Surgical Management of Complications with Peritoneal Dialysis.

This report reviews the most common surgical interventions and complications of chronic peritoneal dialysis (PD) patients. Based on the current knowledge as well as our experience we detail the role of these surgical procedures. We supplement the reported knowledge in the field with our own experience in this area. The areas discussed include early complications such as surgical wound hemorrhage, bleeding from the catheter, intestinal perforation and urinary bladder perforation, dialysate leakage through the wound, as well as late complications including catheter kinking or occlusion, retention of fluid in the peritoneal recess, hernias and hydrothorax, and encapsulating peritoneal sclerosis. We also briefly cover the surgical aspects of exit-site infection and peritonitis. An understanding by nephrologists of the role for surgical intervention in PD patients will improve their care and outcomes.

Gastrointestinal tract anastomoses with the biofragmentable anastomosis ring: is it still a valid technique for bowel anastomosis? Analysis of 203 cases and review of the literature.

PURPOSE: Biofragmentable anastomosis ring (BAR) is an alternative to manual and stapled anastomoses performed within the upper and lower gastrointestinal (GI) tract. The aim of this study was to evaluate the effectiveness of BAR utility for bowel anastomoses based on our own material. METHODS: A retrospective analysis was performed to a total of 203 patients who underwent bowel surgery with the use of BAR anastomosis within upper and lower gastrointestinal tract between 2004 and 2014. Data for the analysis was collected based on medical records, treatment protocols, and the results of histological examinations. RESULTS: The study group consisted of 86 women and 117 men. The most common underlying pathology was a malignant disease (n = 165). Biofragmentable anastomosis ring (BAR) size 31 was the most commonly used (n = 87). A total of 169 colocolic or colorectal anastomoses and 28 ileocolic and 8 enteroenteric anastomoses were performed. The mortality rate was 0.5 % (n = 1) whereas re-surgery rate within 30 days was 8.4 % (n = 17). Twenty-eight patients developed perioperative complications with surgical site infection as the most common one (n = 11). Eight patients developed specific complications associated with BAR including an anastomotic leak (n = 6) and intestinal obstruction (n = 2). The mean time of hospital stay after surgery was 12.7 days. CONCLUSIONS: The use of BAR for the GI tract anastomoses is simple and rapid method and it is characterized with an acceptable number of perioperative mortality and complication rates. Based on our experience, we recommend the use of BAR anastomosis in different types of intestinal anastomosis in varying clinical scenarios.

Epineural Sheath Jacket as a New Surgical Technique for Neuroma Prevention in the Rat Sciatic Nerve Model.

BACKGROUND: Terminal neuromas resulting from severe nerve injuries and traumatic or surgical limb amputations can become a source of pain, and significantly impair patients' quality of life. Recently, the number of patients with peripheral nerve injuries increased due to modern war conflicts, natural disasters, and traffic accidents. This study investigated the efficacy of the epineural sheath jacket (ESJ) as a novel technique for neuroma prevention in the rat sciatic nerve model. METHODS: A 20-mm segment of the right sciatic nerve was excised in 18 Lewis rats, and the animals were divided into 3 experimental groups (n = 6/group): group I-control, nerve stump without protection; group II-muscle burying group, nerve stump buried in the muscle; group III-ESJ group, nerve stump protected by ESJ. The ESJ was created from the excised sciatic nerve and applied as a "cap" over the proximal nerve stump. The presence of neuropathic pain was assessed weekly by pinprick test and Tinel sign, up to 24 weeks postsurgery. At 24 weeks, assessments, such as macroscopic evaluation, retrograde neuronal labeling analysis, histomorphometry, and neural/connective tissue ratio were performed. RESULTS: Epineural sheath jacket significantly reduced neuroma formation, which was associated with decreased Tinel sign (16.7%, P < 0.05) response compared with the nerve stump control. Moreover, ESJ reduced axonal sprouting, bulb-shaped nerve ending formation and perineural adhesions, as confirmed by macroscopic evaluation. Histological evaluation confirmed that nerve stumps protected with the ESJ showed less fibrosis and presented well-organized axonal structure. Neural/connective tissue ratio and retrograde neuronal labeling analysis revealed significantly improved results in the ESJ group compared to the control nerve stump group (P = 0.032 and P = 0.042, respectively). CONCLUSIONS: The protective effect of the ESJ against neuroma formation was confirmed by behavioral and histological analyses, showing outcomes comparable to the muscle burying technique-the criterion standard of neuroma management.

