Bowel Stoma Research Articles

Quality of life and need for care in patients with an ostomy: a survey of 2647 patients of the Berlin OStomy-Study (BOSS).

Although ostomies are sometimes necessary, it is unclear which type of ostomy is advantageous for quality of life (QoL). In an observational study of 2647 patients, QoL after colostomy (CS) and small bowel stoma (SBS) formation was evaluated. The European Organisation for Research and Treatment of Cancer (EORTC)-QLQ-C30 and CR-38 questionnaires were used. Patient characteristics, retrospective information about the ostomy and previous treatments, and current stoma-related complications were recorded. All questionnaires were distributed and collected by stoma therapists at the homecare company PubliCare®. In all, 1790 patients had a CS, and 756 had an SBS. The mean Global Health Score (mGHS-a general QoL indicator) was 52.33 in CS and 49.40 in SBS patients (p=0.004), but the effect size (Cohen's d) was 0.1. In SBS patients, all functional scores were lower and most of the symptom scores were higher. QoL differed significantly for CS and SBS patients, but the effect size was marginal. The care of certain patient groups, particularly (female) patients who receive emergency surgeries, must be improved. More professional education and guidance are necessary for a larger proportion of patients. This survey provided reference data for quality of life in patients with an ostomy.

Beneficial effects of mucous fistula refeeding in necrotizing enterocolitis neonates with enterostomies

BackgroundNecrotizing enterocolitis in premature neonates often results in bowel resection and stoma formation. One way to promote bowel adaptation before stoma closure is to introduce proximal loop effluents into the mucous fistula. In this study, we reviewed our experience with distal loop refeeding with respect to control group. MethodsAll patients with necrotizing enterocolitis between 2000 and 2014 necessitating initial diverting enterostomies and subsequent stoma closure in a tertiary referral center were included. Medical records were retrospectively reviewed. Demographic data, surgical procedures, and postoperative outcomes were analyzed. Results92 patients were identified, with 77 patients receiving mucous fistula refeeding. The refeeding group showed less bowel ends size discrepancy (25 vs 53%, p=0.034) and less postoperative anastomotic leakage (3 vs 20%, p=0.029). Fewer refeeding group patients developed parenteral nutrition related cholestasis (42 vs 73%, p=0.045) and required shorter parenteral nutrition support (47 vs 135days, p=0.002). The mean peak bilirubin level was higher in the non-refeeding group (155 vs 275μmol/L, p<0.001). No major complication was associated with refeeding. ConclusionsMucous fistula refeeding is safe and can decrease risk of anastomotic complication and parental nutrition related cholestasis. It provides both diagnostic and therapeutic value preoperatively and its use should be advocated.Level III Treatment Study in a Case Control Manner.

MON-P049: Incidence of Fluid and Electrolyte Abnormalities and Weight Change after Formation of a Small Bowel Stoma

MON-P049: Incidence of Fluid and Electrolyte Abnormalities and Weight Change after Formation of a Small Bowel Stoma

Routine contrast enema is not required for all infants prior to ostomy reversal: A 10-year single-center experience

IntroductionThe incidence of intestinal stricture is low for most conditions requiring a primary small bowel stoma in infants. Routine performance of contrast enemas (CE) prior to stoma closure adds cost and radiation exposure. We hypothesized that routine CE prior to ostomy reversal is not necessary in all infants, and sought to identify a subset of patients who may benefit from preoperative CE. MethodsMedical records of infants under age 1 (N=161) undergoing small bowel stoma reversal at a single institution between 2003 and 2013 were retrospectively reviewed. Student's T-test was used to compare groups. ResultsContrast enemas were performed on 80% of all infants undergoing small bowel ostomy reversal during the study period. Infants with necrotizing enterocolitis (NEC) were more likely to have a CE than those with intestinal atresia (p=0.03) or those with all other diagnoses combined (p=0.03). Nine strictures were identified on CE. Of those, 8 (89%) were in patients with NEC, and only 4 were clinically significant and required operative resection. The overall relevant stricture rate was 2.5%. No patient that underwent ostomy takedown without CE had a stricture diagnosed intraoperatively or an unrecognized stricture that presented clinically after stoma takedown. ConclusionsRoutine CE is not required prior to small bowel ostomy reversal in infants. We recommend judicious use of enema studies in patients with NEC and high likelihood of stricture.

