Stomal Revision Research Articles

Robotic Pauli repair of parastomal hernia.

Robotic retro-muscular mesh repair of parastomal hernia (PH) is possible with transversus abdominis release. The aim of this study is to report mid-term results with this method. Patients who underwent surgery for PH were enrolled in a prospective study. Patients with concomitant midline hernia also underwent Rives repair. Polypropylene meshes with an absorbable buffer mesh were used in the retro-muscular pocket-except PTFE was chosen for inflammatory bowel disease patients. Follow-up was by telephone and physical examination and CT if suspicion of complication. Of the 56 included ostomy patients, 44 had colostomies, 10 had ileostomies, and two had urostomies. Thirty-nine percent had a concomitant hernia, and 25% had recurrent PH. The mean operating time without accessory repair was 156min (SD 37), and with accessory repairs 220min (SD 62). One bowel lesion and one vascular injury to the stoma occurred, prompting intraoperative stoma revision without postoperative morbidity. Postoperative complications ensued in 12 patients (23%). One patient had stoma necrosis after 3weeks and the stoma was relocated. One patient had a mesh infection, 3 patients temporary ileus, one patient hypovolemic renal failure, and two patients experienced a flare-up of their Crohn's Disease. One parastomal abscess was drained percutaneously. The median postoperative stay was 3days (1-21; mean 3.7days), and the readmission rate was 8.9%. The recurrence rate at mean and median 24months follow-up is 5.4%, two in ileostomy patients and one colostomy patient with unaltered bulging where CT shows a relatively large prolapse and recorded as a failure. Robotic Pauli repair has shown promising results. However, repair fails of PH at small bowel ostomies with short mesentery. ePauli/TAR is now the preliminary choice for eligible patients at our site. Comparative studies with the intraperitoneal mesh standard are needed.

Major stoma complications in pediatric patients in a tertiary hospital in a low-middle-income country: a retrospective cohort study.

Intestinal stomas are one of the most common parts of pediatric surgical care,and complications arising from it have significant impact on overall patient outcomes. However, data on major complications in low-middle-income countries remain limited. This pilot retrospective cohort study aimed to investigate the prevalence, types, and management of major stoma complications in pediatric patients at a tertiary government hospital in the Philippines. Medical records of pediatric patients with major stoma complications classified as Clavien-Dindo III-V from June 2018 to June 2023 were reviewed. Patient-related factors (age, sex, diagnosis) and surgery-related factors (stoma type and location, surgeon expertise) were analyzed. Descriptive statistics characterized demographic profiles, while Chi-square and t tests analyzed categorical and continuous variables, respectively. Multivariable logistic regression evaluated independent associations with major stoma complications. Out of 1041 pediatric patients with stomas, 102 cases had major complications, representing a prevalence rate of 9.8%. Mortality directly attributed to stoma complications accounted for 1.3% of the total cases, or 14 deaths in 5years. Neonates comprised a significant portion, primarily diagnosed with congenital conditions like anorectal malformation and Hirschsprung's disease. Ileostomies exhibited a higher incidence of major complications compared to other stoma types. Stomal prolapse and adhesive bowel obstruction are the most common reported stoma complications requiring surgical intervention while stoma revision is the most frequent corrective procedure. The median time from stoma creation to presentation of major complication was 14months, with nearly half of the complications occurring within the first year. Only the presence of ileostomy had significant association with the development of major complications among the risk factors analyzed. This study provides useful insights into stoma complications in pediatric patients in a low-middle income country. Despite the lack of significant associations between the patient-related and surgeon-related factors, and major stoma complications, further investigation into other contributing factors is warranted. Improvements in data collection methods and prospective studies with larger sample sizes are recommended to enhance understanding and optimize care of major stoma complications. Addressing the challenges identified in this study could lead to a comprehensive and tailored approach to pediatric stoma care and their complications.

Robotic modified Sugarbaker technique for parastomal hernia repair: a standardized approach.

