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Yi X, Yang H, Li H, Feng X, Liao W, Lin J, Chen Z, Diao D, Ouyang M. Analysis of decision-making factors for defunctioning ileostomy after rectal cancer surgery and their impact on perioperative recovery: a retrospective study of 1082 patients. Surg Endosc 2024:10.1007/s00464-024-11149-3. [PMID: 39160312 DOI: 10.1007/s00464-024-11149-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 08/04/2024] [Indexed: 08/21/2024]
Abstract
OBJECTIVE To explore the decision-making factors for defunctioning ileostomy (DI) after rectal cancer surgery and to analyze the impact of the DI on perioperative outcomes. METHODS A retrospective case-control study was conducted that included rectal cancer patients who underwent low anterior resection from January 2013 to December 2023. Among them, 33 patients did not undergo DI but with anastomotic leakage (AL) after surgery, and 1030 patients were without AL. Preoperative, operative and tumor factors between these two groups were compared to explore the decision-making factors for DI. Meanwhile, the differences of perioperative outcomes between the DI group of 381 cases and non-DI group of 701 cases were compared. RESULTS For preoperative factors, the proportions of male patients and preoperative chemoradiotherapy (CRT) in the AL with non-DI group were greater than those in the non-AL group (p < 0.05); for operative factors, the proportion of patients in the AL with non-DI group with a surgical time > 180 min were greater (p < 0.05); for tumor factors, the proportion of T3-4 stage was higher in the AL with non-DI group (p < 0.05). Multiple regression analysis revealed that male sex and preoperative CRT were the independent risk factors affecting DI. For perioperative outcomes, the DI did not reduce the incidence of all and symptomatic AL and non-AL postoperative complications (p > 0.05) but with 12.07% stoma-related complications, and increase hospitalization costs (p < 0.05); however, it can shorten the postoperative hospital stay, pelvic drainage tube removal time, and reduce the anal tube placement rate and readmission rate (all p < 0.05). CONCLUSION Male patients and preoperative CRT were the independent risk factors affect the decision of DI in our study, and DI can shorten the postoperative hospitalization, pelvic drainage tube removal time, and decrease the anal tube placement rate and readmission rate during the perioperative period but with a higher economic cost.
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Affiliation(s)
- Xiaojiang Yi
- Department of Gastrointestinal Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Shunde, Foshan, 528300, Guangdong, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510080, Guangdong, China
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Huaguo Yang
- First Department of General Surgery, Luzhou Hospital of Traditional Chinese Medicine, Luzhou, 646000, Sichuan, China
| | - Hongming Li
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Xiaochuang Feng
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Weilin Liao
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Jiaxin Lin
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Zhifeng Chen
- Department of Hepatobiliary Gastrointestinal Thyroid Surgery, Meizhou Hospital of Traditional Chinese Medicine, Meizhou, 514000, Guangdong, China
| | - Dechang Diao
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China.
| | - Manzhao Ouyang
- Department of Gastrointestinal Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Shunde, Foshan, 528300, Guangdong, China.
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510080, Guangdong, China.
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Mukai T, Matsui S, Sakurai T, Yamaguchi T, Akiyoshi T, Fukunaga Y. Short-term outcomes of the "minimal skin incision and no stoma" procedure in needlescopic intersphincteric resection and delayed coloanal anastomosis for low rectal cancer. Tech Coloproctol 2024; 28:110. [PMID: 39150556 DOI: 10.1007/s10151-024-02979-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/12/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Needlescopic surgery is a minimally invasive procedure that uses thin trocars with 3-mm diameter. We used Turnbull-Cutait pull-through and delayed coloanal anastomosis in needlescopic surgery to avoid diverting ileostomy during intersphincteric resection for low rectal cancer. In this study, we aim to assess the diverting ileostomy avoidance rate and technical safety of this "minimal skin incision and no stoma" procedure. METHODS This single-center retrospective study was conducted at the Cancer Institute Hospital, a tertiary referral center in Japan. Between January 2017 and December 2020, 11 patients underwent needlescopic intersphincteric resection with diverting ileostomy (NSI group), and 19 patients underwent needlescopic intersphincteric resection with delayed coloanal anastomosis (NSD group) for low rectal cancer. Data regarding patient backgrounds and short-term outcomes, including diverting ileostomy avoidance rate, pathological results, and postoperative defecatory function, were compared between the groups. RESULTS There were no statistically significant differences between the NSI and NSD groups with respect to patient background, operation time (239 min versus 220 min, p = 0.68), estimated blood loss (45 g versus 25 g, p = 0.29), R0 resection rate (100% versus 100%, p = 1.00), and length of postoperative hospital stay (16 days versus 17 days, p = 0.42). The diverting ileostomy avoidance rate was 94.4% in the NSD group. The LARS and Wexner scores 12 months after surgery were not significantly different between the two groups. CONCLUSIONS Needlescopic intersphincteric resection and delayed coloanal anastomosis can be safely performed in selected patients with a high rate of diverting ileostomy avoidance and comparable short-term outcomes.
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Affiliation(s)
- T Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan.
| | - S Matsui
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - T Sakurai
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - T Yamaguchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - T Akiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - Y Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
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Cheng Y, Tian Z, Gao S, Zhao S, Li R, Zhou J, Sun Q, Wang D. A nomogram of anastomotic stricture after rectal cancer: a retrospective cohort analysis. Surg Endosc 2024; 38:3661-3671. [PMID: 38777891 DOI: 10.1007/s00464-024-10885-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Anastomotic stricture significantly impacts patients' quality of life and long-term prognosis. However, current clinical practice lacks accurate tools for predicting anastomotic stricture. This study aimed to develop a nomogram to predict anastomotic stricture in patients with rectal cancer who have undergone anterior resection. METHODS A total of 1542 eligible patients were recruited for the study. Least absolute shrinkage selection operator (Lasso) analysis was used to preliminarily select predictors. A prediction model was constructed using multivariate logistic regression and presented as a nomogram. The performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration diagrams, and decision curve analysis (DCA). Internal validation was conducted by assessing the model's performance on a validation cohort. RESULTS 72 (4.7%) patients were diagnosed with anastomotic stricture. Participants were randomly divided into training (n = 1079) and validation (n = 463) sets. Predictors included in this nomogram were radiotherapy, diverting stoma, anastomotic leakage, and anastomotic distance. The area under the ROC curve (AUC) for the training set was 0.889 [95% confidence interval (CI) 0.840-0.937] and for the validation set, it was 0.930 (95%CI 0.879-0.981). The calibration curve demonstrated a strong correlation between predicted and observed outcomes. DCA results showed that the nomogram had clinical value in predicting anastomotic stricture in patients after anterior resection of rectal cancer. CONCLUSION We developed a predictive model for anastomotic stricture following anterior resection of rectal cancer. This nomogram could assist clinicians in predicting the risk of anastomotic stricture, thus improving patients' quality of life and long-term prognosis.
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Affiliation(s)
- Yifan Cheng
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Zhen Tian
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Shuyang Gao
- Northern Jiangsu People's Hospital Affiliated to Dalian Medical University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Shuai Zhao
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Ruiqi Li
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Jiajie Zhou
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Qiannan Sun
- Northern Jiangsu People's Hospital, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Daorong Wang
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China.
- Northern Jiangsu People's Hospital, Yangzhou, 225001, China.
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China.
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China.
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China.
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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.
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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
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Okui J, Shigeta K, Kato Y, Mizuno S, Sugiura K, Seo Y, Nakadai J, Baba H, Kikuchi H, Hirata A, Makino A, Kondo T, Matsui S, Seishima R, Okabayashi K, Obara H, Sato Y, Kitagawa Y. Delayed-Onset Organ/Space Surgical Site Infection Worsens Prognosis in High-Risk Stage II and III Colorectal Cancer. J Gastrointest Surg 2023; 27:2515-2525. [PMID: 37740145 DOI: 10.1007/s11605-023-05836-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/31/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND It is unclear how early- and delayed-onset organ/space surgical site infections (SSIs) affect the long-term prognosis of patients with colorectal cancer, who are potential candidates for adjuvant chemotherapy. This study aimed to investigate the association between the timing of SSI onset and clinical outcome. METHODS This retrospective, multicenter cohort study evaluated patients who were diagnosed with high-risk stage II or III colorectal cancer and underwent elective surgery between 2010 and 2020. Five-year recurrence-free survival (RFS) was the primary endpoint and was compared between early SSI, delayed SSI (divided based on the median date of SSI onset), and non-SSI groups. RESULTS A total of 2,065 patients were included. Organ/space SSI was diagnosed in 91 patients (4.4%), with a median onset of 6 days after surgery. The early-onset SSI group had a higher proportion of patients with Clavien-Dindo grade ≥IIIb SSI than the delayed-onset SSI. Patients who received adjuvant chemotherapy (AC) had earlier organ/space SSI onset than those who did not. The adjusted hazard ratio of 5-year RFS in the delayed-onset SSI was 2.58 (95% confidence interval: 1.43-4.65; p = 0.002): higher than that in the early-onset SSI, with the non-SSI as the reference. CONCLUSIONS Delayed-onset organ/space SSI worsened long-term prognosis compared to early-onset, and this may be due to delayed initiation of AC. Patients who are clinically suspected of having lymph node metastasis might need additional intervention to prevent delays in commencing AC due to the delayed SSI.
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Affiliation(s)
- Jun Okui
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Kohei Shigeta
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Yujin Kato
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shodai Mizuno
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kiyoaki Sugiura
- Department of Surgery, Japan Red Cross Ashikaga Hospital, Tochigi, Japan
| | - Yuki Seo
- Department of Surgery, Japan Red Cross Ashikaga Hospital, Tochigi, Japan
| | - Jumpei Nakadai
- Department of Gastrointestinal Surgery, Saitama City Hospital, Saitama, Japan
| | - Hideo Baba
- Department of Gastrointestinal Surgery, Saitama City Hospital, Saitama, Japan
| | - Hiroto Kikuchi
- Department of Surgery, Hiratsuka City Hospital, Hiratsuka, Kanagawa, Japan
| | - Akira Hirata
- Department of Surgery, Hiratsuka City Hospital, Hiratsuka, Kanagawa, Japan
| | - Akitsugu Makino
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Takayuki Kondo
- Department of Surgery, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan
| | - Shimpei Matsui
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Seishima
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Koji Okabayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Schreiber ME, Schneider MA, Murray FR, Turina M, Gubler C. Routine Endoscopy Prior to Surgical Ostomy Closure: An Obsolete Concept. Dig Dis Sci 2023; 68:4130-4139. [PMID: 37707748 PMCID: PMC10570172 DOI: 10.1007/s10620-023-08088-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/20/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Closure of temporary diverting ostomies is commonly preceded by an endoscopic study of the colonic mucosa and anastomosis, despite lacking evidence of its relevance and impact on subsequent operative management. AIM We sought to determine the incidence of pathological findings and therefore evaluate the clinical benefit of routine pre-operative endoscopy in asymptomatic patients, hypothesizing sole evaluation of the anastomotic integrity to be sufficient in these cases. METHODS We retrospectively identified all adult patients with ostomy installations who were followed up for potential reversal surgery between 2002 and 2020 at the University Hospital of Zurich, Switzerland. Main outcome measures were the incidence of endoscopically identified pathological findings in the asymptomatic case cohort and their impact on the subsequent course of treatment. RESULTS Pre-procedural endoscopic data of 187 cases evaluated for ostomy closure were evaluated. Relevant mucosal findings in the asymptomatic cohort were documented in 26.3% and findings at the anastomotic site detected in 8.7%. A change in subsequent surgical management was noted in 10 patients of the entire cohort (5.3%) and in 9 (5.1%) of all asymptomatic cases. Upon multivariate analyses, the age range of 51 to 60 years old was found to be significantly linked to the presence of endoscopic findings entailing a change in patient management. CONCLUSION Our findings strongly suggest ostomy closure surgery without previous assessment of the bowel mucosa by means of endoscopy to be acceptable in asymptomatic patients. However, we found it to be indicated in all patients meeting the screening criteria for colorectal carcinoma.