Anatomic variations of brachial and lumbosacral plexus models in different rat strains.

PURPOSE: Selection of an appropriate model for preclinical assessment of new methods of peripheral nerve injury management is crucial. This report presents anatomic variations within brachial and lumbosacral plexuses in three selected rat strains Sprague Dawley (Hsd:Sprague Dawley SD), Lewis (LEW/SsNHsd), and Athymic Nude (Hsd:RH-Foxn1rnu ) rats. METHODS: Based on their strain eighteen rats were divided into three groups. A total of 90 brachial plexus nerves (axillary, musculocutaneous, median, ulnar, and radial nerves) and 72 lumbosacral plexus nerves (sciatic, tibial, common peroneal, and sural nerves) were analyzed for the length, diameter and correlation with the body weight. A detailed anatomic course of each nerve within the brachial and lumbosacral plexuses was outlined. RESULTS: The sural nerve was the longest nerve in all studied rat strains, whereas the sciatic nerve had the largest diameter. Comparison of all the nerves' length demonstrated that the Lewis rat sciatic and sural nerves were significantly shorter (P < 0.05). No significant differences in nerve diameters were found among the analyzed rat strain groups. Significant correlation was revealed between the length of sciatic nerve and the rats' weight, which is irrelevant to the rats' genetic background. CONCLUSIONS: This study confirmed that nerves' length within rat's brachial and lumbosacral plexus depends on the inter-individual variations within the rat strains rather than on the differences in the peripheral nerve development, which is inherent to the specific rat strain. Correlation between the nerve length and body weight, suggests that bigger rats should be considered for studies requiring access to the long nerves. © 2016 Wiley Periodicals, Inc. Microsurgery 37:327-333, 2017.

Conservative Measures for Managing Constipation in Patients Living With a Colostomy.

PURPOSE: The purpose of this study was to determine the effect of a conservative regimen for the treatment of constipation in persons living with a colostomy. DESIGN: Prospective, noncontrolled, single-center study. SUBJECTS AND SETTING: The study sample comprised 35 patients with a colostomy who were diagnosed with constipation. Subjects with morphologic changes causing constipation such as stomal stenosis and neoplastic and inflammatory changes were excluded. The study was conducted in the Proctology and Stoma Outpatient Clinic at Poznan University of Medical Sciences. METHODS: Patients at our Stoma Outpatient Clinic underwent baseline evaluation, and those with symptoms of constipation (prolonged periods between bowel movements, passage of pasty or hardened fecal effluent, and associated symptoms such as abdominal discomfort or bloating, flatulence, and pain with passage of effluent into the stoma) received individualized dietary recommendations that typically included an increase in dietary fiber and fluid intake, along with increased fluid intake. The outcomes of dietary changes were evaluated during a follow-up visit 3 months later. If dietary changes alone did not improve constipation symptoms, we prescribed a psyllium-based bulk-forming agent, an osmotic stool softener, and a probiotic, with or without a prokinetic agent such as metoclopramide taken 3 times daily. RESULTS: Dietary interventions alone were deemed successful in 60% of study subjects (n = 21); the remaining 14 patients required additional treatment. CONCLUSIONS: Dietary modifications alone relieved constipation in more than half of a group of 35 patients with constipation. We therefore recommend a trial of dietary modifications prior to the initiation of pharmacotherapy in patients with a colostomy.

Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: a multicentre observational study.