Parastomal hernia (PSH) is a prevalent long-term morbidity associated with stoma construction, and the optimal operative management remains uncertain. This study addresses the need for a standardized approach to symptomatic PSH repair, focusing on the robotic-assisted modified Sugarbaker technique with composite permanent mesh. The study, conducted in a high-volume colon and rectal surgery referral practice, outlines a systematic approach to patient selection, surgical procedures, and postoperative care. Preoperative evaluations include detailed medical and surgical histories, impact assessments of PSH, and oncological history reviews. The surgical technique involves the Da Vinci Xi™ robotic platform for adhesiolysis, hernia content reduction, stoma revision if needed, narrowing of the enlarged stoma trephine, lateralization of the stoma limb of bowel, and securing the mesh to the abdominal wall. Outcomes are reported for 102 patients undergoing robotic parastomal hernia repair from January 2021 to July 2023. Conversion to open surgery occurred in only one case (0.9%). Postoperative complications affected 39.2% of patients, with ileus being the most frequent (24.5%). Recurrence was observed in 5.8% of cases during an average follow-up of 10 months. In conclusion, parastomal hernia, a common complication post-stoma creation, demands surgical intervention. The robotic-assisted modified Sugarbaker repair technique, as outlined in this paper, offers promising results in terms of feasibility and outcomes.

Use of temporary tracheostomy occlusion to reduce the risk of sternal wound infection after sternotomy in congenital cardiac surgery.

To describe a method of reducing the risk of sternal wound infection after sternotomy in children with a pre-existing tracheostomy. To report our outcomes using this method from 1 January, 2013 to 31 August, 2023. We describe a method for temporarily occluding the tracheal stoma with a removable implant with the primary goal of reducing the risk of sternotomy wound infection by preventing soilage due to tracheostomal secretions. We then performed a retrospective review of all children who underwent temporary tracheostomal occlusion between 1 January, 2013 and 31 August, 2023 at our quaternary care children's hospital. Clinical variables were extracted from the hospital medical records. The rates of antibiotic use and minor and major complications during the period when the stoma plug was in place were recorded. Totally, 19 patients underwent tracheal stoma plugging prior to sternotomy and were included in our analysis. There were two cases of sternal wound infection; one case occurred while the stoma plug was in place, and one developed four days following plug removal. There was one minor complication, with one patient requiring stoma revision via serial dilation at bedside at the time of recannulation. There were no deaths. Temporary occlusion of the tracheal stoma with an impermeable plug is a viable option for reducing the risk of sternal wound infection in children with a pre-existing tracheostomy who are undergoing sternotomy.

Macedo ileal catheterizable reservoir adding the scissors maneuver of channel continence: Long term follow-up

The Macedo ileal catheterizable channel was published in 2000 and consists of an enterocystoplasty with a catheterizable channel that precludes the need of the appendix for the efferent channel. After 25 years of experience with this technique, we decided to review our experience in a select subgroup of cases performed and followed exclusively by the author in a non-teaching hospital facility after the latest modifications of the procedure. Since 2008, we have refined our technique with the following modifications: small skin transverse incision instead of longitudinal one, with a semicircular flap for further stoma creation in the midline and importantly the scissors maneuver. This maneuver consists of crossing two 2cm rectus abdominis muscle flaps in the midline to create a neosphincter over the catheterizable channel. Follow-up was defined as the interval between the date of surgery and last visit to the clinic. We defined stoma continence if the dry interval between catheterization was 4hs. Early and late complications were reported as well as the reintervention rate. Additional procedures in association with bladder augmentation were also appointed. We have treated 49 patients. Indications were spinal dysraphism (71.4%), mainly myelomeningocele (65.3%), and others (PUV, exstrophy, anorectal anomalies). Urodynamic evaluation showed bladder pressure of high risk for upper urinary tract involvement (66%), urinary incontinence (24.5%), conversion of incontinent urinary diversion (3.8%), one exstrophy patient not considered (1.9%). Mean age at surgery was 88 months (7.3 years), 21 patients had additional surgeries in addition to Macedo ileal catheterizable channel: Macedo-Malone LACE procedure in 21 patients and bladder neck surgery to improve continence in 5 patients. Urinary stoma continence was 93.9% (46/49) after first surgery, one patient had a serous line valve revised, two patients still leak after 2h and await revision. Overall enterocystoplasty complications rate was 12.24% and consisted of urinary leakage in 3 cases and channel/stoma stricture in 3 cases. All patients treated for sphincteric deficiency associated with bladder reconstruction are continent per urethra. Urinary stoma revision for stricture was done in 2 cases and consisted on suprafascial approach and reanastomosis, one patient resolved with dilatation of the channel to the stoma. Mean follow up is 100 months (8.3 years). We confirmed in a long term follow-up based on face-to-face visits with 8.3 years mean follow-up that the Macedo procedure associated with the scissors maneuver is associated with 93.9% continence of the stoma. Overall complications rate was 12.24%. The cosmetic aspect with a small transverse incision and a midline stoma is another strength of the technique.

