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Lundström S, Buchwald P, Agger E. A retrospective cohort study on renal morbidity related to stoma type in inflammatory bowel disease patients following colectomy and ileal pouch-anal anastomosis surgery. Scand J Surg 2024; 113:202-210. [PMID: 38414142 DOI: 10.1177/14574969241228411] [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: 02/29/2024]
Abstract
BACKGROUND AND OBJECTIVE Defunctioning loop ileostomy (DLI) is frequently used to decrease the consequences of anastomotic leak after ileal pouch-anal anastomosis (IPAA) surgery but is controversial because of stoma-associated morbidity. The aim of this study was to describe stoma-associated morbidity in IPAA-DLI patients compared with terminal ileostomy patients. METHODS Patients treated with colectomy for inflammatory bowel disease at Skåne University Hospital, Sweden, between 2005 and 2021 were eligible for inclusion. Terminal stoma-related morbidity was measured until 12 months after colectomy, IPAA surgery, or conversion to ileorectal anastomosis, whichever occurred first. DLI-related morbidity was measured until 12 months after IPAA surgery or stoma closure, whichever occurred first. Laboratory data were reviewed up to 18 months after surgery since patients without complications were rarely subjected to blood sampling. Data on patient characteristics, renal function, surgical complications, and readmissions were collected retrospectively. Primary outcomes were DLI- and terminal ileostomy-related renal morbidity, whereas secondary outcomes focused on stoma-related complications. RESULTS The study cohort consisted of 165 patients with terminal ileostomy after colectomy (median (interquartile range (IQR)): stoma time 30 (15-74) months) and 42 patients with IPAA-DLI (median (IQR): stoma time 4 (3-5) months). One case of anastomotic IPAA leakage was observed. IPAA-DLI patients more often required hospital care due to high-volume stoma output immediately after surgery (0-30 days, 29%) compared with terminal ileostomy patients (4%, p < 0.001). There were no significant differences in acute renal injury (p = 0.073) or chronic renal failure (p = 0.936) incidences between the groups. DLI closure was achieved in 95% of IPAA-DLI patients, with 5% suffering Clavien-Dindo complications > 2. CONCLUSIONS IPAA-DLI patients exhibited higher incidence of short-term high-volume stoma output without higher rates of acute renal injury or chronic renal failure compared with terminal ileostomy patients in this small single-center retrospective study suggesting that the risk of renal morbidity in IPAA-DLI patients may have been overestimated.
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Affiliation(s)
- Simon Lundström
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Erik Agger
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Sun Z, Cao L, Chen Y, Song T, Guo Z, Zhu W, Li Y. The impact of delayed closure of ileostomy on postoperative complications in patients with Crohn's disease: a case-matched study. Updates Surg 2024; 76:1339-1345. [PMID: 38238543 DOI: 10.1007/s13304-023-01722-1] [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: 10/13/2023] [Accepted: 11/29/2023] [Indexed: 08/24/2024]
Abstract
Ileostomy creation is a common procedure to mitigate postoperative complications in Crohn's disease (CD) patients. However, the optimal timing for ileostomy closure remains controversial. This study aims to investigate whether delayed ileostomy closure (> 6 months post formation) affects postoperative complications compared to early closure (≤ 6 months post formation). Consecutive CD patients who underwent ileostomy reversal at a tertiary care center between January 1, 2013, and December 1, 2021, were included. The study compared patients who underwent early ileostomy closure to matched patients undergoing delayed ileostomy closure. The 90-day postoperative complications were compared between the two groups. The study included 352 eligible patients for ileostomy reversion. Our data showed that patients undergoing delayed ileostomy closure had higher incidence of ileostomy-related infectious complications (12% vs. 4%, p = 0.008), a longer postoperative hospital stay (10 days with an IQR of 7-12 days versus 8 days with an IQR of 7-11 days, p = 0.024), and increased rate of ileus (28% versus 15%, p = 0.003). There were 256 patients included after 1:1 propensity score matching. The results revealed no significant differences in postoperative hospital stay, infectious or non-infectious complications except for a statistically significant increase in the incidence of ileus in the delayed closure group (p = 0.01). Patients undergoing delayed ileostomy closure has similar outcomes to early closure in terms of postoperative complications, except for a higher incidence of ileus.
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Affiliation(s)
- Zhenya Sun
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Lei Cao
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Yusheng Chen
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Tianrun Song
- Department of General Surgery, Jinling Clinical School of Medicine (Eastern Theater General Hospital), Nanjing Medical University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Zhen Guo
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China
| | - Weiming Zhu
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China.
| | - Yi Li
- Department of General Surgery, Affiliated Hospital of Medical School, Jinling Hospital, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, China.
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Rafaqat W, Nzenwa IC, Abiad M, Lagazzi E, Panossian VS, Ghaddar K, Hoekman AH, Arnold SC, DeWane MP, Kaafarani HM, Velmahos GC, Hwabejire JO. Discharge to Skilled Nursing Facility Is a Risk Factor for Readmission: A Nationwide Propensity-Matched Study. J Surg Res 2024; 300:485-493. [PMID: 38875947 DOI: 10.1016/j.jss.2024.05.027] [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: 11/21/2023] [Revised: 05/14/2024] [Accepted: 05/18/2024] [Indexed: 06/16/2024]
Abstract
INTRODUCTION General surgery procedures place stress on geriatric patients, and postdischarge care options should be evaluated. We compared the association of discharge to a skilled nursing facility (SNF) versus home on patient readmission. METHODS We retrospectively reviewed the Nationwide Readmission Database (2016-2019) and included patients ≥65 y who underwent a general surgery procedure between January and September. Our primary outcome was 30-d readmissions. Our secondary outcome was predictors of readmission after discharge to an SNF. We performed a 1:1 propensity-matched analysis adjusting for patient demographics and hospital course to compare patients discharged to an SNF with patients discharged home. We performed a sensitivity analysis on patients undergoing emergency procedures and a stepwise regression to identify predictors of readmission. RESULTS Among 140,056 included patients, 33,916 (24.2%) were discharged to an SNF. In the matched population of 19,763 pairs, 30-d readmission was higher in patients discharged to an SNF. The most common diagnosis at readmission was sepsis, and a greater proportion of patients discharged to an SNF were readmitted for sepsis. In the sensitivity analysis, emergency surgery patients discharged to an SNF had higher 30-d readmission. Higher illness severity during the index admission and living in a small or fringe county of a large metropolitan area were among the predictors of readmission in patients discharged to an SNF, while high household income was protective. CONCLUSIONS Discharge to an SNF compared to patients discharged home was associated with a higher readmission. Future studies need to identify the patient and facility factors responsible for this disparity.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ikemsinachi C Nzenwa
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - May Abiad
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vahe S Panossian
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karen Ghaddar
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anne H Hoekman
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Suzanne C Arnold
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Haytham M Kaafarani
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Bradley SE, Vitous CA, Marzoughi M, Dualeh SHA, Rivard SJ, Duby A, Hendren S, Suwanabol PA. Patient adherence to an oral rehydration solution intervention to prevent dehydration following ileostomy creation: A qualitative study. Am J Surg 2024; 233:120-124. [PMID: 38448319 DOI: 10.1016/j.amjsurg.2024.02.045] [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: 01/05/2024] [Revised: 02/14/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Patients undergoing surgery for ileostomy creation frequently experience postoperative dehydration and subsequent renal injury. The use of oral rehydration solutions (ORS) has been shown to prevent dehydration, but compliance may be variable. METHODS Semi-structured qualitative interviews were conducted with 17 patients who received a postoperative hydration kit and dehydration education to assess barriers and facilitators to compliance with ORS kit instructions. RESULTS Qualitative analysis revealed five themes affecting patient adherence to the ORS intervention: (1) patient's perception of the effectiveness of the ORS solution, (2) existing co-morbidities, (3) kit quality and taste of the ORS product, (4) quality of the dehydration education, and (5) social support. CONCLUSIONS Given that patient adherence can greatly affect the success of an ORS intervention, the design of future ORS interventions should emphasize the educational component, the "patient friendliness" of the ORS kit, and ways that social supports can be leveraged to increase adherence.
