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Wang S, Du K, Duan M, Xu Y, Guo Z, Gong J, Zhu W, Li Y. Reversal Surgery for Split Stoma with Peristomal Incision is Associated with Improved Postoperative Outcome in Patients with Crohn's Disease. J INVEST SURG 2024; 37:2363179. [PMID: 38862416 DOI: 10.1080/08941939.2024.2363179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 05/29/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Temporary stoma formation is common in Crohn's disease (CD), while stoma reversal is associated with postoperative morbidity. This study aimed to evaluate the postoperative outcomes of split stoma reversal, SSR (i.e., exteriorization of proximal and distal ends of the stoma through a small common opening) and end stoma closure, ESC (i.e., the proximal stump externalized, and distal end localized abdominally. METHODS Patients with CD who underwent stoma reversal surgeries between January 2017 and December 2021 were included. Demographic, clinical, and postoperative data were collected and analyzed to evaluate outcomes of reversal surgery. RESULTS A total of 255 patients who underwent stoma reversal surgeries met the inclusion criteria. SSR was superior to ESC in terms of operative time (80.0 vs. 120.0, p = 0.0004), intraoperative blood loss volume (20.0 vs. 100.0, p = 0.0002), incision length (3.0 vs. 15.0, p < 0.0001), surgical wound classification (0 vs. 8.3%, p = 0.04), postoperative hospital stay (7.0 vs. 9.0, p = 0.0007), hospital expense (45.6 vs. 54.2, p = 0.0003), and postoperative complications (23.8% vs. 44.3%, p = 0.0040). Although patients in the ESC group experienced more surgical recurrence than those in the SSR group (8.3% vs. 3.2%) during the follow-up, the Kaplan-Meier curve analysis revealed no statistical difference (p = 0.29). CONCLUSIONS The split stoma can be recommended when stoma construction is indicated in patients with Crohn's disease.
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Affiliation(s)
- Shixian Wang
- Department of General Surgery, Jinling Medical School of Nanjing Medical University, Nanjing, China
| | - Kangling Du
- Department of General Surgery, Jinling Medical School of Nanjing Medical University, Nanjing, China
| | - Ming Duan
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yihan Xu
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Medical School of Nanjing Medical University, Nanjing, China
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Li
- Department of General Surgery, Jinling Medical School of Nanjing Medical University, Nanjing, China
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Ohara Y, Owada Y, Kim J, Moue S, Akashi Y, Ogawa K, Takahashi K, Shimomura O, Furuya K, Hashimoto S, Enomoto T, Oda T. Clinical Benefits of Reducing Dead Space Using a Closed Suction Drain and Subcutaneous Large-bite Buried Suture Technique to Prevent Superficial Surgical-site Infections Following Primary Closure of a Diverting Stoma. J Anus Rectum Colon 2024; 8:70-77. [PMID: 38689778 PMCID: PMC11056535 DOI: 10.23922/jarc.2023-047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/26/2023] [Indexed: 05/02/2024] Open
Abstract
Objectives Surgical-site infections (SSIs) are the most common complication after stoma closure. We propose a new method for wound closure using the subcutaneous large-bite buried suture (SLBS) technique and a closed suction drain (CSD). In this study, we aimed to investigate the efficacy of a combination of the SLBS technique and a CSD to prevent superficial SSIs following stoma closure. Methods We retrospectively analyzed patients who underwent stoma closure between January 2019 and July 2022. Primary closure of the stomal site was performed using the SLBS technique and a CSD for wound closure. The CSD was placed until postoperative day 7. The occurrence of superficial postoperative SSIs was also evaluated. Results In total, 67 patients were included in the study. Within 30 days postoperatively, nine patients (13%) developed superficial SSIs. Considering the type of stoma, only 1 (2%) of 45 patients with ileostomy showed superficial SSIs, whereas 8 (36%) of 22 patients with colostomy showed superficial SSIs. Univariate analysis of the risk factors associated with the occurrence of superficial SSIs revealed that colostomy (p < 0.001) and hand-sewn anastomosis were significant risk factors (p = 0.019). Multivariate analysis of the risk factors associated with the occurrence of superficial SSIs revealed that colostomy was significant risk factor (p = 0.003). Conclusions This new method of stoma closure is feasible for preventing superficial SSIs, especially in ileostomy closure.
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Affiliation(s)
- Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Jaejeong Kim
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shoko Moue
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yoshimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Osamu Shimomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kinji Furuya
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shinji Hashimoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
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Chau TCY, Nguyen H, Robertson IK, Harvey X, Tan B, Tan M, Yang CM. Factors affecting timing of loop ileostomy closure: a regional centre's experience with 106 patients. ANZ J Surg 2024; 94:193-198. [PMID: 37876156 DOI: 10.1111/ans.18729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 09/15/2023] [Accepted: 10/01/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION The burden of defunctioning ileostomy is significant with up to two thirds of patients reporting stoma-related morbidity. While timely reversal is safe and cost-effective, the time to reversal in regional Australian hospitals is not well described in professional publications. We aim to assess the current timeliness of ileostomy closure and identify possible reasons for delaying closure. METHODS A retrospective analysis of loop ileostomies created and reversed in Launceston General Hospital for both rectal cancer surgery and other benign indications was undertaken. Patients with loop ileostomy created between 2010 and 2020 were included. Clinical data of timing of events, complications, readmission and stoma follow-up were recorded; and analysed using multivariate regression analyses to identify clinically relevant risk factors for delayed closure. RESULTS A total of 123 patients underwent loop-ileostomy formation during the study period, of which 106 patients (86.2%) were reversed. Median time to closure was 8.5 months (IQR 5.2-12.4) for patients with rectal cancers, compared to 5.2 months (IQR 3.6-9.3) for patients who did not have rectal cancer, with a difference of 3.4 months (95% CI 0.9, 5.9; P = 0.008). Adjuvant chemotherapy and unexpected readmission to hospital were associated with delayed reversal (P = 0.0081 and P = 0.0005, respectively). CONCLUSION Stoma reversal is often scheduled 3-6 months after creation. More than two-thirds of patients experienced delays due to changing clinical concerns and non-clinical factors, such as unexpected delays at each stage of surgical planning. Early placement on the waiting list and better-coordinated follow-ups may expedite reversal surgery and reduce associated morbidities.
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Affiliation(s)
- Tedman Cheuk-Yiu Chau
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Hung Nguyen
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Iain K Robertson
- School of Health Sciences, University of Tasmania, Hobart, Tasmania, Australia
| | - Xavier Harvey
- Department of General Surgery, St John of God Bunbury Hospital, Bunbury, Australia
| | - Brendan Tan
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Mitchell Tan
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Caroline M Yang
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
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McKechnie T, Tessier L, Anpalagan T, Chu M, Lee Y, Logie K, Doumouras A, Amin N, Hong D, Eskicioglu C. Laparoscopic versus open loop ileostomy reversal: A systematic review and meta-analysis. SURGERY IN PRACTICE AND SCIENCE 2023. [DOI: 10.1016/j.sipas.2023.100161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023] Open
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Shen Y, Wei M, Yang TH, Shu Y, Xia L, Wu Q, Huang H, Deng X, Meng W, Wang ZQ. Day-case loop ileostomy reversal based on the community hospital joined enhanced recovery after surgery (CHJ-ERAS) program in China: Safe and feasible. Am J Surg 2023:S0002-9610(23)00027-2. [PMID: 36740505 DOI: 10.1016/j.amjsurg.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study was performed to determine the feasibility of Day-case loop ileostomy reversal (DLIR) in China based on the community hospital joined enhanced recovery after surgery (CHJ-ERAS) program. METHOD Patients who underwent loop ileostomy were enrolled in the CHJ-ERAS program for DLIR after rigorous evaluation. The primary outcome was the results of short-term follow-ups. RESULTS From August 2017 to April 2022, 216 patients have been enrolled in the CHJ-ERAS program for DLIR. After DLIR, 14 patients (14/216, 6.5%) have recorded 17 episodes of postoperative complications within 1 month after surgery, including 10 readmission and 2 reoperation. Compared with in-patient loop ileostomy reversal, DLIR based on CHJ-ERAS did not increase the postoperative complications and reoperations. CONCLUSION The CMJ-ERAS program for DLIR in our center is a safe and feasible alternative option for inpatient LIR and an acceptable transitional approach for the development of day-case DLIR in developing countries.
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Affiliation(s)
- Yu Shen
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Mingtian Wei
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Ting-Han Yang
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Ye Shu
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Lin Xia
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Qingbin Wu
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Hao Huang
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Xiangbing Deng
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China.
| | - Wenjian Meng
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China.
| | - Zi-Qiang Wang
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China.
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Caminsky NG, Moon J, Morin N, Alavi K, Auer RC, Bordeianou LG, Chadi SA, Drolet S, Ghuman A, Liberman AS, MacLean T, Paquette IM, Park J, Patel S, Steele SR, Sylla P, Wexner SD, Vasilevsky CA, Rajabiyazdi F, Boutros M. Patient and surgeon preferences for early ileostomy closure following restorative proctectomy for rectal cancer: why aren't we doing it? Surg Endosc 2023; 37:669-682. [PMID: 36195816 DOI: 10.1007/s00464-022-09580-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 08/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC. METHODS A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively. RESULTS Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients. CONCLUSIONS Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.
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Affiliation(s)
- Natasha G Caminsky
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada.,Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Jeongyoon Moon
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada.,Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Karim Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, MA, USA
| | - Rebecca C Auer
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Liliana G Bordeianou
- Department of Surgery, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sami A Chadi
- Minimally Invasive and Colorectal Surgery, University Health Network and Princess Margaret Hospital, Toronto, ON, Canada
| | - Sébastien Drolet
- Department of Surgery, Centre Hospitalier Universitaire (CHU) de Québec, Laval University, Quebec City, QC, Canada
| | - Amandeep Ghuman
- Division of Colon and Rectal Surgery, St. Paul's Hospital, Vancouver, BC, Canada
| | - Alexander Sender Liberman
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Tony MacLean
- Department of Surgery, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jason Park
- Department of Surgery, St. Boniface General Hospital, University of Manitoba, Winnipeg, MB, Canada
| | - Sunil Patel
- Department of Surgery, Queens University, Kingston, ON, Canada
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
| | - Marylise Boutros
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada. .,Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada.
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Comparison of postoperative complication rates between a novel endoluminal balloon-assisted drainage and diverting stoma after low rectal cancer. Clin Transl Oncol 2022; 24:1347-1353. [PMID: 35029803 DOI: 10.1007/s12094-021-02775-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
Abstract
AIM To introduce a novel endo-luminal balloon-assisted drainage (EBAD) and compare postoperative complication rates between EBAD and diverting stoma (DS) groups. METHODS The single center prospective non-random cohort study included a total of 163 patients in convenience patients with rectal cancer between January 2019 and January 2021. Out of 163 patients, 83 underwent DS and 80 EBAD. Primary endpoints were postoperative complication rate. RESULTS The total number of complications was 28 in the DS group vs. 22 in the EBAD group (P = 0.388). 18 patients (21.7%) in the DS group and 14 patients (17.5%) in the EBAD group developed postoperative complication (P = 0.501). There were no differences identified for anastomotic leak rates between the two groups (P = 0.677). The rate of the pelvic abscess was lower in the EBAD group (1/80, 1.3%) than in the DS group (4/83, 4.8%) but with no statistical significance (P = 0.386). Compared with the DS group, the median operative time was shorter in the EBAD group (225 vs. 173.5 min, P < 0.001). Regarding incomplete small bowel obstruction, a higher prevalence was observed in the DS group compared to the EBAD group (7.2% vs 2.5%, P = 0.301). 7 patients (11.3%) in the DS group developed a para-stomal hernia, while no patient suffered a catheter-related complication. The median postoperative hospital stay was shorter in the DS groups than in the EBAD group (7 vs 8 days, P = 0.009). The median residence time of endo-luminal balloon-assisted drainage was 5.41 days. The median average and total volume of drainage were 51.57 ml/day and 255 ml, respectively. CONCLUSION EBAD is feasible and safe with similar postoperative complications when compared with a DS. EBAD may replace DS after rectum resection.
