Colonic invagination anastomosis in surgery of complicated forms of diverticular disease

AIM: to evaluate the prospects of using a colorectal invaginated anastomosis in patients with complicated diverticular disease (CDD).PATIENTS AND METHODS: during the period from 2014 to 2020, colorectal invaginated anastomosis, was used in 42 patients: 18 patients with CDD and 20 patients with colorectal cancer for stoma closure after Hartmann’s procedure. The comparison group consisted of 24 patients with CDD and 20 patients with colorectal cancer for stoma closure after Hartmann’s procedure: colorectal anastomosis was created here using traditional double-row handsewn technique. All patients underwent surgery with open access, while the primary anastomosis was performed in 20 (47.6%) patients, and in 22 (52.4%) patients of the group underwent stoma takedown.RESULTS: no anastomosis leakage developed in the main group. Moreover, the presence of single small diverticula with a diameter of 2–3 mm near the area of the anastomosis was not an indication to extend the resection borders. In the control group, in 13 (54.2%) patients, small diverticula were detected in the anastomosis are as well and required to expand the proximal border of resection. In this group, anastomosis leakage occurred in 2 (6.8%) patients with diverticular disease and required Hartmann’s procedure.CONCLUSION: the colorectal invaginated anastomosis is justified for patients with CDD during stoma takedown because it minimizes the risk of anastomosis leakage.

PROphylactic MESH (PROMESH) for stoma closure: does it reduce the incidence of incisional hernia? Protocol for a triple-blinded randomised controlled trial

IntroductionApplication of a prophylactic mesh during stoma closure was shown to reduce the incidence of incisional hernia at the site of stoma closure. Our objective is to provide high quality evidence to validate this finding.Methods and analysisThe study will be a randomised controlled triple-blinded superiority parallel monocentric trial. Patients undergoing elective ileostomy or colostomy closure after surgery for digestive cancer will be eligible for inclusion. Patients allergic to the mesh, immunosuppressed or refusing to participate will be excluded. Randomisation will be performed based on a 1:1 allocation ratio between stoma closure with application of a non-absorbable mesh in the sublay position (intervention) and stoma closure without a mesh (control). The primary outcome will be the 1-year incidence of incisional hernia at the site of stoma closure, determined clinically and by CT. Secondary outcomes will be the 31-day incidence of surgical site infection and the modified Carolinas Comfort Scale. Patients, radiologists and investigators performing the assessment at 1 year will be blinded for the allocated study group. Analysis will be performed in intention-to-treat. The trial will include 68 patients (34 with mesh, 34 without mesh).Ethics and disseminationThe present randomised controlled trial was registered into clinicaltrials.gov (NCT 04510558) and was accepted by the local ethic committee (Geneva, Switzerland: CCER 2021-00053). The results will be presented at national and international congresses in the fields of colorectal surgery and general surgery, and published in a peer-reviewed journal.

Physical activity levels after low anterior resection for rectal cancer: one-year follow-up

Background Overall survival rates after rectal cancer have increased. Therefore, functional outcomes rightly deserve more interest. The aims of this study were to assess progression in total, sports, occupational and household physical activity levels of rectal cancer survivors, from preoperatively to 12 months after surgery/stoma closure and to explore predictive factors. Methods Multi-center prospective study with 125 patients who underwent low anterior resection for rectal cancer. The Flemish Physical Activity Computerized Questionnaire was completed concerning all physical activity levels at baseline (past preoperative year) and at 1, 4, 6 and 12 months after surgery/stoma closure. At these timepoints, questionnaires (LARS−/ COREFO-questionnaire) regarding bowel symptoms were also filled out. Results were analyzed using linear mixed models for repeated measures. Results Total physical activity levels up to 12 months remained significantly lower than preoperative. Occupational and sports physical activity levels remained significantly lower until 6 and 4 months postoperative, respectively. Predictive factors for decreased physical activity levels at a specific timepoint were: younger age and no stoma (total physical activity, 1 month), low/mid rectal tumor, no stoma, non-employed status (total, 4 months), higher COREFO-scores (occupational, 4 months) and non-employed status (total, 12 months). At all timepoints, lower COREFO-scores were associated with higher total physical activity levels; male gender and lower educational levels with higher occupational levels; younger age, normal BMI, employed status and adjuvant therapy with higher sports levels; and female gender, lower educational level and unemployed status with higher household levels. Conclusions One year after rectal cancer treatment, total physical activity levels were still not recovered. Rectal cancer patients, especially those at risk for decreased physical activity levels and with major bowel complaints, should be identified and guided to increase their activities. Trial registration This trial has been registered at Netherlands Trial Register (NTR6383, 23/01/2017).

