Stoma Bridge Types and Their Impact on Patient Outcomes: A Retrospective Analysis and Prospective Global Survey of Surgical Practice.

PURPOSE: The purpose of this study was to describe the effect of rigid or flexible stoma bridges used for loop ostomy diversions on peristomal skin integrity. Additional aims were to describe surgeon practices related to stoma bridges, and determine the availability of an ostomy nurse specialist. DESIGN: Retrospective chart review and cross-sectional survey. SAMPLE AND SETTING: The sample used to address the first aim (effect of stoma bridges) comprised 93 adult patients cared for at Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, an acute care facility. Data provided by 355 colorectal surgeons from 30 countries were used to describe surgeon practice in this area and determine the availability of an ostomy nurse specialist. Respondents were invited from an international roster of colorectal surgeons obtained with permission from the American Society of Colon and Rectal Surgeons (ASCRS). METHODS: In order to accomplish the initial aim, we retrospectively reviewed medical records of patients who underwent ostomy surgery from 2008 to 2015 and met inclusion criteria. In order to meet our additional aims, analyzed data were obtained from a survey of colorectal surgeons that queried practices related to stoma bridges, and availability of an ostomy nurse specialist. RESULTS: Patients managed with a rigid bridge were significantly more likely to experience leakage beneath the pouching system faceplate than were patients managed by a flexible bridge (42% vs 11%, P < .001). Slightly less than one quarter of patients who developed leakage (n = 22, 24%) experienced pressure and moisture-related peristomal skin complications. Peristomal wounds, inflammation, and infection were significantly higher when a rigid bridge was used (χ test, P < .003). The surgeon's survey (N = 355) showed variability in the use of bridges. Ninety-three percent of all surgeons indicated an ostomy nurse specialist was part of their health care team. CONCLUSIONS: Rigid ostomy bridges were associated with a higher likelihood of leakage from underneath the faceplate of the pouching system and impaired peristomal skin integrity. Analysis of colorectal surgeon responses to a survey indicated no clear consensus related to bridge use in patients undergoing loop ostomies.

Reduction in surgical stoma rates in Crohn's disease: a population-based time trend analysis.

AIM: Trends in surgical rates for Crohn's disease (CD) in the biological era are controversial. We aim to assess modern trends in the formation rates of surgical stomas. METHOD: Population-based surveillance in the Calgary Health Zone (CHZ), Canada, was conducted between 1 April 2002 and 31 March 2011, using the Discharge Abstract Database to identify adult patients with CD admitted to hospital and treated with surgical stoma formation (n = 545). Annual stoma incidence was calculated by dividing the number of incident stomas by the prevalence of CD in the CHZ. Time trend analysis of the stoma-formation rate was performed, expressed as annual percentage change (APC) with 95% CI. Stoma-formation rates were stratified according to procedure (emergency vs elective) and duration of stoma [temporary (reversed within 2 years of formation) vs permanent]. RESULTS: The overall rate of stoma formation between 2002 and 2011 showed a downwards trend, of a mean of 5.2% (95% CI: -8.5 to -1.8) per year, from a rate of 2.30 stomas/100 person-years (PY) in 2002 to 1.51 stomas/100 PY in 2011. The rate of emergency stoma formation decreased significantly from 2002 to 2011 (mean APC = -9.4%; 95% CI: -15.6 to -2.8), while the rate of elective ostomies essentially showed no change (mean APC = -0.9%; 95% CI: -5.3 to 3.8). The rate of temporary stoma formation decreased significantly, by 4.6% (95% CI: -7.3 to -1.8) per year, while permanent stoma formation was stable (APC = 1.0%; 95% CI: -4.0 to +6.3). CONCLUSION: A reduction in the overall rate of stoma formation in CD has been driven by fewer emergency stomas, although rates of permanent stoma have remained stable.

Changing Trends in Reconstruction of Complex Anterior Urethral Strictures: From Skin Flap to Perineal Urethrostomy.

