Terminal Ileostomy Research Articles

Early Surgery for the Treatment of Toxic Megacolon

Background: Toxic megacolon (TM) is a potentially lethal complication of idiopathic inflammatory bowel disease or infectious colitis, characterized by total or segmental non-obstructive colonic dilatation of at least 6 cm associated with systemic toxicity. Methods: Overall, 15 patients had surgery for TM at our institutions over a 10-year period (1993–2003). In contrast to other studies that used medical therapy as the first-line treatment for TM, in our experience all patients underwent surgery as soon as possible after diagnosis of TM (early surgery). Results: 14 patients underwent subtotal colectomy with terminal ileostomy, while for 1 patient the surgical procedure consisted only in a decompressive cecostomy. Two major complications occurred consisting of 2 cases of multiple organ failure leading to death. No other major complications or deaths were reported. The overall mortality rate was therefore 13% (0% in patients <65 years). Conclusion: This study shows that early surgery has the potential to represent a valid therapeutic strategy for patients with TM resulting in a small number of TM-related complications and deaths. Elderly patients seem to have a high risk of multiple organ dysfunction syndrome and post-surgical death.

Surgery for Pediatric Patients With Chronic Intestinal Pseudo‐Obstruction Syndrome

Surgery for Pediatric Patients With Chronic Intestinal Pseudo‐Obstruction Syndrome

Poliposis familiar: Alternativas terapéuticas y estudio de los familiares

To reduce the mortality associated to Familial Adenomatous Polyposis (FAP), screening of close relatives of patients with the disease is crucial. To analyze the results of the surgical treatment of patients with FAP, and to evaluate the family screening. Clinical records of patients operated in our institution since 1977, were reviewed analyzing surgical and pathological results, and follow up. In their family members, we evaluated and analyzed the performance of screening tests, former surgeries, history of disease-related cancer and mortality, all due to FAP. Between January 1977 and August 2002, 15 patients were operated on. Of these, only 33% consulted on the setting of a familial screening. A proctocolectomy and terminal ileostomy was performed in 27% of patients; 20% had a proctocolectomy and ileal pouch, and 53% underwent a total colectomy with ileo-rectal anastomosis. Morbidity and mortality were 7% and 0%, respectively. Twenty percent had a colorectal cancer. During a median of 68 months follow-up, the disease-related survival was 92%; no cancer of the rectal stump was detected. Of the 122 family members identified, only 33% with clear indication of screening underwent a colonoscopy. Twenty-nine percent had a confirmed FAP and were operated: in 61% of them a colorectal cancer was found, and 91% of these died. The results of the surgical treatment of FAP are satisfactory. Nevertheless, family screening should be improved to reduce the high rates of mortality revealed in the study of other family members.

Dietary peptides increase endogenous amino acid losses from the gut in adults

Accurate estimates of endogenous ileal total nitrogen and amino acid flows are necessary to ascertain true dietary amino acid digestibility coefficients and for the factorial estimation of dietary amino acid requirements. The objective was to ascertain endogenous amino acid losses from the small bowel in human subjects consuming a protein-free diet or a diet with enzyme-hydrolyzed casein (EHC; MW <5000) as the sole source of nitrogen. The subjects were 8 men and women with terminal ileum ileostomies after ulcerative colitis who consumed the protein-free and EHC-based diets in a crossover design. Each subject received each test diet in single meals followed by 2 consecutive 9-h total collections of digesta. Digesta samples for the EHC treatment were centrifuged and ultrafiltered (10 000 MW cutoff), with the precipitate-plus-retentate fraction (>10 000 MW) providing a measurement of endogenous ileal amino acids. The mean endogenous flows for most of the amino acids and nitrogen were significantly (P < 0.05) higher when determined with the EHC-based diet than with the protein-free diet. Mean (n = 8) endogenous ileal nitrogen flows were 2061 and 4233 mug/g dry matter intake for the protein-free and EHC-based diets, respectively. The traditional protein-free method underestimates endogenous ileal amino acid loss in adults.

