Small bowel anastomosis in emergency surgery.

BACKGROUND: Emergency laparotomy is associated with a high morbidity and mortality rate. The decision on whether to perform an anastomosis or an enterostomy in emergency small bowel resection is guided by surgeon preference alone, and not evidence based. We examined the risks involved in small bowel resection and anastomosis in emergency surgery. METHODS: A retrospective study from 2016 to 2019 in a university hospital in Denmark, including all emergency laparotomies, where small-bowel resections, ileocecal resections, right hemicolectomies and extended right hemicolectomies where performed. Demographics, operative data, anastomosis or enterostomy, as well as postoperative complications were recorded. Primary outcome was the rate of bowel anastomosis. Secondary outcomes were the anastomotic leak rate, mortality and complication rates. RESULTS: During the 3.5-year period, 370 patients underwent emergency bowel resection. Of these 313 (84.6%) received an anastomosis and 57 (15.4%) an enterostomy. The 30-day mortality rate was 12.7% (10.2% in patients with anastomosis and 26.3% in patients with enterostomy). The overall anastomotic leak rate was 1.6%, for small-bowel to colon 3.0% and for small-bowel to small-bowel 0.6%. CONCLUSION: A primary anastomosis is performed in more than eight out of 10 patients in emergency small bowel resections and is associated with a very low rate of anastomotic leak.

Two Novel, Nonoperative Methods of Stoma Prolapse in Newborns: 3 Case Reports.

BACKGROUND: Prolapse is a common complication following enterostomy; the defect and consequences of a prolapse significantly affect health-related quality of life. Creative techniques must be employed to manage the prolapse. CASES: This article describes management of 3 neonates with stoma prolapse. CONCLUSION: Management of stoma prolapse should be individualized, employing successful nonoperative techniques rather than more difficult operative procedures to prevent recurrent prolapse.

Treatment of jejunoileal atresia by primary anastomosis or enterostomy: Double the operations, double the risk of complications.

PURPOSE: No study has evaluated complication rates of the combined operations needed for temporary Enterostomy compared to primary anastomosis in the treatment of Jejunoileal Atresia. Therefore the aim of this study is: 1) to compare the occurrence of severe postoperative complications (defined as Clavien-Dindo ≥III within 30 days) and 2) to compare the occurrence of different short- and long-term complications following treatment for Jejunoileal atresia either by primary anastomosis or the combined Enterostomy procedures. METHODS: All consecutive neonates treated for Jejunoileal Atresias between January 1998 and February 2021 at our tertiary academic centres were retrospectively included. Perioperative characteristics and severity of postoperative complications (Clavien-Dindo) were extracted and evaluated, using chi-squared statistics, following each operation per treatment. RESULTS: Eighty patients were included of whom 48 (60%) received a primary anastomosis and 32 (40%) an Enterostomy. Perioperative baseline characteristics were comparable, apart from significantly more patients with a gastroschisis and significantly less patients with jejunum atresia in the Enterostomy group. Our results showed that 1) significantly (p ≤ 0.01) more CD ≥III occur following treatment by Enterostomy. 2) Both short-term (surgical site infection, wound dehiscence) and long-term (short bowel syndrome, adhesive bowel obstruction) complications occurred significantly more in those treated by Enterostomy. We showed no significant difference in anastomotic leakage/stenosis and mortality rates between both treatment strategies. CONCLUSION: Although perioperative factors might necessitate an Enterostomy, we advise a low threshold for performing a primary anastomosis when in doubt, taking into account the double risk of major complications found in patients treated with a temporary Enterostomy.

A Review on Safety and Outcomes of Mucous Fistula Refeeding in Neonates.

