Stoma Closure Research Articles

Long-term Outcomes of Straight Ileoanal Anastomoses Converted to Ileal Pouch Anal Anastomoses

While ileal pouch anal anastomosis (IPAA) is the recommended way to restore intestinal continuity after total proctocolectomy, straight ileoanal anastomoses (SIAA) are still selectively performed, especially in the pediatric population. In case of SIAA failure, conversion to IPAA is possible, but reports on its outcomes are scarce. We retrospectively analyzed our prospectively collected database on pelvic pouches, and identified patients with a SIAA that was converted to IPAA. Our aim was long-term functional outcomes. Twenty-three patients were included (14 females, median age at SIAA 15 years, median age at conversion to IPAA 19 years). The indication for SIAA was ulcerative colitis in 17 (74%) cases, indeterminate colitis in 2 (9%) cases, and familial adenomatous polyposis in 4 (17%) cases. The indication for IPAA conversion was incontinence/poor quality of life in 12 (52%) cases, sepsis in 8 (35%) cases, anastomotic stricture in 2 (9%) cases, and prolapse in one (4%) case. The majority were diverted at IPAA conversion (22, 96%). Three (13%) patients never had stoma closure, due to patient wishes, failed healing of vaginal fistula, and pelvic sepsis, respectively. After a median follow up of 109 months (28-170), pouch failure occurred in 5 additional patients. Overall pouch survival was 71% at 5 years. Median quality of life was 8/10, of health 8/10, and of energy 7/10. Median satisfaction with surgery was 9.5/10. Conversion of SIAA to IPAA leads to acceptable long-term outcomes and good quality of life, and can safely be offered to patients with problems related to SIAA. IV.

Deterioration in renal function after stoma creation: a retrospective review from a Middle Eastern tertiary care center.

Stomas are associated with multiple complications including dehydration which ultimately affects renal function. These complications begin with changes in the estimated glomerular filtration rate (GFR). Evaluate changes in GFR after stoma creation by stoma type and identify how different types of stoma affect GFR. Retrospective, analytical cohort SETTING: Tertiary care center in Saudi Arabia PATIENTS AND METHODS: The colorectal surgery database was reviewed for all adult patients who underwent stoma creation (permanent and temporary ileostomies and colostomies) or reversal in 2000-2015. GFR was estimated at the first encounter, before the index surgery, at the time of stoma reversal, and upon the last follow-up. Patients with renal impairment, including low GFR before stoma creation, patients who had a temporary stoma converted to a permanent stoma, and patients who died with a stoma were excluded. We studied the association of several demographic and clinical factors on changes in GFR by univariate and multivariate analysis. Estimated GFR at the last clinic visit for the permanent stoma group and at stoma closure for the temporary stoma group. 394 patients (149 ileostomates, 245 colostomates) RESULTS: Thirty-three (8.4%) of the 394 patients had a low GFR: 11 (7.4%) in the ileostomy group and 22 (9%) in the colostomy group (P= .579). The rate of readmissions with ileostomies was higher (11.4%) than with colostomies (3.3%) (P≤.001). The number of temporary ileostomies (n=9, 7.0%) differed from temporary colostomies (n=2, 1.9%) but the difference was not statistically significant (P=.06). In the multivariate analysis, stoma permanency, hypertension, chemotherapy and nephrotoxic drugs were risk factors associated with low GFR. Ileostomies were not associated with a high rate of renal function deterioration in comparison to colostomies, but had a significantly higher rate of readmission due to dehydration and electrolytes imbalance possibly due to the hot climate in Saudi Arabia. Retrospective nature and limited sample size which may have resulted in a type 2 statistical error. None.

