Temporary Ileostomy Research Articles

Is Ileostomy Always Necessary Following Rectal Resection for Deep Infiltrating Endometriosis?

ObjectiveTo verify the hypothesis that in most patients bowel segmental resection to treat endometriosis can be safely performed without creation of a stoma and to discuss the limitations of this statement. DesignRetrospective study (Canadian Task Force classification III). SettingTertiary referral center. PatientsForty-one women with sigmoid and rectal endometriotic lesions who underwent segmental resection. InterventionSegmental resection procedures performed between 2004 and 2011. Patient demographic, operative, and postoperative data were compared. Measurements and Main ResultsSigmoid resection was performed in 6 patients (15%), and rectal anterior resection in 35 patients (high in 21 patients [51%], and low, i.e., <10 cm from the anal verge, in 14 [34%]). In 4 patients a temporary ileostomy was created. There was 1 anastomotic leak (2.4%), in a patient with an unprotected anastomosis, which was treated via laparoscopic surgery and creation of a temporary ileostomy. Other postoperative complications included hemoperitoneum, pelvic abscess, pelvic collection, and a ureteral vaginal fistula, in 1 patient each (all 2.4%). ConclusionA protective stoma may be averted in low anastomosis if it is >5 cm from the anal verge and there are no adverse intraoperative events.

Risk factors for bowel dysfunction after sphincter-preserving rectal cancer surgery: a prospective study using the Memorial Sloan Kettering Cancer Center bowel function instrument.

Until recently, no studies have prospectively evaluated bowel function after sphincter-preserving surgery for rectal cancer with the use of a validated bowel function scoring system. The aim of this study was to investigate possible risk factors for altered bowel function after sphincter-preserving surgery. This was a prospective study. The study was conducted between January 2006 and May 2012 at the authors' institution. Patients who underwent sphincter-preserving rectal cancer surgery were recruited. Bowel function was assessed 1 day before (baseline) and at 1 year after sphincter-preserving surgery or temporary ileostomy takedown with the use of the Memorial Sloan Kettering Cancer Center questionnaire. Multivariable analysis was performed to identify the factors associated with altered bowel function after surgery. Overall, 266 patients were eligible for the analysis. The tumor was located in the upper, middle, and lower rectum in 68 (25.5%), 113 (42.5%), and 85 (32.0%) patients. Intersphincteric resection and temporary ileostomy were performed in 18 (6.8%) and 129 (48.5%) patients. The mean Memorial Sloan Kettering Cancer Center score was 64.5 ± 7.6 at 1 year after sphincter-preserving surgery or temporary ileostomy takedown. The Memorial Sloan Kettering Cancer Center score decreased in 163/266 patients (61.3%) between baseline and 1 year after surgery. Tumor location (p = 0.01), operative method (p = 0.03), anastomotic type (p = 0.01), and temporary ileostomy (p = 0.01) were associated with altered bowel function after sphincter-preserving surgery in univariate analyses. In multivariable analysis, only tumor location was independently associated with impaired bowel function after sphincter-preserving rectal cancer surgery. This study was limited by its nonrandomized design and the lack of measurement before preoperative chemoradiotherapy. We suggest that preoperative counseling should be implemented to inform patients of the risk of bowel dysfunction, especially in patients with lower rectal cancer, although this study cannot exclude the effect of chemoradiotherapy owing to the limitation of study.

A temporary loop ileostomy affects renal function.