INTRODUCTION: The utility of mucous fistula refeeding (MFR) in neonates with short bowel syndrome is widely debated. Our purpose is to review MFR and outline methods, reported complications, and clinical outcomes (survival, weight gain, dependence on parenteral nutrition [PN], and time to enteral autonomy). MATERIALS AND METHODS: We performed a MEDLINE literature search and reference review from January 1980 to May 2020 for terms ("mucous fistula re-feeding" or "enteral re-feeding") and neonates. We included studies that utilized conventional MFR in the neonatal period. Non-English language articles were excluded. RESULTS: We identified 11 relevant articles. Internationally, there was no consensus on methods of MFR. A total of 197 neonates underwent MFR. Within a single study, four neonates developed major complications; however, the procedure was well tolerated without major complications in 10 of the 11 studies. A mortality of nine patients during MFR highlights the burden of disease within the study population; however, of these, only one was directly attributable to MFR. Minor complications were seldom quantified. Three studies demonstrated a higher rate of weight gain and shorter PN support versus controls. Neonates who underwent MFR had lower chance of anastomotic leak and quicker progression to full feed after reversal versus controls. The influence of microorganisms in MFR was only investigated in one study. CONCLUSION: Current evidence suggests benefits of MFR; however, an international consensus is yet to be reached on the optimal method. A large prospective study investigating the influence of MFR on the enteric system is required.

Transumbilical laparoscopy-assisted Malone procedure for fecal incontinence in children.

BACKGROUND: Transumbilical laparoscopy-assisted Malone procedure (TULAM) is a single-incision laparoscopic procedure in which the appendicostomy is made at umbilicus. The aim of this study is to evaluate the outcomes of TULAM. METHODS: With IRB approval, the medical records of the patients who underwent TULAM were retrospectively reviewed between July 2013 and December 2018. The data collected included ages, gender, underlying diseases, operative techniques, complications, stoma continence, parental satisfaction and follow-up duration. RESULTS: Fifteen patients underwent TULAM at the median age of 5.0 years (2.9-10.7 years). There were 4 girls and 11 boys. Thirteen patients had anorectal malformations or cloaca; the other two patients had spina bifida. All patients presented with fecal incontinence; 9 of them had concomitant constipation. TULAM was successfully accomplished in 14 patients; one patient required conversion to the three-port procedure. The median follow-up period was 1.7 years (0.5-3.2 years). One patient required tube replacement under endoscopy guidance in the operation room. One patient required surgical revision because the appendix was disrupted after an episode of enterocolitis. All patients were socially continent with antegrade enemas. 12 patients were stoma continent, and 3 patients had minor leaking less than once a month. The stoma cosmesis was satisfactory. All parents expressed satisfaction with TULAM. CONCLUSION: TULAM is effective in the management of fecal incontinence and constipation, and provides a continent stoma with excellent cosmesis.

Variation of plasma citrulline as a predictive factor for weaning off long-term parenteral nutrition in children with neonatal short bowel syndrome.

BACKGROUND & AIMS: Long-term parenteral nutrition (PN) is the mainstay of the therapeutic strategy in intestinal failure (IF) due to neonatal short bowel syndrome (SBS). Our aim was to identify prognostic factors for PN weaning and to assess if measuring plasma citrulline concentrations over time could account for the intestinal adaptation in progress. METHODS: This retrospective study included children with neonatal SBS with surgical measurement of the residual bowel length and repeated plasma citrulline assessments during a 4-year follow-up. The degree of IF was assessed by the PN dependency index (PN caloric intake/Resting energy expenditure). The analysis was carried out according to SBS anatomical groups: end-jejunostomy (type 1), jejuno-colic (type 2) and jejuno-ileal anastomosis (type 3). RESULTS: Fifty-five patients (8 type 1, 27 type 2, 20 type 3) were included. None of the patients with SBS type 1, 11 (41%) with type 2 and 11 (55%) with type 3 were weaned off during the follow-up period. Plasma citrulline levels significantly increased with time in patients who were finally weaned off PN; conversely, the levels did not consistently increase in patients who were still on PN at the end of the study period. There was an inverse relationship between plasma citrulline levels and the PN dependency index. The increasing citrulline levels had a positive effect on the probability of weaning, 2.7 times higher for each point increase in citrulline. No significant effect of age and residual bowel length at baseline was found. CONCLUSION: The increased plasma citrulline level over time in addition to the SBS anatomical type is a reliable marker for subsequent PN weaning. The prediction of PN weaning assessed solely by the residual bowel length or a single measurement of citrulline is insufficient and should also take into account the anatomical type of SBS and repeated measurements of plasma citrulline levels.

