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PubMed1996

Primary repair for colonic gunshot wounds.

BACKGROUND: Penetrating injuries of the colon have been managed traditionally by diverting colostomy. Recently, a trend towards primary repair has been observed, particularly for knife injuries. The purpose of this study is to evaluate the safety of primary repair for colonic gunshot wounds in the presence of certain clinical risk factors. METHODS: A retrospective analysis of 223 patients with colonic bullet injuries in a period of 3 years (1990-93) was performed. RESULTS: Of 223 patients with colonic trauma, 168 were primarily repaired (group A) and 55 underwent a colostomy (group B). Intra-abdominal septic complications occurred in 5.9% of group A patients and 10.9% of group B patients (P > 0.05, NS). These patients were, furthermore, stratified according to well-known risk factors for the development of complications, namely, site of injury, presence of shock on admission, degree of faecal contamination and number of associated injuries. We were unable to find any statistically significant differences in intra-abdominal septic complication rates between patients treated with primary repair and patients treated with colostomy. CONCLUSIONS: Primary repair seems to be a safe therapeutic option for gunshot wounds of the colon. Even in the presence of the above-mentioned risk factors, colostomy may be avoided in most cases as primary repair does not appear to be associated with higher complication rates.

Adolescent↗
PubMedDate not supplied

Effects of oral supplement of L-glutamine on diverted colon wall.

Diverted colorectal segments can present trophic and inflammatory changes. These alterations are of special importance in the patients whose colostomy becomes permanent, as well as in the differential diagnosis with other inflammatory diseases. This study was accomplished to quantify these alterations and to determine if oral supplement of L-glutamine would avoid them. Twenty-six adult male Wistar rats were distributed in three groups: control, colostomized and colostomized+L-glutamine. The colostomized group received a loop colostomy. The colostomized+L-glutamine group received a colostomy similar to the previous group and oral supplement of L-glutamine. Partial volumes of all layers of the colonic wall were measured by image analysis stereology. The diversion caused a decrease of partial volumes of the mucosa and the epithelium as well, and also of the height of the intestinal crypts (p<0.05). There was an increase of partial volumes of the lamina propria, of the submucosa and of the muscularis mucosae vs controls (p<0.05). The partial volume of the muscularis propria didn't show significant alteration. The supplementation of L-glutamine was effective in preventing the atrophy of mucosa and epithelium (p<0.05), also avoiding the increase of partial volumes of the submucosa and lamina propria (p<0.05). This supplement didn't change significantly the muscular layers. In conclusion, colostomy causes the atrophy of the colon wall, mainly due to the atrophy of the epithelium. The supplementation of L-glutamine is able to avoid these changes.

Animals↗
PubMed2005

Role of biological mesh in surgical treatment of paracolostomy hernias.

BACKGROUND: Paracolostomy hernia is a frequent complication of intestinal stoma. Its correction can be made through relocation of the colostomy or by keeping it in place and performing abdominal wall reinforcement through direct suturing with or without a prosthesis. METHOD: Results of surgical treatment of paracolostomy hernias were analyzed in 22 patients who underwent surgery in our hospital during the past 15 years, with or without biological mesh (bovine pericardium). All patients had terminal colostomies after abdominoperineal excision of the rectum. RESULTS: In 15 (68.2%) patients, hernia correction was made by maintaining the colostomy in place, in 2 of them (9.1%) without reinforcement, and in the other 13 (59.1%) through reinforcement of the aponeurosis with biological mesh. In the 7 (31.8%) other patients, hernia correction was accomplished by relocation of the colostomy. The mean follow-up period was 50.2 months. Recurrence was observed in 3 (13.6%) patients after a median of 16 months post-correction. CONCLUSION: Paracolostomy hernia remains a surgical challenge due to its high recurrence rate. Primary repair using a prosthesis of biological material may be preferable since muscle-aponeurotic weakness is frequently observed.

Bioprosthesis↗
PubMed2003

Congenital H-type anovestibuler fistula.

The congenital H-type fistula between the anorectum and genital tract besides a normal anus is a rare entity in the spectrum of anorectal anomalies. We described a girl with an anovestibuler H-type fistula and left vulvar abscess. A 40-day-old girl presented symptoms after her parents noted the presence of stool at the vestibulum. On the physical examination, anus was in normal location and size, and had normal sphincter tone. A vestibuler opening was seen in the midline just below of the hymen. A fistulous communication was found between the vestibuler opening and the anus, just above the dentate line. There was a vulvar abscess which had a left lateral vulvar drainage opening 15 mm left lateral to the perineum. After the management of local inflammation and abscess, the patient was operated for primary repair of the fistula. A protective colostomy wasn't performed prior the operation. A profuse diarrhea started after 5 hours of postoperation. After the diarrhea, a recurrent fistula was occurred on the second postoperative day. A divided sigmoid colostomy was performed. 2 months later, and anterior sagital anorectoplasty was reconstructed and colostomy was closed 1 month later. Various surgical techniques with or without protective colostomy have been described for double termination repair. But there is no consensus regarding surgical management of double termination.

