Restoration Of Bowel Continuity Research Articles

Prevalence of Clostridium Difficile in Excluded Colons

Clostridium difficile infection is associated with substantial morbidity and mortality, increased duration of hospitalization, and a marked economic impact. Several case reports and case series have described C. difficile infection in excluded bowels or immediately after reversal of defunctioning ileostomy. The aim of this prospective study is to detect whether the excluded colon is associated with a higher rate of C. difficile colonization than the normal population, which may increase the risk of C. difficile infection. Patients with defunctioning loop ileostomy, undergoing closure of ileostomy to restore bowel continuity, were prospectively recruited. Two stool samples were collected from the ileostomy effluent before closure of ileostomy and two after the procedure including the first bowel movement. All samples were cultured for C. difficile and analyzed for toxins A and B by a Premier EIA test. Demographic data and possible confounding factors were observed and recorded. Twenty-fine adult patients were recruited to this study; five patients were subsequently excluded. Two patients had positive stool cultures for C. difficile in the postoperative samples and another patient developed clinical pseudomembranous colitis with positive toxin. This indicates a possible colonization rate of 3 to 38 per cent (95% confidence interval). Four observed cases out of the 20 subjects taking part in this study would confidently conclude that C. difficile colonization in the excluded colon is 6 to 44 per cent, i.e., higher than the incidence in the healthy adult population, which is 3 per cent. However, the findings of this study prompt larger and well-powered studies to confirm these findings.

Sigmoid volvulus: long-term surgical outcomes and review of the literature.

Little has been published regarding long-term surgical outcome after the initial management of acute sigmoid colon volvulus. Patients undergoing primary resection and anastomosis (PRA) or Hartmann's procedure (HP) for sigmoid volvulus between September 1992 and August 2000 were reviewed. Eligible patients who had had the initial procedure at least 5 years previously were contacted and completed a questionnaire regarding recurrence, current symptoms and bowel habits. Data on 42 PRA patients and 36 HP patients were analysed. Follow-up (mean 7.2 years, range 5 - 11 years) was completed for 63 patients (37 PRA, 26 HP). Restoration of bowel continuity was successfully performed in 25 of 26 HP patients. No patient had megacolon. Constipation was reported by 83% of PRA and 65% of HP patients. Of these patients, 51% regularly used laxatives. No patient complained of incontinence, and no recurrences of sigmoid volvulus were recorded during the follow-up period. Sigmoidectomy with primary anastomosis is a good option for the definitive management of sigmoid volvulus. Despite the high constipation rate, no recurrence occurred during long-term follow-up.

Stoma Issues in the Obese Patient

Stoma creation in the obese patient presents technical challenges beyond the usual considerations that surround stoma creation. Both short-term and long-term stoma complication rates are higher in the obese patient. One must always strive to create a protruding well-vascularized stoma while maximizing the potential to restore bowel continuity in the future. This article will discuss the potential complications and difficulties associated with the creation of a stoma in the obese patient. It will also discuss the traditional techniques for creating the stoma and include modifications that may be required in the obese patient. It will cover technical tips that may help to avoid the complications and pitfalls of creating a stoma in the obese patient.

Risk Factors for Fecal Incontinence After Intersphincteric Resection for Rectal Cancer

Restoration of bowel continuity is a major goal after surgical treatment of rectal cancer. Intersphincteric resection allows sphincter preservation in low rectal cancer but may have poor functional results, including frequent bowel movements, urgency, and incontinence. This study aimed to evaluate long-term functional outcome after intersphincteric resection to identify factors predictive of good continence. Descriptive observational study. Follow-up of surgery in tertiary care university hospital. Eligible patients were without recurrence 1 year or more after surgery for low rectal cancer. Intersphincteric resection. : Bowel function was assessed with a standardized questionnaire sent to patients. Functional outcome was considered as good if the Wexner score was 10 or less. Univariable and multivariable regression analyses were used to evaluate impact of age, gender, body mass index, tumor stage, tumor location, distance of the tumor from the anal verge and from the anal ring, type of surgery, colonic pouch, height of the anastomosis, pelvic sepsis, and preoperative radiotherapy on functional outcome. Of 125 eligible patients, 101 responded to the questionnaire. Median follow-up was 51 (range, 13-167) months. In multivariate analyses, the only independent predictors of good continence were distance of the tumor greater than 1 cm from the anal ring (OR, 5.88; 95% CI, 1.75-19.80; P = .004) and anastomoses higher than 2 cm above the anal verge (OR, 6.59; 95% CI, 1.12-38.67; P = .037). The study is limited by its retrospective, observational design and potential bias due to possible differences between those who responded to the questionnaire and those who did not. Patient characteristics do not appear to influence functional outcome at long-term follow-up after intersphincteric resection. The risk of fecal incontinence depends mainly on tumor level and height of the anastomosis.

