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Pompeu BF, Pasqualotto E, Pigossi BD, Marcolin P, de Figueiredo SMP, Bin FC, Formiga FB. Turnbull-Cutait pull-through coloanal anastomosis versus standard coloanal anastomosis plus diverting ileostomy for low anterior resection: a meta-analysis and systematic review. Langenbecks Arch Surg 2024; 409:187. [PMID: 38888662 DOI: 10.1007/s00423-024-03379-9] [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] [Received: 04/27/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Coloanal anastomosis with loop diverting ileostomy (CAA) is an option for low anterior resection of the rectum, and Turnbull-Cutait coloanal anastomosis (TCA) regained popularity in the effort to offer patients a reconstructive option. In this context, we aimed to compare both techniques. METHODS PubMed, Cochrane, and Scopus were searched for studies published until January 2024. Odds ratios (RRs) with 95% confidence intervals (CIs) were pooled with a random-effects model. Statistical significance was defined as p < 0.05. Heterogeneity was assessed using the Cochran Q test and I2 statistics, with p-values inferior to 0.10 and I2 >25% considered significant. Statistical analysis was conducted in RStudio version 4.1.2 (R Foundation for Statistical Computing). Registered number CRD42024509963. RESULTS One randomized controlled trial and nine observational studies were included, comprising 1,743 patients, of whom 899 (51.5%) were submitted to TCA and 844 (48.5%) to CAA. Most patients had rectal cancer (52.2%), followed by megacolon secondary to Chagas disease (32.5%). TCA was associated with increased colon ischemia (OR 3.54; 95% CI 1.13 to 11.14; p < 0.031; I2 = 0%). There were no differences in postoperative complications classified as Clavien-Dindo ≥ IIIb, anastomotic leak, pelvic abscess, intestinal obstruction, bleeding, permanent stoma, or anastomotic stricture. In subgroup analysis of patients with cancer, TCA was associated with a reduction in anastomotic leak (OR 0.55; 95% CI 0.31 to 0.97 p = 0.04; I2 = 34%). CONCLUSION TCA was associated with a decrease in anastomotic leak rate in subgroups analysis of patients with cancer.
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Affiliation(s)
- Bernardo Fontel Pompeu
- Department of Colorectal Surgery, Heliopolis Hospital, São Paulo, Brazil.
- USCS - University of São Caetano do Sul, Rua Santo Antônio, 50 - Centro, São Caetano do Sul, SP, 09521-160, Brazil.
| | | | | | | | | | - Fang Chia Bin
- Department of Colorectal Surgery, Medical Science College of Santa Casa de São Paulo, São Paulo, Brazil
| | - Fernanda Bellotti Formiga
- Department of Colorectal Surgery, Heliopolis Hospital, São Paulo, Brazil
- Department of Colorectal Surgery, Medical Science College of Santa Casa de São Paulo, São Paulo, Brazil
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Yang S, Tang G, Zhang Y, Wei Z, Du D. Meta-analysis: loop ileostomy versus colostomy to prevent complications of anterior resection for rectal cancer. Int J Colorectal Dis 2024; 39:68. [PMID: 38714581 PMCID: PMC11076370 DOI: 10.1007/s00384-024-04639-2] [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: 04/25/2024] [Indexed: 05/10/2024]
Abstract
PURPOSE Anastomotic leakage is a serious complication of colorectal cancer surgery, prolonging hospital stays and impacting patient prognosis. Preventive colostomy is required in patients at risk of anastomotic fistulas. However, it remains unclear whether the commonly used loop colostomy(LC) or loop ileostomy(LI) can reduce the complications of colorectal surgery. This study aims to compare perioperative morbidities associated with LC and LI following anterior rectal cancer resection, including LC and LI reversal. METHODS In this meta-analysis, the Embase, Web of Science, Scopus, PubMed, and Cochrane Library databases were searched for prospective cohort studies, retrospective cohort studies, and randomized controlled trials (RCTs) on perioperative morbidity during stoma development and reversal up to July 2023, The meta-analysis included 10 trials with 2036 individuals (2 RCTs and 8 cohorts). RESULTS No significant differences in morbidity, mortality, or stoma-related issues were found between the LI and LC groups after anterior resection surgery. However, patients in the LC group exhibited higher rates of stoma prolapse (RR: 0.39; 95%CI: 0.19-0.82; P = 0.01), retraction (RR: 0.45; 95%CI: 0.29-0.71; P < 0.01), surgical site infection (RR: 0.52; 95%CI: 0.27-1.00; P = 0.05) and incisional hernias (RR: 0.53; 95%CI: 0.32-0.89; P = 0.02) after stoma closure compared to those in the LI group. Conversely, the LI group showed higher rates of dehydration or electrolyte imbalances(RR: 2.98; 95%CI: 1.51-5.89; P < 0.01), high-output(RR: 6.17; 95%CI: 1.24-30.64; P = 0.03), and renal insufficiency post-surgery(RR: 2.51; 95%CI: 1.01-6.27; P = 0.05). CONCLUSION Our study strongly recommends a preventive LI for anterior resection due to rectal cancer. However, ileostomy is more likely to result in dehydration, renal insufficiency, and intestinal obstruction. More multicenter RCTs are needed to corroborate this.
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Affiliation(s)
- Shilai Yang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gang Tang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yudi Zhang
- College of Combination of Chinese and Western Medicine, Chongqing College of Traditional Chinese Medicine, No. 61, Puguobao Road, Bicheng Street, Bishan District, Chongqing, 402760, P.R. China
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Donglin Du
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Chau TCY, Nguyen H, Robertson IK, Harvey X, Tan B, Tan M, Yang CM. Factors affecting timing of loop ileostomy closure: a regional centre's experience with 106 patients. ANZ J Surg 2024; 94:193-198. [PMID: 37876156 DOI: 10.1111/ans.18729] [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: 02/28/2023] [Revised: 09/15/2023] [Accepted: 10/01/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION The burden of defunctioning ileostomy is significant with up to two thirds of patients reporting stoma-related morbidity. While timely reversal is safe and cost-effective, the time to reversal in regional Australian hospitals is not well described in professional publications. We aim to assess the current timeliness of ileostomy closure and identify possible reasons for delaying closure. METHODS A retrospective analysis of loop ileostomies created and reversed in Launceston General Hospital for both rectal cancer surgery and other benign indications was undertaken. Patients with loop ileostomy created between 2010 and 2020 were included. Clinical data of timing of events, complications, readmission and stoma follow-up were recorded; and analysed using multivariate regression analyses to identify clinically relevant risk factors for delayed closure. RESULTS A total of 123 patients underwent loop-ileostomy formation during the study period, of which 106 patients (86.2%) were reversed. Median time to closure was 8.5 months (IQR 5.2-12.4) for patients with rectal cancers, compared to 5.2 months (IQR 3.6-9.3) for patients who did not have rectal cancer, with a difference of 3.4 months (95% CI 0.9, 5.9; P = 0.008). Adjuvant chemotherapy and unexpected readmission to hospital were associated with delayed reversal (P = 0.0081 and P = 0.0005, respectively). CONCLUSION Stoma reversal is often scheduled 3-6 months after creation. More than two-thirds of patients experienced delays due to changing clinical concerns and non-clinical factors, such as unexpected delays at each stage of surgical planning. Early placement on the waiting list and better-coordinated follow-ups may expedite reversal surgery and reduce associated morbidities.
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Affiliation(s)
- Tedman Cheuk-Yiu Chau
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Hung Nguyen
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Iain K Robertson
- School of Health Sciences, University of Tasmania, Hobart, Tasmania, Australia
| | - Xavier Harvey
- Department of General Surgery, St John of God Bunbury Hospital, Bunbury, Australia
| | - Brendan Tan
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Mitchell Tan
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Caroline M Yang
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
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Cheng HH, Shao YC, Lin CY, Chiang TW, Chen MC, Chiu TY, Huang YL, Chen CC, Chen CP, Chiang FF. Impact of chemotherapy on surgical outcomes in ileostomy reversal: a propensity score matching study from a single centre. Tech Coloproctol 2023; 27:1227-1234. [PMID: 36973527 DOI: 10.1007/s10151-023-02790-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 03/14/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE In patients with chemotherapy, there is no consensus on the timing of ileostomy closure. Ileostomy reversal could improve the quality of life and minimise the long-term adverse events of delayed closure. In this study, we evaluated the impact of chemotherapy on ileostomy closure and searched for the predictive factors for complications. METHODS We retrospectively analysed 212 patients with rectal cancer who underwent ileostomy closure surgery during and without chemotherapy and were consecutively enrolled between 2010 and 2016. As a result of the heterogeneity of the two groups, propensity score matching (PSM) was performed with a 1:1 PSM cohort. RESULTS A total of 162 patients were included in the analysis. The overall stoma closure-related complications (12.4% vs. 11.1%, p = 1.00) and major complications (2.5% vs. 6.2%, p = 0.44) were not significantly different between the two groups. Multivariate analysis demonstrated that chronic kidney disease and bevacizumab use are risk factors for major complications. CONCLUSION Patients with oral or intravenous chemotherapy can safely have ileostomy closure with an adequate time delay from chemotherapy. When patients use bevacizumab, major complications related to ileostomy closure should still be cautioned.
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Affiliation(s)
- H-H Cheng
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan.
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan.
| | - Y-C Shao
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Colorectal Surgery, Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - C-Y Lin
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - T-W Chiang
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - M-C Chen
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - T-Y Chiu
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Y-L Huang
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - C-C Chen
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - C-P Chen
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - F-F Chiang
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
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Sakowitz S, Bakhtiyar SS, Mallick S, Khoraminejad B, Olmedo M, Croman M, Benharash P, Lee H. Decreasing rates of colectomy for benign neoplasms: A nationwide analysis. PLoS One 2023; 18:e0293389. [PMID: 37878628 PMCID: PMC10599571 DOI: 10.1371/journal.pone.0293389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms. METHODS All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups. RESULTS Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001). CONCLUSIONS The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Aurora, CO, United States of America
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Baran Khoraminejad
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Manuel Olmedo
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Millicent Croman
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Hanjoo Lee
- Department of Surgery, University of California, Los Angeles, CA, United States of America
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6
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Geisler BP, Cao KN, Ryschon AM, Alavi K, Komen N, Pietzsch JB. Cost associated with diverting ostomy after rectal cancer surgery: a transnational analysis. Surg Endosc 2023; 37:7759-7766. [PMID: 37580581 DOI: 10.1007/s00464-023-10300-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/12/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Diverting ileostomy and colostomy after total mesorectal excision reduces the risk of complications related to anastomotic leakages but is associated with a reduction in health-related quality of life and long-term economic consequences that are unknown. Our objective was to estimate the lifetime costs of stoma placement after rectal cancer resection in the U.S., England, and Germany. METHODS Input parameters were derived from quasi-systematic literature searches. Decision-analytic models with survival from colorectal cancer-adjusted life tables and country-specific stoma reversal proportions were created for the three countries to calculate lifetime costs. Main cost items were stoma maintenance costs and reimbursement for reversal procedures. Discounting was applied according to respective national guidelines. Sensitivity analysis was conducted to explore the impact of parameter uncertainty onto the results. RESULTS The cohort starting ages and median survival were 63 and 11.5 years for the U.S., 69 years and 8.5 years for England, and 71 and 6.5 years for Germany. Lifetime discounted stoma-related costs were $26,311, £9512, and €10,021, respectively. All three models were most sensitive to the proportion of ostomy reversal, age at baseline, and discount rate applied. CONCLUSION Conservative model-based projections suggest that stoma care leads to significant long-term costs. Efforts to reduce the number of patients who need to undergo a diverting ostomy could result in meaningful cost savings.
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Affiliation(s)
- Benjamin P Geisler
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Khoa N Cao
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Anne M Ryschon
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Karim Alavi
- Department of Surgery/Division of Colon and Rectal Surgery, UMass Memorial Health/UMass Chan Medical School, Worcester, MA, USA
| | - Niels Komen
- Department Abdominal Surgery, Universitair Ziekenhuis Antwerpen/ReSURG, Antwerp Surgical Training, Anatomy and Research Center, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Jan B Pietzsch
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA.
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Baloyiannis I, Perivoliotis K, Mamaloudis I, Bompou E, Sarakatsianou C, Tzovaras G. Determination of Factors Related to the Reversal and Perioperative Outcomes of Defunctioning Ileostomies in Patients Undergoing Rectal Cancer Surgery: A Regression Analysis Model. J Gastrointest Cancer 2023; 54:782-790. [PMID: 36063314 DOI: 10.1007/s12029-022-00862-8] [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: 08/30/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Defunctioning ileostomies are often performed during rectal cancer surgery. However, stomas are sometimes associated with complications, while 20-30% of them are never reversed. Additionally, ileostomy closure can have associated morbidity, with rates as high as 45%, with the respective literature evidence being scarce and conflicting. Thus, we evaluated the stoma reversal outcomes and the risk factors for non-closure after rectal cancer surgery. METHODS This is a retrospective analysis of a prospectively collected database of all patients who had a defunctioning ileostomy at the time of resection for rectal cancer. All operations were performed by the same surgical team. A multivariable regression model was implemented. RESULTS In this study, 129 patients (male: 68.2%, female: 31.8%) were included. Ileostomy formation was associated with a total of 31% complication rate. Eventually 73.6% of the stomas were reversed at a mean time to closure of 26.6 weeks, with a morbidity of 13.7%. Non-reversal of ileostomy was correlated with neoadjuvant CRT (OR: 0.093, 95% CI: 0.012-0.735), anastomotic leakage (OR: 0.107, 95% CI: 0.019-0.610), and lymph node yield (OR: 0.946, 95% CI: 0.897-0.998). Time to reversal was affected by the N status, the LNR, the need for adjuvant chemotherapy, and the histologic grade. CONCLUSION In patients with rectal cancer resections, defunctioning stoma closure rate and time to closure were associated with several perioperative and pathological outcomes.
