STOMAS AND DIVERTICULITIS

Transcription

1 STOMAS AND DIVERTICULITIS Jean-Jacques Jacques HOUBEN U.L.B. CENTRE HOSPITALIER INTERREGIONAL EDITH CAVELL First Post-Graduate course of the BSCRS colorectal section BRUSSELS 2002 gastrospace.com

2 DIGESTIVE STOMAS OESOPHAGOSTOMY GASTROSTOMY JEJUNOSTOMY ILEOSTOMY COLOSTOMY

3 DIGESTIVE STOMAS DIVERSION ALIMENTARY TEMPORARY DEFINITIVE Ileostomy for Ileo-anal anastomose protection Colostomy after Miles Abdomino- Perineal resection Gastrostomy for Caustic oesophagitis Jejunostomy for enteral nutrition in Non-resecable cancer

4 RIGHT AND TRANSVERSE COLOSTOMY DIVERSION TEMPORARY DEFINITIVE ADULT ISCHEMIC COLITIS LEFT COLECTOMY WITH LOST OF SPHINCTER FUNCTION INFANT N.E.C. HIRSCHSPRUNG EXCEPTIONAL

5 LEFT COLOSTOMY DIVERSION TEMPORARY DEFINITIVE ADULT HARTMAN PROCEDURE FOR DIVERTICULAR SIGMOIDITIS RECTAL INCONTINENCE MILES ABDOMINOPERINEAL RESECTION INFANT HIRSCHSPRUNG EXCEPTIONAL

6 COLON DIVERTICULOSIS MAY AFFECT THE WHOLE COLON FROM THE AGE OF 35. THE PREVALENCE INCREASES TO 60 % AFTER 80 YEARS. THE PROGRESSIVE HYPERTROPHY OF THE MUSCULARIS PROPRIA, ASSOCIATED WITH CONSTIPATION INDUCES THE HERNIATION OF THE MUCOSA THOUGH THE MUSCLE. IF THE DISEASE AFFECTS, IN A LESS PROPORTION THE RIGHT COLON (CAUSE OF HAEMORRHAGE), THE INFLAMMATION OF THE DIVERTICULA AROUND ALIMENTARY IMPACTIONS ESSENTIALLY CONCERNS THE SIGMOID COLON. gastrospace.com

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10 DIVERTICULOSIS REMAINS ASYMPTOMATIC UNTIL COMPLICATIONS. THE MICROABCESSES LOCATED IN THE HYPERTROPHIC STENOSIC SIGMOID PROVOKE AN ACUTE DIVERTICULITIS OR PERISIGMOÏDITIS. Diverticutitis and stoma brussels dec 2002

11 IF CHRONIC DIVERTICULITIS AND LOCAL FORMS ARE SYSTEMATICALLY CONTROLLED BY ANTIBIOTICS, THE COMPLICATED FORMS SHOULD BE OPERATED. THE MORTALITY AND THE MORBIDITY REMAIN HIGH BECAUSE MOST OF THE PHYSICIANS AND SURGEONS ARE EXPECTING FOR SEVERE COMPLICATIONS BEFORE ANY SURGICAL PROPOSITION. THE TYPICAL PATIENT IS 75 YEARS OLD, ADMITTED IN EMERGENCY, NOT PREPARED, OFTEN AFFECTED BY SIDE-DISEASES, SEVERELY INFECTED, AND MANAGED BY A YOUNG INEXPERIENCED EXHAUSTED SURGEON. Diverticutitis and stoma brussels dec 2002

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14 MOREOVER, THE RESIDENT IS CONFRONTED TO THE DECISION OF A DIFFICULT PRIMARY COLO-RECTAL ANASTOMOSIS IN POOR CONDITIONS. THE QUESTION IS : WHEN TO DO A PROTECTIVE STOMA? THE MEDLINE REVIEW IS PRESENTED UNDER THE LIGHT OF ERASMUS AND CAVELL EXPERIENCES. FROM 1997 TO 2002, 46 PAPERS HAVE BEEN CONSIDERED FOR THEIR CONTRIBUTION EC. 30 USA-CANADA, 9 SWITZERLAND 4 SCANDINAVIA 2 EASTERN EUROPE 1 THE INCIDENCE OF ACUTE DIVERTICULITIS SEEMS THE HIGHEST IN SWITZERLAND. Diverticutitis and stoma brussels dec 2002

