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PubMed2003

Peri-operative factors predicting the outcome of hepatic porto-enterostomy in infants with biliary atresia.

INTRODUCTION: Without hepatic transplantation, hepatic porto-enterostomy is the only definitive surgical therapy for infants with biliary atresia. Unfortunately, clearance of jaundice by the procedure is not promising. Pre-operative data that may predict the outcome is of great value in the selection of surgical candidates. Early post-operative determinants of outcome also help in follow-up planning. OBJECTIVE: To determine peri-operative factors influencing jaundice clearance after hepatic porto-enterostomy in infants with biliary atresia. PATIENTS AND METHOD: Clinical and laboratory data of pediatric patients undergoing hepatic porto-enterostomy in Songklanagarind Hospital from 1988 to 2001 were reviewed regarding age at operation, clinical presentation, gross pathology of bile duct atresia, liver function profiles and changes after the procedure, liver pathology and post-operative ascending cholangitis. Univariate comparison followed by multivariate logistic regression analysis was analyzed against the clearance of jaundice. Statistical analysis was aided by the Stata 7.0 program. Statistical significance was set at p-value less than 0.05. RESULTS: There were 62 infants operated on during the thirteen-year period. Four cases of operative death and a case lost to follow-up before the second post-operative month was excluded. The median age at the operation was 78 days (34-326 days). Twenty-four cases (42.1%) presented with signs of portal hypertension. After the operation, 19 cases (33.4%) were jaundice free, 6 cases (10.5%) had fair clearance and 32 cases (56.1%) had a poor result. Univariate analysis revealed an association between age at surgery and jaundice clearance. Post-operative stool color and decline of total bilirubin level at one month after surgery were significantly correlated with the outcome (p < 0.01). Cholangitis within the first post-operative month significantly had an adverse effect on the short-term survival probability. Multivariate analysis showed an independent association of jaundice clearance with age at surgery and type of bile duct atresia. CONCLUSION: Age of the infants younger than 60 days and type I of bile duct atresia were the key determinants of successful hepatic porto-enterostomy. Early cholangitis was an accelerator of progressive cirrhosis. Stool color and bilirubin level at one month after surgery can be used as predictors of jaundice clearance.

Analysis of Variance↗
PubMedDate not supplied

Temporary Witzel enterostomy in decompensated small-bowel obstruction or paralytic ileus.

The technique of temporary Witzel enterostomy and its indications are reported and results in 81 patients (99 enterostomies) retrospectively reviewed. The procedure is recommended as an adjunct to primary surgery in cases of small-bowel obstruction with severe distention, extensive peritoneal defects and compromised vascularity, in paralytic ileus due to generalized peritonitis and in peritoneal carinomatosis. With the Witzel tunnel, postoperative bowel paralysis can be prevented, endangered anastomosis protected, bowel function directly monitored and long-term intestinal decompression achieved in patients with obstruction due to peritoneal carcinomatosis. The tube is easily removed when bowel function has normalized. The overall mortality in the series was 25% and the rate of enterostomyrelated complications 10%. There were no enterocutaneous fistulas requiring surgical correction. Possible long-term complications due to narrowing at the enterostomy site could not be assessed. Carefully constructed Witzel enterostomy, used on suitable indications, is an effective procedure in the management of small-bowel obstruction and peritonitis.

Adolescent↗
PubMed2006

Santulli enterostomy revisited: indications in adults.

BACKGROUND: Surgical patients frequently need some type of intestinal stomas for a wide spectrum of disorders. Maintaining effective and enough decompression of gastrointestinal tract, securing distal bowel segments and anastomosis are the primary goals of ostomy formation as well as providing a minimum complication rate of closure or "take-down". METHOD: In this report, we present five adult patients who were operated for some kind of intestinal disease and required enterostomy. We preferred Santulli type of enterostomy which was formerly used by pediatric surgeons. In this technique, the proximal afferent bowel is fashioned into a stoma and anastomosed side-to-end with double layer sutures into the distal efferent bowel. RESULT: One of the five patients died of systemic problems, other four did well in terms of surgical outcome of the stoma. CONCLUSION: We concluded that; although indications are limited, Santulli enterostomy can be performed in adult patients as effective as pediatric age group, particularly for its advantages in early restoration of intestinal continuity and diminished risk for post-closure complications.

