In animal models, the small intestine responds to massive small bowel resection (SBR) through a compensatory process termed adaptation, characterized by increases in both villus height and crypt depth. This study seeks to determine whether similar morphologic alterations occur in humans following SBR.
Clinical data and pathologic specimens of infants who had both a SBR for necrotizing enterocolitis (NEC) and an ostomy takedown from 1999–2009 were reviewed. Small intestine mucosal morphology was compared in the same patients at the time of SBR and the time of ostomy takedown.
For all samples, there was greater villus height (453.6±20.4 vs. 341.2±12.4 μm, p<0.0001) and crypt depth (178.6±7.2 vs. 152.6±6 μm, p<0.01) in the ostomy specimens compared to the SBR specimens. In infants with paired specimens, there was an increase of 31.7±8.3% and 22.1±10.0% in villus height and crypt depth, respectively. There was a significant correlation between the amount of intestine resected and the percent change in villus height (r=0.36, p<0.05).
Mucosal adaptation after SBR in human infants is similar to what is observed in animal models. These findings validate the use of animal models of SBR utilized to understand the molecular mechanisms of this important response.
small intestine; adaptation; small bowel resection; adaptation in humans
The optimal timing of ostomy closure is a matter of debate. We performed a systematic review of outcomes of early ostomy closure (EC, within 8 weeks) and late ostomy closure (LC, after 8 weeks) in infants with necrotizing enterocolitis.
PubMed, EMbase, Web-of-Science, and Cinahl were searched for studies that detailed time to ostomy closure, and time to full enteral nutrition (FEN) or complications after ostomy closure. Patients with Hirschsprung’s disease or anorectal malformations were excluded. Analysis was performed using SPSS 17 and RevMan 5.
Of 778 retrieved articles, 5 met the inclusion criteria. The median score for study quality was 9 [range 8–14 on a scale of 0 to 32 points (Downs and Black, J Epidemiol Community Health 52:377–384, 1998)]. One study described mean time to FEN: 19.1 days after EC (n = 13) versus 7.2 days after LC (n = 24; P = 0.027). Four studies reported complication rates after ostomy closure, complications occurred in 27 % of the EC group versus 23 % of the LC group. The combined odds ratio (LC vs. EC) was 1.1 [95 % CI 0.5, 2.5].
Evidence that supports early or late closure is scarce and the published articles are of poor quality. There is no significant difference between EC versus LC in the complication rate. This systematic review supports neither early nor late ostomy closure.
Ostomy closure; Complications; Infants; Necrotizing enterocolitis; Systematic review
Although duodenal perforation is currently an infrequent complication of medical procedures, its incidence in the future predictably will increase as endoscopic treatment of duodenal neoplasms becomes more frequently used. In some cases, duodenal perforation is difficult to treat even surgically. We report here a novel technique called ‘triple-tube-ostomy’ for the treatment of iatrogenic duodenal perforation. Since November 2009, there have been three cases of iatrogenic perforation of the duodenum, due to various causes, which we have treated with our novel technique. The main principles of the technique are biliary diversion, decompression of the duodenum, and early enteral nutrition. All patients who underwent the triple-tube-ostomy procedure had good postoperative courses, with few complications. The novel surgical technique we describe in this report is safe, reliable, easy to learn and perform, and led to a good postoperative course in all cases where we performed it.
Duodenal perforation; Endoscopy; Postoperative course
The study presents a short historical background and practical application of intestinal ostomy as a treatment method of various intestinal disorders and injuries. Ostomy is a purposeful connection of the lumen of the intestine with abdominal integuments by surgery. After the surgical formation of the intestinal fistula, the patient must adjust to the new situation, gain basic knowledge and learn procedures of ostomy care. Thus, professional medical assistance is extremely important. The study aims to discuss basic notions concerning ostomy and ostomy equipment. Providing high-standard care and assistance for patients with ostomy requires both appropriate knowledge and practical skills.
colostomy; historical background; the supply of ostomy equipment
Adolescents with IBD requiring ostomy surgery experience perioperative needs that may exceed those of patients experiencing other major abdominal surgery . This procedure requires ongoing and vigilant daily care and management. Gastrointestinal symptoms and complications impose psychological and social stresses on young patients , and the procedure results in body image changes and daily regimens of self-care. This study aimed to explore adolescents' experiences and quality of life following ostomy surgery.