Historical Cohort Study of Congenital Isolated Hypoganglionosis of the Intestine: Determining the Best Surgical Interventions.

No standard diagnostic method or surgical treatment for congenital isolated hypoganglionosis (CIHG) has been established. This study aimed to analyze the clinical outcomes of patients with CIHG and identify the best surgical interventions provided thus far. Data on surgical interventions in 19 patients were collected between 1992 and 2020, including the type of enterostomy, type of revision, and length of the intestines. Ganglion cells in the myenteric plexus were enumerated using Hu C/D staining. The ratio of the length of the small intestine to its height was defined as the intestinal ratio (IR). The outcomes were assessed using the stoma output, growth parameters including the body mass index (BMI), and parenteral nutrition (PN) dependency. All patients required a diverting enterostomy. The IR ranged from 0.51 to 1.75 after multiple non-transplant surgeries. The stoma types were tube-stoma, end-stoma, Santulli-type, and Bishop-Koop (BK)-type. Patients with Santulli- or BK-type stomas had better BMIs and less PN dependency in terms of volume than those with end-stomas or tube-stomas. Two patients with BK-type stomas were off PN, and three who underwent an intestinal transplantation (Itx) achieved enteral autonomy. The management of CIHG involves a precise diagnosis using Hu C/D staining, neonatal enterostomy, and stoma revision using the adjusted IR and Itx if other treatments do not enable enteral autonomy.

Management of Stoma Prolapse Using Polypropylene Mesh Strip: A Novel and Easy Technique.

Stomal prolapse is one of the most common complications of enterostoma. Stoma if persistent and significant often requires revision of stoma. The techniques described often require laparotomy with resection or internal fixation of the bowel. Such procedures may make further laparotomy more difficult. We herein describe the use of a relatively simple procedure for the correction of stomal prolapse.

Pull-Through of Ganglionic Stoma in Children with Hirschsprung’s Disease Living in a Low Resource Context Spares Further Surgery for Colostomy Reversal: A Report from a Tanzanian Regional Referral Hospital

Abstract Background: One-step pull-through for Hirschsprung’s disease (HSCR) is already standard in many tertiary African paediatric surgical centres where radiology and frozen sections are available. However, limited resources in many peripheral areas associated with advanced age at referral or complicated presentation make recourse to colostomy often unavoidable with a consequent three-step surgery. To simplify these children’s clinical course and spare the burden of a third procedure for colostomy reverse, a direct pull-through of the proximal ganglionic stoma is proposed. Materials and Methods: Twenty children (male/female ratio 19/1) between 3 months and 13 years with a colostomy for a suspected HSCR were selected for stoma pull-through among patients admitted to a regional Tanzanian hospital between 2016 and 2022. Histological diagnosis was always confirmed by rectal biopsies and, in some cases, colonic specimens taken during the stoma confection or revision. A ganglionic stoma was always ascertained before the pull-through procedure (11 Transanal Endorectal, 4 Soave and 5 Duhamel). Results: One death was registered in a child with Down syndrome, unrelated to surgery, and another due to HSCR acute associated enterocolitis. One stenosis required stricturoplasty, and one anastomotic leakage needed temporary ileostomy. No relationship was found between complications and the procedure of choice. Passage of stools started on the 2nd day and became regular and without soiling in a week. Conclusions: Straightforward pull-through of the ganglionic stoma may be a feasible solution for patients with HSCR and a diverting colostomy to avoid a three-step procedure. The correct position of the stoma at the transition zone must be ascertained to avoid the risk of including in the resection segment of the ganglionic bowel.

