Peristomal Pyoderma Gangrenosum Responding to Risankizumab.

ABSTRACT: Evidence to support available therapies for pyoderma gangrenosum (PG) is limited. Many patients do not respond to topical therapies such as tacrolimus or topical steroids. Currently favored oral systemic treatments (eg, cyclosporine and steroids) achieve complete remission in only 50% of patients and have unfavorable adverse effect profiles. There is a growing body of evidence to support biologic agents for the treatment of PG, but their exact role remains unclear. Here the authors present a patient with peristomal PG, the first reported case of PG responding to treatment with risankizumab, an anti-interleukin 23 monoclonal antibody. Risankizumab may represent an effective and relatively safe treatment for PG that merits additional exploration in prospective, controlled studies.

Meta-analysis and single-center experience on the protective effect of negative suction drains on wound healing after stoma reversal.

BACKGROUND: Compromised wound healing following stoma reversal is a frequent problem. The use of negative suction drainage for reduction of complications remains controversial. METHODS: The patient database of our center was reviewed for patients with ileostomy reversal between 2007 and 2017. Risk factors for wound complications were analyzed using multivariate regression analysis. Systematic review and meta-analysis was performed. Ultimately, results of this study were integrated into meta-analysis to assess the effect of drainage placement on wound healing. RESULTS: In our institutional analysis, a total of 406 patients with ileostomy reversal were included (n = 240 (59.1%) with drainage vs. n = 166 (40.8%) without drainage). In multivariate analysis, body mass index (BMI) was a risk factor for wound complications (odds ratio (95% CI) 1.06 (1.02-1.12)). Patients with drainage needed significantly fewer interventions than those without drainage (17.1% vs. 28.9%, p = 0.005). Placement of drainage significantly reduced the risk of wound complications even in the group with elevated BMI (odds ratio (95% CI) 0.462 (0.28-0.76), p = 0.003). Meta-analysis identified 6 studies with a total of 1180 patients eligible for further analysis (2 prospectively randomized trials; 4 retrospective cohort studies). Overall analysis revealed a significantly beneficial effect of wound drainage following ileostomy reversal (RR (95% CI) 0.47 (0.34, 0.66); p < 0.0001). CONCLUSION: In our institutional analysis as well as meta-analysis, the use of subcutaneous suction drains was beneficial for prevention of wound healing complications following ostomy reversal. Drainage placement is especially valuable in high-risk situations such as in obese patients.

A Four-step Technique for Effluent Diversion of Enteroatmospheric Fistulas.

BACKGROUND: Isolation of the enteroatmospheric fistula (EAF) opening and prevention of contamination of the rest of the wound by effluent are important factors in the management of EAF. OBJECTIVE: The aim of this study is to describe an easily reproducible technique for effluent control in patients with EAF. MATERIALS AND METHODS: A retrospective analysis was conducted on all patients who underwent the present technique between 2013 and 2015. The surgical technique included condom-EAF anastomosis, fistula ring creation, negative pressure wound therapy (NPWT), and adaptation of an ostomy bag. RESULTS: A total of 7 patients with a Björck grade 4 abdomen were included. All fistulas were located in the small bowel with a median number of 2 EAFs (range, 2-3) in each patient, and the majority had moderate output volume. The mean number of NPWT changes was 10 (range, 5-18), the mean time of NPWT use was 75.7 days (range, 60-120 days), and the mean length of stay was 108.2 days (range, 103-160 days). The mean time of ostomy formation to restitution of bowel continuity was 14.3 months (range, 8-20 months). Open anterior component separation was employed in all cases for closure of the abdominal wall. No mortality, ventral herniation, or refistulization was registered in the study. The mean follow-up time was 8.5 months (range, 6-12 months). CONCLUSIONS: This is an easily reproducible and safe technique for effluent control in patients with Björk grade 4 abdomen with established EAF.

Peristomal Medical Adhesive-Related Skin Injury: Results of an International Consensus Meeting.

