Temporary Ileostomy Research Articles

Evidence-based treatment of patients with rectal cancer.

Rectal cancer is a worldwide disease whose incidence has increased significantly. Evidence-based medicine is a category of medicine that optimizes decision making by using evidence from well-designed and conducted research. Evidence-based medicine can be used to formulate a reasonable treatment plan for newly diagnosed rectal cancer patients. The current review focuses on the application of evidence-based treatment on patients with rectal cancer. The relationship between perioperative blood transfusion and recurrence of rectal cancer after surgery, the selection between minimally invasive laparoscopic surgery and traditional laparotomy, choice of chemotherapy for patients with rectal cancer prior to surgery, selection between stapled and hand-sewn methods for colorectal anastomosis during rectal cancer resection, and selection between temporary ileostomy and colostomy during the surgery were addressed. Laparoscopy is considered to have more advantages but is time-consuming and has high medical costs. In addition, laparoscopic rectal cancer radical resection is preferred to open surgery. In radical resection surgery, use of a stapling device for anastomosis can reduce postoperative anastomotic fistula, although patients should be informed of possible anastomotic stenosis.

Surgical management of abdominal tuberculosis: a retrospective study from Central India

Background: Abdominal tuberculosis is a diagnostic and therapeutic challenge in resource limited countries. The vague clinical presentation is a barrier to early diagnosis. The study aims to highlight the role of surgery in the diagnosis and treatment of abdominal tuberculosis.Methods: This is a descriptive study of abdominal tuberculosis cases, which were operated in the Department of Surgery, Peoples College of Medical Sciences & Research Centre, Bhopal from August 2010 to July 2015. Cases were analyzed in terms of demography, clinical features, investigations, operative treatment, and outcome.Results: 72 cases of abdominal tuberculosis were operated during the study period. The median age was 30 years with male to female ratio of 3:2. Primary abdominal tuberculosis was 79.2%. Intestinal tuberculosis was the commonest with terminal ileum and ileo-caecal region being predominantly involved. 58% of the patients required emergency surgery. Surgical procedures performed were: resection of the diseased segment including right hemi-colectomy 32 (44.44%), release of band/adhesions 23 (31.9%), perforation repair 11 (15.3%), stricturoplasty 4(5.5%), etc. In the presence of gross peritonitis, temporary ileostomy was performed. Complication and mortality rates were 33.3% and 2.6% respectively. No patient had post-operative intestinal-leak.The median duration of hospital stay was 14 days.Conclusions: Early diagnosis is the key factor in avoiding systemic and local complications of intestinal tuberculosis. In emergency cases, prompt surgical exploration and vigilant care is met with good recovery. Resection-anastomosis in the form of right hemi-colectomy or segmental resection has largely been adopted instead of simple bypass of obstructive lesions with good results.

Liver Cirrhosis/Severe Fibrosis Is a Risk Factor for Anastomotic Leakage after Colorectal Surgery.

Purpose. Liver cirrhosis associated with high perioperative morbidity/mortality. This retrospective study determines whether liver cirrhosis represents a risk factor for anastomotic leakage after colonic anastomosis or not. Methods. Based on a prospective database with all consecutive colorectal resections performed at the authors' institution from 07/2002 to 07/2012 (n = 2104) all colonic and rectal anastomoses were identified (n = 1875). A temporary loop ileostomy was constructed in 257 cases (13.7%) either due to Mannheimer Peritonitis-Index > 29 or rectal anastomosis below 6 cm from the anal verge. More than one-third of the patients (n = 691) had postoperative contrast enema, either at the occasion of another study or prior to closure of ileostomy. The presence of liver cirrhosis and the development of anastomotic leakage were assessed by chart review. Results. The overall anastomotic leakage rate was 2.7% (50/1875). In patients with cirrhosis/severe fibrosis, the anastomotic leakage rate was 12.5% (3/24), while it was only 2.5% (47/1851) in those without (p = 0.024). The difference remained statistically significant after correction for confounding factors by multivariate analysis. Conclusion. Patients with liver cirrhosis/severe fibrosis have an increased risk of leakage after colonic anastomosis.

Distant Metastasis in Colorectal Cancer is a Risk Factor for Anastomotic Leakage.

