Protective ileostomy: complications and mortality associated with its closure.

INTRODUCTION: diverting loop ileostomies are widely used in colorectal surgery to protect low rectal anastomoses. However, they may have various complications, among which are those associated with the subsequent stoma closure. The present study analyses our experience in a series of patients undergoing closure of loop ileostomies. METHOD: retrospective study of all the patients undergoing ileostomy closure at our hospital between 2006-2010. There were 89 patients: 56 males (63%) and 33 females (37%) with a mean age of 55 (38-71) years. The most common indication for ileostomy was protection of a low rectal anastomosis, 81 patients (91%). The waiting time until stoma closure, type and frequency of the complications, length of hospital stay and mortality rate are analysed. RESULTS: waiting time before surgery was 8 (1-25) months. Forty-one patients (45,9%) developed some type of complication, three were reoperated (3.37%) and one patient died (1.12%). The most important complications were intestinal obstruction (32.6%), diarrhoea(6%), surgical wound infection (6%), enterocutaneous fistula (4.5%), rectorrhagia (3.4%) and anastomotic leak (1.12%). The mean length of patient stay was 7.54 (2-23) days. CONCLUSIONS: protective ostomies in low rectal anastomoses have proved to be the only preventive measure for reducing the morbidity and mortality rates for anastomotic leakage. However, creation means subsequent closure, which must not be considered a minor procedure but an operation with possibly significant complications, including death, as has been shown in publications on the subject and in our own series.

Ileostomías de protección: complicaciones y mortalidad asociadas a su cierre / Protective ileostomy: complications and mortality associated with its closure

Introducción: las ileostomías derivativas son ampliamente utilizadas para proteger anastomosis rectales bajas. Sin embargo no están desprovistas de inconvenientes, como la posibilidad de presentar distintas complicaciones, entre las cuales figuran las asociadas al cierre ulterior del estoma. Analizamos nuestra experiencia en una serie de pacientes sometidos a cierre de ileostomías derivativas. Método: estudio retrospectivo de los pacientes sometidos a cierre de ileostomías en nuestro hospital, en un periodo comprendido entre 2006-2010. En total son 89 pacientes; 56 hombres (63%) y 33 mujeres (37%), con una edad media de 55 (38-71) años. La indicación más frecuente para llevar a cabo la ileostomía fue la protección de una anastomosis rectal baja, en un total de 81 pacientes (91%). Se analiza el tiempo de espera hasta el cierre del estoma, el tipo y frecuencia de las complicaciones, la estancia hospitalaria y la mortalidad. Resultados: el tiempo medio de espera entre la elaboración de la ileostomía y su cierre fue de 8 (1-25) meses. Cuarenta y un pacientes (45,9%) desarrollaron algún tipo de complicación, 3 de los cuales (3,37%) fueron reintervenidos y uno fue éxitus (1,12%). Las complicaciones más importantes fueron: obstrucción intestinal (32,6%), diarrea (6%), infección de la herida quirúrgica (6%), fístula enterocutánea (4,5%), rectorragia (3,4%), y dehiscencia anastomótica (1,12%). La estancia media de los pacientes fue de 7,54 (2-23) días. Conclusiones: la realización de ostomías de protección en las anastomosis rectales bajas ha demostrado ser la única medida preventiva eficaz para disminuir la morbi-mortalidad de las dehiscencias de las mismas. Sin embargo su cierre no debe considerarse un procedimiento menor, sino una intervención con posibles e importantes complicaciones(AU)

Introduction: diverting loop ileostomies are widely used in colorectal surgery to protect low rectal anastomoses. However, they may have various complications, among which are those associated with the subsequent stoma closure. The present study analyses our experience in a series of patients undergoing closure of loop ileostomies. Method: retrospective study of all the patients undergoing ileostomy closure at our hospital between 2006-2010. There were 89 patients: 56 males (63%) and 33 females (37%) with a mean age of 55 (38-71) years. The most common indication for ileostomy was protection of a low rectal anastomosis, 81 patients (91%). The waiting time until stoma closure, type and frequency of the complications, length of hospital stay and mortality rate are analysed. Results: waiting time before surgery was 8 (1-25) months. Fortyone patients (45,9%) developed some type of complication, three were reoperated (3.37%) and one patient died (1.12%). The most important complications were intestinal obstruction (32.6%), diarrhoea (6%), surgical wound infection (6%), enterocutaneous fistula (4.5%), rectorrhagia (3.4%) and anastomotic leak (1.12%). The mean length of patient stay was 7.54 (2-23) days. Conclusions: protective ostomies in low rectal anastomoses have proved to be the only preventive measure for reducing the morbidity and mortality rates for anastomotic leakage. However, creation means subsequent closure, which must not be considered a minor procedure but an operation with possibly significant complications, including death, as has been shown in publications on the subject and in our own series(AU)

