1
|
Ascari F, Barugola G, Ruffo G. Diverting ileostomy in benign colorectal surgery: the real clinical cost analysis. Updates Surg 2024:10.1007/s13304-024-01879-3. [PMID: 38801603 DOI: 10.1007/s13304-024-01879-3] [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: 05/15/2023] [Accepted: 07/29/2023] [Indexed: 05/29/2024]
Abstract
There are three types of complications stoma related: ones related to its construction, ones related to its function and related to closure. The aim of this study was to assess the risk of complications related to the stoma presence and to identificate variables related to complications. We conducted a retrospective study of patients who underwent sphincter-preserving elective surgery for benign condition between January 2013 and December 2020 at IRCCS Sacro Cuore Don Calabria Hospital in Negrar, Verona. Data were collected regarding demographics and complications associated with primary surgery, stoma closure and the interval period. Univariable and multivariable analysIs were conducted. A total of 446 (12.2%) diverting loop ileostomies were performed. At index procedure, 76 (17%) patients had complications and 34 patients had complications related to ileostomy creation. Twenty patients (4.4%) were re admitted before stoma closure for dehydration. One hundred and eighty-seven patients (41.9%) suffered from ileostomy management's problems. At univariate analysis, complications of having stoma are more frequent in elder patients (p = 0.013), ASA score > 2 (p = 0.02), IBD diagnosis (p = < 0.001) and patients who had ileostomy creation complications (p = 0.04). At stoma closure, 55 (12.3%) patients had complications. Forty-seven patients (10.5%) presented incisional hernia in the stoma closure site. Ileostomy closure complications are more common with ASA score > 2 (p = 0.01) and IBD diagnosis (p < 0.001). IBD was found an independent factor of poor outcome at the time of ileostomy creation and closure. Developing complications at the time of ileostomy creation is statistically related to develop complications during ileostomy maintenance at multivariable analysis A loop ileostomy is usually created to limit the potentially life-threatening consequenceS of anastomotic leakage, but it is not able to decrease the leak-related mortality, wound sepsis, postoperative bleeding and small bowel obstruction. Debate rises not only for its uncertain efficacy but also because of the significant morbidity related to stoma. The surgeon could use these data in order to tailor his surgical strategy to the patients and their disease.
Collapse
Affiliation(s)
- F Ascari
- Chirurgia Generale Ospedale Ramazzini, AUSLModena, Carpi, Modena, Italy.
| | - G Barugola
- Chirurgia Generale IRCCS Sacro Cuore Don Calabria, NegrarDiValpolicella, Verona, Italy
| | - G Ruffo
- Chirurgia Generale IRCCS Sacro Cuore Don Calabria, NegrarDiValpolicella, Verona, Italy
| |
Collapse
|
2
|
Geisler BP, Cao KN, Ryschon AM, Alavi K, Komen N, Pietzsch JB. Cost associated with diverting ostomy after rectal cancer surgery: a transnational analysis. Surg Endosc 2023; 37:7759-7766. [PMID: 37580581 DOI: 10.1007/s00464-023-10300-w] [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: 03/21/2023] [Accepted: 07/12/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Diverting ileostomy and colostomy after total mesorectal excision reduces the risk of complications related to anastomotic leakages but is associated with a reduction in health-related quality of life and long-term economic consequences that are unknown. Our objective was to estimate the lifetime costs of stoma placement after rectal cancer resection in the U.S., England, and Germany. METHODS Input parameters were derived from quasi-systematic literature searches. Decision-analytic models with survival from colorectal cancer-adjusted life tables and country-specific stoma reversal proportions were created for the three countries to calculate lifetime costs. Main cost items were stoma maintenance costs and reimbursement for reversal procedures. Discounting was applied according to respective national guidelines. Sensitivity analysis was conducted to explore the impact of parameter uncertainty onto the results. RESULTS The cohort starting ages and median survival were 63 and 11.5 years for the U.S., 69 years and 8.5 years for England, and 71 and 6.5 years for Germany. Lifetime discounted stoma-related costs were $26,311, £9512, and €10,021, respectively. All three models were most sensitive to the proportion of ostomy reversal, age at baseline, and discount rate applied. CONCLUSION Conservative model-based projections suggest that stoma care leads to significant long-term costs. Efforts to reduce the number of patients who need to undergo a diverting ostomy could result in meaningful cost savings.
Collapse
Affiliation(s)
- Benjamin P Geisler
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Khoa N Cao
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Anne M Ryschon
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Karim Alavi
- Department of Surgery/Division of Colon and Rectal Surgery, UMass Memorial Health/UMass Chan Medical School, Worcester, MA, USA
| | - Niels Komen
- Department Abdominal Surgery, Universitair Ziekenhuis Antwerpen/ReSURG, Antwerp Surgical Training, Anatomy and Research Center, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Jan B Pietzsch
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA.
| |
Collapse
|
3
|
Batistotti P, Montale A, Bruzzone M, Amato A, Binda GA. Protective ileostomy after low anterior resection for extraperitoneal rectal cancer: does the reversal surgery timing affect closure failure? Updates Surg 2023; 75:1811-1818. [PMID: 37428410 DOI: 10.1007/s13304-023-01573-w] [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: 01/31/2023] [Accepted: 06/22/2023] [Indexed: 07/11/2023]
Abstract
Loop ileostomy is commonly performed after LAR with TME to temporarily protect the anastomosis. Usually, defunctioning stoma is closed after 1-6 months, although sometimes it becomes definitive de facto. The aim of this study is to investigate the long-term risk of no-reversal of protective ileostomy after LAR for middle-low rectal cancer and the predictive risk factors. A retrospective analysis of a consecutive cohort of patients who underwent curative LAR with covering ileostomy for extraperitoneal rectal cancer in two colorectal units was performed. A different policy for scheduling stoma closure was applied between centers. All the data were collected through an electronic database (Microsoft Excel®). Descriptive statistical analysis was performed using Fisher's exact and Student's t test. Multivariate logistic regression analysis was conducted. Two-hundred twenty-two patients were analysed: reversal procedure was carried out in 193 patients, in 29 cases stoma was never closed. The mean interval time from index surgery was 4.9 months (Center1: 3 vs. Center2: 7.8). At the univariate analysis, mean age and tumor stage were significantly higher in the "no-reversal" group. Unclosed ostomies were significantly lower in Center 1 than Center 2 (8% vs. 19.6%). At the multivariate analysis female gender, anastomotic leakage and Center 2 had significant higher risk of unclosed ileostomy. Currently, no clinical recommendations have been established and the policy of scheduling stoma reversal is variable. Our study suggests that an established protocol could avoid closure delay, decreasing permanent stomas. Consequently, ileostomy closure should be weighed as standardized step in cancer therapeutic pathway.
Collapse
Affiliation(s)
- P Batistotti
- General Surgical Department, Ospedale Di Imperia, Via Sant'Agata 57, 18100, Imperia, Italy.
| | - A Montale
- Department of Gastroenterology and Digestive Endoscopy, E. O. Ospedali Galliera, Mura Delle Cappuccine 14, 16128, Genoa, Italy
| | - M Bruzzone
- Clinical Epidemiology Unit, IRCCS Ospedale San Martino, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - A Amato
- General Surgical Department, Ospedale Di Imperia, Via Sant'Agata 57, 18100, Imperia, Italy
| | - G A Binda
- General Surgery, Biomedical Institute, Genoa, Italy
| |
Collapse
|
4
|
Baloyiannis I, Perivoliotis K, Mamaloudis I, Bompou E, Sarakatsianou C, Tzovaras G. Determination of Factors Related to the Reversal and Perioperative Outcomes of Defunctioning Ileostomies in Patients Undergoing Rectal Cancer Surgery: A Regression Analysis Model. J Gastrointest Cancer 2023; 54:782-790. [PMID: 36063314 DOI: 10.1007/s12029-022-00862-8] [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] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Defunctioning ileostomies are often performed during rectal cancer surgery. However, stomas are sometimes associated with complications, while 20-30% of them are never reversed. Additionally, ileostomy closure can have associated morbidity, with rates as high as 45%, with the respective literature evidence being scarce and conflicting. Thus, we evaluated the stoma reversal outcomes and the risk factors for non-closure after rectal cancer surgery. METHODS This is a retrospective analysis of a prospectively collected database of all patients who had a defunctioning ileostomy at the time of resection for rectal cancer. All operations were performed by the same surgical team. A multivariable regression model was implemented. RESULTS In this study, 129 patients (male: 68.2%, female: 31.8%) were included. Ileostomy formation was associated with a total of 31% complication rate. Eventually 73.6% of the stomas were reversed at a mean time to closure of 26.6 weeks, with a morbidity of 13.7%. Non-reversal of ileostomy was correlated with neoadjuvant CRT (OR: 0.093, 95% CI: 0.012-0.735), anastomotic leakage (OR: 0.107, 95% CI: 0.019-0.610), and lymph node yield (OR: 0.946, 95% CI: 0.897-0.998). Time to reversal was affected by the N status, the LNR, the need for adjuvant chemotherapy, and the histologic grade. CONCLUSION In patients with rectal cancer resections, defunctioning stoma closure rate and time to closure were associated with several perioperative and pathological outcomes.
Collapse
Affiliation(s)
- Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Konstantinos Perivoliotis
- Department of Surgery, General Hospital of Volos, Polymeri 134, 38222, Volos, Greece.
- University of Thessaly, Viopolis, 41500, Larissa, Greece.
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110, Larissa, Greece.
| | - Ioannis Mamaloudis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Effrosyni Bompou
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Chamaidi Sarakatsianou
- Department of Anesthesiology, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| |
Collapse
|
5
|
Ellebæk MB, Perdawood SK, Steenstrup S, Khalaf S, Kundal J, Möller S, Bang JC, Støvring J, Qvist N. Early versus late reversal of diverting loop ileostomy in rectal cancer surgery: a multicentre randomized controlled trial. Sci Rep 2023; 13:5818. [PMID: 37037856 PMCID: PMC10085999 DOI: 10.1038/s41598-023-33006-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 04/05/2023] [Indexed: 04/12/2023] Open
Abstract
Diverting loop ileostomy has become routine in low anterior resection (LAR) for rectal cancer. The optimal time for stoma reversal is controversial. The aim of the present study was to compare the results after planned early (within 8-12 days) versus late (> 3 months) stoma reversal. The primary outcomes were morbidity and mortality, as measured by the Comprehensive Complication Index (CCI) within 30 days after stoma reversal, and the secondary outcomes were morbidity and mortality within 90 days after LAR. This was a multicentre trial including all patients scheduled for anterior low resection for rectal cancer with curative intent. Inclusion period was from April 2011 to December 2018. All patients were randomized 1:1 prior to surgery. Among 257 consecutive and eligible patients, a total of 214 patients were randomized: 107 patients to early stoma reversal and 107 to late reversal. A total of 68 patients were excluded for various reasons, and 146 patients completed the study, with 77 in the early reversal group and 69 in the late reversal group. The patients were asked to complete the Gastrointestinal Quality of Life Index before surgery (baseline) and at 6 and 12 months after LAR. Ostomy-related complications were evaluated by dedicated ostomy staff using the validated DET score. ClinicalTrials Identifier: NCT01865071. Fifty-three patients (69%) in the early reversal group and 60 patients (87%) in the late reversal group received the intended treatment. There were no significant differences in CCI within 90 days after index surgery with the LAR and within 30 days after stoma reversal between the two groups. There were no differences in patient-reported quality of life but significantly more stoma-related complications in the late reversal group. A total of 5 patients experienced anastomotic leakage (AL) after stoma reversal, 4 in the early reversal group and one in the late reversal group. Early and late stoma reversal showed similar outcomes in terms of overall complications and quality of life. The risk of developing anastomotic leakage after early ostomy reversal is a concern.
Collapse
Affiliation(s)
- Mark Bremholm Ellebæk
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark.
- OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | | | - Signe Steenstrup
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sardar Khalaf
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jette Kundal
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Jens Støvring
- Department of Surgery, Hospital South West Jutland, Esbjerg, Denmark
| | - Niels Qvist
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
6
|
Barnard J, Milne T, Teo K, Weston M, Israel L, Peng SL. Causes and costs of delayed closure of ileostomies in rectal cancer patients in Australasian units. ANZ J Surg 2023; 93:636-642. [PMID: 36203387 DOI: 10.1111/ans.18092] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Defunctioning loop ileostomies (DLIs) are a frequent adjunct to rectal cancer surgery. Delayed closure of DLIs is common and associated with increased morbidity. The reasons for delayed DLI closure are often unknown. The economic burden of delayed DLI closure is not quantified. The present study aimed to determine the reasons for, and economic burden of, delayed DLI closure. METHODS Clinical and economic data were audited from a prospective database of patients in two Australasian colorectal cancer centres. Patients treated at each unit with low/ultra-low anterior resection for rectal cancer with formation of DLI between January 2014 and December 2019 were included. Post-operative complication rate, stoma-related complication rate and costs of hospital admissions and stoma care were recorded and analysed. Multivariate linear regression analysis was used to investigate risk factors for delay to closure. RESULTS 146 patients underwent low/ultra-low anterior resection with DLI; 135 patients (92.5%) underwent reversal. The median duration to reversal was 7 months (IQR 4.5-9.5). Sixty-six percent of patients underwent reversal >6 months after their index surgery. Neoadjuvant and adjuvant chemotherapy were associated with delayed reversal (P < 0.001). Non-English speakers waited longer for DLI closure (P = 0.028). The costs of outpatient stoma care (P < 0.001), post-operative care (P = 0.004), and total cost of treatment (P = 0.014) were significantly higher in the delayed closure group, with a total cost of treatment difference of $3854 NZD per patient. CONCLUSIONS Causes of delay include systemic factors and demographic factors that can be addressed directly, addressing such causes may alleviate a significant economic burden.
Collapse
Affiliation(s)
- Jon Barnard
- Coloreectal Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tony Milne
- General Surgery, Nelson Hospital, Nelson, New Zealand
| | - Keith Teo
- General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Maree Weston
- General Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Lincoln Israel
- General Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Sze-Lin Peng
- General Surgery, Middlemore Hospital, Auckland, New Zealand
| |
Collapse
|
7
|
D'Eusebio C, Merlo FD, Ossola M, Bioletto F, Ippolito M, Locatelli M, De Francesco A, Anrò M, Romagnoli R, Strignano P, Bo S, Aimasso U. Mortality and parenteral nutrition weaning in patients with chronic intestinal failure on home parenteral nutrition: A 30-year retrospective cohort study. Nutrition 2023; 107:111915. [PMID: 36566610 DOI: 10.1016/j.nut.2022.111915] [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: 08/18/2022] [Revised: 11/06/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is the standard treatment for patients with chronic intestinal failure (CIF). Mortality and weaning rates of these patients differ widely among cohorts; however, these outcomes were often considered independent-rather than competing-events, leading to an upward bias of the retrieved estimates. OBJECTIVES The aim of this retrospective cohort study was to evaluate, evaluating through a competing risk analysis, the rates and predictors of mortality and weaning in CIF patients from an Italian referral center. METHODS All adult patients with CIF receiving > 3 mo HPN from 1985 until 2016 were enrolled. Clinical information was collected from the database of the Intestinal Failure Unit of Torino, Italy. Patients were stratified according to the presence or not of short bowel syndrome (SBS). RESULTS The cumulative incidences of death and weaning were 27.3% and 32.3% and 39.0% and 33.7% at 5 and 10 y from HPN initiation, respectively. At multivariable competing risk analyses, mortality was predicted by age (sub-distribution hazard ratio [SHR] = 1.65 per 10-y increase; 95% CI, 1.35-2.01), type 3 SBS (SHR = 0.38; 0.15-0.94), small bowel length ≥ 100 cm (SHR = 0.42; 0.22-0.83), and reconstructive surgery (SHR = 0.11; 0.02-0.64) in SBS patients, and by age (SHR = 1.38 per 10-y increase; 1.16-1.64) and presence of stoma (SHR = 0.30; 0.12-0.78) in non-SBS patients. In the same model, weaning was predicted by type 3 SBS (SHR = 6.86; 3.10-15.16), small bowel length ≥ 100 cm (SHR = 3.54; 1.99-6.30), and reconstructive surgery (SHR = 2.86; 1.44-5.71) in SBS patients, and by age (SHR = 0.79 per 10-y increase; 0.66-0.94) and presence of stoma (SHR = 2.64; 1.38-5.07) in non-SBS patients. CONCLUSIONS Surgical procedures strongly affected mortality and weaning risk in CIF patients.
Collapse
Affiliation(s)
- Chiara D'Eusebio
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Fabio Dario Merlo
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy.
| | - Marta Ossola
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Fabio Bioletto
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Mirko Ippolito
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Monica Locatelli
- Food Chemistry, Biotechnology and Nutrition Unit, University of Piemonte Orientale, 28100 Novara, Italy
| | - Antonella De Francesco
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Marta Anrò
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Renato Romagnoli
- General Surgery 2U, Liver Transplantation Unit, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Paolo Strignano
- General Surgery 2U, Liver Transplantation Unit, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Simona Bo
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy.
| | - Umberto Aimasso
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| |
Collapse
|
8
|
Pyo DH, Huh JW, Lee WY, Yun SH, Kim HC, Cho YB, Park Y, Shin JK. The role of transanal tube after low anterior resection in patients with rectal cancer treated with neoadjuvant chemoradiotherapy: A propensity score-matched study. Surgery 2023; 173:335-341. [PMID: 36494274 DOI: 10.1016/j.surg.2022.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/11/2022] [Accepted: 10/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The protective efficacy of transanal tube for anastomosis was compared with that of diverting stoma in patients with rectal cancer treated with neoadjuvant chemoradiotherapy. METHODS We included consecutive patients with rectal cancer treated with neoadjuvant chemoradiotherapy and curative surgery from January 2013 to December 2019. The patients were grouped into transanal tube or diverting stoma, according to the protection methods they received. Propensity score-matching with 1:1 ratio was done. The primary outcome was the incidence of anastomotic leakage. RESULTS Of the 656 eligible patients, 207 (31.6%) and 385 (58.7%) patients were grouped into transanal tube and diverting stoma, respectively, and 64 (9.7%) patients who did not undergo either transanal tube or diverting stoma were excluded. After matching, the incidence of anastomotic leakage was 9.7% and 10.6% in diverting stoma and transanal tube, respectively (P = .871). The overall morbidity was 23.2% and 15.0% in diverting stoma and transanal tube, respectively (P = .045). In the multivariate analysis, tumor size >2.5 cm and level of anastomosis <4 cm were significant risk factors for anastomotic leakage. In a subgroup analysis for patients with the level of anastomosis >4 cm, the incidence of anastomotic leakage was not significantly different between the transanal tube and diverting stoma groups. However, for patients with a level of anastomosis <4 cm, the incidence of grade C anastomotic leakage was significantly greater in the transanal tube than in the diverting stoma group (2.5% vs 9.9%, P = .040). CONCLUSION The protective efficacy of transanal tube may be comparable to diverting stoma, especially for those with a level of anastomosis >4 cm.
Collapse
Affiliation(s)
- Dae Hee Pyo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoonah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Kyong Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
9
|
Matak L, Mikuš M, Ćorić M, Spagnol G, Matak M, Vujić G. Comparison end-to-end anastomosis with ostomy after secondary surgical cytoreduction for recurrent high-grade serous ovarian cancer: observational single-center study. Arch Gynecol Obstet 2023; 308:231-237. [PMID: 36680573 DOI: 10.1007/s00404-023-06918-9] [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: 09/17/2022] [Accepted: 01/08/2023] [Indexed: 01/22/2023]
Abstract
We conducted an observational single-center cohort study on patients with recurrent high-grade serous ovarian carcinoma that underwent secondary surgical cytoreduction with extent of partial ileectomy and/or colectomy, followed by adjuvant chemotherapy (Paclitaxel-Carboplatin). All patients performed previously primary debulking surgery without residual disease, followed by three cycles of adjuvant chemotherapy. The aim of this study was to compare survival in patients with ostomy or end-to-end anastomosis that underwent secondary cytoreduction. Furthermore, we investigated the morbidity, the rate, timing and complications of the ostomy or end-to-end anastomosis after secondary cyto-reduction.
Collapse
Affiliation(s)
- Luka Matak
- Department of Obstetrics and Gynecology, General Hospital Zadar, Bože Peričića 5, 23000, Zadar, Croatia.
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mario Ćorić
- Department of Obstetrics and Gynecology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Giulia Spagnol
- Department of Women and Children's Health, Clinic of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Magdalena Matak
- Department of Dermatovenearology, General Hospital Zadar, Zadar, Croatia
| | - Goran Vujić
- Department of Obstetrics and Gynecology, University Hospital Center Zagreb, Zagreb, Croatia
| |
Collapse
|
10
|
He J, Li J, Fan B, Yan L, Ouyang L. Application and evaluation of transitory protective stoma in ovarian cancer surgery. Front Oncol 2023; 13:1118028. [PMID: 37035215 PMCID: PMC10081540 DOI: 10.3389/fonc.2023.1118028] [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: 12/28/2022] [Accepted: 03/15/2023] [Indexed: 04/11/2023] Open
Abstract
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.
Collapse
|
11
|
Closure timing of a temporary ileostomy in patients with rectal cancer undergoing anus-preserving operation: a retrospective cohort study. Surg Today 2023; 53:116-129. [PMID: 35861894 DOI: 10.1007/s00595-022-02543-2] [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: 01/23/2022] [Accepted: 05/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To investigate the optimal closure time of a temporary ileostomy in patients with rectal cancer receiving anus-preserving operation. METHODS Patients with rectal cancer were enrolled from the Affiliated Hospital of Jiangsu University from May 2010 to June 2019. The eligible patients were grouped according to their actual ileostomy closure time after stoma creation. Outcomes were complications during stoma closure and complications within one year after stoma closure. RESULTS This study included 361 qualified subjects, with 108 patients in the 3-5 months group, 133 in the 5-7 months group and 120 in the ≥ 7 months group. Compared with the risk of complications during stoma closure in the 3-5 months group, that in the 5-7 months group was significantly reduced (odds ratio [OR]: 0.36, 95% confidence interval [CI] 0.13-0.99), and that in the ≥ 7 months group was significantly increased (OR: 5.88, 95% CI 2.38-14.56). In contrast to the 3-5 months group, the 5-7 months group showed a significantly decreased risk (OR: 0.21, 95% CI 0.07-0.67), and the ≥ 7 months group showed a significantly increased risk (OR: 4.21, 95% CI 1.61-11.01) of complications within 1 year after stoma closure. CONCLUSION 5-7 months after the ileostomy is created may be the optimal time for its closure.
