A Four-step Technique for Effluent Diversion of Enteroatmospheric Fistulas.

BACKGROUND: Isolation of the enteroatmospheric fistula (EAF) opening and prevention of contamination of the rest of the wound by effluent are important factors in the management of EAF. OBJECTIVE: The aim of this study is to describe an easily reproducible technique for effluent control in patients with EAF. MATERIALS AND METHODS: A retrospective analysis was conducted on all patients who underwent the present technique between 2013 and 2015. The surgical technique included condom-EAF anastomosis, fistula ring creation, negative pressure wound therapy (NPWT), and adaptation of an ostomy bag. RESULTS: A total of 7 patients with a Björck grade 4 abdomen were included. All fistulas were located in the small bowel with a median number of 2 EAFs (range, 2-3) in each patient, and the majority had moderate output volume. The mean number of NPWT changes was 10 (range, 5-18), the mean time of NPWT use was 75.7 days (range, 60-120 days), and the mean length of stay was 108.2 days (range, 103-160 days). The mean time of ostomy formation to restitution of bowel continuity was 14.3 months (range, 8-20 months). Open anterior component separation was employed in all cases for closure of the abdominal wall. No mortality, ventral herniation, or refistulization was registered in the study. The mean follow-up time was 8.5 months (range, 6-12 months). CONCLUSIONS: This is an easily reproducible and safe technique for effluent control in patients with Björk grade 4 abdomen with established EAF.

Complicaciones de ileostomías y colostomías de protección en cirugía por cáncer de recto / Ileostomy and colostomy complications of protection in rectal cancer surgery

Introducción: en los últimos años, la tradicional colostomía lateral utilizada para proteger las anastomosis colorrectales bajas, ha sido reemplazada en muchos centros por una ileostomía en asa. Si bien se ha generado cierta controversia entre ambas técnicas, aún no ha quedado claramente demostrado qué técnica es la más recomendada. Objetivo: comparar el índice de complicaciones de ileostomías y colostomías de protección en cirugías por cáncer de recto. Material y Método: se analizaron retrospectivamente todos los pacientes operados de cáncer de recto, entre 2002 y 2012, a los que se les realizó una ostomía de protección. Se excluyó a los pacientes a los cuales por diversas razones nunca se les restableció el tránsito intestinal. Los parámetros analizados fueron: edad, sexo, complicaciones del ostoma, complicaciones del cierre del ostoma y mortalidad. Las complicaciones fueron clasificadas con la escala STROC. Se analizó un total de 106 pacientes (59 hombres y 47 mujeres). La edad promedio fue de 64 años (24 a 89). Se realizaron 80 ileostomías en asa (Grupo IA) y 26 colostomías laterales transversas (Grupo CLT). Se utilizó para el análisis estadístico el test de Fisher. Resultados: hubo 12 complicaciones relacionadas con la confección de las ostomías (11.3%). Esto incluye 11 complicaciones de ileostomías (13,7%) y una de las colostomías (3,8%) (p=0,15). No hubo mortalidad. Con relación al cierre del ostoma, hubo 18 complicaciones con una incidencia del 16,9%; de estas, 10 correspondieron al grupo IA (12,5%), y 8 al grupo CLT (30,8%) (p=0,03). Dentro de estas complicaciones del cierre de los ostomas, la más frecuente fue la infección de la herida quirúrgica, de la que se registraron 7 casos, 2 en el grupo IA y 5 en el grupo CLT (p=0,009)... (TRUNCADO)