Diverting Enterostomy Improves Overall Survival of Patients With Severe Steroid-refractory Gastrointestinal Acute Graft-Versus-Host Disease.

OBJECTIVE: The aim of this study was to evaluate the benefit of diverting enterostomy (DE) in patients with severe steroid-refractory (SR) gastrointestinal acute graft-versus-host-disease (GI-aGVHD) following allogeneic hematopoietic stem-cell transplantation (ASCT). SUMMARY AND BACKGROUND DATA: Severe GI-aGVHD refractory to the first-line steroid therapy is a rare but dramatic life-threatening complication. Second lines of immunosuppressors have limited effects and increase the risk of sepsis. Data suggest that limiting GI bacterial translocation by DE could restrain severe GI-aGVHD. METHODS: From 2004 to 2018, we retrospectively reviewed all consecutive patients undergoing ASCT for hematologic malignancies who developed severe SR GI-aGVHD. We compared patients in whom a proximal DE was performed (Enterostomy group) with those not subjected to DE (Medical group). The primary endpoint was the 1-year overall survival (OS) measured from the onset of GI-aGVHD. Secondary endpoints were the 2-year OS and causes of death. RESULTS: Of the 1295 patients who underwent ASCT, 51 patients with severe SR GI-aGVHD were analyzed (13 in Enterostomy group and 38 in Medical group). Characteristics of patients, transplantation modalities, and aGVHD severity were similar in both groups. The 1-year OS was better after DE (54% vs 5%, P = 0.0004). The 2-year OS was also better in "Enterostomy group" (31% vs 2.5%; P = 0.0015), with a trend to lower death by sepsis (30.8% vs 57.9%; P = 0.091). CONCLUSION: DE should be considered for severe GI-aGVHD as soon as resistance to the corticosteroid is identified.

The mediating role of perceived stress on the relationship between perceived social support and self-care ability among Chinese enterostomy patients.

PURPOSE: Enterostomy patients were exposed to various stressors, and self-care ability played an important role in their daily lives. This study aimed to examine the relationship between perceived social support and self-care ability among Chinese enterostomy patients and to explore whether perceived stress mediated this relationship. METHODS: A sample of 410 enterostomy patients aged 59.68 ± 12.95 years old were recruited in the study. Participants completed a set of questionnaires including demographics, perceived stress scale, perceived social support scale, and ostomy self-care ability scale. RESULTS: A total of 392 valid questionnaires were finally used in the data analyses among 410 questionnaires; the effective response rate was 95.6%. Results demonstrated that the scores of perceived social support were positively correlated with scores of self-care ability scores and negatively with perceived stress scores. And the effect of perceived social support on self-care ability was partially mediated by perceived stress (51.53%). CONCLUSIONS: This study explained the mediating model that connects perceived social support with self-care ability through perceived stress, which enhances our understanding about the mediating role of perceived stress. Thus, when focusing on the self-care ability of enterostomy patients, perceived stress was as important as perceived social support.

Adjuncts to bowel management for fecal incontinence and constipation, the role of surgery; appendicostomy, cecostomy, neoappendicostomy, and colonic resection.

Constipation and fecal incontinence are common problems in children after repair of an anorectal malformation (ARM). While many children can be effectively managed with an oral laxative regimen, others require a mechanical colonic washout to achieve social continence. Appendicostomy and cecostomy are two techniques which permit antegrade access to the colon for the purpose of enema delivery, which improves compliance and quality of life for patients and families. The purpose of this article is to review, using a case-based approach, the indications for placement of a channel for antegrade enema access, clinical scenarios in which one technique would be preferred over another, common complications following each procedure.