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Kostov G, Dimov R, Doykov M. Diverting ileostomy in low anterior resection: single center retrospective analysis. POLISH JOURNAL OF SURGERY 2022; 94:26-32. [DOI: 10.5604/01.3001.0015.8171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<b> Introduction:</b> Low anterior resection (LAR) is the standard procedure for distal rectal cancer allowing anal sphincter preservation. Anastomotic leakage remains one of the most dangerous complications following LAR and its management is difficult. </br></br> <b>Aim:</b> This study reviews our experience of LAR with and without protective ileostomy (PI). </br></br> <b> Methods:</b> One hundred ninety-nine patients undergoing LAR resection for low rectal cancer in this centre during the period 2015–2019 were divided retrospectively into two groups. Group A underwent rectal resection and coloanal/rectal anastomosis with diverting ileostomy and group B without ileostomy. </br></br> <b> Results:</b> Among our patients, 20 had a covering ileostomy (stoma group);179 did not (control group). The stoma group comprised 14 men and 6 women ranging in age from 36 to 89 years (mean, 64.2 ± 10.5 years). Conventional v. minimally invasive surgery was 6/14. Anastomotic leakage occurred in 16/179 (8.93%) patients without a PI, and in 6/20 (30%) with a stoma (Tab. I.). Of the 16 patients experiencing an anastomotic leak, 3 (18.75%) from Group A and 5 (83.33%) from Group B were classified as Grade B leakage and were treated conservatively. As many as 13/16 (81.25%) in Group A and 1/6 (16.77%) in Group B were classified as Grade C leakage and required emergency surgery. </br></br> <b>Conclusion:</b> These results do not show a preventive effect on the occurrence of anastomotic leakage in low anterior resection, but may significantly reduce the need for further surgery due to septic complications in the early postoperative period. Selection of patients for protective ileostomy requires great care as its creation and closure are associated with severe complications.
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Affiliation(s)
- Gancho Kostov
- Department of Special Surgery, Medical University - Plovdiv, Bulgaria, University Hospital “Kaspela” - Plovdiv, Bulgaria
| | - Rosen Dimov
- Department of Special Surgery, Medical University - Plovdiv, Bulgaria, University Hospital “Kaspela” - Plovdiv, Bulgaria
| | - Mladen Doykov
- Department of Urology and General Medicine, Medical University - Plovdiv, Bulgaria, University Hospital “Kaspela” - Plovdiv, Bulgaria
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Nakao T, Shimada M, Yoshikawa K, Tokunaga T, Nishi M, Kashihara H, Takasu C, Wada Y, Yoshimoto T, Yamashita S, Iwakawa Y. Risk factors for postoperative ileus after diverting loop ileostomy closure. BMC Surg 2022; 22:131. [PMID: 35392877 PMCID: PMC8991585 DOI: 10.1186/s12893-022-01583-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative ileus is one of the most common complications after diverting loop ileostomy closure. Some reports have investigated the risk factors for postoperative complications or ileus after ileostomy closure; however, these studies did not evaluate the index surgery sufficiently. In this study, we evaluated the risk factors, including the details of the index surgery, for ileus after diverting ileostomy closure. METHODS This was a retrospective study of patients who underwent ileostomy closure following index surgery for rectal cancer. Patients who developed postoperative ileus [POI (+)] and patients who did not [POI (-)] after ileostomy closure were compared. RESULTS Sixty-eight patients were evaluated and were divided into two groups: POI (+) (n = 11) and POI (-) (n = 57), and the groups were compared. There were no significant differences in the details of the index surgery, operative procedure, transanal total mesorectal excision, lateral lymph node dissection, operating time, or blood loss. The incidence of Clavien-Dindo grade ≥ III complications and adjuvant chemotherapy after index surgery were significantly higher in the POI (+) group. CONCLUSIONS The incidence of Clavien-Dindo grade ≥ III complications and adjuvant chemotherapy after index surgery may increase the risk of postoperative ileus after ileostomy closure.
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Affiliation(s)
- Toshihiro Nakao
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan.
| | - Mitsuo Shimada
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
| | - Kozo Yoshikawa
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
| | - Takuya Tokunaga
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
| | - Masaaki Nishi
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
| | - Hideya Kashihara
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
| | - Chie Takasu
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
| | - Yuma Wada
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
| | - Toshiaki Yoshimoto
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
| | - Syoko Yamashita
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
| | - Yosuke Iwakawa
- Department of Digestive and Transplant Surgery, Tokushima University Hospital, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 7708503, Japan
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Park SS, Kim MJ, Lee DE, Park SC, Han KS, Hong CW, Sohn DK, Chang HJ, Oh JH. Diverting ileostomy itself may not increase the rate of postoperative readmission related to dehydration after low anterior resection. Ann Surg Treat Res 2021; 101:111-119. [PMID: 34386460 PMCID: PMC8331557 DOI: 10.4174/astr.2021.101.2.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/21/2021] [Accepted: 06/16/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was performed to evaluate the risk of readmission in the first year after low anterior resection (LAR) for patients with rectal cancer and to identify the contributing factors for readmission related to dehydration specifically. Methods This was a retrospective analysis of 570 patients who underwent LAR for rectal cancer at National Cancer Center, Republic of Korea. A diverting loop ileostomy was performed in 357 (62.6%) of these patients. Readmission was defined as an unplanned visit to the emergency room or admission to the ward. The reasons for readmission were reviewed and compared between the ileostomy (n = 357) and no-ileostomy (n = 213) groups. The risk factors for readmission and readmission due to dehydration were analyzed using multivariable logistic and Cox proportional hazard model. Results Dehydration was the most common cause of readmission in both groups (ileostomy group, 6.7%, and no-ileostomy group, 4.7%, P = 0.323). On multivariable analysis, risk factors for readmission were an estimated intraoperative blood loss of ≥400 mL (odds ratio [OR], 1.757; 95% confidence interval [CI], 1.058-2.918; P = 0.029), and postoperative chemotherapy (OR, 2.914; 95% CI, 1.824-4.653; P < 0.001). On multivariable analysis, postoperative chemotherapy, and not a diverting loop ileostomy, was an independent risk factor for dehydration-related readmission (OR, 5.102; 95% CI, 1.772-14.688; P = 0.003). Conclusion The most common cause of readmission after LAR for rectal cancer was dehydration, as reported previously. Postoperative chemotherapy, not the creation of a diverting ileostomy, was identified as the risk factor associated with readmission related to dehydration.
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Affiliation(s)
- Sung Sil Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Min Jung Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong-Eun Lee
- Biostatistics Collaboration Team, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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11
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AKTURK OM, CAKIR M. Classification of the complications of the loop-ileostomy closure procedure according to the Clavien-Dindo grading system. Chirurgia (Bucur) 2021. [DOI: 10.23736/s0394-9508.20.05135-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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12
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Yellinek S, Krizzuk D, Gilshtein H, Moreno-Djadou T, de Sousa CAB, Qureshi S, Wexner SD. Early postoperative outcomes of diverting loop ileostomy closure surgery following laparoscopic versus open colorectal surgery. Surg Endosc 2021; 35:2509-2514. [PMID: 32458288 DOI: 10.1007/s00464-020-07662-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although diverting loop ileostomy (DLI) formation reduces the consequences of anastomotic leak and may also decrease the incidence of this severe complication, DLI closure can result in significant complications. The laparoscopic approach in colorectal surgery has numerous benefits, including reduced length of stay (LOS), less wound infection, and better cosmesis. The aim of this study was to determine whether a laparoscopic approach at the time of the ileostomy creation has a beneficial effect on the outcomes of ileostomy closure. METHODS A retrospective analysis of an IRB-approved prospective database was performed for all patients who underwent DLI closure between 2010 and 2017. Patients' demographics, operative reports, and postoperative course were reviewed. Statistical analyses were performed using SPSS software and included descriptive statistics, Chi-square for categorical variables, and Student's t tests for continuous variables. Skewed variables were compared using the non-parametric Mann-Whitney U test. Regression analysis for overall complications and LOS were preformed to further assess the impact of laparoscopy. RESULTS We identified 795 patients (363 females) who underwent DLI reversal surgery. The surgical approach in the index operation was laparoscopy in 65% of patients. Conversion to laparotomy at the ileostomy closure occurred in 6.1% of patients. The overall complication rate was lower and the LOS was shorter for patients who underwent DLI closure following laparoscopic surgery. Laparoscopy at the index operation was also associated with a lower incidence of postoperative ileus and a lower estimated blood loss (EBL) at the time of DLI reversal. Multivariate regression analysis found laparoscopy to have significant benefits compared to laparotomy for overall complications and for LOS. CONCLUSION Ileostomy closure following laparoscopic colorectal surgery offers benefits including reductions in LOS and overall complications.
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Affiliation(s)
- Shlomo Yellinek
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Dimitri Krizzuk
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Hayim Gilshtein
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Teresa Moreno-Djadou
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | | | - Sana Qureshi
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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13
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Segev L, Assaf D, Elbaz N, Schtrechman G, Westrich G, Adileh M, Nissan A, Goitein D. Outcomes of diverting loop ileostomy reversal in the elderly: a case-control study. ANZ J Surg 2021; 91:E382-E388. [PMID: 33870605 DOI: 10.1111/ans.16871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/28/2021] [Accepted: 04/04/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although diverting loop ileostomy (DLI) reversal is considered to be a relatively simple procedure, it is not immune from major morbidity. We aimed to compare outcomes of DLI reversal between elderly and non-elderly patients. METHODS Retrospective review of all patients who underwent DLI reversal at a single tertiary medical centre between 2010 and 2020. The elderly group consisted of patients 70 or older compared to a control group of those younger than 70 years. RESULTS During the study period, 307 patients underwent DLI reversal. Of these, 76 patients were in the elderly group (mean age 75.6) and 231 in the control group (mean age 55.3). The groups were comparable in terms of mean time interval between the creation of the ileostomy and reversal (242 versus 255 days, respectively, P = 0.5), choice between stapled and hand-sewn anastomoses (97.4% stapled anastomosis versus 93.1%, P = 0.086), median post-operative length of stay (5 days in both, P = 0.086), rates of post-operative complications (26.3% versus 26.8%, P = 0.99), severe complications (5.3% versus 6.9%, P = 0.81) and 30-day readmission rates (13.2% versus 10.8%, P = 0.58). Multivariate analysis found the time interval between the creation of the stoma and its reversal to be the only significant risk factor for major post-operative morbidity. Age was not found to be correlated with post-operative morbidity. CONCLUSION The outcomes of loop ileostomy reversal in elderly patients are similar to non-elderly patients. Efforts should be made to decrease the time interval between the creation of the stoma and its reversal as this is a significant risk factor for major post-operative morbidity.
