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Yang S, Lin Y, Zhong W, Xu W, Huang Z, Cai S, Chen W, Zhang B. Impact of ileostomy on postoperative wound complications in patients after laparoscopic rectal cancer surgery: A meta-analysis. Int Wound J 2023; 21:e14493. [PMID: 37989718 PMCID: PMC10898402 DOI: 10.1111/iwj.14493] [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: 10/17/2023] [Revised: 10/25/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023] Open
Abstract
To prevent anastomotic leakage and other postoperative complications after laparoscopic rectal cancer surgery, a protective ileostomy is often used. However, the necessity of performing ileostomy after laparoscopic rectal cancer remains controversial. The aim of this meta-analysis was to assess the benefit of ileostomy on wound infection after laparoscopic rectal cancer. The Cochrane Library, EMBASE, Web of Science, and PubMed were used to retrieve all related documents up to September 2023. Completion of the trial literature was submitted once the eligibility and exclusion criteria were met and the literature quality assessment was evaluated. This study compared the post-operative post-operative complications of an ileostomy with that of non-ileostomy in a laparoscope. We used Reman 5.3 to analyse meta-data. Controlled studies were evaluated with ROBINS-I. The meta-analyses included 525 studies, and 5 publications were chosen to statistically analyse the data according to the classification criteria. There was no statistically significant difference in the rate of postoperative wound infections among ostomate and nonostomate (odds ratio [OR], 1.79; 95% confidence interval [CI], 0.66, 4.84; p = 0.25). In 5 trials, the incidence of anastomotic leak was increased after surgery in nonostomate patients (OR, 0.26; 95% CI, 0.12, 0.57; p = 0.0009). Two studies reported no significant difference in the length of operation time when nonstomal compared to stomal operations in patients with rectal cancer (mean difference, 0.87; 95% CI, -2.99, 4.74; p = 0.66). No significant difference was found in the rate of wound infection and operation time after operation among the two groups, but the incidence of anastomosis leak increased after operation. Protective ileostomy after laparoscopic rectal cancer was effective in reducing the risk of anastomotic leakage in patients, and we found no additional risk of infection. We cautiously conclude that protective ileostomy is active and necessary for patients with a high risk of anastomotic leakage after surgery, which needs to be further confirmed by high-quality studies with larger samples.
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Affiliation(s)
- Shu Yang
- Department of Traditional Chinese Medicine, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yuting Lin
- Department of Traditional Chinese Medicine, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Wenjin Zhong
- Department of Clinical Laboratory, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Wenji Xu
- Department of Gastroenterology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Zhongxin Huang
- Department of Pathology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Suqin Cai
- Department of Pathology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Wen Chen
- Department of Traditional Chinese Medicine, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Baogen Zhang
- Department of Traditional Chinese Medicine, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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Zenger S, Gurbuz B, Can U, Balik E, Yalti T, Bugra D. Comparative study between ghost ileostomy and defunctioning ileostomy in terms of morbidity and cost-effectiveness in low anterior resection for rectal cancer. Langenbecks Arch Surg 2021; 406:339-347. [PMID: 33537875 DOI: 10.1007/s00423-021-02089-w] [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] [Received: 10/13/2020] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE The aim of this study was to compare ghost ileostomy (GI) and defunctioning ileostomy (DI) in patients who underwent low anterior resection (LAR) for rectal cancer in terms of postoperative morbidity, rehospitalization rates, and total costs. METHODS Patients with an anastomosis level between 5 and 10 cm from the anal verge after LAR were analyzed retrospectively. Clinical characteristics, operative outcomes, postoperative morbidity, rehospitalization rates, and total costs were compared. RESULTS A total of 123 patients were enrolled as follows: 42 patients in the GI group and 81 patients in the DI group. Anastomotic leakage (AL) was identified in three patients who underwent GI, and in all of them, GI was easily converted to DI. There were 96.3% of the patients with DI rehospitalized at least one time because of surgery-related and/or stoma-related complications or stoma closure. When we did not take into account the patients who were rehospitalized for stoma closure, the rates of rehospitalization were 4.7% and 22.2% in the GI and DI groups, respectively (P= 0.01). The mean total costs calculated by removing additional surgical procedures and adding all of the rehospitalization costs were 25,767 USD and 41,875 USD in the GI and DI groups, respectively (P= 0.0001). CONCLUSION GI may be a safe and cost-effective method in patients who underwent LAR with low or medium risk factors for AL. It is possible to avoid unnecessary ileostomy and reduce unwanted outcomes due to it, such as postoperative complications, rehospitalizations, and increased total costs by performing GI.
