science for articles published before November 2020. Search criteria contained broad terminology for ileostomy site neoplasms without language, date, or publication limitations. A full-text review of the abstracts confirmed primary malignant pathologies and was evaluated for study inclusion. Literature search discovered 858 publications, with 76 meeting eligibility criteria. The final sample contained 91 patients, with equal males and females. The mean age of patients with ileostomy site malignancy was 62.0 ± 12.2, with an average ileostomy age of 29.4 ± 12.4. The most common indications for ileostomy creation were inflammatory bowel disease (IBD) (73.6%) and familial adenomatous polyposis (FAP) (20.9%). There was a total of eight ileostomy malignant pathologies reported, with adenocarcinoma being the most common (76.9%), followed by squamous cell carcinoma (SCC) (11.0%). Adenocarcinoma was diagnosed at a younger age than SCC (59.7 vs. 72.3) and developed over a shorter time (28.8 vs. 37.0). Patients with FAP almost exclusively developed adenocarcinoma (94.4%) at a younger stoma age (25.8 vs. 31.4) than those with IBD who developed seven diverse pathologies. With a median follow-up of 0.75years, four patients developed disease recurrence and received oncologic resection of their cancer less often than the 55 negative patients (p = 0.04). Ileostomy site malignancies are late-appearing complications that require curative surgery. Their presentation is associated with ileostomy duration and creation indication, such as FAP or IBD. We recommend screening at a stoma age ≥ 20 or patient age ≥ 50 for patients with FAP, while stoma age ≥ 25 or patient age ≥ 60 for IBD patients.

The Effectiveness of Contralateral Drainage in Reducing Superficial Incisional Surgical Site Infection in Loop Ileostomy Closure: Prospective, Randomized Controlled Trial

Loop ileostomy reduces the rates of morbidity due to colorectal anastomotic dehiscence. For its part, ileostomy closure is associated with low mortality (0-4%) but substantial morbidity (11-37%). Incisional surgical site infection (SSI) is one of the most frequent complications (2-40%). A single-center, prospective, randomized controlled clinical trial of two study groups: control (conventional primary skin closure) and experimental (primary skin closure with a contralateral Penrose® drain). Seventy patients undergoing loop ileostomy closure between April 2013 and June 2017 were included (35 per branch). Four were later removed from the study. Six of the remaining 66 patients (per protocol analysis) were diagnosed with incisional SSI (9.1%); there were no statistically significant differences between the two groups (control group: 9.7%; experimental group: 8.6%) or between the risk factors associated with incisional SSI. Rates of overall and relevant morbidity (Clavien ≥ III) were considerable (28.1% and 9.1%, respectively), and there were no statistically significant differences between the two groups. No patients died. Contralateral drainage does not significantly affect the results of primary ileostomy closure. The rate of incisional SSI was similar in the drainage and non-drainage groups, and the overall rate of 9.1% was in the low range of those reported in the literature. The absence of mortality (0%) and the non-negligible rates of overall and relevant morbidity (28.1% and 9.1%, respectively) in our series suggest that loop ileostomy is a safe procedure. However, the bowel reconstruction involves risks that must be borne in mind. The study was registered and approved by the clinical research ethics committee of the study center (reference number 2012076). Clinical trial was registered in ClinicalTrial.gov (identification number NCT02574702 and reference: ILEOS-ISS_2013).

