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.

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.

[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.

Barriers to rehabilitation of colorectal cancer patients

BACKGROUND

Colorectal cancer is one of the most common cancers in the United States. Since 1993 there has been a decrease in colorectal cancer mortality. Thus, there are more cancer survivors. In this manuscript potential barriers encountered during the rehabilitation of the colorectal cancer patient will be discussed.

METHODS

A literature review of manuscripts dealing with the rehabilitation and quality of life of the colorectal cancer patient was performed with specific emphasis on barriers for rehabilitation.

RESULTS

There is not much literature regarding barriers to the rehabilitation of the colorectal cancer patient. The rehabilitation of the colorectal cancer patient is a complex continuum. In order to maximize the potential for rehabilitation a team approach where the patient, family, friends and health care providers participate actively should be undertaken. The most common barriers are in the domains of knowledge, patient, health care system, and therapy. The impact of these barriers will vary from patient to patient.

CONCLUSIONS

There is a paucity of literature regarding barriers to the rehabilitation of the colorectal cancer patient. Prospective databases as well as prospective longitudinal studies need to be established so that the barriers that colorectal cancer patients encounter during their rehabilitation are more clearly identified and understood.

Living with a stoma: a review of the literature

AIMS AND OBJECTIVES

This systematic review looks at the psychological and social impact of stoma surgery on peoples' lives.

BACKGROUND

The formation of a stoma can have a negative effect on a person's quality of life and affect lifestyle in a number of ways.

METHODS

The review examines nursing literature from 1990 to date and focuses on how stoma patients' lives are affected by the presence of a stoma. It informs nursing practice so nurses are better able to help individuals improve, maintain or recover their health following ostomy surgery.

RESULTS

The findings of the review indicate that stoma surgery can impact on individuals' lives in many different ways.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of the problems stoma patients can experience can help nurses plan care in an individualized way. Recommendations for nursing practice and future research are made.

Maintenance of mouse male germ line stem cells in vitro

The proliferation and differentiation of a stem cell are regulated intrinsically by the stem cell and extrinsically by the stem cell niche. Elucidation of regulatory mechanisms of spermatogonial stem cells (SSCs), the stem cell of the postnatal male germ line, would be facilitated by in vitro studies that provide a defined microenvironment reconstituted ex vivo. We analyzed the effect of in vitro environment on the maintenance of adult and immature SSCs in a 7-day culture system. Although the number of adult and immature SSCs decreased in a time-dependent manner, nearly one in four stem cells (24%) could be maintained in vitro for 7 days. Stem cell maintenance was enhanced by coculture with OP9 bone marrow stroma or L fibroblast cell lines, addition of glial cell line-derived neurotrophic factor, or utilization of specific culture medium. In contrast, coculture with TM4 or SF7 Sertoli cell lines and addition of activin A or bone morphogenetic protein 4 (BMP4) reduced stem cell maintenance in vitro. Only 4% of the stem cells remained when cultured with TM4 cells or activin A, and 6% remained when cultured with SF7 cells or BMP4. These results lead to the hypothesis that suppression of germ cell differentiation improves in vitro maintenance of SSCs by interrupting the unidirectional cascade of spermatogenesis and blocking stem cell differentiation.

Quality of life of stoma patients: temporary ileostomy versus colostomy

Ileostomy for proximal diversion as a preferred option over colostomy has been a recent topic of interest. Our study evaluated the quality of life (QOL) of patients with a temporary ileostomy and compared it with that of patients with a temporary colostomy. The QOL of 25 patients with an ileostomy (median age 42 years, range 22-76 years) was compared with that for 25 patients with a colostomy (median age 44 years, range 18-70 years). Indications for a stoma were rectal carcinoma, trauma, inflammatory bowel disease, anastomotic leak, or incontinence following an operative procedure for rectal prolapse. The study was conducted at a median of 8 weeks (range 6-16 weeks) for ileostomy patients and of 9 weeks (range 5-17 weeks) for colostomy patients following stoma creation. A self-administered structured questionnaire was used, with responses obtained for 10 QOL questions on a visual analog rating scale (0-100 mm); they were graded good (71-100), satisfactory (31-70), or poor (0-30). Altogether, 22 (88%) patients with an ileostomy, compared with 16 (64%) patients with a colostomy, were able to purchase their stomal appliances ( p = 0.09, chi(2): NS). Effluent was tolerable in 18 (72%) patients with an ileostomy compared with 7 (28%) patients with a colostomy ( p = 0.002, chi(2)). Appetite was not affected in any of the patients with an ileostomy (100%), compared with 64% of patients with a colostomy ( p = 0.002, chi(2)), travel by public transport 32% compared to 28% with colostomy (NS), dress in 20% compared to 24% with colostomy (NS), and daily activities 28% compared to 24% with colostomy (NS). Moreover, 68% with an ileostomy did not have a problem with hygiene compared with 40% with a colostomy (NS); 95% with an ileostomy abstained from sexual activity compared with 81% with a colostomy ( p = 0.21, chi(2): NS). Both ileostomy and colostomy resulted in significant QOL impairment. However, with ileostomy, the effluent was more tolerable, had less of an impact on personal hygiene, and preserved the appetite compared with colostomy. There were no differences in travel, dress, daily chores, or sexual activity between the two groups.

