Sigmoid Loop Colostomy Research Articles

Anorectal avulsion-an unusual anorectal trauma

Anorectal avulsion is a rare trauma. In this type of lesion, the anus and the sphincter complex are pulled up by a tremendous compression of the pelvic floor. Frequently, this trauma is associated with other injured organs, like pelvic bones or urethra. We report a case of a young man who was admitted with a total anorectal avulsion associated with a pelvic fracture. A multidisciplinary treatment included external fixation of the broken pelvis, suprapubic cystostomy, sigmoid loop colostomy and reimplanting the anal complex in the original position with appropriate drainage. Anorectal injuries are uncommon and represent about less than 10% of rectal trauma, but anorectal avulsion is extremely rare. These cases often require a quick decision making and multidisciplinary approaches to reduce the possibilities of morbidity and mortality.

Repair of stoma prolapse with the "peristomal cerclage" method using vessel tape.

Stoma prolapse is one of the most common late complications following stoma construction. Although prolapses can be managed conservatively, they often require surgical revision. This study aimed to describe a revision method called peristomal cerclage applied with local anesthesia to treat stoma prolapse. A 66-year-old male patient with advanced rectal cancer underwent sigmoid loop colostomy one year ago due to a distal occlusive tumor. A revision of the colostomy prolapse that developed postoperatively was planned. After the reduction of the 12 cm prolapse into the abdomen under local anesthesia, a repair was performed in the form of peristomal wrapping of a vessel tape; except for short-term abdominal distension, no complications developed in the patient. He is currently in the postoperative 26th month and terminal period, and his colostomy is working normally. The present report aimed to describe the peristomal cerclage method, a minimally invasive revision procedure applied to patients with stoma prolapse, and to deliver its long-term results. It is important to report the results obtained with the more widespread use of this method.

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

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

STUDY OF INDICATIONS AND COMPLICATIONS OF SMALL AND LARGE INTESTINAL STOMAS IN EMERGENCY SITUATIONS

Background: Stoma is a surgically created opening in the anterior abdominal wall with a purpose to divert the feces away from the distal bowel loops in order to relieve obstruction or product anastomosis (1) in emergency situations. Stomas may produce multiple complications (2). Most of the stoma complications are minor, can be managed with proper care, only little complications require intervention by means of surgery which may produce high morbidity and mortality (3). To study the Aims & Objectives: various types and indications of small and large intestinal stomas in emergency situations. To identify the various early complications encountered after the construction of emergency intestinal stomas. To assess the ways in which these complications can be minimized and managed in a better way. Observational Prospective Study of 40 patients undergoi Methods: ng emergency small and large intestinal stoma construction in tertiary care government hospital from March 2020-August 2021 according to inclusion and exclusion criteria with a follow up of 3 months post-operation. Data is analyzed using descriptive statistics. Out Results & Conclusion: of 40 patients underwent emergency small and large intestinal stoma construction, males were 34 and females were 6 with mean age of 45.38 years. The most common indication for stoma construction was Intestinal obstruction followed by Enteric perforation. The most common stoma constructed was loop ileostomy followed by loop sigmoid colostomy. The most common early complication of stoma was skin excoriation followed by stoma retraction. Most stoma complications are managed conservatively.

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

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

P240 Candida nivariensis infection in South East Asia: series of case reports from Selayang Hospital, Malaysia and South East Asia Region