The Reversal of Stoma Following Open Abdomen Management.

Bowel stoma formation is very often required during open abdomen (OA) management; we aim to report our stoma reversal series following OA management retrospectively. A retrospective analysis of 31 patients who underwent the reversal of the stoma created during OA management between January 2008 and September 2014 was performed. Twenty-eight of these 31 patients were included in this study. The stoma-related complications are more common after OA management during waiting time interval for reversal. At this time interval, patients with jejunostomy had more stoma-related complications than patients with ileostomy (p = 0.008) and colostomy. (p = 0.001). Waiting time interval was shorter for reversal of jejunostomy than reversal of ileostomy (p = 0.014) and colostomy (p = 0.001). Operation time for jejunostomy (p = 0.016) and colostomy reversal (p = 0.001) were significantly longer than the ileostomy reversal. There was no difference between early and late reversal of stoma regarding morbidity and mortality. The stoma-related complications are more common following OA management during waiting time interval for stoma reversal. The reversal time is more critical for this kind of patients especially with life-threatening complicated jejunostomy. For loop stoma created during OA management, the reversal may be performed after average 50days without increasing morbidity and mortality. The reversal of end stoma created during OA management has high morbidity. If it is possible, loop stoma should be preferred during OA management.

Adhesive Small Bowel Obstruction: Early Operative versus Observational Management

We assessed the nonoperative and operative management of adhesive small bowel obstruction (ASBO) and compared complication rates and surgical outcomes. ASBO is a common complication of abdominopelvic surgery. Although patients may respond to nonoperative management, many require surgery. We retrospectively studied patients admitted to Mount Sinai Hospital with a diagnosis of complete ASBO to determine outcomes of nonoperative management. Patients admitted with complete ASBO from 2001 to 2011 were included. Patients with no previous abdominopelvic surgery, surgery within the six weeks preceding admission and obstruction due to other identifiable causes, such as incarcerated hernia, were excluded. Complication rates and outcomes were compared between patients managed with immediate surgery and those managed initially with nonoperative strategies. Of 460 patients admitted with complete ASBO, 106 (23.0%) had surgery within 24 hours of admission. At surgery, 20 (18.9%) had ischemic bowel and 8 (7.5%) had perforations. The remaining 354 patients had a trial of nonoperative management lasting at least 24 hours. Of 354 patients managed initially without surgery, 100 (28.2%) patients were discharged without operative intervention during their index admissions. Among the patients having surgery more than 24 hours after admission, indications for surgery were generally failure to resolve, worsening clinical status, and change in imaging findings. Of those patients observed for at least 24 hours, 40 (15.7%) were found to have ischemic bowel and 5 (2.0%) had perforation at surgery. Rates of bowel resection, stoma creation and postoperative complications were similar for the immediate and delayed surgery groups. Among the delayed surgery group, 71 (28.0%) required a bowel resection and 11 (4.3%) stoma creation. Twenty one per cent had postoperative complications, most commonly ileus. There were no statistically significant differences in the outcomes between immediate and delayed groups regardless of duration of delay. Among patients observed with complete ASBO, 24.6 per cent of patients with adhesive obstruction resolved without surgery or readmission. Delaying operative management did not affect surgical findings or complication rates.

