Considerations in Stoma Reversal

The Outcome of Purse-string Versus Conventional Wound Closure Techniques in Patients Undergoing Stoma Reversal: A Randomized Controlled Trial

BACKGROUND

Patients undergoing stoma reversal may experience surgical site infections and poor scarring. A purse-string closure approach may lower the incidence of surgical site infections due to its inherent ability to drain wound exudates. This study compared the frequency of surgical site infections and the cosmetic outlook of the scar among patients undergoing stoma reversal with linear and purse-string skin closure techniques.

SETTING AND DURATION

Department of Pediatric Surgery, University of Child Health Sciences Lahore with a duration of one year (June 2021 to June 2022).

METHODS

This randomized controlled trial (TCTR20210417001) was conducted with IRB approval. A total of 124 patients undergoing stoma reversal were randomly assigned to two groups (62 in each): Group A received conventional linear skin closure, while Group B received purse-string wound closure. The study evaluated surgical site infection, cosmetic outcome, and length of stay.

RESULTS

Both groups had similar age, gender ratio, indication for surgery, and length of stay. The purse-string group had a significantly lower incidence of SSI (38.7 % vs. 14.5 %; p = 0.002) and better scar quality (Manchester scar scale showed 'good' scar quality in 63 % of patients vs. 22.6 % in the linear closure group, p-value <0.0001).

CONCLUSION

The purse-string technique for skin closure resulted in fewer surgical site infections and improved scar appearance.

The Effect of Stoma Site Marking on Stomal Complications: A Long-term Retrospective Study

OBJECTIVE

To identify the effect of stoma site marking on stoma-related complications.

METHODS

The study sample included 639 individuals with stomas who were followed up in a stomatherapy unit in Turkey between January 1, 2017, and June 20, 2021. Researchers collected patient data from nursing records. Data were evaluated using number, percentage, χ2, and logistic regression tests.

RESULTS

Of the individuals with stomas, 60.6% (n = 387) were men, and 72.6% (n = 464) had a cancer diagnosis. Their mean age was 60.16 (SD, 14.81) years. The stoma site was marked preoperatively in of 67.1% of patients (n = 429), and 17.1% (n = 109) developed stoma-related complications. The complication rate was higher in individuals with unmarked stoma sites (25.7%; P = .000), emergency surgeries (25.0%; P = .006), colostomies (23.9%; P = .042), and permanent stomas (28.3%; P = .002). The three most common complications were peristomal skin problems (56.9%), mucocutaneous separation (13.8%), and edema (9.2%).

CONCLUSIONS

The incidence of stoma-related complications in the postoperative period was higher in individuals with unmarked stoma sites. The authors recommend that stoma and wound care nurses mark the stoma site in individuals for whom stoma creation is planned.

Prophylactic negative pressure wound therapy to improve wound healing rates following ileostomy closure: a randomized controlled trial

BACKGROUND

Reversal of ileostomy is associated with morbidity including wound infection and prolonged wound healing. Negative pressure wound therapy (NPWT) has been shown to reduce time to wound healing by secondary intention. The aim of this study was to determine whether NPWT improved wound healing rates, compared with simple wound dressings, in patients undergoing reversal of ileostomy where the skin wound is closed with a purse-string suture.

METHODS

This was a dual-centre, open-label, randomized controlled trial with two parallel intervention arms. Patients undergoing elective loop ileostomy reversal were randomized 1:1 to receive NPWT or simple wound dressings. The primary endpoint of the study was assessment of complete wound healing at day 42 post reversal of ileostomy and the secondary endpoints were patient-reported wound cosmesis using a visual analogue scale and rates of surgical site infection (SSI).

RESULTS

The study was conducted from June 2018 to December 2021. The trial was approved by the local ethics committee. We enrolled 40 patients, 20 in each arm. One patient in each arm was lost to follow up. Nine patients (9/19, 47.36%) in the simple dressing group had wound healing vs. 13 patients (13/19, 68.42%) in the NPWT group (P = 0.188). There was no significant difference in patient- reported wound cosmesis or SSI.

CONCLUSION

There was no difference in wound healing rates when comparing NPWT to simple wound dressings at early and late time points post reversal of ileostomy, where the skin wound was closed with a purse-string suture.

Quality of life amongst patients with diverting umbilical stomas in rectal surgery: a single centre prospective randomized controlled pilot study

BACKGROUND

The umbilical stoma (umbistoma) has been proposed as a viable alternative site for a temporary defunctioning stoma. Suggested advantages of the umbistoma include decreased number of surgical incisions required, improved cosmesis and ease of reversal surgery. This study aimed to assess the patient experience of umbilical loop ileostomies in rectal surgery, with the primary outcome being patient reported quality of life (QoL).

METHODS

A total of 20 patients undergoing laparoscopic rectal cancer surgery were randomly allocated to have a defunctioning ileostomy at a conventional site (right iliac fossa) or at the umbilicus. Patient-reported QoL was assessed at 6 weeks using the Stoma-QoL questionnaire. Secondary outcomes were number of stomas reversed, length of time awaiting stoma reversal surgery, duration of operative time for stoma reversal, length of hospital stay following stoma reversal and rate of parastomal or post reversal incisional hernias.

RESULTS

Patients who had an umbilical stoma scored significantly lower on the Stoma-QoL questionnaire compared to the conventional group, particularly on questions regarding feelings of tiredness, body insecurity and anxiety. No significant differences were observed between the two groups in relation to secondary outcomes.

CONCLUSION

There may be potential disadvantages to the umbilical stoma with negative impacts on body image and subsequent increased social anxiety. Patient selection and adequate counselling will be important when considering an umbilical stoma. Further larger scale prospective studies are required to further validate the feasibility and longer-term safety of umbilical stomas in both clinical outcomes as well as patient QoL.

Impact of chemotherapy on surgical outcomes in ileostomy reversal: a propensity score matching study from a single centre

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.

Routine Endoscopy Prior to Surgical Ostomy Closure: An Obsolete Concept

BACKGROUND

Closure of temporary diverting ostomies is commonly preceded by an endoscopic study of the colonic mucosa and anastomosis, despite lacking evidence of its relevance and impact on subsequent operative management.

AIM

We sought to determine the incidence of pathological findings and therefore evaluate the clinical benefit of routine pre-operative endoscopy in asymptomatic patients, hypothesizing sole evaluation of the anastomotic integrity to be sufficient in these cases.

METHODS

We retrospectively identified all adult patients with ostomy installations who were followed up for potential reversal surgery between 2002 and 2020 at the University Hospital of Zurich, Switzerland. Main outcome measures were the incidence of endoscopically identified pathological findings in the asymptomatic case cohort and their impact on the subsequent course of treatment.

RESULTS

Pre-procedural endoscopic data of 187 cases evaluated for ostomy closure were evaluated. Relevant mucosal findings in the asymptomatic cohort were documented in 26.3% and findings at the anastomotic site detected in 8.7%. A change in subsequent surgical management was noted in 10 patients of the entire cohort (5.3%) and in 9 (5.1%) of all asymptomatic cases. Upon multivariate analyses, the age range of 51 to 60 years old was found to be significantly linked to the presence of endoscopic findings entailing a change in patient management.

CONCLUSION

Our findings strongly suggest ostomy closure surgery without previous assessment of the bowel mucosa by means of endoscopy to be acceptable in asymptomatic patients. However, we found it to be indicated in all patients meeting the screening criteria for colorectal carcinoma.

Diet After Ileostomy Study: an observational study describing dietary intake and stoma-related symptoms in people with an ileostomy

BACKGROUND

People with ileostomy are frequently advised to avoid specific foods and food groups, making it plausible that they are at risk of a range of nutrition-related adverse health consequences. Despite this there has been no recent study in the United Kingdom describing dietary intake, symptoms and food avoidance in people with ileostomy or post-reversal.

