Sigmoid Colostomy Research Articles

Primary adenocarcinoma of the appendix in a child: A case report

BackgroundPrimary adenocarcinoma of the appendix is a rare disease in clinical practice. Moreover, primary adenocarcinoma of the appendix in the pediatric age group is even rarer with very little cases being published. Here, we report a case of primary adenocarcinoma of the appendix with local invasion into adjacent organs in a child who was initially diagnosed as having an acute appendicitis.Case presentationA 13-year-old girl presented with abdominal pain of 3-month duration. Imaging study showed a mass including the fecalith that occupied her pelvic and right lower abdominal cavity. Drainage of the abscess and appendectomy were performed by the preoperative diagnosis of an acute appendicitis with an appendiceal mass. Postoperative histopathological examinations revealed the appendiceal adenocarcinoma. She then received the whole mass resection, ileocecal resection with lymph node dissection. The masses were tightly adherent with infiltration into the sigmoid colon, uterus, and right ovary. These organs were all dissected, and subsequent sigmoid colostomy was performed. We preserved the left ovary for her fertility. The pathological findings demonstrated negative margins and no lymph node invasions, and final pathological stage was pT4(SI)N0M0, stage II. After the operation, she received the chemotherapy with 6 cycles of 5-fluorouracil (5-FU), leucovorin (LV), and oxaliplatin (mFOLFOX6) and subsequent 6 cycles of simplified LV and 5-FU (sLV5FU2). The patient is doing well till today on follow-up without progression of the disease 5 years after the operation.ConclusionPrimary adenocarcinoma of the appendix is exceedingly rare in children. In this report, we described one of the youngest primary adenocarcinomas of an appendix case ever reported. When encountering atypical cases of the appendicitis, we should consider the possibility of primary adenocarcinoma of the appendix as it has an extremely poor prognosis and is usually diagnosed in advanced stages.

Single-incision laparoscopic parastomal hernia repair employing fascial defect closure and sandwich technique

Parastomal hernia (PSH) is a common complication following stoma creation. However, surgical strategies for PSH are complicated and involve several techniques with different recurrence rates. We hereby present the video of a patient undergoing single-incision laparoscopic PSH repair, employing the fascial defect closure and sandwich technique. The patient was a 76-year-old woman who noticed a reducible non-tender mass around the sigmoid colostomy, and a computed tomography (CT) revealed a PSH measuring 5 cm in size. We performed a single-incision laparoscopic PSH repair employing a fascial defect closure and the sandwich technique. After laparoscopic adhesiolysis of the remnant descending colon, the hernia orifice was closed by non-absorbable 2-0 sutures. We introduced the keyhole mesh into the abdominal cavity and placed it around the colostomy without any gaps. Then, we introduced the Sugarbaker mesh into the abdominal cavity and appropriately placed it after pulling up and fixing the descending colon to the abdominal wall. The patient was discharged on the postoperative day 2 without any complications. Single-incision laparoscopic PSH is technically complex; therefore, employing both a fascial defect closure and the sandwich technique makes the procedure even more difficult. However, this procedure promises minimal invasion and produces very effective surgical results. Further studies and long-term results should further demonstrate the low recurrence rate of this technique.

Short-term outcome of transanal total mesorectal excision for male low rectal cancer patients with "difficult pelvis" : a single center report from Peking University Cancer Hospital

To explore the applicable value of transanal total mesorectal excision (taTME) in male low rectal cancer patients with narrow pelvis-"difficult pelvis", which remains difficult for both open and laparoscopic sphincter-saving operations. Clinical data of male low rectal cancer patients diagnosed by pathology undergoing taTME between June 2016 and January 2018 at Peking University Cancer Hospital were collected. A retrospective cohort study was performed. Patients were selected according to the following criteria: (1) low rectal cancer, the distance between inferior margin of tumor and anal verge ≤5 cm; (2) the distance between two sciatic tubercles <5 cm; (3) body mass index (BMI) >25 kg/m2; (4) tumor horizontal diameter ≤4 cm. Operation time, intraoperative blood loss, postoperative hospital stay, postoperative complications and anal function were analyzed. A total of 20 patients were included in this study. All the patients received preoperative neoadjuvant chemoradiation and hybrid transabdominal and transanal surgery. The median BMI was 27.7(26.2-36.4) kg/m2; the median distance between two sciatic tubercles was 92.5 (78-100) mm; the median distance between the inferior margin of tumor to the anal verge was 4 (2-5) cm; the median operation time was 302 (215-402) min; the median intraoperative blood loss was 100 (50-200) ml; the median postoperative hospital stay was 9 (5-15) d. Postoperative complications occurred in 5 patients (25%), including 3 pelvic infection, 1 intestinal obstruction, 1 anastomotic leakage receiving sigmoid colostomy. There was no perioperative death. Sphincter-preservation rate was 100%. Nineteen patients received anal manometry 1 month after operation with normal resting pressure (41.5±8.6) mmHg and squeeze pressure (121.0±11.6) mmHg. All the patients were followed up to March 2018, and the median follow-up time was 4.5 months. Only 1 patient had supraclavicular lymph node metastasis and no local recurrence was found. The safety of transanal total mesorectal excision for male patients with low rectal cancer and difficult pelvis is acceptable. TaTME is helpful to preserve the anal sphincter.

