Stoma formation for fecal diversion: a plea for the laparoscopic approach

Abstract Background The aim of this study was to assess the results of laparoscopic stoma creation for fecal diversion, specifically focussing on feasibility, safety, and efficacy, as well as indications and techniques. Methods Within a 10-year-period, all patients requiring laparoscopic stoma creation were evaluated prospectively. Patients profiles and indications, procedures and results of operation, conversion, morbidity, mortality and short-term complications (stoma-related, laparoscopy-associated) were analyzed. Results A total of 80 patients (39 males, 41 females) with a mean age of 55.5 years (range, 17–91) underwent laparoscopic stoma creation. Most common indications were unresectable advanced colorectal cancer (n=20), pelvic malignant cancer (e. g. ovarian, cervix and prostate cancer, n=16), and perianal Crohns disease with complex fistulas (n=16). Only in one female patient with pelvic malignant disease was the procedure converted to laparotomy due to obesity (conversion rate, 1.3%). 79 patients underwent laparoscopic stoma creation (completion rate, 98.7%) including loop ileostomy (n=30), loop sigmoid colostomy (n=40) and end sigmoid colostomy (n=9). Postoperative complications were documented in 9 patients (overall morbidity rate, 11.4%), including 4 minor complications treated conservatively (2 cases of prolonged atonia and 1 case each of pneumonia and urinary tract infection) and 5 major complications requiring reoperation (reoperation rate, 6.3%): one parastomal abscess (drainage), one stoma retraction following rod dislocation (laparoscopic stoma recreation), small bowel obstruction in two patients (small bowel resection), one port-site hernia (fascial closure), and hemorrhage (managed by re-laparoscopy). Mean operation time was 74 min (range, 30–245 min). Mean blood loss volume was 80 ml (range, 30–400 ml). Patients were discharged from hospital after a mean of 10.3 days (range, 3–47). Within a 1-year follow-up, no further stoma complications were documented. Conclusions The advantages of laparoscopic stoma creation are low morbidity and reoperation rates, and no procedure-related mortality; our results suggest that laparoscopic stoma creation for fecal diversion is safe, feasible and effective. Therefore, at our institution, laparoscopic stoma creation is the method of choice for fecal diversion.     

Laparoscopic colorectal surgery in obese and nonobese patients: Do differences in body mass indices lead to different outcomes?

Background The aim of this prospective study was to compare the outcome of laparoscopic colorectal surgery in obese and nonobese patients.Methods All patients who underwent laparoscopic surgery for both benign and malignant disease within the past 5 years were entered into the prospective database registry. Body mass index (BMI; kg/m²) was used as the objective measure to indicate morbid obesity. Patients with a BMI >30 were defined as obese, and patients with a BMI <30 were defined as nonobese. The parameters analyzed included age, gender, comorbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion rate, overall morbidity rate including major complications (requiring reoperation), minor complications (conservative treatment) and late-onset complications (postdischarge), stay on intensive case unit, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Students t test and chi-square analysis. Statistical significance was assessed at the 5% level (p < 0. 05 statistically significant).Results A total of 589 patients were evaluated, including 95 patients in the obese group and 494 patients in the nonobese group. There was no significant difference in conversion rate (7.3% in the obese group vs 9.5% in the nonobese group, p > 0.05) so that the laparoscopic completion rate was 90.5% (n = 86) in the obese and 92.7% (n = 458) in the nonobese group. The rate of females was significantly lower among obese patients (55.8% in the obese group vs 74.2% in the nonobese group, p = 0.001). No significant differences were observed with respect to age, diagnosis, procedure, duration of surgery, and transfusion requirements (p > 0.05). In terms of morbidity, there were no significant differences related to overall complication rates with respect to BMI (23.3% in the obese group vs 24.5% in the nonobese group, p > 0.05). Major complications were more common in the obese group without showing statistical significance (12.8% in the obese group vs 6.6% in the nonobese group, p = 0.078). Conversely, minor complications were more frequently documented in the nonobese group (8.1% in the obese group vs 15.5% in the nonobese group, p = 0.080). In the postoperative course, no differences were documented in terms of return of bowel function, duration of analgesics required, oral feeding, and length of hospitalization (p > 0.05).Conclusion These data indicate that laparoscopic colorectal surgery is feasible and effective in both obese and nonobese patients. Obese patients who are thought to be at increased risk of postoperative morbidity have the similar benefit of laparoscopic surgery as nonobese patients with colorectal disease.     

