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Blanco Terés L, Cerdán Santacruz C, Correa Bonito A, Delgado Búrdalo L, Rodríguez Sánchez A, Bermejo Marcos E, García Septiem J, Martín Pérez E. Early diverting stoma closure is feasible and safe: results from a before-and-after study on the implementation of an early closure protocol at a tertiary referral center. Tech Coloproctol 2024; 28:32. [PMID: 38349559 DOI: 10.1007/s10151-023-02905-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/18/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Evidence on early closure (EC) of defunctioning stoma (DS) after colorectal surgery shows a favorable effect when patients are carefully selected. Therefore, a clinical pathway adapted to the implementation of an EC strategy was developed in our center. The aim of this study was to carry out a comparative analysis of time until DS closure and DS-related morbidity before and after the implementation of an EC protocol (ECP). METHODS This study is a before-and-after comparative analysis. Patients were divided into two cohorts according to the observational period: patients from the period before the ECP implementation (January 2015-December 2019) [Period 1] and those from the period after that (January 2020-December 2022) [Period 2]. All consecutive patients subjected to elective DS closure within both periods were eligible. Early closure was defined as the reversal within 30 days from DS creation. Patients excluded from EC or those not closed within 30 days since primary surgery were analyzed as late closure (LC). Baseline characteristics and DS-related morbidity were recorded. RESULTS A total of 145 patients were analyzed. Median time with DS was shorter in patients after ECP implementation [42 (21-193) days versus 233 (137-382) days, p < 0.001]. This reduction in time to closure did not impact the DS closure morbidity and resulted in less DS morbidity (68.8% versus 49.2%, p = 0.017) and fewer stoma nurse visits (p = 0.029). CONCLUSIONS The ECP was able to significantly reduce intervals to restoration of bowel continuity in patients with DS, which in turn resulted in a direct impact on the reduction of DS morbidity without negatively affecting DS closure morbidity.
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Affiliation(s)
- L Blanco Terés
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.
| | - C Cerdán Santacruz
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - A Correa Bonito
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - L Delgado Búrdalo
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - A Rodríguez Sánchez
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - E Bermejo Marcos
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - J García Septiem
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - E Martín Pérez
- General Surgery Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
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Zamaray B, Veld JV, Brohet R, Consten EC, Tanis PJ, van Westreenen HL. Timing of restoration of bowel continuity after decompressing stoma, in left-sided obstructive colon cancer: a nationwide retrospective cohort. Int J Surg 2024; 110:864-872. [PMID: 37916947 PMCID: PMC10871576 DOI: 10.1097/js9.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/22/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND With the increasing use of decompressing stoma as a bridge to surgery for left-sided obstructive colon cancer (LSOCC), the timing of restoration of bowel continuity (ROBC) is a subject of debate. There is a lack of data on immediate ROBC during elective resection as an alternative for a 3-stage procedure. This study analysed if immediate ROBC during tumour resection is safe and of any benefit for patients who underwent decompressing stoma for LSOCC. METHODS In a Dutch nationwide collaborative research project, 3153 patients who underwent resection for LSOCC in 75 hospitals (2009-2016) were identified. Extensive data on disease and procedural characteristics, and outcomes was collected by local collaborators. For this analysis, 332 patients who underwent decompressing stoma followed by curative resection were selected. Immediate ROBC during tumour resection was compared to two no immediate ROBC groups, (1) tumour resection with primary anastomosis (PA) with leaving the decompressing stoma in situ, and (2) tumour resection without PA. RESULTS Immediate ROBC was performed in 113 patients (34.0%) and no immediate ROBC in 219 patients [168 with PA (50.6%) and 51 patients without PA (15.4%)]. No differences at baseline between the groups were found for age, ASA score, cT, and cM. Major surgical complications (8.8% immediate ROBC vs. 4.8% PA with decompressing stoma and 7.8% no PA; P =0.37) and mortality (2.7% vs. 2.4% and 0%, respectively; P =0.52) were similar. Immediate ROBC resulted in a shorter time with a stoma (mean 41 vs. 240 and 314 days, respectively; P <0.001), and fewer permanent stomas (7% vs. 21% and 80%, respectively; P <0.001) as compared to PA with a decompressing stoma or no PA. CONCLUSION After a decompressing stoma for LSOCC, immediate ROBC during elective resection appears safe, reduces the total time with a stoma and the risk of a permanent stoma.