TU4.9 Major elective colorectal surgery at a non-acute site: is it safe or not?

Abstract Introduction Recent reorganisation resulted in elective surgical services being separated from emergency facilities due to a new hospital site in our Health Board. Clinicians were initially concerned with regards to postoperative complications and the potential need for transfer to the acute site (6 miles away) for ongoing emergency management. There are no ICU or emergency theatre facilities at the cold site. We audited the first year of the service reconfiguration. Methods This study looked at unexpected transfer of major colorectal surgical patients occurring between December 2020 to 2021 from the elective hospital to the acute site. The prospectively maintained departmental database was interrogated. Results There were 263 patients undergoing colorectal operations over 12 months. 31 patients (12%) required step-up to the acute hospital for further post-operative care. 10 returned to theatre (4 anastomotic leaks, 1 anastomotic bleed, 1 fluid collection washout, 3 SBO, 1 stoma revision). The remaining 21 patients were managed conservatively by the surgical team (8) or taken over by the medical team (13). The main surgical reason for step-up was due to anastomotic leakage (7). Other step-up reasons included cardiorespiratory compromise (9), infection (6), bowel obstruction (3) and bleeding (2). Median time for transfer was day 4 (range 0–11 days) postoperatively. No transfer delay causing harm was reported. The 30-day mortality rate for all 263 patients was 0%. Conclusion Transfer to the acute site seems to have been safe, timely and effective in its first year. Patients have received appropriate and emergency care for these unpredictable complications.

Colostomy for Fournier's Gangrene with Rectum Exposure

Fournier's gangrene (FG) can be treated with prompt surgical debridement. Stoma revision has also been performed to prevent fecal contamination. However, recent advances in stool and wound management have reduced the need for colostomy. We report four cases of severe FG with an exposed rectum and discuss the conditions under which colostomy is indispensable. All four peoples developed FG, and an emergency debridement was performed, resulting in exposure of the rectum. Two peoples with perirectal infectious inflammation extending to the anterior rectum underwent colostomy because the inflammation had reached the retroperitoneum, but the other two, where the inflammation was confined to the dorsal-lateral rectum, were treated successfully without colostomy. We believe that colostomy can be avoided by using suitable wound management devices, except in severe cases where soft tissue infection and necrosis extend to the peritoneum and retroperitoneum and there is concern about rectal ischemia. Number of similar cases published: 0.

Learning curve for single-port robot-assisted rectal cancer surgery.

PurposeWe analyzed the learning curve of single-port robotic (SPR)-assisted rectal cancer surgery.MethodsFifty-seven consecutive SPR-assisted rectal cancer surgery cases performed by the same surgeon were considered in surgical interventions for rectal cancer. Total operation time (OT), docking time (DT), and surgeon console time (SCT) measured during surgery were used to parametrize the learning curve. The parameters representing the learning curve were evaluated using the cumulative sum (CUSUM).ResultsThe mean value of total OT was 241.8 ± 91.7 minutes, the mean value of DT was 20.6 ± 19.1 minutes, and the mean value of SCT was 135.9 ± 66.7 minutes. The learning curve was divided into phase 1 (initial 16 cases), phase 2 (second 16 cases), and phase 3 (subsequent 25 cases). The peak on the CUSUM graph occurred in the 21st case. The longest OT among phases was in phase 2. Complications were most frequent in phase 2. However, complications of Clavien-Dindo (CD) grade IIIb were most frequent in phase 3 with 2 patients. The most common complications were fluid collection and urinary retention (7 patients each). Complications of CD grade IIIb required one stomal revision due to stoma obstruction and one irrigation and loop ileostomy due to anastomosis leakage.ConclusionImprovement in surgical performance of SPR assisted rectal cancer operation was achieved after 21 cases. The three phases identified in the cumulative sum analysis showed a significant decrease in operative time after the middle stage of the learning curve without an increase in the complication rate.