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Affiliation(s)
- Lior Segev
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Assaf
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Elbaz
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gal Schtrechman
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gal Westrich
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohammad Adileh
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Nissan
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Goitein
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Zenger S, Gurbuz B, Can U, Balik E, Yalti T, Bugra D. Comparative study between ghost ileostomy and defunctioning ileostomy in terms of morbidity and cost-effectiveness in low anterior resection for rectal cancer. Langenbecks Arch Surg 2021; 406:339-347. [PMID: 33537875 DOI: 10.1007/s00423-021-02089-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE The aim of this study was to compare ghost ileostomy (GI) and defunctioning ileostomy (DI) in patients who underwent low anterior resection (LAR) for rectal cancer in terms of postoperative morbidity, rehospitalization rates, and total costs. METHODS Patients with an anastomosis level between 5 and 10 cm from the anal verge after LAR were analyzed retrospectively. Clinical characteristics, operative outcomes, postoperative morbidity, rehospitalization rates, and total costs were compared. RESULTS A total of 123 patients were enrolled as follows: 42 patients in the GI group and 81 patients in the DI group. Anastomotic leakage (AL) was identified in three patients who underwent GI, and in all of them, GI was easily converted to DI. There were 96.3% of the patients with DI rehospitalized at least one time because of surgery-related and/or stoma-related complications or stoma closure. When we did not take into account the patients who were rehospitalized for stoma closure, the rates of rehospitalization were 4.7% and 22.2% in the GI and DI groups, respectively (P= 0.01). The mean total costs calculated by removing additional surgical procedures and adding all of the rehospitalization costs were 25,767 USD and 41,875 USD in the GI and DI groups, respectively (P= 0.0001). CONCLUSION GI may be a safe and cost-effective method in patients who underwent LAR with low or medium risk factors for AL. It is possible to avoid unnecessary ileostomy and reduce unwanted outcomes due to it, such as postoperative complications, rehospitalizations, and increased total costs by performing GI.
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Affiliation(s)
- Serkan Zenger
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey.
| | - Bulent Gurbuz
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey
| | - Ugur Can
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey
| | - Emre Balik
- Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey
| | - Tunc Yalti
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey.,Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey
| | - Dursun Bugra
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey.,Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey
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15
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Baik H, Bae KB. Low albumin level and longer interval to closure increase the early complications after ileostomy closure. Asian J Surg 2021; 44:352-357. [DOI: 10.1016/j.asjsur.2020.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/17/2020] [Accepted: 09/01/2020] [Indexed: 01/26/2023] Open
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16
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Zhang L, Zheng W, Cui J, Wu YL, Xu TL, Zhang HZ. Risk factors for nonclosure of defunctioning stoma and stoma-related complications among low rectal cancer patients after sphincter-preserving surgery. Chronic Dis Transl Med 2020; 6:188-197. [PMID: 32908969 PMCID: PMC7451586 DOI: 10.1016/j.cdtm.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Indexed: 12/15/2022] Open
Abstract
Background Defunctioning stoma is widely used to reduce anastomotic complications in rectal cancer surgery. However, the complications of stoma and stoma reversal surgery should not be underestimated. Furthermore, in some patients, stoma reversal failed. Here, we investigated the complications of defunctioning stoma surgery and subsequent reversal surgery and identify risk factors associated with the failure of getting stoma reversed. Methods In total, 154 patients who simultaneously underwent low anterior resection and defunctioning stoma were reviewed. Patients were divided into two groups according to whether their stoma got reversed or not. The reasons that patients received defunctioning stoma and experienced stoma-related complications and the risk factors for failing to get stoma reversed were analysed. Results The mean follow-up time was 47.54 (range 4.0–164.0) months. During follow-up, 19.5% of the patients suffered stoma-related long-term complications. Only 79 (51.3%) patients had their stomas reversed. The morbidity of complications after reversal surgery was 45.6%, and these mainly consisted of incision-related complications. Multivariate analyses showed that pre-treatment comorbidity (HR = 3.17, 95% CI 1.27–7.96, P = 0.014), postoperative TNM stage (HR = 2.55, 95% CI 1.05–6.18, P = 0.038), neoadjuvant therapy (HR = 2.75, 95% CI 1.07–7.05, P = 0.036), anastomosis-related complications (HR = 4.52, 95% CI 1.81–11.29, P = 0.001), and disease recurrence (HR = 24.83, 95% CI 2.90–213.06, P = 0.003) were significant independent risk factors for a defunctioning stoma to be permanent. Conclusions Defunctioning stoma is an effective method to reduce symptomatic anastomotic leakage, but the stoma itself and its reversal procedure are associated with high morbidity of complications, and many defunctioning stomas eventually become permanent. Therefore, surgeons should carefully assess preoperatively and perform defunctioning stomas in very high risk patients. In addition, doctors should perform stoma reversal surgery more actively to prevent temporary stomas from becoming permanent.
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Affiliation(s)
- Lin Zhang
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Wei Zheng
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Jian Cui
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Yun-Long Wu
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Tian-Lei Xu
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Hai-Zeng Zhang
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
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17
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de Paula TR, Nemeth S, Kiran RP, Keller DS. Predictors of complications from stoma closure in elective colorectal surgery: an assessment from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP). Tech Coloproctol 2020; 24:1169-1177. [PMID: 32696174 PMCID: PMC7373840 DOI: 10.1007/s10151-020-02307-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/13/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is significant morbidity after diverting ileostomy closure, so identifying predictors of complications could be of great benefit. The aim of our study was to evaluate the incidence and risk factors for postoperative morbidity after elective ileostomy closure. METHODS The ACS-NSQIP dataset was evaluated for elective ileostomy closures from 1/1/2015 to 12/31/2016. Demographic characteristics, operative, and postoperative outcomes were evaluated. The primary outcome was 30-day major morbidity (Clavien class III and greater). Secondary outcomes were rates and predictors of major morbidity, superficial site infection (SSI), reoperation, and readmission from multivariate logistic regression modeling. RESULTS We retrospectively evaluated 1885 patients. The median operative time was 65 (IQR 50-90) minutes and median length of stay was 3 (IQR 2-5) days. Major morbidity was recorded in 6.7%, including mortality (1.0%), deep/organ space SSI (2.6%), dehiscence (0.8%), reintubation (0.5%), sepsis (1.7%), septic shock (0.8%), and reoperation (3.7%). Readmission was recorded in 9.7% and 6.2% had SSI. Multivariate logistic regression showed male sex (OR 1.584; 95% CI 1.068-2.347; p = 0.022) and longer operative time (OR 1.004; 95% CI 1.001-1.007; p = 0.009) were among those variables associated with increased odds of major morbidity. Dyspnea (OR 2.431; 95% CI 1.139-5.094; p = 0.021) and longer operative time (OR 1.003; 95% CI 1.001-1.007; p = 0.034) were among the independent risk factors for SSI. Male sex (OR 2.246; 95% CI 1.297-3.892; p = 0.004, chronic obstructive pulmonary disease (OR 2.959; 95% CI 1.153-7.591; p = 0.024), and longer operative time (OR 1.005; 95% CI 1.001-1.009; p = 0.011) were associated with increased odds of reoperation. Chronic obstructive pulmonary disease (OR 2.578; 95% CI 1.338-4.968; p = 0.005), wound infection (OR 2.680; 95% CI 1.043-6.890; p = 0.041), and inflammatory bowel disease (OR 2.565; 95% CI 1.203-5.463; p = 0.015) were associated with increased odds of readmission. CONCLUSIONS Elective stoma closure has significant risk of morbidity. Patients with longer operative times were at increased risk for major morbidity, overall SSI, and reoperation. From the analysis, factors specifically associated with major morbidity, overall infectious complications, readmissions, and reoperations were identified. This information can be used to prospectively prepare for these high-risk patients, potentially improving postoperative outcomes.
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Affiliation(s)
- T R de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - S Nemeth
- Columbia HeartSource, Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY, USA
| | - R P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - D S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA. .,Division of Colon and Rectal Surgery, Department of Surgery, Herbert Irving Comprehensive Cancer Center, NewYork-Presbyterian, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 8th Floor, New York, NY, 10032, USA.
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18
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Jafari MD, Halabi WJ, Jafari F, Nguyen VQ, Stamos MJ, Carmichael JC, Mills SD, Pigazzi A. Morbidity of Diverting Ileostomy for Rectal Cancer: Analysis of the American College of Surgeons National Surgical Quality Improvement Program. Am Surg 2020. [DOI: 10.1177/000313481307901016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There is controversy regarding the potential benefits of diverting ileostomy after low anterior resection (LAR). This study aims to examine the morbidity associated with diverting ileostomy in rectal cancer. A retrospective review of LAR cases was performed using the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2011). Patients who underwent LAR with and without diversion were selected. Demographics, intraoperative events, and postoperative complications were reviewed. Among the 6337 cases sampled, 991 (16%) received a diverting ileostomy. Patients who were diverted were younger (60 vs 63 years), predominantly male (64 vs 53%), and more likely to have received pre-operative radiation (39 vs 12%). There was no significant difference in steroid use, weight loss, or intraoperative transfusion. Postoperatively, there was no significant difference in length of stay, rate of septic complications, wound infections, and mortality. The rate of reoperation was lower in the diverted group (4.5 vs 6.9%). Diversion was associated with a higher risk-adjusted rate of acute renal failure (OR 2.4; 95% CI (1.2, 4.6); P < 0.05). The use of diverting ileostomy reduces the rate of reoperation but is associated with an increased risk of acute renal insufficiency. These findings emphasize the need for refinement of patient selection and close follow-up to limit morbidity.
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Affiliation(s)
- Mehraneh D. Jafari
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Wissam J. Halabi
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Fariba Jafari
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Vinh Q. Nguyen
- Department of Statistics, University of California Irvine, Irvine, California
| | - Michael J. Stamos
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Joseph C. Carmichael
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Steven D. Mills
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
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19
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Belvedere S, Foster JD, Soucisse ML, Warrier SK, Heriot AG. Toxic megacolon due to Salmonella acute infectious colitis requiring total colectomy following loop ileostomy closure. ANZ J Surg 2020; 90:E200-E201. [PMID: 32396679 DOI: 10.1111/ans.15973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Shane Belvedere
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of General Surgical Specialities, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jake D Foster
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Mikael L Soucisse
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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20
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Neumann PA, Reischl S, Berg F, Jäger C, Friess H, Reim D, Ceyhan GO. Meta-analysis and single-center experience on the protective effect of negative suction drains on wound healing after stoma reversal. Int J Colorectal Dis 2020; 35:403-411. [PMID: 31875261 DOI: 10.1007/s00384-019-03492-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Compromised wound healing following stoma reversal is a frequent problem. The use of negative suction drainage for reduction of complications remains controversial. METHODS The patient database of our center was reviewed for patients with ileostomy reversal between 2007 and 2017. Risk factors for wound complications were analyzed using multivariate regression analysis. Systematic review and meta-analysis was performed. Ultimately, results of this study were integrated into meta-analysis to assess the effect of drainage placement on wound healing. RESULTS In our institutional analysis, a total of 406 patients with ileostomy reversal were included (n = 240 (59.1%) with drainage vs. n = 166 (40.8%) without drainage). In multivariate analysis, body mass index (BMI) was a risk factor for wound complications (odds ratio (95% CI) 1.06 (1.02-1.12)). Patients with drainage needed significantly fewer interventions than those without drainage (17.1% vs. 28.9%, p = 0.005). Placement of drainage significantly reduced the risk of wound complications even in the group with elevated BMI (odds ratio (95% CI) 0.462 (0.28-0.76), p = 0.003). Meta-analysis identified 6 studies with a total of 1180 patients eligible for further analysis (2 prospectively randomized trials; 4 retrospective cohort studies). Overall analysis revealed a significantly beneficial effect of wound drainage following ileostomy reversal (RR (95% CI) 0.47 (0.34, 0.66); p < 0.0001). CONCLUSION In our institutional analysis as well as meta-analysis, the use of subcutaneous suction drains was beneficial for prevention of wound healing complications following ostomy reversal. Drainage placement is especially valuable in high-risk situations such as in obese patients.