[Colorectal stents: efficacy and complications in our center]. / Prótesis de colon y recto: eficacia y complicaciones en nuestro centro.

BACKGROUND: in emergency surgery, colorectal mortality is very high compared with elective surgery. An alternative is placement of endoscopic stents to correct the bowel obstruction and then allow elective surgery. Moreover, it is possible to use stents in the palliative treatment of patients at high surgical risk or with unresecable tumors. The aim of this study is to evaluate the rates of technical and clinical success and complications of colorectal stent placement over the past 5 years. METHODS: retrospective study of 33 patients in which stents were placed since 2006 to 2011. Variables were analyzed: 1) the indication (palliation or "bridge to surgery"), 2) rates of technical success and clinical success, and 3) complications (perforation, migration, bleeding, and reocclusion). RESULTS: in 24 patients the prosthesis was placed as a palliative treatment (72.7%) and in 9 cases as a "bridge to surgery". The technical success rate was 87.87% and 82.14% clinical success. There were five cases of bowel perforation with high pneumoperitoneum and a case of microperforation (18.1%). Five patients had reocclusion (17.2%); there were 3 and 4 with bleeding and migration. Three patients died within 24 hours after endoscopic treatment. In 9 cases of "bridge to surgery," technical success was 100% and 77% clinical success. One patient required emergency surgery due to migration of the prosthesis and reocclusion and another colonic perforation. CONCLUSIONS: endoscopic treatment is a good option as a transitional step to elective surgery or palliative treatment. But serious complications such as perforation or reocclusion should be considered.

Gastrointestinal bleeding and bowel obstruction as a presentation of Bouveret syndrome.

BACKGROUND: Bouveret syndrome is a rare entity consisting of duodenal obstruction due to a gallstone from the gallbladder. CLINICAL CASES: We present two patients with very different ages and comorbidities whose conditions were resolved in two different ways: a 41-year-old female with right upper quadrant pain and vomiting who underwent surgical correction of obstruction and fistula, and an 81-year-old female with a high bowel obstruction, only treating the obstruction without intervention of the fistula. CONCLUSIONS: It is important to include high gastrointestinal obstruction in the differential diagnosis. Diagnosis can be made either by radiological or endoscopic techniques and therapeutic options are diverse, ranging from endoscopic removal to surgery (with the resolution of obstruction and fistula in the same surgical procedure). This condition usually affects elderly patients with high comorbidities and high surgical risk; therefore, most authors recommend using the most conservative possible treatment.

Evaluation of a clinical pathway to improve colorectal cancer outcomes.

The aims of this preintervention and postintervention study were to monitor and evaluate the clinical pathway (CP) for colorectal cancer (CRC) over a 5-year period and to compare 2 groups of patients (before and after the intervention) with regard to different variables of effectiveness. Group I comprised 68 patients who underwent planned surgery between January 2002 and January 2003. Group II comprised a sample of 202 patients who underwent surgery between January 2004 and December 2008. No significant differences were found in the majority of the parameters measured: postoperative stay, compliance with antibiotic prophylaxis, compliance with the staging study, mortality, rate of infection, and reoperations. The mean length of stay (±standard deviation) for patients without complications was reduced significantly (9.2 ± 3.6 in group I versus 7.7 ± 1.7 in group II, P = .031). The CP for CRC did not achieve most of the objectives for which it was designed.

Unnoticed small bowel perforation as a complication of lumbar discectomy.

