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Ascari F, Barugola G, Ruffo G. Diverting ileostomy in benign colorectal surgery: the real clinical cost analysis. Updates Surg 2024; 76:1761-1768. [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] [MESH Headings] [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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Doğru V, Akova U, Esen E, Wong DJ, da Luz Moreira A, Erkan A, Kirat J, Grieco MJ, Remzi FH. Temporary diverting loop ileostomy in Crohn's disease surgery; indications and outcome. Langenbecks Arch Surg 2024; 409:247. [PMID: 39120756 DOI: 10.1007/s00423-024-03404-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/03/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION Crohn's disease can present with complex surgical pathologies, posing a significant risk of morbidity and mortality for patients. The implementation of a loop ileostomy for selected patients may help minimize associated risks. METHODS In this retrospective cohort study, we investigated the utilization of temporary fecal diversion through the creation of a loop ileostomy in Crohn's surgery. Closure of all ostomies involved a hand-sewn single-layer technique. We then conducted bivariate analysis on 30-day outcomes for closures, focusing on favorable recovery defined as the restoration of bowel continuity without the occurrence of two challenges in recovery: newly developed organ dysfunction or the necessity for reoperation. RESULTS In total, 168 patients were included. The median age of the patients was 38 years (IQR 27-51). The most common indication for a loop ostomy was peritonitis (49%). After ileostomy closure, 163 patients (97%) achieved favorable recovery, while five encountered challenges; four (2.4%) underwent abdominal surgery, and one (0.6%) developed acute renal failure requiring dialysis. Two patients (1.2%) had a re-creation of ileostomy. Patients encountering challenges were older (56 [IQR 41-61] vs. 37 [IQR 27-50]; p 0.039) and more often required secondary intention wound healing (40% vs. 6.7%; p 0.049) and postoperative parenteral nutrition following their index surgery (83% vs. 26%; p 0.006). CONCLUSION Selectively staging the Crohn's disease operations with a loop ileostomy is a reliable practice with low morbidity and high restoration rates of bowel continuity. Our hand-sewn single-layer technique proves effective in achieving successful surgical recovery.
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Affiliation(s)
- Volkan Doğru
- Akdeniz University Hospital, Antalya, Türkiye
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Umut Akova
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | - Eren Esen
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Daniel J Wong
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Arman Erkan
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
- Center for Advanced Inflammatory Bowel Disease Care, Northwell Health, 125 Community Drive, Manhasset, NY, 11030, USA
| | - John Kirat
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Michael J Grieco
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Feza H Remzi
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA.
- Center for Advanced Inflammatory Bowel Disease Care, Northwell Health, 125 Community Drive, Manhasset, NY, 11030, USA.
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Braschi C, Salzman GA, Russell MM. Association of Frailty With Post-Operative Outcomes of Older Adults Undergoing Elective Ostomy Reversal. Am Surg 2024; 90:75-84. [PMID: 37528803 DOI: 10.1177/00031348231191240] [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] [Indexed: 08/03/2023]
Abstract
BACKGROUND Ostomy reversal is a common surgical procedure; however, it is not without associated risks. Patient selection for this elective procedure is therefore critically important. Elderly patients represent a growing population and a substantial proportion of patients that present for evaluation after ostomy creation due to the most common etiologies. This study aims to assess the impact of frailty on the outcomes of ostomy reversal among older adults. METHODS Patients ≥65 years who underwent ostomy reversal from 2015 to 2019 were identified in the NSQIP database. Frailty was calculated using the 5-item Modified Frailty Index (MFI). Multivariate regression was performed to evaluate the association of frailty with post-operative 30-day mortality, 30-day serious complications, discharge to a facility, and 30-day readmission. RESULTS A total of 13,053 patients were included, of which 18.7% were frail (MFI ≥ 2). Patients who underwent colostomy reversal had higher rates of serious complications (P < .0001) and discharge to facility (P < .0001) compared to other reversals. In multivariate analysis, frailty was associated with increased odds of serious complications (OR 1.52, 95% CI 1.31-1.77), discharge to facility (OR 2.14, 95% CI 1.79-2.57), and readmission (OR 1.23, 95% CI 1.04-1.46), but not mortality. Frail patients had predicted probabilities 1.4 times higher for serious complications and 1.7-2.2 times greater for discharge to facility than non-frail patients. CONCLUSIONS Among older adults undergoing elective ostomy reversal, frailty is independently associated with increased odds of 30-day serious complications, discharge to facility, and 30-day readmission. As a potentially modifiable risk factor, identification of frailty offers the opportunity for shared decision-making and prehabilitation.
