Eating marshmallows reduces ileostomy output: a randomized crossover trial

AIM: Anecdotally, many ostomates believe that eating marshmallows can reduce ileostomy effluent. There is a plausible mechanism for this, as the gelatine contained in marshmallows may thicken small bowel fluid, but there is currently no evidence that this is effective. METHOD: This was a randomized crossover trial. Adult patients with well-established ileostomies were included. Ileostomy output was measured for 1 week during which three marshmallows were consumed three times daily, and for one control week where marshmallows were not eaten. There was a 2-day washout period. Patients were randomly allocated to whether the control or intervention week occurred first. In addition, a questionnaire was administered regarding patient's subjective experience of their ileostomy function. RESULTS: Thirty-one participants were recruited; 28 completed the study. There was a median reduction in ileostomy output volume of 75 ml per day during the study period (P = 0.0054, 95% confidence interval 23.4-678.3) compared with the control week. Twenty of 28 subjects (71%) experienced a reduction in their ileostomy output, two had no change and six reported an increase. During the study period, participants reported fewer ileostomy bag changes (median five per day vs six in the control period, P = 0.0255). Twenty of 28 (71%) reported that the ileostomy effluent was thicker during the study week (P = 0.023). Overall 19 (68%) participants stated they would use marshmallows in the future if they wanted to reduce or thicken their ileostomy output. CONCLUSION: Eating marshmallows leads to a small but statistically significant reduction in ileostomy output.

Loop ileostomy closure: comparison of cost effectiveness between suture and stapler

Closure of loop ileostomy can be safely performed using sutures or staplers. The aim of the present study was to compare the cost effectiveness of three different techniques.

Early closure of ileostomy is associated with less postoperative nausea and vomiting

Background/Aims: Temporary loop ileostomy is increasingly used in colorectal surgery but necessitates secondary closure. We evaluated postoperative complications, particularly nausea and vomiting, in patients with early, intermediate, or late elective ileostomy closure. Methods: We included all patients undergoing ileostomy closure from 2001 to 2008. Time from ileostomy construction to closure was classified as early (EC, <12 weeks), intermediate (IC, 12–18 weeks), and late (LC, >18 weeks). Using multivariable logistic regression, we compared the frequency of postoperative complications between the groups. Results: We included 134 patients (87 males; median age 71 years, range 29–91). Carcinoma of the rectum (n = 67, 50%) was the main reason for ileostomy construction. The median time to ileostomy closure was 103 days (range 8–461). Among patients with EC, IC, and LC, postoperative nausea occurred in 50.0, 73.1, and 78.6%, respectively (p = 0.006), and postoperative vomiting in 22.5, 57.7, and 59.5%, respectively (p = 0.001). Adjusting for important covariates, the odds ratio for postoperative nausea was 2.0 (95% CI 0.76–5.1) for IC and 4.1 (95% CI 1.2–14.3) for LC compared to EC (p = 0.069). For postoperative vomiting, adjusted odds ratios were 3.8 (95% CI 1.4–10.4) for IC and 4.6 (95% CI 1.4–15.5) for LC (p = 0.012). Other complications did not differ between the groups. Conclusions: These findings suggest that early ileostomy closure might reduce postoperative nausea and vomiting.

Is a sustaining rod necessary for diverting loop ileostomy?

Objective: Whether or not a protective stoma reduces the rate of anastomotic leakage after distal colorectal anastomosis is still discussed controversially. It does however facilitate clinical management once leakage has occurred. Loop ileostomies seem to be associated with a lower morbidity and a better quality of life compared to loop colostomies. Generally, diverting loop ileostomies are secured at skin level by means of a supporting device in order to prevent retraction of the ileostomy into the abdomen. However, due to the supporting rod, difficulties may occur in applying a stoma bag correctly and leakage of faeces onto the skin may occur even with correct eversion of the afferent limb. Our aim was to compare morbidity and time to self-sufficient stoma-care in patients having a loop ileostomy with rod to those without rod. Methods: A total of 60 patients necessitating loop ileostomy were analyzed. Patients received surgery in of the two involved institutions according to inhouse standard procedures. 30 patients had an ileostomy with rod (VCHK Inselspital) and a further 30 without rod (KSW Winterthur). Morbidity and time to self-sufficiency regarding stoma care was analyzed during the first 90 postoperative days. Morbidity was determined according to a scoring system ranging from 0 to 4 points for any given set of possible complications (bleeding, necrosis, skin irritation, abscess, stenosis, retraction, fistula, prolapse, parastomal hernia, incomplete diversion), where 0 = no complication and 4 = severe complication. Continuous variables were expressed as median (95% Confidence Interval). For comparisons between the groups the Mann-Whitney U test was used, between categorical variables the X2 test was applied. Results: There were no significant differences in length of hospital stay or time to self-sufficient stoma-care between the groups. Although not significant, patients with a rod ileostomy had a tendency towards more stoma-related complications as well as stoma-related reoperations. The number of patients reaching total self-sufficiency regarding stoma care was higher after rodless ileostomy. Conclusion: According to our data, rodless ileostomies seemto fare just as well as those with a supporting rod, with equal morbidity rates and more patients reaching self-sufficient stoma care. Therefore routine application of a rod for diverting loop ileostomy seems unnecessary

