Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a meta-analysis

Shared Decision-Making, Sphincter Preservation, and Rectal Cancer Treatment: Identifying and Executing What Matters Most to Patients

Rectal cancer treatment often encompasses multiple steps and options, with benefits and risks that vary based on the individual. Additionally, patients facing rectal cancer often have preferences regarding overall quality of life, which includes bowel function, sphincter preservation, and ostomies. This article reviews these data in the context of shared decision-making approaches in an effort to better inform patients deliberating treatment options for rectal cancer.

Risk factors for stoma prolapse after laparoscopic loop colostomy

BACKGROUND

Stoma prolapse (SP) is a common stoma-related complication, particularly in loop colostomies. This study aimed to investigate potential risk factors for SP development after laparoscopic loop colostomy.

METHODS

In total, data from 140 patients who underwent laparoscopic loop colostomy were analyzed between September 2016 and March 2022. Risk factors for SP were investigated retrospectively.

RESULTS

The median follow-up duration after colostomy was 12.5 months, and SP occurred in 33 (23.6%) patients. Multivariate analysis showed that being overweight (body mass index ≥ 25; odds ratio [OR], 8.69; 95% confidential interval [CI], 1.61-46.72; p = 0.012) and having a thin rectus abdominis penetration of the stoma (< 8.9 mm; OR, 8.22; 95% CI, 2.50-27.05; p < 0.001) were independent risk factors for SP. Other patient characteristics and surgical factors associated with stoma construction were unrelated to SP development.

CONCLUSIONS

Being overweight and the route penetrating the thinner rectus abdominis during stoma construction was associated with a significantly higher incidence of SP after laparoscopic loop colostomy. Selecting a construction site that penetrates the thicker rectus abdominis muscle may be crucial for preventing SP.

Surgical management of ostomy complications: a MISSTO-WSES mapping review

BACKGROUND

The creation of an ileostomy or colostomy is a common surgical event, both in elective and in emergency context. The main aim of stoma creation is to prevent postoperative complications, such as the anastomotic leak. However, stoma-related complications can also occur and their morbidity is not negligible, with a rate from 20 to 70%. Most stomal complications are managed conservatively, but, when this approach is not resolutive, surgical treatment becomes necessary. The aim of this mapping review is to get a comprehensive overview on the incidence, the risk factors, and the management of the main early and late ostomy complications: stoma necrosis, mucocutaneous separation, stoma retraction, stoma prolapse, parastomal hernia, stoma stenosis, and stoma bleeding.

MATERIAL AND METHODS

A complete literature research in principal databases (PUBMED, EMBASE, SCOPUS and COCHRANE) was performed by Multidisciplinary Italian Study group for STOmas (MISSTO) for each topic, with no language restriction and limited to the years 2011-2021. An international expert panel, from MISSTO and World Society of Emergency Surgery (WSES), subsequently reviewed the different issues, endorsed the project, and approved the final manuscript.

CONCLUSION

Stoma-related complications are common and require a step-up management, from conservative stoma care to surgical stoma revision. A study of literature evidence in clinical practice for stoma creation and an improved management of stoma-related complications could significantly increase the quality of life of patients with ostomy. Solid evidence from the literature about the correct management is lacking, and an international consensus is needed to draw up new guidelines on this subject.

Risk factors of acute renal failure in patients with protective ileostomy after rectal cancer surgery

BACKGROUND

Despite the potential benefits of protective ileostomy in rectal surgery, diverting loop ileostomy construction is not free of specific medical consequences implying unplanned hospital readmissions. The most common reason for readmission in these patients is a dehydration with a prevalence of acute renal failure (ARF) of 20%. The objective of this study was to establish the predictive factors of ARF in patients with protective ileostomy after surgery for rectal cancer from a bicentric study.

METHODS

we conducted a bicentric retrospective cohort study to identify the risk factor of ARF. This study was carried out on 277 patients operated for rectal cancer with necessity of a protective ileostomy during the study period. ARF was measured at any endpoint between ileostomy creation and reversal. Multiple logistic regressions were performed to identify independent risk factors.

RESULTS

A total of 277 patients were included, and 18% (n = 50) were readmitted for ARF. In multivariate logistic regression, increased age (OR 1.02, p = 0.01), Psychiatric diseases (OR 4.33, p = 0.014), Angiotensin II receptor blockers (OR 5.15, p < 0.001) and the ASA score ≥ 3 (OR 9.5, p < 0.001) were significantly associated with ARF.

CONCLUSION

Acute renal failure is a prevalent and significant event in the postoperative course of ileostomy patients. Patients at risk should be risk stratified before discharge and targeted for intensive preventive measures.

A comparative study of stoma-related complications from diverting loop ileostomy or colostomy after colorectal surgery

PURPOSE

Even though minor, stoma-related complications significantly impact quality of life, they are often excluded from clinical analyses that compare short-term postoperative outcomes of loop ileostomy and loop colostomy. This study compares stoma-related complications between loop ileostomy and loop colostomy after rectal resection, including minor complications, and discusses the characteristics of diverting stoma types.

METHODS

A retrospective review was conducted in patients who underwent diverting stoma construction after rectal resection. Data on patient background and postoperative short-term outcomes, including stoma-related complications and morbidity after stoma closure, were collected and compared between loop ileostomy and loop colostomy groups. Morbidities of all severity grades were targeted for analysis.

RESULTS

A total of 47 patients (27 loop ileostomy, 20 loop colostomy) underwent diverting stoma construction following rectal resection. Overall stoma-related complications, incidence of skin irritation, high-output stoma, and outlet obstruction were significantly higher in the loop ileostomy group but high-output stoma and outlet obstruction were absent in the loop colostomy group. Regarding morbidity after stoma closure, operation times and surgical site infections were significantly higher in the loop colostomy group while anastomotic leakage after diverting stoma closure occurred (2 cases; 15%) in the loop colostomy group but not the loop ileostomy group.

CONCLUSION

Because stoma-related complications were significantly higher in the loop ileostomy group, and even these minor complications may impair QOL, early loop ileostomy closure is recommended. For loop colostomy, stoma-related morbidities are lower but post-closure leakage is a calculated risk.

Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going?

Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.

Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis

Anastomotic leakage (AL) is the most fearsome complication in low rectal resection. The temporary diverting stoma (DS) is recommended to prevent AL, but it may cause relevant morbidity and needs a second surgical procedure to be closed. Therefore, the use of a transanal drainage tube (TDT) has been proposed as an alternative. We performed a systematic review and meta-analysis concerning the peri-operative outcomes in patients undergoing elective anterior rectal resection (ARR) with TDT alone or DS alone. Six studies were meta-analyzed, including a total of 735 patients. The meta-analysis showed that the incidences of AL, surgery-related complications, infective complications, and 30-day reoperation after ARR with low colorectal or coloanal anastomosis did not differ significantly between patients undergoing positioning of TDT and those undergoing DS. Furthermore, overall complications were significantly rarer in patients undergoing TDT. A meta-analysis of the randomized control trial (RCT) and no-RCT subgroups did not detect any statistically significant differences in any outcomes. These results suggest that it might be reasonable to employ a TDT in place of a DS to protect low colorectal and coloanal anastomosis, with consequent considerable advantages in terms of the short- and long-term post-operative outcomes. However, more well-designed RCTs are needed to definitively assess this issue.