Results of application of the technique of the extraperitoneal closure of loop intestinal stoma

The OBJECTIVE was to evaluate the efficacy and safety of the original technique of extraperitoneal closure of a loop intestinal stoma.METHODS AND MATERIALS. A comparative analysis of the results of surgical treatment of 80 ostomy patients who underwent reconstructive and restorative interventions was carried out. The main group included 40 patients operated on according to the original method of extraperitoneal closure of the intestinal stoma. The control group consisted of 40 patients who underwent restoration of the intestinal tract continuity using a standard method with intra-abdominal access.RESULTS. The incidence of postoperative complications in the main and control groups was 10 % and 22.5 %, and the failure of the intestinal anastomosis was 5 % and 7.5 %, respectively (p>0.05). After applying the original technique, this complication in no case led to the development of peritonitis, and the closure of the intestinal fistula was achieved by local treatment. In two patients of the control group, anastomosis failure led to the development of peritonitis, which required relaparotomy with separation of the anastomosis and reformation of the stoma, which prevented the goal of hospitalization from being realized. In the main group restoration of intestinal continuity was achieved in all patients.CONCLUSION. The use of the original technique for extraperitoneal closure of loop intestinal stoma can reduce the incidence of complications, prevent the development of peritonitis in case of anastomosis failure, creating prerequisites for increasing the efficiency of the reconstructive and restorative stage of treatment.

Intestinal Stomas in Abdominal Surgery: Etiological Circumstances, Indications, High Gravity Factors and Complications.

This is a retrospective study of 264 intestinal stomas performed in the surgical unit of the Emergency Clinical Hospital "Bagdasar Arseni", Bucharest, within a 7-year period (2015-2021) aiming to evaluate their evolutive complications, risk factors, management and prevention strategies. Material and method. Colostomies: 218 (82.57%) cases, ileostomies 46 (17.43%) cases. Temporary stomas (103 cases or 39.02%) were isolated stomas of discharge in 45 cases and associated with other colorectal procedures in 58 cases. Postoperative complications included general systemic complications in 60 (22.72%) cases and local complications specific to stomas in 84 (31.81%) cases and common to abdominal surgery in 94 (35.60%) cases, which were solved by reoperation in 51 cases, with a reintervention rate of 19.31%. Stoma closures were performed in 34 (33.0%) of the 103 patients with temporary stomas. Of these, 26 (25.24%) patients died in the early postoperative period (< 30 days), the remaining 60 patients refused reintervention or were lost to follow-up. Conclusions. Faecal diversion still represents a therapeutic option for a wide range of benign or malignant digestive or extra-digestive abdominal diseases performed in emergency or scheduled surgeries, mostly for colorectal cancer and its complications.

A novel nomogram to predict low anterior resection syndrome (LARS) after ileostomy reversal for rectal cancer patients.

Low anterior resection syndrome (LARS) in patients undergoing low or ultra-low anterior resection (LAR) is a common problem and significantly impacts the quality of life. Patients with an ileostomy after LAR are more likely to develop LARS. However, there hasn't been a model predicting LARS occurrence in these patients. This study aims to construct a nomogram to predict the probability of LARS occurrence in patients with temporary ileostomy and guide preventive strategies before reversal. 168 patients undergoing LAR with ileostomy from one center were enrolled as the training cohort, and 134 patients of the same inclusion criteria from another center were enrolled as the validation cohort. The training cohort was screened for risk factors for major LARS using univariate and multivariate logistic regression. The nomogram was constructed using the filtered variables, the ROC curve was used to describe the model's discrimination, and the calibration was used to describe the accuracy. The optimal cut-off value for stoma closure time was 128 days. Three risk factors were identified using logistic regression analysis: preoperative radiotherapy (OR=3.038, [95%CI 1.75-5.015], P=0.005), stoma closure time (OR=2.298, [95%CI 1.088-4.858], P=0.029) and pN stage (OR=1.739, [95%CI 1.235-3.980], P=0.001). A nomogram was constructed based on these three variables and showed good performance predicting major LARS after stoma reversal. The area under the curve (AUC) was 0.827 in the training group and 0.821 in the validation group; The calibration curve suggested good precision in both groups. This novel nomogram can accurately predict the probability of major LARS occurrence after ileostomy reversal for rectal cancer patients. This model can help screen ileostomy patients with high risks and guide individualized preventive strategies before stoma reversal.

