A previously healthy 46-year-old woman with a history of rectal adenocarcinoma, first discovered on colonoscopy 1 year ago who is status post low anterior resection with a diverting loop ileostomy returns to clinic 3 months after her low anterior resection for a preoperative appointment for her ileostomy reversal. Over the past 3 months she has had good ileostomy output as well as occasional loose stools per rectum. What workup does she need to have prior to ileostomy reversal?
A flexible endoscopic examination and a contrast enema (Gastrografin) are recommended prior to closure to ensure that the anastomosis has not leaked and is patent.
A 75-year-old woman undergoes a right hemicolectomy and end ileostomy for right-sided perforated diverticulitis. What is the most concerning adverse outcome in the short term of this procedure and will require revision?
Stoma necrosis may occur in the early postoperative period and is usually caused by skeletonizing the distal small bowel and/or creating an overly tight fascial defect. Limited mucosal necrosis above the fascia may be treated expectantly, but necrosis below the level of the fascia requires surgical revision. Stoma retraction may occur early or late and may be exacerbated by obesity. Local revision may be necessary.
A 19-year-old man with medically refractor ulcerative colitis undergoes a total colectomy with J-pouch creation. What are some of the late complications of ileal pouchanal reconstruction?
The functional outcome of ileal pouch-anal reconstruction is not always perfect. Patients should be counseled to expect 8 to 10 bowel movements per day. Up to 50% have some degree of nocturnal incontinence. Pouchitis occurs in nearly 50% of patients who undergo the operation for chronic ulcerative colitis, and small bowel obstruction is common. Pouches fail in 5 to 10% of patients.
A 50-year-old woman who underwent a total colectomy with ileal pouch-anal reconstruction 5 years ago presents to the emergency room with diarrhea, fever, 2 weeks of malaise, and severe abdominal pain. What is the most appropriate differential diagnosis?
This patient is likely presenting with pouchitis. Pouchitis is an inflammatory condition that affects both ileoanal pouches and continent ileostomy reservoirs. The incidence of pouchitis ranges from 30 to 55%. Symptoms include increased diarrhea, hematochezia, abdominal pain, fever, and malaise. Diagnosis is made endoscopically with biopsies. Differential diagnosis includes infection and undiagnosed Crohn disease.
A 68-year-old man is undergoing a right hemicolectomy for a cecal mass. He asks what the current research has shown about decreasing postoperative infection after this procedure. When should antibiotics always be used for this procedure?
Prospective randomized trials are needed to better understand the role of oral antibiotic prophylaxis in colorectal surgery. In contrast, long-standing, convincing data support the efficacy of parenteral antibiotic prophylaxis at the time of surgery. Broad-spectrum parenteral antibiotic(s) with activity against aerobic and anaerobic enteric pathogens should be administered just prior to the skin incision and redosed as needed depending on the length of the operation. There is no proven benefit to using antibiotics postoperatively after an uncomplicated colectomy.
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