Securing the loop--historic review of the methods used for creating a loop colostomy

A prospective randomized controlled trial comparing early postoperative complications in patients undergoing loop colostomy with and without a stoma rod

AIM

A stoma rod or bridge has been traditionally placed under the bowel loop while constructing a loop colostomy. This is believed to prevent stomal retraction and provide better faecal diversion. However, the rod can cause complications such as mucosal congestion, oedema and necrosis. This single-centre prospective randomized controlled trial compared outcomes after creation of loop colostomy with and without a supporting stoma rod. The primary outcome studied was stoma retraction rate; other stoma-related complications were studied as secondary outcomes.

METHOD

One hundred and fifty-one patients were randomly allotted to one of two arms, colostomy with or without a supporting rod. Postoperative complications such as retraction, mucocutaneous separation, congestion and re-exploration for stoma-related complications were recorded.

RESULTS

There was no difference in the stoma retraction rate between the two arms (8.1% in the rod arm and 6.6% in the no-rod arm; P = 0.719). Stomal necrosis (10.7% vs 1.3%; P = 0.018), oedema (23% vs 3.9%; P = 0.001), congestion (20.3% vs 2.6%; P = 0.001) and re-admission rates (8.5% vs 0%; P = 0.027) were significantly increased in the arm randomized to the rod.

CONCLUSION

The stoma rod does not prevent stomal retraction. However, complication rates are significantly higher when a stoma rod is used. Routine use of a stoma rod for construction of loop colostomy can be avoided.

Intestinal stoma in patients with colorectal cancer from the perspective of 20-year period of clinical observation

Introduction

Intestinal stoma is a procedure most often performed in patients with colorectal cancer.

Aim

To identify the percentage of patients with colorectal cancer in which the intestinal stoma was performed.

Material and methods

We retrospectively analysed 443 patients treated during a 20-year period (1994–2013) due to colorectal cancer, in which the intestinal stoma was made during the first surgical intervention.

Results

In the second analysed decade, a significant decrease in the percentage of created stomas, definitive stomas in particular, was observed. Stomas were made significantly more often in patients with a tumour located in the rectum, the left half of the colon, and in patients undergoing urgent surgeries. An increased incidence of intestinal stomas was associated with a higher severity of illness and higher proportion of unresectable and non-radical procedures. The definitive stomas were significantly more often made in men and in patients with tumours located in the rectum, whereas temporary stomas were created significantly more often in patients undergoing urgent operations.

Conclusions

In the last decade (2004–2013) the number of intestinal stomas in patients operated due to colorectal cancer was significantly reduced.

Protective stomy as a complement to anterior rectal resection. Analysis of authors' material and literature review

Anastomotic leak after anterior rectal resection for cancer is one of the most dangerous complications of the procedure. Protective stomy is a way to avoid life-threatening consequences of this complication. The procedure is still under evaluation.The aim of the study was to evaluate the usefulness of forming a protective stomy as part of anterior rectal cancer resection on the basis of an analysis of the authors' material.

MATERIAL AND METHODS

In 2008 - 2009, we treated 111 patients with rectal cancer. Thirty-two of those patients received preoperative radio(chemo)therapy. Eighty-four patients (76%) underwent resection of the primary tumour. In 20 patients (24%), we performed abdominoperineal or abdominosacral resection; in 6 (7%) cases the Hartmann procedure was used and in 58 (69%) cases anterior rectal resection was performed. In 53 of 58 cases, the resections were assessed as curative and in 5 as palliative. In 18 of 58 (31%) patients, anterior resections were defined as low anterior resections. Twelve (67%) of these patients were subjected to preoperative radio(chemo)therapy. Two of 58 patients, who underwent anterior resection, had been treated by stomy creation before the radical procedure. One of them required neoadjuvant radiotherapy. In the second patient with the stomy, we restored the intestinal continuity during the primary tumour resection. Among the remaining 40 patients, only one underwent protective stomy creation during the resective procedure. This patient did not require preoperative radiotherapy.

RESULTS

We have not found any clinical indications of anastomotic leak in the analysed group of 58 patients subjected to anterior rectal resection for cancer.

CONCLUSIONS

Our modest experience reaffirms our conviction that anterior rectal cancer resection does not require routine protective stomy creation, also when low anterior resection follows preoperative radiotherapy.

Historical landmarks in operations on the colon--surgeons courageous

PURPOSE

The nearly 300-year history of surgery of the colon is replete with creative daring among surgeons who conquered the challenges of operating on this highly contaminated organ, housed in the sacrosanct peritoneal cavity.

METHODS

Alexis Littre's suggestion in 1710 that a colostomy may be successful in treating an infant with imperforate anus began an evolutionary process of extraperitoneal colostomy for obstructing carcinomas, and then, an intraperitoneal approach, which enhanced surgical evaluation of the tumor and optimal placement of the stoma. Reybard's introduction of sigmoid resection in 1823, followed by post-Lister contributions of Mickulicz, Paul, Murphy, Miles, Hartmann, and other 19th- and early 20th-century surgeons, paved the way for current successes in colon surgery.

RESULTS

The morbidity and mortality, which still accompanies surgery on the colon, often results from a failure of today's surgeon to apply those principles so meticulously documented by colon and rectum surgery historians.

CONCLUSIONS

The individual, who performs a Miles abdominoperineal resection, a Hartmann procedure, or any other of the classic operations on the colon, gains much by studying the original philosophy and technique of these pioneers in the field.