“Virtual ileostomy” combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report

Virtual Ileostomy as an Option for Complicated Colorectal Resections

When surgery requires a colorectal anastomosis, a diverting ostomy may be created to decrease the clinical impact of anastomotic failure. Unfortunately, diverting ileostomies are also associated with significant morbidity. Recent literature suggests that diverting ostomies are not necessary for the majority of patients undergoing colorectal anastomosis and that creation of a virtual ileostomy (VI) may spare patients the complications that accompany diverting ileostomy creation. We present 4 patients with complex medical histories who underwent colorectal resections with primary anastomoses and VI creation. None of these patients suffered anastomotic leak or required conversion of VI to defunctioning ileostomy and there were no major complications associated with VI creation. Our results, although limited by sample size, support the creation of a virtual ileostomy as a safe and effective alternative to diverting ileostomy creation at the time of colorectal anastomosis.

Ostomy Does Not Lead to Worse Outcomes After Bowel Resection With Ovarian Cancer: A Systematic Review

Background

Debulking cytoreduction surgery with bowel resection is a common intervention for ovarian cancer. It is controversial whether ostomy causes worse survival outcomes and how clinical physicians should choose which patients to undergo ostomy. During this study, we performed a systematic review to determine whether ostomy leads to worse outcomes after bowel resection compared to anastomosis. We also summarized the possible indications for ostomy.

Methods

We searched PubMed, Embase, and Cochrane for articles containing the phrase "ovarian cancer with bowel resection" that were published between 2016 and 2021. We included studies that compared primary anastomosis with ostomy. We mainly focused on differences in the anastomotic leakage rate, length of hospital stay, overall survival, and other survival outcomes associated with the two procedures.

Results and Conclusion

Of the 763 studies, three were ultimately included in the systematic review (N=1411). We found that ostomy did not contribute to worse survival outcomes, and that the stoma-related complications were acceptable. Indications for ostomy require further study. Bowel resection segment margins and the distance from the anastomosis to the anal verge require consideration.

Evaluation of Bowel Function After Surgical Treatment for Intestinal Endometriosis: A Prospective Study

BACKGROUND

Defecation symptoms related to intestinal deep infiltrative endometriosis are caused by anatomical and functional disorders and are probably linked to the course of the disease and surgical treatment.

OBJECTIVE

The primary aim of this study was to assess bowel function before and after intestinal deep infiltrative endometriosis surgery. Secondarily, we sought to correlate defecatory symptoms with preoperative risk factors.

DESIGN/SETTINGS

This is a single-center prospective cohort study, using the low anterior resection syndrome score to evaluate bowel function 4 weeks before, as well as at 6 months and 1 year after surgery. The Wilcoxon signed-rank test and logistic multiple regression analyses were performed to compare preoperative and postoperative scores. The level of significance was set at <0.05 for all comparisons.

PATIENTS

Thirty-seven adult female patients who underwent intestinal resection for deep infiltrative endometriosis between 2015 and 2017 were included.

MAIN OUTCOME MEASURES

The primary outcome was bowel function appraisement in deep infiltrative endometriosis intestinal surgery.

RESULTS

During the preoperative evaluation, 48.6% of patients reported low anterior resection syndrome score ≥21. This group presented a mean score of 17.9 ± 13.7, with a median of 20 and a range of 5 to 30. After 1 year, the mean score was decreased to 9.6 ± 11.1, with a median of 4 and a range of 0 to 22. A significant difference was detected when comparing the post- and preoperative scores (p = 0.0006). Improvements in defecatory symptoms such as reduced fecal incontinence for flatus (p = 0.004) and liquid stools (p = 0.014) were also reported. The clustering of stools (p = 0.005) and fecal urgency (p = 0.001) also improved 1 year after surgery. The preoperative multiple logistic regression showed that dyschezia was the only independent variable associated with bowel symptoms.

LIMITATIONS

This is a well-documented prospective study, but the data presented have a relatively small population.