Stomal and peristomal skin complications (PSCs) are prevalent in persons living with an ostomy; more than 80% of individuals with an ostomy will experience a stomal or peristomal complication within 2 years of ostomy surgery. Peristomal skin problems are especially prevalent, and a growing body of evidence indicates that they are associated with clinically relevant impairments in physical function, multiple components of health-related quality of life, and higher costs. Several mechanisms are strongly linked to PSCs including medical adhesive-related skin injuries (MARSIs). Peristomal MARSIs are defined as erythema, epidermal stripping or skin tears, erosion, bulla, or vesicle observed after removal of an adhesive ostomy pouching system. A working group of 3 clinicians with knowledge of peristomal skin health completed a scoping review that revealed a significant paucity of evidence regarding the epidemiology and management of peristomal MARSIs. As a result, an international panel of experts in ostomy care and peristomal MARSIs was convened that used a formal process to generate consensus-based statements providing guidance concerning the assessment, prevention, and treatment of peristomal MARSIs. This article summarizes the results of the scoping review and the 21 consensus-based statements used to guide assessment, prevention, and treatment of peristomal MARSIs, along with recommendations for research priorities.

Outcomes of Ostomy Location in Children: Placement of the Ostomy at the Umbilicus.

PURPOSE: Neonatal exploratory laparotomies are often performed with a transumbilical incision in our institution, so umbilical ostomy placement has become more common. The purpose of our study is to evaluate the outcomes of neonates with ostomy placement at the umbilicus in comparison to more traditional stoma locations. MATERIAL AND METHODS: Retrospective study of neonates that underwent an exploratory laparotomy with ostomy creation between January 2010 and September 2015. Demographics, presentation, feedings, ostomy position, postoperative complications, and outcomes were collected. Comparative analysis was performed in STATA with P-value <.05 determined as significant. Results reported as means ± standard deviation and medians with interquartile ranges. RESULTS: Fifty-four children were included, 37% (n = 20) had stomas at the umbilicus. Most common other stoma location was the right lower quadrant (63%, n = 34). Necrotizing enterocolitis (NEC) was the most common indication for surgery in both groups. Days to stoma output were similar between the two groups, [3 (1, 6) versus 2 (1, 5), P = .96]. Days to initiation of feeds were delayed in the umbilical ostomy group [15 (9.5, 23.5) versus 6 (4, 10), P = .02]. Comparing only NEC patients, initiation of feeds was similar [22 (14, 56) versus 15.5 (8, 43), P = .73]. Umbilical ostomies had an increase in prolapse/peristomal hernias (7 versus 3, P = .01), but no patients required operative revision. CONCLUSION: Umbilical ostomies had similar time to stoma function compared to other sites, but a delay in initiation of oral feeds likely secondary to a higher percentage of patients with NEC.

A qualitative study exploring what it takes to be physically active with a stoma after surgery for rectal cancer.

PURPOSE: Many adults must cope with the adverse effects of cancer and adjuvant therapies, which may limit their engagement in health-enhancing behaviors such as physical activity (PA). Furthermore, the placement of a stoma during surgery for rectal cancer may cause additional challenges to being physically active. The aim of this study was to explore the experiences of rectal cancer survivors who were living with a stoma and the impact on their engagement in PA. METHODS: Interpretive phenomenological analysis was used as the approach for this qualitative study. Fifteen rectal cancer survivors took part in a semi-structured interview post-chemotherapy, and thematic analysis was used to identify themes within their accounts. RESULTS: Three themes captured participants' personal lived experience: (1) reasons for engaging in PA, (2) deterrents to engaging in PA, and (3) practical implications. CONCLUSIONS: Participants' accounts offered insight into both their cancer and stoma-related experiences, highlighting both reasons for and deterrents to engaging in PA. Further, findings helped to identify tangible strategies that those learning to be physically active with a stoma may find useful.

Purse-string approximation vs. primary closure with a drain for stoma reversal surgery: results of a randomized clinical trial.