Proximal colonic atresia: is right hemicolectomy inevitable?

Proximal colonic atresia often results in a marked discrepancy of the atretic ends presenting a technical challenge for restoration of bowel continuity. We review our series of colonic atresia patients with particular reference to the techniques for restoring bowel continuity. Case notes of all patients diagnosed with colonic atresia and admitted to our unit between 1997 and 2011 were reviewed. There were 13 patients with a median gestational age of 39weeks. Location of the atresia was ascending colon (n=1), hepatic flexure (n=9), proximal transverse colon (n=2) and sigmoid colon (n=1). The primary procedure was: primary anastomosis (n=1), right hemicolectomy followed by ileo-colic anastomosis (n=2), right hemicolectomy and stoma formation (n=3). Six patients underwent stoma formation, of which five subsequently had a right hemicolectomy at a later procedure. In total, 10/12 patients required right hemicolectomy to facilitate restoration of bowel continuity. Median time to full feeds was 11days (4-46). Median follow up time was 11months (22days-5.6years). A temporising stoma does not reduce the discrepancy in the calibre of the atretic ends in proximal colonic atresia. Right hemicolectomy and ileo-colic anastomosis should therefore be considered at the initial surgery.

Laparoscopic colostomy reversal after a Hartmann procedure: a prospective series, literature review and an argument against laparotomy as the primary approach

Open restoration of bowel continuity after a Hartmann procedure has been associated with significant morbidity, including anastomotic leak, incisional hernia, wound infections and inability to re-establish intestinal continuity. Few studies have examined the role of laparoscopy in performing a Hartmann reversal. The aim of this study was to review our laparoscopic Hartmann reversal (LHR) experience with an emphasis on intra- and postoperative adverse events. A prospectively collected laparoscopic colorectal database involving 3 surgeons in 4 academic centres between 1991 and 2008 was reviewed. Factors evaluated were patient demographics, diagnosis, duration of surgery, intra- and postoperative complications, recovery of bowel function and length of stay in hospital. Twenty-eight consecutive patients (13 men, 15 women) with a mean age of 61.1 (standard deviation [SD] 15.3) years and a mean weight of 72.3 (SD 20.1) kg underwent LHR. The diagnosis at initial surgery was complicated diverticulitis in 19 patients (67.9%), cancer in 6 patients (21.4%) and "other" in 3 patients (10.7%). The median duration of surgery was 166.2 (SD 74.4) minutes. There were no conversions. There was 1 major intraoperative complication (bleeding; 3.6%). There were 3 postoperative complications (10.7%): 1 abscess, 1 prolonged ileus and 1 wound hematoma. Only 1 patient with an abscess required readmission. There were no observed clinical anastomotic leaks. All patients underwent successful reanastomosis. The median time to return of bowel function was 4 (interquartile range [IQR] 3-4) days. The median length of stay in hospital was 5 (IQR 3-6) days. There was no mortality. Laparoscopic colostomy reversal after a Hartmann procedure is safe and feasible in experienced hands. It is associated with low morbidity, quick return of bowel function and short stay in hospital.

Restoration of intestinal continuity after Hartmann's procedure—not a benign operation. Are there predictors for morbidity?

