A prospective, randomized assessment of a novel, local antibiotic releasing platform for the prevention of superficial and deep surgical site infections.

BACKGROUND: Despite significant advances in infection control guidelines and practices, surgical site infections (SSIs) remain a substantial cause of morbidity, prolonged hospitalization, and mortality among patients having both elective and emergent surgeries. D-PLEX100 is a novel, antibiotic-eluting polymer-lipid matrix that supplies a high, local concentration of doxycycline for the prevention of superficial and deep SSIs. The aim of our study was to evaluate the safety and efficacy of D-PLEX in addition to standard of care (SOC) in preventing superficial and deep surgical site infections for patients undergoing elective colorectal surgery. METHODS: From October 10, 2018 to October 6, 2019, as part of a Phase 2 clinical trial, we randomly assigned 202 patients who had scheduled elective colorectal surgery to receive either standard of care SSI prophylaxis or D-PLEX100 in addition to standard of care. The primary objective was to assess the efficacy of D-PLEX100 in superficial and deep SSI reduction, as measured by the incidence of SSIs within 30 days, as adjudicated by both an individual assessor and a three-person endpoint adjudication committee, all of whom were blinded to study-group assignments. Safety was assessed by the stratification and incidence of treatment-emergent adverse events. RESULTS: One hundred and seventy-nine patients were evaluated in the per protocol population, 88 in the intervention arm [51 males, 37 females, median age (64.0 range: 19-92) years] and 91 in the control arm [57 males, 34 females, median age 64.5 (range: 21-88) years]. The SSI rate within 30 day post-index surgery revealed a 64% relative risk reduction in SSI rate in the D-PLEX100 plus standard of care (SOC) group [n = 7/88 (8%)] vs SOC alone [n = 20/91 (22%)]; p = 0.0115. There was no significant difference in treatment-emergent adverse events. CONCLUSIONS: D-PLEX100 application leads to a statistically significant reduction in superficial and deep surgical site infections in this colorectal clinical model without any associated increase in adverse events.

Synchronous Hartmann reversal and incisional hernia repair is associated with higher complication rate compared to a staged procedure.

Post operative ventral hernias are common following Hartmann's procedure. There is a debate whether hernia repair is safe when performed concomitantly with colostomy closure. In this study we aimed to evaluate the outcomes of synchronous Hartmann reversal (HR) with a hernia repair, compared to a staged procedure. A retrospective multi-center study was conducted, including all patients who underwent Hartmann's procedure from January 2004 to July 2017 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. Two hundred and seventy-four patients underwent colostomy reversal following Hartmann's procedure. In 107 patients (39%) a concomitant ventral hernia was reported during the Hartmann's reversal. Out of this cohort, 62 patients (58%) underwent hernia repair during follow-up. Thirty two patients (52%) underwent a synchronous hernia repair and 30 patients (48%) underwent hernia repair as a separate procedure. Post operative complication rate was significantly higher in the colostomy reversal with synchronous hernia repair group when compared to HR alone group (53% vs. 20%; p < 0.01; OR 4.5). In addition, severe complication rate (Clavien-Dindo score ≥ 3) was higher in the synchronous hernia repair group (25% vs. 7%). A tendency for higher hernia recurrence rate was noted in the synchronous group (56% vs. 40%). Median follow up time was 2.53 years (range 1-13.3 years). Synchronous colostomy closure and ventral hernia repair following Hartmann's procedure carries a significant risk for post operative complications, indicating that a staged procedure might be preferable.

Timing of colostomy reversal following Hartmann's procedure for perforated diverticulitis.

AIM: Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. PATIENTS AND METHODS: A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. RESULTS: One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4). CONCLUSION: Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.

Adherence to the Mediterranean diet is associated with decreased fecal calprotectin in patients with ulcerative colitis after pouch surgery.