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Affiliation(s)
- Maxine E. Schreiber
- Department of Gastroenterology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Marcel A. Schneider
- Department of Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Fritz R. Murray
- Department of Gastroenterology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Department of Gastroenterology, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zurich, Switzerland
| | - Matthias Turina
- Department of Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Christoph Gubler
- Department of Gastroenterology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Department of Gastroenterology, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zurich, Switzerland
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Wang H, Wang X, Wang P, Lv K, He H, Yuan W, Fu M, Chen J, Yang H. Defunctioning stoma and anastomotic stricture in rectal cancer surgery: a propensity score matching study. Langenbecks Arch Surg 2023; 408:384. [PMID: 37770772 DOI: 10.1007/s00423-023-03118-6] [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: 06/28/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND In cases of rectal cancer surgery, patients at high risk of anastomotic leakage often receive a defunctioning stoma (DS). However, its role in postoperative anastomotic strictures (AS) remains unclear. This study aimed to investigate the correlation between DS and AS and outcomes of transanal endoscopic microsurgery (TEM) in treating rectal AS. METHODS This retrospective study was conducted from January 2019 to September 2021 and included patients who underwent rectal cancer surgery. A 1:1 ratio was used for propensity score matching (PSM). Univariate analyses were performed to identify statistically significant variables, and multivariate analyses were conducted to determine the factors affecting AS. RESULTS This study included 383 patients. The results of the univariate analysis suggested that surgery time (HR 4.597, 95% CI 1.563-13.525, P=0.006), postoperative anastomotic leakage (HR 11.830, 95% CI 3.773-37.094, P<0.001), and DS (HR 15.475, 95% CI 6.042-39.641, P<0.001) were significantly associated with AS. In the multivariate analysis, postoperative anastomotic leakage (HR 7.596, 95% CI 1.987-29.044, P= 0.003) and DS (HR 11.252, 95% CI 4.113-30.779, P<0.001) were identified as significant risk factors for AS. After matching, the univariate analysis revealed that postoperative anastomotic leakage (HR 8.333, 95% CI 1.541-45.052, P= 0.014) and DS (HR 9.965, 95% CI 2.200-45.142, P= 0.003) were associated with AS. The multivariate analysis indicated that postoperative anastomotic leakage (HR 14.549, 95% CI 1.765-119.913, P= 0.013) and DS (HR 12.450, 95% CI 2.418-64.108, P= 0.003) were significant risk factors for AS. CONCLUSIONS This study provides evidence that DS is independently associated with AS, and postoperative anastomotic leakage increases the risk of AS. Furthermore, this study suggests that TEM could be a valuable treatment option for AS.
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Affiliation(s)
- Haoran Wang
- Department of General Surgery, School of Clinical Medicine, Weifang Medical University, Weifang, 261053, Shandong, China
| | - Xiao Wang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Key Laboratory of Metabolism and Gastrointestinal Tumor, Key Laboratory of Laparoscopic Technology, Shandong Medicine and Health Key Laboratory of General Surgery, No.16766 Jingshi Road, Jinan, 250000, Shandong, China
| | - Peng Wang
- The Fifth People's Hospital of Jinan, Jinan, 250117, China
| | - Kai Lv
- Department of General Surgery, School of Clinical Medicine, Weifang Medical University, Weifang, 261053, Shandong, China
| | - Haoqing He
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Key Laboratory of Metabolism and Gastrointestinal Tumor, Key Laboratory of Laparoscopic Technology, Shandong Medicine and Health Key Laboratory of General Surgery, No.16766 Jingshi Road, Jinan, 250000, Shandong, China
| | - Wenguang Yuan
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Key Laboratory of Metabolism and Gastrointestinal Tumor, Key Laboratory of Laparoscopic Technology, Shandong Medicine and Health Key Laboratory of General Surgery, No.16766 Jingshi Road, Jinan, 250000, Shandong, China
| | - Mofan Fu
- Department of General Surgery, School of Clinical Medicine, Weifang Medical University, Weifang, 261053, Shandong, China
| | - Jingbo Chen
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Key Laboratory of Metabolism and Gastrointestinal Tumor, Key Laboratory of Laparoscopic Technology, Shandong Medicine and Health Key Laboratory of General Surgery, No.16766 Jingshi Road, Jinan, 250000, Shandong, China.
| | - Hui Yang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Key Laboratory of Metabolism and Gastrointestinal Tumor, Key Laboratory of Laparoscopic Technology, Shandong Medicine and Health Key Laboratory of General Surgery, No.16766 Jingshi Road, Jinan, 250000, Shandong, China.
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8
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Wang YJ, Lin KH, Kang JC, Hu JM, Chen CY, Pu TW. Benefits of laparoscopy-assisted ileostomy in colorectal cancer patients with bowel obstruction. World J Clin Cases 2023; 11:5660-5665. [PMID: 37727726 PMCID: PMC10505990 DOI: 10.12998/wjcc.v11.i24.5660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Ileostomies are commonly performed after colon and rectal surgeries. Laparoscopy-assisted ileostomy with adhesion lysis may have potential benefits over conventional open surgery. AIM To compare the outcomes of laparoscopy-assisted and conventional ileostomies. METHODS Data from 48 consecutive patients who underwent ileostomy at our institution between May 2021 and May 2022 were retrospectively analyzed. The groups comprised 26 and 22 patients who underwent laparoscopic ileostomy (laparoscopic group) and conventional ileostomy (conventional group), respectively, performed by a single surgeon. Patient demographics, operative characteristics, postoperative outcomes, and 30-d morbidities and mortality rates were analyzed. RESULTS The two groups had comparable mean ages, sex distributions, American Society of Anesthesiologists scores, and body mass indices. However, the laparoscopic group showed similar operative time, better visualization for adhesion lysis, and lower visual analog scale scores than the conventional group. CONCLUSION Laparoscopy-assisted ileostomy is a safe and efficient method that produces lower visual analog scale scores, better intraoperative visualization for effective adhesion lysis, and similar operative time compared with conventional ileostomy.
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Affiliation(s)
- Yi-Jie Wang
- Department of Surgery, Tri Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Kuan-Hsun Lin
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Jung-Cheng Kang
- Division of Colon and Rectal Surgery, Department of Surgery, Taiwan Adventist Hospital, Taipei 105, Taiwan
| | - Je-Ming Hu
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Chao-Yang Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Ta-Wei Pu
- Division of Colon and Rectal Surgery, Department of Surgery, Songshan branch, Tri-Service General Hospital, National Defense Medical Center, Taipei 105, Taiwan
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Xu J, Yang Y, Hu D. Predictors of cognitive impairment in patients undergoing ileostomy for colorectal cancer: a retrospective analysis. PeerJ 2023; 11:e15405. [PMID: 37304889 PMCID: PMC10249619 DOI: 10.7717/peerj.15405] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/21/2023] [Indexed: 06/13/2023] Open
Abstract
Background Early detection of cognitive impairment in patients undergoing ileostomy for colorectal cancer may help improve patient outcomes and quality of life. Identifying risk factors and clinically accessible factors is crucial for prevention and treatment. Objective This retrospective study aimed to identify risk factors for post-operative cognitive impairment in patients undergoing ileostomy for colorectal cancer and to explore potential factors for its prevention and treatment. Methods A total of 108 cases were selected and included in the study. Patient data including general characteristics, disease stage, complications, and chemotherapy status were collected, and sleep quality and cognitive function were assessed using questionnaires and follow-up. Patients were randomly divided into training and validation groups. A random forest model was used to rank clinical features based on their contribution to predicting the prognosis of cancer-related cognitive impairment (CRCI). Nomograms were constructed using the support vector machine-recursive feature elimination (SVM-RFE) method, and the minimal root-mean-square error (RMSE) values were compared to select the best model. Regression analysis was performed to determine independent predictors. Results Significant differences were observed in age, body mass index (BMI), alcohol consumption, frequency of physical activity, comorbidity, and cancer-related anemia (CRA) between the CRCI and non-CRCI groups. Random forest analysis revealed that age, BMI, exercise intensity, PSQI scores, and history of hypertension were the most significant predictors of outcome. Univariate logistic regression analysis of 18 variables revealed that age, alcohol consumption, exercise intensity, BMI, and comorbidity were significantly associated with the outcome of CRCI (p < 0.05). Univariate and multivariate models with P-values less than 0.1 and 0.2, respectively, showed better predictive performance for CRCI. The results of univariate analysis were plotted on a nomogram to evaluate the risk of developing CRCI after colorectal cancer surgery. The nomogram was found to have good predictive performance. Finally, regression analysis revealed that age, exercise intensity, BMI, comorbidity, and CRA were independent predictors of CRCI. Conclusions This retrospective cohort study revealed that age, exercise intensity, BMI, comorbidity, CRA, and mobility are independent predictors of cognitive impairment in patients undergoing ileostomy for colorectal cancer. Identifying these factors and potential factors may have clinical implications in predicting and managing post-operative cognitive impairment in this patient population.
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Affiliation(s)
- Jing Xu
- Department of Gastroenterology, Changxing People’s Hospital, Changxing, China
| | - Yuelan Yang
- Department of Rehabilitation Medicine, Changxing People’s Hospital, Changxing, China
| | - Die Hu
- Department of Ultrasound Medicine, Changxing People’s Hospital, Changxing, China
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10
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Dreifuss NH, Casas MA, Angeramo CA, Schlottmann F, Laxague F, Bun ME, Rotholtz NA. Sigmoid resection and primary anastomosis for perforated diverticulitis with peritonitis: To divert or not to divert-A systematic review and meta-analysis. Surgery 2023:S0039-6060(23)00241-6. [PMID: 37258308 DOI: 10.1016/j.surg.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/19/2023] [Accepted: 04/27/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND The role of proximal diversion in patients undergoing sigmoid resection and primary anastomosis for diverticulitis with generalized peritonitis is unclear. The aim of this study was to compare the clinical outcomes of sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with a proximal diversion in perforated diverticulitis with diffuse peritonitis. METHOD A systematic literature search on sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with proximal diversion for diverticulitis with diffuse peritonitis was conducted in the Medline and EMBASE databases. Randomized clinical trials and observational studies reporting the primary outcome of interest (30-day mortality) were included. Secondary outcomes were major morbidity, anastomotic leak, reoperation, stoma nonreversal rates, and length of hospital stay. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes. RESULTS A total of 17 studies involving 544 patients (sigmoid resection and primary anastomosis: 287 versus sigmoid resection and primary anastomosis with proximal diversion: 257) were included. Thirty-day mortality (odds ratio 1.12, 95% confidence interval 0.53-2.40, P = .76), major morbidity (odds ratio 1.40, 95% confidence interval 0.80-2.44, P = .24), anastomotic leak (odds ratio 0.34, 95% confidence interval 0.099-1.20, P = .10), reoperation (odds ratio 0.49, 95% confidence interval 0.17-1.46, P = .20), and length of stay (sigmoid resection and primary anastomosis: 12.1 vs resection and primary anastomosis with diverting ileostomy: 15 days, P = .44) were similar between groups. The risk of definitive stoma was significantly lower after sigmoid resection and primary anastomosis (odds ratio 0.05, 95% confidence interval 0.006-0.35, P = .003). CONCLUSION Sigmoid resection and primary anastomosis with or without proximal diversion have similar postoperative outcomes in selected patients with diverticulitis and diffuse peritonitis. However, further randomized controlled trials are needed to confirm these results.
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Affiliation(s)
- Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Maria A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Cristian A Angeramo
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Francisco Laxague
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Maximiliano E Bun
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
| | - Nicolás A Rotholtz
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina; Colorectal Surgery Division, Department of Surgery, Hospital Alemán of Buenos Aires, Argentina.
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Howie EE, Dharanikota H, Gunn E, Ambler O, Dias R, Wigmore SJ, Skipworth RJE, Yule S. Cognitive Load Management: An Invaluable Tool for Safe and Effective Surgical Training. JOURNAL OF SURGICAL EDUCATION 2023; 80:311-322. [PMID: 36669990 DOI: 10.1016/j.jsurg.2022.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
This article highlights the importance of considering Cognitive Load (CL) and Cognitive Load Theory (CLT) during surgical training, focusing on the acquisition of intra-operative skills. It describes the basis of CLT with the overarching aim of describing CLT-based techniques to enhance current training strategies and surgical performance, many of which are instinctively already employed in surgical practice. Currently, methods of feedback and assessment are imperfect - typically subjective, unsystematic, opportunistic, or retrospective, and at risk of human bias. Surgical Sabermetrics, the advanced analytics of surgical and audio-visual data, aims to enhance this feedback by providing objective, real-time, digital-based feedback. This article introduces the benefit of real-time measurement of CL to enhance feedback and its applications to surgical performance that follow the ethos of Surgical Sabermetrics.1 The 2022 theme for ICOSET was "Making it Better." Cognitive Load and Surgical Sabermetrics principles provide tools to make Surgical training better, with the goal of higher quality care for patients.