Application and evaluation of transitory protective stoma in ovarian cancer surgery

Ovarian cancer is the most fatal of all female reproductive cancers. The fatality rate of OC is the highest among gynecological malignant tumors, and cytoreductive surgery is a common surgical procedure for patients with advanced ovarian cancer. To achieve satisfactory tumor reduction, intraoperative bowel surgery is often involved. Intestinal anastomosis is the traditional way to restore intestinal continuity, but the higher rate of postoperative complications still cannot be ignored. Transitory protective stoma can reduce the severity of postoperative complications and traumatic stress reaction and provide the opportunity for conservative treatment. But there are also many problems, such as stoma-related complications and the impact on social psychology. Therefore, it is essential to select appropriate patients according to the indications for the transitory protective stoma, and a customized postoperative care plan is needed specifically for the stoma population.

Anastomotic Considerations in Diverticulitis

Diverticulitis is a common indication for colorectal surgery, both in the acute and the elective setting. The anastomosis between the colon and rectum is a critical component of colectomy for diverticular disease and should be approached thoughtfully. This article reviews important surgical considerations when creating a colorectal anastomosis in the setting of diverticular disease, whether following the reversal of an end colostomy, during an acute episode of diverticulitis, or electively for chronic or complicated disease. Timing of surgery and preoperative assessment, minimally invasive approaches, and intraoperative maneuvers and considerations are discussed.

Impact of gastric and bowel surgery on gastrointestinal drug delivery

General surgical procedures on the gastrointestinal tract are commonly performed worldwide. Surgical resections of the stomach, small intestine, or large intestine can have a significant impact on the anatomy and physiological environment of the gastrointestinal tract. These physiological changes can affect the effectiveness of orally administered formulations and drug absorption and, therefore, should be considered in rational drug formulation design for specific pathological conditions that are commonly associated with surgical intervention. For optimal drug delivery, it is important to understand how different surgical procedures affect the short-term and long-term functionality of the gastrointestinal tract. The significance of the surgical intervention is dependent on factors such as the specific region of resection, the degree of the resection, the adaptive and absorptive capacity of the remaining tissue, and the nature of the underlying disease. This review will focus on the common pathological conditions affecting the gastric and bowel regions that may require surgical intervention and the physiological impact of the surgery on gastrointestinal drug delivery. The pharmaceutical considerations for conventional and novel oral drug delivery approaches that may be impacted by general surgical procedures of the gastrointestinal tract will also be addressed.

Temporary loop ileostomy versus transverse colostomy for laparoscopic colorectal surgery: a retrospective study

PURPOSE

To compare the surgical outcomes of ileostomy vs. transverse colostomy and investigate which is more suitable for a diverting stoma.

METHODS

We assessed stoma-related complications and surgical outcomes, retrospectively, for 146 patients who underwent laparoscopic colorectal surgery with a temporary loop ileostomy or transverse colostomy. Complications after secondary stoma closure surgery were also analyzed.

RESULTS

After the primary surgery, the incidence of prolapse was significantly higher in the transverse colostomy group, whereas high-output stoma and skin irritation were seen more frequently in the ileostomy group. The median interval to stoma closure was shorter in the ileostomy group than in the transverse colostomy group (144 vs. 196 days). After secondary closure surgery, the incidence of wound infection was significantly higher in the transverse colostomy group than in the ileostomy group. None of the patients in the ileostomy group had severe complications. The median postoperative hospital stay was significantly shorter in the ileostomy group than in the transverse colostomy group (10 vs. 13 days).

CONCLUSIONS

The findings of this study suggest that ileostomy should be the procedure of choice for short-term temporary diverting stoma, but that transverse colostomy is more appropriate for patients who require a long-term or permanent stoma.

A diversion stoma after anterior resection for rectal cancer

This review covers the problem of forming a diverting stoma during resections of the rectum with primary anastomosis. The incidence of rectal cancer tends to increase, and surgical resection remains the main method of treatment. Anastomotic leakage significantly increases the postoperative mortality. The most effective way to prevent severe complications is the formation of a diverting stoma. However, the indications, the choice of a specific technique and the timing of the stoma elimination are not clearly defined. This review discusses the state of the problem, special attention is paid to the choice of the level of stoma formation (ileostomy or transversostomy).

Diverting ileostomy is a risk factor for renal impairment during CAPOX therapy

PURPOSE

Temporary ileostomy is sometimes created after colorectal surgery and may cause renal impairment. However, the impact of ileostomy on renal function during adjuvant chemotherapy for colorectal cancer (CRC) remains unknown. The aim of the present study was to examine the effects of ileostomy on renal function during adjuvant chemotherapy.

METHODS

We examined 184 patients who received adjuvant CAPOX therapy (capecitabine and oxaliplatin) for CRC with or without ileostomy between January 2011 and December 2020 at the University of Tokyo Hospital. Clinicopathological factors, including renal function, were retrospectively reviewed in association with temporary ileostomy. Factors associated with reductions in the estimated glomerular filtration rate (eGFR) during CAPOX therapy were analyzed.

RESULTS

Eighteen patients (10%) underwent temporary ileostomy. The maximum decrease in eGFR during CAPOX therapy was significantly higher in patients with than in those without ileostomy (- 16.1 vs. - 5.6 mL/min/1.73m², p = 0.003). A multivariate analysis identified ileostomy as one of factors independently associated with reductions in eGFR during CAPOX therapy (p = 0.003). The cumulative number of readmission due to dehydration was also higher in patients with ileostomy (33% vs. 1%, p < 0.001).

CONCLUSIONS

Ileostomy significantly reduced eGFR during adjuvant CAPOX therapy. Therefore, renal function needs to be monitored during CAPOX therapy, particularly in patients with ileostomy.

Mechanical and oral antibiotic bowel preparation in ovarian cancer debulking: Are we lowering or just trading surgical complications?

OBJECTIVES

To examine postoperative complications associated with preoperative mechanical and oral antibiotic bowel preparation (MOABP) for patients with ovarian cancer who underwent bowel resection at cytoreductive surgery (CRS).