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Affiliation(s)
- Sarah E Bradley
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - C Ann Vitous
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | | | - Shukri H A Dualeh
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Samantha J Rivard
- Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Ashley Duby
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Samantha Hendren
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Pasithorn A Suwanabol
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Hu J, Zhang X, Sun J, Hu H, Tang C, Ba L, Xu Q. Supportive Care Needs of Patients With Temporary Ostomy in Enhanced Recovery After Surgery: A Mixed-Methods Study. J Nurs Res 2024; 32:e329. [PMID: 38727228 DOI: 10.1097/jnr.0000000000000610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS), a global surgical quality improvement initiative, reduces the length of stay in the hospital. Temporary stoma care for rectal cancer is complex, and patients require prolonged care services to adjust to the stoma. The shorter stay durations in the new model challenge the conventional care pathways and create new patient needs. PURPOSE This study was designed to explore the supportive care needs of patients under the new surgical model to provide a reference for the design of ERAS nursing care plans. METHODS A convergent parallel mixed-methods design was used in this study. Patients with temporary stomas for rectal cancer were recruited using a convenience sampling method in gastrointestinal surgery wards and wound & stoma clinics in two public tertiary care hospitals in China. Standardized questionnaires were administered to 140 patients to collect quantitative data, and semistructured interviews were conducted individually with 13 patients to collect qualitative data. The questionnaire data were analyzed using descriptive statistics, and the interview data were analyzed using thematic analysis. RESULTS "Health system and information needs" and "care and support needs" were identified in both the qualitative and quantitative analyses as the most significant unmet needs of the participants. In addition, the qualitative analysis identified receiving focused stoma care instructions and easily understandable information as essential to fulfilling health system and information needs. Care and support needs included access to continued postdischarge services and attention from medical professionals. CONCLUSION/IMPLICATIONS FOR PRACTICE The participants in this study experienced a variety of unmet supportive care needs under the ERAS protocol, with gaps particularly notable in two categories: "health system and information needs" and "care and support needs." Increased perioperative care and shorter hospital stays under the ERAS protocol reduce opportunities for patients to receive targeted instruction and shift much of the ostomy education and care workload out of the hospital, requiring greater attention from clinical nurses to ensure quality of care.
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Affiliation(s)
- Jieman Hu
- PhD, RN, Lecturer, School of Nursing, Nanjing Medical University, Nanjing, China
| | - Xiuling Zhang
- BSN, RN, Department of Gastrointestinal Colorectal and Anal Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jianan Sun
- MS, RN, Department of Gastrointestinal Colorectal and Anal Surgery, The First Hospital of Jilin University, Changchun, China
| | - Haiyan Hu
- BSN, RN, Head Nurse, Department of Gastrointestinal Colorectal and Anal Surgery, The First Hospital of Jilin University, Changchun, China
| | - Chulei Tang
- PhD, RN, Lecturer, School of Nursing, Nanjing Medical University, Nanjing, China
| | - Lei Ba
- PhD, Associate Professor, National Health Commission Contraceptives Adverse Reaction Surveillance Center, Jiangsu Health Development Research Center, Nanjing, China
| | - Qin Xu
- MS, RN, Professor, School of Nursing, Nanjing Medical University, Nanjing, China
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de la Motte L, Nordenvall C, Martling A, Buchli C. Preoperative use of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and diuretics increases the risk of dehydration after ileostomy formation: population-based cohort study. BJS Open 2024; 8:zrae051. [PMID: 38818959 PMCID: PMC11140823 DOI: 10.1093/bjsopen/zrae051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/07/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Readmission rates following ileostomy formation are high. Dehydration and consecutive renal failure are common causes of readmission, potentially pronounced by drugs affecting the homeostasis. The aim of the study was to assess the risk of dehydration after ileostomy formation in patients treated with angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB) or diuretics. METHOD This nationwide population-based cohort study used data derived from the Colorectal Cancer Data Base of several Swedish healthcare registers. The study included all patients operated on with elective anterior resection and temporary ileostomy for rectal cancer clinically staged I-III in Sweden in 2007-2016. Exposure was at least two dispensations of ACEI, ARB or diuretics within 1 year prior to surgery. Outcome was 90-day readmission due to dehydration including acute renal failure. RESULTS In total, 3252 patients were included with 1173 (36.1%) exposed to ACEI, ARB or diuretics. The cumulative incidence for 90-day readmission due to dehydration was 29.0% (151 of 520) for exposed versus 13.8% (98 of 712) for unexposed. The proportion of readmissions due to any reason was 44.3% (520 of 1173) for exposed compared to 34.2% (712 of 2079) for unexposed. The incidence rate ratio for readmission due to dehydration was 2.83 (95% c.i. 2.21 to 3.63, P < 0.001). The hazard rate ratio was 2.45 (95% c.i. 1.83 to 3.27, P < 0.001) after adjusting for age, gender and comorbidity. CONCLUSION Medication with ACEI, ARB or diuretics defines a vulnerable patient group with increased risk of readmission due to dehydration after ileostomy formation.