Outcome of meconium ileus in a tertiary care hospital

Background: Meconium ileus is a common form of congenital intestinal obstruction. The condition results from the accumulation of sticky inspissated meconium in distal ileum. In about half the cases, however, the pathologic condition is complicated by volvulus, gangrene, perforation with meconium peritonitis. Relief of the obstruction is commonly accomplished with a variety of operative procedures. A number of operative procedures are in use, including Bishop-Koop enterostomy, Mikulicz ileostomy and primary closureObjective: Aim of this study was to evaluate the outcome of meconium ileus and its complications in two commonly practiced enterostomy procedure.Method: In this retrospective study from July 2007 to Jun 2017, a total of 52 cases of meconium ileus were included. Diagnosis of suspected cases was confirmed after laparotomy. Two commonly practiced ileostomy procedure were Mikulicz ileostomy and Bishop Koop ileostomy in this study. Survivors of all primary enterostomy underwent ileostomy closure after 3-6 months.Result: Mikulicz enterostomy was done in 38 cases and Bishop Koop ileostomy in 14 cases. After primary ileostomy 5 patients died following Mikulicz ileostomy and 2 after Bishop Koop ileostomy Among the 41 cases those who reached ileostomy closure, 35 were survived.Conclusion: Complications were more common after Mikulicz ileostomy and difficult to manage in our observation. Overall survival of meconium ileus was 66% in our study without any facilities of intensive neonatal care.Bang Med J (Khulna) 2017; 50 : 31-34

Ileostomy in Typhoid Perforation

This is a prospective observational study carried out during last five years (Jan, 1998 to Nov, 2002) The purpose was to study guidelines of case selection for different available procedures to treat typhoid perforations. Ninety cases of typhoid perforation were treated by different procedures. The complete records were maintained and a designed protocol of management was observed. Male to Female ratio was 4 to 1. Average age 26 years (7 cases below 10 years and 6 cases above 40 years) Only 17 cases (18.88%) presented within 24 hours, the largest group of 31 cases (34.44%) presented after 72 hours. Although complication rate was very high in the late reporting, no significant mortality difference was noted. Primary ileostomy (group 1) 18 cases had no mortality, 53 cases of simple perforation closure had 5 mortalities (9.43%), resection anastmosis group that is 19 cases had 2 mortalities (10.5%), closure of the ileostomies (19 cases) had no mortality and a very low complication rate. In our study ileostomy is a good life saving procedure to be used judiciously, accepting its inconvenience to the patient.

Temporary loop versus end ileostomy for faecal diversion in ileal perforation: a case matched study

The disease ileal perforation is a frequently encountered surgical emergency in developing countries [1]. Typhoid fever is the most common cause for this dreaded complication;tuberculosis, trauma and non-specific enteritis follow closely [2]. The incidence of perforation in various studies in typhoid fever has been reported to be between 0.8% to 18% [3]. The compromised patients of perforation peritonitis due to typhoid fever are best managed with faecal diversion by performing an ileostomy. The other indications of faecal diversion include inflammatory bowel disease, familial adenomatous polyposis, colorectal cancer, non-gastro intestinal obstructing tumours, pelvic sepsis, trauma, diverticulitis, fistula, ischaemic bowel disease, radiation enteritis, pseudomembranous enterocolitis, faecal incontinence and paraplegia [4]. The standard treatment after diagnosis of secondary peritonitis due to hollow viscous perforation is resuscitation followed by laparotomy. The ileal perforation is either closed primarily, or resection and anastomosis of the small bowel is performed, or a diverting stoma is created depending on the site and number of perforations, the severity of peritonitis and the general condition of the patient [5]. The ileostomy serves the purpose of diversion, decompression and exteriorization. A primary ileostomy has been found to be useful in decreasing the morbidity and mortality especially in moribund patients or those with delayed presentation, where it has proved to be a lifesaving procedure [6]. However, ileostomies may result in a significant number of complications as well. The most common complication of ileostomy is peristomal skin irritation leading to skin excoriation, followed by fluid and electrolyte imbalance and nutritional depletion [7]. Other complications post-ileostomy are bleeding, ischaemia, obstruction, prolapse, retraction, stenosis, parastomal hernia, fistula, residual abscess, wound infection and incisional hernia. In addition, an ileostomy is also known to adversely affect the patient's quality of life due to physical restrictions and psychological problems [8]. An ileostomy can be performed as an end ileostomy or loop ileostomy, and both techniques have their own pros and cons. Different authors in the past have compared the results of the two types of ileostomies performed for inflammatory bowel disease and colorectal cancer. Based on their findings, some authors prefer a loop ileostomy whilst others recommend an end ileostomy as a temporary measure for faecal diversion [9-11]. However, these studies are from western countries and include elective procedures whereas patients with perforation peritonitis present as a surgical emergency and their parameters are entirely different. The temporary diverting ileostomy [end or loop ileostomy] is performed as a life saving measure in such cases and existing literature is silent on comparison of these two procedures in perforation peritonitis.

