Stoma Bridge Types and Their Impact on Patient Outcomes: A Retrospective Analysis and Prospective Global Survey of Surgical Practice.

PURPOSE: The purpose of this study was to describe the effect of rigid or flexible stoma bridges used for loop ostomy diversions on peristomal skin integrity. Additional aims were to describe surgeon practices related to stoma bridges, and determine the availability of an ostomy nurse specialist. DESIGN: Retrospective chart review and cross-sectional survey. SAMPLE AND SETTING: The sample used to address the first aim (effect of stoma bridges) comprised 93 adult patients cared for at Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, an acute care facility. Data provided by 355 colorectal surgeons from 30 countries were used to describe surgeon practice in this area and determine the availability of an ostomy nurse specialist. Respondents were invited from an international roster of colorectal surgeons obtained with permission from the American Society of Colon and Rectal Surgeons (ASCRS). METHODS: In order to accomplish the initial aim, we retrospectively reviewed medical records of patients who underwent ostomy surgery from 2008 to 2015 and met inclusion criteria. In order to meet our additional aims, analyzed data were obtained from a survey of colorectal surgeons that queried practices related to stoma bridges, and availability of an ostomy nurse specialist. RESULTS: Patients managed with a rigid bridge were significantly more likely to experience leakage beneath the pouching system faceplate than were patients managed by a flexible bridge (42% vs 11%, P < .001). Slightly less than one quarter of patients who developed leakage (n = 22, 24%) experienced pressure and moisture-related peristomal skin complications. Peristomal wounds, inflammation, and infection were significantly higher when a rigid bridge was used (χ test, P < .003). The surgeon's survey (N = 355) showed variability in the use of bridges. Ninety-three percent of all surgeons indicated an ostomy nurse specialist was part of their health care team. CONCLUSIONS: Rigid ostomy bridges were associated with a higher likelihood of leakage from underneath the faceplate of the pouching system and impaired peristomal skin integrity. Analysis of colorectal surgeon responses to a survey indicated no clear consensus related to bridge use in patients undergoing loop ostomies.

Non-cutaneous AIDS-associated Kaposi's sarcoma presenting as recurrent rectal abscesses.

Kaposi's sarcoma is a fatal disease that typically presents with cutaneous manifestations in immunocompromised individuals. There are a small number of documented cases where patients diagnosed with this disease present without cutaneous lesions. We present a 35-year-old man with recurrent rectal abscesses and fistula-in-ano, which required multiple drainage procedures. Further investigation revealed a diagnosis of HIV-AIDS, and biopsy of a rectal mass confirmed the diagnosis of visceral Kaposi's sarcoma, despite the absence of cutaneous involvement. Workup revealed hepatic metastasis and a second pulmonary primary malignancy. The patient denied chemotherapy or further intervention and was subsequently lost to follow-up. Prompt diagnosis of Kaposi's sarcoma and initiation of treatment is vital to decrease disease progression. A high index of suspicion should be present in immunocompromised patients, and clinicians must recognise atypical presentations in order to improve long-term survival.

Port site hernias following robotic colorectal surgery in people with obesity.

Port site hernias are a rare complication following robotic surgery that can result in disastrous outcomes. We describe incarcerated port site hernias in two patients with obesity. Both patients required laparoscopic reduction. Following laparoscopic reduction, one patient's postoperative course was complicated by pneumatosis intestinalis, requiring exploratory laparotomy and subsequent small bowel resection. It is standard practice to not close the fascia of port sites less than 12 mm in robotic surgery. However, this allows for the rare possibility of small bowel herniation through the port site. We suggest that our patients' history of obesity and metabolic dysfunction contributed to difficult port retention during the case, and longer operating times which caused an increased amount of torque at the port site. Additionally, compared with laparoscopic surgery, robotic surgery is associated with increased torque at port sites. The combination of these risk factors extended the fascial defect, ultimately leading to the incarceration of small bowel in the port site.

Endoscopic tattooing to mark distal margin for low anterior rectal and select sigmoid resections.

Obtaining a reliable distal margin during anterior colorectal resection can be difficult. In this study, endoscopic transmural tattoos were placed to mark the distal transection point in patients with distal colorectal neoplasms who undergo bowel resection. In the operating room, before surgery, sigmoidoscopy is performed with a 2-channel scope using CO2 insufflation. Through channel 1, a biopsy forceps, marked 5 cm from its end, is inserted to the tumor's distal edge; in channel 2, a sclerotherapy catheter is placed. The scope is then withdrawn and forceps inserted at the same rate until the mark is seen, next, via the needle catheter, 4 tattoos are placed at that level circumferentially. After rectal mobilization, visible external tattoos guide stapler placement. If no tattoo is seen, sigmoidoscopy is done and the tattoos used to guide stapler placement. In all 27 patients, the tattoos guided stapler placement; tattoos were seen via the abdomen in 26 and the stapler placed as per tattoos in 25. In 2 patients, repeat endoscopy was done and tattoos used to guide or confirm stapler placement. The margin was ≤1 cm from target in 74% while in 22% the margin was 2 to 3.5 cm off target (mean deviation from target margin = 0.33 cm). In conclusion, this method facilitates stapler placement and provides more reliable margins.