METHODS

This was a single-institution retrospective study of patients with ovarian cancer undergoing CRS from 01/2011-12/2020 using ICD-10 diagnoses and procedure codes. Patients were stratified by those who underwent bowel resection versus no resection. Bowel resection patients were further stratified by those who underwent MOABP versus no bowel preparation. Patient demographics, tumor data, and perioperative metrics were collected. Unadjusted and adjusted logistic regression evaluated odds of 30-day postoperative complications in patients with bowel resection versus no resection and those with MOABP versus no bowel preparation.

RESULTS

Of 919 patients identified, 215 (23.3%) required bowel resection, which included 81 (37.7%) who received MOABP. Patient characteristics, co-morbidities, and cancer data were similar between MOABP versus no bowel preparation patients. MOABP patients underwent more interval CRS (34.6% versus 9.0%), more optimal surgical resections (96.3% versus 83.8%), fewer diverting ostomies (13.5% versus 33.5%), and shorter hospital stays (7.1 versus 9.4 days) than no bowel preparation patients. On adjusted analyses, MOABP patients experienced significantly lower odds of deep/organ-space surgical infections and 30-day readmissions but higher odds of unplanned intensive care unit (ICU) admissions and grade 3 or higher cardiac and gastrointestinal complications.

CONCLUSIONS

Patients who underwent preoperative MOABP prior to ovarian cancer CRS with bowel resection had lower odds or deep/organ-space infections and readmissions, shorter hospital stays, fewer diverting ostomies, and more optimal resections. However, these patients also experienced higher odds of ICU admissions and grade 3 or higher cardiac and gastrointestinal complications. The positive and negative postoperative outcomes in this population should be considered in clinical practice.

A technique for constructing diverting loop ileostomy to prevent outlet obstruction after rectal resection and total colectomy: a retrospective single-center study

PURPOSE

Preventing outlet obstruction associated with a diverting stoma is important. Previously, we constructed a diverting loop ileostomy with the proximal limb of the small intestine on the caudal side, namely the oral inferior (OI) method. However, to address the issue of twisting and stenosis of the small intestine, we recently constructed a diverting loop ileostomy with the proximal limb on the cranial side, namely the oral superior (OS) method. We compared the incidence of outlet obstruction between the two methods.

METHODS

The subjects of this retrospective study were 133 patients who underwent colorectal resection or total colectomy, with D2 or more lymph node dissection and diverting loop ileostomy construction, between April, 2001 and December, 2018, at our hospital. The OI method was performed in 54 patients and the OS method was performed in 79 patients.

RESULTS

In the OS group, a history of laparotomy, neoadjuvant therapy, clinical stage III, and the use of anti-adhesion materials were more common, whereas blood loss and the incidence of outlet obstruction were significantly lower. Multivariate analysis identified only OS placement as a significant factor for reducing the incidence of outlet obstruction.

CONCLUSION

When constructing a diverting loop ileostomy, placing the proximal limb on the cranial side is important.

Short-term outcomes in patients undergoing laparoscopic surgery for deep infiltrative endometriosis with rectal involvement: a single-center experience of 168 cases

Purpose

The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI).

Methods

A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections.

Results

The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4-16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7-18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy.

Conclusion

In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.

Outcomes on diverting ostomy formation and reversal after low anterior resection in the older more advanced rectal cancer patient

BACKGROUND

To decrease morbidity caused by anastomotic leakages after a low anterior resection (LAR) with primary anastomosis, a diverting ostomy is often created. Reversal of a diverting ostomy is associated with morbidity, which may result in non-reversal, particularly in the elderly. This study aimed to describe the diverting ostomy-related outcomes in elderly patients with more advanced rectal cancer after LAR.

MATERIALS AND METHODS

All rectosigmoid and rectal cancer patients ≥70 years who underwent LAR with primary anastomosis between 2006 and 2019 in the Catharina Hospital (Eindhoven, The Netherlands) were included for analyses. Reversal rates, ostomy-related complications, morbidity and mortality after ostomy reversal, and definitive ostomy rates were evaluated.

RESULTS

In total 164 patients were included, of which 150 (91.5%) underwent primary or secondary ostomy creation. Ostomy-related complications were reported in 34.7% (95%-CI 27.1-42.9%). In total, 72.5% (95%-CI 64.2-79.7%) reversed their diverting ostomy. Non-reversal was mostly due to relapsing disease (52.6%). Median time to ostomy reversal was 3.2 months (IQR 2.3-5.0). No or minor complications after ostomy reversal were observed in 84.0% (95%-CI 75.3-90.6%). Over time, ostomy recreation was performed in 15.0% (95%-CI 8.6-23.5%), and ultimately 65.8% (95%-CI 57.8-73.2%) were ostomy-free after the median follow-up of 3.8 years.

CONCLUSION

Although most elderly successfully reversed their diverting ostomy after LAR with limited morbidity, attention should be paid for the risk of non-reversal and ostomy recreation over time. Preoperative patient counselling is important in every individual to be able to decide if LAR with primary anastomosis or a permanent end colostomy is preferred.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

Hydration by colonic enteroclysis: An alternative to parenteral hydration in patients with high-output double enterostomy

BACKGROUND

High-output double enterostomies (DESs) result in sodium and fluid loss responsible for frequent episodes of dehydration and hospitalizations. Hydration by enteroclysis (HE) is an alternative to parenteral hydration when the small bowel, or the downstream colon, is accessible and functional.

METHODS

A retrospective analysis was conducted on all consecutive patients admitted in our institution with high-output (≥1200 ml per 24 h) DES and access to downstream intestine (including colon), who were treated by enteroclysis between 2015 and 2019. A sodium chloride and bicarbonate solution was instilled through a tube inserted in the colon. The objectives were diuresis >1 L, natriuresis >40 mmol/24 h, and urinary sodium-to-potassium ratio >1.

RESULTS

HE was conducted in 52 patients (24 female, 28 male). Initially, 30 patients received intravenous support. Fifteen patients (50%) were weaned from all parenteral support, of whom 11 of 12 (92%) received fluid and electrolyte support and 4 of 18 (22%) received parenteral nutrition (PN). When intravenous fluids were still required, daily volumes decreased from 2714 ± 1424 to 1578 ± 1000 ml per 24 h (P = .001), as did the energetic intake (NS), from 1439 ± 556 to 1230 ± 362 kcal per 24 h (P = .096).

CONCLUSION

HE through the efferent intestine limits the requirement for parenteral hydration in patients with high-output DES. For patients with intestinal failure dependent on PN, it reduces daily infused volumes.

Patient-Related Factors Associated With Stoma and Peristomal Complications Following Fecal Ostomy Surgery: A Scoping Review

PURPOSE

Ostomy creation is often an integral part of the surgical management of various diseases including colorectal malignancies and inflammatory bowel disease. Stoma and peristomal complications may occur in up to 70% of patients following ostomy surgery. The aim of this scoping literature review was to synthesize evidence on the risk factors for developing complications following creation of a fecal ostomy.

