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Sun L, Zhou J, Ji L, Wang W, Zhang Q, Qian C, Zhao S, Li R, Wang D. Clinical application of the B-type sutured ileostomy in robotic-assisted low anterior resection for rectal cancer: a propensity score matching analysis. J Robot Surg 2024; 18:159. [PMID: 38578352 DOI: 10.1007/s11701-024-01924-8] [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: 02/16/2024] [Accepted: 03/24/2024] [Indexed: 04/06/2024]
Abstract
Currently, there is no consensus on the position and method for temporary ileostomy in robotic-assisted low anterior resection for rectal cancer. Herein, this study introduced the B-type sutured ileostomy, a new temporary ileostomy technique, and compared it to the traditional one to assess its efficacy and safety. Between September 2020 and December 2022 in our centre, B-type sutured ileostomy was performed on 124 patients undergoing robotic-assisted low anterior resection for rectal cancer. A retrospective review of a prospectively collected database identified patients who underwent robotic-assisted low anterior resection for rectal cancer with a temporary ileostomy between January 2018 and December 2022. Patients who underwent B-type sutured ileostomy (B group) were matched in a 1:1 ratio with patients who underwent traditional ileostomy (Control group) using a propensity score based on age, sex, BMI, Comorbidity, American Society of Anesthesiologists (ASA) score, and Prior abdominal surgery history. Surgical and postoperative outcomes, health status, and stoma closure data were analyzed for both groups. ClinicalTrials.gov Identifier:NCT05915052. The B group (n = 118) shows advantages compared to the Control group (n = 118) regarding total operation time (155.98 ± 21.63 min vs 168.92 ± 21.49 min, p = 0.001), postoperative body pain (81.92 ± 4.12 vs 78.41 ± 3.02, p = 0.001) and operation time of stoma closure (46.19 ± 11.30 min vs 57.88 ± 11.08 min, p = 0.025). The two groups had no other notable differences. The B-type sutured ileostomy is a safe and feasible option in robotic-assisted low anterior resection for rectal cancer. The B-type sutured ileostomy may offer advantages such as shorter overall surgical duration, lighter postoperative pain, and shorter second-stage ostomy incorporation surgery. However, attention should be directed towards the occurrence of stoma prolapse.
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Affiliation(s)
- Longhe Sun
- Clinical Medical College, Yangzhou University, Yangzhou, 225001, China
- The Forth People's Hospital of Taizhou, Taizhou, 225300, China
| | - Jiajie Zhou
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China
| | - Lili Ji
- The Forth People's Hospital of Taizhou, Taizhou, 225300, China
| | - Wei Wang
- Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Qi Zhang
- Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Chunhua Qian
- The Forth People's Hospital of Taizhou, Taizhou, 225300, China
| | - Shuai Zhao
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China
| | - Ruiqi Li
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China
| | - Daorong Wang
- Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, 225001, China.
- Northern Jiangsu People's Hospital, Yangzhou Institute of General Surgery, Yangzhou University, Yangzhou, 225001, China.
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Disease, Yangzhou, China.