BACKGROUND: Mediterranean diet (MED) is associated with health benefits, yet scarce data exist regarding the role of MED in inflammatory bowel diseases (IBD). Herein, we aimed to evaluate the association between MED and inflammatory markers in patients with IBD after pouch surgery. METHODS: Consecutive patients after pouch surgery due to ulcerative colitis (UC) were recruited at a comprehensive pouch clinic. Adherence to MED was calculated according to MED score, ranging from 0 (low adherence) to 9 (high adherence), based on food-frequency questionnaires. Pouch behavior was defined as normal pouch (NP) or pouchitis based on Pouchitis Disease Activity Index (PDAI) and disease activity was defined as active or inactive. C-reactive protein (CRP) and fecal calprotectin were assessed. RESULTS: Overall 153 patients were enrolled (male gender 47%; mean age 46 ± 14 years; mean pouch age 9.5 ± 7 years). MED scores were higher in patients with normal vs. elevated CRP and calprotectin levels (4.6 ± 1.8 vs. 4.4 ± 1.6, p = 0.28; 4.8 ± 1.8 vs. 4.07 ± 1.7, p < 0.05, respectively). In a multivariate regression, MED score was associated with decreased calprotectin levels (OR = 0.74 [0.56-0.99]). Adherence to MED was associated with dietary fiber and antioxidants intake. Finally, in a subgroup of patients with NP followed up for 8 years, higher adherence to MED trended to be inversely associated with the onset of pouchitis (log rank = 0.17). CONCLUSIONS: In patients with UC after pouch surgery, adherence to MED is associated with decreased calprotectin levels. Thus, MED may have a role in modifying intestinal inflammation in IBD.

Fruit Consumption is Associated with Alterations in Microbial Composition and Lower Rates of Pouchitis.

BACKGROUND: Patients with ulcerative colitis [UC] who undergo proctocolectomy with an ileal pouch-anal anastomosis commonly develop pouch inflammation [pouchitis]. Pouchitis develops in a previously normal small intestine and may involve environmental factors. We explored whether diet and microbiota alterations contributed to the pathogenesis of pouchitis. METHODS: Patients were recruited and prospectively followed at a comprehensive pouch clinic. Pouch behaviour was clinically defined as a normal pouch [NP] or pouchitis. Patients completed Food Frequency Questionnaires [FFQs]. Faecal samples were analysed for microbial composition [16S rRNA gene pyrosequencing]. RESULTS: Nutritional evaluation was performed in 172 patients [59% females], and of these, faecal microbial analysis was performed in 75 patients (microbiota cohort: NP [n = 22], pouchitis [n = 53]). Of the entire cohort, a subgroup of 39 [22.6%] patients had NP at recruitment [NP cohort]. Of these, 5 [12.8%] developed pouchitis within a year. Patients at the lowest tertile of fruit consumption [<1.45 servings/day] had higher rates of pouchitis compared with those with higher consumption [30.8% vs 3.8%, log rank, p = 0.03]. Fruit consumption was correlated with microbial diversity [r = 0.35, p = 0.002] and with the abundance of several microbial genera, including Faecalibacterium [r = 0.29, p = 0.01], Lachnospira [r = 0.38, p = 0.001], and a previously uncharacterized genus from the Ruminococcaceae family [r = 0.25, p = 0.05]. Reduction in fruit consumption over time was associated with disease recurrence and with reduced microbial diversity [Δ = -0.8 ± 0.3, p = 0.008]. CONCLUSIONS: Fruit consumption is associated with modification of microbial composition, and lower consumption was correlated with the development of pouchitis. Thus, fruit consumption may protect against intestinal inflammation via alteration of microbial composition.

The outcome of ulcerative colitis patients undergoing pouch surgery is determined by pre-surgical factors.

BACKGROUND: Pouch surgery, a common intervention for ulcerative colitis (UC) complications, is often associated with the development of pouchitis. AIM: To identify predictors of pouch outcome in a cohort of patients with UC. METHODS: We conducted a retrospective unmatched case-cohort study in a tertiary IBD referral centre. Adult patients with UC were classified into the worst phenotype throughout follow-up: normal pouch, a form of chronic pouchitis (either chronic pouchitis or Crohn's like disease of pouch [CLDP]), or episodic recurrent acute pouchitis (RAP). Risk factors for pouchitis (chronic forms) were detected using statistical models. RESULTS: Two hundred and fifty-three pouch patients were followed up for 13.1±7.3 years. Only 71 patients (28.1%) maintained a favourable outcome of a sustained normal pouch. These patients were older at UC diagnosis (27.8±12.5 vs 23.0±11.4 years), had longer UC duration until surgery (13.4±9.5 vs 8.2±7.9 years), and had higher rates of referral to surgery due to nonrefractory (dysplasia/neoplasia) complications (42.3% vs 16.2%) compared with pouchitis patients. Median survival for sustained normal pouch was 10.8 years (95% CI 8.9-12.7 years), and it was longer in the nonrefractory group (20.3 vs 9.4 years for the refractory group, HR=2.37, 95% CI 1.25-3.52, P=.004). CONCLUSIONS: Most patients with UC undergoing pouch surgery will develop pouchitis. Patients operated for nonrefractory indications have a more favourable outcome. These results may contribute to pre- and post-surgical decision-making. The findings imply that the processes determining UC severity may be similar to that causing pouchitis.