Collapse
|
12
|
Leijtens JWA, Smits LJH, Koedam TWA, Orsini RG, van Aalten SM, Verseveld M, Doornebosch PG, de Graaf EJR, Tuynman JB. Long-term oncological outcomes after local excision of T1 rectal cancer. Tech Coloproctol 2023; 27:23-33. [PMID: 36028782 PMCID: PMC9807482 DOI: 10.1007/s10151-022-02661-6] [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: 02/21/2022] [Accepted: 07/07/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND A growing proportion of patients with early rectal cancer is treated by local excision only. The aim of this study was to evaluate long-term oncological outcomes and the impact of local recurrence on overall survival for surgical local excision in pT1 rectal cancer. METHODS Patients who only underwent local excision for pT1 rectal cancer between 1997 and 2014 in two Dutch tertiary referral hospitals were included in this retrospective cohort study. The primary outcome was the local recurrence rate. Secondary outcomes were distant recurrence, overall survival and the impact of local recurrence on overall survival. RESULTS A total of 150 patients (mean age 68.5 ± 10.7 years, 57.3% males) were included in the study. Median length of follow-up was 58.9 months (range 6-176 months). Local recurrence occurred in 22.7% (n = 34) of the patients, with a median time to local recurrence of 11.1 months (range 2.3-82.6 months). The vast majority of local recurrences were located in the lumen. Five-year overall survival was 82.0%, and landmark analyses showed that local recurrence significantly impacted overall survival at 6 and 36 months of follow-up (6 months, p = 0.034, 36 months, p = 0.036). CONCLUSIONS Local recurrence rates after local excision of early rectal cancer can be substantial and may impact overall survival. Therefore, clinical decision-making should be based on patient- and tumour characteristics and should incorporate patient preferences.
Collapse
Affiliation(s)
- J. W. A. Leijtens
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands ,Department of Surgery, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands
| | - L. J. H. Smits
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, The Netherlands ,Department of Surgery, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands
| | - T. W. A. Koedam
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, The Netherlands ,Department of Surgery, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands
| | - R. G. Orsini
- Department of Surgery, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands ,Department of Surgery, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands
| | - S. M. van Aalten
- Department of Surgery, Groene Hart Ziekenhuis, Gouda, The Netherlands ,Department of Surgery, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands
| | - M. Verseveld
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, The Netherlands ,Department of Surgery, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands
| | - P. G. Doornebosch
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, The Netherlands ,Department of Surgery, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands
| | - E. J. R. de Graaf
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, The Netherlands ,Department of Surgery, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands
| | - J. B. Tuynman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, The Netherlands ,Department of Surgery, IJsselland Ziekenhuis, Capelle Aan Den IJssel, The Netherlands
| |
Collapse
|
13
|
Kuo CY, Lin YK, Wei PL, Chi-Yong Ngu J, Lee KD, Chen CL, Huang Y, Chen CC, Kuo LJ. Clinical assessment for non-reversal stoma and stoma re-creation after reversal surgery for rectal cancer patients after sphincter-saving operation. Asian J Surg 2022; 46:1944-1950. [PMID: 36229306 DOI: 10.1016/j.asjsur.2022.09.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 03/18/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study aimed to identify the risk factors for permanent stoma (PS) in patients who underwent sphincter-saving operations for rectal cancer. METHODS We retrospectively reviewed 597 consecutive patients with rectal cancer from January 2012 to December 2020 at Taipei Medical University Hospital. Univariate and multivariable analyses were used to analyze risk factors for PS. RESULTS After a mean follow-up of 47.3 months (range 7-114 months), 59 patients (15.1%) were alive with a PS, including 46 patients who did not undergo reversal surgery and 13 patients who underwent stoma re-creation after reversal surgery. The mean period between primary surgery and stoma reversal was 6.0 months. Multivariate analysis revealed that the risk factors for PS were local recurrence [odd ratio (OR), 25.58; 95% confidence interval (CI), 4.428-147.761; p < 0.001], perirectal abscess [OR, 154.34; 95% CI, 15.806 - >999; p < 0.001], anastomosis site stenosis [OR, 187.081; 95% CI, 22.193 - >999; p < 0.001], perineural invasion [OR, 4.782; 95% CI, 1.22-18.736; p = 0.025], and operation time (min) [OR, 1.008; 95% CI, 1.002-1.014; p = 0.01]. CONCLUSIONS Local recurrence, perirectal abscess, anastomosis site stenosis, perineural invasion, and operation time were independent risk factors for PS. Therefore, before a patient undergoes surgery for rectal cancer, surgeons should consider the possibility of the need for a PS, and patients should be informed before the operation that closure of the temporary stoma may not always be possible.
Collapse
|
14
|
Hu K, Tan K, Li W, Zhang A, Li F, Li C, Liu B, Zhao S, Tong W. The impact of postoperative complications severity on stoma reversal following sphincter-preserving surgery for rectal cancer. Langenbecks Arch Surg 2022; 407:2959-2967. [PMID: 35802267 DOI: 10.1007/s00423-022-02589-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Currently, the relationship between temporary stoma reversal and the severity of postoperative complications (POCs) after the index surgery based on the Clavien-Dindo classification has not yet been explored. METHODS From July 2010 to June 2016, 380 patients undergoing sphincter-preserving surgery for rectal cancer with a temporary stoma in our hospital were included. Temporary stoma nonclosure rates, disease-free survival rates, and overall survival rates were estimated utilizing the Kaplan-Meier method. RESULTS Of all the 380 patients, primary stomas were created in 335 patients and secondary stomas in 45 patients. After the index surgery, 36.6% (139/380) of patients developed at least one postoperative complication. In the first analysis, which included all the patients, 24.7% of temporary stomas remained unclosed. In the second analysis for 335 patients with a primary stoma, 23.3% were left with unclosed stomas. After the COX regression analysis, both major POCs and minor POCs were found to be independent risk factors for the permanent stoma, and there was an increasing tendency toward the risk of permanent stoma with the increase in POC severity. CONCLUSION POCs are independent predictors of permanent stoma after rectal cancer surgery. Even minor POCs may affect the outcome, while there is a clear direct relationship between POC severity and permanent stoma rates.
Collapse
Affiliation(s)
- Kang Hu
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Ke Tan
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Wang Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Anping Zhang
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Fan Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Chunxue Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Baohua Liu
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Song Zhao
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Weidong Tong
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China.
| |
Collapse
|
15
|
Turner GA, Clifford KA, Holloway R, Woodfield JC, Thompson‐Fawcett M. The impact of prolonged delay to loop ileostomy closure on postoperative morbidity and hospital stay: A retrospective cohort study. Colorectal Dis 2022; 24:854-861. [PMID: 35156285 PMCID: PMC9545668 DOI: 10.1111/codi.16095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 12/13/2022]
Abstract
AIM There is increasing evidence that delayed loop ileostomy closure is associated with an increase in postoperative morbidity. In the context of a publicly funded health service with constrained theatre access, we review the impact of delay in loop ileostomy closure. METHOD A retrospective cohort study of patients undergoing loop ileostomy closure at the Dunedin Public Hospital between 2000-2017 was performed. Cases and complications were identified from the prospectively maintained Otago Clinical Audit database. Patient demographics, ASA score, indications for ileostomy, reasons for delay in closure, length of stay (LOS) after ileostomy closure and complications were collected. LOS and overall complication rate were assessed using univariable and multivariable analyses. RESULTS A total of 292 patients were included in the study, of whom 74 (25.3%) were waiting for longer than 12 months for ileostomy closure. The overall complication rate was 21.5%. This was 8% up to 90 days, 20% between 90-360 days, 28% between 360-720 days and 54% after 720 days. Delay was associated with an increased risk of any complication (RR 1.06 for every 30 days with stoma, p < 0.001), including Ileus (OR [95% CI] 1.06 [1.00-1.11], p = 0.024). Overall mean LOS was 5.9 days (range 1-63), being 4.6 days up to 180 days, 5.6 between 180-720 days and 8.7 after 720 days. LOS significantly increased with increasing stoma duration (p = 0.04). CONCLUSION Increasing time with loop ileostomy is detrimental for patients, being associated with an increase in complication rates, and is detrimental for hospitals due to increased length of stay. Resources should be allocated for timely closure of loop ileostomies.
Collapse
Affiliation(s)
| | - Kari A. Clifford
- Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| | - Rossi Holloway
- Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| | - John C. Woodfield
- Department of SurgeryDunedin HospitalDunedinNew Zealand,Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| | - Mark Thompson‐Fawcett
- Department of SurgeryDunedin HospitalDunedinNew Zealand,Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| |
Collapse
|
16
|
Werner JM, Kupke P, Ertl M, Opitz S, Schlitt HJ, Hornung M. Timing of Closure of a Protective Loop-Ileostomy Can Be Crucial for Restoration of a Functional Digestion. Front Surg 2022; 9:821509. [PMID: 35419403 PMCID: PMC8999839 DOI: 10.3389/fsurg.2022.821509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/28/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Protective loop-ileostomy is one of the most common interventions in abdominal surgery to provide an alternative intestinal outlet until sufficient healing of a distal anastomosis has occurred. However, closure of a loop-ileostomy is also associated with complications. Thus, knowledge of the optimal time interval between primary and secondary surgery is crucial. Methods Data from 409 patients were retrospectively analyzed regarding complications and risk factors in closure-associated morbidity and mortality. A modified Clavien-Dindo classification of surgical complications was used to evaluate the severity of complications. Results A total of 96 (23.5%) patients suffered from postoperative complications after the closure of the loop-ileostomy. Early closure within 150 days from enterostomy (n = 229) was associated with less complications (p < 0.001**). Looking at the severity of complications, there were significantly more (p = 0.014*) mild postoperative complications in the late closure group (>150 days). Dysfunctional digestive problems—either (sub-) ileus (p = 0.004*), diarrhea or stool incontinence (p = 0.003*)—were the most frequent complications associated with late closure. Finally, we could validate in a multivariate analysis that “time to closure” (p = 0.002*) is independently associated with the development of complications after closure of a protective loop-ileostomy. Conclusion Late closure (>150 days) of a loop-ileostomy is an independent risk factor in post-closure complications in a multivariate analysis. Nevertheless, circumstances of disease and therapy need to be considered when scheduling the closure procedure.
Collapse
|
17
|
Calvo Espino P, Sánchez Movilla A, Alonso Sebastian I, García Schiever J, Varillas Delgado D, Sánchez Turrión V, López Monclús J. Incidence and risk factors of delayed development for stoma site incisional hernia after ileostomy closure in patients undergoing colorectal surgery with temporary ileostomy. Acta Chir Belg 2022; 122:41-47. [PMID: 33176613 DOI: 10.1080/00015458.2020.1846941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Stoma site incisional hernias after ileostomy closure are complex hernias that can be associated with abdominal pain, discomfort, and a diminished quality of life. The aim of this study was to determine the incidence of incisional hernia (IH) following temporary ileostomy reversal in patients undergoing colorectal surgery, and the risk factors associated with its development. METHODS This was a prospective, single-centre, cohort study of patients undergoing ileostomy reversal between January 2010 and December 2016. Comorbidities, operative characteristics, comparison between early and late ileostomy closure and postoperative complications were analysed. RESULTS A total of 202 consecutive patients were prospectively evaluated (median follow-up 46 months; range: 12-109). Stoma site incisional hernia occurred in 23% of patients (n = 47), diagnosed by physical examination or imaging tests. The reasons for the primary surgery were colorectal cancer (n = 141, 69.8%), inflammatory bowel disease (n = 14, 6.9%), emergency surgery (n = 35, 17.3%), and other conditions (n = 12, 5.9%). Secondary outcomes: a statistically significant risk factors for developing an IH was obesity (higher BMI) (OR 1.15, 95% CI: 1.05-1.26) p = .003). CONCLUSIONS 23% of patients developed surgical site IH, a higher BMI being the only risk factor found to be statistically significant in the development of an incisional hernia.