The purpose of this study was to evaluate renal morbidity after a temporary loop ileostomy and to identify possible preoperative risk factors. Consecutive patients at four hospitals serving 1,520,000 inhabitants who received a temporary loop ileostomy and underwent subsequent closure were identified and retrospectively studied from 1 January 2007 until 28 February 2010. Serum creatinine levels were obtained 1week before index surgery and 1week before closure of the loop ileostomy. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula. Three hundred eight patients with median age of 64 were identified. The indication for the loop ileostomy was colorectal cancer (226), inflammatory bowel disease (41), diverticulosis (8), and other conditions (33). Median time until closure was 161days (3-873). There was a decrease in eGFR at time of closure (89 vs. 83; p < 0.0001), and the number of patients with renal impairment (eGFR <60) increased (7.5 vs. 21%, p < 0.0001). Preoperative risk factors for eGFR <60 at closure were age and hypertension. This study found that a loop ileostomy is associated with a reduced renal function for most patients, especially for older and hypertensive patients. This should be considered before constructing a loop ileostomy, and perhaps another stoma should be chosen if possible in patients at risk. Evaluation of medications before discharge and early and frequent postoperative follow-up could also reduce the risk of a reduced renal function.

A piece of my mind. The M&M game.

I am a physician who specializes in neonatology. There are few specialties more grounded in pure physiology. I am also a cancer patient. In the summer of 2010 I was diagnosed with a locally advanced rectal carcinoma. I received the best care medicine has to offer, from skilled and compassionate physicians: preoperative radiochemotherapy, a low anterior resection, a temporary ileostomy, and 12 cycles of chemotherapy. I worked throughout the entire ordeal and am told I “sailed through” chemo. I’ve made the mistake of reading tales of ghastly complications, misdiagnoses, and treatment failures on Internet chats devoted to my disease, and I know how lucky I am.

Rectal injury associated with insertion of a vaginal delineator tube during total laparoscopic hysterectomy: A case report and review of the literature

We present a case of rectal injury during total laparoscopic hysterectomy (TLH) associated with placement of a vaginal delineator tube. The patient was a 43-year-old virgin woman who presented with hypermenorrhea secondary to a large submucosal leiomyoma and underwent TLH. On insertion of a vaginal delineator tube, the boundary between the posterior vaginal fornix and the rectum was misjudged and the rectum was cut. The patient subsequently required transvaginal repair and a temporary ileostomy. With more widespread use of a vaginal delineator tube in TLH, sharing this rare experience with our colleagues will minimize such a complication.

Die Therapie des komplizierten Morbus Crohn

During their disease course, the majority of Crohn's disease patients will develop a complicated disease which is characterized by the occurrence of fistulas and/or stenosis. Symptomatic, perianal fistulas should be surgically drained before anti-inflammatory therapy will be initiated. Antibiotics, such as metronidazole, improve disease symptomatic however, they are not sufficient to induce continuous fistula closure. For this purpose, azathioprine/6-mercaptopurine as well as anti-TNF antibodies are useful when administered continuously. Surgical options include seton drainage, fistula excision, fistula plugs and mucosa flaps. As ultima ratio, temporary ileostomy and proctectomy are to be discussed. Non-perianal fistulas often require surgical approaches. Symptomatic strictures or stenosis can be treated by anti-inflammatory medications (only if they are cause by inflammation), endoscopic balloon dilatation or surgery.

Reversal of Ileostomy following elective anterior resection for rectal cancer: a review of current practice

Anterior resection for rectal cancer is typically performed with a covering temporary loop ileostomy. The authors carried out a review of practice to assess the timing of ileostomy reversal following anterior resection to determine if the patient information was accurate. Although the review was small, the findings correlated to those of previous larger studies. The median length of time for reversal was 5 months, which was longer than expected, and 9 months if patients required chemotherapy However, 11% of patients were found not to have their temporary ileostomy reversed. Fewer patients—28.6%—had an ileostomy than previously thought following anterior resection. This review has resulted in a change of practice, with patients being offered reversal in 3–4 months following anterior resection or on completion of chemotherapy. Patients are now contacted by their clinical nurse specialist before their reversal and provided with pre- and postoperative information, advice, and support to manage the effects of bowel dysfunction.

