HIV-associated rectovaginal fistulae in children: a single-centre retrospective study in the antiretroviral era.

PURPOSE: Acquired rectovaginal fistulae (RVF) are a complication of paediatric HIV infection. We report our experience with the surgical management of this condition. METHODS: We retrospectively reviewed the records of paediatric patients with HIV-associated RVF managed at Chris Hani Baragwanath Academic Hospital (2011-2023). Information about HIV management, surgical history, and long-term outcomes was collected. RESULTS: Ten patients with HIV-associated RVF were identified. Median age of presentation was 2 years (IQR: 1-3 years). Nine patients (9/10) underwent diverting colostomy, while one demised before the stoma was fashioned. Fistula repair was performed a median of 17 months (IQR: 7.5-55 months) after colostomy. An ischiorectal fat pad was interposed in 5/9 patients. Four (4/9) patients had fistula recurrence, 2/9 patients developed anal stenosis, and 3/9 perineal sepsis. Stoma reversal was performed a median of 16 months (IQR: 3-25 months) after repair. Seven patients (7/9) have good outcomes without soiling, while 2/9 have long-term stomas. Failure to maintain viral suppression after repair was significantly associated with fistula recurrence and complications (φ = 0.8, p < 0.05). CONCLUSION: While HIV-associated RVFs remain a challenging condition, successful surgical treatment is possible. Viral suppression is a necessary condition for good outcomes.

Low Hartmann's procedure versus abdominoperineal resection for rectal cancer, a propensity score matching cohort study.

BACKGROUND: This study aimed to compare low Hartmann's procedure (LHP) with abdominoperineal resection (APR) for rectal cancer (RC) regarding postoperative complications. METHOD: RC patients receiving radical LHP or APR from 2015 to 2019 in our center were retrospectively enrolled. Patients' demographic and surgical information was collected and analyzed. Propensity score matching (PSM) was used to balance the baseline information. The primary outcome was the incidence of major complications. All the statistical analysis was performed by SPSS 22.0 and R. RESULTS: 342 individuals were primarily included and 134 remained after PSM with a 1:2 ratio (50 in LHP and 84 in APR). Patients in the LHP group were associated with higher tumor height (P < 0.001). No significant difference was observed between the two groups for the incidence of major complications (6.0% vs. 1.2%, P = 0.290), and severe pelvic abscess (2% vs. 0%, P = 0.373). However, the occurrence rate of minor complications was significantly higher in the LHP group (52% vs. 21.4%, P < 0.001), and the difference mainly lay in abdominal wound infection (10% vs. 0%, P = 0.006) and bowel obstruction (16% vs. 4.8%, P = 0.028). LHP was not the independent risk factor of pelvic abscess in the multivariate analysis. CONCLUSION: Our data demonstrated a comparable incidence of major complications between LHP and APR. LHP was still a reliable alternative in selected RC patients when primary anastomosis was not recommended.

Postoperative morbidity following Hartmann's procedure in comparison to anterior resection and abdominoperineal resection for rectal cancer-a population-based study.

AIM: There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry. METHODS: All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry. RESULTS: A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality. CONCLUSIONS: For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.

Long-term restoration of bowel continuity after rectal cancer resection and the influence of surgical technique: A nationwide cross-sectional study.

