Quality of life in stoma patients

Cost analysis of early versus delayed loop ileostomy closure: a case-matched study

BACKGROUND/AIMS

The optimal timing for the closure of loop ileostomies remains controversial. The aim of the current study was to investigate whether early ileostomy closure (EC) (<2 weeks post-formation) results in significant healthcare savings as against late closure (LC).

METHODS

Patients with available cost data that underwent EC between January 2008 and December 2012 were compared against matched patients undergoing LC during the same period. Direct hospital costs for the two groups were compared.

RESULTS

There were 42 EC patients and 61 LC patients. EC patients had significantly less ileostomy-related complications (p < 0.001) and hospital readmissions (p < 0.001). Operative time (p < 0.001) and operative cost (p = 0.002) were also both significantly less in the EC group. Community nursing costs favoured the LC group (p = 0.047). The EC group had an increased post-closure wound infection rate (p = 0.02). The mean total direct cost per patient was NZD 13,724 (SD NZD 3,736) for EC and NZD 16,728 (SD NZD 8,028) for LC. Representing an average costs saving of NZD 3,004 per patient favouring EC (p = 0.012).

CONCLUSION

Although EC increases the post-closure wound infection rate, EC reduces ileostomy complications, hospital readmissions and operative costs resulting in significant healthcare savings. In order to improve patient outcomes and make EC even more cost effective, efforts should be taken to reduce wound infections.

Surgical outcome in patients undergoing reversal of Hartmann's procedures: a multicentre study

AIM

Recent evidence has suggested that a laparoscopic rather than an open approach to reversal of Hartmann's procedure (ROH) may be associated with fewer complications. Much of the data for comparison are historical or based on small case series. The aims of this study were to determine the morbidity and mortality of ROH in 10 hospitals in the modern era and to identify risk factors for complications.

METHOD

A multicentre study of patients undergoing ROH (2007-2013) was performed. Data were collected retrospectively from perioperative health databases and casenotes where appropriate on patient demographics, laboratory investigations and operative details. Complications were classified as minor (I-II) or major (III-IV) based on the Clavien-Dindo criteria. Risk factors for complications were assessed by multivariate analysis with calculation of OR with 95% CI.

RESULTS

Ten hospitals in Scotland provided data on 252 patients undergoing ROH. Most operations were open (85%) with 15% started laparoscopically (conversion rate 64%). In the postoperative period, 35 (14%) patients had a major complication, including anastomotic leakage in 10 (4%) and postoperative death in one (0.4%). Patients with a complication stayed significantly longer in hospital (12 days vs 7 days, P < 0.001). On multivariate analysis, a wound complication after the original Hartmann's procedure (OR = 3.85, 95% CI: 1.08-13.75, P = 0.038) was associated with any complication after ROH, but only American Society of Anesthesiologists (ASA) grade (OR = 3.35, 95% CI: 1.38-8.09, P = 0.007) was independently associated with the development of a major complication.

CONCLUSION

ROH has a low postoperative mortality but significant morbidity. Most operations are still performed by open surgery, and in those attempted laparoscopically, the conversion rate is high.

Addressing the appropriateness of elective colon resection for diverticulitis: a report from the SCOAP CERTAIN collaborative

OBJECTIVE

To assess the reported indications for elective colon resection for diverticulitis and concordance with professional guidelines.

BACKGROUND

Despite modern professional guidelines recommending delay in elective colon resection beyond 2 episodes of uncomplicated diverticulitis, the incidence of elective colectomy has increased dramatically in the last 2 decades. Whether surgeons have changed their threshold for recommending a surgical intervention is unknown. In 2010, Washington State's Surgical Care and Outcomes Assessment Program initiated a benchmarking and education initiative related to the indications for colon resection.

METHODS

Prospective cohort study evaluating indications from chronic complications (fistula, stricture, bleeding) or the number of previously treated diverticulitis episodes for patients undergoing elective colectomy at 1 of 49 participating hospitals (2010-2013).

RESULTS

Among 2724 patients (58.7 ± 13 years; 46% men), 29.4% had a chronic complication indication (15.6% fistula, 7.4% stricture, 3.0% bleeding, 5.8% other). For the 70.5% with an episode-based indication, 39.4% had 2 or fewer episodes, 56.5% had 3 to 10 episodes, and 4.1% had more than 10 episodes. Thirty-one percent of patients failed to meet indications for either a chronic complication or 3 or more episodes. Over the 4 years, the proportion of patients with an indication of 3 or more episodes increased from 36.6% to 52.7% (P < 0.001) whereas the proportion of those who failed to meet either clinical or episode-based indications decreased from 38.4% to 26.4% (P < 0.001). The annual rate of emergency resections did not increase significantly, varying from 5.6 to 5.9 per year (P = 0.81).

CONCLUSIONS

Adherence to a guideline based on 3 or more episodes for elective colectomy increased concurrently with a benchmarking and peer-to-peer messaging initiative. Improving adherence to professional guidelines related to appropriate care is critical and can be facilitated by quality improvement collaboratives.

Colonic salvage with antiperistaltic cecorectal anastomosis

BACKGROUND

Following colon resection, the construction of a well-perfused, tension-free isoperistaltic anastomosis can be made difficult by multiple factors including prior abdominal surgery or compromised vascular supply. Here, we describe the technique of antiperistaltic cecorectal anastomosis as a method for preserving viable colon without compromising functional outcome.

TECHNIQUE

Following extensive colorectal resection, different techniques for isoperistaltic reconstruction using the cecum and ascending colon have been described, including the Deloyers procedure and limited isoperistaltic cecorectal anastomosis. However, these isoperistaltic reconstructions often require ligation of the middle colic and right colic arteries and/or sacrifice of viable distal colon to aid reconstruction. In complex situations that require preservation of normal vascular anatomy, an antiperistaltic cecorectal anastomosis can be constructed that maintains the orientation of the vascular pedicle. In addition to the preservation of the colonic arterial supply, a distinguishing feature of this technique is the substantial portion of antiperistaltic colon that is preserved and interposed to reestablish continuity.

RESULTS

In a case where it was used, construction of an antiperistaltic cecorectal anastomosis was technically successful and led to a good functional outcome.

CONCLUSION

Antiperistaltic cecorectal anastomosis should be considered as an option in colonic reconstruction for patients with extensive prior abdominal surgery or when complex anatomic issues require preservation of native vascular anatomy. In these situations, this technique offers several advantages over isoperistaltic reconstruction and may be the only option for reconstruction that uses the remaining cecum and colon.

Establishment of a regional Danish database for patients with a stoma

AIM

To present the Danish Stoma Database Capital Region with clinical variables related to stoma creation including colostomy, ileostomy and urostomy.

METHOD

The stomatherapists in the Capital Region of Denmark developed a database covering patient identifiers, interventions, conditions, short-term outcome, long-term outcome and known major confounders. The completeness of data was validated against the Danish National Patient Register.

RESULTS

In 2013, five hospitals included data from 1123 patients who were registered during the year. The types of stomas formed from 2007 to 2013 showed a variation reflecting the subspecialization and surgical techniques in the centres. Between 92 and 94% of patients agreed to participate in the standard programme aimed at handling of the stoma and more than 88% of patients having planned surgery had the stoma site marked pre-operatively.

CONCLUSION

The database is fully operational with high data completeness and with data about patients with a stoma from before surgery up to 12 months after surgery. The database provides a solid basis for professional learning, clinical research and benchmarking.