Aged↗
PubMed2004

Surgery for necrotising enterocolitis: primary anastomosis or enterostomy?

The ideal surgical management of neonates with necrotising enterocolitis (NEC) is still a matter of debate. The purpose of this study was to compare the results of bowel resection with primary anastomosis with the results of bowel resection with enterostomy. Sixty-three neonates with NEC had a bowel resection in the acute phase of the disease in the period between February 1990 and March 2001. Thirty-four of them (54%) underwent resection of the bowel with primary anastomosis (Group A), and 29 (46%) had resection with enterostomy (Group B). Group A had a lower gestational age and lower birth weight. Mortality, complication rate, and postoperative weight gain were not significantly different between the groups. However, Group B had a significantly longer primary hospital stay (80 +/- 49 days versus 58 +/- 31 days, P < 0.04) and needed a 2nd hospital stay for restoring gastrointestinal continuity. For both reasons, it can be argued that primary anastomosis is superior to enterostomy after resection.

Anastomosis, Surgical↗
PubMed2006

Enterostomy site hernias: a clinical and computerized tomographic evaluation.

PURPOSE: Parastomal hernia continues to be an important clinical problem with a reported incidence of up to 50 percent. In studies using computerized tomography in selected cases for detection of parastomal hernia, physical examination alone was underestimating the true incidence. Also after closure of the enterostomy, the ostomy site could still be a potential area of herniation. In this study in addition to physical examination, we used computerized tomography to determine the true incidence of parastomal hernia and ostomy closure site hernias. METHODS: We examined patients with enterostomies and with closed enterostomy sites both with physical examination and computerized tomography for the detection of hernias, hernia content, and relation to rectus muscles. Risk factors for hernia formation, such as age, gender, body mass index, associated medical problems, and surgical site infections, were determined. RESULTS: Evaluation of 23 patients with ostomies resulted in 52 percent incidence of parastomal hernia, whereas the addition of tomography examination gave a corrected incidence of 78 percent. In a second subset of 23 patients with closed ostomies, although 26 percent of the patients were found to have ostomy site hernias with physical examination alone, this incidence increased to 48 percent when combined with computerized tomography. The potential risk factors for hernia formation, such as body mass index, surgical site infection, and ostomy site whether pararectus or transrectus, were not proven to have a significant role in this study. CONCLUSIONS: Parastomal hernia and closed ostomy site incisional hernias have a high incidence, and computerized tomography has been shown to be a valuable diagnostic tool.

Enterostomy↗
PubMed2006

Enterostomy tube placement in children with spinal muscular atrophy type 1.

OBJECTIVE: To determine the major complication rate in the first 30 days after enterostomy tube insertion in infants with spinal muscular atrophy (SMA) type 1. STUDY DESIGN: A retrospective case review of all children with SMA type 1 who had a gastrostomy or gastrojejunostomy tube placed by the image-guided technique at the Hospital for Sick Children from 1994-2004. Major complications were classified as peritonitis, aspiration pneumonia, respiratory failure, nonelective admission to the pediatric intensive care unit, and death. RESULTS: Twelve children were identified as having SMA type 1 with an enterostomy tube insertion. The median age at tube insertion was 6.1 months (range 2.2 to 15.8 months). Major complications in the first 30 days after the procedure included aspiration pneumonia (5/12 patients [41.6%]), respiratory failure requiring admission to the pediatric intensive care unit (4/12 [33%]), and death (2/12 [16.7%]). Children with development of aspiration pneumonia were significantly older at time of tube insertion (P < .05) than those with no aspiration. CONCLUSIONS: Major complications including death are seen in children with SMA type 1 in the first 30 days after enterostomy tube insertion.

Enteral Nutrition↗
PubMed1996

Necrotizing enterocolitis: late surgical results after enterostomy without resection.