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Affiliation(s)
- Emma E Howie
- Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom.
| | | | - Eilidh Gunn
- Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom; Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - Olivia Ambler
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom; Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Roger Dias
- STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Stephen J Wigmore
- Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom; Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - Richard J E Skipworth
- Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom; Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - Steven Yule
- Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom; Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom; STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, Massachusetts
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12
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Pencovich N, Silverman JS, Horesh N, Nevo N, Eshkenazy R, Kent I, Ram E, Nachmany I. Readmission with acute kidney injury following ileostomy: patterns and predictors of a common phenomenon. Langenbecks Arch Surg 2023; 408:96. [PMID: 36805819 DOI: 10.1007/s00423-023-02842-3] [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: 05/13/2022] [Accepted: 02/13/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE Ileostomy is associated with various complications, often necessitating rehospitalization. High-output ileostomy is common and may lead to acute kidney injury (AKI). Here we describe the temporal pattern of readmission with AKI following ileostomy formation and identify risk factors. METHODS Patients that underwent formation of ileostomy between 2008 and 2021 were included in this study. Readmission with AKI with high output ileostomy was defined as readmission with serum creatinine > 1.5-fold compared to the level at discharge or latest baseline (at least stage-1 AKI according to Kidney Disease: Improving Global Outcome (KDIGO) criteria), accompanied by ileostomy output > 1000 ml in 24 h. Patient characteristics and perioperative course were assessed to identify predictors for readmission with AKI. RESULTS Of 1191 patients who underwent ileostomy, 198 (16.6%) were readmitted with a high output stoma and AKI. The mean time to readmission with AKI was 98.97 ± 156.36 days. Eighty-six patients (43.4%) had early readmission (within 30 days), and 66 (33%) were readmitted after more than 90 days. Over 90% of patients had more than one readmission, and 110 patients (55%) had 5 or more. Patient-related predictors for readmission with AKI were age > 65, body mass index > 30 kg/m2, and hypertension. Factors related to the postoperative course were AKI with creatinine > 2 mg/dl, postoperative hemoglobin < 8 g/dl or blood transfusion, albumin < 20 g/dl, high output stoma and need for loperamide, and length of hospital stay > 20 days. Factors related to early versus late readmissions and multiple readmissions were also analyzed. CONCLUSIONS Readmission with AKI following ileostomy formation is a consequential event with distinct risk factors. Acknowledging these risk factors is the foundation for designing interventions aiming to reduce frequency of AKI readmissions in predisposed patient populations.
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Affiliation(s)
- Niv Pencovich
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel.
| | - Jacob Samuel Silverman
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Nir Horesh
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Nadav Nevo
- Department of General Surgery, Faculty of Health Sciences, Assuta Medical Center, Ashdod, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Rony Eshkenazy
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Ilan Kent
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Edward Ram
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
| | - Ido Nachmany
- Department of General Surgery and Transplantation, Faculty of Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Tel-Aviv, Israel
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13
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Shao S, Zhao Y, Lu Q, Liu L, Mu L, Qin J. Artificial intelligence assists surgeons' decision-making of temporary ileostomy in patients with rectal cancer who have received anterior resection. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:433-439. [PMID: 36244844 DOI: 10.1016/j.ejso.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/27/2022] [Accepted: 09/28/2022] [Indexed: 10/07/2022]
Abstract
BACKGROUND Due to the difficult evaluation of the risk of anastomotic leakage (AL) after rectal cancer resection, the decision to perform a temporary ileostomy is not easily distinguishable. The aim of the present study was to develop an artificial intelligence (AI) model for identifying the risk of AL to assist surgeons in the selective implementation of a temporary ileostomy. MATERIALS AND METHODS The data from 2240 patients with rectal cancer who received anterior resection were collected, and these patients were divided into one training and two test cohorts. Five AI algorithms, such as support vector machine (SVM), logistic regression (LR), Naive Bayes (NB), stochastic gradient descent (SGD) and random forest (RF) were employed to develop predictive models using clinical variables and were assessed using the two test cohorts. RESULTS The SVM model indicated good discernment of AL, and might have increased the implementation of temporary ileostomy in patients with AL in the training cohort (p < 0.001). Following the assessment of the two test cohorts, the SVM model could identify AL in a favorable manner, which performed with positive predictive values of 0.150 (0.091-0.234) and 0.151 (0.091-0.237), and negative predictive values of 0.977 (0.958-0.988) and 0.986 (0.969-0.994), respectively. It is important to note that the implementation of temporary ileostomy in patients without AL would have been significantly reduced (p < 0.001) and which would have been significantly increased in patients with AL (p < 0.05). CONCLUSION The model (https://alrisk.21cloudbox.com/) indicated good discernment of AL, which may be used to assist the surgeon's decision-making of performing temporary ileostomy.
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Affiliation(s)
- Shengli Shao
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Yufeng Zhao
- Department of Vascular Surgery, First Hospital of Lanzhou University, 730030, Lanzhou, China
| | - Qiyi Lu
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Lu Liu
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Lei Mu
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Jichao Qin
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
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Ammendola M, Ammerata G, Filice F, Filippo R, Ruggiero M, Romano R, Memeo R, Pessaux P, Navarra G, Montemurro S, Currò G. Anastomotic Leak Rate and Prolonged Postoperative Paralytic Ileus in Patients Undergoing Laparoscopic Surgery for Colo-Rectal Cancer After Placement of No-Coil Endoanal Tube. Surg Innov 2023; 30:20-27. [PMID: 35582732 DOI: 10.1177/15533506221090995] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is the second most common gastrointestinal tumor in men and the third in women. Left-hemicolectomy (LC) and low anterior resection (LAR) are considered the gold standard curative treatment. In this retrospective study, we evaluated the presence or absence of post-operative complications, in all patients who underwent Video-laparoscopic (VLS) LAR/LC with No Coil trans-anal tube positioning, and compared the data with the current literature on the topic. METHODS Thirty-nine patients diagnosed with CRC of the descending colon, splenic flexure, sigma, and rectum were recruited. LC was performed for sigmoid and descending colon cancers, while LAR was applied for tumors of the upper two-thirds of the rectum. The No Coil trans-anal tube (SapiMed Spa, Alessandria, Italy) was placed in all patients of the study at the end of surgical treatment. RESULTS Eighteen patients received a LAR-VLS (46%) and 21 patients received a LC-VLS (54%). The average length of hospital stay after surgery was 7 days. PPOI occurred in only one in 39 patients (2.6%) who had undergone LAR-VLS. As for complications, in no patient of the study did AL (0%) occur. CONCLUSION In patients undergoing LAR-VLS and LC-VLS, we performed colorectal anastomosis and in the same surgical operation we introduced the No-Coil device. Although this is a preliminary study and subject to further investigation, we believe that the No Coil tube positioning may reduce the time of presence of first flatus and feces and the risk of AL.
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Affiliation(s)
- Michele Ammendola
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Giorgio Ammerata
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Francesco Filice
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Rosalinda Filippo
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Michele Ruggiero
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Roberto Romano
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Riccardo Memeo
- Hepato-Biliary and Pancreatic Surgical Unit, "F. Miulli" Hospital, Bari, Italy
| | - Patrick Pessaux
- Department of General, Digestive and Endocrine Surgery,IHU-Strasbourg, Institute of Image-Guided Surgery, IRCAD, Research Institute Against Cancer of the Digestive System, University Hospital of Strasbourg, Strasbourg, France
| | - Giuseppe Navarra
- Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, "G. Martino" Hospital, University of Messina, Messina, Italy
| | - Severino Montemurro
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Giuseppe Currò
- Science of Health Department, General Surgery Unit, University "Magna Graecia" Medical School, Catanzaro, Italy
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Hartmann's reversal is associated with worse outcomes compared to elective left colectomy: A NSQIP analysis of 36,794 cases. Am J Surg 2022; 224:1351-1355. [PMID: 36272826 DOI: 10.1016/j.amjsurg.2022.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/21/2022] [Accepted: 10/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hartmann's reversal (HR) is associated with significant technical difficulty and morbidity. Using the ACS-NSQIP database, we assessed the outcomes of HR as compared to elective left colectomy (LC). METHODS The 2016-2019 ACS-NSQIP datasets were queried to identify patients undergoing HR and elective LC. Patients' demographics, comorbidities, and short-term surgical outcomes were evaluated using both univariable and multivariable methods. RESULTS The study included 7,632 HR cases and 29,162 LC cases. The HR group had more patients with ASA grade III (50% vs. 42.4%). HR had more open-operative cases (69.4 vs. 18.5%) and longer mean operative times (213 vs. 191 min) than LC. Postoperatively, the HR group had a longer mean hospital stay (5.5 vs. 4.1 days) and higher complication rate (18.3% vs. 10.3%). HR was associated with increased odds of having a concurrent ileostomy (OR 2.11), deep space/organ infection (OR 1.55), and at least one complication (OR 1.56). CONCLUSION HR is a more challenging operation with patients who fared worse than their LC counterparts. Consideration should be given to alternatives of the index Hartmann's procedure.
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Chang Z, Liu L, She C, Ren W, Chen H, Zhou C. A meta‐analysis examined the effect of stoma on surgical site wound infection in colorectal cancer. Int Wound J 2022; 20:1578-1583. [PMID: 36401595 PMCID: PMC10088842 DOI: 10.1111/iwj.14013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/20/2022] Open
Abstract
To assess the impact of a stoma on surgical site wound infection in colorectal cancer, we conducted a meta-analysis. A thorough review of the literature up to September 2022 revealed that 3223 participants had colorectal cancer at the start of the investigations; 258 of them had a stoma, while 2965 did not have a stoma. Using dichotomous or contentious methods and a random or fixed-effect model, odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CIs) were estimated to evaluate the impact of a stoma on surgical site wound infection in colorectal cancer. The stoma present had significantly higher surgical site wound infections (OR, 4.37; 95% CI, 3.08-6.21; P < 0.001) with no heterogeneity (I2 = 12%) compared to stoma absent in colorectal cancer. The stoma present had significantly higher surgical site wound infections compared to the stoma absent in colorectal cancer. The low number of selected studies in the meta-analysis calls for care when analysing the results.
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Affiliation(s)
- Zimeng Chang
- Department of Hospital Infection Control Affiliated Changsha Hospital, Hunan Normal University Hunan China
- Department of Nursing Tangdu Hospital Shaanxi China
| | - Liang Liu
- School of Medicine Hunan Normal University Hunan China
| | - Canfang She
- School of Medicine Hunan Normal University Hunan China
| | - Wei Ren
- Department of Nursing Xijing Hospital Shaanxi China
| | - Hua Chen
- School of Medicine Hunan Normal University Hunan China
| | - Caihong Zhou
- Department of Hospital Infection Control Affiliated Changsha Hospital, Hunan Normal University Hunan China
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17
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Gozalichvili D, Binquet C, Boisson C, Guiraud A, Facy O, Ortega-Deballon P. Early detection of anastomotic leak with C-reactive protein increases the chances of anastomotic salvage. Colorectal Dis 2022; 25:728-737. [PMID: 36323646 DOI: 10.1111/codi.16399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 09/16/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
AIM Anastomotic leak results in increased morbidity and affects functional and oncological outcomes after colectomy. Measurement of C-reactive protein (CRP) allows early detection of anastomotic leaks. The aim of this study was to evaluate the benefit to the patient of earlier diagnosis and management of anastomotic leaks, namely avoiding takedown of the anastomosis. METHOD Patients with an anastomotic fistula after elective colorectal surgery from 2010 to 2020 were included. Three periods were defined according to progressive adherence to the CRP protocol in our department. A comparison was made between the periods 'before' (2010-2013) and 'after' (2016-2020) in terms of morbidity, mortality, anastomotic salvage, days spent in hospital within the first postoperative month, timely adjuvant chemotherapy and anastomotic stenosis. RESULTS Out of 2655 elective colorectal operations, 171 patients presented with an anastomotic leak and 123 patients were included in the study. In univariate analysis, patients in the 'after' group had fewer severe complications (Clavien-Dindo Grade III to IV, 66.7% vs. 56.9; p = 0.017); the difference did not reach significance regarding timely postoperative chemotherapy (p = 0.058) and anastomotic stenosis (p = 0.682). In both, univariate and multivariate analysis, the 'after' period increased the chances of preserving the anastomosis (OR = 2.37 [1.08-5.17]) and increased the number of days out of hospital (p = 0.0002). CONCLUSION A CRP-based protocol for the screening of anastomotic leaks after colorectal surgery was related to increased anastomotic conservation, a decreased impact and severity of the leak and a shorter length of hospital stay.