METHODS

A cross-sectional study was conducted at different time points in people with ileostomy and reversal. Participants were recruited at 6-10 weeks post-formation (n = 17) and ≥12 months with established ileostomy (n = 16) and with reversal (n = 20). In all participants, ileostomy/bowel-related symptoms in the previous week were assessed using a study-specific questionnaire. Dietary intake was assessed using three online diet recalls or 3-day dietary records. Food avoidance and reasons for food avoidance were assessed. Data were summarised using descriptive statistics.

RESULTS

Participants reported a few ileostomy/bowel-related symptoms in the previous week. However, over 85% of participants reported avoiding foods, particularly fruits and vegetables. At 6-10 weeks the most common reason was being advised to do so (71%), although 53% avoided foods due to gas. At ≥12 months the most common reasons were foods visible in the bag (60%) or advised to do so (60%). Reported intakes of most nutrients were comparable to population medians, apart from lower fibre in people with ileostomy. Intakes of free sugars and saturated fats were above recommended levels in all groups, due to high consumption of cakes and biscuits and sugar-sweetened drinks.

CONCLUSION

After the initial healing period, foods should not be automatically excluded unless found to be problematic after reintroduction. There may be a need for healthy eating advice for people with established ileostomies and post-reversal, targeting discretionary high-fat, high-sugar foods.

The lived experience of colorectal cancer patients with a temporary ileostomy and the patient's perception of the ostomy nurses' educational interventions

PURPOSE

This study is aimed at exploring the lived experiences of colorectal cancer patients regarding temporary ileostomy and the educational interventions of ostomy nurses.

METHODS

This study is conducted using Heideggerian phenomenological focus group. Focus group interviews were conducted from November 2021 to February 2022 using a semi-structured guide with nine colorectal cancer patients having a temporary ileostomy. The interview data were analyzed using latent content analysis RESULTS: Four main categories and 13 sub-categories are identified as the result of data analysis. Main categories were "colorectal cancer and ileostomy: patient's adaptation," "supporting resources for the patient with ileostomy," "ileostomy closure: hope and concerns," and "ostomy nurse's professionalism." The main categories reflect the shared experiences and perceptions of colorectal cancer patients, across the timeline from colorectal cancer diagnosis to ileostomy closure.

CONCLUSION

This study provides a timely response to a pilot project for recognizing ostomy nurse's education for patients with stomas. Also, the findings of this study contribute to nursing knowledge by providing patients' perspectives on the education provided to them by the ostomy nurse. Lastly, this study inspires future studies to evaluate and recognize ostomy nurse's practice by using various methodological approaches.

Laparoscopic versus open Hartmann reversal: a propensity score matching analysis

PURPOSE

The purpose of this study was to compare the short-term outcomes between laparoscopic Hartmann reversal (LHR) and open Hartmann reversal (OHR) in patients who had undergone Hartmann surgery for colorectal cancer (CRC).

METHODS

The patients who underwent Hartmann reversal (HR) at the First Affiliated Hospital of Chongqing Medical University from Jun 2013 to Jun 2022 were retrospectively enrolled. The LHR group and the OHR group were compared using propensity score matching (PSM) analysis.

RESULTS

A total of 89 patients who underwent Hartmann reversal (HR) were enrolled in this study. There were 48 (53.9%) patients in the LHR group and 41 (46.1%) patients in the OHR group. After 1:1 ratio PSM, no difference in baseline information remained (p > 0.05). There was no significant difference in operation time, blood loss, postoperative hospital stay, and postoperative complications (p > 0.05) before and after PSM. In the multivariable logistic regression analysis, pre-operative albumin < 42.0 g/L was an independent risk factor (p = 0.013 < 0.05, OR = 0.248, 95% CI = 0.083-0.741) for the HR-related complications; however, LHR/OHR was not a predictive risk factor (p = 0.663, OR = 1.250, 95% CI = 0.500-3.122).

CONCLUSION

Based on the current evidence, although there was no difference in short-term prognosis, LHR still had some advantages considering that it was less invasive to the patient.

Satisfactory short-term outcomes of totally laparoscopic ileostomy reversal compared to open surgery in colorectal cancer patients

Background

Recently, totally laparoscopic (TLAP) surgery has suggested its potential on ileostomy reversal. This study aimed to compare the short-term outcomes between TLAP and traditional open ileostomy reversal.

Patients and methods

From September 2016 to September 2021, 107 eligible patients underwent TLAP (n = 48) or open (n = 59) loop ileostomy reversal were retrospectively enrolled. Surgical parameters, postoperative recovery and complications were identified and compared between TLAP technique vs. open surgery.

Results

The operation time and estimated blood loss showed no obvious difference between TLAP and open group. However, TLAP reversal significantly decreased the incision length (4.5cm vs. 6cm, P < 0.001). Furthermore, patients underwent TLAP surgery showed quicker first ground activities (1 day vs. 2 days, P < 0.001), faster first flatus passage (2 days vs. 3 days, P = 0.004) and shorter postoperative stay (5 days vs. 7 days, P = 0.007). More importantly, postoperative complications were significantly reduced after TLAP reversal (3 cases vs. 10 cases, P = 0.026). Further logistic regression analyses also indicated the TLAP technique was associated with lower incidence of complications (OR=3.316, CI, 1.118-9.835; P = 0.031).

Conclusions

TLAP surgery is competitive in promoting postoperative recovery as well as reducing complications compared to the traditional open ileostomy reversal.

Progress in Multidisciplinary Treatment of Fournier's Gangrene

Fournier's gangrene (FG) is a life-threatening and special form of necrotizing fasciitis, characterized by occult onset, rapid progress and high mortality, occurring mainly in men over 50 years of age. Risk factors of FG include diabetes, HIV infection, chronic alcoholism and other immunosuppressive state. FG was previously considered as an idiopathic disease, but in fact, three quarters of the infections originated from the skin, urethra and gastrointestinal tract. Initial symptoms of FG are often inconsistent with severity and can progress promptly to fatal infection. Although the treatment measures of FG have been improved in recent years, the mortality does not seem to have decreased significantly and remains at 20% - 30%. The time to identify FG and the waiting period before surgical debridement are directly related to the prognosis. Therefore, in addition to the combination of intensive fluid resuscitation and broad-spectrum antibiotics, treatment of FG should particularly emphasize the importance of early surgical debridement assisted with fecal diversion and skin reconstruction when necessary. This paper is to briefly summarize the progress in the definition, epidemiology, clinical manifestations, diagnosis, treatment and prognosis of Fournier's gangrene in recent years, more importantly, illustrates the importance of multidisciplinary cooperation in the management of FG.

A Cost-Utility Analysis of Mesh Prophylaxis in the Prevention of Incisional Hernias following Stoma Closure Surgery

BACKGROUND

Stoma closure is a widely performed surgical procedure, with 6295 undertaken in England in 2018 alone. This procedure is associated with significant complications; incisional hernias are the most severe, occurring in 30% of patients. Complications place considerable financial burden on the NHS; hernia costs are estimated at GBP 114 million annually. As recent evidence (ROCSS, 2020) found that prophylactic meshes significantly reduce rates of incisional hernias following stoma closure surgery, an evaluation of this intervention vs. standard procedure is essential.

METHODS

A cost-utility analysis (CUA) was conducted using data from the ROCSS prospective multi-centre trial, which followed 790 patients, randomly assigned to mesh closure (n = 394) and standard closure (n = 396). Quality of life was assessed using mean EQ-5D-3L scores from the trial, and costs in GBP using UK-based sources over a 2-year time horizon.

RESULTS

The CUA yielded an incremental cost-effectiveness ratio (ICER) of GBP 128,356.25 per QALY. Additionally, three univariate sensitivity analyses were performed to test the robustness of the model.

CONCLUSION

The results demonstrate an increased benefit with mesh prophylaxis, but at an increased cost. Although the intervention is cost-ineffective and greater than the ICER threshold of GBP 30,000/QALY (NICE), further investigation into mesh prophylaxis for at risk population groups is needed.