Association of Risk Factors for the Mortality and Morbidity of Stoma Closure

Background: Anastomal leakage is a main surgical difficulty and requires stoma closure. Objective: To find associated risks for mortality and morbidity of stoma closure. Study Design: Retrospective cohort study Place and Duration of Study: Department of Surgery Ward 2, Jinnah Sindh Medical University/Jinnah Postgraduate Medical Centre Karachi from 1st July 2020 to 30th June 2021. Methodology: One hundred and twenty patients undergone rectal carcinoma surgeries were enrolled. The complications were graded by Clavien-Dindo classification system. The stoma closure was done by two different methods; the anterior wall technique or resection with anastomosis. Time duration of surgery, scoring by American Society of Anaesthesiologists was done and clinical and demographic information documented. Results: There were 62.5% males while 37.5% females and mean age was 65.5±8.5 years range between 31 to 72 years. Vascular blood supply affected leaking anastomaly. No significant effect of stoma type or closing technique was seen. However the time of stoma (p=0.044) and ASA score closure was a main risk for causing complications and increasing morbidity or mortality chances. Conclusion: Time of closure, American Society of Anaesthesiologists score as well as vascular supply are risk factors for morbidity or mortality in stoma closure. Keywords: Surgical stoma closure, Risk factors, Morbidity, Mortality

When to use a prophylactic mesh after stoma closure: a case–control study

Purpose The closure of a stoma is frequently associated with an acceptable morbidity and mortality. One of the most frequent complications is incisional hernia at the stoma site, which occurs in 20%–40% of cases, higher than incisions in other parts of the abdomen. The objective of this study was to identify the risk factors associated with the presentation of incisional hernia after stoma closure, this in order to select patients who are candidates for prophylactic mesh placement during closure. Methods An unpaired case–control study was conducted. This study involved 164 patients who underwent a stoma closure between January 2014 and December 2019. Associated factors for the development of incisional hernia at the site of the stoma after closure were identified, for which it was performed a logistic regression analysis. Results 41 cases and 123 controls were analyzed, with a mean follow-up of 35.21 ± 18.42 months, the mean age for performing the stoma closure was 65.28 ± 14.07 years, the most frequent cause for performing the stoma was malignant disease (65.85%). Risk factor for the development of incisional hernia at the stoma site after its closure was identified as a history of parastomal hernia (OR 5.90, CI95% 1.97–17.68). Conclusions The use of prophylactic mesh at stoma closure should be considered in patients with a history of parastomal hernia since these patients present a significantly higher risk of developing a hernia.

Using Prophylactic Prolene Mesh to Reduce the Incidence of Incisional Hernia at the Site of Stoma Closure