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Affiliation(s)
- Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Konstantinos Perivoliotis
- Department of Surgery, General Hospital of Volos, Polymeri 134, 38222, Volos, Greece.
- University of Thessaly, Viopolis, 41500, Larissa, Greece.
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110, Larissa, Greece.
| | - Ioannis Mamaloudis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Effrosyni Bompou
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Chamaidi Sarakatsianou
- Department of Anesthesiology, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
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Mori S, Tanabe K, Wada M, Hamada Y, Yasudome R, Sonoda T, Matsushita D, Shimonosono M, Arigami T, Sasaki K, Kurahara H, Nakajo A, Ohtsuka T. Modified pull-through coloanal anastomosis to avoid permanent stomas and reduce postoperative complications for lower rectal tumors. Surg Endosc 2023:10.1007/s00464-023-10184-w. [PMID: 37311894 DOI: 10.1007/s00464-023-10184-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: 04/03/2023] [Accepted: 05/30/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND We performed pull-through hand-sewn coloanal anastomosis immediately after sphincter-preserving ultralow anterior resection (ULAR) [pull-through ultra (PTU)] to avoid permanent stoma and reduce postoperative complications of lower rectal tumors. This study aimed to compare the clinical outcomes of PTU versus non-PTU (stapled or hand-sewn coloanal anastomosis with diverting stoma) after sphincter-preserving ULAR for lower rectal tumors. METHODS This retrospective cohort study analyzed prospectively maintained data from 100 consecutive patients who underwent PTU (n = 29) or non-PTU (n = 71) after sphincter-preserving ULAR for rectal tumors between January 2011 and March 2023. In PTU, hand-sewn coloanal anastomosis was immediately performed using 16 stitches of 4-0 monofilament suture during primary surgery. The clinical outcomes were assessed. The primary outcomes were rates of permanent stomas and overall postoperative complications. RESULTS The PTU group was significantly less likely to require a permanent stoma than the non-PTU group (P < 0.01). None of the patients in the PTU group required permanent stoma and the rate of overall complications was significantly lower in the PTU group (P = 0.01). The median operative time was comparable between the two groups (P = 0.33) but the median operative time during the second stage was significantly shorter in the PTU group (P < 0.01). The rates of anastomotic leakage and complications of Clavien-Dindo grade III were comparable between the two groups. Diverting ileostomy was performed in two patients with an anastomotic leak in the PTU group. The PTU group was significantly less likely to require a diverting ileostomy than those in the non-PTU group (P < 0.01). The composite length of hospital stay was significantly shorter in the PTU group (P < 0.01). CONCLUSIONS PTU via immediate coloanal anastomosis for lower rectal tumors is a safe alternative to the current sphincter-preserving ULAR with diverting ileostomy for patients who wish to avoid a stoma.
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Affiliation(s)
- Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan.
| | - Kan Tanabe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Masumi Wada
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Yuki Hamada
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Ryutaro Yasudome
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Tomohiro Sonoda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Daisuke Matsushita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Masataka Shimonosono
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Akihiro Nakajo
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
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Chen H, Huang F, Yang M, Zhao Z, Guan X, Liu Z, Jiang Z, Liu Q, Zheng Z, Wang X. Comparative short-term and survival outcomes of three specimen extraction techniques in laparoscopic low rectal cancer surgery: does it affect ileostomy closure? BMC Surg 2023; 23:122. [PMID: 37170142 PMCID: PMC10176932 DOI: 10.1186/s12893-023-01995-8] [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: 11/27/2022] [Accepted: 04/07/2023] [Indexed: 05/13/2023] Open
Abstract
INTRODUCTION This study aimed to compare the short-term and survival outcomes in laparoscopic low rectal cancer surgery with three different specimen extraction techniques, and whether it affects loop ileostomy closure. MATERIALS AND METHODS A consecutive series of patients with low rectal cancer who underwent laparoscopic low anterior resection plus protective loop ileostomy (LAR-PLI) were enrolled. Three main techniques, namely specimen extraction through auxiliary incision (EXAI), specimen extraction through stoma incision (EXSI), and specimen eversion and extra-abdominal resection (EVER), were employed. The postoperative short-term and survival outcomes of the three techniques and the impact on loop ileostomy closure were compared. RESULTS In all, 254 patients were enrolled in this study: 104 (40.9%) in the EXAI group, 104 (40.9%) in the EXSI group, and 46 (18.1%) in the EVER group. For primary surgery, EXAI group had significantly longer operative time (P < 0.001), more intraoperative bleeding (P < 0.001), longer length of abdominal incision (P<0.001), longer time to first flatus (P < 0.001), longer time to first defecation (P < 0.001), longer time to first eat (P < 0.001), and longer postoperative hospital stays (P = 0.005) than the EXSI and EVER groups. The primary postoperative complication rate in the EXAI and EVER group was significantly higher than in the EXSI group (P = 0.005). In loop ileostomy closure, EXAI group had significantly longer operative time (P = 0.001), more bleeding volume, and longer postoperative hospital stays (P < 0.001) than the EXSI and EVER groups. For survival outcomes, the 3-year local recurrence-free survival (LRFS) is 92.6% for all patients. The 3-year LRFS for patients in EXAI, EXSI, and EVER were 90.1%, 95.4%, and 92.7%, with P = 0.476. CONCLUSIONS Our single-center results found that in LAR-PLI surgery for low rectal cancer, the short-term outcomes of specimen extraction through the stoma incision or anus were better than that through the auxiliary incision, but the 3-year LRFS was no statistically different.
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Affiliation(s)
- Haipeng Chen
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Huang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Yang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhixun Zhao
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Guan
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng Jiang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian Liu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Science and Peking Union Medical College, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
| | - Zhaoxu Zheng
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Science and Peking Union Medical College, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
| | - Xishan Wang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/ Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Science and Peking Union Medical College, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
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10
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Ellebæk MB, Perdawood SK, Steenstrup S, Khalaf S, Kundal J, Möller S, Bang JC, Støvring J, Qvist N. Early versus late reversal of diverting loop ileostomy in rectal cancer surgery: a multicentre randomized controlled trial. Sci Rep 2023; 13:5818. [PMID: 37037856 PMCID: PMC10085999 DOI: 10.1038/s41598-023-33006-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 04/05/2023] [Indexed: 04/12/2023] Open
Abstract
Diverting loop ileostomy has become routine in low anterior resection (LAR) for rectal cancer. The optimal time for stoma reversal is controversial. The aim of the present study was to compare the results after planned early (within 8-12 days) versus late (> 3 months) stoma reversal. The primary outcomes were morbidity and mortality, as measured by the Comprehensive Complication Index (CCI) within 30 days after stoma reversal, and the secondary outcomes were morbidity and mortality within 90 days after LAR. This was a multicentre trial including all patients scheduled for anterior low resection for rectal cancer with curative intent. Inclusion period was from April 2011 to December 2018. All patients were randomized 1:1 prior to surgery. Among 257 consecutive and eligible patients, a total of 214 patients were randomized: 107 patients to early stoma reversal and 107 to late reversal. A total of 68 patients were excluded for various reasons, and 146 patients completed the study, with 77 in the early reversal group and 69 in the late reversal group. The patients were asked to complete the Gastrointestinal Quality of Life Index before surgery (baseline) and at 6 and 12 months after LAR. Ostomy-related complications were evaluated by dedicated ostomy staff using the validated DET score. ClinicalTrials Identifier: NCT01865071. Fifty-three patients (69%) in the early reversal group and 60 patients (87%) in the late reversal group received the intended treatment. There were no significant differences in CCI within 90 days after index surgery with the LAR and within 30 days after stoma reversal between the two groups. There were no differences in patient-reported quality of life but significantly more stoma-related complications in the late reversal group. A total of 5 patients experienced anastomotic leakage (AL) after stoma reversal, 4 in the early reversal group and one in the late reversal group. Early and late stoma reversal showed similar outcomes in terms of overall complications and quality of life. The risk of developing anastomotic leakage after early ostomy reversal is a concern.
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Affiliation(s)
- Mark Bremholm Ellebæk
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark.
- OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | | | - Signe Steenstrup
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sardar Khalaf
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jette Kundal
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Jens Støvring
- Department of Surgery, Hospital South West Jutland, Esbjerg, Denmark
| | - Niels Qvist
- Research Unit of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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11
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Keramati MR, Meshkati Yazd SM, Shahriarirad R, Ahmadi Tafti SM, Kazemeini A, Behboudi B, Fazeli MS, Keshvari A. Hand-sewn direct repair versus resection and hand-sewn anastomosis techniques for the reversal of diverting loop ileostomy after lower anterior rectal resection surgery: A randomized clinical trial. J Surg Oncol 2023; 127:798-805. [PMID: 36576493 DOI: 10.1002/jso.27185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/27/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Several techniques have been proposed for the closure of loop ileostomy. This is the first study comparing bowel function and outcomes of two different hand-sewn surgical techniques used for the closure of diverting protective loop ileostomy. METHOD In this prospective, randomized, double-blind clinical trial, 40 patients with a history of rectal cancer, low anterior resection, and diverting loop ileostomy who were candidates for ileostomy reversal were included and randomly assigned into two groups, hand-sewn direct repair of the ileal defect (group A) and resection and hand-sewn anastomosis of the ileum (group B). RESULTS The mean age of patients was 56.42 and 52.10 years in groups A and B, respectively. Regarding early postoperative period, group A developed earlier first gas passage (1.68 vs. 2.25 days, p = 0.041) and stool passage (2.10 vs. 2.80 days, p = 0.032). Group A also revealed shorter operating time (83.68 vs. 89.50 min, p = 0.040) and hospital stay (4.73 vs. 6.80 days, p = 0.001). None of the participants in both groups developed signs of bowel obstruction during the early and late postoperative follow-up period. CONCLUSIONS Direct hand-sewn repair for the closure of diverting loop ileostomy is a safe technique with better postoperative bowel function, oral diet tolerance, and less hospital stay compared to resection and hand-sewn anastomosis of the ileum.
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Affiliation(s)
- Mohammad Reza Keramati
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mostafa Meshkati Yazd
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Mohsen Ahmadi Tafti
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Kazemeini
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Behboudi
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sadegh Fazeli
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Keshvari
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
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12
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Sandberg S, Bock D, Lydrup ML, Park J, Rutegård M, Angenete E. The impact of the anastomotic configuration on low anterior resection syndrome 3 years after total mesorectal excision for rectal cancer: a national cohort study. Colorectal Dis 2023. [PMID: 36794476 DOI: 10.1111/codi.16523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/16/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023]
Abstract
AIM After low anterior resection, the bowel can be anastomosed in different ways. It is not clear which configuration is optimal from a functional and complication point of view. The primary aim was to investigate the impact of the anastomotic configuration on bowel function evaluated by the low anterior resection syndrome (LARS) score. Secondarily, the impact on postoperative complications was evaluated. METHOD All patients who had undergone low anterior resection from 2015 to 2017 were identified in the Swedish Colorectal Cancer Registry. Three years after surgery, patients were sent an extensive questionnaire and were analysed based on anastomotic configuration ('J-pouch/side-to-end anastomosis' or 'straight anastomosis'). Inverse probability weighting by propensity score was used to adjust for confounding factors. RESULTS Among 892 patients, 574 (64%) responded, of whom 494 patients were analysed. After weighting, the anastomotic configuration had no significant impact on the LARS score (J-pouch/side-to-end OR 1.05, 95% confidence interval [CI] 0.82-1.34). The J-pouch/side-to-end anastomosis was significantly associated with overall postoperative complications (OR 1.43, 95% CI 1.06-1.95). No significant difference was seen regarding surgical complications (OR 1.14, 95% CI 0.78-1.66). CONCLUSION This is the first study investigating the impact of the anastomotic configuration on long-term bowel function, evaluated by the LARS score, in an unselected national cohort. Our results suggested no benefit for J-pouch/side-to-end anastomosis on long-term bowel function and postoperative complication rates. The anastomotic strategy may be based upon the anatomical conditions of the patient and surgical preference.
