Paradoxical herniation associated with hyperbaric oxygen therapy after decompressive craniectomy: A case report

BACKGROUND Whether hyperbaric oxygen therapy(HBOT)can cause paradoxical herniation is still unclear.CASE SUMMARY A 65-year-old patient who was comatose due to brain trauma underwent decompressive craniotomy and gradually regained consciousness after surgery.HBOT was administered 22 d after surgery due to speech impairment.Paradoxical herniation appeared on the second day after treatment,and the patient’s condition worsened after receiving mannitol treatment at the rehabilitation hospital.After timely skull repair,the paradoxical herniation was resolved,and the patient regained consciousness and had a good recovery as observed at the follow-up visit.CONCLUSION Paradoxical herniation is rare and may be caused by HBOT.However,the underlying mechanism is unknown,and the understanding of this phenomenon is insufficient.The use of mannitol may worsen this condition.Timely skull repair can treat paradoxical herniation and prevent serious complications.

Predictive visual field outcomes after optic chiasm decompressive surgery by retinal vessels parameters using optical coherence tomography angiography

AIM:To evaluate the predictive value of superficial retinal capillary plexus(SRCP)and radial peripapillary capillary(RPC)for visual field recovery after optic cross decompression and compare them with peripapillary nerve fiber layer(pRNFL)and ganglion cell complex(GCC).METHODS:This prospective longitudinal observational study included patients with chiasmal compression due to sellar region mass scheduled for decompressive surgery.Generalized estimating equations were used to compare retinal vessel density and retinal layer thickness preand post-operatively and with healthy controls.Logistic regression models were used to assess the relationship between preoperative GCC,pRNFL,SRCP,and RPC parameters and visual field recovery after surgery.RESULTS:The study included 43 eyes of 24 patients and 48 eyes of 24 healthy controls.Preoperative RPC and SRCP vessel density and pRNFL and GCC thickness were lower than healthy controls and higher than postoperative values.The best predictive GCC and pRNFL models were based on the superior GCC[area under the curve(AUC)=0.866]and the tempo-inferior pRNFL(AUC=0.824),and the best predictive SRCP and RPC models were based on the nasal SRCP(AUC=0.718)and tempo-inferior RPC(AUC=0.825).There was no statistical difference in the predictive value of the superior GCC,tempo-inferior pRNFL,and tempo-inferior RPC(all P>0.05).CONCLUSION:Compression of the optic chiasm by tumors in the saddle area can reduce retinal thickness and blood perfusion.This reduction persists despite the recovery of the visual field after decompression surgery.GCC,pRNFL,and RPC can be used as sensitive predictors of visual field recovery after decompression surgery.

Should we perform decompressive laparotomy during severe acute pancreatitis with intra-abdominal hypertension below 25 mmHg:Only the gut knows

We suggest that during severe acute pancreatitis(SAP)with intra-abdominal hypertension,practitioners should consider decompressive laparotomy,even with intra-abdominal pressure(IAP)below 25 mmHg.Indeed,in this setting,non-occlusive mesenteric ischemia(NOMI)may occur even with IAP below this cutoff and lead to transmural necrosis if abdominal perfusion pressure is not promptly restored.We report our experience of 18 critically ill patients with SAP having undergone decompressive laparotomy of which one third had NOMI while IAP was mostly below 25 mmHg.

Which Type of Decompressive Craniectomy Is Better? Advantages and Challenges of Fresh Cadaver Practices Based on Experiences from the Last 20 Years. The Effect of Jesus Prayers in Science

