结直肠吻合术后预防性回肠造口与结肠造口比较的Meta分析

目的 比较结直肠吻合术后预防性回肠造口与结肠造口的并发症,探讨何种造口方式更具有优势.方法 检索PubMed,Embase,The Cochrane Library数据库公开发表的比较回肠造口与结肠造口的研究和相关文献.通过采用RevMan 5.0统计软件,合并及比较两者并发症,选择计算相对危险度(95％CI)作为效应尺度指标来评估这两种方式的有效性及安全性.结果 5篇随机对照研究和7篇非随机对照研究符合纳入标准,共计1687例患者.随机对照研究的Meta分析结果表明回肠造口组发生造口脱垂(相对危险度0.15,95％ CI:0.04～0.48,P=0.001)的风险较小,非随机对照研究的Meta分析结果显示回肠造口组发生造口脱垂(相对危险度0.26,95％CI 0.10～0.67,P=0.005)和由造口回纳引起切口感染(相对危险度0.28,95％ CI 0.15 ～0.52,P＜0.0001)的风险较小.对于其他并发症如吻合口瘘、造口旁疝、由造口回纳引起的肠梗阻及造口周围皮炎等,分析结果差异无统计学意义(P＞0.05).结论 两种预防性造口方式各有利弊,相对于结肠造口而言,更支持回肠造口.然而,到目前为止仍然没有足够的证据表明何种方式更具优势.因此,大样本的随机对照试验和高质量的研究需要被开展以进一步论证.     

Methods for siting emergency stomas in the absence of a stoma therapist

Introduction

Stomas often have to be sited in emergencies by trainees who may have had little training in this. Emergency stomas and stomas where the site has not been marked preoperatively by a stoma therapist are more prone to complications. These complications may severely affect a patient’s quality of life. Advice in the literature on how to best site stomas is conflicting. We compared two easy anatomical methods of siting stomas to sites chosen by a stoma therapist and looked at how this site was affected by the patients’ body mass index (BMI).

Methods

Patients undergoing elective colorectal surgery were seen either pre or postoperatively. Each patient’s BMI was recorded and the positions of three different potential stoma positions (site G: the gold standard, marked by a stoma therapist; site S: marked using a pair of scissors against the umbilicus; site H: halfway between the umbilicus and anterior superior iliac spine) were compared.

Results

The two fixed anatomical methods described (method S and method H) both gave poor results. The most common reason for poor siting was the proximity of a skin crease. There was a statistically significant correlation between the patient’s BMI and the laterality of the gold standard site.

Conclusions

The two simple anatomical methods described here do not provide a shortcut to effective siting. A more effective method may be calculating the laterality of the site using the patient’s BMI, and then moving up/down to avoid a skin crease and improve the patient’s view for changing the bag. This deserves further study.     

Betel leaf in stoma care

Background/Purpose

Construction of a stoma is a common procedure in pediatric surgical practice. For care of these stomas, commercially available devices such as ostomy bag, either disposable or of longer duration are usually used. These are expensive, particularly in countries like Bangladesh, and proper-sized ones are not always available. We have found an alternative for stoma care, betel leaf, which is suitable for Bangladeshis. We report the outcome of its use.

Methods

After construction of stoma, at first zinc oxide paste was applied on the peristomal skin. A betel leaf with shiny, smooth surface outwards and rough surface inwards was put over the stoma with a hole made in the center according to the size of stoma. Another intact leaf covers the stomal opening. When bowel movement occurs, the overlying intact leaf was removed and the fecal matter was washed away from both. The leaves were reused after cleaning. Leaves were changed every 2 to 3 days. From June 1998 to December 2005, in the department of pediatric surgery, Chittagong Medical College and Hospital, Chittagong, Bangladesh, a total of 623 patients had exteriorization of bowel. Of this total, 495 stomas were cared for with betel leaves and 128 with ostomy bags.

Results

Of 623 children, 287 had sigmoid colostomy, 211 had transverse colostomy, 105 had ileostomy, and 20 had jejunostomy. Of the 495 children under betel leaf stoma care, 13 patients (2.6%) developed skin excoriation. There were no allergic reactions. Of the 128 patients using ostomy bag, 52 (40.65%) had skin excoriation. Twenty-four (18.75%) children developed some allergic reactions to adhesive. Monthly costs for betel leaves were 15 cents (10 BDT), whereas ostomy bags cost about US$24.

Conclusion

In the care of stoma, betel leaves are cheap, easy to handle, nonirritant, and nonallergic.     

Laparoscopic stoma formation with a prophylactic prosthetic mesh

Background  

One year after stoma formation with an open technique, the rate of parastomal hernia is almost 50%. The herniation rate can be reduced to 10% with the use of a prophylactic mesh in a sublay position. For stomas formed with a laparoscopic technique, a surgical method with the use of prophylactic mesh should be sought.     