Endoscopic Ultrasound-Guided Antegrade Radiofrequency Ablation and Metal Stenting With Hepaticoenterostomy for Malignant Biliary Obstruction: A Prospective Preliminary Study.

OBJECTIVES: Endobiliary radiofrequency ablation (RFA) for malignant biliary obstruction is a promising option for improving biliary stent patency, but its efficacy and safety with endoscopic ultrasound (EUS)-guided biliary drainage are uncertain. We examined the feasibility of EUS-guided hepaticoenterostomy with antegrade stenting (EUS-HEAS) and RFA in patients with unresectable malignant biliary obstruction. METHODS: This was a prospective, single-center, single-arm, preliminary study. Twenty patients who met the eligibility criteria for inclusion between August 2018 and January 2020 were enrolled. We evaluated the technical success, functional success, recurrent biliary obstruction (RBO), and adverse events other than RBO associated with EUS-HEAS with RFA. RESULTS: The technical and functional success rates were both 80% (16/20). The procedure was unsuccessful in a total of 4 patients due to failure to insert the RFA catheter through the fistula (2 patients) or failure to pass the RFA catheter through the stricture (2 patients). Early and late adverse events other than RBO occurred in 10% (2/20) and 13% (2/16) of subjects, respectively. The RBO rate was 25% (4/16), and the median time to RBO was 276 days. The success rate of endoscopic reintervention using hepaticoenterostomy was 100% (4/4). DISCUSSION: This preliminary study showed that EUS-HEAS with RFA achieves good results but RFA catheter insertion can be difficult. Further evaluation and device improvements are warranted.

[Gunsight closure versus purse-string closure techniques in loop stoma reversal: a multicenter prospective randomized controlled trial].

Objective: To compare the wound healing time, Surgical site infection (SSI) rate and other postoperative outcomes between the gunsight closure and purse-string closure technique in loop stoma closure. Methods: Between November 2013 and December 2017, a total of 143 patients who underwent gunsight stoma reversal were included in this multicenter prospective randomized controlled trial. The patients were randomized to undergo gunsight (gunsight group, n=72) or purse-string closure technique (purse-string group, n=71). The primary endpoint was wound healing time. The second endpoints were the incidence of SSI, morbidity, and patient satisfaction. Statistical analysis between groups was performed using the t-test, repeated measures analysis of variance, Mann-Whitney U test, χ(2) test or Fisher's exact test. Results: There were 45 males and 27 females with age of 67 (11) (M(Q(R))) years in gunsight group, 42 males and 29 females with age of 65 (20) years in purse-string group. The body mass index, American Society of Anesthesiologist classification, comorbidities, primary diagnosis, the type of ostomy, intraoperative blood loss, perioperative complications, postoperative hospital stay, hospitalization cost, SSI rate and incisional hernia (stoma site) between the 2 groups were not significantly different (P>0.05). Although had a statistically longer operating time (80(10) minutes vs. 70(10) minutes, Z=-2.381, P=0.017), patients who underwent gunsight procedure and a significantly shorter wound healing time (17(2) days vs. 25(4) days, Z=-10.199, P<0.01), higher patient satisfaction score with regards to wound healing time (3(1) vs. 3(1), Z=-4.526, P<0.01), and higher total patient satisfaction score (25(3) vs. 25(3), Z=-2.529, P=0.011) compared with those who underwent purse-string procedure. Conclusions: The gunsight and purse-string techniques are effective procedures for stoma reversal and both have low SSI rate. The gunsight technique is associated with shorter wound healing time, higher levels of patient satisfaction compared with purse-string technique, and is recommended as the closure technique of choice.

Chyme Reinfusion in Intestinal Failure Related to Temporary Double Enterostomies and Enteroatmospheric Fistulas.

