Santulli Procedure Revisited in Congenital Intestinal Malformations and Postnatal Intestinal Injuries: Preliminary Report of Experience

In our experience, the Santulli procedure (SP) can improve bowel recovery in congenital intestinal malformations, necrotizing enterocolitis (NEC), and bowel perforation. All cases managed at our institution using SP between 2012 and 2017 were included in this study. Forty-one patients underwent SP (median age: 39 (0–335) days, median weight: 2987 (1400–8100) g) for intestinal atresia (51%, two gastroschisis), NEC (29%), midgut volvulus (10%), Hirschsprung’s disease (5%), or bowel perforation (5%), with at least one intestinal suture below the Santulli in 10% of cases. The SP was performed as a primary procedure (57%) or as a double-ileostomy reversal. Anal-stool passing occurred within a median of 9 (2–36) days for 95% of patients, regardless of the diversion level or the underlying disease. All three patients requiring repeated surgery for Santulli dysfunction had presented with stoma prolapse (p < 0.01). Stoma closure was performed after a median of 45 (14–270) days allowing efficient transit after a median of 2 (1–6) days. After a median follow-up of 2.9 (0.7–7.2) years, two patients died (cardiopathy and brain hemorrhage), full oral intake had been achieved in 90% of patients, and all survivors had normal bowel movement. Whether used as primary or secondary surgery, the SP allows rapid recovery of intestinal motility and function.

Application of a Temporary Ileostomy via Median Specimen Extraction Site in Laparoscopic Low Anterior Resection

Objective: To evaluate the feasibility and safety of temporary ileostomy via median specimen extraction site in the lower abdomen. Methods: Twenty-two patients who underwent laparoscopic radical resection for rectal cancer and needed temporary ileostomy were prospectively enrolled. Temporary ileostomy was placed on the median specimen extraction site of the lower abdomen. Intraoperative and postoperative conditions, stoma-related complications and ileostomy reversal surgery were observed. d. Results: Among the 22 patients, there were 14 female patients and 8 male patients: the average age was 56 ±14 years; the average body mass index was 22.0 ±3.4 kg/m2; the average tumour size was 4.4 ±2.2 cm; the average distance between the tumour and the dentate line was 5.9 ±2.3 cm; the average time of laparoscopic low anterior resection was 221 ±56 minutes; the average blood loss was 168 ±91 ml; and the average postoperative hospital stay was 9.9 ±3.9 days. The average ileostomy reversal surgery time was 72 ±15 minutes, the average blood loss was 50 ±27 ml, and the average postoperative hospital stay was 5.9 ±1.0 days. Stoma-related complications occurred in 5 patients, of which one was treated by emergency surgery. Conclusion: In laparoscopic low anterior resection, patients with temporary ileostomy via the median specimen extraction site did not have serious complications that required surgical intervention during hospitalization, and there was no mortality during the perioperative period. It is safe and feasible to perform temporary ileostomies via the median specimen extraction site in the lower abdomen, but for permanent ileostomies, the median site in the lower abdomen should be carefully selected as the ileostomy site.

Less is more—the best test for anastomotic leaks in rectal cancer patients prior to ileostomy reversal

Purpose No clear consensus exists on how to routinely assess the integrity of the colorectal anastomosis prior to ileostomy reversal. The objective of this study was to evaluate the accuracy of contrast enema, endoscopic procedures, and digital rectal examination in rectal cancer patients in this setting. Methods A systematic literature search was performed. Studies assessing at least one index test for which a 2 × 2 table was calculable were included. Hierarchical summary receiver operating characteristic curves were calculated and used for test comparison. Paired data were used where parameters could not be calculated. Methodological quality was assessed with the QUADAS-2 tool. Results Two prospective and 11 retrospective studies comprising 1903 patients were eligible for inclusion. Paired data analysis showed equal or better results for sensitivity and specificity of both endoscopic procedures and digital rectal examination compared to contrast enema. Subgroup analysis of contrast enema according to methodological quality revealed that studies with higher methodological quality reported poorer sensitivity for equal specificity and vice versa. No case was described where a contrast enema revealed an anastomotic leak that was overseen in digital rectal examination or endoscopic procedures. Conclusions Endoscopy and digital rectal examination appear to be the best diagnostic tests to assess the integrity of the colorectal anastomosis prior to ileostomy reversal. Accuracy measures of contrast enema are overestimated by studies with lower methodological quality. Synopsis of existing evidence and risk–benefit considerations justifies omission of contrast enema in favor of endoscopic and clinical assessment. Trial registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019107771

Appendicitis in an Appendicostomy

A 25-year-old man presented with right lower quadrant abdominal wall erythema, a punctum of purulence, and localized pain at the site of a previous appendicostomy. Cross-sectional imaging revealed appendicitis at his previous appendicostomy with a fecalith near the skin. He was managed with appendectomy. The surgical approach mimicked a loop ileostomy reversal by circumferentially dissecting the tissue around the appendicostomy to the level of the fascia and then dividing the appendix at the base of the cecum through a small two-centimeter incision. Appendicitis in a previous appendicostomy is uncommon and has only been described in three previous case reports (two adults and one child) and was surgically approached through a low-midline laparotomy. Our case is unique as it is an uncommon presentation of a common disease managed with a minimally invasive approach not previously described.