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Affiliation(s)
- Bobby Zamaray
- Department of Surgery, Isala Hospital, Zwolle
- Department of Surgery, University Medical Centre Groningen, Groningen
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam
| | - Joyce V. Veld
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam
| | | | - Esther C.J. Consten
- Department of Surgery, University Medical Centre Groningen, Groningen
- Department of Surgery, Meander hospital, Amersfoort
| | - Pieter J. Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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Chau TCY, Nguyen H, Robertson IK, Harvey X, Tan B, Tan M, Yang CM. Factors affecting timing of loop ileostomy closure: a regional centre's experience with 106 patients. ANZ J Surg 2024; 94:193-198. [PMID: 37876156 DOI: 10.1111/ans.18729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 09/15/2023] [Accepted: 10/01/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION The burden of defunctioning ileostomy is significant with up to two thirds of patients reporting stoma-related morbidity. While timely reversal is safe and cost-effective, the time to reversal in regional Australian hospitals is not well described in professional publications. We aim to assess the current timeliness of ileostomy closure and identify possible reasons for delaying closure. METHODS A retrospective analysis of loop ileostomies created and reversed in Launceston General Hospital for both rectal cancer surgery and other benign indications was undertaken. Patients with loop ileostomy created between 2010 and 2020 were included. Clinical data of timing of events, complications, readmission and stoma follow-up were recorded; and analysed using multivariate regression analyses to identify clinically relevant risk factors for delayed closure. RESULTS A total of 123 patients underwent loop-ileostomy formation during the study period, of which 106 patients (86.2%) were reversed. Median time to closure was 8.5 months (IQR 5.2-12.4) for patients with rectal cancers, compared to 5.2 months (IQR 3.6-9.3) for patients who did not have rectal cancer, with a difference of 3.4 months (95% CI 0.9, 5.9; P = 0.008). Adjuvant chemotherapy and unexpected readmission to hospital were associated with delayed reversal (P = 0.0081 and P = 0.0005, respectively). CONCLUSION Stoma reversal is often scheduled 3-6 months after creation. More than two-thirds of patients experienced delays due to changing clinical concerns and non-clinical factors, such as unexpected delays at each stage of surgical planning. Early placement on the waiting list and better-coordinated follow-ups may expedite reversal surgery and reduce associated morbidities.
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Affiliation(s)
- Tedman Cheuk-Yiu Chau
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Hung Nguyen
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Iain K Robertson
- School of Health Sciences, University of Tasmania, Hobart, Tasmania, Australia
| | - Xavier Harvey
- Department of General Surgery, St John of God Bunbury Hospital, Bunbury, Australia
| | - Brendan Tan
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Mitchell Tan
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Caroline M Yang
- Department of General Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
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Batistotti P, Montale A, Bruzzone M, Amato A, Binda GA. Protective ileostomy after low anterior resection for extraperitoneal rectal cancer: does the reversal surgery timing affect closure failure? Updates Surg 2023; 75:1811-1818. [PMID: 37428410 DOI: 10.1007/s13304-023-01573-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/22/2023] [Indexed: 07/11/2023]
Abstract
Loop ileostomy is commonly performed after LAR with TME to temporarily protect the anastomosis. Usually, defunctioning stoma is closed after 1-6 months, although sometimes it becomes definitive de facto. The aim of this study is to investigate the long-term risk of no-reversal of protective ileostomy after LAR for middle-low rectal cancer and the predictive risk factors. A retrospective analysis of a consecutive cohort of patients who underwent curative LAR with covering ileostomy for extraperitoneal rectal cancer in two colorectal units was performed. A different policy for scheduling stoma closure was applied between centers. All the data were collected through an electronic database (Microsoft Excel®). Descriptive statistical analysis was performed using Fisher's exact and Student's t test. Multivariate logistic regression analysis was conducted. Two-hundred twenty-two patients were analysed: reversal procedure was carried out in 193 patients, in 29 cases stoma was never closed. The mean interval time from index surgery was 4.9 months (Center1: 3 vs. Center2: 7.8). At the univariate analysis, mean age and tumor stage were significantly higher in the "no-reversal" group. Unclosed ostomies were significantly lower in Center 1 than Center 2 (8% vs. 19.6%). At the multivariate analysis female gender, anastomotic leakage and Center 2 had significant higher risk of unclosed ileostomy. Currently, no clinical recommendations have been established and the policy of scheduling stoma reversal is variable. Our study suggests that an established protocol could avoid closure delay, decreasing permanent stomas. Consequently, ileostomy closure should be weighed as standardized step in cancer therapeutic pathway.