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Affiliation(s)
- Philipp-Alexander Neumann
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany.
| | - Stefan Reischl
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany
| | - Felix Berg
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany
| | - Carsten Jäger
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany
| | - Daniel Reim
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany
| | - Güralp O Ceyhan
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Str. 22, 81675, Munich, Germany.,Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
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21
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The Safety of Outpatient Stoma Closure: on the Verge of a Paradigm Shift? J Gastrointest Surg 2019; 23:2019-2026. [PMID: 30350192 DOI: 10.1007/s11605-018-4001-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/28/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND An area of contention among colorectal surgeons is when it is safe to discharge patients who have undergone closure of diverting ostomies. This study aimed to review the trends in outpatient stoma closure (OSC), to assess the safety of this practice, and to identify appropriate surgical candidates for the outpatient procedure. METHODS Patients were queried from the ACS National Surgical Quality Improvement Program database (2005-2016). Main outcomes included Clavien-Dindo (C-D) III-V class surgical complications, and readmission. Outpatient stay was defined as a hospital stay of less than or equal to 1 day. Multivariable logistic regression analysis was used to identify risk factors for C-D III-V complications and readmission. RESULTS Of 24,393 patients, 668 (2.74%) underwent an OSC. OSC has increased over the last decade (3.16% 2005-2006, 4.14% 2016, p < 0.001). Outpatients had significantly lower ASA class and fewer comorbidities than inpatients. Outpatient complication rate was significantly lower than the inpatient rate (2.99% vs. 7.25%, p < 0.001). Readmissions were comparable (8.92% outpatient vs. 9.77% inpatient, p = 0.54). ASA > 2, smoking, COPD, dyspnea, steroid use, bleeding disorder, and partial/total dependency were associated with increased risk of complications and readmission. Patients without any risk factors had lower complication (4.75%) and readmission rates (8.09%) compared to those with ≥ 2 risk factors (11.50% complication and 13.07% readmission rate, p < 0.001). CONCLUSIONS There is an increasing trend in the percentage of stoma closures being performed as outpatient procedures. Appropriate selection of patients preoperatively who are suitable candidates for OSC can be helpful in managing patient expectations and hospital resources.
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Factors affecting the morbidity and mortality of diverting stoma closure: retrospective cohort analysis of twelve-year period. Radiol Oncol 2019; 53:331-336. [PMID: 31553701 PMCID: PMC6765168 DOI: 10.2478/raon-2019-0037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/15/2019] [Indexed: 12/13/2022] Open
Abstract
Background Diverting stoma is often performed in rectal cancer surgery for reducing the consequences of possible anastomotic failure. Closing of stoma follows in most cases after a few months. The aim of our study was to evaluate morbidity and mortality after diverting stoma closure and to identify risk factors for complications of this procedure. Patients and methods At our department, we have performed a retrospective cohort analysis of data for 260 patients with diverting stoma closure from 2003 to 2015. Age, stoma type, patient's preoperative ASA score, surgical technique and time to stoma closure were investigated as factors which could influence the complication rate. Results 218 patients were eligible for investigation. Postoperative complications developed in 54 patients (24.8%). Most common complications were postoperative ileus (10%) and wound infection (5%). Four patients died (1.8%). There was no effect on complication rate regarding type of stoma, closing technique, patient's ASA status and patient age. The only factor influencing the complication rate was the time to stoma closure. We found that patients which had the stoma closed prior to 8 months after primary surgery had lower overall complication rate (p<0. 05). Conclusions To reduce overall complication rate, our data suggest a shorter period than 8 months after primary surgery before closure of diverting stoma. As diverting stoma closure is not a simple operation, all strategies should be taken to reduce significant morbidity and mortality rate.
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Garfinkle R, Savage P, Boutros M, Landry T, Reynier P, Morin N, Vasilevsky CA, Filion KB. Incidence and predictors of postoperative ileus after loop ileostomy closure: a systematic review and meta-analysis. Surg Endosc 2019; 33:2430-2443. [PMID: 31020433 DOI: 10.1007/s00464-019-06794-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/09/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Postoperative ileus (POI) is regarded as the most clinically significant morbidity following loop ileostomy closure; however, its incidence remains poorly understood. Our objective was therefore to determine the pooled incidence of POI after loop ileostomy closure and identify risk factors associated with its development. METHODS We systematically searched MEDLINE (via Ovid and PubMed), Embase, the Cochrane Library, Biosis Previews, and Scopus to identify studies reporting the incidence of POI in patients who underwent loop ileostomy closure. Two independent reviewers extracted data and appraised study quality. Cumulative incidence proportions were pooled across studies using a random-effects meta-analytic model. RESULTS Sixty-seven studies, including 9528 patients, met our inclusion criteria. The pooled estimate of POI was 8.0% (95% CI 6.9-9.3%; I2 = 74%). The estimated incidence varied by POI definition: studies with a robust definition of POI (n = 8) demonstrated the highest estimate of POI (12.4%, 95% CI 9.2-16.5%; I2 = 79%) while studies that did not report an explicit POI definition (n = 38) demonstrated the lowest estimate (6.7%, 95% CI 5.3-8.3%; I2 = 61%). Small bowel anastomosis technique (hand-sewn) and interval time from ileostomy creation to closure (longer time) were the factors most commonly associated with POI after loop ileostomy closure. However, most comparative studies were not powered to examine risk factors for POI. CONCLUSIONS POI is an important complication after loop ileostomy closure, and its incidence is dependent on its definition. More research aimed at studying this complication is required to better understand risk factors for POI after loop ileostomy closure.
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Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Paul Savage
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.,Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Tara Landry
- Medical Libraries, McGill University Health Center, Montreal, QC, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada. .,Department of Medicine, McGill University, Montreal, QC, Canada.
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Abstract
PURPOSE To identify factors associated with timing of stoma reversal after rectal cancer surgery in a large Swedish register-based cohort. METHODS Three thousand five hundred sixty-four patients with rectal cancer who received a protective stoma during surgery in 2007-2013 were identified in the Swedish colorectal cancer register. Time to stoma reversal was evaluated over a follow-up period of one and a half years. Factors associated with timing of stoma reversal were analysed using Cox regression analysis. Reversal within 9 months (12 months if adjuvant chemotherapy) was considered latest expected time to closure. RESULTS Stoma reversal was performed in 2954 (82.9%) patients during follow-up. Patients with post-secondary education had an increased chance for early stoma reversal (HR 1.13; 95% CI 1.02-1.25). Postoperative complications (0.67; 0.62-0.73), adjuvant chemotherapy (0.63; 0.57-0.69), more advanced cancer stage (stage III 0.74; 0.66-0.83 and stage IV 0.38; 0.32-0.46) and higher ASA score (0.80; 0.71-0.90 for ASA 3-4) were associated with longer time to reversal. Two thousand four hundred thirty-seven (68.4%) patients had stoma reversal within latest expected time to closure. Factors associated to decreased chance of timely reversal were more advanced cancer stage (stage III 0.64; 0.50-0.81 and stage IV 0.19; 0.13-0.27), postoperative complications (0.50; 0.42-0.59) and higher ASA score (0.77; 0.61-0.96 for ASA 3-4). CONCLUSIONS Patients with a high level of education had a higher chance of timely reversal but medical factors had a stronger association to time to reversal. Patients with advanced rectal cancer are at high risk for non-reversal and should be considered for permanent stoma.
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Bhama AR, Batool F, Collins SD, Ferraro J, Cleary RK. Risk Factors for Postoperative Complications Following Diverting Loop Ileostomy Takedown. J Gastrointest Surg 2017; 21:2048-2055. [PMID: 28971302 DOI: 10.1007/s11605-017-3567-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 08/27/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Diverting loop ileostomies are frequently created to divert the fecal stream in an effort to protect downstream anastomoses. These are later reversed to restore intestinal continuity. The goal of this study is to evaluate risk factors for postoperative complications following diverting loop ileostomy takedown. MATERIALS AND METHODS Patients who underwent diverting loop ileostomy takedown between January 1, 2010 and April 28, 2015 were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified and a hierarchical logistic regression model was used to identify risk factors for postoperative complications. RESULTS 1,737 patients met the inclusion criteria. Rates of postoperative complications were generally low. Mean length of stay (LOS) was 5.6 (± 4.5) days. Outcomes of interest were the following: overall morbidity, serious morbidity, extended LOS, SSI, UTI, pneumonia, readmission, reoperation, and mortality. Risk factors for these outcomes included the following: ASA class, bleeding disorder, prolonged operative time, race, tobacco use, gender, steroid use, peripheral vascular disease, weight loss, and functional status. CONCLUSIONS Diverting loop ileostomy takedown has a complication rate of approximately 20%. Higher ASA class, longer operative times, history of bleeding disorder, and functional status were identified as risk factors for most complications.
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Affiliation(s)
- Anuradha R Bhama
- Division of Colon and Rectal Surgery, Department of Surgery, St. Joseph Mercy Health System - Ann Arbor, Ann Arbor, MI, 48106, USA.
| | - Farwa Batool
- Division of Colon and Rectal Surgery, Department of Surgery, St. Joseph Mercy Health System - Ann Arbor, Ann Arbor, MI, 48106, USA
| | - Stacey D Collins
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI, 48104, USA
| | - Jane Ferraro
- Division of Colon and Rectal Surgery, Department of Surgery, St. Joseph Mercy Health System - Ann Arbor, Ann Arbor, MI, 48106, USA
| | - Robert K Cleary
- Division of Colon and Rectal Surgery, Department of Surgery, St. Joseph Mercy Health System - Ann Arbor, Ann Arbor, MI, 48106, USA
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Holmgren K, Kverneng Hultberg D, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study. Colorectal Dis 2017; 19:1067-1075. [PMID: 28612478 DOI: 10.1111/codi.13771] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/13/2017] [Indexed: 12/11/2022]
Abstract
AIM Fashioning a defunctioning stoma is common when performing an anterior resection for rectal cancer in order to avoid and mitigate the consequences of an anastomotic leakage. We investigated the permanent stoma prevalence, factors influencing stoma outcome and complication rates following stoma reversal surgery. METHOD Patients who had undergone an anterior resection for rectal cancer between 2007 and 2013 in the northern healthcare region were identified using the Swedish Colorectal Cancer Registry and were followed until the end of 2014 regarding stoma outcome. Data were retrieved by a review of medical records. Multiple logistic regression was used to evaluate predefined risk factors for stoma permanence. Risk factors for non-reversal of a defunctioning stoma were also analysed, using Cox proportional-hazards regression. RESULTS A total of 316 patients who underwent anterior resection were included, of whom 274 (87%) were defunctioned primarily. At the end of the follow-up period 24% had a permanent stoma, and 9% of patients who underwent reversal of a stoma experienced major complications requiring a return to theatre, need for intensive care or mortality. Anastomotic leakage and tumour Stage IV were significant risk factors for stoma permanence. In this series, partial mesorectal excision correlated with a stoma-free outcome. Non-reversal was considerably more prevalent among patients with leakage and Stage IV; Stage III patients at first had a decreased reversal rate, which increased after the initial year of surgery. CONCLUSION Stoma permanence is common after anterior resection, while anastomotic leakage and advanced tumour stage decrease the chances of a stoma-free outcome. Stoma reversal surgery entails a significant risk of major complications.
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Affiliation(s)
- K Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - D Kverneng Hultberg
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M M Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - J Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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Pakraftar S, Ramalingam L, Shuai Y, Jones HL, Pingpank JF, Ahrendt SS, Holtzman MP, Zureikat AH, Zeh HJ, Bartlett DL, Choudry HA. Institutional Experience with Ostomies Created During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion. Ann Surg Oncol 2017; 24:3811-3817. [PMID: 29019111 DOI: 10.1245/s10434-017-6114-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS-HIPEC) is a complex procedure that often requires ostomy creation to protect high-risk anastomoses. This study aimed to evaluate the authors' institutional experience with CRS-HIPEC-associated ostomies, determine predictors of ostomy creation and reversal, and assess their impact on survival. METHODS The study analyzed clinicopathologic, perioperative, and oncologic data from a prospective database of 1435 CRS-HIPEC procedures for peritoneal metastases. The Kaplan-Meier method was used to estimate survival. Multivariate analyses identified associations with ostomy creation/reversal and survival. RESULTS Ostomies were created in 34% of the patients, most commonly loop ileostomies (82%). Loop ileostomies were reversed in the majority of patients (83%), whereas non-loop ileostomies were infrequently reversed (< 10% reversal rate). In a multivariate logistic regression model, intermediate or high tumor grade, colectomy/proctectomy, longer operative time, and lower Charlson comorbidity index were associated with loop ileostomy creation, whereas incomplete macroscopic resection, colorectal histology, and major postoperative complications were associated with non-reversal of loop ileostomy. In a multivariate Cox proportional hazards model, intermediate or high tumor grade and non-reversal of loop ileostomy were associated with worse overall survival. CONCLUSIONS Loop ileostomies were almost always reversed, whereas non-loop ileostomies were almost always permanent. Hospital readmissions for loop ileostomy-related complications were common. Therefore, formal outpatient protocols for prevention and management should be implemented. Non-reversal of loop ileostomy was associated with very poor survival.