Durability of the Malone antegrade continence enema in pregnancy

The Malone antegrade continence enema (MACE) is a therapeutic option to treat chronic constipation and fecal incontinence in patients with neurogenic bowel. Previous reports have described the short-term success of this procedure, but no report has described the durability of the procedure during pregnancy. We present the case of a spinal cord injury patient who underwent an uncomplicated pregnancy after a MACE procedure with no stomal catheterization difficulties or leakage during or after the pregnancy.

[Bridging artery defect with autogenous vein under required anastomosing tension--a theoretical analysis based on related biomechanical evidence]

This study was aimed to establish a rabbit model of bridging artery defect with autogenous vein under required tension by selecting and appropriate length of graft. The uniaxial loading test in longitudinal direction was performed using 14 femoral arteries and 14 femoral veins. The tension(F)-strain(lambda) curve was measured and the exponential form F = m1 * [em2(lambda-1)-1] was employed to fit the curve. The results showed that with the range of 35.0 mm actual isolated length (AIL), the exponential form Fa = 0.22[e5.75(lambda a-1)-1] and Fv = 6.15 * 10(-3) [e7.89(lambda v-1)-1] could well fit the experimental data of rabbit's femoral artery and vein respectively. Therefore to make sure the required anastomosing tension F, the length of vein graft(LVG) should qualify the equation: (LVG/1.64) x lambda v + [(AIL - ADL)/1.58] x lambda a = AIL while 1.65 and 1.58 are the physiological stretch ratio of artery and vein, lambda v and lambda a stand for that of vein and artery under tension F, respectively.

[Intestinal pouches: gastric reconstruction]

Reconstruction of the intestinal passage after a total gastrectomy is usually based on a direct esophagojejunostomy with end-to-side implantation of the afferent loop. The second principle of reconstruction is based on preservation of the duodenal passage. Long-term problems such as weight loss and malnutrition are further considerations that lead to the concept that gastric reconstruction should have the form of a reservoir. In addition to the construction of the reservoir itself, the clinical concern of avoiding gastroesophageal reflux is a further requirement for the choice of reconstruction type. Diversion of the duodenal content via a Roux-en-Y end-to-side anastomosis is considered to be the standard procedure. Interposition of a sufficiently long duodenal loop with maintenance of the duodenal passage also has the effect of preventing duodenal reflux. A theoretical advantage of this procedure is the linking of the motility of the duodenum with that of the interposed segment with improved synchronization of the aboral nutrient passage. When one considers complicated reconstructive procedures, the present literature suggests construction of a pouch is definitely functionally superior to the simple esophagojejunostomy. Whether the duodenal passage should be maintained or whether a Roux-Y technique should be used is a question that is still open for discussion.

[The physiology of intestinal pouches]