Pelvic exenteration for primary and recurrent malignancies in urology department

Objective The objectives of present study is to investigate the safety and efficacy of pelvic exenteration (PE) for the treatment of pelvic malignancies in urology department. Methods From April 2010 to December 2014, 20 patients with primary or recurrent pelvic malignancy accepted anterior pelvic exenteration (APE) or total pelvic exenteration(TPE) surgery, including 7 males and 13 females, ranged from 35 to 87 years old with an average of 65 years old. Ten case accepted APE and 10 for TPE. The ilium conduit was done in 5 cases for APE and 6 cases for TPE as urinary diversion, cutaneous ureterostomy was done in 5 cases for APE and 4 cases for TPE as urinary diversion. There were 6 cases primary tumor in APE group and 3 primary tumors in TPE. All of the patients had 13 cases of the urinary tract tumor group, and none of the urinary tract tumor group in 7 cases. There were 4 cases received preoperative chemotherapy in the urinary tract tumor group. No case received preoperative radiotherapy. 3 cases received preoperative chemotherapy in none of the urinary tract tumor group, 3 cased received preoperative radiotherapy. After induction of general anesthesia using a laryngeal mask for airway management. All patients took the abdominal incision, then dissected lymph nodes on both sides of the iliac vessels, freed bilateral ureters to the end of the swollen bladder, separated the peritoneal space.The bilateral vas deferens was cutted and ligated, then isolated and ligated the seminal vesicles between the posterior wall of the bladder and the anterior wall of the rectum.Lateral ligaments of bladder was cuted, then cuted ligament of prostate and puboprostatic ligament, sutured and cut deep vein of penis. Urethra of apex prostate was freed and cuted. Female patients needed to free the uterus and the posterior wall, cut the cardinal ligament and round ligament of uterus, isolate the posterior wall of the uterus to the posterior vaginal wall. Rectal resection adopted Miles operation.And sigmoid colostomy was performed on the left side of the abdominal wall. The perioperative characters, pathological results and patients′ survival data were collected and analyzed. Results The average operation time for APE was 3.8 hours and 5.2 hours for TPE (P=0.173). Median length of hospital stay was 17.9 (7-47) days. The median blood loss was 300ml (80-2 500 ml) for APE and 400ml (50-6 000 ml) for TPE (P=0.909). The median follow-up time was 12.5 months (1-41months). The estimated 2-year survival rate for APE was 55.6% and 45.0% for TPE (P=0.642). Urinary system tumors group and non urinary system tumors group were analyzed and compared, The median survival time was 28 months and 13 months (P=0.538) in the two groups.The incidence of gastrointestinal complications of urinary system tumors and non-urinary system tumors was 7.7% and 28.6%, incision complications was 7.7% and 28.6%. Complications of urinary diversion only occurred in the non urologic tumor group, the incidence was 14.3%. The incidence of transfusion in two groups was 46.2% and 28.6%. Conclusions Pelvic exenteration (APE and TPE) could be a safe and reliable choice for local advanced primary and recurrent pelvic malignancy. Even for the recurrent malignancies, the survival results of the patients were satisfactory. Key words: Pelvic malignancy; Anterior pelvic exenteration; Total pelvic exenteration

Left transverse loop colostomy versus high sigmoid loop colostomy for high-type anorectal malformations: Early outcome analysis