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Affiliation(s)
- P Batistotti
- General Surgical Department, Ospedale Di Imperia, Via Sant'Agata 57, 18100, Imperia, Italy.
| | - A Montale
- Department of Gastroenterology and Digestive Endoscopy, E. O. Ospedali Galliera, Mura Delle Cappuccine 14, 16128, Genoa, Italy
| | - M Bruzzone
- Clinical Epidemiology Unit, IRCCS Ospedale San Martino, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - A Amato
- General Surgical Department, Ospedale Di Imperia, Via Sant'Agata 57, 18100, Imperia, Italy
| | - G A Binda
- General Surgery, Biomedical Institute, Genoa, Italy
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Calderillo-Ruíz G, López-Basave HN, Muñoz-Montaño WR, Díaz-Romero MC, Carbajal-López B, Castillo-Morales C, Pérez-Yépez EA, Albarran-García A. Impact of ileostomy in the adjuvant treatment and outcome of colon cancer. Int J Colorectal Dis 2023; 38:158. [PMID: 37261538 DOI: 10.1007/s00384-023-04421-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND After tumor resection, a preventive diverting loop ileostomy creation is a routine surgical procedure to prevent anastomotic leakage and infections and to preclude secondary surgeries. Despite its benefits, several studies have proposed potential complications that extend the disease course by impairing the feasibility of adjuvant chemotherapy and adherence. PURPOSE The aim of this study was to evaluate the impact of ileostomy complications on the adherence to adjuvant treatment and overall survival (OS) of colon cancer (CC) patients. METHODS Retrospective, observational study. Patients diagnosed with colon adenocarcinoma were treated between January 2010 and December 2020 at the National Cancer Institute in Mexico. STATISTICAL ANALYSIS χ2 and t-test, Kaplan-Meier, log-rank, and Cox regression. Statistical significance differences were assessed when p was bilaterally < 0.05. RESULTS The most frequent complications of loop-derived ileostomy were hydro-electrolytic dehydration (50%), acute kidney injury (AKI) (26%), grade 1-2 diarrhea (28%), and grade 3-4 diarrhea (21%) (p = 0.001). Patients with complete chemotherapy did not reach the median OS. In contrast, the median OS for patients with non-complete chemotherapy was 56 months (p = 0.023). Additionally, 5-year OS reached to 100% in the early restitution group, 85% in the late restitution group, and 60% in the non-restitution group (p = 0.016). Finally, AKI (p = 0.029; 95% confidence interval (CI) 3.348 [1.133-9.895]), complete chemotherapy (p = 0.028; 95% CI 0.376 [0.105-0.940]), and reversed ileostomy (p = 0.001; 95% CI 0.125 [0.038-0.407]) remained as predictors of overall survival for patients with CC treated with a loop ileostomy. CONCLUSIONS Our results emphasize the early stoma reversal restitution as a safe and feasible alternative to prevent severe complications related to ileostomies which improve chemotherapy adherence and overall survival of colon cancer patients. This is one of the pioneer studies analyzing the impact of ileostomy on treatment adherence and outcome of Latin American patients with colon cancer. TRIAL REGISTRATION Retrospective study No. 2021/045, in April 2021.