预防性植入合成补片在腹腔镜造口术中的应用

目的探究腹腔镜造口术中预防性应用补片的效果。方法将腹腔镜乙状结肠造口术中预防性地在腹膜外植入大孔径、轻量型补片的病例纳入研究。术后随访至少12个月。结果 2003-2007年共有25例病人接受了乙状结肠造口术。平均年龄为65(31～89)岁,BMI平均为26(21～32),其中15例为女性。术后1例病人发生造口坏死,2例发生轻度切口感染。在所有接受随访的20例中(平均随访时间19个月,11～31个月),有3例(15%)发生了造口旁疝。无术后瘘管形成和造口狭窄,也未发生补片感染和再次手术移除补片的情况。结论在腹腔镜造口术中预防性地在腹膜外植入大网孔、轻量型补片是简单安全的操作,并且能有效降低术后造口旁疝的发生率。     

Is parastomal hernia repair with polypropylene mesh safe?

BACKGROUND: Concern over the safety of polypropylene mesh in parastomal hernia repairs has led some to avoid its use. We reviewed our rate of complications and outcomes with polypropylene mesh. METHODS: From January 1988 through May 2002, 58 patients underwent parastomal hernia repair with polypropylene mesh. After closure of the fascia, the stoma was pulled through the center of the mesh, which was placed either above or below the fascia. Multivariate analysis was performed to determine independent predictors for the development of complications. RESULTS: There were 31 end colostomies, 24 end ileostomies, and 3 loop transverse colostomies. Mean follow-up with 50.6 months. Overall complications related to the polypropylene mesh was 36% (recurrence 26%, surgical bowel obstruction 9%, prolapse 3%, wound infection 3%, fistula 3%, and mesh erosion 2%). None of the patients had extirpation of their mesh. Complications were significantly associated with younger age (59.6 versus 67 years, P = 0.04). Cancer patients with stomas had fewer complications (P = 0.02, odds ratio 0.34). Inflammatory bowel disease, stomal type, mesh location, urgent procedures, steroid use, and surgical approaches were not significantly associated with an increased complication rate. Of the 15 patients with recurrence, 7 underwent successful repair for an overall success rate of 86%. CONCLUSIONS: Parastomal hernia repair with polypropylene mesh is safe and effective.     

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.     

Miles手术的结肠造瘘口并发症防治

目的 探讨Miles手术结肠痿口并发症的原因和防治措施。方法 回顾性分析126例Miles手术所出现的造口并发症。结果 造口并发症发生98例,其中造口坏死5例、造口回缩7例、造口脓肿、脱出各l例、造口狭窄9例、造口切口旁疝7例和造口周围皮肤炎症97例。结论 并发症常由于术中或术后处理不当引起。     

结肠襻式和回肠襻式造口并发症发生风险的Meta分析

目的 评价结肠襻式造口和回肠襻式造口的并发症发生风险.方法 检索Medline、Embase、Cochrane Library、Google Scholar及万方数据库公开发表的比较结肠襻式造口和回肠襻式造口并发症发生风险的论文;检索文献发表时间至2011年4月15日.通过Meta分析,定量评价两者的并发症发生率,采用Z检验分析数据,采用Q检验检测异质性.结果 本研究一共纳入5篇随机对照研究和8篇非随机对照研究,共有1752例研究对象.与回肠襻式造口术比较,结肠襻式造口发生造口脱垂的风险较大,差异有统计学意义(OR =3.46,95％CI为1.81～6.63,P＜0.05);两种造口术后发生造口出血、狭窄、切口感染、造口坏死、造口周围皮炎、造口旁疝等并发症风险比较,差异无统计学意义.与回肠襻式造口回纳术比较,结肠襻式造口回纳术后发生切口感染的风险较大,差异有统计学意义(OR =3.44,95％CI为1.95～6.05,P＜0.05);回肠襻式造口回纳术后肠梗阻的发生风险较大,差异有统计学意义(OR=0.43,95％ CI为0.20～0.91,P＜0.05);两种造口回纳术后发生肠液漏风险比较,差异无统计学意义(P＞0.05).结论 结肠襻式造口术后发生造口脱垂及回纳术后切口感染的风险较大,而回肠攀式造口回纳术后肠梗阻发生的风险较大.     