Some temporary double enterostomies (DES) or entero-atmospheric fistulas (EAF) have high output and are responsible for Type 2 intestinal failure. Intravenous supplementations (IVS) for parenteral nutrition and hydration compensate for intestinal losses. Chyme reinfusion (CR) artificially restores continuity pending surgical closure. CR treats intestinal failure and is recommended by European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) when possible. The objective of this study was to show changes in nutritional status, intestinal function, liver tests, IVS needs during CR, and the feasibility of continuing it at home. A retrospective study of 306 admitted patients treated with CR from 2000 to 2018 was conducted. CR was permanent such that a peristaltic pump sucked the upstream chyme and reinfused it immediately in a tube inserted into the downstream intestine. Weight, plasma albumin, daily volumes of intestinal and fecal losses, intestinal nitrogen, and lipid absorption coefficients, plasma citrulline, liver tests, and calculated indices were compared before and during CR in patients who had both measurements. The patients included 185 males and 121 females and were 63 ± 15 years old. There were 37 (12%), 269 (88%) patients with EAF and DES, respectively. The proximal small bowel length from the duodeno-jejunal angle was 108 ± 67 cm (n = 232), and the length of distal small intestine was 117 ± 72 cm (n = 253). The median CR start was 5 d (quartile 25-75%, 2-10) after admission and continued for 64 d (45-95), including 81 patients at home for 47 d (28-74). Oral feeding was exclusive 171(56%), with enteral supplement 122 (42%), or with IVS 23 (7%). Before CR, 211 (69%) patients had IVS for nutrition (77%) or for hydration (23%). IVS were stopped in 188 (89%) 2 d (0-7) after the beginning of CR and continued in 23 (11%) with lower volumes. Nutritional status improved with respect to weight gain (+3.5 ± 8.4%) and albumin (+5.4 ± 5.8 g/L). Intestinal failure was cured in the majority of cases as evidenced by the decrease in intestinal losses by 2096 ± 959 mL/d, the increase in absorption of nitrogen 32 ± 20%, of lipids 43 ± 30%, and the improvement of citrulline 13.1 ± 8.1 µmol/L. The citrulline increase was correlated with the length of the distal intestine. The number of patients with at least one liver test >2N decreased from 84-40%. In cases of Type 2 intestinal failure related to DES or FAE with an accessible and functional distal small bowel segment, CR restored intestinal functions, reduced the need of IVS by 89% and helped improve nutritional status and liver tests. There were no vital complications or infectious diarrhea described to date. CR can become the first-line treatment for intestinal failure related to double enterostomy and high output fistulas.

The Influence of the Type of Surgery on the Immediate Postoperative Results in Patients with Colorectal Cancer Operated in Emergency.

The emergency surgery for colorectal cancer is associated with high rates of morbidity and mortality due to factors related to the characteristics of the patients but also the therapeutic attitude. This study aims to identify the surgical interventions associated with the postoperative complications, with the main causes of morbidity, with the reinterventions and with the postoperative deaths. We included in this retrospective study 431 patients hospitalized and operated in an emergency for complicated colorectal malignant tumors in the Surgery II Clinic of the Clinical Emergency County Hospital "Sf. Ap. Andrei from Galati, in the period 2008-2017. The patients data were collected from observation sheets, operative protocols, pathological, imaging and laboratory bulletins, at the time of the emergency intervention, as well as from those of subsequent admissions in patients who benefited from serial interventions. The postoperative morbidity was 10.44%. The resections with anastomosis were associated with the presence of postoperative complications (p 0.01): pseudomembranous colitis, (p 0.01) and postoperative intestinal occlusion (p 0.01). The practice of lymph node dissection was associated with postoperative complications (p 0.01): pseudomembranous colitis (p 0.01) and intestinal occlusion (p 0.01). The reinterventions were associated with resections with anastomosis (p 0.01), lymph node dissection (p 0.01) or patients with open /semi-open abdomen (p 0.04). The postoperative mortality was 9.28%. It was associated with the practice of lymph node dissection (p 0.01), of the ileostomy (p 0.01), with the open /semi-open abdomen (p 0.04). Patients with colostomy had the lowest number of hospitalization days (p 0.01). The resections with anastomosis per primam and the lymph node dissection were associated with morbidity. The type of main surgery did not influence the postoperative mortality, this being associated with the concomitant surgery: the lymph node dissection, the ileostomy, and the abdomen closure type. The reinterventions were associated with resections with anastomosis per primam, with lymph node dissection and with the open /semi-open abdomen. The duration of hospitalization was significantly shorter in patients with a colostomy.