PURPOSE: Stoma reversal carries a risk of surgical site infection (SSI). Purse-string approximation (PSA) has been reported as an attractive alternative to conventional primary wound closure for stoma reversal, but its efficacy is still under debate. METHODS: Patients undergoing elective stoma reversal were randomized to undergo PSA or primary closure with a drain (PCD). All patients received preoperative bowel cleansing and antimicrobial prophylaxis. The primary endpoint was the incidence of wound healing at the stoma site 30 days after surgery. The secondary endpoint was the 30-day SSI rate after surgery. RESULTS: A total of 159 patients (PCD group, n = 79; PSA group, n = 80) were eligible for this study. The incidence of wound healing at the stoma site was 92.4% in the PCD group and 62.5% in the PSA group [difference (95% confidence interval - 29.9% (- 42.9 to - 16.9%)]. The 30-day SSI rate at the stoma site, as the secondary endpoint, was 8.9% in the PCD group and 5.0% in the PSA group (P = 0.35). CONCLUSIONS: These results suggest that PCD may remain the standard procedure for stoma reversal surgery.

Care of patients with stomas in general practice.

BACKGROUND: Intestinal stomas are formed for emergency, elective, benign and malignant conditions. They may be temporary or permanent. The complication rates of intestinal stomas are reported as high as 56%. OBJECTIVE: The aim of this article is to provide an overview of intestinal stomas and common related issues, to inform general practitioners (GPs) and improve stoma-related care. DISCUSSION: There are a variety of early and late complications associated with intestinal stomas. It is important that patients have access to an informed GP, stomal therapy nurse and surgeon to provide optimal ongoing care. Good stoma care contributes to good quality of life for patients.

Quality of life in patients with a permanent stoma after rectal cancer surgery.

AIM: Health-related quality of life (HRQoL) assessment is important in understanding the patient's perspective and for decision-making in health care. HRQoL is often impaired in patients with stoma. The aim was to evaluate HRQoL in rectal cancer patients with permanent stoma compared to patients without stoma. METHODS: 711 patients operated for rectal cancer with abdomino-perineal resection or Hartman's procedure and a control group (n = 275) operated with anterior resection were eligible. Four QoL questionnaires were sent by mail. Comparisons of mean values between groups were made by Student´s independent t test. Comparison was made to a Swedish background population. RESULTS: 336 patients with a stoma and 117 without stoma replied (453/986; 46 %). A bulging or a hernia around the stoma was present in 31.5 %. Operation due to parastomal hernia had been performed in 11.7 % in the stoma group. Mental health (p = 0.007), body image (p < 0.001), and physical (p = 0.016) and emotional function (p = 0.003) were inferior in patients with stoma. Fatigue (p = 0.019) and loss of appetite (p = 0.027) were also more prominent in the stoma group. Sexual function was impaired in the non-stoma group (p = 0.034). However in the stoma group, patients with a bulge/hernia had more sexual problems (p = 0.004). Pain was associated with bulge/hernia (p < 0.001) and fear for leakage decreased QoL (p < 0.001). HRQoL was impaired compared to the Swedish background population. CONCLUSION: Overall HRQoL in patients operated for rectal cancer with permanent stoma was inferior compared to patients without stoma. In the stoma group, a bulge or a hernia around the stoma further impaired HRQoL.

Eating marshmallows reduces ileostomy output: a randomized crossover trial.

AIM: Anecdotally, many ostomates believe that eating marshmallows can reduce ileostomy effluent. There is a plausible mechanism for this, as the gelatine contained in marshmallows may thicken small bowel fluid, but there is currently no evidence that this is effective. METHOD: This was a randomized crossover trial. Adult patients with well-established ileostomies were included. Ileostomy output was measured for 1 week during which three marshmallows were consumed three times daily, and for one control week where marshmallows were not eaten. There was a 2-day washout period. Patients were randomly allocated to whether the control or intervention week occurred first. In addition, a questionnaire was administered regarding patient's subjective experience of their ileostomy function. RESULTS: Thirty-one participants were recruited; 28 completed the study. There was a median reduction in ileostomy output volume of 75 ml per day during the study period (P = 0.0054, 95% confidence interval 23.4-678.3) compared with the control week. Twenty of 28 subjects (71%) experienced a reduction in their ileostomy output, two had no change and six reported an increase. During the study period, participants reported fewer ileostomy bag changes (median five per day vs six in the control period, P = 0.0255). Twenty of 28 (71%) reported that the ileostomy effluent was thicker during the study week (P = 0.023). Overall 19 (68%) participants stated they would use marshmallows in the future if they wanted to reduce or thicken their ileostomy output. CONCLUSION: Eating marshmallows leads to a small but statistically significant reduction in ileostomy output.