Collapse
Affiliation(s)
| | | | | | | | | | - Víctor Sánchez Turrión
- Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
- Universidad Autonoma de Madrid, Madrid, Spain
| | | |
Collapse
|
18
|
Pandiaraja J, Chakkarapani R, Arumugam S. A study on patterns, indications, and complications of an enteric stoma. J Family Med Prim Care 2021; 10:3277-3282. [PMID: 34760744 PMCID: PMC8565109 DOI: 10.4103/jfmpc.jfmpc_123_21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 07/01/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Stoma could be a surgically created opening within the abdominal wall. The main purpose of the stoma is to divert the excreta off from the distal intestinal loops to relieve an obstruction or protect anastomosis. The indications for stoma creation are intestinal obstruction due to benign or malignant tumors, perforation peritonitis, inflammatory bowel disease, colorectal malignancies, and anorectal malformations. Aim of the study: The study aimed to identify the patterns, indications, and complications that occur following the creation of enteric stomas. Materials and Methods: It is a prospective observational study conducted from May 2012 to October 2015 on a hundred patients, who were admitted in the department of general surgery, surgical gastroenterology, and pediatric surgery, Government Stanley Medical College and Hospital. The sampling method followed here is the non-probability convenience sampling technique. The data is collected from all the patients who come under the inclusion criteria. Results: Of 100 patients, the majority of the patients belonged to 26–35 years and 46–55 years (n = 25). Based on the study, loop colostomy is more common with age less than one year and loop ileostomy is more common in 26–55 years. The foremost common indication of an enteric stoma is a gastrointestinal malignancy (25%) followed by abdominal trauma (22%). In our study, an ileostomy (80%) is the most common type of stoma created followed by colostomy. Within the ileostomy, loop ileostomy is the more common (60%) followed by end ileostomy (20%). Among the complications related to an enteric stoma, skin excoriation (54.4%) is most common followed by surgical site infections (8.5%). Conclusion: Our study shows stoma creation is higher in the adult and old age group, mostly done as an emergency procedure compared to an elective procedure. So, better preoperative planning in both emergency and elective settings can reduce the number of stoma and its related complications. The duration of hospital stay is higher in stoma patients. So, the reduction in stoma creation leads to a reduction in complication, duration of hospital stays and indirectly reduces expenditure related to it. In our study, most of the stoma is created for obstruction in malignancy and perforation in trauma patients. From our study, we can observe early diagnosis of intestinal malignancy with a well-planned elective procedure or bride procedure like colonic stenting in malignant obstruction can reduce the number of stoma creation. Skin excoriation is the most complication followed by surgical site infections. These complications can be reduced by better postoperative stoma care and early reversal of stoma.
Collapse
Affiliation(s)
- Jayabal Pandiaraja
- Department of General Surgery, Appasamy Hospital, Chennai, Tamilnadu, India
| | - Rajesh Chakkarapani
- Department of General Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Science and Research, Melmaruvathur, Tamilnadu, India
| | - Shalini Arumugam
- Department of Community Medicine, ACS Medical College and Hospital, Chennai, Tamilnadu, India
| |
Collapse
|
19
|
Layec S, Seynhaeve E, Dussaulx L, Carsin-Mahé M, Barbottin E, Trivin F, Picot D. Hydration by colonic enteroclysis: An alternative to parenteral hydration in patients with high-output double enterostomy. Nutr Clin Pract 2021; 37:625-633. [PMID: 34520595 DOI: 10.1002/ncp.10769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Sabrina Layec
- Réadaptation Digestive et Nutritionnelle, Clinique Saint Yves, Rennes, France
| | - Eloi Seynhaeve
- Réadaptation Digestive et Nutritionnelle, Clinique Saint Yves, Rennes, France
| | - Laurence Dussaulx
- Réadaptation Digestive et Nutritionnelle, Clinique Saint Yves, Rennes, France
| | - Marie Carsin-Mahé
- Réadaptation Digestive et Nutritionnelle, Clinique Saint Yves, Rennes, France
| | - Elise Barbottin
- Réadaptation Digestive et Nutritionnelle, Clinique Saint Yves, Rennes, France
| | - Florence Trivin
- Réadaptation Digestive et Nutritionnelle, Clinique Saint Yves, Rennes, France
| | - Denis Picot
- Réadaptation Digestive et Nutritionnelle, Clinique Saint Yves, Rennes, France
| |
Collapse
|
20
|
Guidolin K, Jung F, Spence R, Quereshy F, Chadi SA. Extended duration of faecal diversion is associated with increased ileus upon loop ileostomy reversal. Colorectal Dis 2021; 23:2146-2153. [PMID: 33999494 DOI: 10.1111/codi.15739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022]
Abstract
AIM The timing of ileostomy reversal has been the subject of controversy, with researchers investigating the safety of early versus late stoma closure. Anecdotally, a longer duration of faecal diversion is associated with a greater incidence of postoperative ileus. We sought to investigate the association between duration of diversion and postoperative ileus. METHOD We conducted an institutional retrospective cohort study on 173 patients undergoing ileostomy closure between 2012 and 2018. Our primary outcome was ileus; secondary outcomes included postoperative complications and descriptive factors. We investigated the association between duration of diversion and ileus using several analyses to ensure that time was treated appropriately as a continuous, nonlinear variable. RESULTS In all, 20.2% of patients had an ileus. Multivariate analysis did not identify a significant association between any independent predictors and ileus, although there was a trend towards increased risk of ileus with increasing duration of diversion. When treated as a categorical variable, a duration of diversion >328 days independently increased the odds of ileus (OR = 3.25, P = 0.033). Duration of diversion was associated with days to first flatus and to first diet (P = 0.025 and P = 0.004, respectively). When patients received nasogastric intubation, the mean duration of intubation was 3.2 days. CONCLUSION Greater duration of diversion was associated with a trend towards increased risk of ileus; this risk tripled when diversion lasted more than 328 days.
Collapse
Affiliation(s)
- Keegan Guidolin
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Flora Jung
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Richard Spence
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Fayez Quereshy
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Surgery, University Health Network, Toronto, ON, Canada
| | - Sami A Chadi
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Surgery, University Health Network, Toronto, ON, Canada
| |
Collapse
|
21
|
Clinical Outcomes of Ileostomy Closure before Adjuvant Chemotherapy after Rectal Cancer Surgery: An Observational Study from a Chinese Center. Gastroenterol Res Pract 2021; 2021:5592721. [PMID: 34335738 PMCID: PMC8294951 DOI: 10.1155/2021/5592721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background The optimal timing of temporary ileostomy closure with respect to the time of adjuvant chemotherapy following sphincter-saving surgery for rectal cancer remains unclear. The aim of this study is to investigate the clinical and oncological outcomes of ileostomy closure before, during, and after adjuvant chemotherapy following curative rectal cancer resection. Methods Patients diagnosed with rectal adenocarcinoma who underwent low anterior resection and temporary loop ileostomy during May 2015 and September 2019 were retrospectively evaluated. Patients undergoing ileostomy closure before adjuvant chemotherapy (Group I) were compared to patients undergoing closure during (Group II) and after (Group III) adjuvant chemotherapy. Results A total of 225 patients were evaluated for eligibility, and 132 were finally selected and divided into 3 groups (24 in Group I, 53 in Group II, and 55 in Group III). No significant differences were observed in operative time, postoperative hospital stay, postoperative complications, total adjuvant chemotherapy cycles, and low anterior resection syndrome scores among the three groups. There was no significant difference in disease-free survival (p = 0.834) and overall survival (p = 0.462) between the three groups. Conclusion Temporary ileostomy closure before adjuvant chemotherapy following curative rectal cancer resection can achieve a clinical and oncological safety level equal to stoma closure during or after chemotherapy in selected patients.
Collapse
|
22
|
Vogel I, Reeves N, Tanis PJ, Bemelman WA, Torkington J, Hompes R, Cornish JA. Impact of a defunctioning ileostomy and time to stoma closure on bowel function after low anterior resection for rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 2021; 25:751-760. [PMID: 33792822 PMCID: PMC8187190 DOI: 10.1007/s10151-021-02436-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/10/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Impaired bowel function after low anterior resection (LAR) for rectal cancer is a frequent problem with a major impact on quality of life. The aim of this study was to assess the impact of a defunctioning ileostomy, and time to ileostomy closure on bowel function after LAR for rectal cancer. METHODS We performed a systematic review based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Comprehensive literature searches were conducted using PubMed, Embase and Cochrane databases for articles published from 1989 up to August 2019. Analysis was performed using Review Manager (version 5.3) using a random-effects model. RESULTS The search yielded 11 studies (1400 patients) that reported on functional outcome after LAR with at least 1 year follow-up, except for one study. Five scales were used: the Low Anterior Resection Syndrome (LARS) score, the Wexner score, the Memorial Sloan Kettering Cancer Centre Bowel Function Instrument, the Fecal Incontinence Quality of Life scale, and the Hallbook questionnaire. Based on seven studies, major LARS occurred more often in the ileostomy group (OR 2.84, 95% CI, 1.70-4.75, p < 0.0001: I2 = 60%, X2 = 0.02). Based on six studies, a longer time to stoma closure increased the risk of major LARS with a mean difference in time to closure of 2.39 months (95% CI, 1.28-3.51, p < 0.0001: I2 = 21%, X2 = 0.28) in the major vs. no LARS group. Other scoring systems could not be pooled, but presence of an ileostomy predicted poorer bowel function except with the Hallbook questionnaire. CONCLUSIONS The risk of developing major LARS seems higher with a defunctioning ileostomy. A prolonged time to ileostomy closure seems to reinforce the negative effect on bowel function; therefore, early reversal should be an important part of the patient pathway.
Collapse
Affiliation(s)
- I Vogel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK.
| | - N Reeves
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J Torkington
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - R Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J A Cornish
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| |
Collapse
|
23
|
Chu L, Wang H, Qiu S, Shao B, Huang J, Qin Q, He Y, Xue J, Li X, Huang X, Huang R. Risk Factors of Delayed Recovery of Gastrointestinal Function After Ileostomy Reversal for Rectal Cancer Patients. Cancer Manag Res 2021; 13:5127-5133. [PMID: 34234556 PMCID: PMC8254522 DOI: 10.2147/cmar.s311715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The aim of this study was to identify the risk factors associated with delayed recovery of gastrointestinal function after ileostomy reversal for rectal cancer patients. METHODS In this retrospective study, the data of rectal cancer patients who underwent ileostomy reversal from January 2018 to December 2019 at the Sixth Affiliated Hospital of Sun Yat-sen University were assessed to investigate potential risk factors of delayed flatus after ileostomy reversal. RESULTS A total of 282 patients were eligible for this study. Postoperative first flatus time ranged from 1 to 9 days, of which 58.8% patients presented with delayed flatus that was longer than 3 days. Univariate analysis showed that delayed postoperative flatus was significantly associated with the length of postoperative hospital stay (P<0.001) and postoperative complications (P=0.037). Multivariate analysis showed that intravenous fluid infusion at postoperative day 1 (POD1) (OR=1.001, 95% CI: 1.001-1.002, P=0.001) and duration of stoma ≥6 months (OR=2.005, 95% CI:1.155-3.657, P=0.014) were independent risk factors for delayed flatus. CONCLUSION Increased intravenous fluid infusion at POD1 and duration of stoma ≥6 months were related to delayed recovery of gastrointestinal function after ileostomy reversal for rectal cancer patients.
Collapse
Affiliation(s)
- Lili Chu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Hui Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Suyu Qiu
- Department of General Surgery, Shunde New Rongqi Hospital, Foshan, Guangdong, 510655, People’s Republic of China
| | - Biyan Shao
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Jia Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Qiyuan Qin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Yanjiong He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Jing Xue
- Department of Pharmacy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Xiaoyan Li
- Department of Pharmacy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Xiaoyan Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Rongkang Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| |
Collapse
|
24
|
Agnes A, Puccioni C, D'Ugo D, Gasbarrini A, Biondi A, Persiani R. The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review. BMC Surg 2021; 21:83. [PMID: 33579260 PMCID: PMC7881582 DOI: 10.1186/s12893-021-01087-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery. METHODS We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics. RESULTS According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection. CONCLUSIONS The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.
Collapse
Affiliation(s)
- Annamaria Agnes
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Caterina Puccioni
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
| | - Domenico D'Ugo
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Alberto Biondi
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy.