CONCLUSIONS

This study provides evidence that intestinal deep infiltrative endometriosis surgery improves bowel function and has a positive impact on evacuation symptoms. See Video Abstract at http://links.lww.com/DCR/B534.

EVALUACIN DE LA FUNCIN INTESTINAL DESPUS DEL TRATAMIENTO QUIRRGICO PARA LA ENDOMETRIOSIS INTESTINAL UN ESTUDIO PROSPECTIVO

ANTECEDENTES:Se considera que los síntomas defecatorios relacionados con la endometriosis intestinal infiltrativa profunda, son causados por trastornos anatómicos y funcionales, y probablemente estén relacionados con el curso de la enfermedad y tratamiento quirúrgico.OBJETIVO:El objetivo principal fue evaluar la función intestinal antes y después de la cirugía por endometriosis intestinal infiltrativa profunda. En segundo lugar, correlacionar los síntomas defecatorios con los factores de riesgo preoperatorios.DISEÑO / AJUSTES:Es un estudio de cohorte prospectivo de un solo centro, utilizando la puntuación del síndrome de resección anterior baja (LARS Score) para evaluar la función intestinal 4 semanas antes, 6 meses y un año después de la cirugía. Se realizaron pruebas de rango firmado de Wilcoxon y análisis de regresión logística múltiple para comparar puntuaciones preoperatorias y postoperatorias. Para todas las comparaciones, el nivel de significancia se estableció en <0.05.ENTORNO CLINICO:Se incluyeron 37 mujeres adultas sometidas a resección intestinal por endometriosis infiltrativa profunda entre 2015 y 2017.PRINCIPALES MEDIDAS DE VALORACION:El resultado principal, fue la evaluación de la función intestinal en cirugía de endometriosis infiltrativa profunda intestinal.RESULTADOS:Durante la evaluación preoperatoria, el 48,6% de los pacientes reportaron Síndrome de Resección Anterior Baja ≥ 21. Este grupo presentó una puntuación media de 17,9 ± 13,7, con una mediana de 20 y un rango de 5 a 30. Después de un año, la puntuación media se redujo a 9,6 ± 11,1, con una mediana de 4 y un rango de 0 a 22 Se detectó una diferencia significativa al comparar las puntuaciones postoperatorias y preoperatorias (p = 0,0006). Se informó de mejoras en los síntomas defecatorios como la reducción de la incontinencia fecal por flatos (p = 0,004) y heces líquidas (p = 0,014). La agrupación de heces (p = 0,005) y la urgencia fecal (p = 0,001) presentaron mejoría a un año después de la cirugía. La regresión logística múltiple preoperatoria mostró que la disquecia fue la única variable independiente asociada con los síntomas intestinales.LIMITACIONES:A pesar de que es un estudio prospectivo bien documentado, los datos presentados son de una población relativamente pequeña.CONCLUSIONES:El estudio proporciona evidencia de que la cirugía intestinal por endometriosis infiltrativa profunda, mejora la función intestinal y tiene un impacto positivo en los síntomas de evacuación. Consulte Video Resumen en http://links.lww.com/DCR/B534.

Comparative study between ghost ileostomy and defunctioning ileostomy in terms of morbidity and cost-effectiveness in low anterior resection for rectal cancer

PURPOSE

The aim of this study was to compare ghost ileostomy (GI) and defunctioning ileostomy (DI) in patients who underwent low anterior resection (LAR) for rectal cancer in terms of postoperative morbidity, rehospitalization rates, and total costs.

METHODS

Patients with an anastomosis level between 5 and 10 cm from the anal verge after LAR were analyzed retrospectively. Clinical characteristics, operative outcomes, postoperative morbidity, rehospitalization rates, and total costs were compared.