Background: in recent years, the traditional lateral colostomy used to protect low colorectal anastomosis has been replaced in many centers by a loop ileostomy. While some controversy was generated between the two techniques it has not yet been clearly demonstrated which of them is the best choice. Objective: to compare the rate of complications of ileostomy and colostomy protection after rectal cancer surgery. Material and Methods: we retrospectively analyzed all patients undergoing rectal cancer surgery who needed a protective stoma between 2002 and 2012. We excluded patients to whom intestinal transit was never restored. The parameters analyzed were: age, sex, stoma complications, closure of stoma complications and mortality. Complications were classified according to STROC scale. We analyzed a total of 106 patients (59 men and 47 women), mean age was 64 years (24-89). This included 80 loop ileostomies (Group IA) and 26 lateral transverse colostomies (CLT Group). Fisher’s test was used for statistical analysis. Results: there were 12 complications related to the making of the ostomy (11,3%). This included 11 ileostomy complications (13,7%), and one after a colostomy (3,8%) (p=0,15). There was no mortality. Regarding the closure of the stoma, there were 18 complications with an incidence of 16,9%. Of these, 10 occurred in group IA (12,5%), and 8 in CLT group (30,8%) (p=0,03). Within stoma closure complications, infection of the surgical wound was the most common, with 7 cases, 2 in group IA and 5 in the CLT group (p = 0,009). The mortality rate was 2,8%, 2,5% corresponded to the ileostomy group and 3,8% corresponded to the colostomy group (p=0,57). Conclusions: the implementation of a stoma should be clearly justified since the procedure is not without complications... (TRUNCATED)

Preliminary results from digestive adaptation: a new surgical proposal for treating obesity, based on physiology and evolution.

CONTEXT AND OBJECTIVE: Most bariatric surgical techniques include essentially non-physiological features like narrowing anastomoses or bands, or digestive segment exclusion, especially the duodenum. This potentially causes symptoms or complications. The aim here was to report on the preliminary results from a new surgical technique for treating morbid obesity that takes a physiological and evolutionary approach. DESIGN AND SETTING: Case series description, in Hospital Israelita Albert Einstein and Hospital da Polícia Militar, São Paulo, and Hospital Vicentino, Ponta Grossa, Paraná. METHODS: The technique included vertical (sleeve) gastrectomy, omentectomy and enterectomy that retained three meters of small bowel (initial jejunum and most of the ileum), i.e. the lower limit for normal adults. The operations on 100 patients are described. RESULTS: The mean follow-up was nine months (range: one to 29 months). The mean reductions in body mass index were 4.3, 6.1, 8.1, 10.1 and 10.7 kg/m2, respectively at 1, 2, 4, 6 and 12 months. All patients reported early satiety. There was major improvement in comorbidities, especially diabetes. Operative complications occurred in 7% of patients, all of them resolved without sequelae. There was no mortality. CONCLUSIONS: This procedure creates a proportionally reduced gastrointestinal tract, leaving its basic functions unharmed and producing adaptation of the gastric chamber size to hypercaloric diet. It removes the sources of ghrelin, plasminogen activator inhibitor-1 (PAI-1) and resistin production and leads more nutrients to the distal bowel, with desirable metabolic consequences. Patients do not need nutritional support or drug medication. The procedure is straightforward and safe.

Preliminary results from digestive adaptation: a new surgical proposal for treating obesity, based on physiology and evolution / Resultados preliminares de adaptação digestiva: nova proposta cirúrgica para tratamento cirúrgico da obesidade baseada na fisiologia e na evolução

CONTEXT AND OBJECTIVE: Most bariatric surgical techniques include essentially non-physiological features like narrowing anastomoses or bands, or digestive segment exclusion, especially the duodenum. This potentially causes symptoms or complications. The aim here was to report on the preliminary results from a new surgical technique for treating morbid obesity that takes a physiological and evolutionary approach. DESIGN AND SETTING: Case series description, in Hospital Israelita Albert Einstein and Hospital da Polícia Militar, São Paulo, and Hospital Vicentino, Ponta Grossa, Paraná. METHODS: The technique included vertical (sleeve) gastrectomy, omentectomy and enterectomy that retained three meters of small bowel (initial jejunum and most of the ileum), i.e. the lower limit for normal adults. The operations on 100 patients are described. RESULTS: The mean follow-up was nine months (range: one to 29 months). The mean reductions in body mass index were 4.3, 6.1, 8.1, 10.1 and 10.7 kg/m², respectively at 1, 2, 4, 6 and 12 months. All patients reported early satiety. There was major improvement in comorbidities, especially diabetes. Operative complications occurred in 7 percent of patients, all of them resolved without sequelae. There was no mortality. CONCLUSIONS: This procedure creates a proportionally reduced gastrointestinal tract, leaving its basic functions unharmed and producing adaptation of the gastric chamber size to hypercaloric diet. It removes the sources of ghrelin, plasminogen activator inhibitor-1 (PAI-1) and resistin production and leads more nutrients to the distal bowel, with desirable metabolic consequences. Patients do not need nutritional support or drug medication. The procedure is straightforward and safe.

