Reconstrucción poscirugía de Hartmann / Stoma reversal after the Hartmann's procedure

RESUMEN Antecedentes: la reconstrucciónn del tránsito intestinal luego de una operación de Hartmann es un procedimiento habitualmente complejo y con alta morbilidad. Objetivo: analizar la tasa de reconstrucción después de la cirugía de Hartmann y resultados posoperatorios en nuestra experiencia. Material y métodos: análisis retrospectivo de pacientes a los que se les practicó la reconstrucción del tránsito intestinal posterior a una cirugía de Hartmann en un período 16 años. Revisamos la bibliografía y nuestra base de datos. Luego traspasamos la información disponible a una grilla de datos construida con variables habitualmente analizadas en la literatura. Finalmente, analizamos los resultados mediante medidas básicas de tendencia central. Resultados: en 16 años realizamos 92 operaciones de Hartmann, de las cuales 69 (75%) llegaron a la reconstrucción. Edad promedio: 58 años. El 52% de los pacientes fueron hombres. La operación de Hartmann fue de urgencia en el 48% y 58% resultaron malignas. Tiempo transcurrido hasta la reconstrucción: en promedio, 9 meses, y el 90% (N 62) de los casos se realizó por vía laparoscópica. Morbilidad general 38% y ajustada a los grados III y IV de Clavien-Dindo fue 11,5%. No hubo mortalidad. Conclusión: los resultados obtenidos son semejantes a los publicados y nuestra experiencia nos motiva a continuar eligiendo el abordaje laparoscópico.

ABSTRACT Background: Background: Stoma reversal after Hartman's operation is usually a complex procedure and is associated high morbidity. Objective: To analyze the rate of reversal after the Hartmann's procedure and the postoperative outcomes in our experience. Material and methods: We conducted a retrospective analysis of patients undergoing reversal after the Hartmann's procedure over a 16-year period with review of the literature and of our database and transferred the available information to a data grid constructed with variables commonly analyzed in the literature. Finally, we analyzed the results using basic measures of central tendency. Results: Over a 16-year period, we performed 92 Hartmann's operations; 69 (75%) reached the reversal stage. Mean age was 58 years and 52% were men. Forty-eight percent of the Hartmann's procedures were emergency surgeries and 58% were due to cancer. Mean time to reversal was 9 months and 90% (n = 62) were laparoscopic procedures. Overall morbidity and adjusted for complications grade III and IV of the Clavien-Dindo classification were 38% and 11.5%, respectively. None of the patients died. Conclusion: The results obtained are similar to those published and our experience motivates us to continue choosing the laparoscopic approach.

Thirty years of the health care service for ostomy patients in Juiz de Fora and surroundings / Trinta anos do serviço de atenção à saúde da pessoa ostomizada de Juiz de Fora e região

ABSTRACT Objective: to establish the epidemiological profile of ostomized patients treated at the Health Care Service for Ostomy Patients in Juiz de Fora and region (SASPO/JF) and to quantify the pathologies that led to the stoma as well as the ostomy-related complications. Method: a retrospective study was carried out with the analysis of 496 medical records of patients registered at HCSOP/JF over 30 years and who remained in at the service in June 2018. The following variables were considered: age, sex, pathology that led to the stoma, type, time, location and complications of stomas. Results: 53.43% were male patients and 46.57% female. The average age was 56.24 years among men and 58.40 years among women. Eight patients had two types of ostomies simultaneously and a total of 504 ostomies were as follows: 340 colostomies (67.46%), 117 ileostomies (23.21%) and 47 urostomies (9.33%). Additionally, 47.65% of the colostomies and 76.92% of the ileostomies were temporary, while all urostomies were permanent. In 70.24% of cases, the reason for making the stoma was malignancy. There were 277 stomas with one or more complications (54.96%). Conclusions: most of the ostomized patients were over 50 years old and the main diagnosis that led to the stoma was malignancy. Ileostomies had a higher percentage of complications than colostomies and urostomies and, for all types of stomas, the most frequent complication was dermatitis.