Traditional lateral ileostomy versus percutaneous ileostomy by exclusion probe for the protection of extraperitoneal colo-rectal anastomosis: The ALPPI (Anastomotic Leak Prevention by Probe Ileostomy) trial. A randomized controlled trial

Low colo-rectal anastomoses have a relevant risk of leakage. The protective stomas (ileostomy or colostomy) have always been utilized to reduce the complications due to anastomotic leakage. The stoma not only causes relevant morbidity but also needs a second operation to be closed, with an added risk of complications. For this reason we planed and carried out a temporary percutaneous ileostomy by a jejunal probe introduced in the distal ileum, that can be removed without a surgical procedure and with negligible complications. The ALPPI trial is a randomized controlled, open, parallel, equivalence multicenter study. Patients undergoing elective laparoscopic or laparotomic surgery for rectal cancer with extraperitoneal anastomosis, will be randomly allocated to undergo either lateral ileostomy or percutaneous ileostomy by exclusion probe. The primary endpoint is the protection of the extraperitoneal colo-rectal anastomosis in terms of incidence of symptomatic and asymptomatic anastomotic leakages. The secondary endpoints are the evaluation of complications due to the placement and the removal of the exclusion probe for percutaneous ileostomy. The ALPPI trial is designed to provide the surgical community with an evidence based new technique in the protection of low colo-rectal anastomosis, alternative to the conventional stomas. The ALPPI trial was approved by the Ethical Committee of Regional Public Health System of Umbria, Italy, (Protocol Number 28657/11/AV, study code RO-MA 01) and it is registered in the International Standard Randomised Controlled Trial Number (ISRCTN) Register with identification number ISRCTN99356919.

Impact of Ileostomy-Related Complications on the Multidisciplinary Treatment of Rectal Cancer

Radical resection is the primary treatment for rectal cancer. When anastomosis is possible, a temporary ileostomy is used to decrease morbidity from a poorly healed anastomosis. However, ileostomies are associated with complications, dehydration, and need for a second operation. We sought to evaluate the impact of ileostomy-related complications on the treatment of rectal cancer. We conducted a retrospective study of patients who underwent sphincter-preserving surgery between January 2005 and December 2010 at a tertiary cancer center. The primary outcome was the overall rate of ileostomy-related complications. Secondary outcomes included complications related to ileostomy status, ileostomy closure, anastomotic complications at primary resection, rate of stoma closure, and completion of adjuvant chemotherapy assessed by multivariate logistic regression. Of 294 patients analyzed, 32% (n = 95) were women. Two hundred seventy-one (92%) received neoadjuvant chemoradiation. The median tumor distance from the anal verge was 7 cm (interquartile range 5-10 cm). Two hundred eighty-one (96%) underwent stoma closure at a median of 7 months (interquartile range 5.4-8.3 months). The most common complication related to readmission was dehydration (n = 32-11%). Readmission within 60 days of primary resection was associated with delay in initiating adjuvant chemotherapy (odds ratio 3.01, 95% confidence interval 1.42-6.38, p = 0.004). Diverting ileostomies created during surgical treatment of rectal cancers are associated with morbidity; however, this is balanced against the risk of anastomosis-related morbidity at rectal resection. Given the potential benefit of fecal diversion, patient-oriented interventions to improve ostomy management, particularly during adjuvant chemotherapy, can be expected to yield marked benefits.

A Novel Use of the Gracilis Muscle as a “Walking” Flap for Repair of a Rectovaginal Fistula

INTRODUCTION: Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained.1–2 Case Report: We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30 mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed, but failed. The right gracilis flap was then re-used successfully as a “walking” flap. The medial femoral circumflex vessels were ligated and the proximal muscle was released and wrapped in a tubed piece of acellular dermal matrix (Figure 1). One week later, the fistula was divided and primary closure of the rectum and vagina was obtained. Subsequently, the proximal muscle was tunneled between the rectum and vagina and tacked 3 cm above the suture lines of both the rectal and vaginal defects and down to the opening of the perineal wound (Figure 2). At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later.Figure 1: Ligation of medial femoral circumflex vessels and release of the proximal gracilis muscle followed by wrapping in a tubed piece of acellular dermal matrix (ADM).Figure 2: Inset of the delayed gracilis flap between the rectum and the vagina - saggital view (green color = proximal end of the muscle, yellow color = distal end of the muscle).CONCLUSION: To our knowledge, this is the first report of the use of a gracilis muscle as a “walking” flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.

