Background: Defunctioning ileostomy is widely used to protect a low colorectal anastomosis. However, the use of an ileostomy may have an impact on long-term bowel function and quality of life after anterior resection. The objectives were to compare bowel function and quality of life outcomes between patients undergoing an anterior resection for rectal cancer, with and without the formation of a diverting ileostomy, and to compare outcomes for early versus late closure of diverting ileostomy. Method: A systematic literature review was performed to identify studies published between 2007 and 2018 comparing bowel function and quality of life outcomes after an anterior resection for rectal cancer in those with and without formation of a diverting ileostomy. Results: Four studies (three randomized controlled trials) reported bowel function and quality of life outcomes. Pooled analysis for 227 participants showed that having an ileostomy is associated with twice the risk of suffering from low anterior resection syndrome (odds ratio (major low anterior resection syndrome) 1.96, 95% confidence interval 1.1, 3.5; P = 0.02). There were no consistent differences in quality of life. Based on single studies there is limited evidence of some improvements in bowel function but no difference in quality of life after early compared to late closure of ileostomy. Conclusion: There is some evidence for an association between low anterior resection syndrome and the use of a diverting ileostomy to protect a rectal anastomosis. Potential confounders include height of the anastomosis. Further research into the mechanisms underlying this potential association may inform methods to mitigate the harms of an ileostomy.© 2019 Royal Australasian College of Surgeons ANZ J Surg 90 (2020) 687-692

Background High-output enterostomies and enteroatmospheric fistulas are common causes of intestinal failure, and may necessitate parenteral nutrition and prolonged hospital stay. Reinfusing lost chyme into the distal gut is known to be beneficial, but implementation has been limited because manual reinfusion is unpleasant and labour-intensive, and no devices are available. A new device is presented for reinfusing chyme easily and efficiently, with first-in-human data. Methods The device comprises a compact centrifugal pump that fits inside a standard stoma appliance. The pump is connected to an intestinal feeding tube inserted into the distal intestinal limb. The pump is activated across the appliance by magnetic coupling to a hand-held driver unit, effecting intermittent bolus reinfusion while avoiding effluent contact. Safety, technical and clinical factors were evaluated. Results Following microbiological safety testing, the device was evaluated in ten patients (median duration of installation 39·5 days; total 740 days). Indications included remediation of high-output losses (8 patients), dependency on parenteral nutrition (5), and gut rehabilitation before surgery (10). Reinfusion was well tolerated with use of regular boluses of approximately 200 ml, and no device-related serious adverse events occurred. Clinical benefits included resumption of oral diet, cessation of parenteral nutrition (4 of 5 patients), correction of electrolytes and liver enzymes, and hospital discharge (6 of 10). Of seven patients with intestinal continuity restored, one experienced postoperative ileus. Conclusion A novel chyme reinfusion device was developed and found to be safe, demonstrating potential benefits in remediating high-output losses, improving fluid and electrolyte balance, weaning off parenteral nutrition and improving surgical recovery. Pivotal trials and regulatory approvals are now in process.

In routine practice, regional anaesthesia is less commonly used for clavicular fracture compared to general anaesthesia. We report two cases of clavicle fracture for which operative treatment was done under combined superficial cervical plexus andinterscalene brachial plexus block. Inboththe cases combination of ropivacaine anddexmeditomidine was used forblock. Both the patients exhibited comfort and there was no additional analgesic demand in both the cases.Thuscombination ofinterscalene and superficial cervical plexus block can prove to be useful in patients with clavicle fracture where administration of general anaesthesia and its adverse effects could be avoided. [PubMed]

Background High‐output double enterostomies (DESs) and enteroatmospheric fistulas (EAFs) of the small bowel account for substantial patient morbidity and mortality. Management may include parenteral nutrition (PN) and prolonged admissions, at high cost. Reinfusion of chyme into the distal bowel is a proposed therapeutic alternative when the distal DES limb is accessible; however, standardized information on this technique is required. This review aimed to critically assess the literature regarding chyme reinfusion (CR) to define its current status and future directions. Methods A systematic search of medical databases was conducted for articles investigating CR in adults. Articles reporting indications, methods, benefits, technical issues, and complications resulting from CR were reviewed. A narrative synthesis of the retrieved data was undertaken. Results In total, 24 articles reporting 481 cases of CR were identified, although articles were heterogeneous in their structure and reporting. CR was most frequently performed for remediation of high‐output DES and intestinal failure and for proximally located DES. Effluent output collection was commonly manual, with distal reinfusion more commonly automated, and with few dedicated systems. Multiple benefits attributed to CR were reported, encompassing weight gain, cessation of PN, and improvements in liver function. Technical problems included distaste, labor‐intensive methods, reflux of contents, and tube dislodgement. No serious AEs or mortality directly attributable to CR were reported. Conclusions CR appears to be a promising, safe and well‐validated intervention for small bowel DES and EAF. However, more efficient and acceptable methods are required to promote greater adoption of the practice of CR.

Aim Ileostomy formation is a commonly performed procedure with substantial associated morbidity. Patients with an ileostomy experience high rates of unplanned hospital readmission with dehydration, and such events have a long‐term health and economic impact. Reports of the significant risk factors associated with these readmissions have been inconsistent. This study aimed to identify the significant risk factors for readmission with dehydration following ileostomy formation. Method A systematic search was conducted using the Medline, Embase, Cochrane and CINAHL databases. All original research articles reporting risk factors for readmission with dehydration following ileostomy formation in adults were included. The primary outcome was the pooled risk ratio of clinically relevant variables potentially associated with dehydration‐related readmission following ileostomy formation. The secondary outcome was the incidence of dehydration‐related readmission. Results Ten studies (27 089 patients) were included. The incidences of 30‐ and 60‐day readmission with dehydration were 5.0% (range 2.1%–13.2%) and 10.3% (range 7.3%–14.1%), respectively. Eight variables were found to be significantly associated with dehydration‐related readmission: age ≥65 years, body mass index ≥30 kg/m2, diabetes mellitus, hypertension, renal comorbidity, regular diuretic use, ileal pouch–anal anastomosis procedure and length of stay after index admission. A preoperative diagnosis of colorectal cancer was less likely to result in readmission with dehydration. Conclusion Readmission with dehydration following ileostomy formation is a significant issue with several risk factors. Awareness of these risk factors will help inform the design of future studies addressing risk prediction, allow risk stratification of ileostomates and aid in the development of personalized prevention strategies.