Transcolostomy colectomy: A stoma revision technique to treat complex stoma prolapse

Colostomies are commonly performed operation in colorectal surgery. These are not free of complications which vary from acute retraction, and malfunction to delayed stoma prolapse. Prolapse is an annoying complication that may lead to excoriation, obstruction, and gangrene. There are various ways of treating stoma prolapse. Here, we discuss and report one simple technique of stoma revision, called transcolostomy colectomy.

O23 SURGICAL REPAIR OF PARASTOMAL BULGING - A REGISTER-BASED STUDY

Abstract Aim To examine the incidence of primary and recurrent repair and types of repair performed in patients with parastomal bulging. Material and Methods We linked prospectively collected data on parastomal bulging from the Danish Stoma Database to surgical data on repair of parastomal bulging from the Danish National Patient Register. Survival statistics provided cumulative incidences and time until primary and recurrent repair Results Of 1016 patients, registered from 2010-2017 with a permanent stoma and a parastomal bulge, 180 (18%) underwent surgical repair. The cumulative incidence of a primary repair was 9% (95% CI [8%; 11%]) within 1 year and 19% (95% CI [17%; 22%]) within 5 years after the occurrence of a parastomal bulge. For colostomies and ileostomies, we found similar probability of undergoing primary repair. For recurrent repair, the 5-year cumulative incidence was 5% (95% CI [3%; 7%]). The probability of undergoing further recurrent repair was 33% (95% CI [21%; 46%]) within 5 years. For primary repair, open or laparoscopic repair with mesh (43%) and stoma revision (39%) were performed almost equally frequent. Stoma revision and repair with mesh could precede and follow one another as primary and recurrent repair. Stoma reversal was performed in 17% of patients. Conclusions Our data offered a new and comprehensive view of the course of surgical treatment of parastomal bulging. Five years after the occurrence of a parastomal bulge the estimated probability of undergoing a repair was 19%. The probability of undergoing recurrent repair was high and stoma reversal more common than expected.

Robotic Assisted Repair of Post-Ileal Conduit Parastomal Hernia: Technique and Outcomes

ObjectiveTo describe a novel method of robotic assisted laparoscopic parastomal hernia repair (RAL-PHR), including the evolving use of the Da Vinci Single Port (SP) robotic system. MethodsDemographic, intraoperative, and postoperative variables were collected for patients who underwent RAL-PHR. The technique for RAL-PHR utilizes a 3 cm incision in the contralateral upper quadrant for the robotic trocar and a 12 mm assistant port. The hernia sac is freed from the fascial defect. Dual Surface Mesh is approximated to the fascial edges with a portion excised to tailor the conduit. ResultsFour patients underwent RAL-PHR and three utilized the SP robot. Median age was 74.4 (range: 69.0-76.9) and median BMI 28.6 (26.5-43.2). All patients underwent cystectomy for bladder cancer and median time from index operation to parastomal hernia repair was 47.3 (40.4-11.48) months. Concurrent operations to hernia repair included ureteroenteric stricture repair, panniculectomy, abdominal wall reconstruction, stoma revision, and incisional hernia repair. Median operative time was 3.9 (2.6-8.7) hours including concurrent operations, median EBL was 50 (10-100) cc, mesh used in 3 cases, with no intraoperative complications reported. Median length of stay was 1 day and 1 post-operative complication greater than Clavien 2 reported. At median follow up of 18.3 (3.63-38.3) months, no recurrences were reported and 1 patient had undergone stoma dilation in the OR. ConclusionRAL-PHR using the SP system maximizes advantages of laparoscopic repair while allowing for flexibility to perform concurrent procedures and safer takedown of adhesions through just two incisions. RAL-PHR is a safe and effective alternative to open and laparoscopic parastomal hernia repair with several additional benefits.