Background: High sigmoid (divided) colostomy has been recommended by various studies for the management of high-type anorectal malformation (ARM). It is postulated to be associated with fewer complications. Aims: To compare the complications related to left transverse loop colostomy and high sigmoid loop colostomy done in male patients with high-type ARM and share our experience. Materials and Methods: A prospective study on all male neonates admitted with high-type ARM at our high-volume tertiary care institute from January 2014 to March 2016 was carried out. The patients were randomized and divided into two groups (group A: left transverse loop colostomy and group B: high sigmoid loop colostomy). The patient's clinical presentation, operative course, and complications were recorded. Results: Of 158 male neonates who were subjected to loop colostomy, 93 (58.9%) were in group A and 65 (41.1%) in group B. Mortality was higher in group B (16.9%) than group A (8.6%), but none directly related to the type of colostomy. Intraoperative complications (technical difficulties) such as difficulty in approaching the sigmoid colon with dilated small bowel loops and identifying the proximal and distal parts of sigmoid colon along with handling of the bowel (including serosal tears) were significantly more in group B (20%) than group A (1.07%) where transverse colon was easily exteriorized. The average time taken for the procedure, pericolostomy excoriation, and bowel obstruction was more in group B when compared with group A. Conclusion: Left transverse loop colostomy works well to relieve the obstruction and is less time-consuming, particularly with late presentation. We recommend left transverse loop colostomy in cases of high-type male ARM because of the ease of procedure and comparatively low complication rates.

An appraisal of intestinal stomas at a tertiary hospital in South Western, Nigeria

Background: Intestinal stomas are frequently constructed as part of abdominal surgeries in our center especially for colorectal cancer (CRC). There has been no previous documentation of the experience at our tertiary center. Objective: The objective of this study is to document the indications, types, and complications of intestinal stomas in our center to make necessary recommendations. Patients and Methods: This was a retrospective descriptive study of all patients who had intestinal stomas constructed during a 4-year period. The demographic data of patients, the information on indications, types, and complications of intestinal stomas were obtained from theatre records, and case notes. Data were analyzed using SPSS version 23. Results: A total of 85 intestinal stomas were constructed during the study period. Forty-four (51.8%) were males and 41 (48.2%) females with a male-female ratio of 1.07 to 1. The common indications were large bowel obstruction due to CRC (21.2%), anastomotic dehiscence (15.3%), and rectal/sigmoid injuries (12.7%). The intestinal stomas constructed in patients included defunctioning stomas (61.2%), decompression stomas (31.8%), permanent end colostomy following abdominoperineal resection of rectum for cancer (3.5%), and palliative sigmoid colostomy (3.5%) in patients with anal cancer. Sigmoid loop was the commonest stoma, constructed in 26 patients (30.6%). The common complications were peristoma skin excoriation (53.5%), retraction (11.6%) pouch leakage (9.3%), and prolapse (9.3%). Conclusion: Malignant intestinal obstruction due to CRC was the most common indication for stoma construction at our institution. Consequently, massive health education campaign to ensure early presentation of CRC is needed to reduce the need for stoma creation.

Chylothorax mimicking as anastomotic leak in a case of esophageal atresia

Chylothorax, as a complication of surgery for esophageal atresia (EA), is rare. It can be misdiagnosed as reflux of milk into the chest cavity. Here, we present a case of EA complicated by chylothorax. A preterm neonate with anorectal malformation and EA (Gross type C) underwent high sigmoid colostomy and posterolateral thoracotomy. Intraoperatively, the baby was found to have a wide gap between the upper and lower end of the esophagus not amenable to primary repair. The lower esophageal end was closed using 4-0 vicryl interrupted sutures. The cervical esophagostomy, feeding gastrostomy, and chest tube insertion were done. The chest tube started draining milky fluid 2 days after starting gastrostomy feeds. It was suspected to be lower esophageal stump blow-out with reflux of gastrostomy feeds onto the chest cavity. Dye study and biochemical analysis of pleural fluid helped to make the correct diagnosis of chylothorax. Successful conservative management of chylothorax was done. In conclusion, chylothorax can mimic as anastomotic leak or reflux of gastric contents into the chest cavity and should be kept in differential diagnosis after surgery for EA. Pleural fluid analysis showing lymphocytic predominant fluid with high fluid/serum triglyceride ratio can clinch the diagnosis.