P344 Diverting ileostomy in Inflammatory Bowel Disease's surgery: the real clinical cost analysis

Abstract Background A loop ileostomy does not prevent an anastomotic leak and it is not risk-free, but it can decrease the clinical impact of dehiscence. Inflammatory bowel disease condition is more complex than other benign situations candidated to colorectal surgery. The aim of our study was to assess the risk of complications related to the stoma presence and to identificate variables related with complications in a series of IBD’s patients undergoing various colorectal surgeries along with primary diverting stoma. Methods We conducted a retrospective study of patients who underwent sphincter-preserving elective surgery for IBD between January 2014 to December 2020 at IRCCS Sacro Cuore Don Calabria Hospital. Data were collected regarding baseline demographics, operative techniques and complications. Ileostomy-related complications were separated into three categories: complications related to stoma creation at the time of index surgery within 30 days; complications of having an ileostomy; complications of ileostomy closure. Results Fifty-six diverting loop ileostomies were performed and included in our study (table 1). Seventeen patients (30%) at index procedures had the following complications: 5 had anastomotic leak or pelvic abscess (8.9%), 3 had bowel obstruction (5.4%) and 7 (12.5%) bleeding requiring transfusion. Two patients had complications related to ileostomy creation: 1 had prolapse (1.8%) and 1 rotation with obstruction (1.8%). Seven patients (12.5%) required reoperation. Seven patients (12.5%) were readmitted within 30 days after index surgery for dehydratation. Twenty-four patients (42.1%) suffered during the same time from ileostomy management’s problems. Eighteen patients (32.1%) at stoma closure had the following complications: 6 had anastomotic leak or pelvic abscess (10.7%), 7 had SSI (12.5%), 5 had bowel obstruction (8.9%) and 2 bleeding requiring transfusions (3.6%). Nine patients (16%) required reoperation. At univariate analysis complications of ileostomy status are more frequent in male (p=0.01) and in patients who had ileostomy creation complications (p=0.04). Ileostomy closure complications are more common in male patients (p=0.005). Complications at the time of ileostomy creation were found at multivariate analysis statistically related to complications during ileostomy maintenance. Conclusion Ileostomy alone cannot mitigate the overall high rate of complications expected in IBD’s patients, also in consideration of potential problems stoma it-self related. Even if our study is retrospective and presents a small court, when resection is necessary despite patient's conditions we propose to resect without anastomosis at the time of index procedure and restore the bowel continuity only after patient's status optimization.

P489 Surgery for enterocutaneous fistula: the strongest predictor of postoperative mortality in Crohn’s disease patients

Abstract Background To access the risk of bowel resection in Crohn’s disease patients with enterocutaneous fistulae. Methods Consecutive patients undergoing intestinal resections for Crohn’ disease between 1992 and 2021 were included in the present prospective observational study. Exclusion criteria were: a) abdominoperineal resections for perianal disease, b) surgery for colorectal cancer complicating Crohn’s disease, c) abdominal surgery without intestinal resection (e.g. stoma formation or closure, mere adhesiolysis etc. Enterocutaneous fistulae occurring after previous bowel resection were named “postresection fistulae”, all other – “non-postresection fistulae”. Results 750 patients were included. At all, 70 patients (9%) underwent intestinal resections due to enterocutaneous fistulae. The frequency of surgery for enterocutaneous fistula decreased significantly during the last decade of the study (1992-2000: 13% of surgeries, 2001-2010: 12% of surgeries, 2011-2021: 6% of surgeries; p=0.05). The postoperative intraabdominal septic complication rate was 15% (n=111), six patients (0.8%) died. The mortality rate was 7% (5 of 79%) in patients with enterocutaneous fistulae. All latter death occurred only in patients with postresection fistulae. By multivariate analysis, surgery for enterocutaneous fistula (Hazard ratio 27.4, 95% CI: 2.9 – 255.6; p=0.004), age of 50 years and older (Hazard ratio 13.2; 95% CI: 2.0 – 87.7; p=0.008) and presence of intraabdominal abscess (Hazard ratio 11.8; 95% CI: 1.2 – 116.5; p=0.035) were associated with an increased risk of postoperative death. Age over 50 years was associated with an increased risk of death in patients with enterocutaneous fistulae (mortality rate 20% vs. 3.6%, Hazard ratio 16.61; 95% CI: 1.28 – 216.07; p=0.032). Conclusion Surgery for enteroctunaeous fistulae still poses significant risks, specially, when they occurred after bowel resection and in older patients.

