compression and in whom gastrostomy was not thoughtappropriate. We also used this approach in individualson longterm chemotherapy.The procedure was acceptedwith mixed emotions. No major bleeding or infectiousproblems were encountered while placing the puncturefrom within the pharynx. But we did not have highlongterm acceptance by either the patient or the staff. Ofnote, saliva or salivary leakage were of particularconcern.

The authors have demonstrated a nice, minimally in-vasive concept for these patients and their problems. Wedo wonder if their usage of the left side of the neck maylend itself to less patient dissatisfaction and fewercomplications.

REFERENCE

1. Mackey R, Chand B, Oishi H, et al. Percutaneous transesopha-geal gastrostomy tube for decompression of malignant obstruc-tion: report of the first case in our series in the US. J Am Coll Surg2005;201:695–700.

Construction and Closureof Temporary Loop Ileostomy

W John B Hodgson, MD, FACS, FRCS, FACG

Larchmont, NY

Drs Orit Kaidar-Person, Benjamin Person, and StevenWexner, in their article, “Complications of Construc-tion and Closure of Temporary Loop Ileostomy,”1 cov-ered much ground, but I was surprised to see that theproblems with use of a rod did not include ischemiculceration of the skin and total pressure separation of thetwo loops of the ileostomy.

When I was a lecturer in surgery and honorary seniorregistrar to Bryan Brooke in the early 1970s, amongother things, I learned the Brooke-Turnbull spout loopileostomy, which does not require a rod, and the use ofthe skin bridge to support ostomies, which also does notrequire a rod. In fact, I have never used a rod again in myattending career.

As your article points out, Brooke developed thespout ileostomy because the bud ileostomy can haveserious skin complications and serositis from the excori-ating effects of the liquid content of the ileum. With aloop ileostomy supported by a rod, after the rod is

withdrawn, the same complications can occur. This isavoided by the Brooke-Turnbull procedure. The firststeps are to rotate the ileostomy loop, then make a trans-verse incision on the antimesenteric side of the distalloop, and sew the lower edge to the skin. The remainderof the prolapsed loop is then scored on the antimesen-teric serosa with a No. 15 blade, which divides the serosa(and some muscle) into 3-mm blocks. This allows thesurgeon to turn the scored part of the proximal loopback on itself so that it can also be sutured to the skin, onthe caudad side, and a proximal spout will form. It is notnecessary to support this spout at the mesenteric level.This ileostomy is as easy to manage as a standard Brookeend ileostomy.

The skin bridge is also very simple, but is more usefulwith colostomies. All that is required is to incise the skinin a V shape with a deep fatty base, but with a thin apex,about 3 cm long on all sides. This flap is lifted up, accessis gained to the peritoneal cavity, and the loop of bowelis pulled up. The apex of the V is pulled through amesenteric defect by an Allis clamp, and sutured to theskin on the other side with nylon sutures. This is neat,application of the ostomy bag is easy, and pressure ne-crosis does not occur. The worst that can happen is thatthe apex of the V pulls away under excessive tensionwhere the mesentery is short. Retraction and pressurenecrosis do not occur.

REFERENCE

1. Kaidar-Person O, Person B, Wexner S. Complications of con-struction and closure of temporary loop ileostomy. J Am CollSurg 2005;201:759–773.

ReplySteven D Wexner, MD, FACS, FRCS, FRCS(ED)

Cleveland, OH

We wish to thank Dr Hodgson for his insightful com-ments. Although we do accept that there are alternativetechniques, such as the skin bridge, and we are indeedintrigued by them, we do not use them. And although healludes to retraction and pressure necrosis, fortunately,we have not experienced this complication, perhaps be-cause, in general, we remove the rod 5 to 7 days afterstoma construction.

1026 Letter J Am Coll Surg