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Introduction Candida nivariensis, first described from Spain in 2005 is an emerging fungal pathogen. Malaysia has captured a total of 11 cases since its first reported here in 2014. Indonesia, Thailand, and Vietnam are among South East Asia countries that reported its occurrence too.ObjectivesThe occurrence and characteristics of Candida nivariensis in South East Asia are studied. We would like to highlight two cases from Selayang Hospital, Malaysia that occurred during pandemic COVID-19 in 2020 and 2022.Case DescriptionIn July 2020, a 60-year-old lady underlying poorly controlled diabetes mellitus, CKD stage V approaching ESRD, congestive cardiac failure, hypertension, and dyslipidemia was diagnosed as complicated MSSA bacteremia secondary to right gluteal carbuncle. Appropriate antibiotics were commenced. Aggressive source control including incision and drainage, cauterization of right gluteal carbuncle, and multiple wound debridement for the infected gluteal wound was performed. She underwent a trephine sigmoid loop colostomy. Tracheostomy was done following prolong ventilation. Anidulafungin as empirical fungal coverage was commenced in ICU as she further deteriorated. Candida nivariensis was isolated later from her blood culture.In February 2022, a 74-year-old man underlying Diabetes mellitus, chronic kidney disease, hypertension, ischemic heart disease with two vessels disease stented, post-Whipple's procedure due to necrotizing pancreatitis in 2014 complicated with chronic abdominal pain with hyperalgesia admitted to the ward for acute right lacunar infarct with failed swallowing test and neurogenic bladder. His general condition deteriorated with worsening of biochemical and septic parameters. His blood culture grew C. nivariensis following which anidulafungin was started. No distant seeding and no signs of endophthalmitis. He then required mechanical ventilatory support complicated with multiorgan failure, leading to ICU admission.MethodsFor both cases, yeast isolates were subcultured on Sabouraud dextrose agar and CHROMagar. Matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) with molecular testing was performed for confirmation of isolates. Phylogenetic tree among isolates from Malaysia was analyzed. Antifungal susceptibility test (AFST) to study the minimum inhibitory concentration (MIC) among treatment options was performed using the e-test method.ResultsWide use of MALDI-TOF MS with molecular testing increased the detection rate of the species. Isolation sites in Malaysia and South East Asia region include blood culture, peritoneal fluid, high vaginal swab, and oropharyngeal swab. Risk factors namely immunocompromised status, indwelling vascular catheter, abdominal surgeries, renal failure or on dialysis support, polymicrobial usage, and prolonged stay in ICU. AFST established susceptibility towards fluconazole, high MIC to itraconazole and low MIC against amphotericin B, anidulafungin and voriconazole for both patients who unfortunately succumbed to their illness.ConclusionDiagnosing C. nivariensis is challenging due to its closely related phylogenetic with C. glabrata, and C. bracarensis, thus molecular testing is vital. Inadequate antifungal coverage or delay of treatment could be detrimental to patient's outcome. Continuous epidemiological surveillance is crucial to address this potential invasive fungal pathogen and to observe emerging of drug resistance.

EARLY OUTCOMES AFTER POSTERIOR SAGITTALANORECTOPLASTY FOR ANORECTAL MALFORMATION

Anorectal malformations (ARM) are one of the commonest causes of intestinal obstruction in the new-born. It comprises a wide spectrum of anomalies which affect the distal part of gastrointestinal tract with or without urogenital system and sacral involvement. Childrens born with this condition, therefore, have no anal opening in the expected site of anal orice. The aim of this prospective observational study of 75 patients is to study early outcome of ARM after posterior sagittal anorectoplasty (PSARP), to study Incidence, Classication, Clinical Presentation & Management of ARM, to study associated abnormalities with ARM. The study shows mean age of study subjects at the time of surgery is 10.74 ± 2.33 months. Majority of cases are male 73% and female 27%. Among these 75 cases, cases with Imperforate anus 55, Rectovaginal stula 9, Recto-vestibular stula 11, high level anomaly found in 39%, intermediate 35% and low level 26% cases. Primary management Sigmoid loop Colostomy is done in 72 cases and denitive management PSARP is done in 75 cases. Outcome of anorectal malformation after PSARP presented as, Constipation 15, Wound infection 7, Wound dehiscence 4, Fecal impaction 4 and Anal stenosis found in 1 case

EP.TU.693A rare case of anal melanoma: An entity to be aware of

Abstract Aims Anal melanoma is a rare but aggressive malignancy representing a small percentage anorectal cancers. We report a rare case incidentally detected during bowel screening. Methods A 74-year-old female presented for endoscopy after a positive qFIT. She was asymptomatic. During endoscopy, perianal examination revealed a jet black naevus of approximately 3x3cm from 9 to 12’O clock position, overlying the perianal body, involving anal margin to the posterior vagina. General physical, abdominal and rectal examinations were unremarkable. During colonoscopy, a benign polyp was removed from the sigmoid colon. She underwent examination of rectum and vagina under general anaesthetic, and incisional biopsies were obtained. Histopathology confirmed an invasive, superficial spreading malignant melanoma, with a Breslow thickness of 1.5mm and Clark Level IV invasion. Staging CT scans did not reveal metastasis. Following loco-regional MDT discussion, a combined colorectal and plastic surgery was offered. She underwent wide local excision from the posterior vaginal fourchette to the anal canal, bilateral perforator flap reconstruction, and defunctioning sigmoid loop colostomy. Results There were no intraoperative complications. She recovered well post-operatively. After histopathology, her tumour was staged as pT2b, N0, M0. She did not require further treatment post-operatively as per MDTdiscussion. No disease recurrence has been detected yet with 30 months follow up, and she is awaiting reversal of colostomy. Conclusions Prognosis is generally poor in anal melanoma. This case report adds to the limited literature and emphasizs that despite no consensus on management, early detection and surgical resection offers the best chance for favorable outcomes.

