Acquired Microcolon after 20 Years of Colostomy: Can it be Saved?

Objectives: To report a case of a stoma reversal in a patient with an acquired, extreme microcolon after a long-standing transversostomy and to give a review of the current literature. Methods: Case report and literature review by performing a PubMed database search, using the keywords Santulli enterostomy, anal atresia, posterior sagittal anorectoplasty and acquired microcolon. Results: An 18-year-old patient with a previous history of anal, rectal and sigmoid atresia, was admitted to our hospital with an acquired microcolon due to a long-standing transversostomy. The patient had a posterior sagittal anorectoplasty at the age of one year, but by reason of an enormous dilatation of the ascending colon and the associated discrepancy of the caliber of the proximal and distal colon, the colostomy was maintained. The patient was lost in follow-up during several years. Now, 16 years later, the patient requested closure of the colostomy. Since barium enemas still showed a dilated colon ascendens and a microcolon descendens, a staged approach was chosen. First, a right hemicolectomy was performed and a Santulli enterostomy was created by constructing an ileocolostomy just proximal of an end ileostomy. Progressively, more transanal bowel movements were seen and barium enemas showed a progressive expansion of the remaining colon and rectum. Test closing of the enterostomy using an inflated bladder catheter did not cause signs of obstruction. During the second stage, 17 months later, at the age of 20 years, the stoma was closed. Now, the patient has two to three solid stools a day, with a complete fecal continence. Discussion: The used technique is well known in pediatric surgery. We successfully implemented it in the treatment of a microcolon in an adult. The advantage is that we can feed the distal colon to achieve expansion, while the enterostomy functions as a venting system, hereby preventing obstructive complaints when the caliber of the colon is still narrow. In conclusion, long-standing colostomas with a concurrent microcolon can be closed but require a step-by-step approach.

Increased mortality and altered local immune response in secondary peritonitis after previous visceral operations in mice

Postoperative peritonitis is characterized by a more severe clinical course than other forms of secondary peritonitis. The pathophysiological mechanisms behind this phenomenon are incompletely understood. This study used an innovative model to investigate these mechanisms, combining the models of murine Colon Ascendens Stent Peritonitis (CASP) and Surgically induced Immune Dysfunction (SID). Moreover, the influence of the previously described anti-inflammatory reflex transmitted by the vagal nerve was characterized. SID alone, or 3 days before CASP were performed in female C57BL/6 N mice. Subdiaphragmatic vagotomy was performed six days before SID with following CASP. The immune status was assessed by FACS analysis and measurement of cytokines. Local intestinal inflammatory changes were characterized by immunohistochemistry. Mortality was increased in CASP animals previously subjected to SID. Subclinical bacteremia occurred after SID, and an immunosuppressive milieu occurred secondary to SID just before the induction of CASP. Previous SID modified the pattern of intestinal inflammation induced by CASP. Subdiaphragmatic vagotomy had no influence on sepsis mortality in our model of postoperative peritonitis. Our results indicate a surgery-induced inflammation of the small intestine and the peritoneal cavity with bacterial translocation, which led to immune dysfunction and consequently to a more severe peritonitis.

Description of a rat model of polymicrobial abdominal sepsis mimicking human colon perforation

Objective Standard rodent sepsis models as cecal ligation and puncture models (CLP) or cecal ligation and incision models (CLI) are frequently not suited experiments, mainly because they lack surgical repair, and they are difficult to control for severity. The colon ascendens stent peritonitis model (CASP) overcomes some of these limitations. Result Here we present our modification of the rodent CASP model, where severity of sepsis can be controlled by timing of surgical repair and treatment, and by diameter of the stent. Further, basic hemodynamic monitoring (blood pressure and heart rate) and frequent blood sampling can be achieved, which might guide further treatment.

Description of a Rat Model of Polymicrobial Abdominal Sepsis Mimicking Human Colon Perforation

Objective: Standard rodent sepsis models as cecal ligation and puncture models (CLP) or cecal ligation and incision models (CLI) are frequently not suited experiments, mainly because they lack surgical repair, and they are difficult to control for severity. The colon ascendens stent peritonitis model (CASP) overcomes some of these limitations. Result: Here we present our modification of the rodent CASP model, where severity of sepsis can be controlled by timing of surgical repair and treatment, and by diameter of the stent. Further, basic hemodynamic monitoring (blood pressure and heart rate) and frequent blood sampling can be achieved, which might guide further treatment.