The aim of this study was to investigate whether metastatic colorectal cancer (Union for International Cancer Control stage IV disease) represents a risk factor for anastomotic leakage after colorectal surgery without major hepatic resection. This retrospective cohort study was based on an existing prospective colorectal database of all consecutive colorectal resections undertaken at the authors' institution from July 2002 to July 2012 (n = 2104). All patients with colorectal resection and primary anastomosis for colorectal cancer were identified (n = 500). A temporary loop ileostomy was constructed in low rectal anastomosis up to 6 cm from the anal verge (n = 128 cases, 26%). A routine contrast enema was undertaken at the occasion of other prospective studies in 254 patients. UICC stage IV disease was present in 94 patients (19%), while 406 patients (81%) had UICC stage I-III disease. The overall anastomotic leak rate was 2.6% (13/500), 2.2% (11/500) for both clinical and radiological leaks, and 0.8% (2/254) for radiological leaks only. Four were managed conservatively and nine (1.8%) required revision laparotomy. In the case of UICC stage IV disease, the anastomotic leak rate was 6.3% (6/94), while in the case of UICC stage I-III disease the leak rate was 1.7% (7/406). UICC stage IV disease [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.3-14.4; p = 0.015] and diabetes (OR 5.7, 95% CI 1.7-18.7; p = 0.004) were independent risk factors for anastomotic leakage after colorectal surgery. Patients with stage IV colorectal cancer have an increased anastomotic leak rate after colorectal surgery. Whether this is due to an impaired immune system remains speculative.

Risk factors for permanent stoma after rectal cancer surgery with temporary ileostomy

Although creation of a temporary diverting ileostomy during resection for rectal cancer surgery is used widely to decrease the risk of anastomotic leakage, a frequent outcome is maintenance of this "temporary" ileostomy as a permanent stoma (PS). Our aim was to assess the incidence of PS and identify potential risk factors. This observational study included patients who underwent rectal cancer surgery with temporary ileostomy with curative intent between January 2001 and December 2008. Patient demographics, perioperative outcomes, and complications were analyzed. Incidences of primary PS (present at the endpoint of the study without stoma reversal) and secondary PS (created after closure of the primary stoma) were investigated. Univariate and multivariate analyses were conducted to determine risk factors. Of 673 enrolled patients, 64 (9.5%) developed PS, including 23 cases of primary PS and 41 of secondary PS. The causes of primary PS were systemic metastases (n = 12), anastomosis stricture (n = 4), poor general condition (n = 3), patient refusal (n = 2), and other (n = 2). The causes of secondary PS were local recurrence (n = 12), uncontrolled pelvic abscess (n = 11), unsatisfactory anorectal function (n = 10), anastomosis stricture (n = 6), and other (n = 2). In multivariate analysis, anastomosis leakage (P < .001), involvement of the circumferential resection margin (P = .013), and stage III tumor (P = .001) were independent risk factors for PS. Patients with advanced cancer or anastomotic leakage are at high risk of PS after temporary ileostomy. Surgeons should be aware and patients should be informed of the possibility of PS formation.

Presentation and management of rectovaginal fistulas after delivery.

Obstetric trauma leading to rectovaginal fistula (RVF) formation results from perineal laceration and/or from prolonged ischemia and necrosis following obstructed labor. Due to modern obstetric care fistulas are rare in industrialized countries. Patients undergoing surgery for a RVF between January 2005 and December 2014 at the Department of Obstetrics and Gynecology, Tuebingen, Germany, were identified and their records were reviewed retrospectively. Of 48 patients, 13 developed RVF of obstetric etiology. Parity ranged from 2 to 4. RVF repair was performed in all patients using a transvaginal approach: fistula excision and multilayer closure (7 of 13) with Martius flap interposition (1 of 7) and sphincteroplasty (5 of 13). One RVF closed spontaneously. Due to significant destruction of the anal canal, large RVF and RVF recurrence, 4 of the 13 patients needed a temporary protective ileostomy. Fistula closure was achieved in 12 of 13 patients. The choice of RVF repair should be tailored to the underlying pathology and type of repair done previously and the patient's wishes.