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Affiliation(s)
- Germán Calderillo-Ruíz
- Oncología Médica, Unidad Funcional de Gastroenterología, Instituto Nacional de Cancerología, Av. San Fernando No. 22, Sección XVI, 14080, Tlalpan, Mexico City, Mexico.
| | - Horacio Noé López-Basave
- Oncología Médica, Unidad Funcional de Gastroenterología, Instituto Nacional de Cancerología, Av. San Fernando No. 22, Sección XVI, 14080, Tlalpan, Mexico City, Mexico
| | - Wendy Rossemary Muñoz-Montaño
- Oncología Médica, Unidad Funcional de Gastroenterología, Instituto Nacional de Cancerología, Av. San Fernando No. 22, Sección XVI, 14080, Tlalpan, Mexico City, Mexico
| | - María Consuelo Díaz-Romero
- Cátedra-CONACYT, Dirección de Cátedras (CONACYT), Mexico, Laboratorio de Genómica, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Berenice Carbajal-López
- Oncología Médica, Unidad Funcional de Gastroenterología, Instituto Nacional de Cancerología, Av. San Fernando No. 22, Sección XVI, 14080, Tlalpan, Mexico City, Mexico
| | - Carolina Castillo-Morales
- Investigación Clínica, Unidad Funcional de Gastroenterología, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Eloy Andrés Pérez-Yépez
- Investigación Clínica, Unidad Funcional de Gastroenterología, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Alejandra Albarran-García
- Investigación Clínica, Unidad Funcional de Gastroenterología, Instituto Nacional de Cancerología, Mexico City, Mexico
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6
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Barnard J, Milne T, Teo K, Weston M, Israel L, Peng SL. Causes and costs of delayed closure of ileostomies in rectal cancer patients in Australasian units. ANZ J Surg 2023; 93:636-642. [PMID: 36203387 DOI: 10.1111/ans.18092] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Defunctioning loop ileostomies (DLIs) are a frequent adjunct to rectal cancer surgery. Delayed closure of DLIs is common and associated with increased morbidity. The reasons for delayed DLI closure are often unknown. The economic burden of delayed DLI closure is not quantified. The present study aimed to determine the reasons for, and economic burden of, delayed DLI closure. METHODS Clinical and economic data were audited from a prospective database of patients in two Australasian colorectal cancer centres. Patients treated at each unit with low/ultra-low anterior resection for rectal cancer with formation of DLI between January 2014 and December 2019 were included. Post-operative complication rate, stoma-related complication rate and costs of hospital admissions and stoma care were recorded and analysed. Multivariate linear regression analysis was used to investigate risk factors for delay to closure. RESULTS 146 patients underwent low/ultra-low anterior resection with DLI; 135 patients (92.5%) underwent reversal. The median duration to reversal was 7 months (IQR 4.5-9.5). Sixty-six percent of patients underwent reversal >6 months after their index surgery. Neoadjuvant and adjuvant chemotherapy were associated with delayed reversal (P < 0.001). Non-English speakers waited longer for DLI closure (P = 0.028). The costs of outpatient stoma care (P < 0.001), post-operative care (P = 0.004), and total cost of treatment (P = 0.014) were significantly higher in the delayed closure group, with a total cost of treatment difference of $3854 NZD per patient. CONCLUSIONS Causes of delay include systemic factors and demographic factors that can be addressed directly, addressing such causes may alleviate a significant economic burden.
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Affiliation(s)
- Jon Barnard
- Coloreectal Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tony Milne
- General Surgery, Nelson Hospital, Nelson, New Zealand
| | - Keith Teo
- General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Maree Weston
- General Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Lincoln Israel
- General Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Sze-Lin Peng
- General Surgery, Middlemore Hospital, Auckland, New Zealand
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Caminsky NG, Moon J, Morin N, Alavi K, Auer RC, Bordeianou LG, Chadi SA, Drolet S, Ghuman A, Liberman AS, MacLean T, Paquette IM, Park J, Patel S, Steele SR, Sylla P, Wexner SD, Vasilevsky CA, Rajabiyazdi F, Boutros M. Patient and surgeon preferences for early ileostomy closure following restorative proctectomy for rectal cancer: why aren't we doing it? Surg Endosc 2023; 37:669-682. [PMID: 36195816 DOI: 10.1007/s00464-022-09580-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 08/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC. METHODS A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively. RESULTS Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients. CONCLUSIONS Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.
