Terminal Stoma Research Articles

Хірургічне лікування природженої аноректальної вади розвитку з ректовезикальною норицею в хлопчиків

Congenital rectovesical fistula (RVF) is the most complex variant of anorectal malformations (ARM) in boys, characterized by a fistula connecting the rectum with the bladder. Purpose - to evaluate the results of surgical correction of RVF in children, using a differentiated approach to the diagnosis of this defect, depending on the anatomical options, the clinical course of associated defects, and, based on this, to develop the main tactical requirements for the treatment of this complex congenital ARM in children. Materials and methods. The study included 9 boys: 7 - RVF without pouch colon and 2 - RVF with congenital pouch colon, which accounted for 5.8% of all treated anorectal anomalies (n=154). Results. In patients with RVF without pouch colon: a double-stem disconnecting colostomy was performed in 3 (33.3%) and a double-stem loop colostomy in 4 (44.4%) boys. In children with RVF and pouch colon: a longitudinal, narrowing, stapler coloplasty of the large intestinal "pouch" was performed, with removal of the terminal stoma (n=1); formation of a double-stem disconnecting stoma without separation of the RVF, and at the II stage - elimination of the RVF, removal of the large intestinal «bag» and preservation of the ileostomy - as a permanent, lifelong stoma (n=1). In 7 (100%) patients with RVF without pouch colon at the II stage, abdomino-perineal posterosagittal anorectoplasty with separation of RVF was performed (n=5). At the III stage, 5 patients with RVF without a pouch colon underwent local access stoma closure. At the stages of primary correction of RVF 55.6% (n=5) of children had coloproctological complications. Conclusions. The use of a differentiated approach to diagnosis and methods of anorectoplasty, as well as the use of a complex of rehabilitation treatment in patients with RVF without a pouch colon made it possible to obtain good results in 50% and satisfactory results in 50% of children. Congenital pouch colon - a significant expansion of part or the entire colon already in the fetus, makes it possible to suspect and diagnose this defect in the prenatal period, and to carry out delivery and surgical correction in a specialized perinatal center. The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of the institution mentioned in the work. Informed consent of the patients was obtained for the research. No conflict of interests was declared by the author.

Challenges in restoring bowel continuity: An analysis of 91 patients undergoing a reversal procedure

Introduction: The restoration of bowel continuity is associated with significant postoperative morbidity. Aim: The aim of the study was to report the outcomes of restoring intestinal continuity in a large patient cohort. Material and methods: A retrospective analysis was conducted on 91 patients with terminal stoma who were qualified for restoration of GI tract continuity between January 2015 and March 2020. The following demographic and clinical characteristics were analyzed: age, gender, BMI, comorbidities, indication for stoma creation, operative time, the need for blood replacement, the site and type of the anastomosis, and complication and mortality rates. Results: The study group was comprised of 40 women (44%) and 51 men (56%). The mean BMI was 26.8 ±4.9 kg/m2. Only 29.7% of the patients (n = 27) were at normal weight (BMI: 18.5–24.9) and only 11% (n = 10) did not suffer from any comorbidities. The most common indications for index surgery were complicated diverticulitis (37.4%) and colorectal cancer (21.9%). The stapled technique was used in the majority of patients (n = 79, 87%). The mean operative time was 191.7 ±71.4 min. Nine patients (9.9%) required blood replacement peri- or postoperatively, whereas 3 patients (3.3%) required intensive care unit admission. The overall surgical complication rate was 36.2% (n = 33) and the mortality rate was 1.1% (n = 1). Discussion: Restoration of bowel continuity is quite a demanding and complex procedure and thus should be performed by an experienced surgical team. In the majority of patients, the complication rate represents only minor complications. The morbidity and mortality rates are acceptable and comparable to other publications.

Cholecystocolonic Fistula. Case Report

A cholecystocolonic fistula is a rare complication of gallbladder stone disease. Its incidence is 0.06% to 0.14% and it usually presents asymptomatically in elderly patients. Currently there is no imaging study that is proven to be superior to the others for its adequate preoperative diagnosis. We present the case of a patient with nonspecific symptoms in which 3 different imaging studies evidenced an abnormal communication between the gallbladder and the hepatic flexure of the colon, the patient underwent cholecystectomy and intestinal resection with terminal stoma and subsequent recanalization without complications.

Principles and parallels of prevention and repair of parastomal hernia with meshes