Retrospective analysis of long-term defunctioning stoma complications after colorectal surgery

Objective Defunctioning stoma is a common surgical procedure, but the choice of stoma remains controversial. The preference for colostomy or ileostomy depends on the type of surgery and on the surgeon who performs the procedure. Stoma reversal is often performed a few weeks after colorectal resection but few studies have analysed the long‐term complications of different types of stoma. This study aims to determine which type of stoma is associated with a lower rate of long‐term complications. Method A retrospective study of patients undergoing colorectal surgery from 1998 to 2004 with stoma creation after was conducted. Only patients followed up by our enterostomal therapist for a minimum of 3 months were included. Both emergency and elective procedures were considered. All stoma‐related complications were recorded. Kruskal–Wallis and Mann‐Whitney U‐test were used for statistical analysis (Reviewer 2, n. 5). Results 132 patients were considered suitable for the analysis. Patients were divided into loop ileostomy (44), loop colostomy (77) and end colostomy (11) group. Mean age was 68 years. Mean follow up was 4 months (range: 3–23). The overall complication rate was 60%. The most common complication included dermatitis, parastomal hernia, leakage and stenosis. The stoma with the lowest complications rate was end colostomy (P = 0.026). Age <68 years was significantly associated with less complications (P = 0.01). Indication for surgery, emergency procedure, gender, morbidity and preoperative site were not significant factors. Conclusion In this long term follow‐up study, end colostomy and younger patients had a lower incidence of complications. A large prospective trial is needed to confirm our results.     

Laparoscopic cholecystectomy in acute cholecystitis: indication,technique, risk and outcome

Background Laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic cholelithiasis. However, the laparoscopic approach has remained controversial for patients with acute cholecystitis (AC) because of technical difficulties that, compared with open cholecystectomy (OC), might lead to higher complication rates, particularly common bile duct (CBD) injuries and infection.Methods We reviewed recent clinical findings on feasibility, safety and potential benefits of LC in patients with AC. An electronic search using the PubMed and MEDLINE databases was performed using the terms laparoscopic cholecystectomy, open cholecystectomy and acute cholecystitis. Pertinent references from articles and books not identified by the search engines were also retrieved. Relevant surgical textbooks were also reviewed.Conclusions The early laparoscopic approach has been shown to be technically feasible and at least equally as safe as the open approach. However, extensive inflammation, adhesions and consequent increased oozing can make laparoscopic dissection of Calots triangle and recognition of the biliary anatomy hazardous and difficult. Therefore, conversion to OC remains an important treatment option to secure patient safety in such difficult conditions. The question of whether intraoperative cholangiography (IOC) should be used routinely or only selectively has never been resolved. Proponents for each side have put forward compelling arguments.     

Incisional hernia at the site of a stoma

Objective  Incisional hernia at the site where a patient had previously had a stoma has not been clearly studied. The aim of this study is to determine the incidence and associated factors that may lead to an incisional hernia related to the reversal of an intestinal stoma. Patients and methods  An analysis was made of 70 cases of intestinal reconnection. All patients received Cefotaxime or Ceftazidime during anaesthesia induction and two more doses at 1–8 h in the post-operative period. In all of the cases, closure of the stoma site was effected as a primary closure using no. 1 polyglycolic acid continuous suture. There followed wound lavage with iodopovidone, and the skin was closed with simple sutures using polypropylene 3/0. No drain was left in situ in any of the cases. The study considered the following aspects: demographic characteristics of the study group; illnesses giving rise to the need for stoma formation; the stoma site itself; clinical aspects, including body mass index (BMI); the incidence of incisional hernia; and any complications involving the surgical wound. Results  At this hospital, the cause of requiring treatment with stoma formation was diverticular disease of the colon principally, and the age of the patients varied from 36 to 87 years (median 61). The incidence of incisional hernia at the stoma site was 22 cases (31.4%), presenting equally in both sexes and with greater frequency under the following circumstances: during the first year of follow-up and in patients with concomitant illnesses, principally diabetes. Local complications involving the surgical wound occurred in six cases (8.5%). Conclusion  The incidence of incisional hernia at the stoma site was found to be 31.4% in this study, which is a high incidence of hernias with simple repair.     

Parastomal evisceration as an extremely rare complication of a common procedure

The creation of an abdominal stoma is a common procedure performed as part of the treatment for many conditions. Common complications include poor stoma siting, high output, skin irritation, ischaemia, retraction, parastomal hernia and prolapse. An extremely rare stoma complication is parastomal evisceration. We present a case of a 48-year-old woman who presented to us with parastomal evisceration as a late complication of a transverse colostomy. It is the second case reported as acomplication of this procedure but the first that occurred after such a long postoperative period (almost 18 months).     

