Early versus late closure of temporary ileostomy after rectal cancer surgery: a meta-analysis

Timing of Loop Ileostomy Closure Does Not Play a Pivotal Role in Terms of Complications-Results of the Liquidation of iLEOstomy (LILEO) Study

Loop ileostomy is commonly performed by colorectal and general surgeons to protect newly created large bowel anastomoses. The optimal timing for ileostomy closure remains debatable. Defining the timing associated with the best postoperative outcomes can significantly improve the clinical results for patients undergoing ileostomy closure. The LILEO study was a prospective multicenter cohort study conducted in Poland from October 2022 to December 2023. Full data analysis involved 159 patients from 19 surgical centers. Patients were categorized based on the timing of ileostomy reversal: early (<4 months), standard (4-6 months), and delayed (>6 months). Data on demographics, clinical characteristics, and perioperative outcomes were analyzed for each group separately and compared. No significant differences were observed in length of hospital stay (p = 0.22), overall postoperative complications (p = 0.43), or 30-day reoperation rates (p = 0.28) across the three groups. Additional analysis of Clavien-Dindo complication grades was performed and did not show significant differences in complication severity (p = 0.95), indicating that the timing of ileostomy closure does not significantly impact perioperative complications or hospital stay. Decisions on ileostomy reversal timing should be personalized and should consider individual clinical factors, including the type of adjuvant oncological treatment and the preventive measures performed for common postoperative complications.

Early versus late closure of protective loop ileostomy: functional significant results in a preliminary analysis

BACKGROUND

Protective loop ileostomy (PLI), commonly performed in rectal cancer surgery, is one of the most reliable methods to reduce the risk of sepsis associated with anastomotic complications. The correct timing of PLI closure is not well defined. Recently, most surgeons proposed to close early the PLI. The aim of this study was to evaluate the impact of the timing of stoma closure on postoperative outcomes.

METHODS

We analyzed prospectively data of patients who received PLI anterior resection for rectal cancer between January 2020 to June 2022. Patients were divided into 2 groups according to the timing of stoma closure, until four weeks (EC group) and more than four weeks (LC group). Outpatient clinic follow-up, perioperative data, postoperative complications and evidence of anterior resection syndrome with the Low-Anterior Resection Score (LARS) score were recorded.

RESULTS

In the EC group 24 patients were included while 27 patients were considered for LC group. There were no differences between the groups with respect to all parameters, except for recourse to adjuvant therapy, higher for LC group. Perioperative analyzed characteristics were similar among groups. There was no statistically significant difference between the EC group and the LC group for complication rate. LARS score was higher in the LC group for score >20 and >30.

CONCLUSIONS

Timing of PLI closure was not a significant independent predictor of post-closure complications rate. LARS incidence was significantly related to longer time of closure, with probably late recovery of motility function, but this should be confirmed by randomized studies.

Discharge teaching quality positively predicts quality of life in colorectal cancer patients with temporary enterostomy: The mediating role of readiness for hospital discharge and stoma self-efficacy

OBJECTIVES

This study aimed to examine the mediating role of readiness for hospital discharge (RHD) and stoma self-efficacy (SSE) in the relationship between quality of discharge teaching (QDT) and health-related quality of life (HRQOL) in colorectal cancer patients with temporary enterostomy, and the gender difference of mediating effect.

BACKGROUND

It is not clear how RHD, QDT, SSE and HRQOL interact in colorectal cancer patients with temporary enterostomy.

METHODS

This was a prospective follow-up survey. 221 colorectal cancer patients with temporary enterostomy were conveniently recruited from a general hospital in Southeast China. The Quality of Discharge Teaching Scale, Readiness for Hospital Discharge Scale, Stoma Self-Efficacy Scale, and Stoma Quality of Life Scale were used to collect data. Pearson's correlation and structural equation models were used to analyze the data. SPSS 26.0 and Amos 28.0 software were used for analysis the collected data.