After formation of a permanent terminal stoma by enterostomy, parastomal hernia (PSH) occurs in up to 80% of cases and leads to a wide variety of symptoms and complications with a high rate of emergency operations due to incarceration (ca. 15%). Consequently, greater consideration should be given to PSH prevention even as early as the time of enterostomy and generously applied indications for elective repair of manifest PSH. The aim of this article is to summarize and evaluate the current evidence for PSH repair and prevention. Poor postoperative results after attempted repair of manifest PSH with slit meshes in different layers of the abdominal wall shift the focus onto stoma lateralization (sandwich and Sugarbaker techniques) or 3‑dimensional tunnel-shaped implants with meshes to cover the stomal edges. To date, the best strategy for PSH prevention has still not been defined and techniques with slit meshes show different results. Nevertheless, 10 prospective randomized trials, meta-analyses, aCochrane review and guidelines from the European Hernia Society (EHS) about various slit-mesh devices in sublay, onlay and intraperitoneal positions confirmed significantly reduced rates of PSH after mesh augmentation compared to conventionally sutured enterostomy without morbidity associated with the implanted material. Despite the positive data situation PSH prevention is seldom performed in daily practice, which is due to uncertainty surrounding the most suitable surgical strategy, the necessity to spend additional time at the end of ademanding operation, the aversion to implanting meshes into acontaminated operative field and the lack of remuneration of preventive surgical procedures. Future trials should, therefore, no longer compare standard enterostomy techniques with one prevention method in general but should have anew focus on techniques providing adequate results in PSH repair (Sugarbaker, sandwich and 3‑Dtunnel meshes), probe the advantages and evaluate the differences in outcome between these strategies.

Stomal construction: Technical tricks for difficult situations, prevention and treatment of post-operative complications

The creation of a digestive stoma, whether it is a lateral stoma or a terminal stoma, is an essential gesture in colorectal surgery, but that may result in post-operative complications in 35% of patients. Surgeons are aware of the situations at the origin of complications, although there is little factual data in the literature to discriminate them. They are related to patient-specific factors (obesity, cirrhosis, portal hypertension) or to the underlying pathology (colon obstruction) or the conditions under which the intervention is performed (emergency). The aim of this review is to describe these different situations and the data from the literature that may allow reduction of the risk of an unsatisfactory or even complicated stoma.

Current indications for the Hartmann procedure

The Hartmann procedure is used in the case of left-sided colonic disease, especially in the setting of emergency where intraoperative conditions contraindicate completion of an anastomosis. This procedure has been initially described for the management of colorectal cancer and is based on a sigmoïdectomy without restoration of intestinal continuity, including a left-sided iliac terminal stoma and closure of the rectal stump. Both procedure and underlying risk factors explain high rates of mortality and morbidity, around 15 and 50% respectively, and a low overall rate of subsequent restoration of internal continuity, less than 50%. The purpose of this review was to evaluate the value of the Hartmann procedure and its equivalents in colonic surgery, according to its indications: colorectal cancer, peritonitis from diverticular disease, anastomotic complications, ischemic colitis, left-sided colonic volvulus and abdominal trauma.

Hirschsprung's disease in children with Mowat-Wilson syndrome.

Hirschsprung's disease (HSCR) is cited as a classical component in the constellation of features found in children with Mowat-Wilson syndrome (MWS), which is caused by a mutation of the ZEB2 gene. The prevalence and phenotype of HSCR in those with MWS has yet to be determined. Similarly, it is not known if children with MWS who undergo a curative pull-through operation experience similar functional outcomes. We aimed to delineate the clinical features of those with MWS and HSCR and to determine if these patients experience unfavourable outcomes following pull-through surgery. A systematic review of the literature using the key search term "Mowat Wilson" was performed using three online databases. Clinical data were collected on all patients with a diagnosis of MWS confirmed by ZEB2 analysis. Data regarding bowel function in children with biopsy-proven HSCR were recorded where available. Statistical analysis was performed using SPSS (v. 20.0). Fifty-two articles were reviewed in the final analysis, incorporating data on 256 patients with a diagnosis of MWS. HSCR was diagnosed in 111 patients (43.4%). Males with HSCR had a slightly increased risk of genital tract anomalies (e.g. hypospadias) compared to those without HSCR (RR 1.79, p = 0.05). Data pertaining to disease phenotype and functional outcome were only available on 42 and 13 patients, respectively. Rectosigmoid aganglionosis was the most common sub-type of HSCR, being described 26 patients (66.7%), albeit accounting for a lower proportion than would normally be expected in an HSCR population. Only two patients (15.4%) were described as having normal bowel function at follow-up with the remainder having terminal stomas, or experiencing troublesome persistent bowel symptoms and recurrent enterocolitis. Hirschsprung's disease is present in approximately 45% of patients diagnosed with MWS. Although there is a relative lack of data available on the clinical phenotype of HSCR in this group and their functional outcome following pull-through operation, our data suggest an increased prevalence of long-segment aganglionosis and an increased risk of clinically significant persistent bowel symptoms following pull-through surgery, in many cases necessitating terminal stoma formation.

Deviationsstoma

The deviation of feces is a very old and still largely applied technique used by general surgeons. Indications divide into elective and emergency operations. Among the elective cases, rectal carcinoma, extensive perianal fistulae and neurogenic disorders of the distal colon are the most common indications. In an emergency situation causes such as extensive peritonitis (e.g. due to anastomotic leakage) and extensive trauma to the pelvis/rectum quite often result in a stoma. All segments of the intestine, from the first loop after the ligament of Treitz down to the sigmoid colon, are feasible for a deviation procedure depending on the indications and the anatomical conditions. The decision whether to create a loop ostomy or a terminal stoma is reached with respect to the underlying indications and the anatomical and pathophysiological situation. The aim of the procedure is a complete and adequate stool deviation as well as a situation where the patient is able to take care of the ostomy in a convenient and reliable fashion while guided and educated by a stoma therapist. The prevention and treatment of complications, such as stoma necrosis or retraction are absolutely crucial in order to have satisfying long-term results and an acceptable quality of life.

