Conventional Linear versus Purse-string Skin Closure after Loop Ileostomy Reversal: Comparison of Wound Infection Rates and Operative Outcomes.

PURPOSE: Wound infection after an ileostomy reversal is a common problem. To reduce wound-related complications, purse-string skin closure was introduced as an alternative to conventional linear skin closure. This study is designed to compare wound infection rates and operative outcomes between linear and purse-string skin closure after a loop ileostomy reversal. METHODS: Between December 2002 and October 2010, a total of 48 consecutive patients undergoing a loop ileostomy reversal were enrolled. Outcomes were compared between linear skin closure (group L, n = 30) and purse string closure (group P, n = 18). The operative technique for linear skin closure consisted of an elliptical incision around the stoma, with mobilization, and anastomosis of the ileum. The rectus fascia was repaired with interrupted sutures. Skin closure was performed with vertical mattress interrupted sutures. Purse-string skin closure consisted of a circumstomal incision around the ileostomy using the same procedures as used for the ileum. Fascial closure was identical to linear closure, but the circumstomal skin incision was approximated using a purse-string subcuticular suture (2-0 Polysorb). RESULTS: Between group L and P, there were no differences of age, gender, body mass index, and American Society of Anesthesiologists (ASA) scores. Original indication for ileostomy was 23 cases of malignancy (76.7%) in group L, and 13 cases of malignancy (77.2%) in group P. The median time duration from ileostomy to reversal was 4.0 months (range, 0.6 to 55.7 months) in group L and 4.1 months (range, 2.2 to 43.9 months) in group P. The median operative time was 103 minutes (range, 45 to 260 minutes) in group L and 100 minutes (range, 30 to 185 minutes) in group P. The median hospital stay was 11 days (range, 5 to 4 days) in group L and 7 days (range, 4 to 14 days) in group P (P < 0.001). Wound infection was found in 5 cases (16.7%) in group L and in one case (5.6%) in group L (P = 0.26). CONCLUSION: Based on this study, purse-string skin closure after a loop ileostomy reversal showed comparable outcomes, in terms of wound infection rates, to those of linear skin closure. Thus, purse-string skin closure could be a good alternative to the conventional linear closure.

Transvaginal endoscopic appendectomy.

Since Kalloo and colleagues first reported the feasibility and safety of a peroral transgastric approach in the porcine model in 2004, various groups have reported more complex natural orifice transluminal endoscopic surgery (NOTES) procedures, such as the cholecystectomy, splenectomy and liver biopsy, in the porcine model. Natural orifice access to the abdominal cavity, such as transgastric, transvesical, transcolonic, and transvaginal, has been described. Although a novel, minimally invasive approach to the abdominal cavity is a peroral endoscopic transgastric approach, there are still some challenging issues, such as the risk of infection and leakage, and the method of gastric closure. Hybrid-NOTES is an ideal first step in humans. Human hybrid transvaginal access has been used for years by many surgeons for diagnostic and therapeutic purposes. Here, we report a transvaginal flexible endoscopic appendectomy, with a 5-mm umbilical port using ultrasonic scissors in a 74-year-old woman with acute appendicitis.

What prognostic factors are important for resected intrahepatic cholangiocarcinoma?

BACKGROUND AND AIM: Our aim was to evaluate the predictive factors for survival and disease-free survival of patients with resected intrahepatic cholangiocarcinoma (ICC). METHODS: Between October 1994 and 2005, 97 patients with ICC underwent curative hepatic resection. The tumors in 97 patients were reviewed retrospectively to examine the prognosis of ICC. RESULTS: The 1-, 3- and 5-year survival rates were 74.9%, 51.8% and 31.1%, respectively. The 1-, 3- and 5-year disease-free survival rates were 21.3%, 6.4% and 2.1%, respectively. Univariate analysis showed that tumor size, tumor number, the gross type, resection margin status, T-stage and lymph node involvement were significant prognostic factors. Multiple tumors and cancer cells in the resection margin were found in multivariate analysis to be significantly related to the prognosis. In the multivariate analysis disease free survival was poor for the patients with a large tumor, multiple lesions, a high CA 19-9 level, cancer in the resection margin, advanced T-stage and lymph node involvement. CONCLUSIONS: The overall 5-year survival rate of ICC was 31.1%. Multiple intrahepatic lesions were a sign of a poor prognosis for ICC. Better survival could be achieved by curative resection with a tumor-free margin.