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Affiliation(s)
- Sofia Sandberg
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - David Bock
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Institution for Clinical Sciences Malmö, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
| | - Jennifer Park
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Eva Angenete
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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13
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Wang J, Ye X, Zhou Q, Xu C, Fan Y, Luan N, Zhu X. Parachute-like pull-through anastomosis for low rectal cancer: a new method for preservation of anal function. Langenbecks Arch Surg 2023; 408:86. [PMID: 36781494 PMCID: PMC9925529 DOI: 10.1007/s00423-023-02768-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 11/29/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND With recent improvements in surgical technique, oncological outcomes of low rectal cancer have improved over time. But the QoL impairment as a result of anal functional disorder cannot be ignored. And the incidence of anastomosis-related complications cannot be ignored. To address these problems, a personal technique for pull-through coloanal anastomosis (parachute-like intussuscept pull-through anastomosis) was introduced and evaluated. This technique can relatively reduce surgical complications, minimize the impact of anal function, and obviate a colostomy creation. METHODS Between June 2020 and April 2021, 14 consecutive patients with rectal cancer underwent laparoscopic-assisted resection of rectal cancer in our hospital. Parachute-like pull-through anastomosis method was performed in all patients. Anal function, perioperative details, and postoperative outcomes were analyzed. RESULTS The mean (SD) operative time of first stage was 282.1 min (range 220-370) with an average estimated blood loss of 90.3 mL (range 33-200). And the mean (SD) operative time of second was 46 min (range 25-76) with an average estimated blood loss of 16.1 mL (range 5-50). Wexner scores declined significantly during the median follow-up of 18 months. Four postoperative anastomosis-related complications occurred in 14 patients, including perianastomotic abscess: 1 case (7%), anastomotic stricture: 1 case (7%), and colonic ischemia of the exteriorized colonic segment: 2 cases (14%). CONCLUSION The results suggest that the method can facilitate safe and easy completion of coloanal anastomosis, using parachute-like pull-through anastomosis, with acceptable anal function.
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Affiliation(s)
- JianWei Wang
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road 88th, Hangzhou, China.
- Department of Surgery, 4th Affiliated Hospital, School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China.
| | - Xun Ye
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road 88th, Hangzhou, China
| | - Qin Zhou
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road 88th, Hangzhou, China
| | - ChengCai Xu
- Department of Surgery, 4th Affiliated Hospital, School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - YiQun Fan
- Department of Surgery, 4th Affiliated Hospital, School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Na Luan
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road 88th, Hangzhou, China
| | - XiaoLing Zhu
- Department of Surgery, 4th Affiliated Hospital, School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
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14
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Tyler R, Foss H, Phelan L, Radley S, Geh I, Karandikar S. Impact of surgeon volume on 18-month unclosed ileostomy rate after restorative rectal cancer resection. Colorectal Dis 2023; 25:253-260. [PMID: 36222737 DOI: 10.1111/codi.16368] [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: 07/26/2022] [Accepted: 10/03/2022] [Indexed: 02/08/2023]
Abstract
AIM The impact of surgeon volume on 18-month unclosed ileostomy rates after rectal cancer surgery has not been fully explored. The aim of this study was to describe the effect of surgeon volume and evaluate factors predictive of an unclosed ileostomy. METHOD Patients undergoing anterior resection with a diverting ileostomy for rectal cancer from March 2004 to October 2018 were identified from a prospectively maintained database. The unclosed ileostomy rate was determined by those with an unclosed ileostomy at 18 months. High- and low-volume surgeons (HVS and LVS, respectively) were classed as those performing five or more or fewer than five rectal cancer resections per year, respectively. Data on sex, age, American Society of Anesthesiologists grade, neoadjuvant chemoradiotherapy (CRT), tumour height, T-stage, anastomotic leak, surgical approach and adjuvant chemotherapy were also collected. Factors predictive of an unclosed ileostomy at 18 months were explored using a multivariate binary logistic regression analysis. RESULTS A total of 415 patients (62.4% male) with a median age of 67 were eligible for analysis. Of these, 115 (27.7%) had an unclosed ileostomy at 18 months. HVS had an unclosed ileostomy rate of 24.6% (72/292) compared with 34.9% (43/123) for LVS. Volume was associated with an unclosed ileostomy in univariable analysis (p = 0.032) but not in multivariate analysis (OR 1.75, 95% CI 0.92-3.32, p = 0.08). Independent factors predictive of an unclosed ileostomy were anastomotic leak (OR 10.41, 3.95-27.0, p < 0.01), adjuvant chemotherapy (OR 2.23, 1.24-3.96, p < 0.01) and neoadjuvant CRT (OR 2.16, 1.15-5.75, p = 0.01). CONCLUSION LVS were associated with a higher unclosed ileostomy at 18 months compared with HVS. This study adds further weight to the call for adoption of a minimum annual case threshold in rectal cancer surgery.
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Affiliation(s)
| | - Helen Foss
- Birmingham Heartlands Hospital, Birmingham, UK
| | - Liam Phelan
- Birmingham Heartlands Hospital, Birmingham, UK
| | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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15
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Closure timing of a temporary ileostomy in patients with rectal cancer undergoing anus-preserving operation: a retrospective cohort study. Surg Today 2023; 53:116-129. [PMID: 35861894 DOI: 10.1007/s00595-022-02543-2] [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: 01/23/2022] [Accepted: 05/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To investigate the optimal closure time of a temporary ileostomy in patients with rectal cancer receiving anus-preserving operation. METHODS Patients with rectal cancer were enrolled from the Affiliated Hospital of Jiangsu University from May 2010 to June 2019. The eligible patients were grouped according to their actual ileostomy closure time after stoma creation. Outcomes were complications during stoma closure and complications within one year after stoma closure. RESULTS This study included 361 qualified subjects, with 108 patients in the 3-5 months group, 133 in the 5-7 months group and 120 in the ≥ 7 months group. Compared with the risk of complications during stoma closure in the 3-5 months group, that in the 5-7 months group was significantly reduced (odds ratio [OR]: 0.36, 95% confidence interval [CI] 0.13-0.99), and that in the ≥ 7 months group was significantly increased (OR: 5.88, 95% CI 2.38-14.56). In contrast to the 3-5 months group, the 5-7 months group showed a significantly decreased risk (OR: 0.21, 95% CI 0.07-0.67), and the ≥ 7 months group showed a significantly increased risk (OR: 4.21, 95% CI 1.61-11.01) of complications within 1 year after stoma closure. CONCLUSION 5-7 months after the ileostomy is created may be the optimal time for its closure.
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16
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Shabunin AV, Bagatelija ZA, Kulushev VM, Hmylov LM, Maksimkin AI. [Prognostic factors of dehydration and renal damage in patients with formed preventive ileostomy during rectal resection for cancer]. Khirurgiia (Mosk) 2023:23-29. [PMID: 36583490 DOI: 10.17116/hirurgia202301123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Despite the potential advantages of a preventive intestinal stoma after the formation of a low colon anastomosis during rectal resections, the formation of a preventive loop ileostomy is associated with a significant frequency of complications. OBJECTIVE To determine the potential prognostic factors of complications associated with ileostomy dysfunction in patients who have undergone rectal resection for cancer. MATERIAL AND METHODS We retrospectively analyzed patients over the age of 18 who underwent open and laparoscopic resection of the rectum with the formation of a preventive ileostomy from January 2015 to May 2022. To determine the influence of potential predictors on the frequency of complications associated with large ileostomy losses, a single-factor logistic regression analysis was used. Complications associated with large ileostomy losses were primarily water-electrolyte disorders, dehydration and acute renal failure, which required intensive therapy and re-hospitalization. RESULTS Of the 120 patients included in the study, 26 (21.7%) suffered complications associated with large losses of fluid and electrolytes in the stoma. In this group of patients, at least one repeated emergency hospitalization to a medical institution was required (average value 1.6). Factors associated with ileostomy dysfunction in a single-factor analysis were: the presence of signs of intestinal obstruction (OR=2.6; p=0.047), the development of postoperative complications (OR=3; p=0.024), steroid use (OR=4.3; p=0.010), smoking (OR=4.8; p=0.017) the average amount of discharge from the stoma at discharge is more than 1000 ml/24 h (OR=3.2; p=0.016) and the need for Loperamide at the time of discharge (OR=2.8; p=0.032). Multivariate logistic regression analysis revealed an independent risk factor for complications leading to re-hospitalization: ileostomy losses at discharge ≥1000 ml/24 h (OR=3.3 (1.18-9.37); p=0.023). CONCLUSION In our study, those patients whose ileostomy discharge exceeded 1000 ml/24 h at discharge were at increased risk of dehydration, hypokalemia, hypocalcemia, acute prerenal renal failure, which led to repeated hospitalization to correct these disorders, sometimes in the intensive care unit.
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Affiliation(s)
- A V Shabunin
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia.,Botkin Hospital, Moscow, Russia
| | - Z A Bagatelija
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia.,Botkin Hospital, Moscow, Russia
| | | | | | - A I Maksimkin
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
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17
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Zamaray B, Veld JV, Burghgraef TA, Brohet R, van Westreenen HL, van Hooft JE, Siersema PD, Tanis PJ, Consten ECJ, Amelung F, Bastiaenen V, van der Bilt J, Burghgraef T, Draaisma W, de Groot J, Kok N, Kusters M, Nagtegaal I, Zwanenburg E. Risk factors for a permanent stoma after resection of left-sided obstructive colon cancer - A prediction model. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 49:738-746. [PMID: 36641294 DOI: 10.1016/j.ejso.2022.12.008] [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: 09/27/2022] [Revised: 11/07/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In patients with left-sided obstructive colon cancer (LSOCC), a stoma is often constructed as part of primary treatment, but with a considerable risk of becoming a permanent stoma (PS). The aim of this retrospective multicentre cohort is to identify risk factors for a PS in LSOCC and to develop a pre- and postoperative prediction model for PS. MATERIALS AND METHODS Data was retrospectively obtained from 75 hospitals in the Netherlands. Patients who had curative resection of LSOCC between January 1, 2009 to December 31, 2016 were included with a minimum follow-up of 6 months after resection. The interventions analysed were emergency resection, decompressing stoma or stent as bridge-to-elective resection. Main outcome measure was presence of PS at the end of follow-up. Multivariable logistic regression analysis was performed to identify risk factors for PS at primary presentation (T0) and after resection, in patients having a stoma in situ (T1). These risk factors were used to construct a web-based prediction tool. RESULTS Of 2099 patients included in the study (T0), 779 had a PS (37%). A total of 1275 patients had a stoma in situ directly after resection (T1), of whom 674 had a PS (53%). Median follow-up was 34 months. Multivariable analysis showed that older patients, female sex, high ASA-score and open approach were independent predictors for PS in both the T0 and T1 population. Other predictors at T0 were sigmoid location, low Hb, high CRP, cM1 stage, and emergency resection. At T1, subtotal colectomy, no primary anastomosis, not receiving adjuvant chemotherapy and high pTNM stage were additional predictors. Two predictive models were built, with an AUC of 0.74 for T0 and an AUC of 0.81 for T1. CONCLUSIONS PS is seen in 37% of the patients who have resection of LSOCC. In patients with a stoma in situ directly after resection, 53% PS are seen due to non-reversal. Not only baseline characteristics, but also treatment strategies determine the risk of a PS in patients with LSOCC. The developed predictive models will give physicians insight in the role of the individual variables on the risk of a PS and help in informing the patient about the probability of a PS.
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Affiliation(s)
- Bobby Zamaray
- Department of Surgery, Isala Hospital, Zwolle, the Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - J V Veld
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - T A Burghgraef
- Department of Surgery, Meander Hospital, Amersfoort, the Netherlands
| | - R Brohet
- Department of Surgery, Isala Hospital, Zwolle, the Netherlands
| | | | - J E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Location AMC, the Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands; Department of Oncological and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands; Department of Surgery, Meander Hospital, Amersfoort, the Netherlands.
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Defunctioning stoma in rectal cancer surgery - A risk factor for Low Anterior Resection Syndrome? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2518-2524. [PMID: 35798597 DOI: 10.1016/j.ejso.2022.06.025] [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: 01/21/2022] [Revised: 06/04/2022] [Accepted: 06/19/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND In rectal cancer surgery the formation of a defunctioning stoma is common in order to reduce the consequences of an anastomotic leakage. The role of a defunctioning stoma and time to stoma reversal, in relation to major Low Anterior Resection Syndrome (LARS) in the long-term perspective, is still unclear. The aim of the study was to investigate the association between a defunctioning stoma and long-term bowel function. METHOD Patients who underwent curative rectal cancer surgery between 2007 and 2013 in Stockholm county, Sweden, who had no history of anastomotic leakage, without a remaining stoma, free of cancer and alive in April 2017 were eligible for the study. The exposures were (i) use of defunctioning stoma at cancer surgery and (ii) time to stoma reversal. Main outcome was major LARS with information retrieved from the LARS score questionnaire. Multivariable logistic regression model was used to calculate odds ratios (OR) primary comparing major LARS to no LARS. RESULTS A total of 430 patients were included in analysis. The mean follow-up time was 6.7 years after surgery (range 3.4-10.7 years). The use of a defunctioning stoma was associated to major LARS with an adjusted OR of 2.43 (95% CI 1.14-5.20) when compared to no stoma. There were no evident associations between time to stoma reversal and the risk of major LARS. CONCLUSION This study indicates that the presence of a defunctioning stoma is associated with impaired bowel function in the long-term perspective, while failing to show any clear association to time to stoma reversal.
