Seminars in Colon and Rectal Surgery最新文献

The management of colorectal liver metastases (CRLM) is complex and should be individualized to each patient. Resectable CRLM benefit from surgical resection, preferably minimally invasive and parenchymal sparing, when feasible. Ablation is a viable alternative. Chemotherapy in this setting is potentially indicated in select patients, however, it has a clear role in unresectable CRLM. Newer locoregional therapies may benefit some unresectable CRLM with resistance to chemotherapy. Liver transplantation, a new therapy on the horizon for unresectable disease, has encouraging preliminary long-term survival outcomes for carefully selected patients.

Peritoneal metastases from colorectal cancer have a dismal natural history and poor response to systemic chemotherapy. Cytoreductive surgery, the mainstay of locoregional control of peritoneal carcinomatosis, with hyperthermic intraperitoneal chemotherapy (HIPEC) has shown survival benefit in selected patients. While recent studies such as the PRODIGE 7 trial have not demonstrated added benefit of HIPEC, these trials have limitations (i.e. choice of HIPEC agent, patient population), and more studies are needed. The efficacy of prophylactic HIPEC in patients at high risk for peritoneal recurrence remains controversial. Ongoing trials, including intraperitoneal delivery of novel anti-cancer agents, may yield significant new therapeutic options.

Stoma prolapse is a common late complication that approximately 30% of ostomates experience. Interventions vary from simple local revisions to trans-abdominal approaches for resection and re-siting of the prolapsed stoma. Definitively addressing stoma prolapse frequently requires surgical treatment of an associated parastomal hernia. Stoma prolapse infrequently leads to incarceration or strangulation requiring emergent surgical intervention. The decisions regarding intervention depend on acuity of patient presentation, the severity of the prolapse, and patient fitness for operative intervention.

Ileostomies are commonly created for a variety of gastrointestinal disease; however, anatomic and physiologic alterations often render ileostomy patients vulnerable to high outputs, dehydration, and electrolyte derangements. Proactive dietary, medical, and behavioral strategies can decrease ileostomy outputs and minimize complications related to high outputs. This article discusses physiology and pathophysiology relating to ileostomies and high-output ileostomies. Diagnostic assessments, work-up, and treatment options for patients with high output ileostomies are thoroughly reviewed through the lens of a healthcare provider.

Ongoing partnership between the surgeon, ostomy nurse, and patient beginning before surgery and continuing past surgery increases the likelihood of the patient's independence and confidence in ostomy care and decreases complications. This article provides tips and wish lists created by ostomy nurses to address the importance of preoperative patient education and stoma site marking, ideal stoma characteristics, basic ostomy care, the role of the ostomy nurse in follow-up care, and common ostomy complications.

After bladder removal, bowel is commonly utilized in the construction of a urinary diversion. There are two types of urinary diversions: incontinent diversions, in which urine continuously drains from a stoma; and continent diversions, in which urine does not freely drain from a stoma. Continent diversions may further be subcategorized as orthotopic, in which voiding occurs via the native urethra; and continent cutaneous, in which voiding occurs via clean intermittent catheterization. Herein, we review the most common types of urinary diversions and their relevant complications.

Patients undergoing colorectal surgery may need a stoma for a variety of clinical or disease related factors. Stoma creation can result in short- and long-term complications particularly when performed in demanding situations. In addition, a problematic stoma may have longstanding implications for overall functional outcomes and patient satisfaction. This manuscript seeks to identify high risk patient populations for challenging stoma creation and pragmatic techniques to mitigate complications.

The distress of stoma creation coupled with the ubiquity of stomas renders stoma-related care and education an underserved orphan interest. Fortuitously, multiple educational resources exist to help empower patients to adapt to life with an ostomy, improve their quality of life, and reduce complications and readmissions. Patients and their home caregivers should be educated pre- and post-operatively to understand their stoma to improve their quality of life, decrease preventable complications, and decrease health system resource utilization. A variety of outpatient stoma support groups and internet resources provide a venue for ongoing educational support for the ostomate.

Intestinal stoma formation continues to be an essential tool in the surgical armamentarium used in a variety of conditions for temporary or permanent fecal diversion. Despite the best efforts of surgeons and wound, ostomy, and continence nurses, patients continue to suffer high rates of peristomal skin complications with associated quality of life and financial morbidity. A proactive approach to maintain peristomal skin health coupled with early recognition and treatment of skin complications is essential to optimize patient outcomes.

Loop ostomies, fashioned either from the terminal ileum, transverse colon, or sigmoid colon are well-established methods for diverting the fecal stream. Important anatomic considerations, such as patency of the left colic artery and marginal artery and competency of the ileocecal valve, must be considered when creating diverting loop ostomies. Diverting loop ileostomies are associated with higher rates of dehydration and renal insufficiency due to higher stoma output, but have lower rates of prolapse than loop colostomies. Closure of loop ileostomies is associated with lower rates of wound infection but higher rates of post-closure obstruction versus loop colostomies. In emergent cases with a distended remaining colon, diverting loop transverse colostomies may be indicated due to the presence of a competent ileocecal valve.