The novel iron chelator, DIBI, attenuates inflammation and improves outcome in colon ascendens stent peritonitis-induced experimental sepsis

BACKGROUND: Sepsis is the result of a dysregulated host immune response to an infection. An ideal therapy would target both the underlying infection and the dysregulated immune response. DIBI, a novel iron-binding polymer, was specifically developed as an antimicrobial agent and has also demonstrated in vivo anti-inflammatory properties. OBJECTIVE: This study aimed to further investigate the effects of DIBI with and without the antibiotic imipenem (IMI) in colon ascendens stent peritonitis (CASP)-induced experimental sepsis. METHODS: Vehicle, DIBI and/or IMI were administered in C57BL/6 mice after CASP surgery. Intestinal leukocyte activation and capillary perfusion was evaluated by intravital microscopy. Moreover, bacterial load in peritoneal lavage fluid and blood, and plasma cytokine levels were assessed. In a second series of experiments, surgery to repair the colon was performed at 5 hr and these mice were followed for long-term survival over 7 days. RESULTS: DIBI reduced leukocyte adhesion, improved capillary blood flow, and decreased key plasma cytokines levels. DIBI also improved survival of infected mice and greatly improved IMI efficacy. Survivors treated with IMI and DIBI were found to be free of systemic infection. CONCLUSIONS: DIBI has promising potential for sepsis treatment including its use as a sole or an adjunct therapeutic with antibiotics.

Discontinuation of metformin to prevent metformin-induced high colonic FDG uptake: is 48 h sufficient?

Objective In this retrospective, single-center observational study, we investigated whether discontinuing metformin for at least 48 h prevents metformin-induced [18F]fluorodeoxyglucose (FDG) uptake in all segments of the colon. Methods Patients with type 2 diabetes who were using metformin before undergoing an FDG PET/CT scan were included. Two groups were created: patients who discontinued metformin for less than 48 h (< 48 h group) and patients who discontinued metformin for between 48 and 72 h (≥ 48 h group). A control group comprised non-diabetic patients who were not using metformin before undergoing an FDG PET/CT. We visually scored the uptake of FDG in four segments of the colon—the ascendens, transversum, descendens, and rectosigmoid—using a four-point scale (1–4) and considered scores of 3 or 4 to be clinically significant. Results Colonic FDG uptake in the ≥ 48 h group (n = 23) was higher than uptake in the control group (n = 96) in the colon descendens [odds ratio (OR) 14.0; 95% confidence interval (CI) 4.8–40.9; p value: 0.001] and rectosigmoid (OR 11.3; 95% CI 4.0–31.9; p value: 0.001), and there was no difference in the colon ascendens and transversum. Colonic FDG uptake in the < 48 h group (n = 25) was higher than uptake in the ≥ 48 h group (n = 23) in the colon transversum (OR 4.8; 95% CI 1.3–18.5; p value: 0.022) and rectosigmoid (p value: 0.023), and there was no difference in the colon ascendens and descendens. Conclusions Discontinuing metformin for 48 h before undergoing an FDG PET/CT still gives a high uptake in the distal parts of the colon when compared with non-diabetic patients who are not using metformin. Discontinuing metformin for 48 h seems to be useful for scanning the more proximal segments of the colon.

Vastagbéldaganat a koronavírusjárvány idején – idős, multimorbid nőbeteg COVID–19-tüdőgyulladásának gyógyulása