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From Formation to Closure: Aggregate Morbidity and Mortality Associated With Defunctioning Loop Ileostomies. Dis Colon Rectum 2022; 65:1135-1142. [PMID: 34840304 DOI: 10.1097/dcr.0000000000002185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Defunctioning loop ileostomies are used commonly, but there are significant morbidities. OBJECTIVE This study aimed to describe the morbidity and mortality associated with the formation and closure of defunctioning loop ileostomies. DESIGN This descriptive study is based on electronic health records and claims data. SETTINGS This study was conducted at academic and community hospitals in Ontario, Canada. PATIENTS Adult patients who had a low anterior resection with concurrent defunctioning loop ileostomy from 2002 to 2014 were included. MAIN OUTCOME MEASURES Outcomes of interest included 30-day major complications, acute kidney injury, transfusion, and deep space infection. The rate of ileostomy reversal and the percentage of permanent ostomies were also collected. RESULTS The cohort consists of 4658 patients who underwent low anterior resection with concurrent defunctioning loop ileostomy. The 30-day, 90-day, and 1-year mortality rates of these patients were 1.2%, 2.2%, and 5.1%. The rate of reoperation was 5.5%, the rate of hospital readmission was 13.4%, the rate of major complications was 28.5%, the rate of deep organ/space infection requiring percutaneous intervention was 5.2%, and the rate of acute kidney injury requiring hospitalization was 10.4%. Eighty-six percent had their ileostomy reversed, leaving 13.2% with a permanent ostomy. After ileostomy reversal, 30-day and 90-day mortality rates were 0.6% and 0.9%. The rate of major complications was 10.3%, bowel obstruction 7%, ventral hernia 10.5%, deep space infection 1.7%, and repeat operation 2.3%. LIMITATIONS This study is based on electronic health records and claims data and, thus, the accuracy of results depends on the accuracy of data administration' which can be variable across institutions. CONCLUSIONS Morbidity and mortality of defunctioning loop ileostomies are significant. One in 8 patients will have a permanent ostomy. See Video Abstract at http://links.lww.com/DCR/B810 . DESDE LA FORMACIN HASTA EL CIERRE AGREGADA MORBILIDAD Y MORTALIDAD ASOCIADA CON LAS ILEOSTOMAS EN ASA DERIVATIVA ANTECEDENTES:Las ileostomías en asa derivativa se utilizan con frecuencia, pero existen morbilidades importantes.OBJETIVO:Describir la morbilidad y mortalidad asociadas con la formación y cierre de ileostomías en asa derivativa.DISEÑO:Estudio descriptivo basado en historias clínicas electrónicas y datos de reclamaciones.ENTORNO CLINICO:Hospitales académicos y comunitarios en Ontario, Canadá.PACIENTES:Pacientes adultos sometidos a resección anterior baja con concurrente ileostomía en asa derivativa de 2002 a 2014.PRINCIPALES MEDIDAS DE VALORACION:Los resultados de interés incluyeron complicaciones mayores a los 30 días, lesión renal aguda, transfusión e infección del espacio profundo. También se recolectó la tasa de reversión de la ileostomía y el porcentaje de ostomías permanentes.RESULTADOS:La cohorte consistió de 4658 pacientes sometidos a resección anterior baja con concurrente ileostomía en asa derivativa. La mortalidad de estos pacientes, a treinta días, 90 días y un año, fue del 1,2%, 2,2% y 5,1%, respectivamente. La tasa de reintervención fue del 5,5%, el reingreso hospitalario fue del 13,4%, la complicación mayor fue del 28,5%, la infección profunda de órganos / espacios que requirieron intervención percutánea fue del 5,2%, y la lesión renal aguda que requirió hospitalización fue del 10,4%. Ochenta y seis por ciento tuvieron reversión de su ileostomía, dejando al 13.2% con una ostomía permanente. Después de la reversión de la ileostomía, la mortalidad a los 30 días y 90 días fue de 0,6% y 0,9%, respectivamente. La tasa de complicaciones mayores fue del 10,3%, obstrucción intestinal del 7%, hernia ventral del 10,5%, infección del espacio profundo del 1,7% y reintervención del 2,3%.LIMITACIONES:El estudio se basa en registros médicos electrónicos y datos de reclamos y, por lo tanto, la precisión de los resultados depende de la precisión en la administración de datos, que pueden variar entre instituciones.CONCLUSIONES:La morbilidad y la mortalidad de las ileostomías en asa derivativa son significativas. Uno de cada 8 pacientes tendrá una ostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/B810 . (Traducción-Dr. Fidel Ruiz Healy ).
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SEGURA GIMÉNEZ MJ, RODRÍGUEZ CARRILLO R, AZORÍN SAMPER MDC, ALARCÓN IRANZO M, RUIZ CARMONA MD, LOZOYA TRUJILLO R, SOLANA BUENO A, ALÓS COMPANY R. Impact of defunctioning loop ileostomy on renal function and hydroelectrolyte balance in rectal cancer patients. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05325-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Diverting ileostomy is a risk factor for renal impairment during CAPOX therapy. Int J Clin Oncol 2022; 27:1616-1623. [PMID: 35867198 DOI: 10.1007/s10147-022-02217-6] [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: 05/05/2022] [Accepted: 07/02/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Temporary ileostomy is sometimes created after colorectal surgery and may cause renal impairment. However, the impact of ileostomy on renal function during adjuvant chemotherapy for colorectal cancer (CRC) remains unknown. The aim of the present study was to examine the effects of ileostomy on renal function during adjuvant chemotherapy. METHODS We examined 184 patients who received adjuvant CAPOX therapy (capecitabine and oxaliplatin) for CRC with or without ileostomy between January 2011 and December 2020 at the University of Tokyo Hospital. Clinicopathological factors, including renal function, were retrospectively reviewed in association with temporary ileostomy. Factors associated with reductions in the estimated glomerular filtration rate (eGFR) during CAPOX therapy were analyzed. RESULTS Eighteen patients (10%) underwent temporary ileostomy. The maximum decrease in eGFR during CAPOX therapy was significantly higher in patients with than in those without ileostomy (- 16.1 vs. - 5.6 mL/min/1.73m2, p = 0.003). A multivariate analysis identified ileostomy as one of factors independently associated with reductions in eGFR during CAPOX therapy (p = 0.003). The cumulative number of readmission due to dehydration was also higher in patients with ileostomy (33% vs. 1%, p < 0.001). CONCLUSIONS Ileostomy significantly reduced eGFR during adjuvant CAPOX therapy. Therefore, renal function needs to be monitored during CAPOX therapy, particularly in patients with ileostomy.
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Pinson J, Tuech JJ, Ouaissi M, Mathonnet M, Mauvais F, Houivet E, Lacroix E, Rondeaux J, Sabbagh C, Bridoux V. Role of protective stoma after primary anastomosis for generalized peritonitis due to perforated diverticulitis-DIVERTI 2 (a prospective multicenter randomized trial): rationale and design (nct04604730). BMC Surg 2022; 22:191. [PMID: 35578267 PMCID: PMC9112494 DOI: 10.1186/s12893-022-01589-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background Traditionally, patients with peritonitis Hinchey III and IV due to perforated diverticulitis were treated with Hartmann’s procedure. In the past decade, resection and primary anastomosis have gained popularity over Hartmann’s procedure and recent guidelines recommend Hartmann’s procedure in two situations only: critically ill patients and in selected patients with multiple comorbidity (at high risk of complications). The protective stoma (PS) is recommended after resection with primary anastomosis, however its interest has never been studied. The aim of this trial is to define the role of systematic PS after resection and primary anastomosis for peritonitis Hinchey III and IV due to perforated diverticulitis. Methods/design This DIVERTI 2 trial is a multicenter, randomized, controlled, superiority trial comparing resection and primary anastomosis with (control group) or without (experimental group) PS in patients with peritonitis Hinchey III and IV due to perforated diverticulitis. Primary endpoint is the overall 1 year morbidity according to the Clavien–Dindo classification of surgical complications. All complications occurring during hospitalization will be collected. Late complications occurring after hospitalization will be collected during follow-up. In order to obtain 80% power for a difference given by respective main probabilities of 67% and 47% in the protective stoma and no protective stoma groups respectively, with a two-sided type I error of 5%, 96 patients will have to be included in each group, hence 192 patients overall. Expecting a 5% rate of patients not assessable for the primary end point (lost to follow-up), 204 patients will be enrolled. Secondary endpoints are postoperative mortality, unplanned reinterventions, incisional surgical site infection (SSI), organ/space SSI, wound disruption, anastomotic leak, operating time, length of hospital stay, stoma at 1 year after initial surgery, quality of life, costs and quality-adjusted life years (QALYs). Discussion The DIVERTI 2 trial is a prospective, multicenter, randomized, study to define the best strategy between PS and no PS in resection and primary anastomosis for patients presenting with peritonitis due to perforated diverticulitis. Trial registration ClinicalTrial.gov: NCT04604730 date of registration October 27, 2020. https://clinicaltrials.gov/ct2/show/NCT04604730?recrs=a&cond=Diverticulitis&draw=2&rank=12.
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Affiliation(s)
- Jean Pinson
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Mehdi Ouaissi
- Department of Digestive Surgery, Tours University Hospital, Chambray-lès-Tours, France
| | - Murielle Mathonnet
- Department of Digestive Surgery, Limoges University Hospital, Limoges, France
| | - François Mauvais
- Department of Digestive Surgery, Beauvais General Hospital, Beauvais, France
| | - Estelle Houivet
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Elie Lacroix
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Julie Rondeaux
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Charles Sabbagh
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
| | - Valérie Bridoux
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France. .,Department of Digestive Surgery, Rouen University Hospital, 1 rue Germont, 76031, Rouen Cedex, France.
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Werner JM, Kupke P, Ertl M, Opitz S, Schlitt HJ, Hornung M. Timing of Closure of a Protective Loop-Ileostomy Can Be Crucial for Restoration of a Functional Digestion. Front Surg 2022; 9:821509. [PMID: 35419403 PMCID: PMC8999839 DOI: 10.3389/fsurg.2022.821509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/28/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Protective loop-ileostomy is one of the most common interventions in abdominal surgery to provide an alternative intestinal outlet until sufficient healing of a distal anastomosis has occurred. However, closure of a loop-ileostomy is also associated with complications. Thus, knowledge of the optimal time interval between primary and secondary surgery is crucial. Methods Data from 409 patients were retrospectively analyzed regarding complications and risk factors in closure-associated morbidity and mortality. A modified Clavien-Dindo classification of surgical complications was used to evaluate the severity of complications. Results A total of 96 (23.5%) patients suffered from postoperative complications after the closure of the loop-ileostomy. Early closure within 150 days from enterostomy (n = 229) was associated with less complications (p < 0.001**). Looking at the severity of complications, there were significantly more (p = 0.014*) mild postoperative complications in the late closure group (>150 days). Dysfunctional digestive problems—either (sub-) ileus (p = 0.004*), diarrhea or stool incontinence (p = 0.003*)—were the most frequent complications associated with late closure. Finally, we could validate in a multivariate analysis that “time to closure” (p = 0.002*) is independently associated with the development of complications after closure of a protective loop-ileostomy. Conclusion Late closure (>150 days) of a loop-ileostomy is an independent risk factor in post-closure complications in a multivariate analysis. Nevertheless, circumstances of disease and therapy need to be considered when scheduling the closure procedure.
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La Raja C, Foppa C, Maroli A, Kontovounisios C, Ben David N, Carvello M, Spinelli A. Surgical outcomes of Turnbull-Cutait delayed coloanal anastomosis with pull-through versus immediate coloanal anastomosis with diverting stoma after total mesorectal excision for low rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:603-613. [PMID: 35344150 DOI: 10.1007/s10151-022-02601-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 02/16/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Theoretical advantages of Turnbull-Cutait pull-through delayed coloanal anastomosis (DCAA) are a reduced risk of anastomotic leak and therefore avoidance of stoma. Gradually abandoned in favor of immediate coloanal anastomosis (ICAA) with diverting stoma, DCAA has regained popularity in recent years in reconstructive surgery for low RC, especially when combined with minimally invasive surgery (MIS). The aim of this study was to perform the first meta-analysis, exploring the safety and outcomes of DCAA compared to ICAA with protective stoma. METHODS A systematic search of MEDLINE, EMBASE, and CENTRAL and Google Scholar databases was performed for studies published from January 2000 until December 2020. The systematic review and meta-analysis were performed according to the Cochrane Handbook for Systematic Review on Interventions recommendations and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. RESULTS Out of 2626 studies screened, 9 were included in the systematic review and 4 studies in the meta-analysis. Outcomes included were postoperative complications, pelvic sepsis and risk of definitive stoma. Considering postoperative complications classified as Clavien-Dindo III, no significant difference existed in the rate of postoperative morbidity between DCAA and ICAA (13% versus 21%; OR 1.17; 95% CI 0.38-3.62; p = 0.78; I2 = 20%). Patients in the DCAA group experienced a lower rate of postoperative pelvic sepsis compared with patients undergoing ICAA with diverting stoma (7% versus 14%; OR 0.37; 95% CI 0.16-0.85; p = 0.02; I2 = 0%). The risk of definitive stoma was comparable between the two groups (2% versus 2% OR 0.77; 95% CI 0.15-3.85; p = 0.75; I2 = 0%). CONCLUSIONS According to the limited current evidence, DCAA is associated with a significant decrease in pelvic sepsis. Further prospective trials focusing on oncologic and functional outcomes are needed.
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Affiliation(s)
- C La Raja
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - C Foppa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - A Maroli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - C Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - N Ben David
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - M Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - A Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy. .,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy.