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Affiliation(s)
- Sam Pakraftar
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lekshmi Ramalingam
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yongli Shuai
- The University of Pittsburgh Cancer Institute Biostatistics Facility, Pittsburgh, PA, USA
| | - Heather L Jones
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - James F Pingpank
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven S Ahrendt
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew P Holtzman
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Herbert J Zeh
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - David L Bartlett
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Haroon A Choudry
- Division of Surgical Oncology, Koch Regional Perfusion Center, University of Pittsburgh, Pittsburgh, PA, USA.
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Loop Ileostomy Closure as an Overnight Procedure: Institutional Comparison With the National Surgical Quality Improvement Project Data Set. Dis Colon Rectum 2017; 60:852-859. [PMID: 28682971 DOI: 10.1097/dcr.0000000000000793] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Enhanced recovery pathways have decreased length of stay after colorectal surgery. Loop ileostomy closure remains a challenge, because patients experience high readmission rates, and validation of enhanced recovery pathways has not been demonstrated. This study examined a protocol whereby patients were discharged on the first postoperative day and instructed to advance their diet at home with close telephone follow-up. OBJECTIVE The hypothesis was that patients can be safely discharged the day after loop closure, leading to shorter length of stay without increased rates of readmission or complications. DESIGN Patients undergoing loop ileostomy closure were queried from the American College of Surgeons National Surgical Quality Improvement Project and compared with a single institution (2012-2015). Length of stay, 30-day readmission, and 30-day morbidity data were analyzed. SETTINGS The study was conducted at a tertiary university department. PATIENTS The study includes 1602 patients: 1517 from the National Surgical Quality Improvement Project database and 85 from a single institution. MAIN OUTCOME MEASURES Length of stay and readmission rates were measured. RESULTS Median length of stay was less at the single institution compared with control (2 vs 4 d; p < 0.001). Thirty-day readmission (15.3% vs 10.4%; p = 0.15) and overall 30-day complications (15.3% vs 16.7%; p = 0.73) were similar between cohorts. Estimated adjusted length of stay was less in the single institution (2.93 vs 5.58 d; p < 0.0001). There was no difference in the odds of readmission (p = 0.22). LIMITATIONS The main limitations of this study include its retrospective nature and limitations of the National Surgical Quality Improvement Program database. CONCLUSIONS Next-day discharge with protocoled diet advancement and telephone follow-up is acceptable after loop ileostomy closure. Patients can benefit from decreased length of stay without an increase in readmission or complications. This has the potential to change the practice of postoperative management of loop ileostomy closure, as well as to decrease cost. See Video Abstract at http://links.lww.com/DCR/A310.
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Schneider V, Lee LD, Stroux A, Buhr HJ, Ritz JP, Kreis ME, Lauscher JC. Risk factors for reoperation after ileostomy reversal - Results from a prospective cohort study. Int J Surg 2016; 36:233-239. [PMID: 27815185 DOI: 10.1016/j.ijsu.2016.10.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 10/01/2016] [Accepted: 10/30/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Ileostomy reversal is frequently performed in abdominal surgery. Postoperative complications after ileostomy reversal are encountered in around 20% of patients. Data regarding risk factors for reoperation after ileostomy closure are scarce. The purpose of this prospective trial was to determine risk factors for operative revision after ileostomy closure. MATERIALS AND METHODS This is an additional post hoc analysis of a two center prospective trial. After enrollment, patient characteristics and intraoperative details were analyzed. Patients were followed up at one postoperative visit before discharge and at a three months postoperative visit by standardized questionnaire. All reoperations occurring in the three months period after surgery were analyzed, and immediate reoperations which were directly related to the ileostomy reversal were analyzed separately. RESULTS 118 patients with elective ileostomy reversal were included in the trial. 12 out of 106 patients (11.3%) underwent any reoperation within three months after surgery (Clavien-Dindo grade IIIb). On multivariate analysis, anemia was associated with any reoperation p = 0.004; OR 6.93 (95% CI 1.37-30.07). Six out of 114 patients (5.3%) required an immediate reoperation (small bowel perforation, anastomotic leakage, postoperative ileus, deep wound infection) due to surgical complications directly related to the ileostomy reversal. Higher body mass index and anemia were associated with immediate reoperations (BMI: p = 0.038; OR 0.73 (95% CI 0.55-0.98); anemia: p = 0.001; OR 25.50 (95% CI 3.87-168.21). CONCLUSION Surgical complications after ileostomy reversal occurred to a substantial extent. Rate of reoperations was associated with anemia and high body mass index. Optimizing patients in terms of preoperative hemoglobin and BMI may reduce surgical complications after ileostomy closure.
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Affiliation(s)
- V Schneider
- Department of General, Visceral, and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
| | - L D Lee
- Department of General, Visceral, and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
| | - A Stroux
- Institute of Biometry and Clinical Epidemiology, Charité Campus Mitte, Charitéplatz 1, 10098 Berlin, Germany
| | - H J Buhr
- German Society for General and Visceral Surgery, Schiffbauerdamm 40, 10117 Berlin, Germany
| | - J P Ritz
- Department of General and Visceral Surgery, HELIOS Kliniken Schwerin, Wismarsche Straße 393-397, 19049 Schwerin, Germany
| | - M E Kreis
- Department of General, Visceral, and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
| | - J C Lauscher
- Department of General, Visceral, and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
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Lauscher JC, Schneider V, Lee LD, Stroux A, Buhr HJ, Kreis ME, Ritz JP. Necessity of subcutaneous suction drains in ileostomy reversal (DRASTAR)-a randomized, controlled bi-centered trial. Langenbecks Arch Surg 2016; 401:409-18. [PMID: 27138020 DOI: 10.1007/s00423-016-1436-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/13/2016] [Indexed: 01/24/2023]
Abstract
PURPOSE Data regarding length of hospital stay of patients undergoing ileostomy reversal are very heterogeneous. There are many factors that may have an influence on the length of postoperative hospital stay, such as postoperative wound infections. One potential strategy to reduce their incidence and to decrease hospital stay is to insert subcutaneous suction drains. The purpose of this study was to examine the influence of the insertion of subcutaneous suction drains on hospital stay and postoperative wound infections in ileostomy reversal. Risk factors for postoperative wound infection were determined. METHODS This is a randomized controlled two-center non-inferiority trial with two parallel groups. The total length of hospital stay as primary endpoint and the occurrence of a surgical site infection, the colonization of the abdominal wall with bacteria, and the occurrence of hematomas/seromas as secondary endpoints were monitored. RESULTS One hundred eighteen patients with elective ileostomy reversal were included. Fifty-nine patients were randomly assigned to insertion of a subcutaneous suction drain, and 59 patients were randomly assigned to receive no drain. After 3 months of follow-up, 50 patients in the group with drain and 53 patients in the group without drain could be analyzed. Median total length of hospital stay was 8 days in the SD group and 9 days in the group without SD (p = 0.17). Fourteen percent of patients with SD and 17 % without SD developed SSI, p = 0.68. Multivariate analysis revealed anemia (p < 0.01), intraoperative bowel perforation (p = 0.02) and resident (p = 0.04) or fellow (p = 0.048) performing the operation as risk factors for SSI. CONCLUSIONS This trial shows that the omission of subcutaneous suction drains is not inferior to the use of subcutaneous suction drains after ileostomy reversal in terms of length of hospital stay, surgical site infections, and hematomas/seromas.
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Affiliation(s)
- J C Lauscher
- Department of General, Visceral, and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - V Schneider
- Department of General, Visceral, and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - L D Lee
- Department of General, Visceral, and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - A Stroux
- Institute of Biometry and Clinical Epidemiology, Charité Campus Mitte, Charitéplatz 1, 10098, Berlin, Germany
| | - H J Buhr
- German Society for General and Visceral Surgery, Schiffbauerdamm 40, 10117, Berlin, Germany
| | - M E Kreis
- Department of General, Visceral, and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - J P Ritz
- Department of General and Visceral Surgery, HELIOS Kliniken Schwerin, Wismarsche Straße 393-397, 19049, Schwerin, Germany
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Man VCM, Choi HK, Law WL, Foo DCC. Morbidities after closure of ileostomy: analysis of risk factors. Int J Colorectal Dis 2016; 31:51-7. [PMID: 26245947 DOI: 10.1007/s00384-015-2327-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Low anterior resection is commonly performed for carcinoma of the distal rectum. Diverting ileostomy has been used to decrease the septic consequence of anastomotic leakage and to reduce the re-operation rate. Nevertheless, subsequent closure of ileostomy can be associated with considerable morbidities. This study aimed to evaluate the morbidities after closure of ileostomy and to identify possible risk factors associated with the morbidities. METHODS Data of patients who underwent closure of ileostomy, after a previous low anterior resection and defunctioning ileostomy for rectal cancer, was reviewed retrospectively. Patient's demographics, coexisting morbidities, operative details, and post-operative outcomes were analyzed. RESULTS From January 2000 to September 2012, 213 patients who underwent ileostomy closure were included. Thirty-five patients developed post-operative complications. The overall complication rate was 16.4 %. The majority of complications could be managed by conservative treatment. Only one patient required re-operation due to intestinal obstruction. There was no 30-day mortality. Age >80 years was an independent risk factor for post-operative complications. Age >80 years was also an independent risk factor for developing urinary retention (p = 0.001) and prolonged ileus (p = 0.02). Closure of ileostomy with hand-sewn techniques showed a higher incidence of post-operative intestinal obstruction (p = 0.049) compared to closure using stapler. CONCLUSION Closure of ileostomy following low anterior resection is associated with acceptable morbidities. Elderly patients tend to have a more complicated post-operative course and require more medical attention. The use of stapler is the preferred method for ileostomy closure as it is associated with less post-operative intestinal obstruction.
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Affiliation(s)
- Vivian Chi Mei Man
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Hok Kwok Choi
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Wai Lun Law
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong.
| | - Dominic Chi Chung Foo
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
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Sakamoto Y, Sakamoto Y, Miyamoto Y, Tokunaga R, Ohuchi M, Kiyozumi Y, Nakamura K, Kosumi K, Izumi D, Harada K, Kurashige J, Hiyoshi Y, Iwagami S, Baba Y, Yoshida N, Watanabe M, Baba H. Cryptogenic repetitive severe colitis after ileostomy closure. Int Cancer Conf J 2015; 5:104-106. [PMID: 31149435 DOI: 10.1007/s13691-015-0237-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 09/03/2015] [Indexed: 11/26/2022] Open
Abstract
We describe a case of cryptogenic repetitive severe colitis after ileostomy closure. A 50-year-old man was referred to our hospital for treatment of advanced rectal cancer. The patient underwent laparoscopic intersphincteric resection combined with synchronous partial liver resection for colorectal liver metastasis detected intraoperatively and construction of a diverting ileostomy. Ileostomy closure was performed 3 months later. Five days following ileostomy closure, the patient complained of lower abdominal pain and developed multiple daily fever episodes. Colonoscopy revealed multiple ulcers in the sigmoid colon and rectum. Because symptoms did not improve despite fasting and antibiotic therapy, ileostomy reconstruction was performed. Re-closure was performed 6 months after the previous ileostomy closure; however, severe colitis recurred with similar symptoms, and construction of a colostomy at the transverse colon was then performed. Despite varied examinations, the cause of the colitis was not identified. To our knowledge, there are no previous reports of repetitive severe colitis after ileostomy closure.