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Affiliation(s)
- Serkan Zenger
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey.
| | - Bulent Gurbuz
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey
| | - Ugur Can
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey
| | - Emre Balik
- Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey
| | - Tunc Yalti
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey.,Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey
| | - Dursun Bugra
- Department of General Surgery, VKF American Hospital, Guzelbahce Street, No:20, Sisli, Istanbul, Turkey.,Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey
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Zenger S, Gurbuz B, Can U, Bilgic C, Sobutay E, Balik E, Yalti T, Bugra D. Is Ghost Ileostomy an Effective Method in Various Indications for Colorectal Surgery? Indian J Surg 2021. [DOI: 10.1007/s12262-020-02334-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Baloyiannis I, Perivoliotis K, Diamantis A, Tzovaras G. Virtual ileostomy in elective colorectal surgery: a systematic review of the literature. Tech Coloproctol 2019; 24:23-31. [PMID: 31820192 DOI: 10.1007/s10151-019-02127-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 11/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic leak (AL) following colorectal surgery can be a life-threatening complication. The use of a diverting stoma has been proposed, to prevent or reduce morbidity and mortality associated with AL. Stomas, however, have their own distinct complications. Thus, virtual ileostomy (VI) has been proposed as an alternative to diverting stoma. The aim of the present study was to further evaluate the role of VI through systematic review of existing literature. METHODS A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane handbook for systematic reviews of interventions. The primary endpoint of our study was the estimation of the overall VI complication rate. Secondary endpoints included the identification of the VI-specific adverse outcomes, perioperative endpoints such as the length of hospital stay, transfusion and postoperative leak rates, description of the operative variations of VI reported VI operative variations and details regarding the primary operation and previous neoadjuvant therapy. RESULTS In total, 11 studies and 554 patients were included in this systematic review. Overall, 158 laparoscopic and 191 open procedures were performed. The AL and VI conversion rates were 11.9% and 10.46%, respectively. The total complication rate was estimated to be 13.9%, while VI-specific adverse events were recorded in 2.1% of all cases. CONCLUSIONS VI could be a safe and effective alternative to a diverting stoma. Although currently, VI is not widely used, it could have a widespread application in laparoscopic surgery. However, definitive trials are needed before firm recommendations on the use of VI can be made.
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Affiliation(s)
- I Baloyiannis
- Department of Surgery, University Hospital of Larissa, Biopolis, Mezourlo, 41110, Larissa, Greece.
| | - K Perivoliotis
- Department of Surgery, University Hospital of Larissa, Biopolis, Mezourlo, 41110, Larissa, Greece
| | - A Diamantis
- Department of Surgery, University Hospital of Larissa, Biopolis, Mezourlo, 41110, Larissa, Greece
| | - G Tzovaras
- Department of Surgery, University Hospital of Larissa, Biopolis, Mezourlo, 41110, Larissa, Greece
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Xynos E, Tekkis P, Gouvas N, Vini L, Chrysou E, Tzardi M, Vassiliou V, Boukovinas I, Agalianos C, Androulakis N, Athanasiadis A, Christodoulou C, Dervenis C, Emmanouilidis C, Georgiou P, Katopodi O, Kountourakis P, Makatsoris T, Papakostas P, Papamichael D, Pechlivanides G, Pentheroudakis G, Pilpilidis I, Sgouros J, Triantopoulou C, Xynogalos S, Karachaliou N, Ziras N, Zoras O, Souglakos J. Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO). Ann Gastroenterol 2016; 29:103-26. [PMID: 27064746 PMCID: PMC4805730 DOI: 10.20524/aog.2016.0003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.