CONTEXTO E OBJETIVO: A maioria das técnicas de cirurgia bariátrica inclui anastomoses ou bandas ou exclusões de segmentos digestivos, principalmente o duodeno, que podem gerar sintomas ou complicações. O objetivo do estudo foi apresentar os resultados dos dois primeiros anos de uso de uma nova técnica no tratamento cirúrgico da obesidade: gastrectomia vertical com omentectomia e enterectomia segmentar. TIPO DE ESTUDO E LOCAL: Descrição de série de casos operados no Hospital Israelita Albert Einstein, Hospital da Polícia Militar, São Paulo, e Hospital Vicentino, Ponta Grossa, Paraná, Brazil. MÉTODO: A técnica utiliza a gastrectomia vertical, omentectomia maior e enterectomia segmentar (incluindo jejuno basicamente) que deixa três metros de intestino delgado (jejuno inicial e a maior parte do íleo), em comprimento no limite inferior do que se considera normal para humanos adultos. Os 100 primeiros pacientes são descritos. RESULTADOS: Com acompanhamento de até 29 meses pós-operatórios (média de oito meses) a redução no índice de massa corpórea foi de 4.3, 6.1, 8.1, 10.1, 10.7 kg/m², respectivamente nos meses 1, 2, 4, 6 e 12 de pós-operatório. Todos os pacientes acusam saciedade precoce. Houve melhora acentuada das doenças associadas em especial a diabetes. Complicações cirúrgicas ocorreram em 7 por cento dos pacientes todas resolvidas sem seqüelas. Não houve óbitos. CONCLUSÕES: O procedimento cria um trato gastrointestinal proporcionalmente reduzido, mas com suas funções digestivas intactas. O procedimento retira fontes de produção de grelina, inibidor do ativador do plasminogênio-1 (PAI-1), resistina e permite que mais nutrientes sejam absorvidos no intestino distal, com as desejáveis conseqüências metabólicas. Os pacientes não precisam de suporte nutricional ou de medicações. O procedimento é fácil e seguro.

Estudo retrospectivo dos casos de enterolitíase e corpo estranho em intestino grosso de eqüinos, no período de janeiro de 1993 a janeiro de 2003 / Retrospective study of enterolithiasis and foreign bodies found in the large intestine of horses (january 1993 to january 2003)

No período de janeiro de 1993 a janeiro de 2003, foram realizados 195 procedimentos cirúrgicos de abdômen agudo em eqüinos, no Serviço de Cirurgia de Grandes Animais do Hospital Veterinário da Faculdade de Medicina Veterinária e Zootecnia da Universidade de São Paulo. Dentre eles, foram diagnosticados 30 casos de enterolitíase e sete casos de corpo estranho, localizados em intestino grosso. Das 37 laparotomias, 35 foram realizadas em decúbito dorsal com acesso pela linha média e duas em estação com acesso pelo flanco. Os animais apresentaram idade variando de um a dezoito anos com média de oito anos, sendo 25 machos e 13 fêmeas. As formações e corpos estranhos apresentaram a seguinte localização: 13 (35,14%) em cólon maior, 19 (51,35%) em cólon menor, 03 (8,10%) em cólon transverso e 02 (5,41 %) em cólon transverso e menor. Em relação à evolução, 23 (62,16%) receberam alta e 14 (37,84%) evoluíram para óbito (6) ou foram submetidos à eutanásia (8). Seis procedimentos de eutanásia, foram realizados no período trans-operatório e dois no período pós-operatório. Dentre os animais que apresentaram evolução satisfatória, destacam-se um caso em que foram retirados sete enterólitos e outro em que a ponta de um prego que era o núcleo do enterólito se mantinha proeminente e em contato com a mucosa intestinal. Comparativamente às demais afecções do intestino grosso dos eqüinos e pela análise dos resultados obtidos neste estudo, conclui-se que os processos obstrutivos causados por enterólitos ou corpos estranhos apresentam prognóstico favorável.