Aim of Study: Reviewing the large number of publications about DC in the case of severe traumatic brain swelling, there is no clear position on which one is preferable for the patient. Bifrontal or bilateral fronto-parieto-temporo-partial occipital craniectomy. One of the most critical points, the behaviour of brainstem and its vascular structures during the protrusion of the traumatized swelling brain, which can expand in different directions, depending on where the skull has been opened. Method: After the high ICP created on a simple fresh cadaver model, we examined the brainstem displacements and compressions with the help of an endoscope-guided transnasal transsphenoidal transclival and analyzed their possible harmful effects on brainstem structures and blood vessels. Results: In bilateral bifronto-parieto-temporo-partial occipital craniotomy, no significant bulging or forward movement of the brainstem was detected. In the course of bifrontal craniectomy, significant forward movement and thus compression of vascular structures and pons were detected. Conclusion: Our assumption has been confirmed. In bifrontal craniectomy, the expansion is not parallel to the course of the brainstem, but perpendicular so that the pons and the blood vessels running along its anterior surface are compressed by moving forward against the clivus, which leads to circulatory compression and damage to the brainstem. In bilateral DC, the expansion is axially parallel to the course of the brainstem. Based on the fresh cadaver model, the use of the latter method is preferable for the traumatized swelling brain. In both cases, bridging veins of the protruding brain at the bone edge must be protected by the vascular tunnel method against compression. We examined this scientific question not only from a neurosurgical perspective but also in terms of the general ethical possibilities and psychological difficulties of conducting fresh cadaver practices. Additionally, we provided an answer on how we can ease the work of research doctors practicing on the deceased through the power of spiritual exercises and prayer. The dissection room offers fantastic opportunities for surgeons to discover new paths.

Is decompressive craniectomy for malignant middle cerebral artery infarction of any worth?

Objective: Malignant middle cerebral artery (MCA) infarction is characterized by mortality rate of up to 80%. The aim of this study was to determine the value of decompressive craniectomy in patients presenting malignant MCA infarction compared with those receiving medical treatment alone. Methods: Patients with malignant MCA infarction treated in our hospital between January 1996 and March 2004 were included in this retrospective analysis. The National Institute of Health Stroke Scale (NIHSS)was used to assess neurological status on admission and at one week after surgery. All patients were followed up for assessment of functional outcome by the Barthel index (BI) and modified Rankin Scale (RS) at 3 months after infarction. Results: Ten out of 24patients underwent decompressive craniectomy. The mean interval between stroke onset and surgery was 62.10 h. The mortality was 10.0% compared with 64.2% in patients who received medical treatment alone (P<0.001). The mean NIHSS score before surgery was 26.0 and 15.4 after surgery (P<0.001). At follow up, patients who underwent surgery had significantly better outcome with mean BI of 53.3, RS of 3.3 as compared to only 16.0 and 4.60 in medically treated patients. Speech function also improved in patients with dominant hemispherical infarction. Conclusion: Decompressive craniectomy in patients with malignant MCA infarction improves both survival rates and functional outcomes compared with medical treatment alone. A randomized controlled trial is required to substantiate those findings.

Combination of dura turning-over and decompressive craniectomy： a new pattern of surgery for cerebral infarction caused by craniocerebral gunshot injury

Background:Craniocerebral gunshot injury refers to a wound caused by a bullet passing through or lodged in brain tissue,resulting in the loss of function of a certain area or other fatal damage to the human brain.Craniocerebral gunshot injury is usually life-threatening and is very common in modern warfare,accounting for the majority of battle casualties.Most of the patients suffer from acute cerebral infarction caused by vascular injury.Lack of early and solid battlefield emergency medical interference adds to the risk of death among the wounded.Case presentation:We present a 24-year-old man who was shot with a shotgun from a distance of 15m in an accidental injury.Forty-seven grape shots were found on his body surface by physical examination.A computed tomography(CT)scan demonstrated large areas of low-density shadows in his right parietal lobe and right temporal lobe with the midline shifting to the left side 2 days later.Afterwards,the patient was transferred to our emergency medical center at Changzheng Hospital in Shanghai.Cranial computed tomography angiography(CTA)showed a high-density shadow in the initial part of the right middle cerebral artery.The branches after the initial part were obliterated.Prompt medical attention and decompressive craniotomy(DC)surgery contributed to the final recovery from cerebral infarction of this patient.Conclusion:Bullets can penetrate or be lodged in the brain,causing intracranial hypertension.The bullets lodged in the brain can result in stenosis and embolism of a cerebral artery,causing acute cerebral infarction.Combining dura turning-over surgery with DC surgery can not only decrease intracranial pressure,which can increase the blood supply for hypertension-induced vessel stenosis,but also help vessels outside the dura mater grow into ischemic areas of the cerebral cortex.However,this new pattern of surgery needs further support from evidence-based medicine.