A randomized controlled trial examining the effectiveness of a STOMA psychosocial intervention programme on the outcomes of colorectal patients with a stoma: study protocol

AIMS

To report a study protocol that evaluates the effects of a psychosocial intervention on patients with a newly formed stoma.

BACKGROUND

With the loss of a significant body function and distorted body image, stoma patients experience physical, psychological and social challenges. Nurses have an important role in helping patients' make a smooth transition to living with their stoma. Limited studies have examined the effects of psychosocial interventions on improving stoma-related health outcomes.

DESIGN

A randomized controlled trial is planned.

METHODS

Eighty-four patients with newly formed stoma in a tertiary hospital in Singapore (Research Ethics Committee approval obtained in January 2013) will be recruited. Participants will be randomly assigned to either a control group who receive routine care or an intervention group who receive STOMA psychosocial intervention besides routine care. Outcome variables include stoma care self-efficacy, days to stoma proficiency, length of hospital stay, acceptance of stoma, anxiety and depression and quality of life. Data will be collected at four time points: before randomization and intervention (baseline), on the day of discharge (mid-intervention), at 4 weeks after discharge (postintervention 1) and at 4 months after discharge (postintervention 2).

DISCUSSION

This study will develop a psychosocial intervention programme, which may improve patients' stoma-related outcomes. The findings will provide direction to health professionals about education and the type of support that could be offered to patients concerning stoma care in the hospital setting, which will eventually improve their quality of life.

Clinical and financial impact of hospital readmissions after colorectal resection: predictors, outcomes, and costs

BACKGROUND

After passage of the Affordable Care Act, 30 -day hospital readmissions have come under greater scrutiny. Excess readmissions for certain medical conditions and procedures now result in penalizations on all Medicare reimbursements.

OBJECTIVE

The purpose of this work was to define the risk factors, outcomes, and costs of 30-day readmissions after colorectal surgery.

DESIGN

Adults undergoing colorectal surgery were studied using data from the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify patient-related risk factors for, and 30-day outcomes of, readmission after colorectal surgery.

SETTINGS

This study was conducted at an academic hospital and its affiliates.

PATIENTS

Adults ≥18 years of age who underwent colorectal surgery for cancer, diverticular disease, IBD, or benign tumors between 2008 and 2011 were included in this study.

MAIN OUTCOME MEASURES

Readmission within 30 days of index discharge was the main outcome measured.

RESULTS

A total of 70,484 patients survived the index hospitalization after colorectal surgery; 9632 (13.7%) were readmitted within 30 days of discharge. The strongest independent predictors of readmission were length of stay ≥4 days (OR 1.44; 95% CI 1.32-1.57), stoma (OR 1.54; 95% CI 1.46-1.51), and discharge to skilled nursing (OR 1.62; 95% CI 1.49-1.76) or rehabilitation facility (OR 2.93; 95% CI 2.53-3.40). Of those readmitted, half of the readmissions occurred within 7 days, 13% required the intensive care unit, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was more than 2 times higher ($26,917 vs $13,817; p < 0.001) for readmitted than for nonreadmitted patients.

LIMITATIONS

Follow-up was limited to 30 days after initial discharge.

CONCLUSIONS

Readmissions after colorectal resection occur frequently and incur a significant financial burden on the health-care system. Future studies aimed at targeted interventions for high-risk patients may reduce readmissions and curb escalating health-care costs.

Rethinking elective colectomy for diverticulitis: A strategic approach to population health

Diverticulitis is one of the leading indications for elective colon resection. Surgeons are trained to offer elective operations after a few episodes of diverticulitis in order to prevent future recurrences and potential emergency. However, most emergency surgery happens during the initial presentation. After recovery from an episode, much of the subsequent management of diverticulitis occurs in the outpatient setting, rendering inpatient “episode counting” a poor measure of the severity or burden of disease. Evidence also suggests that the risk of recurrence of diverticulitis is small and similar with or without an operation. Accordingly, contemporary evaluations of the epidemiologic patterns of treatments for diverticulitis have failed to demonstrate that the substantial rise in elective surgery over the last few decades has been successful at preventing emergency surgery at a population level. Multiple professional societies are calling to “individualize” decisions for elective colectomy and there is an international focus on “appropriate” indications for surgery. The rethinking of elective colectomy should come from a patient-centered approach that considers the risks of recurrence, quality of life, patient wishes and experiences about surgical and medical treatment options as well as operative morbidity and risks.

Long-term outcome of stenting as a bridge to surgery for acute left-sided malignant colonic obstruction

AIM

This study aimed to evaluate both the short- and long-term outcomes associated with colonic stenting as a bridge to surgery in patients with obstructing adenocarcinoma of the colon.

METHOD

Patients with potentially curable acute left-sided colonic obstruction treated with stenting as a bridge to surgery (n = 28) or with emergency surgical resection (n = 39) from January 1998 to December 2008 were identified from a prospectively maintained database. Short-term data on postoperative mortality, morbidity, necessity of intensive care and length of hospital stay were compared. Overall survival and disease-free survival were also analysed.

RESULTS

Patients in the two study arms had similar demographic profiles. Those receiving preoperative stenting had a higher likelihood of a laparoscopic resection (P < 0.001). The emergency surgery group had a higher rate of postoperative complications (P = 0.024), rate of intensive care unit admission (P = 0.013) and longer total length of hospital stay (9 vs 12 days, P = 0.001). With a median follow-up of 26.5 and 31.3 months for the stenting and surgical resection groups, there was no difference in overall and disease-free survival (overall survival 30 vs 31 months, P = 0.858; disease-free survival 13 vs 12 months, P = 0.989). There was no difference in the rate of systemic recurrence (8 vs 13, P = 0.991).

CONCLUSION

Stenting as a bridge to surgery is a safe strategy for acute left-sided colonic obstruction with improved short-term outcome and comparable long-term oncological results.

Is ileostomy always necessary following rectal resection for deep infiltrating endometriosis?

OBJECTIVE

To verify the hypothesis that in most patients bowel segmental resection to treat endometriosis can be safely performed without creation of a stoma and to discuss the limitations of this statement.

DESIGN

Retrospective study (Canadian Task Force classification III).

SETTING

Tertiary referral center.

PATIENTS

Forty-one women with sigmoid and rectal endometriotic lesions who underwent segmental resection.

INTERVENTION

Segmental resection procedures performed between 2004 and 2011. Patient demographic, operative, and postoperative data were compared.

MEASUREMENTS AND MAIN RESULTS

Sigmoid resection was performed in 6 patients (15%), and rectal anterior resection in 35 patients (high in 21 patients [51%], and low, i.e., <10 cm from the anal verge, in 14 [34%]). In 4 patients a temporary ileostomy was created. There was 1 anastomotic leak (2.4%), in a patient with an unprotected anastomosis, which was treated via laparoscopic surgery and creation of a temporary ileostomy. Other postoperative complications included hemoperitoneum, pelvic abscess, pelvic collection, and a ureteral vaginal fistula, in 1 patient each (all 2.4%).

CONCLUSION

A protective stoma may be averted in low anastomosis if it is >5 cm from the anal verge and there are no adverse intraoperative events.