In the period from January 1993 to January 2003, 195 surgical procedures of equine acute abdomen were performed at the Service of Large Animal Surgery of the Veterinary Hospital of the School of Veterinary Medicine and Zootechnics of the University of São Paulo. From these 195 cases there were 30 enterolithiasis and seven foreign bodies located in the colono Thirty-five out of 37 laparotomies were performed in dorsal recumbency, with access through the ventral midline and two were performed through the flank, with the animal in standing position. Of the 37 animals, 25 were male and 12 were females. Age varied from one to 18 years old with any average of eight years of age. Location of enteroliths and foreign bodies was as follows: 13 (35.14%) in large colon, 19 (51.35%) in small colon, 03 (8.10%) in transverse colon and 02 (5.41 %) in both transverse and small colon. In regards to the clinical evolution, six were humenely eutmanized killed during surgery. From the 31 remaining, 23 (74,19%) were discharged,6 (19,36%) died and 2 (6,45%) were killed eutmanized during the post-operative period. Among those animals with satisfactory evolution two animals stand out. One of them had seven enteroliths and in the other, the nucleus of the mass was the tip of a nail, which protruded from the mass and was in constant contact with the intestinal mucosa. In spite of the large incidence of obstruction caused by enteroliths or foreign bodies in comparison of other studies, the prognosis of post-operative recovery is favourable.

Estudo retrospectivo dos casos de enterolitíase e corpo estranho em intestino grosso de eqüinos, no período de janeiro de 1993 a janeiro de 2003 / Retrospective study of enterolithiasis and foreign bodies found in the large intestine of horses (january 1993 to january 2003)

No período de janeiro de 1993 a janeiro de 2003, foram realizados 195 procedimentos cirúrgicos de abdômen agudo em eqüinos, no Serviço de Cirurgia de Grandes Animais do Hospital Veterinário da Faculdade de Medicina Veterinária e Zootecnia da Universidade de São Paulo. Dentre eles, foram diagnosticados 30 casos de enterolitíase e sete casos de corpo estranho, localizados em intestino grosso. Das 37 laparotomias, 35 foram realizadas em decúbito dorsal com acesso pela linha média e duas em estação com acesso pelo flanco. Os animais apresentaram idade variando de um a dezoito anos com média de oito anos, sendo 25 machos e 13 fêmeas. As formações e corpos estranhos apresentaram a seguinte localização: 13 (35,14%) em cólon maior, 19 (51,35%) em cólon menor, 03 (8,10%) em cólon transverso e 02 (5,41 %) em cólon transverso e menor. Em relação à evolução, 23 (62,16%) receberam alta e 14 (37,84%) evoluíram para óbito (6) ou foram submetidos à eutanásia (8). Seis procedimentos de eutanásia, foram realizados no período trans-operatório e dois no período pós-operatório. Dentre os animais que apresentaram evolução satisfatória, destacam-se um caso em que foram retirados sete enterólitos e outro em que a ponta de um prego que era o núcleo do enterólito se mantinha proeminente e em contato com a mucosa intestinal. Comparativamente às demais afecções do intestino grosso dos eqüinos e pela análise dos resultados obtidos neste estudo, conclui-se que os processos obstrutivos causados por enterólitos ou corpos estranhos apresentam prognóstico favorável.(AU)

In the period from January 1993 to January 2003, 195 surgical procedures of equine acute abdomen were performed at the Service of Large Animal Surgery of the Veterinary Hospital of the School of Veterinary Medicine and Zootechnics of the University of São Paulo. From these 195 cases there were 30 enterolithiasis and seven foreign bodies located in the colono Thirty-five out of 37 laparotomies were performed in dorsal recumbency, with access through the ventral midline and two were performed through the flank, with the animal in standing position. Of the 37 animals, 25 were male and 12 were females. Age varied from one to 18 years old with any average of eight years of age. Location of enteroliths and foreign bodies was as follows: 13 (35.14%) in large colon, 19 (51.35%) in small colon, 03 (8.10%) in transverse colon and 02 (5.41 %) in both transverse and small colon. In regards to the clinical evolution, six were humenely eutmanized killed during surgery. From the 31 remaining, 23 (74,19%) were discharged,6 (19,36%) died and 2 (6,45%) were killed eutmanized during the post-operative period. Among those animals with satisfactory evolution two animals stand out. One of them had seven enteroliths and in the other, the nucleus of the mass was the tip of a nail, which protruded from the mass and was in constant contact with the intestinal mucosa. In spite of the large incidence of obstruction caused by enteroliths or foreign bodies in comparison of other studies, the prognosis of post-operative recovery is favourable.(AU)

[Theoretical study of the demarcation of the intestinal stoma]. / Estudo teórico da demarcação do estoma intestinal.