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Affiliation(s)
- Caitlyn Braschi
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Garrett A Salzman
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Mirande MD, McKenna NP, Bews KA, Shawki SF, Cima RR, Brady JT, Colibaseanu DT, Mathis KL, Kelley SR. Risk factors for surgical site infections and trends in skin closure technique after diverting loop ileostomy reversal: A multi-institutional analysis. Am J Surg 2023; 226:703-708. [PMID: 37567817 DOI: 10.1016/j.amjsurg.2023.07.042] [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: 06/21/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique. METHODS A retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary + drain, or purse-string closure. The primary outcome was SSI at the former DLI site. RESULTS A SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure + drain, and 2.7% for purse-string closure (p = 0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p < 0.0001). CONCLUSIONS This study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time.
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Affiliation(s)
| | | | - Katherine A Bews
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Sherief F Shawki
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Justin T Brady
- Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA; Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
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Closed-wound negative pressure therapy dressing after loop ostomy closure: a retrospective comparative study. Sci Rep 2022; 12:7790. [PMID: 35550575 PMCID: PMC9098839 DOI: 10.1038/s41598-022-11856-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/25/2022] [Indexed: 11/09/2022] Open
Abstract
Closed-wound negative pressure wound therapy (NPWT) dressings were recently introduced with the purpose to reduce incisional surgical site infections (iSSI) in high-risk wounds. The aim of this study was to compare iSSI rates in patients after ostomy closure with and without additional application of a closed-wound NPWT dressing. Single-center retrospective analysis of consecutive patients undergoing ileo- or colostomy closure over an 8-year period (January 2013-January 2021). Intradermal non-purse string technique with absorbable sutures were used in all patients. Since November 2018, all patients (study group) received a NPWT device for a maximum of 5 days postoperatively (PICO, SMITH AND NEPHEW). Primary outcome was iSSI rate within 30 days of surgery. SSI was defined in accordance with the Center of Disease Control (CDC) classification and included superficial and deep incisional SSI. Data was retrieved from the institutional enhanced recovery after surgery (ERAS) database, with standardized complication assessment by trained abstractors. In total, 85 patients (25%) in the study group were comparable with 252 (75%) patients in the control group regarding demographics (age, gender, body mass index, ASA score), ostomy type and anastomotic technique (all p > 0.05), but not wound contamination class (class III: 5% vs 0%, p < 0.001). Median time to NPWT removal was 4 (IQR 3-5) days. Incisional SSI were observed in 4 patients (4.7%) in the study group and in 27 patients (10.7%) in the control group (p = 0.097). These preliminary results suggest a potential benefit of systematic application of the NPWT device after loop ostomy closure. A randomized controlled study is needed.
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Johnson BH, Rai P, Jang SR, Johnston SS, Chen BPH. Real-World Outcomes of Patients Undergoing Open Colorectal Surgery with Wound Closure Incorporating Triclosan-Coated Barbed Sutures: A Multi-Institution, Retrospective Database Study. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:65-75. [PMID: 33658869 PMCID: PMC7917355 DOI: 10.2147/mder.s297671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/10/2021] [Indexed: 12/19/2022] Open
Abstract
Purpose Open colorectal surgery is associated with a high rate of postoperative wound complications. This is a single-arm study of real-world outcomes of triclosan-coated barbed suture (Ethicon's STRATAFIXTM Symmetric PDSTM Plus Knotless Tissue Control Device [SSPP]) used in open colorectal surgery. Methods Retrospective cohort study using the Premier Healthcare Database. The study included patients who underwent an inpatient open colorectal surgery with wound closure using SSPP (size 0 or 1 to increase the likelihood the suture was used in fascia) between October 2015-September 2019 (N=593). Wound complications, hospital length of stay, total hospital costs (2019 US$), and all-cause readmissions post-discharge were measured. Post-hoc multivariable analyses compared wound complications between non-elective admissions and elective. Results The overall incidence of wound complications within 30-days post-procedure was 7.1%, with the majority of those being surgical site infections (SSI) (6.0%). Mean operation time was 190 (standard deviation [SD]=64.4) mins, postoperative length of stay was 8.1 (SD=11.9) days, 30-day readmission rate was 11.8%, and total hospital costs were $31,693 (SD=$40,076). As compared with published literature on the rate of SSI in colorectal surgery, the 30-day rate of SSI in the present study (6.0%) fell within the range of 5.4% to 18.2% for open colorectal surgery and from 4.3% to 21.5% for combined open and minimally invasive procedures. Multivariable-adjusted incidence proportions of wound complications were slightly lower for non-elective admissions and did not differ significantly from those of elective admissions. Conclusion The rate of wound complications observed in the present study falls within the range of rates previously reported in the literature, suggesting a safe and effective role for SSPP in open colorectal surgery. In post hoc analyses, the adjusted rate of wound complications was similar between non-elective and elective admissions. Head-to-head studies are required to determine comparative advantages or disadvantages for SSPP versus other sutures.
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Affiliation(s)
- Barbara H Johnson
- Real World Data Analytics and Research, Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
| | - Pragya Rai
- Real World Data Analytics and Research, Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
| | - Se Ryeong Jang
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stephen S Johnston
- Real World Data Analytics and Research, Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
| | - Brian Po-Han Chen
- Health Economics and Market Access, Ethicon Inc., Somerville, NJ, USA
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