Morbidity of Temporary Loop Ileostomy in Patients with Colorectal Cancer

Leakage of low colorectal anastomoses after total mesorectal excision is a dreaded complication. Hence, an ileostomy is commonly performed during anterior resection especially in patients who have received neoadjuvant radiation. The aim of this study was to quantify the temporary loop ileostomy-related benefits as well as morbidity in patients with colorectal cancer. We did a retrospective study including all patients who underwent anterior resection with diversion ileostomy for biopsy-proven rectal carcinoma at our institute from 1 Jan 2016 to 31 Dec 2017 with follow-up of 2 years. A total of 104 patients were included in the study. In our series, 6.7% patients had an anastomotic dehiscence which precluded patients from stoma reversal. 12.5% of the patients had a stoma-related complication. 5.7% patients had complications following a stoma reversal. Eighty percent of the patients who developed clinically evident dehiscence in the immediate postoperative period were managed conservatively because of the presence of stoma. We did not have any mortality related to the stoma. 18.3% patients did not have their stomas reversed. The stoma non-reversal due to anastomotic dehiscence or stricture could be attributed to in 7.7% patients. 3.8% had to have their ileostomies converted to a permanent colostomy due to either a rectovaginal fistula or dehiscence or stricture. The complications associated with ileostomy are not insignificant. In our study, the tumor location in lower rectum was the only significant factor for non-reversal. We have to objectively identify patients who are at low risk for leakage and avoid ileostomy in them, and also try to minimize the morbidity of ileostomy by methods like early closure.

Risk factor for the development of surgical site infection following ileostomy reversal: a single-center report

PURPOSE

Postoperative surgical site infection (SSI) is not uncommon in patients with ileostomy reversal. The appropriate index to predict the postoperative SSI in these individuals remains unclear. The aim of this study is to evaluate the risk factor for SSI after ileostomy reversal.

METHODS

A consecutive cohort of 201 patients who underwent elective ileostomy reversal between January 2015 and January 2020 were retrospectively analyzed. Patients were divided into two groups: SSI group and non-SSI group. Univariate and multivariate analyses were conducted to identify risk factors for postoperative SSI.

RESULTS

Postoperative SSI occurred in 37 (18.4%) patients. Compared with the non-SSI group, patients in SSI group had higher incidence of nutrition risk (56.77% vs 39.02%, P = 0.049), higher C-reactive protein (CRP) level (10.81 ± 16.49 vs 4.86 ± 4.14 mg/L, P < 0.001), and longer postoperative hospital stay (13.08 ± 3.71 vs 7.47 ± 2.38 days, P < 0.001). By analyzing the receiver-operating characteristic (ROC) curve, CRP have the value in predicting the occurrence of SSI. The areas under the ROC curves of CRP for SSI was 0.671 (95% confidence interval 0.568-0.774, P = 0.001) with an optimal diagnostic cut-off value of 8.0 mg/L. By the univariate and multivariate analyses, preoperative C-reactive protein (CRP) ≥ 8 mg/L(P < 0.001) and conventional linear closure method (P = 0.004) were independent risk factors for postoperative SSI.

CONCLUSIONS

Preoperative CRP levels can be served as a predictive index for postoperative SSI after stoma reversal. Purse-string closure technique is the treatment of choice to minimize stoma site SSI in patients with stoma reversal.

Life with a stoma across five European countries-a cross-sectional study on long-term rectal cancer survivors

PURPOSE

Stoma-related problems are known to be important to patients and potentially affect everyday life. The prevalence of stoma-related problems in rectal cancer survivors remains undetermined. This study aimed to examine aspects of life with a long-term stoma, stoma management, and stoma-related problems and explore the impact of stoma-related problems on daily life.

METHODS

In total, 2262 patients from 5 European countries completed a multidimensional survey. Stoma-related problems were assessed using the Colostomy Impact score. Multivariable regression analysis, after adjusting for potential confounding factors, provided odds ratio (OR) and 95% confidence intervals (CI) for stoma-related problems' association with restrictions in daily life.

RESULTS

The 2262 rectal cancer survivors completed the questionnaire at a median of 5.4 years (interquartile range 3.8-7.6) after stoma formation. In the total sample, leakage (58%) and troublesome odour (55%) were most prevalent followed by skin problems (27%) and pain (21%). Stoma-related problems were more prevalent in patients with parastomal bulging. A total of 431 (19%) reported feeling restricted in daily activities in life with a stoma. Leakage, odour, skin problems, stool consistency, and frequent appliance changes were significantly associated with restrictions in daily life. The highest risk of experiencing restrictions was seen for patients having odour (OR 2.74 [95% CI: 1.99-3.78]) more than once a week and skin problems (OR 1.77 [95% CI: 1.38-2.27]).

CONCLUSION

In this large cohort with rectal cancer, stoma-related problems were highly prevalent and impacted daily life. Supportive care strategies should entail outreach to patients with a long-term stoma.

Factors Predicting the Reversal of Hartmann’s Procedure

Aim

This paper investigates the risk factors preventing the reversal and nonreversal of Hartmann's procedure, as a surgical technique that has been performed in our clinic for ten years.

Methods

The study involved a ten-year Hartmann's procedure followed up at our center. The patients were divided into Hartmann reversal and nonreversal groups. Groups were examined in terms of age, gender, diagnosis, stage of malignancy, ASA score, comorbidity, perioperative morbidity-mortality, and the length of the operation.

Results

Age (p < 0.001), ASA score (p < 0.001), stage in case of malignancy (p = 0.002), and comorbidities (p < 0.001) were significant risk factors. The ratio of patients without any comorbidities to those with one or more comorbidities was 2.63 (95% CI 1.12–6.20). Among the malignant patients, the ratio of early-stage patients to advanced-stage patients in the group with reversal of Hartmann's colostomy was 2.82 (95% CI 1.30–6.10). In addition, the ratio of older patients to younger patients in group 2 was 0.95 (95% CI 0.92–0.98). A univariate analysis revealed that younger patients, those with lower ASA scores, those without comorbidities, and those with early-stage malignancy had a greater chance of closure of the stoma.

Conclusion

Although Hartmann's procedure is performed in emergency surgery, the nonreversal of the colostomy is a problem in itself. It should be kept in mind that patients who have high risks are likely to have a permanent stoma.

Circular Mini-Incision in the Left Iliac Fossa Followed by Purse-String Closure as a Minimally Invasive Approach for the Sigmoid Volvulus: A Technical Note

Introduction: Volvulus of the sigmoid is a common cause of intestinal obstruction in Morocco. It is a serious condition with substantial mortality. Initial endoscopic decompression followed by resection of the redundant colon via laparotomy or laparoscopy is the procedure of choice. Exteriorization of the sigmoid colon through a linear skin incision in the left iliac fossa has been described as an alternative approach for the classic midline incision, with or without laparoscopic assistance, with acceptable results.

Methods: We describe herein a novel, minimally invasive approach for fit patients with non-complicated volvulus sigmoid. This approach consists of a skin-disk incision in the left iliac fossa, exteriorization of the redundant colon, and resection with or without primary anastomosis, followed by a purse-string closure.

Results: A 65-year-old patient with no prior notable medical history, presented to the emergency department with his first episode of sigmoid volvulus. A skin-disk incision was made in the left iliac fossa, exteriorization of the sigmoid was done easily through the incision, and resection and manual anastomosis were done. The closure was made in a purse-string fashion. Recovery was uneventful and the patient was discharged home on the fourth postoperative day. No wound infection was noted and the cosmetic result was satisfactory.

Conclusion: Left iliac skin-disk incision followed by a purse-string closure is an option for approaching the abdomen in the case of sigmoid volvulus. It has been demonstrated that this technique helps reduce wound-related complications in patients undergoing stoma reversal. Authors suggest that cosmetic results are better and the incidence of surgical site infection can be lower with this technique as compared to the classic linear skin incision. Results, however, should be confirmed by larger studies.