RESULTS

Regarding the relationship of QDT and HRQOL, only QDT-T had a direct effect among colorectal cancer patients with stomas (b = 0.233, P<0.001, percentile 95% CI = [0.145, 0.314]). However, both QDT-T and QDT-R can predict HRQOL indirectly through three paths: (1) the mediating role of SSE (b = 0.050, P = 0.009, percentile 95% CI = [0.013, 0.098]; b = 0.077, P = 0.008, percentile 95% CI = [0.021, 0.164]), (2) the mediating role of RHD (b = 0.044, P = 0.004, percentile 95% CI = [0.014, 0.085]; b = 0.044, P = 0.005, percentile 95% CI = [0.010, 0.102]), and (3) the chain mediating role of SSE and RHD (b = 0.030, P = 0.003, percentile 95% CI = [0.011, 0.059]; b = 0.047, P = 0.003, percentile 95% CI = [0.015, 0.103]). The similar chain mediating effect in male stoma patients was also found (b = 0.041, P = 0.002, percentile 95% CI = [0.016, 0.080]; b = 0.046, P = 0.004, percentile 95% CI = [0.011, 0.114]).

CONCLUSIONS

Stoma self-efficacy and readiness for hospital discharge played important intermediary roles in the relationship between quality of discharge teaching and health-related quality of life in colorectal cancer patients with stomas. Health care providers can design SSE-enhancing and RHD-enhancing discharge planning for colorectal cancer patients with temporary enterostomies.

Impact of the laparoscopic approach, early closure and preoperative stimulation on outcomes of ileostomy closure after rectal resection

AIM

To evaluate the clinical outcome of early closure of a protective ileostomy and preoperative stimulation of the efferent limb in a cohort of patients with rectal cancer treated surgically, primarily using the laparoscopic approach.

METHODS

We performed an observational retrospective cohort study in a prospectively recorded series of patients with rectal cancer who underwent laparoscopic surgery with a protective loop ileostomy between 2017 and 2022. Ileostomy closure was programmed for within 3 months after surgery. All patients underwent stimulation of the efferent limb. Primary outcomes were morbidity and mortality, length of stay (LOS), and re-admission.

RESULTS

Between 2017 and 2022, 108 patients underwent resection for rectal cancer and protective ileostomy. The laparoscopic approach was performed in 84.3% of patients (n = 91). Permanent ileostomy was performed in 5 patients (4.6%). Ileostomy closure was thus performed in 95.4% of patients (n = 103). Median time to closure was 74.5 days (range 57-113). In 63.1% (n = 65) of patients, reconstructive surgery was performed within 90 days. Prior to closure, efferent limb stimulation was performed in 77.8% (n = 84) of patients. Global morbidity was 26.2% (n = 27) (85.19%, n = 23 Clavien-Dindo I and 7.41%, n = 2 Clavien-Dindo II). The main causes of morbidity were postoperative ileus (10.7%, n = 11) and rectal bleeding (8.7%, n = 9). Anastomosis leakage occurred in 2 patients. Median hospital stay was 6 days (5-7). Readmission was needed in 6.8% (n = 7) of patients.

CONCLUSION

A previous laparoscopic approach, early closure and stimulation of the efferent limb could be a useful strategy to reduce the morbidity and mortality of temporary ileostomy closure.

Early closure compared to late closure of temporary ileostomy in rectal cancer: a randomized controlled trial study

BACKGROUND

A temporary loop ileostomy is one of the most common methods for the prevention of anastomotic leakage in rectal cancer patients who underwent low anterior resection. However, the optimal timing of loop ileostomy reversal remains unknown. The main objective of this study was to evaluate the debilitating complications caused by early closure of ileostomy in comparison with late closure in rectal cancer patients.

DESIGN

A randomized, controlled, unblinded, and monocentric trial.

METHODS

A total of 104 rectal cancer patients were randomly assigned to the case group of early closure of ileostomy (n = 50) and the control group of late closure of ileostomy (n = 54). This trial was undertaken in a single colorectal institution, a university-affiliated teaching hospital in Tehran, Iran. Randomization and allocation to the trial group were conducted by using variable block randomization based on quadruple numbers. The primary endpoint of this trial was determined by the complications of early ileostomy closure versus those of late closure in rectal cancer patients who had undergone low anterior resection. In early closure, loop ileostomy is reversed 2-3 weeks after the first two courses of adjuvant chemotherapy, while in late closure, the ileostomy is reversed 2-3 weeks after the last course of adjuvant chemotherapy.