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Affiliation(s)
- Yuki Sakamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Yasuo Sakamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Ryuma Tokunaga
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Mayuko Ohuchi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Yuki Kiyozumi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Kenichi Nakamura
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Keisuke Kosumi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Daisuke Izumi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Kazuto Harada
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Junji Kurashige
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Shiro Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
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Poskus E, Kildusis E, Smolskas E, Ambrazevicius M, Strupas K. Complications after Loop Ileostomy Closure: A Retrospective Analysis of 132 Patients. VISZERALMEDIZIN 2015; 30:276-80. [PMID: 26288601 PMCID: PMC4513804 DOI: 10.1159/000366218] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Closure of a loop ileostomy is a relatively simple procedure although many studies have demonstrated high morbidity rates following it. Methods to reduce the number of complications, such as timing of closure or different surgical closure techniques, are investigated. The aim of this study was to evaluate the experience of the Abdominal Surgery Center at Vilnius University Hospital (VUH) 'Santariskiu klinikos' to review the complications after closure of loop ileostomy and to identify potential risk factors for postoperative complications. METHODS Data from 132 patients who underwent closure of loop ileostomy from 2003 to 2013 at the Abdominal Surgery Center of VUH were collected, including demographics, causes of ileostomy formation, additional diseases, time from creation to closure of ileostomy, anastomotic technique, duration of the operation, postoperative complications, and hospital stay after surgery. The operations were performed by 15 surgeons with varying experience assisted by surgical residents. Experience in ileostomy closure was defined by the number of procedures performed. RESULTS Complications occurred in 24 patients (18.2%), with 20 of them having surgical complications: bowel obstruction (9 (6.8%)), wound infection (4 (3.0%)), peritonitis due to anastomotic leak (3 (2.3%)), intra-abdominal abscess (2 (1.5%)), anastomotic leak with enterocutaneous fistula (1 (0.76%)), and bleeding (1 (0.76%)). 4 patients had non-surgical complications: postoperative diarrhea (2 (1.5%)), urinary retention (1 (0.76%)), and deep vein thrombosis (1 (0.76%)). Most complications were classified as group II according to the Clavien-Dindo classification. 2 patients died (1.5%). The anastomotic technique used did not affect the outcome. The experience of the surgeon as judged by the frequency of the procedure was the main factor affecting postoperative morbidity significantly (p = 0.03). CONCLUSION Our study revealed that the rate of postoperative complications and a smooth postoperative course after the closure of ileostomy was influenced by surgical experience.
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Affiliation(s)
- Eligijus Poskus
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania ; Center of Abdominal Surgery, Vilnius University Hospital 'Santariskiu Klinikos', Vilnius University, Vilnius, Lithuania
| | - Edvinas Kildusis
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania ; Center of Abdominal Surgery, Vilnius University Hospital 'Santariskiu Klinikos', Vilnius University, Vilnius, Lithuania
| | | | - Marijus Ambrazevicius
- Center of Abdominal Surgery, Vilnius University Hospital 'Santariskiu Klinikos', Vilnius University, Vilnius, Lithuania
| | - Kestutis Strupas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania ; Center of Abdominal Surgery, Vilnius University Hospital 'Santariskiu Klinikos', Vilnius University, Vilnius, Lithuania
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Doud AN, Levine EA, Fino NF, Stewart JH, Shen P, Votanopoulos KI. Stoma Creation and Reversal After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2015; 23:503-10. [PMID: 26077915 DOI: 10.1245/s10434-015-4674-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC) often includes stoma creation. We evaluated the indications, morbidity, and mortality associated with stoma creation and reversal after CRS/HIPEC. METHODS Retrospective analysis of a prospective database of 1149 CRS-HIPEC procedures was performed. Patient demographics, type of malignancy, comorbidities, Clavien-graded morbidity, mortality, indications for stoma creation, and outcomes of subsequent reversal were abstracted. RESULTS Sixteen percent (186/1149) of CRS/HIPEC procedures included stoma creation, whereas 1.1 % (11/963) of patients without initial stoma creation developed anastomotic leaks requiring stoma. Patients who required a stoma had worse preoperative performance status (ECOG 0/1: 77.2 vs. 86.1 %, p = 0.002), greater burden of disease (PCI 17.6 vs. 12.9, p < 0.0001), and were more likely to have R2 resections (74.5 vs. 48.8 %, p < 0.0001) than those without stoma creation. Stomas were intended to be permanent in 17.5 % (35/199). Of 164 patients with potentially reversible ostomies, only 26.2 % (43/164) underwent reversal. Disease progression (43/164, 26.2 %) and death (40/164, 24.3 %) most commonly precluded reversal. After reversal, 27.9 % (12/43) suffered a Clavien I/II morbidity, 27.9 % (12/43) suffered Clavien III/IV morbidity, and 30-day mortality was 4.7 % (2/43). Anastomotic leak occurred after 9 % (3/33) of ileostomy and 10 % (1/10) of colostomy reversals. CONCLUSIONS Stomas are more common among CRS/HIPEC patients with a high burden of disease and poor functional status. Reversal is uncommon and is associated with significant major morbidity. Preoperative counseling for those with high disease burden and poor functional status should include the risk of permanent stoma.
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Affiliation(s)
- Andrea N Doud
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA.
| | - Edward A Levine
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA
| | - Nora F Fino
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, USA
| | - John H Stewart
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA
| | - Perry Shen
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA
| | - Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA.
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Chu DI, Schlieve CR, Colibaseanu DT, Simpson PJ, Wagie AE, Cima RR, Habermann EB. Surgical site infections (SSIs) after stoma reversal (SR): risk factors, implications, and protective strategies. J Gastrointest Surg 2015; 19:327-34. [PMID: 25217092 DOI: 10.1007/s11605-014-2649-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/27/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Stoma reversals (SRs) are commonly performed with potentially significant postoperative complications including surgical site infections (SSIs). Our aim was to determine the incidence and risk factors for SSIs in a large cohort of SR patients. DESIGN We reviewed our institutional 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 30-day SSIs in patients undergoing SR. Records were additionally reviewed for 10 non-ACS-NSQIP variables. The primary outcome was SSI after SR. Secondary outcomes were additional 30-day postoperative complications and length-of-stay. Predictors of SSIs were identified using multivariable logistic regression. RESULTS From 528 SR patients, 36 patients developed a SSI (6.8 %). Most patients underwent SR for loop ileostomies (76.5 %) after index operations for ulcerative colitis (38.6 %) and colorectal cancer (27.8 %). SSI patients had fewer subcutaneous drains compared to patients with no SSI and had significantly higher rates of smoking, ASA 3-4 classification and laparotomies at SR (p < 0.05). Patients with SSI had increased length-of-stay and 30-day morbidities including sepsis and returns to the operating room (p < 0.05) compared to no-SSI patients. On multivariable analysis, subcutaneous drain placement was suggestive of SSI protection (odds ratio [OR] 0.52, 95 % confidence interval [CI] 0.2-1.1), but only smoking was significantly associated with an increased risk for SSI (OR 2.4, 95 % CI 1.1-5.4). CONCLUSIONS Smoking increased the risk of SR SSIs in patients by over twofold, and SR SSIs are associated with additional significant morbidities. Smoking cessation should be an important part of any SSI risk-reduction strategy.
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Affiliation(s)
- Daniel I Chu
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1720 2nd Avenue South, KB427, Birmingham, AL, 35294, USA,
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Comparing methods of ileostomy closure constructed in colorectal surgery in Turkey. GASTROENTEROLOGY REVIEW 2014; 9:291-6. [PMID: 25396004 PMCID: PMC4223118 DOI: 10.5114/pg.2014.46165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 12/28/2013] [Accepted: 01/02/2014] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Stoma construction is a life saver method for emergent and elective operations in colorectal surgery. However, they are associated with high rates of morbidity and mortality. AIM To compare the operative findings, early postoperative complications, and costs of stapled and hand-sewn closures in loop ileostomies that are constructed in emergent and elective colorectal surgery. MATERIAL AND METHODS The data of 68 patients requiring loop ileostomies during colorectal surgery were retrospectively evaluated. SPSS (version 20) was used for data analysis. RESULTS The study group consisted of 44 men and 24 women with a mean age of 55.5 years. The ileostomy closures were performed with hand-sewn method in 36 patients (group 1) and stapled method in 32 patients (group 2). The mean operation time was 75.4 min in group 1 and 46.7 min in group 2 (p < 0.001). Early postoperative complications were wound infection (8.8%), small bowel obstruction (6.06%), and anastomotic leakage (2.9%). Total costs, flatulence and faeces outlet time, oral feeding starting time, time of hospital stay, and early postoperative complications were lower in the stapled group. CONCLUSIONS Morbidity and mortality rates of stoma construction and its closure are still considerable. Lower anastomotic leakage rate, complication rate, and costs and shorter operative times in the stapled group make this method preferable.
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Does Preoperative Radio(chemo)therapy Increase Anastomotic Leakage in Rectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials. Gastroenterol Res Pract 2014; 2014:910956. [PMID: 25477955 PMCID: PMC4244918 DOI: 10.1155/2014/910956] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 10/22/2014] [Indexed: 12/15/2022] Open
Abstract
Objective. Preoperative radio(chemo)therapy (pR(C)T) appears to increase postoperative complications of rectal cancer resection, but clinical trials have reported conflicting results. The objective of this meta-analysis was performed to assess the effects of pR(C)T on anastomotic leak after rectal cancer resection. Methods. PubMed, Embase, and the Cochrane Library were searched from January 1980 to January 2014. Randomized controlled trials included all original articles reporting anastomotic leak in patients with rectal cancer, among whom some received preoperative radiotherapy or chemoradiotherapy while others did not. The analysed end-points were the anastomotic leak. Result. Seven randomized controlled trials with 3375 patients were included in the meta-analysis. 1660 forming the group undergoing preoperative radiotherapy or chemoradiotherapy versus 1715 patients undergoing without preoperative radiotherapy or chemoradiotherapy. The meta-analyses found that pR(C)T was not an independent risk factor for anastomotic leakage (OR 1.02, 95% CI 0.80-1.30; P = 0.88). Subgroups analysis was performed and the result was not altered. Conclusions. Current evidence demonstrates that pR(C)T did not increase the risk of postoperative anastomotic leak after rectal cancer resection in patients.
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Abstract
BACKGROUND AND OBJECTIVE Most surgeons suggest the use of fecal diversion in patients undergoing low anterior resections of rectal tumors at high risk for anastomotic leakage. We describe an exploratory study to evaluate the efficacy and safety of a new diversion method called a spontaneously closing cannula ileostomy, which was designed to protect rectal anastomoses in patients at high risk for anastomotic leakage. The outcomes of patients treated with cannula ileostomy were compared to those of patients treated with loop ileostomy. MAIN OUTCOME MEASURES Outcomes included the rates of anastomotic leakage, reoperation and other complications, as well as length of hospital stay and cost. DESIGN AND PATIENTS From January 2011 to December 2012, 294 patients undergoing low colorectal or coloanal anastomosis were treated with ileum diversion using cannula ileostomy or traditional loop ileostomy. Demographics, clinical features, and operational data were recorded. RESULTS The anastomotic leakage rates were 8.1% (12/149) in the cannula ileostomy group and 8.3% (12/145) in the loop ileostomy group (p = 1.0). The reoperation rate was 3% (4/149) in patients treated with a cannula ileostomy and 3.4% (5/145) in those who underwent a loop ileostomy (p = 0.75). The median length of the hospital stay was 8.6 days in the cannula ileostomy group and 17.1 days (p < 0.01) in the loop ileostomy group, including time for the initial and reversal operations. In the cannula ileostomy group, the median time to defecation from the anus was 16.5 days after the operation. During the follow-up period, 13 patients in the loop ileostomy group retained their stoma, as compared to 2 in the cannula ileostomy group (p < 0.01). LIMITATIONS This study was a nonrandomized design and lacked contrast enema data to identify anastomotic leaks. CONCLUSIONS Cannula ileostomy is a safe and effective diverting technique that protects low colorectal and coloanal anastomoses. Patients receiving a cannula ileostomy had shorter hospital stays and lower rates of permanent stoma than those receiving a loop ileostomy.