Does residual microscopic disease after chemoradiotherapy for locally advanced rectal cancer translate into a good clinical outcome?

AIM: This study aimed to assess the progression-free and overall survival of patients with residual microscopic disease following neoadjuvant chemoradiotherapy and rectal resection for locally advanced rectal cancer. METHOD: Two-hundred and thirty-four consecutive rectal cancer patients who had neoadjuvant chemoradiotherapy followed by radical resection (from May 2000 to April 2012) were divided according to pathological tumour response: residual microscopic disease (MIC), complete response (pCR) and partial/no response (non-CR). Data on the neoadjuvant regime, treatment-to-surgery interval, final pathology, type of operation, operative time, postoperative complications, length of hospital stay, disease recurrence and mortality were compared between the groups. RESULTS: There were 13 (5.5%) MIC patients, 48 (20.5%) with pCR and 173 (73.9%) with non-CR group. The groups were demographically comparable. MIC patients had more retrieved lymph nodes compared with the non-CR and pCR patients (median 13 compared with 8 and 10, respectively, P = 0.0086). The 5-year overall survival rates were 93.4% for the pCR and MIC patients vs 82.1% for the non-CR patients (P = 0.0324). The 5-year progression-free survival was 85.2% for the pCR and MIC patients vs 73.8% for the non-CR patients (P = 0.086). CONCLUSION: We have identified and assessed a new pathological subgroup of rectal cancer patients who had residual microscopic disease after neoadjuvant therapy. The survival analysis aligned them closely with pCR patients.

Clinical recurrence and re-resection rates after extensive vs. segmental colectomy in Crohn's colitis: a retrospective cohort study.

BACKGROUND: The aim of the present study was to document long-term clinical recurrence and re-resection rates of segmental and extended colectomy in patients with Crohn's colitis and to identify risk factors causing recurrence. METHODS: Records of patients with isolated colonic Crohn's disease who underwent colectomy between 1995 and 2013 and were followed at our medical center were identified. Data on age at diagnosis, gender, smoking, disease location at diagnosis, perianal and rectal disease, indication for surgery, preoperative disease duration, type of operation, primary anastomosis at first operation, length of resected specimen, recurrence of symptoms, postoperative medication, reoperation, and total follow-up time were retrieved. RESULTS: Thirty-five suitable patients (18 segmental colectomy, 17 extensive colectomy; 17 males; mean age at operation 36.6 years) were identified. Mean age at primary operation was 36 years. The mean preoperative disease duration was 121 months. Postoperative medical treatment was needed in 10 (56 %) patients undergoing segmental colectomy and in 16 (94 %) of those undergoing extensive colectomy (p = 0.01). There was longer reoperation-free survival in the segmental colectomy patient group (p = 0.02) and also a trend toward longer symptom-free survival compared to the extensive colectomy patient group (p = 0.105). There was no correlation between the length of resected bowel and recurrence. Patients operated on at a younger age did not have a higher rate of recurrence of symptoms. Shorter disease duration, smoking, and male gender were risk factors for clinical recurrence. CONCLUSIONS: Segmental resection with primary anastomosis can be safely performed in patients with limited Crohn's colitis with reasonable clinical recurrence rates.

Restorative proctocolectomy impairs fertility and pregnancy outcomes in women with ulcerative colitis.

AIM: The effect of restorative proctocolectomy (RPC) on fertility and pregnancy in women with ulcerative colitis (UC) was evaluated. METHOD: Post-RPC female patients with UC who were attempting to become pregnant filled out questionnaires on fertility and pregnancy. Demographic and pouch data of pregnancies ending with delivery were collected from a prospective database. RESULTS: Forty-one women, 44 ± 10 years of age, completed the questionnaires. The median follow-up period post-RPC was 167 (range, 20-352) months. Before RPC, 26 women had 70 pregnancies and 62 deliveries. After RPC, 17 women had 32 pregnancies and 26 deliveries (P = 0.0035). Post-RPC, 10 (37%) of 27 patients failed to conceive compared with 26/26 successful attempts before RPC (P = 0.0006). The number of offspring per patient was 2.38 ± 1.27 before, and 0.68 ± 0.93 after, RPC (P < 0.0001). A higher number of spontaneous pregnancies occurred before (56/62; 90%) than after (15/25; 60%) RPC (P = 0.0004). The time to conception was longer (5.0 ± 11.6 vs 16.3 ± 25.1 months; P = 0.039) and there were more in-vitro fertilization procedures (three vs six) post-RPC. The gestation period was similar, but after RPC more deliveries were by Caesarean section (12.9% vs 46.2%; P = 0.0007). Babies born before RPC weighed more than those born after RPC (3.16 ± 0.61 kg vs 2.79 ± 0.68 kg, respectively; P = 0.0327). CONCLUSION: RPC is associated with an increased risk of infertility, similar duration of gestation and lower birthweight. Female candidates for RPC who have not finished family planning should be counselled accordingly.