The management of enteroatmospheric fistula (EAF) in open abdomen (OA) therapy is challenging and associated with a high mortality rate. The introduction of negative pressure wound therapy (NPWT) in open abdomen management significantly improved the healing process and increased spontaneous fistula closure. Retrospectively, we analysed 16 patients with a total of 31 enteroatmospheric fistulas in open abdomen management who were treated using NPWT in four referral centres between 2004 and 2014. EAFs were diagnosed based on clinical examination and confirmed with imaging studies and classified into low (<200 ml/day), moderate (200-500 ml/day) and high (>500 ml/day) output fistulas. The study group consisted of five women and 11 men with the mean age of 52·6 years [standard deviation (SD) 11·9]. Since open abdomen management was implemented, the mean number of re-surgeries was 3·7 (SD 2·2). There were 24 EAFs located in the small bowel, while four were located in the colon. In three patients, EAF occurred at the anastomotic site. Thirteen fistulas were classified as low output (41·9%), two as moderate (6·5%) and 16 as high output fistulas (51·6%). The overall closure rate was 61·3%, with a mean time of 46·7 days (SD 43·4). In the remaining patients in whom fistula closure was not achieved (n = 12), a protruding mucosa was present. Analysing the cycle of negative pressure therapy, we surprisingly found that the spontaneous closure rate was 70% (7 of 10 EAFs) using intermittent setting of negative pressure, whereas in the group of patients treated with continuous pressure, 57% of EAFs closed spontaneously (12 of 21 EAFs). The mean number of NPWT dressing was 9 (SD 3·3; range 4-16). In two patients, we observed new fistulas that appeared during NPWT. Three patients died during therapy as a result of multi-organ failure. NPWT is a safe and efficient method characterised by a high spontaneous closure rate. However, in patients with mucosal protrusion of the EAFs, spontaneous closure appears to be impossible to achieve.

Botulinum Toxin Injection for Treatment of Chronic Anal Fissure: Is There Any Dose-Dependent Efficiency? A Meta-Analysis.

BACKGROUND: Chronic anal fissure (CAF) is a linear split of the anoderm. The minimally invasive management of CAF such as botulinum toxin (BT) injection is recommended. However, the exact efficient dose of BT, number of injections per session and the injection sites are still debatable. The aim of this analysis was to assess the dose-dependent efficiency of botulinum toxin injection for CAF. METHODS: PubMed and Web of Science databases were searched for terms: "anal fissure" AND "botulinum toxin." Studies published between October 1993 and May 2015 were included and had to meet the following criteria: (1) chronic anal fissure, (2) prospective character of the study, (3) used simple BT injection without any other interventions and (4) no previous treatment with BT. RESULTS: A total of 1577 patients from 34 prospective studies used either Botox or Dysport formulations were qualified for this meta-analysis. A total number of BT units per session ranged from 5 to 150 IU, whereas the efficiency across analyzed studies ranged from 33 to 96 %. Surprisingly, we did not observe a dose-dependent efficiency (Spearman's rank correlation coefficient, ρ = 0.060; p = 0.0708). Moreover, there were no BT dose-dependent postoperative complications or fecal incontinence and significant difference in healing rates compared BT injection into the anal sphincter muscles. CONCLUSIONS: BT injection has been an accepted method for the management of CAF. Surprisingly, there is no dose-dependent efficiency, and the postoperative incontinence rate is not related to the BT dosage regardless the type of formulation of botulinum neurotoxin used. Moreover, no difference in healing rate has been observed in regard to the site and number of injections per session.

Large bowel mucosal neoplasia in the original specimen may increase the risk of ileal pouch neoplasia in patients following restorative proctocolectomy for ulcerative colitis.

PURPOSE: Restorative proctocolectomy is a current gold standard procedure for patients who require a colectomy for ulcerative colitis. The incidence of ileal pouch neoplasia is low. The aims of this study were to assess the prevalence of neoplasia in ileal pouch and investigate the risk factors for ileal pouch neoplasia. METHODS: A total of 276 patients who underwent restorative proctocolectomy for ulcerative colitis between 1984 and 2009 were analyzed. Results of histological examinations of both original specimen and biopsies from the J-pouch taken during routine pouch endoscopy were evaluated. Patients' records were analyzed for ulcerative colitis duration, the time from pouch creation to pouch neoplasia, presence of pouchitis, as well as the concurrent primary sclerosing cholangitis. RESULTS: Analyzing the original specimen of large bowel, fifty-six lesions of low-grade dysplasia, twenty-five high-grade dysplasia, and five adenocarcinoma were revealed. All patients with dysplasia (n = 8) or adenocarcinoma (n = 1) of the J-pouch were positive for dysplasia in the original specimen. Duration of ulcerative colitis before surgery and duration time following restorative proctocolectomy were found as risk factors for J-pouch neoplasia with a significant difference (p = 0.01 and p = 0.0003, respectively). Patients with pouch neoplasia developed significantly more severe pouchitis (p = 0.00001). CONCLUSIONS: Neoplasia of the J-pouch is rare. Patients with neoplasia in the original specimen are more susceptible to develop neoplasia in the J-pouch. Precise follow-up in patients with neoplasia lesions in the original specimen should be recommended. Moreover, in patients with risk factors, the exact surveillance pouch endoscopy should be recommended.

