Laparoscopically assisted reversal of Hartmann’s procedure

Background Restoration of bowel continuity after Hartmann’s procedure is a major surgical procedure associated with substantial morbidity and occasional mortality. The authors review their experience with laparoscopically assisted reversal of Hartmann’s procedure (LARH) to assess difficulties and potential advantages associated with this procedure. Methods A retrospective chart review of a prospectively entered database was performed to identify patients who underwent LARH over a period of 7 years. Data regarding demographic and clinical characteristics, surgical details, and postoperative course were reviewed. Specifically, age, gender, diagnosis at initial operation, American Society of Anesthesiology (ASA) score, comorbidities, operative time, conversion, surgical team, complications, postoperative bowel movements, and hospital stay were assessed. All surgeries were performed by six experienced laparoscopic surgeons. Results A total of 27 patients, 17 men and 10 women, with mean ages of 58.1 and 62.9 years, respectively, underwent LARH. The procedure was laparoscopically completed for 23 patients. Conversion to laparotomy was required for four patients (14.8%) because of dense adhesions after the initial Hartmann’s procedure in three patients and rectal perforation in one patient. The median operative time was 226 min, and the median hospital stay was 6 days. The overall morbidity rate was 33% (9 patients), attributable to colostomy site infection in 5 of the 9 patients. One patient required reoperation because of intraabdominal bleeding. No anastomotic leaks or intraabdominal abscesses were recorded. There was no operative mortality. Conclusions Laparoscopically assisted reversal of Hartmann’s procedure is technically challenging and time consuming. However, in the hands of experienced laparoscopic surgeons, it is safe and associated with a reasonably low conversion rate. Furthermore, the relatively low morbidity rate, short hospital stay, and earlier return of bowel function may be beneficial to patients. Poster presentation at the 12th International Congress of the European Association for Endoscopic Surgery (EAES), Barcelona, Spain, 9–12 June 2004     

Failed vasectomy reversal: is a further attempt using microsurgery worthwhile?

OBJECTIVE: To determine, in failed vasectomy reversal, the usefulness of a revised anastomosis using microsurgery in achieving sperm in the ejaculate and fertility, and to relate the outcome to the site of the anastomosis, length of time from vasectomy, and presence or absence of sperm in the vas at surgery. PATIENTS AND METHODS: In a series of 28 patients with confirmed anastomotic obstruction undergoing vasectomy reversal (over a 10-year period), a microsurgical technique using an oblique end-to-end two-layer interrupted anastomosis with 10/0 Nylon was used to establish vasal continuity. Subsequent seminal analysis at 3-6 months and ensuing paternity were related to several variables. The results were compared with those obtained after 137 cases of primary microsurgical vasovasostomy. RESULTS: Sperm was restored to the ejaculate in 16 (57%) of the patients and successful fertilization was reported in nine (32%). The interval between vasectomy and reversal surgery was relevant to the outcome, with four out of four men having sperm in the ejaculate within 5 years and three achieving paternity. However, the fertility rate was still moderate after an interval of 6-10 years (two of six) and at > 10 years (four of 18). The presence of sperm in the ejaculate was related to whether or not sperm were found in the testicular end of the vas at operation, but absence did not preclude a successful outcome. The overall results were not significantly different from those after primary microsurgical reversal surgery. CONCLUSION: Microscopic vasovasostomy after previous obstructive failure provides the patient with a further reasonable chance of becoming fertile; although diminishing with time from vasectomy, even after a prolonged period there can be success. The absence of sperm at the time of vasovasostomy does not necessarily indicate failure, but in these cases the presence of thick creamy fluid in the vas predicts a poor outcome, and alternative methods of management should be considered. A microsurgical technique extending, if necessary, well into the convoluted part of the vas, is recommended. Microsurgical skills, relevant equipment and adequate time are required.     

Is Clostridium difficile infection a particular problem after reversal of ileostomy?

Aim Clostridium difficile infection (CDI) is a cause of morbidity and mortality in hospitals. Various independent risk factors have been identified, including age and antibiotic exposure. This study attempted to determine whether surgery and associated antibiotic use influence the development of CDI. Method A retrospective review of all patients with a diagnosis of CDI diagnosed during admission to a colorectal unit was conducted over a 20‐month period. Patient records were cross‐referenced with a microbiology database to identify previous episodes of infection and cases of recurrence. Results There were 38 CDI episodes in 29 patients, including nine with recurrence. In 33, the use of antibiotics prior to the onset of CDI was documented, but in 14 (37%) patients this was limited to perioperative prophylaxis. The incidence of CDI after various procedures was as follows: ileostomy closure (4.2%), right hemicolectomy (2.1%) and anterior resection (1%). Conclusion Ileostomy closure may carry a higher risk of CDI.     