DESIGN

Scoping literature review.

SEARCH STRATEGY

Two independent researchers completed a search of the online bibliographic databases PubMed, MEDLINE, Cochrane, Google Scholar, and EMBASE for all articles published between January 1980 and December 2018. The search comprised multiple elements including systematic literature reviews with meta-analysis of pooled findings, randomized controlled trials, cohort studies, observational studies, other types of review articles, and multiple case reports. We screened 307 unique titles and abstracts; 68 articles met our eligibility criteria for inclusion. The methodological rigor of study quality included in our scoping review was variable.

FINDINGS/CONCLUSIONS

We identified 6 risk factors associated with an increased likelihood of stoma or peristomal complications (1) age more than 65 years; (2) female sex; (3) body mass index more than 25; (4) diabetes mellitus as a comorbid condition; (5) abdominal malignancy as the underlying reason for ostomy surgery; and (6) lack of preoperative stoma site marking and WOC/ostomy nurse specialist care prior to stoma surgery. We also found evidence that persons with a colostomy are at a higher risk for prolapse and parastomal hernia.

IMPLICATIONS

Health care professionals should consider these risk factors when caring for patients undergoing fecal ostomy surgery and manage modifiable factors whenever possible. For example, preoperative stoma site marking by an ostomy nurse or surgeon familiar with this task, along with careful perioperative ostomy care and education of the patient by an ostomy nurse specialist, are essential to reduce the risk of modifiable risk factors related to creation of a fecal ostomy.

Is routine splenic flexure mobilization always necessary in laparotomic or laparoscopic anterior rectal resection? A systematic review and comprehensive meta-analysis

Splenic flexure mobilization (SFM) is one of the most difficult steps in laparoscopic colorectal surgery and its role is harshly debated. Some surgeons considered it routinely necessary to obtain a safe anastomosis and to respect oncologic criteria; for others SFM is frequently unnecessary, not ensuring the aspects mentioned above and increasing the risk of morbidity (splenic, bowel and vessels injury, lengthened procedure). We performed a systematic review and a comprehensive meta-analysis, without any language restriction, about the peri-operative and post-operative outcomes (anastomotic leakage, intra-operative complication, conversion rate, operative time, post-operative bleeding, intra-abdominal collection, prolonged ileus, wound infection, anastomotic stricture, overall complications, hospital stay, re-operation, post-operative mortality, R0 margin resection, local recurrence) in patients undergoing elective anterior rectal resection (ARR) with or without SFM, both in laparotomic (LT) and laparoscopic (LS) approach. Fourteen studies were meta-analyzed with a total amount of 42,221 patients. The comprehensive meta-analysis shows that the mobilization or the preservation (SFP) of the splenic flexure does not statistically influence the incidence of colorectal anastomotic leakage, conversion rate, post-operative bleeding, intra-abdominal collection, prolonged ileus, wound infection, anastomotic stricture, overall complications, hospital stay, re-operation, R0 margin resection, and local recurrence results. The operative time is significantly longer in every group of patients undergoing SFM. The incidence of intra-operative complication is statistically increased in overall patients and also in the LS subgroup of patients undergoing SFM, in which also higher incidence of wound infection and re-operation is shown. The meta-analysis shows that SFM may be considered not necessary to ensure better peri-operative and post-operative outcomes in both LT and LS ARR.

Revising Our Concepts about Stoma Covering a Low Rectal Anastomosis

Introduction There has been conclusive evidence that defunctioning stoma with either transverse colostomy or ileostomy mitigates the serious consequences of anastomotic leakage. However, whether transverse colostomy or ileostomy is preferred for defunctioning a rectal anastomosis remains controversial. The present study was designed to identify the best defunctioning stoma for colorectal anastomosis.

Objective To improve the quality of life in patients with rectal resection and anastomosis and reduce the morbidity before and after closure of the stoma.

Patients and Methods The present study included 48 patients with elective colorectal resection who were randomly arranged into 2 equal groups, with 24 patients each. Group I consisted of patients who underwent ileostomy, and group II consisted of patients who underwent colostomy as a defunctioning stoma for a low rectal anastomosis. All surviving patients were readmitted to have their stoma closed and were followed-up for 6 months after closure of their stomas. All data regarding local and general complications of construction and closure of the stoma of the two groups were recorded and blotted against each other to clarify the most safe and tolerable procedure.

Results We found that all nutritional deficiencies, dehydration, electrolytes imbalance, peristomal dermatitis, and frequent change of appliances are statistically more common in the ileostomy group, while stomal retraction and wound infection after closure of the stoma were statistically more common in the colostomy group. There were no statistically significant differences regarding the total hospital stay and mortality between the two groups.

Conclusion and Recommendation Ileostomy has much higher morbidities than colostomy and it also has a potential risk of mortality; therefore, we recommend colostomy as the ideal method for defunctioning a distal colorectal anastomosis.

Risk and consequences of dehydration following colorectal cancer resection with diverting ileostomy. A systematic review and meta-analysis

AIM

This systematic review aims to assess dehydration prevalence and dehydration-related morbidity from diverting ileostomy compared to resections without ileostomy formation in adults undergoing colorectal resection for cancer.

METHOD

MEDLINE, Embase, CENTRAL and ClinicalTrials.gov were searched for studies of any design that reported dehydration, renal function and dehydration-related morbidity in adult colorectal cancer patients with diverting ileostomy (last search 12 August 2020). Bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias in randomized trials and the Risk of Bias in Non-randomized Studies of Interventions tool.

RESULTS

Of 1927 screened papers, 22 studies were included (21 cohort studies and one randomized trial) with a total of 19 485 patients (12 209 with ileostomy). The prevalence of dehydration was 9.00% (95% CI 5.31-13.45, P < 0.001). The relative risk of dehydration following diverting ileostomy was 3.37 (95% CI 2.30-4.95, P < 0.001). Three studies assessing long-term trends in renal function demonstrated progressive renal impairment persisting beyond the initial insult. Consequences identified included unplanned readmission, delay or non-commencement of adjuvant chemotherapy, and development of chronic kidney disease.

DISCUSSION

Significant dehydration is common following diverting ileostomy; it is linked to acute kidney injury and has a long-term impact on renal function. This study suggests that ileostomy confers significant morbidity particularly related to dehydration and renal impairment.