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Emile SH, Horesh N, Garoufalia Z, Gefen R, Ray-Offor E, Wexner SD. Outcomes of Early Versus Standard Closure of Diverting Ileostomy After Proctectomy: Meta-analysis and Meta-regression Analysis of Randomized Controlled Trials. Ann Surg 2024; 279:613-619. [PMID: 37788345 DOI: 10.1097/sla.0000000000006109] [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: 10/05/2023]
Abstract
OBJECTIVE We aimed to compare outcomes of early and standard closure of diverting loop ileostomy (DLI) after proctectomy and determine risk factors for anastomotic leak (AL) and complications. BACKGROUND Formation of DLI has been a routine practice after proctectomy to decrease the incidence and potential adverse sequela of AL. METHODS PubMed, Scopus, and Web of Science were searched for randomized controlled trials (RCTs) that compared outcomes of early versus standard closure of DLI after proctectomy. Main outcome measures were postoperative complications, AL, ileus, surgical site infection, reoperation, readmission, and hospital stay following DLI closure. RESULTS Eleven RCTs (932 patients; 57% male) were included. Early closure group included 474 patients and standard closure 458 patients. Early closure was associated with higher odds of AL [odds ratio (OR): 2.315, P =0.013] and similar odds of complications (OR: 1.103, P =0.667), ileus (OR: 1.307, P =0.438), surgical site infection (OR: 1.668, P =0.079), reoperation (OR: 1.896, P =0.062), and readmission (OR: 3.431, P =0.206). Hospital stay was similar (weighted mean difference: 1.054, P =0.237). Early closure had higher odds of AL than standard closure when early closure was done ≤2 weeks (OR: 2.12, P =0.047) but not within 3 to 4 weeks (OR: 2.98, P =0.107). Factors significantly associated with complications after early closure were diabetes mellitus, smoking, and closure of DLI ≤2 weeks, whereas factors associated with AL were ≥ American Society of Anesthesiologists II classification and diabetes mellitus. CONCLUSIONS Early closure of DLI after proctectomy has a higher risk of AL, particularly within 2 weeks of DLI formation. On the basis of this study, routine early ileostomy closure cannot be recommended.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat-Gan, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Israel
| | - Emeka Ray-Offor
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
- Department of Surgery, University of Port Harcourt, Choba, Rivers State, Nigeria
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
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He F, Yang F, Tang C, Chen D, Zhao D, Xiong J, Zou Y, Huang G, Qian K. Clinical Outcomes of Ileostomy Closure during versus after Adjuvant Chemotherapy in Patients with Rectal Cancer. Can J Gastroenterol Hepatol 2024; 2024:2410643. [PMID: 38550348 PMCID: PMC10977340 DOI: 10.1155/2024/2410643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/10/2023] [Accepted: 01/02/2024] [Indexed: 04/02/2024] Open
Abstract
Background Protective ileostomy can effectively prevent severe anastomotic leakage after rectal cancer surgery; however, the optimal timing for ileostomy closure during adjuvant chemotherapy remains unclear. This study aimed to explore the safety and long-term outcomes of early ileostomy closure during adjuvant chemotherapy. Method Patients who underwent laparoscopic rectal cancer surgery combined with protective ileostomy and adjuvant chemotherapy between April 2017 and April 2021 were retrospectively evaluated. Patients were divided into an early closure group during chemotherapy (group A) and a late closure group after chemotherapy (group B). Results A total of 215 patients were included in this study, with 115 in group A and 100 in group B. There were no significant differences in demographic and clinical characteristics between the two groups. In group A, durations of stoma status (p < 0.001) and low anterior resection syndrome (LARS) (p < 0.001) were shorter, and rectal stenosis (p=0.036) and stoma-related complications (p=0.007), especially stoma stenosis (p=0.041), were less common. However, compliance with chemotherapy was worse (p=0.009). There were no significant differences in operative time, postoperative hospital stay, postoperative complications, incidence and severity of LARS, disease-free survival, or overall survival between groups. Conclusion Early ileostomy closure can effectively reduce the duration of stoma status, duration of LARS, rectal stenosis, and stoma-related complications while not affecting surgical complications and oncological outcomes. Ileostomy closure should not be delayed because of adjuvant chemotherapy. However, follow-up should be strengthened to increase compliance and integrity with chemotherapy.