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Affiliation(s)
- Natasha G Caminsky
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada.,Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Jeongyoon Moon
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada.,Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Karim Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, MA, USA
| | - Rebecca C Auer
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Liliana G Bordeianou
- Department of Surgery, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sami A Chadi
- Minimally Invasive and Colorectal Surgery, University Health Network and Princess Margaret Hospital, Toronto, ON, Canada
| | - Sébastien Drolet
- Department of Surgery, Centre Hospitalier Universitaire (CHU) de Québec, Laval University, Quebec City, QC, Canada
| | - Amandeep Ghuman
- Division of Colon and Rectal Surgery, St. Paul's Hospital, Vancouver, BC, Canada
| | - Alexander Sender Liberman
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Tony MacLean
- Department of Surgery, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jason Park
- Department of Surgery, St. Boniface General Hospital, University of Manitoba, Winnipeg, MB, Canada
| | - Sunil Patel
- Department of Surgery, Queens University, Kingston, ON, Canada
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
| | - Marylise Boutros
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada. .,Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada.
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8
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Turner GA, Clifford KA, Holloway R, Woodfield JC, Thompson‐Fawcett M. The impact of prolonged delay to loop ileostomy closure on postoperative morbidity and hospital stay: A retrospective cohort study. Colorectal Dis 2022; 24:854-861. [PMID: 35156285 PMCID: PMC9545668 DOI: 10.1111/codi.16095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 12/13/2022]
Abstract
AIM There is increasing evidence that delayed loop ileostomy closure is associated with an increase in postoperative morbidity. In the context of a publicly funded health service with constrained theatre access, we review the impact of delay in loop ileostomy closure. METHOD A retrospective cohort study of patients undergoing loop ileostomy closure at the Dunedin Public Hospital between 2000-2017 was performed. Cases and complications were identified from the prospectively maintained Otago Clinical Audit database. Patient demographics, ASA score, indications for ileostomy, reasons for delay in closure, length of stay (LOS) after ileostomy closure and complications were collected. LOS and overall complication rate were assessed using univariable and multivariable analyses. RESULTS A total of 292 patients were included in the study, of whom 74 (25.3%) were waiting for longer than 12 months for ileostomy closure. The overall complication rate was 21.5%. This was 8% up to 90 days, 20% between 90-360 days, 28% between 360-720 days and 54% after 720 days. Delay was associated with an increased risk of any complication (RR 1.06 for every 30 days with stoma, p < 0.001), including Ileus (OR [95% CI] 1.06 [1.00-1.11], p = 0.024). Overall mean LOS was 5.9 days (range 1-63), being 4.6 days up to 180 days, 5.6 between 180-720 days and 8.7 after 720 days. LOS significantly increased with increasing stoma duration (p = 0.04). CONCLUSION Increasing time with loop ileostomy is detrimental for patients, being associated with an increase in complication rates, and is detrimental for hospitals due to increased length of stay. Resources should be allocated for timely closure of loop ileostomies.