Comparison of the clinical outcomes of skin bridge loop ileostomy and traditional loop ileostomy in patients with low rectal cancer

To compare the clinical results of patients with low rectal cancer who underwent skin bridge loop ileostomy and traditional loop ileostomy, and provide clinical evidence for choosing a better ostomy method. We retrospectively collected data of 118 patients with rectal cancer who underwent low anterior resection and loop ileostomy. To investigate the patients characteristics, postoperative stoma-related complications and the frequency of exchanged ostomy bags. The differences of these indicators between the two groups of patients who underwent skin bridge loop ileostomy and traditional loop ileostomy were compared. The Visual Analog Scale (VAS) score of the skin bridge loop ileostomy group was lower than that of the traditional ileostomy loop group (P < 0.05). The skin bridge group had a lower Discoloration, Erosion, Tissue overgrowth (DET) score and incidence of mucocutaneous separation than the traditional group at the 1st and 2nd weeks after operation (P < 0.05). The average number of weekly exchanged ostomy bags was significantly less in the skin bridge group than in the traditional group within 4 weeks after surgery (P < 0.05). Our experience demonstrates that the skin bridge loop ileostomy may significantly reduce early postoperative stoma-related complications, the frequency of exchanged ostomy bags and patients' medical costs after discharge.

A meta-analysis of the role of diverting ileostomy after rectal cancer surgery

PURPOSE

Anastomotic leak is a feared complication of rectal cancer surgery. A diverting stoma is believed to act as a safety mechanism against this undesirable outcome. This meta-analysis aimed to examine the role of loop ileostomy in the prevention of this complication.

METHODS

The Medline, Embase and Cochrane databases were searched for randomized controlled trials (RCTs) comparing anastomotic complications after rectal cancer surgery in the presence or absence of diverting ileostomy. The need for reoperation and postoperative complications were also analysed. The length of hospital stay, intraoperative blood loss and operating time were analysed as secondary endpoints.

RESULTS

A significantly higher number of anastomotic leaks was detected in patients with no diverting ileostomies than in those with diversion (odds ratio (OR) 0.292 and 95% confidence interval (CI) 0.177-0.481), and more patients required reoperations in this group (OR 0.219 and 95% CI 0.114-0.422). The rate of complications other than anastomotic leak was significantly higher in patients with diverting ileostomies than in those without (OR 3.337 and 95% CI of 1.570-7.093). The operating time was longer in the ileostomy group than in the no ileostomy group (P 0.001), but no significant differences in the intraoperative blood loss or postoperative hospital stay length were observed between the two groups(P 0.199 and 0.191 respectively).

CONCLUSION

A lower leak rate in the presence of diverting ileostomy is supported by relatively weak evidence. While mitigating the consequences of leakage, diverting ileostomies lead to numerous other complications. High-quality RCTs are needed before routine ileostomy diversions can be recommended after rectal cancer surgery.

Postoperative morbidity and mortality after anterior resection with preventive diverting loop ileostomy versus loop colostomy for rectal cancer: A updated systematic review and meta-analysis

The purpose of this meta-analysis was to evaluate the perioperative morbidity after anterior resection with diverting loop ileostomy (LI) versus colostomy (LC) and its reversal for rectal cancer. The studies on the application of loop ileostomy versus loop colostomy in anterior resection published from January 2000 to January 2020 were searched in the databases of Pubmed, Embase, Cochrane library, and Clinical trials. All randomized controlled trials (RCTs) and cohort studies were included according to inclusion criteria. Eight studies (2 RCTs and 6 cohort studies) totaling 1451 patients (821 LI and 630 LC) were included in the meta-analysis. The morbidity related to stoma formation and closure did not demonstrate significant differences. Significantly more LCs were complicated by stoma prolapse & retraction (OR:0.26,95%CI:0.11-0.60,P = 0.001), parastomal hernia (OR = 0.52,95%CI:0.30-0.88, P = 0.01), surgical site infection (SSI) (OR = 0.24,95%CI:0.11-0.49,P < 0.0001) and incisional hernias (OR = 0.39,95%CI:0.19-0.83,P = 0.01) than by LIs. Patients with LI demonstrated significantly more complications related to the stoma, such as dehydration (OR = 0.52,95%CI:0.30-0.88, P = 0.01) and ileus (OR = 2.23,95%CI:1.12-4.43, P = 0.02) than patients with LC. While after the subgroup analysis of different publication years, LI could reduce the risk of the morbidity after stoma formation in previous years group (P = 0.04) with a lower heterogeneity (I² = 37%); LC could reduce the incidence of parastomal dermatitis in recent years group (P < 0.0001) without heterogeneity in each subgroup (I² = 0%). Cumulative meta-analysis detected significant turning points in dehydration, SSI, and ileus. This meta-analysis recommends diverting LI in the anterior resection for rectal cancer, but there is a risk of dehydration, irritant dermatitis, and ileus.

A nomogram to predict the incidence of permanent stoma in elderly patients with rectal cancer

Background

Creation of a temporary diverting stoma during rectal cancer surgery is used widely to prevent undesirable outcomes related to anastomotic leakage (AL). The transition from temporary stoma (TS) to permanent stoma (PS) is a frequent outcome. Elderly patients may have a greater probability of PS. We aimed to identify risk factors of PS and developed a nomogram to predict the rate of PS for elderly patients.

Methods

We enrolled elderly patients (≥70 years) who underwent rectal cancer surgery with a TS between January 2014 and December 2017 at our hospital. We divided patients into two groups: a TS group and a PS group. We then identified the risk factors for PS and developed a nomogram to predict the possibility of PS.

Results

Of the 278 elderly patients who received a diverting stoma, 220 (79.14%) eventually underwent stoma reversal, and 58 (20.86%) had PS. The proportion of males in the PS group was significantly higher than that of the TS group (P=0.048). Univariate and multivariate analysis showed that American Society of Anesthesiologists (ASA) score (P<0.001), laparotomy (P=0.004), AL (P<0.001), and tumor recurrence (P<0.001) were significantly correlated with PS. These four factors were included to construct the nomogram. The consistency index of the nomogram was 0.833 and the model yielded an area under the curve of 0.833.

Conclusions

ASA score (≥3), laparotomy, AL, and tumor recurrence were independent risk factors for PS in elderly patients. Our nomogram exhibited moderate predictive ability.

Predictors of morbidity related to stoma closure after colorectal cancer surgery

PURPOSE

A defunctioning stoma is essential in reducing symptomatic leakage after colorectal surgery, particularly after lower anterior resection. Subsequent stoma closure is associated with morbidity and rarely mortality. This study aimed to identify the risk factors associated with post-operative complications related to stoma closure.

METHODS

This retrospective cohort included patients who have undergone elective stoma closure between 2015 and 2017. Patient demographics, pre-morbidities, use of systemic therapy, stoma characteristics, and post-operative complications were retrieved from electronic records. Univariate and multivariate analysis was carried out to identify risk factors of stoma closure related morbidity.