DEFINING LONG-TERM QUALITY OF LIFE AND FUNCTIONAL OUTCOMES AFTER REDO ILEAL POUCH ANAL ANASTOMOSIS: WHAT SHOULD PATIENTS AND PROVIDERS EXPECT?

Abstract BACKGROUND Pouch failure after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) occurs in up to 15% of cases. A redo pouch procedure can be offered to maintain intestinal continuity after pouch failure, but little is known on quality of life (QoL) after redo pouch. We aimed to describe long-term QoL and functional outcomes after redo pouch. METHODS We retrospectively analyzed our prospectively collected redo pouch registry, and identified patients who had completed at least one Cleveland Global Quality of Life (CGQL) questionnaire after redo pouch. Figures are number (proportion) or median (interquartile range). RESULTS Out of 532 patients, CGQL were available for 375 (70%): 212 (57%) females, median age at redo pouch 40 (28 – 48) years. Diagnosis at index pouch was ulcerative colitis in 325 (87%) cases, indeterminate colitis in 13 (3%), Crohn’s disease in 15 (4%), familial adenomatous polyposis in 21 (6%). The median interval between index and redo pouch was 4 (2 – 6) years. The indication for redo pouch was sepsis in 230 (61%) cases, mechanical in 114 (31%), functional in 19 (5%), and dysplasia or cancer in 11 (3%). The anastomosis was handsewn in 72% cases. After redo pouch, 351 (95%) had their stoma closed, while 18 (5%) never had stoma closure due to complications, and 5 (1%) due to patient preference. The median interval between redo pouch and latest CGQL was 4 (1 – 9) years. The overall CGQL score (0 – 1) was 0.7 (0.5 – 0.8), with median quality of life 7 (5 – 9), quality of health 7 (5 – 8) and quality of energy 6.5 (5 – 8). There were no differences in CGQL scores in patients who had a redo pouch due to septic complications versus other indications. The median number of bowel movements was 6 (5 – 8) during the daytime, 2 (1 – 3) during the nighttime, for a total of 8 (6 – 10) bowel movements per 24 hours. Dietary restrictions were reported by 50% patients, social restrictions by 34%, work restrictions by 38%, and sexual restrictions by 37% (Figure 1). Urgency occurring daily or most days was reported by 24% patients, incontinence by 10%. Consistency of stool was reported as liquid by 76% of patients. Seepage during the day was experience by 52% of patients, nocturnally in 68%, with 53% of patients reporting daytime pad use, and 61% at night. Median happiness with surgery was 8 (5 – 10): 80% patients would undergo surgery again, and 84% patients would recommend it to other people. During follow-up, 84 (22.5%) pouch failures occurred. CONCLUSION A redo pouch procedure allows a majority of patients to maintain intestinal continuity with good quality of life. Most patients would undergo redo pouch again and recommend it to others. Before redo pouch, patients need to be counselled regarding function expectations in regards to stool frequency and consistency, urgency, incontinence, seepage, and overall success rates.

Gracilis muscle transposition in complex anorectal fistulas of diverse types and etiologies: long-term results of 60 cases