Discriminatory influence of Pinpoint perfusion imaging on diversion ileostomy after laparoscopic low anterior resection

While still debated, it was advised to perform a protective temporary ileostomy after a low anterior resection (LAR). This might help to decrease the leak rate and therefore offers the patient better outcomes. Anastomotic leak can occur in many situations after a LAR and the control of the risk factors helps to adapt the need of an ileostomy. Near infrared technology allows assessing the microvascularisation of the anastomosis at the time of surgery and therefore might be an important tool to avoid a stoma in given situation. This article reviews the evidences with the use of this technology.

Selecting appropriate appliances and accessories for ileostomates

This article will look at the appliances and accessories available for patients who have an ileostomy, whether temporary or permanent. Predisposing factors for the formation of an ileostomy include inflammatory bowel diseases (IBD), which is compromised of Crohn's disease and ulcerative colitis, and rectal cancer. With advances in bowel surgery for rectal cancer and the ability to perform procedures lower in the colon with an anastomosis, often a temporary ileostomy is needed while the patient undergoes adjuvant therapy. There are approximately 20 000 people in the UK and Ireland who have had their colon removed (Ileostomy Association, 2015). Problems can occur at any time following the formation of an ileostomy, either with the appliance or peristomal skin problems or other issues related to the ileostomy.

Bioprosthetic mesh reinforcement during temporary stoma closure decreases the rate of incisional hernia: A blinded, case-matched study in 94 patients with rectal cancer

This case-matched study aimed to assess the feasibility and the potential benefits of placement of a prophylactic bioprosthetic collagen porcine mesh during closure of the temporary ileostomy after total mesorectal excision (TME) for rectal cancer. From September 2012 to March 2013, 30 consecutive patients underwent placement of a retromuscular bioprosthetic mesh in the abdominal wall during closure of a diverting ileostomy after sphincter-saving laparoscopic TME for rectal cancer (mesh group). These 30 patients were matched individually to all identical patients who underwent a closure of the ileostomy without mesh after laparoscopic TME extracted from our prospective database (control group). The matching process was performed according to sex, age, body mass index, medically treated diabetes mellitus, neoadjuvant radiotherapy, and the delay between TME and closure of the ileostomy. The primary endpoint was stoma site incisional hernia, assessed in a blinded fashion by CT 1 year later. Mesh placement was feasible in all mesh group patients. There was no postoperative mortality. Overall postoperative morbidity rates were similar between mesh and control groups (n = 5 [17%] vs n = 7 [11%], respectively; P = .512). On the 1-year CT, incisional hernia at the site of stomal closure was less in the mesh group (n = 1) compared with the control group (n = 12; P = .043). Reoperation for incisional hernia at the site of stomal closure was performed in 8 patients (13%) in the control group, whereas no patient from the mesh group required repair of the hernia (P = .052). Placement of a bioprosthetic collagen porcine mesh during closure of the temporary ileostomy after laparoscopic TME for rectal cancer seems to decrease the chance of hernia formation at the stoma site, at least at the 1-year follow-up.

Intestinal tuberculosis previously mistreated as Crohn's disease and complicated with perforation: a case report and literature review.

IntroductionTuberculosis is known as a notorious mimicker and distinguishing between intestinal tuberculosis and Crohn’s disease is a huge diagnostic challenge. Case descriptionHere, we report a case of hollow organ perforation due to intestinal tuberculosis that was previously mistreated as Crohn’s disease. Staged operation with emergency resection of the diseased small bowel and temporary ileostomy was performed for the perforation, followed by 6-month standard treatment for miliary tuberculosis, which was diagnosed on the basis of the presence of acid-fast bacilli in the diseased bowel and positive culture of Mycobacterium tuberculosis from sputum, ascites, and stool samples. Ileostomy takedown was performed, and the continuity of the gastrointestinal tract was restored 6 months after the first surgery. The patient recovered well thereafter.ConclusionTimely surgical intervention can help establish the finial diagnosis of tuberculosis, rescue the patient from abdominal emergency, and provide a chance for cure.

Factors affecting timing of closure and non-reversal of temporary ileostomies.