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Affiliation(s)
- Louise de la Motte
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Buchli
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
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Litchinko A, Buchs N, Balaphas A, Toso C, Liot E, Meurette G, Ris F, Meyer J. Score prediction of anastomotic leak in colorectal surgery: a systematic review. Surg Endosc 2024; 38:1723-1730. [PMID: 38418633 PMCID: PMC10978556 DOI: 10.1007/s00464-024-10705-1] [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: 10/10/2023] [Accepted: 01/18/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Predicting the risk of anastomotic leak (AL) is of importance when defining the optimal surgical strategy in colorectal surgery. Our objective was to perform a systematic review of existing scores in the field. METHODS We followed the PRISMA checklist (S1 Checklist). Medline, Cochrane Central and Embase were searched for observational studies reporting on scores predicting AL after the creation of a colorectal anastomosis. Studies reporting only validation of existing scores and/or scores based on post-operative variables were excluded. PRISMA 2020 recommendations were followed. Qualitative analysis was performed. RESULTS Eight hundred articles were identified. Seven hundred and ninety-one articles were excluded after title/abstract and full-text screening, leaving nine studies for analysis. Scores notably included the Colon Leakage Score, the modified Colon Leakage Score, the REAL score, www.anastomoticleak.com and the PROCOLE score. Four studies (44.4%) included more than 1.000 patients and one extracted data from existing studies (meta-analysis of risk factors). Scores included the following pre-operative variables: age (44.4%), sex (77.8%), ASA score (66.6%), BMI (33.3%), diabetes (22.2%), respiratory comorbidity (22.2%), cardiovascular comorbidity (11.1%), liver comorbidity (11.1%), weight loss (11.1%), smoking (33.3%), alcohol consumption (33.3%), steroid consumption (33.3%), neo-adjuvant treatment (44.9%), anticoagulation (11.1%), hematocrit concentration (22.2%), total proteins concentration (11.1%), white blood cell count (11.1%), albumin concentration (11.1%), distance from the anal verge (77.8%), number of hospital beds (11.1%), pre-operative bowel preparation (11.1%) and indication for surgery (11.1%). Scores included the following peri-operative variables: emergency surgery (22.2%), surgical approach (22.2%), duration of surgery (66.6%), blood loss/transfusion (55.6%), additional procedure (33.3%), operative complication (22.2%), wound contamination class (1.11%), mechanical anastomosis (1.11%) and experience of the surgeon (11.1%). Five studies (55.6%) reported the area under the curve (AUC) of the scores, and four (44.4%) included a validation set. CONCLUSION Existing scores are heterogeneous in the identification of pre-operative variables allowing predicting AL. A majority of scores was established from small cohorts of patients which, considering the low incidence of AL, might lead to miss potential predictors of AL. AUC is seldom reported. We recommend that new scores to predict the risk of AL in colorectal surgery to be based on large cohorts of patients, to include a validation set and to report the AUC.
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Affiliation(s)
- Alexis Litchinko
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.
- Medical School, University of Geneva, Rue Michel-Servet 1, 1205, Geneva, Switzerland.
| | - Nicolas Buchs
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
- Medical School, University of Geneva, Rue Michel-Servet 1, 1205, Geneva, Switzerland
| | - Alexandre Balaphas
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
- Medical School, University of Geneva, Rue Michel-Servet 1, 1205, Geneva, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
- Medical School, University of Geneva, Rue Michel-Servet 1, 1205, Geneva, Switzerland
| | - Emilie Liot
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Guillaume Meurette
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
- Medical School, University of Geneva, Rue Michel-Servet 1, 1205, Geneva, Switzerland
| | - Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
- Medical School, University of Geneva, Rue Michel-Servet 1, 1205, Geneva, Switzerland
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Andersen FB, Kjellberg J, Ibsen R, Sternhufvud C, Petersen B. The clinical and economic burden of illness in the first two years after ostomy creation: a nationwide Danish cohort study. Expert Rev Pharmacoecon Outcomes Res 2024; 24:567-575. [PMID: 38433657 DOI: 10.1080/14737167.2024.2324047] [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: 11/09/2023] [Accepted: 02/21/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Living with an ostomy is often associated with costly complications. This study examined the burden of illness the first two years after ostomy creation. METHODS Data from Danish national registries included all adult Danes with an ostomy created between 2002 and 2014. RESULTS Four cohorts consisted, respectively, of 11,385 subjects with a colostomy and 4,574 with an ileostomy, of which 1,663 subjects had inflammatory bowel disease (IBD) and 1,270 colorectal cancer as cause of their ileostomy. The healthcare cost was significantly higher for cases versus matched controls for all cohorts. In the first year, the total healthcare cost per person-year was €27,962 versus €4,200 for subjects with colostomy, €29,392 versus €3,308 for subjects with ileostomy, €15,947 versus €2,216 when IBD was the underlying cause, and €32,438 versus €4,196 when it was colorectal cancer. Healthcare costs decreased in the second year but remained significantly higher than controls. Hospitalization and outpatient services were primary cost drivers, with ostomy-related complications comprising 8-16% of hospitalization expenses. CONCLUSION Compared to controls, subjects with an ostomy bear a significant health and financial burden attributable to ostomy-related complications, in addition to the underlying disease, emphasizing the importance of better ostomy care to enhance well-being and reduce economic strain.
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Aubert M, Buscail E, Duchalais E, Cazelles A, Collard M, Charleux-Muller D, Jeune F, Nuzzo A, Pellegrin A, Theuil L, Toutain A, Trilling B, Siproudhis L, Meurette G, Lefevre JH, Maggiori L, Mege D. Management of adult intestinal stomas: The 2023 French guidelines. J Visc Surg 2024; 161:106-128. [PMID: 38448363 DOI: 10.1016/j.jviscsurg.2024.02.002] [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: 03/08/2024]
Abstract
AIM Digestive stoma are frequently performed. The last French guidelines have been published twenty years ago. Our aim was to update French clinical practice guidelines for the perioperative management of digestive stoma and stoma-related complications. METHODS A systematic literature review of French and English articles published between January 2000 and May 2022 was performed. Only digestive stoma for fecal evacuation in adults were considered. Stoma in children, urinary stoma, digestive stoma for enteral nutrition, and rare stoma (Koch, perineal) were not included. RESULTS Guidelines include the surgical landmarks to create digestive stoma (ideal location, mucocutaneous anastomosis, utility of support rods, use of prophylactic mesh), the perioperative clinical practice guidelines (patient education, preoperative ostomy site marking, postoperative equipment, prescriptions, and follow-up), the management of early stoma-related complications (difficulties for nursing, high output, stoma necrosis, retraction, abscess and peristomal skin complications), and the management of late stoma-related complications (stoma prolapse, parastomal hernia, stoma stenosis, late stoma retraction). A level of evidence was assigned to each statement. CONCLUSION These guidelines will be very useful in clinical practice, and allow to delete some outdated dogma.
