Antiperistaltic ileostomy using the long terminal ileal segment

Segmental reversal of the small bowel can end permanent parenteral nutrition dependency: an experience of 38 adults with short bowel syndrome

OBJECTIVE

This study aimed to assess the results of segmental reversal of the small bowel (SRSB) in patients with short bowel syndrome (SBS) who were "permanently" dependent on parenteral nutrition (PN) and to identify possible prognostic factors for weaning.

SUMMARY BACKGROUND DATA

SRSB is a nontransplant surgical option for patients with SBS who require long-term PN. Few studies have reported outcomes in humans.

METHODS

: All patients who were permanently dependent on PN and underwent a SRSB between 1985 and 2010 for SBS were included. The data were retrospectively retrieved.

RESULTS

Thirty-eight patients underwent SRSB. The median age was 55.5 years (range, 18-76). The median length of the small bowel remnant was 49 cm (20-140), including a reversed segment of 10 cm (6-15). The median follow-up was 57.7 months (1-304). At the 5-year follow-up, 17 patients had been weaned from PN (45%). In the remaining patients, PN dependency had decreased from 7 ± 1 to 4 ± 1 days per week. The survival rate was 84%. The prognostic factors for weaning were a short time between subtotal enterectomy and SRSB (P = 0.036), a longer than typical stay in the nutrition unit (P = 0.035), and an SRSB longer than 10 cm (P = 0.024).

CONCLUSIONS

SRSB has a role as a conservative alternative to small bowel transplantation in patients with SBS permanently dependent on PN. With a segmental reversal of 10 to 12 cm, almost half of the patients can be expected to be weaned from PN.

Anti-peristaltic ileocolonproctoplasty: a salvage procedure in extensive resective colorectal surgery

BACKGROUND

In a few patients undergoing extensive colorectal resections, a short intermediate colon segment could be saved and interposed between the ileum and the anorectum, although technical problems usually lead to its loss.

CASES PRESENTATION

Two cases of anti-peristaltic ileocolonproctoplasty after demolitive surgery of both proximal and distal colon (necrosis of the colonic stump after debulking of ovarian cancer and Crohn's disease) are reported. Because the length of the colonic stump was insufficient to allow for a regular clockwise rotation of the colon and an orthotopic, iso-peristaltic colorectal anastomosis, the remnant colon was rotated in an anti-clockwise fashion and an anti-peristaltic anastomosis was performed, similar to a technique we have recently proposed (anti-peristaltic cecorectal anastomosis) for slow-transit constipation. Owing to the different pathological and surgical findings, two technical variants were adopted, involving the preservation of the middle colic artery and the left colic artery, respectively.

RESULTS

Post-operative course was uneventful, and the patients shortly recovered normal bowel habits (a mean of 4 and 3 motions over 24 h, respectively).

CONCLUSIONS

In selected patients, the anti-peristaltic interposition of a saved intermediate colon segment between the ileum and the rectal remnant is an advisable technical solution to preserve some re-absorption and reservoir function and to reduce the risk of diarrhoea, incontinence and urgency.

Ileostomy diarrhea

Ileostomy diarrhea is not an uncommon problem and can lead to considerable loss of quality of life. Unfortunately, well-designed therapeutic trials are lacking, and thus, treatment of patients with ileostomy diarrhea remains largely empiric. The majority of individuals will have "idiopathic" ileostomy diarrhea, or increased output due to proctocolectomy with limited ileal resection alone. Once other, less common causes are excluded, empiric treatment should be initiated with the safest, least costly option. In general, this consists of a dietary evaluation and symptomatic treatment with loperamide and advancing as needed to other, more expensive options, frequently with an increase in side effect profile. Other more recently evaluated treatment options include budesonide and oleic acid; however, efficacy has only been demonstrated in preliminary studies; further evaluation is needed. Limited data exist regarding success of surgical therapy such as reversed peristaltic ileal segments. It remains to be seen if surgery, other than ileostomy revision, has a role in the treatment of ileostomy diarrhea.