V10-12 ROBOTIC ASSISTED REPAIR OF POST-ILEAL CONDUIT PARASTOMAL HERNIA: TECHNIQUE AND OUTCOMES

You have accessJournal of UrologyLower Tract Reconstruction (V10)1 Sep 2021V10-12 ROBOTIC ASSISTED REPAIR OF POST-ILEAL CONDUIT PARASTOMAL HERNIA: TECHNIQUE AND OUTCOMES Alex Xu, Nabeel Shakir, Min Jun, and Lee Zhao Alex XuAlex Xu More articles by this author , Nabeel ShakirNabeel Shakir More articles by this author , Min JunMin Jun More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002061.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ileal conduits remain the primary form of urinary diversion after cystectomy, and parastomal hernia (PSH) is not an infrequent postoperative complication with considerable recurrence rates after open surgical repair, leading to both functional and cosmetic deficits. There is a paucity of literature examining robotic assisted laparoscopic parastomal hernia repair (RAL-PHR). We report a novel method of PSH repair using the Da Vinci Single Port (SP) robotic system. METHODS: We retrospectively reviewed 4 patients who underwent RAL-PHR by a single surgeon (LCZ) from June 2018 to February 2020. Variables included patient demographics, intraoperative considerations, and post-operative course. RAL-PHR is performed using a 3cm incision in the contralateral upper quadrant for the robotic trocar. The hernia is freed from the fascial defect and the defect tacked to the fascial edge. Mesh is then approximated to the fascial edges with a portion excised to tailor to the conduit. RESULTS: A total of 4 patients underwent RAL-PHR. The 3 most recent cases utilized the SP robot. Median age was 74.4 (range: 69.0–76.9) and median BMI was 28.6 (26.5–43.2). All patients underwent cystectomy for bladder cancer and the median time from index operation to PSH repair was 47.3 (40.4–11.48) months. One patient had a prior failed repair at an outside institution.Median operative time was 3.9 (2.6–8.7) hours, median estimated blood loss was 50 (10–100) cc, mesh was used in 3 of the 4 cases, and no intraoperative complications were reported. One patient underwent concurrent ureteral reimplant, abdominal wall reconstruction, and stoma revision and another patient had concurrent repair of an incisional hernia. Median length of stay was 1 day and 1 post-operative complication greater than Clavien 2 was reported. At median follow-up of 10.25 (3.2–14.4) months, no recurrences were reported. CONCLUSIONS: RAL-PHR using the SP system maximizes advantages of laparoscopic repair including providing a clear view of the hernia, fascial defect, and ileal conduit as well as ease of mesh placement and decreased length of stay, morbidity, and recurrence rates. Additionally, the SP system allows for flexibility to perform concurrent procedures such as ureteral reimplant and stoma revision and leads to safer takedown of adhesions through the use of fewer incisions versus the Xi system. Our data suggests that RAL-PHR is a safe and effective alternative technique to open and laparoscopic PSH repair with several additional benefits. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e758-e758 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alex Xu More articles by this author Nabeel Shakir More articles by this author Min Jun More articles by this author Lee Zhao More articles by this author Expand All Advertisement Loading ...

Split appendix catheterizable urinary channels are at no higher risk of undergoing revision compared to channels made with the intact appendix

To assess long-term APV and split-appendix MACE durability and to compare split and intact appendix APVs in a large patient cohort. This retrospective cohort study included consecutive patients ≤21 years old undergoing an APV at our institution (1990-2019). Main outcomes were stomal and subfascial revisions. Kaplan Meier survival and Cox proportional hazards analysis were used. A total of 339 patients underwent APV creation at a median 7.4 years old (41% female vs. 59% male; 37% umbilical stoma vs. 63% other). In total, 36 patients underwent a stomal revision and 19 a subfascial revision (median channel follow-up 6.3 years). On survival analysis, the risk of stomal revision of the APV was 9.1% at 5 years, 12.6% at 10 years and 16.5% at 15 years. Risk of subfascial revision of the APV was 5.1% at 5 years, 7.0% at 10 years and 8.2% at 15 years. A split-appendix APV was performed in 118 (34.8%) of 339 patients. They had a shorter follow-up compared to those with an intact APV (5.1 vs. 7.0 years, p=0.03). After correcting for differential follow-up time, there was no significant difference between groups for stomal revisions (HR 1.11, p=0.76) or subfascial revisions (HR 0.80, p=0.67, Figure). Risk of APV stomal revision was independent of stomal location and age at surgery (p≥0.37). Similarly, risk of subfascial APV revision was independent of stomal location and age at surgery (p≥0.18). Risk of stomal revision for split-appendix MACE channels was 16.2% at 5, 10 and 15 years (similar to split-appendix APV and all APVs, p≥0.26). Risk of MACE subfascial revision was 5.5% at 5 years, 5.5% at 10 years and 14.7% at 15 years (similar to split-appendix APV and all APVs, p≥0.36). We focused on surgical complications, as these entail the highest morbidity, however, we did not assess non-surgical, percutaneous or endoscopic management which also impact long-term outcome and patient quality of life. We did not compare the outcomes of the split-appendix MACE to an intact-appendix MACE cohort, as this patient population was not captured in this review. The split-appendix technique has durable long-term results for both the APV and MACE channels, which are comparable to the technique utilizing the intact appendix. Channel complications occur over the channel's lifetime, as 1 in 8 APVs in the entire cohort underwent a stomal revision and 1 in 14 APVs underwent a subfascial revision at 10 years after surgery.