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Overall readmissions and readmissions related to dehydration after creation of an ileostomy: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:333-349. [PMID: 35192122 PMCID: PMC9018644 DOI: 10.1007/s10151-022-02580-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/18/2022] [Indexed: 12/19/2022]
Abstract
Background Hospital readmissions after creation of an ileostomy are common and come with a high clinical and financial burden. The aim of this review with pooled analysis was to determine the incidence of dehydration-related and all-cause readmissions after formation of an ileostomy, and the associated costs.
Methods A systematic literature search was conducted for studies reporting on dehydration-related and overall readmission rates after formation of a loop or end ileostomy between January 1990 and April 2021. Analyses were performed using R Statistical Software Version 3.6.1.
Results The search yielded 71 studies (n = 82,451 patients). The pooled incidence of readmissions due to dehydration was 6% (95% CI 0.04–0.09) within 30 days, with an all-cause readmission rate of 20% (CI 95% 0.18–0.23). Duration of readmissions for dehydration ranged from 2.5 to 9 days. Average costs of dehydration-related readmission were between $2750 and $5924 per patient. Other indications for readmission within 30 days were specified in 15 studies, with a pooled incidence of 5% (95% CI 0.02–0.14) for dehydration, 4% (95% CI 0.02–0.08) for stoma outlet problems, and 4% (95% CI 0.02–0.09) for infections. Conclusions One in five patients are readmitted with a stoma-related complication within 30 days of creation of an ileostomy. Dehydration is the leading cause for these readmissions, occurring in 6% of all patients within 30 days. This comes with high health care cost for a potentially avoidable cause. Better monitoring, patient awareness and preventive measures are required. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02580-6.
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Liu Z, Fang L, Lv L, Niu Z, Hou L, Chen D, Zhou Y, Guo D. Self-administered succus entericus reinfusion before ileostomy closure improves short-term outcomes. BMC Surg 2021; 21:440. [PMID: 34961502 PMCID: PMC8713408 DOI: 10.1186/s12893-021-01444-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 12/14/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The study aims to assess whether reinfusion of succus entericus prior to ileostomy closure can decrease postoperative length of stay and ameliorate low anterior resection score. METHODS This study is a retrospective analysis based on prospectively collected data. Patients were screened from May 2016 to November 2019. A total of 30 patients who underwent reinfusion with succus entericus (SER) were enrolled in the SER group and 42 patients without SER were enrolled in the non-SER group. RESULTS There was no significant difference in the incidence of postoperative ileus between succus entericus reinfusion (SER) group and the control group. Time to first passage of flatus or stool after surgery in the SER group (27.9 ± 6.02 h) is significantly shorter than the control group (32.3 ± 6.26, hours p = 0.004). Compared with the control group (5.52 (4.0-7.0) days), postoperative length of stay in the SER group was 4.90 (3.0-7.0)days (p = 0.009). As for low anterior resection score(LARS), the SER group had a lower score 1 week after discharge than the control group (p = 0.034). However, 1 month after discharge, the LARS in the two groups had no significant difference. CONCLUSIONS Self-administered succus entericus reinfusion is a feasible prehabilitation management for outpatients and can improve better outcomes. Compared with non-reinfusion group, succus enterius reinfusion group displays significantly shorter time for gastrointestinal function recovery and postoperative hospital stay without increasing complication, and it can bring better quality of life in a short term.
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Affiliation(s)
- Zhen Liu
- Department of Emergency Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Liang Fang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Liang Lv
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China
| | - Zhaojian Niu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China
| | - Litao Hou
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Dong Chen
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China
| | - Dong Guo
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China.
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Relationship between diverting stoma and adjuvant chemotherapy in patients with rectal cancer: a nationwide study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Int J Clin Oncol 2021; 27:545-552. [PMID: 34783935 DOI: 10.1007/s10147-021-02079-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients at risk of recurrence after curative surgery for rectal cancer usually receive adjuvant chemotherapy. Postoperative recovery after low anterior resection (LAR) for rectal cancer can be improved by placement of a diverting stoma to reduce anastomotic leakage. However, it remains unclear how a diverting stoma affects administration of adjuvant chemotherapy in these patients. METHODS We identified Japanese patients with rectal cancer who underwent LAR in 2014 and received adjuvant chemotherapy within 12 months of surgery in the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Doses of five types of chemotherapy administered (tegafur/uracil, tegafur/gimeracil/oteracil potassium, capecitabine, 5-fluorouracil, and oxaliplatin) were assessed according to the presence or absence of diverting stoma and the timing of stoma closure. RESULTS There was no significant difference in the cumulative doses of chemotherapy administered in the 12 months after LAR between patients with and without diverting stoma, but more doses were administered in the early postoperative period (0-2 months after LAR) in patients without diverting stoma. Also, more doses of chemotherapy, regardless of type, were administered in the late closure group (7-12 months after LAR) than in the early closure (≤ 6 months) and no closure groups. CONCLUSION Presence of a diverting stoma did not influence the dose of adjuvant chemotherapy administered within 12 months after LAR but could have delayed the start of adjuvant chemotherapy. Patients with late closure of a diverting stoma received more doses of adjuvant chemotherapy administered over 12 months.
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Abstract
BACKGROUND Elective stoma closure is a common, standardized procedure in digestive surgery. OBJECTIVE This study aimed to evaluate the feasibility of day-case surgery for elective stoma closure. DESIGN This is a prospective, single-center, nonrandomized study of consecutive patients undergoing day-case elective stoma closure. SETTING This study was performed at a French tertiary hospital between January 2016 and June 2018. PATIENTS Elective stoma closure was performed by local incision with an ASA score of I, II, or stabilized III. OUTCOME MEASURES The primary end point was the day-case surgery success rate in the overall population (all patients having undergone elective stoma closure) and in the per protocol population (patients not fulfilling any of the preoperative or perioperative exclusion criteria). The secondary end points (in the per protocol population) were the overall morbidity rate (according to the Clavien-Dindo classification), the major morbidity rate (Clavien score ≥3), and day-case surgery quality criteria (unplanned consultation, unplanned hospitalization, and unplanned reoperation). RESULTS Between January 2016 and June 2018, 236 patients (the overall population; mean ± SD age: 54 ± 17; 120 men (51%)) underwent elective stoma closure. Fifty of these patients (21%) met all the inclusion criteria and constituted the per protocol population. The day-case surgery success rate was 17% (40 of 236 patients) in the overall population and 80% (40 of 50 patients) in the per protocol population. In the per protocol population, the overall morbidity rate was 30% and the major morbidity rate was 6%. Of the 40 patients with successful day-case surgery, the unplanned consultation rate and the unplanned hospitalization rate were both 32.5%. There were no unplanned reoperations. LIMITATIONS This was a single-center study. CONCLUSION In selected patients, day-case surgery for elective stoma closure is feasible and has acceptable complication and readmission rates. Day-case elective stoma closure can therefore be legitimately offered to selected patients. See Video Abstract at http://links.lww.com/DCR/B583. RESULTADOS A CORTO PLAZO DEL CIERRE DE ESTOMA AMBULATORIO UN ESTUDIO OBSERVACIONAL Y PROSPECTIVO ANTECEDENTES:El cierre electivo de un estoma es un procedimiento común y estandarizado en cirugía digestiva.OBJETIVO:Evaluar la viabilidad de la cirugía ambulatoria para el cierre electivo de estomas.DISEÑO:Un estudio prospectivo, unicéntrico, no aleatorizado de pacientes consecutivos sometidos a cierre de estoma electivo ambulatorio.ESCENARIO:Un hospital terciario francés entre enero de 2016 y junio de 2018.PACIENTES:Cierre electivo de estoma realizado por incisión local con una puntuación de la American Society of Anesthesiologists de I, II o III estabilizado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue la tasa de éxito de la cirugía ambulatoria en la población general (todos los pacientes habiendo sido sometidos a cierre de estoma electivo) y en la población por protocolo (pacientes que no cumplían con ninguno de los criterios de exclusión preoperatorios o perioperatorios). Los resultados secundarios (en la población por protocolo) fueron la tasa de morbilidad general (según la clasificación de Clavien-Dindo), la tasa de morbilidad mayor (puntuación de Clavien ≥ 3) y los criterios de calidad de la cirugía ambulatoria (consulta no planificada, hospitalización no planificada y reoperación no planificada).RESULTADOS:Entre enero de 2016 y junio de 2018, 236 pacientes (la población general; edad media ± desviación estándar: 54 ± 17; 120 hombres (51%)) se sometieron al cierre electivo del estoma. Cincuenta de estos pacientes (21%) cumplieron todos los criterios de inclusión y constituyeron la población por protocolo. La tasa de éxito de la cirugía ambulatoria fue del 17% (40 de 236 pacientes) en la población general y del 80% (40 de 50 pacientes) en la población por protocolo. En la población por protocolo, la tasa de morbilidad general fue del 30% y la tasa de morbilidad mayor fue del 6%. De los 40 pacientes con cirugía ambulatoria exitosa, la tasa de consultas no planificadas y la tasa de hospitalización no planificada fueron ambas del 32.5%. No hubo reoperaciones no planificadas.LIMITACIONES:Este fue un estudio de un solo centro.CONCLUSIÓN:En pacientes seleccionados, la cirugía ambulatoria para el cierre electivo de estoma es factible y tiene tasas aceptables de complicaciones y reingreso. Por lo tanto, se puede ofrecer legítimamente el cierre electivo ambulatorio de estoma a pacientes seleccionados. Consulte Video Resumen en http://links.lww.com/DCR/B583.
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Loire M, Bridoux V, Mege D, Mathonnet M, Mauvais F, Massonnaud C, Regimbeau JM, Tuech JJ. Long-term outcomes of Hartmann's procedure versus primary anastomosis for generalized peritonitis due to perforated diverticulitis: follow-up of a prospective multicenter randomized trial (DIVERTI). Int J Colorectal Dis 2021; 36:2159-2164. [PMID: 34086087 DOI: 10.1007/s00384-021-03962-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surgical management of Hinchey III and IV diverticulitis involves Hartmann's procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. These procedures were evaluated in four randomized controlled trials. Early results from these trials demonstrated similar rates of complications but higher rates of colonic restoration after PRA than HP. Long-term follow-up has not been reported to date. The aim of this study was to analyze long-term outcomes and quality of life (QoL) in patients previously enrolled in a prospective randomized trial comparing HP and PRA for generalized peritonitis due to perforated diverticulitis (DIVERTI trial). STUDY DESIGN Follow-up data were available for 78 of 102 patients. Demographic data, incisional hernia rate, need for additional surgery related to the primary procedure, and QoL were recorded. RESULTS The overall survival rate was 76% and did not differ between the two groups. Incisional hernia was reported in 21 (52%) patients in the HP arm and in 11 (29%) patients in the PRA arm (p = 0.035). The HP arm demonstrated significantly lower SF-36 physical and mental component scores. The mean general QoL (EQ-VAS) and mean EQ-5D index scores were better after PRA than after HP, but this difference was not statistically significant. The results of GIQLI, which measures intestine-specific QOL, did not differ between the two groups. CONCLUSIONS This follow-up study with a median follow-up time of > 9 years among living patients indicates that PRA for perforated diverticulitis is associated with fewer long-term complications and better QoL than HP. PRA significantly reduced the incisional hernia rate and the need for reoperation. Long-term survival was not jeopardized by the PRA approach. Future studies are needed to address the utility of protective stoma.
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Affiliation(s)
- M Loire
- Department of Digestive Surgery, Rouen University Hospital, 76000, Rouen Cedex, France
| | - V Bridoux
- Department of Digestive Surgery, Rouen University Hospital, 76000, Rouen Cedex, France
| | - D Mege
- Department of Digestive Surgery, Marseille University Hospital La Timone, Marseille, France
| | - M Mathonnet
- Department of Digestive Surgery, Limoges University Hospital, Limoges, France
| | - F Mauvais
- Department of Digestive Surgery, Beauvais General Hospital, Beauvais, France
| | - C Massonnaud
- Department of Biostatistics, Rouen University Hospital, 76000, Rouen, France
| | - J M Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
| | - J J Tuech
- Department of Digestive Surgery, Rouen University Hospital, 76000, Rouen Cedex, France.
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Chu L, Wang H, Qiu S, Shao B, Huang J, Qin Q, He Y, Xue J, Li X, Huang X, Huang R. Risk Factors of Delayed Recovery of Gastrointestinal Function After Ileostomy Reversal for Rectal Cancer Patients. Cancer Manag Res 2021; 13:5127-5133. [PMID: 34234556 PMCID: PMC8254522 DOI: 10.2147/cmar.s311715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The aim of this study was to identify the risk factors associated with delayed recovery of gastrointestinal function after ileostomy reversal for rectal cancer patients. METHODS In this retrospective study, the data of rectal cancer patients who underwent ileostomy reversal from January 2018 to December 2019 at the Sixth Affiliated Hospital of Sun Yat-sen University were assessed to investigate potential risk factors of delayed flatus after ileostomy reversal. RESULTS A total of 282 patients were eligible for this study. Postoperative first flatus time ranged from 1 to 9 days, of which 58.8% patients presented with delayed flatus that was longer than 3 days. Univariate analysis showed that delayed postoperative flatus was significantly associated with the length of postoperative hospital stay (P<0.001) and postoperative complications (P=0.037). Multivariate analysis showed that intravenous fluid infusion at postoperative day 1 (POD1) (OR=1.001, 95% CI: 1.001-1.002, P=0.001) and duration of stoma ≥6 months (OR=2.005, 95% CI:1.155-3.657, P=0.014) were independent risk factors for delayed flatus. CONCLUSION Increased intravenous fluid infusion at POD1 and duration of stoma ≥6 months were related to delayed recovery of gastrointestinal function after ileostomy reversal for rectal cancer patients.