Restoration of intestinal continuity is usually the second step after Hartmann's procedure and an established procedure in abdominal surgery, particularly for complicated diverticular disease. This descriptive study aimed to examine the morbidity and mortality associated with the procedure and to define potential risk factors. Data from 161 consecutive patients (median age 62 years, median BMI 25.2) undergoing elective surgery with restoration of bowel continuity between October 2001 and November 2008 at the Department of Surgery, University of Heidelberg, were included in this study. The association of potential prognostic variables with postoperative morbidity and mortality were examined by univariate and multivariate analyses. The median time between the initial operation and the restoration of bowel continuity was 7 months. The median operation time was 185 min with a blood loss of 150 ml and median postoperative hospital stay of 9 days. Fifty-one percent of the patients had an uneventful recovery, whereas 49% had a postoperative complication. Surgical infections occurred in 18% of patients, 3.8% suffered from anastomotic leakage, and surgical re-exploration was necessary in 11.2%. Medical complications occurred in 21.1% of the patients, with pneumonia in 2.5% and urinary tract infections in 1.3%. One patient died 17 days after surgery. Univariate analysis showed that patients taking immunosuppressant drugs had significantly more wound infections and, interestingly, protective ileostomy was associated with postoperative anastomotic stenosis in our cohort. The administration of PRBC and a prolonged hospital were significantly associated with increased postoperative morbidity in the multivariate analysis. Restoration of bowel continuity is a surgical procedure with high overall morbidity. The high morbidity confirmed in our study and various other papers justify a randomized clinical study to investigate the one-stage concept with primary anastomosis against the Hartmann's procedure and its reversal.

Die Hartmann-Operation bei perforierter Divertikulitis und maligner linksseitiger kolorektaler Obstruktion und Perforation

This review comments on the question whether laparoscopic techniques and interventional strategies have in the last ten years changed the emergency management of perforated diverticulitis and malignant colorectal obstruction or perforation with regard to the broad spectrum of indications for Hartmann's procedure (HP). Colon resection with primary anastomosis and defunctioning stoma is the optimal strategy for patients with perforated diverticulitis. HP should be considered for older patients with multiple comorbidities, realising that restoration of bowel continuity is no longer an issue. Laparoscopic peritoneal lavage is an alter-native to HP in Hinchey-III diverticulitis with promising results in experienced centers which should be further evaluated. OBSTRUCTIVE / PERFORATED LEFT-SIDED COLORECTAL CANCER: In perforated left-sided colorectal cancer HP may be generously indicated. In malignant obstruction, however, a temporary colostomy or -colonic stenting in case of appropriate expertise has been suggested as preoperative treatment -before elective surgery, allowing higher rates of RPA. HP remains relevant, especially in high-risk patients and after hours and during the weekend, when the most experienced surgeon is not always available. However, subspecialised colorectal surgeons obtain with single-stage resection in this situation at least comparable results with respect to morbidity and mortality, but better patient quality of life.

An alternative management option for colonic atresia preventing loss of the ileocecal valve

Purpose Management of colonic atresia is contentious, with primary anastomosis having a notable risk of anastomotic leak. In addition, resection of the terminal ileum and ileocecal (i-c) valve is frequently performed, risking side effects such as diarrhea, vitamin B 12 deficiency, and gall stone formation. Methods The hospital coding system was searched for all patients with a diagnosis of colonic atresia between July 2005 and July 2008. Four term neonates were managed by formation of an ileostomy, a “blow hole” stoma just proximal to the atresia, and a mucus fistula distal to the atresia. Results Average time to full feeds was 7.5 days (range, 3-12 days), and average length of stay was 23 days (range, 13-47 days). Stoma management, problematic in 2 infants, was individualized by a specialist stoma nurse. Ileostomy output was refed into the mucus fistula. Complications included 3 episodes of prolapse of the blow hole stoma in infant 2. All of the infants returned to the operating theater at 1 to 3 months of age for restoration of bowel continuity and closure of the ileostomy. The atretic segment was resected, and an end-to-end anastomosis was performed. Recovery was straightforward in all cases. Conclusion A procedure that retains the i-c valve and most of the colon through creation of a blow hole stoma in the distended proximal colon with a diverting ileostomy and mucus fistula is described. The technique is recommended in selected infants as bowel length and anatomy can be preserved, despite the use of multiple stomas.

Bowel dysfunction after sphincter-preserving surgery.