Correction of skin contour defects in leaking stomas by filler injection: a novel approach for a difficult clinical problem

Background

Stomal leaks can be associated with significant social, psychological and physical morbidity for ostomy patients. Poor fitting of the stoma appliance due to irregularities of skin contours is one cause of stoma leaks which commonly result in secondary irritant dermatitis prompting presentation to a dermatologist. In addition to skin-directed topical therapy and review of stoma appliances, correction of contour defects with intradermal injections of filler materials is one possible treatment to improve adhesion and reduce leaks.

Cases

We report eight cases of ostomy patients, who presented with stoma leaks and associated dermatitis, who were treated with intradermal injections of the porcine collagen (Permacol™) or subcutaneous injections of polyacrylamide hydrogel (Aquamid Reconstruction™) for correction of skin contour defects. Resolution or improvement of symptoms was achieved for five patients, and no complications were noted as a result of treatment.

Conclusions

This report represents the largest series of ostomy patients treated for correction of peristomal skin contour defects with injection therapy. Treatment was well tolerated and performed in the outpatient setting under local anesthetic. Attempted correction of peristomal skin contour defects using injection of filler materials represents a potential alternative to surgical intervention and can result in significant benefits for the patient.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-014-0058-x) contains supplementary material, which is available to authorized users.

"I didn't feel like I was a person anymore": realigning full adult personhood after ostomy surgery

Colorectal cancer (CRC) is the third most common cancer in the United States. For some CRC patients, cancer treatment involves creating a permanent or temporary intestinal ostomy. Having an ostomy often results in complex social and physical concerns-including unpredictable and at times publicly noticeable bowel output. In this article, we discuss findings from 30 in-depth interviews with female CRC survivors with ostomies in the western United States. We highlight how having an ostomy disrupts culturally sanctioned practices of continence that mark the attainment of full-adult personhood. We discuss how survivors reclaim a sense of full personhood after ostomy surgery through a process of realignment that entails both learning how to manage ostomy equipment to conceal bowel activity and reappraising their illness and suffering. We suggest that the anthropological categories of personhood and personhood realignment be incorporated into research and interventions aimed at increasing support among cancer survivors living with bodily impairments.

The role of primary colectomy after successful endoscopic stenting in patients with obstructive metastatic colorectal cancer

BACKGROUND

Although the initial clinical efficacy of self-expandable metal stents is acceptable, doubt still remains about long-term clinical outcomes and complications.

OBJECTIVE

The aim of this study was to evaluate the stoma formation rate and risk factors for complications after successful stenting in patients with obstructive metastatic colorectal cancer.

DESIGN

This was a tertiary-care center retrospective study.

PATIENTS

From January 2000 to December 2010, 130 patients with unresectable obstructive colorectal cancer received successful self-expandable metal stent placement. Among them, 14 patients received primary colectomy after successful stenting.

INTERVENTIONS

Self-expandable metal stent placement and primary colectomy were performed.

MAIN OUTCOME MEASURES

The stoma formation rate and complications were measured.

RESULTS

In patients with successful stenting, stoma formation rates at 1 and 2 years were 15.6% (95% CI, 8.74-22.4) and 24.4% (95% CI, 13.8-35.0), and the median patency duration was 157 days (range, 2-1590 days). However, long-term complications occurred in 58 patients (44.6%), including reobstruction (32.6%), stent migration (10.3%), and perforation (7.8%), and a large number of reinterventions (45.7%) and hospitalizations (37/9%) were needed to manage complications. In multivariate analysis, primary colectomy after successful endoscopic stenting was a negative predictive factor for reobstruction (OR, 0.12; 95% CI, 0.02-0.99; p = 0.04).

LIMITATIONS

This was a retrospective, single-center study.

CONCLUSIONS

To reduce stent-related late complications, primary colectomy after successful endoscopic stenting could be a therapeutic option in patients who have unresectable colorectal cancer with obstruction, especially in those who expect long-term survival.

Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome

AIM

UK cancer guidelines recommend patients with colonic obstruction due to suspected malignancy be considered for stenting with a self-expanding metal stent (SEMS). Considerable variation in practice exists due to a lack of expertise, technical difficulties and other, as yet ill-defined features. This retrospective multi-centre study aims to determine the outcome following colonic stenting for large bowel obstruction and identify factors associated with successful intervention.

METHOD

A regional programme of colonic stenting for large bowel obstruction, in five UK centres from 2005 to 2010 was evaluated for outcome including technical and clinical success, survival, complications and reoperation.

RESULTS

A SEMS was inserted in 334 patients, including 264 (79.0%) for palliation and 52 (15.6%) as a bridge to surgery. Technical success was achieved in 292 (87.4%) patients, with 46 (13.8%) experiencing a complication or technical failure. Reoperation was required in 39 (14.8%) patients stented for palliation of colorectal cancer of whom 16 (6.1%) subsequently required a colostomy. A one-stage primary anastomosis was achieved in 35 (67.3%) of the 52 patients undergoing stenting as a bridge to resection. Technical success did not vary by indication or site of obstruction (P = 0.60) but was higher for operators who had performed more than 10 procedures (OR 3.34, P = 0.001). ASA grade ≥3 predicted a worse clinical outcome (OR 0.43, P = 0.04). The through-the-scope (TTS) endoscopy technique was more successful than radiological placement alone (90.3% vs 74.8%, P < 0.001).

CONCLUSION

Experienced operators using a TTS technique achieved a better outcome for the emergency management of large bowel obstruction. Older, sicker patients and those with extracolonic and benign strictures fared less well.

Systematic review of self-expanding stents in the management of benign colorectal obstruction

AIM

Colorectal obstruction due to benign disease is likely to become more prevalent. Self-expanding stents have been shown to be effective in reducing morbidity and allowing one-stage resection or improved palliation in colorectal cancer. This review assessed the use of self-expanding stents in benign colorectal obstruction.

METHOD

A systematic review was performed using PubMed, Embase and the Cochrane Library. Keywords included: 'benign disease' 'colorectal obstruction', 'stent', 'endoprosthesis' and 'prosthesis' Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. The main outcome measures assessed were technical and clinical success, perforation, reobstruction and stoma avoidance in the bridge to surgery population.

RESULTS

The search strategy identified 130 articles; the 21 included studies yielded a pooled analysis of 122 patients. Diverticulitis was the predominant aetiology (66/122, 54%). Technical success was achieved in 115/122 (94%) and clinical success in 108/120 (87%) patients. Overall, the perforation rate was 12% (15/122) and the reobstruction rate was 14% (17/122). A stoma was avoided in 48% (23/48) of bridge to surgery patients. Perforation and stoma avoidance in the bridge to surgery group were worse with an aetiology of diverticulitis.

CONCLUSION

Complication rates in stenting for benign colorectal obstruction are higher than for malignant obstruction. On the basis of limited published evidence, stenting cannot be recommended for benign colorectal obstruction.

Failing to reverse a diverting stoma after lower anterior resection of rectal cancer

BACKGROUND

A diverting stoma is an accepted adjunct to low anterior resection (LAR) for rectal cancer. However, some patients do not undergo a subsequent procedure to have the stoma reversed. We aim to determine incidence and risk factors for nonclosure of the diverting stoma.

METHODS

This is a retrospective study of stage I to III rectal cancer patients at a single institution having LAR with curative intent and a diverting stoma.

RESULTS

We studied 162 patients. Prevalence of nonclosure of the temporary stoma was 14.5% within 13 months of the index surgery. On a multivariate linear regression model, nonclosure was associated with anastomotic leak (odds ratio 9.89, 2.31 to 43.93, P < .001) and age older than 65 (odds ratio 2.76, 1.08 to 7.48, P < .036).