BackgroundAlthough stoma closure is considered a simple surgical intervention, the interval between construction and reversal is often prolonged, and some ileostomies may never be reversed. We evaluated possible predictors for non-reversal and prolonged interval between construction and reversal.Material and methodsIn a cohort study of ileostomy patients treated in a large teaching hospital, we collected data from the surgical complication and enterostomal therapists’ registries between January 2001 and December 2011. Parameters responsible for morbidity, mortality, length of stay and time interval between construction and reversal were analysed.ResultsOf 485 intentionally temporary ileostomies, 359 were reversed after a median of 5.6 months (IQR 3.8–8.9 months), while 126 (26 %) remained permanent.End ileostomy and intra-abdominal abscess independently delayed reversal. Age, end ileostomy, higher body mass index and preoperative radiotherapy were independent factors for non-reversal. Median duration of hospitalisation for reversal was 7.0 days (5–13 days). Morbidity and mortality were 31 and 0.9 %, respectively. In 20 patients (5.5 %), re-ileostomy was necessary.ConclusionsA substantial number of ileostomies that are intended to be temporary will never be reversed. If reversed, the interval between construction and reversal is longer than anticipated, while morbidity after reversal and duration of hospitalisation are considerable. Besides a temporary ileostomy, there are two other options: no diversion or a permanent colostomy. Shared decision-making is to be preferred in these situations.

PTH-262 Laparoscopic surgery for rectal cancer after preoperative chemoradiotherapy

Introduction In 2004, we started to perform total mesorectal excision and prophylactic lateral dissection by open surgery after preoperative chemoradiotherapy in patients with advanced lower rectal cancer. Since 2010, we have extended the radiation field to include the lateral lymph nodes and performed laparoscopic surgery for rectal cancer. Since 2013, we have laparoscopically performed lateral lymph-node dissection in patients who have enlarged lateral lymph nodes before surgery. Preoperative chemoradiotherapy can reduce tumour size, allowing a good visual field of the pelvic cavity to be obtained. Method We focused on techniques for obtaining a good visual field of the intrapelvic cavity and on procedures for perirectal dissection and safe transection of the rectum during laparoscopic surgery for rectal cancer in patients who had received preoperative chemoradiotherapy. The study group comprised 50 patients who underwent laparoscopic surgery for rectal cancer after preoperative chemoradiotherapy from 2010 through 2014. The primary tumour was located below the peritoneal reflection (Rb) in 40 patients and above and below the peritoneal reflection (Rab) in 10. Up to 2010, laparoscopic rectal surgery was indicated for the treatment of clinical T2 disease. Subsequently, we extended the indication to include advanced rectal cancer after chemoradiotherapy in patients with no enlarged lateral lymph nodes. From 2013 onward, we laparoscopically performed lateral lymph-node dissection in patients with enlarged lateral lymph nodes before surgery. A temporary ileostomy was performed in patients who underwent anastomosis. Results The surgical procedures performed were low anterior resection in 29 patients, Miles’ operation in 20, and Hartmann’s surgery in 1. The operation time was 351 min. The blood loss was 125 mL. The median postoperative hospital stay was 13 days. Nine patients (18%) had postoperative complications. Suture failure occurred in 3 patients (10%) and improved after internal drainage. Ileus developed in 2 patients (4%), and perineal wound infection occurred in 2 patients (4%). The response to chemoradiotherapy was Grade 1 in 25 patients, Grade 2 in 11, and Grade 3 in 14. The pathological stage was complete response in 13 patients (26%), stage I in 12, stage II in 15, stage IIIa in 8, and stage IIIb in 2. Conclusion Surgery for rectal cancer after chemoradiotherapy provided good results in terms of clinical response and postoperative short-term outcomes. Tumour shrinkage allowed a good field of vision to be easily obtained; surgery could thus be performed more safely and reliably. Disclosure of interest None Declared.

