Jejuno-colonic anastomosis to restore intestinal continuity in a case of intestinal failure due to type I short bowel syndrome

Short bowel syndrome is a rare surgical complication associated with high morbidity and mortality, significant decrease in quality of life and increasing costs to the healthcare system. In some cases, this condition can be mitigated and even reversed if the intestinal transit is restored with a minimum of 75-100 centimeters of small intestine and a segment of the colon. Some of the surgical techniques available within autologous gastrointestinal reconstruction are Serial transverse enteroplasty (STEP), Longitudinal intestinal lengthening (LILT), and as a last resort, intestinal transplantation. We presented a case of intestinal failure due to type I short bowel syndrome who improved in clinical stage from D4 to D2 after intestinal continuity restitution was performed with a jejuno-colonic anastomosis.

Surgical Techniques and Outcomes of Colorectal Anastomosis after Left Hemicolectomy with Low Anterior Rectal Resection for Advanced Ovarian Cancer

Extended colon resection is often performed in advanced ovarian cancer. Restoring intestinal continuity and avoiding stoma creation improve patients’ quality of life postoperatively. We tried to minimize the number of anastomoses, restore intestinal continuity, and avoid stoma creation for 295 patients with stage III/IV ovarian cancer who underwent low anterior rectal resection (LAR) with or without colon resection during cytoreductive surgery. When the remaining colon could not reach the rectal stump after left hemicolectomy with LAR, we used the following techniques for tension-free anastomosis: right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, or an additional colic artery division. Rates of stoma creation and rectal anastomotic were 3% (9/295) and 6.6% (19/286), respectively. Among 21 patients in whom the remaining colon did not reach the rectal stump after left hemicolectomy with LAR, 20 underwent tension-free anastomosis, including eight, six, and six patients undergoing right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, and an additional colic artery division, respectively. Colorectal anastomosis is feasible for patients with extended colonic resection. Low anastomotic leakage and stoma rates can be achieved with careful attention to colonic mobilization and tension-free anastomosis.

Review of Management of Ileosigmoid Knotting

Ileosigmoid knotting (ISK) is a rare type of intestinal obstruction caused by knotting of the mesentery of the ileum or sigmoid colon that rapidly progresses to gangrene with a high risk of mortality and high morbidity. The incidence of ISK is not well established, but it is higher in regions with high rates of sigmoid volvulus and in countries along the sigmoid belt. Clinical presentation is that of both small-bowel and large bowel obstruction and includes vomiting and nausea, abdominal pain, tenderness, and distention, with constipation. A contrast-enhanced computer tomography (CT) scan is the preferred modality for imaging. Management involves hemodynamic stabilisation with correction of shock using aggressive fluid resuscitation, electrolyte balance and commencement of antibiotics. Principles of surgery include resection of the knot, resection of the gangrenous bowel and establishing intestinal continuity. The outcome is generally complicated by peritonitis and sepsis that lead to mortality.

Spontaneous enterocutaneous fistula in an infant

Background: Enterocutaneous fistulae (ECF) most commonly occurs following intestinal surgery. Spontaneous ECF is a rare entity in infants. Early presentation to the hospital decreases complications. Case Presentation: A 2.5-month-old infant developed spontaneous ECF below the umbilicus following abdominal wall erythema and abdominal wall abscess. The bowel mucosa prolapsed out on straining efforts. Work-up was uneventful. At operation, the fistula was mobilized, and intestinal continuity was restored. Postoperative recovery was uneventful. Conclusion: Spontaneous development of ECF is a rare entity in children. Every effort should be made to identify the etiology before labeling it as spontaneous. Keywords: Enterocutaneous fistula, Necrotizing fasciitis, Primary closure.

Short bowel syndrome in infancy: recent advances and practical management

Short bowel syndrome (SBS) is a rare condition characterised by extensive loss of intestinal mass secondary to congenital or acquired disease. The outcomes are determined by dependency on parenteral nutrition (PN), its possible complications and factors that influence intestinal adaptation. In order to achieve the best results, patients should be managed by a specialised multidisciplinary team with the aims of promoting growth and development, stimulating intestinal adaptation and preventing possible complications. This involves timely surgical management aimed at rescuing maximum bowel length and eventually re-establishing intestinal continuity where appropriate. A combination of enteral and parenteral nutrition needs to be targeted towards maintaining a balance between fulfilling the nutritional and metabolic needs of the child while preventing or at least minimising potential complications. Enteral nutrition and establishment of oral feeding play a fundamental role in stimulating bowel adaptation and promoting enteral autonomy. Other measures to promote enteral autonomy include the chyme recycling in patients where bowel is not in continuity, autologous gastrointestinal reconstruction and pharmacological treatments, including promising new therapies like teduglutide. Strategies such as lipid reduction, changing the type of lipid emulsion and cycling PN are associated with a reduction in the rates of intestinal failure–associated liver disease. Even though vast improvements have been made in the surgical and medical management of SBS, there is still lack of consensus in many aspects and collaboration is essential.