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Lee JT, Marquez TT, Clerc D, Gie O, Demartines N, Madoff RD, Rothenberger DA, Christoforidis D. Pursestring closure of the stoma site leads to fewer wound infections: results from a multicenter randomized controlled trial. Dis Colon Rectum 2014; 57:1282-9. [PMID: 25285695 DOI: 10.1097/dcr.0000000000000209] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical site infection after stoma reversal is common. The optimal skin closure technique after stoma reversal has been widely debated in the literature. OBJECTIVE We hypothesized that pursestring near-complete closure of the stoma site would lead to fewer surgical site infections compared with conventional primary closure. DESIGN This study was a parallel prospective multicenter randomized controlled trial. SETTINGS This study was conducted at 2 university medical centers. PATIENTS Patients (N = 122) presenting for elective colostomy or ileostomy reversal were selected. INTERVENTIONS Pursestring versus conventional primary closure of stoma sites were compared. MAIN OUTCOME MEASURES Stoma site surgical site infection within 30 days of surgery, overall surgical site infection, delayed healing (open wound for >30 days), time to wound epithelialization, and patient satisfaction were the primary outcomes measured. RESULTS The pursestring group had a significantly lower stoma site infection rate (2% vs 15%, p = 0.01). There was no difference in delayed healing or patient satisfaction between groups. Time to epithelialization was measured in only 51 patients but was significantly longer in the pursestring group (34.6 ± 20 days vs 24.1 ± 17 days, p = 0.02). LIMITATIONS This study was limited by the variability in procedures and surgeons, the limited follow-up after 30 days, and the inability to perform blinding. CONCLUSION Pursestring closure after stoma reversal has a lower risk of stoma site surgical site infection than conventional primary closure, although wounds may take longer to heal with the use of this approach. REGISTRATION NUMBER NCT01713452 (www.clinicaltrials.gov).
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Affiliation(s)
- Janet T Lee
- 1Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota 2Department of Surgery, Mercy Clinic, Saint Louis, Missouri 3Division of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Lee J, Kang MJ, Kim HS, Shin SH, Kim HY, Kim EK, Choi JH. Enterostomy closure timing for minimizing postoperative complications in premature infants. Pediatr Neonatol 2014; 55:363-8. [PMID: 24582165 DOI: 10.1016/j.pedneo.2014.01.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/23/2013] [Accepted: 01/18/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND For premature infants with advanced acute abdomen, creating a temporary enterostomy is believed to be an appropriate surgical management. However, there is no consensus regarding the timing of enterostomy reversal. The aim of this study was to determine the optimal timing for enterostomy closure (EC) by analyzing EC-related complications. METHODS This was a retrospective study of preterm infants who underwent enterostomy for suspected acute abdomens and subsequent closure. RESULTS EC-related complications occurred in 35 of 54 infants (65%). A univariate analysis determined the following risk factors for EC-related complications: lower weight and younger age at the time of EC and a shorter stoma duration. In a multiple logistic regression analysis, the only significant risk factor was a weight under 2660 g at the time of the closure operation. Infants with EC-related complications were ventilated longer, were administered more vasopressors, and were more likely to undergo reoperation. Additionally, these infants required parenteral nutrition for a longer duration, had a longer length of hospital stay after EC, and had a significantly lower weight and height at a corrected age of 7-10 months than infants without EC-related complications. CONCLUSION Body weight may be one of the most important factors to consider for minimizing EC-related complications.
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Affiliation(s)
- Juyoung Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Min-Jung Kang
- Department of Medical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Seung-Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hwan Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
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Hanju H, Jiahe X, Caizhao L, Sen L, Jianjiang L. Use of cannula ileostomy to protect a low colorectal anastomosis in patients having preoperative neoadjuvant chemoradiotherapy. Colorectal Dis 2014; 16:O117-22. [PMID: 24128335 DOI: 10.1111/codi.12456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 07/19/2013] [Indexed: 12/12/2022]
Abstract
AIM This study evaluated the efficacy and safety of ileal diversion, using a tracheal cannula, to protect from a low colorectal anastomosis in patients treated with neoadjuvant chemoradiotherapy. METHOD Fifty patients who presented with rectal cancer and who had accepted neoadjuvant chemoradiotherapy were included. All underwent a low anterior resection with ileal diversion by either tracheal cannula ileostomy (n = 28) or conventional loop ileostomy (n = 22). Demographics, clinical features and operation data were recorded. RESULTS Two patients developed anastomotic dehiscence after completion of the cannula ileostomy but neither patient required any further operation. There was no difference in anastomotic dehiscence, peritonitis or requirement for further surgery in patients treated with cannula ileostomy and loop ileostomy. CONCLUSION Cannula ileostomy is a safe, quick, effective and convenient means of intestinal diversion after low anterior resection. Its obvious advantage over loop ileostomy is a reduced overall hospital stay and avoidance of the need to close the stoma.
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Affiliation(s)
- H Hanju
- Department of Colorectal Surgery, First Affiliated Hospital, Zhejiang University, Zhejiang, China
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Vallribera Valls F, Villanueva Figueredo B, Jiménez Gómez LM, Espín Bassany E, Sánchez Martinez JL, Martí Gallostra M, Armengol Carrasco M. [Ileostomy closure in a colorectal surgery unit. Comparative analysis of different techniques]. Cir Esp 2014; 92:182-7. [PMID: 24412284 DOI: 10.1016/j.ciresp.2013.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 04/25/2013] [Accepted: 04/28/2013] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The objective of this study is to assess whether the results of loop ileostomy closure in terms of morbidity and hospital stay are influenced by the type of anastomosis and suture used. METHOD All patients who underwent loop ileostomy closure were reviewed. A retrospective cohort study comparing morbidity and hospital stay according to the type of anastomosis (TT/LL) and the type of suture (hand sewn/mechanical) was performed. RESULTS From January 2003 to November 2011 a total of 167 loop ileostomy closures were analized. The groups were: type of anastomosis (TT 95/LL 72) and type of suture (manual 105/stapled 62). In 76% of the observed population the underlying disease was cancer. Mortality occurred in one case. The stratified morbidity analysis by type of complications showed no significant differences between the groups in terms of local (7.4% TT, LL 8.3%, 6.7% hand sewn, stapled 9.7%), general (TT 9.5%, 16.7% LL, hand sewn 6.7%, 6.5% stapled) and surgical (TT 15.8%, 19.4% LL, hand sewn 17.1%, 17.7% stapled) complications, nor in the rate of reoperations (TT 6.3%, 6.9% LL, hand sewn 6.7%, 6.5% stapled) and hospital stay in days (TT 7.8, 8 LL, hand sewn 8.6, stapled 6.7) CONCLUSIONS: Closure of loop ileostomy can be performed regardless of the type of suture or anastomosis used, with the same rate of morbidity and hospital stay.
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Affiliation(s)
- Francesc Vallribera Valls
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - Borja Villanueva Figueredo
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España.
| | - Luis Miguel Jiménez Gómez
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - Eloi Espín Bassany
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - José Luis Sánchez Martinez
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - Marc Martí Gallostra
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - Manuel Armengol Carrasco
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
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Identifying causes for high readmission rates after stoma reversal. Surg Endosc 2013; 28:1263-8. [PMID: 24281432 DOI: 10.1007/s00464-013-3320-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 11/04/2013] [Indexed: 01/29/2023]
Abstract
BACKGROUND Unplanned readmissions after colorectal surgery impact patient and financial outcomes. Our goal was to identify factors related to readmission in ostomy reversal patients. METHODS Review of a prospective department database was performed from 2006 to 2012 to identify patients who underwent an ostomy reversal. Patients were stratified into nonreadmitted and readmitted within 30 days of ostomy reversal. The main outcome measures were predictors of readmission and characteristics of patients readmitted and not readmitted. RESULTS A total of 351 ostomy reversals (86 % ileostomy and 14 % colostomy) were analyzed; 44 patients were readmitted (12.5 %). Readmitted and nonreadmitted patients were similar in age, body mass index, gender, comorbidities, indications for the index operation, and time to ostomy reversal. Readmitted patients had longer operative times (p = 0.002) and length of stay (p = 0.001), more intraoperative blood loss (p = 0.003), intraoperative complications (p = 0.005), ICU requirements (p < 0.0001), need for temporary nursing at discharge (p < 0.001), and higher total hospital costs than nonreadmitted patients (p = 0.0162). Longer operative time [odds ratio (OR) 1.006, 95 % confidence interval (CI) 1.001-1.012], intraoperative complications (OR 7.334, 95 % CI 1.23-43.761), ICU stay (OR 1.291, 95 % CI 1.18-1.893), delayed discharge (OR 1.085, 95 % CI 1.003-1.173), and discharge to skilled nursing facility (OR 6.936, 95 % CI 1.531-31.332) were independent predictors of readmission. Ostomy type had no independent effect on readmission. CONCLUSIONS Differences in perioperative and outcomes variables exist between readmitted and nonreadmitted patients after ostomy reversal. Longer operative times, intraoperative complications, intensive care unit care, longer length of stay, and skilled nursing at discharge were independently predictive of readmission. These findings can be used to identify high-risk patients prospectively, potentially improving clinical outcomes and healthcare utilization.
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Vogel JD. Liposome bupivacaine (EXPAREL®) for extended pain relief in patients undergoing ileostomy reversal at a single institution with a fast-track discharge protocol: an IMPROVE Phase IV health economics trial. J Pain Res 2013; 6:605-10. [PMID: 23935387 PMCID: PMC3735342 DOI: 10.2147/jpr.s46950] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background Postoperative opioid use following ileostomy reversal procedures contributes to postoperative ileus. We assessed the impact of a liposome bupivacaine-based, opioid-sparing multimodal analgesia regimen versus a standard opioid-based analgesia regimen on postsurgical opioid use. We also assessed health economic outcomes in patients undergoing ileostomy reversal at our institution, which employs an enhanced recovery discharge protocol. Methods In this single-center, open-label study, patients undergoing ileostomy reversal received postsurgical pain therapy via multimodal analgesia that included a single intraoperative administration of liposome bupivacaine or opioid-based patient-controlled analgesia (PCA) with intravenous morphine or hydromorphone. Rescue analgesia (intravenous [IV] opioids and/or oral opioid + acetaminophen) was available to all patients. Primary efficacy measures included postsurgical opioid use, hospital length of stay (LOS), and hospitalization costs. Secondary measures included: time to first rescue opioid use; patient satisfaction with analgesia; additional medical intervention; and opioid-related adverse events. Results Forty-three patients were enrolled and met eligibility criteria (IV opioid PCA group = 20; liposome bupivacaine-based multimodal analgesia group = 23). Postsurgical opioid use was significantly less in the multimodal analgesia group compared with the IV opioid PCA group (mean [standard deviation]: 38 mg [46 mg] versus 68 mg [47 mg]; P = 0.004). Postsurgical LOS between-group differences (median: 3.0 days versus 3.8 days) and geometric mean hospitalization costs (US $6,611 versus US$6,790) favored the multimodal analgesic group but did not achieve statistical significance. Median time to first opioid use was 1.1 hours versus 0.7 hours in the multimodal analgesia and IV opioid PCA groups, respectively; P = 0.035. Two patients in the multimodal analgesia group and one in the IV opioid PCA group experienced opioid-related adverse events. Conclusion A liposome bupivacaine-based multimodal analgesic regimen reduced postoperative opioid consumption in patients undergoing ileostomy reversal under a fast-track discharge protocol. A reduction of 21% in LOS (0.8 days) was noted which, although not statistically significant, may be considered clinically meaningful given the already aggressive fast-track discharge program.