AIM: Literature on nationwide long-term permanent stoma rates after rectal cancer resection in the minimally invasive era is scarce. The aim of this population-based study was to provide more insight into the permanent stoma rate with interhospital variability (IHV) depending on surgical technique, with pelvic sepsis, unplanned reinterventions and readmissions as secondary outcomes. METHOD: Patients who underwent open or minimally invasive resection of rectal cancer (lower border below the sigmoid take-off) in 67 Dutch centres in 2016 were included in this cross-sectional cohort study. RESULTS: Among 2530 patients, 1470 underwent a restorative resection (58%), 356 a Hartmann's procedure (14%, IHV 0%-42%) and 704 an abdominoperineal resection (28%, IHV 3%-60%). Median follow-up was 51 months. The overall permanent stoma rate at last follow-up was 50% (IHV 13%-79%) and the unintentional permanent stoma rate, permanent stoma after a restorative procedure or an unplanned Hartmann's procedure, was 11% (IHV 0%-29%). A total of 2165 patients (86%) underwent a minimally invasive resection: 1760 conventional (81%), 170 transanal (8%) and 235 robot-assisted (11%). An anastomosis was created in 59%, 80% and 66%, with corresponding unintentional permanent stoma rates of 12%, 24% and 14% (p = 0.001), respectively. When corrected for age, American Society of Anesthesiologists classification, cTNM, distance to the anorectal junction and neoadjuvant (chemo)radiotherapy, the minimally invasive technique was not associated with an unintended permanent stoma (p = 0.071) after a restorative procedure. CONCLUSION: A remarkable IHV in the permanent stoma rate after rectal cancer resection was found. No beneficial influence of transanal or robot-assisted laparoscopy on the unintentional permanent stoma rate was found, although this might be caused by the surgical learning curve. A reduction in IHV and improving preoperative counselling for decision-making for restorative procedures are required.

Optimizing stoma closure: A laparoscopic technique yielding the least contamination.

In this study, we introduce a novel method for stoma closure, aiming to reduce wound infection rates. This method involves creating the common channel of both limbs of a loop stoma extracorporeally, which is particularly beneficial during laparoscopic stoma closure surgery by potentially avoiding contamination of the wound. We applied this technique in 23 patients undergoing laparoscopic stoma reversal surgery, comprising both loop colostomy and ileostomy cases. Notably, postoperative outcomes were promising: only two patients experienced postoperative ileus, and importantly, there were no instances of wound infection. These findings suggest that our laparoscopic stoma reversal surgery approach is not only safe and feasible but also offers a significant advantage in reducing wound infection rates.

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies.

BACKGROUND: The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence. OBJECTIVE: To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction. DATA SOURCES: A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023. STUDY SELECTION: Randomized controlled trials and propensity score-matched studies. INTERVENTIONS: Emergency colonic resection, self-expanding metallic stent, and decompressing stoma. MAIN OUTCOME MEASURES: Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates. RESULTS: Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively. LIMITATIONS: There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction. CONCLUSIONS: This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Management of the Difficult Stoma.

Fecal ostomy creation is a commonly performed procedure with many indications. Better outcomes occur when preoperative patient education and stoma site marking are provided. Despite a seemingly simple operation, ostomy creation is often difficult and complications are common. Certain risk factors, particularly obesity, are strongly associated with stoma-related complications. The ability to optimize the ostomy and stoma in the operating room and to troubleshoot frequently encountered post-operative stoma-related issues are critical skills for surgeons and ostomy nurses alike.

Primary anastomosis with diverting loop ileostomy vs. Hartmann's procedure for acute diverticulitis: what happens after discharge? Results of a nationwide analysis.

BACKGROUND: Current guidelines recommend resection with primary anastomosis with diverting loop ileostomy over Hartmann's procedure if deemed safe for acute diverticulitis. The primary objective of the current study was to compare the utilization of these strategies and describe nationwide ostomy closure patterns and readmission outcomes within 1 year of discharge. METHODS: This was a retrospective, population-based, cohort study of United States Hospitals reporting to the Nationwide Readmissions Database from January 2011 to December 2019. There were 35,774 patients identified undergoing non-elective primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis. Rates of ostomy closure, unplanned readmissions, and complications were compared. Cox proportional hazards and logistic regression models were used to control for patient and hospital-level confounders as well as severity of disease. RESULTS: Of the 35,774 patients identified, 93.5% underwent Hartmann's procedure. Half (47.2%) were aged 46-65 years, 50.8% female, 41.2% publicly insured, and 91.7% underwent open surgery. Primary anastomosis was associated with higher rates of 1-year ostomy closure (83.6% vs. 53.4%, p < 0.001) and shorter time-to-closure [median 72 days (Interquartile range 49-103) vs. 115 (86-160); p < 0.001]. Primary anastomosis was associated with increased unplanned readmissions [Hazard Ratio = 2.83 (95% Confidence Interval 2.83-3.37); p < 0.001], but fewer complications upon stoma closure [Odds Ratio 0.51 (95% 0.42-0.63); p < 0.001]. There were no differences in complications between primary anastomosis and Hartmann's procedure during index admission [Odds Ratio = 1.13 (95% Confidence Interval 0.96-1.33); p = 0.137]. CONCLUSION: Patients who undergo primary anastomosis for acute diverticulitis are more likely to undergo ostomy reversal and experience fewer postoperative complications upon stoma reversal. These data support the current national guidelines that recommend primary anastomosis in appropriate cases of acute diverticulitis requiring operative treatment.

