Hidden ileostomy as a rescue procedure in major colorectal surgeries: a novel technique to prevent re-laparotomy in anastomotic leak cases

Background Anastomotic leak is a major cause of morbidity and mortality of patients worldwide, and it has remained stable over the last years. Routine construction of protective ileostomy is associated with stoma and negatively affects patients’ quality of life. Developing another technique to minimize those drawbacks with at least the same clinical success can help patients with anastomotic leak. We present the novel technique “Hidden Ileostomy” as an alternative to protective ileostomy that can achieve that balance. Materials and methods Eight patients presented to our department underwent the novel technique “Hidden Ileostomy” as a rescue procedure for different reasons. The associated risk factors and clinical scenarios, together with the follow-up data, are presented. Results For the eight cases in this study, one patient was ASA grade 1, 3 patients were classified as ASA grade 2, and 4 were grade 3. The mean ± SD operative time and blood loss were 196.3 ± 16.4 min and 325 ± 204.6 ml, respectively. The hidden ileostomy was removed after an average of 8 days. Only Case 6 reported an anastomotic leak on a postoperative day 10. Conclusion A hidden ileostomy is an alternative and feasible technique in selected cases in colorectal surgery. This technique could be adopted in our practice instead of routine instruction of ileostomy, especially in the equivocal anastomosis.

Laparoscopic hand-sewn cardioplasty: an alternative procedure for end-stage achalasia

Background Primary achalasia is a rare oesophageal motor disorder characterized by the absence of swallow-induced relaxation of the lower oesophageal sphincter and diminished or absent oesophageal body peristalsis. Around 5% of these patients will develop end-stage achalasia, where oesophagectomy may be advocated. We present the laparoscopic hand-sewn cardioplasty as an alternative ‘oesophagus-preserving’ procedure in patients with end-stage achalasia. Methods We present a retrospective review of four patients who underwent laparoscopic hand-sewn cardioplasty. Data collected included pre-operative demographic information and investigations; and post-operative outcomes. Patients were scored pre- and post-operatively using Reflux Symptom Index, Eating Assessment Tool-10 and Voice Handicap Index-10 questionnaires. Results Four patients underwent laparoscopic hand-sewn cardioplasty during the study period. In one patient, it was performed as a rescue procedure during attempted myotomy following multiple perforations of friable mucosa. In the other three patients, laparoscopic hand-sewn cardioplasty was performed for end-stage achalasia. None of the patients had post-operative complications and all patients were discharged on the second post-operative day. All patients experienced improvement in swallowing symptoms (EAT-10; p = 0.03) but developed post-operative gastroesophageal reflux. Conclusion To our knowledge, this is the first published case series of laparoscopic hand-sewn cardioplasty for end-stage achalasia. It appears to be a safe and effective procedure for the treatment of end-stage achalasia, offering an alternative minimally invasive procedure to oesophagectomy. Laparoscopic hand-sewn cardioplasty can also be used as a ‘rescue’ procedure during myotomy in patients who have poor-quality mucosa which perforates intra-operatively or is at high risk of perforation/leaking post-operatively.

Clinical Significance of Low-Flow Time in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation: Results from the RESCUE Registry

Limited data are available on the association between low-flow time and survival in patients with in-hospital cardiac arrest (IHCA) who undergo extracorporeal cardiopulmonary resuscitation (ECPR). We evaluated data from 183 IHCA patients who underwent ECPR as a rescue procedure. Patients were divided into two groups: patients undergoing extracorporeal membrane oxygenation as an adjunct to standard cardiopulmonary resuscitation for less than 38 min (n = 110) or for longer than 38 min (n = 73). The ECPR ≤ 38 min group had a significantly greater incidence of survival to discharge compared to the ECPR > 38 min group (40.0% versus 24.7%, p = 0.032). The incidence of good neurologic outcomes at discharge tended to be greater in the ECPR ≤ 38 min group than in the ECPR > 38 min group (35.5% versus 24.7%, p = 0.102). The incidences of limb ischemia (p = 0.354) and stroke (p = 0.805) were similar between the two groups, but major bleeding occurred less frequently in the ECPR ≤ 38 min group compared to the ECPR > 38 min group (p = 0.002). Low-flow time ≤ 38 min may reduce the risk of mortality and fatal neurologic damage and could be a measure of optimal management in patients with IHCA.