Open Pelvic Fracture with Rectal Laceration: A Case Report

Open pelvic fractures are rare but represent a serious clinical problem with high mortality rates. Acute mortality is often associated with haemorrhage and delayed mortality is most often associated with sepsis and multiple organ failure. An aggressive multidisciplinary approach is of paramount importance to prevent catastrophe. It involves emergency resuscitation, stabilization of unstable fracture with an external fixator, and faecal diversion for rectal injury. Here, a case of open pelvic fracture with rectal laceration has been presented.

Feasibility and efficacy of ghost ileostomy in typhoid ileal perforations: A prospective observational study

Loop ileostomy is commonly performed for typhoid ileal perforations as temporary faecal diversion. This is associated with several stoma-related complications and also requires further surgery for its closure. Thus, we were prompted to conduct a prospective observational study on the safety, feasibility and efficacy of ghost ileostomy in typhoid ileal perforations. After dealing with the perforation, a ghost ileostomy was performed in 10 selected patients with favourable circumstances; otherwise, a conventional loop ileostomy was performed in 19 patients. The two groups were comparable (p > 0.05) for morbidity and mortality except for stoma-related complications, seen only in the loop ileostomy group. Body weight was better preserved in the ghost ileostomy group. One patient in the ghost ileostomy group required conversion to loop ileostomy owing to signs of intra-peritoneal suture leak, without any detriment to outcome. Our study shows safety, feasibility and efficacy of ghost ileostomy in selected patients with typhoid ileal perforations, thus avoiding loop ileostomy in one-third of patients.

Magnitude and outcomes of complex perineal injury – A retrospective analysis of five years’ data from a Level 1 trauma centre

Complex perineal injuries pose a major diagnostic and therapeutic challenge to trauma surgeons. A retrospective review of the hospital records of 29 patients with complex perineal injury following blunt trauma was done. Demographic profile, management and outcomes were collected. Quality of life analysis was conducted for patients with complex perineal injuries who were discharged. The most predominant mode of injury was a road crash: being a pedestrian run over by a heavy motor vehicle. Pelvic fracture was seen in 20, anorectal involvement in 22 and urogenital injuries in 14. Urgent surgical debridement was done in all patients, faecal diversion in 27 and urinary diversion in 14. There were nine deaths, three from haemorrhage, and the remainder from sepsis and multi-organ dysfunction. Complex perineal injury remains a major cause of morbidity and mortality in trauma patients. There is a need to ensure adequate rehabilitation services for such patients.

Highly selective diversion with proactive leakage management after low anterior resection for rectal cancer

In this single center case series with nine percent primary diversion, 86 of 94 patients alive and with complete follow-up at one year had a functioning anastomosis. Seventy-five of the initial 99 patients never had a stoma. Meaning: Highly selective fecal diversion in combination with proactive leakage management, low anastomoses can be preserved safely, and the majority of patients will be spared all disadvantages of a diverting stoma. In this single-centre case series, with a primary diversion rate of 9 per cent, 86 of 94 patients who were alive and had complete follow-up at 1 year had a functioning anastomosis. Seventy-five of the initial 99 patients never had a stoma. The results indicate that, with highly selective faecal diversion in combination with proactive leakage management, low anastomoses can be preserved safely, and the majority of patients will be spared the disadvantages of a diverting stoma.

The Role of Colostomy in Management of Fournier’s Gangrene

Study Objective: The colostomy is not used systematically for the treatment of Fournier’s gangrene. Through our study, we compared two groups of patients who had faecal diversion and those how did not .we tried to get the advantages of this method and his impact on wound healing and duration of hospitalization Patients and Methods: This is a 14-years retrospective study from 1st January 2005 to 31st December 2018. We collected 86 cases of Fournier's gangrenes, of which 30 patients benefited from a derivative colostomy, done by the same surgical team. We divided the two groups by aetiology and morbidly-mortality. Results: In the group with colostomy, prevalent disease was perianal suppurations with the presence of risk factors in75% of cases such as diabetes, immunosuppressive therapy or patients age over 70 years old .While these factors are found only in 52% of the other group. The average days of hospital stay in the group with colostomy was 25 days and 32 in the other group, 67% of patients had a colostomy with hyperbaric oxygen therapy against 70% in the other group. Mortality was 30% in first group with colostomy, an 12.5% in the second one, the overall mortality was19% globally in the two groups. Conclusions: In our series only 35% benefited from a colostomy: Patient with major deterioration and the presence of others diseases. But overall mortality in our series is comparable to that of teams practicing colostomy systematically.

