A review of closure of Hartmann's colostomy was undertaken to establish guidelines for the timing and technique of reversal. Between 1984 and 1990 there were 69 reversals; 48 patients originally had diverticular disease and 21 had carcinoma. One-third underwent reversal before 4 months and two-thirds after this time. The operative mortality rate was 3 per cent and the anastomotic leak rate 4 per cent. Significant morbidity occurred in 30 per cent. There was no advantage in delayed closure. Complications occurred in 24 per cent of patients undergoing reversal before and 35 per cent undergoing reversal after 4 months. Thirty-five anastomoses were hand-sewn and 34 stapled. There were no differences in operating time for the two techniques, but a greater number were stapled after 4 months than before (P less than 0.05), which may reflect increased rectal stump shrinkage with time. There were no differences in complication rates whether the anastomosis was hand-sewn (34 per cent) or stapled (26 per cent). Closure of Hartmann's colostomy is a safe procedure but has a significant morbidity in nearly one-third of cases. On the basis of these results, there is no indication to delay closure after 4 months have elapsed, and earlier reversal, when the rectal stump is most accessible, is recommended.

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Gastric electrical stimulation can provide symptomatic relief for patients with refractory gastroparesis. Traditionally, these wires are placed through a midline laparotomy. This paper describes and illustrates, in detail, the laparoscopic technique for successful implantation. Thirty-one consecutive patients from October 2003 to March 2005 underwent laparoscopic insertion of gastric stimulating wires for gastroparesis. Twenty-six patients were female. Four laparoscopic ports were used to insert a pair of electrodes. Anterior, cephalad retraction of the gastric wall is critical for accurate seromuscular placement of gastric leads. Intraoperative endoscopy was used to verify the seromuscular placement of the leads. Both leads were secured to a subcutaneous generator and electrical parameters were immediately established in the operating room. Patient demographics, operative details, and postoperative morbidities were recorded. All procedures were completed laparoscopically. The mean operative time was 114.4 +/- 20.9 minutes (range, 95-140). No perioperative mortality occurred. Two patients developed cellulitis at the generator site postoperatively and oral antibiotics were prescribed for one week postoperatively. No hardware was removed. Two patients had their generators repositioned due to pain at the pocket site. Gastric electrical stimulation is a novel treatment modality for patients with refractory gastroparesis and can be accomplished safely via laparoscopy. Laparoscopic insertion is successful even in patients with prior surgery and intact gastrointestinal tubes. Long-term follow-up and the current prospective multicenter trial continue to assess the efficacy of this treatment modality.