OBJECTIVE: To evaluate procedural trends and outcomes for reconstruction of complex strictures at our tertiary center over the last decade. METHODS: We retrospectively reviewed complex urethral reconstruction comparing 3 techniques: (1) buccal mucosal graft (BMG), (2) penile skin flap, or (3) perineal urethrostomy (PU) at our center (2007-2017) with ≥6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management. RESULTS: Among 1129 strictures cases, 403 complex strictures were identified for analysis (median length 4.5 cm). Median age was 53.2 years (standard deviation ± 14.9). Reconstruction was most commonly performed using BMG (61.3%), followed by penile skin flap (21.6%) and PU (19.1%). PU use has increased steadily over the past decade, rising from 4.3% of case volume in 2008 to 38.7% in 2017 (P = .01). Over time, the proportion of reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized. Over a median follow-up of 50.7 months, 16.9% (68/403) patients failed at a median of 13.9 months. Success rates were higher following PU (94.8%) compared to BMG and skin flaps (78.5% and 78.2%, respectively) (P = .003) despite PU patients being older (median age 62.6 years), having longer strictures (median 5.0 cm) and more commonly having lichen sclerosus (LS) (22.1%). CONCLUSION: Over a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps.

The influence of hospital volume on long-term oncological outcome after rectal cancer surgery.

PURPOSE: The association between hospital volume and outcome in rectal cancer surgery is still subject of debate. The purpose of this study was to assess the impact of hospital volume on outcomes of rectal cancer surgery in the Netherlands in 2011. METHODS: In this collaborative research with a cross-sectional study design, patients who underwent rectal cancer resection in 71 Dutch hospitals in 2011 were included. Annual hospital volume was stratified as low (< 20), medium (20-50), and high (≥ 50). RESULTS: Of 2095 patients, 258 patients (12.3%) were treated in 23 low-volume hospitals, 1329 (63.4%) in 40 medium-volume hospitals, and 508 (24.2%) in 8 high-volume hospitals. Median length of follow-up was 41 months. Clinical tumor stage, neoadjuvant therapy, extended resections, circumferential resection margin (CRM) positivity, and 30-day or in-hospital mortality did not differ significantly between volume groups. Significantly, more laparoscopic procedures were performed in low-volume hospitals, and more diverting stomas in high-volume hospitals. Three-year disease-free survival for low-, medium-, and high-volume hospitals was 75.0, 74.8, and 76.8% (p = 0.682). Corresponding 3-year overall survival rates were 75.9, 79.1, and 80.3% (p = 0.344). In multivariate analysis, hospital volume was not associated with long-term risk of mortality. CONCLUSIONS: No significant impact of hospital volume on rectal cancer surgery outcome could be observed among 71 Dutch hospitals after implementation of a national audit, with the majority of patients being treated at medium-volume hospitals.

Pioderma gangrenoso periestomal: presentación de 4 casos y revisión de los factores de riesgo y la respuesta terapéutica / A Case Series of 4 Patients With Peristomal Pyoderma Gangrenosum: Review of Risk Factors and Treatment Response

La literatura del pioderma gangrenoso periestomal (PGP) es escasa, y las series publicadas tienen un número de pacientes limitado. En dicho contexto es difícil determinar la frecuencia de la enfermedad, así como sus factores de riesgo, y valorar la eficacia de los distintos tratamientos disponibles. Presentamos una serie de casos de PGP diagnosticados en nuestro centro entre los años 2013 y 2014 y revisamos las características clínicas y la respuesta terapéutica. Se incluyeron un total de 4 pacientes, 3 de los cuales estaban diagnosticados de enfermedad inflamatoria intestinal, mientras que uno de los casos se asoció a carcinoma de recto. Tres pacientes presentaron evolución favorable tras el tratamiento inicial con tacrolimus 0,1% en pomada (2 casos en monoterapia y uno asociado a otros inmunosupresores), con recurrencia en todos ellos tras la suspensión del tratamiento precisando reintroducción o cambio de tratamiento

The literature on peristomal pyoderma gangrenosum (PPD) is scarce, and studies to date have included few patients. It is therefore difficult to determine the incidence of PPD, investigate risk factors, or evaluate the effectiveness of the different treatments available. We report on a series of 4 patients diagnosed with PPD at our hospital in 2013 and 2014, and review the clinical characteristics and responses to treatment. Three of the patients had inflammatory bowel disease and 1 had rectal cancer. Three patients responded favorably to initial treatment with 0.1% tacrolimus ointment (administered as monotherapy in 2 cases and combined with immunosuppressants in the other). However, on withdrawal of tacrolimus, the disease recurred in all 3 patients, requiring treatment reintroduction or modification

Transanal tube NO COIL® after rectal cancer proctectomy. The "G. Paolo II" Cancer Centre experience.