In Vitro Studies of Antibacterial and Antifungal Wound Dressings Comprising H2TiO3 and SiO2 Nanoparticles.

The incidence rate of the infected and complex wound is established at approximately 40,000/1 million of the world's adult population. The aim of this study was to assess the efficiency of three novel types of wound dressings comprising sodium chloride, metatitanic acid and silicon dioxide nanoparticles. The study design was to prove their antimicrobial properties against the microorganisms most commonly causing wound infections. The study evaluated the antimicrobial effect of tested dressings on referenced strains of bacteria (ATCC collection, Argenta, Poland) and strains of fungi species (our own collection of fungi cultured from patients). The dressings were tested with both bacterial and fungal strains on solid media (Mueller-Hinton, Sobouraud, bioMerieux, France) in the standard method. The results confirmed the inhibition of growth of bacteria and revealed zones of inhibition for Escherichia coli, Staphylococcus aureus and Enterococcus faecalis. Significant zones of inhibition were established for Staphylococcus aureus and for fungi species of the Candida sp. These results would be crucial due to the fact of the low availability of antifungal therapeutics for both systemic and topical usage. Moreover, the current standard of antifungal treatment is associated with high costs and high toxicity in general. The preliminary results are very promising but further studies are necessary. Based on the obtained results, the tested dressings may contribute to the development of the surgical armamentarium of complex wound management in the near future.

Negative Pressure Level and Effects on Bacterial Growth Kinetics in an in vitro Wound Model.

Negative Pressure Wound Therapy (NPWT) has been widely adopted in wound healing strategies due to its multimodal mechanism of action. While NPWT's positive impression on wound healing is well-established, its effect on bacterial load reduction remains equivocal. This study investigates NPWT's efficacy in reducing bioburden using an in vitro porcine skin model, focusing on the impact of Staphylococcus aureus and Staphylococcus epidermidis. Custom-made negative pressure chambers were employed to apply varying negative pressures. Porcine skin was cut into 5 × 5 cm squares and three standardized wounds of 6 mm each were created using a biopsy punch. Then, wounds were infected with S. aureus and S. epidermidis bacterial suspensions diluted 1:10,000 to obtain a final concentration of 1.5 × 104 CFU/ml and were placed in negative pressure chambers. After incubation, bacterial counts were expressed as colony-forming units (CFU) per ml. For S. aureus at 120 hours, the median CFU, mean area per colony, and total growth area were notably lower at -80 mmHg when compared to -250 mmHg and -50 mmHg, suggesting an optimal negative pressure for the pressure-dependent inhibition of the bacterial proliferation. While analyzing S. epidermidis at 120 hours, the response to the negative pressure was similar but less clear, with the minor CFU at -100 mmHg. The influence of intermittent negative pressure on the S. epidermidis growth showed notably lower median CFU with the interval therapy every hour compared to the S. aureus control group. This study contributes valuable insights into NPWT's influence on the bacterial load, emphasizing the need for further research to reformulate its role in managing contaminated wounds.

Analysis of risk factors for conversion in laparoscopic adrenalectomy: a single-institution series of 256 patients.

Introduction: Although introduction of the laparoscopic approach for adrenal gland surgery revolutionized the strategy in management of adrenal gland tumors, open surgery is still a method of choice in some clinical scenarios. Moreover, laparoscopy may have limitations resulting in conversion. Aim: To assess risk factors predisposing for conversion based on our own material, including 256 laparoscopic adrenalectomies performed in 2009-2016. Material and methods: A retrospective analysis of patients who underwent adrenalectomies between 2009 and 2016 was conducted. Patients were analyzed for sex, body mass index (BMI), size of the adrenal gland lesion, final histopathological diagnosis and operated side of the adrenal gland, its impact on conversion rate. Results: A total of 256 patients underwent laparoscopic adrenalectomy. The reported study comprised of 94 (36.7%) men and 162 (63.3%) women. The most common indication for adrenalectomy were adrenal cortex adenoma (n = 149; 58.2%) and pheochromocytoma (n = 48; 18.75%). The conversion rate was 3.91% (n = 10 patients). Mean BMI of patients without conversion was 27.6 kg/m2, whereas in the group of patients with conversion, BMI was 29.7 kg/m2 (p > 0.05). The conversion rate was precisely the same when comparing the right (5/126; 3.9%) and left (5/126; 3.9%) adrenal gland. There was no correlation between the size of the adrenal lesion and the risk of conversion. Conclusions: The laparoscopic approach remains an efficient and safe procedure for adrenal gland tumors. Based on our study, obese patients and those with pheochromocytoma are associated with a higher risk of conversion but without any statistical significance. There was no difference in the conversion rate when analyzing the size of the adrenal gland tumor. No difference was also revealed in the conversion rate when comparing both sides of laparoscopic adrenalectomy.