Ethnographic interviews and a subsequent focus group were conducted with 20 adolescents with an ostomy or j-pouch being treated at the Hospital for Sick Children in Toronto, Canada. Interviews were transcribed verbatim and subjected to theme generation.
Findings suggest that adolescents are profoundly affected by their ostomy. Adolescents convey strength as well as adjustment struggles. Identified impacts include body intrusion and body image changes, decreased independence, secrecy about the ostomy, adjustment over time, challenges for the family, and strategies for constructively moving forward.
Implications address the importance of ensuring meaningful opportunities to understand and reframe the stresses of illness. An ongoing clinical challenge involves the promotion of a healthy self-esteem and psychosocial adjustment for these adolescents and their families. Finding effective ways to minimize stress and embarrassment and reframe personal shame, constitute important clinical priorities. Opportunities for peer support and family dialogue may assist in clarifying worries and easing the burden carried by these young persons. Flexible and adequately funded resources are advocated in fostering quality of life.
Colorectal cancer (CRC) survivors with ostomies can face complex concerns regarding sexuality. We used an anthropological perspective to examine the experiences of 30 female CRC survivors with ostomies to shed light on the sexual challenges and adaptations made in the wake of cancer surgery and treatment. Participants fell into four categories with regard to their sexual experience post surgery; however, not all women found their altered sexuality to be particularly problematic. This type of phenomenological examination can inform a more patient centered, less biomedically focused paradigm for assessing and improving the sexual health of cancer survivors.
cancer; sexuality; lifecourse; quality of life
INTRODUCTION: As stoma formation is thought to be declining, we performed a study to evaluate the rate of stoma formation and the impact on stoma complication rates, together with risk factors for complications. PATIENTS AND METHODS: Stoma incidence, individual complications and mortality rates were retrieved from a stoma nurse database of 345 stomas created over an 8-year period. RESULTS: Stoma formation increased over the study period, although the incidence of complications declined. Stoma complications were more frequently seen in emergency surgery. A significant association between stoma complications and mortality was identified. CONCLUSIONS: Age of patient, urgency of surgery and diagnosis were associated with high levels of morbidity and mortality. Stomas are often formed in frail patients unsuitable for anastomosis formation, which may explain the high mortality in ostomy patients.
Few studies are available comparing open with laparoscopic treatment of Hirschsprung’s disease. This study compares a laparoscopic series of 30 patients with a historical open series of 25 patients.
The charts of all patients having had a Duhamel procedure in the period from June 1987 through July 2003 were retrospectively reviewed. Open procedures were performed until March 1994. Patients with extended aganglionosis, pre-Duhamel ostomy, or syndrome were excluded from the study. End points were intraoperative complications, postoperative complications, time to first feeding, hospital stay, and outcome at follow-up such as stenosis, enterocolitis, constipation, fecal incontinence, and enuresis.
Twenty-five patients had an open Duhamel (OD) and 30 had a laparoscopic one (LD). There were no differences in patient characteristics and there were no intraoperative complications in either group. Time to first oral feeds was significantly longer in the OD group as was the duration of hospital stay. No significant differences at follow-up were observed but there was a tendency for a higher enterocolitis rate in the LD group. In contrast, the adhesive obstruction and enuresis rates were higher in the OD group. Cosmetic results were superior in the LD group.
Except for a significantly shorter hospital stay and shorter time to first oral feeds in favor of LD, no significant differences could be observed. The cosmetic result was not an end point but there was no doubt that it was better in the LD group. Although not statistically significant different, there were no adhesive bowel obstructions in the LD group compared with 3 of 25 in the OD group. Fecal incontinence was not encountered in either group.
Aganglionosis; Hirschsprung; Duhamel; Laparoscopy; Child
Extra-cardiac conduit (ECC) and Lateral atrial tunnel (LAT) total cavopulmonary connection are both widely used in management of functionally univentricular hearts. The impact of the type of connection on early outcomes after Fontan operation remains unclear. We evaluated the impact of Fontan type on early outcome in a large clinical database.
Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database undergoing the Fontan operation (2000–2009) were included. In multivariable analysis, we evaluated the impact of Fontan type (ECC vs. LAT) on in-hospital mortality, Fontan takedown/revision, Fontan failure (in-hospital mortality or Fontan takedown/revision), post-operative length of stay (LOS), and complications, adjusting for patient, procedural, and center factors.
A total of 2747 patients from 68 centers were included: 61% were male and 45% had a right dominant ventricle. ECC Fontan (vs. LAT) was performed in 63%; in all 65% were fenestrated. In multivariable analysis with adjustment for patient, procedural (including fenestration), and center factors (including Fontan volume), ECC Fontan was associated with significantly higher Fontan takedown/revision (OR 2.73, 95%CI 1.09–6.87) and Fontan failure (OR 2.28, 95%CI 1.13–4.59), and longer post-operative length of stay (adjusted estimated difference in LOS: +1.4 days).
These multicenter data suggest that of the two prevalent forms of Fontan connection in current use, the LAT Fontan may be associated with superior early outcomes.
Congenital Heart Disease; Outcomes; Fontan
There is very little data regarding trace mineral nutrition in infants with small intestinal ostomies. Here we evaluated 14 infants with jejunal or ileal ostomies to measure their zinc absorption and retention and biochemical zinc and copper status. Zinc absorption was measured using a dual-tracer stable isotope technique at two different time points when possible. The first study was conducted when the subject was receiving maximal tolerated feeds enterally while the ostomy remained in place. A second study was performed as soon as feasible after full feeds were achieved after intestinal repair. We found biochemical evidence of deficiencies of both zinc and copper in infants with small intestinal ostomies at both time points. Fractional zinc absorption with an ostomy in place was 10.9% ± 5.3%. After reanastamosis, fractional zinc absorption was 9.4% ± 5.7%. Net zinc balance was negative prior to reanastamosis. In conclusion, our data demonstrate that infants with a jejunostomy or ileostomy are at high risk for zinc and copper deficiency before and after intestinal reanastamosis. Additional supplementation, especially of zinc, should be considered during this time period.
zinc; copper; ostomy; jejunostomy; ileostomy; nutrient absorption
The medical records of 52 children with biliary atresia treated by portoenterostomy and evaluated for liver transplantation were reviewed to determine the frequency of stoma variceal bleeding and the optimal strategies for prevention and treatment. Eighteen patients had had prior stoma closure, four by preperitoneal closure without takedown from the abdominal wall. Three of the four developed occult variceal bleeding from the stoma closure site. Twenty-two patients had a stoma present at evaluation. All 22 patients with stomas (100%) had at least one bleeding episode requiring transfusion. Treatment included transfusion and local pressure (9), suture ligation of the bleeding site (5), and stoma closure and / or takedown (11). Local treatment led to recurrences in eight of 14 (57%) of the cases. To reduce the high mortality in patients with biliary atresia awaiting liver transplantation, multiple variceal bleeding episodes should be prevented. To eliminate one source, stoma variceal bleeding, the stoma, whether functioning or nonfunctioning should be taken down and closed. Preperitoneal closure alone does not prevent stoma bleeding.
Biliary atresia; portal hypertension; stoma varices; liver transplantation; portoenterostomy
Therapeutic procedures may not only treat disease but also affect patient quality of life. Therefore, quality of life should be measured in order to assess the impact of disease and therapeutic procedures. To identify clients’ problems, it is necessary to assess several dimensions of quality of life, including physical, spiritual, economic, and social aspects. In this regard, we conducted a qualitative study to explore quality of life and its dimensions in ostomy patients referred to the Iranian Ostomy Association.
Fourteen patients were interviewed about their quality of life dimensions by purposeful sampling. Data were gathered by semistructured interviews and analyzed using the content analysis method.
Nine main themes emerged using this approach, including physical problems related to colostomy, impact of colostomy on psychological functioning, social and family relationships, travel, nutrition, physical activity, and sexual function, as well as religious and economic issues.
The findings of the study identified a number of challenges in quality of life for patients with ostomy. The results can be used by health care providers to create a supportive environment that promotes better quality of life for their ostomy patients.
ostomy; colostomy; qualitative study; quality of life
Stomas provide fecal diversion in emergent and elective settings. Preoperative planning and counseling are extremely important to the creation of an acceptable and functional ostomy for the surgeon and patient. Proper site selection will help decrease the incidence of postoperative complications. Ileostomy, colostomy, and cecostomy indications and techniques are discussed.