Colostomy↗
PubMedDate not supplied

[The indications and surgical treatment in the complications of colonic diverticular disease].

In this work the authors describe the different stages of diverticulosis and analyze the pathogenetic principal factors. During the period from 1979 to 1998 they observed 420 patients affected by diverticular disease (224 M; 196 F), 42 (10%) of them were operated on for complications. Fifteen patients operated on in elective time underwent a one stage procedure of resection and anastomosis with derivative colostomy; 27 patients were operated on in emergency: 6 patients had one stage procedure of resection and anastomosis with derivative colostomy, 16 patients Hartmann's procedure, 3 patients Mikulicz's procedure and 2 patients colostomy and peritoneal drainage. Two patients died from septic shock. There was absence of postoperative complications for the patients operated on in elective time, while 8 cases (29.6%) showed peritoneal sepsis and 4 cases (14.8%) infection of wound in the patients operated on in emergency. The Authors describe the different surgical options in the treatment of colonic complicated diverticular disease and conclude that the surgical treatment is not definite. A tendency is to make a one-stage procedure of resection and anastomosis and to reduce the Hartmann's procedure or the simple colostomy with drainage of abdominal cavity.

Aged↗
PubMedDate not supplied

Anorectoplasty in children in Papua New Guinea.

The posterior sagittal anorectoplasty (PSARP) procedure for the definitive repair of children with imperforate anus was described in 1982. Unfortunately, surgeons in Papua New Guinea (PNG) have until recently not had the opportunity of being trained in the technique. Through the Medical Officer, Nursing and Allied Health Sciences Training Project (MONAHP) and Pacific Islands Project (PIP) of the Royal Australasian College of Surgeons, 65 Papua New Guinean children with an anorectal anomaly have undergone a repair, in conjunction with training of the surgical staff and medical students. A new technique for the management of a prolapsed colostomy has been developed and a protocol for management of PSARP patients postoperatively has been formulated. Patients referred to the paediatric surgical visiting teams were diagnosed and treated according to the stage their management had reached. Patients with a low anomaly were treated by a cutback procedure, those with a colostomy and a high lesion were managed by a PSARP and those with failed previous surgery were managed with a redo anorectoplasty, often without a covering colostomy. Data were collected on the patients treated and, where possible, the patients were followed during subsequent visits. 65 patients with an anorectal anomaly were treated, of whom 6 were treated with a cutback and 43 had a primary repair of a major anomaly. 5 of these 43 involved an abdominoperineal procedure. 19 children had redo surgery, 3 of whom had a second operation by the senior author, due to failure of initial postoperative management; 1 of these was for a failure to carry out the postoperative dilatations and 2 were due to poorly controlled constipation in the early postoperative period. A protocol for the postoperative dilatations was developed using shaped candles. Major complications were uncommon, in particular infections were rare despite the relative lack of facilities. However, difficulties with outpatient follow-up resulted in problems that could have been avoided. A large number of anorectal anomalies have been successfully treated as part of the MONAHP and PIP projects with local surgeons learning the technique. A protocol for follow-up and a technique for the management of colostomy prolapse have been developed.

Anus, Imperforate↗
PubMedDate not supplied

Laparoscopic stoma creation.