CONCLUSIONS

Prevalence of nonclosure of a diverting stoma after LAR for rectal cancer is substantial (14.5%). Patients should be counselled regarding this risk with particular attention to potential risk factors.

Health related quality of life may increase when patients with a stoma attend patient education--a case-control study

Introduction

Adaptation to living with a stoma is complex, and studies have shown that stoma creation has a great impact on patients' health related quality of life. The objective was to explore the effect of a structured patient education program on health related quality of life. Therefore, we implemented interventions aimed at increasing health related quality of life during and after hospital admission.

Materials and Methods

We designed a case/control study aimed at adult patients admitted to the surgical ward for stoma creation, irrespective of type of stoma or reason for creation of stoma. We included 50 patients in the study. Health related quality of life was measured before hospital discharge, three months and six months after stoma creation. The program included educational interventions involving lay-teachers, alongside health professional teachers.

Results

We found a significant rise in health related quality of life in the intervention group (P<0.001) and no significant change in the control group (P = 0.144). However, we found no significant differences when comparing between groups at 3 and 6 months (p = 0.12 and p =  0.63, respective). Additionally, there were differences in scores in health related quality of life baseline (p = 0.045) with lower scores in the intervention group compared with the intervention group. However, there were no significant differences in the demographic variables at baseline

Conclusions

Educational activities aimed at increase in knowledge and focusing on patients' psychosocial needs may lead to a rise in patients' health related quality of life. When patients with a stoma attend a structured patient education program it is possible to improve their health related quality of life compared with patients with a stoma, who do not attend the program.

Trial Registration

ClinicalTrials.gov NCT01154725

Management of anastomotic leakage in a nationwide cohort of colonic cancer patients

BACKGROUND

The mortality associated with anastomotic leakage (AL) after colonic cancer surgery is high and management often results in permanent fecal diversion. Preservation of bowel continuity in combination with proximal loop diversion (salvage) may reduce the number of permanent ostomies without jeopardizing safety.

STUDY DESIGN

This nationwide study used prospective data from the database of the Danish Colorectal Cancer Group, the National Patient Registry, and patient files. Patients with AL requiring surgery (grade C) were categorized according to the type of surgical treatment as anastomotic takedown with an end-ostomy or salvage. Thirty-day mortality, long-term mortality, and permanent ostomy rates were analyzed using multivariable logistic and Cox regression analyses.

RESULTS

Anastomotic leakage occurred in 593 of 9,333 patients (6.4%), of whom 507 with grade C were included. Takedown and salvage were undertaken in 433 (85.4%) and 74 (14.6%) patients, respectively. Salvage was performed more frequently for Hinchey I-II or minor anastomotic defects and resulted in increased likelihood of stoma reversal (adjusted hazard ratio 3.24, 95% CI 2.04 to 5.16, p < 0.001), corresponding to a risk of permanent fecal diversion of 16.8%, compared with 54.5% after takedown. Adjusted mortality rates were comparable between the groups. A second episode of AL after stoma reversal occurred more frequently in patients with end-ileostomies (10 of 64) than in patients with end-colostomies (1 of 64) or loop-ileostomies (3 of 36), p = 0.017.

CONCLUSIONS

Patients with Hinchey I-II and small anastomotic defect were safely managed by anastomotic salvage, which reduced the risk of permanent fecal diversion. Anastomotic salvage is a viable option for this subset of patients.

Changes in management and outcome of patients with rectal cancer in Northern Ireland: 1996-2006

AIM

This study aimed to document developments in rectal cancer services in a UK population and evaluate changes in outcome over a 10-year period.

METHOD

Patients diagnosed with primary rectal carcinoma in 1996, 2001 and 2006 were identified by the Northern Ireland Cancer Registry. Data were retrospectively collected on presentation, investigation, treatment and staging. Differences over the period were analysed using the chi-squared test; Kaplan-Meier and Cox regression tests were used for survival analysis.

RESULTS

After exclusions there were 636 patients, including 187 presenting in 1996, 203 in 2001 and 246 in 2006. The use of preoperative MRI of the rectum, endorectal ultrasound and abdominal CT increased during the study period. For patients treated by surgery, total mesorectal excision (TME) increased from 19% in 1996 to 64% in 2006 (P < 0.001). The use of radiotherapy (27% in 1996, 47% in 2006) and chemotherapy (21% in 1996, 32% in 2006) increased. The overall 5-year survival improved significantly between 1996 and 2006 from 34% in 1996 to 45% in 2006 (P = 0.02). Among patients having surgery, 5-year survival increased from 43% in 1996 to 63% in 2006 (P < 0.001). Multivariate analysis showed that the improvement in survival was associated with TME and chemotherapy, while radiotherapy was not.

CONCLUSION

Survival of patients with rectal cancer in Northern Ireland has improved significantly over the last decade, probably due to the increased use of TME and chemotherapy.

Predictors of outcome in palliative colonic stent placement for malignant obstruction

BACKGROUND

Emergency surgery for large bowel obstruction carries significant morbidity and mortality. After initially promising results, concerns have been raised over complication rates for self-expandable metal stents (SEMS) in both the palliative and bridge-to-surgery settings. This article documents the technique used at the authors' institution, and reports on success and complication rates, as well as identifying predictors of endoscopic reintervention or surgical treatment.

METHODS

Data were collected for a prospective cohort of consecutive patients undergoing attempted colonoscopic SEMS insertion at a single institution between 1998 and 2013. Multivariable logistic models were fitted to assess possible predictors of endoscopic reintervention and surgical treatment.

RESULTS

Palliative SEMS insertion was attempted in 146 patients. Primary colorectal cancer was the most common cause of obstruction (95.2 per cent). The majority of patients (77.4 per cent) were treated in an acute setting, with a high technical success rate of 97.3 per cent. The perforation rate was 4.8 per cent and the 30-day procedural mortality rate 2.7 per cent. No predictors of early complications were identified, although patients with metastases and those who received chemotherapy were more likely to have late complications. Some 30.8 per cent of patients required at least one further intervention, with 11.0 per cent of the cohort requiring a stoma. Endoscopic reintervention was largely successful.

CONCLUSION

SEMS offer a valid alternative to operative intervention in the palliative management of malignant large bowel obstruction. Patients receiving chemotherapy are more likely to receive endoscopic reintervention, which is largely successful.

Experiences of intimacy among people with bladder exstrophy

Previous research investigating the psychosocial and psychosexual impact of living with the complex genitourinary condition bladder exstrophy has been limited in scope and methodological quality. However, the limited evidence suggests that people with bladder exstrophy commonly encounter difficulties that might negatively impact their experiences of intimacy. We conducted an interpretative phenomenological analysis to explore intimacy in 6 participants aged 16 to 56 years. Participants discussed how their parents and later they themselves concealed their health condition. This concealment was associated with feeling safe and protected, yet shameful. Participants also discussed developing intimate knowledge of their own emerging identity while developing intimacy with others, as well as the importance of sharing the experience of bladder exstrophy with others in the development of intimate relationships. We discuss the findings in relation to theoretical issues of concealment, shame, attachment, psychosocial development, intimacy, and chronic illness.