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Affiliation(s)
- David Gozalichvili
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France
| | - Christine Binquet
- INSERM, CIC1432, Dijon, France.,Clinical Investigation Centre, Dijon University Hospital, Dijon, France
| | - Cyril Boisson
- INSERM, CIC1432, Dijon, France.,Clinical Investigation Centre, Dijon University Hospital, Dijon, France
| | - Adeline Guiraud
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France
| | - Olivier Facy
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France.,INSERM UMR 1231, University of Bourgogne-Franche-Comté, Dijon, France
| | - Pablo Ortega-Deballon
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France.,INSERM, CIC1432, Dijon, France.,Clinical Investigation Centre, Dijon University Hospital, Dijon, France.,INSERM UMR 1231, University of Bourgogne-Franche-Comté, Dijon, France
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When Is a Diverting Stoma Indicated after Low Anterior Resection? A Meta-analysis of Randomized Trials and Meta-Regression of the Risk Factors of Leakage and Complications in Non-Diverted Patients. J Gastrointest Surg 2022; 26:2368-2379. [PMID: 35915378 DOI: 10.1007/s11605-022-05427-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a potentially life-threatening complication after low anterior resection (LAR). This meta-analysis aimed to compare outcomes of LAR with and without diverting stoma and to determine factors associated with AL in non-diverted patients. METHODS This was a PRISMA-compliant systematic review of electronic databases (PubMed, Scopus, and Web of Science). Randomized controlled trials comparing LAR with and without diverting stoma were included. Main outcome measures were AL, complications, and operation time in the two groups and risk factors of AL in non-diverted patients. RESULTS Nine randomized control trials (RCTs) (946 patients; 53.2% male) were included. The diverting stoma group had lower odds of complications (OR: 0.61, 95%CI: 0.461-0.828; p < 0.001), AL (OR: 0.362, 95%CI: 0.236-0.555; p < 0.001, I2 = 0), abscess (OR: 0.392, 95%CI: 0.174-0.883; p < 0.024, I2 = 0), and reoperation (OR: 0.352, 95%CI: 0.222-0.559, p < 0.001, I2 = 0) than the no-diversion group. Both groups had comparable odds of bowel obstruction, surgical site infection, and perioperative mortality. The weighted mean operation time in the diverting stoma group was longer than the no-diversion group (WMD: 34.804, 95%CI: 14.649-54.960, p < 0.001). Factors significantly associated with AL in non-diverted patients were higher body mass index (BMI), ASA ≥ 3, lower tumor height, neoadjuvant therapy, open surgery, end-to-end anastomosis, and longer operation time. CONCLUSIONS Non-diverted patients with increased body mass index, high American Society of Anesthesiologists scores, low rectal cancers, received neoadjuvant therapy, underwent open surgery, end-to-end anastomosis, and longer operation times were at a higher risk of AL after LAR.
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Deng SY, Xing JD, Liu MX, Xu K, Tan F, Yao ZD, Zhang N, Yang H, Zhang CH, Cui M, Su XQ. Effect of the transanal drainage tube on preventing anastomotic leakage after laparoscopic surgery for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:1739-1750. [PMID: 35789424 DOI: 10.1007/s00384-022-04201-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leakage (AL) is a common postoperative complication of rectal cancer, and transanal drainage tube (TDT) efficacy is still contentious. This study aimed to evaluate the TDT effect on AL prevention. METHODS All relevant papers were searched by using a predefined search strategy (two randomized controlled trials (RCTs), one prospective study, and four retrospective studies). Meta-analysis was conducted to estimate AL and re-operation pooled rates. RESULTS A total of 7 studies (1556 patients) were included: No significant statistic difference was found between two groups on AL rate (odds ratio (OR) 0.61, P = 0.11) and re-operation rate (OR 0.52, P = 0.10). For subgroup analysis, significant statistic difference was found between two groups on AL rate (OR 0.29, P = 0.002) and re-operation rate (OR 0.15, P = 0.04) in patients without neoadjuvant therapy. As for patients without diverting stoma, the AL rate (OR 0.35, P = 0.002) was significantly lower than that in patients without TDT. CONCLUSIONS TDT may reduce AL morbidity and re-operation rate for patients without high risk of AL, but may be useless for those in high-risk situations.
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Affiliation(s)
- Shun-Yu Deng
- Peking University Health Science Center, Beijing, 100038, China
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Jia-Di Xing
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Mao-Xing Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Kai Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Fei Tan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Zhen-Dan Yao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Nan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Hong Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Cheng-Hai Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Ming Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Xiang-Qian Su
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China.
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20
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Revised risk factors and patient characteristics for failure to close a defunctioning ileostomy following low anterior resection for locally advanced rectal cancer. Int J Colorectal Dis 2022; 37:1611-1619. [PMID: 35705724 DOI: 10.1007/s00384-022-04188-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our clinical experience led us to raise questions about the validity of the reported risk factors and patient characteristics associated with permanent stomas after sphincter-preserving resection for rectal cancer. OBJECTIVE The present retrospective study aimed to identify and compare our center's incidence and risk factors for a permanent ostomy after low anterior resection (LAR) with a diverting stoma for locally advanced mid and low rectal cancer with those in published reports. PATIENTS A total of 239 patients underwent a sphincter-preserving procedure (LAR) for rectal cancer between 2000 and 2018, and 236 of them (age range 33-83 years, 100 males (42%)) were included in the analysis. The study cohort was divided into 2 groups comprised of patients with and without permanent stomas after rectal cancer surgery. RESULTS Only 25 of the 236 operated patients (10.6%) remained with permanent stomas after rectal cancer surgery. Factors associated with stoma non-closure in the multivariate analysis were pathological stage 3 (13 (52%) vs 51 (24.2%) for patients with closed stomas, p = 0.032), disease recurrence (14 (56%) vs 40 (18.9%), respectively, p = 0.048), length of stay > 10 days, p = 0.032), and anastomotic leaks with a Clavien-Dindo score > 2 or reoperations (6 (24%) vs 13 (6.1%), p = 0.019). CONCLUSIONS Sphincter-preserving surgery for rectal cancer was associated with a lower incidence of stoma non-closure than published values. The major risk factors for non-closure were aggressive disease and severe complications of surgery.
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21
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Kang SI, Kim S, Kim JH. Two-year follow-up results of the use of a fecal diverting device as a substitute for a defunctioning stoma. Int J Colorectal Dis 2022; 37:835-841. [PMID: 35238980 DOI: 10.1007/s00384-022-04117-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Our previously published clinical studies described the short-term outcomes of a newly developed intraluminal fecal diverting device (FDD). FDD was a safe and effective substitute for a defunctioning stoma. However, the long-term efficacy and safety of this device remain unknown. We investigated the long-term outcomes of the use of the FDD as a substitute for a defunctioning stoma. METHODS We examined the medical records of patients who participated in our two previous FDD clinical studies. The main outcome was the number of patients with bowel continuity for 2 years after undergoing the FDD procedure or defunctioning stoma creation. RESULTS Between May 2015 and July 2018, 85 patients were screened for inclusion in this study. Of those, 27 patients underwent a defunctioning ileostomy after proctectomy. The remaining 58 underwent the FDD procedure after proctectomy. Seventy-two patients (ileostomy group, n = 22; FDD group, n = 50) with a follow-up duration > 24 months were included in this analysis. The mean duration of fecal diversion was significantly shorter (p < 0.001) in the FDD group (3.1 [1.6-6.1] weeks) than in the ileostomy group (16.7 [10.0-31.6] weeks). However, the rate of permanent stoma creation was not statistically different between the two groups (ileostomy and FDD groups, 13.6% [3/22] and 10.0% [5/50], respectively; p = 0.693). CONCLUSIONS The FDD procedure is a feasible substitute for a defunctioning stoma after proctectomy. Multicenter large-scaled clinical studies are required to validate our results.
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Affiliation(s)
- Sung Il Kang
- Department of Surgery, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-Gu, Daegu, 42415, Korea.
| | - Sohyun Kim
- Department of Surgery, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-Gu, Daegu, 42415, Korea
| | - Jae Hwang Kim
- Department of Surgery, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-Gu, Daegu, 42415, Korea
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22
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Rouanet P, Selvy M, Jarlier M, Bugnon C, Carrier G, Mourregot A, Colombo PE, Taoum C. Tailored Management with Highly-Selective Diversion for Low Colorectal Anastomosis: Biochemical Postoperative Follow-Up and Long-Term Results from a Single-Institution Cohort. Ann Surg Oncol 2022; 29:2514-2524. [PMID: 34994889 DOI: 10.1245/s10434-021-11197-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Defunctioning stoma (DS) can decrease the rate of symptomatic anastomotic leakage (AL). Since 2010, we have used tailored, highly selective DS management for low colorectal anastomosis (LCRA). METHODS In total, 433 rectal cancer patients underwent the same standardized procedure. Non-stoma (NS) management was used in patients with no surgical difficulties as well as good colonic preparation and quality of anastomoses. In all other cases, DS was used. C-reactive protein was measured during postoperative follow-up. Imbalance in the initial population was adjusted using propensity-score matching according to sex, age, body mass index, tumor location, and American Society of Anesthesiologists score. Rate of AL within 30 days, 5-year overall survival, local relapse-free survival, and disease-free survival were recorded. RESULTS Anastomosis was mostly ultra-low and was performed equally by laparoscopy or robotic surgery. The overall rate of AL was 13.4%, with no significant differences between groups (DS, 12.2%; NS, 14.6%; p = 0.575). Operative time, blood loss, and hospital stay were significantly lower for NS patients. The rate of secondary stoma was 11.4% overall. Pathological results were similar, with a 98% R0 resection rate. With a median follow-up of 5.5 years for the NS and DS groups, the overall survival was 84.9% and 73.4%, respectively (p = 0.064), disease-free survival was 67.0% and 55.8%, respectively (p = 0.095), and local relapse-free survival was 95.2% and 88.7%, respectively (p = 0.084). The long-term, stoma-free rate was 89.1% overall. CONCLUSIONS Tailoring DS for LCRA seems safe and could provide potential benefits in postoperative morbidity with the same long-term oncological results in NS patients. Prospective, multicentric studies should validate this approach.
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Affiliation(s)
- Philippe Rouanet
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France.
| | - Marie Selvy
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | - Marta Jarlier
- Biometrics Unit, Montpellier Cancer Institute, Montpellier, France
| | - Caroline Bugnon
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | - Guillaume Carrier
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | - Anne Mourregot
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | | | - Christophe Taoum
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
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23
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La Raja C, Foppa C, Maroli A, Kontovounisios C, Ben David N, Carvello M, Spinelli A. Surgical outcomes of Turnbull-Cutait delayed coloanal anastomosis with pull-through versus immediate coloanal anastomosis with diverting stoma after total mesorectal excision for low rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:603-613. [PMID: 35344150 DOI: 10.1007/s10151-022-02601-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 02/16/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Theoretical advantages of Turnbull-Cutait pull-through delayed coloanal anastomosis (DCAA) are a reduced risk of anastomotic leak and therefore avoidance of stoma. Gradually abandoned in favor of immediate coloanal anastomosis (ICAA) with diverting stoma, DCAA has regained popularity in recent years in reconstructive surgery for low RC, especially when combined with minimally invasive surgery (MIS). The aim of this study was to perform the first meta-analysis, exploring the safety and outcomes of DCAA compared to ICAA with protective stoma. METHODS A systematic search of MEDLINE, EMBASE, and CENTRAL and Google Scholar databases was performed for studies published from January 2000 until December 2020. The systematic review and meta-analysis were performed according to the Cochrane Handbook for Systematic Review on Interventions recommendations and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. RESULTS Out of 2626 studies screened, 9 were included in the systematic review and 4 studies in the meta-analysis. Outcomes included were postoperative complications, pelvic sepsis and risk of definitive stoma. Considering postoperative complications classified as Clavien-Dindo III, no significant difference existed in the rate of postoperative morbidity between DCAA and ICAA (13% versus 21%; OR 1.17; 95% CI 0.38-3.62; p = 0.78; I2 = 20%). Patients in the DCAA group experienced a lower rate of postoperative pelvic sepsis compared with patients undergoing ICAA with diverting stoma (7% versus 14%; OR 0.37; 95% CI 0.16-0.85; p = 0.02; I2 = 0%). The risk of definitive stoma was comparable between the two groups (2% versus 2% OR 0.77; 95% CI 0.15-3.85; p = 0.75; I2 = 0%). CONCLUSIONS According to the limited current evidence, DCAA is associated with a significant decrease in pelvic sepsis. Further prospective trials focusing on oncologic and functional outcomes are needed.
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Affiliation(s)
- C La Raja
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - C Foppa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - A Maroli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - C Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - N Ben David
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - M Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - A Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy. .,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy.
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24
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Biondi A, Mele MC, Agnes A, Lorenzon L, Cintoni M, Rinninella E, Marincola G, D’Ugo D, Gasbarrini A, Persiani R. OUP accepted manuscript. BJS Open 2022; 6:6530619. [PMID: 35179186 PMCID: PMC8855525 DOI: 10.1093/bjsopen/zrac002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/15/2021] [Accepted: 01/09/2022] [Indexed: 11/14/2022] Open
Abstract
Background Early postoperative discharge after colorectal surgery within the enhanced recovery after surgery (ERAS) guidelines has been demonstrated to be safe, although its applicability has not been universal. The primary aim of this study was to identify the predictors of early discharge and readiness for discharge in a study population. Methods Early discharge was defined as discharge occurring in 72 h or less after surgery. The characteristics and clinical outcomes of the patients in the early and non-early discharge groups were compared, and variables associated with early discharge were identified. Additionally, independent variables associated with the readiness for discharge within 48 h were evaluated. Results Of 965 patients who underwent colorectal surgery between January 2015 and July 2020, 788 were included in this study. No differences in readmission, reoperation, or 30-day mortality were observed between the early and non-early discharge groups. Both early discharge and readiness for discharge had a positive association with adherence to 80 per cent or more of the ERAS items and a negative association with the female sex, duration of surgery, drain positioning, and postoperative complications. Conclusion Early discharge after colorectal surgery is safe and feasible, and is not associated with a high risk of readmission or reoperation. Discharge at 48 h can be reliably predicted in a subset of patients. Future studies should collect prospective data on early discharge related to safety, as well as patients’ expectations, possible organizational issues, and effective costs reduction in Italian clinical practice.
