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.     

Mortality and complications after stoma closure

HYPOTHESIS: This study was undertaken to evaluate factors contributing to hospital mortality and complications of stoma closure. DESIGN: Retrospective cohort study. SETTING: Department of Surgery of a 2500-bed university hospital. PATIENTS: Consecutive eligible patients who underwent stoma closure were selected from a local registry containing 30 219 patients. The medical records of 587 adult patients were reviewed according to a predefined extraction form. Patients with additional, unrelated surgical interventions or younger than 18 years were excluded. Follow-up was complete for all included patients. MAIN OUTCOME MEASURES: The primary outcome variable was 30-day mortality; the secondary outcome variable was presence of surgery-related complications within 30 days. RESULTS: We analyzed 533 patients with stoma closure between 1993 and 2001. The overall stoma closure-related mortality rate was 3% (15 patients); the overall stoma closure-related surgical complications rate was 20% (107 patients). Wound infections (9%) and anastomotic leakage (5%) were the most common surgical complications. Age was the only significant risk factor for survival (P = .02). Use of a soft silicone drain for intraperitoneal drainage (odds ratio, 1.62 [95% confidence interval, 1.07-2.45]; P = .03) was the only significant risk factor for complications. In patients with carcinoma as the primary disease (odds ratio, 0.61 [95% confidence interval, 0.40 to 0.93]; P = .02), we observed significantly fewer complications. CONCLUSIONS: We found considerable mortality and complications after stoma closure. Apart from age, we could not identify any predictor for mortality in patients with stoma closure. Randomized studies are needed to determine whether certain types of drains influence outcome.     

A technique for wound closure that minimizes sepsis after stoma closure

Background: The aim of the present study was to assess the incidence of wound sepsis following closure of ileostomies and colostomies in our institution. Methods: Circumferential subcuticular wound approximation was used in 51 patients in our institution. Evidence of wound sepsis (assessed by the presence of cellulitis, induration and or purulent discharge) was documented both in the postoperative period and in outpatient follow‐up. Results: A wound infection rate of 0% was achieved, both in the immediate postoperative period and upon 6‐week follow‐up. Conclusions: Circumferential subcuticular wound approximation is, therefore, a safe and efficacious technique for dealing with the skin woundafter stomal closure, virtually abolishing wound sepsis.     

新生儿坏死性小肠结肠炎造瘘术后关瘘时机的选择

目的 多数具有手术指征的新生儿坏死性小肠结肠炎（NEC）患儿需要行坏死肠管切除+肠造瘘术。而对于术后多长时间关闭造瘘口较为合适,目前尚无共识。因此,本研究的目的是明确NEC造瘘术后关瘘的理想时机。方法 本研究回顾性分析了深圳市儿童医院新生儿外科2010年8月至2019年1月之间因NEC行坏死肠管切除+肠造瘘术并在术后一段时间后行关瘘术的患儿资料。为便于分析,我们将早期关瘘（EC）定义为造瘘术后8周内（含8周）,而晚期关瘘（LC）定义为造瘘术后8周后。结果 在58例患儿中,男35例,女23例。手术指征为气腹40例、保守治疗无法控制的感染18例,其中27例为早期关瘘（EC）,31例为晚期关瘘（LC）。关瘘术后EC组有18例患儿需要呼吸机支持（66.67%）,而LC组为10例（32.26%）（P<0.05）;EC组比LC组需要更长时间肠外营养支持;而且EC组的住院时间远高于LC组;共有13例患儿因粘连性肠梗阻的并发症接受了再次手术（其中EC组7例,LC组6例）;4例EC组患儿术后出现切口愈合不良,2例EC患儿因败血症死亡,1例EC患儿因短肠综合征和严重的营养不良死亡,而LC组患儿术后切口均恢复良好,无一例死亡。结论 本研究提示,NEC肠造瘘术后晚期关瘘比早期关瘘能为患儿带来更大的益处。     

Primary closure of stoma site wounds after ostomy takedown

Background

Ostomy reversal is considered a contaminated surgery and, thus, primary closure is believed to increase infection. Various closure techniques have been described and postulated to be superior to primary closure in regards to decreasing stoma site wound infections. The literature has varied in its support for this hypothesis.

Methods

A retrospective review was performed evaluating several variables including stomal closure method, patient demographics, steroid/immunosuppressant use, chemotherapy or radiation, perioperative antibiotics, and surgical indication to determine whether there was any association with the development of wound infections.

Results

Of 75 patients undergoing ostomy reversal, delayed primary closure/packing/secondary intention was used in 49 (65%), and 26 underwent primary closure (35%). Four patients (5.3%) developed stoma site infections; all had delayed primary closure or packing of their wound (P = .39). No variable was associated significantly with an increased risk of stoma site wound infections.