Early vs. standard reversal ileostomy: a systematic review and meta-analysis

Background

Formation of a defunctioning loop ileostomy is common after mid and low rectal resection. Historically, they were reversed between 3 and 6 months after initial resection. Recently, earlier closure (< 14 days) has been suggested by some current randomised controlled trials. The aim of this study was to investigate the effect of early stoma closure on surgical and patient outcomes.

Methods

A systematic review of the current randomised controlled trial literature comparing early and standard ileostomy closure after rectal surgery was performed. Specifically, we examined surgical outcomes including; morbidity, mortality and quality of life.

Results

Six studies met the predefined criteria and were included in our analysis. 275 patients underwent early stoma closure compared with 259 patients having standard closure. Overall morbidity was similar between both groups (25.5% vs. 21.6%) (OR, 1.47; 95% CI 0.75–2.87). However, there tended to be more reoperations (8.4 vs. 4.2%) (OR, 2.02, 95% CI 0.99–4.14) and small bowel obstructions/postoperative ileus (9.3% vs. 4.4%) (OR 0.44, 95% CI 0.22–0.90) in the early closure group, but no difference across the other domains.

Conclusions

Early closure appears to be a feasible in highly selective cases after good perioperative counselling and shared decision-making. Further research on quality of life outcomes and long term benefits is necessary to help define which patients are suitable candidates for early closure.

Timing of Closure of a Protective Loop-Ileostomy Can Be Crucial for Restoration of a Functional Digestion

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.

Single Center Experience with Umbilical Stomas Following Colorectal Surgery

Background: The umbilicus is commonly used as an access site to perform minimally invasive colorectal surgery. Umbilical stomas are becoming an attractive option as an alternative site for temporary stomas since they reduce the need for additional abdominal incisions. Methods: We retrospectively evaluated patients who underwent umbilical stoma creation after colorectal resection for diagnosis of rectal cancer, diverticulitis, or ulcerative colitis between January 2020 and July 2021. Surgical technique, clinical and perioperative outcomes, complications, and cosmetic end results were described. Results: A total of 11 patients underwent umbilical stoma creation. There were no major surgical complications. Peristomal skin irritation was secondary to difficulties with the management of the pouching system. One patient presented with ostomy prolapse. Three patients experienced incisional hernia after stoma reversal. There were no wound infections. Conclusion: Umbilical stomas appear to be a safe alternative to conventional stomas and provide superior cosmetic outcomes.

Application of PREVENA (Surgical Incision Protection System) in reducing surgical site infections following reversal of ileostomy or colostomy: the PRIC study protocol

AIM

There is a current lack of evidence in the literature to support the routine use of negative pressure wound therapy (NPWT) to reduce the risk of surgical site infections (SSI) in the setting of ileostomy or colostomy reversal. The aim of this study is to examine whether routine NPWT confers a lower rate of SSI than conventional dressings following reversal of ileostomy or colostomy.

METHODS

The PRIC study is a randomized, controlled, open-label, multi-centre superiority trial to assess whether routine NPWT following wound closure confers a lower rate of SSI following reversal of ileostomy or colostomy when compared to conventional dressings. Participants will be consecutively identified and recruited. Eligible participants will be randomized in a 1:1 allocation ratio, to receive either the NPWT (PREVENA) dressings or conventional dressings which will be applied immediately upon completion of surgery. PREVENA dressings will remain applied for a duration of 7 days. Surgical wounds will then be examined on post-operative day seven as well as during follow-up appointments in OPD for any evidence of SSI. In the interim, public health nurses (PHN) will provide out-patient support services incorporating wound assessment and care as part of a routine basis. Study investigators will liaise with PHN to gather the relevant data in relation to the time to wound healing. Our primary endpoint is the incidence of SSI within 30 days of stoma reversal. Secondary endpoints include measuring time to wound healing, evaluating wound healing and aesthetics and assessing patient satisfaction.

CONCLUSION

The PRIC study will assess whether routine NPWT following wound closure is superior to conventional dressings in the reduction of SSI following reversal of ileostomy or colostomy and ascertain whether routine NPWT should be considered the new standard of care.

Intervenciones de Enfermería en la reversión del estoma intestinal: revisión integrativa

Introducción: los estomas intestinales representan un impacto significativo en la calidad de vida de las personas; sin embargo, estos deben revertirse después de haberse restituido el tránsito intestinal o la resolución del proceso inflamatorio inicial. Por otro lado, la negación de la persona para su reversión puede deberse a la falta de información y orientación por parte de los profesionales de la salud. Por lo anterior es importante identificar las intervenciones de Enfermería en la atención de la persona con reversión del estoma intestinal. Materiales y métodos: se realizó una revisión integrativa de la literatura de alcance descriptivo en el período comprendido entre los años 2015 a 2020, a través de las bases de datos Wos, Pubmed, Scopus, Scielo y Cochrane. Se seleccionaron 36 artículos que cumplieron con los criterios de inclusión y exclusión con el respectivo análisis metodológico. Resultados: Se identificaron las siguientes intervenciones de Enfermería, para el preoperatorio: valoración preoperatoria, preparación intestinal y seguimiento a comorbilidades. El intraoperatorio: profilaxis, preparación de la piel, técnica quirúrgica y cierre de la pared abdominal. En el posoperatorio: cuidado de la herida quirúrgica, calidad de vida y educación. Discusión: es importante la reflexión sobre el tiempo de reversión, la técnica quirúrgica y la importancia de las intervenciones por Enfermería. Conclusión: Enfermería cumple un papel importante en la reversión del estoma, no solo por los cuidados físicos y la educación que se brinda, sino también en las intervenciones aplicables al contexto social y emocional que afectan el estilo de vida de la persona.

Symptom clusters in patients with colorectal cancer after colostomy: a longitudinal study in Shanghai

Objective

Research is lacking regarding the experiences of patients after colostomy, which is needed so as to take necessary specific actions. In this study, we aimed to describe the trajectory of symptom clusters experienced by patients after colostomy over time.

Methods

This was a longitudinal observational study using data from 149 patients with colorectal cancer after colostomy. We investigated symptoms and symptom clusters at 2 weeks, 1 month, 3 months, 6 months, and 1 year after colostomy.

Results

Four main symptom clusters were identified, including a psychological symptom cluster, digestive and urinary symptom cluster, lack of energy symptom cluster, and pain symptom cluster in patients after colostomy in the first year after surgery. We further explored the symptom trajectory.

Conclusions

We explored symptom clusters and the trajectory of symptom resolution in patients after colostomy during the first year after surgery. Four stages were proposed to describe the different statuses of symptom clusters experienced by patients. Our findings may provide insight into how to improve symptom management and postoperative quality of life for patients after colostomy.

The assessment of sarcopenia using psoas muscle thickness per height is not predictive of post-operative complications in IBD

BACKGROUND

Sarcopenia is associated with postoperative complications in inflammatory bowel disease. It has most commonly been defined using the skeletal muscle index, computed after analysis of cross-sectional muscle area at L3. Psoas muscle thickness normalized to height (PMTH), which is easier to derive, is a potential surrogate of SMI and sarcopenia in patients with cirrhosis and chronic pancreatitis. We investigate whether sarcopenia defined by PMTH has utility in predicting post-operative outcomes in patients with inflammatory bowel disease.

METHODS

We performed a retrospective study of adults undergoing IBD-related surgery from 2009 to 2019 at two hospitals. Sarcopenia was defined by sex-specific PMTH at the umbilicus on cross-sectional imaging using a 50^th percentile median cutoff. Predictive models were created using variables (BMI, age, sex, smoking status, albumin, INR, platelets, hemoglobin, hypertension, diabetes, CAD, medications) that may be associated with complications (mortality, reoperation, readmission, transfusions, ICU admission, infection, DVT/PE), and sarcopenia for comparison.