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy.
| | - Roberto Persiani
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| |
Collapse
|
25
|
Taylor D, Besson A, Faragher IG, Chan STF, Yeung JM. Investigations and time trends in loop ileostomy reversals following anterior resections: a single Australian institution seven-years' experience. ANZ J Surg 2020; 91:938-942. [PMID: 33300280 DOI: 10.1111/ans.16483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/16/2020] [Accepted: 11/21/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Currently no consensus exists regarding what pre-reversal investigations are required to assess integrity of the rectal anastomosis. The objective of this study was to compare pre-reversal assessments of anastomotic integrity and to evaluate trends that might have influenced timings for reversal. METHODS From a prospectively maintained database, patients with colorectal cancer resections between March 2012 and October 2019 were identified. Patient characteristics, pre-reversal contrast enema and flexible sigmoidoscopy findings were recorded, and management of complications were recorded. Time-to-ileostomy reversal and time series for trends were analysed. RESULTS There were 154 patients included. Pre-reversal contrast enema or sigmoidoscopy detected a possible stricture or leak at the rectal anastomotic site in 11% (15/132) and 15% (18/112), respectively. When both modalities were used there was concordance of 86.1% and a positive likelihood ratio of 5.73. Of 125 (81.2%) ileostomies reversed, the median time-to-reversal was 11.99 months; time series analysis over the 7-year period showed no significant trend for average patient-days from booking to reversal (P = 0.60). Cox regression modelling did not identify any influential risk factors for the times taken to reversal. CONCLUSION This study supports the use of both contrast enema and flexible sigmoidoscopy in the assessment of rectal anastomosis integrity. Most patients with complications can have their ileostomies reversed. Patients who have adjuvant chemotherapy have a prolonged time to reversal.
Collapse
Affiliation(s)
- Danielle Taylor
- Department of Surgery, Western Health, Melbourne, Victoria, Australia
| | - Alex Besson
- Department of Surgery, Western Health, Melbourne, Victoria, Australia
| | - Ian G Faragher
- Department of Colorectal Surgery, Western Health, Melbourne, Victoria, Australia
| | - Steven T F Chan
- Department of Surgery, Western Health, Melbourne, Victoria, Australia.,Department of Surgery, Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia
| | - Justin M Yeung
- Department of Surgery, Western Health, Melbourne, Victoria, Australia.,Department of Colorectal Surgery, Western Health, Melbourne, Victoria, Australia.,Department of Surgery, Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia.,Western Health Chronic Disease Alliance, Western Health, Melbourne, Victoria, Australia
| |
Collapse
|
26
|
Guner OS, Tumay LV. Turnbull-Cutait technique without ileostomy after total mesorectal excision is associated with acceptably low early post-operative morbidity. ANZ J Surg 2020; 91:132-138. [PMID: 33124139 PMCID: PMC7984288 DOI: 10.1111/ans.16412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/30/2020] [Accepted: 10/04/2020] [Indexed: 11/29/2022]
Abstract
Background This study aimed to compare the standard one‐stage coloanal anastomosis (CAA) technique plus diverting ileostomy and the Turnbull–Cutait (T–C) technique with delayed CAA in terms of early post‐operative morbidity in patients with low rectal cancer. Methods A total of 33 patients with non‐metastatic distal rectal cancer who were operated with one of the two different reconstruction methods (one‐stage CAA plus diverting ileostomy or two‐stage T–C technique with delayed CAA) after total mesorectal excision were included in this retrospective study. The two groups were compared for early post‐operative morbidity within 30 post‐operative days using complication frequency, Clavien–Dindo classification and Comprehensive Complication Index scores. Results The two groups did not differ in terms of morbidity parameters, including frequency of any morbidity, presence of grade 3b morbidity requiring management under general anaesthesia, as well as Comprehensive Complication Index score (P > 0.05 for all). Conclusion Our findings suggest that the two techniques did not differ in terms of early post‐operative morbidity. Owing to its comparable morbidity and safety to CAA plus concomitant ileostomy performed at the same session, the T–C technique may be considered in distal rectal cancer patients refusing to have a temporary stoma and in patients in whom CAA poses technical difficulties during the initial operation.
Collapse
Affiliation(s)
- Osman Serhat Guner
- Department of Surgery, Acibadem Bodrum Hospital, Bodrum, Turkey.,Operating Room Services, Acibadem University, Vocational School of Health Sciences, Istanbul, Turkey
| | - Latif Volkan Tumay
- Operating Room Services, Acibadem University, Vocational School of Health Sciences, Istanbul, Turkey.,Department of Surgery, Acibadem Bursa Hospital, Bursa, Turkey
| |
Collapse
|
27
|
Coakley KM, Davis BR, Kasten KR. Complicated Diverticular Disease. Clin Colon Rectal Surg 2020; 34:96-103. [PMID: 33642949 DOI: 10.1055/s-0040-1716701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.
Collapse
Affiliation(s)
- Kathleen M Coakley
- Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Bradley R Davis
- Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Kevin R Kasten
- Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| |
Collapse
|
28
|
Low preoperative maximum squeezing pressure evaluated by anorectal manometry is a risk factor for non-reversal of diverting stoma. Langenbecks Arch Surg 2020; 406:131-139. [PMID: 33074347 DOI: 10.1007/s00423-020-02011-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE A diverting stoma is created to prevent anastomotic leakage and related complications impairing sphincteric function in rectal surgery. However, diverting stoma may be left unclosed. This study is aimed to analyze preoperative factors including anorectal manometric data associated with diverting stoma non-reversal before rectal surgery. We also addressed complications related to diverting stoma in patients undergoing surgery for rectal malignant tumor. METHODS A total of 203 patients with rectal malignant tumor who underwent sphincter-preserving surgery with diverting stoma were retrospectively evaluated. The risk factors for non-reversal of diverting stoma were identified by univariate and multivariate analyses. For these analyses, anorectal manometric data were measured before rectal surgery. The association between stoma-related complications and other clinicopathological features was also analyzed. RESULTS During the median follow-up of 46.4 months, 24% (49 patients) did not undergo stoma reversal. Among parameters that were available before rectal surgery, age ≥ 75 years, albumin < 3.5 g/dl, tumor size ≥ 30 mm, tumor distance from the anal verge < 4 cm, and maximum squeezing pressure (MSP) < 130 mmHg measured by anorectal manometry (ARM) were independent factors associated with stoma non-reversal. The most common stoma-related complication was peristomal skin irritation (25%). Ileostomy was the only factor associated with peristomal skin irritation. CONCLUSION The current study demonstrated that low preoperative MSP evaluated by ARM, old age, hypoalbuminemia, and a large tumor close to the anus were predictive of diverting stoma non-reversal. Stoma site should be well deliberated when patients have the aforementioned risk factors for diverting stoma non-reversal.
Collapse
|
29
|
Sun G, Lou Z, Zhang H, Yu GY, Zheng K, Gao XH, Meng RG, Gong HF, Furnée EJB, Bai CG, Zhang W. Retrospective study of the functional and oncological outcomes of conformal sphincter preservation operation in the treatment of very low rectal cancer. Tech Coloproctol 2020; 24:1025-1034. [PMID: 32361871 PMCID: PMC7522072 DOI: 10.1007/s10151-020-02229-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 04/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Conformal sphincter preservation operation (CSPO) is a new surgical procedure for very low rectal cancers (within 4-5 cm from the anal verge). CSPO preserves more of the dentate line and distal rectal wall and also avoids injuring nerves in the intersphincteric space, resulting in satisfactory anal function after resection. The aim of this study was to analyze the short-term surgical results and long-term oncological and functional outcomes of CSPO. METHODS Consecutive patients with very low rectal cancer, who had CSPO between January 2011 and October 2018 at Changhai Hospital, Shanghai were included. Patient demographics, clinicopathological features, oncological outcomes and anal function were analyzed. RESULTS A total of 102 patients (67 men) with a mean age of 56.9 ± 10.8 years were included. The median distance of the tumor from the anal verge was 3 (IQR, 3-4) cm. Thirty-five patients received neoadjuvant chemoradiation (nCRT). The median distal resection margin (DRM) was 0.5 (IQR, 0.3-0.8) cm. One patient had a positive DRM. All circumferential margins were negative. There was no perioperative mortality. The postoperative complication rate was 19.6%. The median duration of follow-up was 28 (IQR, 12-45.5) months. The local recurrence rate was 2% and distant metastasis rate was 10.8%. The 3-year overall survival and disease-free survival rates were 100% and 83.9%, respectively. The mean Wexner incontinence and low anterior resection syndrome scores 12 months after ileostomy reversal were 5.9 ± 4.3, and 29.2 ± 6.9, respectively. CONCLUSIONS For patients with very low rectal cancers, fecal continence can be preserved with CSPO without compromising oncological results.
Collapse
Affiliation(s)
- G Sun
- Department of Colorectal Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Z Lou
- Department of Colorectal Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China
| | - H Zhang
- Department of Colorectal Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China
| | - G Y Yu
- Department of Colorectal Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China
| | - K Zheng
- Department of Colorectal Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China
| | - X H Gao
- Department of Colorectal Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China
| | - R G Meng
- Department of Colorectal Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China
| | - H F Gong
- Department of Colorectal Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China
| | - E J B Furnée
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - C G Bai
- Department of Pathology, Changhai Hospital, Shanghai, China
| | - W Zhang
- Department of Colorectal Surgery, Changhai Hospital, 168 Changhai Rd, Shanghai, 200433, China.
| |
Collapse
|
30
|
Zhuang CL, Zhang FM, Wang Z, Jiang X, Wang F, Liu ZC. Precision functional sphincter-preserving surgery (PPS) for ultralow rectal cancer: a natural orifice specimen extraction (NOSE) surgery technique. Surg Endosc 2020; 35:476-485. [PMID: 32989539 DOI: 10.1007/s00464-020-07989-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients with ultralow rectal cancer, surgical resection of the tumor without impairing sphincter function remains a technical challenge. The purpose of this study was to describe a new technique of transanal natural orifice specimen extraction (NOSE) surgery using our independently developed devices, aiming to achieve precise cancer resection and preserve sphincter function in patients with ultralow rectal cancer. METHODS Precision functional sphincter-preserving surgery (PPS) was performed on nineteen patients with ultralow rectal cancer between June 2019 and April 2020. With the help of our independently developed devices, surgeons directly and accurately removed the lower edge of the tumor and retained healthy rectal tissue on the nontumorous side. Hand-sewn anastomosis with a mattress suture was used to achieve sturdy anastomosis. Preoperative baseline characteristics, operative details, 90-day postoperative complications, costs, and anal function score at 6 months after surgery were documented. RESULTS Nineteen ultralow rectal cancer patients with a median distance to the dentate line of 2.0 cm successfully underwent PPS without serious postoperative complications. Six out of nineteen patients (31.6%) received a prophylactic stoma. The average cost was 62164.1 yuan. At 6 months after surgery, the average Wexner anal function score and the average Vaizey score were both 3 points. CONCLUSIONS PPS can be employed to precisely resect rectal tumors and preserve sphincter function in ultralow rectal cancer patients. The use of our devices enhanced surgical efficiency, reduced the need for prophylactic stoma, reduced surgery-related costs, and prevented abdominal surgical incisions.