PurposeComplex fistulas often require several attempts at repair and continue to be a challenging task for the surgeon, but above all, a major burden for the affected patient. This study is aimed at evaluating the potential of gracilis muscle transposition (GMT) as a therapeutic option for complex fistulas of diverse etiologies.MethodsA retrospective study was conducted over a period of 16 years with a total of 60 patients (mean age 50 years). All were treated for complex fistula with GMT at St. Josef’s Hospital in Regensburg, Germany. Follow-up data were collected and analyzed using a prospective database and telephone interview. Success was defined as the absence of fistula.ResultsA total of 60 patients (44 women, 16 men; mean age 50 years, range 24–82 years) were reviewed from January 2005 to June 2021. Primary fistula closure after GMT was achieved in 20 patients (33%) and 19 required further interventions for final healing. Overall healing rate was 65%. Fistula type was heterogeneous, with a dominant subgroup of 35 rectovaginal fistulas. Etiologies of the fistulas were irradiation, abscesses, obstetric injury, and iatrogenic/unknown, and 98% of patients had had previous unsuccessful repair attempts (mean 3.6, range 1–15). In 60% of patients with a stoma (all patients had a stoma, 60/60), stoma closure could be performed after successful fistula closure. Mean follow-up after surgery was 35.9 months (range 1–187 months). No severe intraoperative complications occurred. Postoperative complications were observed in 25%: wound healing disorders (n = 6), gracilis necroses (n = 3), incisional hernia (n = 2), scar tissue pain (n = 2), suture granuloma (n = 1), and osteomyelitis (n = 1). In 3 patients, a second gracilis transposition was performed due to fistula recurrence (n = 2) or fecal incontinence (n = 1).ConclusionBased on the authors’ experience, GMT is an effective therapeutic option for the treatment of complex fistulas when other therapeutic attempts have failed and should therefore be considered earlier in the treatment process. It should be seen as the main but not the only step, as additional procedures may be required for complete closure in some cases.

Postoperative Morbidity Following Loop Ileostomy Reversal after Primary Elective or Urgent Surgery: A Retrospective Study with 145 Patients.

Temporary loop ileostomy is usually performed to protect distal anastomosis or to treat urgent surgical cases. The aim of this study is to evaluate whether, after primary urgent stoma construction, patients undergoing ileostomy reversal have different postoperative outcomes compared with patients who have protective stoma performed in an elective setting. A retrospective observational study was conducted including patients who underwent ileostomy reversal. Baseline patient characteristics and perioperative outcomes were collected in a single database. The overall morbidity rate during recovery was fixed as a primary outcome. Between 2011 and 2021, the complete data records of 145 patients were evaluated. After ileostomy reversal, the postoperative morbidity rate did not differ between groups (14.4% vs. 11.5%, p = 0.790). Even considering each complication, such as ileus, small bowel obstruction, bleeding and wound infection, no significant difference was detected. Similarly, the time to first flatus was 2.25 ± 1.24 vs. 2.1 ± 0.99 (p = 0.379) and the length of hospital stay was 5.43 ± 3.03 vs. 5.84 ± 5.15 (p = 0.568). The only significant factor associated with postoperative complications on logistic regression analysis was the presence of comorbidities (OR 4.49; 95% CI 1.19-29.4, p = 0.05). In the present cohort of patients, there was no difference in the postoperative complication rate after stoma closure following elective or urgent indication for surgery.

The safety and effectiveness of Santulli enterostomy in neonatal intestinal conditions.

As an end stoma, Santulli enterostomy provides early restoration of intestinal continuity without formal laparotomy. Short amputation of the common limb enables closure on a side to restore anatomic continuity without sacrificing valuable intestine; additionally, the procedure is simple and safe. Most newborns who require enterostomy might benefit from Santulli enterostomy; however, several pediatric surgeons lack information regarding this procedure. Therefore, we have reviewed our experience about Santulli enterostomy and explore the advantages and indications in neonatal intestinal conditions. The clinical data of 76 neonates who underwent enterostomywere obtained. The patients were divided into two groups: the Santulli group with 33 cases who underwent Santulli enterostomy, and the control group with 43 cases who underwent double- or single-lumen ostomy. The general data of the two groups were analyzed, and the perioperative/postoperative complications, clinical data and the long-term outcomes were compared. There was no difference in the demographic informations, the level of enterostomy, the rate of high-sight stoma, the operative time and bleeding of enterostomy between the two groups. Compared to the control group, the operative time of ostomy closure was less in the Santulli group (53.00 vs. 152.47, P < 0.001). The duration of parenteral nutrition (27.45 vs. 44.56, P = 0.010), the mean interval of initial enterostomy to stomal closure (131.21 vs. 216.42, P < 0.001), and length of stay (46.00 vs. 67.60, P = 0.007) were shorter, while the incidence of postoperative complications and hospitalization costs (11.21 vs. 15.49, P = 0.006) were lower. The Santulli procedure can reduce the morbidity of high output ostomy (2 vs. 10, P = 0.042) and short bowel syndrome (3 vs. 132, P = 0.025), shorten the discrepancy of diameter between the proximal and distal segments, maximize the available intestine, and monitor the movement of the distal bowel. The length of incision was shorter, and the catch-up growth was significantly faster in the Santulli group. Santulli enterostomy is a superior procedure in the treatment of neonatal intestinal conditions, in terms of fewer complications, faster catch-up growth, shorter hospitalization time and treatment duration. It should be the procedure of choice in several newborns with intestinal conditions that require ostomy.