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Affiliation(s)
- Mathilde Aubert
- Department of Digestive Surgery, hôpital Timone, Aix Marseille University, AP-HM, Marseille, France
| | - Etienne Buscail
- Digestive Surgery Department, hôpital Rangueil, Toulouse, France
| | | | - Antoine Cazelles
- Digestive Surgery Department, hôpital européen Georges-Pompidou, AP-HP, Paris, France
| | - Maxime Collard
- Digestive Surgery Department, hôpital Saint-Antoine, AP-HP, Sorbonne université, 75012, Paris, France
| | | | - Florence Jeune
- Digestive Surgery Department, hôpital Saint-Louis, AP-HP, Paris, France
| | - Alexandre Nuzzo
- Digestive Surgery Department, hôpital Beaujon, AP-HP, Paris, France
| | | | | | - Amandine Toutain
- Digestive Surgery Department, hôpital Saint-Louis, AP-HP, Paris, France
| | | | | | | | - Jérémie H Lefevre
- Digestive Surgery Department, hôpital Saint-Antoine, AP-HP, Sorbonne université, 75012, Paris, France
| | - Léon Maggiori
- Digestive Surgery Department, hôpital Saint-Louis, AP-HP, Paris, France
| | - Diane Mege
- Department of Digestive Surgery, hôpital Timone, Aix Marseille University, AP-HM, Marseille, France.
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Conroy DE, Marks J, Cutshaw A, Ram N, Thomaz E, Streeper NM. Promoting fluid intake to increase urine volume for kidney stone prevention: Protocol for a randomized controlled efficacy trial of the sip IT intervention. Contemp Clin Trials 2024; 138:107454. [PMID: 38253254 PMCID: PMC10923155 DOI: 10.1016/j.cct.2024.107454] [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: 11/19/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Risk of kidney stone recurrence can be reduced by increasing fluid intake and urine production but most patients fail to adhere to recommended clinical guidelines. Patients have indicated that common barriers to fluid intake include a lack of thirst, forgetting to drink, and not having access to water. We developed the sipIT intervention to support patients' fluid intake with semi-automated tracking (via a mobile app, connected water bottle and a smartwatch clockface that detects drinking gestures) and provision of just-in-time text message reminders to drink when they do not meet the hourly fluid intake goal needed to achieve the recommended volume. This trial evaluates the efficacy of sipIT for increasing urine output in patients at risk for recurrence of kidney stones. METHOD/DESIGN Adults with a history of kidney stones and lab-verified low urine production (<2 L/day) will be randomly assigned to receive either usual care (education and encouragement to meet fluid intake guidelines) or usual care plus the sipIT intervention. The primary outcome is 24-h urine volume; secondary outcomes include urinary supersaturations, past week fluid intake, and experienced automaticity of fluid intake. Outcomes will be assessed at baseline, 1 month, 3 months, and 12 months. CONCLUSIONS The sipIT intervention is the first to prompt periodic fluid intake through integration of just-in-time notifications and semi-automated tracking. If sipIT is more efficacious than usual care, this intervention provides an innovative treatment option for patients needing support in meeting fluid intake guidelines for kidney stone prevention.
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Affiliation(s)
- David E Conroy
- Department of Kinesiology, The Pennsylvania State University, University Park, PA 16802, USA.
| | - James Marks
- Department of Urology, The Pennsylvania State University, Hershey, PA 17033, USA
| | - Alyssa Cutshaw
- Department of Kinesiology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Nilam Ram
- Department of Communication and Psychology, Stanford University, Palo Alto, CA 94305, USA
| | - Edison Thomaz
- Department of Electrical and Computer Engineering, University of Texas, Austin, TX 78712, USA
| | - Necole M Streeper
- Department of Urology, The Pennsylvania State University, Hershey, PA 17033, USA
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Huang CK, Shih CH, Kao YS. Elderly Rectal Cancer: An Updated Review. Curr Oncol Rep 2024; 26:181-190. [PMID: 38270849 DOI: 10.1007/s11912-024-01495-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE OF REVIEW Treatment of rectal cancer patients of advanced age should be modulated by life expectancy and tolerance. Due to the rapid advance of this field, we aim to conduct an updated review of this topic. RECENT FINDINGS The field of elderly rectal cancer has advanced a lot. This review covers all the treatment aspects of elderly rectal cancer, including the prognostic factor, surgery, radiotherapy, chemotherapy, and palliative treatment. We also provide the future aspect of the management of elderly rectal cancer. The advancement of prognostic factor research, surgery, radiotherapy, chemotherapy, and palliative treatment has made the care of elderly rectal cancer patients better. The future of these fields should focus on the definition of the elderly and the application of particle therapy.
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Affiliation(s)
- Chih-Kai Huang
- Division of General Surgery, Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Chi-Hsiu Shih
- Division of Hematology and Oncology, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Yung-Shuo Kao
- Department of Radiation Oncology, Taoyuan General Hospital, Ministry of Health and Welfare, No.1492, Zhongshan Rd., Taoyuan Dist., Taoyuan City, 330, Taiwan.