AIMS AND BACKGROUND: Covering stoma is the main method used to protect low-lying anastomosis after cancer proctectomy. Intraluminal rectal pressure could be a potential risk factor for anastomotic leakage. We present our personal experience with an alternative and original device, the transanal tube NO COIL®, evaluating its feasibility and safety based on a preliminary manometric study. METHODS: From May 1998 to March 1999, an experimental manometric study on 35 subjects was performed to assess the pathophysiological basis of intraluminal rectal pressure with or without the transanal tube. Subsequently, from April 1999 to December 2009, 184 patients (107 males, 77 females, average age 68.2 ± 10 years) with primary adenocarcinoma of the rectum (≤12 cm from anal verge) were selected. Eighty-two underwent total proctectomy and 102 subtotal proctectomy. No stoma were fashioned. At the end of the operation, the silicone transanal tube NO COIL ®, 60-80 mm long, 2 mm thick with a calibre of up to 2 cm, was applied and secured to the perineal skin by two stitches, then removed on the seventh postoperative day if no signs of leakage occurred. RESULTS: The intraluminal rectal pressure with transanal tube was strongly reduced from 13.8 + 8.5 mmHg to 4.8 + 3.7 mmHg (P <0.01). Nine patients (4.8%) developed an anastomotic leakage, 2 males and 7 females. In 10 patients, the transanal tube NO COIL® did not remain in situ for the planned seven days, and 18 patients suffered from ulcers in the perianal skin. Leakage subsided with conservative treatment in 4 patients, whereas 5 patients required loop colostomy. The stoma rate was 2.7%. No leakage-related deaths occurred, and overall mortality was 1.3%. CONCLUSIONS: The transanal tube NO COIL® does not abolish the risk of anastomotic leakage but could be an alternative option to covering stoma after cancer proctectomy in selected patients. In our experience, this simple and cheap device could reduce the rate of stoma without leakage-related mortality. Further studies within a randomized controlled trial are required to better define our results.

«El neocricoides». Una nueva técnica quirúrgica para prevenir y tratar las estenosis del traqueostoma postlaringectomía total infracricoidea / «The neocricoid»’: a new surgical technique to prevent and treat tracheostomal stenosis after total infracricoid laryngectomy

El objetivo es presentar una técnica quirúrgica novedosa, para prevenir y tratar las estenosis del traqueostoma postlaringectomía total infracricoidea. Se explican los conceptos en los que se basa, se describe la técnica tal como se realiza y se presentan tres pacientes tratados con ella y su resultado(AU)

The goal is to present a new surgical technique that may solve and prevent tracheostomal stenosis after total infracricoid laryngectomy. The concepts on which the technique is based are explained and the technique as performed is described. The complete success achieved in three clinical cases treated with this technique is also presente (AU)

Resultados del uso de la técnica de Mitrofanoff en pacientes con disfunción neurógena de la vejiga: Análisis de la experiencia en el Hospital Universitario San Vicente de Paul / Outcomes the Mitrofanoff technique in the management of patients with neurogenic bladder: the experience in the San Vicente de Paul Universitary Hospital