Stoma; ileostomy; colostomy; cecostomy
Many patients with intestinal failure require intestinal transplantation (ITx) to survive. Acute cellular rejection poses a challenge in ITx because its biologic components are incompletely understood. New methodologies for its integrative and longitudinal analysis are needed.
In this study, we characterized episodes of acute cellular rejection in ITx recipients using a noninvasive proteomic analysis. Ostomy effluent was obtained from all patients undergoing ITx at University of California, Los Angeles from July 2008 to September 2009 during surveillance endoscopies in the first 8 weeks post-ITx. Effluent was analyzed using 17-plex Luminex technology and matrix-assisted laser desorption/ionization proteomics.
Of 56 ostomy effluent samples from 17 ITx recipients, 14% developed biopsy-proven rejection at a median of 25 days post-ITx. Six had mild rejection, two were indeterminate for rejection, and no graft loss was seen in the first 3 months posttransplantation. Effluent levels of five innate immune cytokines were elevated in the posttransplantation phase: granulocyte colony-stimulating factor, interleukin-8, tissue necrosis factor-α, interleukin-1β, and interferon-γ. Proteomic analysis revealed 17 protein features differentially seen in rejection, two identified as human neutrophil peptide 1 and 2. This was confirmed by the presence of human neutrophil peptide-positive lamina propria neutrophils in biopsy tissue samples.
Proteomic and cytokine analysis of ostomy effluents suggests an early and unappreciated role of innate immune activation during rejection.
Intestinal transplantation; Rejection; Proteomics; Innate immunity
Post-operative infectious complications following penetrating abdominal trauma are a major cause of morbidity and contribute significantly to increased length of hospitalization and costs of patient care. Our recent study suggests the individual patient's probability of major infection following traumatic intestinal perforation is high and can be predicted from risk factors identified at the time of surgery. The determinant of primary importance for development of infection confirmed by this study is peritoneal contamination by intestinal contents. Other significant risk factors (p less than 0.05) were number of organs injured, number of units of blood administered, ostomy formation for left colon injury, and the patient's age. Risk of infection can be calculated from these data and could potentially be used to guide post-operative decisions. Areas of trauma care in which alteration of therapy might result in significant savings include choice of antibiotics, duration of antibiotic administration, and wound management. This study supports the use of standardized operative procedures and parenteral antibiotics effective against endogenous aerobic and anaerobic organisms. If such observations continue to be supported by further randomized prospective studies, there is tremendous potential to further tailor surgical management for the individual patient in a more cost-effective manner.
To report conversion from tracheostomy (TIV) to noninvasive intermittent positive pressure ventilation (NIV) for a continuously ventilator-dependent patient with high-level spinal cord injury (SCI) with no measurable vital capacity (VC = 0 mL) to resolve tracheostomy-associated complications.
A case report of a 38-year-old female in a chronic care facility in Japan with a 10-year history of ventilator-dependent tetraplegia (C1 ASIA-A) presented for increasing difficulty vocalizing. She had been using a fenestrated cuffed tracheostomy tube to produce speech with the cuff deflated. Speech was increasingly hypophonic, because of tracheostoma enlargement, tube migration, and tracheal granulation.
The NIV was provided via nasal and oral interfaces, the ostomy was surgically closed, and vocalization resumed. Airway secretions were expulsed using manually assisted coughing. The patient returned to the community.
Conversion to NIV should be considered for ventilator-dependent patients with SCI who have adequate bulbar-innervated muscle function to permit effective speech and assisted coughing.
cough; mechanical ventilation; respiratory paralysis; spinal cord injury; tetraplegia
Among long-term (≥5 years) colorectal cancer survivors with permanent ostomy or anastomosis, we compared the incidence of medical and surgical complications and examined the relationship of complications with health-related quality of life.
The incidence and effects of complications on long-term health-related quality of life among colorectal cancer survivors are not adequately understood.