Thermography: a new option to monitor filtering bleb function?

PURPOSE: To evaluate the filtering bleb function after trabeculectomy using a new ocular surface thermography device. METHODS: Thirty-five eyes of 35 patients after trabeculectomy were included in this prospective study. The filtering bleb function was tested with a new ocular surface-oriented, infrared radiation thermographic device in a noncontact manner (TG 1000). The eyes were classified into poorly controlled and well-controlled intraocular pressure (IOP) groups according to the patients' postoperative IOP. According to Kawasaki and colleagues, the mean temperature decrease in the filtering bleb (TDB) for evaluating bleb function was used, where TDB=(mean temperature of the temporal and nasal bulbar conjunctiva)-(mean temperature of the filtering bleb). Furthermore, the filtering bleb was evaluated during 10 seconds of eye opening and a new parameter was introduced, the TB10sec. TDB and TB10sec were analyzed statistically. RESULTS: The TDB was 0.911°C (±0.467) and the TB10sec was -1.027°C (±0.312) in the well-controlled IOP group. The TDB was 0.599°C (±0.499), and the TB10sec was -0.623°C (±0.265) in the poorly controlled IOP group, respectively. The difference in TDB (P=0.045), as well as that of TB10sec (P<0.001), between the well-controlled and poorly controlled IOP groups was significant. CONCLUSIONS: Temperature decrease in the filtering bleb provides information about its function. Because of the easy handling and reproducible measurements, thermography using Tomey TG 1000 may be a useful tool in the evaluation of filtering bleb function.

Patients' Experiences of Performing Self-care of Stomas in the Initial Postoperative Period.

BACKGROUND: With the loss of an important bodily function and the distortion in body image, a stoma patient experiences physical, psychological, and social changes. With limited current studies exploring experiences of patients in the management of their stoma, there is a need to explore their experiences, their needs, and factors that influence their self-management. OBJECTIVE: The aim of this study was to investigate patients' experiences of performing self-care of stomas in the initial postoperative period. METHODS: This study adopted a descriptive qualitative approach from the interpretive paradigm. Semistructured interviews were conducted with 12 patients 1 month postoperatively in a colorectal ward in a hospital in Singapore. Thematic analysis was applied to the interview data. RESULTS: Five themes were identified: process of acceptance and self-management of stoma, physical limitations, psychological reactions, social support, and need for timely and sufficient stoma preparation and education. CONCLUSIONS: This study highlights the importance of health professionals' role in helping patients adjust preoperatively and postoperatively and accept the presence of a stoma. Health professionals need to be aware of the physical, psychological, and social impact of stoma on patients in the initial 30-day postoperative period. IMPLICATIONS FOR PRACTICE: Research findings informed the type and level of assistance and support to be offered to patients by nurses and the importance of encouraging patients to be involved in stoma care at an early stage, which will ultimately contribute to effective and independent self-management. Patients can be prepared preoperatively to reduce the psychological and social impact of stoma after creation of their stoma.

Surgical access through the stoma for laparoscopic reversal of Hartmann procedures.

The rate of stoma reversal after Hartmann procedure is low, principally because of the technically demanding nature of the reversal procedure and preexisting comorbid disease frequently present in this patient group. Laparoscopic reversal of Hartmann procedure is an attractive alternative that can reduce perioperative morbidity but the feasibility of completing the procedure laparoscopically is often limited by extensive adhesion formation present after the initial open operation. We describe a technique for laparoscopic reversal of Hartmann procedure where the stoma is mobilized externally and a pneumoperitoneum established through this preexisting defect. Results for the first 7 cases show a median operative duration of 132 minutes and length of hospital stay of 6 days with no conversions. Insertion of the operating ports under direct vision and a more limited dissection to facilitate the anastomosis represents an alternative operative strategy that can be performed successfully, even in patients with comorbid disease.