Predicting bowel function after diverting stoma closure in patients with rectal cancer.

Patients with rectal cancer undergoing laparoscopic anterior resection and diverting stomas often suffer from bowel dysfunction after stoma closure, impairing their quality of life. This study aims to develop a machine learning tool to predict bowel function after diverting stoma closure. Clinicopathological data and post-operative follow-up information from patients with mid-low rectal cancer after diverting stoma closure were collected and analyzed. Patients were randomly divided into training and test sets in a 7:3 ratio. A machine learning model was developed in the training set to predict major low anterior resection syndrome (LARS) and evaluated in the test set. Decision curve analysis (DCA) was used to assess clinical utility. The study included 396 eligible patients who underwent laparoscopic anterior resection and diverting stoma in Tongji Hospital affiliated with Huazhong University of Science and Technology from 1 January 2012 to 31 December 2020. The interval between stoma creation and closure, neoadjuvant therapy, and body mass index were identified as the three most crucial characteristics associated with patients experiencing major LARS in our cohort. The machine learning model achieved an area under the receiver operating characteristic curve (AUC) of 0.78 [95% confidence interval (CI): 0.74-0.83] in the training set (n=277) and 0.74 (95% CI: 0.70-0.79) in the test set (n=119), and area under the precision-recall curve (AUPRC) of 0.73 and 0.69, respectively, with sensitivity of 0.67 and specificity of 0.66 for the test set. DCA confirmed clinical applicability. This study developed a machine learning model to predict major LARS in rectal cancer patients after diverting stoma closure, aiding their decision-making and counseling.

Retrospective Analysis of the Outcome of Stoma Closure in Children without Preoperative Mechanical Bowel Preparation.

Stoma closure is one of the most frequently performed surgical procedures by pediatric surgeons worldwide. In this study, we studied the outcome of children undergoing stoma closures without mechanical bowel preparation (MBP) in our department. This is a retrospective observational study of children <18 years undergoing stoma closure from 2017 to 2021. The primary endpoints were surgical site infection (SSI), incisional hernia, anastomotic leak, and mortalities. The categorical data are expressed in percentages and the continuous data are in medians and interquartile ranges. The postoperative complications were classified according to the Clavien-Dindo system. A total of 89 patients underwent stoma closure without bowel preparation during the study. The anastomosis leak and incisional hernia were seen in one patient each. The SSIs occurred in 23 patients (25.9%), which were superficial in 21 and deep in 2 patients. The Clavien-Dindo Grade III complications occurred in 2 (2.2%) patients. The median duration to start feeds and pass first stools was significantly longer in patients with ileostomy closure (P = 0.04 and 0.001, respectively). The outcome of stoma closures without MBP was favorable in our study and hence it can be suggested that the use of MBP in colostomy closures can be safely avoided in children.

Can Neonatal Pull-through Replace Staged Pull-through for the Management of Anorectal Malformation? A Systematic Review and Meta-analysis.

