Contemporary Trends and Outcomes of Blunt Traumatic Colon Injuries Requiring Resection.

BACKGROUND: After traumatic injury, primary anastomosis after colon resection has overtaken ostomy diversion. Improved technology facilitating primary anastomosis speed and integrity may have driven this change. Trends in ostomy versus anastomosis have yet to be quantified, and recent literature comparing outcomes is incomplete. METHODS: The National Trauma Databank (2007-2014) was queried for all blunt colon injuries requiring resection. Patients were dichotomized into study groups based on whether they underwent ostomy creation. Ostomy creation frequency was compared over time. After subgrouping patients by colon injury location, multivariate regression adjusted for baseline characteristics and evaluated the impact of ostomy on clinical outcomes. RESULTS: A total of 13,949 colon injuries requiring colectomy were identified. Ostomy frequency did not vary by study year (P = 0.536). Univariate analysis showed that patients undergoing ostomy were older (median, 40 versus 32; P < 0.001) and more often had comorbidities (65% versus 56%; P < 0.001). Multivariate analysis showed that ostomy creation was significantly associated with lower mortality after sigmoid colon injury (odds ratio, 0.512; P = 0.011) and higher rates of unplanned reoperation after transverse colon injury (odds ratio, 3.135; P = 0.048). Across all colon injuries, ostomies were significantly associated with longer hospital length of stay, intensive care unit length of stay, and ventilator days. CONCLUSIONS: Ostomy creation for colonic injury has reached an equilibrium trough. The impact of ostomy creation varies by not only clinical outcome but also injury location. Further study is needed to define the optimal surgical management for blunt colon injuries requiring resection.

The Decline of Elective Colectomy Following Diverticulitis: A Population-Based Analysis.

BACKGROUND: The indications for interval elective colectomy following diverticulitis are unclear; evidence lends increasing support for nonoperative management. OBJECTIVE: This study aims to evaluate the temporal trends in the use of elective colectomy following diverticulitis. DESIGN: This is a population-based retrospective cohort study using administrative discharge data. SETTING: This study was conducted in Ontario, Canada. PATIENTS: Patients who had had an episode of diverticulitis managed nonoperatively and were eligible for elective colectomy, from 2002 to 2012, were selected. MAIN OUTCOME MEASURES: Changes in the proportion of patients who undergo elective colectomy following an episode of diverticulitis treated nonoperatively were evaluated. Cochran-Armitage was used to test for trends; adjusted analysis was performed by using multivariable logistic regression with generalized estimating equations. RESULTS: A total of 14,124 patients were admitted with an episode of diverticulitis and treated nonoperatively, making them eligible for interval elective colectomy. Median follow-up was 3.9 years (maximum, 10; interquartile range, 1.7-6.4). Overall, 1342 (9.5%) patients underwent elective colectomy; 33% of these colectomies were performed laparoscopically, and 7.5% patients received an ostomy. In-hospital mortality was 0.2%. The majority (76%) of elective operations were performed within 1 year of discharge (median, 160 days; interquartile range, 88-346). The proportion of patients undergoing elective colectomy within 1 year of discharge declined from 9.6% of patients in 2002 to 3.9% by 2011 (p < 0.001). The decline was most pronounced in patients <50 years of age (from 17% to 5%), and those with complicated disease (from 28% to 8%) (all p < 0.001). In multivariable regression, younger age, lower medical comorbidity, complicated disease, and early readmission were associated with elective colectomy. After adjusting for changes in patient characteristics, the odds of elective surgery decreased by 0.93 per annum (adjusted OR; 95% CI, 0.90-0.95). LIMITATIONS: Administrative health databases contain limited clinical detail; the rationale for elective surgery was not available. CONCLUSIONS: Consistent with evolving practice guidelines, there has been a decrease in the use of elective colectomy following an episode of diverticulitis.

Trends in the Surgical Management of Crohn's Disease.

