Stephanie García-Botello

A Prospective Audit of the Complications of Loop Ileostomy Construction and Takedown

Aim: A prospective review of the complications of ileostomy construction and takedown. Materials and Methods: One hundred twenty-seven consecutive patients undergoing construction of a loop ileostomy were included in a prospective nonrandomized computer database. Complications of the loop ileostomy were assessed prior to and after closure. Three closure techniques were performed [enterotomy suture (25.7%), resection and hand sewn (31.2%) or stapled anastomosis (43.1%)] and compared. Results: One hundred twenty-seven (73 male, 54 female) patients, mean age 54 years were included from 1992 to 2002. Seventy-two patients underwent anterior resection for low rectal carcinoma, 30 an ileoanal pouch for ulcerative colitis and 25 for miscellaneous conditions. Fifty-nine pre-takedown complications occurred in 50 (39.4%) patients. The most common were dermatitis (12.6%) and erythema (7.1%). The most severe were dehydration in 1 patient and stomal prolapse in 4 patients. Closure was associated with a complication rate of 33.1% and a mortality rate of 0.9%. Wound infection occurred in 18.3% and small bowel obstruction in 4.6%. Anastomotic leak requiring reanastomosis occurred in 2.8% and enterocutaneous fistula treated conservatively in 5.5%. There were no statistically significant differences in morbidity between closure techniques (p = 0.892). There were no statistically significant differences in complications (p = 0.516) between patients with ulcerative colitis and those with neoplasia (39.29% vs. 32.2%). Conclusions: Loop ileostomy construction and takedown is associated with considerable morbidity, mostly minor. No differences exist between technique used for closure or the baseline pathology of the patient.

Early Prediction of Anastomotic Leak in Colorectal Cancer Surgery by Intramucosal pH

PurposeAdequate oxygenation is necessary for anastomotic healing, and ischemia has been found to be one of the most important factors in anastomotic leakage. This study was designed to assess the value of early postoperative intramucosal pH measurements for the prediction of anastomotic leakage in patients with colorectal anastomosis.MethodsA prospective study of 90 patients with rectal or sigmoid cancer with primary anastomosis was conducted. In all patients intramucosal pH was determined by using tonometry at the anastomotic and gastric levels during the first 24 and 48 hours postoperatively. Seven other variables also were tested by univariate and multivariate analysis for any association with anastomotic leakage.ResultsThe rate of clinical anastomotic leakage was 6.6 percent. Multivariate analysis showed that only the intramucosal pH at the anastomosis was an independent factor for the development of anastomotic leakage. The risk of leakage was 22 times higher in patients with an anastomotic intramucosal pH < 7.28 in the first 24 hours after surgery.ConclusionsMeasurement of anastomotic intramucosal pH in the early postoperative period can more accurately predict the risk of anastomotic leakage and benefit those patients who would need additional measures to improve the viability of the anastomosis.

Randomized clinical trial to evaluate the effects of perioperative supplemental oxygen administration on the colorectal anastomosis

Perioperative supplemental oxygen therapy may have beneficial effects on wound healing following colorectal surgery. The aim of this study was to evaluate the effects of such therapy on colorectal anastomotic pH and partial pressure of carbon dioxide (PCO2) gap.

Review of the anatomic concepts in relation to the retrorectal space and endopelvic fascia: Waldeyer’s fascia and the rectosacral fascia

Objective  A precise anatomical study of the fascias within the retrorectal space is reported, analyzing and clarifying the anatomical concepts previously employed to describe Waldeyer’s and the rectosacral fascia.

Prospective evaluation of intraoperative peripheral nerve injury in colorectal surgery.

Aim  Intraoperative peripheral nerve injury can have permanent neurological consequences. Its incidence is not known and varies according to the location and the surgical specialty. This study was a prospective analysis of intraoperative peripheral nerve injury as a complication of abdominal colorectal surgery.

The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy

Objective  To evaluate the relationship between extent of internal sphincter division following open and closed sphincterotomy, as assessed by anal endosonography, with fissure persistence/recurrence and faecal incontinence.

Prognostic implications of circumferential location of distal rectal cancer

Aim  This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers.