O cuidado familiar à criança portadora de estomias intestinais no contexto domiciliar

O avanço e a modernização tecnológica e farmacológica nos diversos campos de atenção a saúde, tem garantido a sobrevivência de muitas crianças, especialmente as que nascem ou são portadoras de distúrbios funcionais complexos. Entretanto, se por um lado estes avanços tecnológicos permitiram a sobrevivência de crianças com diferentes distúrbios fisiológicos, por outro, gerou crianças com necessidades especiais de saúde, como as estomizadas. A emergência da criança estomizada e seu crescimento no território nacional circunscreve a problemática do estudo, uma vez que para o atendimento das demandas de cuidados desta criança, é necessário transcender os cuidados habituais, uma vez que a criança estomizada requer cuidados específicos. Objeto de estudo: o cuidado familiar à criança com estomia intestinal no contexto domiciliar. Objetivos: descrever os locais e pessoas com quem os familiares cuidadores aprenderam a cuidar da criança com estomia intestinal, identificar as práticas de cuidados realizadas pelos cuidadores e discutir os desafios que os familiares cuidadores encontraram para atender as demandas de cuidados das crianças com estomias intestinais no domicilio. Acreditando que os familiares adquirem conhecimentos para cuidar das crianças com estomias a partir de sua interação com outros sujeitos no seu ambiente social, os alicerces teóricos deste estudo estão pautados na aprendizagem social de Vygotsky e no Cuidado Centrado na Família. Descrição metodológica: a pesquisa qualitativa foi desenvolvida segundo método criativo sensível, sendo implementadas as dinâmicas de criatividade e sensibilidade Mapa Falante e Corpo Saber no domicílio de seis grupos de familiares cuidadores. A análise de discurso francesa foi aplicada à interpretação e à explicação dos materiais empíricos emergentes do trabalho de campo. Resultados: O hospital, o ambulatório, o domicilio e o contexto societal, emergiram como locais de aprendizado dos familiares cuidadores, cuja mediação foi realizada por profissionais de saúde e pelas mães cuidadoras. A vivência diária dos familiares no cuidado a criança com colostomia e ileostomia, fizeram com que eles criassem novas possibilidades de cuidar através de tentativas, erros e acertos na busca por uma melhor qualidade de vida de seus filhos. Os desafios relacionados às dimensões subjetivas, da prática do cuidar, social e econômica representaram algumas das situações de enfrentamento vivenciadas pelos familiares. O estudo aponta a necessidade de repadronização dos cuidados, onde novos dispositivos tecnológicos de saúde sejam criados e disponibilizados para esta clientela. A falta desses dispositivos faz com que o familiar cuidador tenha a necessidade de adaptações no cuidado da criança a fim de tornar possível o atendimento das demandas relativas a cada etapa de seu desenvolvimento infantil. Além disso, novas políticas públicas de saúde devem ser pensadas a fim de atender integralmente às múltiplas demandas da criança portadora de colostomia ou ileostomia.

Diversion of intestinal flow decreases the numbers of interleukin 4 secreting and interferon gamma secreting T lymphocytes in small bowel mucosa.