A Case of Superior Mesenteric Artery Syndrome in Perianal Crohnʼs Disease

Superior Mesenteric Artery (SMA) syndrome is a rare condition caused by compression of the duodenum between the aorta and SMA due to loss of mesenteric and retroperitoneal fat. Among IBD patients, SMA syndrome occurs more commonly in patients with ulcerative colitis (UC) after ileal pouch anal anastomosis (IPAA). This is the first reported case of SMA syndrome in a patient with perianal Crohn's disease (CD). A 32 year old female with perianal CD and diverting loop sigmoid colostomy on infliximab presented with 1 month of progressive, colicky, postprandial abdominal pain, nausea, sitophobia, diarrhea, and a 7 lb weight loss leading to an episode of orthostatic syncope. Contrast enhanced computed tomography showed distension of the stomach and proximal duodenum, but no obstruction, bowel wall thickening, or intraabdominal abscess. Small bowel follow through showed delayed transit through the duodenum in the region of the SMA as well as small bowel dilation proximal to the region of the SMA consistent with SMA syndrome. Magnetic resonance enterography showed no evidence of active CD. Serum inflammatory markers were within normal limits. Alternative etiologies such as delayed motility from diabetes, hypothyroidism, and other metabolic neuropathies were ruled out, and she was diagnosed with SMA syndrome. Despite modest improvement of her nausea with scheduled metoclopramide, total parenteral nutrition was started for inadequate nutrition prior to hospital discharge. SMA syndrome in IBD patients is most commonly associated with IPAA, which is performed for refractory ulcerative colitis or for resection of IBD-associated colon cancer. One proposed mechanism for this phenomenon is surgery-induced stretching of the SMA, flattening it against the aorta to cause duodenal narrowing. This is the first reported case of SMA syndrome in perianal CD status post diverting loop sigmoid colostomy. Perianal CD is an uncommon variant of CD and phenotypically mimics limited UC. Although our patient's surgery did not involve significant bowel resection as in an IPAA, perhaps this phenotypic similarity and post-surgical anatomic changes predisposed her to increased risk of SMA syndrome. For IBD patients presenting with obstructive symptoms such as nausea, vomiting, sitophobia, and abdominal pain, clinicians must maintain a low threshold for considering SMA syndrome since treatment differs significantly from treatment of IBD exacerbation.Figure: CT abdomen and pelvis axial image showing compression of duodenum between the superior mesenteric artery (SMA) and aorta.Figure: CT abdomen and pelvis sagittal image showing acute angulation of the superior mesenteric artery (SMA) and the aorta.

Varied facets of rectal atresia and rectal stenosis.

Rectal atresia (RA) and rectal stenosis (RS) are rare anomalies with varied treatment options. A thorough literature review was done on reported cases/series of RA and RS. Based on evidence from cases managed over last 15years, new insights into embryology were hypothesized. A comprehensive review was compiled with updated knowledge on diagnosis and management. RA is classified into five types I: II: III: IV: V as RS: RA with septal defect: RA with a fibrous cord between two atretic ends: RA with a gap: Multiple RA and/or RS. Current definitive surgical repair of these anomalies preserves the anal canal, dentate line, and sphincter complex. Most neonates with RA undergo sigmoid colostomy except few with RS who can rarely decompress adequately. Membranous RS and septal RA may seldom respond to dilatation or be amenable to transanal repair. Posterior sagittal anorectoplasty with an end-to-end/side repair is recommended for RA and most intramural RS. RS may be associated with a presacral mass and colonic/rectal motility disorders. The expected postoperative outcome is good if the normally developed anal sphincter complex is retained undamaged. Early recognition of the type of anomaly is necessary for appropriate management.

Role of Laparoscopy in Radiation Proctitis: Case Report and Review of Literature

Introduction: The radiation proctitis is a known complication following the pelvic radiation therapy. Radiation proctitis is categorized as acute and chronic. Most of the cases are managed conservatively except in grade four chronic radiation proctitis, which active surgical management is needed. Previously these surgeries were done by conventional open technique. With the evolution of minimal access surgery it has now possible to do these surgeries by laparoscopic methods. Case Presentation: We here by present a case of 75 year old male patient presented with passage of dark colored blood mixed stools with tenesmus, pain and diarrhea. Patient had surgical history of transurethral resection of the prostrate (TURP) done for Benign Prostatic Hypertrophy. The tissue diagnosis of specimen was adenocarcinoma of prostate. Patient had received radiotherapy 9 months back for that prostatic carcinoma. The colonoscopy was suggestive of severe distal rectal proctitis, which was managed by laparoscopic proctectomy with partial sigmoidectomy and permanent end sigmoid colostomy. Conclusions: Laparoscopy has definitive role in management of chronic radiation proctitis, blessing the patient with benefits of minimal access surgery.