Atypical Hemolytic Uremic Syndrome after Traumatic Rectal Injury: A Case Report

Atypical hemolytic uremic syndrome (aHUS) is a rare, progressive, life-threatening condition of thrombotic microangiopathy characterized by thrombocytopenia, microangiopathic hemolytic anemia, and renal impairment. The mechanisms underlying aHUS remain unclear. Herein, we present the first case in the literature of aHUS after a traumatic injury. A 55-year-old male visited the emergency department after a traumatic injury caused by a tree limb. Abdominal computed tomography revealed a rectal wall defect with significant air density in the perirectal space and preperitoneum, implying rectal perforation. Due to the absence of intraperitoneal intestinal perforation, we performed diverting sigmoid loop colostomy. An additional intermittent simple repair was performed due to perianal and anal injuries. One day postoperatively, his urine output abruptly decreased and serum creatinine level increased. His platelet level decreased, and a spiking fever occurred after 2 days. The patient was diagnosed with acute renal failure secondary to aHUS and was treated with fresh frozen plasma replacement. Continuous renal replacement therapy (CRRT) was also started for oliguria and uremic symptoms. The patient received CRRT for 3 days and intermittent hemodialysis thereafter. After hemodialysis and subsequent supportive treatment, his urine output and renal function improved. The hemolytic anemia and thrombocytopenia also gradually improved. Dialysis was terminated on day 22 of admission and the patient was discharged after recovery. This case suggests that that a traumatic event can trigger aHUS, which should be considered in patients who have thrombocytopenia and acute renal failure with microangiopathic hemolytic anemia. Early diagnosis and appropriate management are critical for favorable outcomes.

Minimally invasive colostomy with endoscopy as a novel technique for creation of a trephine stoma

The conventional approach of trephine stoma creation is associated with various limitations, including poor elevation of the sigmoid colon, misidentification of the target organs, and poor visualization of the operative field, which may require conversion to an open approach. Our study aimed to evaluate the safety, feasibility, and complications of minimally invasive colostomy with endoscopy (MICE), a new technique for trephine stoma creation. This retrospective cohort study included 14 patients. Patients diagnosed with obstructive rectal cancer or bladder and rectal disorders due to spinal cord injury or bone metastasis requiring sigmoid loop colostomy were eligible for the procedure. MICE was performed using a combination of endoscopic and fluoroscopic procedures. The primary endpoint was the technical success of MICE. Technical success using MICE was achieved in all 14 cases. The mean total operative time was 52.6 (range 32–107) min, and mean blood loss was 18.9 (range 1–50) mL. There was no incidence of conversion to open surgery. Postoperative complications included peristomal abscess formation and ischemic colitis in each case. MICE may be useful as a minimally invasive approach for trephine stoma creation that overcomes the problems of a conventional approach in high-risk patients.

Pelvic actinomycosis

Abstract Background Actinomycosis is a rare infectious disease caused by Actinobacteria. It has a wide spectrum of presenting symptoms depending on anatomical location and can occasionally mimic pelvic malignancy and cause diagnostic difficulty. Case A female in her seventies presented with altered bowel habit, anorexia and abdominal discomfort with a history of diverticulosis. CT-AP revealed a sigmoid lesion causing large bowel obstruction. She underwent a laparoscopic defunctioning sigmoid loop colostomy and limited sigmoidoscopy. Subsequent endoscopy showed no dysplastic change but obvious stricturing. A diagnosis of locally perforated diverticular disease was made. Subsequent imaging showed rapid progression with hydroureter and hydronephrosis, now suggesting locally perforated sigmoid tumour or gynaecological malignancy. Tumour markers were normal. She underwent surgical exploration and resection. Specimen evaluation revealed Actinomyces likely originating from diverticular disease. Treatment involved long-term antibiotics for 12 months. Conclusion Pelvic Actinomyces is a difficult diagnosis to make on clinical and radiological findings. It should be considered in differential diagnoses of progressive pelvic lesions.