RESUMO Objetivo: elaborar o perfil epidemiológico dos pacientes estomizados atendidos no Serviço de Atenção à Saúde da Pessoa Ostomizada de Juiz de Fora e região (SASPO/JF) e quantificar tanto as patologias que levaram à confecção, quanto as complicações presentes nas estomias. Método: realizado estudo retrospectivo com análise de 496 prontuários de pacientes cadastrados no SASPO/JF ao longo de 30 anos e que permaneciam em atendimento no serviço em junho de 2018. Foram consideradas as seguintes variáveis: idade, sexo, patologia que levou à confecção do estoma, tipo, caráter temporal, localização e complicações das estomias. Resultados: 53,43% dos pacientes eram do sexo masculino e 46,57% do sexo feminino. A média de idade entre os homens foi de 56,24 anos e entre as mulheres foi de 58,40 anos. Oito pacientes apresentaram dois tipos de estomias simultaneamente e o total de 504 estomias foi distribuído da seguinte forma: 340 colostomias (67,46%), 117 ileostomias (23,21%) e 47 urostomias (9,33%). Além disso, 47,65% das colostomias e 76,92% das ileostomias foram temporárias, enquanto todas as urostomias foram permanentes. Em 70,24% dos casos, o motivo para confecção do estoma foi a neoplasia maligna. Foram encontrados 277 estomas com uma ou mais complicações (54,96%). Conclusão: as estomias predominaram em pacientes com mais de 50 anos e o principal diagnóstico que levou à confecção dos estomas foi a neoplasia maligna. As ileostomias apresentaram maior percentual de complicações do que as colostomias e urostomias e, para todos os tipos de estomas, a complicação mais frequente foi a dermatite.

Postoperative outcomes and functional results after Deloyer's procedure - a retrospective cohort study / Desfechos pós-operatórios e resultados funcionais após o procedimento de Deloyer ­ um estudo de coorte retrospectivo

ABSTRACT Introduction: The objective of our study was to describe surgical outcomes of Deloyers procedure in our referral center, and to compare the results of patients with and without protective ileostomy. Methods: Patients undergoing a Deloyers procedure from 2013 to 2016 were prospectively included. General characteristics, intraoperative variables, postoperative course, and functional outcomes were analyzed. Patients were compared into two groups: group (1) patients undergoing Deloyers procedure without ileostomy, and group (2) Deloyers procedure with protective ileostomy. Results: Sixteen patients undergoing isoperistaltic transposition of the right colon remnant were included, of which 9 (63%) were males with a median age of 47 (range 22-76) years. The main surgical indication was the restoration of bowel transit (62.5%). There was higher major morbidity rate in the Deloyers procedure with protective ileostomy group, but without statistical significance (20% vs. 9%, p = 0.92). No leaks or deaths were reported. The length of hospital stay was 7 days. The mean number of bowel movements per day was 4 at 18 months of follow up. Only four (25%) patients used irregularly loperamide. Conclusions: The Deloyers procedure has satisfactory results and is reproducible with low morbidity. The major and minor morbidity rates were similar between groups, suggesting that the costs and risks of a second procedure can be avoided by providing a safe primary anastomosis.

RESUMO Introdução: O objetivo de nosso estudo foi descrever os resultados cirúrgicos do procedimento de Deloyer em nosso centro de referência e comparar os resultados de pacientes com e sem ileostomia de proteção. Métodos: Pacientes submetidos ao procedimento de Deloyer de 2013 a 2016 foram incluídos prospectivamente. Foram analisadas as características gerais, as variáveis intraoperatórias, o curso pós-operatório e os desfechos funcionais. Os pacientes foram comparados em dois grupos: Grupo 1) pacientes submetidos ao procedimento de Deloyer (PD) sem ileostomia, e grupo 2) procedimento de Deloyer com ileostomia de proteção (IP). Resultados: Foram incluídos 16 pacientes submetidos à transposição isoperistáltica da porção remanescente do cólon direito, dos quais 9 (63%) eram do sexo masculino com idade média de 47 anos (variação de 22-76) anos. A principal indicação cirúrgica foi a restauração do trânsito intestinal (62,5%). Houve maior morbidade maior no grupo IP, mas sem significância estatística (20% vs. 9%, p = 0,92). Nenhum vazamento ou óbito foi relatado. A duração da hospitalização foi de 7 dias. O número médio de evacuações por dia foi 4, aos 18 meses de seguimento. Apenas quatro (25%) pacientes utilizaram irregularmente a loperamida. Conclusões: O procedimento de Deloyer tem resultados satisfatórios e é reprodutível com baixa morbidade. As taxas de morbidades maiores e menores foram semelhantes entre os grupos, sugerindo que os custos e riscos de um segundo procedimento podem ser evitados proporcionando-se uma anastomose primária segura.

