Morbidity after closure of a defunctioning loop ileostomy.

PURPOSE: A low pelvic anastomosis is associated with a substantial risk of leakage. A defunctioning stoma (DS) reduces the clinical anastomotic leak rate and the need for re-operation, but stoma closure has its own risk of morbidity and mortality. This study aims to audit morbidity and mortality after loop ileostomy (LI) closure. PATIENTS AND METHODS: The medical records of 197 consecutive patients who underwent closure of a defunctioning LI between August 2003 and July 2008 were reviewed. Postoperative morbidity and mortality were recorded. RESULTS: Transverse closure of the enterotomy was performed in 149 patients (75.6%), segmental enterectomy with hand-sewn end-to-end anastomosis in 26 (13.2%) and stapled side-to-side anastomosis in 22 (11.2%). Overall postoperative morbidity and mortality were 32.0% and 0.5%, respectively. The surgical complication rate was 30.5%, including prolonged ileus (11.2%), small bowel obstruction (4.1%), anastomotic leak (3.0%) and wound infection (4.6%). Surgical complications were more frequent in male patients (p = 0.005). Prolonged ileus was more frequent when the interval to stoma reversal exceeded 12 weeks (14.3% versus 3.5% ; p = 0.02). The incidence of complications was not influenced by the closure technique. Nineteen patients (9.6%) required re-operation for anastomotic leak (n = 8), wound infection (n = 1), small bowel obstruction (n = 3) and incisional herniation (n = 7). CONCLUSION: LI closure is associated with clinically relevant morbidity and mortality. This association should be taken into account in the context of a routine DS policy and should be part of the patient's information.

Can vacuum-assisted closure and instillation therapy (VAC-Instill therapy) play a role in the treatment of the infected open abdomen?

Severe superimposed infection during open abdomen treatment with development of intra-abdominal sepsis is a challenging complication associated with high mortality rates. We report our experience with VAC-Instill therapy (KCI, San Antonio, USA) used for treatment of an infected open abdomen following pancreatic surgery. A literature search revealed no analogous case reports using VAC-Instill therapy for treatment of an infected laparostomy. The encouraging result of the case presented seems to indicate that VAC-Instill therapy could be used as adjunctive treatment in the management of the infected open abdomen when traditional therapy fails to control the infection.

Internal herniation after Roux-en-Y gastric bypass: case reports and a review of the literature.

Internal herniation, defined as a protrusion of the bowel through a peritoneal or mesenteric aperture into a compartment of the abdominal cavity, is a potentially serious complication following Roux-en-Y gastric bypass. In view of the high risk of strangulation and volvulus with possible progression to necrotic bowel, sepsis and multiple organ failure, early diagnosis and prompt surgical intervention are crucial to minimise morbidity and mortality rates. As little is known about internal herniation, pathogenesis, consequences, clinical presentation and diagnostic approach are discussed in this article. A review of the literature and the consideration of three cases make it clear that diagnosis is often delayed due to a vague, non-specific clinical presentation and the frequently negative radiological investigations. Displacement of the superior mesenteric artery (SMA) with crowding, stretching and engorgement of its visceral branches, mesenteric swirl and a clustered appearance of small bowel loops are CT findings with a high specificity but low sensitivity. A high degree of vigilance, communication between radiologists and surgeons and a low threshold for surgical exploration is therefore necessary.