Laparoscopic stoma creation and closure

Laparoscopic surgery has demonstrated advantages over conventional open procedures. Specifically, avoiding an abdominal incision and allowing the complete inspection of the abdominal cavity, as well as the ability to obtain a biopsy sample, are some of the reasons that made this method of stoma creation advantageous. The creation of stomas by laparoscopy is one of the simpler laparoscopic procedures and is associated with a shorter learning curve compared with other colorectal procedures. This section discusses the indications, methods, and complications associated with the laparoscopic creation of stomas.     

Eradication of cryptosporidium from a defunctionalized colon limb by refeeding stoma effluent

Over the last 40 years, cryptosporidium has increasingly been recognized as a cause of acute self-limiting diarrhea in normal hosts. In the immunocompromised patient, cryptosporidium may cause severe illness with prolonged diarrhea and malabsorption. Pharmacologic therapy of cryptosporidium relies on adequate delivery of drug metabolites to the colon. Here we describe a patient who developed toxic megacolon during induction therapy for leukemia, requiring ileostomy formation to proceed with leukemia treatment. Although the megacolon resolved promptly, the resulting isolation of the colon from the fecal stream prevented luminal delivery of active metabolites of anti-protozoal drugs, resulting in persistent cryptosporidiosis. Refeeding of the ileostomy output into the colon effectively eradicated cryptosporidium from the colon and permitted closure of the ileostomy.     

Causes and management of a high‐output stoma

Aim Patients with a high‐output stoma (HOS) (> 2000 ml/day) suffer from dehydration, hypomagnesaemia and under‐nutrition. This study aimed to determine the incidence, aetiology and outcome of HOS. Method The number of stomas fashioned between 2002 and 2006 was determined. An early HOS was defined as occurring in hospital within 3 weeks of stoma formation and a late HOS was defined as occurring after discharge. Results Six‐hundred and eighty seven stomas were fashioned (456 ileostomy/jejunostomy and 231 colostomy). An early HOS occurred in 75 (16%) ileostomies/jejunostomies. Formation of a jejunostomy (defined as having less than 200 cm remaining of proximal small bowel; n = 20) and intra‐abdominal sepsis? obstruction (n = 14) were the commonest causes identified for early HOS. It was possible to stop parenteral infusions in 53 (71%) patients treated with oral hypotonic fluid restriction, glucose‐saline solution and anti diarrhoeal medication. In 46 (61%) patients, the HOS resolved and no drug treatment was needed, 20 (27%) patients continued treatment, six (8%) of whom went home and continued to receive parenteral or subcutaneous saline, and nine died. Twenty‐six patients had late HOS. Eleven were admitted with renal impairment and four had intermittent small‐bowel obstruction. Eight patients were given long‐term subcutaneous or parenteral saline and two also received parenteral nutrition. All had hypomagnesaemia. Conclusion Early high output from an ileostomy is common and although 49% resolved spontaneously, 51% needed ongoing medical treatment, usually because of a short small‐bowel remnant.     

Morbidity of Ostomy Takedown

Purpose Creation of a temporary ostomy is a surgical tool to divert stool from a more distal area of concern (anastomosis, inflammation, etc). To provide a true benefit, the morbidity/mortality from the ostomy takedown itself should be minimal. The aim of our study was therefore to evaluate our own experience and determine the complications and mortality of stoma closure in relation to the type and location of the respective ostomy. Methods Patients undergoing an elective takedown of a temporary ostomy at our teaching institution between January 1999 and July 2005 were included in our analysis, and the medical records were retrospectively reviewed. Excluded were only patients with relevant chart deficiencies and nonelective stoma revisions/takedowns. Data collected included general demographics; the type and location of the stoma; the operative technique; and the type, timing, and impact of complications. Perioperative morbidity was defined as complications occurring within 30 days from the operation. Results 156 patients (median age 45 years, range 18–85) were included in the analysis: 31 loop and 59 end colostomy reversals and 56 loop and 10 end ileostomy takedowns. Mean follow-up was 6 months. The overall mortality rate was low (0.65%, 1/156 patients). However, the morbidity rate was 36.5% (57 patients), with 6 (3.8%) systemic complications and 51 (32.7%) local complications. Minor would infection (34 patients, 21.8%) and postoperative ileus (9 patients, 5.7%) were the most common surgery-related complications, but they generally resolved with conservative management. Anastomotic leak and formation/persistence of an enterocutaneous fistula (6 patients, 3.8%) were the most serious local complications and required reintervention in all of the patients. Closure of a loop colostomy accounted for half and Hartmann reversals for one third of these complications, as opposed to ileostomy takedowns, which accounted for only one sixth (1.8% absolute risk). Conclusion Takedown of a temporary ostomy has a low mortality but a nonnegligible morbidity. The stoma location (large vs. small bowel) has a higher impact than the type of stoma construction (end vs. loop) on the incidence and severity of complications.