title: Dual endoscopic-assisted endoluminal colostomy reversal: a feasibility study.
abstract: BACKGROUND
  Emergent colostomies are associated with increased morbidity related to second closure operations. The purpose of this canine pilot study was to create a minimally invasive procedure that would reduce the time interval and morbidity involved with colostomy reversals after left colon end colostomies.
  
  
  METHODS
  Six mongrel dogs underwent modified laparoscopic Hartmann's procedures in which the stapled end of the rectal stump was approximated to the left colon proximal to the stoma. After 1 week, they underwent an endoluminal colostomy reversal with a computer-mediated, circular stapling device and varying anvil insertion methods. Variables recorded included anvil insertion technique and feasibility, OR time, complications, and number of days to first meal and bowel movement. A contrast enema performed 1 week post colostomy reversal ruled out anastomosis leaks and stenosis. The dogs were euthanized and subjected to necropsy.
  
  
  RESULTS
  Of four anvil insertion techniques tested, the most feasible employed a large-bore needle to perforate through the stapled end of the Hartmann pouch into the lumen of the left colon. Simultaneous endoluminal views of the rectal stump with a sigmoidoscope and the left colon lumen with an endoscope permitted a controlled and safe needle puncture. Through the needle, a guide wire was inserted to withdraw the anvil via the colostomy into place. A transanally inserted stapler was then married to the anvil under fluoroscopic guidance, thus completing the anastomosis. The colostomy was then taken down and transected at the level of the colocolostomy. Average operating time was 126 min (range 90-180), diet was tolerated within 1.5 days, and average number of days to first bowel movement was 2.5. The absence of stenosis, leaks, and inadvertent visceral injuries confirmed feasibility.
  
  
  CONCLUSIONS
  In this canine model, a dual endoscopic-assisted colostomy reversal with a computer-mediated, circular stapling device is feasible. Using this technique, colostomy reversals can possibly be performed 1 week post-colostomy without entering the peritoneal cavity, thus reducing the number of invasive operations and subsequent morbidity required to manage emergent colon perforations.
authors.affiliation: Division of Laparoscopic Surgery, Department of Surgery, Mount Sinai School of Medicine, 5 E 98th Street, 15th Floor, New York, NY 10029, USA.
authors.forename: B P
authors.initials: BP
authors.lastname: Jacob
authors.forename: M
authors.initials: M
authors.lastname: Gagner
authors.forename: T I
authors.initials: TI
authors.lastname: Hung
authors.forename: S
authors.initials: S
authors.lastname: Fukuyama
authors.forename: A
authors.initials: A
authors.lastname: Waage
authors.forename: L
authors.initials: L
authors.lastname: Biertho
authors.forename: W W
authors.initials: WW
authors.lastname: Kim
authors.forename: N
authors.initials: N
authors.lastname: Sekhar
mesh_terms: D000714:Anastomosis, Surgical; D000818:Animals; D003106:Colon / Q000601:surgery*; D003125:Colostomy; D004285:Dogs; D019723:Endoscopes; D004724:Endoscopy / Q000379:methods*; D004867:Equipment Design; D005260:Female; D005471:Fluoroscopy; D009339:Needles; D010865:Pilot Projects; D011183:Postoperative Complications; D012007:Rectum / Q000601:surgery; D020694:Sigmoidoscopes; D013525:Surgical Instruments; D017792:Surgical Stapling