Risk factors for chronic pouchitis after ileal pouch-anal anastomosis: a prospective cohort study.

AIM: The association between various demographic, clinical and pathological parameters and the evolution of chronic pouchitis was evaluated. METHOD: All ulcerative colitis patients who underwent ileal pouch anal anastomosis (1981-2009) were followed prospectively in a comprehensive pouch clinic. We examined risk factors including the presence of appendiceal inflammation and backwash ileitis in the colonic specimen, gender, ethnicity, age at disease onset, disease duration, extent of colitis, presence of extraintestinal manifestations (e.g. primary sclerosing cholangitis), family history of inflammatory bowel disease, indication for surgery, medical treatment, age at operation, staged procedure, diverting ileostomy and length of follow-up. Univariate analysis was performed on all risk factors followed by logistic regression analysis. RESULTS: The 201 enrolled patients (106 women, age at surgery 35 ± 15 years) were followed for a mean of 108 months. One hundred and thirty-eight (69%) had either a normal pouch or episodes of acute pouchitis and 63 (31%) developed chronic pouchitis. On univariate analysis the presence of an ileostomy (P = 0.017), pancolitis (P = 0.008), shorter disease duration (P = 0.04) and longer follow-up (P = 0.01) were identified as risk factors for chronic pouchitis. Multivariate analysis showed that patients with pancolitis (OR 3.26, 95% CI 1.20-8.85) and longer follow-up (OR 1.09, 95% CI 1.01-1.18) were more likely to develop chronic pouchitis. There was also an association to disease duration but this did not reach a level of significance. CONCLUSIONS: Pancolitis and longer follow-up are directly related to the development of chronic pouchitis.

Colorectal carcinoma in inflammatory bowel disease: a comparison between Crohn's and ulcerative colitis.

AIM: The study assessed the clinicopathological features and survival rates of inflammatory bowel disease (IBD) patients with colorectal carcinoma (CRC), which accounts for ∼ 15% of all IBD associated death. METHOD: The medical records of patients operated on for CRC in three institutions between 1992 and 2009 were reviewed, and those with Crohn's colitis (CC) and ulcerative colitis (UC) were identified. Data on age, gender, disease duration, colitis severity, surgical procedure, tumour stage and survival were retrieved. RESULTS: Fifty-three patients (40 UC and 13 CC, 27 men, mean age at operation 54 years) were found. All parameters were comparable between the groups. Mean disease duration before CRC was 22.7 years for UC and 16.6 years for CC patients (P = 0.04). CRC was diagnosed preoperatively in 43 (81%) patients. Twenty-eight patients had colon cancer, 23 had rectal cancer and two patients had more than one cancer. All malignancies were located in segments with colitis. Over one-half were diagnosed at an advanced stage (36% stage III; 17% stage IV). At a mean follow up of 56 ± 65 months, 60% were alive (54% disease free) and 40% were dead from cancer-related causes. The 5-year survival rate was 61% for the UC and 37% for the CC patients (P = NS). CONCLUSION: CRC in IBD patients is frequently diagnosed at an advanced stage, a factor that contributes to poor prognosis. The risk of CRC in CC patients is comparable to those with UC. Long-term surveillance is recommended for patients with long-standing CC and UC.

Three-dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry.