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12
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Seow-En I, Wu J, Tan IEH, Zhao Y, Seah AWM, Wee IJY, Ying-Ru Ng Y, Kwong-Wei Tan E. Transanal Total Mesorectal Excision With Delayed Coloanal Anastomosis (TaTME-DCAA) Versus Laparoscopic Total Mesorectal Excision (LTME) and Robotic Total Mesorectal Excision (RTME) for Low Rectal Cancer: A Propensity Score-Matched Analysis of Short-term Outcomes, Bowel Function, and Cost. Surg Laparosc Endosc Percutan Tech 2024; 34:54-61. [PMID: 37987634 PMCID: PMC10829900 DOI: 10.1097/sle.0000000000001247] [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: 05/27/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Total mesorectal excision (TME) with delayed coloanal anastomosis (DCAA) is surgical option for low rectal cancer, replacing conventional immediate coloanal anastomosis (ICAA) with bowel diversion. This study aimed to assess the outcomes of transanal TME (TaTME) with DCAA versus laparoscopic TME (LTME) with ICAA versus robotic TME (RTME) with ICAA. METHODS This was a retrospective propensity score-matched analysis of patients who underwent elective TaTME-DCAA between November 2021 and June 2022. Patients were propensity-score matched in a ratio of 1:3 to patients who underwent LTME-ICAA and RTME-ICAA from January 2019 to December 2020. Outcome measures were histopathologic results, postoperative morbidity, function, and inpatient costs. RESULTS Twelve patients in the TaTME-DCAA group were compared with 36 patients in the LTME-ICAA and RTME-ICAA groups each after propensity score matching. Histopathologic results and postoperative morbidity rates were statistically similar. Overall stoma-related complication rates in the ICAA groups were 11%. Median total length of hospital stays for TME plus stoma reversal surgery was similar across all techniques (10 vs. 10 vs. 9 days; P =0.532). Despite a significantly shorter duration of follow-up, bowel function after TaTME-DCAA was comparable to that of LTME-ICAA and RTME-ICAA. Overall median inpatient costs of TaTME-DCAA were comparable to LTME-ICAA and significantly cheaper than RTME-ICAA ($31,087 vs. $29,927 vs. $36,750; P =0.002). CONCLUSIONS TaTME with DCAA is a feasible and safe technique compared with other minimally invasive methods of TME, while avoiding bowel diversion and stoma-related complications, as well as comparing favorably in terms of overall hospitalization costs.
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Affiliation(s)
- Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital
| | - Jingting Wu
- Department of Colorectal Surgery, Singapore General Hospital
| | | | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore
| | | | - Ian Jun Yan Wee
- Department of Colorectal Surgery, Singapore General Hospital
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Mthombeni F, Cawson M, Chan G, Boisen EB, Rethmeier LO, Pearson-Stuttard J. The economic burden of stomas in the UK: a retrospective observational study of health records and hospital encounters. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S12-S20. [PMID: 38060389 DOI: 10.12968/bjon.2023.32.22.s12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Stomas divert waste from the small intestine (ileostomy), large intestine (colostomy) or ureters (urostomy), and complications are common. AIMS This study evaluated healthcare resource utilisation (HCRU) and costs of stomas from a UK perspective. METHODS This was a retrospective observational study of adults with new stomas (New Stoma Group) or new/existing stomas and >6 months of follow-up (Established Stoma Group) using health records linked with hospital encounters (January 2009-December 2018). Age- and sex-matched controls were identified for each stoma case (1:50). FINDINGS Both the New (n=8533) and Established (n=9397) stoma groups had significantly higher HCRU (all P<0.0001) and associated costs (all P<0.01), driven by inpatient admissions. New Stoma Group: colostomy versus controls, £3227 versus £99 per person; ileostomy, £2576 versus £78 per person; and urostomy, £2850 versus £110 per person (all P<0.0001). Findings were similar in the Established Stoma Group. CONCLUSION Stomas are associated with a substantial economic burden in the UK driven by hospital care. (Supplementary data tables can be obtained from the authors.).
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Affiliation(s)
| | | | - Gerald Chan
- Health Economics Manager, Coloplast Ltd, Peterborough
| | - Esben Bo Boisen
- Health Economics Manager, Coloplast A/S, Humblebaek, Denmark
| | | | - Jonathan Pearson-Stuttard
- Health Economics Manager, Health Analytics, Lane Clark & Peacock LLP, London, Northumbria Healthcare NHS Foundation Trust, and School of Public Health, Imperial College London
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Clancy C, Connelly TM, Jia X, Lipman J, Lightner AL, Hull T, Steele SR, Holubar SD. Defining the safety of early ileostomy closure after ileal pouch anal anastomosis. Tech Coloproctol 2023; 27:1257-1263. [PMID: 37209279 DOI: 10.1007/s10151-023-02811-4] [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: 12/14/2022] [Accepted: 04/24/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE The safety of early ileostomy reversal after ileal pouch anal anastomosis (IPAA) has not been established. Our hypothesis was that ileostomy reversal before 8 weeks is associated with negative outcomes. METHODS This was a retrospective cohort study from a prospectively maintained institutional database. Patients who underwent primary IPAA with ileostomy reversal between 2000 and 2021 from a Pouch Registry were stratified on the basis of timing of reversal. Those reversed before 8 weeks (early) and those reversed from 8 weeks to 116 days (routine) were compared. The primary outcome was overall complications according to timing and reason for closure. RESULTS Ileostomy reversal was performed early in 92 patients and routinely in 1908. Median time to closure was 49 days in the early group and 93 days in the routine group. Reasons for early reversal were stoma-related morbidity in 43.3% (n = 39) and scheduled closure in 56.7% (n = 51). The complication rate in the early group was 17.4% versus 11% in the routine group (p = 0.085). When early patients were stratified according to reason for reversal, those reversed early for stoma-related morbidity had an increased complication rate compared to the routine group (25.6% vs. 11%, p = 0.006). Patients undergoing scheduled reversal in the early group did not have increased complications (11.8% vs. 11%, p = 0.9). There was a higher likelihood of pouch anastomotic leak when reversal was performed early for stoma complications compared to routinely (OR 5.13, 95% CI 1.01-16.57, p = 0.049). CONCLUSIONS Early closure is safe but could be delayed in stoma morbidity as patients may experience increased complications.