Adenocarcinoma After Ileoanal Anastomosis for Familial Adenomatous Polyposis: Review of Risk Factors and Current Surveillance Apropos of A Case

Restorative proctocolectomy has become the most common surgical option for familial adenomatous polyposis (FAP) patients, based on the premise that it provides good functional results and reduces colorectal cancer risk. But several adenomas may develop in the pouch mucosa over the years, and even cancer at the anastomosis or in the pouch mucosa has been reported rarely. This article aims to describe a case of pouch cancer after restorative proctocolectomy for FAP, reviewing the possible causes of this unfortunate outcome. A 40-year-old man started presenting with fecal blood loss 12 years after restorative proctocolectomy with mucosectomy and hand-sewn anastomosis for FAP. Proctologic examination revealed an elevated mass 3 cm from the anal margin, which biopsy determined to be a mucinous adenocarcinoma. The patient underwent pouch excision and terminal ileostomy. Histologic analysis showed a 2.2 cm mucinous adenocarcinoma between the ileal and anal mucosa (T2N0Mx) and multiple tubular microadenomas in the ileal pouch. The present case and the data presented here suggest that restorative proctocolectomy is not a "cancer-free" alternative to ileorectal anastomosis, because it does not remove the risk of metachronous intestinal neoplasia. Although the long-term risk of malignancy is not known, lifelong follow-up seems to be necessary after restorative proctocolectomy. Current recommendations for pouch surveillance are presented.

Gangrene of the right colon after blast injury caused by abdominal gunshot wounds

To present a patient with an indirect secondary non-perforating blast injury of the right colon following abdominal gunshot injury, which led to necrosis and the right colon gangrene, and was surgically managed. A 26-year-old male was shot in the abdomen by four projectiles causing the secondary indirect blast injury of the right colon that turned into gangrene after 24 hours. Two days after admission, laparotomy was performed, but the primary anastomosis was not done because of the stomach and pancreatic injury, and the resection of the colon with terminal ileostomy was done instead. Three months later, the reconstruction of the colon was performed using ileocolotransverso-terminolatetral anastomosis. Secondary blast injuries should be anticipated in gunshot injuries, and could be expected to any organs, particularly the air filled ones.

Small Bowel Obstruction by the Silicone Tube of the Gastric Band

A wide range of operations are used today for morbid obesity. Adjustable gastric banding (AGB) is one of the most widespread. Numerous complications after AGB are known, namely gastric perforation, band slippage, penetration of the band into stomach, port disconnection, port-site infection, etc. The authors present a case of small bowel obstruction caused by the intra-abdominal silicone tube of the gastric band in a woman with AGB performed 9 years before, with a very good result and considerable weight loss. She was operated as an emergency, and part of the terminal ileum was found incarcerated around and between the silicone tube and the anterior abdominal wall. Bowel resection for intestinal necrosis, with terminal ileostomy, was performed, followed 1 month later by an end-to-end ileo-ileal anastomosis. The patient recovered without sequelae.

Reasons for creation of permanent ileostomy for the management of idiopathic chronic constipation.

The aim of the present study was to examine the reasons for initiation of end ileostomy for management of intractable constipation over the last 35 years. A total of 62 patients with intractable constipation, on whom an end ileostomy was created during the period from 1966 to 2001, were recorded. The incidence of initiating a terminal ileostomy as a further surgical intervention to the total number of managed patients in examined studies varied from 2 to 25%. Preoperative unevaluated anal and rectal abnormalities formed the highest proportion compared with other reasons (65%, 40/62). A better understanding of the functional colonic and anorectal abnormalities may facilitate changes in surgical therapy.

Colic Perforation as a Complication of Tension-Free Vaginal Tape Procedure

The tension-free vaginal tape (TVT) procedure was first described as a minimally invasive surgical technique for the treatment of female stress urinary incontinence. The most common complications associated with TVT are bladder perforations and postoperative voiding difficulties. We report a case of bowel perforation occurring during the insertion of TVT. CASE REPORT A 52-year-old nonobese woman with a history of appendectomy, open pelvic retroperitoneal ureterolithotomy and laparoscopic fallopian tube section presented with genuine stress urinary incontinence without pelvic prolapse. Urodynamic study demonstrated normal urethral closure pressure and no bladder instability. TVT placement was elected. The patient was placed under general anesthesia and the TVT procedure was performed. Perioperatively bladder perforation was observed on the left side, indicating a change in the position of the trocar. On postoperative day 1 the patient had acute general abdominal pain with fever. X-ray of the abdomen showed a pneumoperitoneum, which indicated urgent laparotomy exploration (fig. 1). At laparotomy we discovered general stercoral peritonitis, with the right tape penetrating the pelvic peritoneum and transfixing the cecum. The left tape was observed penetrating the right third segment of the transverse colon. We noted that the cecum and colon had a massive adhesion to the bladder, retropubic space and pelvic peritoneum. The tape was cut in its intraperitoneal portion and then totally removed through the vaginal incision of the TVT procedure. Right hemicolectomy with a terminal ileostomy was done. Postoperatively the patient recovered with antibiotic management and was discharged home on day 6 after laparotomy. Three months later intestinal continuity was successfully established. At followup visits the patient has had a recurrence of the stress incontinence without urge incontinence but she has refused further surgical repair. DISCUSSION