Stoma close to the abdominal wound: a real technical problem. A description of a novel care strategy.

IntroductionIn some clinical scenarios, stoma site may be located close to the abdominal wound edge impeding optimal wound management and stoma care. We present a novel strategy of utility NPWT for management of simultaneous abdominal wound healing with stoma presence. Material and methodsRetrospective analysis of seventeen patients treated with a novel wound care strategy was conducted. Application of NPWT within wound bed, around stoma site and skin between allows for: 1) separating wound from stoma site, 2) maintaining the optimal environment for wound healing, 3) protecting peristomal skin and 4) facilitating application of ostomy appliances.ResultsThe study group comprised of twelve female (70,6 %) and five male (29,4%) with the mean age of 49.1 18.4 years The most common underlying pathology was Crohn s disease (n-5; 29,4%). Since NPWT was implemented, patients had undergone from 1 to 13 surgeries. Thirteen patients (76,5%) required intensive care unit admission. The mean time of hospital stay was 65,3 28,6 days (range: 36 134). The mean session of NPWT was 10.8 5.2 (range: 5 - 24) per patient. The range of the level of negative pressure was from -80 to 125 mmHg. In all patients, progress in wound healing was achieved resulting in granulation tissue formation, minimizing wound retraction and thus reduction of the wound area. As a result of NPWT, wound was granulated entirely, tertiary intension closure were achieved or patients were qualified for reconstructive surgery.DiscussionNPWT is safe and useful therapy for complicated abdominal wounds with the presence of stoma close to wounds edges. A novel care strategy allows for simultaneous technical opportunity to separate stoma from wound bed and facilitate wound healing.

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: 18.5­24.9) 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.

Endoscopy-assisted minimally invasive loop ileostomy after previous restorative proctocolectomy.

BACKGROUND: Complications after proctocolectomy with ileal pouch-anal anastomosis may impair pouch function. Loop ileostomy can be performed to allow recovery of function before intestinal continuity is restored. To minimize operative trauma and to form the stoma with as little damage to the abdominal wall as possible, the invasiveness of the procedure should be minimized as far as possible. OBJECTIVE: To minimize the extent of surgical invasion, we developed a technical modification of loop ileostomy in which lower endoscopy is used to assist the procedure. PROCEDURE: The procedure requires only a single incision, which is made at the site of the ileostomy. While the surgeon incises the fascia and peritoneum, the endoscopist advances a flexible endoscope through the pouch to the distal part of the ileum up to approximately 40 cm above the anal verge. The operation lamp is switched off, allowing the surgeon to see the lighted end of the endoscope in a loop of the ileum near the incision. This loop is drawn out through the incision and the stoma is created in a standard manner. LIMITATIONS: Clinical factors such as the presence of adhesions or obesity limit the use of the procedure in certain patients. CONCLUSIONS: We believe this technique of endoscopic-assisted loop ileostomy is a safe method for minimizing the invasiveness of surgery in patients who require ileostomy after restorative proctocolectomy.

Effect of closed incision negative pressure wound therapy on incidence rate of surgical site infection after stoma reversal: a pilot study.