Collapse
Affiliation(s)
- Cheng-Le Zhuang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Feng-Min Zhang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Zheng Wang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Xun Jiang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Feng Wang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Zhong-Chen Liu
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China.
| |
Collapse
|
31
|
A Systematic Review of Early versus Late Closure of Loop Ileostomy. Surg Res Pract 2020; 2020:9876527. [PMID: 32953972 PMCID: PMC7481925 DOI: 10.1155/2020/9876527] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 07/30/2020] [Accepted: 08/12/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction A Loop ileostomy is one of the most common techniques used in colorectal surgery to establish a reversible faecal diversion and bypass the large bowels, in order to protect either a downstream colorectal anastomosis or a coloanal anastomosis. However, it is a procedure that can cause a plethora of complications including long term ones such as the psychological effects. Currently, there is no consensus regarding the optimal time to perform closure of a loop ileostomy. Some studies suggested the early reversal of ileostomy procedure as a solution to reduce these complications. This study aims to review the available literature in order to ascertain the benefits behind early closure of loop ileostomy. Methods The literature was searched for all studies that included a comparison between the outcomes of early and late closure of loop ileostomy in terms of morbidity, mortality, or quality of life, where available. Early closure of loop ileostomy is defined as closure less than three months and late as more than three months, in accordance with conventional literature. The resultant articles were filtered using our inclusion and exclusion criteria. Finally, the remaining articles were assessed for quality and their results were compared to one another in order to draw our conclusions. Results and Discussion. The results were slightly inclined toward early closure of loop ileostomy. However, there were limitations of the studies reviewed, including the heterogenicity of studies, selection bias, lack of clear definition of measured outcomes, and small sample size. Taking that into consideration, the results of early closure of loop ileostomies in the selected patients were promising and require further investigation.
Collapse
|
32
|
Munshi E, Bengtsson E, Blomberg K, Syk I, Buchwald P. Interventions to reduce dehydration related to defunctioning loop ileostomy after low anterior resection in rectal cancer: a prospective cohort study. ANZ J Surg 2020; 90:1627-1631. [PMID: 32840053 DOI: 10.1111/ans.16258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/25/2020] [Accepted: 08/04/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Defunctioning loop ileostomy (DLI) in low anterior resection (LAR) in rectal cancer patients reduces the morbidity of anastomotic leakages. In our previous study, 30% of patients developed dehydration due to DLI, mostly during the first 6 weeks. This interventional study aimed to reduce these figures by establishing a surveillance programme. METHODS An interventional study of rectal cancer patients undergoing LAR and DLI between 2013 and 2015 was carried out. A historical study group was used as control. Stoma care nurses educated the intervention group about high-output stoma. Blood tests, including creatinine and electrolytes, were taken every second week until 8 weeks post-operatively and an additional control in case of subjective high-output stoma. RESULTS Eighty-seven patients underwent LAR and DLI during the study period. Twenty-one (24%) developed dehydration episodes, and nine (43%) of them required readmission. There was no difference compared to the control group, where 29% developed dehydration, and about half (52%) needed readmission (P = 0.62 and P = 0.57, respectively). However, when explicitly examining patients demonstrating symptomatic dehydration, there was a significant difference, that is 10 (11%) versus 27 (29%) (P < 0.005). Overall, the dehydrated group was older and more likely to take diuretics compared to the non-dehydrated group. CONCLUSION Our results indicate that reducing dehydration episodes and readmission after DLI is a challenging process. The proposed surveillance was only effective in preventing symptomatic dehydration. Subjects taking diuretics and the elderly are at risk of dehydration and should be followed cautiously.
Collapse
Affiliation(s)
- Eihab Munshi
- Colorectal Unit, Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Surgery, University of Jeddah, Jeddah, Saudi Arabia
| | - Eva Bengtsson
- Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | - Karin Blomberg
- Colorectal Unit, Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Ingvar Syk
- Colorectal Unit, Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Pamela Buchwald
- Colorectal Unit, Department of Surgery, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
33
|
Assessment of the risk of permanent stoma after low anterior resection in rectal cancer patients. World J Surg Oncol 2020; 18:207. [PMID: 32795302 PMCID: PMC7427951 DOI: 10.1186/s12957-020-01979-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/30/2020] [Indexed: 12/21/2022] Open
Abstract
Background One of the most severe complications of low anterior rectal resection is anastomotic leakage (AL). The creation of a loop ileostomy (LI) reduces the prevalence of AL requiring surgical intervention. However, up to one-third of temporary stomas may never be closed. The first aim of the study was to perform a retrospective assessment of the impact of LI on the risk of permanent stoma (PS) and symptomatic AL. The second aim of the study was to assess preoperative PS risk factors in patients with LI. Methods A total of 286 consecutive patients who underwent low anterior rectal resection were subjected to retrospective analysis. In 101 (35.3%) patients, diverting LI was performed due to low anastomosis, while in the remaining 185 (64.7%) patients, no ileostomy was performed. LIs were reversed after adjuvant treatment. Analyses of the effect of LI on symptomatic AL and PS were performed. Among the potential risk factors for PS, clinical factors and the values of selected peripheral blood parameters were analysed. Results PS occurred in 37.6% and 21.1% of the patients with LI and without LI, respectively (p < 0.01). Symptomatic ALs were significantly more common in patients without LI. In this group, symptomatic ALs occurred in 23.8% of patients, while in the LI group, they occurred in 5% of patients (p < 0.001). In the LI group, the only significant risk factor for PS in the multivariate analysis was preoperative plasma fibrinogen concentration (OR = 1.007, 97.5% CI 1.002–1.013, p = 0.013). Conclusions Although protective LI may reduce the incidence of symptomatic AL, it can be related to a higher risk of PS in this group of patients. The preoperative plasma fibrinogen concentration can be a risk factor for PS in LI patients and may be a useful variable in decision-making models.
Collapse
|
34
|
Abstract
BACKGROUND Operative approaches for Hinchey III diverticulitis include the Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage. Several randomized controlled trials and meta-analyses have compared these approaches; however, results are conflicting and previous studies have not captured the complexity of balancing surgical risks and quality of life. OBJECTIVE This study aimed to determine the optimal operative strategy for patients with Hinchey III sigmoid diverticulitis. DESIGN We developed a Markov cohort model, incorporating perioperative morbidity/mortality, emergency and elective reoperations, and quality-of-life weights. We derived model parameters from systematic reviews and meta-analyses, where possible. We performed a second-order Monte Carlo probabilistic sensitivity analysis to account for joint uncertainty in model parameters. SETTING This study measured outcomes over patients' lifetime horizon. PATIENTS The base case was a simulated cohort of 65-year-old patients with Hinchey III diverticulitis. A scenario simulating a cohort of highly comorbid 80-year-old patients was also planned. INTERVENTIONS Hartmann procedure, primary resection and anastomosis (with or without diverting ileostomy), and laparoscopic lavage were performed. MAIN OUTCOME MEASURES Quality-adjusted life years were the primary outcome measured. RESULTS Following surgery for Hinchey III diverticulitis, 39.5% of patients who underwent the Hartmann procedure, 14.3% of patients who underwent laparoscopic lavage, and 16.7% of patients who underwent primary resection and anastomosis had a stoma at 12 months. After applying quality-of-life weights, primary resection and anastomosis was the optimal operative strategy, yielding 18.0 quality-adjusted life years; laparoscopic lavage and the Hartmann procedure yielded 9.6 and 13.7 fewer quality-adjusted life months. A scenario analysis for elderly, highly comorbid patients could not be performed because of a lack of high-quality evidence to inform model parameters. LIMITATIONS This model required assumptions about the long-term postoperative course of patients who underwent laparoscopic lavage because few long-term data for this group have been published. CONCLUSIONS Although the Hartmann procedure is widely used for Hinchey III diverticulitis, when considering both surgical risks and quality of life, both laparoscopic lavage and primary resection and anastomosis provide greater quality-adjusted life years for patients with Hinchey III diverticulitis, and primary resection and anastomosis appears to be the optimal approach. See Video Abstract at http://links.lww.com/DCR/B223. ESTRATEGIA OPERATIVA ÓPTIMA EN DIVERTICULITIS HINCHEY III DE SIGMOIDES: UN ANÁLISIS DE DECISION: Los enfoques quirúrgicos para la diverticulitis Hinchey III incluyen el procedimiento de Hartmann, la resección primaria y anastomosis, y el lavado laparoscópico. Varios ensayos controlados aleatorios y metanálisis han comparado estos enfoques; sin embargo, los resultados son contradictorios y los estudios previos no han captado la complejidad de equilibrar los riesgos quirúrgicos y la calidad de vida.Determinar la estrategia operativa óptima para pacientes con diverticulitis Hinchey III de sigmoides.Desarrollamos un modelo de cohorte de Markov, incorporando morbilidad / mortalidad perioperatoria, reoperaciones electivas y de emergencia, y pesos de calidad de vida. Derivamos los parámetros del modelo de revisiones sistemáticas y metaanálisis, cuando fue posible. Realizamos un análisis de sensibilidad probabilístico Monte Carlo de segundo orden para tener en cuenta la incertidumbre conjunta en los parámetros del modelo.Seguimiento de por vida.El caso base fue una cohorte simulada de pacientes de 65 años con diverticulitis de Hinchey III. También se planeó un escenario que simulaba una cohorte de pacientes de 80 años altamente comórbidos.Procedimiento de Hartmann, resección primaria y anastomosis (con o sin desviación de ileostomía) y lavado laparoscópico.Años de vida ajustados por calidad.Después de la cirugía para la diverticulitis de Hinchey III, el 39.5% de los pacientes que se sometieron al procedimiento de Hartmann, el 14.3% de los pacientes que se sometieron a un lavado laparoscópico, y el 16.7% de los pacientes que se sometieron a resección primaria y anastomosis tuvieron un estoma a los 12 meses. Después de aplicar el peso de la calidad de vida, la resección primaria y la anastomosis fueron la estrategia operativa óptima, que dio como resultado 18.0 años de vida ajustados en función de la calidad; el lavado laparoscópico y el procedimiento de Hartmann arrojaron 9.6 y 13.7 meses de vida ajustados en función de la calidad, respectivamente. No se pudo realizar un análisis de escenarios para pacientes de edad avanzada altamente comórbidos debido a la falta de evidencia de alta calidad para informar los parámetros del modelo.Este modelo requirió suposiciones sobre el curso postoperatorio a largo plazo de pacientes que se sometieron a lavado laparoscópico, ya que se han publicado pocos datos a largo plazo para este grupo.Aunque el procedimiento de Hartmann se usa ampliamente para la diverticulitis de Hinchey III, cuando se consideran tanto los riesgos quirúrgicos como la calidad de vida, tanto el lavado laparoscópico como la resección primaria y la anastomosis proporcionan una mayor calidad de años de vida ajustada para los pacientes con diverticulitis de Hinchey III y la resección primaria y anastomosis parece ser el enfoque óptimo. Consulte Video Resumen en http://links.lww.com/DCR/B223.
Collapse
|
35
|
Diverting Ileostomy Duration Is the Main Determinant of Ileostomy-Related Complications after Surgical Treatment of Rectum Cancer. JOURNAL OF ONCOLOGY 2020; 2020:4186857. [PMID: 32322269 PMCID: PMC7166299 DOI: 10.1155/2020/4186857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/16/2020] [Indexed: 01/02/2023]
Abstract
Background This study aimed to investigate factors associated with the development of ileostomy complications in rectal cancer patients, including those who received neoadjuvant treatment. Methods This retrospective trial included 133 consecutive patients who underwent surgery for rectal cancer with temporary diverting ileostomy. Patients' demographic characteristics as well as the pre- and postclosure outcomes and complications were analyzed. Results In logistic regression analysis, longer duration of ileostomy emerged as a significant independent predictor of any complication during ileostomy. The respective odds ratios for 3–6 months and >6 months vs. <3 months of ileostomy duration were as follows: OR, 4.5 (95% CI, 1.2–16.7), p=0.023; and OR, 15.2 (95% CI, 3.1–75.2), p=0.001. An additional stepwise model also identified hypertension as a significant predictor. In stepwise logistic regression model, adjuvant chemoradiotherapy emerged as significant independent predictor of “any ileostomy-related complication after ileostomy closure”: OR, 4.5 (2.0–10.2), p < 0.001. Conclusion Duration of ileostomy appears to be the main determinant of ileostomy-related complications. Patients who had received neoadjuvant or adjuvant therapy had longer ileostomy duration, which may be attributed to the concerns of the surgeon or to the complications themselves.