Valor actual de la ecografía endoanal en el diagnóstico de la enfermedad proctológica benigna

Resumen La utilizacion de la ecografia endoanal es, sin lugar a dudas, uno de los mayores avances de la ultima decada en la evaluacion de la enfermedad anorrectal y del suelo de la pelvis. Las indicaciones principales de la ecografia endoanal son el estudio morfologico del aparato esfinteriano en la incontinencia fecal, el estudio de localizacion de abscesos y fistulas perianales, la estadificacion del cancer de ano, asi como el estudio evolutivo despues del tratamiento conservador del cancer epidermoide, y el estudio del aparato esfinteriano en pacientes con fisura de ano, asi como la confirmacion morfologica de la esfinterotomia interna en esta misma enfermedad y otras. En esta revision realizamos un repaso de las principales indicaciones y de la utilidad en la actualidad de la ecografia endoanal en el diagnostico de la patologia proctologica benigna.

Estomas de protección en cirugía colorrectal. ¿Cuándo y cómo realizarlos?

Resumen En los ultimos anos, el empleo de estomas de proteccion en cirugia colorrectal se ha incrementado, y tiene fundamentalmente tres grandes indicaciones: 1) traumatismos ano-recto-colicos graves; 2) enfermedad de Crohn con importante afectacion anorrectal y perineal, y 3) prevencion de complicaciones derivadas del fracaso anastomotico, fundamentalmente tras reseccion anterior baja por neoplasia de recto y tras proctocolectomia restauradora por colitis ulcerosa o poliposis colica familiar. En cuanto al tipo de estoma a realizar, en los casos de enfermedad o traumatismo anorrectal, lo habitual sera realizar una sigmoidostomia en asa, por lo que la derivacion se situa inmediatamente proximal a la zona lesionada. En los casos de enfermedades y procedimientos en el colon izquierdo o recto, permanece la controversia entre realizar una ileostomia en asa o una colostomia transversa en asa, por lo que se debe analizar la facilidad en la confeccion y cierre, y su posible morbilidad, sin olvidar la percepcion del paciente con respecto a su manejo.

Three-dimensional endoanal ultrasound for diagnosis of perianal fistulas: reliable and objective technique

AIM To evaluate accuracy of three-dimensional endoanal ultrasound (3D-EAUS) as compared to 2D-EAUS and physical examination (PE) in diagnosis of perianal fistulas and correlate with intraoperative findings. METHODS A prospective observational consecutive study was performed with patients included over a two years period. All patients were studied and operated on by the Colorectal Unit surgeons. The inclusion criteria were patients over 18, diagnosed with a criptoglandular perianal fistula. The PE, 2D-EAUS and 3D-EAUS was performed preoperatively by the same colorectal surgeon at the outpatient clinic prior to surgery and the fistula anatomy was defined and they were classified in intersphincteric, high or low transsphincteric, suprasphincteric and extrasphincteric. Special attention was paid to the presence of a secondary tract, the location of the internal opening (IO) and the site of external opening. The results of these different examinations were compared to the intraoperative findings. Data regarding location of the IO, primary tract, secondary tract, and the presence of abscesses or cavities was analysed. RESULTS Seventy patients with a mean age of 47 years (range 21-77), 51 male were included. Low transsphincteric fistulas were the most frequent type found (33, 47.1%) followed by high transsphincteric (24, 34.3%) and intersphincteric fistulas (13, 18.6%). There are no significant differences between the number of IO diagnosed by the different techniques employed and surgery (P > 0.05) and, there is a good concordance between intraoperative findings and the 2D-EAUS (k = 0.67) and 3D-EAUS (k = 0.75) for the diagnosis of the primary tract. The ROC curves for the diagnosis of transsphincteric fistulas show that both ultrasound techniques are adequate for the diagnosis of low transsphincteric fistulas, 3D-EAUS is superior for the diagnosis of high transsphincteric fistulas and PE is weak for the diagnosis of both types. CONCLUSION 3D-EAUS shows a higher accuracy than 2D-EAUS for assessing height of primary tract in transsphincteric fistulas. Both techniques show a good concordance with intraoperative finding for diagnosis of primary tracts.