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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.
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.
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.
Iron deficiency anaemia is common following vagotomy and gastro-enterostomy, and this study has shown that all the anaemic patients had low gastric secretion. After correction of their anaemia, gastric secretion was increased, but was still very low, and when these levels were compared with secretion in fit non-anaemic patients it was found that the latter group had a significantly higher secretion, and that a high proportion of them showed evidence of incomplete vagotomy. These results suggest that there is a relationship between the levels of gastric secretion in patients after vagotomy and gastro-enterostomy and the development pf anaemia. It may be that inadequate gastric secretion impairs the release of elemental iron from the diet and its subsequent absorption.
During the 14 yr from 1965 through 1978, 49 infants presented shortly after birth with intestinal obstruction due to impacted meconium. Three of these patients did not have fibrocystic disease. Eight patients were cured by a Gastrografin enema. There were 18 patients who had complications that included associated atresia, volvulus, and/or peritonitis. Various operations were done including resection with either primary anastomosis or enterostomy or varieties of the foregoing. Twenty-three babies had the simple uncomplicated form of meconium ileus. Eleven of these underwent resection and six patients died. Twelve patients were treated by laparotomy, ileotomy through a purse-string suture and prolonged irrigations using acetylcysteine. Of this group only one succumbed. This latter course of management is recommended for patients with simple uncomplicated meconium ileus as it involves no resection, no enterostomy, nor any primary anastomosis.
To accelerate the self-healing of an intestinal fistula the author developed 2 variants of enterostomy based on the principle of valvular closure of the serous canal after the removal of the tube. The serous canal around the tube forms from the lateral walls of both bends of intestinal loop a fold in the shape of an angle. In the first variant the tube enters the intestinal lumen along the intestinal loop curvature line; in the second - through the lateral wall of one of the intestinal loop bends. The angular jejunostomy was applied as feeding fistula in 49 cases. The angular ileostomy was carried out on 24 cases to obtain the decompression of the small intestine. There were no cases of complications or fatal outcome resulting from the application of the angular enterostomy method.
The exchange of enterostomy feeding catheters may be facilitated by the use of a recently developed hydrophilic polymer guide wire. This has been found especially useful in the insertion of catheters constructed of polyurethane or silastic-type materials.
Repeated or prolonged organic obstruction of the small intestine in the neonatal period can lead to severe refeeding problems, despite a transient ostomy. These problems are thought to result from a postobstructive enteropathy (POE) of the apparently normal small intestine segment above the obstruction. Ten infants with a POE, characterized by limited oral caloric and carbohydrate intakes and increased ostomy effluent, were compared with 8 controls with an enterostomy and a normal postoperative refeeding pattern. There was no statistical difference in the histomorphometric appearance of the mucosa or its digestive or absorptive capacity (brush-border hydrolases, glucose transport) between the two groups. The effluent and duodenal floras of the two groups were similar. However, all POE patients showed significant abnormal peristalsis characterized by barium and carmin transit times. This suggests that repeated or prolonged obstruction in the neonatal period could lead to a POE, caused by chronic motricity abnormalities of the small intestine above the obstruction. Although this POE is more frequent after small bowel atresia, it may also occur with other conditions causing prenatal and postnatal intestinal obstruction.
A rectus abdominis myocutaneous flap was successfully transferred in a patient in whom a mucous fistula had previously been brought through the midportion of the muscle. The flap was used to close a large defect in a paraplegic. Previous enterostomy is not a contraindication to the use of this flap. Preoperative arteriography to confirm the presence of a patent deep inferior epigastric artery is recommended prior to flap transfer.
Eighty-two percutaneous enterostomies were performed at three institutions with the Cope suture anchor for stomach or jejunal wall stabilization during alimentation tube placement. The anchors were successfully placed into the stomach or jejunum in 81 cases. Early in the series, two anchors were misplaced, with no sequelae. There were no other complications at the time of placement. In all successful cases, excellent immobilization of the viscus was achieved. Tract dilation and tube placement were easily performed, and there were no guidewire or tube dislodgments.
A retrospective study of patients who had undergone enterostomy and subsequent follow-up in the past 9 years was carried out with the aim of identifying differences with relation to symptoms of depression, the deterioration of social relations and sexual disturbances between elderly (age greater than or equal to 65) and non-elderly patients (age less than 65). Depressive symptoms were present to a greater extent in elderly (48.6%) than in non-elderly patients (34.8%), whereas sexual disturbances were experienced more in non-elderly (34.8%) than elderly (21.6%) patients. No striking differences were noted with regard to the deterioration of social relations. The differences observed, although marked in terms of percentage, were not statistically significant given the relatively small number of cases examined.