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Affiliation(s)
- C Clancy
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - T M Connelly
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - X Jia
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - J Lipman
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - A L Lightner
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - T Hull
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S R Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S D Holubar
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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Chan MS, Moore Z, Patton D, McNamara D, O'Connor T, Avsar P. A systematic review of patient risk factors for complications following stoma formation among adults undergoing colorectal surgery. Int J Colorectal Dis 2023; 38:238. [PMID: 37747515 DOI: 10.1007/s00384-023-04523-5] [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] [Accepted: 09/08/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Stoma formation is a commonly performed procedure both during and following colorectal surgery. When designed correctly, stomas can dramatically improve patients' quality of life, but the reverse may occur when complications arise. Given the significant negative impact of complications following stoma formation, understanding risk factors that may be mitigated pre-operatively is important. METHOD A systematic search of publications using MEDLINE, CINAHL, and Cochrane databases was conducted in May 2022. Data was extracted and a narrative synthesis undertaken. The evidence-based librarianship (EBL) checklist assessed the methodological quality of the included studies. The systematic review includes various research designs such as randomised controlled trials (RCT), case-control studies, and observational cohort studies written in English. Reviews, conference papers, opinion papers, and those including participants < 18 years old were excluded. No restrictions on the date of publication and study setting were applied. RESULTS This review included 17 studies, conducted between 2001 and 2020. The study designs were prospective audit, prospective analysis, retrospective analysis, longitudinal analysis and multivariate analysis of self-reported questionaires/surveys. Twenty-two possible risk factors for the development of stoma complications following stoma formation were identified. These include demographical risk factors, underlying medical condition, type of surgery, elective vs emergency surgery, stoma factors, surgical factors, indications for surgery and factors which may impact healing. Furthermore, high BMI, emergency surgery, and stoma type were identified as the most frequently occurring risk factors. CONCLUSION Given the large number of risk factors identified, the implementation of a risk stratification tool may decrease the incidence and prevalence of stoma complication development. This, in turn, would decrease the associated healthcare-related costs, and negative impact on mortality, length of stay and quality of life.
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Affiliation(s)
- Mai Shanley Chan
- School of Medicine, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - Zena Moore
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
- School of Nursing and Midwifery, Griffith University, Queensland, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Monash, Australia
- Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Lida Institute, Shanghai, China
- University of Wales, Cardiff, UK
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith, QLD, Australia
| | - Declan Patton
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
- School of Nursing and Midwifery, Griffith University, Queensland, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Deborah McNamara
- Beaumont Hospital, Dublin, Ireland
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tom O'Connor
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
- School of Nursing and Midwifery, Griffith University, Queensland, Australia
- Lida Institute, Shanghai, China
| | - Pinar Avsar
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland.
- School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland.
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Carlsson E, Forsmark A, Sternhufvud C, Scheffel G, Andersen FB, Persson EI. Short- and long-term direct and indirect costs of illness after ostomy creation - a Swedish nationwide registry study. BMC Health Serv Res 2023; 23:837. [PMID: 37553576 PMCID: PMC10408161 DOI: 10.1186/s12913-023-09850-5] [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: 01/27/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Despite advance in care of people with an ostomy, related complications remain prevalent. The objective of this study was to examine short- and long-term healthcare resource utilization and associated costs after ostomy creation. METHODS This observational study was based on retrospectively collected data from national and regional Swedish registries. The population consisted of people living in Sweden, who had an ostomy created. The earliest index date was 1 January 2006, and people were followed for ten years, until death, reversal of temporary ostomy, termination of purchases of ostomy products, or end of study, which was 31 December 2019. Each person with an ostomy was matched with two controls from the general population based on age, gender, and region. RESULTS In total, 40,988 persons were included: 19,645 with colostomy, 16,408 with ileostomy, and 4,935 with urostomy. The underlying diseases for colostomy and ileostomy creations were primarily bowel cancer, 50.0% and 55.8% respectively, and additionally inflammatory bowel disease for 20.6% of ileostomies. The underlying cause for urostomy creation was mainly bladder cancer (85.0%). In the first year after ostomy creation (excl. index admission), the total mean healthcare cost was 329,200 SEK per person with colostomy, 330,800 SEK for ileostomy, and 254,100 SEK for urostomy (100 SEK was equivalent to 9.58 EUR). Although the annual mean healthcare cost decreased over time, it remained significantly elevated compared to controls, even after 10 years, with hospitalization being the main cost driver. The artificial opening was responsible for 19.3-22.8% of 30-day readmissions after ostomy creation and for 19.7-21.4% of hospitalizations during the entire study period. For the ileostomy group, dehydration was responsible for 13.0% of 30-day readmissions and 4.5% of hospitalization during the study period. CONCLUSIONS This study reported a high disease burden for persons with an ostomy. This had a substantial impact on the healthcare cost for at least ten years after ostomy creation. Working ability seemed to be negatively impacted, indicated by increased cost of sickness absence and early retirement. This calls for improved management and support of ostomy care for the benefit of the affected persons and for the cost of society.
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Affiliation(s)
- Eva Carlsson
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | - Eva I Persson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
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Zizzo M, Morini A, Zanelli M, Tumiati D, Sanguedolce F, Palicelli A, Mereu F, Ascani S, Fabozzi M. Short-Term Outcomes in Patients Undergoing Virtual/Ghost Ileostomy or Defunctioning Ileostomy after Anterior Resection of the Rectum: A Meta-Analysis. J Clin Med 2023; 12:jcm12113607. [PMID: 37297802 DOI: 10.3390/jcm12113607] [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: 04/05/2023] [Revised: 05/02/2023] [Accepted: 05/20/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Anterior rectal resection (ARR) represents one of the most frequently performed methods in colorectal surgery, mainly carried out for rectal cancer (RC) treatment. Defunctioning ileostomy (DI) has long been chosen as a method to "protect" colorectal or coloanal anastomosis after ARR. However, DI does not rule out risks of more or less serious complications. A proximal intra-abdominal closed-loop ileostomy, the so-called virtual/ghost ileostomy (VI/GI), could limit the number of DIs and the associated morbidity. MATERIALS AND METHODS We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Meta-analysis was performed by use of RevMan [Computer program] Version 5.4. RESULTS The five included comparative studies (VI/GI or DI) covering an approximately 20-year study period (2008-2021). All included studies were observational ones and originated from European countries. Meta-analysis indicated VI/GI as significantly associated with lower short-term morbidity rates related to VI/GI or DI after primary surgery (RR: 0.21, 95% CI: 0.07-0.64, p = 0.006), fewer dehydration (RR: 0.17, 95% CI: 0.04-0.75, p = 0.02) and ileus episodes after primary surgery (RR: 0.20, 95% CI: 0.05-0.77, p = 0.02), fewer readmissions after primary surgery (RR: 0.17, 95% CI: 0.07-0.43, p = 0.0002) and readmissions after primary surgery plus stoma closure surgery (RR: 0.14, 95% CI: 0.06-0.30, p < 0.00001) than the DI group. On the contrary, no differences were identified in terms of AL after primary surgery, short-term morbidity after primary surgery, major complications (CD ≥ III) after primary surgery and length of hospital stay after primary surgery. Conclusions: Given the significant biases among meta-analyzed studies (small overall sample size and the small number of events analyzed, in particular), our results require careful interpretation. Further randomized, possibly multi-center trials may be of paramount importance in confirming our results.