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Affiliation(s)
- Alberto Biondi
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Cristina Mele
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Annamaria Agnes
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Correspondence to: Annamaria Agnes, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy (e-mail: )
| | - Laura Lorenzon
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Cintoni
- Scuola di Specializzazione in Scienza dell’Alimentazione, Università di Roma Tor Vergata, Rome, Italy
| | - Emanuele Rinninella
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Domenico D’Ugo
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberto Persiani
- Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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25
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Uchiyama S, Ikeda N, Oyama T, Eguchi M, Ito A, Sato R, Toyosaki R, Kitazono M, Suenaga T. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac236. [PMID: 35599998 PMCID: PMC9116574 DOI: 10.1093/jscr/rjac236] [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: 04/05/2022] [Accepted: 05/03/2022] [Indexed: 11/15/2022] Open
Abstract
Cases of delayed colo-anal anastomosis (DCAA) are currently reported instead of the colo-anal anastomosis with a protective loop ileostomy for rectal cancer. Post-operative colonic ischemia is considered as one of the serious complications of colorectal resection. Although indication of DCAA should be carefully selected, we experienced a case of post-operative stenosis caused by colonic ischemia after low anterior resection for rectal cancer, followed by this procedure.
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Affiliation(s)
- Shuichiro Uchiyama
- Correspondence address. Department of Surgery, Nanpuh Hospital, 14- 3 Nagata-cho, Kagoshima 892-8512, Japan. Tel: +81-99-226-9111; Fax: +81-99-223-1573; E-mail:
| | - Naotaka Ikeda
- Department of Surgery, Nanpuh Hospital, Kagoshima-city, Kagoshima, Japan
| | - Tomohiro Oyama
- Department of Surgery, Nanpuh Hospital, Kagoshima-city, Kagoshima, Japan
| | - Mayumi Eguchi
- Department of Surgery, Nanpuh Hospital, Kagoshima-city, Kagoshima, Japan
| | - Ayaka Ito
- Department of Surgery, Nanpuh Hospital, Kagoshima-city, Kagoshima, Japan
| | - Rikiya Sato
- Department of Surgery, Nanpuh Hospital, Kagoshima-city, Kagoshima, Japan
| | - Ryoichi Toyosaki
- Department of Surgery, Nanpuh Hospital, Kagoshima-city, Kagoshima, Japan
| | - Masaki Kitazono
- Department of Surgery, Nanpuh Hospital, Kagoshima-city, Kagoshima, Japan
| | - Toyokuni Suenaga
- Department of Surgery, Nanpuh Hospital, Kagoshima-city, Kagoshima, Japan
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Favuzza J. Risk Factors for Anastomotic Leak, Consideration for Proximal Diversion, and Appropriate Use of Drains. Clin Colon Rectal Surg 2021; 34:366-370. [PMID: 34853556 DOI: 10.1055/s-0041-1735266] [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: 10/19/2022]
Abstract
Anastomotic leaks are a major source of morbidity after colorectal surgery. There is a myriad of risk factors that may contribute to anastomotic leaks. These risk factors can be categorized as modifiable, nonmodifiable, and intraoperative factors. Identification of these risk factors allows for preoperative optimization that may minimize the risk of anastomotic leak. Knowledge of such high-risk features may also affect intraoperative decision-making regarding the creation of an anastomosis, consideration for proximal diversion, or placement of a drain. A thorough understanding of the interplay between risk factors, indications for proximal diversion, and utility of drain placement is imperative for colorectal surgeons.
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Affiliation(s)
- Joanne Favuzza
- Division of Colon and Rectal Surgery, Department of Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
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27
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Bloomfield I, Dobson B, Von Papen M, Clark D. Incisional hernia following ileostomy closure: who's at risk? The Gold Coast experience. ANZ J Surg 2021; 92:146-150. [PMID: 34791754 DOI: 10.1111/ans.17359] [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: 07/01/2021] [Revised: 10/20/2021] [Accepted: 10/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diverting ileostomy is utilized to protect high-risk anastomoses, though it is not shown to reduce the leak rate it may reduce the severe consequences of an anastamotic leak. In recent years mesh development has advanced to allow placement of meshes into potentially contaminated fields, such as an ostomy closure site. METHOD A retrospective review of all ileostomy closure procedures in Gold Coast from 1st January 2011 until 31st December 2018 were included. Patient demographics and surgical outcomes and follow up reviewed to identify any cases of incisional hernia relating to ostomy closure. RESULTS A total of 193 patients were identified, after exclusions 171 were suitable for analysis within the study, a total of 25 incisional hernia detected radiologically or clinically. Two independent risk factors were identified BMI >30 and ASA 3-4. Both had significant association with development of incisional hernia with a 3- and 2-fold RR increase, respectively. This was also reflected in a subset analysis of BMI ranges demonstrating increased risk in the obese and severely obese group. DISCUSSION The high-risk group in our population was elevated BMI and ASA, these are the patients we would expect to benefit the most from targeted therapy to reduce the incidence of incisional hernia. Future studies to look at whether reducing BMI or prophylactic mesh placement are effective.
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Affiliation(s)
- Ian Bloomfield
- Medical and Health Sciences, Logan Hospital, Griffith University, Meadowbrooks, Queensland, Australia
| | | | | | - David Clark
- Royal Brisbane Hospital, Brisbane, Queensland, Australia
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28
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Closure of Temporary Ileostomy 2 Versus 12 Weeks After Rectal Resection for Cancer: A Word of Caution From a Prospective, Randomized Controlled Multicenter Trial. Dis Colon Rectum 2021; 64:1398-1406. [PMID: 34343161 PMCID: PMC8492188 DOI: 10.1097/dcr.0000000000002182] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The optimum timing for temporary ileostomy closure after low anterior resection is still open. OBJECTIVE This trial aimed to compare early (2 wk) versus late (12 wk) stoma closure. DESIGN The study included 2 parallel groups in a multicenter, randomized controlled clinical trial. SETTINGS The study was conducted at 3 Swiss hospitals. PATIENTS Patients undergoing low anterior resection and temporary ileostomy for cancer were included. INTERVENTIONS Patients were randomly allocated to early or late stoma closure. Before closure, colonic anastomosis was examined for integrity. MAIN OUTCOME MEASURES The primary efficacy outcome was the Gastrointestinal Quality of Life Index 6 weeks after resection. Secondary end points included safety (morbidity), feasibility, and quality of life 4 months after low anterior resection. RESULTS The trial was stopped for safety concerns after 71 patients were randomly assigned to early closure (37 patients) or late closure (34 patients). There were comparable baseline data between the groups. No difference in quality of life occurred 6 weeks (mean Gastrointestinal Quality of Life Index: 99.8 vs 106.0; p = 0.139) and 4 months (108.6 vs 107.1; p = 0.904) after index surgery. Intraoperative tendency of oozing (visual analog scale: 35.8 vs 19.3; p = 0.011), adhesions (visual analog scale: 61.3 vs 46.2; p = 0.034), leak of colonic anastomosis (19% vs 0%; p = 0.012), leak of colonic or ileal anastomosis (24% vs 0%; p = 0.002), and reintervention (16% vs 0%; p = 0.026) were significantly higher after early closure. The concept of early closure failed in 10 patients (27% vs 0% in the late closure group (95% CI for the difference, 9.4%-44.4%)). LIMITATIONS The trial was prematurely stopped because of safety issues. The aimed group size was not reached. CONCLUSIONS Early stoma closure does not provide better quality of life up to 4 months after low anterior resection but is afflicted with significantly adverse feasibility and higher morbidity when compared with late closure. See Video Abstract at http://links.lww.com/DCR/B665. CIERRE DE LA ILEOSTOMA TEMPORAL VERSUS SEMANAS POSTERIOR A LA RESECCIN RECTAL POR CNCER UNA ADVERTENCIA DE UN ESTUDIO MULTICNTRICO CONTROLADO RANDOMIZADO PROSPECTIVO ANTECEDENTES:El momento óptimo para el cierre temporal de la ileostomía posterior a la resección anterior baja es aun controversial.OBJETIVO:Este estudio tuvo como objetivo comparar el cierre del estoma temprano (2 semanas) versus tardío (12 semanas).DISEÑO:Estudio clínico controlado, randomizado, multicéntrico, de dos grupos paralelos.ENTORNO CLINICO:El estudio se llevó a cabo en 3 hospitales suizos.PACIENTES:Se incluyeron pacientes sometidos a resección anterior baja e ileostomía temporal por cáncer.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente al cierre del estoma temprano o tardío. Antes del cierre, se examinó la integridad de la anastomosis colónica.PRINCIPALES MEDIDAS DE VALORACION:El principal resultado de eficacia fue el Índice de Calidad de Vida Gastrointestinal 6 semanas después de la resección. Los criterios secundarios incluyeron la seguridad (morbilidad), factibilidad y calidad de vida 4 meses posterior a la resección anterior baja.RESULTADOS:El estudio se detuvo por motivos de seguridad después de que 71 pacientes fueron asignados aleatoriamente a cierre temprano (37 pacientes) o cierre tardío (34 pacientes). Hubo datos de referencia comparables entre los grupos. No se produjeron diferencias en la calidad de vida 6 semanas (índice de calidad de vida gastrointestinal, media 99,8 vs. 106; p = 0,139) y 4 meses (108,6 vs 107,1, p = 0,904) después de la cirugía inicial. Tendencia intraoperatoria de supuración (escala analógica visual 35,8 vs 19,3, p = 0,011), adherencias (escala analógica visual 61,3 vs 46,2, p = 0,034), fuga de anastomosis colónica (19% vs 0%, p = 0,012), fuga de anastomosis colónica o ileal (24% vs 0%, p = 0,002) y reintervención (16% vs 0%, p = 0,026) fueron significativamente mayores después del cierre temprano. El concepto de cierre temprano fracasó en 10 pacientes (27% vs ninguno en el grupo de cierre tardío (intervalo de confianza del 95% para la diferencia: 9,4% a 44,4%)).LIMITACIONES:El estudio se detuvo prematuramente debido a problemas de seguridad. No se alcanzó el tamaño del grupo previsto.CONCLUSIÓN:El cierre temprano del estoma no proporciona una mejor calidad de vida hasta 4 meses posterior a una resección anterior baja, esto se ve afectado por efectos adversos significativos durante su realización y una mayor morbilidad en comparación con el cierre tardío. Consulte Video Resumen en http://links.lww.com/DCR/B665.
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Choi ET, Lim SB, Lee JL, Kim CW, Kim YI, Yoon YS, Park IJ, Yu CS, Kim JC. Effects of anchoring sutures at diverting ileostomy after rectal cancer surgery on peritoneal adhesion at following ileostomy reversal. Ann Surg Treat Res 2021; 101:214-220. [PMID: 34692593 PMCID: PMC8506021 DOI: 10.4174/astr.2021.101.4.214] [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: 05/17/2021] [Revised: 08/10/2021] [Accepted: 08/20/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose During diverting ileostomy reversal for rectal cancer patients who underwent previous sphincter-saving surgery, the extent of adhesion formation around the ileostomy site affects operative and postoperative outcomes. Anchoring sutures placed at the time of the ileostomy procedure may reduce adhesions around the ileostomy. This study aimed to evaluate the effects of anchoring sutures on the degree of adhesion formation and the postoperative course at the time of ileostomy reversal. Methods Patients who underwent sphincter-saving surgery with diverting ileostomy for rectal cancer between January 2013 and December 2017 were enrolled. Variables including the peritoneal dhesion index (PAI) score, operation time, the length of resected small bowel, operative complications, and postoperative hospital stay were collected prospectively and compared between the anchoring group (AG) and non-anchoring group (NAG). Results A total of 90 patients were included in this study, with 60 and 30 patients in the AG and NAG, respectively. The AG had shorter mean operation time (46.88 ± 16.37 minutes vs. 61.53 ± 19.36 minutes, P = 0.001) and lower mean PAI score (3.02 ± 2.53 vs. 5.80 ± 2.60, P = 0.001), compared with the NAG. There was no significant difference in the incidence of postoperative complications between the AG and NAG (5.0% vs. 13.3%, respectively; P = 0.240). Conclusion Anchoring sutures at the formation of a diverting ileostomy could decrease the adhesion score and operation time at ileostomy reversal, thus may be effective in improving perioperative outcomes.