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Affiliation(s)
- Evaghelos Xynos
- General Surgery, InterClinic Hospital of Heraklion, Greece (Evangelos Xynos)
| | - Paris Tekkis
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Nikolaos Gouvas
- General Surgery, Metropolitan Hospital of Piraeus, Greece (Nikolaos Gouvas)
| | - Louiza Vini
- Radiation Oncology, Iatriko Center of Athens, Greece (Louza Vini)
| | - Evangelia Chrysou
- Radiology, University Hospital of Heraklion, Greece (Evangelia Chrysou)
| | - Maria Tzardi
- Pathology, University Hospital of Heraklion, Greece (Maria Tzardi)
| | - Vassilis Vassiliou
- Radiation Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Vassilis Vassiliou)
| | - Ioannis Boukovinas
- Medical Oncology, Bioclinic of Thessaloniki, Greece (Ioannis Boukovinas)
| | - Christos Agalianos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | - Nikolaos Androulakis
- Medical Oncology, Venizeleion Hospital of Heraklion, Greece (Nikolaos Androulakis)
| | | | | | - Christos Dervenis
- General Surgery, Konstantopouleio Hospital of Athens, Greece (Christos Dervenis)
| | - Christos Emmanouilidis
- Medical Oncology, Interbalkan Medical Center, Thessaloniki, Greece (Christos Emmanouilidis)
| | - Panagiotis Georgiou
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Ourania Katopodi
- Medical Oncology, Iaso General Hospital, Athens, Greece (Ourania Katopodi)
| | - Panteleimon Kountourakis
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - Thomas Makatsoris
- Medical Oncology, University Hospital of Patras, Greece (Thomas Makatsoris)
| | - Pavlos Papakostas
- Medical Oncology, Ippokrateion Hospital of Athens, Greece (Pavlos Papakostas)
| | - Demetris Papamichael
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - George Pechlivanides
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | | | - Ioannis Pilpilidis
- Gastroenterology, Theageneion Cancer Hospital, Thessaloniki, Greece (Ioannis Pilpilidis)
| | - Joseph Sgouros
- Medical Oncology, Agioi Anargyroi Hospital of Athens, Greece (Joseph Sgouros)
| | | | - Spyridon Xynogalos
- Medical Oncology, George Gennimatas General Hospital, Athens, Greece (Spyridon Xynogalos)
| | - Niki Karachaliou
- Medical Oncology, Dexeus University Institute, Barcelona, Spain (Niki Karachaliou)
| | - Nikolaos Ziras
- Medical Oncology, Metaxas Cancer Hospital, Piraeus, Greece (Nikolaos Ziras)
| | - Odysseas Zoras
- General Surgery, University Hospital of Heraklion, Greece (Odysseas Zoras)
| | - John Souglakos
- Medical Oncology, University Hospital of Heraklion, Greece (John Souglakos)
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Musters GD, Atema JJ, van Westreenen HL, Buskens CJ, Bemelman WA, Tanis PJ. Ileostomy closure by colorectal surgeons results in less major morbidity: results from an institutional change in practice and awareness. Int J Colorectal Dis 2016; 31:661-7. [PMID: 26732261 PMCID: PMC4773497 DOI: 10.1007/s00384-015-2478-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Previous institutional analysis of ileostomy closure revealed substantial morbidity. This subsequent study aimed at determining if a change in clinical practice resulted in reduced complication rates. METHODS Between June 2004 and January 2014, all consecutive adult patients undergoing ileostomy closure were retrospectively identified. Postoperative outcome after change in clinical practice consisting of routine participation of a colorectal surgeon, stapled side-to-side anastomosis and increased clinical awareness (cohort B) was compared with our previously published historical control group (cohort A). The primary outcome was major morbidity, defined as Clavien-Dindo grade three or higher. Independent risk factors of major morbidity were identified using multivariable analysis. RESULTS In total, 165 patients underwent ileostomy closure in cohort A, and 144 patients in cohort B. At baseline, more primary diverting ileostomies were present in cohort A (94 vs. 82%; p = 0.001) with a similar rate of loop and end-ileostomy between the two cohorts (p = 0.331). A significant increase in colorectal surgeon participation (89 vs. 53%; p < 0.001) and stapled side-to-side anastomosis was observed (63 vs. 16%; p < 0.001). The major morbidity rate was 11% in cohort A, which significantly reduced to 4% in cohort B (p = 0.03). Surgery being performed or supervised by a colorectal surgeon (odds ratio [OR] 0.28, 95% CI 0.11-0.67) and loop-ileostomy compared to end-ileostomy (OR 0.18, 95% CI 0.07-0.52) were independently associated with lower major morbidity. CONCLUSION Ileostomy closure appears to be more complex surgery then generally considered, especially end-ileostomy closure. Postoperative outcome could be significantly improved by a change in surgical practice.