Risk factors for stoma prolapse after laparoscopic loop colostomy.

BACKGROUND: Stoma prolapse (SP) is a common stoma-related complication, particularly in loop colostomies. This study aimed to investigate potential risk factors for SP development after laparoscopic loop colostomy. METHODS: In total, data from 140 patients who underwent laparoscopic loop colostomy were analyzed between September 2016 and March 2022. Risk factors for SP were investigated retrospectively. RESULTS: The median follow-up duration after colostomy was 12.5 months, and SP occurred in 33 (23.6%) patients. Multivariate analysis showed that being overweight (body mass index ≥ 25; odds ratio [OR], 8.69; 95% confidential interval [CI], 1.61-46.72; p = 0.012) and having a thin rectus abdominis penetration of the stoma (< 8.9 mm; OR, 8.22; 95% CI, 2.50-27.05; p < 0.001) were independent risk factors for SP. Other patient characteristics and surgical factors associated with stoma construction were unrelated to SP development. CONCLUSIONS: Being overweight and the route penetrating the thinner rectus abdominis during stoma construction was associated with a significantly higher incidence of SP after laparoscopic loop colostomy. Selecting a construction site that penetrates the thicker rectus abdominis muscle may be crucial for preventing SP.

Restoration of intestinal continuity following emergency sigmoid colectomy for sigmoid volvulus: An American College of Surgeons National Surgical Quality Improvement Program analysis using coarsened exact matching.

BACKGROUND: There is limited data to guide decision-making between performing a primary anastomosis and fashioning an end colostomy following emergency sigmoid colectomy for patients with sigmoid volvulus. The aim of this study was to compare the outcomes of these two approaches. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2021 was retrospectively analyzed. Missing data were multiply imputed, and coarsened exact matching was performed to generate matched cohorts. Rates of major complications and other postoperative outcomes were evaluated among patients who had a primary anastomosis as compared with matched controls who had an end colostomy following emergency sigmoid colectomy. RESULTS: Overall, 4041 patients who had a primary anastomosis and 1240 who had an end colostomy met the inclusion criteria. After multiple imputation and coarsened exact matching, 895 patients who had a primary anastomosis had a matched control. The rate of major complications was lower in patients who had an end colostomy (33.2% vs. 36.7%), but this difference was not statistically significant (OR 0.86, 95% CI 0.70-1.05). Results were similar in subgroup analyses of higher-risk patients. There were no significant differences in overall complication rate, mortality, length of hospital stay, or readmission rate. Patients with a colostomy were more likely to be discharged to a care facility (OR 1.35, 95% CI 1.09-1.67). CONCLUSION: Differences in rates of major complications and many other outcomes after primary anastomosis as compared with end colostomy were not statistically significant following emergency sigmoid colectomy for sigmoid volvulus.

Clinical application of middle descending colon-double lumen ostomy with distal stoma narrowing in the treatment of anorectal malformation.