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Affiliation(s)
- Fan He
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fuyu Yang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Chenglin Tang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Defei Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Dongqin Zhao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Junjie Xiong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yu Zou
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Guoquan Huang
- Hubei Provincial Key Lab of Selenium Resources and Bioapplications, No. 158 Wuyang Avenue, Enshi 445000, Hubei, China
| | - Kun Qian
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Blanco Terés L, Cerdán Santacruz C, Correa Bonito A, Delgado Búrdalo L, Rodríguez Sánchez A, Bermejo Marcos E, García Septiem J, Martín Pérez E. Early diverting stoma closure is feasible and safe: results from a before-and-after study on the implementation of an early closure protocol at a tertiary referral center. Tech Coloproctol 2024; 28:32. [PMID: 38349559 DOI: 10.1007/s10151-023-02905-z] [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: 07/27/2023] [Accepted: 12/18/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Evidence on early closure (EC) of defunctioning stoma (DS) after colorectal surgery shows a favorable effect when patients are carefully selected. Therefore, a clinical pathway adapted to the implementation of an EC strategy was developed in our center. The aim of this study was to carry out a comparative analysis of time until DS closure and DS-related morbidity before and after the implementation of an EC protocol (ECP). METHODS This study is a before-and-after comparative analysis. Patients were divided into two cohorts according to the observational period: patients from the period before the ECP implementation (January 2015-December 2019) [Period 1] and those from the period after that (January 2020-December 2022) [Period 2]. All consecutive patients subjected to elective DS closure within both periods were eligible. Early closure was defined as the reversal within 30 days from DS creation. Patients excluded from EC or those not closed within 30 days since primary surgery were analyzed as late closure (LC). Baseline characteristics and DS-related morbidity were recorded. RESULTS A total of 145 patients were analyzed. Median time with DS was shorter in patients after ECP implementation [42 (21-193) days versus 233 (137-382) days, p < 0.001]. This reduction in time to closure did not impact the DS closure morbidity and resulted in less DS morbidity (68.8% versus 49.2%, p = 0.017) and fewer stoma nurse visits (p = 0.029). CONCLUSIONS The ECP was able to significantly reduce intervals to restoration of bowel continuity in patients with DS, which in turn resulted in a direct impact on the reduction of DS morbidity without negatively affecting DS closure morbidity.
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Affiliation(s)
- L Blanco Terés
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.
| | - C Cerdán Santacruz
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - A Correa Bonito
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - L Delgado Búrdalo
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - A Rodríguez Sánchez
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - E Bermejo Marcos
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - J García Septiem
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - E Martín Pérez
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
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Blanco N, Oliva I, Tejedor P, Pastor E, Alvarellos A, Pastor C, Baixauli J, Arredondo J. ILEOSTIM trial: a study protocol to evaluate the effectiveness of efferent loop stimulation before ileostomy reversal. Tech Coloproctol 2023; 27:1251-1256. [PMID: 37106220 PMCID: PMC10638139 DOI: 10.1007/s10151-023-02807-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE A protective loop ileostomy is the most useful method to reduce sequelae in the event of an anastomotic leakage (AL) after rectal cancer surgery. However, it requires an additional stoma reversal surgery with its own potential complications. Postoperative ileus (POI) remains the most common complication after ileostomy reversal, which leads to an increase in morbidity, length of hospital stay (LOS) and overall healthcare costs. Several retrospective studies carried out in this field have concluded that there are insufficient evidence-based recommendations about the routine application of preoperative bowel stimulation in clinical practice. Here we discuss whether stimulation of the efferent limb before ileostomy reversal might reduce POI and improve postoperative outcomes. METHODS This is a multicentre randomised controlled trial to determine whether mechanical stimulation of the efferent limb during the 2 weeks before the ileostomy reversal would help to reduce the development of POI after surgery. This study was registered on Clinicaltrials.gov (NCT05302557). Stimulation will consist of infusing a solution of 500 ml of saline chloride solution mixed with a thickening agent (Resource©, Nestlé Health Science; 6.4 g sachet) into the distal limb of the ileostomy loop. This will be performed within the 2 weeks before ileostomy reversal, in an outpatient clinic under the supervision of a trained stoma nurse. CONCLUSION The results of this study could provide some insights into the preoperative management of these patients.