Risk Factors of Permanent Stomas in Patients with Rectal Cancer after Low Anterior Resection with Temporary Stomas

PURPOSE: The aim of this study was to identify risk factors influencing permanent stomas after low anterior resection with temporary stomas for rectal cancer. MATERIALS AND METHODS: A total of 2528 consecutive rectal cancer patients who had undergone low anterior resection were retrospectively reviewed. Risk factors for permanent stomas were evaluated among these patients. RESULTS: Among 2528 cases of rectal cancer, a total of 231 patients had a temporary diverting stoma. Among these cases, 217 (93.9%) received a stoma reversal. The median period between primary surgery and stoma reversal was 7.5 months. The temporary and permanent stoma groups consisted of 203 and 28 patients, respectively. Multivariate analysis showed that independent risk factors for permanent stomas were anastomotic-related complications (p=0.001) and local recurrence (p=0.001). The 5-year overall survival for the temporary and permanent stoma groups were 87.0% and 70.5%, respectively (p<0.001). CONCLUSION: Rectal cancer patients who have temporary stomas after low anterior resection with local recurrence and anastomotic-related complications may be at increased risk for permanent stoma.

Risk Factors of Permanent Stomas in Patients with Rectal Cancer after Low Anterior Resection with Temporary Stomas

PURPOSE: The aim of this study was to identify risk factors influencing permanent stomas after low anterior resection with temporary stomas for rectal cancer. MATERIALS AND METHODS: A total of 2528 consecutive rectal cancer patients who had undergone low anterior resection were retrospectively reviewed. Risk factors for permanent stomas were evaluated among these patients. RESULTS: Among 2528 cases of rectal cancer, a total of 231 patients had a temporary diverting stoma. Among these cases, 217 (93.9%) received a stoma reversal. The median period between primary surgery and stoma reversal was 7.5 months. The temporary and permanent stoma groups consisted of 203 and 28 patients, respectively. Multivariate analysis showed that independent risk factors for permanent stomas were anastomotic-related complications (p=0.001) and local recurrence (p=0.001). The 5-year overall survival for the temporary and permanent stoma groups were 87.0% and 70.5%, respectively (p<0.001). CONCLUSION: Rectal cancer patients who have temporary stomas after low anterior resection with local recurrence and anastomotic-related complications may be at increased risk for permanent stoma.

An exploratory analysis of the epidemiology and surgical management of perforated diverticular disease over a two-year period at a Referral Centre in the Caribbean / Análisis exploratorio de la epidemiología y el tratamiento quirúrgico de la enfermedad diverticular perforada durante un período de dos años en un Centro de Remisión en el Caribe