Robotic Total Pelvic Exenteration With Intracorporeal Sigmoid Conduit and Colostomy: Step-by-Step Technique

To describe our technique for robotic total pelvic exenteration with intracorporeal sigmoid conduit and colostomy using the da Vinci Si robot. Three 8-mm robotic ports and two 12-mm laparoscopic ports are placed in a "W" configuration, approximately 2-3 cm more cephalad than for radical prostatectomy (Fig.1). The robot is docked between the legs with the patient in steep Trendelenburg. The ureters are dissected out from the iliac vessels to the rectovesical pouch, where they are clipped and transected. The sigmoid colon is stapled across at the rectosigmoid junction and reflected into the abdomen. A posterior plane is developed below the rectum (Fig.2A), if space allows, or through the rectum. The endopelvic fascia is exposed and incised bilaterally. After sequentially controlling the bladder and prostatic pedicles (Fig.2B) using the Harmonic scalpel, the urethra is transected at the prostatic apex, and the anterior rectal wall is incised (Fig.2C). Any remaining attachments are divided, the rectal remnant is excised, and the specimen is bagged and extracted (Fig.2D). Adjacent segments of left and sigmoid colon are harvested for the conduit and colostomy, avoiding a bowel anastomosis. The ureters are anastomosed to the conduit, maintaining separation between the gastrointestinal and the urinary systems. The conduit and left end colostomy are matured (Fig.3). The technique is performed entirely intracorporeally with specimen extraction through the anus, avoiding a large open incision. We present the case of a high-functioning (Eastern Cooperative Oncology Group performance status 1) 73-year-old man with metastatic castrate-resistant prostate cancer following failed primary brachytherapy. Despite a good systemic response to chemotherapy and complete androgen blockade, his prostate-specific antigen level continued to rise (to 33 ng/mL) because of an enlarging prostatic pelvic mass. He suffered from progressive local symptoms, including intractable pelvic pain, obstructive uropathy, and impending rectal obstruction. The indication for pelvic exenteration was local palliation. Total robotic time was 5.4 hours. The perioperative course was complicated by disseminated intravascular coagulation secondary to metastatic prostate cancer, which resulted in a transient ischemic attack. The disseminated intravascular coagulation resolved with blood product transfusion, and the patient recovered well without permanent disability. In-patient length of stay was 8 days. Complete local palliation was achieved until the patient's death from prostate cancer 5 months later. We demonstrate our step-by-step technique for robotic total pelvic exenteration with intracorporeal sigmoid conduit.

Anorectal Agenesis with Rectovaginal Fistula: A Rare/Regional Variant.

Aims and Objectives:The anatomical types of female anorectal malformation (ARM) are complex and include several rare and regional variants. The aim of this report is to highlight the diagnosis and management of cases of anorectal agenesis with rectovaginal fistula (RVF).Materials and Methods:This is a retrospective chart review of cases of RVF who underwent definitive surgery between November 2000 and September 2016 in a single institution.Results:Of the 244 female patients with anorectal anomalies treated in our institution over a 16-year period, there were 15 cases of RVF with anorectal agenesis giving it an incidence of 6%. All cases of RVF with anorectal agenesis presented with absence of anal opening, varying degree of abdominal distension, and history of passage of fecal matter per vaginum. The mean age of presentation was 3 months (newborn to 1 year). Sigmoid colostomy was done in 13 cases. Distal colostogram demonstrated high RVF which was further confirmed by examination under anesthesia (EUA) and endoscopy before definitive surgery. With the posterior sagittal approach, division of the RVF and anorectoplasty was possible in 14 cases; however, one patient required an abdominal mobilization of the colon for pull through due to a very short distal bowel segment. During a mean postoperative follow-up of 5 years, cosmetic and functional results were satisfactory.Conclusion:RVF with anorectal agenesis is a rare/regional variant of female ARMs. Clinical examination along with distal colostogram, EUA, and endoscopy clinches the diagnosis. Anorectal reconstruction by posterior sagittal anorectoplasty results in a satisfactory outcome.

Challenges of hirschsprung's disease presenting in an adult: A case report

Hirschprung’s disease is rare in adults; it is often misdiagnosed or undiagnosed. We present a 34 year old man illustrating the clinical characteristic of the pathology, the diagnostic clues and assessing the therapeutic approach. Definitive diagnosis is established on histology specimen from the rectum and the disease was confined to the rectosigmoid .Treatment involved sigmoid colostomy, anterior resection with colorectal anastomosis with a posterior myotomy.

One or Two Stages Procedure for Repair of Rectovestibular Fistula: Which is Safer? (A Single Institution Experience).