Colostomy prolapse and hernia following window colostomy in congenital pouch colon

Congenital pouch colon, a variant of anorectal malformation, is a rare anomaly with a high incidence in North India and although the anatomy and diagnostic features have been well described, the surgical treatment continues to be challenging. This report describes the complications following a less preferred but often practised surgical option-a temporizing window colostomy in three babies. A window colostomy predisposes to prolapse of the entire pouch colon with herniation of bowel loops, intestinal obstruction and failure to thrive. Depending on the state of the child, either a proximal diverting stoma or tubularization of the pouch with a terminal stoma is recommended as the procedure of choice for the initial surgical management of this complex and rare malformation.

Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum

Between 1985 and 1996, 190 patients underwent a low anterior rectal resection with coloanal anastomosis for adenocarcinoma of the lower one-third of the rectum. This article reports on 31 (17 males) of these patients with a very low localization of the tumor (distal tumor margin 1.3 +/- 0.9 cm above the dentate line). If the function of the sphincter was acceptable and we could exclude tumor infiltration into the sphincter through endosonography, we relocated the resection plane distally into the intersphincteric region to attain an acceptable margin of safety. In all of these cases, it was impossible for us to perform the usual surgical procedure of a mechanical anastomosis by means of a circular stapler. After intersphincteric rectal resection, the anastomosis was handsewn, using interrupted sutures from the perineal approach, 2.5 to 3 cm above the anal verge, implementing Parks' retractor. A protective stoma was performed in all cases. All data were documented prospectively. Postoperative mortality was 0 percent. Postoperatively, none of the patients showed an indication for relaparotomy. The leakage rate was 48 percent. Only 16 percent later needed additional surgery for anastomotic strictures or for rectovaginal fistulas. Long-term observations showed that the anastomosis healed well in 27 patients (87.1 percent). Four patients (12.9 percent) decided to have a terminal colostomy performed (anastomotic stricture, 3 patients; anorectal incontinence, 1 patient). During the follow-up period of 6.8 +/- 3.7 years, six patients (19.4 percent) developed a tumor progression (9.7 percent local recurrences and 12.9 percent distant spread). The five-year survival rate was 79 percent (Dukes A, 100 percent (n = 18); Dukes B, 67 percent (n = 4); and Dukes C, 44 percent (n = 9)). Continence: One-third of patients developed anorectal incontinence for liquid (29.6 percent) or solid stool (3.7 percent). Average stool frequency was 3.3 times per day. Resting pressure decreased significantly by 29 percent (preoperative, 105 +/- 37 cm H2O and postoperative, 75 +/- 19 cm H2O; P < 0.05), whereas squeeze pressure did not change. In selected patients with tumors close to the dentate line, an intersphincteric resection of the rectum may help to avoid an abdominoperineal excision of the rectum with a terminal stoma, without any curtailment of oncologic standards. A protective stoma for three months is advantageous.

Bleeding from peristomal varices

Peristomal variceal bleeding is a serious complication in patients with chronic liver disease undergoing colon surgery with a stoma. Our aim was to examine the morbidity of bleeding for peristomal, perianastomotic, and esophageal varices in a group of patients with chronic liver disease who underwent colectomy at the Mayo Clinic between 1970 and 1988. Morbidity was evaluated in terms of the number of major bleeding episodes and the number of units of blood transfused. The treatment of bleeding was also evaluated. One hundred seventeen patients (74 males and 43 females) aged 11-78 years were studied. Sixty-two patients (53 percent) had a permanent stoma, while 55 patients (47 percent) had a colonic resection and anastomosis. Sixty-seven patients (62 percent) had chronic ulcerative colitis and primary sclerosing cholangitis. In the stoma group, bleeding appeared from stomal and/or esophageal varices in 19 patients (31 percent), while, in the non-stoma group, bleeding exclusively from the esophageal varices occurred in eight patients (15 percent). Perianastomotic variceal bleeding was never observed. The 5-year cumulative probabilities of one major bleed occurring from gastrointestinal varices appeared to be similar between the two groups. Patients who bled from peristomal varices with or without esophageal bleeding (n = 17) rebled more frequently (6.5 +/- 5.5 vs. 3 +/- 1.6; P less than 0.05) and were transfused more often (14.9 +/- 12.3 vs. 7.5 +/- 4.1; P less than 0.05) than patients who bled exclusively from esophageal varices (n = 10). No difference was found in the incidence of recurrent bleeding and the number of units of blood transfused between patients who bled exclusively from peristomal varices (n = 10) and those who bled from both peristomal and esophageal varices (n = 7). Medical and local measures were more effective in controlling esophageal bleeding than in controlling peristomal bleeding. Therefore, patients with chronic liver disease who must undergo colectomy should have a distal anastomosis rather than a terminal stoma.