Introducción: El cuidado de los niños con vejiga neurogénica, debe ser integral, multidisciplinario y busca preservar la función renal, alcanzar continencia urinaria y fecal, logrando que el paciente sea una persona autosuficiente y útil a la sociedad. Métodos: Describimos el resultado del uso de la técnica de Mitrofanoff en el manejo de pacientes con disfunción vesical neurógena, utilizada en el HUSVP desde 1998 al 2003, y las condiciones actuales de los pacientes con respecto a su enfermedad y tratamiento. Se realizó un estudio observacional descriptivo, retrospectivo 1998-2002 y prospectivo durante el 2003, analizando una serie de casos. Resultados: Fueron intervenidos 41 pacientes con vejiga neurogénica. Edad promedio 10.2 años; seguimiento promedio 27,2 meses; enfermedad de base más frecuente mielomeningocele (46,3%); vejiga disinérgica en 46,3%, esfínter hipotónico en 41,5%. Se realizo aumento vesical al 68,3%, utilizándose ileon en 71,4%, y alguna intervención sobre el cuello vesical al 51,2%. Se hizo una derivación tipo Mitrofanoff al 95,1% con continencia completa en 70,8%, incontinencia completa en 14.6% e incontinencia ocasional en 14,6%. En 31,7% se realizó un Malone con adecuada continencia fecal en 90,2%. De los estomas el 19% presentaron estenosis y el 21,9% presentaron escape de orina. Se encuentran socialmente adaptados 80% de los pacientes. Conclusiones: Los estomas continentes cateterizables son útiles para tratar la incontinencia urinaria y fecal. Los conductos realizados con ileon tuvieron mayores complicaciones que los elaborados con apéndice, por lo cual el apéndice debe ser el tejido de elección para realizar las derivaciones, cuando esté disponible (AU)

Introduction: The care for children with neurogenic bladder, should be integral, multidisciplinary look to preserve renal function and to accomplish urinary and fecal continence, achieving that the patient becomes self-sufficient and useful to society. Methods: The result of the use of the Mitrofanoff technique for the treatment of patients with neurogenic dysfunction bladder used in the HUSVP 1998- 2003, and the current condition of the patients with respect to their illness and treatment are described in this article. A descriptive retrospective study 1998- 2002 and a prospective study during 2003 were done, in which a series of cases were analyzed. Results: 41 patients had surgery. Average age 10.2 years; average follow–up time 27.2 months; the most frequent illness was myelomeningocele (46.3%) and 46.3% had dysinergic bladder. Bladder augmentation was performed on 63.3%, of which 71.4% were constructed with ileum. A surgical intervention of the bladder neck was done on 51.2%. A continent conduct (Mitrofanoff) was performed on 95.1% of the patients with complete continence 70.4%, complete incontinence 14.6% and occasional incontinence 14.6%. 31.7% had Malone surgery with adequate fecal management on 90.2%. 19% of the stomas presented stenosis and 21.9% presented urine leakage. 80% reached appropriate social adaptation. Conclusions: The continent catheterizable stomas are useful for the treatment of urinary and fecal incontinence. The conducts constructed with ileum had more complications than the conducts done with cecal appendix, which is why the appendix is the choice tissue to perform the continent catheterizable stomas, as long as it is available (AU)

Ostomy options for clients with ileostomies.

Quality of life with an external appliance has a significant impact on decision making when considering an incontinent or continent ostomy. A majority of clients with external pouches are content with their pouches and enjoy a good quality of life. For others, not having to deal with an external appliance is reason enough to consider surgery. Major physical and psychological lifestyle changes occur with the ileostomy, particularly with body image and self-concept (Reynaud & Meeker, 2002). Having an external appliance can lead to depression for the client because of skin irritation, leakage of stool, and difficulty securing the appliance. Other issues include moving wrong while sleeping, which can create an uncomfortable feeling of warmth across the abdomen, and putting on a seatbelt can be a challenge.

[Optimization of diagnostic and therapeutic programs in modern neonatal surgery]. / Optimizatsiia diagnosticheskikh i lechebnykh programm v khirurgii novorozhdennykh na sovremennom étape.

Tendencies in neonatal surgery research are presented. Based on 187 cases, indications to preventive intestinal stomas creation in the newborns and also time of their closure are regarded. Surgical correction of malformation or treatment of acute process in the abdominal organs with intestinal stoma closing is finished to month 2-3 of childs life. The developed differential-diagnostic criteria of functional and organic lesion of ureteropelvic and ureterovesicular segments based on diuretic sonography permitted one to reveal early age pathology of urinary system and to correct it with surgical methods. The developed algorithm of diagnosis and treatment of newborns with eruct syndrome permits one to determine indications to surgery in 10% infants with gastroesophageal reflux.