Background:Rectovestibular fistula (RVF) is the most common type of anorectal malformations in females. The need for a diverting colostomy during correction of defect has ignited a heated debate. In this study, we reviewed the girls with RVF that had been treated by either one or two stage procedure in the past 10 years in our institution to define whether one stage or two stage procedures is safer and more beneficial for the patients.Materials and Methods:Seventy girls with RVF that had been operated from January 2005 to January 2015 were studied retrospectively. Data were obtained from medical hospital records. The cases were divided into two groups. Group A (46 patients): were operated by two stages technique (simultaneous sigmoid colostomy and anterior sagittal anorectoplasty [ASARP]). Group B (24 patients): were operated by one stage (ASARP without covering colostomy). The short-term outcome as regard wound infection, wound dehiscence, anal stenosis, anal retraction, recurrence of fistula as well as complications of colostomy was reported. The long-term outcome as regard soiling, constipation and voluntary bowel movement was evaluated.Results:The age of patients at the time of surgery ranged from 3 months to 2 years (mean; 9.5 months). In Group A, seven patients (15.2%) developed wound infection, two patients developed wound disruption. One patient developed anterior anal retraction and required redo-operation, anal stenosis was noticed in five (10.9%) patients. Complications from colostomy had occurred in nine patients (19.5%). In Group B, wound infection occurred in ten patients (41.7%). Seven patients (29.2%) developed wound disruption. Anal stenosis occurred in eight patients (33.3%). Five patients required redo-operation because of anal retraction in three patients and recurrence of fistula in the other two patients. Constipation recorded in 15 patients (32.6%) of Group A and in ten patients (41.3%) of Group B. Soiling was reported in six girls (13.04%) of Group A and five girls (20.8%) of Group B.Conclusion:The avoidance of colostomy is not outweighed achieving sound operation and continent child. Two stages correction of RVF is safer and more beneficial than one stage procedure, especially in our locality and for our paediatric surgeons during their learning curve.

Exceptional Therapeutic Outcome of Metastatic Neuroendocrine Tumor with Peptide Receptor Radionuclide Therapy with Brief Review of Literature

NETs are rare, heterogeneous group of neoplasm presented as chronic oncologic disease. Somatostatin analogue is the standard first line systemic therapy for mainly hormone control. No standard second line systemic treatment is available except everolimus which has no reported complete response. PRRT is an innovative molecular targeted treatment based on theragnostic concept for well differentiated NETs. We presented here a 63-year-old lady with grade 1 NET of rectum with lymphnodal and liver metastasis. She underwent sigmoid colostomy for bowel symptoms and started on sandostatin LAR. After progression, patient was treated with 4 cycles of 7.4GBq of 177Lu-DOTATATE at 10 weeks interval. No hematological and renal toxicity were noticed. Patient showed complete response in liver lesions & lymphnodes and partial response in rectal lesion on 68Ga-DOTANOC PET-CT. After multispecialty clinic board discussion, patient underwent curative surgery for residual rectal lesion and colostomy closer later on. Our case highlights a common presentation of NETs but an uncommon outcome with currently approved drugs. With this potential of disease cure in metastasis, PRRT may also be offered for locally advance disease as an adjuvant treatment for down staging.fv

Hudson's landmark contribution to ovarian cancer surgery.