INTRODUCTION: Although medical management of Crohn's disease has changed in recent years, it is unclear whether surgical management has altered. We examined rate changes of surgical interventions, stoma constructions, and subset of ileostomy and colostomy constructions. MATERIALS AND METHODS: We reviewed the Nationwide Inpatient Sample database from 1988 to 2011. We examined the number of Crohn's-related operations and stoma constructions, including ileostomies and colostomies; a multivariable logistic regression model was developed. RESULTS: A total of 355,239 Crohn's-related operations were analyzed. Operations increased from 13,955 in 1988 to 17,577 in 2011, p < 0.001. Stoma construction increased from 2493 to 4283, p < 0.001. The subset of ileostomies increased from 1201 to 3169, p < 0.001 while colostomies decreased from 1351 to 1201, p = 0.05. Operation percentages resulting in stoma construction increased from 18 to 24 %, p < 0.001. Weight loss (OR 2.25, 95 % CI 1.88, 2.69) and presence of perianal fistulizing disease (OR 2.91, 95 % CI 2.31, 3.67) were most predictive for requiring stoma construction. CONCLUSIONS: Crohn's-related surgical interventions and stoma constructions have increased. The largest predictors for stoma construction are weight loss and perianal fistulizing disease. As a result, nutrition should be optimized and the early involvement of a multidisciplinary team should be considered.

A systematic review and meta-analysis of randomized controlled trials comparing interventions for peristomal skin care.

Standard skin care procedures for percutaneous endoscopic gastrostomy (PEG) tubes and peristomal skin care for colostomy and ileostomy patients are not always sufficient to prevent peristomal skin problems. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to compare the effectiveness of standard peristomal skin care to adjunctive techniques or barriers (including glycogel dressings, gelatin- and pectin-based skin barriers, glycerin hydrogel wound dressing, Acacia senegal fiber pockets, hydrocolloid powder crusting, and German chamomile) to manage or treat patients with a stoma. Using systematic literature search techniques, all healthcare databases were searched up through September 2014. No language restrictions were applied. Studies were included if they met criteria for published RCTs or quasi-RCTs that evaluated the outcome of standardized peristomal skin care and other adjunctive techniques or barriers used among patients with a stoma or PEG tube. A meta-analysis was performed to calculate a pooled effect size by using random-effect models for the primary (skin irritation/reaction) and secondary (length of pouch wear time) outcomes. Six RCTs comprising 418 total patients were identified. Four evaluated the outcome of colostomy or ileostomy peristomal skin care, and no significant differences were detected in the incidence of skin problems (RR 0.67; 95% CI: 0.31-1.41). In the two studies that included length of pouch wear time, no significant differences were observed (RR 0.48; 95% CI: 0.03-7.97). No significant differences were seen in the rate of skin irritations of gastrostomy patients (RR 0.56; 95% CI: 0.20-1.59), but the difference in treatment outcomes of peristomal damage in patients with a colostomy was significant (P = 0.01). The limited number of studies, study quality, heterogeneity of variability in peristomal care strategies and techniques, clinical factors, and nonuniform reporting of clinical parameters contributed to the heterogeneity among the trials. Well-designed RCTs are needed to investigate the efficacy of various barriers and techniques for peristomal skin care and to help develop evidence-based standards of caring for the skin of patients with a colostomy, ileostomy, or gastrostomy.

Colonic volvulus in the United States: trends, outcomes, and predictors of mortality.

INTRODUCTION: Colonic volvulus is a rare entity associated with high mortality rates. Most studies come from areas of high endemicity and are limited by small numbers. No studies have investigated trends, outcomes, and predictors of mortality at the national level. METHODS: The Nationwide Inpatient Sample 2002-2010 was retrospectively reviewed for colonic volvulus cases admitted emergently. Patients' demographics, hospital factors, and outcomes of the different procedures were analyzed. The LASSO algorithm for logistic regression was used to build a predictive model for mortality in cases of sigmoid (SV) and cecal volvulus (CV) taking into account preoperative and operative variables. RESULTS: An estimated 3,351,152 cases of bowel obstruction were admitted in the United States over the study period. Colonic volvulus was found to be the cause in 63,749 cases (1.90%). The incidence of CV increased by 5.53% per year whereas the incidence of SV remained stable. SV was more common in elderly males (aged 70 years), African Americans, and patients with diabetes and neuropsychiatric disorders. In contrast, CV was more common in younger females. Nonsurgical decompression alone was used in 17% of cases. Among cases managed surgically, resective procedures were performed in 89% of cases, whereas operative detorsion with or without fixation procedures remained uncommon. Mortality rates were 9.44% for SV, 6.64% for CV, 17% for synchronous CV and SV, and 18% for transverse colon volvulus. The LASSO algorithm identified bowel gangrene and peritonitis, coagulopathy, age, the use of stoma, and chronic kidney disease as strong predictors of mortality. CONCLUSIONS: Colonic volvulus is a rare cause of bowel obstruction in the United States and is associated with high mortality rates. CV and SV affect different populations and the incidence of CV is on the rise. The presence of bowel gangrene and coagulopathy strongly predicts mortality, suggesting that prompt diagnosis and management are essential.

