Long segment “Hanging-snout” end ileosotmy a safe “Surgical disaster mitigating” technique for an “Un-brookeable” end ileum: a study of 23 cases over 12 years

Background: In 1952, Professor Bryan Brooke described his technique for everting an ileostomy in order to minimise skin excoriation1. Pouting, mucosa-everting Brooke’s ileostomy have been accepted as the best technique for stoma formation in almost all cases, save a few difficult situations – such as edematous friable bowel with bulky short mesentry! In such cases formation of standard Brooke’s ‘Pouting’ ileostomy is not only difficult, but an impossible and a dangerous surgical exercise! In these situations where the bowel is “Un-Brookeable” due to aforementioned causes. Over a period of 12 years we could device a formula – “Ray’s Criteria” to decide at operation, if a given ileum in a particular patient, is safely “Brookeable” (i.e. evertable into a neat Brooke, spouting ileostomy) or is “Un-Brookeable”.Methods: 23 patients were included in this study over 12 years, who due to the peculiarity of their body morphology (obesity or thick abdominal fat), edematous friable bowel with bulky mesentry, the ileum could not be drawn outside the abdomen and everted as Brooke’s ileostomy. The “Brookeability” of the exteriorized ileum was decided based on satisfying two issues of Ray’s criteria.Results: By using “Ray’s criteria”, we could seggregate patients safely as “Brookeable” and “Un-Brookeable”. Those deemed “Un-Brookable” underwent “Long segment Hanging snout” end ileostomy, which is the theme of our study.Conclusions: We are emphatic in stating that by using “Ray’s criteria” we could accurately segregate cases into “Brookeable” and “Un-Brookeable” ileum.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

The frequency of early stomal, peristomal and skin complications

Background: The incidence of early complications after stoma formation (within 30 days of surgery) is difficult to determine and has been reported to be in a range of 3%–82%. Aim: The aim of this study was to analyse the onset of stomal, peristomal and skin complications one month (30 days) after ostomy creation. Method: This review analysed enteral stoma therapy nurse reports on patients who had an ostomy created between January 2016 and December 2020. Findings: Complications were analysed according to ostomy type: colostomy, ileostomy and urostomy. There were 1292 incidences of complications: skin complications were the most common (26%), and abscess the least common (0%). Conclusion: A majority (63%) of patients experienced at least one or more complications within 30 days of surgery. Haemorrhage was reported as a complication (2%) but the authors found no data on its incidence in the literature. In addition to early complications, late complications were detected.

Quality of Life in Patients with Stoma

Objective: To determine the quality of life of patients with stoma at tertiary care Hospital. Methodology: This prospective study has been conducted at the general surgery department, Pakistan Institute of Medical Sciences hospital Islamabad (PIMS). The study was conducted from September 2019 to February 2020. All the patients having age more than 12 years, underwent intestinal stoma formation and either gender were included for study. Patients were interviewed regarding their routine activities after stoma and the impact of it on their social life including working status, sexual activities and life satisfaction. All the information of patients including demographic data was documented via self-derived proforma. Analysis of data was done by SPSS version 20. Results: Total 46 patients were studied having a stoma and were interviewed regarding their quality of life. The patient's mean age was 44.93+6.78 years. Out of all 34.8% were working currently and rest of the patients were still on bed rest. 34.8% were satisfied with sexual life. 71.7% were depressed after stoma surgery and 52.2% were hopeful about their future. 63% were socialised with peoples as before, 58.7% replied that stoma has affected their recreational activities and 52.2% answered that they can’t travel in any way. However according to overall satisfaction, 32.6% of patients were disagreeing, 34.8% were agreeing and 30.4% were undecided. Conclusion: It was concluded that almost half of the patients were satisfied and they are performing social and daily life activities however almost half of the patients needed psychological, financial, and relative support. Key words: Stoma, Quality of life

Common surgical procedures

This chapter addresses common surgical procedures. These include laparotomy; diagnostic laparoscopy; inguinal hernia repair; appendicectomy; cholecystectomy; perforated peptic ulcer repair; haemorrhoidectomy; and excision of pilonidal sinus. Laparotomy is a surgical incision into the abdominal wall to gain access into the abdominal cavity. Minimal invasive surgery aims to cause at least surgical trauma as possible to patients compared to ‘conventional’ open surgery. Benefits include shorter hospital stay, less pain, quicker functional recovery, and superior cosmesis. Pneumoperitoneum induction is the primary step in performing laparoscopy surgery. The chapter then studies stoma formation; small bowel resection and anastomosis; right hemicolectomy; wide local excision of breast lesion; femoral embolectomy; and below knee amputation.

Probability of Stoma in Incident Patients With Crohn’s Disease in Sweden 2003-2019: A Population-based Study

Background Surgery rates in patients with Crohn’s disease have decreased during the last few decades, and use of antitumor necrosis agents (anti-TNF) has increased. Whether these changes correlate with a decreased probability of stoma is unknown. The objective of this study was to investigate the incidence of stoma in patients with Crohn’s disease over time. Methods Through linkage of national registers, we identified patients who were diagnosed with Crohn’s disease in 2003–2014 and were followed through 2019. We compared formation and closure of stomas over the calendar periods of diagnosis (2003–2006, 2007–2010, and 2011–2014). Results In a nationwide cohort of 18,815 incident patients with a minimum 5 years of follow-up, 652 (3.5%) underwent formation of a stoma. This was mostly performed in conjunction with ileocolic resection (39%). The 5-year cumulative incidence of stoma formation was 2.5%, with no differences between calendar periods (P = .61). Less than half of the patients (44%) had their stoma reversed. Stomas were more common in elderly-onset compared with pediatric-onset disease: 5-year cumulative incidence 3.6% vs 1.3%. Ileostomies were most common (64%), and 24.5% of the patients who underwent stoma surgery had perianal disease at end of follow-up. Within 5 years of diagnosis, 0.8% of the incident patients had a permanent stoma, and 0.05% had undergone proctectomy. The time from diagnosis to start of anti-TNF treatment decreased over calendar periods (P < .001). Conclusions Despite increasing use of anti-TNF and a low rate of proctectomy, the cumulative incidence of stoma formation within 5 years of Crohn’s disease diagnosis has not decreased from 2003 to 2019.