In this journal in 1968 Christopher Hudson, a Resident Assistant Physician Accoucheur at St Bartholomew's Hospital, London, described a pioneering approach to surgical resection of ovarian cancer (OC) from the pelvis (Hudson J Obstet Gynaecol Br Cwlth 1968;75:1155–60). Hudson's ‘radical oophorectomy’ was intended to remove an ‘ovarian tumour fixed in the pelvis intact with the whole of the peritoneum from surrounding structures still attached’. It was applicable to cancers confined to the pelvis or with early omental involvement, but not in the presence of more widespread disease, including bulky para-aortic lymph nodes. The principle steps included entry into the presacral space to mobilise the rectum, and dissection of the bladder from the upper vagina, allowing the vagina to be transected to gain entry to the rectovaginal space. The pelvic tumour with peritoneum of the entire pouch of Douglas and bladder peritoneum, if necessary, could then be removed as a ‘false’ capsule (Figure 1). Subsequently, Hudson reported on 25 women (23 with cancer) undergoing the procedure between 1965 and 1972 (Hudson Gynecol Oncol 1973;1:370–8). Non-gynaecological organs including bladder, small bowel, rectosigmoid colon, ureter and appendix might require surgical procedures. When possible the rectum was preserved but three rectosigmoid re-anastomoses were performed and one sigmoid colostomy. Complications included two rectovaginal fistulae and one death from haemorrhage 4 weeks after surgery. Twelve women received postoperative chemotherapy and seven received radiotherapy, with 16 alive at the time of the report. Although in 1934 Meigs in Boston wrote that ‘removal of as much tumour as possible’ was beneficial for survival (Meigs Tumors of the Female Pelvic Organs, New York: Macmillan Company, 1934), it took several decades to establish that maximal surgery to no visible disease was the most important prognostic factor for survival in OC. The principles of Hudson's procedure form the foundation for complete resection of OC from the pelvis today. Metastatic disease in the upper abdomen became the biggest barrier to resection for gynaecological oncologists, but with the development of techniques of upper abdominal surgery, including peritonectomies described by Paul Sugarbaker (Ann Surg 1995;221:29–42), together with improvements in perioperative management, this has now been overcome. Hudson wrote ‘only time will tell whether this can influence the salvage in this disease’. He would be gratified to know that clearance of the pelvis as part of removing all visible cancer has a major role to play in survival of women with advanced OC today. Rightly, there is increasing concern that survival for women with OC in the UK lags behind many other countries, a fact stressed by the Chief Medical Officer of England in her most recent Annual Report, as she recommended that training of gynaecological oncologists include the necessary surgery to reduce mortality (Department of Health 2015). Christopher Hudson went on to become Professor of Obstetrics and Gynaecology at the University of Sydney, Australia. In 1980 he delivered the Victor Bonney Lecture at the Royal College of Obstetricians and Gynaecologists. The College can be proud of Hudson, and women with OC can be thankful for his contribution to the field. Thanks go to the pioneers of ovarian cancer treatment, past and present, including Professor Robert Bristow who previously highlighted the contribution of Hudson (Bristow et al. J Am Coll Surg 2003;197:565–74). None declared. Completed disclosure of interests form available to view online as supporting information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Changes in cholinergic and nitrergic systems of defunctionalized colons after colostomy in rabbits

BackgroundThis study was designed to assess smooth muscle function and motility in defunctionalized colonic segments and subsequent changes in pathways responsible for gastrointestinal motility. MethodsTwo-month-old New Zealand rabbits were randomly allocated into control and study groups. Sigmoid colostomies were performed in the study group. After a 2-month waiting period, colonic segments were harvested in both groups. For the in vitro experiment, the isolated circular muscle strips which were prepared from the harvested distal colon were used. First, contraction responses were detected using KCl and carbachol; relaxation responses were detected using papaverine, sodium nitroprusside, sildenafil, and l-arginine. The neurologic responses of muscle strips to electrical field stimulation (EFS) were evaluated in an environment with guanethidine and indomethacin. EFS studies were then repeated with atropine, Nω-nitro-l-arginine methyl ester, atropine, and Nω-nitro-l-arginine methyl ester–added environments. ResultsAlthough macroscopic atrophy had developed in the distal colonic segment of the colostomy, the contraction and relaxation capacity of the smooth muscle did not change. EFS-induced nitrergic-peptidergic, cholinergic-peptidergic, and noncholinergic nonnitrergic responses significantly decreased at all frequencies (0.5-32 Hz) in the study group compared with those in the control group (P < 0.05). ConclusionsAlthough the contraction capacity of the smooth muscle was not affected, the motility of the distal colon deteriorated owing to the defective secretion of presynaptic neurotransmitters such as acetylcholine, nitric oxide, and neuropeptides.