Operationsstandards bei Colitus ulcerosa

The severely ill patient with ulcerative colitis is routinely operated with a colectomy and ileostomy, the rectum is left behind. For definite treatment there are in principal 4 options: proctectomy or proctocolectomy with an ileal pouch anal anastomosis which seems to be the most frequently used alternative today. A majority of patients will have a good quality of life but there are problems with residual anal rectal mucosa, sexual dysfunction, mainly female infertility. The ileorectal anastomosis in an alternative that is reconsidered. It is a relatively minor operation with probably less risk of sexual dysfunction with a good functional outcome provided the rectum is not inflamed. Still there are a few patients for whom the traditional proctocolectomy with a terminal ileostomy might be a good option. There is also in certain situations still an indication for the continent ileostomy.

Ileoanal pouch as rectal substitute

The ileoanal pouch procedure (IAPP) was the most remarkable breakthrough in the surgical therapy of ulcerative colitis (UC) and familial adenomatous polyposis (FAP) in the last 20 years. The underlying disease is under control, the function preserved and the quality of life markedly improved. Alternative procedures (terminal ileostomy, ileorectal anastomosis) are only indicated in special cases. In the last 16 years we have operated on 662 patients (n = 493 UC; n = 169 FAP) with an ileoanal J-pouch, short rectal cuff, complete mucosectomy and hand-sewn anastomosis. Normally there is a good function for UC and FAP patients after IAPP. Surgical experience, technical modifications concerning the pouch design and the pouch-anal anastomosis, and a differentiated indication lead to a further improvement of these complex procedures with consecutive reduction of complications. Specific complications concerned mainly the pouch-anal anastomosis (fistulas, abscesses, consecutive stenosis) and inflammation of the pouch mucosa (pouchitis). A multivariate analysis showed, that increasing experience of the specialized center is a significant factor reducing inflammatory problems at the anastomosis. The cumulative incidence of pouchitis was 29%. In general there is no problem in successful treatment. But patients with chronic pouchitis are a problematic group (6.2%). Chronic pouchitis is difficult to treat. It is likely that there exists an inflammation dysplasia carcinoma sequence for the ileal pouch mucosa, analogous to the colorectum. Recently we diagnosed the first case of a real ileum pouch carcinoma with associated epithelial dysplasias following chronic pouchitis. Therefore patients with chronic pouchitis must be followed up by endoscopy and random biopsies in a surveillance program. Patients with UC and FAP can gain the life quality of healthy controls, if postoperative complications can be avoided or treated successfully. For the further development of the procedure and the individual long-term success a qualified follow-up and therapy of complications is essential. Both can be carried out only by a specialized center.

Creation of a neoabdominal wall to facilitate emergency placement of a terminal ileostomy in a morbidly obese patient

Morbid obesity of the abdominal area creates difficulty with creation of a Brooke ileostomy because of thickened, foreshortened mesentery of the terminal ileum, limitation to mobilization, and thickness of the abdominal wall through which the terminal ileum must be placed in the stoma, causing undue tension on the vasculature with a higher frequency of retraction and necrosis. Such a problem may be ameliorated by performing a subcutaneous lipectomy about the stoma and creating a thinned neoabdominal wall to facilitate the creation of a temporary Brooke stoma. Despite initial difficulty with stoma appliances, this operative technique in selected obese patients outweighs the limited complications that may be encountered.

Water and electrolyte balance after ileal J pouch-anal anastomosis in ulcerative colitis and familial adenomatous polyposis.