PWE-072 Long-term outcome of endoscopic dilatation in patients with crohn’s anastomotic strictures is affected by disease activity and medical therapy

Introduction A clinically relevant stricture is usually defined as a luminal narrowing with pre-stenotic dilatation and obstructive symptoms. Surgical resection is an effective treatment for Crohn’s anastomotic strictures, however disease recurrence after 15 years is more than 50%, often with the need for a further resection.1The long-term outcome of endoscopic balloon dilatation is unclear as most cohorts have a follow-up time of less than 3 years. Method All endoscopic balloon dilatations performed at a single centre for patients with anastomotic Crohn’s strictures between 2004–2009 were retrospectively reviewed with the aim of collecting long-term follow up data. The stricture length, signs of disease activity and evidence of upstream dilatation were assessed from imaging. Clinical data on medical therapy and escalation to anti-TNF or thiopurines was obtained. Endoscopic data including disease activity, balloon size and therapeutic success, along with histological reports were recorded. Results A total of 54 patients were identified with a median age of 52 years (46–62). The median follow-up period was 6.48 years (5.34–7.42) with a disease duration of 28 years (19–32). Stricture length at cross-sectional imaging was described in all cases with a median of 20 mm (10–30) with features of active mucosal inflammation at the anastomosis in 38/54(70%) and upstream dilatation in 25/54(46%). At the time of endoscopy, active disease was described in 37/54(68%) of cases, a median balloon dilatation of 15 mmHg was used to achieve therapeutic success in 48/54 (89%). 10/54(18%) subsequently required surgical resection. The median number of dilatations was 2(1–9) with a time to repeat dilatation of 23 months (7.2–56.9) with 31/44 (70%) of patients being managed endoscopically requiring repeat dilatations. There was one perforation which resulted in a resection of the anastomosis and temporary ileostomy. Active disease at time of first endoscopy (p = 0.049) and stricture length >20 mm (p = 0.015) predicted need for repeat dilatations (Table 1). Furthermore, escalation of medical therapy to either azathioprine or anti-TNF appeared to delay time to further dilatation. Conclusion At long term follow-up, 18% of patients required surgical resection. 32% of patients were well with no further endoscopic intervention required. 68% required intercurrent endoscopic dilatations. This is the longest follow-up period in the literature and demonstrates that the effects can be durable if patients have escalation in medical therapy to thiopurine or anti-TNF and avoidance of surgery is possible in a group of patients with anastomotic strictures. Disclosure of interest None Declared. Reference Predictability of the postoperative course of CD. Gastroent. 1990;99:956

Perforation of viscera, a dramatic complication of liposuction: a review of 19 cases evaluated by experts in France between 2000 and 2012.

Perforation of one or several intraperitoneal organs during a liposuction procedure is an exceptional but underestimated complication. Knowledge of this complication is essential because of frequent delay in diagnosis and possible dramatic consequences. Nineteen cases were evaluated by experts and are presented in a retrospective analysis. Sixteen women and three men, aged 24 to 72 years, were operated on in France between July of 2001 and January of 2012. Abdominal liposuction (200 to 2400 ml) was performed in combination or not with an abdominoplasty. Uncommon pain and an intestinal obstruction were present in all of the patients. The peritonitis was never frank, replaced frequently by infraclinic peritonitis with septic and/or hypovolemic shock. Diagnosis, performed by abdominal scan between days 1 and 7, revealed intraperitoneal gas or liquid. Perforation, unique or multiple, because of the intraperitoneal passage of the cannula, often in the umbilical region and promoted by the presence of a hernia, involved the following organs: ileum (14 cases), jejunum (two cases), spleen (two cases), transverse colon (one case), cecum (one case), and sigmoid (one case). Death occurred in three cases, between days 2 and 11. Eleven patients had temporary ileostomy or colostomy. Associated complications were abdominal wall cellulitis, necrotizing fasciitis, thrombophlebitis, lung collection, and late subobstructive syndrome. Visceral perforation during liposuction, a severe and sometimes fatal complication with late and difficult diagnosis, is not often reported. Careful technique, particularly if an umbilical approach is used, should avoid this dramatic complication. Therapeutic, IV.

Can Postoperative Nutrition be Favourably Maintained by Oral Diet in Patients with Emergency Temporary Ileostomy? A Tertiary Hospital Based Study.