3657 Background: Alterations in bowel function following sphincter-preserving surgery (SPS) for rectal cancer have not been well studied, limiting our ability to effectively counsel patients regarding appropriate surgery. Methods: A prospective single-institution longitudinal study of stage I-III rectal cancer patients undergoing SPS was performed from 1/07-7/09. Patients completed the validated MSKCC Bowel Function Instrument (BFI) and EORTC-QOL30/38. Comparisons between preoperative and 6 month responses were made using paired t test; predictors of 6 month bowel function were assessed with t test. Results: 91 of 117 (78%) rectal cancer patients completed surveys preoperatively and 6 months post restoration of bowel continuity (Table). Significant dysfunction at 6 months was reported; >57% reported >4 bowel movements/day. 15 of 18 BFI items were reported in >75% of patients, many severe. 80% reported altering their activities to compensate for bowel dysfunction. Compared to preoperative scores, 6 month scores were worse on all BFI subscales (frequency (p=0.003), urgency (p<0.001), dietary (p<0.001)), EORTC-CRC38 GI subscale (p=0.002) and total BFI score (p<0.001). Predictors of poor function included male gender, radiation, low tumor, hand-sewn anastomosis (Table). Conclusions: Post SPS bowel function is significantly worse 6 months after restoration of bowel continuity, and is associated with patient and treatment factors. Longer follow-up of this cohort will provide better assessment of long-term bowel function after SPS, enabling us to better counsel rectal cancer patients preoperatively. N 6-mo BFI total score (range 14-70) p Gender Male 55 51 (31-66) 0.016 Female 36 47 (28-64) Median age 54 (25-85) <55 47 (28-66) ≥55 48 (34-65) 0.79 Pre-op atage I/II 30 N/A III 61 Median level of tumor from anal verge (cm) 8 (1-16) <8 cm 46 (28-65) ≥8 cm 48 (37-66) 0.022 Pre-op therapy No RT (18 CT only) 39 50 (36-66) 0.006 Combined CT/RT 52 48 (28-64) Surgery LAR 26 48 (37-66) 0.30 LAR/CAA 63 48 (28-65) TAE 2 Too small LAR and LAR/CAA No. pouch vs straight 20 vs. 59 51 (28-65) vs. 48 (31-66) 0.07 No. hand sewn vs. stapled 24 vs. 65 45 (31-64) vs. 50 (28-66) 0.003 Temp stoma vs. no stoma 67 vs. 24 47 (29-65) vs. 51 (37-66) 0.09 No significant financial relationships to disclose.

The role of pouch compliance measurement in the management of pouch dysfunction

Ileal pouch anal anastomosis is an established option for patients who require total proctocolectomy and restoration of bowel continuity. However, the functional results are not always good and low pouch compliance has been suggested as one possible cause. We aimed to review the results of pouch compliance tests over 11 years to assess whether measuring pouch compliance is a useful diagnostic tool to guide management of pouch dysfunction. The results of pouch compliance tests performed between 1996 and 2007 together with the details of symptoms, treatments and outcome were reviewed. One hundred and forty-one pouch compliance tests were performed. There was no difference in pouch compliance between those with overt pathology (pouchitis, pelvic sepsis or anastomotic stricture) and those with idiopathic pouch dysfunction. In this second group, there was no difference in pouch compliance between patients with and without each of the symptoms of increased defaecatory frequency, incontinence and evacuation difficulties. The results of the compliance testing did not influence the clinical decision making on idiopathic pouch dysfunction (p=0.77) nor diverted pouches (p=0.07). Measuring pouch compliance does not offer new information accounting for idiopathic pouch dysfunction and has little influence on the clinical management.