Anorectal malformations (ARMs) are managed classically in three stages - colostomy at birth, anorectal pull-through after 2-3 months, and stoma closure. Single-stage pull-through has been contemplated in neonatal age aimed to reduce the number of procedures, better long-term continence, the better psycho-social status of the child, and reduced cost of treatment, especially in resource-strained countries. We conducted a systematic review comparing neonatal single-stage pull-through with stage pull-through and did a meta-analysis for the outcome and complications. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. PubMed and Scopus databases were searched and RevMan 5.4.1 was used for the meta-analysis. Fourteen comparative studies including one randomized controlled trial were included in the systematic review for meta-analysis. The meta-analysis included 1845 patients including 866 neonates undergoing single-stage pull-through. There was no statistically significant difference for the occurrence of surgical site infection (odds ratio [OR] 0.82, 95% confidence interval [CI]: 0.24-2.83), urinary tract injury (OR 1.82, 95% CI: 0.85-3.89), rectal prolapse (OR 0.98, 95% CI: 0.21-5.04), anal stenosis/stricture, voluntary bowel movements (OR 0.97, 95% CI: 0.25-3.73), constipation (OR 1.01, 95% CI: 0.61-1.67), soiling (OR 0.89, 95% CI: 0.52-1.51), mortality (OR 1.19, 95% CI: 0.04-39.74), or other complications. However, continence was seen to be better among patients undergoing neonatal pull-through (OR 1.63, 95% CI: 1.12-2.38). Thus, we can recommend single-stage pull-through for managing patients with ARMs in the neonatal age.

One-stage reconstructive jejunogastroplasty after previous multiple abdominal surgeries for left-sided diaphragm rupture complicated by gastric incarceration and necrosis

Acute gastric necrosis is a rare event requiring organ resection. Delayed reconstruction is advisable in patients with peritonitis and sepsis. The most common complication of gastrectomy with reconstruction is failure of esophagojejunostomy and duodenal stump. In case of severe esophagojejunostomy failure, appropriate surgical approach and timing of reconstructive stage should be analyzed. We report one-stage reconstructive surgery in a patient with multiple fistulas after previous gastrectomy. Surgery included reconstructive jejunogastroplasty with jejunal graft interposition. The patient underwent previous several unsuccessful reconstructive procedures complicated by failure of esophagojejunostomy and duodenal stump with external intestinal, duodenal and esophageal fistulas. Nutritional insufficiency, water and electrolyte disorders due to significant loss of proteins and intestinal juice through the drain tubes deteriorated clinical status. Surgical procedures finished reconstruction, provided closure of multiple fistulas and stomas and restored physiological duodenal passage.

Ten Cases of Early Stoma Closure after Rectal Resection

Ten Cases of Early Stoma Closure after Rectal Resection

Analysis of factors related to the decision of Hartmann's procedure and its reversal: a single-center experience.

Hartmann's procedure (HP) is commonly applied to resolve acute clinical conditions in most cases with colonic obstruction or perforation. HP and the closure of the end colostomy are associated with high morbidity-mortality rates. In our study, we aimed to report our clinical experience in HP. Demographic data and outcomes of Hartmann procedures performed between 2015 and 2023 were retrospectively reviewed. The median age of our study was 63 (18-94) years; 65 of the patients were female, and 97 were male. Colorectal malig-nancies were the primary etiology in 50% of patients who underwent HP, with 70% presenting with obstruction and 30% with perfora-tion. Two-thirds of the patients were American Society of Anesthesiologists-2 or higher. Postoperative complications did not develop in 74.7% of patients. Our mortality rate was 33.3%. The colostomy was closed in 59 patients during an average 2-year follow-up. The median closure time was 311 (57-1319) days. A stapler was used in 89.8% of patients during the closure. A diverting ileostomy was created in only two patients. The median hospital stay was 8 (5-70) days. Post-operative complications did not develop in 25.4% of patients, while four patients died. In our population, HP was more commonly performed for colorectal cancer. The procedure and closure of the ostomy result in low stoma closure rates, high morbidity, and mortality rates, as well as surgical difficulties.