Indications for, and outcomes of, end ileostomy revision procedures.

Ileostomy complications have been reported in >70% of cases. Older studies have shown ileostomy revision to be required in 23%-38% of patients over a 5-10year period. There is a paucity of recent data addressing ileostomy revision surgery. We aimed to review end ileostomy revisions in a tertiary centre and analyse indications, procedures performed, outcomes and risks for such surgery. This was a retrospective review in a single institution colorectal referral practice. All patients aged >17years who underwent a revision of an ileostomy at our institution from 2008 to 2019 were included. Indication for ileostomy revision, operative technique (parastomal vs. intra-abdominal) and outcomes including length of stay, readmission rates, wound complications, medical complications and rate of stoma re-revision were assessed. Fifty-three patients who underwent 72 end ileostomy revision procedures were included; 20 (27.8%) were re-revision procedures. The majority (76.4%) had their original ileostomy created for inflammatory bowel disease. Indications for ileostomy revision were stoma retraction (36.1%), prolapse (22.2%), stenosis (18.1%) and parastomal hernia (29.2%). Of stoma revisions, 55.6% were performed by a parastomal approach vs. 44.4% by an intra-abdominal approach. Procedures were a combination of laparotomy, laparoscopy or both. The average length of stay was statistically significantly lower in the parastomal approach revision group (2.3days) compared to the intra-abdominal approach revision group (10.3days) (P<0.001). Readmission and wound complication rates were 6.9% and 15.3%, respectively, in the intra-abdominal approach group alone. Medical complication rates were 20.8%. End ileostomy complications are common and surgical treatment may result in significant morbidity, readmission and reoperation. Patients should be counselled about these possibilities.

Surgical repair of parastomal bulging: a retrospective register-based study on prospectively collected data.

The aim of this work was to examine (1) the incidence of primary repair, (2) the incidence of recurrent repair and (3) the types of repair performed in patients with parastomal bulging. Prospectively collected data on parastomal bulging from the Danish Stoma Database were linked to surgical data on repair of parastomal bulging from the Danish National Patient Register. Survival statistics provided cumulative incidences and time until primary and recurrent repair. In the study sample of 1016 patients with a permanent stoma and a parastomal bulge, 180 (18%) underwent surgical repair. The cumulative incidence of a primary repair was 9% [95% CI (8%; 11%)] within 1year and 19% [95% CI (17%; 22%)] within 5years after the occurrence of a parastomal bulge. We found a similar probability of undergoing primary repair in patients with ileostomy and colostomy. For recurrent repair, the 5-year cumulative incidence was 5% [95% CI (3%; 7%)]. In patients undergoing repair, the probability was 33% [95% CI (21%; 46%)] of having a recurrence requiring repair within 5years. The main primary repair was open or laparoscopic repair with mesh (43%) followed by stoma revision (39%). Stoma revision and repair with mesh could precede or follow one another as primary and recurrent repair. Stoma reversal was performed in 17% of patients. Five years after the occurrence of a parastomal bulge the estimated probability of undergoing a repair was 19%. Having undergone a primary repair, the probability of recurrent repair was high. Stoma reversal was more common than expected.