Komplizierte Divertikulitis

ZusammenfassungHintergrund: Die Sigmadivertikulitis nimmt in 10–20% einen komplizierten Verlauf, der der chirurgischen Therapie bedarf. Neben freier Perforation, Abszess und Blutung sind Fisteln eine Indikation. Vergleichsweise selten handelt es sich dabei um sigmoidovaginale Fisteln.Methodik: Der Stellenwert der Laparoskopie bei komplizierter Divertikulitis ist kontrovers. Sie kann jedoch ein sicheres und effektives Operationsverfahren darstellen. Anhand der verfügbaren Literatur greifen die Autoren gezielt die Erfahrungen mit der minimalinvasiven Chirurgie (MIC) bei sigmoidovaginaler Fistel auf und präsentieren mit drei Fallbeispielen ein eigenes Therapiekonzept. Hierbei werden die laparoskopische Sigmaresektion und primäre Anastomosierung um eine intraabdominelle Naht der Scheide sowie plastische Deckung mittels Netzplombe ergänzt.Ergebnisse: Alle Operationen wurden laparoskopisch vollendet. Die mittlere Operationsdauer betrug 243 Minuten. Hinsichtlich der Morbidität (1 Majorkomplikation, 1 Minorkomplikation) und Letalität (0) stand der postoperative Verlauf in guter Übereinstimmung mit der Literatur. Der Kostaufbau beanspruchte im Mittel 1,7 Tage (flüssige Kost) bzw. 6,3 Tage (feste Kost), die Aufenthaltsdauer 13 Tage. Fistelrezidive traten während der 30-tägigen Nachbeobachtung nicht auf.Schlussfolgerung: Die Ergebnisse bestätigen den Stellenwert der Laparoskopie als operatives Standardverfahren bei komplizierter Divertikulitis an der eigenen Klinik.     

Laparoscopic colectomy for diverticulitis is not associated with increased morbidity when compared with non-diverticular disease

Background and aims It was the aim of this prospective study to compare the outcome of laparoscopic sigmoid and anterior resection for diverticulitis and non-diverticular disease.Patients and methods All patients who underwent laparoscopic colectomy for benign and malignant disease within a 10-year period were entered into the prospective PC database registry. For outcome analysis, patients who underwent laparoscopic sigmoid and anterior resection for diverticular disease were compared with patients who underwent the same operation for non-inflammatory (non-diverticular) disease. The parameters analyzed included age, gender, co-morbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion, morbidity including major (requiring reoperation), minor (conservative treatment) and late-onset (postdischarge) complications, stay in the ICU, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Students t-test and chi-square analysis (p<0.05 was considered statistically significant).Results A total of 676 patients were evaluated including 363 with diverticular disease and 313 with non-inflammatory disease. There were no significant differences in conversion rates (6.6 vs. 7.3%, p>0.05), so that the laparoscopic completion rate was 93.4% (n=339) in the diverticulitis group and 92.7% (n=290) in the non-diverticulitis group. The two groups did not differ significantly in age or presence of co-morbid conditions (p>0.05). In the diverticulitis group, recurrent diverticulitis (58.4%), and complicated diverticulitis (27.7%) were the most common indications, whereas in the non-diverticulitis group, outlet obstruction by sigmoidoceles (30.0%) and cancer (32.4%) were the main indications. The most common procedure was laparoscopic sigmoid resection, followed by sigmoid resection with rectopexy and anterior resection. No significant differences were documented for major complications (7.4 vs. 7.9%), minor complications (11.5 vs. 14.5%), late-onset complications (3.0 vs. 3.5), reoperation (8.6 vs. 9.3%) or mortality (0.6 vs. 0.7%) between the two groups (p>0.05). In the postoperative course, no differences were noted in terms of stay in the ICU, postoperative ileus, parenteral analgesics, oral feeding, and length of hospitalization (p>0.05).Conclusion These data indicate that laparoscopic sigmoid and anterior resection can be performed with acceptable morbidity and mortality for both diverticular disease and non-diverticular disease. The results show in particular that laparoscopic resection for inflammation is not associated with increased morbidity.The data were presented at the 121th Congress of the German Society of Surgery, Berlin, 27–30 April 2004     

Laparoskopische Chirurgie bei chronisch-entzündlichen Darmerkrankungen

Zusammenfassung Hintergrund: Die technische Machbarkeit laparoskopisch assistierter Verfahren bei Morbus Crohn und Colitis ulcerosa ist mehrfach beschrieben. Sie erfordert einen in chronisch-entzündlichen Darmerkrankungen (CED) und laparoskopischen Techniken erfahrenen Operateur. Eigene Daten: Wir untersuchten prospektiv dokumentierte laparoskopische Eingriffe bei Morbus Crohn und Colitis ulcerosa. Seit 1994 erfolgte bei 64 Patienten mit Morbus Crohn und seit 1996 bei 22 Patienten mit Colitis ulcerosa ein minimalinvasiver Eingriff. Schlussfolgerung: Laparoskopische Chirurgie bei CED ist mit hoher Sicherheit durchführbar. Die Vorteile der laparoskopischen Chirurgie sind auch für dieses Patientenspektrum gegeben.     