RESULTS

Ninety patients were included with a median age of 65 years, of which 58 (64.4%) of them were male. Sixty-nine (76.7%) patients had loop colostomy, while the rest had loop ileostomy. Fifty-four (60%) patients received neoadjuvant or adjuvant therapy. The median time interval from stoma creation to closure was 15 months. Nineteen (21.1%) patients had post-operative complications. The two most commonly observed post-operative complications were wound complications (16.7%) and intra-abdominal collections (6.7%). Fifteen (16.7%) patients developed an incisional hernia. The median follow-up time was 29 months. There was no 30-day mortality in this cohort. In multivariate analysis, adjuvant chemotherapy was associated with a higher risk of wound complications (p = 0.027). Higher risk of incisional hernia was seen in patients with history of hypertension (p = 0.046), use of adjuvant chemotherapy (p = 0.042) and stoma-related complications before closure (p = 0.002). Male patients might be associated with a higher risk of incisional hernia.

CONCLUSION

Adjuvant chemotherapy is associated with a higher risk of post-operative complications, particularly with wound complications. Male patients, hypertension, adjuvant chemotherapy, and stoma-related complications are associated with a higher risk of incisional hernia.

Changes to gastrointestinal function after surgery for colorectal cancer

Bowel function is increasingly considered as an important outcome for patients undergoing surgery for colorectal cancer. Increasing technical skills and technological advances have meant fewer patients require a long-term stoma but this comes at the cost, often, of poor function. With a larger range of treatment options available for a given cancer, both function and oncology should be considered in parallel when counselling patients before surgery. In the perioperative phase, bowel function can be improved with minimally invasive surgery and enhanced recovery after surgery protocols, with limited evidence for targeted medical therapies. Early detection and sound management of surgical complications such as anastomotic leak and stricture can mitigate their adverse effects on bowel function. Long-term gastrointestinal dysfunction manifests as diarrhoea and low anterior resection syndrome for colon and rectal cancer respectively. Multi-modal strategies for low anterior resection syndrome are emerging to improve significantly quality of life after restorative rectal cancer surgery.

Imaging Postoperative Abdominal Hernias: A Review with a Clinical Perspective

Postoperative internal hernia is a challenging but critical diagnosis in postoperative patients presenting with acute abdomen. Postoperative internal hernias are increasingly being recognized after Roux-en-Y gastric bypass (RYGB) and bariatric surgeries. These internal hernias have a high risk of closed-loop obstruction and bowel ischemia; therefore, prompt recognition is necessary. Computed tomography (CT) is the imaging modality of choice in cases of postoperative acute abdomen. Understanding the types of postoperative internal hernia and their common imaging features on CT is crucial for the abdominal radiologist. Postoperative external hernias are usually a result of defect or weakness of the abdominal wall created because of the surgery. CT helps in the detection, delineation, diagnosis of complications, and surgical planning of an external hernia. In this article, the anatomy, pathophysiology, and CT features of common postoperative hernias are discussed. Afterreading this review, the readers should be able to (1) enumerate the common postoperative internal and external abdominal hernias, (2) explain the pathophysiology and surgical anatomy of Roux-en-Y gastric bypass-related hernia, (3) identify the common imaging features of postoperative hernia, and (4) diagnose the complications of postoperative hernias.

A Modified Side-to-Side Anastomosis Using a Circular Stapler Reduces Anastomotic Leakage in Colonic Surgery

Background. Anastomotic leakage (AL) remains one of the serious complications after colonic surgery. Method. A prospective interventional study to assess a modified technique of creating the ileocolic, colic-colic, and colorectal side-to-side anastomoses using a circular stapler. The primary endpoint was to evaluate the safety and efficacy of this technique in the reduction of AL. Computed tomography scan was performed when AL was clinically suspected. Result. One hundred and forty-five patients who underwent colonic resection between January 2015 and August 2018 were included. One patient underwent surgery for severe inflammatory bowel disease, and the others underwent surgery for colonic cancer. The procedures were open surgeries, including right hemicolectomy (n = 79 [54.5%]), left hemicolectomy (n = 29 [20%]), sigmoidectomy (n = 30 [20.7%]), and transverse colectomy (n = 7 [4.8%]). In 23 patients with ascending colonic obstruction, emergency right colectomy with primary anastomosis was performed. Two surgeons performed the operations (52.4% and 47.6%, respectively), and intraoperative blood loss was 50 to 100 mL. The operative time was 160 to 240 minutes. There was no mortality postoperatively, and 26 (17.9%) patients developed complications. One patient who underwent transverse colonic cancer resection developed a clinical AL (0.7%). After ileostomy, the patient was discharged with no other serious complication. The median of postoperative hospital stay was 8 days (range = 5-18 days). Conclusion. This modified technique is a safe and efficient method for anastomotic configuration in colonic surgery.

Early renal dysfunction after temporary ileostomy construction

PURPOSE

Loop ileostomy is often used to prevent complications after colorectal surgery, but it has been reported to cause renal impairment. This study aimed to evaluate the changes in the renal function after ileostomy and to compare these with the renal function after low anterior resection without ileostomy (low-ANT).

METHODS

The subjects included 58 patients who underwent ileostomy construction and closure for rectal cancer. The estimated glomerular filtration rate (eGFR) was calculated at specific time points after the index surgery. In addition, we conducted a case-matched study on 147 patients who underwent low-ANT.

RESULTS

The eGFR was significantly lower at 1 month after ileostomy than at the time of ileostomy construction (78.8 vs. 84.0, p < 0.0001) and did not improve after ileostomy closure. The only risk factor for a reduced eGFR was preoperative chemotherapy or chemoradiotherapy. In the case-matched study, 36 patients were allocated for each of the two groups. The number of ileostomy patients with a reduced eGFR was significantly increased 1 month after the index surgery (p = 0.005).

CONCLUSIONS

The eGFR began to decrease at one month after ileostomy construction and did not improve after ileostomy closure.

Intestinal Ostomy

BACKGROUND

About 100 000 ostomy carriers are estimated to live in Germany today. The creation of an ostomy represents a major life event that can be associated with impaired quality of life. Optimal ostomy creation and proper ostomy care are crucially important determinants of the success of treatment and of the patients' quality of life.

METHODS

This article is based on pertinent publications retrieved by a selective search in PubMed, GoogleScholar, and Scopus, and on the authors' experience.

RESULTS

Intestinal stomata can be created using either the small or the large bowel. More than 75% of all stomata are placed as part of the treatment of colorectal cancer. The incidence of stoma-related complications is reported to be 10-70%. Skin irritation, erosion, and ulceration are the most common early complications, with a combined incidence of 25-34%, while stoma prolapse is the most common late complication, with an incidence of 8-75%. Most early complications can be managed conservatively, while most late complications require surgical revision. In 19% of cases, an ostomy that was initially planned to be temporary becomes permanent. Inappropriate stoma location and inadequate ostomy care are the most common causes of early complications. Both surgical and patient-related factors influence late complications.