RESULTS

85 patients with IBD were included. Lower albumin level (OR = 0.52, p = 0.039) and biologic use (OR = 5.92, p = 0.006) were associated with postoperative complications. There was no significant difference using PMTH compared to a model incorporating hypoalbuminemia and biologic use in predicting complications. Sarcopenia on univariate analysis was associated with a lower 30 day rate of reoperation (p = 0.04).

CONCLUSIONS

A low status of PMTH was not associated with increased postoperative complications, however hypoalbuminemia and biologic use were. PMTH as a surrogate for sarcopenia requires further study, ideally with prospective studies comparing PMTH with accepted radiographic surrogates for sarcopenia, to determine its role in clinical decision making.

Extended duration of faecal diversion is associated with increased ileus upon loop ileostomy reversal

AIM

The timing of ileostomy reversal has been the subject of controversy, with researchers investigating the safety of early versus late stoma closure. Anecdotally, a longer duration of faecal diversion is associated with a greater incidence of postoperative ileus. We sought to investigate the association between duration of diversion and postoperative ileus.

METHOD

We conducted an institutional retrospective cohort study on 173 patients undergoing ileostomy closure between 2012 and 2018. Our primary outcome was ileus; secondary outcomes included postoperative complications and descriptive factors. We investigated the association between duration of diversion and ileus using several analyses to ensure that time was treated appropriately as a continuous, nonlinear variable.

RESULTS

In all, 20.2% of patients had an ileus. Multivariate analysis did not identify a significant association between any independent predictors and ileus, although there was a trend towards increased risk of ileus with increasing duration of diversion. When treated as a categorical variable, a duration of diversion >328 days independently increased the odds of ileus (OR = 3.25, P = 0.033). Duration of diversion was associated with days to first flatus and to first diet (P = 0.025 and P = 0.004, respectively). When patients received nasogastric intubation, the mean duration of intubation was 3.2 days.

CONCLUSION

Greater duration of diversion was associated with a trend towards increased risk of ileus; this risk tripled when diversion lasted more than 328 days.

Clinical Outcomes of Ileostomy Closure before Adjuvant Chemotherapy after Rectal Cancer Surgery: An Observational Study from a Chinese Center

Background

The optimal timing of temporary ileostomy closure with respect to the time of adjuvant chemotherapy following sphincter-saving surgery for rectal cancer remains unclear. The aim of this study is to investigate the clinical and oncological outcomes of ileostomy closure before, during, and after adjuvant chemotherapy following curative rectal cancer resection.

Methods

Patients diagnosed with rectal adenocarcinoma who underwent low anterior resection and temporary loop ileostomy during May 2015 and September 2019 were retrospectively evaluated. Patients undergoing ileostomy closure before adjuvant chemotherapy (Group I) were compared to patients undergoing closure during (Group II) and after (Group III) adjuvant chemotherapy.

Results

A total of 225 patients were evaluated for eligibility, and 132 were finally selected and divided into 3 groups (24 in Group I, 53 in Group II, and 55 in Group III). No significant differences were observed in operative time, postoperative hospital stay, postoperative complications, total adjuvant chemotherapy cycles, and low anterior resection syndrome scores among the three groups. There was no significant difference in disease-free survival (p = 0.834) and overall survival (p = 0.462) between the three groups.

Conclusion

Temporary ileostomy closure before adjuvant chemotherapy following curative rectal cancer resection can achieve a clinical and oncological safety level equal to stoma closure during or after chemotherapy in selected patients.

New Scoring System for Predicting the Risk of Surgical Site Infections Following Stoma Reversal

BACKGROUND

Surgical site infections (SSI) are one of the most frequent complications following stoma reversal (SR-SSI) and lead to multiple problems such as decreased mobility of the patients or increased hospital costs. Several risk factors for SR-SSI have been reported, but there are no risk scoring systems for predicting SR-SSI. The current study aimed to analyze the risk factors for SR-SSI and develop a scoring system.

MATERIALS AND METHODS

Multivariate analysis of risk factors for SR-SSI was performed in patients who underwent elective SR and were followed-up during the first month after surgery. A logistic regression model was used to identify risk factors and construct a predictive score.

RESULTS

Of the 182 patients, 53 (29.1%) developed SSI. In multivariate analysis, three variables as preoperative risk factors were associated with increased SR-SSI incidence: subcutaneous fat thickness (≥ 20 mm) (odds ratio [OR]: 8.46 [95% confidence interval (CI): 3.45-20.7], P <0.001), period from stoma creation (≤ 20 weeks) (OR: 2.88 [95% CI: 1.14-7.28], P = 0.025), and SSI after the primary operation (OR: 3.06 [95% CI: 1.19-7.90], P = 0.021). Each of these variables contributed 2,1, and 1 points to the risk score, respectively. The SR-SSI rate was 2.9%, 20.3%, 34.2%, 54.5%, and 81.8% for the scores of 0,1,2,3, and 4 points, respectively. The area under the receiver operating characteristic curve was 0.773 (95% CI: 0.703-0.844).

CONCLUSIONS

A simple clinical scoring system based on three preoperative variables may be useful in predicting the risk of SR-SSI.

Management and 1-year outcomes of anastomotic leakage after elective colorectal surgery

PURPOSE

To analyze different types of management and one-year outcomes of anastomotic leakage (AL) after elective colorectal resection.

METHODS

All patients with anastomotic leakage after elective colorectal surgery with anastomosis (76/1,546; 4.9%), with the exclusion of cases with proximal diverting stoma, were followed-up for at least one year. Primary endpoints were as follows: composite outcome of one-year mortality and/or unplanned intensive care unit (ICU) admission and additional morbidity rates. Secondary endpoints were as follows: length of stay (LOS), one-year persistent stoma rate, and rate of return to intended oncologic therapy (RIOT).

RESULTS

One-year mortality rate was 10.5% and unplanned ICU admission rate was 30.3%. Risk factors of the composite outcome included age (aOR = 1.08 per 1-year increase, p = 0.002) and anastomotic breakdown with end stoma at reoperation (aOR = 2.77, p = 0.007). Additional morbidity rate was 52.6%: risk factors included open versus laparoscopic reoperation (aOR = 4.38, p = 0.03) and ICU admission (aOR = 3.63, p = 0.05). Median (IQR) overall LOS was 20 days (14-26), higher in the subgroup of patients reoperated without stoma. At 1 year, a stoma persisted in 32.0% of patients, higher in the open (41.2%) versus laparoscopic (12.5%) reoperation group (p = 0.04). Only 4 out of 18 patients (22.2%) were able to RIOT.

CONCLUSION

Mortality and/or unplanned ICU admission rates after AL are influenced by increasing age and by anastomotic breakdown at reoperation; additional morbidity rates are influenced by unplanned ICU admission and by laparoscopic approach to reoperation, the latter also reducing permanent stoma and failure to RIOT rates.

TRIAL REGISTRATION

ClinicalTrials.gov # NCT03560180.

Relationship between diversional stoma and mortality rate in Fournier's gangrene: a systematic review and meta-analysis

PURPOSE

Fournier's gangrene (FG) is a rare potentially lethal necrotising infection of the perineum. While the gold standard management is early and aggressive surgical debridement, the evidence in the literature is unclear as to the role and outcomes of diversional stoma.

METHODS

A systematic review was conducted to identify studies investigating the relationship between stoma formation and FG. Meta-analyses were performed using a random-effects model.

RESULTS

Twenty-seven studies (n=1482) were included. There was no significant difference in disease severity scores between the stoma and no stoma groups. Mortality rate was significantly higher in patients who required diversional stoma (OR 1.71, 95% CI 1.13-2.59, p=0.01). Significantly more surgical procedures were performed on patients who underwent stoma formation, and the total hospital cost was also higher in this group. This study may have been limited by bias in patients with more fulminant course or sphincter damage requiring stoma as a medical necessity.