INTRODUCTION: The stoma reversal (SR) procedure is associated with a relatively high risk of perioperative complications with surgical site infection (SSI) as the most common. Recently closed incision negative pressure wound therapy (ciNPWT) was applied widely to prevent SSI. AIM: To investigate the efficiency of ciNPWT in terms of the incidence rate of SSI after SR surgery. MATERIAL AND METHODS: As an exploratory observational cohort study patients were treated either with ciNPWT (n = 15) or standard sterile dressing (SSD) (n = 15). CiNPWT was applied every 3 days whereas SSD was changed every day. Clinical evaluation for SSI signs, C-reactive protein level and pain assessment using the visual analogue scale (VAS) were analyzed. RESULTS: The incidence rate of SSI was in 13% (2/15) in the ciNPWT group and 26% (4/15) in the SSD group (p = 0.651, OR = 0.44, 95% CI: 0.03-3.73). All patients in the SSD group who developed SSI presented both local and generalized signs of infection. Pain-VAS levels assessed on the 1st (MdnciNPWT = 4, MdnSSD = 5, p = 0.027, W = 51.5) and 3rd postoperative day (MdnciNPWT = 2, MdnSSD = 4, p = 0.014, W = 45.5) were significantly lower in the ciNPWT group than in the SSD group. CONCLUSIONS: CiNPWT seems not to have a benefit to reduce SSI after the SR procedure. Further investigation is needed to establish firmly the benefit of using ciNPWT in this group of patients.

Endoscopic vacuum therapy with instillation (iEVT) - a novel endoscopic concept for colorectal anastomotic leak and perianal complications.

INTRODUCTION: Anastomotic leaks remain the most fearful complications. AIM: We present a novel endoscopic salvage therapy known as endoscopic vacuum therapy with instillation (iEVT) as a combination of standard endoscopic vacuum therapy (EVT) and negative pressure wound therapy with instillation (iNPWT). MATERIAL AND METHODS: A case series of 6 consecutive patients treated with iEVT is presented. A Redon drain and a central venous catheter were introduced within polyurethane foam used as a self- made device for iEVT and antimicrobial solution was instilled. RESULTS: A total of 6 patients with the mean age of 29.5 ±8.9 were treated with iEVT. The mean number of iEVT sessions was 5.8 ±2.3. The mean time of iEVT management was 20.7 ±8.8 days. Locally, a reduction in purulent discharge and defect's dimension with contraction were revealed confirmed with imaging studies. CONCLUSIONS: iEVT is a very encouraging, novel method for complicated perianal diseases and anastomotic leak.

LapVac - a laparoscopic approach for negative pressure wound therapy application in open abdomen management: a porcine animal model.

INTRODUCTION: Negative pressure wound therapy (NPWT) in the open abdomen (OA) is recognized as a gold standard management method. Currently minimally invasive procedures are implemented in many clinical scenarios. AIM: To demonstrate the feasibility of using negative pressure wound therapy in a laparoscopic approach for OA management in a porcine model termed as a laparoscopic vacuum (LapVac). MATERIAL AND METHODS: An adult female swine underwent a laparoscopic procedure. Briefly, a small incision was made and secured with a wound protector, pneumoperitoneum was created and two additional ports were placed. Then, a non-adhesive layer was precisely placed within the abdominal cavity. RESULTS: Finally, polyurethane foam and adhesive drape were applied. A volume of 200 ml of saline solution was instilled and drained completely within 30 min. We did not observe any technical problems with NPWT application. CONCLUSIONS: This study confirmed the technical feasibility of NPWT application in the laparoscopic approach. LapVac seems to be a promising technique which may minimize the trauma and lead to better outcomes.

Ileal pouch anal anastomosis leak after restorative proctocolectomy without protective stoma successfully treated with endoscopic vacuum therapy.

Aim An ileal pouch anal anastomosis (IPAA) leak is one of the most severe complication after restorative proctocoletomy (RPC). We present a rare case of a successful management of IPAA leak after RPC without defunctionig stoma with the utility of endoscopic vacuum therapy. Methods A 57-year-old male with a ileal pouch anal anastomosis leak after RPC due to ulcerative colitis with presacral abscess was qualified for endoscopic vacuum therapy (EVT). The abscess of the left buttock was drained and secured with suction drain (redon drain). Due to the lack of defunctioning stoma, a system for contain and divert fecal matter was placed within afferent limb of the J-pouch and EVT was placed directly within IPAA dehiscence. EVT was changed every third day. Results The patient underwent a total of five EVT sessions. Improvement of patient's general condition characterized with lack of pelvic pain, fever and reduction of inflammatory markers was achieved. Locally, anastomosis dehiscence was healed with prominent reduction in the defect's dimension, contraction and revascularization. Based on imaging studies no chronic presacral sinus or any other perianal disturbances were revealed at the time of five months follow up. Conclusions EVT is a promising method for management of IPAA leak. Although, it remains extremely difficult, EVT may serve as a method of choice in early pouch-related septic complications after RPC performed without defunctioning stoma.