BACKGROUND/AIMS: The intestinal immune system faces large amounts of antigens, and its regulation is tightly balanced by cytokines. In this study, the effect of intestinal flow diversion on spontaneous secretion of interleukin (IL)-4 and interferon (IFN)- gamma was analysed. METHODS: Eight patients (two with Crohn's disease, four with ulcerative colitis, and two with previous colon cancer) carrying a double lumen small bowel stoma after a total colectomy procedure were included in the study. For each patient, eight biopsy samples were taken endoscopically from both the diverted and non-diverted part of the small bowel. Intraepithelial lymphocytes (IELs) and lamina propria lymphocytes (LPLs) were isolated separately and assayed for numbers of cells spontaneously secreting IL-4 and/or IFN-gamma by an ELISPOT technique. RESULTS: Compared with the non-diverted mucosa, a significant decrease in the number of spontaneously IFN-gamma secreting CD3 lymphocytes was observed in the diverted small bowel mucosa among both IELs (p = 0.008) and LPLs (p = 0.007). The same results, although less significant, were obtained for IL-4, especially in LPLs (p = 0.01). CONCLUSION: The intestinal content influences the spontaneous secretion of IFN-gamma and IL-4 by intestinal lymphocytes. These results could help to elucidate the anti-inflammatory role of split ileostomy in patients suffering from inflammatory bowel diseases.

A Multicenter Randomized Clinical Trial of Primary Anastomosis or Hartmann's Procedure for Perforated Left Colonic Diverticulitis With Purulent or Fecal Peritonitis.

OBJECTIVES: : To evaluate the outcome after Hartmann's procedure (HP) versus primary anastomosis (PA) with diverting ileostomy for perforated left-sided diverticulitis. BACKGROUND: : The surgical management of left-sided colonic perforation with purulent or fecal peritonitis remains controversial. PA with ileostomy seems to be superior to HP; however, results in the literature are affected by a significant selection bias. No randomized clinical trial has yet compared the 2 procedures. METHODS: : Sixty-two patients with acute left-sided colonic perforation (Hinchey III and IV) from 4 centers were randomized to HP (n = 30) and to PA (with diverting ileostomy, n = 32), with a planned stoma reversal operation after 3 months in both groups. Data were analyzed on an intention-to-treat basis. The primary end point was the overall complication rate. The study was discontinued following an interim analysis that found significant differences of relevant secondary end points as well as a decreasing accrual rate (NCT01233713). RESULTS: : Patient demographics were equally distributed in both groups (Hinchey III: 76% vs 75% and Hinchey IV: 24% vs 25%, for HP vs PA, respectively). The overall complication rate for both resection and stoma reversal operations was comparable (80% vs 84%, P = 0.813). Although the outcome after the initial colon resection did not show any significant differences (mortality 13% vs 9% and morbidity 67% vs 75% in HP vs PA), the stoma reversal rate after PA with diverting ileostomy was higher (90% vs 57%, P = 0.005) and serious complications (Grades IIIb-IV: 0% vs 20%, P = 0.046), operating time (73 minutes vs 183 minutes, P < 0.001), hospital stay (6 days vs 9 days, P = 0.016), and lower in-hospital costs (US $16,717 vs US $24,014) were significantly reduced in the PA group. CONCLUSIONS: : This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.

Fermentation of resistant starches: influence of in vitro models on colon carcinogenesis

Resistant starch type 2 (RS2) and type 3 (RS3) containing preparations were digested using a batch (a) and a dynamic in vitro model (b). Furthermore, in vivo obtained indigestible fractions from ileostomy patients were used (c). Subsequently these samples were fermented with human feces with a batch and a dynamic in vitro method. The fermentation supernatants were used to treat CAC02 cells. Cytotoxicity, anti-genotoxicity against hydrogen peroxide (comet assay) and the effect on barrier function measured by trans-epithelial electrical resistance were determine. Dynamically fermented samples led to high cytotoxic activity, probably due to additional compounds added during in vitro fermentation. As a consequence only batch fermented samples were investigated further. Batch fermentation of RS resulted in an anti-genotoxic activity ranging from 9-30% decrease in DNA damage for all the samples, except for RS2-b. It is assumed that the changes in RS2 structures due to dynamic digestion resulted in a different fermentation profile not leading to any anti-genotoxic effect. Additionally, in vitro batch fermentation of RS caused an improvement in integrity across the intestinal barrier by approximately 22% for all the samples. We have demonstrated that batch in vitro fermentation of RS2 and RS3 preparations differently pre-digested are capable of inhibiting the initiation and promotion stage in colon carcinogenesis in vitro.