CONCLUSION

Every step from the planning of a stoma to its postoperative care should be discussed with the patient in detail. Preoperative marking is essential for an optimal stoma site. Optimal patient management with the involvement of an ostomy nurse increases ostomy acceptance, reduces ostomy-related complications, and improves the quality of life of ostomy carriers.

Indications for and complications of intestinal stomas in the children and adults at a tertiary care hospital in a resource-limited setting: a Tanzanian experience

BACKGROUND

An intestinal stoma, though a life-saving procedure on the care of many gastrointestinal conditions, carries significant number of complications. This study describes the common indications, complications, and management of stomas and identifies the factors that are associated with these complications in a tertiary care hospital in Tanzania.

METHODS

A cross-sectional study of patients with intestinal stomas was conducted at Bugando Medical Centre (BMC) between July 2016 and June 2017. Ethical approval to conduct the study was obtained from relevant authority before the commencement of the study.

RESULTS

A total of 167 patients (M: F = 1.2:1) were enrolled in the study. The mean age at diagnosis was 0.6 ± 1.4 years for children and mean age for adults was 36.7 ± 15.8 years. Anorectal malformation (110, 89.4%) was the most common indication for intestinal stoma formation in children, while bowel perforation (14, 31.8%) was the main indications in adults. The sigmoid colon (137, 82.0%) was the most common anatomical site for stoma formation followed by the ileum (18, 10.8%). Stoma prolapse (18, 41.9%) was the most frequent complication of a stoma, whereas, surgical site infection (9, 34.6%) was the most frequent complication after stoma closure. Thirty five (26.7.%) of the children developed stomal complications, while only 8 (22.2%) of the adults developed complications. The level of training of operating surgeon and timing of surgery were the main predictors of stoma-related complications (p < 0.034 and 0.013), whereas the level of training of the operating surgeon and the type of stoma closure were significantly associated with the complications related to stoma closure (p < 0.001).

CONCLUSION

The intestinal stomas performed at BMC are associated with various complications, which in turn, become a burden to the patients. The insights observed in the current study may apply to other tertiary hospitals in Tanzania and Africa at large. We suggest that the keystones for improvement and control in the formation and complications of intestinal stomas are the following; colostomy formation should rarely be done in transverse colon, the procedure should be carried out by senior doctors (specialist) or junior doctors under close and direct supervision of the specialists, using proper meticulous techniques, and the need to determine and/or improve techniques for early detection of complications.

Defunctioning loop ileostomy for rectal anastomoses: predictors of stoma outlet obstruction

PURPOSE

Creation of defunctioning loop ileostomy is a standard procedure in laparoscopic lower rectal surgery. Stoma-related obstruction sometimes occurs, but its cause has not been fully analyzed. This study aims to assess stoma obstructive complications and clarify the risk factors of stoma-related obstructions.

METHODS

Two hundred and thirty consecutive patients who underwent laparoscopic rectal cancer surgery with defunctioning loop ileostomy between April 2007 and December 2017 were recruited, numbering 230. We statistically examined the frequency and risk factor of stoma outlet obstruction.

RESULTS

Postoperative stoma-related complications developed in 41 patients (17.8%) overall, and there was no 30-day mortality. Stoma outlet obstructions occurred in 16 patients (7.0%) during postoperative course. Thick subcutaneous fat at the stoma-marking site (vertical distance ≥ 20 mm) and body mass index (≥ 22.2) were significantly associated with the risk of stoma outlet obstruction in univariate analysis. Thick subcutaneous fat was a significant predictive factor of stoma outlet obstruction according to multivariate analysis (odds ratio 3.80).

CONCLUSIONS

This report investigates significant predictors of stoma outlet obstruction in laparoscopic rectal cancer surgery for the first time. In laparoscopic procedure, stoma outlet obstruction should be particularly considered in obese patients who have especially thick subcutaneous fat of the abdominal wall.

Diverting Ostomy: For Whom, When, What, Where, and Why

Fecal diversion is an important tool in the surgical armamentarium. There is much controversy regarding which clinical scenarios warrant diversion. Throughout this article, we have analyzed the most recent literature and discussed the most common applications for the use of a diverting stoma. These include construction of diverting ileostomy or colostomy, ostomy for low colorectal/coloanal anastomosis, inflammatory bowel disease, diverticular disease, and obstructing colorectal cancer. We conclude the following: diverting loop ileostomy is preferred to loop colostomy, an ostomy should be used for a pelvic anastomosis < 5 to 6 cm including coloanal anastomosis and ileo-anal-pouch anastomosis, severe perianal Crohn's disease frequently requires diversion, a primary anastomosis with diverting ileostomy in the setting of diverticular perforation is safe, and a diverting stoma can be used as a bridge to primary resection in the setting of an obstructing malignancy.

Comparative outcomes between palliative ileostomy and colostomy in patients with malignant large bowel obstruction

Objectives: Palliative stoma creation should be considered in patients at high risk of colonic metallic stent failure. However, it is unclear whether ileostomy or colostomy is superior. This study compared short-term outcomes between palliative ileostomy and colostomy. Methods: We identified 82 patients with malignant large bowel obstruction, caused by various advanced cancers, between January 2005 and December 2016. We compared short-term outcomes between the ileostomy group (n = 33) and the colostomy group (n = 49). Results: For all 82 patients, clinical success was achieved. Three patients with ileostomy died within 30 days of ostomy formation. The ileostomy group had statistically significant differences in median operative time (113 vs. 129 minutes, p = 0.045) and blood loss (8 vs. 40 g, p = 0.037) in comparison with the colostomy group. No statistically significant differences were observed in the surgical complications (30.3 vs. 38.8%, p = 0.431), in the median period to oral intake (3 vs. 4 days, p = 0.335) and in the hospital stay after surgery (32 vs. 27 days, p = 0.509) between the two groups. Overall stoma-related complications occurred in 27 (32.9%) patients. Stoma-related complications occurred more frequently in the ileostomy group (16/33 vs. 11/49 patients, p = 0.014). High output stoma (6 patients) and irritation (5 patients) occurred more frequently in the ileostomy group. Conclusions: Palliative colostomy is superior to ileostomy due to fewer stoma-related complications. When ileostomy is required, aggressive interventions for high output stomas should be implemented.

The influence of diverting loop ileostomy vs. colostomy on postoperative morbidity in restorative anterior resection for rectal cancer: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate the morbidity of loop ileostomy (LI) and loop colostomy (LC) creation in restorative anterior resection for rectal cancer as well as the morbidity of their reversal.