The water and electrolyte balance was studied in 31 patients with ulcerative colitis (UC) and 22 with familial adenomatous polyposis (FAP) who underwent staged surgery involving colectomy and ileal J pouch-anal anastomosis (IAA), preoperatively, after terminal ileostomy, after high ileostomy, and after ileostomy closure. Serum electrolytes did not differ between each surgical stage. After terminal or high ileostomy, daily urine volume and urinary sodium loss was significantly lower, and daily fecal weight and fecal sodium loss was significantly higher than preoperatively. After ileostomy closure, urinary and fecal sodium loss became closer to preoperative value. Daily urinary potassium loss was significantly higher and fecal loss was lower after terminal and high ileostomy than preoperatively and did not show a significant change after ileostomy closure. The urinary sodium to potassium ratio after ileostomy closure was lower than preoperatively, but was higher than that after terminal and high ileostomy. Plasma aldosterone and renin levels were only significantly increased after high ileostomy. These findings indicate that high or terminal ileostomy caused chronic dehydration, which was compensated for by activation of the renin-aldosterone axis, while the water and electrolyte balance became closer to normal after ileostomy closure following ileoanal anastomosis.

Rapid cholesterol nucleation time and cholesterol gall stone formation after subtotal or total colectomy in humans.

Changes in biliary lipid composition, pH, ionised calcium, total and unconjugated bilirubin, and cholesterol nucleation time of gall bladder bile samples were examined in six patients who had undergone subtotal or total colectomy between five months and seven years previously, and values were compared with those in control patients with no gall stones. The colectomy group mainly comprised patients with ulcerative colitis and familial adenomatosis coli, in whom only a short length of the terminal ileum (mean (SEM) 2.25 (0.57) cm) had been resected. The reconstruction procedures were ileoanal anastomosis in two patients, terminal ileostomy in two, ileorectal anastomosis in one, and J shaped ileal pouch-anal anastomosis in one patient. The distributions of age, sex, and relative body weight were similar in the two groups. The gall bladder bile was lithogenic in the post colectomy group--these patients had a significantly increased cholesterol saturation index (p < 0.01) and rapid cholesterol nucleation time (p < 0.05) compared with the control group. A significant increase in the molar percentage of cholesterol and a decrease in that of total bile acid associated with significantly decreased secondary bile acids (p < 0.05) were observed in the post colectomy group. Gall stones formed in two of six patients after colectomy were cholesterol stones containing more than 80% cholesterol by dry weight. Total and unconjugated bilirubin, pH, and ionised calcium values were similar in the two groups. The results indicate that after total or subtotal colectomy the composition of gall bladder bile increases the risk of cholesterol gall stone formation.

Amino acid losses in ileostomy fluid on a protein-free diet

The contribution of losses via the gastrointestinal tract to maintenance amino acid requirements was assessed by collecting the ileostomy fluid of volunteers given a protein-free diet for 5 d. The subjects were eight adult men and women with terminal ileum ileostomies after ulcerative colitis. Four consecutive 24-h collections of both digesta and urine were made. On the last 2 d an antibiotic was given that suppressed microbial activity in the digesta and slightly reduced ileostomy outflow. Mean daily amino acid excretion in ileostomy fluid ranged from 32 mg/d for methionine to approximately 330 mg/d for aspartate and glutamate. These losses were compared with current international estimates of amino acid requirements. For most essential amino acids gastrointestinal losses accounted for 14-33% of daily maintenance requirements but for threonine the contribution was 61%.

Treatment of Crohn's disease recurrence after ileoanal anastomosis by azathioprine

Ileoanal anastomosis is a surgical procedure performed in patients with ulcerative colitis. In a small number of patients operated on for ulcerative colitis, Crohn's disease occurs in the reservoir, mimicking pouchitis, and may lead to pouch excision and to a permanent terminal ileostomy. Two patients with recurrent Crohn's disease in the reservoir after ileoanal anastomosis were treated with azathioprine for 18 and 24 months, respectively. Azathioprine induced a complete clinical and endoscopic remission. These two observations suggested that immunosuppressive drugs were a good option for permanent ileostomy in cases of recurrence of Crohn's disease in the reservoir after ileoanal anastomosis.