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Affiliation(s)
- Eu-Tteum Choi
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Il Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Terada Y, Miyake T, Ueki T, Shimizu T, Kojima M, Takebayashi K, Maehira H, Kaida S, Yamaguchi T, Iida H, Tani M. Incidence of surgical site infections with triclosan-coated monofilament versus multifilament sutures in elective colorectal surgery. Surg Today 2021; 52:652-659. [PMID: 34664093 DOI: 10.1007/s00595-021-02383-6] [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: 05/27/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Surgical site infections (SSIs) are the most frequent complication of abdominal surgery. Using triclosan-coated sutures for abdominal wall closure reportedly reduces the incidence of SSIs. However, the SSI incidence has not been compared between the use of triclosan-coated multifilament and triclosan-coated monofilament sutures. We, therefore, compared the incidence of incisional SSIs between the use of triclosan-coated polyglactin 910 sutures (Vicryl Plus) and triclosan-coated polydioxanone sutures (PDS Plus). METHODS This observational cohort study was conducted on 318 consecutive patients who underwent elective colorectal cancer surgery at the Shiga University of Medical Science Hospital from January 2015 to December 2018. Based on the suture type for abdominal wall closure, 151 patients were enrolled in the PDS Plus group, and 167 were enrolled in the Vicryl Plus group. RESULTS The two suture groups were not significantly different in terms of risk factors for SSIs. Other postoperative complications also did not differ markedly between the two groups. In the multivariate logistic regression analysis, the presence of stoma was the only independent risk factor for incisional SSIs. CONCLUSION The incidence of incisional SSIs was unaffected by the type of triclosan-coated sutures. The presence of stoma was an independent risk factor for incisional SSIs.
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Affiliation(s)
- Yoshitaka Terada
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Toru Miyake
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan.
| | - Tomoyuki Ueki
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Tomoharu Shimizu
- Division of Medical Security and Patient Safety, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Masatsugu Kojima
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Katsushi Takebayashi
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Hiromitsu Maehira
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Sachiko Kaida
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Tsuyoshi Yamaguchi
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Hiroya Iida
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Masaji Tani
- Division of Gastrointestinal, Breast and General Surgery, Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
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Morss-Walton PC, Yi JZ, Gunning ME, McGee JS. Ostomy 101 for dermatologists: Managing peristomal skin diseases. Dermatol Ther 2021; 34:e15069. [PMID: 34309140 DOI: 10.1111/dth.15069] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022]
Abstract
An estimated 1 million North Americans live with ostomies, with up to 80% of ostomy patients developing stoma-related skin morbidities. While ostomy nurses are often the first line of management, dermatologists may be involved in the care of ostomy patients with complex or persistent peristomal skin complications. Therefore, an understanding of the ostomy apparatus and possible peristomal skin conditions that may arise allows dermatologists to identify skin complications early and work effectively with a multidisciplinary team. In this article, we aim to review the ostomy apparatus, discuss the differential diagnoses, and provide practical guidelines for the management of peristomal skin conditions. Pubmed, Ovid Medline, and Google Scholar were searched for relevant articles assessing peristomal skin complications and their management. Peristomal skin complications may be local (e.g., contact dermatitis, infection, fistula, and mechanical trauma) or secondary to systemic disease (e.g., inflammatory bowel disease, pyoderma gangrenosum, and psoriasis). Ensuring appropriate ostomy fit and proper use of ostomy accessory products helps to reduce effluent leakage and prevent damage to the peristomal skin. For persistent peristomal skin conditions, corticosteroid sprays, systemic therapies, and surgical interventions may be warranted.
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Affiliation(s)
| | - Julie Z Yi
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Mary-Ellen Gunning
- Nursing Wound Ostomy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jean S McGee
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Hoffman RL, Consuegra H, Long K, Buzas C. Anastomotic leak in patients with acute complicated diverticulitis undergoing primary anastomosis: risk factors and the role of diverting loop ileostomy. Int J Colorectal Dis 2021; 36:1543-1550. [PMID: 34041593 DOI: 10.1007/s00384-021-03957-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent data has suggested that primary anastomosis (PA), with or without a diverting loop ileostomy (DLI), is a safe option for the treatment of acute complicated diverticulitis. This study aimed to evaluate risk factors associated with anastomotic leak in patients who underwent a sigmoid colectomy with PA and to determine whether a DLI was protective against a clinically significant anastomotic leak. METHODS Patients with acute complicated diverticulitis who underwent a laparoscopic or open sigmoid colectomy with PA, with or without a DLI, were identified in the NSQIP PUF(2016-2017). The rates of anastomotic leak, receipt of DLI, and type of leak management were compared. Multivariate logistic regression was performed. RESULTS There were 497 patients identified. Seventy-nine(15.9%) patients had a DLI, while 418 (84.1%) did not. Twenty-six anastomotic leaks were identified (5.2%). On multivariate analysis, current smoking (OR 4.02; 95% CI 1.44-11.26) and chronic steroid use (OR 3.84; 95% CI 1.16-12.69) were significantly associated with an increased risk of leak. Of the 26 patients with anastomotic leaks, 5 (19.2%) had a DLI. There was no significant difference in the rate of leak between those with a DLI(5; 6.3%) and those without(21; 5.3%; p = 0.59). Patients who had a DLI were significantly less likely to experience an anastomotic leak requiring re-operation (p < 0.01). CONCLUSIONS Regardless of the presence of a DLI, chronic steroid use and smoking are associated with an increased risk of anastomotic leak in patients with acute complicated diverticulitis undergoing colectomy with PA. The presence of a diverting loop ileostomy is protective against re-operation.
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Affiliation(s)
- Rebecca L Hoffman
- Division of Colorectal Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA.
| | - Hadassah Consuegra
- Division of Colorectal Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Kevin Long
- Division of Colorectal Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Christopher Buzas
- Division of Colorectal Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
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Altomare DF, Delrio P, Shelgyn Y, Rybakov E, Vincenti L, De Fazio M, Simone M, Graziano G, Picciariello A. Transanal reinforcement of low rectal anastomosis versus protective ileostomy after total mesorectal excision for rectal cancer. Preliminary results of a randomized clinical trial. Colorectal Dis 2021; 23:1814-1823. [PMID: 33891798 DOI: 10.1111/codi.15685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022]
Abstract
AIM The study aimed to show if transanal reinforcement of the suture line can prevent anastomotic leakage (AL) after rectal cancer surgery, thus avoiding the need for a covering ileostomy. METHODS This is a prospective, multicentre, parallel-arm randomized controlled equivalence trial. After standard total mesorectal excision, patients with anastomotic line at 1-3 cm from the dentate line were randomized to have transanal suture reinforcement (TAR group) or protective ileostomy (PI group). RESULTS Twenty-nine patients had PI, 25 had TAR. The two groups were comparable both for baseline characteristics and intra-operative aspects. Clinically evident AL occurred in four (16%) and five (17.24%) patients of the TAR and PI group, respectively, resulting in a difference of -1.20% (90% CI -17.93, 15.45), while subclinical AL at proctography was absent in 15 (65.22%) and 13 (50%) patients of the TAR and PI groups, respectively, resulting in a difference of 15% (90% CI -7.74 to 38.17). CONCLUSION Preliminary data suggest that transanal reinforcement of the suture line performed in rectal cancer patients with suture line at 1-3 cm from the dentate line carries a similar (even if not equivalent) AL rate to covering ileostomy, suggesting that a covering ileostomy could be avoided in this selected group of patients. This indication needs to be addressed with future larger trials (clinicaltrials.gov ID number NCT02279771).
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Affiliation(s)
- Donato Francesco Altomare
- Surgical Unit Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari,, Italy.,Surgical Department, IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, 'Fondazione Giovanni Pascale' IRCCS, Naples, Italy
| | - Yuri Shelgyn
- Oncoproctology Department, State Scientific Centre of Coloproctology, Moscow, Russia
| | - Evgeny Rybakov
- Oncoproctology Department, State Scientific Centre of Coloproctology, Moscow, Russia
| | - Leonardo Vincenti
- Surgical Unit Azienda Ospedaliero-Universitaria Policlinico Bari, Bari, Italy
| | - Michele De Fazio
- Surgical Unit Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari,, Italy
| | - Michele Simone
- Surgical Department, IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy
| | - Giusy Graziano
- Center for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - Arcangelo Picciariello
- Surgical Unit Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari,, Italy
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Baloyiannis I, Perivoliotis K, Vederaki S, Koukoulis G, Symeonidis D, Tzovaras G. Current evidence regarding the role of adjuvant chemotherapy in rectal cancer patients with pathologic complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:1395-1406. [PMID: 33772323 DOI: 10.1007/s00384-021-03915-9] [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] [Accepted: 03/18/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this meta-analysis was to investigate the role of adjuvant chemotherapy (AC) in rectal cancer patients with pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) and curative resection. METHODS This study was completed in accordance to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic scholar databases (Medline, Web of Science, Scopus) were screened for eligible articles. The level of evidence (LoE) was assessed using the GRADE methodology. RESULTS Overall, 23 non-randomized studies and 17,406 patients were included in the present meta-analysis. Pooled comparisons confirmed that AC improved overall survival (HR: 0.68, p=0.0003), but not disease-free (p=0.22) and recurrence-free survival (p=0.39). However, the LoE for all outcomes was characterized as "very low," due to the absence of RCTs. CONCLUSIONS Considering the study limitations and the lack of randomized studies, further high-quality RCTs are required to confirm the findings of our study.
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Affiliation(s)
- Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | | | - Styliani Vederaki
- Faculty of Medicine, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | - Georgios Koukoulis
- Faculty of Medicine, University of Thessaly, Mezourlo, 41110, Larissa, Greece
- Department of Surgery, Koutlimbaneio and Triantafylleio General Hospital of Larissa, Larissa, Greece
| | - Dimitrios Symeonidis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
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Gu J, Deng S, Cao Y, Mao F, Li H, Li H, Wang J, Wu K, Cai K. Application of endoscopic technique in completely occluded anastomosis with anastomotic separation after radical resection of colon cancer: a case report and literature review. BMC Surg 2021; 21:201. [PMID: 33879122 PMCID: PMC8056686 DOI: 10.1186/s12893-021-01202-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/11/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Anastomosis-related complications are common after the radical resection of colon cancer. Among such complications, severe stenosis or completely occluded anastomosis (COA) are uncommon in clinical practice, and the separation of the anastomosis is even rarer. For such difficult problems as COA or anastomotic separation, clinicians tend to adopt surgical interventions, and few clinicians try to solve them through endoscopic operations. CASE PRESENTATION In this article, we present a case of endoscopic treatment of anastomotic closure and separation after radical resection for sigmoid carcinoma. After imaging examination and endoscopic evaluation, we found that the patient had a COA accompanied by a 3-4 cm anastomotic separation. With the aid of fluoroscopy, we attempted to use the titanium clip marker as a guide to perform an endoscopic incision and successfully achieved recanalization. We used a self-expanding covered metal stent to bridge the intestinal canal to resolve the anastomotic separation. Finally, the patient underwent ileostomy takedown, and the postoperative recovery was smooth. The follow-up evaluation results showed that the anastomotic stoma was unobstructed. CONCLUSIONS We reported the successful application of endoscopic technique in a rare case of COA and separation after colon cancer surgery, which is worth exploring and verifying through more clinical studies in the future.
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Affiliation(s)
- Junnan Gu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shenghe Deng
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yinghao Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Fuwei Mao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Hang Li
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Huili Li
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jiliang Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ke Wu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Kailin Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Segev L, Assaf D, Elbaz N, Schtrechman G, Westrich G, Adileh M, Nissan A, Goitein D. Outcomes of diverting loop ileostomy reversal in the elderly: a case-control study. ANZ J Surg 2021; 91:E382-E388. [PMID: 33870605 DOI: 10.1111/ans.16871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/28/2021] [Accepted: 04/04/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although diverting loop ileostomy (DLI) reversal is considered to be a relatively simple procedure, it is not immune from major morbidity. We aimed to compare outcomes of DLI reversal between elderly and non-elderly patients. METHODS Retrospective review of all patients who underwent DLI reversal at a single tertiary medical centre between 2010 and 2020. The elderly group consisted of patients 70 or older compared to a control group of those younger than 70 years. RESULTS During the study period, 307 patients underwent DLI reversal. Of these, 76 patients were in the elderly group (mean age 75.6) and 231 in the control group (mean age 55.3). The groups were comparable in terms of mean time interval between the creation of the ileostomy and reversal (242 versus 255 days, respectively, P = 0.5), choice between stapled and hand-sewn anastomoses (97.4% stapled anastomosis versus 93.1%, P = 0.086), median post-operative length of stay (5 days in both, P = 0.086), rates of post-operative complications (26.3% versus 26.8%, P = 0.99), severe complications (5.3% versus 6.9%, P = 0.81) and 30-day readmission rates (13.2% versus 10.8%, P = 0.58). Multivariate analysis found the time interval between the creation of the stoma and its reversal to be the only significant risk factor for major post-operative morbidity. Age was not found to be correlated with post-operative morbidity. CONCLUSION The outcomes of loop ileostomy reversal in elderly patients are similar to non-elderly patients. Efforts should be made to decrease the time interval between the creation of the stoma and its reversal as this is a significant risk factor for major post-operative morbidity.