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Affiliation(s)
- G. D. Musters
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - J. J. Atema
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
| | | | - C. J. Buskens
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - W. A. Bemelman
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - P. J. Tanis
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
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D'Hoore A, Albert MR, Cohen SM, Herbst F, Matter I, Van Der Speeten K, Dominguez J, Rutten H, Muldoon JP, Bardakcioglu O, Senagore AJ, Ruppert R, Mills S, Stamos MJ, Påhlman L, Choman E, Wexner SD. COMPRES: a prospective postmarketing evaluation of the compression anastomosis ring CAR 27(™) /ColonRing(™). Colorectal Dis 2015; 17:522-9. [PMID: 25537083 DOI: 10.1111/codi.12884] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 11/11/2014] [Indexed: 02/08/2023]
Abstract
AIM Preclinical studies have suggested that nitinol-based compression anastomosis might be a viable solution to anastomotic leak following low anterior resection. A prospective multicentre open label study was therefore designed to evaluate the performance of the ColonRing(™) in (low) colorectal anastomosis. METHOD The primary outcome measure was anastomotic leakage. Patients were recruited at 13 different colorectal surgical units in Europe, the United States and Israel. Institutional review board approval was obtained. RESULTS Between 21 March 2010 and 3 August 2011, 266 patients completed the study protocol. The overall anastomotic leakage rate was 5.3% for all anastomoses, including a rate of 3.1% for low anastomoses. Septic anastomotic complications occurred in 8.3% of all anastomoses and 8.2% of low anastomoses. CONCLUSION Nitinol compression anastomosis is safe, effective and easy to use and may offer an advantage for low colorectal anastomosis. A prospective randomized trial comparing ColonRing(™) with conventional stapling is needed.