Severe hyperkalemia following colon diversion surgery in a patient undergoing chronic hemodialysis: a case report

IntroductionPotassium (K+) homeostasis in healthy subjects is maintained mainly by urinary excretion of K+. In patients with end-stage renal disease, the intestinal tract might assume an accessory K+ excretory role in the face of declining renal excretory function. Here, we report the case of a patient with end-stage renal disease who developed severe hyperkalemia following colon diversion surgery.Case presentationA 56-year-old Caucasian woman undergoing hemodialysis experienced ischemic colitis, leading to ileocecal resection and a temporary ileostomy. She made a good recovery and her dietary intake improved. However, her pre-dialysis serum K+ level three weeks later was 7.2mmol/L, which was much higher than her previous level (range 4.9 to 6.1mmol/L). Despite dietary restriction of K+ and use of oral cation-exchange resin and low K+ dialysate, her serum K+ level remained high (6.1 to 8.3mmol/L). Six months later, her bowel continuity was restored and her serum K+ decreased to the previous level. Her fecal K+ concentration before and after stoma reversal showed a marked difference: 23mmol/L before and 60mmol/L after.ConclusionsWe assume that the severe hyperkalemia seen in our patient was caused by reduced colonic K+ secretion due to the colon diversion. Our patient’s case demonstrates the importance of colonic K+ secretion for the maintenance of K+ homeostasis in patients with end-stage renal disease.

Pilot study evaluating the efficacy of AlloMEM™ for prevention of intraperitoneal adhesions and peritoneal regeneration after loop ileostomy

This study was designed to evaluate the feasibility of AlloMEM™, a novel lyophililzed human peritoneal membrane, at peritoneal reconstitution, and decreasing adhesion formation after temporary loop ileostomy. In a pilot study, ten patients had AlloMEM™ used during elective formation of a temporary diverting loop ileostomy for benign or malignant colorectal disease. A blinded investigator and the operating surgeon analyzed the change in adhesion formation and peritoneal remodelling using ileostomy mobilization time and a 5-point adhesion scale grading intra-abdominally and at the subcutaneous and fascial levels. The mean body mass index was 31 [standard deviation (SD) 5.6], and 40 % of patients had previous abdominal surgery. Ileostomies were reversed after a mean 14 weeks (SD 6.0). The mean ileostomy mobilization time was 27.2 min (SD 12.0). From baseline to ileostomy reversal, there were significant increases in adhesions at the subcutaneous (p = 0.0002) and fascial levels (p = 0.0024). The increased subcutaneous adhesions were associated with improved peritoneal remodeling. There was no significant increase in adhesions from baseline to ileostomy reversal at the intra-abdominal points (p = 0.9393) or around the ileostomy site (p = 0.6128). The median hospital length of stay was 2.6 days (range, 2-3). A single adverse event related to product packaging led to redesign of the packaging process. Use of AlloMEM™ in ileostomy closures suggested improvement in adhesions around the fascia and promotion of peritoneal remodeling. AlloMEM™ was safe, feasible, and easy to use in this pilot study. Comparative research is needed to assess the outcomes with this novel product.

Tu1529 Stapled Loop Ileostomy Closure: Does Stapler Length Matter?

S A T A b st ra ct s mean age (range) undergoing IAA in group A, B, and C was 25 (17-36), 37 (21-48), and 48 (29-66), respectively. The mean time interval (range) bewteen the closure of temporary covering ileostomy and contruction of permanent ileostomy in group A, B, and C was 9.5 (3-23 years), 5.8 (2 months-9 years), and 2.3 (1 month-5 years) years, respectively. Thus patients who required permanent ileostomy because of fistula tended to undergo IAA at relatively young age and had long time interval, while those who necessitated permanent ileostomy because of fecal incontinence tended to undergo IAA at relatively old age and had short time interval. Conclusions: These results indicate that, in patients necessitating permanent ileostomy after IAA for UC, the surgical indication for permanent ileostomy was associated with age undergoing IAA and time interval between the closure of temporary ileostomy and the contruction of permanent ileostomy. The Long term follow-up is important, because some patients required permanent ileostomy over 20 years after restorative proctocolectomy for UC.