Spouses of patients with a stoma lack information and support and are restricted in their social and sexual life: a systematic review

PURPOSE

A permanent stoma has a large impact on everyday life with several physical, mental, and social impairments for the individual. It seems obvious that if persons with stomas are affected socially by the stoma creation, it is likely that the family and/or relatives will be affected as well. The objective of this systematic review was to explore how stoma creation may affect spouses of patients with stomas.

METHODS

A systematic review was undertaken based on database searches including studies published from 1950 to 2012. We applied a method of synthesis based on narrative summaries of both qualitative and quantitative results being assessed in parallel processes and finally included in a joint synthesis of results on a study level.

RESULTS

We identified 17 studies and included 6 studies. Spouses wanted to be more involved in the stoma education and specifically wanted more focus on the psychosocial aspects of stoma creation. Furthermore, spouses' sexual life was seriously affected, and their social life was restricted. In general, spouses wished for more support from the health care sector as well as from family and friends.

CONCLUSIONS

There is a need for further research focusing on spouses or relatives. Talking about worries and concerns regarding the new life situation may alleviate suffering and reduce uncertainty. Stoma nurses and other health professionals play an important role in the care of patients as well as spouses, and a greater insight into the worries and concerns affecting spouses is warranted to improve postoperative counseling and education.

Morbidity associated with colostomy reversal after cytoreductive surgery and HIPEC

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has improved the survival in selected colorectal cancer patients with peritoneal metastases. In these patients, the risk of a low anastomosis is sometimes diminished through the creation of a colostomy. Currently, the morbidity and mortality associated with the reversal of the colostomy in this population is unknown.

METHODS

Our study involved two prospectively collected databases including all patients who underwent CRS-HIPEC. We identified all consecutive patients who had a colostomy and requested a reversal. The associations between four clinical and ten treatment-related factors with the outcome of the reversal procedure were determined by univariate analysis.

RESULTS

21 of 336 patients (6.3 %) with a stoma with a mean age of 50.8 (standard deviation 10.2) years underwent a reversal procedure. One patient was classified as American Society of Anesthesiologists (ASA) grade III, 6 as ASA grade II, and the remaining as ASA grade I. Median time elapsed between HIPEC and reversal was 394 days (range 133-1194 days). No life-threatening complications or mortality were observed after reversal. The reversal-related morbidity was 67 %. Infectious complications were observed in 7 patients (33 %). Infectious complications after HIPEC were negatively correlated with the ultimate restoration of bowel continuity (P = 0.05). Bowel continuity was successfully restored in 71 % of the patients.

CONCLUSIONS

Although the restoration of bowel continuity after CRS-HIPEC was successful in most patients, a relatively high complication rate was observed. Patients with infectious complications after HIPEC have a diminished chance of successful restoration of bowel continuity.

Validation of a stoma-specific quality of life questionnaire in a sample of patients with colostomy or ileostomy

AIM

The aim of this study was to determine how socio-demographic and clinical variables affect quality of life (QoL) and to assess the validity of a 20-item scale in a sample of Italian subjects with colostomy, ileostomy and multiple stomata.

METHOD

A cross-sectional multicentre survey was carried out in Italy between 2009 and 2010 in 73 stoma centres coordinated by the University of Padova. Patients aged 18 years old and above with a history of nontemporary stoma were included in the study. The Stoma Care QoL scale was measured and validated using a Rasch model. Socio-demographic and clinical characteristics were considered in the analyses.

RESULTS

Two hundred and fifty-one patients were recruited for the study; the mean age was 62 years, 58% were men, 72% had colostomy and 25% ileostomy; approximately 70% of patients had intestinal cancer requiring a stoma, 13% a complication and 10% an inflammatory disease. No significant differences were observed throughout strata in the Stoma Care QoL scale index, except for geographical area, where subjects from south Italy showed a significantly lower index than subjects living in other parts of Italy (P < 0.01). Colostomy and ileostomy patients reported very similar QoL. Cronbach's alpha for the Stoma Care QoL scale was 0.90 (95% CI 0.88-0.92). Rasch analysis supported the viability of the Stoma Care QoL scale questionnaire and showed acceptable goodness-of-fit. Three under-fitted items were observed.

CONCLUSION

The study confirms the validity of the 20-item Stoma Care QoL scale questionnaire as a research tool for stoma patients but the number of items could be reduced.

A meta-analysis of endoscopic stenting as bridge to surgery versus emergency surgery for left-sided colorectal cancer obstruction

The best approach to resolve colonic obstruction in patients with left-sided colon cancer is not established. In this meta-analysis the efficacy of stenting as bridge-to-surgery was compared to emergency surgery for the management of left-sided colonic obstruction. Fourteen studies (randomized and non controlled studies) were identified, including 405 patients in the stent group and 471 in the emergency group. The difference between proportions was evaluated as effect size (ESi). There was large heterogeneity among the studies. Stenting offered advantages over emergency surgery in terms of increase in primary anastomosis (ES=25.1%, p<0.001), successful primary anastomosis (ES=23.7%, p<0.001), reduction of stoma creation (ES=-27.1%, p=0.03), infections (ES=-7.9%, p=0.006) and other morbidities (ES=-13.4%, p<0.001). The interventions were similar in regards to length of hospitalization, preoperative mortality and long-term survival.

Palliative treatment for incurable malignant colorectal obstructions: A meta-analysis

AIM: To perform a meta-analysis of palliative stent placement vs palliative surgical decompression for management of incurable malignant colorectal obstructions.

METHODS: The databases of Medline, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to July 2012 for studies (prospective, retrospective, randomized controlled trials, and case-control trials) designed as comparative analyses of patients with incurable malignant colorectal obstructions treated by self-expanding metallic stents (SEMS) or palliative surgery. No language restrictions were imposed. The main outcome measures were hospital stay, intensive care unit admission, clinical success rate, 30-d mortality, stoma formation, complications, and overall survival time. The data extraction was conducted by two investigators working independently and using a standardized form. The Mantel-Haenszel χ² method was used to estimate the pooled risk ratios with 95%CI under a fixed-effects model; when statistical heterogeneity existed in the pooled data (as evaluated by Q test and I² statistics, where P < 0.10 and I² < 25% indicated heterogeneity), a random-effects model was used.

RESULTS: Thirteen relevant articles, representing 837 patients (SEMS group, n = 404; surgery group, n = 433), were selected for analysis. Compared to the surgery group, the SEMS group showed lower clinical success (99.8% vs 93.1%, P = 0.0009) but shorter durations of hospital stay (18.84 d vs 9.55 d, P < 0.00001) and time to initiation of chemotherapy (33.36 d vs 15.53 d, P < 0.00001), and lower rate of stoma formation (54.0% vs 12.7%, P < 0.00001). Additionally, the SEMS group experienced a significantly lower rate of 30-d mortality (4.2% vs 10.5%, P = 0.01). Stent-related complications were not uncommon and included perforation (10.1%), migration (9.2%), and occlusion (18.3%). Surgery-related complications were slightly less common and included wound infection (5.0%) and anastomotic leak (4.7%). The rate of total complications was similar between these two groups (SEMS: 34.0% vs surgery: 38.1%, P = 0.60), but the surgery-related complications occurred earlier than stent-related complications (rate of early complications: 33.7% vs 13.7%, P = 0.03; rate of late complications: 32.3% vs 12.7%, P < 0.0001). The overall survival time of SEMS- and surgery-treated patients was not significantly different (7.64 mo vs 7.88 mo).