Management of Rectal Stump During Laparoscopic Subtotal Colectomy for Inflammatory Bowel Disease: A Comparative Cohort Study from Six Referral Centres.

BACKGROUND AND AIMS: There is no consensus on the best management of the rectum after subtotal colectomy for refractory colitis complicating inflammatory bowel disease [IBD]. The objective was to evaluate the impact of rectal stump management during laparoscopic subtotal colectomy [LSTC] for IBD. METHODS: Patients who underwent LSTC with double-end ileo-sigmoidostomy [Gr.A] or end ileostomy with closed rectal stump [Gr.B] for IBD were included from a retrospective database of six European referral centres. RESULTS: In total, 314 patients underwent LSTC and were allocated to Gr.A [n = 102] and B [n = 212]. After LSTC, stoma-related complications occurred more frequently in Gr.A [12%] than in Gr.B [4%, p = 0.01]. Completion proctectomy with ileal pouch-anal anastomosis [IPAA] was performed as a three-stage procedure in all patients from Gr.A, and in 88 patients from Gr.B [42%; Gr.B1]. The other 124 patients from Gr.B underwent a modified two-stage procedure [58%; Gr.B2]. The second stage was performed laparoscopically in all patients from Gr.A compared with 73% of Gr.B1 [p < 0.0001] and 65% of Gr.B2 patients [p < 0.0001]. When laparoscopy was intended for 2nd stage IPAA, conversion to laparotomy occurred less frequently in Gr.A when compared with B1 [0 vs 5%, p = 0.06] or B2 [10%, p = 0.001]. When all surgical stages were included [LSCT and IPAA], cumulative stoma-related complications occurred more frequently in Gr.A [n = 19] than in Gr.B1 [n = 6, p = 0.02] and Gr.B2 [n = 6, p = 0.001]. CONCLUSION: This study suggests that both techniques of double-end ileosigmoidostomy and end ileostomy with closed rectal stump are safe and effective for rectal stump management after laparoscopic subtotal colectomy.

Timing of enterostomy closure for neonatal isolated intestinal perforation.

PURPOSE: No consensus guidelines exist for timing of enterostomy closure in neonatal isolated intestinal perforation (IIP). This study evaluated neonates with IIP closed during the initial admission (A1) versus a separate admission (A2) comparing total length of stay and total hospital cost. METHODS: Using 2012 to 2017 Pediatric Health information System (PHIS) data, 359 neonates with IIP were identified who underwent enterostomy creation and enterostomy closure. Two hundred sixty-five neonates (A1) underwent enterostomy creation and enterostomy closure during the same admission. Ninety-four neonates (A2) underwent enterostomy creation at initial admission and enterostomy closure during subsequent admission. For the A2 neonates, total hospital length of stay was calculated as the sum of hospital days for both admissions. A1 neonates were matched to A2 neonates in a 1:1 ratio using propensity score matching. Multivariate models were used to compare the two matched pair groups for length of stay and cost comparisons. RESULTS: Prior to matching, the basic demographics of our study population included a median birthweight of 960 g, mean gestational age of 29.5 weeks, and average age at admission of 4 days. Eighty-seven pairs of neonates with IIP were identified during the matching process. Neonates in A2 had 91% shorter total hospital length of stay compared to A1 neonates (HR: 1.91; 95% CI for HR: 1.44-2.53; p < .0001). The median length of stay for A1 was 95 days (95% CI: 78-102 days) versus A2 length of stay of 67 days (95% CI: 56-76 days). Adjusting for the same covariates, A2 neonates had a 22% reduction in the average total cost compared A1 neonates (RR: 0.78; 95% CI for RR: 0.64-0.95; p-value = 0.014). The average total costs were $245,742.28 for A2 neonates vs. $315,052.21 for A1 neonates (p < 0.001). CONCLUSION: Neonates with IIP have a 28 day shorter hospital length of stay, $75,000 or 24% lower total hospital costs, and a 22 day shorter post-operative course following enterostomy closure when enterostomy creation and closure is performed on separate admissions. TYPE OF STUDY: Prognosis Study. LEVEL OF EVIDENCE: Level II.