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Affiliation(s)
- Jon D Vogel
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Department of Colorectal Surgery, Cleveland, OH, USA
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Marcet JE, Nfonsam VN, Larach S. An extended paIn relief trial utilizing the infiltration of a long-acting Multivesicular liPosome foRmulation Of bupiVacaine, EXPAREL (IMPROVE): a Phase IV health economic trial in adult patients undergoing ileostomy reversal. J Pain Res 2013; 6:549-55. [PMID: 23901290 PMCID: PMC3720574 DOI: 10.2147/jpr.s46467] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Opioid analgesics are effective for postsurgical pain but are associated with opioid-related adverse events, creating a significant clinical and economic burden. Gastrointestinal surgery patients are at high risk for opioid-related adverse events. We conducted a study to assess the impact of an opioid-sparing multimodal analgesia regimen with liposome bupivacaine, compared with the standard of care (intravenous [IV] opioid-based, patient-controlled analgesia [PCA]) on postsurgical opioid use and health economic outcomes in patients undergoing ileostomy reversal. METHODS In this open-label, multicenter study, sequential cohorts of patients undergoing ileostomy reversal received IV opioid PCA (first cohort); or multimodal analgesia including a single intraoperative administration of liposome bupivacaine (second cohort). Rescue analgesia was available to all patients. Primary outcome measures were postsurgical opioid use, hospital length of stay, and hospitalization costs. Incidence of opioid-related adverse events was also assessed. RESULTS Twenty-seven patients were enrolled, underwent the planned surgery, and did not meet any intraoperative exclusion criteria; 16 received liposome bupivacaine-based multimodal analgesia and eleven received the standard IV opioid PCA regimen. The multimodal regimen was associated with significant reductions in opioid use compared with the IV opioid PCA regimen (mean, 20 mg versus 112 mg; median, 6 mg versus 48 mg, respectively; P < 0.01), postsurgical length of stay (median, 3.0 days versus 5.1 days, respectively; P < 0.001), and hospitalization costs (geometric mean, $6482 versus $9282, respectively; P = 0.01). CONCLUSION A liposome bupivacaine-based multimodal analgesic regimen resulted in statistically significant and clinically meaningful reductions in opioid consumption, shorter length of stay, and lower inpatient costs than an IV opioid-based analgesic regimen.
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Affiliation(s)
- Jorge E Marcet
- Department of Surgery, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Sharma A, Deeb AP, Rickles AS, Iannuzzi JC, Monson JRT, Fleming FJ. Closure of defunctioning loop ileostomy is associated with considerable morbidity. Colorectal Dis 2013; 15:458-62. [PMID: 22974343 DOI: 10.1111/codi.12029] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM An elective defunctioning ileostomy is commonly employed to attenuate the morbidity that may arise from distal anastomotic leakage. The magnitude of risk associated with subsequent ileostomy closure is difficult to estimate as many of the data arise from small series. This study looked at the rate of complications and predictive factors in a large series of patients. METHODS The National Surgical Quality Improvement Program database was queried for patients who had an elective closure of ileostomy between 2005 and 2010. Patient demographics, preoperative risk factors and operative variables were recorded. The primary outcome was occurrence of major (mortality, sepsis, return to the operating room, renal failure, major cardiac, neurological or respiratory episode) or minor (wound infection, urinary tract infection) complications within 30 days. Univariate and multivariate regression was used to evaluate the effect of these clinical factors on the complication rate. RESULTS In total, 5401 patients underwent closure of ileostomy, of whom 502 (9.3%) patients had major complications. The incidence of minor complications was 8.4% (452 patients). There were 32 (0.6%) deaths. American Society of Anesthesiologists grade, functional status, prolonged operative time, history of chronic obstructive pulmonary disease, dialysis and disseminated cancer were independent predictors of major complications. There was no significant increase in complication rates in patients over the age of 80. Major complications were associated with a significant increase in postoperative stay (13.9 vs 4.7 days, P < 0.0001). CONCLUSION Closure of ileostomy is associated with a significant complication rate. It may use as many resources as the primary surgery and is not a minor follow-up operation.
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Affiliation(s)
- A Sharma
- Division of Colorectal Surgery and SHORE, University of Rochester Medical Center, Rochester, New York, USA.
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Åkesson O, Syk I, Lindmark G, Buchwald P. Morbidity related to defunctioning loop ileostomy in low anterior resection. Int J Colorectal Dis 2012; 27:1619-23. [PMID: 22576906 DOI: 10.1007/s00384-012-1490-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2012] [Indexed: 02/04/2023]
Abstract
AIM A defunctioning loop ileostomy in low anterior resection reduces the incidence and morbidity of an anastomotic leakage, but complications related to the stoma may occur. We explored stoma-associated complications during the stoma period and after stoma reversal. METHODS A retrospective analysis of rectal cancer patients operated with low anterior resection and a defunctioning loop ileostomy at Helsingborg Hospital and Malmö University Hospital from January 2007 to June 2009 was undertaken. RESULTS Ninety-two patients were included, of whom 82 (89 %) underwent stoma reversal. The median stoma period was 6.2 ± 3.2 months. Sixty-six percent of the patients suffered from minor or major stoma-associated morbidity. The complication rate was significantly related to the stoma time (p < 0.01). Twenty-nine percent (27/92) had at least one episode of dehydration, leading to readmittance in half of the cases. Elderly patients were more prone to develop dehydration. Dehydration most commonly occurred early in the postoperative period (mean, 5.8 weeks). The mean hospital stay for stoma reversal was 6.5 ± 4.0 days. Forty percent (33/82) had some complication associated with the reversal. CONCLUSION This study indicates high morbidity associated with defunctioning loop ileostomy. Our data suggest that the stoma time should be limited to reduce complications. Monitoring and early stoma reversal should be considered in elderly patients. Furthermore, stoma reversal is not uneventful, and more studies are needed to address how to minimize complications.
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Affiliation(s)
- Oscar Åkesson
- Colorectal Unit, Department of Surgery, Helsingborg Hospital, 251 87, Helsingborg, Sweden
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Gessler B, Haglind E, Angenete E. Loop ileostomies in colorectal cancer patients--morbidity and risk factors for nonreversal. J Surg Res 2012; 178:708-14. [PMID: 22940030 DOI: 10.1016/j.jss.2012.08.018] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 07/24/2012] [Accepted: 08/09/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND In colorectal cancer patients, loop ileostomies are used to protect an anastomosis, in salvage surgery after a complication, and as a palliative measure. The aim of this study was to identify complications to the ileostomy, time until reversal, and risk factors for nonclosure or a permanent stoma. MATERIAL AND METHODS Consecutive patients who received a loop ileostomy with the diagnosis of colorectal cancer at index surgery in four hospitals in Region Västra Götaland, Sweden, from January 1, 2007 until February 28, 2010 were retrospectively studied. Demography, events during index surgery, complications related to the ileostomy and technique, and complications during closure were registered. RESULTS A total of 262 patients received a loop ileostomy. Loop iliostomies were constructed during emergency surgery in 15% of patients. Forty-three percent had complications related to the ileostomy; most common were high-volume output and leakage of stomal output. Morbidity after closure was high, at 28%, and mortality was 1%. Eighty-six percent had their stoma closed, median time 178 (3-700) d. Risk factors for nonreversal were postoperative complications to index surgery and advanced cancer disease. Eleven percent received a secondary stoma, and at the end of the study 23% had a permanent stoma. CONCLUSIONS The morbidity related to loop ileostomies and loop ileostomy closure is considerable. One in five patients will have a permanent stoma, and our conclusion is that for emergency patients with advanced disease another type of stoma should be chosen, if possible, to reduce the morbidity.
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Affiliation(s)
- Bodil Gessler
- Department of Surgery, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Russek K, George JM, Zafar N, Cuevas-Estandia P, Franklin M. Laparoscopic loop ileostomy reversal: reducing morbidity while improving functional outcomes. JSLS 2012; 15:475-9. [PMID: 22643501 PMCID: PMC3340955 DOI: 10.4293/108680811x13176785203950] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The main advantage of a laparoscopic loop ileostomy reversal was found to be visualization of adhesions for lysis and mobilization of the stoma and small bowel. Introduction: Loop ileostomy reduces the morbidity associated with pelvic sepsis. However, its reversal carries a 10% to 30% complication rate. We present our technique for laparoscopic ileostomy closure. Methods: We conducted a retrospective chart review of subjects undergoing laparoscopic-assisted loop ileostomy closure between 2006 and 2009. Operating time, length of hospital stay, return of bowel function, and complication rates were assessed. Results: There were 24 (13 males) patients. Average age was 63 with a BMI of 25.9. Eighteen (75%) had a planned loop ileostomy, and 6 (25%) were emergent. Average time to reversal was 135 days. Average length of surgery was 79 minutes (range, 48 to 186), average stay was 4 days and return to bowel function was 3.6 days. We had no wound infections. Our complication rate was 29% (n=7), and reoperation rate was 12.5% (n=3). Only 1 major complication occurred, an anastomotic dehiscence. Conclusion: A thorough, well-visualized lysis of adhesions and mobilization of the stoma and surrounding small bowel is the main advantage of our approach. We had no wound infections and no reoperation for bowel obstruction, which we feel is a direct advantage of our technique. Our complication rate and surgical time are comparable to those of the open technique.
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Affiliation(s)
- Karla Russek
- Texas Endosurgery Institute, San Antonio, TX, USA.
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Faunø L, Rasmussen C, Sloth KK, Sloth AM, Tøttrup A. Low complication rate after stoma closure. Consultants attended 90% of the operations. Colorectal Dis 2012; 14:e499-505. [PMID: 22340709 DOI: 10.1111/j.1463-1318.2012.02991.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM To evaluate complications after stoma closure. METHOD Using a retrospective review of 997 medical records, data were collected from all patients undergoing stoma closure at the Department of Surgery P, Aarhus University Hospital, Denmark, from 1996 to 2010. Patient data after Hartmann reversal and loop-ileostomy closure were compared. Data regarding the grade of the operating surgeon and assistant were extracted. RESULTS Out of 997 patients, 700 (70.6%) had a loop-ileostomy closure and 172 (17.4%) had a Hartmann reversal. Postoperative mortality was 0.5%. Seven patients required re-operation (0.7%). Morbidity was registered in 31.9% of the patients, with 131 (13.1%) having early complications and 187 (18.8%) having late complications. Wound infection was the most frequent early complication, which occurred in 31 patients (3.1%). Only 10 patients (1%) had an anastomotic leak. Incisional hernia was the most frequent late complication, occurring in 92 patients (9.3%). A consultant attended 90% of the operations. Junior surgeons never performed stoma closure without supervision. Body mass index was significantly associated with the development of incisional hernia. Hartmann reversal was associated with higher rates of complications compared with loop-ileostomy closure. In patients with Hartmann reversal, stapled anastomosis was associated with stricture in 12 out of 95 cases (12.6%), whereas hand-sewn anastomosis was not associated with stricture (0 out of 64 patients; 0%; P < 0.05). CONCLUSION Stoma closure is associated with low rates of leakage. A favourable case mix and high degree of consultant attendance may explain the good results.
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Affiliation(s)
- L Faunø
- Department of Surgery P, University Hospital of Aarhus, Aarhus C, Denmark
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