CONCLUSION: SEMS is less effective than surgery for palliation of incurable malignant colorectal obstructions, but is associated with a shorter time to chemotherapy and lower 30-d mortality.

Evaluating a nurse-led survivorship care package (SurvivorCare) for bowel cancer survivors: study protocol for a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is the most common cancer affecting both men and women in Australia. The illness and related treatments can cause distressing adverse effects, impact on emotional and psychological well-being, and adversely affect social, occupational and relationship functioning for many years after the end of treatment or, in fact, lifelong. Current models of follow-up fail to address the complex needs arising after treatment completion. Strategies to better prepare and support survivors are urgently required. We previously developed a nurse-led supportive care program (SurvivorCare) and tested it in a pilot study involving 10 CRC survivors. The intervention was found to be highly acceptable, appropriate, relevant and useful.

METHODS/DESIGN

This study is a multisite, randomised controlled trial, designed to assess the impact of the addition of the SurvivorCare intervention to usual post-treatment care, for people with potentially cured CRC. SurvivorCare comprises the provision of survivorship educational materials, a tailored survivorship care plan, an individually tailored nurse-led, face-to-face end of treatment consultation and three subsequent telephone calls. Eligible patients have completed treatment for potentially cured CRC. Other eligibility criteria include stage I to III disease, age greater than 18 years and adequate understanding of English. All consenting patients complete questionnaires at three time points over a six-month period (baseline, two and six months). Measures assess psychological distress, unmet needs and quality of life.

DISCUSSION

This supportive care package has the potential to significantly reduce individual suffering, whilst reducing the burden of follow-up on acute cancer services through enhanced engagement with and utilisation of general practitioners and community based services. If the intervention is successful in achieving the expected health benefits, it could be disseminated readily. All training and supporting materials have been developed and standardised. Furthermore, the intervention could easily be adapted to other cancer or chronic disease settings.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12610000207011.

A systematic review and meta-analysis of laparoscopic vs open restorative proctocolectomy

AIM

The benefits of a laparoscopic approach to restorative proctocolectomy (RPC) are controversial. The aim of this meta-analysis was to compare the outcome following laparoscopic and open RPC, with particular attention to adverse events and long-term function.

METHOD

A systematic search of the MEDLINE, EMBASE and Ovid databases was performed for studies published until March 2012. The primary end-point was long-term function. Secondary end-points were intra-operative details, short-term postoperative outcome and postoperative adverse events. Weighted mean difference (WMD) and odds ratio (OR) were calculated using fixed/random effect meta-analytic techniques.

RESULTS

The final analysis included 27 comparative studies of 2428 patients, of whom 1097 (45.1%) underwent laparoscopic surgery. A laparoscopic approach was associated with a significantly longer operation time (WMD 70.1 min, P < 0.001), shorter length of hospital stay (WMD -1.00 day, P < 0.001), reduced intra-operative blood loss (WMD -89.10 ml, P < 0.001) and a lower incidence of wound infection (OR 0.60, P < 0.005). No significant differences were observed in the rate of pouch failure. Although there was no significant difference in the number of daily bowel movements (OR 0.04, P = 0.950), laparoscopic surgery led to fewer nocturnal bowel movements (WMD -1.14, P < 0.001) and reduced pad usage during the day (OR 0.22, P < 0.001) and night (OR 0.33, P < 0.001). The post hoc power to detect differences in adverse event rates ranged from 5% to 42%.

CONCLUSION

Laparoscopic and open approaches to RPC produced equivalent adverse event rates and long-term functional results. However, the present evidence is underpowered to detect true differences in adverse event rates.

A health-related quality-of-life study comparing Vitala continence control device versus traditional pouch system only in patients with end colostomy

PURPOSE

The aim of this study was to evaluate the health-related quality-of-life (HRQL) impact of using the Vitala continence control device (CCD) in addition to the traditional pouch system among patients with an end colostomy.

MATERIALS AND METHODS

End colostomy patients aged 18 years or older from the Czech Republic, Netherlands, and UK who were using at least 15 Vitala CCDs per month for at least 3 months and those using only pouches were surveyed over the Internet when possible or alternatively using a local personal computer arranged by a professional recruiter. The survey included the EQ-5D, Stoma Quality of Life Scale, Stoma Appliance-specific Questionnaire (SAQ), in addition to demographics and medical history. Univariate and regression analyses were performed to compare the HRQL between the patient groups.

RESULTS

A total of 165 patients completed the survey: 103 (62.4%) from the Czech Republic, 11 (6.7%) from the Netherlands, and 51 (30.9%) from the UK. Of these, 70 (42%) were Vitala CCD users. The mean age (±SD) was 62.5 (±10.9) years and 61.2% of the patients were men. Patients using the Vitala CCD on average had significantly higher scores on EQ-5D utility (0.84±0.20 vs. 0.75±0.25, P=0.013), EQ Visual Analog Scale (77.0±17.06 vs. 71.2±18.49, P=0.043), and SAQ (27.1±4.21 vs. 24.9±4.29, P=0.001). The Stoma Quality of Life Scale scores did not differ significantly between the groups. A higher proportion of Vitala CCD users had 'no problems' on all five EQ-5D domains (44.3 vs. 25.3%, P=0.010). A higher proportion of Vitala CCD users' scores were at or above the mean score of patients indicating 'enjoyed life' 'most of the time', for both the EQ-5D (64.3 vs. 48.4%, P=0.043) and the EQ Visual Analog Scale (67.1 vs. 51.6%, P=0.045).

CONCLUSION

Findings from this study demonstrate that patients using the Vitala CCD appear to have better HRQL compared with those using only pouches. The difference might be meaningful to the patients, as reflected in the generic EQ-5D and the device-specific SAQ measures.

Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma

BACKGROUND

Traditionally, left-sided acute bowel obstruction is treated by a staged procedure because immediate resection and anastomosis in a massive distended and unprepared colon carries a high complication rate. Total abdominal colectomy is a one-stage procedure that will remove synchronous proximal neoplasms, reduce the risk of subsequent metachronous tumor, and avoid stoma. Colorectal stents are being used for palliation and as a bridge to surgery in obstructing colorectal carcinoma, making elective surgery straightforward, enabling easily mobilization and resection of the colon with a possible trend toward reduction in postoperative complication rates compared to emergency surgery. The purpose of this work was to compare the procedures of endoscopic stenting followed by elective colectomy versus total abdominal colectomy and ileorectal anastomosis in the management of acute obstructed carcinoma of the left colon as regards feasibility, safety, and clinical outcomes

METHODS

From January 2009 through May 2012, 60 patients were randomized to either emergency stenting followed by elective resection (ESER group) or total abdominal colectomy and ileorectal anastomosis (TACIR group).

RESULTS

Twenty nine patients (96.7 %) had successful stenting and underwent elective surgery 7-10 days later (ESER group). Postoperative complications were encountered in four patients in the ESER group compared to 15 patients in the TACIR group (p = 0.012). Anastomotic leakage was encountered in one patient (3.3 %) in the TACIR group. There were no operative mortalities in the present study. Within the first three postoperative months, the TACIR group patients had significantly more frequent bowel motions per day compared to the ESER group patients although (p = 0.013). In both study groups, the follow-up duration ranged from 6 to 40 months with a median of 18 months. Recurrent disease was encountered in five patients (17.2 %) in the ESER group compared to four patients (13.3 %) in the TACIR group (p = 0.228).