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Affiliation(s)
- Lior Segev
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Assaf
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Elbaz
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gal Schtrechman
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gal Westrich
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohammad Adileh
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Nissan
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Goitein
- Department of General and Oncological Surgery - Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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37
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Ourô S, Ferreira MP, Albergaria D, Maio R. Loop ileostomy in rectal cancer surgery: factors predicting reversal and stoma related morbidity. Langenbecks Arch Surg 2021; 406:843-853. [PMID: 33851240 DOI: 10.1007/s00423-021-02169-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/02/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Loop ileostomy is performed in rectal cancer surgery to decrease the impact of anastomotic leak but it is associated with a significant complication rate. This study aimed to analyze the morbidity related to diverting ileostomy and to identify factors predictive of complications related to stoma management and reversal, as well as conversion into a permanent ileostomy. METHODS A retrospective study was conducted on 112 patients submitted to oncological rectal resection and defunctioning ileostomy in a Portuguese colorectal unit between March 2012 and March 2019. RESULTS Loop ileostomy was responsible for 13% of index surgery morbidity and 15% of patients' readmissions due to high output, stoma stenosis and parastomal hernia. Ileostomy was reversed in 89% cases with 7% Clavien-Dindo ≥ IIIb complications. An association was established between diabetes and higher stoma management morbidity (OR: 3.28 [95% CI: 1.039-10.426]. p = 0.041). Likewise, diabetes (OR: 0.17 [95% CI: 0.038; 6.90], p=0.015), oncological disease stage ≥ III (OR: 0.10 [95% CI: 0.005; 0.656], p=0.047) and index rectal surgery morbidity (OR: 0.23 [95% CI: 0.052; 0.955], p=0.041) were associated with less ileostomy closure. Complications of the index surgery also related to higher stoma reversal morbidity (OR: 5.11 [95% CI: 1.665; 16.346], p=0.005). CONCLUSIONS Diabetes and complications of index rectal surgery were identified as predictive of ileostomy morbidity, closure rate and associated complications. It is essential to adjust treatment decisions to patient's morbidity risk and adopt a more selective approach concerning the use of an ileostomy.
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Affiliation(s)
- Susana Ourô
- Surgical Department, Hospital Beatriz Ângelo, Lisbon, Portugal. .,NOVA Medical School, Lisbon, Portugal.
| | | | - Diogo Albergaria
- Surgical Department, Hospital Beatriz Ângelo, Lisbon, Portugal.,NOVA Medical School, Lisbon, Portugal
| | - Rui Maio
- Surgical Department, Hospital Beatriz Ângelo, Lisbon, Portugal.,NOVA Medical School, Lisbon, Portugal
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Morare NMT, Motha MN, Moeng MS. Out of the Loop: The Value of a Preoperative Loopogram for Colostomy Reversal in Trauma. World J Surg 2021; 45:2009-2014. [PMID: 33723670 DOI: 10.1007/s00268-021-06064-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Stoma is occasionally fashioned during trauma surgery. A loopogram is routinely conducted in the surgical planning for stoma reversal. This is associated with medical and cost implications. A study was undertaken to evaluate the influence of loopograms on the management of trauma patients at a Johannesburg hospital. METHODS A retrospective analysis of records in the stoma database (January 2013 to December 2018) was conducted. The patient demographics, method of injury, stoma-type, loopogram findings and post-operative courses were analysed. RESULTS 112 records were obtained. 9 (8%) patients were excluded for pending investigations or surgery. 13 (11.6%) patients were excluded for incomplete data. The remaining 90 (80.3%) patients, with a mean age of 32.9 had non-contributory loopograms and underwent a reversal procedure. 43 (47.8%) had a loop colostomy while 47 (52.2%) had undergone a Hartmann's procedure. Mechanism of injury was stab wounds (81.4%L; 61.7%H); gunshot wounds (13.9%L; 29.7%H) and blunt trauma (L5% and 9%H). The post-operative complication rate was 30% for the loop group (2.3% ≥ Clavien-Dindo 3) and 25.5% for the Hartmann's group (4% ≥ Clavien-Dindo 3). The average timing to reversal was 38 weeks (range 12-60) in the Hartmann's group and 22 weeks (range 12-32) the loop colostomy group. CONCLUSION Significant findings are infrequent on loopogram for trauma patients. When these findings are detected, the effect on management is questionable. They are not without complications and have cost and time implications. Loopograms are helpful in selective cases rather than as a routine investigation, particularly in resource-limited settings.
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Affiliation(s)
| | | | - Maeyane Stephens Moeng
- University of Witwatersrand, Parktown, Johannesburg, 2193, South Africa
- Academic Head of Trauma, Charlotte Maxeke Johannesburg Academic Hospital, Parktown, Johannesburg, 2193, South Africa
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39
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Brind'Amour A, Pravong V, Sidéris L, Dubé P, De Guerke L, Fortin S, Auclair MH, Trilling B, Tremblay JF. Rectal anastomosis and hyperthermic intraperitoneal chemotherapy: Should we avoid diverting loop ileostomy? Eur J Surg Oncol 2021; 47:2346-2351. [PMID: 33637373 DOI: 10.1016/j.ejso.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/18/2021] [Accepted: 02/08/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Literature on rectal anastomosis and diverting ileostomy in patients treated with hyperthermic intraperitoneal chemotherapy (HIPEC) is limited. This study assesses the safety of rectal anastomoses during cytoreductive surgery (CRS) and HIPEC, with and without fecal diversion, and its morbidity when performed. MATERIALS AND METHODS From January 2012 to January 2020, patients with peritoneal metastases who underwent CRS and HIPEC that required a rectal anastomosis were included in this single-hospital retrospective chart review. RESULTS 84 patients were included, of which 29 had a diverting loop ileostomy. The rectal anastomotic leak (AL) rate for the series was 8.3%. Factors associated with AL were male gender (p = 0.031) and increased BMI (p < 0.0005). Diverting loop ileostomy was associated with a significant decrease of clinically significant rectal AL (0% vs 12.7%, p = 0.045). However, the 90-day readmission rate was higher in this group (37.9% vs 10.9%, p = 0.003). Stoma reversal surgery was performed for all patients, but 3 patients experienced AL (10.7%). CONCLUSIONS This study suggests that creation of a diverting loop ileostomy may be an effective strategy to prevent symptomatic rectal AL following CRS with HIPEC. However, it is also associated with an increased readmission rate and increased risk of AL following reversal surgery.
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Affiliation(s)
| | - Vera Pravong
- Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Lucas Sidéris
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Pierre Dubé
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Lara De Guerke
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Gynecology & Obstetrics, University of Montreal, Montreal, QC, Canada
| | - Suzanne Fortin
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Gynecology & Obstetrics, University of Montreal, Montreal, QC, Canada
| | - Marie-Hélène Auclair
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Gynecology & Obstetrics, University of Montreal, Montreal, QC, Canada
| | - Bertrand Trilling
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Jean-François Tremblay
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada.
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Dreifuss NH, Bras Harriott C, Schlottmann F, Bun ME, Rotholtz NA. Laparoscopic resection and primary anastomosis for perforated diverticulitis: with or without loop ileostomy? Updates Surg 2021; 73:555-560. [PMID: 33486710 DOI: 10.1007/s13304-020-00952-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Evidence is growing about the benefits of laparoscopic resection with primary anastomosis (RPA) in perforated diverticulitis. However, the role of a diverting ileostomy in this setting is unclear. The aim of this study was to analyze the outcomes of laparoscopic RPA with or without a proximal diversion in Hinchey III diverticulitis. METHODS This is a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for perforated Hinchey III diverticulitis during the period 2000-2019. The sample was divided into two groups: RPA without diversion (G1) and RPA with protective ileostomy (G2). Primary outcomes of interest were 30-day overall morbidity, mortality, length of hospital stay (LOS), and urgent reoperation rates. Secondary outcomes of interest included operative time, readmission, and anastomotic leak rates. RESULTS Laparoscopic RPA was performed in 94 patients: 76 without diversion (G1) and 18 with proximal loop ileostomy (G2). Mortality (G1: 1.3% vs. G2: 0%, p = 0.6), urgent reoperation (G1: 7.9% vs. G2: 5.6%, p = 0.73), and anastomotic leak rates (G1: 5.3% vs. G2: 0%, p = 0.32) were comparable between groups. Higher overall morbidity (G1: 27.6% vs. G2: 55.6%, p = 0.02) and readmission rates (G1: 1.3% vs. G2: 11.1%, p = 0.03), and longer LOS (G1: 6.3 vs. G2: 9.2 days, p = 0.02) and operative time (G1: 182.4 vs. G2: 230.2 min, p = 0.003) were found in patients with proximal diversion. CONCLUSION Laparoscopic RPA had favorable outcomes in selected patients with Hinchey III diverticulitis. The addition of a proximal ileostomy resulted in increased morbidity, readmissions, and length of stay. Further investigation is needed to establish which patients might benefit from proximal diversion.
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Affiliation(s)
- Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | | | - Maximiliano E Bun
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina.,Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon 1640, C1118AAT, Buenos Aires, Argentina
| | - Nicolás A Rotholtz
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina. .,Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon 1640, C1118AAT, Buenos Aires, Argentina.
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Farzaneh CA, Jafari MD, Duong WQ, Grigorian A, Carmichael JC, Mills SD, Brady MT, Pigazzi A. Evaluation of Pelvic Anastomosis by Endoscopic and Contrast Studies Prior to Ileostomy Closure: Are Both Necessary? A Single Institution Review. Am Surg 2021; 86:1296-1301. [PMID: 33284668 DOI: 10.1177/0003134820964227] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Contrast enema is the gold standard technique for evaluating a pelvic anastomosis (PA) prior to ileostomy closure. With the increasing use of flexible endoscopic modalities, the need for contrast studies may be unnecessary. The objective of this study is to compare flexible endoscopy and contrast studies for anastomotic inspection prior to defunctioning stoma reversal. Patients with a protected PA undergoing ileostomy closure between July 2014 and June 2019 at our institution were retrospectively identified. Demographics and clinical outcomes in patients undergoing preoperative evaluation with endoscopic and/or contrast studies were analyzed. We identified 207 patients undergoing ileostomy closure. According to surgeon's preference, 91 patients underwent only flexible endoscopy (FE) and 100 patients underwent both endoscopic and contrast evaluation (FE + CE) prior to reversal. There was no significant difference in pelvic anastomotic leak (2.2% vs. 1%), anastomotic stricture (1.1% vs. 6%), pelvic abscess (2.2% vs. 3.0%), or postoperative anastomotic complications (4.4% vs. 9%) between groups FE and FE + CE (P > .05). Flexible endoscopy alone appears to be an acceptable technique for anastomotic evaluation prior to ileostomy closure. Further studies are needed to determine the effectiveness of different diagnostic modalities for pelvic anastomotic inspection.
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Affiliation(s)
- Cyrus A Farzaneh
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, CA, USA
| | - Mehraneh D Jafari
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, CA, USA
| | - William Q Duong
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, CA, USA
| | - Joseph C Carmichael
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, CA, USA
| | - Steven D Mills
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, CA, USA
| | - Matthew T Brady
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, CA, USA
| | - Alessio Pigazzi
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, CA, USA
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Ammendola M, Ruggiero M, Talarico C, Memeo R, Ammerata G, Capomolla A, Filippo R, Romano R, Pallio S, Navarra G, Montemurro S, Currò G. No Coil® placement in patients undergoing left hemicolectomy and low anterior resection for colorectal cancer. World J Surg Oncol 2020; 18:327. [PMID: 33302970 PMCID: PMC7731543 DOI: 10.1186/s12957-020-02096-z] [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: 10/28/2020] [Accepted: 11/26/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the most common tumor of the gastrointestinal tract. Anastomotic leak (AL) and prolonged postoperative ileus (PPOI) are two important complications of colorectal surgery. In this observational retrospective study, we evaluated the positive effects of transanal tube No Coil® in patients with CRC undergoing low anterior resection (LAR) and left hemicolectomy (LC). METHODS Thirty-eight cases and forty controls resulted eligible for the final sample. No Coil® placement (SapiMed Spa, Alessandria, Italy) was considered an inclusion criteria for the case group. No Coil® was placed immediately after the end of surgical treatment. RESULTS PPOI was significantly more frequent in the control group. AL was evident in 1 patient (2.6%) of cases and 3 patients (7.5%) of controls. No statistical difference was found in AL occurrence between groups. POI days and AL resulted associated with hospital stay. POI days were negatively associated with No Coil placement and positively with AL. CONCLUSION With our preliminary data, we suggest that No Coil® placement can be considered as a valuable procedure assisting colorectal surgery, but further studies are required to confirm and enlarge actual evidence.