Collapse
|
36
|
Schwandner F, Klimars U, Gock M, Schiffmann L, Witte M, Schiergens T, Rentsch M, Klar E, Kühn F. The Water-Holding Procedure for Ensuring Postoperative Continence Prior Restoring Intestinal Continuity. J Gastrointest Surg 2020; 24:411-417. [PMID: 30825120 DOI: 10.1007/s11605-019-04171-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/13/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND A defunctioning stoma can become necessary in a relevant number of patients undergoing gastrointestinal surgery. As a matter of course, patients seek an early closure of the stoma. However, preoperative management of these patients varies and the prediction of continence after stoma removal can become challenging. Patients might be fully continent despite low manometric pressures and vice versa. An easy and reliable way to predict continence after stoma reversal would improve patients' management and outcome. Although frequently performed in various surgical centers in Germany, there is no published data on the water-holding test. Hence, this is the first study evaluating the role of the test in clinical practice. METHOD We performed a prospective pilot study to evaluate the role of anorectal manometry and the water-holding procedure as a predictor of postoperative continence prior to stoma reversal. Inclusion criteria were a successfully passed water-holding test, any type of fecal diversion and the possibility of restoring intestinal continuity. Preoperative low manometric pressure levels were not an exclusion criteria for stoma reversal. Fifty-two patients with ostomy were consecutively enrolled in this study between October 2013 and February 2016. Anorectal manometry was performed in all patients prior to stoma reversal. After stoma removal, patients were followed-up for 6 months. Postoperative incontinence was determined using the Wexner incontinence score. RESULTS A total of 52 patients (38 males, 14 females) were included at an average age of 59 (range 33-83) years. Most frequent indications for intestinal diversion were rectal cancer surgery, IBD-related surgery, or surgery for diverticular disease. Low anterior rectal resection was performed in 17 patients (32.7%), followed by a proctocolectomy in 9 (17.3%), colectomy in 9 (17.3%), and recto-sigmoid resection in 7 patients (13.5%). Median time from stoma creation to reversal was 206 days (range 48-871 days). All patients had successfully passed the standardized water-holding test. At the same time, the majority of patients had low preoperative manometric pressure values and would normally not have been reversed at that point. The median postoperative Wexner incontinence score was at 1.5 (range 0-20), 0.5 (range 0-14), and 0 (range 0-11) at 14, 60, and 180 days after stoma reversal. Low preoperative manometric squeeze and/or resting pressure levels were not associated with a higher postoperative incontinence score at 14, 60, or 180 days after stoma reversal. CONCLUSION A standardized water-holding test can function as an easy and reliable method before stoma reversal to predict sufficient postoperative fecal continence. In case of a sufficient water-holding test despite low manometric pressure levels, the risk for postoperative anal incontinence seems to be low. Preoperative manometric pressure levels do not appear to predict postoperative continence.
Collapse
Affiliation(s)
- Frank Schwandner
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Ulrich Klimars
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Leif Schiffmann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Maria Witte
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Tobias Schiergens
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| |
Collapse
|
37
|
Resio BJ, Jean R, Chiu AS, Pei KY. Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis. JAMA Surg 2019; 154:218-224. [PMID: 30476948 DOI: 10.1001/jamasurg.2018.4359] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown. Objective To investigate the association of the timing of colostomy reversal with operative outcomes. Design, Setting, and Participants This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018. Exposures Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing. Main Outcomes and Measures Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age. Results In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups. Conclusions and Relevance Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.
Collapse
Affiliation(s)
- Benjamin J Resio
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Raymond Jean
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Y Pei
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
38
|
Ambe PC, Kurz NR, Nitschke C, Odeh SF, Möslein G, Zirngibl H. Intestinal Ostomy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:182-187. [PMID: 29607805 DOI: 10.3238/arztebl.2018.0182] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 07/25/2017] [Accepted: 11/16/2017] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Peter C Ambe
- Department of; Visceral, Minimally Invasive, and Oncological Surgery, Marien Hospital Düsseldorf; Department of General and Visceral Surgery, Chair of Surgery II, Helios University Hospital Wuppertal, University of Witten/Herdecke Helios University Hospital Wuppertal, University of Witten/Herdecke; Center for Hereditary Gastrointestinal Tumors, Chair of Surgery II, Helios; University Hospital Wuppertal, University of Witten/Herdecke
| | | | | | | | | | | |
Collapse
|
39
|
Gröne J. Zeitpunkt und Technik der Stomarückverlagerung unter Berücksichtigung früher und später Stomakomplikationen. COLOPROCTOLOGY 2019. [DOI: 10.1007/s00053-019-00401-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
40
|
Garfinkle R, Filion KB, Bhatnagar S, Sigler G, Banks A, Letarte F, Liberman S, Brown CJ, Boutros M. Prediction model and web-based risk calculator for postoperative ileus after loop ileostomy closure. Br J Surg 2019; 106:1676-1684. [DOI: 10.1002/bjs.11235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/13/2019] [Accepted: 04/16/2019] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Postoperative ileus (POI) is a significant complication after loop ileostomy closure given both its frequency and impact on the patient. The purpose of this study was to develop and externally validate a prediction model for POI after loop ileostomy closure.
Methods
The model was developed and validated according to the TRIPOD checklist for prediction model development and validation. The development cohort included consecutive patients who underwent loop ileostomy closure in two teaching hospitals in Montreal, Canada. Candidate variables considered for inclusion in the model were chosen a priori based on subject knowledge. The final prediction model, which modelled the 30-day cumulative incidence of POI using logistic regression, was selected using the highest area under the receiver operating characteristic curve (AUC) criterion. Model calibration was assessed using the Hosmer–Lemeshow goodness-of-fit test. The model was then validated externally in an independent cohort of similar patients from the University of British Columbia.
Results
The development cohort included 531 patients, in whom the incidence of POI was 16·8 per cent. The final model included five variables: age, ASA fitness grade, underlying pathology/treatment, interval between ileostomy creation and closure, and duration of surgery for ileostomy closure (AUC 0·68, 95 per cent c.i. 0·61 to 0·74). The model demonstrated good calibration (P = 0·142). The validation cohort consisted of 216 patients, and the incidence of POI was 15·7 per cent. On external validation, the model maintained good discrimination (AUC 0·72, 0·63 to 0·81) and calibration (P = 0·538).
Conclusion
A prediction model was developed for POI after loop ileostomy closure and included five variables. The model maintained good performance on external validation.
Collapse
Affiliation(s)
- R Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - K B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, Montreal, Quebec, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - S Bhatnagar
- Department of Epidemiology, Biostatistics and Occupational Health, Montreal, Quebec, Canada
| | - G Sigler
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - A Banks
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - F Letarte
- Division of General Surgery, Department of Surgery, University Hospital of Quebec, Quebec City, Quebec, Canada
- Division of General Surgery, Department of Surgery, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - S Liberman
- Division of General Surgery, Department of Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - C J Brown
- Division of General Surgery, Department of Surgery, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - M Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| |
Collapse
|
41
|
van den Hil LCL, van Steensel S, Schreinemacher MHF, Bouvy ND. Prophylactic mesh placement to avoid incisional hernias after stoma reversal: a systematic review and meta-analysis. Hernia 2019; 23:733-741. [PMID: 31302788 PMCID: PMC6661031 DOI: 10.1007/s10029-019-01996-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/20/2019] [Indexed: 12/13/2022]
Abstract
Purpose To provide an overview of the available literature on prevention of incisional hernias after stoma reversal, with the use of prophylactic meshes. Methods A literature search of Pubmed, MEDLINE and EMBASE was performed. Search terms for stoma, enterostomy, mesh, prophylaxis and hernia were used. Search was updated to December 31th 2018. No time limitations were used, while English, Geman, Dutch and French were used as language restrictions. The primary outcome was the incidence of incisional hernia formation after stoma reversal. Secondary outcomes were mesh-related complications. Data on study design, sample size, patient characteristics, stoma and mesh characteristics, duration of follow-up and outcomes were extracted from the included articles. Results A number of 241 articles were identified and three studies with 536 patients were included. A prophylactic mesh was placed in 168 patients to prevent incisional hernias after stoma reversal. Follow-up ranged from 10 to 21 months. The risk of incisional hernia in case of prophylactic mesh placement was significantly lower in comparison to no mesh placement (OR 0.10, 95% CI 0.04–0.27, p < 0.001, I2 = 0%, CI 0–91.40%). No differences in surgical site infections were detected between the groups. Conclusions The use of a prophylactic mesh seems to reduce the risk on incisional hernias after stoma reversal and therefore mesh reinforcement should be considered after stoma reversal. Electronic supplementary material The online version of this article (10.1007/s10029-019-01996-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- L C L van den Hil
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands.
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands.
- Department of General Surgery, Maastricht University Medical Centre, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - S van Steensel
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
| | - M H F Schreinemacher
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
| | - N D Bouvy
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
| |
Collapse
|
42
|
Outcomes following small bowel obstruction due to malignancy in the national audit of small bowel obstruction. Eur J Surg Oncol 2019; 45:2319-2324. [PMID: 31378418 DOI: 10.1016/j.ejso.2019.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Patients with cancer who develop small bowel obstruction are at high risk of malnutrition and morbidity following compromise of gastrointestinal tract continuity. This study aimed to characterise current management and outcomes following malignant small bowel obstruction. METHODS A prospective, multicentre cohort study of patients with small bowel obstruction who presented to UK hospitals between 16th January and 13th March 2017. Patients who presented with small bowel obstruction due to primary tumours of the intestine (excluding left-sided colonic tumours) or disseminated intra-abdominal malignancy were included. Outcomes included 30-day mortality and in-hospital complications. Cox-proportional hazards models were used to generate adjusted effects estimates, which are presented as hazard ratios (HR) alongside the corresponding 95% confidence interval (95% CI). The threshold for statistical significance was set at the level of P ≤ 0.05 a-priori. RESULTS 205 patients with malignant small bowel obstruction presented to emergency surgery services during the study period. Of these patients, 50 had obstruction due to right sided colon cancer, 143 due to disseminated intraabdominal malignancy, 10 had primary tumours of the small bowel and 2 patients had gastrointestinal stromal tumours. In total 100 out of 205 patients underwent a surgical intervention for obstruction. 30-day in-hospital mortality rate was 11.3% for those with primary tumours and 19.6% for those with disseminated malignancy. Severe risk of malnutrition was an independent predictor for poor mortality in this cohort (adjusted HR 16.18, 95% CI 1.86 to 140.84, p = 0.012). Patients with right-sided colon cancer had high rates of morbidity. CONCLUSIONS Mortality rates were high in patients with disseminated malignancy and in those with right sided colon cancer. Further research should identify optimal management strategy to reduce morbidity for these patient groups.
Collapse
|
43
|
Long distance to hospital is not a risk factor for non-reversal of a defunctioning stoma. Int J Colorectal Dis 2019; 34:993-1000. [PMID: 30747282 DOI: 10.1007/s00384-019-03258-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE To see if road distance to hospital influences stoma reversal rate, time from index operation to stoma reversal, and occurrence of permanent stoma. METHODS Data from all diagnosed cases of rectal cancer from three counties in northern Sweden were extracted from the Swedish Rectal Cancer Registry. The three counties are sparsely populated, with a population density roughly one fifth the average density in Sweden. Distances to nearest, operating, and largest hospital were obtained using Google Maps™. Matched data on socioeconomic variables were retrieved from Statistics Sweden. RESULTS In univariate logistic regression analysis, patients living closer to the operating hospital had a higher likelihood of non-reversal than those living farther away (OR 0.3; 95% CI 0.12-0.76). However, no difference was seen in the multivariate analysis. Of the 717 cases included, 54% received a permanent stoma and 38% a defunctioning stoma at index surgery. The reversal rate of a defunctioning stoma was 83%. At follow-up, 61% still had a stoma, 89% of these were permanent, and 11% non-reversed defunctioning stomas. Median time to stoma reversal was 287 days (82-1557 days). Of all 227 stoma reversals, 77% were done more than 6 months after index surgery. CONCLUSIONS Longer distance to hospital is not a risk factor for non-reversal of a defunctioning stoma. Only 23% had their defunctioning stoma reversed within 6 months after index surgery. Future studies aiming to determine reversal rate need to extend their follow-up time in order to receive accurate results.