OBJECTIVE: We present an exploratory analysis of data collected on perforated diverticular disease (PDD) in Barbados and suggest possible areas for further study. SUBJECTS AND METHODS: All cases of perforated diverticular disease treated at the Queen Elizabeth Hospital (QEH) Barbados, between January 1, 2005 and December 31, 2006 were reviewed. The patient's age, gender, location of disease, Hinchey stage, operative procedure, rate of colostomy reversal, length of hospitalization, incidence of peri-operative morbidity and postoperative mortality were analysed using principal components analysis (PCA). RESULTS: Fourteen cases of PDD were treated at the QEH during this period. Six (43%) of the patients had perforated right-sided diverticulitis (PRSD). In the PCA, Dimensions 1 and 2 were the two dimensions examined, as they both had Eigenvalues over 1. Dimension 1 can be taken as an indicator of the intensity of the disease. On dimension 2, length of hospitalization had the highest component loading (0.875). The mean hospital stay was 10.6 days in PRSD, 9.5 in left-sided perforations with primary anastomosis, and 16.2 days for those with a Hartmann's procedure. The overall peri-operative morbidity was 28% and there was no mortality in the series. CONCLUSION: This preliminary study seems to show a relatively high incidence of PRSD in a predominantly Afro-Caribbean population. More research is needed to determine the exact aetiology of this disease. In our experience, primary anastomosis in carefully selected patients with either PRSD or perforated left-sided diverticulitis (PLSD) may result in shorter hospitalization.

OBJETIVO: Presentamos un análisis exploratorio de la enfermedad diverticular perforada (EDP) en Barbados, y sugerimos posibles áreas de análisis ulterior. SUJETOS Y MÉTODOS: Se revisaron todos los casos de enfermedad diverticular perforada tratados en el Hospital Queen Elizabeth (QEH) de Barbados, entre enero 1 de 2005 y diciembre 31 de 2006. Mediante el análisis de componentes principales (ACP), se analizaron los siguientes: edad del paciente, género, localización de la enfermedad, estadio de Hinchey, procedimiento operatorio, tasa de colostomía inversa, tiempo de hospitalización, incidencia de morbilidad perioperatoria, y mortalidad postoperatoria. RESULTADOS: Catorce casos de EDP fueron tratados en el HQE durante este período. Seis (43%) de los pacientes presentaban diverticulitis del lado derecho perforada (DLDP). En el ACP, las dimensiones 1 y 2 fueron las dos dimensiones examinadas, ya que ambas tenían valores propios por encima de 1. La dimensión 1 puede tomarse como indicador de la intensidad de la enfermedad. En la dimensión 2, el tiempo de hospitalización tuvo la carga de componente más alta (0.875). La estadía promedio en el hospital fue de 10.6 días en los casos de DLDP, 9.5 en las perforaciones del lado izquierdo con anastomosis primaria, y 16.2 días para aquellos con procedimiento de Hartmann. La morbilidad perioperatoria fue 28% y no hubo mortalidad en la serie. CONCLUSIÓN: Este estudio preliminar parece mostrar una incidencia relativamente alta de DLDP en una población predominantemente afro-caribeña. Se necesita más investigación a fin de determinar la etiología exacta de esta enfermedad. En nuestra experiencia, la anastomosis primaria en pacientes cuidadosamente seleccionados, que sufren de DLDP o padecen diverticulitis del lado izquierdo perforada (DLIP), puede tener por resultado una hospitalización más corta.

frequency and management of intestinal Tuberculosis; a hospital based study

To determine the frequency of clinical manifestation of intestinal tuberculosis and outcome of different treatment modalities. This descriptive study was conducted at Lady Reading Hospital Peshawar from July 2005 to June 2006. Fifty cases having radiological evidence of tuberculosis in the intestines were included in the study. Various parameters like age, sex, presentation, investigation and various treatment modalities were studied. Twenty three [46%] patients presented with subacute and 13 [26%] with acute intestinal obstruction and 12 [24%] with signs of peritonism. Presenting symptoms were: pain abdomen and anorexia in 47[94%] patients, nausea / vomiting in 30 [60%] patients and constipation in 28 [56%] patients. Tenderness was present in 48 [96%] patients and distension of abdomen in 35 [70%]. Two [4%] patients were treated conservatively and 48 patients [96%] were managed by surgery [emergency surgery 34 cases, semi-elective surgery 14 cases]. In 47 [94%] patients, diagnosis was confirmed by characteristic caseating granuloma. Resection of the small bowel with ileo-ileal anastamosis was done in 16 cases and limited right hemicolectomy with ileo-colic anastamosis in 14 cases. Two staged procedures were performed in 8 cases. Only three [6%] cases needed re-admission for complications, two [4%] for sub-acute obstruction and one [2%] for ileostomy prolapse. Abdominal tuberculosis presents with pain abdomen, anorexia, vomiting and with signs of intestinal obstruction. The surgical procedures like resection with primary anastomosis have satisfactory outcome. Two stage surgical procedures are advisable if the risk of anastamotic leakage and faecal fistula formation is high