Economic analysis of medical management applied for left colostomy.

PURPOSE: This paper presents an analysis of surgical treatment costs for left colostomy, aiming to calculate a medium cost per procedure and to identify the means to maximize the economic management of this type of surgicale procedure. MATERIALS AND METHOD: A retrospective study was conducted on a group of 8 patients hospitalized in the 4th Surgery Department,Emergency University Hospital Bucharest, during the year 2012 for left colic neoplasms with obstruction signs that were operated on with a left colostomy. The followed parameters in the studied group of patients were represented by medical expenses, divided in: preoperative, intra-operative and immediate postoperative (postop. hospitalization). RESULTS: Two major types of colostomy were performed: left loop colostomy with intact tumour for 6 patients and left end colostomy and tumour resection (Hartmann's procedure) for 2 patients. The medium cost of this type of surgical intervention was 4396.807 RON, representing 1068.742 euro. Statistic data analysis didn't reveal average costs to vary with the type of procedure. The age of the study subjects was between 49 and 88, with an average of 61 years, without it being possible to establish a correlation between patient age and the level of medical spendings. CONCLUSIONS: Reducing the costs involved by left colostomy can be efficiently done by decreasing the number of days of hospitalisation in the following ways: preoperative preparation and assessment of the subject in an outpatient regimen; the accuracy of the surgical procedure with the decrease of early postoperative complications and antibiotherapy- the second major cause of increased postoperative costs.

The impact of technology dependence on children and their families.

Advances in medical care and technologies have prolonged life for many children with medical complexity. These advances and their effects reinforce the need for further research to determine how children and their families are being affected by technology dependence and their quality of life. A review of the literature suggests that children, as well as their family members, are negatively affected by technology dependence in a variety of psychosocial domains. Implications for clinical care and future research of this population are discussed.

Desgarro rectovaginal con esfínter anal íntegro: una complicación obstétrica infrecuente / Rectovaginal tear with intact anal sphincter: an uncommon obstetric complication

El desgarro rectovaginal aislado es una complicación de baja incidencia en el ámbito de la obstetricia. Existen pocas publicaciones al respecto, factor que contribuye a la ausencia de consenso en cuanto a su manejo. En el presente artículo, describimos la ocurrencia de dos lesiones de este tipo en nuestro hospital (1.800 partos/año) en el curso de 10 años. Mediante revisión bibliográfica exponemos factores de riesgo y principios de tratamiento. Resulta fundamental la detección precoz de la lesión, así como su reparación quirúrgica minuciosa. En cuanto a la prevención, el fórceps parece ser el principal factor asociado, por lo que resulta conveniente optar por instrumentos menos lesivos, especialmente en pacientes añosas, primíparas o fetos macrosómicos (AU)

The incidence of isolated rectovaginal tear is low in obstetrics and the scarcity of publications on the subject contributes to the lack of consensus on its management. The present article describes the occurrence of two such injuries in our hospital (1800 births / year) over the course of 10 years. Through a literature review, we discuss the risk factors and principles of treatment. Early detection of the injury is essential, as well as meticulous surgical repair. Forceps seems to be the main causative factor and therefore choice of less harmful instruments is advisable, especially in the elderly, primiparous patients, and macrosomic fetuses (AU)

Management of anorectal malformation: Changing trend over two decades in Zaria, Nigeria.