CONCLUSION

Both techniques are feasible, safe, and produce comparable oncological outcomes. However, endoscopic stenting followed by elective resection was associated with significantly less postoperative complications and bowel motions per day.

Association between operative approach and complications in patients undergoing Hartmann's reversal

BACKGROUND

Complications following reversal of Hartmann's procedure are common, with morbidity rates of up to 50 per cent, and a mortality rate as high as 10 per cent. This is based on case series with heterogeneous data collection and analysis. This study determined risk factors for complications following Hartmann's reversal.

METHODS

Patients who underwent elective open and laparoscopic Hartmann's reversal were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2010). The programme collects patient demographics, preoperative medical history, clinical findings and laboratory investigations. Postdischarge data were obtained by a certified reviewer. Complications were categorized as major, septic or incisional. Risk-adjusted 30-day outcomes were assessed by univariable and multivariable analyses, adjusting for patient characteristics, co-morbidity and operative approach.

RESULTS

During the study period 7996 patients had a Hartmann's procedure and 2567 cases of Hartmann's reversal were identified, including 336 laparoscopic procedures (13·1 per cent). Major, septic and incisional complication rates were 13·3, 8·5 and 15·7 per cent respectively, with a mortality rate of 0·5 per cent. A laparoscopic approach was found to be independently associated with fewer major (odds ratio (OR) 0·53, 95 per cent confidence interval 0·34 to 0·81), septic (OR 0·48, 0·27 to 0·83) and incisional (OR 0·54, 0·37 to 0·80) complications. A history of chronic obstructive pulmonary disease (OR 1·78-2·00), steroid use (OR 1·75), body mass index at least 30 kg/m² (OR 1·48), diabetes (OR 1·40), smoking (OR 1·33-1·40), American Society of Anesthesiologists fitness grade III and IV (OR 1·46-1·48) and prolonged operating time (OR 1·02) were other factors associated with complications.

CONCLUSION

A laparoscopic approach to Hartmann's reversal was associated with fewer complications than open surgery in this highly selected group of patients.

The persistent challenge of parastomal herniation: a review of the literature and future developments

AIM

The aim of this review article was to outline current evidence relating to the treatment and prevention of parastomal herniation with a view to guide surgeons dealing with patients potentially affected by this complication.

METHOD

Medline and PubMed databases were searched using the keywords 'parastomal hernia/herniation', 'stoma hernia/herniation' and 'stoma complications'. Evidence was obtained from randomized and non-randomized studies. Case reports and articles not written in English were excluded. Qualitative assessment of all included studies was performed using the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence.

RESULTS

The search revealed a total of 228 publications of which 115 fulfilled the selection criteria. Stoma formation through the rectus muscle is complicated by parastomal herniation in up to 50% of cases. There is no conclusive evidence that alternative techniques (e.g. extraperitoneal, lateral rectus abdominis positioned stoma) are superior. Open and laparoscopic parastomal hernia repair have similar recurrence rates up to 50%. The 'Sugarbaker' technique appears to be superior to the 'keyhole' technique when a laparoscopic approach is used. Prophylactic mesh reinforcement of the stoma trephine appears to reduce the herniation rate to approximately 15% and is accompanied by a decrease in symptomatic hernias requiring repair without any difference in stoma-related morbidity.

CONCLUSION

Large prospective controlled trials are required to compare surgical techniques of stoma formation in reducing the incidence of parastomal herniation. Despite limited evidence, routine prophylactic mesh reinforcement of the stoma trephine should be offered to all patients undergoing permanent stoma formation.

The Easy-X magnetic stoma connector system. A future concept for stomal dressing?

AIM

A considerable proportion of stoma patients are disabled for various reasons and are elderly. To be able to dress their stoma themselves is of crucial importance for their integrity and social life. This study evaluates a novel stomal dressing system based on a magnetic connector--the Easy-X system.

METHOD

Twenty patients (8 women, mean age of 40-89 years) with a well-functioning colostomy tested the Easy-X system for 6 weeks. The system was judged by the patients using a multiple choice scale, and by the stoma nurses using a 10-grade VAS.

RESULTS

Eighteen of 20 patients completed the trial. Ten patients rated the Easy-X as better than their ordinary system, 3 as equal to and 4 deemed it inferior. Despite this, only three were prepared to change to the Easy-X system. Eleven of 18 patients experienced discomfort with the new adhesive plate. Three patients suffered leakage less often and five patients more often than with their ordinary system. Stoma nurse ratings were available for 14 patients. Their evaluation of the magnetic connector in the Easy-X system was positive in eight cases, neutral in one case and negative in three cases. Global impression ratings were 3 positive, 3 negative and 5 neutral.

CONCLUSION

The Easy-X system showed potential advantages over conventional stomal dressing systems, but the system must be improved in terms of a varied assortment of dressing products enabling individual fitting before a larger trial can be carried out on disabled patients. Furthermore, the increased use of metal has to be handled with an ecologic recycling system. WHAT IS NEW IN THIS PAPER: A new stomal dressing system with a magnetic connector has potential advantages over conventional stomal dressings for disabled persons.

Perioperative outcomes after ultra low anterior resection in the era of neoadjuvant chemoradiotherapy

PURPOSE

Data on perioperative outcomes of sphincter preserving ultra low anterior resections (ULAR) following neoadjuvant chemoradiotherapy (NA-CTRT) is sparsely reported in literature.

METHODS

Prospective data of 68 patients was reviewed retrospectively. Patients who received preoperative chemoradiotherapy (CTRT, Group A, n = 45) were compared with those who were operated upfront (Group B, n = 23).

RESULTS

Overall, mean distance of the tumor from anal verge was 5.1 cm (range 3-8). In Groups A and B, it was 5.2 and 5.1 cm, respectively. In Group A, 3 patients had complete response, 40 had partial response and 2 had progressive disease. Overall, the mean distance of the anastomosis performed from the anal verge was 2.8 cm (range 1-4). In Groups A and B, it was 2.7 and 2.9 cm, respectively (NS). Mean blood loss in Groups A and B was 510.5 (range 200-2,200) and 345 mL (range 50-800), respectively (p = 0.037). Two patients in Group A required blood transfusion (range 1-2) compared to none in Group B. The overall complication rate was 26.5 % (18/68); in Groups A and B, it was 22.2 % and 34.8 %, respectively. There was no postoperative mortality. Postoperative stay for Groups A and B was 8 and 9.5 days (p = 0.009), respectively. In Group A, 23/45 patients, earlier planned for abdominoperineal resection, ultimately received sphincter-preserving ULAR.

CONCLUSION

ULAR can be performed safely without added morbidity or mortality after neoadjuvant chemoradiation. In some cases, earlier deemed to be suitable for APR, the neoadjuvant approach improved chances of sphincter conservation.

Rapid morphological changes and loss of collagen following experimental acute colonic obstruction

PURPOSE

Anastomosis of an acutely obstructed colon is associated with an increased risk of dehiscence. In experimental models, acute obstruction decreases collagen in the colonic wall, but the time course and propagation along the colon of the biochemical changes are unknown. Furthermore, there is a paucity of information on the correlation between these biochemical changes and histological features.

METHODS

Forty male Sprague Dawley rats were subjected to partial obstruction by placing a silicone ring around the left colon 30 mm above the reflection. Obstruction was maintained for 0, 1, 2, 3 or 4 days. Samples from five different locations along the colon were analysed on circumference, tissue water content, collagen concentration and histomorphology. Neutrophil and macrophage infiltration was characterized immunohistochemically.