RESULTS

Follow-up of 1 year demonstrated a reduction in the risk of complications and an improved quality of life in patients with rectal cancer following low anterior resection and chemotherapy (neoadjuvant and adjuvant) in the case group but did not reach a significant difference (p = 0.555). In addition, there was no significant difference in perioperative outcomes, such as blood loss, operative time, readmission, and reoperation; also, no statistically significant differences were reported between the groups in patients' quality of life or LARS score.

CONCLUSION

In summary, it seems that early closure of ileostomy is not better than late closure in improving patients' quality of life with rectal cancer following low anterior resection and chemotherapy (neoadjuvant and adjuvant); no statistical difference was observed for reduction of risk of ostomy complications. Thus, neither of these methods (early closure versus late closure) is superior to the other, and controversy still exists.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

IRCT20201113049373N1.

[Prognostic factors of dehydration and renal damage in patients with formed preventive ileostomy during rectal resection for cancer]

Despite the potential advantages of a preventive intestinal stoma after the formation of a low colon anastomosis during rectal resections, the formation of a preventive loop ileostomy is associated with a significant frequency of complications.

OBJECTIVE

To determine the potential prognostic factors of complications associated with ileostomy dysfunction in patients who have undergone rectal resection for cancer.

MATERIAL AND METHODS

We retrospectively analyzed patients over the age of 18 who underwent open and laparoscopic resection of the rectum with the formation of a preventive ileostomy from January 2015 to May 2022. To determine the influence of potential predictors on the frequency of complications associated with large ileostomy losses, a single-factor logistic regression analysis was used. Complications associated with large ileostomy losses were primarily water-electrolyte disorders, dehydration and acute renal failure, which required intensive therapy and re-hospitalization.

RESULTS

Of the 120 patients included in the study, 26 (21.7%) suffered complications associated with large losses of fluid and electrolytes in the stoma. In this group of patients, at least one repeated emergency hospitalization to a medical institution was required (average value 1.6). Factors associated with ileostomy dysfunction in a single-factor analysis were: the presence of signs of intestinal obstruction (OR=2.6; p=0.047), the development of postoperative complications (OR=3; p=0.024), steroid use (OR=4.3; p=0.010), smoking (OR=4.8; p=0.017) the average amount of discharge from the stoma at discharge is more than 1000 ml/24 h (OR=3.2; p=0.016) and the need for Loperamide at the time of discharge (OR=2.8; p=0.032). Multivariate logistic regression analysis revealed an independent risk factor for complications leading to re-hospitalization: ileostomy losses at discharge ≥1000 ml/24 h (OR=3.3 (1.18-9.37); p=0.023).

CONCLUSION

In our study, those patients whose ileostomy discharge exceeded 1000 ml/24 h at discharge were at increased risk of dehydration, hypokalemia, hypocalcemia, acute prerenal renal failure, which led to repeated hospitalization to correct these disorders, sometimes in the intensive care unit.

Does temporary ileostomy via specimen extraction site affect the short outcomes and complications after laparoscopic low anterior resection in rectal cancer patients? A propensity score matching analysis

Purpose

The purpose of the current study was to compare the outcomes of temporary stoma through the specimen extraction site (SSES) and stoma through a new site (SNS) after laparoscopic low anterior resection.

Methods

The rectal cancer patients who underwent laparoscopic low anterior resection plus temporary ileostomy were recruited in a single clinical database from Jun 2013 to Jun 2020. The SSES group and the SNS group were compared using propensity score matching (PSM) analysis.

Results

A total of 257 rectal cancer patients were included in this study, there were 162 patients in the SSES group and 95 patients in the SNS group. After 1:1 ratio PSM, there was no difference in baseline information (p > 0.05). The SSES group had smaller intraoperative blood loss (p = 0.016 < 0.05), shorter operation time (p < 0.01) and shorter post-operative hospital stay (p = 0.021 < 0.05) than the SNS group before PSM. However, the SSES group shorter operation time (p = 0.006 < 0.05) than the SNS group after PSM, moreover, there was no significant difference in stoma-related complications (p > 0.05). In the multivariate analysis, longer operation time was an independent factor (p = 0.019 < 0.05, OR = 1.006, 95% CI = 1.001–1.011) for the stoma-related complications.