METHODS

PubMed, EMBASE, MEDLINE via Ovid, and Cochrane Library were systematically searched for records published from 1980 to 2017 by three independent researchers. The primary endpoint was overall morbidity after stoma creation and reversal. Mantel-Haenszel odds ratio (OR) was used to compare categorical variables. Clinical significance was evaluated using numbers needed to treat (NNT).

RESULTS

Six studies (two randomized controlled trials and four observational studies) totaling 1063 patients (666 LI and 397 LC) were included in the meta-analysis. Overall morbidity rate after both stoma creation and closure was 15.6% in LI vs. 20.4% in LC [OR(95%CI) = 0.67 (0.29, 1.58); p = 0.36] [NNT(95%CI) = 21 (> 10.4 to benefit, > 2430.2 to harm)]. Morbidity rate after stoma creation was both statistically and clinically significantly lower after LI [18.2% vs. 30.6%; OR(95%CI) = 0.42 (0.25, 0.70); p = 0.001; NNT(95%CI) = 9 (4.7, 29.3)]. Dehydration rate was 3.1% (8/259) in LI vs. 0% (0/168) in LC. The difference was not statistically or clinically significant [OR(95%CI) = 3.00 (0.74, 12.22); p = 0.13; NNT (95%CI) = 33 (19.2, 101.9)]. Ileus rates after stoma closure were significantly higher in LI as compared to LC [5.2% vs. 1.7%; OR(95%CI) = 2.65 (1.13, 6.18); p = 0.02].

CONCLUSIONS

This meta-analysis found no difference between LI and LC in overall morbidity after stoma creation and closure. Morbidity rates following the creation of LI were significantly decreased at the cost of a risk for dehydration.

Splenic flexure mobilization in rectal cancer surgery: do we always need it?

Splenic flexure (SFM) in rectal cancer surgery is a crucial step which may increase the difficulty of the operation. The aim of this retrospective single-center study is to demonstrate if the selective omission of SFM during anterior rectal resection can reduce the complexity of the operation, without affecting post-operative and oncologic outcomes. Data of 112 consecutive rectal resections for cancer from March 2010 to March 2017 were analyzed and divided into two groups: SFM and No-SFM. A sub-analysis was then performed for laparoscopy and traditional cases. Post-operative and oncologic outcomes, including overall (OS) and cancer-related survival (CRS), were analyzed and compared. SFM was performed in 42% of cases and laparoscopy was used in 73.2%. Operative time resulted significantly lower in the No-SFM group (190 vs. 225 min, p = 0.01). In laparoscopy in the No-SFM group, operative time and post-operative stay were significantly lower (205.5 vs. 222.5 min, p = 0.04; 9 vs. 10 days, p = 0.01). Most of the open resections were performed without SFM (35.4% vs. 14.9%, p = 0.02). No statistical significant differences were found in OS and CRS in the two groups. We support the hypothesis that every surgeon should carry out an accurate intra-operative evaluation to perform a selective SFM. When possible, SFM can be safely avoided with no additional risks in terms of post-operative and oncologic outcomes.

The incidence of stoma related morbidity - a systematic review of randomised controlled trials

Introduction Several stoma related complications can occur following ileostomy or colostomy formation. The reported incidence of these conditions varies widely in the literature. A systematic review of randomised controlled trials reporting the incidence of stoma related complications in adults was performed to provide the most comprehensive summary of existing data. Methods PubMed, CINAHL® (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library were searched for trials assessing the incidence of complications in adults undergoing conventional stoma formation. Data were extracted by two independent reviewers and entered into SPSS® for statistical analysis. The Cochrane Collaboration tool for assessing risk of bias was used to critically appraise each study. Cochran's Q statistic and the I2 statistic were used to measure the level of heterogeneity between studies. Results Overall, 18 trials were included, involving 1,009 patients. The incidence of stoma related complications ranged from 2.9% to 81.1%. Peristomal skin complications and parastomal hernia were the most common complications. End colostomy had the highest incidence of morbidity, followed by loop colostomy and loop ileostomy. There were no trials involving patients with end ileostomy. There was a high level of detection bias and heterogeneity between studies. Conclusions This systematic review has summarised the best available evidence concerning the incidence of stoma related morbidity. The high level of heterogeneity between studies has limited the accuracy with which the true incidence of each stoma related complication can be reported. Large, multicentre trials investigating homogenous participant populations are therefore required.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

ᅟ

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

Loop ostomy following laparoscopic low anterior resection for rectal cancer after neoadjuvant chemoradiotherapy

Background

Both loop ileostomy (LI) and loop transverse colostomy (LTC) could achieve absolute fecal diversion and have several advantages. This study compared LI and LTC following laparoscopic low anterior resection for rectal cancer after neoadjuvant chemoradiotherapy.

Methods

Between January 2009 and December 2016, 186 patients who underwent laparoscopic low anterior resection for rectal cancer and loop ostomy were included. All patients received preoperative neoadjuvant chemoradiotherapy. Of these, 77 underwent LI and 109 underwent LTC. Demographic characteristics, operative details, and complications were analyzed.

Results

In the fecal diversion period, the LTC group showed significantly less dermatitis (p = 0.001) and electrolyte disturbance (p = 0.002), while LI group showed significantly shorter time to first defecation (p = 0.006) and lower incidence of parastomal hernia (p = 0.014). In the stoma closure period, a significantly higher incidence of wound infection was found in LTC group (p = 0.001).

Conclusions

Both LI and LTC have advantages and disadvantages. For its lower wound infection rate, lower incidence of parastomal hernia, and shorter time to first defecation, LI is recommended for all patients except those with potential electrolyte disturbance and sensitive skin.

Stomal Closure: Strategies to Prevent Incisional Hernia

Incisional hernias following ostomy reversal occur frequently. Incisional hernias at the site of a previous stoma closure can cause significant morbidity, impaired quality of life, lead to life-threatening hernia incarceration or strangulation and result in a significant financial burden on health care systems Despite this, the evidence base on the subject is limited. Many recognised risk factors for the development of incisional hernia following ostomy reversal are related to patient factors such as age, malignancy, diabetes, COPD, hypertension and obesity, and are not easily correctable. There is a limited amount of evidence to suggest that prophylactic mesh reinforcement may be of benefit to reduce the post stoma closure incisional hernia rate but a further large scale randomised controlled trial is due to report in the near future. There appears to be weak evidence to suggest that surgeons should favour circular, or "purse-string" closure of the skin following stoma closure in order to reduce the risk of SSI, which in turn may reduce incisional hernia formation. There remains the need for further evidence in relation to suture technique, skin closure techniques, mechanical bowel preparation and oral antibiotic prescription focusing on incisional hernia development as an outcome measure. Within this review, we discuss in detail the evidence base for the risk factors for the development of, and the strategies to prevent ostomy reversal site incisional hernias.