Acute Surgical Repair of Large Incisional Hernia with Significant Loss of Domain: Case Report and Review of Literature

Introduction: Incisional abdominal hernias develop up to 11.5 % of laparotomy incisions. The most difficult to repair are hernias with significant loss of domain. The basic principle of treating abdominal incisional hernia entails restoring the anatomical and physiological integrity of the wall. Ideally, thisinvolves the use of local musculo-aponeurotic tissue with a good blood supply and innervations. In the case of large defects, it is necessary to use alloplastic materials in order to reduce the tension load on the suture itself. Emergency surgery is indicated especially in the case of intestinal obstruction or strangulation. Presentation of Case: The present report describes the case of emergency surgical treatment of intestinal obstruction in large abdominal incisional hernia by 77-year old man. We used reposition and onlay technique with with biodegradable mesh to repair the abdominal wall. Discussion: Emergency surgery for bowel obstruction primarily aims to resolve bowel obstruction and restore intestinal viability. In this case we present that techniques without bowel resection or stoma are safer as the other. Large hernias with loss of domain can be repaired only by an open method and the onlay method is the simplest and most versatile technique in this case. Conlusions: Emergency surgery in incisional hearnias is a challenging surgical problem due to risk of the preoperative and postoperative complications. Team involving general and plastic surgeons and anaesthetist is required.

O-15: ImproveCareNow (ICN) as a quality improvement (QI) tool in a paediatric inflammatory bowel disease (pIBD)

O-15: ImproveCareNow (ICN) as a quality improvement (QI) tool in a paediatric inflammatory bowel disease (pIBD)

PATIENT CHOICE OF LAXATIVE MEDICATION FOR TREATMENT OF OPIOID INDUCED CONSTIPATION (OIC). A SERVICE EVALUATION AT SHEFFIELD CENTRAL CAMPUS

BackgroundOpioid-induced constipation is common in palliative care. The evidence base for most laxatives and rectal interventions is poor, but for sc methylnaltrexone is good. Patient choice is important for individualising...

Diagnosis, management and outcomes of necrotising soft tissue infection within a Plastic and Reconstructive Surgery Unit

Necrotising soft tissue infection (NSTI) is an extremely serious condition that relies on a high index of suspicion, prompt diagnosis and emergent radical surgical treatment. We explored the presentation, management and outcomes of NSTI within our department. We also assessed the potential benefit of using risk predictor scoring system. Retrospective review using departmental electronic database and hospital records. Twenty-four patients were treated for NSTI within our department between 2004 and 2010. Seventeen presented in our hospital to various surgical and medical teams. All patients presented with pain, swelling, erythema and tenderness at palpation. Only 40% of necrotising fasciitis and 28.6% of Fournier's gangrene were diagnosed as NSTI at initial assessment. Average mean interval time from admission to primary surgery was 17.7 h and 4 h from diagnosis to primary surgery. There were four mortalities. The average risk predictor Laboratory Risk Indicator for Necrotising Fasciitis score was 7.9. Significant morbidities post-operatively included bowel stoma, long-term urinary catheter and new diagnoses of carcinomas. Physicians and surgeons need to be suspicious of NSTI in severe cases of soft tissue infection to prevent delay in diagnosis and life-saving treatment. Scoring system can be used judiciously as adjunct to aid diagnosis.

A case of pseudohyperkalaemia secondary to thrombocytosis in a patient with grumbling abdominal sepsis

A case of pseudohyperkalaemia secondary to thrombocytosis in a patient with grumbling abdominal sepsis

Magnesium

Magnesium

Mortality after Steroid Resistant Acute Cellular Rejection and Chronic Rejection Episodes in Adult Intestinal Transplant: Report from a Single Center in Induction/Preconditioning Era