[Impact of abnormal myoelectricity at gastroduodenal anastomosis on gastric emptying in rats].

OBJECTIVE: To explore the impact of abnormal myoelectricity at gastroduodenal anastomosis on gastric emptying in rats. METHODS: Rats were randomly divided into experimental group (n=16) and control group (n=16). Pylorectomy and end-to-end gastroduodenal anastomosis were performed in the experimental group and electrodes were implanted in the serosal surface adjacent to the anastomosis. Slow waves were recorded by the implanted electrode in vivo. Gastric emptying was examined by scintigraphy. RESULTS: At the first week after surgery, antral slow-wave frequency was significantly lower in the experimental group (0.8±1.4 vs. 3.3±1.2, P<0.01), as was the duodenal slow-wave frequency (2.1±0.6 vs. 11.1±0.7, P<0.01). There was no consecutive slow-waves transduction across the pylorus or the anastomosis. Within 12-16 weeks after operation, antral slow-wave frequency in the experimental group and the control group were (8.7±0.6) cpm and (4.0±0.4) cpm, respectively (P<0.01), and duodenal slow-wave frequency were (11.1±0.8) cpm and (10.8±0.7) cpm, respectively (P>0.05). Retrograde and antegrade myoelectricity transduction through the anastomosis were detected. The mean semi-emptying time in the proximal stomach was 14.7 min in the experimental group and 13.6 min in the control group (P>0.05). Radionuclide retention rate was 25.4% in the experimental group and 39.4% in the control group (P>0.05). The mean semi-emptying time in the distal stomach was 25.3 min in the experimental group and 10.5 min in the control group (P<0.01). Radionuclide retention rate was 46.4% in the experimental group and 18.7% in the control group (P<0.01). CONCLUSION: The abnormal myoelectricity in the region of gastroduodenal stoma may delay liquid gastric emptying in pylorectomy rats.

Use of visible spectrophotometry to assess tissue oxygenation in the colostomy stoma.

The aims of this study were to determine the normal range of tissue oxygenation (SO(2)) in the "mature" colostomy stomacolostomy stoma and to investigate whether there were any diurnal variationsdiurnal variations in the SO(2) values. Ten patients with an end colostomy for a minimum duration of three months and using conventional colostomy bags were included in this study. Tissue SO(2) Tissue SO(2) was measured on the stoma using visible wavelength spectroscopy (Whitland RM 200, Whitland Research, Whitland, UK) The measurements were carried out on each patient on three occasions: the first early in the morning (designated "baseline"), a second after 6 h and the third on the next day at 24 h. The results showed that the mean baseline SO(2) in the colostomy stoma was 77.6 +/- 6.8 and there were no differences in the SO(2) measurements between the baseline, 6 h and the 24 h values. There were also no differences in the SO(2) values between the four quadrants of the stomas. In conclusion, visible wavelength spectrophotometry can reliably measure stomal SO(2) in a non-invasive way. No significant diurnal variations in the stomal SO(2) values were detected.

Restoring hindgut continuity in cloacal exstrophy: a valuable method of optimising bowel length.

BACKGROUND: In cloacal exstrophy the hindgut is typically a blind ending segment attached to the exstrophy plate. This section of bowel may be mobilized, its continuity restored with the rest of the bowel, and used to fashion an end colostomy. We review our results using this approach. PATIENTS AND METHODS: A retrospective review of the outcomes was carried out on the basis of the case notes of nine consecutive patients with cloacal exstrophy who had been treated by restoration of hindgut continuity and an end colostomy. RESULTS: The colostomy was fashioned at a median age of 17 days of life. The colostomy was formed as part of the primary repair in all but one patient in whom it was performed as a secondary procedure to treat a previously repaired, dehisced exstrophy repair where the hindgut had originally been left in situ. Seven patients had co-existing spinal anomalies and potentially neuropathic bowel. The median length of hindgut that was restored was 10 cm. Median interval until the stoma produced faeces was six days. There was stoma necrosis in one patient requiring early revision. Six patients underwent further subsequent bowel operations at a median interval of 9.1 months: four had colostomy revision but kept the hindgut, one had excision of the hindgut and a terminal ileostomy, and one had a pull-through operation that was subsequently further revised to an ileostomy. CONCLUSION: Use of the hindgut loop in cloacal exstrophy to form a distal terminal colostomy is effective. Although stoma complications are common, these may be offset against the benefits of: restoration of hindgut electrolyte and fluid absorption; easier to mange stoma effluent; and the siting of the stoma on the left providing greater flexibility for future bladder reconstruction.

Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer.

BACKGROUND: A defunctioning stoma is frequently created to minimize the impact of any subsequent anastomotic leak after a low rectal anastomosis. This review evaluates the need for routine stoma formation. METHODS: A meta-analysis was performed of randomized controlled trials (RCTs) and non-randomized studies with an interventional group evaluating the need for a defunctioning stoma after low anterior resection for rectal cancer. Primary outcomes analysed included clinical anastomotic leak rate, reoperation rate and mortality related to leak. RESULTS: Four RCTs and 21 non-randomized studies, with 11,429 patients in total, were analysed. Meta-analysis of the RCTs showed a lower clinical anastomotic leak rate (risk ratio (RR) 0.39 (95 per cent c.i. 0.23 to 0.66); P < 0.001) and a lower reoperation rate (RR 0.29 (0.16 to 0.53); P < 0.001) in the stoma group. Meta-analysis of the non-randomized studies showed a lower clinical anastomotic leak rate (RR 0.74 (0.67 to 0.83); P < 0.001), lower reoperation rate (RR 0.28 (0.23 to 0.35); P < 0.001) and lower mortality rate (RR 0.42 (0.28 to 0.61); P < 0.001) in the stoma group. CONCLUSION: A defunctioning stoma decreases clinical anastomotic leak rate and reoperation rate. It is recommended after low anterior resection for rectal cancer.

Cloacal exstrophy--pull-through or permanent stoma? A review of 53 patients.

PURPOSE: Patients with cloacal exstrophy have complex anomalies of the genitourinary and gastrointestinal tract with a spectrum of colonic length. Often, colon is lost during the initial management by use of ileostomies and for urologic and genital reconstruction. It is a common belief that these patients require permanent stomas, which we hypothesized is inaccurate, and therefore reviewed our experience with exstrophy, focusing specifically on a patient's potential to undergo a colonic pull-through. METHODS: All patients with exstrophy or exstrophy variant treated by the authors were retrospectively reviewed. Their ability to form solid stool was assessed via bowel management involving a constipating diet, antidiarrheals, bulking agents, and a daily enema through the stoma. Patients who underwent successful bowel management through the stoma were offered a pull-through. RESULTS: Fifty-three patients were treated over a 26-year period, including typical cloacal exstrophy (27), or a covered variant (16), and complex anorectal malformations with short colon (10). Newborn operations (48 done at other institutions, 5 by us) involved ileostomy in 11 or end colostomy in 42. Eight patients with ileostomies suffered acidosis and failure to thrive and underwent "rescue" operations to incorporate all defunctionalized colon into the fecal stream. Four had colon used for their urologic reconstruction and 6 for their genital reconstruction, leaving them borderline or unable to form solid stool. Twenty-three are undergoing bowel management or being observed for growth of the colonic pouch to determine if they are pull-through candidates. Of the others, 90% (27/30) underwent colonic pull-through. Ten percent (3/30) had a permanent stoma. Of 20 available for follow-up after pull-through, 17 are clean with bowel management (85%), 2 (10%) have voluntary bowel movements with occasional soiling, and 1 is incontinent but noncompliant. CONCLUSIONS: Indication for pull-through depends on successful bowel management through the stoma, which depends on the ability to form solid stool. To maximize this potential, it is crucial to use all available hindgut for the initial colostomy and avoid use of colon for urologic or genital reconstruction. Most patients have poor prognosis for bowel control but can remain clean with bowel management. Our experience indicates that a permanent stoma is not required for the most of these patients and that bowel management can keep them clean, which we believe provides them with a better quality of life. Using these criteria, most exstrophy patients, contrary to popular belief, are candidates for a pull-through.