Conclusions

Primary closure does not increase the rate of infection.     

小肠造口还纳术的临床分析

目的探讨小肠造口还纳术病人的临床特征,从而减少并发症。方法对2010年1月至2015年12月于福建医科大学附属龙岩第一医院胃肠外科治疗的131例小肠造口还纳术病人的临床资料进行回顾性研究。根据既往有无严重腹腔感染、腹腔放化疗、多次腹部手术史等高危因素,分为低危组及高危组,低危组96例,高危组35例。病人术前行影像学检查,包括胸腹部增强CT、心电图、电子肠镜、消化道造影、心脏彩超等;实验室检查包括血常规、生化指标、肿瘤标志物、凝血、血气分析及降钙素原等检查。病人入院后给予适当全身支持治疗,根据术前评估情况,切口选择经造瘘口处或腹部正中切口等部位进入,术后予抗感染、营养支持、补充白蛋白、切口换药、腹带包扎、腹腔冲洗等处理。高危组均于小肠造口术后6个月以上接受还纳手术,低危组2~6个月内接受手术。结果低危组住院时间为(8.08±0.98)d,高危组为(12.34±7.55)d。小肠造口还纳术高危组术后发生腹腔感染、切口感染、切口疝气、肠瘘等并发症较低危组显著升高,差异均有统计学意义(均P0.05);病死率较低危组升高,差异有统计学意义(P0.05)。6 min运动试验阳性的病人比阴性病人并发症显著增加,差异有统计学意义(P0.05)。结论合并高危因素的小肠造口还纳术是一个具有极高风险的手术,手术时间长、出血多,常合并不可避免的多处肠管损伤或肠切除,术后肠瘘、腹腔感染、切口感染及切口疝发生率高,恢复慢,费用高。     

Colonic pouchography is not routinely required prior to stoma closure

Background Colonic pouch formation with pouch‐anal anastomosis is now regarded as the procedure of choice for restoration of intestinal continuity following anterior resection for low rectal cancers. The aim of this study was to review the necessity for routine colonic pouchography prior to closure of a diverting loop stoma. Methods This was a prospective study of 52 consecutive patients who underwent colonic pouch formation between 1 June 1999 and 31 May 2002, four of whom have subsequently died. Each pouch was assessed clinically and radiologically prior to stoma closure. Results There were no clinical anastomotic leaks. Forty‐six of 48 surviving patients have had a colonic pouchogram and in no case was either a pouch or pouch‐anal anastomotic defect identified. To date 40 patients have undergone stoma closure without an anastomosis‐related complication. Conclusion Following successful colonic pouch formation, routine study of the pouch by contrast radiology does not add to clinical assessment. As a consequence radiological imaging is unnecessary and can be omitted.     

Major stoma related morbidity in young children following stoma formation and closure: A retrospective cohort study

BackgroundLittle is known about stoma related morbidity in young children. Therefore, the aim of this study is to assess major morbidity after stoma formation and stoma closure and its associated risk factors.MethodsAll consecutive young children (age ≤ three years) who received a stoma between 1998 and 2018 at our tertiary referral center were retrospectively included. The incidence of major stoma related morbidity (Clavien-Dindo grade ≥III) was the primary outcome. This was separately analysed for stoma formation alone, stoma closure alone and all stoma interventions combined. Non-stoma related morbidity was excluded. Risk factors for major morbidity were identified using multivariable logistic regression analysis.ResultsIn total 336 young children were included with a median follow-up of 6 (IQR:2–11) years. Of these young children, 5% (n = 17/336) received a jejunostomy, 57% (n = 192/336) an ileostomy, and 38% (n = 127/336) a colostomy. Following stoma formation, 27% (n = 92/336) of the young children experienced major stoma related morbidity, mainly consisting of high output stoma, prolapse and stoma stenosis. The major morbidity rate was 23% (n = 66/292) following stoma closure, most commonly comprising anastomotic leakage/stenosis, incisional hernia and adhesive obstructions. For combined stoma interventions, major stoma related morbidity was 39% (n = 130/336). Ileostomy was independently associated with a higher risk of developing major morbidity following stoma formation (OR:2.5; 95%-CI:1.3–4.7) as well as following closure (OR:2.7; 95%-CI:1.3–5.8).ConclusionsMajor stoma related morbidity is a frequent and severe clinical problem in young children, both after stoma formation and closure. The risk of morbidity should be considered when deliberating a stoma.     