A Systematic Review of Early versus Late Closure of Loop Ileostomy

Introduction. A Loop ileostomy is one of the most common techniques used in colorectal surgery to establish a reversible faecal diversion and bypass the large bowels, in order to protect either a downstream colorectal anastomosis or a coloanal anastomosis. However, it is a procedure that can cause a plethora of complications including long term ones such as the psychological effects. Currently, there is no consensus regarding the optimal time to perform closure of a loop ileostomy. Some studies suggested the early reversal of ileostomy procedure as a solution to reduce these complications. This study aims to review the available literature in order to ascertain the benefits behind early closure of loop ileostomy. Methods. The literature was searched for all studies that included a comparison between the outcomes of early and late closure of loop ileostomy in terms of morbidity, mortality, or quality of life, where available. Early closure of loop ileostomy is defined as closure less than three months and late as more than three months, in accordance with conventional literature. The resultant articles were filtered using our inclusion and exclusion criteria. Finally, the remaining articles were assessed for quality and their results were compared to one another in order to draw our conclusions. Results and Discussion. The results were slightly inclined toward early closure of loop ileostomy. However, there were limitations of the studies reviewed, including the heterogenicity of studies, selection bias, lack of clear definition of measured outcomes, and small sample size. Taking that into consideration, the results of early closure of loop ileostomies in the selected patients were promising and require further investigation.

Faecal diversion system usage in an adult intensive care unit

OBJECTIVE: To determine the frequency, indications and complications associated with the use of faecal diversion systems (rectal tubes) in critically ill patients. DESIGN: A single centre observational study over 15 months. SETTING: Intensive care unit (ICU). PARTICIPANTS: Patients admitted during this period. MAIN OUTCOME MEASURES: Frequency of rectal tubes utilisation in ICU, as well as associated adverse events, with major events defined as lower gastrointestinal bleeding associated with defined blood transfusion of two or more units of red cells or endoscopy or surgical intervention. RESULTS: Of 3418 admission episodes, there were 111 episodes of rectal tubes inserted in 99 patients. Rectal tubes remained indwelling for a median of 5 days (range, 1–23) for a total of 641 patient-days. The most frequent indication for insertion was excessive bowel motions. A major adverse event was observed in three patients (3%; 0.5 events per 100 device days). Two patients underwent laparotomy and one patient sigmoidoscopy. These patients received between two and 23 units of packed red blood cells. Patients who had a rectal tube inserted had a substantially greater duration of ICU admission (mean, 14 days [SD, 14] v 2.8 days [SD, 3.7]) and hospital mortality (15% v 7.7%; risk ratio, 2.0; 95% CI, 1.2–3.4) as well as an overall higher Australian and New Zealand Risk of Death (ANZROD) score (mean, 27 [SD, 22] v 12.6 [SD, 20]). CONCLUSION: Rectal tubes appear to be frequently inserted and can lead to major adverse events in critically ill patients.

P184 Temporary defunctioning ileostomy in therapy refractory Crohn’s colitis: A viable alternative to immediate colorectal resection?

Background The faecal stream is one of many factors influencing the pathogenesis of Crohn’s disease. Previous research demonstrated some Crohn’s patients benefit from temporary faecal diversion. This study aims to determine the role of temporary faecal diversion by means of a defunctioning ileostomy in treating patients with therapy refractory Crohn’s colitis. Methods Data were retrieved by retrospectively assessing patient records. All patients receiving a temporary ileostomy for therapy refractory Crohn’s colitis from three Dutch hospitals between 2010 and 2018 were included. Patients with previous colorectal resection or malignancy were excluded. Stoma reversal, permanent stoma and extension of colorectal resection at follow-up were determined as primary outcomes. Results Thirty-six patients received a temporary defunctioning ileostomy for therapy refractory Crohn’s colitis. Stoma reversal was attempted in 20 (56%) patients after a mean period of 1 year of which nine underwent additional resection during stoma reversal. After a mean follow-up of 4.2 years, resection was performed in 29 (81%) patients of which 14 (39%) had reduced resection in comparison with the necessary resection at the time of faecal diversion. Among the 14 (39%) patients with restored continuity, three patients remained with full preservation of the colon. Moreover, the presence of proctitis was associated with low stoma reversal rates (p = .007). Conclusion Temporary faecal diversion is associated with reduced resection and reduced risk of permanent ileostomy; therefore, it may be a decent alternative for immediate colorectal resection for patients with isolated Crohn’s colitis. Unfortunately, temporary defunctioning ileostomy is not a viable alternative for resection in Crohn’s patients suffering from proctitis.