Background Incisional hernias at stoma sites are not an infrequent problem, occurring in up to 30% of cases and it also varied in a range of studies from 0-48%. Objectives This is a prospective study to detect the feasibility of application of prolene mesh at the site of stoma closure in reducing the rate of post stomal incisional. INTRODUCTION Abdominal wall hernias are common and are a significant cause of morbidity. Stomas are commonly constructed following colorectal surgery to protect distal anastomosis or when sepsis prevents primary anastomosis. There is a risk of a wide range of morbidity following both stoma formation and stoma reversal (Chow et al., 2009). Incisional hernias at stoma sites are not an infrequent problem, occurring in up to 30% of cases and it also varied in a range of studies from 0-48% (Tilney et al., 2008). They occur over time and are generally under-reported, which may be due to the elderly nature of the population, the significant co-morbidities or early discharge from follow-up (Cingi et al., 2006). One in three patients may develop a hernia after stoma closure, and around half of hernias that are detected require repair.Risk of hernia is greater after colostomy closure than after ileostomy closure(Bhangu et al., 2012). A meta-analysis published in 2012 investigated the incidence of incisional hernia following closure of stoma, The overall mean incisional hernia rate following stoma closures was 7.4%. The authors reported a lower risk of hernia following reversal of ileostomy when compared to respectively (Bhangu et al., 2012). A further systematic review found a similar incidence for stoma site incisional hernias to be 8.3% (0–33.9%) (Nguyen et al., 2014). Two factors should be noted with regard to the incidence of stoma site hernia. Firstly, that the long-term risk is not known and secondly, that clinical examination alone is shown to have a lower detection rate of incisional hernia post stoma closure when compared to clinical imaging (Bhangu et al., 2012; Cingi et al., 2006). Therefore, studies focusing on only clinical examination may be underestimating the prevalence, as radiological detected herniae may become symptomatic over time and may be missed in studies with a short follow-up period. AIM OF THE WORK This is a prospective study to detect the feasibility of application of prolene mesh at the site of stoma closure in reducing the rate of post stomal incisional.

Pull-through Procedure for Hirschsprung’s Disease with Simultaneous Stoma Closure: Insights for Limited-Resource Settings from Mbarara, Uganda

Background: In many resource-limited settings, patients with Hirschsprung’s Disease (HD) undergo initial diverting colostomy, followed by pull-through, and lastly, colostomy closure. This approach allows for decompression of dilated and thickened bowel and improved patient nutritional status. However, this 3-stage approach prolongs treatment duration, with significant stoma morbidity, costs, and impact on quality of life (QOL).Aim: To determine whether pull-through for HD can safely be performed with simultaneous stoma closure, reducing treatment approach from three to two stages.Patients and Methods: Children with HD and diverting colostomy were prospectively followed as they underwent pull-through with simultaneous stoma closure. Their in-hospital course, and 3-month outpatient course, were assessed for postoperative complications. Patients with total colonic HD, redo pull-through, and residual dilated colon were excluded from the study. Results: Of the 20 children, seventeen were male (n = 17, 85%). All patients had rectosigmoid HD. The median weight, age at colostomy formation, and age at pull-through were 11.05 kg (interquartile range [IQR] 10-12.75), 0.9 years (IQR 0.25-2.8), and 2.08 years (IQR 1.28-2.75) respectively. Mean duration with colostomy before pull-through was 1.1 years (SD 1.51). Median hospital length of stay was 6 days (IQR 5-7). Early complications included anastomotic leak (n=1), perianal skin excoriation (n=2), surgical site skin infection (n=3_, and burst abdomen (n=1). Longer-term complications included stricture (n=1, 5%) and enterocolitis (n=2, 10%).Conclusion: In this small case series, we have demonstrated that pull-through with simultaneous stoma closure can be safely performed in resource-constrained settings. Further studies are needed to understand the QOL and economic impact of this change in management for HD patients.

Effectiveness of Negative Pressure Wound Therapy With Instillation and Dwelling After Stoma Closure: A Retrospective and Propensity Score Matching Analysis

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P=0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P=0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

Timing of neonatal stoma closure: a survey of health professional perspectives and current practice

Optimal timing for neonatal stoma closure remains unclear. In this study, we aimed to establish current practice and illustrate multidisciplinary perspectives on timing of stoma closure using an online survey sent to all 27 UK neonatal surgical units, as part of a research programme to determine the feasibility of a clinical trial comparing ‘early’ and ‘late’ stoma closure. 166 responses from all 27 units demonstrated concordance of opinion in target time for closure (6 weeks most commonly stated across scenarios), although there was a high variability in practice. A sizeable proportion (41%) of respondents use weight, rather than time, to determine when to close a neonatal stoma. Thematic analysis of free text responses identified nine key themes influencing decision-making; most related to nutrition, growth and stoma complications. These data provide an overview of current practice that is critical to informing an acceptable trial design.