Colonic Atresia: A Case Report

Atresia of the colon is among the rare types of all gastrointestinal atresias. Descending colon is the rarest site of all the colonic atresias. A case report of 3 days old female baby was presented with the features of distal intestinal obstruction. At laparotomy type I atresia of the middle part of asending colon, with proximal dilatation of caecum and ilum. Microcolon was noticed in ascending colon, transverse colon, descending colon and sigmoid colon when newborn underwent exploration. Primary ileostomy and distal mucus stoma of ascending colon was done. After four weeks, closure of ostomy was done.
 Journal of Armed Forces Medical College Bangladesh Vol.12(1) 2016: 116-119

Defunctioning Ileostomy is not Associated with Reduced Leakage in Proctocolectomy and Ileal Pouch Anastomosis Surgeries for IBD.

Anastomotic leakage is a serious complication after restorative proctocolectomy with ileal pouch-anal anastomosis. Previous studies have shown significantly decreased leak rates in diverted patients with less severe clinical consequences. The aim of this study was to evaluate short- and long-term outcome of selective ileostomy formation in a multicentre cohort of patients undergoing pouch surgery. In a retrospective study, 621 patients undergoing pouch surgery for inflammatory bowel disease [IBD] were identified from three large centres. Anastomotic leakage was defined as any leak confirmed by either contrast extravasation on imaging or during surgical re-intervention. In 305 patients [49.1%], primary defunctioning ileostomy was created during pouch surgery and 41 [6.6%] patients received a secondary ileostomy because of a leaking non-diverted pouch. Primary ileostomy formation was associated with male sex, weight loss, American Society of Anesthesiologists score [ASA] > 2, steroid use, one-stage surgery, hand-sewn anastomosis, and blood transfusion. Leak rates were comparable between diverted and non-diverted patients [16.7% vs 17.1%, p = 0.92], which remained unchanged in subgroups with immunosuppressive medication. Having had an ileostomy was demonstrated to be an independent predictor of small bowel obstruction (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.45 - 4.67) and pouch fistulas [OR 3.05, 95%CI 1.06 - 8.73]. The 10-year pouch survival was comparable for patients with and without ileostomy [89% versus 88%, p = 0.718]. Leakage rates of diverted and non-diverted pouches in IBD patients were similar and relatively high. Defunctioning was independently associated with long-term complications. A staged approach without defunctioning might be the best strategy.

Typhoid ileal perforation: a 13-year experience

Typhoid fever is endemic in many developing countries with a high rate of complications. Aim of this study is to analyse epidemiological features, clinical presentations, complications and therapeutic outcomes of enteric perforation peritonitis diagnosed and treated in our hospital. Records of total number of 646 patients, who presented with perforation peritonitis due to enteric fever in the surgical emergency unit of Dr Ram Manohar Lohia hospital, New Delhi between January 2001 and December 2013, were reviewed retrospectively. Descriptive statistics was used to analyze the data. Out of 646 patients, 62 (9.59%) presented in shock. Stomal, peristomal, local and systemic complications were high in these patients. Primary closure was done in 212 (33.12) patients, primary ileostomy was created in 410 (64.06) patients, and resection and anastomosis was done in 24 (3.75) patients. Thirteen patients (2.01%) died of typhoid intestinal perforation. To prevent complications of typhoid fever, in addition to control sanitation, it is also important to control quackery and malpractices. Awareness and education about the disease, its nature and complications will also be of great help.

Effect of a purse-string approximation following stoma takedown on wound infection and satisfaction.