Management of intestinal stoma

To detect the various complications in all types of intestinal stomas and various operative and non-operative strategies applied in the management of these complications. All four units of Surgical Department including Accident and Emergency department, Nishtar Hospital, Multan. Six months. 100 patients. These 100 patients included in the study were admitted through the OPD and emergency department. Data of patients was recorded on a pre-designed proforma, which was later on used for analysis. Various types of complications were noted. The commonest age group for ileostomies and caecostomies was 13-20 years and for colostomies was 21-30 years. There were 10 female and 40 male patients in total. Labourers were the commonest to have a stoma. This was also true for ileostomies and colostomies; whereas students were the most common to have caecostomies. Nine cases of ileostomy, 6 cases of caecostomy and 35 cases of colostomy were studied. About 10 [20%] colostomies were made in transverse colon, 5 [10%] in descending colon and 20 [40%] in sigmoid colon. Eight [16%] colostomies were the only permanent stomas in this study. There were 3 [60%] tube caecostomies and 2 [40%] formal caecostomies. There were 6 [66.7%] loop ileostomies and 3 [33.3%] end ileostomies. The implementation of proper surgical techniques reduces the chances of local stoma complications

Tratamiento quirúrgico del cáncer de colon: análisis de 120 pacientes consecutivos / Surgical treatment of colon cancer: analysis of 120 consecutive cases

Se revisan en forma retrospectiva los resultados del tratamiento quirúrgico de 120 pacientes intervenidos en forma consecutiva por un cáncer de colon en un periodo de 6,5 años, 83 mujeres y 37 hombres con un promedio etario de 64,6 años. Un 56 por ciento de los tumores se ubicó en Colon Derecho (CD), 38 por ciento en Colon Izquierdo (CI) y un 6 por ciento eran múltiples sincrónicos. La masa palpable y la anemia son síntomas muy sugerentes de una neoplasia de CD. La resecabilidad de la serie fue del 81 por ciento, con un 70 por ciento de intervenciones con intención curativa. El tiempo de hospitalización promedio global fue 11 días, la morbilidad quirúrgica global fue 13 por ciento, 4 casos (3,3 por ciento) se reoperan por complicaciones inmediatas y la mortalidad operatoria global fue 1,6 por ciento (1,2 por ciento en cirugía curativa). En 38 pacientes (30 por ciento) en estadío D/TNM IV se efectuaron 13 resecciones paliativas, con un tiempo de hospitalización, morbilidad y mortalidad similar al subgrupo de pacientes sometidos a cirugía resectiva con intención curativa. El seguimiento promedio en los pacientes con cirugía curativa fue de 40 meses (rango 12-84), de los cuales el 45 por ciento supera los 48 meses de observación. La recurrencia global fue del 11 por ciento (9 pacientes), de los cuales 4 fallecen por cáncer entre 12 y 54 meses de la intervención y 5 están vivos (3 casos sin evidencias de enfermedad luego de una resección por metástasis hepática entre 22 y 72 meses y 2 tienen una recurrencia a distancia con 66 meses de seguimiento cada uno). En el análisis de la recurrencia destaca por una parte la relevancia del compromiso ganglionar a nivel de los troncos vasculares (N3), y por otra, la presencia de otros factores histopatológicos negativos no considerados en ninguna clasificación vigente. Aunque con limitaciones, las clasificaciones de Dukes-Turnbull y la GITSG que discriminan entre ganglios metastásicos alejados y más de 4 ganglios respectivamente, tendrían un valor pronóstico superior al TNM. En esta serie, se confirma la drástica reducción de la morbi-mortalidad operatoria actual asociada a la cirugía electiva del cáncer del colon. La cirugía resectiva con fines paliativos en pacientes incurables requiere de una juiciosa selección de los pacientes y está justificada si se efectúa con índices bajos de morbilidad que no afecte la ya reducida sobrevida del paciente

