左半结肠癌肠梗阻术中排便一期切除吻合术的临床应用

目的 探讨左半结肠癌肠梗阻术中排便一期切除吻合术的安全性和疗效.方法 回顾性总结2000年1月至2008年1月间对43例左半结肠癌合并肠梗阻患者行术中排便一期切除吻合术的临床资料,并与同期行Hartmann术的25例左半结肠癌肠梗阻患者的临床疗效进行比较.结果 两组患者在年龄、性别、营养状态、基础疾病、肿瘤部位、分期等方面差异无统计学意义（P＞0.05）.术中排便一期切除吻合组和Hartmann术组并发症发生率分别为25.6%和28.0%（P=0.761）;手术死亡率分别为2.3%和4.0%（P=0.369）;差异均无统计学意义.术中排便一期切除吻合组总住院时间为（16.6±7.8）d,住院费用为（50 192.8±39 727.4）元;Hartmann术组首次手术切除和二次关瘘的总住院时间为（24.6±9.4）d.两次住院费用为（58 382.1±30 304.9）元;两组比较,分别为P=0.002和P=0.020,差异有统计学意义.结论 对于左半结肠癌肠梗阻患者,术中排便一期切除吻合术疗效与Hartmann术相似,但住院时间和费用明显少于Hartmann术.     

Side-to-end anastomosis in a colostomy for acute malignant large-bowel obstruction: Side-to-end anastomosis with a colostomy (STEC procedure)

This report describes the use of side-to-end anastomosis in a colostomy for an acute malignant large-bowel obstruction. A 59-year-old man presented with a colonic obstruction due to advanced descending colon cancer. The preoperative imaging studies revealed a complete obstruction of the descending colon at the site of the splenic flexure, a remarkably dilated transverse colon, and no other metastatic lesions. Side-to-end anastomosis was performed with the colostomy because of the high comorbidity associated with such cases. When the patient’s general condition improved, a stoma closure was performed under local anesthesia. In conclusion, a side-to-end anastomosis with a colostomy (STEC procedure) was found to be a simple, useful, and cost-effective technique for an acute malignant large-bowel obstruction, particularly in a high-risk patient.     

Comments on: laparoscopically assisted reversal of Hartmann's procedure

We present our comments on the above article.     

Laparoscopic versus open colostomy reversal: A comparative analysis

Open colostomy reversal carries significant rates of wound infection, anastomotic leak, and incisional hernia which often limit its acceptance. We hypothesized that the laparoscopic approach to the restoration of intestinal continuity may result in lower perioperative morbidity and faster postoperative recovery. Twenty-two cases of laparoscopic colostomy reversals performed at a single institution were identified and compared to 22 randomly selected open colostomy closures performed during the same time period. Patients were compared based on demographics, previous indications for colostomy procedures, and perioperative outcomes. A total of 152 patients underwent reversal of left-sided colostomies during the study period. The laparoscopic approach was successful in 20 of 22 cases; there were 2 conversions to open (9%) secondary to inability to adequately mobilize the rectal stump. The laparoscopic and open groups were comparable based on mean age (54 years versus 49 years; P=0.23), BMI (26 kg/m² versus 27 kg/m²; P=0.66), gender (9% males versus 13% males; P=0.23), ASA Class (2.6 versus 2.3; P=0.07), and history of previous intra-abdominal sepsis (17 versus 16 cases). Operative times were similar (158 versus 189 minutes; P=0.16), and estimated blood loss was significantly less in the laparoscopic group (113 versus 270 ml; P=0.01). No intraoperative complications occurred in the laparoscopic group and two enterotomies occurred in the open group. The laparoscopic group had earlier passage of flatus (3.5 versus 5.0 days; P=0.001) and shorter hospitalization (4.2 versus 7.3 days; P=0.001). Perioperative complications occurred in 3 (14%) laparoscopic and 13 (59%) open cases (P=0.01). There was no mortality in this series. The laparoscopic approach can be safely used in the restoration of intestinal continuity. It results in a decreased perioperative morbidity and faster recovery, and it offers distinct advantages over the open approach to colostomy reversal.     

腹腔镜辅助下左半结肠癌根治术30例报告

目的探讨腹腔镜辅助下左半结肠癌根治手术的方法。方法对我院2003年1月～2007年12月行腹腔镜辅助下左半结肠癌根治术（D3）33例的临床资料进行回顾性分析。结果本组完成手术30例,平均手术时间为（120±50）min,平均出血量为（50±20）ml,平均清扫淋巴结（10±5）个。另3例因不同原因而中转开腹。结论腹腔镜辅助下左半结肠癌根治术是安全的,能在创伤小的同时高质量地完成根治性手术。     

Impact of socioeconomic deprivation and primary pathology on rate of reversal of Hartmann's procedure

BACKGROUND: Hartmann's procedure is an operation for left-sided colonic pathology where primary anastomosis is considered unsafe. The aim of this study was to assess the impact of socioeconomic deprivation and primary pathology on the rate of reanastomosis. METHODS: All patients who underwent Hartmann's procedure between 1992 and 2000 in our unit were included. The deprivation category (DEPCAT) scores from 1 (affluent) to 7 (most deprived) were calculated. RESULTS: An emergency procedure was performed in 118 of 124 patients. Primary pathology was malignant in 40 and benign in 84 patients. The DEPCAT scores were high (6,7) in 76 and intermediate (3 to 5) in 42 patients. Of the 102 patients surviving the postoperative period, only 23 underwent reversal. The reversal rate was lower in patients with malignancy (P = 0.005) and higher DEPCAT scores. CONCLUSIONS: Primary diagnosis and socioeconomic deprivation adversely influence the rate of reversal of Hartmann's procedure.     