Retrospective analysis of acute left colon obstructions due to colorectal cancers

Amaç: Kolorektal tümörlere bağlı akut sol kolon tıkanıklığı bulguları gösteren olgularda acil koşullarda uygulanan rezeksiyon primer anastomoz sonuçlarının değerlendirilmesi ve bu sonuçların Hartmann Prosedür uygulanan hastaların sonuçlarıyla karşılaştırılması amaçlanmıştır. Gereç ve Yöntem: Ağustos 2005-Mart 2011 tarihleri arasında Ankara Numune Eğitim ve Araştırma Hastanesi Acil Cerrahi Servisi’ne yatış yapılan kolorektal kansere bağlı akut sol kolon obstrüksiyonu nedeniyle ameliyat edilen 84 hasta çalışmaya alındı ve retrospektif olarak incelendi. Hastaların tümü acil serviste değerlendirilip acil ameliyathanede opere edilmiştir. Hastaların tedavisinde Hartmann kolostomi ve rezeksiyon primer anastomoz cerrahi prosürleri kullanıldı. Barsak temizliği yapılmadan operasyona alındı ve intraoperatif rezeksiyon sonrası tüm hastalara manuel dekompresyon yapıldıktan sonra ya rezeksiyon primer anastomoz ya da Hartmann Prosedür yapıldı. Bulgular: Stoma açılan grupta postoperatif yoğun bakım ihtiyacı olan hasta sayısı 25, ventilatör ihtiyacı olanların sayısı 16, stoma revizyonu yapılan hasta sayısı 3 idi. Kardiyopulmoner morbidite sayısı 10, reoperasyon 9, mortalite sayısı 13 olarak saptandı. Anastomoz yapılan grupta ise postoperatif yoğun bakım ihtiyacı olan hasta sayısı 13, ventilatör ihtiyacı olanların sayısı 4’tü ve anastomoz yapılanların 2’sinde anastomoz kaçağı olduğu görüldü. Yeniden operasyona giren hasta sayısı 2 idi, mortalite sayısı 5 olarak saptandı. Her iki grup arasında postoperatif yoğun bakım ihtiyacı, ventilatör ihtiyacı, reoperasyon ve mortalite açısından p değerleri &amp;lt;0,05 olup anlamlı idi.Sonuç: Kolorektal kansere bağlı akut sol kolon obstrüksiyonu nedeniyle ameliyat edilecek hastalarda; genel durumu iyi, komorbiditesi ve ASA skoru düşük olan hastalara cerrahın tecrübesine dayanarak intraoperatif manuel dekompresyonla rezeksiyon-primer anastomoz yapılmasını önermekteyiz.

Pitfalls in diagnosis and treatment of Hirschsprung's disease

Abstract Background and purpose Hirschsprung's disease (HD) presents itself by delayed passage of meconium, neonatal bowel obstruction and/or chronic constipation. In 80% of cases the disease is diagnosed in the first year of life. Difficulties or misdiagnosing HD are infrequently met. The aim of this case series is to highlight the pitfalls in diagnosis and treatment of HD. Case presentation: case 1&2 A 4 and 6 months old ♂ were diagnosed as rectal perforation in the neonatal period and colostomy was performed. At the age of 4 and 6 months respectively they developed fecal fistula after colostomy closure. Revision of stoma was done and biopsy proved that both had aganglionic rectal biopsy. Abdominal PT was performed for both after 3 and 4 months. Case 3 A 5 years ♀ came with recurrent attacks of intestinal obstruction since the age of 1 year. Both plain X ray and contrast studies were inconclusive. Finally was diagnosed after a second exploration and histopathological biopsies with total colonic aganglionosis. Case 4 A 1.5 years old presented with neonatal intestinal obstruction. His preoperative gastrografen enema were inconclusive. He underwent surgical exploration at the age of 2 weeks ended with right transverse colostomy and multiple colonic and rectal biopsies proved to be aganglionic. Case 5 A 3 months old ♂ came with caecostomy construction because of caecal perforation during neonatal period. Although there was no histopathological report earlier about the colon but his current rectal biopsy was devoid of ganglion cells. Conclusions:High degree of suspicion with physician care plan and routine biopsy are essential in all non NEC neonatal perforation during exploration to avoid missing of HD.