The authors carried out a retrospective study of patients undergoing enterostomy during the past 9 years. From 1981 to present a total of 60 patients (39 males and 21 females) were operated and subsequently followed-up. The aim of the study was to examine the following factors: the diagnosis which led to operation, the type of stoma used, early and late complications, the behaviour of the alvus, psychological disorders and Karnofsky's Performance-Status Index. After having presented the findings, the surgical results obtained are discussed together with the patient's psychological reactions to stoma. All types of early surgical complications were absent in 66.6% of patients, whereas late complications were absent in 41.6%. Even in those cases where surgical techniques and prostheses permitted a satisfactory post-operative outcome, the sociopsychological and sexual problems relating to the wound and the perceived difference between the real and ideal Ego are highlighted.
Little is known about endocrine function of the pancreas after it was treated with pancreatico-enterostomy for its chronic inflammation. In order to study this, an experimental model of chronic pancreatitis was made by ligating the canine main pancreatic duct, which was reconstructed eight weeks later by performing pancreatico-duodenostomy in the study group. Pancreatic endocrine function was studied before ligating the main pancreatic duct, 4, 8, 12, and 16 weeks after the ligation in the control group, or 4 and 8 weeks after the reconstruction in the study group. Histological changes of the whole pancreas were also examined when animal was sacrificed. The results of our study are as follows. 1) The endocrine function, which was studied by using IVGTT and calculating K-values, showed significant deterioration eight weeks after the main pancreatic duct ligation. 2) The endocrine function was significantly recovered eight weeks after the reconstruction. 3) Histological evidence of chronic pancreatitis was demonstrated 8 weeks after the main pancreatic duct ligation which was progressed to acinus loss and fibrosis after 16 weeks. The islets of Langerhans were shown to be structurally preserved 8 weeks after the ligation, but ultrastructural alternations 16 weeks after the ligation included apparent degeneration of islet cells. 4) Compared with the control group, fibrotic change of the pancreas was restrained and most of islets did not show degeneration 8 weeks after the reconstruction in the study group. 5) These results suggest that early surgical intervention is to be warranted for chronic pancreatitis, in order to preserve and recover the endocrine function.
Hepatic porto-enterostomy or cholecystostomy (Kasai's procedure) was successful in restoring bile flow in 31 of 49 patients with "noncorrectable" extrahepatic biliary atresia. However, all but one of the 31 developed acute or chronic complications such as cholangitis, bile peritonitis, or portal hypertension. During a five-year follow-up period, 26 (53%) died while 9 of the 23 survivors continue to manifest chronic or recurrent cholangitis. Thirteen of the 19 survivors who are more than one year of age have developed portal hypertension. These complications limit the prognosis of infants with "noncorrectable" biliary malformations.
The reinstillation of the digestive juice in the lower end of an enterostomy has a retrograde inhibitory effect on the upper digestive secretions (average inhibition of 30,2%) particularly on the intestinal juice during the digestive syndromes associated with one or several interruptions of the continuity of the bovel. It should be noted, however, that the observation has not been made on normal men, but rather on severely ill patients treated in the intensive care unit of a gastro-intestinal disease department.
The special problems of the uretero-enterostomy, which is often followed by disturbances of the electrolyte metabolism such as hyperchloremia, metabolic acidosis and hypokalemia with all complications, are dealt with. The pre-operative treatment of the patient and the postoperative infusion therapy are discussed in detail, suggestions as to the infusion, electrolyte and calorie quantity to be administered are made. The postoperative complications are demonstrated on the basis of a special case, the theories on the causes of the electrolyte imbalances are also mentioned.
Indications, technique and prognosis of 129 enterostomies in Crohn's disease are reported. Advanced perianal or entero-genital fistulas represented the predominant indication (60% of primary, 46% of repeated stomas). 85% of stomas were created in combination with intestinal resections. Preferred type of stoma was a loopileostomy (76% of primary stomas), whereas colostomies were avoided whenever possible because of increased complications. Patients initially presenting with rectal involvement or perianal fistulas were prone to need a stoma during the course of their disease while intraabdominal fistulas, abscesses, age, sex, and longstanding disease where of no prognostic significance. Up to now 50% of all temporary stomas and a third of those created for distal fistulas could be closed. The chance of closure increased significantly with duration of symptoms less than 7 years, not more than one previous operation or absence of rectal involvement.
Treated were 129 patients, who earlier underwent cholecysto-enterostomy in periampullary tumors. At the period of from 3.5 to 5 weeks after the first operation, these patients need thorough clinico-instrumental examination, they should be given aid at a specialized in-patient department.