Profound Reduction in Sedation and Analgesic Requirements Using Extended Dexmedetomidine Infusions in a Patient With an Open Abdomen

We present a 20-year-old previously healthy male who suffered a gunshot wound to the abdomen and underwent multiple surgeries because of abdominal abscess and fistula formation. Pain control was difficult to achieve despite high-dose opioid therapy. Post-traumatic stress disorder was a confounding factor in treating this patient's pain. Ten months after the original injury, the patient returned to the operating room for an exploratory laparotomy with restoration of bowel continuity and abdominal wall closure. The patient presented to the intensive care unit after a 12-hour operation with an open abdomen and the requirement of mechanical ventilation, sedation, and analgesia. Sedation and analgesia were difficult to achieve and maintain with combinations of extremely high doses of midazolam, lorazepam, propofol, and fentanyl (motor assessment activity scale [MAAS] scores of 5), but profoundly achievable with dexmedetomidine. Dexmedetomidine also improved the patient's mental stability, which resulted in improved patient care through compliance with physicians, nurses, and physical therapists.

Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann’s procedure be considered a one‐stage procedure?

Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis. All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal. Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037). Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis.

Colonic J-Pouch, Coloplasty, Side-to-End Anastomosis: Meta-Analysis and Comparison of Outcomes

Preservation of rectal function after low anterior resection or proctectomy with formation of a neorectum has improved the quality of life of many patients with rectal cancers. This would mean preserving the anal sphincters and avoiding a permanent stoma while reconstructing a neorectum to improve the bowel function of patients. Following proctectomy, the traditional anastomosis will be a straight coloanal end-to-end anastomosis to restore bowel continuity. However, this is associated with very poor bowel function. The construction of a colonic J-pouch anastomosis is introduced to reduce this problem. While colonic J-pouch anastomosis is able to obviate some of the functional problems of straight coloanal anastomosis, it comes with an additional problem of pouch evacuation. Therefore, alternatives techniques, such as transverse coloplasty pouch and side-to-end coloanal anastomosis, have been adopted. The postoperative surgical and functional outcomes are discussed and appraised.

Parameters of Healing in Approximative Intestinal Anastomosis

The restoration of bowel continuity using multiple classic anastomoses is mostly impossible in unstable critically ill extremely low birth weight neonates. The parameters of healing of approximative anastomoses in which integrity and continuity of bowel is achieved with limited number of stitches were evaluated in an experimental study. Small bowel anastomoses were performed in twenty-two adult male rats. An approximative ileo-ileal anastomosis was performed with five seromuscular-interrupted sutures only; in the control group the anastomosis was performed with the conventional technique of interrupted sutures. The mechanical and biochemical parameters were compared. All anastomoses in both groups healed well without obstruction. The mean operating time needed for an approximative anastomosis was shorter (16 +/- 7.1 min versus 23.6 +/- 6.2 min, p = 0.016). The strength of the approximative anastomoses on the 1st day after surgery was 55 +/- 15 torr; the strength of the conventional anastomoses was 55 +/- 42 torr. The strength of the approximative anastomoses after 7 days was 249 +/- 39 torr; the strength of the conventional anastomoses was 218 +/- 23 torr (p = 0.118). The activity of the collagenolytic enzymes matrix metalloproteinase-2 and matrix metalloproteinase-9 in the anastomotic area was significantly increased compared with the activity in samples of non-operated bowel. There was no significant difference in collagenolytic activity between both types of anastomoses. The approximative anastomosis is a time-saving alternative to conventional anastomoses with a comparable course of anastomotic healing, anastomotic strength, and changes in collagen metabolism.