15 THE INCIDENCE IS CERTAINLY CORRELATED WITH DIETARY HABITS. FIBERS IN DIET

16 4202 PATIENTS HAVE BEEN COLLECTED BY THE AUTHORS IN 6 YEARS. EXACTLY 50 % HAVE BEEN OPERATED IN EMERGENCY, 23% WITH HARTMANN, 27% WITH PRIMARY ANASTOMOSIS, SOMETIMES PROTECTED BY LOOP COLOSTOMY. THERE IS A CONSENSUS THAT SIGMOID RESECTION IS MANDATORY. ELECTIVE HARTMAN Iary ANASTOMOSIS Diverticutitis and stoma brussels dec 2002

17 20 % ARE MANAGED BY LAPAROSCOPY WITH A CONVERSION RATE RELATED TO THE EXPERIENCE OF THE SURGEON. Diverticutitis and stoma brussels dec 2002

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20 FOR MANY, IF COMPLICATED DIVERTICULITIS HAS BEEN REFINED OVER THE YEARS, DISCUSSION IS STILL ONGOING ABOUT WHETHER A SINGLE OR TWO STAGE PROCEDURE (HARTMANN'S PROCEDURE) SHOULD BE PERFORMED IN PATIENTS WITH PERITONITIS FROM PERFORATION OF A COLONIC DIVERTICULUM. THE HARTMANN PROCEDURE REMAINS THE STANDARD CONCERNING THE SURGICAL TREATMENT OF ACUTE COMPLICATED SIGMOID DIVERTICULITIS, ESPECIALLY IN SEVERE FORMS UNDER THE AGE OF 40, AT ALL AGE IN HINCHEY III AND IV. Diverticutitis and stoma brussels dec 2002

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24 25 TEAMS PROMOTED THE PRINCIPLE OF A PRIMARY ANASTOMOSIS TO AVOID THE COST (USA) AND THE MORBIDITY (EC) OF THE SECOND STAGE OPERATION. THE SUCCESS OF A PRIMARY ANASTOMOSIS IS RELATED TO THE DISPONIBILITY OF A COLORECTAL SURGEON. (DICARLO 2001) THE LATTER USES MORE URETHERAL CATHETER, OBSERVES LESS POST-OPERATIVE INFECTIONS, LESS PRE- OPERATIVE AND POST-OPERATIVE HOSPITAL STAY. THE RATE OF ANASTOMOTIC LEAKAGE IS EQUAL BECAUSE THE GENERAL SURGEON PREFERS A SECURED HARTMANN PROCEDURE. Diverticutitis and stoma brussels dec 2002

25 WHATEVER THE SURGICAL STRATEGY, IT SHOULD BE REMINDED THAT MORTALITY REACH 8 % IN THIS REVIEW OF 2097 OPERATIONS. MORBIDITY IS HIGH. MANY PAPERS PROVE THE POSSIBILITY OF PERFORMING A SECURE PRIMARY ANASTOMOSIS WITHOUT COLOSTOMY IN PATIENTS WITH COMPLICATED ACUTE DIVERTICULITIS. BUT THE CLINICAL AND THE SURGICAL FEELING REMAIN ESSENTIAL IN THIS FIELD. THE RATE OF 35 % ANASTOMOTIC FISTULAS, REPORTED BY SOME IS IN OUR COUNTRY NOT ACCEPTABLE. Diverticutitis and stoma brussels dec 2002

26 WELL DOCUMENTED BY THE TYPICAL CLINICAL SYMPTOMS, CT SCAN OR PERCUTANEOUS ULTRASOUND, THE DISEASE HAS BEEN CLASSIFIED BY HINCHEY IN 4 STAGES. STAGE III AND IV ARE DETERMINED BY PERFORATED ABSCESS AND GENERALIZEDFAECAL PERITONITIS. THE LITERATURE OFTEN REFERS TO THIS CLINICAL CLASSIFICATION TO CHOOSE THE MOST APPROPRIATE SURGICAL TREATMENT. Diverticutitis and stoma brussels dec 2002