The present research focuses on the study of intestinal stoma demarcation. It reviews the historical development of the knowledge produced in this field, considering the advancement implemented in the area of abdominal surgeries which proposes the externalization of intestinal segments. In order to make the demarcation of intestinal stoma, it is necessary to limit the ideal region and to perform it with special pen which will propitiate the making of an anatomically appropriate opening. The stoma should favor the adaptation of devices which do the collection of effluents from the patient's intestines with a minimum of discomfort to the patient. The choice for the localization of the stoma, which is based on scientific principles, is made taking into consideration the structure of the recto-abdominal muscle and the distance from critical areas. At last, the most performed techniques of demarcation of the intestinal stoma are presented, as well as the procedures to be followed by the nurse or by the stoma therapist nurse.

Intestinal intussusception and occlusion caused by small bowel polyps in the Peutz-Jeghers syndrome. Management by combined intraoperative enteroscopy and resection through minimal enterostomy: case report

The Peutz-Jeghers syndrome is a hereditary disease that requires frequent endoscopic and surgical intervention, leading to secondary complications such as short bowel syndrome. CASE REPORT: This paper reports on a 15-year-old male patient with a family history of the disease, who underwent surgery for treatment of an intestinal occlusion due to a small intestine intussusception. DISCUSSION: An intra-operative fiberscopic procedure was included for the detection and treatment of numerous polyps distributed along the small intestine. Enterotomy was performed to treat only the larger polyps, therefore limiting the intestinal resection to smaller segments. The postoperative follow-up was uneventful. CONCLUSION: We point out the importance of conservative treatment for patients with this syndrome, especially those who will undergo repeated surgical interventions because of clinical manifestation while they are still young

Intestinal intussusception and occlusion caused by small bowel polyps in the Peutz-Jeghers syndrome. Management by combined intraoperative enteroscopy and resection through minimal enterostomy: case report.

UNLABELLED: The Peutz-Jeghers syndrome is a hereditary disease that requires frequent endoscopic and surgical intervention, leading to secondary complications such as short bowel syndrome. CASE REPORT: This paper reports on a 15-year-old male patient with a family history of the disease, who underwent surgery for treatment of an intestinal occlusion due to a small intestine intussusception. DISCUSSION: An intra-operative fiberscopic procedure was included for the detection and treatment of numerous polyps distributed along the small intestine. Enterotomy was performed to treat only the larger polyps, therefore limiting the intestinal resection to smaller segments. The postoperative follow-up was uneventful. CONCLUSION: We point out the importance of conservative treatment for patients with this syndrome, especially those who will undergo repeated surgical interventions because of clinical manifestation while they are still young.

Thirty years' experience with biliary tract reconstruction by hepaticoenterostomy and transhepatic T tube.

This study shows long-term results of biliary tract reconstruction in cases of high stenosis of the hepatic duct. Hepaticoenterostomy was performed with transhepatic insertion of a T tube following an original technique. A portion of the horizontal limb of the T tube is placed in the left hepatic duct, the other portion in the duodenum or jejunum, and the vertical limb extends into the right hepatic duct and the right lobe of the liver and is brought out through the abdominal wall. This tube is irrigated daily and removed after 12 months in order to keep the stent in place for a sufficient duration to prevent stenosis. This technique was used in 45 patients who underwent operations from 1954 to 1984. There were 6 postoperative deaths. Of the 39 patients discharged from the hospital, 37 were followed up. Excellent results were obtained in 30 patients who remained asymptomatic after observation from 1 to 14 years. In three patients, results were good, but there were occasional episodes of fever that subsided with antibiotics; one of these patients was observed for 17 years. Results were poor in four patients who developed a recurrent stenosis; three of them underwent reoperations, with satisfactory results. Long-term observation has shown that the described surgical procedure is useful in cases of high stenosis of the hepatic duct, because a stent can be left in place for a year and usually will prevent stenosis at the biliary intestinal anastomosis.