See Article on Page 29-33 A temporary stoma is commonly used following rectal cancer surgery because a stoma has been reported to lower the clinical leak rate and the reoperation rate [1]. The use of a temporary stoma has been increasing due to the introduction and increased use of preoperative chemoradiotherapy (PCRT) in the era of rectal cancer surgery because PCRT was expected to facilitate sphincter preservation in patients with low-lying rectal cancer [2, 3]. Morbidity after stoma takedown, however, is not negligible, and surgical site infection (SSI) is a very common complication; its incidence which varies widely and has been reported to be as high as 40% [4, 5]. Although various methods have been employed to reduce the SSI rate, which technique for closure of a stoma would be the most effective in reducing the SSI rate is still being debated. The pursestring stoma closure described by Banerjee [6] was based on the concept of leaving the wound open to provide drainage and minimize SSI while providing some degree of wound approximation to minimize the healing time. From a morphological viewpoint, an elliptical or circular incision should be closed in a linear fashion for the primary ileostomy takedown wound, so it looked unnatural and the wound was usually larger than the stoma opening made by using an elliptical incision. Recently, a number of studies have reported that the purse-string closure technique resulted in a lower SSI rate than conventional primary closure [7, 8]. The authors of Clinical trial on the incidence of wound infection and patient satisfaction after stoma closure: Comparison of two skin closure techniques comparing purse-string with primary closure for ileostomy wounds demonstrated a lower incidence of SSI and a higher patient satisfaction when ileostomy wounds were closed using the purse-string method [9]. Although the study was a retrospective one, the patient populations in the two arms of the trial were well matched in most respects such as indications, types of stoma, and times to stoma closure. However, because the follow-up time was not long, at best, the study shows a short-term benefit. Regarding patients satisfaction based on a cosmetic viewpoint, that satisfaction might be improved after a longer follow-up because scar shrinkage would have progressed further. In this regard, most studies have shown a more contracted wound at a 1-year follow-up and, thus, and an improved patient satisfaction [7, 8]. The purse-string closure method has been criticized because of the time required for wound healing. However, the wound healing time following purse-string closure has been reported to be shorter than that following primary closure [5, 7], which is the same as the results reported by the authors of Clinical trial on the incidence of wound infection and patient satisfaction after stoma closure: Comparison of two skin closure techniques [9]. The way in which an open wound affects the quality of life of a patient needs to be investigated further because a higher infection rates is also associated with patient dissatisfaction. With the purse-string closure procedure, the wound must be kept clean at home; however, the patient does not need to go to the hospital to receive any special treatment.

Risk factors for Crohn’s disease of the neo-small intestine in ulcerative colitis patients with total proctocolectomy and primary or secondary ileostomies.

De novo Crohn’s disease (CD) of the neo-small intestine in ulcerative colitis (UC) patients after total proctocolectomy (TPC) is a new disease entity, which may persist even after a secondary diverting permanent ileostomy for pouch failure. We sought to compare outcomes of primary ileostomy (PI, i.e., stoma created after colectomy without trying of ileal pouch) and secondary ileostomy (SI, i.e., stoma created after pouch failure) and to evaluate factors associated with the development of CD of the neo-small intestine proximal to ileostomy. A total of 123 eligible patients were identified from our Pouch Center Registry (PI group, n = 57 and SI group, n = 66). Demographics, clinical features and outcomes (CD of theneo-small intestine, non-CD related strictures, requirement of CD-related medications use, ileostomy-associated hospitalization, ileostomy failure with stoma revision/relocation, and shortgut syndrome) were compared. Step-wise logistic regression models were performed. The median follow-up for the whole cohort was 5.0 (2.0–12.0) years. Younger age at diagnosis and surgery, family history of IBD, toxic megacolon/fulminant colitis, pre-diversion severe diarrhea, prediversion anti-TNF biological therapy, arthralgia/arthropathy and staged surgery were more common in the SI group (p < 0.05). In multivariate analysis, the presence of SI [odds ratio (OR), 8.23; 95% confidence interval (CI), 2.43–27.85], family history of IBD (OR, 9.14; 95% CI, 3.13–26.69), and pre-diversion of weight loss (OR, 3.72; 95% CI, 1.23–11.21) were contributing factors for developing CD of the neo-small intestine. CD of the neo-small intestine in stoma patients was associated with the presence of SI, family history of IBD, and pre-diversion poor nutrition status. Patients with secondary ileostomy due to pouch failure should be carefully monitored. Aggressive medical, endoscopic or surgical therapy may be needed in patients at risk, before permanent diversion.