To summarize, J-shaped and W-shaped ileal pouches serve as adequate neorectal reservoirs after proctocolectomy. These pouches anastomosed directly to the anal canal are as distensible and capacious and as readily evacuated as the rectum in health. However, the use of S- or H-shaped ileal pouches, which have efferent limbs positioned between the pouch and the anal canal, sometimes leads to outflow obstruction and incomplete evacuation. There is little doubt that neorectums made of ileum can allow patients to have entirely "normal" patterns of fecal continence. Nonetheless, with pouch distension, large-amplitude, propulsive pouch contractions occur. These large pressure waves bring on the urge to defecate. They stress the anal sphincters more acutely than either the infrequent, small-amplitude, nonpropulsive contractions or clustered contractions of the healthy rectum. Nonetheless, patients learn to recognize the different signals heralding the impending need for evacuation from the ileal pouch and deal with them. Jejunal pouches, because of their greater distensibility and larger capacity, and the greater frequency of interdigestive migrating myoelectric complexes (MMCs) occurring in them, hold the promise of being a better rectal substitute than ileal pouches. They are more difficult to construct, however. Colonic pouches, when anastomosed to the anal canal after rectal resection, also act as adequate fecal reservoirs. Their main drawback is the inability of some patients to empty them. Small (5 cm) colonic pouches seem to empty better than larger (10-15 cm) ones. Jejunal pouches and colonic segments used as gastric substitutes after gastrectomy provide a better reservoir for ingested food than straight jejunal segments. The main drawback of the pouches is their inability to triturate the solid content of a meal and to regulate the rate of its emptying into the small intestine. Liquids and solids likely empty from these pouches at the same rate, in contrast to the slower emptying rate of solids from the healthy stomach. This likely leads to maldigestion of solids, perhaps contributing to the weight loss often found after gastrectomy.

[Cecum reservoir]

The choice of the best reconstruction technique following resection of either the stomach or the rectum remains a matter of discussion. While there is no problem in reconnecting intestinal segments, which do not serve as a reservoir, there are many different operation techniques to replace the stomach and rectum, producing significantly different functional results. The ileocecal segment offers an excellent intestinal reservoir combined with an antireflux mechanism, thus presenting an ideal replacement for the stomach. For replacement of the rectal reservoir as well, the ileocecal segment may be used in the first line of treatment.

METHOD

The ileocecal segment was used in 20 patients following gastric resection and lymphadenectomy to reconstruct the intestinal passage between the esophagus and the duodenal stump (group A). In some further 44 patients (group B) the ileocecal segment was used to replace the rectum between the descending colon and the dentate line following resection for very low-grade rectal cancer. Mortality and morbidity were investigated in both groups. In group A quality of life, weight loss, dumping and reflux symptoms were evaluated. In group B continence, discrimination, defecation quality, urge and the patient satisfaction were investigated. All data were recorded prospectively.

RESULTS

Early and late mortality were not different compared to other reconstruction types. In each group one patient died within 60 days postoperatively due to myocardial infarction. The morbidity following stomach replacement was 20%, following rectal replacement 4.6% during hospitalization and 13.8% during follow-up, respectively. One patient complained about heartburn, but endoscopically no pathology was detected in any patient. Three months postoperatively the patients' weight remained stable or started to increase. Three months following rectal replacement 87% of the patients were continent with further improvement over 2 years. Soiling mainly during the night remained over 2 years in 44%. 88% of the patients were completely satisfied 2 years postoperatively.

CONCLUSION

The replacement of either the stomach or the rectum using the ileocecal segment with an adequate surgical technique is safe and produces excellent functional outcome regarding the reconstruction of the intestinal passage as well as the reservoir function of the primary organ. Furthermore, preservation of the duodenal passage after gastrectomy may prevent dysregulation of the endocrine and exocrine pancreatic hormones.

Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis

BACKGROUND

Anal sphincter function is increasingly preserved following rectal excision for cancer and provides a better quality of life for patients than does a permanent colostomy. However, anastomotic complications may cause considerable morbidity and mortality. This retrospective study examined the incidence of anastomotic complications following two forms of reconstruction after resection for mid-rectal cancer: colonic pouch-anal anastomosis (CPAA) and low colorectal anastomosis (LCRA).

METHODS

Some 258 consecutive patients with mid-rectal cancers between 6 and 11 cm from the anal verge underwent proctectomy with mesorectal excision and either CPAA or LCRA. The incidence of clinical and radiological leaks was determined in these patients who were considered in three groups: LCRA (defunctioning stoma), LCRA (no defunctioning stoma) and CPAA (all defunctioned).

RESULTS

In the LCRA group without a defunctioning stoma, a clinical leak occurred in 17.0 per cent, compared with two of 30 in the LCRA group with a defunctioning stoma. In the CPAA group a clinical leak occurred in 4.9 per cent of patients, which was not significantly different from the rate in those with a defunctioned LCRA. Patients with a non-defunctioned LCRA were more likely to suffer a clinical anastomotic leak (P=0.01), peritonitis (P=0.001) and require unscheduled reoperation (P=0.006) than those with a defunctioned LCRA and/or CPAA.

CONCLUSION

The use of a protective defunctioning stoma is advocated in conjunction with LCRAs.