Endoscopic vacuum therapy for in- and outpatient treatment of colorectal defects

Background Evidence for endoscopic vacuum therapy (EVT) for colorectal defects is still based on small patient series from various institutions, employing different treatment algorithms and methods. As EVT was invented at our institution 20 years ago, the aim was to report the efficacy and safety of EVT for colorectal defects as well as to analyze factors associated with efficacy, therapy duration, and outpatient treatment. Methods Cohort study with analysis of prospectively collected data of patients receiving EVT for colorectal defects at a tertiary referral center in Germany (n = 281). Results The majority of patients had malignant disease (83%) and an American Society of Anesthesiologists classification of III/IV (81%). Most frequent indications for EVT were anastomotic leakage after sigmoid or rectal resection (67%) followed by rectal stump leakage (20%). EVT was successful in 256 out of 281 patients (91%). EVT following multi-visceral resection (P = 0.037) and recent surgical revision after primary surgery (P = 0.009) were risk factors for EVT failure. EVT-associated adverse events occurred in 27 patients (10%). Median treatment duration was 25 days. Previous chemo-radiation (P = 0.006) was associated with a significant longer duration of EVT. Outpatient treatment was conducted in 49% of patients with a median hospital stay reduction of 15 days and 98% treatment success. Younger patient age (P = 0.044) was associated with the possibility of outpatient treatment. Restoration of intestinal continuity was achieved in 60% of patients where technically possible with a 12-month rate of 52%. Conclusions In patients with colorectal defects, EVT appears to be a safe and effective, minimally invasive option for in- and outpatient treatment.

EARLY CLOSURE OF LOOP ILEOSTOMY: IS IT FEASIBLE AND SAFE?

A total of 144 patients of temporary loop ileostomies were treated with early closure at 4 to 6 weeks from its construction. It was found to be feasible, safe and advisable specially on select group of patients with low rate of complications and the results can be compared to classical delayed closure. METHODS This study was carried out in Department of Surgery, Patna Medical College on patients of waiting for closure of loop ileostomies done for both in emergency and routine settings. After a careful selection of cases depending on nutritional status and absence of active infection, closure of ileostomy was done 4 to 6 weeks after the index operation. The post-operative course was closely observed and followed up. RESULTS A total of 144 patients underwent early closure at 4-6 weeks from the construction of ileostomy with the mean duration of closure of 38.2 days. In most of the patients the intestinal loops were mobilised without any significant difficulty and intestinal continuity restored with linear staplers. Most common post-operative complication was wound infection in 38.9% of cases. Other complications included prolonged ileus in 2.8% cases, enterocutaneous fistula in 5.6% and incisional hernia in 6.9% of the cases. None of the patients developed intra peritoneal collection or significant anastomotic leak requiring re laparotomy. No mortality was recorded in the study subjects. The patients were discharged from the hospital ranging from 7-23 days with the average of 9.2 days from the time of stoma closure. Overall, the results may be comparable to those of the delayed conventional closure but at the same time much more convenient to the patient.

EUS-guided recovery of colonic continuity after complete anastomotic stenosis with a nitinol self-expanding stent

Recovery of intestinal continuity is remaining a complex issue in abdominal surgery. Previous operations, such as Hartmann's procedure, are usually done in the emergent setting, often in frail and septic patients. As a result, severe adhesions occur, and recognition of various anatomical structures becomes more difficult.The article describes a clinical case of EUS-guided recovery of rectum's continuity after complete anastomotic stenosis. The operation “EUS-guided formation of rectosigmoid anastomosis using Lumen-Apposing Metal Stent” was performed.In order to obtain a stable anastomosis within 6 months, a session of bougienage and 4 sessions of balloon dilatation were performed. Currently, the diameter of the colon at the stricture level is about 14 mm, clinically stricture is not significant.EUS-guided enterostomy can be used to form an intestinal anastomosis in patients with benign diseases. However, this method alone is not the final method of treatment and requires further supervision of patients.