Alternativas quirúrgicas en la colitis ulcerosa idiopática: análisis de 19 casos / Surgical alternatives in idiopatic ulcerative colitis: analysis of 19 cases

La cirugía de la colitis ulcerosa idiopática ha comenzado a desarrollarse en nuestro país en los últimos años. Frente a esta enfermedad existen varias alternativas quirúrgicas. Presentamos nuestra experiencia en 19 pacientes atendidos y operados en el período comprendido entre 1987 y 1994. La gravedad fue catalogada usando los criterios de Truelove. Se eligió el procedimiento quirúrgico en 1-2 ó 3 tiempos, considerando la edad, la forma de presentación, la gravedad, las complicaciones existentes y el estado del recto y del aparato esfinteriano. Se hizo cirugía en 1 tiempo en 4 pacientes, una proctocolectomía y tres colectomías totales mas anastomosis ileorrectal. Se planteó cirugía en 2 tiempos a 7 pacientes, con reservirios en J y cirugía en 3 tiempos en 8. En estos dos últimos grupos se han hecho 14 reservorios en J, 9 con micosectomía y 5 con técnica de doble stapler. La morbilidad del grupo es alta, destacando las complicaciones sépticas y la dehiscencia ileoanal. No hubo mortalidad en los 19 pacientes operados. Se concluye que ésta es una cirugía de alta complejidad y de baja frecuencia con morbilidad elevada

Estenosis intestinal secundaria a colon tóxico amibiano / Intestinal stenosis secondary to toxic amoebic colitis

En un periodo de 12 años se trataron 10 pacientes con estenosis intestinal secundaria a colon tóxico amibiano. En siete pacientes la estenosis se resolvió mediante su resección, por vía abdominal; en dos pacientes se realizó rectoplastia por vía sagital posterior y en un paciente, mediante dilatación rectal. No hubo complicaciones postoperatorias en ningún paciente

Ileostomías: indicaciones y resultados / Ileostomy: indication and results

Se evalúa nuestra experiencia con 100 ileostomías realizadas en 81 pacientes. Ileostomías terminales son 41 y 59 en asa. La colitis ulcerosa en 34 pacientes (42%), fue el diagnóstico más frecuente como indicación de una ileostomía. La ileostomía terminal se asoció principalmente a colectomías subtotales con conservación del recto en el 85,4% de los casos. La ileostomía en asa fue indicada con mayor frecuencia para proteger un reservorio ileal en 21 pacientes (35,6%) y una anastomosis colorrectal baja en 16 (27,1%). Las complicaciones más frecuentes fueron la infección de la herida operatoria y las alteraciones hidroelectrolíticas. De las 41 ileostomías terminales se reconstituyó el tránsito en 29, y de las 59 ileostomías en asa se han cerrado 46. Fallecieron 4 pacientes (4,9%), ninguno secundario a complicaciones de la ileostomía

Ileostomia en asa como alternativa de colostomia transversa para desfuncionar anastomasis distales / Loop ileostomy since alternative transverse loop colostomy for defunctionalizing distal anastomosis

Se comparan los resultados de 25 casos con colostomía transversa en asa, con los de 25 con ileostomía en asa, realizados para desfuncionalizar anastomosis colorrectales. Ambos procedimientos resultaron igualmente adecuados para el fin propuesto. La ileostomía demostró tiempo de internación menor, recuperación más temprana del tránsito, inferior índice de infecciones paraostómicas y de la herida correspondiente al cierre, menor índice de eventraciones post-cierre y requirió menor recambio de prótesis. Desde el punto de vista técnico, la realización y el cierre, resultaron más sencillos en las ileostomías. La ileostomía constituye una alternativa válida como método para desfuncionalizar una anastomosis colorrectal.