Participants (284 ostomy/395 anastomosis) were long-term colorectal cancer survivors enrolled in an integrated health plan. Health-related quality of life was assessed via mailed survey questionnaire in 2002–2005. Information on colorectal cancer, surgery, co-morbidities, and complications was obtained from computerized data and analyzed using survival analysis and logistic regression.
Ostomy and anastomosis survivors were followed an average 12.1 and 11.2 years, respectively. Within 30 days of surgery, 19% of ostomy and 10% of anastomosis survivors experienced complications (p<0.01). From 31 days on, the percentages were 69% and 67% (after adjustment, p<0.001). Bleeding and post-operative infection were common early complications. Common long-term complications included hernia, urinary retention, hemorrhage, skin conditions, and intestinal obstruction. Ostomy was associated with long-term fistula (odds ratio 5.4; 95% CI 1.4–21.2), and among ostomy survivors, fistula was associated with reduced health-related quality of life (p<0.05).
Complication rates remain high despite recent advances in surgical treatment methods. Survivors with ostomy have more complications early in their survivorship period, but complications among anastomosis survivors catch up after 20 years, when the two groups have convergent complication rates. Among colorectal cancer survivors with ostomy, fistula has especially important implications for health-related quality of life.
The objective of this paper is to describe the complex mixed-methods design of a study conducted to assess health-related quality of life (HRQOL) outcomes and ostomy-related obstacles and adjustments among long-term (>five years) colorectal cancer (CRC) survivors with ostomies (cases) and without ostomies (controls). In addition, details are provided regarding the study sample and the psychometric properties of the quantitative data collection measures used. Subsequent manuscripts will present the study findings.
Research Design and Methods
The study design involved a cross-sectional mail survey for collecting quantitative data and focus groups for collecting qualitative data. The study subjects were individuals identified as long-term CRC survivors within a community-based health maintenance organization's enrolled population. Focus groups comprised of cases and divided by gender and HRQOL high and low quartile contrasts (based on the mail survey data) were conducted.
Main Outcome Measures
The modified City of Hope Quality of Life (mCOH-QOL)-Ostomy and SF-36v2 questionnaires were used in the mail survey. An abridged version of the mCOH-QOL-Ostomy was used for the control subjects. Focus groups explored ostomy-related barriers to self-care, adaptation methods/skills, and advice for others with an ostomy.
The survey response rate was 52% (679/1308) and 34 subjects participated in focus groups. The internal consistency reliability estimates for the mCOH-QOL-Ostomy and SF-36v2 questionnaires were very acceptable for group comparisons. In addition, evidence supports the construct validity of the abridged version of the mCOH-QOL-Ostomy. Study limitations include potential non-response bias and limited minority participation.
We were able to successfully recruit long-term CRC survivors into this study and the psychometric properties of the quantitative measures used were quite acceptable. Mixed-methods designs, such as the one used in this study, may be useful in identification and further elucidation of common problems, coping strategies, and HRQOL outcomes among long-term cancer survivors.
Colorectal cancer; Health-related quality of life; Ostomy; Patient-reported outcomes; Stomas, Qualitative research
Some patients with colorectal cancer (CRC) require a permanent ostomy, which changes bodily function and can create psychosocial distress. However, little is known about the influence of men's support on women's psychosocial adjustment to having an ostomy as a result of CRC.
Participants initially completed the City of Hope-CRC Quality of Life questionnaire. We then conducted in-depth interviews with 30 female participants. Interview questions focused on body image, gender, and sexuality. Interviews were recorded and transcribed. We used qualitative methods to analyze the interview data and compared global HRQOL quartile scores to the overall ways that women discussed husbands' or partners' support regarding psychosocial adjustments to having ostomies.
Of 30 participants, 22 were married or partnered at the time of surgery and 8 were single. The non-partnered respondents are not included in this analysis. Of the 22 married/partnered women, 17 described positive support from husbands being central to their psychosocial adjustment, 3 described a lack or withdrawal of support negatively affecting adjustment, and 2 described support as neither positive nor negative. In 17 cases, women's high or low quantitative HRQOL scores matched the positive or negative qualitative findings. There were 3 cases in which there were positive qualitative data and low HRQOL scores, but each of these cases, women reported serious current co-morbidities.