Between January 1985 and December 1992, 36 neonates were treated for necrotizing enterocolitis (NEC). 13/36 were treated conservatively and 2 (18%) died. 23/36 required surgical treatment at birth and 6/23 (26%) died; 14, out of 17 surviving initial surgery, underwent reintervention to restore intestinal continuity, 3 to 26 months later. In these 14 infants the acute necrotizing process involved the whole colon and ileum in 3 cases, the whole colon in 5, part of the colon in 3, part of the colon and ileum in 2 and was confined to the ileum in 1. 11 cases were perforated. During their first laparotomy all 14 cases had a decompressive enterostomy without resection. 21 reoperations were later needed in these 14 patients: simple enterostomy closure was performed in only 1 case, while resection of delayed strictures was required in 13. 12 cases underwent partial colectomy, 3 of these had multiple segmental resections for skip lesions and only 1 child had a total colectomy. The only postoperative complication was one anastomotic leak. Two children had short-gut syndrome but later outgrew their need for parenteral nutrition. Our experience does not support the need of resecting the gangrenous bowel in the acute phase. A simple diverting enterostomy seems to be effective treatment. Delaying the intestinal resection up to the time of recanalisation allows spontaneous healing and results in the sparing of a significant length of bowel.

Colectomy↗
PubMed1990

[Temporary bitubular enterostomy. A convenient procedure].

In cases where double enterostomy is necessary, it is always possible to introduce a balloon catheter into the distal small bowel and to attach it to the deep surface of the abdominal wall, close to the proximal enterostomy. This "indirect" enterostomy facilitates fitting of the productive orifice, as well as resumption of digestion and, ultimately, restoration of the gastro-intestinal tract.

Catheterization↗
PubMed1985

Chronic intestinal pseudo-obstruction. Management with total parenteral nutrition and a venting enterostomy.

A variety of remedies have been suggested for patients with chronic intestinal pseudo-obstruction. However, none of these treatments have been particularly effective, and many of these patients have died of malnutrition. Therefore, in an effort to maintain nutrition and avoid repetitive nasogastric intubation, 22 patients (12 adults and ten children) with chronic intestinal pseudo-obstruction were managed with long-term total parenteral nutrition (TPN), and 20 also received a "venting" enterostomy. Only two patients had to undergo revision of their gastrostomies. Prior to referral, these 22 patients required 56 admissions for obstruction (1.2 admissions per patient-year). Since the initiation of TPN and placement of a venting enterostomy, these 22 patients required only 17 hospitalizations for obstruction in a total of 80 patient years (0.2 admissions per patient-year). We conclude that patients with chronic intestinal pseudo-obstruction who receive TPN at home and have a venting enterostomy can be safely managed for prolonged periods and require fewer hospitalizations for obstruction.

Adolescent↗
PubMedDate not supplied

Effect of enterostomy on quality of life in spinal cord injury patients.

To determine the difference in the bowel care of spinal cord injury patients before and after enterostomy, we interviewed 20 patients--19 men and one woman. Their ages were 27-75, median 55 years. The paralytic lesions were spastic in ten and flaccid in ten. A total of 24 enterostomies were done for the following reasons: fecal contamination of decubitus ulcer in seven, colonic tumor in six, perforation of the colon in four, prolapse of the large intestine in four, inconvenience of bowel care in two, and perirectal abscess in one. There were 17 sigmoid and five transverse colostomies, and two ileostomies. (Two patients accounted for six procedures.) Follow-up time ranged from three months to six years, median nine months. Bowel care time was reduced from 0.7-14 hours, median 6.0 hours per week preoperatively, to 0.3-7 hours, median 1.0 hours per week postoperatively. Reversal of fecal leakage, abdominal pain, gas and anorexia were also reported. All patients were happier with their bowel care after surgery. We conclude that enterostomy in the spinal cord injury patient makes bowel care considerably more convenient, and improves the quality of life as well.

Adult↗
PubMed2001

A comparison of spur valve and percutaneous enterostomy in Roux-Y portoenterostomy for biliary atresia.

OBJECTIVE: To compare the advantages and disadvantages of two procedures: Roux-Y with enterostomy and Roux-Y with spur valve in the treatment of biliary atresia. METHODS: Twenty-four patients with biliary atresia underwent hepatic portoenterostomy with percutaneous jejunal enterostomy (Group A) and 24 patients underwent Roux-Y with antireflux spur valve (Group B). Clinical data were reviewed retrospectively. RESULTS: Ten patients remained alive in the Group A. Among them, 9 survived without jaundice, the oldest one being 9-years old. One of the 9 patients had portal hypertension. The remaining one who survived with jaundice and portal hypertension was 8-years old at follow up. Ten patients in the Group B remained alive. Of them, 8 survived without jaundice and 2 with jaundice. CONCLUSIONS: Two surgical procedures had similar effects in preventing reflux cholangitis, while spur valve has the benefit of quitting cutaneous enterostomy.