Paradoxical herniation after decompressive craniectomy provoked by mannitol:A case report

BACKGROUND Paradoxical transtentorial herniation is a rare but life-threatening complication of cerebrospinal fluid drainage in patients with large decompressive craniectomy.However,paradoxical transtentorial herniation after rapid intravenous infusion of mannitol has not been reported yet.CASE SUMMARY A 48-year-old male suffered from a right temporal vascular malformation with hemorrhage.In a coma,the patient was given emergency vascular malformation resection,hematoma removal,and the right decompressive craniectomy.The patient woke up on the 1st d after the operation and was given 50 g of 20% mannitol intravenously every 8 h without cerebrospinal fluid drainage.On the morning of the 7th postoperative day,after 50 g of 20% mannitol infusion in the Fowler’s position,the neurological function of the patient continued to deteriorate,and the right pupils dilated to 4 mm and the left to 2 mm.Additionally,computed tomography revealed an increasing midline shift and transtentorial herniation.The patient was placed in a supine position and given 0.9% saline intravenously.A few hours later,the patient was fully awake with purposeful movements on his right side and normal communication.CONCLUSION Paradoxical herniation may occur,although rarely,after infusing high-dose mannitol intravenously in the Fowler’s position in the case of a large craniectomy defect.An attempt should be made to place the patient in the supine position because this simple maneuver may be life-saving.Do not use high-dose mannitol when the flap is severely sunken.

Clinical Outcome of Decompressive Craniectomy Operation for the Management of Acute Traumatic Brain Injury

Objectives: To evaluate the efficacy of Decompressive Craniectomy (DC) on the postoperative clinical state of the patient to define a line of management of these cases. Take in considerations the surrounding circumstances of the patient till he reaches the ER in Egypt and the hospital resources. Methods: 200 patients suffering from acute traumatic brain injury causing DCL resulted from different pathologies causing increased ICP. In group A, patients with acute TBI were managed by surgical intervention in the form of Decompressive Craniectomy and in the control group B, patients were managed by medical treatment. The age range was from 8 to 65 with no history of associated medical disorders with exclusion criteria of non-traumatic causes of increased ICP. Results: Data collected showed: male to female ratio of 3:1. The most common mode of injury was falling from height. Mean time from injury to operative intervention was 4 hours. The leading initial symptoms were DCL. In group A the overall mortality was 60%, functional recovery rate was 30%, and left severely disabled or vegetative was 10%. 50% of the cases had associated injury. 20% suffered from post-operative complications. Conclusion: DC is the ideal solution for the management of acute TBI with persistent increased ICP when the other medical management fails, given an early intervention and taking into consideration other factors affecting surgical outcome.

Cranioplasty after Decompressive Craniectomy Caused an Intracerebral Hemorrhage: A Case Report

Decompressive craniectomy is a common practice for patients with intracranial hypertension. Secondary rigid structural reconstruction following craniectomy can release the effects of atmospheric pressure on the brain, and the brain can become dilated. Although some cases with complications induced by cranioplasty, such as intracranial hematoma, have been reported, no clinical cases with intracerebral hemorrhage after rigid reconstruction have been reported. This case report describes a 39-year-old man with a skull defect following clipping with simultaneous decompressive craniectomy for a subarachnoid hemorrhage. About 25 months later, cranioplasty using a custom-made hydroxyapatite (HAP) ceramic implant was performed. Immediately after the operation, intracerebral hemorrhage was detected on the opposite side by computed tomography (CT). However, there were no physical or neurological findings, the hematoma was completely absorbed within 3 weeks postoperatively, and the skull retained a good shape. This case suggests that rigid reconstruction of a skull defect can influence intracranial conditions, and early postoperative CT is important to detect complications.

Traumatic Acute Subdural Hematoma: Treatment by Evacuation with Decompressive Craniotomy and Cranioplasty, Case Series and Surgical Outcome Analysis