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Affiliation(s)
- Lili Chu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Hui Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Suyu Qiu
- Department of General Surgery, Shunde New Rongqi Hospital, Foshan, Guangdong, 510655, People’s Republic of China
| | - Biyan Shao
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Jia Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Qiyuan Qin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Yanjiong He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Jing Xue
- Department of Pharmacy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Xiaoyan Li
- Department of Pharmacy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Xiaoyan Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
| | - Rongkang Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, Guangdong, People’s Republic of China
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Majbar MA, Courtot L, Dahbi-Skali L, Rafik A, Jouppe PO, Moussata D, Benkabbou A, Mohsine R, Ouaissi M, Souadka A. Two-step pull-through colo-anal anastomosis aiming to avoid stoma in rectal cancer surgery: A "real life" study in a developing country. J Visc Surg 2021; 159:187-193. [PMID: 34092526 DOI: 10.1016/j.jviscsurg.2021.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Delayed colo-anal anastomosis (DCA) is an underused technique rarely performed after resection of primary low rectal adenocarcinoma. The objective of this study was to compare the short-term outcomes of DCA and classical colo-anal anastomosis (CAA). METHODS This is a retrospective comparative study carried out at two tertiary centres in Morocco and France. It included all patients who underwent colo-anal anastomosis after complete mesorectal excision for primary rectal adenocarcinoma between January 2018 and December 2019. The main outcomes were 90-day morbidity and rates completing the surgical steps of DCA and CAA. RESULTS Among 215 rectal resections, 45 patients received colo-anal anastomosis, including 19 DCA and 26 CAA. Seventeen patients in the DCA group completed the two steps compared to 16 in the CAA group (89.5% vs. 61.5%, P=0.04). The rates of severe complications (26.9% vs. 26.3%, P=0.96) and anastomotic leakage (42.3% vs. 31.6%, P=0.46) were not different between the two groups. CONCLUSION This study showed that DCA was associated with a higher rate of completing the two surgical steps, with no difference in overall and severe morbidity. DCA may be a strong alternative to classical colo-anal anastomosis.
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Affiliation(s)
- M A Majbar
- Digestive Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - L Courtot
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic, and Liver Transplant Surgery, Trousseau Hospital, Tours, France
| | - L Dahbi-Skali
- Digestive Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - A Rafik
- Digestive Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - P O Jouppe
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic, and Liver Transplant Surgery, Trousseau Hospital, Tours, France
| | - D Moussata
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic, and Liver Transplant Surgery, Trousseau Hospital, Tours, France
| | - A Benkabbou
- Digestive Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - R Mohsine
- Digestive Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - M Ouaissi
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary, Pancreatic, and Liver Transplant Surgery, Trousseau Hospital, Tours, France
| | - A Souadka
- Digestive Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Rabat, Morocco; Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco.
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Hamamoto H, Okuda J, Yamamoto M, Masubuchi S, Ishii M, Osumi W, Tanaka K, Uchiyama K. Preventing anastomotic leakage after laparoscopic intersphincteric resection without a diverting stoma: "pull-through/reborn". Asian J Endosc Surg 2021; 14:314-317. [PMID: 32662098 DOI: 10.1111/ases.12841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Patients with very low rectal cancer who undergo intersphincteric resection (ISR) often experience anastomotic leakage (AL), even with a diverting stoma. The aim of this study was to introduce a technique for anastomosis after laparoscopic ISR to avoid AL. MATERIALS AND SURGICAL TECHNIQUE In the first ISR procedure, the rectum was mobilized, the mesorectum was excised, and total, subtotal, or partial internal sphincter incision was performed transanally. In the second surgery, the adhesions between the prolapsed colon and the anal canal were bluntly dissected only as needed for suturing. After sufficient blood flow was confirmed using indocyanine green fluorescence imaging, coloanal transanal anastomosis was performed without a diverting stoma. We call this method "pull-through/reborn". DISCUSSION "Pull-through/reborn" method can prevent AL after laparoscopic ISR. However, more cases and more experience are necessary to analyze anal functions after this method is applied.
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Affiliation(s)
- Hiroki Hamamoto
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Junji Okuda
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Masashi Yamamoto
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Shinsuke Masubuchi
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Masatsugu Ishii
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Wataru Osumi
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Keitaro Tanaka
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kazuhisa Uchiyama
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
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Dolan PT, Abelson JS, Symer M, Nowels M, Sedrakyan A, Yeo HL. Colonic Stents as a Bridge to Surgery Compared with Immediate Resection in Patients with Malignant Large Bowel Obstruction in a NY State Database. J Gastrointest Surg 2021; 25:809-817. [PMID: 32939622 DOI: 10.1007/s11605-020-04790-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 09/06/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is controversy surrounding the efficacy and safety of colonic stents as a bridge to surgery compared with immediate resection in patients presenting with an acute malignant large bowel obstruction. METHODS Retrospective longitudinal cohort study using the NYS SPARCS Database. Patients with acute malignant large bowel obstruction who either had stent followed by elective surgery within 3 weeks (bridge to surgery) or underwent immediate resection between October 2009 and June 2016 in the state of New York were included. The primary outcome was rate of stoma creation at index resection. Secondary outcomes were 90-day readmission, reoperation, procedural complications, and discharge disposition. RESULTS A total of 3059 patients were included, n = 2917 (95.4%) underwent an immediate resection and n = 142 (4.6%) underwent bridge to surgery. We analyzed 139 patients in propensity score-matched groups. Patients in the bridge to surgery group were less likely than those in the immediate resection group to get a stoma at the time of surgery (OR 0.33, 95% CI 0.18-0.60). They were also less likely to be discharged to a rehabilitation facility or require a home health aide upon discharge (OR 0.36, 95% CI 0.22-0.61). There were no differences in rates of 90-day readmission, reoperation, or procedural complications between groups. DISCUSSION Colonic stenting as a bridge to surgery leads to less stoma creation, a significant quality of life advantage, compared with immediate resection. Patients should be counseled regarding these potential benefits when the technology is available.
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Affiliation(s)
- Patrick T Dolan
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, 525 East 68th Street, Box 172, New York, NY, 10065, USA
| | - Jonathan S Abelson
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, 525 East 68th Street, Box 172, New York, NY, 10065, USA
| | - Matthew Symer
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, 525 East 68th Street, Box 172, New York, NY, 10065, USA
| | - Molly Nowels
- Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY, USA
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY, USA
| | - Heather L Yeo
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, 525 East 68th Street, Box 172, New York, NY, 10065, USA. .,Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY, USA.
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Quality of Life and Bowel Function Following Early Closure of a Temporary Ileostomy in Patients with Rectal Cancer: A Report from a Single-Center Randomized Controlled Trial. J Clin Med 2021; 10:jcm10040768. [PMID: 33671925 PMCID: PMC7919002 DOI: 10.3390/jcm10040768] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to assess quality of life and bowel function in patients undergoing early vs. standard ileostomy closure. We retrospectively assessed patients from our previous randomized controlled trial. Patients with a temporary ileostomy who underwent rectal cancer surgery and did not have anastomotic leakage or other. Early closure (EC; 30 days after creation) and standard closure (SC; 90 days after creation) of ileostomy were compared. Thirty-six months (17–97) after stoma closure, we contacted patients by phone and filled in two questionnaires—The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and low anterior resection syndrome (LARS) score. This index trial was not powered to assess the difference in bowel function between the two groups. All the patients in the SC group had anastomosis <6 cm from the anal verge compared to 42 of 43 (97.7%) in the EC group. There were no statistically significant differences between EC (26 patients) and SC (25 patients) groups in the EORTC QLQ-C30 and LARS questionnaires. Global quality of life was 37.2 (0–91.7; ±24.9) in the EC group vs. 34.3 (0–100; ±16.2) in the SC (p = 0.630). Low anterior resection syndrome was present in 46% of patients in the EC and 56% in the SC group (p = 0.858). Major LARS was found more often in younger patients. However, no statistical significance was found (p = 0.364). The same was found with quality of life (p = 0.219). Age, gender, ileostomy closure timing, neoadjuvant treatment, complications had no effect of worse bowel function or quality of life. There was no difference in quality of life or bowel function in the late postoperative period after the early vs. late closure of ileostomy based on two questionnaires and small sample size. None of our assessed risk factors had a negative effect on bowel function o quality of life.
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Stigma and Its Influence on Patients With Temporary Ostomy: A Cross-sectional Survey. J Wound Ostomy Continence Nurs 2021; 47:244-248. [PMID: 32384528 DOI: 10.1097/won.0000000000000645] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to explore stigma and its influencing factors in Chinese patients with a temporary ostomy. DESIGN Cross-sectional, descriptive. SUBJECTS AND SETTING Convenience sampling was used to recruit 170 patients living with a temporary ostomy for at least 2 weeks. Participants were recruited from 3 general hospitals in Guangdong province, located in southeastern China. METHODS Respondents completed a questionnaire that included ostomy-related sociodemographic questionnaire, the Social Impact Scale, and the Stoma Self-Efficacy Scale. Multivariate linear regression was used to identify factors influencing stigma. RESULTS Of the 170 questionnaires distributed, 159 (93.5%) respondents who sufficiently completed responses were included in the final analysis. The average score of the Social Impact Scale was 61.63 (SD = 8.39), reflecting a moderate level of stigma, and 27 (17%) experienced high levels of stigma. Multivariate regression analysis revealed that stigma was associated with family relationships (B = 6.139, P = .000), age when ostomy was created (B = -4.038, P = .000), and self-efficacy (B = -0.080, P = .002). CONCLUSIONS The level of stigma in Chinese patients with temporary ostomies is moderate. Multivariate regression analysis identified family relationship, age, and self-efficacy as the main factors that influenced stigma in patients with temporary ostomy.
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Defunctioning stoma and short- and long-term outcomes after low anterior resection for rectal cancer-a nationwide register-based cohort study. Int J Colorectal Dis 2021; 36:1433-1442. [PMID: 33728534 PMCID: PMC8195973 DOI: 10.1007/s00384-021-03877-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE A defunctioning stoma reduces the risk of symptomatic anastomotic leakage after low anterior resection for rectal cancer and mitigates the consequences when a leakage occurs, but the impact on mortality and oncological outcomes is unclear. The aim was to investigate the associations of a defunctioning stoma with short- and long-term outcomes in patients undergoing low anterior resection for rectal cancer. METHODS Data from all patients who underwent curative low anterior resection for rectal cancer between 1995 and 2010 were obtained from the Swedish Colorectal Cancer Register. A total of 4130 patients, including 2563 with and 1567 without a defunctioning stoma, were studied. Flexible parametric models were used to estimate hazard ratios for all-cause mortality, 5-year local recurrence, and distant metastatic disease in relation to the use of defunctioning stoma, adjusting for confounding factors and accounting for potential time-dependent effects. RESULTS During a median follow-up of 8.3 years, a total of 2169 patients died. In multivariable analysis, a relative reduction in mortality was observed up to 6 months after surgery (hazard ratio = 0.82: 95% CI 0.67-0.99), but not thereafter. After 5 years of follow-up, 4.2% (173/4130) of the patients had a local recurrence registered and 17.9% (741/4130) had developed distant metastatic disease, without difference between patients with and without defunctioning stoma. CONCLUSION A defunctioning stoma is associated with a short-term reduction in all-cause mortality in patients undergoing low anterior resection for rectal cancer without any difference in long-term mortality and oncological outcomes, and should be considered as standard of care.
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Clinical characteristics and predictors of permanent stoma in rectal cancer patients underwent anterior resections: the value of preoperative prognostic nutritional index. Int J Clin Oncol 2020; 25:1960-1968. [PMID: 32654048 DOI: 10.1007/s10147-020-01743-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/26/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES This study was aimed to investigate the correlation between preoperative prognostic nutritional index (PNI) and permanent stoma (PS) in patients with defunctioning stoma (DS) after anterior resections and, based on it, to reveal the clinical value of PNI on clinical strategies about the selection of stoma location. METHODS A total of 281 consecutive rectal cancer patients who accepted anterior resection and DS in the National Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University from June 2008 to June 2018 were enrolled in this study. Receiver operating characteristic (ROC) curve for PNI was performed to discriminate PS. Univariate and multivariate analysis were conducted to identify the clinical characteristics and risk factors for PS. Specific reasons for patients with DS turned into PS were reviewed. RESULTS ROC curve analysis defined PNI cutoff level of 45.85 corresponding to PS (area under the curve (AUC) = 0.71, 77% sensitivity, 56.9% specificity). Low PNI (OR = 3.23, P = 0.005), tumor crossing the peritoneal reflection (PR) (OR = 3.42, P = 0.003), postoperative distant metastasis (OR = 6.31, P < 0.001) were independently associated with PS. Besides, anastomotic complications (31.4%), poor oncological outcomes (35.3%), and personal preferences (33.3%) were the specific reasons for patients turning into PS. CONCLUSIONS Preoperative PNI is an independent prognostic factor to predict PS in patients who underwent anterior resection and DS. Therefore, combined with other clinical characteristics and predictors, preoperative measurements of PNI could provide a significant support for clinical decision on patients prepared to accept anterior resection and DS.