AIM: Anal sphincter anatomy on two-dimensional endoanal -ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three-dimensional (3D) measurements yield a better correlation. METHOD: The study group included consecutive patients who underwent 3D EUS for faecal incontinence over a 2-year period. The medical charts were reviewed for Cleveland Clinic Foundation Fecal Incontinence (CCF-FI) score and manometric pressures. Endoanal ultrasonographic images were reviewed for the presence of an external anal sphincter (EAS) defect and its extent, as determined by the radial angle, length in the sagittal plane and percentage volume deficit. Correlational analyses were performed between the clinical and imaging data. RESULTS: Sixty-one patients of median age 53 years (range 15-82) were evaluated. Thirty-two patients had either a complete (17) or partial (15) EAS defect, and 29 patients had an intact sphincter. The CCF-FI scores were similar in patients with and without an EAS defect (12.5 ± 5.6 and 11.4 ± 5.5, respectively). The intact-sphincter group had a significantly greater EAS length (3 ± 0.4 vs 2 ± 0.62 cm, P = 0.02) and higher mean maximal squeeze pressure (MMSP; 99.7 ± 52.6 vs 66.9 ± 52.9 mmHg, P = 0.009). There were no statistically significant correlations between MMSP, CCF-FI score and EAS status on 3D EUS. Mean percentage volume of the defect was similar in patients with complete and partial tears (14.5 ± 5.5 and 17.5 ± 7.2%, P = 0.25) and showed no correlation with physiological tests or symptom scores. CONCLUSION: Improvements in external anal sphincter imaging have not yielded a better association with the clinical findings. The lack of clinical differences between patients with different EAS tears may reflect their similar volumetric defects.

The effect of neoadjuvant Imatinib therapy on outcome and survival after rectal gastrointestinal stromal tumour.

AIM: The study aimed to characterize the pathological and clinical response of rectal gastrointestinal stromal tumours (GISTs) to neoadjuvant Imatinib. METHOD: The medical records of patients with rectal GISTs who were diagnosed and treated in five medical centres in Israel between January 2002 and January 2009 were retrospectively examined. Twelve patients who fulfilled the inclusion criteria of nonmetastatic rectal GIST for which preoperative neoadjuvant treatment with Imatinib was considered were suitable for enrollment. RESULTS: Of the 12 patients, nine received neoadjuvant treatment with Imatinib. The three patients who had immediate surgery were excluded. There were five men and four women with a median age of 63 years and a median follow up of 32 months. All tumours were located in the lower two-thirds of the rectum. One patient had a complete clinical response, six had a partial response and two had stable disease. Seven patients subsequently underwent surgery; six had an R0 resection and one had an R1 resection. Three patients had recurrence. There was no disease-related mortality. The reduction in both tumour size and mitotic activity during preoperative Imatinib therapy was significant. CONCLUSION: Preoperative Imatinib therapy can shrink large rectal GISTs, improving the chances of successful radical surgery and decreasing the risk of considerable morbidity.

Long-term outcome of loose seton for complex anal fistula: a two-centre study of patients with and without Crohn's disease.

OBJECTIVE: Complex anal fistulas traverse a significant portion of the external sphincter muscle, making their treatment a surgical challenge. Several surgical options are used with conflicting results. The aim of this study was to analyse the results of permanent loose seton in the management of high anal fistulas in Crohn's disease (CD) patients and two-stage seton fistulotomy in patients without CD. METHOD: We retrospectively reviewed the clinical records of 77 patients with complex anal fistula treated by loose seton over a 4-year period, in two medical centres. Recorded parameters included demographics, medical history, type of fistula, disease duration, previous surgery, morbidity, recurrence and mortality. RESULTS: Sixty patients without CD underwent 107 fistula-related surgical procedures, and 17 CD patients underwent 29 procedures. Early postoperative complications were recorded in eight (10%) patients. Perioperative complications, mainly local sepsis or bleeding, were recorded in eight (10%) patients. Long-term complications were observed in nine non-CD and four CD patients. During a median follow-up period of 24 months, the recurrence rate was 40% in CD patients and 47% in patients without CD. Five patients (four non-CD patients and one CD patient) developed some degree of faecal incontinence. CONCLUSION: The fistula recurrence rate following two-stage seton fistulotomy in non-CD patients was high. In CD patients the use of permanent loose seton is effective in controlling local sepsis in about half of patients and has low rates of subsequent incontinence.

Is stapled ileal pouch anal anastomosis a safe option in ulcerative colitis patients with dysplasia or cancer?