RESULTS

The colonic circumference and water content increased (p < 0.001), while the collagen concentration decreased by 48 % (p < 0.01) proximal to the obstruction already after 1 day. The degree of dilation and collagen reduction did not change significantly over the subsequent 3 days of obstruction, whereas the water content normalized by day 3. Mucosal and submucosal oedema and the relative neutrophil infiltration were highest after 1 day in the colonic segment proximal to the stenosis while the macrophage population continued to increase to day 4. Muscular necrosis in addition to ganglionitis and neuritis in the nervous plexus increased with duration of obstruction.

CONCLUSIONS

The pronounced and rapid changes of the composition of cells and the extracellular matrix of the colonic wall following acute obstruction may be of guidance for present surgical treatments and future pharmacological interventions.

Clinical evaluation of extraperitoneal colostomy without damaging the muscle layer of the abdominal wall

OBJECTIVE

This study investigated whether extraperitoneal colostomy without damaging the muscle layer of the abdominal wall is an improved surgical procedure compared with conventional sigmoid colostomy in patients undergoing abdominoperineal resection.

METHODS

Patients with rectal cancer undergoing abdominoperineal resection were selected and randomly divided into two groups: the study group received extraperitoneal colostomy without damaging the muscle layer of the abdominal wall and the control group received conventional colostomy. Clinical data from both groups were analysed.

RESULTS

A total of 128 patients were included: 66 received extraperitoneal colostomy without damaging the muscle layer of the abdominal wall and 62 received conventional colostomy. Significant differences between the two groups were found in relation to colostomy operating time, defaecation sensation, bowel control and overall stoma-related complications. Duration of postoperative hospital stay was also significantly different between the study groups.

CONCLUSIONS

Extraperitoneal colostomy without damaging the muscle layer of the abdominal wall was found to be an improved procedure compared with conventional sigmoid colostomy in abdominoperineal resection, and may reduce colostomy-related complications, shorten operating time and postoperative hospital stay, and potentially improve patients' quality of life.

Hartmann reversal: obesity adversely impacts outcome

BACKGROUND

Comprehensive analyses are lacking to identify predictors of postoperative complications in patients who undergo a Hartmann reversal.

OBJECTIVE

The aim of this study is to identify predictive factors for morbidity after reversal.

DESIGN

This study is a retrospective review of prospectively collected data.

SETTINGS

The study was conducted at Cleveland Clinic Florida.

PATIENTS

Consecutive patients from January 2004 to July 2011 who underwent reversal were included.

MAIN OUTCOME MEASURES

Variables pertaining to Hartmann procedure and reversal were obtained for analyses in patients with and without postoperative complications. Univariate and multivariate analyses were performed.

RESULTS

A total of 95 patients (mean age 61 years, 56% male) underwent reversal, with an overall morbidity of 46%. Patients with and without complications had similar demographics, comorbidities, diagnoses, and Hartmann procedure intraoperative findings. Patients with complications after reversal were more likely to have prophylactic ureteral stents (61% vs 41%, p < 0.05) and an open approach (91% vs 75%, p < 0.04). Complications were associated with longer hospital stay (8.8 vs 6.9 days,p < 0.006) and higher rates of reintervention (9% vs 0%, p < 0.03) and readmission (16% vs 2%, p < 0.02). Predictors of morbidity after reversal included BMI (29 vs 26 kg/m, p < 0.04), hospital stay for Hartmann procedure (15 vs 10 days, p < 0.03), and short distal stump (50% vs 31%, p < 0.05). BMI was the only independent predictor of morbidity (p < 0.04). Obesity was associated with significantly greater overall morbidity (64% vs 40%, p < 0.04), wound infections (56% vs 31%, p < 0.04), diverting ileostomy at reversal (24% vs 13%, p < 0.05), and time between procedures (399 vs 269 days, p < 0.02).

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSIONS

Hartmann reversal is associated with significant morbidity; BMI independently predicts complications. Therefore, patients who are obese should be encouraged or even potentially required to lose weight before reversal.

Factors impacting the quality of life of people with an ostomy in North America: results from the Dialogue Study

PURPOSE

The purpose of this study was to evaluate skin condition and quality of life following the use of a double-layer adhesive pouching system. This article reports results from North American participants.

DESIGN

The study was an open-label, noncomparative, multicenter study.

SUBJECTS AND SETTING

Seven hundred forty-three persons with ostomies who reside in North America participated in the study.

INSTRUMENTS

A stoma-quality of life (QOL) questionnaire consisting of 20 questions was used to measure health-related quality of life. The Ostomy Skin Tool was used to assess peristomal skin condition.

METHODS

Peristomal skin and health-related quality of life were assessed by WOC nurses at baseline and again after 6 to 8 weeks following the use of a double-layer adhesive ostomy pouching system. The participants recorded self-reported leakage level, presence of peristomal skin disorder, use of appliance type (e.g., convex, 1- or 2-piece), and frequency of consultation with the WOC nurse.

RESULTS

Participants experienced a significant decrease in frequency of pouch leakage (P < .0001) and accessory use, improvement of skin condition, and overall significant improvement in mean quality of life score (56.8 vs. 58.9, P < .0001). The greatest change on the Stoma-QOL scores was observed in the quartile of participants with the lowest QOL at baseline. Their QOL scores rose from a mean 43.8 at visit 1 to 50.1 at visit 2 (P < .0001).

CONCLUSION

The combination of a regular contact with a WOC nurse and the use of a double-layer adhesive appliance led to a significant reduction in leakage and accessory use, improved skin condition, and significant improvement in health-related quality of life.

Does stenting of left-sided colorectal cancer as a "bridge to surgery" adversely affect oncological outcomes? A comparison with non-obstructing elective left-sided colonic resections

PURPOSE

With a theoretical link between stent insertion and increased risk of tumour seeding, there is concern about long-term survival after the use of self-expanding metallic stents (SEMS) as a "bridge to surgery" in the treatment of left-sided obstructing colorectal cancer. This cohort study aims to determine if preoperative stenting adversely affects long-term survival by comparing a group of patients having preoperative stenting (group A) with a group of patients having elective surgery (group B) in a single centre.

METHODS

The study is retrospective. Survival was calculated with Kaplan-Meier analysis and compared using the log-rank test. Other group characteristics were compared with Fisher's exact test.

RESULTS

From November 1998 to November 2008, 15 patients had preoperative SEMS and were entered in group A. This represented 11.5 % of a total of 130 patients undergoing SEMS insertion in the same period. Group B included 88 consecutive patients undergoing elective left-sided colonic resection for Dukes' B and C cancer excluding mid and low rectal tumours between January 2003 and December 2007. The 30-day mortality rate for groups A and B was 6.7 % (one patient) and 5.7 % (five patients), respectively. The 5-year survival rate was 60 % and 58 %, respectively, with a p value of 0.96.

CONCLUSIONS

In our own practice, patients undergoing SEMS as a "bridge to surgery" have the same long-term survival with those undergoing elective surgery. This finding needs to be confirmed in larger scale studies.

Intestinal stomas: indications, management, and complications

The ability to appropriately construct and care for an ostomy is crucial to good colorectal surgical practice. Enterostomal therapy is critical to the successful management of ostomies and their complications. Although associated with morbidity, a well-constructed ostomy can provide our patients with a good, durable QoL.