These findings suggest that the provision or withdrawal of husbands' or partners' support can have a considerable impact on the psychosocial adjustment of female CRC patients with ostomies. These findings appear to be both short- and long-term. Survivorship assessments should include appraisals of women's relationships to spouses/partners.
Intestinal stomas can pose significant challenges for long-term (≥ 5 years) rectal cancer (RC) survivors. Specifying common challenges and sociodemographic or clinical differences will further the development of tailored interventions to improve health-related quality of life (HRQOL).
Patients and Methods
This was a matched cross-sectional study of long-term RC survivors conducted in three Kaiser Permanente regions. The mailed questionnaire included the modified City of Hope Quality of Life-Ostomy (mCOH-QOL-Ostomy) and Medical Outcomes Study 36-Item Short-Form Health Survey, version 2 (SF-36v2). Groups surveyed were permanent ostomates (cases) and those who did not require an ostomy (controls). RC survivors were matched on sex, age, and time since diagnosis. Comparisons between groups used regression analysis with adjustment for age, comorbidity score, history of radiation therapy, income, and work status.
Response rate was 54% (491 of 909). Cases and controls had similar demographic characteristics. On the basis of the mCOH-QOL-Ostomy, both male and female cases had significantly worse social well-being compared with controls, while only female cases reported significantly worse overall HRQOL and psychological well-being. For younger females (< age 75 years), ostomy had a greater impact on physical well-being compared with older females. Based on the SF-36v2, statistically significant and meaningful differences between female cases and controls were observed for seven of the eight scales and on the physical and mental component summary scores.
Men and women report a different profile of challenges, suggesting the need for targeted or sex-specific interventions to improve HRQOL in this population. This may include focus on physical HRQOL for female ostomy survivors younger than age 75.
The objective is to evaluate efficiency based on data on morbidity and mortality, health-related quality of life and healthcare-related costs after early reversal of temporary ileostomy after rectal resection for cancer compared with the standard procedure (late reversal).
Reversal of a temporary ileostomy is generally associated with a low morbidity and mortality. However, ostomy reversal may cause complications requiring reoperation with subsequent major complications, in ranges from 0% to 7–9% and minor complications varying from 4–5% to 30%. Based on studies exploring and describing the time of closure in previous studies which are mostly of low quality, a recent review concluded that closing a temporary stoma within 2 weeks did not seem to be associated with an increase in morbidity and mortality.
Design and methods
Early closure of temporary ileostomy (EASY), a randomised controlled trial, is a prospective randomised controlled multicentre study which is performed within the framework of the Scandinavian Surgical Outcomes Research Group (http://www.ssorg.net/) and plans to include 200 patients from Danish and Swedish hospitals. The primary end-point of the study is the frequency of complications 0–12 months after surgery (the stoma creation operation). The secondary end-points of the study are (1) comparison of the total costs of the two groups at 6 and 12 months after surgery (stoma creation); (2) comparison of health-related quality of life in the two groups evaluated with the 36-item short-form and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-CR29/CR30 at 3, 6 and 12 months after surgery (stoma creation); and (3) comparison of disease-specific quality of life in the two groups at 3, 6 and 12 months after surgery (stoma creation).
The aim of the EASY trial is to evaluate the efficiency of early reversal of temporary ileostomy after surgery for rectal cancer versus late reversal. The EASY trial is expected to have a huge impact on patient safety as well as an improvement in patient-reported outcome.
Clinical trials identifier
Frequency of complications 0–12 months after initial surgery; comparison of health-related quality of life in the two groups evaluated with the 36-item short-form and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-CR29/CR30 at 3, 6, and 12 months after surgery (stoma creation); and comparison of the total costs of the two groups at 6 and 12 months after the initial surgery (stoma creation).
The significance of the study is the aim of making evidence-based recommendations for timing of the closure of a temporary ileostomy after surgery for rectal cancer.
Strengths and limitations of the study
The dimensions of the study (sample size: 200 patients) allow us to make recommendations. The recommendations will be of central importance to future patients. The results not only incorporate complications and mortality but integrate patient-reported outcome. The limitation is that the follow-up period is limited to 12 months.
Peristomal skin complications (PSCs) are the most common post-operative complications following creation of a stoma. Living with a stoma is a challenge, not only for the patient and their carers, but also for society as a whole. Due to methodological problems of PSC assessment, the associated health-economic burden of medium to longterm complications has been poorly described.