Background: Acute subdural hematoma (ASDH) is considered the most common traumatic brain mass lesion. Its prognosis is still grave despite the improvements in treatment modalities. Its mortality rate was reported to be around 60% until the 1990s. In the last decade, ASDH mortality rate was reduced to the level of 20% - 40%. Standard treatment to decrease intracranial tension via hematoma evacuation is associated with decompressive craniotomy and followed by ICU management. Objective: To evaluate the outcome and prognostic factors in patients of acute subdural hematoma treated by surgical evacuation and decompressive craniotomy. Also, outcome of cranioplasty by repositioning of patients own bone or by synthetic mesh methods is evaluated. Patients and Methods: It is one year retrospective study. It was conducted on 53 patients, in trauma unit, Assiut university hospitals. We report time lag between trauma and performed surgery, initial Glasgow coma scale (GCS), age, sex and presence of other intracranial pathologies. Outcome assessment is based on Glasgow outcome scale (GOS) and fol-low-up extended for 6 months. We include those patients with only (isolated) head trauma, shift of midline more than 5 mm in CT brain. We excluded pa-tients with GCS 3 and fixed dilated pupils as well as patients with GCS higher than 12. We did decompressive craniotomy and duraplasty in all patients. Bone flap of decompressive craniotomy is situated in the abdomen. All func-tionally recovered patients were submitted for cranioplasty with either re-placing patient own bone or by Titanium mesh. Results: We had 39 males and 14 females. Age ranged between 7 and 65 years old. 23 deaths, 10 persis-tent vegetative state, 10 severe disability, 8 moderate disability and 2 good recovery. The outcome analysis was based on 6 month follow-up. Conclu-sion: Acute subdural hematoma is a very serious condition. Mortality and morbidity is intimately related to GCS on admission. Presence of associated cerebral pathology increases mortality and morbidity of patients with post-traumatic acute subdural hematoma. Early evacuation of posttraumatic acute subdural hematoma with decompressive craniotomy is an important method to control raised intracranial tension, reduce shift of midline and very benefi-cial in decreasing mortality and morbidity. Regarding infection and avoiding bone flap resorption, Titanium mesh is better than patient own bone during cranioplasty after patient recovery.

Evaluation of Decompressive Craniectomy

Background and Purpose: Decompressive craniectomy is a surgery used to remove a large bone flap and opening the dura to allow edematous brain tissue to bulge extracranially. However, the efficacy of decompressive surgery to reduce the mortality and improve the outcome in patients with refractory intra-cranial pressure is still unclear. We investigated whether decompressive crani-ectomy is associated with improved conscious state and survival in patients with severely raised intracranial pressure and resistant to conservative management. Methods: We studied 20 patients with clinical and radiological evidence of increased intracranial pressure & indicated for decompressive crani-ectomy. All patients were followed postoperatively in ICU with serial follow up (CT). Consciousness level was evaluated using the Glasgow Coma Scale and Glasgow outcome score. Results: The overall mortality was 11 cases (55%), two cases remain in a vegetative state (10%), one case (5%) was severely disabled and six cases (30%) discharged with mild disability. Conclusion: In 20 cases with severely raised intracranial pressure resistant to conservative management Decompressive Craniectomy allowed (30 %) of cases to be discharged from hospitals with mild degree of disability for rehabilitation.

Functional Outcomes of Decompressive Hemicraniectomy for Treatment of Malignant Infarctions of the Middle Cerebral Artery

Introduction: Malignant middle cerebral artery (MCA) infarction is a devastating entity that is associated with up to 80% mortality. Decompressive Hemicraniectomy has been utilized to treat brain swelling and mass effect secondary to these infarctions in an attempt to improve functional outcome. Aim: To evaluate the functional outcome of decompressive hemicraniectomy in management of malignant MCA infarctions. Methods: The study included 30 patients with malignant MCA infarctions operated upon by decompressive hemicraniectomy and duroplasty with pericranium or fascia lata graft in the period from June 2016 to January 2019. Pre-operative neurological condition, associated morbidity, location and extent of the infarction were assessed. Surgery was performed within 48 hours of the onset of stroke or 12 hours within deterioration of conscious level. Pre-operative CT scan as well as sequential post-operative CT was done. Functional outcome was assessed by the modified Rankin Scale (mRS) at the time of discharge and 3 months following surgery. Results: The study included 18 males and 12 females with a mean age of 54.7 years. The pre-operative GCS was <8 (5 - 7) in 11 patients and 8 or higher (8 - 13) in 19 patients. Good functional outcome (mRS 0 - 3) was achieved in 13 (43.3%) cases while poor outcome (mRS 4 - 5) occurred in 8 (26.7%) cases and mortality (mRS 6) occurred in 9 (30%) cases. Conclusion: Decompressive hemicraniectomy improves functional outcome in cases of malignant MCA infarction. Pre-operative GCS, age, volume of infarction, degree of midline shift, timing of surgery and associated morbidity are the most important factors affecting the outcome.