BACKGROUND: Anorectal malformation is a common congenital defect and its management has evolved over the years. This is a review of the trend in the management of this condition in a major paediatric surgical centre in Nigeria over two decades. MATERIALS AND METHODS: A retrospective analysis of 295 patients with anorectal malformations managed from January 1988 to December 2007 was carried out. RESULTS: There were 188 boys and 107 girls aged 1 day-9 years (median 8 years) at presentation. There were 73 (54.5%) and 106 (65.8%) emergency operations in groups A and B, respectively. There were 61 (45.5%) and 55 (34.2%) elective operations in groups A and B, respectively. Regarding treatment, in group A, patients requiring colostomy had transverse loop colostomy, while in group B, sigmoid (usually divided) colostomy was preferred. The definitive surgery done during the two periods were: group A: cutback anoplasty 29 (47.5%), anal transplant 5 (8.2%), sacroabdominoperineal pull through (Stephen's operation) 6 (9.5%) and others 21 (34.4%). In group B, posterior sagittal anorectoplasty (PSARP) 46 (83.7%), anal transplant 1 (1.8%), posterior sagittal anorectovaginourethroplasty (PSARVUP) 2 (3.6%) and anal dilatation 6 (10.9%) were done. Early colostomy-related complication rates were similar in the two groups (P > 0.05). The overall late complication rate was 65.5% in group A and 16.4% in group B (P < 0.05). The mortality was 25 (18.6%) in group A compared to 17 (10.6%) in group B (P < 0.05). CONCLUSION: There have been significant changes in the management of anorectal malformations in this centre in the last two decades, resulting in improved outcomes.

Trends in diverticulitis management in the United States from 2002 to 2007.

OBJECTIVE: To demonstrate the recent trends of admission and surgical management for diverticulitis in the United States. DESIGN: Retrospective database analysis. SETTING: The National Inpatient Sample database. PATIENTS: Patients admitted to the hospital for diverticulitis from 2002 to 2007. MAIN OUTCOME MEASURES: Patient characteristics, surgical approach, and mortality were evaluated for elective or emergent admission. RESULTS: A total of 1,073,397 patients were admitted with diverticulitis (emergent: 78.3%, elective: 21.7%). The emergent admission rate increased by 9.5% over the study period. For emergent patients, 12.2% underwent urgent surgical resection and 87.8% were treated with nonoperative methods (percutaneous abscess drainage: 1.88% and medical treatment: 85.92%). There was only a 4.3% increase in urgent surgical resections, while elective surgical resections increased by 38.7.%. The overall rate of elective laparoscopic colon resection was 10.5%. Elective laparoscopic surgery nearly doubled from 6.9% in 2002 to 13.5% in 2007 (P < .001). Primary anastomosis rates increased for elective resections over time (92.1% in 2002 to 94.5% in 2007; P < .001). For urgent open operation, use of colostomy decreased significantly from 61.2% in 2002 to 54.0% in 2007 (P < .001). In-hospital mortality significantly decreased in both elective and urgent surgery (elective: 0.53% in 2002 to 0.44% in 2007; P = .001; urgent: 4.5% in 2002 to 2.5% in 2007; P < .001). CONCLUSION: Diverticulitis continues to be a source of significant morbidity in the United States. However, our data show a trend toward increased use of laparoscopic techniques for elective operations and primary anastomosis for urgent operations.

Bowel dysfunction after treatment for rectal cancer.