Should vasectomy reversal be performed in men with older female partners?

PURPOSE: An assumption exists that men with older female partners who seek treatment of post-vasectomy infertility should undergo in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) rather than vasectomy reversal. Although several studies have reviewed ICSI success rates with advancing maternal age, to our knowledge none has compared them to outcomes for vasectomy reversal in men with older partners. MATERIALS AND METHODS: The records of all patients with ovulating partners older than 37 years who underwent vasectomy reversal from 1994 through 1998 were reviewed. Patients were contacted to establish pregnancy and birth rates. Costs of vasectomy reversal, testicular sperm extraction, IVF and ICSI were obtained from the financial office of our institution. RESULTS: A total of 29 patients underwent vasectomy reversal with a followup of 3 to 59 months (median 25). Median male age was 46 years (range 37 to 67) and median female age was 40 years (range 38 to 48). A total of 5 pregnancies and 4 live births were achieved. In the 23 patients followed for more than 1 year the pregnancy rate was 22% and live birth rate was 17%. Using this 17% birth rate at our $4,850 cost for vasectomy reversal the cost per newborn was $28,530. In comparison, using the 8% birth rate per cycle of ICSI for women older than 36 years at a cost of $8,315 for testicular sperm extraction and 1 cycle of IVF with ICSI, the cost per newborn was estimated at $103,940. CONCLUSIONS: Vasectomy reversal appears to be cost-effective to achieve fertility in men with ovulating partners older than 37 years.     

Laparoscopic and open reversal of Hartmann’s procedure—a comparative retrospective analysis

Background

Restoration of intestinal continuity after Hartmann’s procedure has traditionally required laparotomy. This study compares our experience with laparoscopic and open reversal of Hartmann’s procedure.

Study design

All laparoscopic and open Hartmann’s reversal procedures performed between January 1998 and June 2006 were reviewed. Patients with laparoscopic reversal were retrospectively matched by age, body mass index (BMI), and indication to controls with open reversal. Demographic data, perioperative course, and postoperative complications were documented.

Results

We identified 41 patients who underwent laparoscopic reversal of Hartmann’s procedure and these were matched to 41 patients with open reversal. The groups had similar average age and BMI. The predominant indication for surgery in both groups was diverticular disease. Conversion to laparotomy occurred in eight patients (19.5%), and was due to dense adhesions or difficulty in identification of the rectal stump. Adhesions were significantly greater in the conversion group (p <0.05), and the rectal stump was not marked in any of these cases. The most common short-term complications were ileus and surgical site infection. There were no anastomotic leaks and no mortalities. The mean operative times in the laparoscopic and open groups were 193 versus 209 min, respectively (p = 0.33). The laparoscopic group had a significantly lower estimated blood loss of 166 versus 326 mL (p < 0.0005), shorter time to bowel function return (4.1 versus 5.2 days, p < 0.05), and a shorter hospital stay (6.4 versus 8.0 days, p < 0.05). The major complication rate was also significantly lower in the laparoscopic group than in the open group (4.8% versus 12.1%, p < 0.05).

Conclusions

Laparoscopic reversal of Hartmann’s procedure is a safe and practical alternative to open reversal. It can be performed with similar operative time, fewer complications, and a faster recovery time. Conversion during the reversal procedure was significantly impacted by severity of adhesions and marking of the rectal stump.     

Is bariatric surgery resolving NAFLD via microbiota-mediated bile acid ratio reversal? A comprehensive review

Despite the fact that there is still insufficient evidence to consider non-alcoholic fatty liver disease (NAFLD) as an stand-alone indication for bariatric surgery, many clinical and histopathological beneficial effects on both NAFLD and non-alcoholic steatohepatitis (NASH) have been shown. Although weight loss seems to be the obvious mechanism, weight-loss independent factors are also believed to be involved. Among them, changes in gut microbiota and bile acids (BA) composition may be playing an unappreciated role in the improvement of NAFLD. In this review we examine the mechanisms and interdependence of the gut microbiota and BA, and their influence on NAFLD pathogenesis and its reversal following bariatric surgery. According to the currently available evidence, gut microbiota has a major influence on BA composition. In fact, both BA and microbiome disturbances (dysbiosis) play a role in the etiopathogenesis of NAFLD and might be potential therapeutic targets. In addition, bariatric surgery can modify the intraluminal ileal environment in a way that causes significant repopulation of the gut microbiota and a reversal of the plasma primary/secondary BA ratio, which, in turn, induces weigh-independent metabolic improvements.     