NONTRAUMATIC ILEAL PERFORATION : SURGICAL EXPERIENCE IN RURAL POPULATION IN INDIAN SCENARIO

Objective: The purpose of our study was to review the clinical profile, etiology and optimal surgical management of patients with non traumatic ileal perforation. Methods: The study is an observative study carried out for the period of 4 years in the department of surgery. A total of 71 patients admitted through accident & emergency department and patients from medical wards admitted and treated with fever and diagnosed with peritonitis were included in the study. A written informed consent was obtained from each patient/ patient relative. Demographics, anthropometrics and clinical profiles were collected. Lab investigations, x-rays , ultrasound of abdomen & pelvis, operative findings, duration of hospital stay , post operative complications and mortality were recorded . Results: We have assessed and treated 71 cases of non traumatic ileal perforation; the causes for perforation were enteric fever [40(56.33%)], non specific inflammation[23(32.39%)],obstruction[ 7(9.85%)], tuberculosis[ 1(1.04%)] . The surgical procedures performed were simple/ primary closure (n=43), end to side ileotransverse anastomosis (n=2) primary ileostomy( n=6), and resection and end to end anastomosis (n=20). Conclusion: Terminal ileal perforation should be suspected in all cases of peritonitis especially in developing countries . Optimization of surgical techniques should be based on the etiology, delay in surgery and operative findings. Timely surgical intervention within 24 hours with adequate and aggressive resuscitation can decrease morbidity and mortality.

Colonic Atresia: A Case Report

Atresia of the colon is among the rare types of all gastrointestinal atresias. Transverse colon is the rarest site of all the colonic atresias. We report a case of a 3 day old female baby who presented with the features of distal intestinal obstruction. At laparotomy type III atresia of the middle part of transverse colon, with proximal dilatation of caecum and ascending colon and distal part of transverse colon, descending colon and sigmoid colon being microcolon is noticed. Newborn underwent exploration primary ileostomy and distal mucus stoma of transverse colon was done.

W1692 Primary Ileostomy Adenocarcinoma: Rare Condition After Proctocolectomy

W1692 Primary Ileostomy Adenocarcinoma: Rare Condition After Proctocolectomy

Congenital atresia of the intestine in a premature infant

C ONGENITAL atresia of the gastrointestinal tract is an extremely rare anomaly occurring, according to most esthnates, about once in twenty thousand births. Arnhehn 1 tabulated the results of infants treated surgically and reported in the literature from 1911 to ]943. These eases were in infants ranging in age from one hour to 8 days. All were treated by primary anastomosis. Miller 2 stated that primary anastomosis is tile surgical procedure of choice and that primary ileostomy offered absolutely no chance for recovery. That this attitude is well established as authoritative is borne out by a cursory review of the literature. Erb and Smith 3 reported two eases, one with multiple atresias treated by primary anastomosis. Miller, Grecngaard, Rayeroft, and McFadden also reported successful treatment of two cases in this manner. Duncan, Wearn, Jackson, and Waldron 5 successfully treated multiple atresias in a premature infant by short-circuiting anastomosis. Fieeara and Degen G reported a patient who died of meeonium ]oeritonitis after operation. James R. Judd ~ reported the first sueees:sful ease cured by ileostomy alone. A full-term Chinese female infant showed signs of intestinal obstruction following the first feeding. Surgery w~s done in four stages. Supportive measures in the form of blood, vitamins, antibiotics, and parentcral fluids were vigorously employed. This case finds a close para]lel in the following report in a premature infant treated successfully by primary ileostomy.