Hartmann's procedure and laparoscopic reversal versus primary anastomosis and ileostomy closure for left colonic perforation.

PURPOSE: Emergency surgical strategies for acute left-sided colonic perforation are evolving preferring primary anastomosis (PA) with ileostomy to Hartmann's procedure (HP) based on the morbidity and reversal rates. However, HP is still commonly performed. Hartmann's reversal is associated with considerable morbidity. It is of interest whether laparoscopic reversal results in a lower morbidity as retrospective data suggest. Here, we compared the combined morbidity rates for two surgical strategies: strategy A, HP followed by laparoscopic reversal, and strategy B, sigmoid resection with PA followed by ileostomy closure. METHODS: Prospectively collected data of all consecutive patients undergoing HP for benign left-sided colonic perforation between 2010 and 2014 were retrospectively compared to data of patients undergoing PA. Groups were matched for age and Charlson comorbidity index. Additionally, patients were analyzed for American Society of Anesthesiologists score, body mass index, and peritonitis stage. End points were morbidity, operation time, reversal rate, time to reversal, and length of hospital stay. RESULTS: The study included 32 patients for whom Hartmann's reversal was planned, along with 32 matched patients who underwent PA and diverting ileostomy. Median age was 75 and 72 years, Charlson score was 6 (4-9) and 6 (5-7), and patients classified by the American Society of Anesthesiologists (ASA) higher than III were 81 % in both groups. Combined major morbidity rates were 21 % for strategy A and 20 % for strategy B (p = 1.0). Combined comprehensive complication index was 16.4 ± 14.1 and 12.3 ± 19.1 (p = 0.08). HP reversal by laparoscopy was achieved in 71 %. The colostomy reversal rate was 75 % compared to ileostomy closure rate of 88 % (p = 0.34). CONCLUSIONS: Laparoscopic Hartmann's reversal is achievable in a high proportion of patients. Strategy B tends to have lower overall morbidity; meanwhile, major morbidity seems to be similar. Yet, in critically ill patients and in the absence of expertise of the surgeon on call, HP followed by elective laparoscopic reversal represents a viable alternative.

Perineal stapled prolapse resection for external rectal prolapse: is it worthwhile in the long-term?

BACKGROUND: Perineal stapled prolapse (PSP) resection is a novel operation for treating external rectal prolapse. However, no long-term results have been reported in the literature. This study analyses the long-term recurrence rate, functional outcome, and morbidity associated with PSP resection. METHODS: Nine consecutive patients undergoing PSP resection between 2007 and 2011 were prospectively followed. Surgery was performed by the same surgeons in a standardised technique. Recurrence rate, functional outcome, and complication grade were prospectively assessed. RESULTS: All 9 patients undergoing PSP resection were investigated. The median age was 72 years (range 25-88 years). No intraoperative complications occurred. Faecal incontinence, preoperatively present in 2 patients, worsened postoperatively in one patient (Vaizey 18-22). One patient developed new-onset faecal incontinence (Vaizey 18). The median obstructive defecation syndrome score decreased postoperatively significantly from 11 (median; range 8-13) to 5 (median; range 4-8) (p < 0.005). At a median follow-up of 40 months (range 14-58 months), the prolapse recurrence rate was 44 % (4/9 patients). CONCLUSIONS: The PSP resection is a fast and safe procedure associated with low morbidity. However, the poor long-term functional outcome and the recurrence rate of 44 % warrant a cautious patient selection.

Suture repair of umbilical hernia during caesarean section: a case-control study.

PURPOSE: The objective of this study was to investigate the additional burdens in terms of pain, prolongation of surgery and morbidity which is added to elective caesarean section if umbilical hernia suture repair is performed simultaneously. Secondly, patient's satisfaction and hernia recurrence rate were assessed. METHODS: Consecutive women with symptomatic umbilical hernia undergoing internal or external suture repair during elective caesarean were included in this retrospective cohort-control study. Data on post-operative pain, duration of surgery and morbidity of a combined procedure were collected. These patients were matched 1:10 to women undergoing caesarean section only. Additionally, two subgroups were assessed separately: external and internal suture hernia repair. These subgroups were compared for patient's satisfaction, cosmesis, body image and recurrence rate. RESULTS: Fourteen patients with a mean age of 37 years were analysed. Internal suture repair (n = 7) prolonged caesarean section by 20 min (p = 0.001) and external suture repair (n = 7) by 34 min (p < 0.0001). Suture repair did not increase morphine use (0.38 ± 0.2 vs. 0.4 ± 02 mg/kg body weight), had no procedure-related morbidity and prolonged hospitalization by 0.5 days (p = 0.01). At a median follow-up of 37 (5-125) months, two recurrences in each surgical technique, internal and external suture repair, occurred (28 %). Body image and cosmesis score showed a higher level of functioning in internal suture repair (p = 0.02; p = 0.04). DISCUSSION: Despite a high recurrence rate, internal suture repair of a symptomatic umbilical hernia during elective caesarean section should be offered to women if requested. No additional morbidity or scar is added to caesarean section. Internal repair is faster, and cosmetic results are better, additional skin or fascia dissection is avoided, and it seems to be as effective as an external approach. Yet, women must be informed on the high recurrence rate.

Parastomal hernia incarceration due to migrated intragastric balloon.

The temporary placement of intragastric balloons is a common method to achieve rapid weight loss before planned metabolic surgery. We report the case of a 48-year-old morbidly obese patient. Ten years ago the patient underwent emergency sigmoidectomy with creation of a double-barreled ileostomy for perforated diverticulitis. Over time he developed a giant parastomal hernia. For preoperative weight reduction before planned restoration of intestinal continuity, an intragastric balloon was inserted 3 years ago. The patient was admitted to our emergency department with peritonism and a septic shock. After computed tomography showing small bowel ileus, laparotomy was performed, revealing marked ischemia of incarcerated small and large intestine. Only postoperatively was the intragastric balloon found in the resected small bowel, causing a mechanical ileus with consecutive incarceration of the bowel. We review the literature on complications due to the migration of intragastric balloons. This clinical case gives a fair warning of the possible deleterious outcome of intragastric balloons, especially in hernia patients.