Impact of neoadjuvant chemoradiotherapy on post-operative outcome in patients with rectal cancer

Background: Neoadjuvant chemoradiotherapy not only helps in downstaging the rectal cancer, it also reduces the rate of local recurrence but it has its own attendant risk factors. Our aim is to look into the implications of neoadjuvant chemoradiotherapy in patients with rectal cancer in our hospital.Methods: Retrospective data was collected from the infoflex system of database for the patients who underwent neoadjuvant chemoradiotherapy between January 2016-December 2019 in our DGH. The data was analysed for demographics, type of surgery, histology, length of stay, complications and stoma reversal rates.Results: Total 27 patients with rectal cancer during the study period underwent neoadjuvant chemoradiotherapy. 16 were male and 11 females. Age range was 33-82 year. 13 patients underwent APER, 8 Hartmann’s and 6 anterior resection with covering loop ileostomy. 5 patients initially required defunctioning sigmoid loop colostomy and one loop ileostomy prior to the start of neoadjuvant treatment. Histology showed 26 adenocarcinoma, and 1 squamous cell cancer. 3 patients had complete pathological response (cPR). Post-operative stay was from 5-32 days. 12 patients developed pelvic collection, 5 wound infection (4 perineal+1 abdominal), 5 had paralytic ileus, 1 patient had PR bleed, 2 anastomotic leak and 2 patients had chest related complications. Only 4 out of 6 loop ileostomies were reversed. Conclusions: Neoadjuvant treatment benefits come with its attendant complications. The tissue response to radiotherapy and chemotherapy and advanced tumor stage may contribute for the increased morbidity. Hopefully in future with the advent of new armamentarium, the degree of morbidity may come down.

Vesicoureteral reflux increases the risk of urinary tract infection prior to corrective surgery in newborn males with anorectal malformation.

The ideal colostomy type indicated for patients with anorectal malformation (ARM) is disputed. The aim of this study was to analyze the clinical factors associated with urinary tract infection (UTI) prior to corrective surgery in male ARM without perineal fistula having undergone diverting enterostomy. A retrospective review of patients diagnosed with ARM and surgically managed at our center from January 2011 to December 2019 was performed. Logistic regression was used to analyze the association between clinical factors and UTI. Eighty boys with ARM without perineal fistula underwent diverting enterostomy and subsequent corrective surgery via laparoscopic-assisted anorectal pull-through. A sigmoid loop colostomy was most often performed (70 patients, 87.5%). Twenty-nine patients (36.3%) were diagnosed with vesicoureteral reflux (VUR), including 14 (48.3%) with febrile UTIs. Six patients had other concomitant genitourinary anomalies excluding VUR. Multivariate logistic regression analysis revealed the presence of VUR as the only independent factor associated with the occurrence of febrile UTI (OR 17.3, 95% CI 3.51-85.26, p < 0.001). The development of UTI in newborn males with ARM is associated with the presence of VUR, regardless of stoma type. Voiding cystourethrography should be considered in patients with ARM for early diagnosis of VUR and subsequent antibiotic prophylaxis.

Anorectal injury related to a personal watercraft: a case report and literature review

BackgroundDouche injury is a rare consequence of water recreation activities. Generally, this type of trauma occurs when people fall into the water in a sitting position during high-speed activities such as using a personal watercraft (PWC). Here, we report a rare case of anorectal injury caused by water jets from a PWC during sudden acceleration from rest.Case presentationA 21-year-old male passenger on a PWC fell off backward from the rear seat when the craft suddenly accelerated. He fell into the water in a supine position with his legs open, and the water jets of the PWC struck his perineum directly. Thereafter, bleeding from the anus was seen, and he was transferred to our hospital. On physical examination, there was a deep laceration interrupting the external anal sphincter in the posterior rectal wall. Abdominal computed tomography revealed a full-layer perforation of the posterior rectal wall and leakage of feces into the extraperitoneal space, but intraperitoneal free air was not seen. Laparoscopic sigmoid loop colostomy and primary suturing of the sphincter and mucosa were performed. He did not have any complications and was discharged from our hospital 16 days after the surgery. His anal function was almost perfectly preserved, and his diverting colostomy was closed 4 months later.ConclusionAnorectal injuries related to PWCs can occur not only while traveling at high speeds, but also when suddenly accelerating from rest. A diverting colostomy should be performed for this type of trauma. In these trauma cases, clinicians must suspect complex and life-threatening anorectal injuries early.