Modified Laparoscopic Sugarbaker Repair of Parastomal Hernia With a Totally Extraperitoneal Technique

Purpose: Many patients develop a parastomal hernia within the first 2 years of stoma formation, and even surgical repair is associated with high recurrence rates. An intraperitoneal approach is typically used for the laparoscopic repair of parastomal hernia; it is unknown whether a totally extraperitoneal technique (TEP) is feasible. Here we describe a laparoscopic TEP approach using a modified Sugarbaker method for the repair of parastomal hernia.Methods: Seven patients underwent parastomal hernia repair. The retrograde puncture technique was used to create the extrapneumoperitoneum, and the peritoneum was separated with a laparoscopic TEP approach; the mesh was placed using a modified Sugarbaker technique.Results: All patients had an oncologic etiology for stoma creation. The mean (±SD) size of the hernia defect was 3.1 ± 2.7 cm and the mesh size was 303.4 ± 96.8 cm2. The mean operative time was 195.5 ± 20.7 min and average length of hospital stay after surgery was 4.8 ± 2.1 days. One patient had intraoperative subcutaneous emphysema. The average follow-up time was 8.5 ± 2.7 months; mild pain occurred in 2 patients, 3 experienced seroma formation (with no special treatment required), and 1 had early intestinal obstruction (which was treated with conservative care). There was no hernia recurrence, wound complications, or infections of the surgical site or mesh during follow-up.Conclusion: A laparoscopic TEP technique is technically challenging but feasible. Modified laparoscopic Sugarbaker repair of a parastomal hernia with the TEP technique is safe and effective, although the recurrence rate and late complications require confirmation in more cases with long-term follow-up.

EP.WE.205Impact of the Covid-19 Pandemic on Loop Ileostomy Formation

Aim Uncertainty during the early phases of the Covid-19 pandemic regarding availability of critical care beds and peri-operative impact of SARS-CoV-2 led to changing intercollegiate guidance in favour of increased stoma formation. This study assessed the impact the Covid-19 pandemic had on loop ileostomy formation. Methods Data were reviewed from a prospectively collected database on the number of loop ileostomies formed over a 10-month period from 1st March to 31st December 2020. Comparison was made with the same period in 2019. Details were confirmed using clinical letters. Results 114 loop ileostomies were formed in the 20-month period. There was a 10.0% reduction in loop ileostomy formation in 2020 compared with 2019. The median number of loop ileostomies formed per month over the two 10-month periods was 6. This peaked at 11 in April 2020 coinciding with the first wave of Covid-19, falling in subsequent months. All 11 of these loop ileostomies were formed in colorectal cancer patients undergoing anterior resection, after appropriate counselling. Conclusions There was a reduction in the number of ileostomies formed in 2020 compared with 2019 reflecting the impact of the Covid-19 pandemic on both elective and emergency case load and presentations. These results show reactive change in surgical practice corresponding to guidance at a time of maximum uncertainty. Primary anastomosis still occurred but with an increased likelihood of a defunctioning stoma to minimise the consequences of an anastomotic leak. A subsequent reduction in stoma formation in the following months indicates that practice rapidly returned to normal.

EP.WE.409Stoma forming surgery – has lockdown changed our operative practice during COVID 19

Aims This study aimed to establish whether the initial lockdown resulted in a shift towards emergency surgery, changes in stoma formation and in rate of surgery with curative intent. Methods A retrospective data collection was performed. Patients were identified using a local database of all patients with stomas. Data was collected from 16/03/20 to 16/09/20. A comparison data set was taken (16/03/19 to 16/09/19). Data was collected on whether the case was performed as an emergency; the type of stoma formed and whether the operation was performed with curative intent. Results Seventeen patients were identified in the 2020 cohort (age: 51-84, mean age: 67.6, M:F 10:7). Fourteen cases (82.4%) were performed as emergencies, three electively (17.6%). Six (35.3%) had end colostomies, three (17.6%) had loop colostomies, one (5.9%) had a caecostomy, four (23.5%) had an end ileostomy and three (17.6%) had a loop ileostomy. Ten operations were for patients with cancer, three (30%) were performed with curative intent. 38 patients were identified in the 2019 cohort (age: 28-85, mean age: 63.0, M:F 17:21). 23 (60.5%) were emergencies, fifteen (39.5%) were performed electively. Nine (23.7%) had end colostomies, eight (21.1%) had loop colostomies, three (7.9%) had caecostomies, ten (26.3%) had end ileostomies and nine (23.7%) had loop ileostomies. There were nineteen operations for cancer, eight (42.1%) were with curative intent. Conclusions Cessation of elective activity caused a shift towards emergency operating, with an associated shift towards surgery with non-curative intent. The distribution of stomas formed has not changed.