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Affiliation(s)
- Maurizio Zizzo
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Andrea Morini
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Magda Zanelli
- Pathology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - David Tumiati
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Francesca Sanguedolce
- Pathology Unit, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Foggia, 71122 Foggia, Italy
| | - Andrea Palicelli
- Pathology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Federica Mereu
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Stefano Ascani
- Hematology Unit, CREO, Azienda Ospedaliera di Perugia, University of Perugia, 06129 Perugia, Italy
- Pathology Unit, Azienda Ospedaliera S. Maria di Terni, University of Perugia, 05100 Terni, Italy
| | - Massimiliano Fabozzi
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
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Pironi L. Definition, classification, and causes of short bowel syndrome. Nutr Clin Pract 2023; 38 Suppl 1:S9-S16. [PMID: 37115031 DOI: 10.1002/ncp.10955] [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: 11/24/2022] [Revised: 12/30/2022] [Accepted: 01/01/2023] [Indexed: 04/29/2023] Open
Abstract
The term "short bowel syndrome (SBS)" defines "the clinical feature associated with a remaining small bowel in continuity of less than 200 cm from the ligament of Treitz" and is characterized by malabsorption, diarrhea, fatty stools, malnutrition, and dehydration. SBS is the primary pathophysiological mechanism of chronic intestinal failure (CIF), defined as the "reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation (IVS) is required to maintain health and/or growth" in a metabolically stable patient. By contrast, the reduction of gut absorptive function that does not require IVS has been termed "intestinal insufficiency or deficiency" (II/ID). The classification of SBS can be categorized as follows: anatomical (anatomy and length of the residual bowel), evolutional (early, rehabilitative, and maintenance phases), pathophysiological (SBS with or without a colon in continuity), clinical (with II/ID or CIF), and severity of CIF (type and volume of the required IVS). Appropriate and homogeneous patient categorization is the mainstay of facilitating communication in clinical practice and in research.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Centre for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy
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McCartney T, Markwell A, Rauch-Pucher M, Cox-Reber J. CE: Caring for Patients After Ileostomy Surgery. Am J Nurs 2023; 123:36-41. [PMID: 36625529 DOI: 10.1097/01.naj.0000918676.20331.3f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
ABSTRACT After ileostomy surgery, patients require nutrition and hydration modifications to maintain electrolyte balances and prevent postoperative complications. In addition to becoming dehydrated, patients who have ileostomies can develop obstructions if care isn't taken to avoid certain kinds of foods. Moreover, changes to medications may be needed to manage ileostomy output or account for altered absorption. This article provides information on postoperative hydration, medication, and nutritional management to nurses caring for patients after ileostomy surgery.
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Affiliation(s)
- Teresa McCartney
- Teresa McCartney, Ashley Markwell, Mackenzie Rauch-Pucher , and Jessica Cox-Reber are wound ostomy nurses at Beaumont Hospital Dearborn in Dearborn, MI. Contact author: Teresa McCartney, . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise
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Seow-En I, Ng YYR, Tan IBH, Tan EKW. Transanal total mesorectal excision and delayed coloanal anastomosis without stoma for low rectal cancer. Tech Coloproctol 2023; 27:75-81. [PMID: 36029385 DOI: 10.1007/s10151-022-02677-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/28/2022] [Indexed: 01/12/2023]
Abstract
The management of low rectal cancer is a perennial challenge for colorectal surgeons. The benefits of transanal total mesorectal excision (TaTME) in low rectal cancer are to secure the distal margin and avoid surgical space constraints within the deep pelvis. However, anastomotic leak remains an important concern. We report our technique and results combining TaTME with delayed coloanal anastomosis (DCAA) without bowel diversion. First, the splenic flexure, left colon and rectum are laparoscopically mobilized to mid-rectum. TaTME is performed to complete the distal rectal mobilization, and the specimen is delivered transanally and transected. The abdominoperineal colonic pull-through is secured to the anal canal and hypertonic dressing is applied regularly in the ward. The handsewn DCAA is performed one week later. An accompanying video demonstrates this technique. Five consecutive patients with low rectal cancer underwent TaTME with DCAA. All had upfront surgical resection except one who underwent total neoadjuvant therapy. Mean operative duration, blood loss, and length of hospital stay was 290 (250-375) min, 142 (10-200) ml and 11.6 (10-14) days respectively. One patient (20%) suffered a postoperative complication of persistent urinary retention, requiring an indwelling urinary catheter on discharge. There were no cases of open conversion and no instances of anastomotic leakage. Two patients (40%) had minor low anterior resection syndrome (LARS) and one (20%) had major LARS. TaTME and DCAA without stoma are complimentary techniques that augment the minimally invasive effects of laparoscopic sphincter-sparing low rectal cancer surgery, with good perioperative outcomes.
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Affiliation(s)
- I Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore.
| | - Y Y-R Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - I B H Tan
- Department of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - E K-W Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
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Dahlstrand U, Gustafsson P, Näsvall P, Johansson J, Gunnarsson U, Lindforss U. Costs Related to Diverting Ileostomy After Rectal Cancer Surgery: A Population-Based Healthcare Cost Analysis Based on Nationwide Registers. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231212126. [PMID: 38105185 PMCID: PMC10729635 DOI: 10.1177/00469580231212126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/15/2023] [Accepted: 10/18/2023] [Indexed: 12/19/2023]
Abstract
Low anterior resection for rectal cancer often includes a diverting loop-ileostomy to avoid the severe consequences of anastomotic leakage. Reversal of the stoma is often delayed, which can incur health-care costs on different levels. The aim is to, on population basis, determine stoma-related costs, and to investigate habitual and socioeconomic factors associated to the level of cost. Multi-register design with data from the Swedish Rectal Cancer Registry, the National Prescribed Drug Register, Statistics Sweden and cost-administrative data from the National Board of Health and Welfare. Data was gathered for 3564 patients with rectal cancer surgery 2007 to 2013, for 3 years following the surgery. Factors influencing the cost of inpatient care and stoma-related consumables were assessed with linear regression analyses. All monthly costs were higher for females (consumables P < .001 and in-patient care P = .031). Post-secondary education (P = .003) and younger age (P = .020) was associated with a higher cost for consumables while suffering a surgical complication was associated with increased cost for inpatient care (P < .001). Patients who had their stoma longer had lower monthly costs (consumables P < .001 and in-patient care P < .001). Female gender, longer duration of stoma, young age, and higher education are associated with higher costs for the care of a diverting stoma after rectal cancer surgery. This study does not allow for analyses of causality but the results together with deepened analyses of underlying reasons form a proper basis for decisions in health care planning and allocation of resources. These findings may have implications on the debate of equal care for all.