Drainage and Cranioplasty as a Treatment for Traumatic Subdural Hygroma Secondary to Decompressive Craniectomy

Background: Decompressive craniectomy (DC) is performed to accommodate life-threatening brain swelling when medical treatment fails. This procedure carries the risk of developing traumatic subdural hygroma (TSH) that can adversely affect the neurological status of the patient. The treatment for persistence of TSH includes drainage and shunt placement or drainage and membranectomy. In this paper, we present treatment of two patients whose TSH was effectively treated with simple drainage and cranioplasty. Case Presentation: Patient 1: The patient is a 34-year-old female who had bilateral craniectomy for brain swelling. Four weeks later she became less interactive. CT scan showed bilateral subdural hygroma with 2 cm midline shift to the left. Her clinical status improved and CT scans showed resolution of the hygroma after simple evacuation of the hygroma and cranioplasty. Patient 2: The patient is a 57-year-old male who had post-traumatic acute subdural hematoma and brain swelling on the left side. The clot was evacuated and the bone flap was left out. After showing initial improvement, 10 weeks after the initial surgery the patient progressively worsened and became unresponsive. CT scans showed a large subdural hygroma on the right with midline shift to the left. Simple evacuation of the hygroma and cranioplasty was done. This resulted in radiological and clinical improvement of the patient. Conclusions: Both patients underwent simple drainage and cranioplasty, which resulted in clinical and radiological improvement. This finding suggests that other procedures such as membranectomy and shunting may not be necessary to treat TSH.

Mass brain tissue lost after decompressive craniectomy:A case report

BACKGROUND The brain is the most important organ to maintain life.However,the amount of brain tissue required for maintaining life in humans has not been previously reported.CASE SUMMARY A 33-year-old woman fell from the third floor three months before admission to our department.She received a decompressive craniectomy soon after injury.After the operation,operative incision disunion occurred due to the high pressure.Brain tissue flowed from the incision,and intracranial infection occurred.She fell into deep coma and was sent to our hospital.Her right temporal surgical incision was not healed and had a cranial defect of 10 cm×10 cm.Her intracranial cavity was observed from the skull defect,and the brain tissue was largely lost.In addition,no brain tissue was observed by visual inspection.Cranial computed tomography showed that only a small amount of brain tissue density shadow was compressed in the cerebellum and brainstem.Four days after hospitalization in our hospital,her parents transferred her to a hospital near her hometown.The patient died six days after discharge from our hospital.CONCLUSION This rare case provides some proof of the importance of the brainstem in the maintenance of cardiac rhythm and vascular tension.Neurosurgeons should carefully protect brainstem neurons during operations.Clinicians can maintain the cardiac rhythm of patients who lose their major brain tissue with modern technology,but the family of the patients should be aware of death and end-life care.

Decompressive Craniectomy in Posterior Fossa Ischemic Stroke

Ischemic damage produced in the posterior cerebral territory causes significant morbidity and urgently must be considered if the patient need a surgical attitude. Surgical decompression by suboccipital craniectomy seams to be effective to treat secondary edema due to cerebellar damage or in posterior fossa, when medical treatment is not able to control side effects. We report a clinical case of a patient with a subacute ischemic infarction in the vertebro-basilar territory, with perilesional edema, and a posterior fossa decompressive craniectomy (DC) was carried out.

Comparison of the Efficacy of Standard Decompressive Craniectomy Combined with Cerebrospinal Fluid Circulation Reconstruction in the Treatment of Severe Craniocerebral Injury

Objective:To observe and discuss the clinical effect of standard decompressive craniectomy combined with cerebrospinal fluid circulation reconstruction in the treatment of severe craniocerebral injury.Methods:Seventy patients who underwent surgery in our hospital were selected as subjects for this study.The time was from August 2016 to August 2018,and patients were divided into experimental group(35 cases)and control group(35 cases)according to the random number table method.The control group was treated with a single standard decompressive craniectomy according to clinical symptoms.The experimental group was treated with standard decompressive craniectomy combined with cerebrospinal fluid circulation reconstruction.The surgical treatment effect,GCS(Glasgow Coma Scale)score and operation time were compared between the two groups.Results:After comparison,the surgical treatment effect of the experimental group was higher than that of the control group and there was a significant difference between the two groups(P<0.05).The GCS score and operation time of the experimental group were also better than of the control group and there was a significant difference the two groups(P<0.05).Conclusion:The use of standard decompressive craniectomy combined with cerebrospinal fluid circulation reconstruction in the treatment of severe craniocerebral injury is more effective and worthy of widespread promotion and application.