Indocyanine green fluorescence during pediatric stoma closure

Abstract In this paper, we discuss the first two cases who underwent colostomy closure using ICG fluorescence system (Stryker, PINPOINT System®). Case 1 11-months-old female with 21 trisomy and anorectal malformation (rectal atresia without fistula). She had sigmoid loop colostomy in neonatal period and Posterior Sagittal Anorectoplasty (PSARP) in 9 months of life. During the colostomy closure, ICG was intravenously administered to evaluate blood flow of anastomotic site. Twenty-two hours after operation, she had the first defecation which was positive for ICG fluorescence. Case 2 16-months old male with postoperative state of tracheoesophageal fistula and rectovestivular fistula. He had transverse loop colostomy in neonatal period and PSARP in 12 months of life. During the colostomy closure, ICG was intravenously administered to evaluate blood flow of anastomotic site. Twenty-five hours after operation, he had the first defecation which was negative for ICG fluorescence. Forty hours after operation, he had ICG-positive defecation. There were no postoperative complications for both of patients. ICG fluorescence system has two merits for pediatric colostomy closure evaluation of anastomotic blood flow and postoperative bowel function.

Comparison of frequency of complications in loop versus divided colostomy in patients with high variety anorectal malformation

Background: The objective of this study was to compare frequency of stoma related complications of loop versus divided sigmoid colostomy for the management of high variety anorectal malformations. Methodology: This RCT was conducted in the department of Pediatrics Surgery Department of the Children’s Hospital and the Institute of Child Health Lahore, for the period of one year from 1st May 2016 to 1st June 2017. One hundred and twenty patients (Sixty patients in each group) of anorectal malformation meeting inclusion criteria were taken in this study. Patients were divided into two groups randomly using lottery method; loop sigmoid colostomy in Group-A and divided sigmoid colostomy in Group-B. After surgeries patients were followed weekly up till 8 weeks. Stoma related complications (as per operational definition) were noted. Results: The mean age in group –A and group-B were 3.34 ± 1.12 days and 3.36 ± 0.97 days, respectively. In group – A there were 52(86.67%) male and 8(13.33%) females, and in group-B there were 45(75%) male and 15(25%) female patients. In group-A 22(36.66%) patients had complications [3(5.00%) patients had retraction, 8(13.33%) had prolapse, 4(6.67%) had stoma obstruction, parastomal hernia were seen in 4(6.67%), stoma necrosis were seen in 3 (5.00%)] and in group-B, 16(26.66%) patients had different complications [1(1.67%) patients had retraction, 3(5.00%) had prolapse, 5(8.33%) had stoma obstruction, parastomal hernia were seen in 2(3.3%), stoma necrosis were seen 5(8.33%)]. The complications in group-A were higher when compared to group-B, but (p-value = 0.650) were not significant statistically except for stoma prolapse. Conclusion: Though complication rate in both techniques is not statistically different but frequency of stoma prolapse is more in loop colostomy group. Therefore, divide colostomy should be opted as preferred technique.

Two-stage repair for delayed presentation of anorectal malformation with vestibular and perineal fistulae in females

Background/aim In spite of advances in knowledge and techniques in the management of anorectal malformation (ARM), delayed presentation of female ARM with vestibular and perineal fistulae is quite common especially in developing countries. In this literature, there is no standardized surgical algorithm for late presentation of these female ARM. This study aimed to present the experience of two pediatric surgery tertiary centers regarding delayed presentation of vestibular and perineal fistulae using two-stage procedures. Patients and methods This prospective study was conducted on 28 female patients with late presentation of vestibular and perineal fistulae from November 2014 to April 2019. Lower contrast study was done for all patients. Laxative, frequent rectal wash enemas, and Hegar’s dilators were used for 2–3 weeks preoperatively. All patients were repaired by anterior sagittal anorectoplasty (ASARP) with covering high sigmoid loop colostomy, and colostomy closure was performed after 2–3 months. Krickenbeck continence score was used for assessment of anal continence. Results Of 28 patients included, 25 patients completed the study. There were 14 patients with perineal and 11 with vestibular fistulae. The age of patients ranged from 8 months to 18 years. The main reasons for delay were socioeconomic, unawareness, and overlapping causes. Sphincter-saving ASARP was used in 15 patients and the classic ASARP was used in 10 patients. Tapering proctoplasty was needed in one patient. Minor wound infection developed in three patients. Constipation occurred in 11 (44%) patients. Follow-up period ranged from 6 to 50 months (median 30 months). Good continence was obtained. Conclusion Although delayed presentation of vestibular and perineal fistulae in female patients is accompanied by comorbidities, with good surgical management, successful results can be obtained by using two-stage procedure.