RESULTS

A total of 123 patients were enrolled as follows: 42 patients in the GI group and 81 patients in the DI group. Anastomotic leakage (AL) was identified in three patients who underwent GI, and in all of them, GI was easily converted to DI. There were 96.3% of the patients with DI rehospitalized at least one time because of surgery-related and/or stoma-related complications or stoma closure. When we did not take into account the patients who were rehospitalized for stoma closure, the rates of rehospitalization were 4.7% and 22.2% in the GI and DI groups, respectively (P= 0.01). The mean total costs calculated by removing additional surgical procedures and adding all of the rehospitalization costs were 25,767 USD and 41,875 USD in the GI and DI groups, respectively (P= 0.0001).

CONCLUSION

GI may be a safe and cost-effective method in patients who underwent LAR with low or medium risk factors for AL. It is possible to avoid unnecessary ileostomy and reduce unwanted outcomes due to it, such as postoperative complications, rehospitalizations, and increased total costs by performing GI.

Low preoperative maximum squeezing pressure evaluated by anorectal manometry is a risk factor for non-reversal of diverting stoma

PURPOSE

A diverting stoma is created to prevent anastomotic leakage and related complications impairing sphincteric function in rectal surgery. However, diverting stoma may be left unclosed. This study is aimed to analyze preoperative factors including anorectal manometric data associated with diverting stoma non-reversal before rectal surgery. We also addressed complications related to diverting stoma in patients undergoing surgery for rectal malignant tumor.

METHODS

A total of 203 patients with rectal malignant tumor who underwent sphincter-preserving surgery with diverting stoma were retrospectively evaluated. The risk factors for non-reversal of diverting stoma were identified by univariate and multivariate analyses. For these analyses, anorectal manometric data were measured before rectal surgery. The association between stoma-related complications and other clinicopathological features was also analyzed.

RESULTS

During the median follow-up of 46.4 months, 24% (49 patients) did not undergo stoma reversal. Among parameters that were available before rectal surgery, age ≥ 75 years, albumin < 3.5 g/dl, tumor size ≥ 30 mm, tumor distance from the anal verge < 4 cm, and maximum squeezing pressure (MSP) < 130 mmHg measured by anorectal manometry (ARM) were independent factors associated with stoma non-reversal. The most common stoma-related complication was peristomal skin irritation (25%). Ileostomy was the only factor associated with peristomal skin irritation.

CONCLUSION

The current study demonstrated that low preoperative MSP evaluated by ARM, old age, hypoalbuminemia, and a large tumor close to the anus were predictive of diverting stoma non-reversal. Stoma site should be well deliberated when patients have the aforementioned risk factors for diverting stoma non-reversal.

Virtual ileostomy in elective colorectal surgery: a systematic review of the literature

BACKGROUND

Anastomotic leak (AL) following colorectal surgery can be a life-threatening complication. The use of a diverting stoma has been proposed, to prevent or reduce morbidity and mortality associated with AL. Stomas, however, have their own distinct complications. Thus, virtual ileostomy (VI) has been proposed as an alternative to diverting stoma. The aim of the present study was to further evaluate the role of VI through systematic review of existing literature.

METHODS

A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane handbook for systematic reviews of interventions. The primary endpoint of our study was the estimation of the overall VI complication rate. Secondary endpoints included the identification of the VI-specific adverse outcomes, perioperative endpoints such as the length of hospital stay, transfusion and postoperative leak rates, description of the operative variations of VI reported VI operative variations and details regarding the primary operation and previous neoadjuvant therapy.

RESULTS

In total, 11 studies and 554 patients were included in this systematic review. Overall, 158 laparoscopic and 191 open procedures were performed. The AL and VI conversion rates were 11.9% and 10.46%, respectively. The total complication rate was estimated to be 13.9%, while VI-specific adverse events were recorded in 2.1% of all cases.

CONCLUSIONS

VI could be a safe and effective alternative to a diverting stoma. Although currently, VI is not widely used, it could have a widespread application in laparoscopic surgery. However, definitive trials are needed before firm recommendations on the use of VI can be made.