A New Appendicostomy Technique to Prevent Stomal Stenosis.

PURPOSE: Stomal stenosis has been reported to occur in 12% to 45% of patients following Malone antegrade continence enema and Mitrofanoff appendicostomy. The standard stoma technique entails excision of the distal appendix. We evaluated a novel technique with preservation of the appendiceal tip and vessels, and opening the lumen in a more proximal and vascular area to determine whether the incidence of stenosis would be decreased. MATERIALS AND METHODS: Medical records of patients who underwent appendicostomy for Malone antegrade continence enema or urinary diversion were retrospectively evaluated. We included cases with a minimum of 1 year of followup and those in which the distal portion of a complete appendix was oriented for use as the stomal end in the umbilicus. Variables such as age, gender, body mass index, antegrade continence enema or urinary diversion, open or laparoscopic approach, cecal and appendiceal adhesions, retrocecal position, cecal imbrication, technique and stenosis were recorded. Cox proportional hazards analyses were performed to determine association of covariates. RESULTS: A total of 123 patients met inclusion criteria. The incidence of stenosis following standard stoma technique was 13% (12 of 93 patients) with a median followup of 9.4 years. Of these cases 75% occurred within 1 year of surgery. Stomal stenosis did not occur after the new stoma technique in 30 patients with a median followup of 3.3 years. Only technique cohort (standard vs new) was associated with stenosis (p=0.04). CONCLUSIONS: Stomal stenosis of appendicostomy may be lessened by preservation of the distal appendiceal vasculature and tip, and opening the lumen in a more proximal location.

Chyme Reinfusion for Small Bowel Double Enterostomies and Enteroatmospheric Fistulas in Adult Patients: A Systematic Review.

BACKGROUND: High-output double enterostomies (DESs) and enteroatmospheric fistulas (EAFs) of the small bowel account for substantial patient morbidity and mortality. Management may include parenteral nutrition (PN) and prolonged admissions, at high cost. Reinfusion of chyme into the distal bowel is a proposed therapeutic alternative when the distal DES limb is accessible; however, standardized information on this technique is required. This review aimed to critically assess the literature regarding chyme reinfusion (CR) to define its current status and future directions. METHODS: A systematic search of medical databases was conducted for articles investigating CR in adults. Articles reporting indications, methods, benefits, technical issues, and complications resulting from CR were reviewed. A narrative synthesis of the retrieved data was undertaken. RESULTS: In total, 24 articles reporting 481 cases of CR were identified, although articles were heterogeneous in their structure and reporting. CR was most frequently performed for remediation of high-output DES and intestinal failure and for proximally located DES. Effluent output collection was commonly manual, with distal reinfusion more commonly automated, and with few dedicated systems. Multiple benefits attributed to CR were reported, encompassing weight gain, cessation of PN, and improvements in liver function. Technical problems included distaste, labor-intensive methods, reflux of contents, and tube dislodgement. No serious AEs or mortality directly attributable to CR were reported. CONCLUSIONS: CR appears to be a promising, safe and well-validated intervention for small bowel DES and EAF. However, more efficient and acceptable methods are required to promote greater adoption of the practice of CR.

A differentiated approach to repeat small-bowel anastomoses in patients with postoperative peritonitis: a prospective cohort study.