Conclusion

Based on the current evidence, the SSES group had smaller intraoperative blood loss, shorter operation time and shorter post-operative hospital stay before PSM, and shorter operation time after PSM. Therefore, SSES might be superior than SNS after laparoscopic low anterior resection for rectal cancer patients.

Risk factors for postoperative ileus after diverting loop ileostomy closure

BACKGROUND

Postoperative ileus is one of the most common complications after diverting loop ileostomy closure. Some reports have investigated the risk factors for postoperative complications or ileus after ileostomy closure; however, these studies did not evaluate the index surgery sufficiently. In this study, we evaluated the risk factors, including the details of the index surgery, for ileus after diverting ileostomy closure.

METHODS

This was a retrospective study of patients who underwent ileostomy closure following index surgery for rectal cancer. Patients who developed postoperative ileus [POI (+)] and patients who did not [POI (-)] after ileostomy closure were compared.

RESULTS

Sixty-eight patients were evaluated and were divided into two groups: POI (+) (n = 11) and POI (-) (n = 57), and the groups were compared. There were no significant differences in the details of the index surgery, operative procedure, transanal total mesorectal excision, lateral lymph node dissection, operating time, or blood loss. The incidence of Clavien-Dindo grade ≥ III complications and adjuvant chemotherapy after index surgery were significantly higher in the POI (+) group.

CONCLUSIONS

The incidence of Clavien-Dindo grade ≥ III complications and adjuvant chemotherapy after index surgery may increase the risk of postoperative ileus after ileostomy closure.

Ostomy closure rate during COVID-19 pandemic: an Italian multicentre observational study

During the corona virus disease 2019 (COVID-19) pandemic, most of the surgical procedures were performed for emergencies or oncologic reasons to the detriment of the remaining elective procedures for benign conditions. Ileostomy or colostomy creation are sequelae of oncologic or emergency colorectal surgery, but their closure does not fall within the definition of oncologic or emergency surgery. The aim of this retrospective multicentre observational study is to report the impact of COVID-19 pandemic on the ostomy closure rate in Italy. Data regarding ileostomy and colostomy creation and closure from 24 Italian centres, during the study period (March 2020–February 2021) and during the control period (March 2019–February 2020) were collected. Three hospitals (12.5%) were COVID free. The number of colostomies and ileostomies created and closed in the same period was lower ( -18.8% and -30%, respectively) in the study period in comparison to the control period (p = 0.1915 and p = 0.0001, respectively), such as the ostomies closed in the analysed periods but created before (colostomy -36.2% and ileostomy -7.4%, p = 0.2211 and p = 0.1319, respectively). Overall, a 19.5% reduction in ostomies closed occurred in the study period. Based on the present study, a reduction in ostomy closure rate occurred in Italy between March 2020 and February 2021. During the pandemic, the need to change the clinical practice probably prolonged deterioration of quality of life in patients with ostomies, increasing number of stomas that will never be closed, and related management costs, even if these issues have not been investigated in this study.

Comprehensive testing of colorectal anastomosis: results of prospective observational cohort study

BACKGROUND

Anastomotic leakage remains one of the most threatening complications in colorectal surgery. Intraoperative testing of anastomosis may reduce the postoperative anastomotic leakage rates. This study aimed to investigate a novel comprehensive intraoperative colorectal anastomosis testing technique to detect the failure of the anastomosis construction and to reduce the risk of postoperative leak.

METHODS

This multi-centre prospective cohort pilot study included 60 patients who underwent colorectal resection with an anastomosis at or below 15 cm from the anal verge. Comprehensive trimodal testing consisted of indocyanine green fluorescence angiography, tension testing, air-leak, and methylene blue leak tests to evaluate the perfusion, tension, and mechanical integrity of the anastomosis.

RESULTS

Ten (16.7%) patients developed an anastomotic leakage. Trimodal test was positive in 16 (26.6%) patients and the operative plan was changed for all of them. Diverting ileostomy was performed in 14 (87.5%) patients. However, two (12.5%) patients still developed clinically significant anastomotic leakage (Grade B). Forty-four (73.4%) patients had a negative trimodal test, preventive ileostomy was performed in 19 (43.2%), and five (11.4%) patients had clinically significant anastomotic leakage (Grade B and C).