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Affiliation(s)
- Michele Ammendola
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy.
| | - Michele Ruggiero
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Carlo Talarico
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Riccardo Memeo
- Hepato-Biliary and Pancreatic Surgical Unit, "F. Miulli" Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Giorgio Ammerata
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Antonella Capomolla
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Rosalinda Filippo
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Roberto Romano
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Socrate Pallio
- Department of Clinical and Experimental Medicine, Digestive Diseases Endoscopy Unit, "G. Martino" Hospital, University of Messina, Messina, Italy
| | - Giuseppe Navarra
- Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, "G. Martino" Hospital, University of Messina, Messina, Italy
| | - Severino Montemurro
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Giuseppe Currò
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy.,Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, "G. Martino" Hospital, University of Messina, Messina, Italy
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43
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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.
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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
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44
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Xu Z, Qu H, Kanani G, Guo Z, Ren Y, Chen X. Update on risk factors of surgical site infection in colorectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:2147-2156. [PMID: 32748113 DOI: 10.1007/s00384-020-03706-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Surgical site infection (SSI) in colorectal cancer (CRC) has been a serious health care problem due to the delay of postoperative recovery. Our present study aimed to explore the risk factors for SSI in CRC patients. METHODOLOGY We have systematically searched these databases: PubMed, Cochrane Library, and EMBASE as of March 2020 for studies on risk factors associated with SSI. Two investigators independently conducted the quality assessment and data extraction. Related risk factors in the studies were recorded, and a meta-analysis was performed. RESULTS The search initially provided 2262 hits, 1913 studies were screened by two independent investigators. Finally, 15 studies were identified to be relevant for this meta-analysis. In total, 25 risk factors were eligible. Our meta-analysis indicated that eight factors (obesity, male sex, diabetes mellitus, ASA score ≥ 3, stoma creation, intraoperative complications, perioperative blood transfusion, and operation time ≥ 180 min) were significant risk factors for SSI, and one factor (laparoscopic procedure) was protective for SSI. CONCLUSIONS Effective interventions targeting the above factors may reduce the risk of developing postoperative SSI in CRC patients and improve the clinical outcome of patients. Further prospective studies are needed to confirm these findings.
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Affiliation(s)
- Zhaohui Xu
- Dalian Medical University, Dalian, China
| | - Hui Qu
- Dalian Medical University, Dalian, China
| | | | - Zhong Guo
- Dalian Medical University, Dalian, China
| | - Yanying Ren
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, 467 Zhong Shan Road, Dalian, 116023, People's Republic of China
| | - Xin Chen
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, 467 Zhong Shan Road, Dalian, 116023, People's Republic of China.
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45
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Liu RQ, Guo D, Qiao SH, Yin Y, Guo Z, Gong JF, Li Y, Zhu WM. Comparison of primary anastomosis and staged surgery in emergency treatment of complicated Crohn's disease. J Dig Dis 2020; 21:724-734. [PMID: 33012107 DOI: 10.1111/1751-2980.12949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 07/10/2020] [Accepted: 09/29/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Staged surgery (SS) and primary anastomosis (PA) are alternatives to emergency surgery in Crohn's disease (CD). This study aimed to compare postoperative patient outcomes and medical cost of SS and PA for CD emergencies. METHODS Consecutive patients with CD undergoing emergency surgery between December 1997 and January 2017 in three centers were included. The PA and SS groups were compared regarding patient outcomes including postoperative complications and surgical recurrence, as well as hospitalization costs. RESULTS Altogether 96 (39.5%) patients underwent an emergency PA, and 147 (60.5%) underwent an emergency SS. The incidence of intra-abdominal septic complications (IASC) in the PA group was 15.6% compared with 7.5% in the SS group (P = 0.04). The length of hospitalization was longer (32.36 ± 1.76 d vs 19.33 ± 2.36 d, P <0.01) and the hospitalization cost was higher in the SS group (USD 15 811.1 ± 1697.1 vs USD 8345.3 ± 919.5, P <0.01) than the PA group. SS correlated with a lower surgical recurrence rate than PA (log-rank test, P = 0.04). Presence of diffuse peritonitis, perforating or colonic disease, decision of operation choice made by a senior consultant and more than two concurrent surgical indications were related to the need for SS in emergencies. Localized peritonitis, body mass index (>18.5 kg/m2 ) and iatrogenic perforation were significantly associated with a low risk of IASC in the PA group. CONCLUSION SS can be performed with limited IASC and low surgical recurrence rates for surgical emergencies in CD, although it increases hospitalization costs and delays discharge.
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Affiliation(s)
- Rui Qing Liu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China.,Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Dong Guo
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Shuai Hua Qiao
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Yi Yin
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Jian Feng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Wei Ming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
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Rai V, Mishra N. Surgical Management of Recurrent Uncomplicated Diverticulitis. Clin Colon Rectal Surg 2020; 34:91-95. [PMID: 33642948 DOI: 10.1055/s-0040-1716700] [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
Sigmoid diverticulitis represents a most common gastroenterological diagnosis in the western world. There has been a significant change in the management of recurrent uncomplicated diverticulitis in the last 10 to 15 years. The absolute number of previous episodes is not used as criteria to recommend surgery anymore. Young age is no longer considered to be an indication for more aggressive surgical treatment. It is accepted that subsequent episodes of diverticulitis are not significantly worse than the first episode. Laparoscopic surgery is now the standard of care for elective surgery for diverticulitis where expertise is available. There is a consensus that decision to perform sigmoid colectomy should be individualized, after careful risk benefit assessment.
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Affiliation(s)
- Vinay Rai
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Nitin Mishra
- Department of Surgery, Mayo Clinic College of Medicine, Phoenix, Arizona
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47
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Lee N, Lee SY, Kim CH, Kwak HD, Ju JK, Kim HR. The Relationship Between High-Output Stomas, Postoperative Ileus, and Readmission After Rectal Cancer Surgery With Diverting Ileostomy. Ann Coloproctol 2020; 37:44-50. [PMID: 32972101 PMCID: PMC7989563 DOI: 10.3393/ac.2020.08.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose This study aimed to evaluate the relationship between high-output stomas (HOSs), postoperative ileus (POI), and readmission after rectal cancer surgery with diverting ileostomy. Methods We included 302 patients with rectal cancer who underwent restorative resection with diverting ileostomy between January 2011 and December 2015. HOSs were defined as stomas with ≥ 2,000 mL/day output. We analyzed predictive factors for readmission of these patients. Results Forty-eight patients (15.9%) had HOSs during the hospital stay, and 41 patients (13.6%) experienced POI. HOSs were strongly associated with POI (45.8% vs. 7.5%, P < 0.001). The all-cause readmission rate was 16.9%, with 19 (6.3%) and 20 (6.6%) experiencing ileus and acute kidney injury, respectively. HOSs (27.1% vs. 15.0%, P = 0.040) and POI (34.1% vs. 14.2%, P = 0.002) were associated with all-cause readmission, and POI was associated with readmission with ileus (17.1% vs. 4.6%, P = 0.007). POI was an independent risk factor for all-cause readmission (adjusted odds ratio [OR], 2.640; 95% confidence interval [CI], 1.162 to 6.001; P = 0.020) and readmission with ileus (adjusted OR = 3.869; 95% CI 1.387 to 10.792; P = 0.010). Conclusion POI was associated with readmission, particularly for subsequent ileus, in patients with diverting ileostomy. We should make efforts to reduce POI, such as strong control of HOSs, to prevent readmission.
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Affiliation(s)
- Naa Lee
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Soo Young Lee
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Han Deok Kwak
- Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jae Kyun Ju
- Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyeong Rok Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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de Paula TR, Nemeth S, Kiran RP, Keller DS. Predictors of complications from stoma closure in elective colorectal surgery: an assessment from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP). Tech Coloproctol 2020; 24:1169-1177. [PMID: 32696174 PMCID: PMC7373840 DOI: 10.1007/s10151-020-02307-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/13/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is significant morbidity after diverting ileostomy closure, so identifying predictors of complications could be of great benefit. The aim of our study was to evaluate the incidence and risk factors for postoperative morbidity after elective ileostomy closure. METHODS The ACS-NSQIP dataset was evaluated for elective ileostomy closures from 1/1/2015 to 12/31/2016. Demographic characteristics, operative, and postoperative outcomes were evaluated. The primary outcome was 30-day major morbidity (Clavien class III and greater). Secondary outcomes were rates and predictors of major morbidity, superficial site infection (SSI), reoperation, and readmission from multivariate logistic regression modeling. RESULTS We retrospectively evaluated 1885 patients. The median operative time was 65 (IQR 50-90) minutes and median length of stay was 3 (IQR 2-5) days. Major morbidity was recorded in 6.7%, including mortality (1.0%), deep/organ space SSI (2.6%), dehiscence (0.8%), reintubation (0.5%), sepsis (1.7%), septic shock (0.8%), and reoperation (3.7%). Readmission was recorded in 9.7% and 6.2% had SSI. Multivariate logistic regression showed male sex (OR 1.584; 95% CI 1.068-2.347; p = 0.022) and longer operative time (OR 1.004; 95% CI 1.001-1.007; p = 0.009) were among those variables associated with increased odds of major morbidity. Dyspnea (OR 2.431; 95% CI 1.139-5.094; p = 0.021) and longer operative time (OR 1.003; 95% CI 1.001-1.007; p = 0.034) were among the independent risk factors for SSI. Male sex (OR 2.246; 95% CI 1.297-3.892; p = 0.004, chronic obstructive pulmonary disease (OR 2.959; 95% CI 1.153-7.591; p = 0.024), and longer operative time (OR 1.005; 95% CI 1.001-1.009; p = 0.011) were associated with increased odds of reoperation. Chronic obstructive pulmonary disease (OR 2.578; 95% CI 1.338-4.968; p = 0.005), wound infection (OR 2.680; 95% CI 1.043-6.890; p = 0.041), and inflammatory bowel disease (OR 2.565; 95% CI 1.203-5.463; p = 0.015) were associated with increased odds of readmission. CONCLUSIONS Elective stoma closure has significant risk of morbidity. Patients with longer operative times were at increased risk for major morbidity, overall SSI, and reoperation. From the analysis, factors specifically associated with major morbidity, overall infectious complications, readmissions, and reoperations were identified. This information can be used to prospectively prepare for these high-risk patients, potentially improving postoperative outcomes.
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Affiliation(s)
- T R de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - S Nemeth
- Columbia HeartSource, Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY, USA
| | - R P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - D S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA. .,Division of Colon and Rectal Surgery, Department of Surgery, Herbert Irving Comprehensive Cancer Center, NewYork-Presbyterian, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 8th Floor, New York, NY, 10032, USA.
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Robotic treatment of bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 2020; 71:129-143. [PMID: 32684433 DOI: 10.1016/j.bpobgyn.2020.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022]
Abstract
Endometriosis describes a condition with the presence of ectopic endometrial glands and stroma outside the endometrial cavity that affects up to 15% of reproductive-aged women. Of women affected with endometriosis, 3.8-37% will have endometriosis involving the bowel, primarily the rectosigmoid colon. While medical management is often recommended as a first-line therapy, it is not curative, and surgery is often required as an adjunct for the management of symptoms. Minimally invasive surgery has become the standard of care for managing these patients. The use of robotic-assisted laparoscopy offers benefits that may allow surgeons to perform these challenging surgical cases using a minimally invasive technique. For lesions that affect the colon, there are three primary techniques used for removal which include: 1) rectal shaving, 2) discoid excision and 3) segmental resection. The decision to pursue one approach over another is largely dependent on the number of lesions present, a lesion's size and depth of invasion as well as the involved circumference of the bowel. The available evidence of using robotic-assisted laparoscopy in cases of bowel endometriosis is limited in the literature. In this review, we will summarize the role of robotic-assisted laparoscopy in the management of bowel endometriosis.
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Gunnells D, Kennedy GD. Proximal diversion after colectomy: The debate continues. Am J Surg 2020; 220:828-829. [PMID: 32684293 DOI: 10.1016/j.amjsurg.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/07/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Drew Gunnells
- University of Alabama at Birmingham, Department of Gastrointestinal Surgery.
| | - Gregory D Kennedy
- University of Alabama at Birmingham, Department of Gastrointestinal Surgery
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