Fecal and stomal bile acid composition after ileostomy or ileoanal anastomosis in patients with chronic ulcerative colitis and adenomatosis coli

Fecal bile acids (FBA) were analyzed by gas-liquid chromatography in 29 patients [17 with ulcerative colitis (UC) and 12 with adenomatosis coli (AC)] and 5 healthy volunteers. Seven UC and 9 AC patients had undergone total colectomy and J-shaped ileal pouch-anal anastomosis (JAA). The mean daily FBA output was similar for JAA and terminal ileostomy patients (~370 mg/day), and was about 1.5 times that of healthy Japanese volunteers (~235 mg/day). The output of unconjugated bile acids, secondary bile acids, and 7-dehydroxylated bile acid was higher in JAA patients with UC than in terminal ileostomy patients, but there were no significant differences between the groups. The total fecal bacterial count in JAA patients was 10 times that in terminal ileostomy patients but was 1/10 of that in healthy volunteers. In patients with defunctioning high ileostomy, FBA output increased markedly (maximum, 3054 mg/day), and serum cholesterol levels were also significantly lower (P < 0.05). These results suggest that after JAA the bile acid metabolism and fecal bacterial flora undergo more normalization than after terminal ileostomy.

Fecal and stomal bile acid composition after ileostomy or ileoanal anastomosis in patients with chronic ulcerative colitis and adenomatosis coli

Fecal bile acids (FBA) were analyzed by gas-liquid chromatography in 29 patients [17 with ulcerative colitis (UC) and 12 with adenomatosis coli (AC)] and 5 healthy volunteers. Seven UC and 9 AC patients had undergone total colectomy and J-shaped ileal pouch-anal anastomosis (JAA). The mean daily FBA output was similar for JAA and terminal ileostomy patients (approximately 370 mg/day), and was about 1.5 times that of healthy Japanese volunteers (approximately 235 mg/day). The output of unconjugated bile acids, secondary bile acids, and 7-dehydroxylated bile acid was higher in JAA patients with UC than in terminal ileostomy patients, but there were no significant differences between the groups. The total fecal bacterial count in JAA patients was 10 times that in terminal ileostomy patients but was 1/10 of that in healthy volunteers. In patients with defunctioning high ileostomy, FBA output increased markedly (maximum, 3054 mg/day), and serum cholesterol levels were also significantly lower (P less than 0.05). These results suggest that after JAA the bile acid metabolism and fecal bacterial flora undergo more normalization than after terminal ileostomy. (Gastroenterology 1992 Apr;102(4 Pt 1):1278-88)

The glycoconjugate content of human faeces and ileostomy effluents

Normal human faeces and effluent from terminal ileostomies in patients with ulcerative colitis were collected. The results for ileostomy effluent given as g/24 h (mean ± SD; n = 12) were as follows: wet weight, 897 ± 120; total dry weight, 84 ± 8; non-diffusible dry weight 46 ± 5. The corresponding results for faeces ( n = 6) were 104 ± 24; 26 ± 6; 19 ± 5. Whereas approximately 15% of the total dry weight of ileostomy effluent appeared to consist of mucin-derived material, only trace amounts of such material could be detected in faeces.

Effect of faecal stream diversion on recurrence of Crohn's disease in the neoterminal ileum

Aphthous lesions recur in the neoterminal ileum within the first few months after curative resection of the distal ileum in patients with Crohn's disease. These lesions do not originate from microscopic disease that is already present at the time of surgery. To investigate the importance of faecal stream in the pathogenesis of recurrent Crohn's lesions, we have studied 5 patients with Crohn's disease who had ileal resection. After curative resection and ileocolonic anastomosis, a diverting terminal ileostomy was constructed 25-35 cm proximal to the anastomosis thereby excluding the neoterminal ileum, the anastomosis, and the colon from intestinal transit. After six months of exclusion, endoscopy of the ileocolon was undertaken and biopsy specimens were taken. Transit was then restored. Six months after reanastomosis further biopsy specimens were taken. These patients were compared with a control group of 75 patients with Crohn's disaease who underwent a one-step ileal resection and ileocolonic anastomosis. None of the 5 patients had endoscopic lesions in the neoterminal ileum after six months of exclusion and biopsies did not show inflammatory changes characteristic of Crohn's disease. By contrast, 53 of 75 patients with one-step surgery had endoscopic recurrence in the neoterminal ileum within six months of surgery. All 5 patients had an important recurrence of disease, both endoscopically and histologically, at ileocolonoscopy six months after reanastomosis. Our findings strongly support the view that recurrence of Crohn's disease in the neoterminal ileum after curative ileal resection is dependent on faecal stream.