A retrospective case note review of laparoscopic versus open reversal of Hartmann’s procedure

Introduction

First described in 1921, Hartmann’s procedure is the gold standard treatment for complicated sigmoid diverticular disease. It is also used commonly for other causes of perforation of the large bowel. However, the reversal rate in the UK is much lower than in comparable countries, at only 18–22%. Furthermore, laparoscopic reversal (LRH) is used far less frequently than open reversal (ORH) despite evidence that a laparoscopic technique reduces patient morbidity and decreases patient recovery time.

Methods

This retrospective case note review undertook an analysis of all the patients who had undergone Hartmann’s procedure at two centres in Leeds Teaching Hospitals NHS Trust between February 2007 and February 2012. Out of 305 patients, 235 were identified and included in the analysis. Comparisons were then drawn between LRH and ORH groups.

Results

The reversal rate was 21%. Three-quarters (76%) were performed using an open technique, 20% were laparoscopic and 5% were converted to an open procedure. The mean hospital stay was longer for the ORH group (9.82 days, standard deviation [SD]: 5.85 days, 95% confidence interval [CI]: 2.99 days) than for the LRH group (7.29 days, SD: 4.65 days, 95% CI: 11.58 days) p=0.006). Seven ORH patients (21%) were reoperated but only one LRH patient (13%) had a reoperation at six months. Five factors were found to have a significant effect on the likelihood of reversal of Hartmann’s procedure.

Conclusions

The overall reversal rate for Hartmann’s procedure remains low. Shorter hospital stays, lower 6-month reoperation rates and reduced 30-day complication rates are associated with LRH when compared with ORH.     

“Priming” with neostigmine: failure to accelerate reversal of single twitch and train-of-four responses

Train-of-four stimulation can shorten the apparent onset time of neuromuscular blocking drugs. This study was designed to verify whether the same occurred with neostigmine-assisted recovery, and whether this apparent acceleration could explain the previously reported effectiveness of the priming technique for reversal agents. Fourteen adults received atracurium, 0.5 mg.kg-1, during a thiopentone-nitrous oxide-enflurane anaesthetic. The ulnar nerves of both arms were stimulated with train-of-four stimulation every 12 seconds until 1 per cent recovery of first twitch, at which time stimulation in one arm was switched to single twitch. When mean first twitch height reached 10 per cent of control, neostigmine, 0.04 mg.kg-1, was administered either as a single bolus, or as a "priming" dose of 0.01 mg.kg-1, followed 3 min later by 0.03 mg.kg-1. No statistically significant differences were observed between single twitch in one arm and first twitch height of the train-of-four in the other arm for the next 10 min. With priming, first twitch height was 45 +/- (SEM) 5 per cent at 5 min and 85 +/- 6 per cent at 10 min, compared with 72 +/- 5 per cent (p less than 0.05) and 91 +/- 2 per cent (NS) respectively without priming. Train-of-four ratio was 28 +/- 3 per cent at 5 min and 65 +/- 5 per cent at 10 min with priming, versus 53 +/- 4 per cent (P less than 0.05) and 73 +/- 3 per cent (NS) respectively without priming.(ABSTRACT TRUNCATED AT 250 WORDS)     

Vasectomy reversal using a microsurgical three-layer technique: one surgeon's experience over 18 years with 1300 patients

The technique and the results of microsurgical vasectomy reversal in a single-centre study over 18?years are presented. Both vasovasostomy (VV) and epididymovasostomy (EV) were carried out in a three-layer technique. With strict adherence to the strategy, end-to-end VV was only performed if spermatozoa had been demonstrated at the epididymal stump of the vas. In all other cases, EV was carried out in a preocclusive region of the epididymal tubule. The outpatient procedure of refertilization was associated with a very low complication rate, which underlines its minimal-invasive character. The follow-up rate was 71%, the overall patency rate was 89% and the pregnancy rate was 59%. Secondary azoospermia was only observed in 1% of the patients. In relation to the intervals of obstruction, the patency and pregnancy rates were higher after short-term obstruction than after long-term obstruction. Correspondingly, higher success rates were found after VV than after EV. This is understandable because the probability for indication of EV increases with longer periods of obstruction. There is a significant discrepancy between patency and pregnancy rates that is likely to be caused by a relevant number of patients with post-operative asthenozoospermia. The duration of obstruction is an important factor concerning epididymal damage, but it only disproportionately affects the results of refertilization if the technology of EV is implemented consistently in case of an epididymal granuloma. Good clinical results are achieved with this strategy, as evidenced by pregnancy rates and semen analyses.