INTRODUCTION: Rectal cancer is a common disease in Western populations. Improved treatment modalities have resulted in increased survival and tumour control. With increasing survival there is a growing need for knowledge about the long-term side effects and functional results after the treatment. AIM: To describe the long-term functional outcome in patients treated for rectal cancer through a systematic review of the current literature and to provide an outline of the promising developments within this area. RESULTS: Standard resectional surgery with loss of the rectal reservoir function results in poor functional results in up to 50-60% of the patients. New methods of surgery including the construction of a neoreservoir and improvement of the technique for local excision have been developed to minimize the functional disturbances without compromising the oncological result. The addition of chemo and/or radiotherapy approximately doubles the risk of poor functional results. During the last decades the techniques for chemo/radiotherapy has been markedly improved with a positive impact on functional outcome. New methods for treatment of functional disturbances e.g. bowel irrigation and sacral nerve stimulation are currently under development. PERSPECTIVES: To improve the functional outcome in this growing patient population several approaches can be taken. The primary cancer treatment must be improved by minimizing the surgical trauma and optimizing the imaging and radiation techniques. Population screening should be considered in order to find the cancers at an earlier stage, hereby increasing the proportion of patients eligible for local excision without the need for chemo/irradiation. All patients recovering from rectal resection should be examined and registered systematically regarding their functional results and treatment should be offered to the severely affected patients. More studies are still needed to evaluate the efficacy of irrigation and nerve stimulation in this patient group.

Adapting to the changing paradigm of management of colon injuries.

BACKGROUND: Based on the evolution that the management of colonic trauma has undergone since the early 1990s, we hypothesized that the use of diversion has decreased at our institution over the last decade. METHODS: A retrospective review was performed of all patients who presented to our trauma center with colon injuries between 1995 and 2006. RESULTS: A total of 81 patients were analyzed. Twenty-five patients (31%) were treated with diversion and 56 patients (69%) underwent primary repair or resection with anastomosis. The rate of diversion in the first half of the study period as well as the second half of the study period was 31%. There was no difference in the complication rates. CONCLUSIONS: The usage of diversion remains higher than current literature would indicate. As a result, we are implementing a program that will actively encourage our trauma surgeons to improve the quality of patient care by incorporating evidence-based medicine into clinical practice.

Caracterización de las familias como agentes de cuidado a niños ostomizados / Characterization of families as agents of care for stomatized children

Este artículo describe las características de los padres que deben asumir el cuidado de niños/as o adolescentes ostomizados y las alteraciones que el estoma trae para la vida cotidiana de toda la familia. La orientación sociocultural, las prácticas de cuidado, la calidad y disponibilidad de recursos y los factores ambientales propuestos como Factores condicionantes básicos (FBC) que interfieren en la experiencia de salud y enfermedad de los seres humanos propuestos por Dorotea Orem, fueron empleados para formar y discutir las categorías.Este es el segundo reporte de resultados de una investigación realizada con la población de beneficiarios del Programa de cuidado integral al niño y al adolescente ostomizado y sus familias que desarrolla la Facultad de Enfermería de la UniversidadNacional de Colombia en la Fundación Hospital de la Misericordia de Bogotá, D.C.

This article describes the characteristics of the parentswho have to care for stomatized children/ adolescents and the alterations the stomameans for the family’s everyday life. Socio- cultural orientation, care practices, quality and availability of resources and environmental factors proposed as Basic Conditioning Factors (BCF) which interfere with the health experience and illnesses of human beings proposed by DoroteaOremwere used to formanddiscuss categories. This is the second report on the results of an investigation carried out with the population of beneficiaries of the Integral Care for Stomatized Children and Adolescents Program developed by the Nursing Faculty at the Colombia National University in the Fundación Hospital de la Misericordia, Bogotá, D.C.

Morbilidad de la colostomía en niños con malformaciones anorrectales (MAR) / Colostomy morbidity in children with anorectal malformations (ARM)

Objetivo. Describir la incidencia y el tipo de las complicaciones presentadas en los pacientes con MAR a quienes se les realizó una colostomía. Material y métodos. Se revisaron los datos de 246 pacientes atendidos con diagnóstico de MAR colostomizados entre 1994 y 2005. Resultados. La colostomía fue realizada en otros centros en 185 pacientes (75,2%) y en nuestra institución en 61 (24,8%). Doscientos once (85,8%) tuvieron una colostomía sigmoidea. Sólo en 124 fue completamente desfuncionalizante. Se abocó erróneamente el colon sigmoide como transverso en 2 casos. El espacio entre las bocas fue muy escaso en 10 y excesivo en 5. Las complicaciones propias de la colostomía fueron la retracción en 7, el prolapso en 7, el cierre de la boca distal en 5, la estenosis proximal en 3, la necrosis de las bocas en 1 y la hernia paraostomal en 2. Las complicaciones posteriores al cierre de la colostomía fueron una oclusión intestinal, un absceso de pared abdominal y dos hernias incisionales. Conclusiones. La morbilidad de la colostomía en pacientes con MAR es llamativa. Este procedimiento no debería considerarse una intervención de menor complejidad por las implicaciones que tiene en el manejo de los pacientes con MAR (AU)