肠道暂时性造口与还纳方式及适应证选择90例分析

目的探讨肠造口方式对还纳手术的影响及造口还纳手术适应证的把握。方法选择2004年1月至2010年12月肠造口还纳手术的患者90例,统计分析造口原因、造口肠段和方法、造口方式、还纳时间、手术方式、手术时间、术后并发症及住院时间等。结果端式造口59例(其中单腔造口39例,双腔造口20例),袢式造口31例(其中改进式袢式造口18例),端式造口还纳手术时间显著长于袢式造口还纳手术(P<0.05)。手法吻合72例,吻合器吻合18例;端端吻合50例,端侧吻合40例;共发生近期并发症8例,发生率为8.9%,是否使用器械与使用不同吻合方式其并发症发生率无差别。结论暂时性肠造口应尽量选择袢式造口,尤其是改进式袢式造口;肠造口还纳术前应充分检查排除远端肠道狭窄或损伤处未愈合,造口术后3～6个月可行还纳手术,可以根据需要选择端端或端侧吻合、手法或吻合器吻合。     

腹壁缺损关闭法在肠管造口还纳术中的应用

目的探讨腹壁缺损关闭法在肠管造口还纳中的应用效果。方法收集2008年1月至2015年10月间收治的分别应用传统方法(23例)和改良方法(23例)关闭造口部位腹壁缺损的病人46例的临床资料,对两组病人的手术时间、术中出血量、术后首次排便时间、术后疼痛评分、切口感染、住院时间等指标进行比较。结果两组病人手术均顺利完成。与传统方法比较,改良方法组病人手术时间明显缩短[(42.3±12.9)min比(55.4±14.7)min,t=3.212,P=0.002];术后疼痛评分更低[(3.9±2.8)分比(5.5±2.2)分,t=2.155,P=0.037],差异具有统计学意义;术中出血量、术后初次排便时间、切口感染及住院时间差异均无统计学意义(P0.05)。结论消化道造口还纳手术中改良腹壁缺损关闭法手术时间短,术后疼痛症状轻,值得临床应用。     

Association between incisional surgical site infection and the type of skin closure after stoma closure

Purpose  

This study was performed to investigate the effect of subcuticular sutures on the incidence of incisional surgical site infection (SSI) after closure of a diverting stoma.     

Modified triangulating stapling technique for closure of a temporary loop stoma

Purpose  

To describe a new stapling technique for closure of a temporary loop stoma and report the results of a retrospective investigation of its efficacy.     

Randomized clinical trial of early versus delayed temporary stoma closure after proctectomy

Background:

Temporary faecal diversion is recommended with a low colorectal, coloanal or ileoanal anastomosis (LA). This randomized study evaluated early (EC; 8 days) versus late (LC; 2 months) closure of the temporary stoma.

Methods:

Patients undergoing rectal resection with LA were eligible to participate. If there was no radiological sign of anastomotic leakage after 7 days, patients were randomized to EC or LC. The primary endpoints were postoperative morbidity and mortality 90 days after the initial resection.

Results:

Some 186 patients were analysed. There were no deaths within 90 days and overall morbidity rates were similar in the EC and LC groups (31 versus 38 per cent respectively; P = 0·254). Overall surgical complication (both 15 per cent; P = 1·000) and reoperation (both 8 per cent; P = 1·000) rates were similar, but wound complications were more frequent after EC (19 versus 5 per cent; P = 0·007). Small bowel obstruction (3 versus 16 per cent; P = 0·002) and medical complications (5 versus 15 per cent; P = 0·021) were more common with LC. Median (range) hospital stay was reduced by EC (16 (6–59) versus 18 (9–262) days; P = 0·013).

Conclusion:

Early stoma closure is feasible in selected patients, with reduced hospital stay, bowel obstruction and medical complications, but a higher wound complication rate. Registration number: NCT00428636 ( http://www.clinicaltrials.gov ). Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

腹腔镜辅助的全小肠内镜检查

目的:探讨腹腔镜辅助全小肠内镜检查的可行性。方法:腹腔镜辅助下用内镜逐段对实验猪小肠进行检查,发现模拟病变后切除。结果:内镜检查肠管长度250 ~540cm,平均( 320±140 )cm。手术时间40 ~120min,平均( 78±36 )min。动物内镜检查均发现模拟病变,完成模拟病变肠壁切除。结论:腹腔镜辅助全小肠镜检查技术上是可行的。     

Risk factors for surgical site infection after stoma closure comparison between pursestring wound closure and conventional linear wound closure: Propensity score matching analysis

Purpose

Stoma closure has been associated with a high rate of surgical site infection (SSI) and the optimal skin closure method is still controversial. The aim of this study was to compare the short-term and long-term outcomes between the conventional linear closure (CC) and the persestring closure (PC) using propensity score matching analysis.