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Affiliation(s)
- A D'Hoore
- Department of Abdominal Surgery, University Hospital Gasthuisberg Leuven, Leuven, Belgium
| | - M R Albert
- Center for Colon and Rectal Surgery, Altamonte Springs and Florida Hospital, Orlando, Florida, USA
| | - S M Cohen
- Southern Regional Medical Center, Spivey Station Surgery Center, Emory Healthcare, Atlanta, Georgia, USA
| | - F Herbst
- Abteilung für Chirurgie, Barmherzige Brueder, Krankenhaus Wien, Vienna, Austria
| | - I Matter
- Bnai Zion Medical Center, Haifa, Israel
| | | | - J Dominguez
- Department of Colorectal Surgery, Ferrell-Duncan Clinic, Springfield, Missouri, USA
| | - H Rutten
- Catharina Ziekenhuis, Eindhoven, Netherlands
| | - J P Muldoon
- Section of Colon and Rectal Surgery, NorthShore University Healthsystem and University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - O Bardakcioglu
- Department of Surgery, University of Nevada School of Medicine, Las Vegas, Nevada, USA
| | - A J Senagore
- Department of General Surgery, CMU College of Medicine, Saginaw, Missouri, USA
| | - R Ruppert
- Klinikum Neuperlach, Department of Coloproctology, Munich, Germany
| | - S Mills
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, Irvine, Orange, California, USA
| | - M J Stamos
- Department of Surgery, University of California, Irvine, Orange, California, USA
| | - L Påhlman
- Deparment of Surgical Science, Uppsala University, Uppsala, Sweden
| | | | - S D Wexner
- Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Mari FS, Di Cesare T, Novi L, Gasparrini M, Berardi G, Laracca GG, Liverani A, Brescia A. Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial. Surg Endosc 2014; 29:2590-7. [PMID: 25475516 DOI: 10.1007/s00464-014-3974-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 10/28/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anastomotic leakage following anterior rectal resection is the most important and most commonly faced complication of laparoscopy and open surgery. To prevent this complication, the construction of a preventing stoma is usually adopted. It is not easy to decide whether to construct a protective stoma in patients with a medium risk of anastomotic leakage. In these patients, ghost ileostomy (GI), a pre-stage ileostomy that can be externalized and opened if needed, has proved useful. We conducted a prospective, randomized, controlled study to evaluate the advantages of GI in laparoscopic rectal resection. METHODS All patients with surgical indications for laparoscopic rectal resection who were at medium risk for anastomotic leakage from January 2007 to January 2013 were included and were randomly divided in 2 groups. All of the patients were subjected to laparoscopic anterior rectal resection with the performance of GI (group A) or without the construction of any protective stoma (group B). The presence and severity of clinically evident postoperative anastomotic leakage and other postoperative complications and reinterventions were investigated. RESULTS Of the 55 patients allocated to group A, 3 experienced anastomotic leakage compared with 4 in group B. The patients with GI experienced a lower severity of anastomotic leakage and shorter hospitalization compared with the patients in group B. None of the patients with GI and anastomotic leakage required laparotomy to treat the dehiscence. CONCLUSIONS The use of GI in laparoscopic rectal resections in patients at medium risk for anastomotic leakage was useful because it allowed for the avoidance of stoma creation in all of the patients, thus reducing the number of stomas performed, improving the quality of life of the patients and preserving, in most cases, the benefits gained by laparoscopy.
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Affiliation(s)
- Francesco Saverio Mari
- Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea Hospital, School of Medicine and Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Via di Grottarossa 1035, 00189, Rome, Italy,
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10
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Do older Americans undergo stoma reversal following low anterior resection for rectal cancer? J Surg Res 2012; 183:238-45. [PMID: 23298948 DOI: 10.1016/j.jss.2012.11.057] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/21/2012] [Accepted: 11/30/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE For low-lying rectal cancers, proximal diversion can reduce anastomotic leak after sphincter-preserving surgery; however, evidence suggests that such temporary diversions are often not reversed. We aimed to evaluate nonreversal and delayed stoma reversal in elderly patients undergoing low anterior resection (LAR). DESIGN SEER-Medicare-linked analysis from 1991-2007. SETTINGS AND PARTICIPANTS A total of 1179 primary stage I-III rectal cancer patients over age 66 who underwent LAR with synchronous diverting stoma. MAIN OUTCOME MEASURES (1) Stoma creation and reversal rates; (2) time to reversal; (3) characteristics associated with reversal and shorter time to reversal. RESULTS Within 18 mo of LAR, 51% of patients (603/1179) underwent stoma reversal. Stoma reversal was associated with age <80 y (P < 0.0001), male sex (P = 0.018), fewer comorbidities (P = 0.017), higher income (quartile 4 versus 1; P = 0.002), early tumor stage (1 versus 3; P < 0.001), neoadjuvant radiation (P < 0.0001), rectal tumor location (versus rectosigmoid; P = 0.001), more recent diagnosis (P = 0.021), and shorter length of stay on LAR admission (P = 0.021). Median time to reversal was 126 d (interquartile range: 79-249). Longer time to reversal was associated with older age (P = 0.031), presence of comorbidities (P = 0.014), more advanced tumor stage (P = 0.007), positive lymph nodes (P = 0.009), receipt of adjuvant radiation therapy (P = 0.008), more recent diagnosis (P = 0.004), and longer length of stay on LAR admission (P < 0.0001). CONCLUSIONS Half of elderly rectal cancer patients who undergo LAR with temporary stoma have not undergone stoma reversal by 18 mo. Identifiable risk factors predict both nonreversal and longer time to reversal. These results help inform preoperative discussions and promote realistic expectations for elderly rectal cancer patients.