Aim: Steroid resistant ACR and chronic rejection (CR) are still a major concern after intestinal transplantation, especially using grafts without liver: over last 20 years the presence of liver has been shown to have a protective effect on rejection episodes. We report our experience from a single center on adult recipients. Subjects and Methods: We transplanted 48 adult recipients using 49 grafts, from 2001 up to 2011: 85.7% of them were represented by grafts without liver (isolated or modified multivisceral allografts). Induction protocol was used initially on 12 transplants, accomplished by Daclizumab plus Tacrolimus and Steroids, while later we developed a preconditioning protocol, based on Alemtuzumab plus Tacrolimus, on 35 allografts; in 2 cases we preconditioned the recipients by Thymoglobulin followed by Tacrolimus. Results: Overall patient survival was 41.5 % at 10 years while graft survival was 39%. Steroid resistant ACR population: 13 recipients experienced episodes of steroid resistant ACR. Three of them were successfully treated by OKT3, 1 by Alemtuzumab and 1 by Thymoglobuline, while 1 case underwent re-transplantation after OKT3 treatment. Seven recipients died after ACR therapy mainly for sepsis: 2 after Thymoglobulin, 2 with OKT3, 1 after Infliximab, and 2 after combined treatment (Alemtuzumab plus Thymoglobulin and Thymoglobulin plus Infliximab). Twelve allografts out of 13 were grafts without liver. Chronic rejection population: 5 recipients were affected by CR (1 of them primarly transplanted in another center): 4 of them experienced indeterminate to mild episodes of ACR (only one as early as 30 days after transplant) before developing CR while only 1 had a severe episode of rejection. Two of them are still alive: 1 underwent graftectomy without increasing immunosuppressive treatment and was relisted on TPN while 1 recovered oral feeding (supported by TPN) after partial bowel resection plus stoma. The remnant 3 patients died for sepsis, 1 after retransplantation. Majority of them had mesenteric fibrosis as main pathologic feature of CR and diagnosis was always performed on resected specimen. Overall mortality: Steroid resistant ACR mortality was 50% while CR mortality was 60%: overall, 10 patients out of 19 (52.6%) died after steroid resistant ACR or CR. Notably, mortality after Daclizumab was 17.7% in steroid resistant ACR and CR population while after Alemtuzumab the percentage achieved 28.8%. The remnant transplant population (no ACR or steroid sensitive ACR - 27 patients) was affected by mortality percentage of 40.7% (p= NS). Conclusions: In our series steroid resistant ACR affected 29.1 % of our intestinal allografts (all but one without liver) while CR was shown on 8% of our resected bowels, all isolated grafts: CR was often preceded by ACR episodes. Mortality related to steroid resistant ACR and CR still affects intestinal transplant population in induction/preconditioning era.

Mortality after Steroid Resistant Acute Cellular Rejection and Chronic Rejection Episodes in Adult Intestinal Transplant: Report from a Single Center in Induction/Preconditioning Era

Aim: Steroid resistant ACR and chronic rejection (CR) are still a major concern after intestinal transplantation, especially using grafts without liver: over last 20 years the presence of liver has been shown to have a protective effect on rejection episodes. We report our experience from a single center on adult recipients. Subjects and Methods: We transplanted 48 adult recipients using 49 grafts, from 2001 up to 2011: 85.7% of them were represented by grafts without liver (isolated or modified multivisceral allografts). Induction protocol was used initially on 12 transplants, accomplished by Daclizumab plus Tacrolimus and Steroids, while later we developed a preconditioning protocol, based on Alemtuzumab plus Tacrolimus, on 35 allografts; in 2 cases we preconditioned the recipients by Thymoglobulin followed by Tacrolimus. Results: Overall patient survival was 41.5 % at 10 years while graft survival was 39%. Steroid resistant ACR population: 13 recipients experienced episodes of steroid resistant ACR. Three of them were successfully treated by OKT3, 1 by Alemtuzumab and 1 by Thymoglobuline, while 1 case underwent re-transplantation after OKT3 treatment. Seven recipients died after ACR therapy mainly for sepsis: 2 after Thymoglobulin, 2 with OKT3, 1 after Infliximab, and 2 after combined treatment (Alemtuzumab plus Thymoglobulin and Thymoglobulin plus Infliximab). Twelve allografts out of 13 were grafts without liver. Chronic rejection population: 5 recipients were affected by CR (1 of them primarly transplanted in another center): 4 of them experienced indeterminate to mild episodes of ACR (only one as early as 30 days after transplant) before developing CR while only 1 had a severe episode of rejection. Two of them are still alive: 1 underwent graftectomy without increasing immunosuppressive treatment and was relisted on TPN while 1 recovered oral feeding (supported by TPN) after partial bowel resection plus stoma. The remnant 3 patients died for sepsis, 1 after retransplantation. Majority of them had mesenteric fibrosis as main pathologic feature of CR and diagnosis was always performed on resected specimen. Overall mortality: Steroid resistant ACR mortality was 50% while CR mortality was 60%: overall, 10 patients out of 19 (52.6%) died after steroid resistant ACR or CR. Notably, mortality after Daclizumab was 17.7% in steroid resistant ACR and CR population while after Alemtuzumab the percentage achieved 28.8%. The remnant transplant population (no ACR or steroid sensitive ACR - 27 patients) was affected by mortality percentage of 40.7% (p= NS). Conclusions: In our series steroid resistant ACR affected 29.1 % of our intestinal allografts (all but one without liver) while CR was shown on 8% of our resected bowels, all isolated grafts: CR was often preceded by ACR episodes. Mortality related to steroid resistant ACR and CR still affects intestinal transplant population in induction/preconditioning era.