Decompressive Craniotomy and Fast-Track Duraplasty in Acute Subdural Hematomas

Background: Traumatic subdural hematoma is one of the severe injuries to brain with high mortality rates. Dural opening is often associated with brain herniation against the dural edges due to associated edema that would lead to venous infarction. Aim: The objective of this study is to describe a technical note that would allow fast and effective closure of the dura after hematoma evacuation via duraplasty with analysis of the safety and competency of the technique. Subjects and Methods: The fast-track technique was implemented in 15 successive cases with acute subdural hematoma where the fascia lata flap was prepared and sutured to the planned dural incision before opening the dura, which allowed fast and effective closure of the dura before brain herniation. Subdural bridges were planned by using Gelfoam to prevent venous compression. Analysis of the technique effectiveness was performed by the operative detection of brain herniation, as well as clinical and radiological follow-up of patients. Results: All patients had a Glasgow coma score (GCS) below six before the operation. Mean time from trauma to surgery was five hours. The dura could be effectively closed with no brain herniation in all cases. Nine patients survived (60%), where five of them ended up in a vegetative state. Of these two recovered and three continued in a persistent vegetative state. The mortality rate was 40%. Post-operative infarction was detected in post-operative imaging of four patients. Conclusion: The fast-track duraplasty technique is fast and effective in prevention of brain herniation during surgery with favorable clinical outcome in comparison with the poor and severely deteriorated preoperative clinical presentation. More studies to evaluate the impact of the technique on the survival rate are warranted.

Clinical significance of large decompressive craniectomy to control intractable increased intracranial pressure in patients with traumatic brain injury

Objective To investigate the role of decompressive craniectomy (DC) to decrease intractable intracranial hypertension(ICH) due to diffuse brain swelling and / or cerebral edema after severe traumatic brain injury and the time window of DC to affect on prognosis. Methods The clinical record of 132 patients who underwent DC for posttraumatic intractable ICH in our hospital from July 2003 to

The effects of decompressive craniectomy on cerebral blood flow volume and brain metabolism in different aged patients with severe traumatic brain injury

Objective To explore effects of decompressive craniectomy on cerebral blood flow volume and brain metabolism in different aged patients with severe traumatic brain injury. Methods 71 cases were divided into three groups according age: group A( 【 30 years) ,group B ( 30 ～ 50 years) 。

The Use of Hinged Craniotomy in Comparison to Cisternostomy for Avoiding Bone Flap Replacement Second Surgery in Cases of Decompressive Craniotomy in Traumatic Brain Injury

Introduction: Acute post traumatic subdural hematoma is a clinical condition with increased morbidity and mortality despite the developments in neurosurgery and urgent intervention is required to have best clinical outcome. We will evaluate hinged craniotomy technique in terms of offering adequate brain decompression plus avoiding removal of bone flap which requires second replacement surgery in comparison to cisternostomy effect. Material and Methods: A prospective study was conducted over 30 patients with traumatic acute subdural hematoma presented to neurotrauma unit in Cairo University hospitals from January 2017 to February 2018, operated by hinged craniotomy plus evacuation of hematoma and duroplasty. We avoid rapping the head with elastic bandage post-operative. Generous subcutaneous dissection (5 - 7 cm) all around skin flap was done routinely. Effect of brain decompression was evaluated by measuring the level of brain in relation to skull in post-operative computerized topography. Results: Twenty-one patients operated with initial GCS less than eight. Ten cases (33%) show that cortical surface in relation to skull bone was at inner table, nine cases (30%) at diploid layer and two cases (6.7%) at outer table in post-operative CT brain. Twenty patients died (66.7%);eight patients (26.6%) became fully conscious and two patients (6.7%) had vegetative outcome. No re-operation was done in any of our patients. Conclusion: Hinged craniotomy may be a safe and effective alternative technique with comparable results to cisternotomy in cases of traumatic brain injury that require decompression to avoid second surgery, especially in centres lacking cisternostomy experience. Although gaining cisternostomy experience may help in other indications, future prospective studies with larger number are required.