One-step totally robotic Hartmann reversal and complex abdominal wall reconstruction with bilateral posterior component separation: a technical note

Aim

This paper describes a robotic approach to combined gastrointestinal continuity restoration and complex abdominal wall reconstruction after Hartmann's procedure complicated by large midline and parastomal hernias.

Methods

A robotic Hartmann reversal is performed, followed by robotic retromuscular abdominal wall reconstruction of all ventral defects with bilateral posterior component separation using the double-docking approach. Surgical steps are thoroughly described, and the accompanying video highlights critical steps of the procedure, anatomical landmarks and technical details relevant to successful completion.

Results

Complete restoration of the anatomy was achieved with an operative time of 6.5 h. Mobilization occured on day 1, and bowels were opened on day 3. Surgical discharge was possible on day 5. No intra-operative surgical complication occurred and follow-up at 6 months showed no recurrence or mid-term complication.

Conclusion

Combined minimally invasive reconstruction of the gastrointestinal tract and abdominal wall was feasible using a robotic system. In addition, potential advantages of postoperative rehabilitation and reduced surgical site complications are suggested. Prospective evaluation of the technique is ongoing.     

A simple purse string suture technique for treatment of colostomy prolapse and intussusception.

A simple purse string technique for treatment of colostomy prolapse and intussusception is described. It is suggested as an alternative to more complicated procedures.     

Factors associated with portomesenteric venous thrombosis after total colectomy with ileorectal anastomosis or end ileostomy

Background

Porto-mesenteric venous thrombosis (PMVT) is an uncommon but serious complication. Data on the risk factors for PMVT following total colectomy with ileorectal anastomosis or end ileostomy (TC/IRA or EI) is limited. This study aimed to evaluate the factors associated with PMVT after TC/IRA or EI.

Operative management of anastomotic leak after sigmoid colectomy for left-sided diverticular disease: Ileostomy creation may be as safe as colostomy creation

Aim

The management of anastomotic leak after sigmoid colectomy for diverticular disease has not been well defined. Specifically, there is a lack of literature on optimal types of reoperations for leaks. The aim of this study was to describe and compare reoperative approaches and their postoperative outcomes.

Methods

We performed a retrospective cohort study using the NSQIP Colectomy Module (2012–2019) and single-institution chart review. Patients with diverticular disease who underwent elective sigmoid colectomy were included. Primary outcomes were anastomotic leak requiring reoperation and management of anastomotic leak.

Results

Of 37,471 patients who underwent sigmoid colectomy for diverticular disease, 1003 (2.7%) suffered an anastomotic leak, of whom 583 underwent reoperation. Of the 572 patients who were not initially diverted and underwent reoperation for leak, 302 (52.8%) were managed with stoma creation – 200 (35.0%) with colostomy and 102 (17.8%) with ileostomy. The remaining 47.2% underwent colectomy with reanastomosis, suturing of large bowel, and drainage. There were no differences in length of stay, readmission, or mortality between patients who underwent ileostomy or colostomy at reoperation (p > 0.05). Single-institution analysis demonstrated that 100% of patients with ileostomies underwent subsequent ileostomy closure, compared to 60% of patients with colostomies.

Conclusions

In patients who suffer anastomotic leaks after sigmoid colectomy for diverticular disease and undergo reoperations, ileostomy at the time of reoperation appears to be safe, with comparable results to colostomy. Ileostomies were more frequently closed than colostomies. When faced with a colorectal anastomotic leak, ileostomy creation may be considered.     

Laparoscopic colostomy reversal after a Hartmann procedure: a prospective series, literature review and an argument against laparotomy as the primary approach

Background

Open restoration of bowel continuity after a Hartmann procedure has been associated with significant morbidity, including anastomotic leak, incisional hernia, wound infections and inability to re-establish intestinal continuity. Few studies have examined the role of laparoscopy in performing a Hartmann reversal. The aim of this study was to review our laparoscopic Hartmann reversal (LHR) experience with an emphasis on intra- and postoperative adverse events.

Methods

A prospectively collected laparoscopic colorectal database involving 3 surgeons in 4 academic centres between 1991 and 2008 was reviewed. Factors evaluated were patient demographics, diagnosis, duration of surgery, intra- and postoperative complications, recovery of bowel function and length of stay in hospital.

Results

Twenty-eight consecutive patients (13 men, 15 women) with a mean age of 61.1 (standard deviation [SD] 15.3) years and a mean weight of 72.3 (SD 20.1) kg underwent LHR. The diagnosis at initial surgery was complicated diverticulitis in 19 patients (67.9%), cancer in 6 patients (21.4%) and “other” in 3 patients (10.7%). The median duration of surgery was 166.2 (SD 74.4) minutes. There were no conversions. There was 1 major intraoperative complication (bleeding; 3.6%). There were 3 postoperative complications (10.7%): 1 abscess, 1 prolonged ileus and 1 wound hematoma. Only 1 patient with an abscess required readmission. There were no observed clinical anastomotic leaks. All patients underwent successful reanastomosis. The median time to return of bowel function was 4 (interquartile range [IQR] 3–4) days. The median length of stay in hospital was 5 (IQR 3–6) days. There was no mortality.

Conclusion

Laparoscopic colostomy reversal after a Hartmann procedure is safe and feasible in experienced hands. It is associated with low morbidity, quick return of bowel function and short stay in hospital.