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Low preoperative maximum squeezing pressure evaluated by anorectal manometry is a risk factor for non-reversal of diverting stoma. Langenbecks Arch Surg 2020; 406:131-139. [PMID: 33074347 DOI: 10.1007/s00423-020-02011-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE A diverting stoma is created to prevent anastomotic leakage and related complications impairing sphincteric function in rectal surgery. However, diverting stoma may be left unclosed. This study is aimed to analyze preoperative factors including anorectal manometric data associated with diverting stoma non-reversal before rectal surgery. We also addressed complications related to diverting stoma in patients undergoing surgery for rectal malignant tumor. METHODS A total of 203 patients with rectal malignant tumor who underwent sphincter-preserving surgery with diverting stoma were retrospectively evaluated. The risk factors for non-reversal of diverting stoma were identified by univariate and multivariate analyses. For these analyses, anorectal manometric data were measured before rectal surgery. The association between stoma-related complications and other clinicopathological features was also analyzed. RESULTS During the median follow-up of 46.4 months, 24% (49 patients) did not undergo stoma reversal. Among parameters that were available before rectal surgery, age ≥ 75 years, albumin < 3.5 g/dl, tumor size ≥ 30 mm, tumor distance from the anal verge < 4 cm, and maximum squeezing pressure (MSP) < 130 mmHg measured by anorectal manometry (ARM) were independent factors associated with stoma non-reversal. The most common stoma-related complication was peristomal skin irritation (25%). Ileostomy was the only factor associated with peristomal skin irritation. CONCLUSION The current study demonstrated that low preoperative MSP evaluated by ARM, old age, hypoalbuminemia, and a large tumor close to the anus were predictive of diverting stoma non-reversal. Stoma site should be well deliberated when patients have the aforementioned risk factors for diverting stoma non-reversal.
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Jørgensen JB, Erichsen R, Pedersen BG, Laurberg S, Iversen LH. Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study. BJS Open 2020; 4:1162-1171. [PMID: 33022143 PMCID: PMC7709365 DOI: 10.1002/bjs5.50340] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/09/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Data on stoma reversal following restorative rectal resection (RRR) with a diverting stoma are conflicting. This study investigated a Danish population-based cohort of patients undergoing RRR to evaluate factors predictive of stoma reversal during 3 years of follow-up. METHODS Patients from national registries with rectal cancer undergoing RRR or Hartmann's procedure with curative intent between May 2001 and April 2012 were included. Patients with a diverting stoma were followed from the time of primary rectal cancer resection to date of stoma reversal, death, emigration, or end of 3-year follow-up. The cumulative incidence proportion (CIP) of stoma reversal at 1 and 3 years was calculated, treating death as a competing risk. Factors predictive of stoma reversal were explored using Cox regression analysis. RESULTS Of 6859 patients included, 35·7, 41·9 and 22·4 per cent respectively had a RRR with a diverting stoma, RRR without a stoma, and Hartmann's procedure with an end-colostomy. In patients with a diverting stoma, the CIP of stoma reversal was 70·3 (95 per cent c.i. 68·4 to 72·1) per cent after 1 year, and 74·3 (72·5 to 76·0) per cent after 3 years. Neoadjuvant treatment (hazard ratio (HR) 0·75, 95 per cent c.i. 0·66 to 0·85), blood loss greater than 300 ml (HR 0·86, 0·76 to 0·97), anastomotic leak (HR 0·41, 0·33 to 0·50), T3 category (HR 0·63, 0·47 to 0·83), T4 category (HR 0·62, 0·42 to 0·90) and UICC stage IV (HR 0·57, 0·41 to 0·80) were possible predictors of delayed stoma reversal. CONCLUSION In one-quarter of the patients the diverting stoma had not been reversed 3 years after the intended RRR procedure.
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Affiliation(s)
- J. B. Jørgensen
- Departments of SurgeryAarhusDenmark
- Department of SurgeryRanders Regional HospitalRandersDenmark
| | - R. Erichsen
- Clinical EpidemiologyAarhusDenmark
- Department of SurgeryRanders Regional HospitalRandersDenmark
| | | | | | - L. H. Iversen
- Departments of SurgeryAarhusDenmark
- Danish Colorectal Cancer GroupCopenhagenDenmark
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Predisposing factors and clinical impact of high-output syndrome after sphincter-preserving surgery with covering ileostomy for rectal cancer: a retrospective single-center cohort study. Int J Clin Oncol 2020; 26:118-125. [PMID: 32902781 DOI: 10.1007/s10147-020-01781-z] [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: 06/29/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ileostomy-related high-output syndrome has become a major cause of postoperative morbidity after rectal cancer surgery. This study aimed to clarify the predisposing factors and clinical impact of high-output syndrome. METHODS Clinical parameters that were associated with high-output syndrome and clinical impact of high-output syndrome on nutritional status, electrolyte abnormality and renal dysfunction were retrospectively investigated in consecutive patients with rectal cancer undergoing resection with covering ileostomy during 2016-2017. RESULTS High-output syndrome developed in 44/195 eligible patients (22.6%). Multivariable analysis revealed that neoadjuvant (chemo)radiotherapy [odds ratio (OR): 2.4; 95% confidence interval (CI) 1.1-5.2; P = 0.02], postoperative complications (OR: 2.2; 95% CI 1.0-4.6; P = 0.049), postoperative maximal white blood cell ≥ 10,000 cells/μl (OR: 4.0; 95% CI 1.9-8.8; P = 0.0004), and postoperative maximal C-reactive protein ≥ 10 mg/dl (OR: 2.4; 95% CI 1.1-5.2; P = 0.02) were independently associated with high-output syndrome. High-output syndrome was associated with increased renal dysfunction at the time of ostomy closure (29.6% versus 11.9%, patients with high-output syndrome vs. without high-output syndrome, P = 0.008), but not with nutritional imbalance or electrolyte abnormalities. High-output syndrome (OR: 2.5; 95% CI 1.1-5.9; P = 0.03) and postoperative maximal C-reactive protein ≥ 10 mg/dl (OR: 2.4; 95% CI 1.0-5.6; P = 0.04) were independently associated with renal dysfunction at ostomy closure. CONCLUSION Preoperative (chemo)radiotherapy, postoperative inflammatory response, and postoperative complications predisposed to high-output syndrome, and it significantly impacted postoperative renal dysfunction. Active monitoring and early intervention are warranted to prevent renal dysfunction in patients with these factors.
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Biondo S, Trenti L, Espin E, Bianco F, Barrios O, Falato A, De Franciscis S, Solis A, Kreisler E. Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer: A Randomized Clinical Trial. JAMA Surg 2020; 155:e201625. [PMID: 32492131 DOI: 10.1001/jamasurg.2020.1625] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Two-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis seems to provide benefits in terms of postoperative morbidity compared with standard hand-sewn coloanal anastomosis associated with diverting ileostomy and further ileostomy reversal in patients operated on for low rectal cancer. Objective To compare 30-day postoperative and 1-year follow-up results of Turnbull-Cutait pull-through hand-sewn coloanal anastomosis and standard hand-sewn coloanal anastomosis after ultralow rectal resection for rectal cancer. Design, Setting, and Participants Multicenter randomized clinical trial. Neither patients nor surgeons were blinded for technique. Patients were recruited in 3 centers, Bellvitge University Hospital and Valle d'Hebron University Hospital in Spain and Instituto Nazionale Tumori Fondazione G. Pascale-Istituto di Ricovero e Cura a Carattere Scientifico in Italy. Patients undergoing ultralow anterior rectal resection needing hand-sewn coloanal anastomosis were randomly assigned to 2-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis or standard hand-sewn coloanal anastomosis associated with diverting ileostomy. Data were analyzed between June 2012 and October 2018. Interventions All patients underwent ultralow anterior resection. Patients assigned to the 2-stage Turnbull-Cutait pull-through group underwent exteriorization of a segment of left colon through the anal canal and, after 6 to 10 days, the exteriorized colon was resected and a delayed hand-sewn coloanal anastomosis was performed. For patients assigned to standard coloanal anastomosis, the hand-sewn coloanal anastomosis was performed with diverting ileostomy at first operation. Closure of the ileostomy was planned after 6 to 8 months. Main Outcomes and Measures Primary outcome was 30-day postoperative morbidity. For the standard hand-sewn coloanal anastomosis with diverting ileostomy group, overall postoperative morbidity includes 30-day postoperative complications of the ileostomy closure. Results Ninety-two white patients, 72 men and 20 women, with a median age of 62 years, were randomized and included in the analysis. Forty-six patients received standard hand-sewn coloanal anastomosis with diverting ileostomy and 46 received the 2-stage pull-through hand-sewn coloanal anastomosis. Seven patients (15.2%) in the standard hand-sewn coloanal anastomosis group did not undergo reversal ileostomy, and 1 patient (2.2%) in the 2-stage pull-through hand-sewn coloanal anastomosis group did not undergo delayed coloanal anastomosis. The 30-day overall composite postoperative complications rate was similar between the 2 groups (34.8% in 2-stage pull-through hand-sewn coloanal anastomosis group vs 45.7% in standard hand-sewn coloanal anastomosis group; P = .40), with a difference of -10.9 (95% CI, -29.5 to 8.9). Conclusions and Relevance The 2-stage pull-through hand-sewn coloanal anastomosis after ultralow anterior resection for low rectal cancer is safe and does not increase the postoperative morbidity rate compared with standard coloanal anastomosis with covering ileostomy followed by ileostomy closure. Trial Registration ClinicalTrials.gov Identifier: NCT01766661.
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Affiliation(s)
- Sebastiano Biondo
- Colorectal Unit, IDIBELL, Bellvitge University Hospital, Department of General and Digestive Surgery, University of Barcelona, Barcelona, Spain
| | - Loris Trenti
- Colorectal Unit, IDIBELL, Bellvitge University Hospital, Department of General and Digestive Surgery, University of Barcelona, Barcelona, Spain
| | - Eloy Espin
- Colorectal Unit, Vall d'Hebron University Hospital, Department of General and Digestive Surgery, Autonomic University of Barcelona, Barcelona, Spain
| | - Francesco Bianco
- General and Colorectal Surgery Unit, S. Leonardo Hospital/ASL-Na3-sud, Castellammare di Stabia, Naples, Italy
| | - Oriana Barrios
- Colorectal Unit, IDIBELL, Bellvitge University Hospital, Department of General and Digestive Surgery, University of Barcelona, Barcelona, Spain
| | - Armando Falato
- General Surgery Unit, S. Giuliano Hospital, Giugliano, Naples, Italy
| | - Silvia De Franciscis
- Colorectal Cancer Surgery Unit, Istituto Nazionale Tumori di Napoli, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy
| | - Alejandro Solis
- Colorectal Unit, Vall d'Hebron University Hospital, Department of General and Digestive Surgery, Autonomic University of Barcelona, Barcelona, Spain
| | - Esther Kreisler
- Colorectal Unit, IDIBELL, Bellvitge University Hospital, Department of General and Digestive Surgery, University of Barcelona, Barcelona, Spain
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Evaluation of negative-pressure wound therapy for surgical site infections after ileostomy closure in colorectal cancer patients: a prospective multicenter study. Surg Today 2020; 50:1687-1693. [PMID: 32638132 DOI: 10.1007/s00595-020-02068-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/05/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Surgical site infection (SSI) occurs at a high rate after ileostomy closure. The effect of preventive negative-pressure wound therapy (NPWT) on SSI development in closed wounds remains controversial. We conducted a prospective multicenter study to evaluate the usefulness of preventive NPWT for SSI after ileostomy closure. METHODS From January 2018 to November 2018, 50 patients who underwent closure of ileostomy created after surgery for colorectal cancer participated in this study. An NPWT device was applied to each wound immediately after surgery and then treatment was continued for 3 days. The primary endpoint was 30-day SSI, and the secondary endpoints were the incidence of seroma, hematoma, and adverse events related to NPWT. RESULTS No patients developed SSI, seroma, or hematoma. Adverse events that may have been causally linked with NPWT were contact dermatitis in two patients and wound pain in one patient, and there were no cases of discontinuation or decompression of NPWT. CONCLUSION The use of NPWT following ileostomy closure may be useful for reducing the development of SSI in colorectal cancer patients. This is a prospective multicenter pilot study and we are planning a comparative study based on these successful results. TRAIL REGISTRATION Registration number: UMIN000032053 ( https://www.umin.ac.jp/ ).