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Affiliation(s)
- N Blanco
- Department of General Surgery, Clínica Universidad de Navarra, Av. Pío XII 36, 31008, Pamplona, Navarra, Spain
| | - I Oliva
- Department of General Surgery, University Hospital of León, León, Spain
| | - P Tejedor
- Department of General Surgery, University Hospital Gregorio Marañón, Madrid, Spain
| | - E Pastor
- Department of General Surgery, University Hospital of León, León, Spain
| | - A Alvarellos
- Department of General Surgery, Clínica Universidad de Navarra, Madrid, Spain
| | - C Pastor
- Department of General Surgery, Clínica Universidad de Navarra, Madrid, Spain
| | - J Baixauli
- Department of General Surgery, Clínica Universidad de Navarra, Av. Pío XII 36, 31008, Pamplona, Navarra, Spain
| | - J Arredondo
- Department of General Surgery, Clínica Universidad de Navarra, Av. Pío XII 36, 31008, Pamplona, Navarra, Spain.
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6
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Batistotti P, Montale A, Bruzzone M, Amato A, Binda GA. Protective ileostomy after low anterior resection for extraperitoneal rectal cancer: does the reversal surgery timing affect closure failure? Updates Surg 2023; 75:1811-1818. [PMID: 37428410 DOI: 10.1007/s13304-023-01573-w] [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: 01/31/2023] [Accepted: 06/22/2023] [Indexed: 07/11/2023]
Abstract
Loop ileostomy is commonly performed after LAR with TME to temporarily protect the anastomosis. Usually, defunctioning stoma is closed after 1-6 months, although sometimes it becomes definitive de facto. The aim of this study is to investigate the long-term risk of no-reversal of protective ileostomy after LAR for middle-low rectal cancer and the predictive risk factors. A retrospective analysis of a consecutive cohort of patients who underwent curative LAR with covering ileostomy for extraperitoneal rectal cancer in two colorectal units was performed. A different policy for scheduling stoma closure was applied between centers. All the data were collected through an electronic database (Microsoft Excel®). Descriptive statistical analysis was performed using Fisher's exact and Student's t test. Multivariate logistic regression analysis was conducted. Two-hundred twenty-two patients were analysed: reversal procedure was carried out in 193 patients, in 29 cases stoma was never closed. The mean interval time from index surgery was 4.9 months (Center1: 3 vs. Center2: 7.8). At the univariate analysis, mean age and tumor stage were significantly higher in the "no-reversal" group. Unclosed ostomies were significantly lower in Center 1 than Center 2 (8% vs. 19.6%). At the multivariate analysis female gender, anastomotic leakage and Center 2 had significant higher risk of unclosed ileostomy. Currently, no clinical recommendations have been established and the policy of scheduling stoma reversal is variable. Our study suggests that an established protocol could avoid closure delay, decreasing permanent stomas. Consequently, ileostomy closure should be weighed as standardized step in cancer therapeutic pathway.
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Affiliation(s)
- P Batistotti
- General Surgical Department, Ospedale Di Imperia, Via Sant'Agata 57, 18100, Imperia, Italy.
| | - A Montale
- Department of Gastroenterology and Digestive Endoscopy, E. O. Ospedali Galliera, Mura Delle Cappuccine 14, 16128, Genoa, Italy
| | - M Bruzzone
- Clinical Epidemiology Unit, IRCCS Ospedale San Martino, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - A Amato
- General Surgical Department, Ospedale Di Imperia, Via Sant'Agata 57, 18100, Imperia, Italy
| | - G A Binda
- General Surgery, Biomedical Institute, Genoa, Italy
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7
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Climent M, Biondo S. Ileostomy closure: is timing of the essence? Tech Coloproctol 2022; 26:847-849. [PMID: 35941259 DOI: 10.1007/s10151-022-02673-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- M Climent
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, and IDIBELL (Bellvitge Biomedical Investigation Institute), C/Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - S Biondo
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, and IDIBELL (Bellvitge Biomedical Investigation Institute), C/Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
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