Prospective evaluation of selective defunctioning stoma for low anterior resection with total mesorectal excision.

Low anterior resection with total mesorectal excision for rectal carcinoma is associated with a high anastomotic leakage rate, and the effectiveness of a defunctioning stoma in preventing anastomotic leakage remains controversial. In this study a policy of selective defunctioning stoma for stapled colorectal anastomosis after low anterior resection with total mesorectal excision in 148 consecutive patients was evaluated prospectively. A defunctioning stoma was performed in 61 patients (41%) considered at high risk of anastomotic leakage. Clinical leakage occurred in 2 patients (3.3%) with a stoma and 11 patients (12.6%) without a stoma (p = 0.047). Among those without a stoma, the leakage rate among male patients (20.9%) was significantly higher than that for female patients (4. 5%) (p = 0.022). Leakage subsided with conservative treatment in the two patients with a stoma, but seven patients without a stoma developed peritonitis requiring laparotomy. No deaths resulted from leakage, and there was one hospital death (0.6%) in the whole group. Median hospital stay was similar with and without a stoma (13.0 vs. 12.0 days) (p = 0.290). Closure of the stoma was associated with no mortality, a morbidity rate of 8.7%, and a median hospital stay of 6. 0 days. In conclusion, a defunctioning stoma is effective in preventing clinical anastomotic leakage after low anterior resection with total mesorectal excision. The relatively high incidence of leakage in the low risk group indicates the difficulty of predicting anastomotic leakage and hence the need for more liberal use of a defunctioning stoma especially in male patients.

Preoperative and intraoperative localisation of gastrointestinal bleeding of obscure origin.

In the past six years, 37 patients with gastrointestinal bleeding of obscure origin had their bleeding sites localised preoperatively or intraoperatively. Preoperative investigations followed a regime consisting of endoscopy, barium meal and follow through, small bowel enema, 99mTc pertechnetate scan, 99mTc-labelled red blood cell scan and selective coeliac and mesenteric angiography. Bleeding lesions were localised preoperatively in 36 patients. In one patient, diagnostic laparotomy had to be carried out immediately before any investigation because the bleeding was severe. At operation, angiosarcoma of ileum was found. Unless preoperative investigations showed the lesions to be in anatomically fixed organs like the duodenum or colon, the lesions had still to be found at operation. Palpation and transillumination detected the lesion intraoperatively in 21 patients while only some lesions were found in three patients with multiple lesions. Sigmoidoscopy through enterotomies was required in one patient. Intraoperative enteroscopy was done for small lesions not found grossly at operation in nine patients, to detect additional lesions in three patients or to rule out suspicious lesion shown on preoperative tests in one patient. In another patient with diffuse lymphoma of small bowel with bleeding from only a small segment of jejunum, injection of methylene blue intraoperatively through a previously placed angiographic catheter stained the bleeding segment of jejunum blue. This segment was identified easily and resected. These preoperative and intraoperative localisation procedures were simple and effective and we recommend them to be used more freely.

Intra-operative fibreoptic enteroscopy for bleeding lesions in the small intestine.

Twenty-five patients with gastrointestinal bleeding proved to have lesions in the small intestine. Intra-operative fibreoptic enteroscopy was performed on seven patients, in six patients through the anus and in one patient through an enterotomy and the anus. The indications for fibreoptic enteroscopy were inability to find the lesions in the 3 patients, multiple small lesions in 3 patients and to rule out suspicious pathology in the jejunum shown on a small bowel enema in a patient with ileal ulcers. In all instances, the fibreoptic enteroscopy was useful in localizing lesions, in detecting additional lesions and in ruling out the suspicious lesions. It can be performed easily and is safe. No complication developed from its use in this series.