Laparoscopic creation of an intestinal stoma may be preferable to an open operation. We report here our experience with faecal diversions. From April 1992 to April 2003 we performed 55 procedures (23 end colostomies for Miles operations; 21 end colostomies for Hartman procedures; 9 loop colostomies and 3 loop ileostomies). In 45 cases the procedure was completed laparoscopically. Ten (18%) of the cases required conversion due to bulky tumours (6 pts), obesity (2 pts) and adhesions (2 pts). The indications for diversions were rectovaginal fistula (1 pt), anastomosis leakage (1 pt), unresectable rectal cancer (21), rectal cancer resectable by Miles operation (20 pts). The two ileostomies were constructed to protect colo-anal anastomoses. The average duration of surgery was 50 minutes (range: 20-100) and 200 minutes in the case of Miles operations. The average postoperative hospital stay was 3 days (range: 2-5) and 7 days (range: 6-9) after a Miles operation. The demand for analgesics was far lower than with traditional surgery and did not continue after postoperative day two. We had no intraoperative complications. There was no mortality. During the follow-up period all the stomas have functioned well but a prolapse occurred in one case (2.6%). The laparoscopic creation of intestinal stomas is safe, feasible and effective and can be performed with a low morbidity rate. Stoma construction is the simplest of all laparoscopic procedures because it requires little dissection and only minimal mesenteric handling. The length of the procedure is longer in patients who have had prior surgery, but prior surgery is not a contraindication and a laparotomy can be avoided in the majority of patients. Patients who are obstructed or have significant bowel dilation are less prone to damage with laparoscopic procedures. In addition to the benefits of laparoscopic techniques for the patients, a laparoscopic colostomy may be ideal for the surgeon as a basic, initial step in the performance of laparoscopic colorectal procedures.

Colostomy↗
PubMedDate not supplied

[The rectal cancer--between resection and amputation. Surgeon's decalogue].

The surgeon has the opportunity to use a lot of treatment choices taking into account the site, the progression and the aggressiveness of the rectal tumors. If the treatment of anal cancer have been the same over the last years there are a few problems regarding the rectal cancer, especially for the one, which is distal and locally advanced. The therapeutic choice must take into account the following factors: the site of the tumor, the circumferential invasion, the local and distant spread, the complications and loco-regional recurrences, the anatomical shape of the pelvis, the possibility of developing tumor implants on the residual rectum, the equipment of the hospital, the experience of the surgical team, the accuracy of stoma technique, and the previous results in patients survival. In a trial of 381 patients with recto-sigmoidian and anal cancers we performed 171 rectal amputations, 29 Hartmann procedures and 76 laparotomies and colostomies. From the 276 patients with colostomy 172 (62.31%) were followed. The survival rate was: 6-10 months for the patients with laparotomy and colostomy, 16-24 months for those with palliative procedures (55.8%) and 5-17 years for those with radical procedures. From the point of view of the authors the rectal amputation with colostomy it is an alternative between oncological safety and patients comfort. This kind of surgical procedure must be done in specialized centers excepting the emergencies.

Aged↗
PubMedDate not supplied

Treatment of gunshot wounds to the colon: experience in a rural hospital during the civil war in Somalia.

BACKGROUND: In the last few decades there has been a clear tendency in civilian practice towards primary repair of gunshot wounds to the colon, resulting in a substantial decrease in the number of colostomies performed for this type of injury. METHODS: The series described here comprises 24 patients with gunshot wounds to the colon treated at the hospital of Jowar in the Middle Shebelle region of Somalia between 1999 and 2001. All injuries were caused by war arms firing high-velocity projectiles. RESULTS: In 18 patients surgery consisted of resection and immediate anastomosis, while in the remaining six patients colostomies were performed including five loop colostomies and one terminal colostomy. The sepsis-related mortality was 25% (6/24). CONCLUSION: Our experience had a peculiar setting, namely that of a civil war in a developing country. In this kind of "difficult" situation there probably exists no ideal procedure and the decisions taken at the operating table are influenced by various factors that are often related to subjective assessment.

Adolescent↗
PubMed2005

[The use of a self-expanding stent as palliation or before elective surgery in patients with obstructive colorectal carcinoma].

OBJECTIVE: To evaluate the use of colorectal stents. DESIGN: Retrospective. METHOD: Data were collected on all patients treated at the Deventer Hospital, the Netherlands, between 1 April 1996 and 31 December 2003 in whom the placement of a self-expanding colorectal stent was attempted. Each patient's physician was contacted to inquire about the patient's status, including quality of life with the stent in situ. RESULTS: Stent placement was attempted in 57 patients as palliation (n = 45) or before elective surgery (n = 12). Of the 57 patients, 29 were men and 28 were women, and the mean age was 71 years (range: 46-94). All patients had colorectal carcinoma, except 1 patient with stenosis following ischaemic colitis. Passage of air and faeces occurred immediately after stent expansion in 55 of the 57 patients (96%). Perforation during stent placement occurred in 2 patients, who subsequently underwent colostomy. 4 additional patients required a colostomy due to stent migration within a few hours or days after placement (n = 3) or obstruction by tumor growth after 65 days (n = 1). Patients in the palliative group had an acceptable quality of life. Those who received a stent before elective surgery were able to undergo resection, did not require colostomy, and had no postoperative complications. One patient did not undergo surgery because of extensive metastases. CONCLUSION: A colorectal stent can be used in the palliative treatment of terminal patients with colorectal carcinoma before colostomy is considered. Experiences with stents before elective surgery were also positive.