BACKGROUND: Postoperative peritonitis still remains the cause of a high mortality rate in emergency abdominal surgery. Here we aimed to evaluate the efficacy of different surgical strategies for small-bowel perforations that resulted in postoperative peritonitis. METHODS: Surgical management results for 140 patients with postoperative peritonitis due to small-bowel perforations, necrosis and anastomotic leakage were comparatively analyzed. Using the APACHE-II and MPI scoring systems, different surgeon attitudes were examined in three patient groups (primary anastomosis, delayed anastomosis, and enterostomy). RESULTS: The surgical approach in patient group I (n = 47, APACHE-II 11.7 ± 1.2, MPI 14.7 ± 1.3) involved the closure of small-bowel perforations or small-bowel resection to place primary anastomosis. The mortality rate was 17%. Patient group II (n = 48, APACHE-II 16.8 ± 0.7, MPI 19.3 ± 0.3) underwent delayed small-bowel anastomosis during planned relaparotomies. The mortality rate was 18.8%. Because patients in patient group III (n = 45, APACHE-II 22.3 ± 1.3, MPI 24.6 ± 1.2) were in very critical condition, anastomoses were not placed after bowel resection, and the surgical procedure was completed with enterostomy. The highest mortality rate of 37.8% was documented in this patient group. CONCLUSION: The differentiated surgical approach undertaken herein using delayed small-bowel anastomosis in more serious patients with postoperative peritonitis was able to mitigate the risk of recurrent anastomotic leaks and was not accompanied by a considerable rise in mortality. The mortality for primary repair and delayed primary closure was basically the same (17.0% and 18.8%, p = 0.03); however, delayed anastomosis in the patients with postoperative peritonitis at higher APACHE-II and MPI scores for severity of illness showed 15.1% less complications in the form of anastomotic leaks (p = 0.04).

Laparoscopic subtotal colectomy with double-end ileosigmoidostomy in right iliac fossa facilitates second-stage surgery in patients with inflammatory bowel disease.

BACKGROUND: There is no consensus about the most appropriate management of rectal stump in laparoscopic subtotal colectomy (STC) performed for inflammatory bowel disease (IBD). The objective is to report our experience of laparoscopic STC with double-end ileosigmoidostomy in the right iliac fossa for IBD. METHODS: All patients undergoing laparoscopic STC and double-end ileosigmoidostomy in the right iliac fossa for IBD in 2 European expert centres were included. RESULTS: From 1999 to 2017, laparoscopic STC and double-end ileosigmoidostomy in right iliac fossa was performed in 213 consecutive patients, including 74 patients in an emergency setting (35%). Conversion to laparotomy was necessary in 9 patients (4%). One patient died postoperatively (0.5%). Postoperative morbidity occurred in 53 patients (25%) after STC, and was major in 18 patients (8%). A second stage was performed in 199 patients (94%), with a mean delay of 4.7 ± 6 months (range 1.4-77). The second stage was an ileorectal anastomosis (n = 50/199; 25%), performed by an elective open incision in the right iliac fossa in 68% of cases; an ileal pouch-anal anastomosis (IPAA) (n = 139; 70%) successfully performed by laparoscopy in 96% of cases; or an abdominoperineal excision with end ileostomy (n = 10; 5%) successfully performed by laparoscopy in 8 cases. After this second stage, postoperative morbidity occurred in 53 patients (27%), and was major in 15 patients (8%). After a mean follow-up of 3.7 ± 3 years (range 0.1-15), stoma rate (end ileostomy and diverting stoma not closed) was 17%, and small bowel obstruction and incisional hernia occurred in 10 (5%) and 25 (12%) patients, respectively. CONCLUSIONS: Laparoscopic STC and double-end ileosigmoidostomy in right iliac fossa is safe, feasible, and facilitates the second stage for intestinal continuity by either elective incision or laparoscopy in 100% of ileorectal anastomoses and by laparoscopy in 96% of IPAA.