Laparoscopically Assisted Reversal of Hartmann Procedure

Restoration of intestinal continuity following Hartmann procedure is an operation associated with a lengthy stay in hospital, protracted convalescence, and a high morbidity rate. With the aim of using the advantages of minimally invasive surgery, such as rapid mobilization, less postoperative pain, early restoration of bowel function, and a rapid return to a normal diet, and reduced morbidity, the laparoscopic modality was employed. The objective of the present study was to investigate the usefulness of laparoscopic restoration of intestinal continuity following Hartmann procedure. A total of 71 patients who, in the period between 1995 and 2005 within the framework of the prospective multicenter study "Laparoscopic Colorectal Surgery Study Group," underwent a laparoscopically assisted restoration of bowel continuity following Hartmann procedure, were investigated. In 62 patients (87%), the laparoscopic procedure was completed as planned, whereas 9 cases had to be converted to open surgery-mostly on account of massive intra-abdominal adhesions. The 39 male (55%) and 32 female (45%) patients had an average body mass index of 25 (range, 19 to 38), a height of 168 cm (range, 150 to 190 cm), and a weight of 72 kg (range, 49 to 103 kg). Mean operating time was 164 min (range, 60 to 410 min) and the intraoperative blood loss 196 mL (range, 10 to 1000 mL). Five patients (7%) received packed red cells. In all, 85.9% of the procedures (n=61) were free of complications. The most common intraoperative complications were injuries to the bowel and problems with the anastomosis (dehiscence, difficult stapling), each occurring in 5.6% of the cases (n=4). Intraoperative lesions to the ureters (0%), the bladder (n=1/1.4%), and blood vessels (n=1/1.4%) played a numerically subordinate role. Purely parenteral nutrition was applied up to the third postoperative day (range, 0 to seventh postoperative day). In those patients who were able to take a liquid meal on the third postoperative day (range, first to eighth postoperative day), enteral nutrition was initiated on the fifth postoperative day (range, second to tenth postoperative day). On average, bowel movements were restored on the fourth postoperative day (range, second to ninth postoperative day). Patients in whom a bladder catheter was placed for the operation had it removed on the third postoperative day (range, first to twelfth postoperative day) and had normal urination thereafter. In Hartmann procedure, patients without such a catheter, normal urination was possible from postoperative day 1 onward (range, 0 to second postoperative day). Postoperative complications included hematomas/abscesses (n=3/4.2%), transit disorders (n=2/2.8%), surgery-requiring ileus (n=2/2.8%), cardiopulmonary complications (n=1/1.4%), and surgery-requiring hemorrhage (n=1/1.4%), with other complications accounting for 4.2% (n=3). The median hospital stay was 11 days (range, 5 to 35 d); the mortality rate was 1.4% (n=1). Reversal of Hartmann procedure employing the laparoscopic modality is compatible with acceptable morbidity and mortality rates. The elevated conversion rate is a reflection of the fact that the operation is technically demanding.

Effect of bowel transection and fecal passage deprivation on the enteric nervous system in neonatal rats

Introduction A temporary stoma is a relatively common procedure at the neonatal age for a number of disorders. At birth, the enteric nervous system (ENS) is not fully developed; temporary colostomy causes morphological changes in the ENS. We studied whether transection of bowel or deprivation of stool is responsible for these changes. Moreover, reversibility of the ENS changes after stoma closure was investigated. Methods Male Lewis rats aged 3 weeks were randomly divided into 3 groups. Group 1 (stoma group) received a stoma (t = 0), stoma closure 2 weeks later (t = 1), and were killed 2 weeks after stoma closure; group 2 (transection group) had a colon transection and immediate anastomosis (t = 0) and were killed 2 weeks afterward. Group 3 (sham group) had no operation. In all groups, the nerve/muscle fiber ratio (NMR) in the proximal and distal colon was assessed with full thickness biopsy specimens at operation or after killing. The NMR in the stoma, transection, and sham group at t = 1 were used to assess the effect of deprivation of passage of feces and transection itself on the development of the ENS of the colon. Results of the stoma group at t = 1 and t = 2 were compared to assess possible reversibility of ENS changes after stoma closure. Results There was a significantly higher NMR in the distal colon compared to the proximal colon in both the stoma and transection groups at t = 1 (2.0 ± 0.38, P < .001 and 2.8 ± 0.97, P < .001, respectively), whereas there was no significant difference in NMR ratio at t = 1 (1.1 ± 0.18, P = .34) in group 3. In group 1, the NMR ratio increased further after stoma closure to 3.1 ± 0.37, P < .001, at t = 2. Conclusion Transection of the bowel rather than deprivation of fecal passage causes nerve fiber hypertrophy in the distal colon of neonatal rats. Restoration of bowel continuity does not result in recovery of these ENS changes.