Aged↗
PubMed2005

[Surgical treatment of diseases and injuries of the colon].

The results of treatment of 330 patients with complicated diseases and traumas of the colon were analyzed. The treatment included primary resection of the colon with the formation of separate double-trunked (220 patients) and single-trunked (110 patients) colostomies. Postoperative complications were noted in 26.4% of cases. The formation of separate double-trunked colostomies allowed facilitation of surgical rehabilitation of the colostomy patients. The technical elements of formation of separate double-trunked colostomies after resection of the colon are described.

Colon↗
PubMed2006

Sexual dysfunction after curative radical resection of rectal cancer in men: the role of extended systematic lymph-node dissection.

BACKGROUND: This study was designed to determine the incidence and patterns of sexual dysfunction after curative radical resections (CRR) with or without extended systematic lymph-node dissection (ESLND) for rectal cancer Material/Methods: A total of 91 patients with rectal cancer were reviewed with respect to surgical procedures and postoperative sexual functions using the International Index of Erectile Function (IIEF), a 15-item self-administered questionnaire. CCR (abdomino-perineal resections or sphincter-saving anterior resections) was performed in 78 patients (Group I) and ESLND plus CRR in 13 patients (Group II), and sexual functions were also evaluated in the colostomy and non-colostomy subgroups. RESULTS: In the postoperative period, the five domains of IIEF scoring decreased significantly from the preoperative scores in both groups (p<0.05), but the postoperative decreases were not significant between groups I and II (p>0.05). Having a permanent colostomy decreases IIEF scores in all colostomized patients. CONCLUSIONS: CRR and CRR+ESLND both decrease sexual function and lymph-node dissection is not considered to have any additive effect on this decrease. In addition to standard surgery, anxiety about having a malignant disease and permanent colostomy may play an important role in male sexual dysfunction.

Adult↗
PubMed1989

Management of Hirschsprung's disease in adolescents.

It is unusual for Hirschsprung's disease to go undiagnosed until late childhood. Adolescents presenting with Hirschsprung's disease offer unique challenges to the surgeon because of the massively dilated and hypertrophied colon that is invariably present. Five adolescents (four males and one female; ages, 11 1/2 to 16 1/4 years) with newly diagnosed Hirschsprung's disease were managed by slightly different methods between January 1981 and March 1987. Three patients had a "leveling" colostomy, followed by a Swenson procedure in two and a Duhamel procedure with a temporary diverting colostomy in one. One patient had a primary Duhamel procedure with a temporary diverting ileostomy. One patient had a primary Swenson procedure without diversion. Long-term results were uniformly excellent. Based on the experience with these patients the following principles of management emerge: 1) Avoid loop "leveling" colostomies because of their grotesque size and their tendency to retract or prolapse. 2) Rectal tube decompression can often adequately prepare a patient for a primary pull-through procedure. 3) When a diverting ostomy is required, it should be an ileostomy rather than a colostomy because its subsequent closure will not endanger the marginal artery, which if divided, could compromise the blood supply to the pulled-through colon. 4) The Swenson procedure, although difficult in adolescents, can be done with excellent long-term results. 5) Several applications of the stapling instrument are required in the Duhamel procedure to fully divide the septum between the aganglionic rectum anteriorly and the normal colon posteriorly.

Adolescent↗
PubMed1978

[Surgery of complicated diverticular sigmoiditis. Report of 138 cases (author's transl)].

The authors analyse a series of 138 cases of complicated diverticular sigmoiditis treated surgically. They noted 50% of pyostercoral peritonitis, 32% of persigmoid abscesses, 13% of case of intestinal obstruction, and 5% of cases of fistual or hemorrhage. The overall mortality was 28% and depended mainly more on the surgical management adopted than on the type of complication. In this respect, simple colostomy with drainage of the septic focus had a mortality of 18%. The results suggest surgical operation in two stages, in the form of colonic resection, with, depending on each case, an anastomosis straight away with transverse colostomy or segmental colectomy with bitubular colostomy (Mikulicz procedure) or, in rarer cases, simple colostomy. The authors emphasise the interest of early surgery in sigmoiditis with complications and contrast the mortality of cold surgery which is now about 5% compared with 28% in emergency cases with complications.

Abscess↗
PubMed1986

[Emergency surgery in colonic obstructions. Retrospective study of 70 cases].