CONCLUSION

These findings suggest that the use of diversional stoma in FG is a predictor of poor outcomes. This study demonstrated that mortality rate remained high and a diversional stoma did not reduce risk of mortality as suggested by smaller case series. Its use should therefore be individualised based on disease severity and sphincter damage.

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

PURPOSE

Loop ileostomy is performed in rectal cancer surgery to decrease the impact of anastomotic leak but it is associated with a significant complication rate. This study aimed to analyze the morbidity related to diverting ileostomy and to identify factors predictive of complications related to stoma management and reversal, as well as conversion into a permanent ileostomy.

METHODS

A retrospective study was conducted on 112 patients submitted to oncological rectal resection and defunctioning ileostomy in a Portuguese colorectal unit between March 2012 and March 2019.

RESULTS

Loop ileostomy was responsible for 13% of index surgery morbidity and 15% of patients' readmissions due to high output, stoma stenosis and parastomal hernia. Ileostomy was reversed in 89% cases with 7% Clavien-Dindo ≥ IIIb complications. An association was established between diabetes and higher stoma management morbidity (OR: 3.28 [95% CI: 1.039-10.426]. p = 0.041). Likewise, diabetes (OR: 0.17 [95% CI: 0.038; 6.90], p=0.015), oncological disease stage ≥ III (OR: 0.10 [95% CI: 0.005; 0.656], p=0.047) and index rectal surgery morbidity (OR: 0.23 [95% CI: 0.052; 0.955], p=0.041) were associated with less ileostomy closure. Complications of the index surgery also related to higher stoma reversal morbidity (OR: 5.11 [95% CI: 1.665; 16.346], p=0.005).

CONCLUSIONS

Diabetes and complications of index rectal surgery were identified as predictive of ileostomy morbidity, closure rate and associated complications. It is essential to adjust treatment decisions to patient's morbidity risk and adopt a more selective approach concerning the use of an ileostomy.

Permanent stoma: a quality outcome in treatment of rectal cancer and its impact on length of stay

BACKGROUND

This study aimed to identify socioeconomic predictors of permanent stoma in rectal cancer treatment and examine its association with length of stay at the treatment facility.

METHODS

Rectal cancer patients who underwent elective surgery between January 2015 and December 2018 were identified from the Agency for Health Care Administration Florida Hospital Inpatient Discharge Dataset. Multivariate regression models were utilized to identify demographic and socioeconomic factors associated with receiving a permanent stoma as well as the associated length of stay of these patients.

RESULTS

Of 2630 rectal cancer patients who underwent surgery for rectal cancer, 21% had a permanent stoma. The odds of receiving permanent stoma increased with higher Elixhauser score, metastatic disease, advanced age, having open surgery, residence in Southwest Florida, and having Medicaid insurance or no insurance/self-payers (p < 0.05). Patients with a permanent stoma had a significantly extended stay after surgery (p < 0.001).

CONCLUSIONS

Patients with a permanent stoma following cancer resection were more likely to have open surgery, had more comorbidities, and had a longer length of stay. Having permanent stoma was higher in patients living in South West Florida, patients with Medicaid insurance, and in the uninsured. Additionally, the payer type significantly affected the length of stay.

Out of the Loop: The Value of a Preoperative Loopogram for Colostomy Reversal in Trauma

BACKGROUND

Stoma is occasionally fashioned during trauma surgery. A loopogram is routinely conducted in the surgical planning for stoma reversal. This is associated with medical and cost implications. A study was undertaken to evaluate the influence of loopograms on the management of trauma patients at a Johannesburg hospital.

METHODS

A retrospective analysis of records in the stoma database (January 2013 to December 2018) was conducted. The patient demographics, method of injury, stoma-type, loopogram findings and post-operative courses were analysed.

RESULTS

112 records were obtained. 9 (8%) patients were excluded for pending investigations or surgery. 13 (11.6%) patients were excluded for incomplete data. The remaining 90 (80.3%) patients, with a mean age of 32.9 had non-contributory loopograms and underwent a reversal procedure. 43 (47.8%) had a loop colostomy while 47 (52.2%) had undergone a Hartmann's procedure. Mechanism of injury was stab wounds (81.4%L; 61.7%H); gunshot wounds (13.9%L; 29.7%H) and blunt trauma (L5% and 9%H). The post-operative complication rate was 30% for the loop group (2.3% ≥ Clavien-Dindo 3) and 25.5% for the Hartmann's group (4% ≥ Clavien-Dindo 3). The average timing to reversal was 38 weeks (range 12-60) in the Hartmann's group and 22 weeks (range 12-32) the loop colostomy group.

CONCLUSION

Significant findings are infrequent on loopogram for trauma patients. When these findings are detected, the effect on management is questionable. They are not without complications and have cost and time implications. Loopograms are helpful in selective cases rather than as a routine investigation, particularly in resource-limited settings.

Laparoscopic Versus Open Hartmann Reversal: A Case-Control Study

Background

Laparoscopic reversal of Hartmann's procedure (LHR) offers reduced morbidity compared with open Hartmann's reversal (OHR). The aim of this study is to compare the outcome of laparoscopic versus open Hartmann reversal.

Materials and Methods

Thirty-four patients who underwent Hartmann reversal between January 2017 and July 2019 were evaluated. Patients underwent either LHR (n = 17) or OHR (n = 17). Variables such as numbers of patients, patient's age, sex, body mass index (BMI), comorbidities, ASA (American Society of Anesthesiology) score, indication for previous open sigmoid resection, mean operation time, rate of conversion to open surgery, length of hospital stay, mortality, and morbidity were retrospectively evaluated.

Results

The two groups of patients were homogeneous for gender, age, body mass index, cause of primary surgery, time to reversal, and comorbidities. In 97% of the cases, HP was done by open surgery. Our data revealed no difference in mean operation time (LHR: 180.5 ± 35.1 vs. OHR: 225.2 ± 48.4) and morbidity rate, although, in OHR group, there were more severe complications. Less intraoperative blood loss (LHR: 100 ± 40 mL vs. OHR: 450 ± 125 mL; p value <0.001), shorter time to flatus (LHR: 2.4 days vs. OHR: 3.6 days; p value <0.021), and shorter hospitalization (LHR: 4.4 vs. OHR: 11.2 days; p value <0.001) were observed in the LHR group. Mortality rate was null in both groups. Discussion. LHR is feasible and safe even for patients who received a primary open Hartmann's procedure. We suggest careful patient's selection allowing LHR procedures to highly skilled laparoscopy surgeons.

Evaluation of Pelvic Anastomosis by Endoscopic and Contrast Studies Prior to Ileostomy Closure: Are Both Necessary? A Single Institution Review

Contrast enema is the gold standard technique for evaluating a pelvic anastomosis (PA) prior to ileostomy closure. With the increasing use of flexible endoscopic modalities, the need for contrast studies may be unnecessary. The objective of this study is to compare flexible endoscopy and contrast studies for anastomotic inspection prior to defunctioning stoma reversal. Patients with a protected PA undergoing ileostomy closure between July 2014 and June 2019 at our institution were retrospectively identified. Demographics and clinical outcomes in patients undergoing preoperative evaluation with endoscopic and/or contrast studies were analyzed. We identified 207 patients undergoing ileostomy closure. According to surgeon's preference, 91 patients underwent only flexible endoscopy (FE) and 100 patients underwent both endoscopic and contrast evaluation (FE + CE) prior to reversal. There was no significant difference in pelvic anastomotic leak (2.2% vs. 1%), anastomotic stricture (1.1% vs. 6%), pelvic abscess (2.2% vs. 3.0%), or postoperative anastomotic complications (4.4% vs. 9%) between groups FE and FE + CE (P > .05). Flexible endoscopy alone appears to be an acceptable technique for anastomotic evaluation prior to ileostomy closure. Further studies are needed to determine the effectiveness of different diagnostic modalities for pelvic anastomotic inspection.