BACKGROUND: Anorectal malformations (ARMs) are the most common congenital anomaly of the digestive tract. And colostomy should be performed as the first-stage procedure in neonates diagnosed with intermediate- or high-type ARMs. However, the most classic Pe˜na's colostomy still has some disadvantages such as complicated operation procedure, susceptibility to infection, a greater possibility of postoperative incision dehiscence, difficulty of nursing and large surgical trauma and incision scarring when closing the stoma. We aimed to explore the effectiveness of middle descending colon-double lumen ostomy (MDCDLO) in the treatment of high and intermediate types of anorectal malformations. METHODS: We retrospectively reviewed the data of patients who underwent MDCDLO for high or intermediate types of ARMs between June 2016 and December 2021 in our hospital. The basic characteristics were recorded. All patients were followed up monthly to determine if any complication happen. RESULTS: There were 17 boys and 6 girls diagnosed with high or intermediate types of ARMs in our hospital between June 2016 and December 2021. All 23 patients were cured without complications such as abdominal incision infection, stoma stenosis, incisional hernia, and urinary tract infection in the postoperative follow-up time of 6 months to 6 years except one case of proximal intestinal prolapse was restored under anesthesia. CONCLUSION: MDCDLO offers the advantages of simplicity, efficiency, safety, mild trauma, and small scarring in the treatment of high and intermediate types of anorectal malformations.

Novel Repair Technique for Oral and Anal Side Stoma Prolapse of a Loop Colostomy With the Stapled Modified Altemeier Method Using Indocyanine Green Fluorescence Imaging.

BACKGROUND/AIM: Stoma prolapse is a common complication in the late phase after stoma creation. With advances in chemotherapy, a double-orifice colostomy or ileostomy and chemotherapy are used to treat primary unresectable colorectal cancer. Preoperative therapy with a double-orifice colostomy or ileostomy is performed to aid primary colorectal cancer miniaturization. Therefore, the number of stoma prolapses will likely increase in the future. Previous reports on the repair of stoma prolapse focused on unilateral stoma prolapse of loop colostomy, and there are no reports about the bilateral stoma prolapse of loop colostomy or ileostomy. CASE REPORT: We report a novel repair technique for oral and anal side (bilateral) stoma prolapse of a loop colostomy with the stapled modified Altemeier method using indocyanine green (ICG) fluorescence imaging considering the distribution of marginal artery in preventing marginal artery injury which has considerable clinical significance. CONCLUSION: Our novel technique for the oral and anal side prolapse of a loop colostomy is considered effective and safe.

Experience with colostomy and colostomy reversal in children in Bauchi.

Background: Colostomy is one of the common surgical procedures performed in pediatric surgical practice. The aim of this study was to retrospectively review our experience with colostomy and closure (reversal) in children. Patients and Methods: A retrospective review of the data of all children aged 15 years and below who had colostomy and colostomy closure in the past 5 years. Results: Of the 67 children who had colostomy 42 (62.7%) boys and 25 (37.3%) girls, with an age range between 13 months and 8 years. Fifty-six (83.6%) of the children were <2 years. Anorectal malformation 53 (79.1%) was the common indication. Divided colostomy was performed in 62 (92.5%) patients and loop colostomy was performed in 5 (7.5%) patients. All the patients had intraperitoneal colostomy closure. A complication rate of 26.4% was seen. Duration of hospital stay ranged between 4 and 10 days. No mortality was recorded. Conclusion: Colostomy reversal is a safe procedure but morbidity may ensure and can easily manage.

Résumé Contexte: La colostomie est l'une des interventions chirurgicales courantes pratiquées en chirurgie pédiatrique. Le but de cette étude était de revoir rétrospectivement notre expérience en matière de colostomie et de fermeture (inversion) chez les enfants. Méthode: Une revue rétrospective des données de tous les enfants âgés de 15 ans et moins ayant subi une colostomie et une fermeture de colostomie au cours des 5 dernières années. Résultats: Sur les 67 enfants ayant subi une colostomie, 42 (62,7 %) garçons et 25 (37,3 %) filles, avec une tranche d'âge comprise entre 13 mois et 8 ans. Cinquante-six (83,6 %) des enfants avaient moins de 2 ans. La malformation ano-rectale 53 (79,1 %) était l'indication fréquente. Une colostomie divisée a été réalisée chez 62 (92,5 %) patients et une colostomie en anse réalisée chez 5 (7,5 %) patients. Tous les patients ont eu une colostomie intrapéritonéale fermée. Un taux de complications de 26,4 % a été observé. La durée du séjour à l'hôpital variait entre 4 et 10 jours. Aucune mortalité enregistrée. Conclusion: l'inversion de la colostomie est une procédure sûre mais la morbidité peut être assurée et peut être facilement gérée.