Analysis of endoscopic interventions in patients with bowel stomas

Aim. To evaluate potentials and to determine indications for endoscopic interventions in case of bowel stomas surgery. Methods. Case series of 66 patients with bowel stomas who underwent endoscopic interventions at various stages is presented. The causes of stoma formation were: colon cancer (43 patients), colon diverticular disease (10), inflammatory bowel disease (5), colon trauma (4), benign colon tumors (2), dolichosigmo-id (2). Results. Laparoscopic technique was most widely used in cases of acute intestinal obstruction - 39 patients. Laparoscopic subtotal colectomy with Brooke end ileostomy was performed in 3 patients. Laparoscopically assisted reversal was completed in 11 patients after Hartmann’s procedure. Introduction of endoscopic interventions to bowel stoma surgery techniques allowed to reduce the number of post-operative complications. The terms of rehabilitation after radical interventions with complete colon stoma closure in patients with diseases of the colon requiring surgical treatment were decreased to 7-11 days. Conclusion. The use of laparoscopic techniques in bowel stoma surgery is possible at every stage of surgical rehabilitation of patients who underwent colostomy; it is safe and has a number of advantages compared to standard procedures.

Coress feedback

This issue highlights the importance of anatomical orientation, which can sometimes be difficult during bowel anastomosis and stoma formation. The need for good medical communication and an adequate handover, particularly at night and at weekends for patients with medical co-morbidities or following complex surgery, is emphasised in another case.We are grateful to the clinicians who have provided the material for these reports. The online reporting form is on our website, www.coress.org.uk, which also includes all previous feedback reports. Published contributions will be acknowledged by a ‘Certificate of Contribution’, which may be included in the contributor’s record of continuing professional development.

Choosing the correct stoma appliance

Surgery to the bowel or bladder that results in a stoma, whether temporary or permanent, is designed to improve the individual’s situation by removing disease, reducing pain and improving health. Many people are able to adapt to the physical and psychological trauma of stoma surgery, as demonstrated by the return to their everyday activities and relationships. An extensive array of stoma appliances is now available in the drug tariff for General Practitioners (GP) to prescribe, but many GPs will have little knowledge of what to prescribe for the stoma patient. Modern stoma appliances are continually changing and being updated and this article will look at choosing the correct appliance for the patient with a bowel or bladder stoma.

The impact of stoma for bowel management after spinal cord injury

Multi-centre, retrospective self-report postal survey. To characterise spinal cord injured (SCI) individuals with a stoma, their stoma management and outcomes, to identify sources of information and support for decision making and to explore the impact of a stoma on life satisfaction. Five UK spinal cord injury centres. A study-specific questionnaire accompanied by self-concept, life satisfaction and mood measures, and three simple rating scales for satisfaction, impact and restriction on life were sent to all known ostomates at five participating centres. Respondents were 92 individuals, mean age 56 years, mean duration of injury 26 years, 91% with colostomy. Multiple sources of information were utilised in deciding on surgery; discussion with other SCI ostomates was important. Duration of bowel care, faecal incontinence, bowel-related autonomic dysreflexia, dietary manipulation and laxative use were all significantly reduced following surgery. Rectal mucous discharge was the most common and bothersome post-stoma problem. Satisfaction with stoma was high; provision of sufficient information preoperatively was important, those with ileostomy were more dependent and less satisfied. Life satisfaction and physical self-concept were both lower in this sample than in previously reported samples of SCI individuals without reported bowel difficulties or stoma. The findings of this study of self-selected respondents with a stoma for bowel management after SCI emphasised the benefits of stoma in selected individuals and the importance of timely intervention, the complexity of the associated decision-making and of preoperative counselling. The impact of bowel dysfunction on physical self-concept warrants investigation.