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Affiliation(s)
- Ursula Dahlstrand
- Karolinska Institutet, Stockholm, Sweden
- Enköping Hospital, Enköping, Sweden
| | - Pontus Gustafsson
- Karolinska Institutet, Stockholm, Sweden
- Visby Hospital, Visby, Sweden
| | | | - Jeaneth Johansson
- Luleå University of Technology, Luleå, Sweden
- Halmstad University, Halmstad, Sweden
| | | | - Ulrik Lindforss
- Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Stockholm, Sweden
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22
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Tsujinaka S, Suzuki H, Miura T, Sato Y, Shibata C. Obstructive and secretory complications of diverting ileostomy. World J Gastroenterol 2022; 28:6732-6742. [PMID: 36620340 PMCID: PMC9813931 DOI: 10.3748/wjg.v28.i47.6732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/04/2022] [Accepted: 11/26/2022] [Indexed: 12/19/2022] Open
Abstract
This review aimed to highlight the etiology, diagnosis, treatment, and prevention of obstructive and secretory complications associated with diverting ileostomy (DI). Obstructive complications at the stoma site are termed stoma outlet obstruction (SOO) or stoma-related obstruction (SRO). The incidence of SOO/SRO is 5.4%-27.3%, and the risk factors are multifactorial; however, the configuration of the stoma limb and the thickness of the rectus abdominis muscle (RAM) may be of particular concern. Trans-stomal tube decompression is initially attempted with a success rate of 33%-86%. A thick RAM may carry the risk of recurrence. Surgical refinement, including a wider incision of the anterior sheath and adequate stoma limb length, avoids tension and immobility and may decrease SOO/SRO. Secretory complications of DI are termed high output stoma (HOS). Persistent HOS lead to water and sodium depletion, and secondary hyperaldosteronism, resulting in electrolyte imbalances, such as hypomagnesemia. The incidence of HOS is 14%-24%, with an output of 1000-2000 mL/d lasting up to three days. Treatment of HOS is commenced after excluding postoperative complications or enteritis and includes fluid intake restriction, antimotility and antisecretory drug therapies, and magnesium supplementation. Intensive monitoring and surveillance programs have been successful in decreasing readmissions for dehydration.
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Affiliation(s)
- Shingo Tsujinaka
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
| | - Hideyuki Suzuki
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
| | - Tomoya Miura
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
| | - Yoshihiro Sato
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
| | - Chikashi Shibata
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
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23
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Shannon NB, Seow‐En I, Tan EK. Cost‐effectiveness comparison of delayed versus immediate coloanal anastomosis following ultralow anterior resection for rectal cancer. ANZ J Surg 2022; 93:963-969. [PMID: 36358002 DOI: 10.1111/ans.18148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Following ultralow anterior resection for distal rectal cancers, a coloanal anastomosis is usually created along with a defunctioning ileostomy (DI). Recent evidence suggests that abdominoperineal pull-through with delayed coloanal anastomosis (DCAA) is a viable alternative to immediate coloanal anastomosis (ICAA), minimizing the risk of anastomotic leakage and avoiding the need for stoma creation with the risk of stoma-associated morbidity. However, DCAA requires a longer initial hospitalization. We aimed to perform a cost-effectiveness analysis to compare DCAA versus ICAA for elective rectal cancer surgery. METHODS A decision tree model was used to compare the cost-effectiveness of the two strategies. Cost data were obtained from the 2019 to 2020 United Kingdom National Health Service reference costs. Model probabilities were derived from published studies. Univariate and probabilistic sensitivity analyses were used to evaluate the robustness of the results. RESULTS DCAA was the overall cheaper strategy at £13 541 compared with £14 856 for ICAA in the base case analysis. This was explained by the decreased overall costs of hospitalization/surgery, reduction in costs associated with anastomotic or stoma-related complications, specifically dehydration-induced hospital readmissions and avoidance of stoma maintenance costs. Sensitivity analysis demonstrated that DCAA remained consistently more inexpensive except when the duration of total parenteral nutrition exceeded 14 days. CONCLUSION Despite a longer index hospitalization with higher initial costs, this economic analysis demonstrates that DCAA without stoma is overall more cost-effective compared with ICAA with DI following ultralow anterior resection. Cost savings should be considered an additional benefit when selecting the DCAA approach for rectal cancer surgery.
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Affiliation(s)
| | - Isaac Seow‐En
- Department of Colorectal Surgery Singapore General Hospital Singapore
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24
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The INTESTINE study: INtended TEmporary STomas In crohN's diseasE. Protocol for an international multicentre study. Updates Surg 2022; 74:1691-1696. [PMID: 35962277 PMCID: PMC9481503 DOI: 10.1007/s13304-022-01345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/27/2022] [Indexed: 10/25/2022]
Abstract
Surgery for ileocolonic Crohn's disease can result in temporary or permanent stoma formation which can be associated with morbidity as parastomal and incisional hernias, readmissions due to obstruction or high stoma output, and have a negative impact on quality of life. We propose an international retrospective trainee-led study of the outcomes of temporary stomas in patients with Crohn's disease. We aim to evaluate both the short-term (6 month) and mid-term (18 month) outcomes of temporary stomas in patients with Crohn's Disease. Retrospective, multicentre, observational study including all patients who underwent elective or emergency surgery for ileal, colonic and ileocolonic Crohn's disease during a 4-year study period. Primary outcome is the proportion of patients who still have an ileostomy or colostomy 18 months after the initial surgery. Secondary outcomes: complications related to stoma formation and stoma reversal surgery; time interval between stoma formation and stoma reversal; risk factors for stoma formation and non-reversal of the stoma. We present the study protocol for a trainee-led, multicentre, observational study. Previous research has demonstrated significant heterogeneity surrounding the formation and the timing of reversal surgery in patients having a temporary ileostomy following colorectal cancer surgery, highlighting the need to address these same questions in Crohn's disease, which is the aim of our research.
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25
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Cerdán-Santacruz C, Vailati BB, São Julião GP, Habr-Gama A, Pérez RO. Watch and wait: Why, to whom and how. Surg Oncol 2022; 43:101774. [DOI: 10.1016/j.suronc.2022.101774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 12/26/2022]
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