Hartmann's procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study.

PURPOSE: This study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann's procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann's procedure. METHODS: Prospectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis. RESULTS: Altogether, 1141 patients who underwent Hartmann's procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann's procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann's procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann's procedure. CONCLUSIONS: The decision to perform Hartmann's procedure was frequently made intraoperatively. Hartmann's procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.

Development and pilot testing of a patient-reported outcome measure to assess symptoms of parastomal hernia.

AIM: The aim was to develop and pilot a patient-reported outcome measure (PROM) to assess symptoms of parastomal hernia (PSH). METHODS: Standard questionnaire development was undertaken (phases 1-3). An initial list of questionnaire domains was identified from validated colorectal cancer PROMs and from semi-structured interviews with patients with a PSH and health professionals (phase 1). Domains were operationalized into items in a provisional questionnaire, and 'think-aloud' patient interviews explored face validity and acceptability (phase 2). The updated questionnaire was piloted in patients with a stoma who had undergone colorectal surgery and had a computed tomography scan available for review. Patient-reported symptoms were examined in relation to PSH (phase 3). Three sources determined PSH presence: (i) data about PSH presence recorded in hospital notes, (ii) independent expert review of the computed tomography scan and (iii) patient report of being informed of a PSH by a health professional. RESULTS: For phase 1, 169 and 127 domains were identified from 70 PROMs and 29 interviews respectively. In phase 2, 14 domains specific to PSH were identified and operationalized into questionnaire items. Think-aloud interviews led to three minor modifications. In phase 3, 44 completed questionnaires were obtained. Missing data were few: 5/660 items. PSH symptom scores associated with PSH presence varied between different data sources. The scale with the most consistent differences between PSH presence and absence and all data sources was the stoma appearance scale. CONCLUSION: A PROM to examine the symptoms of PSH has been developed from the literature and views of key informants. Although preliminary testing shows it to be understandable and acceptable it is uncertain if it is sensitive to PSH-specific symptoms and further psychometric testing is needed.

The clinical applications of D-type parastomal hernia repair surgery.

OBJECTIVE: This study investigated the use of a modified laparoscopic repair of paraostomy hernia technique, called "D-Type parastomal hernia repair surgery" which combines abdominal wall and extraperitoneal stoma reconstruction, in patients with parastomal hernia (PSH) following colorectal stoma surgery. The aim was to determine whether D-type parastomal hernia repair surgery is a promising surgical approach compared to the traditional laparoscopic repair technique (Sugarbaker method) for patients with PSH. METHODS: PSH patients were selected and retrospectively divided into two groups: the study group underwent D-type parastomal hernia repair, while the control group underwent laparoscopic Sugarbaker repair. Clinical data from both groups were analyzed. RESULT: Compared to control group (n = 68), the study group undergoing D-type stoma lateral hernia repair had significant increase in total operative time (98.82 ± 12.37 min vs 124.61 ± 34.99 min, p < 0.001). The study group also showed better postoperative stoma bowel function scores in sensory ability, frequency of bowel movements, and clothing cleanliness without a stoma bag (p = 0.037, 0.001, 0.002). The treatment cost was significantly higher in the control group (3899.97 ± 260.00$ vs 3215.91 ± 230.03$, p < 0.001). The postoperative recurrence rate in the control group was 26.4%, while in the study group, it was 4.3%, with a significant statistical difference (p = 0.024). In terms of long-term postoperative complications, the study group had an overall lower incidence compared to the control group (p = 0.035). Other parameters showed no significant differences between the two groups. CONCLUSION: The study suggests that D-type parastomal hernia repair surgery is a safe and feasible procedure. Compared to traditional surgery, it can reduce the recurrence of lateral hernia, improve postoperative stoma bowel function, and save medical resources.