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11
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Penninckx F, Beirens K, Fieuws S, Ceelen W, Demetter P, Haustermans K, Van de Stadt J, Vindevoghel K. Risk adjusted benchmarking of clinical anastomotic leakage rate after total mesorectal excision in the context of an improvement project. Colorectal Dis 2012; 14:e413-21. [PMID: 22321047 DOI: 10.1111/j.1463-1318.2012.02977.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Anastomotic leakage (AL) after total mesorectal excision (TME) is a major adverse event. This study evaluates variability in AL between centres participating on a voluntary basis in PROCARE, a Belgian improvement project, and how further improvement of the AL rate might be achieved. METHOD Between January 2006 and March 2011, detailed data on 1815 patients (mean age 65.5 years, 63% male) who underwent elective TME with colo-anal reconstruction for rectal cancer were registered by 48 centres. Variability in early clinical AL rate was analysed before and after adjustment for gender, age > 60 years, American Society of Anesthesiologists score of 3 or more and body mass index > 25 kg/m(2). RESULTS The overall AL rate was 6.7% (95% CI 5.6%-7.9%). Early AL required reoperation in 86.8% of patients. It increased length of hospital stay from 14.7 days to 32.4 days and in-hospital mortality from 1.1% to 4.8%. Statistically significant variability in AL rate between centres was not observed, either before or after risk adjustment. Nonetheless, further improvement may be achievable in some centres by targeting the adjusted performance of better performing centres. These centres used neoadjuvant treatment, rectal irrigation, mobilization of the splenic flexure, resection of the sigmoid colon, side-to-end colo-anastomosis with or without pouch and defunctioning stoma at primary surgery in a significantly higher proportion of patients than less well performing centres. CONCLUSION The overall AL rate was low but needs to be interpreted with caution because of incomplete registration. Further improvement might be achieved by adopting the approach of better performing centres.
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Affiliation(s)
- F Penninckx
- PROCARE p/a Foundation Belgian Cancer Registry, Brussels, Belgium.
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12
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Ludwig K, Kosinski L. How low is low? Evolving approaches to sphincter-sparing resection techniques. Semin Radiat Oncol 2011; 21:185-95. [PMID: 21645863 DOI: 10.1016/j.semradonc.2011.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Although advances in rectal cancer staging may ultimately be accurate enough to reliably exclude disease outside the rectal wall (thereby allowing local approaches to be more widely and safely applied) and advances in the use of neoadjuvant chemo- and radiation therapy may ultimately produce more "complete responders" that can be accurately identified and spared surgery altogether, as it stands, radical resection forms the basis of curative treatment for rectal cancer. However, the concepts that guide the surgeon in choosing the optimal approach in radical resection are changing. In the past, the decision as to how to proceed surgically with radical resection was based primarily on the level of the tumor above the anal verge or anorectal ring. The issue was primarily "How low is the tumor?" and "Is the distal margin safe?" A more modern approach focuses attention on achieving a negative circumferential margin despite what historically may seem to be a very minimal distal margin, the current issue is not "How low is the tumor?" so much as it is "How deep does the tumor go?". This shift in focus has been a major impetus in the evolution of sphincter sparing resection techniques.