PURPOSE: The purpose of this study was to investigate the oncological and clinical outcome of ulcerative colitis (UC) patients with coexisting colorectal cancer/dysplasia following stapled ileal pouch-anal anastomosis (IPAA). MATERIALS AND METHODS: One hundred eighty-five UC patients who underwent stapled IPAA were followed prospectively in a comprehensive pouch clinic. They were divided into three groups: colorectal cancer, dysplasia, and no cancer/dysplasia. Demographic parameters, clinical data, and oncological and functional outcome of the three groups were compared. RESULTS: Sixteen patients had cancer and 14 had dysplasia. Two of the three cancer patients who developed metastatic disease died. One patient who had rectal cancer was found to have cancer cells in the rectal cuff 10 years after IPAA. All other cancer/dysplasia patients were disease-free at 62 months (median). The 5-year survival rate was 87.5% for the cancer group and 100% for the others (p < 0.0001). Chemotherapy (nine patients) did not affect pouch function. Two rectal cancer patients who received radiotherapy did not maintain a functioning pouch. Overall pouch failure rates were 19%, 7%, and 6% for cancer, dysplasia, and no-cancer/dysplasia patients, respectively (p = 0.13). The mean frequency of bowel movements in 24 h was similar between the groups. CONCLUSIONS: Stapled IPAA is a reasonable option for UC patients with cancer/dysplasia. Chemotherapy is safe, but the effect of radiation on pouch outcome is worrisome. Close long-term follow-up for UC patients with cancer/dysplasia is recommended for early detection of possible recurrence.

Intestinal pseudoobstruction.

Intestinal pseudoobstruction is an uncommon clinical condition of varied etiologies. Confusion in its characterization and diagnosis often results in delay in diagnosis as well as inappropriate treatment involving repeated surgery. The various aspects and characteristics of intestinal pseudoobstruction are described by representative case reports of three patients treated in our department with a review of the literature. Heightened awareness, understanding of the physiological dynamics and recognition of the spectrum of its clinical presentation and diagnostic modalities should result in more efficacious treatment.

Wound infection after ileostomy closure: a prospective randomized study comparing primary vs. delayed primary closure techniques.

BACKGROUND: Closure of ileostomy is considered a contaminated operation. The infection rate of the stoma wound is > or = 30%. Several ileostomy-closure techniques intended to reduce the high rate of infection have been described in the literature. Among them, delayed primary closure of the stoma wound is a commonly used method that was reported to reduce the infection rate according to several retrospective studies. We therefore conducted the first prospective randomized trial comparing primary with delayed primary closure of a stoma wound. METHODS: During 2003, 40 patients were admitted to our ward for closure of ileostomy. The ileostomies were taken down by the same team using the same surgical technique except for the technique of wound closure. We randomly divided the patients into two groups. In Group 1 (n = 20), the wound was left open for delayed primary closure and not closed until postoperative day 4. In Group 2, the wound was primarily closed at the end of the procedure. RESULTS: The total wound infection rate was relatively low (15%). Infection occurred more frequently (4 cases, 20%) in Group 1 than in Group 2 (2 cases, 10%). The length of hospital stay was similar for both groups. CONCLUSIONS: In this first prospective comparison of two techniques during ileostomy take down, primary closure unexpectedly produced less wound infection than delayed primary closure.

Pinealoblastoma in a patient with familial adenomatous polyposis: variant of Turcot syndrome type 2? Report of a case and review of the literature.

We report a case of a 23-year-old Turcot female patient who was first diagnosed as having a pinealoblastoma. Thyroid papillary carcinoma was diagnosed a few months later, and multiple colonic polyps were detected three years after that. A genetic workup revealed an APC gene mutation in her family. Long-term survival (i.e., >5 years) of pinealoblastoma is considered to be 20 percent. A review of 25 documented Turcot cases determined that the average age at death is 20.3 years, raising the difficult question of whether she should undergo restorative proctocolectomy. Restorative proctocolectomy may itself cause major morbidity but is currently the only way to prevent colon cancer.

Sentinel-lymph-node biopsy (SLNB) for melanoma is not complication-free.

BACKGROUND AND AIM: Sentinel lymph node biopsy (SLNB) is reportedly associated with insignificant morbidity. The study aims at documenting SLNB-related complications and identifying possible risk factors. METHOD: Data of all melanoma patients who underwent SLNB in our medical center (1994-2002) were analysed. Procedure-related complications were recorded. RESULTS: Three hundred and nine lymphatic basins of 250 patients were explored for SLNB. Overall complication rate was 20%. Sensory morbidity was significantly associated with axillary SLNB (p=0.04) and was more prevalent in younger patients. The use of blue dye alone or combined with a hand-held gamma probe had no statistically significant impact on the identification rate. There were six false-negatives (2.3%), for an overall false-negative rate of 18%. A positive sentinel node was significantly associated with shortened overall survival (p=0.04). CONCLUSION: Wound complications are more frequent than usually reported. Sensory morbidity occurs mostly in the axilla. Neck SLNB is associated with the highest rate of identification failure. Patient age, basin location, and number of excised nodes may serve as prognostic factors of morbidity.