Temporary ileostomy is an emergency procedure performed in cases having septic peritonitis in presence of perforation or obstruction or gangrene of small intestine. These patients usually suffer from gross malnutrition following surgery. To measure nutritional status of patients with emergency temporary ileostomy and to determine whether their postoperative nutrition can be favourably maintained by oral diet alone. Sixty patients were enrolled for the study on the basis of inclusion and exclusion criteria during the study period from January 2012 to December 2013. Oral feeding was started as soon as ileostomy started functioning and patients expressed hunger, about 48-72 hours postoperatively. An individualized diet chart was formulated for each patient using Harris Benedict Equation. Nutritional assessment was done on 1) 1(st) day of oral feeding, 2) After 7 days of oral feeding, 3). After three months of oral feeding. Nutritional parameters (anthropometric, biochemical) employed were tabulated and statistically analysed with SPSS v 17, Chicago. Out of 60 patients, 36 males and 24 females were enrolled in the study. The patients were in the age group of 20-60 years with a mean age of 45 years. After 7 days of oral nutrition the nutritional status deteriorated with a significant decrease in body weight (p<0.001) and serum haemoglobin (p <0.001). However, at the end of the study, the patients had their nutritional status restored satisfactorily with normalization of basic parameters like bodyweight, haemoglobin and serum albumin (p<0.001). Proper dietary advice and oral nutrition were found to be sufficient for gradual restoration and maintenance of satisfactory nutritional status in the postoperative period.

Eculizumab Treatment Improves Outcomes of Pregnancy in Patients with Paroxysmal Nocturnal Hemoglobinuria

Eculizumab Treatment Improves Outcomes of Pregnancy in Patients with Paroxysmal Nocturnal Hemoglobinuria

Anterior Resection Syndrome—A Risk Factor Analysis

BackgroundEvacuatory dysfunction after distal colorectal resection varies from incontinence to obstructed defaecation and is termed anterior resection syndrome. The aim of this study was to identify risk factors for the development of anterior resection syndrome. MethodsAll anterior resections undertaken at Auckland Hospital from 2002 to 2012 were retrospectively evaluated. An assortment of patient and peri-operative variables were recorded. Cases were stratified by the occurrence of anterior resection syndrome symptoms from 1 to 5 years post-operatively. ResultsA total of 277 patients were identified. Prevalence of anterior resection syndrome decreased progressively from 61 % at 1 year to 43 % at 5 years. Univariate analysis identified anastomotic height, surgeon, pT stage, procedure year and temporary diversion ileostomy as recurring significant correlates (p < 0.05). Logistic regression identified lower anastomotic height (odds ratio (OR) 2.11, 95 % confidence interval (CI) 1.05–4.27; p = 0.04) and obstructive presenting symptoms (OR 6.71, 95 % CI 1.00–44.80; p = 0.05) as independent predictors at 1 and 2 years, respectively. Post-operative chemotherapy was a predictor at 1 year (OR 1.93, 95 % CI 1.04–3.57; p = 0.03). Temporary diverting ileostomy was an independent predictor at 2 (OR 2.49, 95 % CI 1.04–5.95; p = 0.04), 3 (OR 4.17, 95 % CI 1.04–16.78; p = 0.04), 4 (OR 8.05, 95 % CI 1.21–53.6; p = 0.03), and 5 years (OR 49.60, 95 % CI 2.17–1134.71; p = 0.02) after adjusting for anastomotic height. ConclusionsAnastomotic height, post-operative chemotherapy and obstructive presenting symptoms were independent predictors at 1 and 2 years. Temporary diversion ileostomy was an independent predictor for the occurrence of anterior resection syndrome at 2, 3, 4 and 5 years even after correcting for anastomotic height. Prospective assessment is required to facilitate more accurate risk factor analysis.

PO-0524 Neonatal Systemic Candidiasis: A 12-year Study

Background Invasive Candida species have become a common cause of late-onset sepsis in neonatal intensive care units. Significant risk factors include low birth weight, exposure to broad spectrum antibiotics, parenteral nutrition, lipid emulsion, central venous catheter and abdominal surgery. Material and method We performed a retrospective study over a period of 12 years (Jan 2002 to Jan 2014) in our hospital NICU. The aims of this study were to investigate the incidence of the systemic candidiasis, mortality rate, the implicated Candida strains, specific risk factors and antifungal treatment. Results All of our cases were outpatients. The average incidence of systemic candidiasis was 5.8% (111 cases) with a specific average mortality of 28%. In 96 cases (86.5%) not albicans Candida species were identified. 83 patients (74.7%) underwent abdominal surgery interventions; from these 42 had malformations of digestive tract and 16 presented abdominal wall defects. 12 operated patients remained with temporary ileostomies, 5 had colostomies and 4 cases associated short bowel syndrome. Also 23 (20.7%) were premature with birth weight under 1500 g; 25 cases presented also a bacterial sepsis. The antifungal therapy consisted of Fluconazol iv during the period 2002–2006; starting 2007 we used mainly Caspofungin iv. Also, starting 2011 all the patients with risk factors received oral prophylaxis with Nistatin. Conclusions Neonatal sepsis with Candida species still has a high rate of mortality and morbidity mainly linked of specific risk factors and other severe illnesses. Thereof more randomised trials regarding both oral and iv prophylaxis are needed.