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Affiliation(s)
- Kirk Ludwig
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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D’Haeninck A, Wolthuis A, Penninckx F, D’Hondt M, D’Hoore A. Morbidity after closure of a defunctioning loop ileostomy. Acta Chir Belg 2011; 111:136-41. [PMID: 21780519 DOI: 10.1080/00015458.2011.11680724] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE A low pelvic anastomosis is associated with a substantial risk of leakage. A defunctioning stoma (DS) reduces the clinical anastomotic leak rate and the need for re-operation, but stoma closure has its own risk of morbidity and mortality. This study aims to audit morbidity and mortality after loop ileostomy (LI) closure. PATIENTS AND METHODS The medical records of 197 consecutive patients who underwent closure of a defunctioning LI between August 2003 and July 2008 were reviewed. Postoperative morbidity and mortality were recorded. RESULTS Transverse closure of the enterotomy was performed in 149 patients (75.6%), segmental enterectomy with hand-sewn end-to-end anastomosis in 26 (13.2%) and stapled side-to-side anastomosis in 22 (11.2%). Overall postoperative morbidity and mortality were 32.0% and 0.5%, respectively. The surgical complication rate was 30.5%, including prolonged ileus (11.2%), small bowel obstruction (4.1%), anastomotic leak (3.0%) and wound infection (4.6%). Surgical complications were more frequent in male patients (p = 0.005). Prolonged ileus was more frequent when the interval to stoma reversal exceeded 12 weeks (14.3% versus 3.5% ; p = 0.02). The incidence of complications was not influenced by the closure technique. Nineteen patients (9.6%) required re-operation for anastomotic leak (n = 8), wound infection (n = 1), small bowel obstruction (n = 3) and incisional herniation (n = 7). CONCLUSION LI closure is associated with clinically relevant morbidity and mortality. This association should be taken into account in the context of a routine DS policy and should be part of the patient's information.
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Affiliation(s)
- A. D’Haeninck
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - A.M. Wolthuis
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - F. Penninckx
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - M. D’Hondt
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - A. D’Hoore
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
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Ghost ileostomy after anterior resection for rectal cancer: a preliminary experience. Langenbecks Arch Surg 2011; 396:997-1007. [PMID: 21479620 DOI: 10.1007/s00423-011-0793-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Accepted: 03/21/2011] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this study was to describe and evaluate the feasibility and the eventual advantages of ghost ileostomy (GI) versus covering stoma (CS) in terms of complications, hospital stay and quality of life of patients and their caregivers after anterior resection for rectal cancer. METHODS In this prospective study, we included patients who had rectal cancer treated with laparotomic anterior resection and confectioning a stoma (GI or CS), in the period comprised between January 2008 and January 2009. Short-term and long-term surgery-related mortality and morbidity after primary surgery (including that stoma-related and colorectal anastomosis-related) and consequent to the intervention of intestinal recanalization (CS group) and GI closure were evaluated. We evaluated hospital stay and quality of life of patients and their caregivers. RESULTS Stoma-related morbidity rate was higher in the CS group than in GI group (37% vs. 5.5%, respectively, P = 0.04). Morbidity rate after intestinal recanalization in the CS group was 25.9% and 0% after GI closure (P = 0.08). Overall stoma morbidity rate was significantly lower in the GI group with respect to CS group (5.5% vs. 40.7%, respectively, P = 0.03). CS group was characterized by a significantly longer recovery time (P = 0.0002). Caregivers and stoma-related quality of life were better in the GI group than in CS group (P < 0.0001 and P = 0.0005, respectively). CONCLUSIONS GI is feasible, characterized by shorter recovery, lesser degree of total, as well as anastomosis-related morbidity and higher quality of life of patients and the caregivers in respect to CS. We suggest that GI (should be evaluated as an alternative to conventional ileostomy) could be indicated in selected patients that do not present risk factors, but require caution for anastomotic leakage for the low level of colorectal anastomosis.
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Penninckx F. Anastomotic leakage: a disaster or a challenge with an impact on survival after rectal cancer surgery? Colorectal Dis 2011; 13:237-8. [PMID: 21320269 DOI: 10.1111/j.1463-1318.2011.02563.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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