OBJECTIVE: To describe the incidence and type of complications presented in the patients with ARM treated with a colostomy. MATERIAL AND METHODS: The patients data with diagnostic of ARM and colostomy beetween 1994 and 2005 were revised. RESULTS: The colostomy was carried out in other centers in 185 patients (75.2%) and in our institution in 61 (24.8%). Two hundred eleven (85.8%) had a sigmoid colostomy. Only 124 patients had a diverting colostomy. Sigmoid colon was erroneously used as transverse in 2 cases. The space among the ostomies was very scarce in 10 and excessive in 5. The colostomy complications were retraction in 7, prolapse in 7, closure of the distal opening in 5, proximal stenosis in 3, ostomy necrosis in 1 and the paraostomal hernia in 2. Complications related to the colostomy closure were intestinal occlusion in 1, abscess of abdominal wall in 1 and incisional hernia in 2. CONCLUSIONS: The colostomy morbidity in patients with ARM is flashy. This procedure should not be considered a procedure of little complexity by the implications that has in the treatment of the patients with ARM (AU)

[Improvement in surgical treatment of rectal cancer in the surgical department of County Hospital, Szekszard]. / Chirurgische Therapie des Rektumkarzinoms: Verbesserung der Behandlungsergebnisse im Bezirkskrankenhaus Szekszard.

247 elective rectal operations were performed between 1st of Jan., 1996 till 31st of Dec., 2001 in our surgical department. The observation period was divided into one 4-year and one 2-year period. 148 operations were performed in the first and 99 in the second period. In the second period some personal, methodical and technical changes occurred. Age and sex distributions were similar, and the groups were comparable. The early postoperative mortality rate decreased from 9% to 4%. Due to the double stapling technique the rate of anterior rectal resections increased from 40% to 69% and the rate of abdomino-perineal rectal extirpation decreased from 43% to 23% in the same time. Large differences were found in the rate of palliative stoma performing operations, the rate decreased from 16% to 8% in the second period, so the quality of life of the patients improved. The operative time, the length of hospital stay and the rate of blood transfusions decreased as did the rate of postoperative infections. The new quality program improved the results significantly.

The state of the standard diversion.

A fecal or urinary diversion is frequently recommended for a variety of patient conditions. This article will review some of the history of stoma creation, discuss current practices in stoma care, and summarize the current literature regarding stomal complications. Outcomes of fecal and urinary diversion procedures will be depicted, and postoperative quality of life will be described. An update of current ostomy equipment will be presented, along with the crucial role of the WOC nurse in stoma care rehabilitation. Areas for future research in the ongoing drive for evidence-based practice will be highlighted.

Colostomy--the Port Harcourt experience.

Over the 7 years period from January 1986 to December 1992, 36 colostomies were performed at the University of Port Harcourt Teaching Hospital (UPTH). The indications for the procedure were classified under congenital, traumatic, neoplastic and miscellaneous groups. Imperforate anus and Hirschsprungs disease, under the congenital group, formed the commonest indication (19 cases); traumatic conditions followed with 9 cases, carcinoma of the rectum comprised 5 cases while there were 3 cases in the miscellaneous group--made up of 2 sigmoid volvulus and one of stercoral perforation of the sigmoid colon. 27 of the colostomies were loop transverse, 6 absolute defunctioning transverse and 3 terminal Permanent). The peculiar problems encountered with this procedure are also highlighted.

Recent advances in colostomy care.

Recent advances in colostomy care are described. A colostomy is a surgically created opening of the large bowel through the abdominal wall. Three kinds of stoma care are presented, paying particular attention to several advances and setbacks. The special conditions of colostomy care in China are described.