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Lin YW, Keller P, Davenport DL, Plymale MA, Totten CF, Roth JS. Parastomal Hernia Repair Outcomes: A Nine-Year Experience. Am Surg 2020. [DOI: 10.1177/000313481908500734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Parastomal hernias (PHs) frequently complicate enterostomy creation. Decision for PH repair (PHR) is driven by patient symptoms due to the frequency of complications and recurrences. The European Hernia Society (EHS) PH classification is based on the PH defect size and the presence/ absence of concomitant incisional hernia. The aim of this study was to evaluate PHR outcomes based on EHS classification. An Institutional Review Board–approved retrospective review of a prospective database between 2009 and 2017 was performed. Patient demographics, enterostomy type, EHS classification, operative technique, and clinical outcomes (postoperative complications, 30-day readmission, and PH recurrence) were obtained. Cases were analyzed by EHS classifications I and II (SmallPH) versus III and IV (LargePH). Sixty-two patients underwent PHR (35: SmallPH, 27: LargePH). Patient groups (SmallPH vs LargePH) were similar based on American Society of Anesthesiologists Class III and obesity. Hernia recurrence was seen in 26 per cent of repairs with no difference between groups. The median recurrence-free survival was 3.9 years. There was no difference in superficial SSI, deep SSI, nonwound complications, or readmission between SmallPH and LargePH. Both small and large PHs experience similar outcomes after repair. Strategies to improve outcomes should be developed and implemented universally across all EHS PH classes.
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Affiliation(s)
- You Wei Lin
- College of Medicine, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Patrick Keller
- College of Medicine, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Daniel L. Davenport
- Department of Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Margaret A. Plymale
- Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Crystal F. Totten
- Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - John Scott Roth
- Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
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Jafari MD, Halabi WJ, Jafari F, Nguyen VQ, Stamos MJ, Carmichael JC, Mills SD, Pigazzi A. Morbidity of Diverting Ileostomy for Rectal Cancer: Analysis of the American College of Surgeons National Surgical Quality Improvement Program. Am Surg 2020. [DOI: 10.1177/000313481307901016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There is controversy regarding the potential benefits of diverting ileostomy after low anterior resection (LAR). This study aims to examine the morbidity associated with diverting ileostomy in rectal cancer. A retrospective review of LAR cases was performed using the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2011). Patients who underwent LAR with and without diversion were selected. Demographics, intraoperative events, and postoperative complications were reviewed. Among the 6337 cases sampled, 991 (16%) received a diverting ileostomy. Patients who were diverted were younger (60 vs 63 years), predominantly male (64 vs 53%), and more likely to have received pre-operative radiation (39 vs 12%). There was no significant difference in steroid use, weight loss, or intraoperative transfusion. Postoperatively, there was no significant difference in length of stay, rate of septic complications, wound infections, and mortality. The rate of reoperation was lower in the diverted group (4.5 vs 6.9%). Diversion was associated with a higher risk-adjusted rate of acute renal failure (OR 2.4; 95% CI (1.2, 4.6); P < 0.05). The use of diverting ileostomy reduces the rate of reoperation but is associated with an increased risk of acute renal insufficiency. These findings emphasize the need for refinement of patient selection and close follow-up to limit morbidity.
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Affiliation(s)
- Mehraneh D. Jafari
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Wissam J. Halabi
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Fariba Jafari
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Vinh Q. Nguyen
- Department of Statistics, University of California Irvine, Irvine, California
| | - Michael J. Stamos
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Joseph C. Carmichael
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Steven D. Mills
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine School of Medicine, Orange, California
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Chang YWW, Davenport D, Dugan A, Patel JA. Significant morbidity is associated with proximal fecal diversion among high-risk patients who undergo colectomy: A NSQIP analysis. Am J Surg 2020; 220:830-835. [PMID: 32482294 DOI: 10.1016/j.amjsurg.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The value of proximal fecal diversion for patients undergoing colectomies is an ongoing debate. Previous studies have shown a benefit in decreased anastomotic leak rates and mitigation of the morbidity of a leak, especially in high-risk populations. However, more recent data suggests increased morbidity with fecal diversion, creating a complication with an unknown degree of anastomotic leak reduction. Therefore, we aimed to determine the impact on morbidity of a diverting loop ileostomy (DLI) in patients with a high risk of anastomotic leak. METHODS The ACS-NSQIP database was queried (via CPT code) for adult patients (age ≥18 years) who underwent a colectomy only or colectomy with ileostomy (CWI) between Jan 2013 and Dec 2016. We compared thirty-day outcomes between a 3:1 propensity-matched colectomy only group to patients who had a CWI. We used risk factors for anastomotic leak as a basis of our propensity match which included preoperative smoking, steroid use, preoperative weight loss, preoperative transfusion, hypoalbuminemia, and leukocytosis; intraoperative match variables included indication for surgery, wound class, duration of operation, primary CPT code, elective vs. emergent, and inpatient vs. outpatient surgery. RESULTS We identified 39,588 patients from the NSQIP database who had a colectomy only or a CWI. The colectomy only group was older (age 63 vs 52 years p < 0.001), overweight (BMI 34 vs 26.7, p < 0.001), more likely to be diabetic (16% vs 9.5%, p < 0.001) and hypertensive (49.3% vs 31.4%). However, the CWI group had higher steroid use (36.8% vs 10%, p < 0.001), preoperative sepsis (13.2% vs 2.5%, p < 0.001), smoking rate (25.7% vs 15.4%, p < 0.001), and preoperative weight loss (12.5% vs 4.9%, p < 0.001). Our propensity analysis matched 2274 colectomy only patients and 758 CWI patients. Baseline demographics were similar between groups. While the mortality rate was similar between groups (1.5% vs 1.8%, p = 0.8), CWI patients had longer length of stay (median 8 vs 7 days, p < 0.001), higher renal injury rates (3.2% vs 0.9%, p < 0.001), higher readmission rates (18.8% vs 11%, p < 0.001) and higher overall NSQIP morbidity (44.5% vs 37.6%, p = 0.001). The anastomotic leak rate was 3.8% in the CWI group and 5.1% in the colectomy only group (p = 0.09). CONCLUSIONS Significant thirty-day morbidity exists with a diverting ileostomy among high-risk colectomy patients with minimal benefit in anastomotic leak rates.
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Affiliation(s)
- Yu-Wei Wayne Chang
- Department of Surgery, University of Kentucky Medical Center, Lexington, KY, USA; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY, USA.
| | - Daniel Davenport
- Department of Surgery, University of Kentucky Medical Center, Lexington, KY, USA
| | - Adam Dugan
- Department of Surgery, University of Kentucky Medical Center, Lexington, KY, USA
| | - Jitesh A Patel
- Department of Surgery, University of Kentucky Medical Center, Lexington, KY, USA; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY, USA
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Kitaguchi D, Enomoto T, Ohara Y, Owada Y, Hisakura K, Akashi Y, Takahashi K, Ogawa K, Shimomura O, Oda T. Exploring optimal examination to detect occult anastomotic leakage after rectal resection in patients with diverting stoma. BMC Surg 2020; 20:53. [PMID: 32192490 PMCID: PMC7081590 DOI: 10.1186/s12893-020-00706-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background When considering “early stoma closure”, both standardized inclusion/exclusion criteria and standardized methods to assess anastomosis are necessary to reduce the risk of occult anastomotic leakage (AL). However, in the immediate postoperative period, neither have the incidence and risk factors of occult AL in patients with diverting stoma (DS) been clarified nor have methods to assess anastomosis been standardized. The aim of this study was to elucidate the incidence and risk factors of occult AL in patients who had undergone rectal resection with DS and to evaluate the significance of computed tomography (CT) following water-soluble contrast enema (CE) to detect occult anastomotic leakage. Methods This was a single institutional prospective observational study of patients who had undergone rectal resection with the selective use of DS between May and October 2019. Fifteen patients had undergone CE and CT to assess for AL on postoperative day (POD) 7, and CT was performed just after CE. Univariate analysis was performed to assess the relationship between preoperative variables and the incidence of occult AL on POD 7. Results The incidence of occult AL on postoperative day 7 was 6 of 15 (40%). Hand-sewn anastomosis, compared with stapled anastomosis, was a significant risk factor. Five more cases with occult AL that could not be detected with CE could be detected on CT following CE; CE alone had a 33% false-negative radiological result rate. Conclusions Hand-sewn anastomosis appeared to be a risk factor for occult AL, and CE alone had a high false-negative radiological result rate. When considering the introduction of early stoma closure, stapled anastomosis and CT following CE could be an appropriate inclusion criterion and preoperative examination, respectively.
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Affiliation(s)
- Daichi Kitaguchi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Katsuji Hisakura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Osamu Shimomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Schwandner F, Klimars U, Gock M, Schiffmann L, Witte M, Schiergens T, Rentsch M, Klar E, Kühn F. The Water-Holding Procedure for Ensuring Postoperative Continence Prior Restoring Intestinal Continuity. J Gastrointest Surg 2020; 24:411-417. [PMID: 30825120 DOI: 10.1007/s11605-019-04171-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/13/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND A defunctioning stoma can become necessary in a relevant number of patients undergoing gastrointestinal surgery. As a matter of course, patients seek an early closure of the stoma. However, preoperative management of these patients varies and the prediction of continence after stoma removal can become challenging. Patients might be fully continent despite low manometric pressures and vice versa. An easy and reliable way to predict continence after stoma reversal would improve patients' management and outcome. Although frequently performed in various surgical centers in Germany, there is no published data on the water-holding test. Hence, this is the first study evaluating the role of the test in clinical practice. METHOD We performed a prospective pilot study to evaluate the role of anorectal manometry and the water-holding procedure as a predictor of postoperative continence prior to stoma reversal. Inclusion criteria were a successfully passed water-holding test, any type of fecal diversion and the possibility of restoring intestinal continuity. Preoperative low manometric pressure levels were not an exclusion criteria for stoma reversal. Fifty-two patients with ostomy were consecutively enrolled in this study between October 2013 and February 2016. Anorectal manometry was performed in all patients prior to stoma reversal. After stoma removal, patients were followed-up for 6 months. Postoperative incontinence was determined using the Wexner incontinence score. RESULTS A total of 52 patients (38 males, 14 females) were included at an average age of 59 (range 33-83) years. Most frequent indications for intestinal diversion were rectal cancer surgery, IBD-related surgery, or surgery for diverticular disease. Low anterior rectal resection was performed in 17 patients (32.7%), followed by a proctocolectomy in 9 (17.3%), colectomy in 9 (17.3%), and recto-sigmoid resection in 7 patients (13.5%). Median time from stoma creation to reversal was 206 days (range 48-871 days). All patients had successfully passed the standardized water-holding test. At the same time, the majority of patients had low preoperative manometric pressure values and would normally not have been reversed at that point. The median postoperative Wexner incontinence score was at 1.5 (range 0-20), 0.5 (range 0-14), and 0 (range 0-11) at 14, 60, and 180 days after stoma reversal. Low preoperative manometric squeeze and/or resting pressure levels were not associated with a higher postoperative incontinence score at 14, 60, or 180 days after stoma reversal. CONCLUSION A standardized water-holding test can function as an easy and reliable method before stoma reversal to predict sufficient postoperative fecal continence. In case of a sufficient water-holding test despite low manometric pressure levels, the risk for postoperative anal incontinence seems to be low. Preoperative manometric pressure levels do not appear to predict postoperative continence.
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Affiliation(s)
- Frank Schwandner
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Ulrich Klimars
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Leif Schiffmann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Maria Witte
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Tobias Schiergens
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Eray İC, Rencüzoğulları A, Yalav O, Topal U, Sarıtaş AG, Dalcı K. Rektum kanser cerrahisi sonrası kalıcı ileostomi insidansı ve risk faktörleri. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.529941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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The Safety of Outpatient Stoma Closure: on the Verge of a Paradigm Shift? J Gastrointest Surg 2019; 23:2019-2026. [PMID: 30350192 DOI: 10.1007/s11605-018-4001-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/28/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND An area of contention among colorectal surgeons is when it is safe to discharge patients who have undergone closure of diverting ostomies. This study aimed to review the trends in outpatient stoma closure (OSC), to assess the safety of this practice, and to identify appropriate surgical candidates for the outpatient procedure. METHODS Patients were queried from the ACS National Surgical Quality Improvement Program database (2005-2016). Main outcomes included Clavien-Dindo (C-D) III-V class surgical complications, and readmission. Outpatient stay was defined as a hospital stay of less than or equal to 1 day. Multivariable logistic regression analysis was used to identify risk factors for C-D III-V complications and readmission. RESULTS Of 24,393 patients, 668 (2.74%) underwent an OSC. OSC has increased over the last decade (3.16% 2005-2006, 4.14% 2016, p < 0.001). Outpatients had significantly lower ASA class and fewer comorbidities than inpatients. Outpatient complication rate was significantly lower than the inpatient rate (2.99% vs. 7.25%, p < 0.001). Readmissions were comparable (8.92% outpatient vs. 9.77% inpatient, p = 0.54). ASA > 2, smoking, COPD, dyspnea, steroid use, bleeding disorder, and partial/total dependency were associated with increased risk of complications and readmission. Patients without any risk factors had lower complication (4.75%) and readmission rates (8.09%) compared to those with ≥ 2 risk factors (11.50% complication and 13.07% readmission rate, p < 0.001). CONCLUSIONS There is an increasing trend in the percentage of stoma closures being performed as outpatient procedures. Appropriate selection of patients preoperatively who are suitable candidates for OSC can be helpful in managing patient expectations and hospital resources.
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Gröne J. Zeitpunkt und Technik der Stomarückverlagerung unter Berücksichtigung früher und später Stomakomplikationen. COLOPROCTOLOGY 2019. [DOI: 10.1007/s00053-019-00401-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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