Novel Application of the EK Glove Port for Single-Incision Diverting Sigmoid Loop Colostomy in Advanced Rectal Cancer.

Background and Objectives:In patients with obstructing rectal cancers who require intestinal diversion before neoadjuvant therapy, minimizing diversion-related recovery and instituting early chemoradiation are critical to optimizing outcomes.Methods:A novel, simple, safe, and inexpensive technique was developed for single-port laparoscopic diverting sigmoid loop colostomy in a low-resource environment.Results:Ten consecutive patients with locally advanced rectal cancer underwent single-port, diverting sigmoid loop colostomy using a novel application of the EK glove port. Operative time averaged 59.5 min (range 40–75 min). There were no conversions to multiport laparoscopy or open surgery. There were no intraoperative or early postoperative surgical complications. All patients started chemoradiation therapy within 1 week of diverting colostomy. No surgical reinterventions were required.Conclusion:Single-port laparoscopic diverting sigmoid loop colostomy utilizing an EK glove port is a novel, technically simple, safe, and cost-effective procedure, especially applicable to patients with obstructing rectal cancer who receive care in a low resource environment.

OPIOID FREE ANESTHESIA IN A PRE-TERM NEONATE: A CASE REPORT

Opioids play a major role in the perioperative management of pain in adults and children. Though there is significant morbidity and mortality associated with overdosage of opioids, they remain the most common means of providing analgesia in the perioperative period. We report the case of a preterm neonate born with low birth weight who underwent high sigmoid loop colostomy for high anorectal malformation using opioid-free general anesthesia with supplementation with caudal block. Successful uncomplicated extubation of preterm baby was achieved with good spontaneous efforts. Opioid free general anesthesia can prevent respiratory depression and the need for postoperative mechanical ventilation even when given to preterm neonates.

1630 Rectal Duplication in a Middle-Aged Adult Presenting With Constipation and Abdominal Mass After Hysterectomy

INTRODUCTION: Alimentary tract duplications are rare congenital malformation that usually presented since childhood. CASE DESCRIPTION/METHODS: A 43–year-old female presented with constipation and progressive enlargement of abdominal mass for 4 years. Her constipation symptoms started after she underwent hysterectomy for myoma uteri. She had straining and fecal soiling that was refractory to laxatives. Physical examination revealed a 25-cm non-tender hard mass at mid-lower abdomen. Digital rectal examination showed anal wink, normal sphincter tone, and empty rectum. Paradoxical anal sphincter contraction was presented while pushing. Other physical findings were unremarkable. CT abdomen showed marked dilatation of rectosigmoid colon with feces content with an abrupt change of caliber at upper rectum. Small bowel was not dilated. Barium enema study was shown in Figure 1. Colonoscopy showed a 1.5-cm opening of a large blind pouch at 10 cm above anal verge. Anorectal manometry revealed dyssynergic defecation type II with rectal hyposensitivity with delayed balloon expulsion time. The patient underwent a complete transabdominal resection of the duplication with temporary loop sigmoid colostomy. Gross findings showed a large uniloculated cyst (Figure 2). Pathological findings showed a cystic lesion lined by complete colonic wall (Figure 3). DISCUSSION: Rectal duplications are rare congenital anomalies (1/200,000 live births) and seventy percent of them are diagnosed before the age of two. They can be classified as type I (cystic) and type II (tubular) with or without communication to rectum or perineum. The wall of the duplications is typically lined with complete rectal wall. Surgical removal is indicated as it prevents septic and carcinogenic complications [1]. Our patient’s symptoms interestingly occurred late in adulthood after surgery. Removal of uterus and myoma uteri might change the angle of the duplication’s opening. Also, the presence of dyssynergic defecation might contribute and cause gradual accumulation of fecal content inside. Three months post-operative anorectal manometry still showed dyssynergia but improved rectal sensitivity. At present, our patient has bowel movement every 1-2 days per colostomy with minimal usage of laxative and is currently undergoing biofeedback training before colostomy closure.