Less is more-the best test for anastomotic leaks in rectal cancer patients prior to ileostomy reversal

PURPOSE

No clear consensus exists on how to routinely assess the integrity of the colorectal anastomosis prior to ileostomy reversal. The objective of this study was to evaluate the accuracy of contrast enema, endoscopic procedures, and digital rectal examination in rectal cancer patients in this setting.

METHODS

A systematic literature search was performed. Studies assessing at least one index test for which a 2 × 2 table was calculable were included. Hierarchical summary receiver operating characteristic curves were calculated and used for test comparison. Paired data were used where parameters could not be calculated. Methodological quality was assessed with the QUADAS-2 tool.

RESULTS

Two prospective and 11 retrospective studies comprising 1903 patients were eligible for inclusion. Paired data analysis showed equal or better results for sensitivity and specificity of both endoscopic procedures and digital rectal examination compared to contrast enema. Subgroup analysis of contrast enema according to methodological quality revealed that studies with higher methodological quality reported poorer sensitivity for equal specificity and vice versa. No case was described where a contrast enema revealed an anastomotic leak that was overseen in digital rectal examination or endoscopic procedures.

CONCLUSIONS

Endoscopy and digital rectal examination appear to be the best diagnostic tests to assess the integrity of the colorectal anastomosis prior to ileostomy reversal. Accuracy measures of contrast enema are overestimated by studies with lower methodological quality. Synopsis of existing evidence and risk-benefit considerations justifies omission of contrast enema in favor of endoscopic and clinical assessment.

TRIAL REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019107771.

The Impact of an Enhanced Recovery Program on Loop Ileostomy Closure

BACKGROUND

The implementation of enhanced recovery after surgery (ERAS) protocols has decreased the length of stay (LOS) and complications in colorectal procedures. However, little data has been published on the subset of patients undergoing loop ileostomy closure. We investigated the outcomes of loop ileostomy reversals prior to and after initiation of an ERAS protocol.

METHODS

Patients undergoing ileostomy reversal over a 5-year period by 4 colorectal surgeons were studied and divided into pre-ERAS patients and ERAS patients in a retrospective, case-control study. Patient demographics, comorbidities, LOS, underlying disease process, index intra-abdominal procedure, readmission rate, and complications were evaluated.

RESULTS

Overall, 208 patients were analyzed 149 pre-ERAS and 59 ERAS-with median LOS significantly lower in the ERAS group than the pre-ERAS group (50.8 hours vs. 96.1 hours, P < .0001). In subgroup analysis, the LOS was significantly lower if the index procedure performed was laparoscopic when comparing ERAS to pre-ERAS (49.9 hours vs. 96.6 hours, P < .001). ERAS did not confer a significant decrease in the LOS during ileostomy reversal with open index procedures (72.9 hours vs. 95.5 hours, P = .05).

CONCLUSION

Utilizing an ERAS protocol is safe and effective for loop ileostomy closure with a shorter LOS and no difference in complication rates or 30-day readmission rates.

Drains, Germs, or Steel: Multidisciplinary Management of Acute Colonic Diverticulitis

The medical and surgical management of uncomplicated diverticulitis has changed over the last several years. Although immunocompetent patients or those without comorbidities can be treated with antibiotics as an outpatient, the efficacy of high-fiber intake or drugs such as mesalamine or rifaximin is not yet clearly established in the treatment of acute episodes and in the prevention of recurrences. On the other hand, the choice between antibiotic treatment and percutaneous drainage is not always obvious in diverticulitis complicated by abscess formation, especially for larger abscesses; although the results of studies comparing the two approaches remain controversial, surgery must be pursued for abscesses > 8 cm. For emergency surgery, the debate is still ongoing regarding laparoscopic lavage and surgical resection followed by primary anastomosis, since for both approaches the published reports are not in agreement regarding possible benefits. Therefore, these approaches are recommended only for selected patients under the care of experienced surgeons. Also, the contribution of elective surgery toward the overall approach has been revised; currently, it is reserved primarily for patients with a high risk of recurrence and whenever more conservative treatments were not effective.

Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis

BACKGROUND

Both endoscopic techniques and transanal surgery are viable options that allow organ preservation for early rectal neoplasms. Whilst endoscopic approaches are less invasive and carry less morbidity, it is unclear whether they are as oncologically effective.

AIM

To compare endoscopic techniques with transanal surgery in the management of early rectal neoplasms.

METHODS

A systematic literature search was performed for randomised and observational studies comparing these techniques. The pre-specified main outcomes measured were en bloc and R0 resection rates and recurrence. Pair-wise meta-analysis was performed.

RESULTS

This review included 1044 patients. Transanal surgery had increased R0 resection rates (odds ratio (OR) 2.66; 95% CI 1.64; 4.31; p < 0.001) versus endoscopic management. The latter was associated with higher rates of incomplete resection (OR 2.25; 95% CI 1.14, 4.46; p = 0.02) and further intervention (OR 1.78; 95% CI 1.09, 2.88; p = 0.02). There was no difference in the rates of late recurrence (OR 1.01; 95% CI 0.53, 1.91; p = 0.99) or further major surgery (OR 0.87; 95% CI 0.39, 1.94; p = 0.73) between the groups. Endoscopic treatment was associated with a shorter operating time (weighted mean difference (WMD) - 12.08; 95% CI - 18.97, - 5.19; p < 0.001) and LOS (WMD - 1.94; 95% CI - 2.43, - 1.44; p < 0.001), as well as lower rates of urinary retention post-operatively (OR 0.12; 95% CI 0.02, 0.63; p = 0.01).

CONCLUSION

Endoscopic techniques should be favoured in the setting of benign early rectal neoplasms given their decreased morbidity and increased cost-effectiveness. However, where malignancy is suspected transanal surgery should be the preferred option given the superior R0 resection rate.

Surgical intervention for mechanical large bowel obstruction at a tertiary hospital: Which patients receive a stoma and how often are they reversed?

BACKGROUND

The surgical management of large bowel obstruction (LBO) is heterogeneous and influenced by multiple variables. The aim of this study was to analyze and compare the surgical interventions and outcomes of patients necessitating surgery for LBO.

METHODS

Patients with LBO between 2000 and 2017 were included. Main outcomes measures are intraoperative findings, operative management, post-operative outcomes and stoma closure rates.

RESULTS

133 patients were included with predominately left-sided obstruction (82%). The most common etiology was colorectal cancer (44%) followed by extrinsic malignant compression (29%). The most common operation performed was fecal diversion without resection (46%). This group had significantly more stage 4 carcinoma, carcinomatosis and had the lowest stoma closure rate (16%). Eighty-six percent of the operated patients underwent fecal diversion, of these, 27% had stoma reversal at 6 months. Patients that had a resection and anastomosis with diverting loop ileostomy were most likely to undergo stoma reversal (p = 0.005) and had the lowest number of patients with stage-IV carcinoma.

CONCLUSIONS

In this single institution analysis, the management of LBO entails high operative and stoma rates, with less than 30% of patient undergoing stoma closure. Resection, anastomosis and DLI had the highest chance of stoma reversal.

Does the timing of protective ileostomy closure post-low anterior resection have an impact on the outcome? A retrospective study

BACKGROUND

The optimal timing for ileostomy closure remains controversial, most of the surgeons are closing ileostomy after two to three months, although ileostomy closure considered a simple procedure, it can cause significant morbidity; this study aims to clarify any relation between the post-closure complications rate and the time from its creation to the repair.