Outcome of Short-Term and Long Term Antibiotic Prophylaxis in Colostomy Closure

Background and Objectives: Antibiotic prophylaxis is a common practice in children undergoing colostomy closure for anorectal malformation, Hirschsprung's disease. Traditionally, antibiotics are given for unnecessarily longer period of time, which consumes scarce health resources having alternate efficient use. The present study was undertaken to compare the outcome between short-term and long-term antibiotic prophylaxis in colostomy closure.&#x0D; Materials &amp; Methods: This randomized clinical trial was conducted in Dhaka Shishu Hospital, Dhaka over a period of 15 months from April 2001 to June 2002. Children admitted with anorectal malformation, Hirschsprung's disease for colostomy closures were the study population. However, immuno-compromised children or children already getting antibiotics were excluded from the study. A total of 46 such children were consecutively included and were randomly allocated to long-term group (n = 21) and short-term group (n = 25). The long-term group received antibiotic up to 5th postoperative day, while the short-term group received the same antibiotic up to 2nd postoperative day. Transverse colostomy was the main procedure employed in colostomy closure; however, a few patients required sigmoid colostomy. The outcome measures were incidence of wound infection, hospital stay and cost of treatment.&#x0D; Result: Majority of the children were between 1 - 5 years of age (75% in short-term and 50% in long-term group) followed by under 1 year (10% in short-term and 40% in long-term group) and &gt; 5 years (15% in short-term and 10% in long-term group). The overall male to female ratio was 3:1. Majority (85%) of the patients in both long­term and short-term groups belonged to lower income group. Over half (52.2%) of the children had anorectal malformations (ARM) and the rest (47.8%) had Hirschsprung's disease (HD). Children were generally malnourished according to Gomez classification. Majority (91%) was operated on by transverse colostomy and few (9%) by sigmoid colostomy. Three patients in each group developed postoperative wound infection. Blood culture of none of these patients yielded growth of any organism, though wound swab culture did so in 5 cases out of 6 infected patients. In 2 cases, the organism was E.coli, in 2 cases, it was Pseudomonas and in one case Staph. aureus. Total cost of antibiotics in short-term therapy was less than 50% of that required in long-term therapy. The outcome in terms of recovery, complications and postoperative hospital stay was no different between groups.&#x0D; Conclusion: The study concluded that short-term antibiotic prophylaxis is as efficacious as long-term in preventing wound infection in patients with colostomy closure for anorectal malformation and Hirschsprung's disease. Short-term antibiotic prophylaxis is cost-effective&#x0D; Ibrahim Cardiac Med J 2014; 4(2): 43-48

Predictors of morbidity in patients undergoing diverting colostomy for non-healing sacral, perineal or ischial wounds

Abstract Background The treatment of non-healing sacral, perineal, or ischial wounds often requires fecal diversion to promote wound healing. The purpose of this study was to identify risk factors for morbidity, rates of colostomy reversal and complications related to type of colostomy. A retrospective chart review was conducted on all patients with non-healing wounds who underwent diverting colostomies. Results Sixty six patients met criteria for inclusion in the study. Complication rates and revision rates were studied. 27% of all stomas required revision. Stoma revision was required in a higher proportion (33%) of all loop colostomies as compared to all end colostomies (10%). During the study period, 26% of diverted patients went on to have a myocutaneous flap. The stoma reversal rate was 5% (3/66). Complications occurred in 32% of patients. The most common complication was parastomal hernia (20%). Other complications included: small bowel obstruction, 8%; stoma prolapse, 6%; stoma bleeding 5%; and stoma retraction, 5%. Patients with loop colostomies had a higher rate of overall complications as compared to end colostomies (37% vs.10%) Conclusions Based on the findings of this study, consideration should be given to fashioning end sigmoid colostomies for fecal diversion in patients with non-healing wounds.

AB193. Rectourethral fistula

ObjectiveTo investigate the treatment of rectourethral fistula.MethodsEleven cases of male patients with rectourethral fistula were treated in our department from 2011 to 2015. Age 16–66 years old. Causes: three cases of patients with congenital closed anus, four cases of traumatic pelvic fracture with urethral distraction and rectum injury, four cases after radical prostatectomy. The size of the fistula was 0.5–1.5 cm. In addition to the leakage of urine in the large fistula, urine mixed with stool samples. Three patients with congenital closed anal postoperative patients with posterior or anterior median sagittal approach for resection of the fistula, hierarchical closed urethral and rectal wall defect, at least three layer (between the urethral and rectal suture layer), indwelling catheter for 3–4 weeks, no cystostomy. Sigmoid colostomy underwent prior to the surgery. Of which six cases were repaired by perineal approach, one case by abdominal perineal approach, one case by abdominal repair. According to size of fistula and the surrounding scar decide whether or not to adopt tissue interposition, this group of five cases with gracilis muscle flap, one case with bulbocavernosus muscle flap interposed between the rectum and urethra; one case repaired by sigmoid colon pull-through procedure. Post-operation indwelling catheterization for 3–4 weeks with cystostomy.ResultsA total of 10 patients were successful, and no leakage of urine was found after removal of the catheter. One patient improved, occasionally a small amount of drops of urine voiding from anus. Reoperation was successful after 6 months. Recovered enteric continuity 3–6 months post-operation.ConclusionsThe median sagittal approach provide good exposure for the repair of congenital rectourethral fistula; perineal approach is a good choice for patients caused by trauma or surgery; complete resection of scar around the fistula, tension-free anastomosis, tissue interposition and sigmoid colostomy provide necessary guarantee for successful operation.