Advantages of the distal sigmoid colostomy in the management of infants with short bowel syndrome

Background Infants with short bowel syndrome (SBS) frequently have proximal enterostomies with the colon excluded from intestinal continuity. Restoring intestinal continuity may create difficulty with perineal soiling. We propose creation of a distal sigmoid colostomy as an option for select infants with SBS. Methods This study involves the descriptive case series of all children with SBS who received a distal sigmoid colostomy. Results Eight infants (mean age, 70 days) received creation of a distal colostomy. In 1, placement of the colostomy was done at the initial surgery for SBS, 2 at the time of intestinal lengthening, and 5 during another procedure. Median length of small bowel was 58 cm. At 60 days postprocedure, median gain in enteral tolerance was 21% ( P = .09), with median stoma output of 125% enteral intake. There were no complications directly attributable to the distal colostomy. Conclusion Establishment of a distal sigmoid colostomy is an excellent management strategy for select children with SBS. It provides the benefits of restoring bowel continuity such as increased fluid and electrolyte absorption, improved energy absorption from fermentation of carbohydrate to short-chain fatty acids, and the theoretical enhancement of glucagonlike peptide 2 secretion that may optimize intestinal adaptation—all while protecting the perineal skin and simplifying quantification and collection of stool.

Combined laparoscopic and endoscopically assisted reversal of Hartmann's procedure (CLEAR technique)

Introduction: Although evidence is growing that most patients who need an operation for a left sided colonic or sigmoid disease can be treated by a single-stage procedure, a two-stage procedure will still be necessary in some patients because of significant sepsis or technical difficulties. Restoration of colorectal continuity is the second step of the procedure originally described by Hartmann in1923 for the treatment of sigmoid colon cancers. It is a complex procedure, which needs a meticulous surgical technique and is associated with a significant morbidity. In recent years, enthusiasm for laparoscopic reversal of Hartmann's procedure has increased, with the outcomes of many series suggesting that it has a reduced morbidity and mortality compared with the open procedure. Aim of the work: The aim of this paper is to describe a new minimally invasive combined laparoscopic and endoscopically assisted approach to restore bowel continuity after Hartmann's procedure. CLEAR= Combined Laparoscopic and Endoscopically Assisted Reversal. Conclusion: In this novel technique, the combination of the laparoscopic and endoscopic views as well as trans-illumination, gives the surgeon additional feedback as regards the proper plane of dissection especially in attempting Hartmann's reversal of a difficult rectal stump.

Multiple Atresia of the Small Intestine: A 20-Year Review

Multiple intestinal atresia (MIA) presents with a wide spectrum of bowel pathologies. Its treatment is a challenging task since restoration of anatomical continuity of the affected intestine must be balanced against preservation of the intestine's maximal length. A retrospective analysis of the medical notes of 26 patients with MIA treated over a 20-year period between 1986 - 2006 was undertaken with a special emphasis on the clinical and surgical perspectives. All 26 cases of MIA were sporadic with no familial history. The mean gestational age and birth weight were 36.1 weeks and 2781 g, respectively. Twenty-three of the infants underwent operative repair within the first days of life. Three patients with gastroschisis had a delayed diagnosis of bowel atresia. The number of atresias per patient ranged from 2 to 10. In 24 newborns atresias were confined to the small bowel, with 2 other patients having additional obstruction of the ascending colon. Various combinations of anatomical types of atresias were found, with type I and type III occurring in 19 patients each. Type II was diagnosed in 7 newborns. Surgical management of MIA consisted of one-stage restoration of bowel continuity with multiple anastomoses and/or enteroplasties in 22 patients. Four patients had an enterostomy performed at initial operation. Early and late postoperative complications requiring operative treatment occurred in 8 patients. The duration of parenteral nutrition ranged from 6 days to 20 months, exceeding 100 days in 6 children. The follow-up ranges from 3 months to 16 years. All the patients are alive and are on a full oral diet. Clinical observations of sporadic cases of MIA confined to the small bowel lend support to the hypothesis of a vascular incident etiology. One-stage restoration of intestinal continuity with preservation of maximal intestinal length should be the basic principle of any operative management of MIA. Despite a relatively high morbidity related to the primary damage of the fetal intestine, excellent results with 100 % survival rates can be obtained. After taking the differences in pathogenesis, anatomical and histological features, and the prognosis for sporadic and hereditary forms of MIA into account, these two entities should be classified separately in a modified classification of intestinal atresia.