Collapse
|
44
|
Bausys A, Kuliavas J, Dulskas A, Kryzauskas M, Pauza K, Kilius A, Rudinskaite G, Sangaila E, Bausys R, Stratilatovas E. Early versus standard closure of temporary ileostomy in patients with rectal cancer: A randomized controlled trial. J Surg Oncol 2019; 120:294-299. [PMID: 31042015 DOI: 10.1002/jso.25488] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/04/2019] [Accepted: 04/18/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES A significant proportion of patients undergoing rectal cancer surgery receive a temporary ileostomy because of its benefits in case of anastomotic dehiscence. However, the best timing for closure remains unclear. METHODS Early closure (EC; 30 days after creation) and standard closure (SC; 90 days after creation) of ileostomy were compared in a single-center randomized controlled trial conducted at National Cancer Institute (Vilnius, Lithuania). Patients with a temporary ileostomy who underwent rectal cancer surgery and did not have anastomotic leakage or other serious complications were randomized to early or standard ileostomy closure groups. Thirty days postoperative morbidity following ileostomy closure was the primary outcome of the study. RESULTS The trial was prematurely terminated due to the safety reason after 86 patients were randomized to EC (43 patients) and SC (43 patients) groups. The overall 30 days postoperative morbidity rate was dramatically higher in the EC group (27.9% vs 7.9%; P = 0.024). Moreover, severe complications (Clavien-Dindo ≥3) were present only after EC of ileostomy in five (11.6%) patients. CONCULSION Early closure of ileostomy at 30 days after radical rectal resection is not safe and should not be performed.
Collapse
Affiliation(s)
- Augustinas Bausys
- Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania.,Clinic of Gastroenterology, nephrourology, and surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Justas Kuliavas
- Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Audrius Dulskas
- Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania.,Clinic of Gastroenterology, nephrourology, and surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Faculty of Health Care, University of Applied Sciences, Vilnius, Lithuania
| | - Marius Kryzauskas
- Clinic of Gastroenterology, nephrourology, and surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kastytis Pauza
- Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Alfredas Kilius
- Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Giedre Rudinskaite
- Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Egidijus Sangaila
- Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Rimantas Bausys
- Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania.,Clinic of Gastroenterology, nephrourology, and surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Eugenijus Stratilatovas
- Department of Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania.,Clinic of Gastroenterology, nephrourology, and surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| |
Collapse
|
45
|
Nair A, Amula VE, Naik V, Kodisharapu PK, Poornachand A, Shyam Prasad MS, Saifuddin MS, Rayani BK. Comparison of Postoperative Analgesia in Patients Undergoing Ileostomy Closure with and Without Dual Transversus Abdominis Plane (TAP) Block: A Randomized Controlled Trial. Rambam Maimonides Med J 2019; 10:RMMJ.10356. [PMID: 30304665 PMCID: PMC6363374 DOI: 10.5041/rmmj.10356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND AIMS Multimodal analgesia comprising opioid, paracetamol, and non-steroidal anti-inflammatory drugs is used for managing postoperative surgical pain after ileostomy closure (IC). We investigated the efficacy of unilateral dual transversus abdominis plane (TAP) block to reduce morphine consumption in the first 24 hours along with a reduction in visual analogue score for pain and in postoperative nausea/vomiting. METHODS This was a single-center, investigator-initiated, prospective, parallel-group, placebo-controlled randomized study involving patients undergoing IC under general anesthesia. We recruited 55 patients in two groups: 28 in a TAP group and 27 in a placebo group. The TAP group patients received 30 mL of 0.375% bupivacaine: 15 mL by a posterior TAP approach and 15 mL by a subcostal approach using ultrasonography. Patients in the placebo group received 30 mL normal saline (placebo) using the same approaches. Blocks were administered at the end of surgery before extubation. To monitor for the primary outcome-24-hour morphine consumption for both groups-patients were transferred to a high-dependency unit. The secondary outcome was to compare postoperative nausea/vomiting in both groups. RESULTS The demographic data, gender distribution, ASA physical status, duration of surgery, and time of first morphine dose was comparable in both groups. The 24-hour morphine consumption was 3.29±2.78 mg and 9.23±2.94 mg for the TAP and placebo groups, respectively, which was statistically significant (P=0.001). CONCLUSION Dual TAP block reduces opioid consumption in the first 24 hours after an IC and can facilitate early recovery with less adverse effects seen than with opioids and NSAIDs.
Collapse
Affiliation(s)
- Abhijit Nair
- To whom correspondence should be addressed. E-mail:
| | | | | | | | | | | | | | | |
Collapse
|
46
|
|
47
|
Emmanuel A, Chohda E, Lapa C, Miles A, Haji A, Ellul J. Defunctioning Stomas Result in Significantly More Short-Term Complications Following Low Anterior Resection for Rectal Cancer. World J Surg 2018; 42:3755-3764. [PMID: 29777268 PMCID: PMC6182750 DOI: 10.1007/s00268-018-4672-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Studies suggest that defunctioning stomas reduce the rate of anastomotic leakage and urgent reoperations after anterior resection. Although the magnitude of benefit appears to be limited, there has been a trend in recent years towards routinely creating defunctioning stomas. However, little is known about post-operative complication rates in patients with and without a defunctioning stoma. We compared overall short-term post-operative complications after low anterior resection in patients managed with a defunctioning stoma to those managed without a stoma. METHODS A retrospective cohort study of patients undergoing elective low anterior resection of the rectum for rectal cancer. The primary outcome was overall 90-day post-operative complications. RESULTS Two hundred and three patients met the inclusion criteria for low anterior resection. One hundred and forty (69%) had a primary defunctioning stoma created. 45% received neoadjuvant radiotherapy. Patients with a defunctioning stoma had significantly more complications (57.1 vs 34.9%, p = 0.003), were more likely to suffer multiple complications (17.9 vs 3.2%, p < 0.004) and had longer hospital stays (13.0 vs 6.9 days, p = 0.005) than those without a stoma. 19% experienced a stoma-related complication, 56% still had a stoma 1 year after their surgery, and 26% were left with a stoma at their last follow-up. Anastomotic leak rates were similar but there was a significantly higher reoperation rate among patients managed without a defunctioning stoma. CONCLUSION Patients selected to have a defunctioning stoma had an absolute increase of 22% in overall post-operative complications compared to those managed without a stoma. These findings support the more selective use of defunctioning stomas. STUDY REGISTRATION Registered at www.researchregistry.com (UIN: researchregistry3412).
Collapse
Affiliation(s)
- Andrew Emmanuel
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Ezzat Chohda
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Christo Lapa
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Andrew Miles
- Department of Colorectal Surgery, Hampshire Hospitals NHS Foundation Trust, Wessex, UK
| | - Amyn Haji
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Joe Ellul
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
48
|
Early ileostomy reversal after minimally invasive surgery and ERAS program for mid and low rectal cancer. Updates Surg 2018; 71:485-492. [PMID: 30288693 DOI: 10.1007/s13304-018-0597-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/29/2018] [Indexed: 01/26/2023]
Abstract
Diverting loop ileostomy following low anterior resection (LAR) is known to decrease quality of life and prolongs the return back to patients' baseline activity. The aim of this retrospective study was to explore feasibility and safety of an early ileostomy reversal strategy in a cohort of patients undergoing minimally invasive LAR within an enhanced recovery after surgery (ERAS) program. Prospectively collected data from 15 patients who underwent minimally invasive LAR and diverting ileostomy at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust between September 2015 and December 2016 were retrospectively analyzed. Of 15 patients, 10 patients underwent laparoscopic LAR and 5 patients a robot-assisted procedure. Post-operative complications were observed in 5 patients. Four patients suffered Clavien-Dindo grade 1 or 2 complications, and one patient required redo surgery due to bowel obstruction at the ileostomy site (grade 3b). Following ileostomy reversal, 10 out of 15 patients experienced complications. Two patients required redo surgery for bowel obstruction (grade 3b), whilst eight patients suffered grade 1 or 2 complications, being surgical site infection the most frequently observed (6 cases). Despite that, 80% of patients had their ileostomy reversed within 30 days and median time from initial surgery to ileostomy reversal was 22 days (range 10-150). Early ileostomy closure after minimally invasive LAR and ERAS program is feasible although it carries non-negligible risk of severe complications which, however, does not hinder its accomplishment.
Collapse
|
49
|
Fonseca AZ, Uramoto E, Santos-Rosa OM, Santin S, Ribeiro M. COLOSTOMY CLOSURE: RISK FACTORS FOR COMPLICATIONS. ACTA ACUST UNITED AC 2018; 30:231-234. [PMID: 29340543 PMCID: PMC5793137 DOI: 10.1590/0102-6720201700040001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 08/22/2017] [Indexed: 12/15/2022]
Abstract
Background : The restoration of intestinal continuity is an elective procedure that is not free of complications; on the contrary, many studies have proven a high level of morbidity and mortality. It is multifactorial, and has factors inherent to the patients and to the surgical technique. Aim : To identify epidemiological features of patients that underwent ostomy closure analyzing the information about the surgical procedure and its arising complications. Method : It was realized a retrospective analysis of medical records of patients who underwent ostomy closure over a period of seven years (2009-2015). Results : A total of 39 patients were included, 53.8% male and 46.2% female, with mean age of 52.4 years. Hartmann´s procedure and ileostomy were the mainly reasons for restoration of intestinal continuity, representing together 87%. Termino-terminal anastomosis was performed in 71.8% of cases, by using mainly the manual technique. 25.6% developed complications, highlighting anastomotic leakage; there were three deaths (7.6%). The surgical time, the necessity of ICU and blood transfusion significantly related to post-operative complications. Conclusion : It was found that the majority of the patients were male, with an average age of 52 years. It was observed that the surgical time, the necessity of blood transfusion and ICU were factors significantly associated with complications.
Collapse
Affiliation(s)
| | - Edson Uramoto
- Department of Surgery, University of Santo Amaro, São Paulo, SP, Brazil
| | | | - Stephanie Santin
- Department of Surgery, University of Santo Amaro, São Paulo, SP, Brazil
| | - Marcelo Ribeiro
- Department of Surgery, University of Santo Amaro, São Paulo, SP, Brazil
| |
Collapse
|
50
|
Bujko K, Glynne-Jones R, Papamichael D, Rutten HJT. Optimal management of localized rectal cancer in older patients. J Geriatr Oncol 2018; 9:696-704. [PMID: 30150020 DOI: 10.1016/j.jgo.2018.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/19/2018] [Accepted: 08/01/2018] [Indexed: 12/13/2022]
Abstract
In advising the optimal management for older patients, health care professionals try to balance the risks from frailty, vulnerability, and comorbidity against the patient's ultimate prognosis, potential functional outcomes and quality of life (QOL). At the same time it is important to involve the patient and incorporate their preferences. But how can we present and balance the potential downside of radical radiotherapy and risks of unsalvageable recurrence against the potential risks of postoperative morbidity and mortality associated with radical surgery? There are currently no nationally approved and evidence-based guidelines available to ensure consistency in discussions with older adults or frail and vulnerable patients. In this overview we hope to provide an insightful discussion of the relevant issues and options currently available.
Collapse
Affiliation(s)
- Krzysztof Bujko
- Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - Rob Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood HA6 2RN, United Kingdom.
| | | | - Harm J T Rutten
- Catharina Hospital Cancer Center Eindhoven, GROW Scholl of oncology and developmental Biology, University of Maastricht, the Netherlands
| |
Collapse
|