Journal Article↗
PubMed1982

A reappraisal of the Mikulicz enterostomy in infants and children.

We performed the Mikulicz procedure in 46 pediatric patients. Thirty-five were high-risk patients, 20 of whom had necrotizing enterocolitis. High risk was defined by the presence of peritonitis, intestinal perforation, poorly demarcated intestinal gangrene, or severe associated systemic illness. The remaining 11 patients had the procedure performed for technical reasons, most commonly a discrepancy in the size of the proximal distal limb ratio greater than 4:1. The procedure consisted of intestinal resection with double-barreled enterostomy, crushing of the spur between stomas, and subsequent lateral closure of the enterostomy. The mortality rate of 30% was due to the underlying disease and in no instance was death caused by a complication of the procedure. Complications (13%) were stricture or prolapse of the stoma and wound infection. Subsequent enterostomy closure in 32 patients had no mortality rate and a 3% complication rate. Because the risk of fatal anastomotic leak and peritonitis is very low, we prefer the Mikulicz procedure to all other intestinal anastomotic techniques for high-risk pediatric patients.

Child↗
PubMed1982

[Easily closed gun-barrel enterostomy. A new technique].

The availability of continuous low rate enteral and parenteral feeding has enlarged the indications of enterostomy, notably in patients with multiple operations. However, closing an enterostomy, which may be high up in the small bowel, rises technical problems and is not always without risk. In this study a new technique of gun-barrel enterostomy easily closed with automatic sutures and without reopening of the abdominal wall is presented.

Humans↗
PubMed1999

Appendicostomy as a venting enterostomy for colonic atresia.

Colonic atresia is usually managed surgically by resection and end-to-end anastomosis but preferably with a venting enterostomy, if presentation is delayed. A new technique of appendicostomy was performed as a venting enterostomy in eight cases of colonic atresia with good results in our children's hospital during the period 1990-1995.

Appendix↗
PubMed1990

[A frequent complication of enterostomy: prolapse].

Among the other complications of enterostomy, prolapse deserves particular mention on account of the therapeutic problems involved in its correction. Based on a report of the authors' personal experience, the paper focuses on the mechanisms of onset and, above all, on the most appropriate forms of treatment, before continuing to describe the different surgical reparative techniques. In conclusion, the authors affirm that an optimal tailoring of the enterostomy and its appropriate preparation represent the ideal method of preventing the onset of prolapse.

Enterostomy↗
PubMed1990

[Enterostomy: preparation, construction and after care over time].

During the last decade the industry has developed material to improve the quality of life of patients with an enterostomy. Patients are better informed and prepared before operation. Postoperative advising by professional nurses help the patient to maintain an odorless, leak-proof and continent stoma. Most of the patients today with enterostomies are able to have a socially integrated life with minimal psychological and physical handicaps.

Adaptation, Psychological↗
PubMed1988

Enterostomy complications in infants.

A retrospective review of 48 infants, less than one year of age, with enterostomies was carried out to analyse the complications. Early complications were encountered in 3 patients (5%). Stoma complications occurred in 7 patients (14.6%) and revision was required in 2 cases. Total or near total parenteral nutrition was needed in 23 patients (48%). Of the 25 who tolerated oral feeding, 16 (64%) required extra sodium in their diet. Stoma-closure in 37 patients had a leakage rate of 8% and no mortality. Careful attention to technical details, diligent postoperative stoma care and early closure of the enterostomy if possible, seems to be the best way of avoiding complications.

Enterostomy↗
PubMed1993

[Early complications of enterostomy. Importance of the type of suture].

The frequency and character of early complications following creation of enterostomies, and their relation to the type of suture material used were studied in 50 consecutive patients. The stomas were matured by muco-cutaneous eversion, and were fixated with Maxon 4-0 and Vicryl 3-0 sutures. Half the stoma circumference was sutured with the one suture type, and the other half with the other. No statistically significant correlation was found between enterostomy type or surgical procedure and complications. The incidence of muco-cutaneous complications was significantly higher following fixation with Vicryl as compared to Maxon sutures. The cause of this difference is uncertain, however, the physical configuration of the sutures seems important, Maxin being monofile versus Vicryl being braided. Whether the chemical structure is significant as well remains undetermined at present.

Adult↗