Laparoscopic ventral mesh rectopexy in the management of solitary rectal ulcer syndrome: a cause for optimism?

The treatment of solitary rectal ulcer syndrome (SRUS) is notoriously difficult. Laparoscopic ventral mesh rectopexy (LVMR) is a nonresectional technique for patients with full thickness external rectal prolapse and internal prolapse with obstructed defaecation syndrome (ODS), features associated in the pathogenesis of SRUS. Our aim was to assess the short- and long-term efficacy of LVMR in treating SRUS. Forty-eight patients with SRUS who underwent LVMR over a 15-year period (December 1996 to July 2012) were identified from a prospectively maintained electronic database. Forty-eight patients, 38 (79%) women, median age 43 (18-80) years, median body mass index 26 (21-40) kg/m(2) underwent LVMR for SRUS after initial biofeedback. The median follow-up was 33 months (95% CI 31-55, range 1-186 months); 52% were followed for more than 3 years and 13 (27%) for more than 5 years. Five (10%) had relapsed following a response to stapled transanal rectal resection (STARR; 10 additional patients have had a continued response to STARR). Eleven (23%) had intermittent reducible external prolapse. Epithelial ulcer healing was reported in all patients at 3 months. The ODS scores improved by 68% (P < 0.0001) and quality of life (QoL; Birmingham Bowel and Urinary Symptoms Questionnaire-22) scores improved by 45% (P < 0.0001). There was a significant improvement in bowel visual analogue scale (VAS) scores at 3 and 12 months (P = 0.0007). Sustained improvement in QoL and VAS scores was maintained at 2 years and continued in the 52% followed up for between 3 and 15 years. There were four (8%) symptomatic ODS recurrences: posterior rectal wall prolapse successfully treated by STARR (3) and one symptom free for 2 years following a temporary loop ileostomy. There were two recurrences (4%). LVMR appears to provide a sustained improvement in QoL, VAS and patient satisfaction in patients with SRUS. Morbidity, recurrence and safety profiles are low.

Should routine contrast study be a norm before stoma reversal? A retrospective study of patients with temporary ileostomy

In the developed nations, temporary ileostomies are usually made in order to protect a distal anastomosis after cancer surgery. However, in India and the neighbouring countries ileal perforation is the most common indication for creating a temporary ileostomy after emergency laparotomy. It seems logical to perform a contrast study when a stoma that was made to protect a bowel anastomosis is being reversed in order to check for anastomosis healing, leak or stenosis. Although we do not know precisely when and why we started this practice, it is customary at our institute to do a contrast study before reversal of a temporary ileostomy. At some institutes a routine contrast study is never done. The utility of this practice has not previously been studied at our institute. This study tries to correlate the surgeon's clinical and operative findings with the contrast study report in order to see if it may be reasonable to reverse the stoma without a routine contrast study in selected patients where the surgeon has clearly documented absence of any gross disease in the distal bowel and who have had an uneventful post-operative period. To our knowledge this appears to be the first such attempt from our country.