Surgical evaluation of patients presenting with congenital pouch colon: A comprehensive study

Background: Congenital pouch colon (CPC) is a rare, complex anorectal malformation often associated with various anomalies. Timely diagnosis and recognition of anatomical variations are crucial for effective management. Late referrals and complications result from limited awareness of this condition. Aims and Objectives: The present study was planned with the objective to evaluate the patients presenting with CPC in terms of – initial presentation; associated anomalies; surgical management – single/staged surgery; and outcomes in terms of complications and continence. Materials and Methods: A study on 54 patients diagnosed with CPC found that most undergo staged surgical management, starting with a pouch ostomy followed by a definitive surgery like abdomino-PSARP or abdominoperineal pull through. Window colostomy is preferred due to its ease and less anesthesia exposure. Follow-ups are conducted 3 weeks after surgery, with regular washouts and uroprophylaxis. Patients with adequate weight, good general condition, and no signs of sepsis underwent definitive surgery, including laparotomy, fistula ligation with pouch excision, and normal bowel pull through. The second stage of surgery was performed after achieving adequate weight gain and good pouch volume. Follow-ups are conducted 3–4-week postsurgery, and patients undergo stoma closure 6–8 weeks after surgery. Results: Presentation typically occurred on the 2nd day of life in male patients (56.66%), while females predominantly presented in the neonatal period (75%). Abdominal distention was the most common presentation (83.33%). Due to delayed presentation with features of sepsis, most patients underwent staged surgeries, with 85.18% receiving a diversion procedure, mainly window colostomy. Definitive surgery was typically planned after the age of 10–12 months, based on weight, general condition, and pouch volume. Colporrhaphy was performed to achieve an adequate length of colon, with 55.55% of patients undergoing colporrhaphy with abdominalperineal (AP) pull-through and 33.33% undergoing posterior sagittal anorectoplasty with colporrhaphy and AP pullthrough. The most common complications included pouch ostomy stenosis (11.11%) and perineal excoriation (9.25%), both showing improvement over time. Continence was evaluated using Kelly’s score, revealing good continence in 35.3% of patients and fair continence with occasional soiling in 64.7% of patients. Conclusion: CPC is a challenging condition requiring multidisciplinary care and staged surgeries. Early diagnosis is vital to prevent complications. The prognosis varies by CPC type, with Types III and IV CPC showing better long-term outcomes due to a normal colon with better absorption capacity. Proper surgical approaches can lead to fair continence, and long-term follow-up is necessary to address complications and fertility concerns in female patients with genital abnormalities.

A Preliminary Monocentric Experience with Minimally Invasive Hepatic Resection of Colorectal Liver Metastasis Exploiting the Access of Synchronous Stoma Closure

A Preliminary Monocentric Experience with Minimally Invasive Hepatic Resection of Colorectal Liver Metastasis Exploiting the Access of Synchronous Stoma Closure

Real-time in vivo distal margin selection using confocal laser endomicroscopy in transanal total mesorectal excision for rectal cancer.

Transanal total mesorectal excision (TaTME) allows patients with ultralow rectal cancer to be treated with sphincter-saving surgery. However, accurate delineation of the distal resection margin (DRM), which is essential to achieve R0 resection for low rectal cancer in TaTME, is technically demanding. To assess the feasibility of optical biopsy using probe-based confocal laser endomicroscopy (pCLE) to select the DRM during TaTME for low rectal cancer. A total of 43 consecutive patients who were diagnosed with low rectal cancer and scheduled for TaTME were prospectively enrolled from January 2019 to January 2021. pCLE was used to determine the distal edge of the tumor as well as the DRM during surgery. The final pathological report was used as the gold standard. The diagnostic accuracy of pCLE examination was calculated. A total of 86 pCLE videos of 43 patients were included in the analyses. The sensitivity, specificity and accuracy of real-time pCLE examination were 90.00% [95% confidence interval (CI): 76.34%-97.21%], 86.96% (95%CI: 73.74%-95.06%) and 88.37% (95%CI: 79.65%-94.28%), respectively. The accuracy of blinded pCLE reinterpretation was 86.05% (95%CI: 76.89%-92.58%). Furthermore, our results show satisfactory interobserver agreement (κ = 0.767, standard error = 0.069) for the detection of cancer tissue by pCLE. There were no positive DRMs (≤ 1 mm) in this study. The median DRM was 7 mm [interquartile range (IQR) = 5-10 mm]. The median Wexner score was 5 (IQR = 3-6) at 6 mo after stoma closure. Real-time in vivo pCLE examination is feasible and safe for selecting the DRM during TaTME for low rectal cancer (clinical trial registration number: NCT04016948).