70 patients with complete colonic obstruction requiring emergency surgery were treated at the "Clinique Chirurgicale C" between 1977 and 1984. Carcinoma was the cause of obstruction in 65 cases. Obstruction was situated on the right colon 8 times, on the splenic flexure 13 times, and on the left colon 49 times. In emergency obstruction of the right colon was treated by right hemicolectomy in 6 cases with 0 death. Obstruction of the splenic flexure was treated in 10 cases by simple loop colostomy, twice by resection with ileo-sigmoid anastomosis, 1 by resection without anastomosis with 5 deaths. Obstruction of the left colon was treated by simple loop colostomy in 46 cases. Of the 34 patients who survived after loop colostomy, 26 were reoperated and in 23 cases a resection could be performed with 2 deaths and the colostomy could be closed in a third stage in 20 cases without death. 5 years survival of curative resection was 57%. It is concluded that primary resection is the best treatment for obstruction of the right colon and of the splenic flexure. But three stage resection seems to be a good procedure for obstruction of the left colon with low mortality, low morbidity and good 5 year survival.

Adult↗
PubMed1985

Analysis of a hospital-based stomatherapy service.

We have analysed the activities of a hospital-based stomatherapy service between 1980 and 1983. The average numbers of patients seen per annum included 395 out-patients, 307 in-patients and 116 home visits. Of the 276 in-patients with colostomies, 72% had underlying malignant disease; 17% were performed as emergencies and 51% were temporary stomas. Hospital mortality for patients with a temporary stoma was 19% and only 59% had their temporary stoma reversed. Only 45% of colostomy patients received preoperative counselling and 11% had no regular follow-up. Complications were recorded at some stage after colostomy in 25% but only 10% required surgical refashioning. Of the 184 in-patients with ileostomies, 52% had ulcerative colitis and 41% had Crohn's disease. Only 13% of ileostomies were performed as emergencies, and only 11% were temporary. In contrast to colostomy, 83% of ileostomy patients received preoperative counselling and adequate follow-up was provided for 98% of patients. Complications were recorded in 57% of patients after ileostomy but surgical reconstruction was needed in only 18%.

Aged↗
PubMed1994

Anastomotic leakage after anterior resection of the rectum.

OBJECTIVE: To evaluate the results of elective colorectal operations, to identify factors that influence the anastomotic leak rate, and to assess the value of a covering colostomy. DESIGN: Retrospective study. SETTING: University hospital. SUBJECT: 134 consecutive patients undergoing elective resection for a neoplasm (125 carcinomas and 10 villous adenomas) of the colon and rectum. INTERVENTIONS: 135 operations (one for a recurrence in the anastomotic line). MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: Two patients died (1%) and there were 29 complications (21%); 16 patients developed clinical anastomotic leaks (12%) and 3 patients symptomatic strictures (2%). One patient who developed a leak died and 11 of the 16 (69%) were re-operated on. The rest settled spontaneously. The only significant risk factor associated with leakage was distance of the anastomosis from the anal verge (all 16 leaks were within 7 cm, compared with 44/118 without leaks, p < 0.001). Four patients who developed leaks were left with permanent colostomies. Protecting stomas had no significant influence, despite the fact that only 1 of those that developed leaks had a colostomy compared with 9/109 that did not. CONCLUSION: Prospective controlled studies are needed to establish the true value of a covering colostomy after low colorectal anastomosis.

Adenoma, Villous↗
PubMed1993

Swenson's operation for neonatal Hirschsprung's disease.

OBJECTIVE: To describe our experience with Swenson's operation for Hirschsprung's disease done during the neonatal period. DESIGN: Retrospective study. SETTING: University department of paediatric surgery. SUBJECTS: 10 Neonates with Hirschsprung's disease. INTERVENTIONS: Rectosigmoidectomy and pull through (Swenson's operation), with covering transverse colostomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and continence. RESULTS: The median age at definitive operation was 25 days (range 15-35). There was one late death three weeks after discharge from hospital of respiratory and cardiac failure. Two patients presented with caecal perforation and two with intestinal obstruction; in all four Hirschsprung's disease was diagnosed on frozen section, a transverse colostomy was done, and the Swenson's operation was done electively. The other six were diagnosed by barium enema examination and biopsy, and underwent total bowel irrigation followed by Swenson's operation and transverse colostomy. The colostomies were closed three to four weeks later. There were no postoperative complications. All nine surviving patients were continent (3-4 stools/day), at a mean (SD) follow up of 21 (5) months. CONCLUSION: With the current high standards of anaesthesia and neonatal intensive care, and an experienced surgeon, Swenson's operation for neonatal Hirschsprung's disease is safe and the procedure of choice for this condition.

Anal Canal↗