V405 ROBOTIC TRANSVESICAL RECTOURETHRAL FISTULA REPAIR FOLLOWING A ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyMale Voiding Dysfunction and Infection1 Apr 2013V405 ROBOTIC TRANSVESICAL RECTOURETHRAL FISTULA REPAIR FOLLOWING A ROBOTIC RADICAL PROSTATECTOMY Brian Linder, Igor Frank, Eric Dozois, and Daniel Elliott Brian LinderBrian Linder Rochester, MN More articles by this author , Igor FrankIgor Frank Rochester, MN More articles by this author , Eric DozoisEric Dozois Rochester, MN More articles by this author , and Daniel ElliottDaniel Elliott Rochester, MN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1794AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Rectourethral fistulas in men are most commonly seen following therapeutic interventions for prostate cancer, whether via prostatectomy, radiation therapy or cryotherapy. We present a video of a robotic assisted technique for surgical repair of recto-urethral fistula. METHODS A 61-year old male developed a rectourethral fistula near the bladder neck following a robotic assisted radical prostatectomy, likely secondary to an unrecognized rectal injury. After failure of conservative measures, including an indwelling Foley catheter and a suprapubic tube, he was referred to our center for surgical repair. Utilizing a 6-port transperitoneal setup, similar to that described for a robotic prostatectomy, we performed a robotic assisted transvesical rectourethral fistula repair. We initially proceeded with cystoscopy to identify the fistula and its location with respect to the ureteral orifices. Following port placement and lysis of adhesions, the bladder dome was identified through retrograde filling through the patientÆs catheter. Then, a horizontal cystotomy was made and the camera and working arms were advanced transvesically to the fistulous opening. A ureteral catheter was placed to aid in protection of the ureteral orifice during dissection. The fistula was then circumferentially mobilized to the base of the tract. The rectal wall and the bladder were closed individually using a 3-0 Maxon suture. Following this, the patientÆs suprapubic tube was exchanged and the cystotomy at the bladder dome was closed in two layers. The cystotomy closure was verified to be water-tight with bladder irrigation. Our colleagues in Colon and Rectal Surgery then performed a temporary loop-ileostomy. RESULTS The operative time was 200 minutes, including cystoscopy and temporary loop ileostomy formation. The patient had an uncomplicated postoperative course and was discharged on hospital day two. The indwelling Foley catheter and suprapubic tubes were removed at three weeks post-operatively following a cystogram showing no residual extravasation. CONCLUSIONS Given this result, a transvesical robotic assisted repair of a rectourethral fistula repair appears technically feasible in appropriately selected candidates. Longer follow up and larger case series will be needed to validate this finding. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e164-e165 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian Linder Rochester, MN More articles by this author Igor Frank Rochester, MN More articles by this author Eric Dozois Rochester, MN More articles by this author Daniel Elliott Rochester, MN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Use of gracilis muscle as a “walking” flap for repair of a rectovaginal fistula

Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained. We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed but failed. The right gracilis flap was then re-used successfully as a "walking" flap. At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later. To our knowledge, this is the first report of the use of a gracilis muscle as a "walking" flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.

Temporary ileostomy versus colostomy for colorectal anastomosis: evidence from 12 studies

Objective. To assess the safety and efficacy of temporary ileostomy and temporary colostomy after a low anterior resection for rectal cancer by comparing the postoperative complications, then investigate which type of stoma is better. Material and methods. Studies comparing temporary ileostomy with colostomy for colorectal anastomosis were searched. The rates of complications (i.e., clinical anastomotic leak or fistula, stoma prolapse, parastomal hernia, wound infection related to stoma closure, obstruction following stoma closure, and skin trouble) were pooled and compared using a meta-analysis. The risk ratios (RRs) were calculated with 95% confidence intervals (CIs). Results. The study included five randomized controlled trials (RCTs) and seven non-randomized studies involving 1687 patients. The meta-analysis of the RCTs demonstrated a lower risk of stoma prolapse (RR 0.15; 95% CI: 0.04–0.48) in the temporary ileostomy group. Meta-analysis of the non-randomized studies showed a lower risk of stoma prolapse and wound infection after stoma closure in the temporary ileostomy group (both p < 0.05). Conclusions. Temporary ileostomy has a minor impact on patients; we endorse temporary ileostomy over colostomy after a low anterior resection for rectal cancer.

