Does an ileostomy cover the surgeon or the anastomosis?

Feasibility of triple assessment of the anastomosis using an anastomotic checklist

BACKGROUND

Colorectal cancer is the third most common cancer and the second highest cause of cancer mortality in Australia. Despite advances in colorectal surgery, anastomotic leak still occurs in low-risk patients and is a substantial cause of morbidity and mortality. Many operative strategies are used to assess anastomotic integrity such as an air leak test or intraoperative flexible sigmoidoscopy, however an objective anastomotic checklist is yet to be developed and studied. This study aims to develop a photodocumentary anastomotic specific checklist and determine its feasibility for implementation.

METHODS

Patients undergoing left sided colorectal resections with primary anastomosis without a de-functioning ileostomy were prospectively included between May 2021 and December 2022. A photographic checklist assessing anastomotic perfusion, integrity via either air test or endoscopic image, evidence of complete operative doughnut specimens and the assessment of tension was implemented. The feasibility of an anastomotic checklist was externally validated by four independent colorectal surgeons from Australia, New Zealand and United States of America.

RESULTS

The anastomotic checklist was completed in 44 patients. Mean age was 62 years, with 43% male and mean BMI 28. Operations included high anterior resection (45%), low anterior resection (18%), ultra-low anterior resection (20%), reversal of Hartmann's (11%). Median length of stay was 4 days. Complications post operatively were documented in six patients with anastomotic leak in 2% and wound infection in 6.8%. Intraclass correlation coefficients were poor amongst all reviewers with air leak and tension having no inter-reviewer correlation.

CONCLUSION

The introduction of an anastomotic checklist was a feasible tool to systematically assess and document anastomotic integrity. Unfortunately, with the small sample size there was significant discrepancy in inter-observer variability, and this led to poor correlation regarding which patients were typically high risk requiring a temporary ileostomy. Larger studies on the implementation of an anastomotic checklist will be needed to evaluate if it is an inherently feasible approach and if there is an effect on anastomotic leak.

Renal dysfunction occurs following ileostomy formation and is independent of readmission

BACKGROUND

Ileostomy formation may be permanent or intended as temporary to defunction a high-risk pelvic anastomosis to reduce the risk of septic consequences of anastomotic leak. However, these procedures have a high rate of readmission, most commonly due to dehydration and associated with acute kidney injury (AKI).

METHODS

A single centre retrospective cohort study of patients who underwent ileostomy formation from 2015 to 2020 and analysed in two groups: those who needed readmission within 60 days and those who did not. Data collected included demographics and renal function and electrolytes at baseline (ileostomy formation) and at elective ileostomy closure.

RESULTS

A total of 171 patients were included in the analysis, with a readmission rate 38% within 60 days of discharge. There was a significant increase in creatinine from baseline blood tests compared to date of elective ileostomy closure in both the readmission and no readmission arms. There was a significant decrease in eGFR from baseline blood tests compared with date of ileostomy closure in both readmission and no readmission arms. There was no significant difference in creatinine or eGFR between readmission and no readmission arms at date of ileostomy closure. Baseline serum sodium levels were lower in the readmission arm compared to no readmission arm.

CONCLUSION

Ileostomy formation is associated with a deterioration in renal function, which occurs independent of whether the patient requires readmission to hospital. Low serum sodium may be used as a predictor for patients with an increased risk of readmission.

Risk taking propensity: Nurse, surgeon and patient preferences for diverting ileostomy

AIM

The decision-making process to defunction a pelvic colorectal anastomosis involves complex heuristics and is framed by surgeon personality factors. Risk taking propensity may be an important factor in these decisions and patient preferences have not been evaluated alongside surgeons and nurses.

METHODS

A prospective cross-sectional study involving a one-off interview and questionnaire assessing how risk taking propensity affects nurse, surgeon and patient preferences for a temporary defunctioning ileostomy (TDI) was performed. The risk taking index (RTI) was employed to evaluate risk taking propensity and the validated prospective measures of preference instruments to evaluate preferences for stoma avoidance in several scenarios by asking the individual to consider trading or gambling years of remaining life expectancy.

RESULTS

One hundred and fifty participants met the inclusion criteria, which included 30 (20.0%) surgical nurses, 20 (13.3%) colorectal surgeons and 100 (66.7%) patients. Surgeons had a significantly higher RTI (mean ± SD: 26.8 ± 6.7) than patients (mean ± SD: 20.0 ± 9.8) and nurses (mean ± SD: 23.0 ± 6.6) p = 0.002. Surgeons would consider that it would be in a patient's best interest to have a TDI at an AL rate of 15% or greater, whereas nurses and patients would do so at 28% and 25%, respectively (p = 0.007).

CONCLUSION

Surgeons were shown to have a higher risk taking propensity than patients and nurses but a significantly lower threshold of AL where they would consider a TDI is in the best interest of the patient.