The aim of the present study was to create a model to estimate treatment costs of PSCs using the standardized assessment Ostomy Skin Tool as a reference. The resultant model was applied to a real-life global data set of stoma patients (n = 3017) to determine the prevalence and financial burden of PSCs.
Eleven experienced stoma care nurses were interviewed to get a global understanding of a treatment algorithm that formed the basis of the cost analysis. The estimated costs were based on a seven week treatment period. PSC costs were estimated for five underlying diagnostic categories and three levels of severity. The estimated treatment costs of severe cases of PSCs were increased 2–5 fold for the different diagnostic categories of PSCs compared with mild cases. French unit costs were applied to the global data set.
The estimated total average cost for a seven week treatment period (including appliances and accessories) was 263€ for those with PSCs (n = 1742) compared to 215€ for those without PSCs (n = 1172). A co-variance analysis showed that leakage level had a significant impact on PSC cost from ‘rarely/never’ to ‘always/often’ p<0.00001 and from ‘rarely/never’ to ‘sometimes’ p = 0.0115.
PSCs are common and troublesome and the consequences are substantial, both for the patient and from a health economic viewpoint. PSCs should be diagnosed and treated at an early stage to prevent long term, debilitating and expensive complications.
Postoperative wound dehiscence is a difficult problem for the general surgeon. Often, patients are too sick, or the wound environment is too hostile, to undergo primary repair. When an eventual repair is performed, a variety of methods are available, but most are associated with unacceptably high morbidity rates, specifically high incidences of recurrences and poor cosmetic outcome. We present here a case of postoperative wound dehiscence following a colostomy takedown repaired in a previously undescribed way—a laparoscopically assisted ventral incisional hernia repair. The method of repair is described, and the current literature regarding alternatives is reviewed.
Buttressing; Dehiscence; Ventral hernia
The treatment of rectal cancer includes both radical resection and local therapy. Radical resection remains the standard treatment, but is associated with increased morbidity and mortality, as well as the potential need for a temporary and occasionally, a permanent ostomy. The benefits of local treatment include a less invasive procedure with maintenance of bowel function and avoidance of a stoma. However, the efficacy of local treatment is now being challenged as the rates of recurrence after local excision alone appear to be much higher than previously thought. Although the primary goal of an oncologic resection is disease eradication, each case must be individualized to determine an optimal care plan.
Rectal cancer; local excision; recurrence; transanal endoscopic microsurgery; radiation therapy; chemotherapy
The optimal management of colon injury patients requiring damage control laparotomy (DCL) is controversial. The objective of this study was to assess the safety of colonic resection and anastomosis versus fecal diversion in trauma patients requiring DCL.
Patients with traumatic colon injuries undergoing DCL between 2000 and 2010 were identified by the database and chart review. Those who died within 48 h were excluded. Patients were divided into two groups: those undergoing one or more colonic anastomoses with or without distal colostomy (group 1) and those undergoing colostomy only or one or more colonic anastomoses with a protecting proximal ostomy (group 2). Variables were compared using Wilcoxon rank sum, χ2, or Fisher exact tests as appropriate.
Sixty-one patients were included (group 1, n = 28 and group 2, n = 33). Fascial closure rates (group 1, 50% versus group 2, 61%; P = 0.45), hospital length of stay (29 versus 23 d; P = 0.89), and in-patient mortality (11% versus 12%; P = 1.0) were similar between groups. There were a total of 11 anastomotic leaks, five of which were related to non-colonic enteric repairs. Colonic anastomosis leak rates were 16% overall (six of the 38 patients), 14% in group 1 (four of the 28 patients), and 20% in group 2 (two of the 10 patients). Compared with patients who did not leak, patients who leaked had a higher median age (37 versus 25 y; P = 0.05), greater likelihood of not achieving facial closure before post-injury day 5 (18% versus 2%; P = 0.003), and a longer hospital length of stay (46 versus 25 d; P = 0.003).
Outcomes after colonic injury in the setting of DCL were similar regardless of the surgical management strategy. Based on these findings, a strategy of diversion over anastomosis cannot be strongly recommended.
Colon; Anastomosis; Damage control; Open abdomen