METHOD

From January 2010 to December 2017, data retrieved for a 405 patients who had protective ileostomy closure after rectal cancer surgery, our sample has been enrolled into two arms, the first arm includes whose ileostomies closed at or before three months, and the second arm involved whose ileostomies closed after three months from the index surgery, statistical analysis was performed and compared in both arms, RESULT: The overall post-closure complications in our hospital was 23.7%, there was no significant difference between the overall complications rate for both early and late closure groups (26.8% and 22.7%) respectively (P = 0.499), The majority of the complications were intestinal obstruction, and superficial surgical site infection, there was no significant association between the interval to ileostomy reversal and the intestinal obstruction although it was higher in the late closure group, in the other hand the surgical site infection complication found to be significantly higher in the early closure group than the late closure group (15.4% Vs 5.1%) with (P = 0.002).

CONCLUSION

The duration between the creation of protective ileostomy and its reversal was not a significant independent predictor of post-closure complications rate.

The multidisciplinary management of rectal cancer

Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.

Risk Factors for Adverse Outcomes after Ostomy Reversal in Infants Less than Six Months Old

The purpose of this study was to determine risk factors for 30-day complications, reoperation, and readmission after ostomy reversal in infants less than six months old. Infants aged two weeks to six months who underwent ostomy reversal were identified in the 2012 to 2016 ACS NSQIP Pediatric database. Demographics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression was used to estimate the independent effects of clinical variables on risk of 30-day complications, reoperation, and readmission. Among 1021 infants, 163 (16%) suffered a 30-day complication. SSIs were the most common complication (5.7%), followed by unplanned reintubation (5.2%) and bleeding (3%). Mortality was 0.4 per cent. Dependence on nutritional support and hematologic disorders were independently associated with postoperative complications. Forty-five children (4.4%) required reoperation and 22 (2.2%) were readmitted for conditions related to the procedure. Younger age and preoperative dependence on oxygen or nutritional support were associated with increased length of stay. SSI, unplanned reintubation, and bleeding are the most frequent complications after ostomy takedown in infants less than six months old. Attention to risk factors predisposing to these complications, including dependence on nutritional support and hematologic disorders, may contribute to improved surgical outcomes.

Conventional Versus Minimally Invasive Hartmann Takedown: A Meta-analysis of the Literature

Although end colostomy closure following Hartmann's procedure is a major surgery that is traditionally performed by conventional celiotomy, over the last decade there has been a growing interest toward the application of different minimally invasive techniques. We aimed at evaluating the relative outcomes of conventional surgery versus minimally invasive surgery by meta-analyzing the available data from the medical literature. The PubMed/MEDLINE, Cochrane Library and EMBASE electronic databases were searched through August 2018. Inclusion criteria considered eligible all comparative studies evaluating open versus minimally invasive procedures. Conventional laparoscopy, robotic and single-port laparoscopy were considered as minimally invasive techniques. Overall morbidity, rate of anastomotic failure, rate of wound complications and mortality were evaluated as primary outcomes. Perioperative details and surgical outcomes were also assessed. The data of a total of 13,740 patients from 26 studies were eventually included in the analysis. There were no significant differences on baseline characteristics such as age, BMI and proportion of high-risk patients between the two groups of patients. As compared to the conventional technique, minimally invasive surgery proved significantly superior in terms of postoperative morbidity, length of hospital stay and rate of incisional hernia. The current literature suggests that minimally invasive surgery should be considered in performing Hartmann's reversal, if technically viable. However, due to the low level of the available evidence it is impossible to draw definitive conclusions.

The Role of Adjuvant Chemotherapy in ypT0N0 Rectal Adenocarcinoma

BACKGROUND

In patients who develop a complete pathologic response (ypT0N0) following neoadjuvant chemoradiation, the benefits of postoperative chemotherapy remain uncertain. This study aims to determine whether treatment with adjuvant chemotherapy in ypT0N0 patients affects short- and long-term outcomes.

METHODS

From January 2000 to December 2015, 992 patients at our institution underwent surgery for rectal adenocarcinoma following treatment with neoadjuvant chemoradiation. A complete pathologic response was noted in 96 (9.7%) patients. Adjuvant chemotherapy was administered to 60 (62.5%) patients. We reviewed clinical and pathological records and compared outcomes in ypT0N0 patients who received adjuvant chemotherapy to those who did not.

RESULTS

The mean age of patients who received adjuvant chemotherapy was 55.6 ± 11.5 years, compared to 62.1 ± 11.7 years for those who did not (p = 0.008). Among the two groups, mean follow-up time after surgery was 5.3 ± 4.1 years for the adjuvant group and 8.3 ± 5.5 years for the non-adjuvant cohort (p = 0.003). The 1, 3, and 5-year survival rates were 100.0%, 97.7%, and 92.1% for patients who received adjuvant chemotherapy and 97.2%, 94.1%, and 90.7% for those who did not (p = 0.382). In a subanalysis of patients with available follow-up information, we observed 3/53 (5.7%) disease recurrences in patients who received adjuvant chemotherapy, compared to 2/18 (11.1%) in those who were not treated postoperatively (p = 0.456).

CONCLUSION

In patients with ypT0N0 rectal adenocarcinoma, we found equivalent survival and recurrence outcomes. Further study will be necessary to determine the importance of adjuvant chemotherapy following ypT0N0 resection.

STROBE-anastomotic leakage after pull-through procedure for Hirschsprung disease

This study was undertaken to explore the causes, diagnosis, and treatment of anastomotic leakage after pull-through (PT) procedure for Hirschsprung disease (HD).A retrospective analysis of patients with anastomotic leakage after a PT procedure in the General Surgery Department of Beijing Children's Hospital from July 2013 to June 2016 was undertaken. The surgical characteristics, diagnosis, and treatment were retrospectively analyzed.Among the 213 patients who underwent PT procedures, 5 patients had a documented anastomotic leakage. The median age of these 5 patients at the time of the PT procedure was 6.8 years old, and this was higher than those without anastomotic leakage (1.7 years old). In all patients, rectal examination in the lithotomy position revealed an anastomotic dehiscence at the 6 o'clock position. The abdominal ultrasonography demonstrated retrorectal pneumatosis with or without an abscess in 4 patients. All patients were treated with ileostomies and anastomotic resuturing. The median delay to management was 4 days (range: 1-29 days). Four patients (4/5, 80%) were cured, and 1 (delay, 29 days) of these 4 patients developed postoperative ileus. The remaining patient (delay, 9 days) was required to undergo a repeat PT procedure. For the 4 cured patients, the median follow-up time was 20 months (range: 15-37 months), and these patients defecated 3 times daily at most without soiling.Older children with HD might be prone to anastomotic leakage. The findings of the rectal examination and ultrasonography were distinctive and useful for the diagnosis. Early ileostomy and resuturing of the anastomosis could be used to treat anastomotic leakage.

Variations of the renal function parameters in rectal cancer patients with a defunctioning loop ileostomy

PURPOSE

The objective of this study is to investigate the impact of the temporary loop ileostomy on renal function and also to assess the factors associated with the change in renal function observed between the index surgery (the moment of the radical surgical procedure) and the closure of the ileostomy (the moment of the secondary surgical act of suppression of the ileostomy).

METHODS

A total of 69 rectal cancer patients from a single referral surgical unit who had a loop ileostomy during low anterior resection of the rectum were included in this study. Serum creatinine levels were evaluated, and estimated glomerular filtration rate (eGFR) was calculated prior to index surgery and closure of the ileostomy.

RESULTS

During this time interval, there was a significant decrease in eGFR levels (mean difference - 4.5 mL/min/1.73 m², 95% CI - 7.8 to - 1.3 mL/min/1.73 m²), and also a significant increase in the serum creatinine values (mean difference 0.07, 95% CI 0.02-0.12 mg/dL). The eGFR decrease was more pronounced in diabetic patients, in those with a baseline Charlson Comorbidity Index score ≥ 1 or in those that received chemotherapy. In a multivariable regression analysis, the use of neoadjuvant chemotherapy was the only variable significantly associated with the change in eGFR levels between the two surgical interventions.

CONCLUSION

Renal function impairment is an important event that the surgeon has to take into consideration when deciding upon opting for a loop ileostomy to temporarily defunction a colorectal anastomosis.