Comparison of in vivo and in vitro digestion on polyphenol composition in lingonberries: potential impact on colonic health

The composition of polyphenols in ileal fluid samples obtained from an ileostomy subject after lingonberry intake was compared with lingonberry extracts obtained after simulated in vitro digestion (IVDL) and subsequent faecal fermentation (IVFL). HPLC-PDA-MS/MS analysis confirmed similar patterns of lingonberry (poly)phenolic metabolism after the in vivo and in vitro digestion, with reduced recovery of anthocyanins and a similar pattern of recovery for proanthocyanidins observed for both methods of digestion. On the other hand, the IVFL sample contained none of the original (poly)phenolic components but was enriched in simple aromatic components. Digested and fermented extracts exhibited significant (P < 0.05) anti-genotoxic (Comet assay), anti-mutagenic (Mutation Frequency assay), and anti-invasive (Matrigel Invasion assay) effects in human cell culture models of colorectal cancer at physiologically-relevant doses (0-50 μg/mL gallic acid equivalents). The ileal fluid induced significant anti-genotoxic activity (P < 0.05), but at a higher concentration (200 μg/mL gallic acid equivalents) than the IVDL. Despite extensive structural modification following digestion and fermentation, lingonberry extracts retained their bioactivity in vitro. This reinforces the need for studies to consider the impact of digestion when investigating bioactivity of dietary phytochemicals.

TOXIC DILATATION OF THE COLON IN CHAGAS-DISEASE

Toxic megacolon occurs in colitis of differing aetiology. This report describes 15 patients with chagasic megacolon with this complication. The clinical signs and symptoms in all patients were pain and progressive abdominal distension accompanied by fever, severe toxaemia and shock. Seven patients developed this clinical pattern after manual removal of faeces. The remaining patients had pain and abdominal distension followed by signs of severe toxaemia when first examined. Nine patients underwent total colectomy with ileostomy (one death), four partial colectomy (all died) and two received medical treatment (both died). At autopsy, three of the four patients undergoing partial colectomy had residual colitis and enteritis. The surgical procedure of choice for this complication of chagasic megacolon is total colectomy.

Fistole retto-vaginali Crohn-relate trattate mediante trasposizione del muscolo gracile: risultati a lungo termine e qualità della vita

OBIETTIVO: Le fistole retto-vaginali Crohn-relate hanno un impatto significativo sulla qualità della vita. Quando il canale anale è alterato da ulcerazioni e stenosi o in pazienti con difetti estesi del perineo, la chirurgia locale produce risultati insoddisfacenti. Lo scopo di questo studio è quello di valutare l'efficacia della trasposizione del muscolo gracile nelle fistole retto-vaginali Crohn-relate e determinare i suoi effetti sulla qualità della vita. MATERIALI E METODI: Da gennaio 2012 a ottobre 2014 sono state trattate 10 pazienti; sono state raccolte alcune variabili (età, BMI, il fumo, CDAI, setone perioperatorio, precedenti procedure, uso di immunomodulatori e steroidi). Tutte le pazienti sono state sottoposte ad ileostomia temporanea prima della graciloplastica. La percentuale di successo è stata misurata come numero di pazienti con fistola guarita dopo la chiusura della stomia. Sono stati utilizzati tre questionari prima della graciloplastica e 3 mesi dopo la chiusura della stomia al fine di valutare la qualità della vita (SF-36), l’ incontinenza fecale e la funzione sessuale. RISULTATI: La fistola retto-vaginale è stata chiusa in 9 pazienti su 10 dopo graciloplastica, con un follow-up medio di chiusura della stomia di 19 mesi (range 4 -34). È stata documentata una recidiva di RVF. Il tempo operatorio era 90-150 minuti (media, 120). La degenza postoperatoria era 7-16 giorni (media 10). Complicanze postoperatorie precoci includevano deiscenza delle suture perineali in 2 casi. Le complicanze a lungo termine includevano disestesia della cicatrice perineale. Nei dati post-operatori abbiamo riportato un miglioramento della qualità di vita, della funzione sessuale e della continenza fecale. CONCLUSIONI: La chiusura della fistola retto-vaginale utilizzando la trasposizione del muscolo gracile è associata a morbidità minima e un alto tasso di successo.

Treatment of fibrostenotic and fistulizing Crohn's disease

The majority of Crohn's disease patients will develop a complicated disease course over time which is characterized by the occurrence of stricturing and penetrating disease. Penetrating disease comprises internal fistulas (e.g. enteroenteric) and perianal disease. A complicated disease course may be associated with considerable morbidity and professional and personal disabilities. Treatment options for fibrostenotic Crohn's disease comprise endoscopic balloon dilation, stricturoplasties and surgical resection. Treatment of symptomatic perianal fistulizing disease is based on antibiotics, immunomodulators and anti-TNF drugs. Surgical measures include fistula drainage by means of setons, temporary ileostomy or a proctectomy. The presence of internal fistulas often necessitates surgical measures. A close collaboration between the gastroenterologist and the surgeon is mandatory to solve these interdisciplinary challenges.