Absztrakt: Az új koronavírus által okozott COVID–19 tüdőgyulladással, heveny légzési elégtelenséggel vagy akár szepszissel járhat. Azoknál a betegeknél alakul ki gyakrabban súlyos állapot, akik valamilyen krónikus alapbetegségben szenvednek. Cikkünk célja felhívni a figyelmet azon esetekre, amelyek elemzése segíthet a COVID–19-tüdőgyulladás lefolyását és mortalitását befolyásoló faktorok felderítésében. Idős betegünk anamnézisében rectumexstirpatio szerepel intraoperatív reanimációval. 2020 januárjában egy időben igazolódott colon ascendens adenocarcinoma, illetve pulmonalis embolia. Hathetes, terápiás dózisú, kis molekulatömegű heparinos (LMWH-) kezelést követően elvégeztük a daganatos szegment reszekcióját. Intraoperatív sikeres reanimáció történt. A műtét után 15 nappal endoszkóposan nem csillapítható, spriccelő anastomosisvérzés miatt akut jobb oldali hemicolectomiát végeztünk. Ezt követően a lázas állapot hátterében COVID–19 igazolódott; tüneti kezelés mellett a beteg láztalanná vált. A továbbiakban anastomosisinsufficientia alakult ki, mely konzervatív terápia alkalmazása mellett szintén gyógyult. Három negatív SARS-CoV-2-vizsgálat után betegünket emittáltuk. Figyelemre méltó, hogy betegünk preoperatív tartós LMWH-kezelésben részesült; az aktív vérzés miatt gyógyszereléséből az angiotenzinkonvertálóenzim (ACE)-gátló elhagyásra került, majd ezt követően SARS-CoV-infekció alakult ki, de multimorbiditása ellenére is meggyógyult. A colorectalis carcinomák a lassan növekvő malignomák közé tartoznak ugyan, ám fontosnak tartjuk ezek megfelelő időben történő kezelését, még súlyos járványügyi helyzetben is. Nagy kihívás elé állít minden orvost a pandémia alatt a betegek megfelelő ellátása, de – mint esetünk is példázza – sikeres lehet a multimorbid betegek sebészeti ellátása is. További következtetésünk, hogy érdemes lenne vizsgálni a társbetegségek kezelésére használt gyógyszerek és a SARS-CoV-2 közötti azon interakciókat, amelyek befolyásolhatják a COVID–19-tüdőgyulladás kimenetelét. Orv Hetil. 2020; 161(25): 1059–1062.

Laparoskopische Hemikolektomie rechts mit kompletter mesokolischer Exzision (CME)

Zusammenfassung Einleitung Die komplette mesokolische Exzision (CME) gehört laut der deutschen S3-Leitlinie bei onkologischen Kolonresektionen zur Guten Klinischen Praxis (GCP, Good Clinical Practice). Diese Empfehlung basiert auf der Evidenz, dass die Entfernung des onkologisch relevanten Mesokolons ohne Verletzung der strukturellen Integrität sowie die zentrale vaskuläre Ligatur mit radikaler Lymphknotendissektion im Rahmen von CME-Kolonresektionen mit besseren histopathologischen Qualitätskriterien und besseren onkologischen Ergebnissen im Vergleich zu konventionellen Kolonresektionen einhergehen. Allerdings weisen Kolonresektionen mit CME besonders im rechten Hemikolon durch die anatomische Nähe zu Magen, Duodenum und Pankreas und einer hohen Variabilität der Gefäßstrukturen (z. B. des Truncus Henle) eine höhere Komplexität auf. Um die Sicherheit von laparoskopischen Hemikolektomien rechts mit CME zu erhöhen und die Weiterbildung dieses Eingriffes sicher und strukturiert zu ermöglichen, wurde von einer deutschen Expertengruppe für die laparoskopische Hemikolektomie rechts ein standardisiertes Vorgehen mit Sicherheitsblicken entwickelt. Im folgenden Video wird die Durchführung einer Hemikolektomie rechts mit CME gemäß dem von der Deutschen Expertengruppe Lap-CME erstbeschriebenen Konzept dargestellt. Indikation Karzinom des Colon ascendens. Prozedur Laparoskopische Hemikolektomie rechts mit kompletter mesokolischer Exzision (CME). Schlussfolgerung Die vorgeschlagene Standardisierung der laparoskopischen Hemikolektomie rechts mit CME nimmt die erhöhte Komplexität der Operation auf und strukturiert sie in wohldefinierte Schritte mit kritischen Sicherheitsblicken als Kontrollinstanzen, was zu einer Minimierung intraoperativer Komplikationen und einer erhöhten Sicherheit für den Patienten sowie zu einer Verbesserung der strukturierten Weiterbildung führen dürfte.