Recurrent lobar atelectasis in a child with cystic fibrosis

Cystic fibrosis pulmonary exacerbations in children usually manifest with increased cough and a fall in lung function. We report a challenging case where an 8-year-old girl has had frequent prolonged exacerbations over the last 3 years needing aggressive management, associated with multi-lobar collapse. She was born at term and presented with meconium ileus needing bowel resection and stoma formation which was reversed during first year of life. Cystic fibrosis was diagnosed on sweat testing, with a ΔF508 homozygous genotype. She has a younger brother aged 5 years, who also has cystic fibrosis. She was admitted as an infant with respiratory syncytial virus bronchiolitis at 7 months of age, requiring CPAP for few days. She was later admitted at 15 months of age with a pulmonary exacerbation, and a chest X-Ray showed left lower lobe collapse. Pseudomonas aeruginosa was isolated for the first time from bronchoalveolar lavage and she was treated with intravenous and nebulized antibiotics; she had a normal chest X-ray few weeks later. Nebulized dornase alpha (DNase) was started at 3 years of age and a gastrostomy inserted at age 6. A port-a-cath was inserted at age 7. Over the last 3 years she has had 2 to 3 pulmonary exacerbations per year requiring prolonged hospital admissions for up to 3 weeks. During these admissions she is treated with intravenous antibiotics, intensive physiotherapy, up to 4 times per day of nebulised hypertonic saline and twice daily DNase. In 2011 she had 5 hospital admissions for pulmonary exacerbations. Pulmonary exacerbations are preceded by trivial viral upper respiratory tract infection followed a few days later by acute onset of tachypnoea, dyspnoea and profound hypoxemia (oxygen saturations of 80–82% on admission). The chest X-ray shows lobar collapse with the left lower lobe most frequently involved as well as involvement of other lobes. Our approach is to treat her with humidified high flow oxygen, intravenous antibiotics, intensive physiotherapy and at least one early therapeutic bronchoscopy to re-inflate the collapsed lobe. Bronchoscopy is usually performed on the first or second day of admission and reveals very thick tenacious mucus, which is difficult to clear. We instill DNase during the procedure, and on some occasions she has chest physiotherapy under general anesthesia. Large mucus plugs can be removed, sometimes as bronchial casts. We believe that early bronchoscopy results in clinical and radiological improvement and she can be discharged home after 2 weeks with no respiratory distress and normal oxygen saturations (Figure 1). Open in a separate window Figure 1 Serial chest X-rays in a typical pulmonary exacerbation. a) X-ray on day of admission showing left, right lower & middle lobe collapse; b) X-ray 36 hr post bronchoscopy showing good inflation of right lung; c) X-ray 6 weeks later showing no lobar collapse

Study on the application of evidence-based nursing in bowel stoma

Objective To explore the effect and care measures of evidence-based nursing in application of health guidance for bowel stoma.Methods 30 cases with bowel stoma in our hospital from June 2010 to January 2011 received the evidence-based nursing.Results All of the patients received the operation successfully,and all of them could nurse themselves by health guidance of bowel stoma.The 30 cases were followed-up for 6 to 12 months and the rate of following-up was 100％.Only 1 case was merged with contact dermatitis and sensitization dermatitis around the bowel stoma.Conclusion The effect of evidence-based nursing in application of health guidance for bowel stoma is obvious,so it is worth being used. Key words: Evidence-based nursing(EBN); Bowel stoma; Health guidance