CONCLUSION

Trimodal testing identifies anastomoses with initial technical failure where reinforcement of anastomosis or diversion can lead to an acceptable rate of anastomotic leakage. Identification of well-performed anastomosis could allow a reduction of ileostomy rate by two-fold. However, anastomotic leakage rate remains high in technically well-performed anastomoses.

Early versus delayed defunctioning ileostomy closure after low anterior resection for rectal cancer: a meta-analysis and trial sequential analysis of safety and functional outcomes

PURPOSE

We performed a systematic review and meta-analysis with trial sequential analysis (TSA) to answer whether early closure of defunctioning ileostomy may be suitable after low anterior resection.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, up to October 2021, for RCTs comparing early closure (EC ≤ 30 days) and delayed closure (DC ≥ 60 days) of defunctioning ileostomy. The risk ratio (RR) with 95% CI was calculated for dichotomous variables and the mean difference (MD) with 95% CI for continuous variables. The GRADE methodology was implemented for assessing Quality of Evidence (QoE). TSA was implemented to address the risk of random error associated with sparse data and/or multiple testing.

RESULTS

Seven RCTs were included for quantitative synthesis. 599 patients were allocated to either EC (n = 306) or DC (n = 293). EC was associated with a higher rate of wound complications compared to DC (RR 2.56; 95% CI 1.33 to 4.93; P = 0.005; I² = 0%, QoE High), a lower incidence of postoperative small bowel obstruction (RR 0.46; 95% CI 0.24 to 0.89; P = 0.02; I² = 0%, QoE moderate), and a lower rate of stoma-related complications (RR 0.26; 95% CI 0.16 to 0.42; P < 0.00001; I² = 0%, QoE moderate). The rate of minor low anterior resection syndrome (LARS) (RR 1.13; 95% CI 0.55 to 2.33; P = 0.74; I² = 0%, QoE low) and major LARS (RR 0.80; 95% CI 0.59 to 1.09; P = 0.16; I² = 0%, QoE low) did not differ between the two groups. TSA demonstrated inconclusive evidence with insufficient sample sizes to detect the observed effects.

CONCLUSION

EC may confer some advantages compared with a DC. However, TSA advocated a cautious interpretation of the results.

PROSPERO REGISTER ID

CRD42021276557.

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project

BACKGROUND AND AIMS

Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients.

METHODS

The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations.

CONCLUSIONS

The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.

Loop ileostomy in rectal cancer surgery: factors predicting reversal and stoma related morbidity

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.

Risk factors for postoperative ileus following loop ileostomy closure

Objectives

The most common intra-abdominal complication following loop ileostomy closure (LIC) is postoperative ileus (POI). The aim of the study was to determine the risk factors of POI development following LIC and make recommendations for its prevention.

Material and Methods

In this study, patients having undergone LIC with peristomal incision following distal colorectal surgery were included. Clavien-Dindo classification was used to evaluate postoperative complications. POI and postoperative leakage were defined based on clinical and radiological criteria. The Centers for Disease Control and Prevention 2017 criteria were used to diagnose surgical site infection (SSI). Postoperative bleeding was diagnosed one day after surgery if there was a >2 g/dL or ≥15% decrease in the hemoglobin level.

Results

Seventy-nine patients were included into the study. In nine of the patients POI developed, six had SSI, five had postoperative bleeding, and two had anastomosis leakage. In the univariate analysis; age <60 years (p= 0.02), presence of comorbidity (p= 0.007), using an open technique in the first surgery (p= 0.02), performing total colectomy in the first surgery (p= 0.048), performing hand-sewn anastomosis of LIC (p= 0.01), and postoperative blood transfusion (p= 0.04) were found to be risk factors for POI. Performing hand-sewn anastomosis of LIC (p= 0.03) and using an open technique in the first surgery (p= 0.03) were found to be independent variables for POI risk.

Conclusion

Using an open technique in the first surgery and performing a hand-sewn anastomosis of LIC may increase POI.