BACKGROUND CONTEXT: Surgery for disc herniation is one of the most common traumas and neurosurgical procedures. Although discectomy has low morbidity, serious intra-abdominal complications can affect retroperitoneal structures, such as the large vessels, small intestine, and ureters. CASE REPORT: A 36-year-old woman in uncontrollable pain presented with left sciatic neuralgia in the L5 region. Magnetic resonance imaging revealed an extruded left paracentral hernia at L5-S1. With the patient in the decubitus prone position, trauma surgeons specializing in spine surgery performed an L5-S1 flavectomy and a simple discectomy. Intraoperative complications were not observed. About 4 hours after surgery, the patient reported sharp abdominal pain and had persistent hypotension. Emergency abdominal computed tomography showed hemoperitoneum in the pouch of Douglas and left parietocolic space. Laparoscopic exploration confirmed hemoperitoneum without visible cause, a seton perforation of the small intestine, and a few adhesions in the right iliac fossa that were consequences of previous appendectomy. A laparotomy was then performed. A lesion was discovered in the mesentery of the rectosigmoid junction coinciding with the S5-L1 space. A segmental bowel resection and mechanical side-to-side anastomosis, with drainage, were done. The patient recovered satisfactorily despite a surgical wound infection. DISCUSSION: Although bowel perforation after discectomy rarely occurs, spine surgeons must try to prevent them by being more cautious during surgery. General surgeons must be highly suspicious of the presence of an intra-abdominal complication when there are signs and symptoms of a postoperative acute abdomen.

Repair of complex incisional hernias using double prosthetic repair: single-surgeon experience with 50 cases.

BACKGROUND: The treatment of complex incisional hernias is still difficult and controversial. With technologic developments we can modify and update the operative techniques described for treating complex abdominal wall hernias. METHODS: This is a prospective study of 50 patients with complex incisional hernias undergoing complex abdominal wall herniorrhaphy at a university hospital. All patients were evaluated in a multidisciplinary clinic dedicated to abdominal wall reconstruction. All patients underwent pre-operative computed tomography. Complex incisional hernias were regarded as those with multiple recurrences (>3 times), a previous mesh complicated by fistula and chronic infection, giant diffuse lumbar hernias, an associated parastomal hernia, or hernias developing after bariatric surgery. The operative technique was a double reconstruction prosthetic mesh. The type of repair as well as clinical, operative, and follow-up data were analyzed. RESULTS: Eight patients had considerable loss of tissue, 5 had trophic skin lesions, and 2 had chronic suppurative infection. The mean size of the defects was 18.2 cm. Morbidity included 5 cases of seroma, 2 neuralgias, and 2 cutaneous necroses. The mean duration of hospital stay was 5 days (range, 2-9). Complete follow-up (mean, 48 months; range, 12-108) showed no recurrent hernias. CONCLUSION: While awaiting a longer follow-up to confirm the results, we conclude that complex incisional hernias can be repaired safely and with a low morbidity and recurrence rate by means of a double prosthetic repair technique.

Treatment of incisional hernias adopting an intra-abdominal approach with a new low-density composite prosthetic material: proceed: our preliminary experience on 50 cases.

INTRODUCTION: The management of incisional hernias remains a challenge for the general surgeon. Repairing by using prosthetic materials has reduced the relapse rate, but intra-abdominal mesh placement continues to be a source of controversy. OBJECTIVE: An evaluation is made of the results of treating incisional hernias with a new intra-abdominal low-density composite mesh through both the open and the laparoscopic approach. PATIENTS AND METHODS: A prospective analysis was made on the first 50 patients operated upon for incisional hernia through the open (n=20) or laparoscopic route (n=30), with intra-abdominal repair using the Proceed composite mesh, composed of low-density polypropylene and a hydrophilic antiadherent membrane of oxidized regenerated cellulose. RESULTS: There were no patient deaths. Reintervention proved necessary in one case due to hemoperitoneum caused by a trocar. The mean duration of stay was 3 days, and all patients recovered bowel transit within 24 hours. During follow-up there were no intra-abdominal complications associated with the use of the mesh (intestinal occlusion or subocclusion, prolonged ileus, infections, rejection, fistulas, or relapses). CONCLUSIONS: Incision hernia repair using the intra-abdominal low-density composite mesh is safe and well tolerated. Proceed mesh facilitates laparoscopic hernioplasty maneuvering.

Nuevo caso de retroneumoperitoneo secundario al lavado con agua oxigenada de un absceso perianal / A new case of retropneumoperitoneum following washout with oxygenated water of a perianal abscess

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