A study of large-bowel volvulus in urban Australia

Background: Large-bowel volvulus is a rare cause of bowel obstruction in the industrialized world. We analyzed the presentation and outcome of 49 patients at the Princess Alexandra Hospital, Brisbane, Australia, who received a diagnosis of colonic volvulus from 1991 to 2001. Methods: A retrospective chart study was carried out. Results: Twenty-nine patients had sigmoid volvulus (59%), 19 patients had cecal volvulus (39%) and 1 patient had a transverse colon volvulus (2%). The diagnosis of sigmoid volvulus was made accurately on plain abdominal radiography or contrast enema in 90% of cases (n = 26), compared with only 42% of cases (n = 8) of cecal volvulus. Twenty-two patients with sigmoid volvulus were treated initially with endoscopic decompression. The success rate was 64% (n = 14). There was a high early recurrence rate of sigmoid volvulus for those treated by endoscopic decompression alone (43%) during a mean period of 32 days. Of the 14 patients with cecal volvulus who were treated with right hemicolectomy, 12 had primary anastomosis and 2 had end ileostomy with mucous fistula formation. There was no anastomotic leak following right hemicolectomy with primary anastomosis, even though 6 of these patients had an ischemic cecum. Conclusions: Endoscopic decompression of the sigmoid volvulus was safe and effective as an initial treatment but has a high early recurrence rate. Any patient who is fit enough to undergo operation should have a definitive procedure during the same admission to avoid recurrence. Cecal volvulus is associated with a higher incidence of gangrene and is treated effectively by right hemicolectomy with or without anastomosis. The need for swift operative intervention is emphasized.

Qualidade de vida de pessoas com estomias intestinais

Ostomy is an open surgical origin, when it is necessary to deviate temporarily or permanently, the normal transit of food and / or deletions. The patient with ostomy disposal is faced with changes in their physiology, also emerging on the need to care collection bag. This study aimed to analyze the quality of life (QOL) of people living with ostomy Intestinal (EI), who attended the Pediatric and Adult Rehabilitation Center of Rio Grande do Norte (CRI / CRA-RN). It is an analytical study with cross-sectional design and quantitative approach, accomplished with 89 people who had EI. The study was approved by the Ethics Committee of the Federal University of Rio Grande do Norte (CEP / UFRN), CAAE: 19866413.3.0000.5537. Held data collection in the period January-March 2015 using two instruments: an adapted general questionnaire covering socio-demographic, clinical and self-care and a specific instrument for assessing QOL of people with stoma titled as City of Hope Quality of Life - Ostomy Questionnaire (COH-QOL-Q), validated and adapted to Portuguese in 2010, composed of four areas, namely: Welfare Body (BEF), Welfare Psychological (BEP), Welfare (BES ) and Spiritual Well-Being (BEE). The collected data were entered into a database in Microsoft Excel 2007 spreadsheet application and processed in computerized software for descriptive and inferential analysis. The results showed that 83.1% had a colostomy and ileostomy 16.9%. Sociodemographic characteristics prevailed in males (57.3%), over 50 (57.3%), mulatto (46.1%), with presence of companion / a (57.3%), retired / beneficiaries (50.5%), monthly income above the minimum wage (68.5%) and who have studied up to elementary school (67.4%). Regarding clinical aspects, it was observed that the main cause that led to the making of the stoma was the neoplasm (59.6%) followed by trauma (21.3%). The sample showed people with stoma for more than six months (79.8%) of permanently (57.3%), in use sink equipment piece drainable (68.5%) of flat base (82.0%). With respect to self-care, 93.3% emptied and washed the bag alone (care related to hygiene) and 75.3% fixed the new exchange on the skin during the exchange (care related to the stock). Patients with more than six months of ostomy and had no partner (a) had higher averages of self-care related hygiene and purse. The average of respondents QoL scores was 68.90% for General QOL; 68.03% for the BEF; 68.38% for the BEP; 66.46% for BES and 75.41% for BEE. Among the aspects that influenced QOL included: physical strength, pain, suffering and gases (physical domain); appearance, care of the stoma and adaptation to new condition (psychological domain); isolation, interference in personal relationships and social activities (social domain) and going to church or synagogue, spiritual activities and positive change after ostomy (spiritual realm). Based on these results, it is concluded that this was a predominantly adult sample / elderly (between 50 and 70 years), with low education and the cause motivating the stoma, neoplasms. However, such findings did not pass at low percentage levels on the self-care capacity to deliver even at low QOL scores.