Laparoscopic Lower Anterior Rectal Resection Using a Curved Stapler: Original Technique and Preliminary Experience

Laparoscopic low anterior rectal resection (LLAR), allowing better visualization and rectal mobilization, can reduce postoperative pain and recovery. A contour curved stapler (CCS) is a very helpful device because of its curved profile that consents better access into the pelvic cavity and allows to perform rectal closure and section in one shot, especially in the presence of a narrow pelvis, complex anatomy, or large tumors. We developed an original technique of laparoscopic rectal resection using CCS. Between 2005 and 2009, in 36 cases, we performed LLAR with a three-trocar technique, starting with mobilization of left colonic flexure followed by the section of inferior mesenteric vessels. The rectum was prepared up to the levator ani with total mesorectal excision. The Lapdisc was inserted trough a suprapubic midline incision, allowing the CCS stapler placement into the pelvic cavity. After the rectal section, the anastomosis was then performed with a circular stapler. Ileostomy was performed if neoadjuvant radiotherapy and chemotherapy have been carried out or if the anastomosis was below 4 cm from the anal verge. Mean operative time was 135 minutes and no intra- or postoperative bleeding occurred. In 27 patients we performed temporary ileostomy. In two cases we observed anastomotic leakage; one of these patients already had ileostomy. No anastomotic stenosis occurred after one-year follow-up. This procedure simplifies the section of the lower rectum, reduces leaking rate resulting from technical difficulties, and does not nullify the benefits of laparoscopy.

Deeply infiltrating endometriosis of the rectum: shave, disc or segmental excision?

Dear Editor, The article by Ruffo et al. [1] describes a single-center series of 750 segmental resections of the mid or low rectum for deeply infiltrating endometriosis. Although the authors’ relatively low complication rate is impressive, we are concerned about the large number of low or very low anastomoses being performed in otherwise well and young (median age, 33 years) women without accompanying report of bowel function. Anterior resection syndrome is well documented, particularly after low rectal anastomoses, the management of which can be difficult [2–4]. Considering that endometriosis surgery is in many ways a quality-of-life operation to alleviate symptoms, we are interested in the authors’ comments. In our experience as well as that of others, most rectal endometriosis can be managed with shave or disc excisions without recourse to segmental resection [5, 6]. Although Ruffo et al. describe pathological confirmation of endometriosis, it will be important to determine the extent of disease on pathology. In our opinion, segmental resection should be reserved for patients with multicentric involvement or where a less invasive procedure is deemed inadequate. The authors did not make any comments on discs or shave excisions; if all patients were managed with segmental resection, then we consider this approach overly aggressive. We recently published our experience with rectal endometriosis and reported that the majority of patients (71 %) can be spared the morbidity of segmental resection by undergoing a disc excision of the anterior rectal wall because most will have focal rectal wall involvement [5]. This avoids the morbidity of full rectal mobilization, which risks rectal denervation and preserves the native rectal reservoir, which in turn reduces the likelihood of bowel dysfunction. Routine mobilization of the splenic flexure, as highlighted by Ruffo et al., necessarily implies a generous segmental resection. We are concerned about the appropriateness of this aggressive approach. We do not contest the safety and feasibility of laparoscopic management of rectal endometriosis, and recent publications testify that rectal resection can indeed be performed with low complication rates. Other than cyclical bleeding in 20 % and a preoperative median dyschezia score of 6.7, it was difficult to grasp the severity of patients’ symptoms in the series of Ruffo et al. to justify such aggressive surgical management. One could argue that even a 3 % anastomotic leak rate, 2 % rectovaginal fistula rate, 0.7 % risk of ureteric injury, and 14.5 % temporary ileostomy rate is excessive if the rectal resection was unwarranted in the first place. As we discuss in our recent article, the literature seems divergent in that there seems to be a lack of consensus as to whether bowel resection is warranted [6]. In the absence of definitive evidence to support one approach or the other, and in an era of patient-centered care, we urge all authors to move away from only reporting on short-term surgical outcomes and instead focus on functional outcomes with regard to symptom control, fertility, and bowel function outcomes. C. E. Koh (&) M. J. Solomon Surgical Outcomes Research Center, Royal Prince Alfred Hospital, Camperdown, NSW, Australia e-mail: cherry_koh@hotmail.com