Whole-bone scaling of the avian pelvic limb

Birds form the largest extant group of bipedal animals and occupy a broad range of body masses, from grams to hundreds of kilograms. Additionally, birds occupy distinct niches of locomotor behaviour, from totally flightless strong runners such as the ratites (moa, kiwi, ostrich) to birds that may walk, dabble on water or fly. We apply a whole-bone approach to investigate allometric scaling trends in the pelvic limb bones (femur, tibiotarsus, tarsometatarsus) from extant and recently extinct birds of greatly different size, and compare scaling between birds in four locomotor groups; flightless, burst-flying, dabbling and flying. We also compare scaling of birds' femoral cross-sectional properties to data previously collected from cats. Scaling exponents were not significantly different between the different locomotor style groups, but elevations of the scaling relationships revealed that dabblers (ducks, geese, swans) have particularly short and slender femora compared with other birds of similar body mass. In common with cats, but less pronounced in birds, the proximal and distal extrema of the bones scaled more strongly than the diaphysis, and in larger birds the diaphysis occupied a smaller proportion of bone length than in smaller birds. Cats and birds have similar femoral cross-sectional area (CSA) for the same body mass, yet birds' bone material is located further from the bone's long axis, leading to higher second and polar moments of area and a greater inferred resistance to bending and twisting. The discrepancy in the relationship between outer diameter to CSA may underlie birds' reputation for having 'light' bones.     

S3-Leitlinie: Analabszess

Background

Anal abscesses are relatively frequent and most common in young men.

Methods

A systematic review of the literature has been undertaken.

Results

The origin of the abscess is usually the proctodeal gland in the intersphincteric space. There are different types of abscesses: intersphincteric, ischioanal and supralevatory abscesses. Anamnesis and clinical examination are sufficient to indicate surgery. Further examinations such as endosonography or magnetic resonance tomography (MRT) should be considered in recurrent or supralevatory abscesses. The timing of surgical intervention depends on clinical symptoms, whereas the acute abscess is an emergency indication. Surgery is the primary therapy approach for anal abscess. Surgical access (transrectal or perianal) depends on the localization of the abscess. The aim of surgery is to broadly drain the infection and protect anal sphincter structures. The wound should be rinsed regularly (showering with clear water). Treatment with local antiseptics carries the risk of zytotoxicity. Antibiotic treatment is necessary only in selected cases. Any attempt to locate a fistula intraoperatively should be undertaken with great care; proven evidence of a fistula is not mandatory. Although the risk of recurrent abscess or secondary fistula is low, these may be caused by insufficient drainage. The primary fistulotomy of superficial fistulas should only be performed by an experienced surgeon. In the case of ambiguous findings or high fistulas, treatment should be carried out in a second surgical procedure.

Conclusion

For the first time in Germany, this clinical S3 guideline provides instructions for the diagnosis and treatment of anal abscesses based on a systematic review of the literature.     

S3-Leitlinie: Kryptoglanduläre Analfisteln

Background

With an incidence of 2 in 10,000/year, fistula-in-ano of cryptoglandular origin is a common disease, affecting predominantly young males. Incorrect treatment can adversely effect quality of life, particularly in terms of stool continence.

Methods

A systematic review of the literature has been undertaken.

Results

Since relevant randomized studies are scant, the level of evidence is low. The classification of anal fistulas depends on the relation between fistula channel and anal sphincter. Anamnesis and clinical examination are sufficient to establish the indication for surgery. In addition, an intraoperative probe and/or staining of the fistula channel should be performed. Endoanal ultrasound and magnetic resonance tomography are similar in predictive value. These modalities may be able to provide additional information in complex fistulas. The treatment of anal fistulas consists of one of the following surgical procedures: lay-open technique, seton drainage, plastic reconstruction with suture of the sphincter or occlusion with biomaterials. The lay-open technique should only be performed in superficial fistulas. The risk of impaired postoperative continence increases with the thickness of the divided sphincter muscle. A sphincter-saving procedure should be undertaken for all high anal fistulas. The results of the different techniques using plastic reconstruction are largely comparable. A lower healing rate is seen with occlusion using biomaterials.

Conclusion

This clinical S3 guideline provides instructions for the diagnosis and treatment of cryptoglandular fistula-in-ano for the first time in Germany.