Efficacy and safety of the C-Qur™ Film Adhesion Barrier for the prevention of surgical adhesions (CLIPEUS Trial): study protocol for a randomized controlled trial.

BackgroundAdhesions develop in over 90% of patients after intra-abdominal surgery. Adhesion barriers are rarely used despite the high morbidity caused by intra-abdominal adhesions. Only one of the currently available adhesion barriers has demonstrated consistent evidence for reducing adhesions in visceral surgery. This agent has limitations through poor handling characteristics because it is sticky on both sides. C-Qur™ Film is a novel thin film adhesion barrier and it is sticky on only one side, resulting in better handling characteristics. The objective of this study is to assess efficacy and safety of C-Qur™ Film to decrease the incidence of adhesions after colorectal surgery.Methods/DesignThis is a prospective, investigator initiated, randomized, double-blinded, multicenter trial. Eligible patients undergoing colorectal resection requiring temporary loop ileostomy or loop/split colostomy by laparotomy or hand assisted laparoscopy will be included in the trial. Before closure, patients are randomized 1:1 to either the treatment arm (C-Qur™ Film) or control arm (no adhesion barrier). Patients will return 8 to 16 weeks post-colorectal resection for take down of their ostomy. During ostomy takedown, adhesions will be evaluated for incidence, extent, and severity. The primary outcome evaluation will be assessment of adhesions to the incision site. It is hypothesized that the use of C-Qur™ Film underneath the primary incision reduces the incidence of adhesion at the incision by 30%. To demonstrate 30% reduction in the incidence of adhesions, a sample size of 84 patients (32 + 10 per group (25% drop out)) is required (two-sided test, α = 0.05, 80% power).DiscussionResults of this study add to the evidence on the use of anti-adhesive barriers in open and laparoscopic ‘hand-assisted’ colorectal surgery. We chose incidence of adhesions to the incision site as primary outcome measure since clinical outcomes such as small bowel obstruction, secondary infertility and adhesiolysis related complications are considered multifactorial and difficult to interpret. Incidence of adhesions at repeat surgery is believed to be the most valuable surrogate endpoint for clinically relevant adhesion prevention, since small bowel obstruction and adhesiolysis at repeat surgery are not likely to occur when complete adhesion reduction in a patient is accomplished.Trial registrationClinicalTrials.gov Identifier NCT01872650, registration date 6 June 2013.

Temporary percutaneous ileostomy for faecal diversion after intestinal resection for acute abdomen in elderly: How to avoid the conventional loop ileostomy

Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colocolic or colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery, as faecal diversion in low colorectal anastomosis. Now we report our experience with the TPI in protecting colocolic and colorectal anastomosis in urgency in elderly.From January 2012 to June 2014, 45 patients underwent urgent surgical procedures for acute abdomen with colonic and/or rectal resections and colocolic or colorectal anastomosis with faecal diversion by TPI. Nineteen out of 45 patients were older than 70. Four low colorectal anastomoses, 10 intra-peritoneal colorectal anastomosis and 4 colocolic anastomosis were performed.Neither intra-operative complications nor post-operative deaths were observed. None of the 19 patients treated had evidence of clinical or radiological leakage of the anastomosis. Post-operative complications occurred in 7 patients and nobody required re-intervention. No intestinal obstruction was reported in the early (30 days) post-operative period.The TPI seems to be a valid alternative to standard ileostomy, ensuring an optimal faecal diversion both in elective surgery and in urgency. The TPI also ensures less patient discomfort and it can be easily removed without surgery, unlike the CLI. The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of this new technique, especially in elderly.