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Affiliation(s)
| | - Kari A. Clifford
- Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| | - Rossi Holloway
- Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| | - John C. Woodfield
- Department of SurgeryDunedin HospitalDunedinNew Zealand,Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| | - Mark Thompson‐Fawcett
- Department of SurgeryDunedin HospitalDunedinNew Zealand,Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
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9
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Taylor D, Besson A, Faragher IG, Chan STF, Yeung JM. Investigations and time trends in loop ileostomy reversals following anterior resections: a single Australian institution seven-years' experience. ANZ J Surg 2020; 91:938-942. [PMID: 33300280 DOI: 10.1111/ans.16483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/16/2020] [Accepted: 11/21/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Currently no consensus exists regarding what pre-reversal investigations are required to assess integrity of the rectal anastomosis. The objective of this study was to compare pre-reversal assessments of anastomotic integrity and to evaluate trends that might have influenced timings for reversal. METHODS From a prospectively maintained database, patients with colorectal cancer resections between March 2012 and October 2019 were identified. Patient characteristics, pre-reversal contrast enema and flexible sigmoidoscopy findings were recorded, and management of complications were recorded. Time-to-ileostomy reversal and time series for trends were analysed. RESULTS There were 154 patients included. Pre-reversal contrast enema or sigmoidoscopy detected a possible stricture or leak at the rectal anastomotic site in 11% (15/132) and 15% (18/112), respectively. When both modalities were used there was concordance of 86.1% and a positive likelihood ratio of 5.73. Of 125 (81.2%) ileostomies reversed, the median time-to-reversal was 11.99 months; time series analysis over the 7-year period showed no significant trend for average patient-days from booking to reversal (P = 0.60). Cox regression modelling did not identify any influential risk factors for the times taken to reversal. CONCLUSION This study supports the use of both contrast enema and flexible sigmoidoscopy in the assessment of rectal anastomosis integrity. Most patients with complications can have their ileostomies reversed. Patients who have adjuvant chemotherapy have a prolonged time to reversal.
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Affiliation(s)
- Danielle Taylor
- Department of Surgery, Western Health, Melbourne, Victoria, Australia
| | - Alex Besson
- Department of Surgery, Western Health, Melbourne, Victoria, Australia
| | - Ian G Faragher
- Department of Colorectal Surgery, Western Health, Melbourne, Victoria, Australia
| | - Steven T F Chan
- Department of Surgery, Western Health, Melbourne, Victoria, Australia.,Department of Surgery, Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia
| | - Justin M Yeung
- Department of Surgery, Western Health, Melbourne, Victoria, Australia.,Department of Colorectal Surgery, Western Health, Melbourne, Victoria, Australia.,Department of Surgery, Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia.,Western Health Chronic Disease Alliance, Western Health, Melbourne, Victoria, Australia
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10
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A Systematic Review of Early versus Late Closure of Loop Ileostomy. Surg Res Pract 2020; 2020:9876527. [PMID: 32953972 PMCID: PMC7481925 DOI: 10.1155/2020/9876527] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 07/30/2020] [Accepted: 08/12/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction A Loop ileostomy is one of the most common techniques used in colorectal surgery to establish a reversible faecal diversion and bypass the large bowels, in order to protect either a downstream colorectal anastomosis or a coloanal anastomosis. However, it is a procedure that can cause a plethora of complications including long term ones such as the psychological effects. Currently, there is no consensus regarding the optimal time to perform closure of a loop ileostomy. Some studies suggested the early reversal of ileostomy procedure as a solution to reduce these complications. This study aims to review the available literature in order to ascertain the benefits behind early closure of loop ileostomy. Methods The literature was searched for all studies that included a comparison between the outcomes of early and late closure of loop ileostomy in terms of morbidity, mortality, or quality of life, where available. Early closure of loop ileostomy is defined as closure less than three months and late as more than three months, in accordance with conventional literature. The resultant articles were filtered using our inclusion and exclusion criteria. Finally, the remaining articles were assessed for quality and their results were compared to one another in order to draw our conclusions. Results and Discussion. The results were slightly inclined toward early closure of loop ileostomy. However, there were limitations of the studies reviewed, including the heterogenicity of studies, selection bias, lack of clear definition of measured outcomes, and small sample size. Taking that into consideration, the results of early closure of loop ileostomies in the selected patients were promising and require further investigation.
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11
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Liu C, Bhat S, O'Grady G, Bissett I. Re-admissions after ileostomy formation: a retrospective analysis from a New Zealand tertiary centre. ANZ J Surg 2020; 90:1621-1626. [PMID: 32808425 DOI: 10.1111/ans.16076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ileostomy formation is a commonly performed procedure in colorectal surgery. The morbidity associated with ileostomies is substantial, particularly for unplanned hospital re-admissions and re-admissions with dehydration. Studies of post-ileostomy re-admissions from an Australasian institution are currently lacking. This retrospective study aimed to quantify the 60-day re-admission rate after ileostomy formation in a New Zealand tertiary centre and to determine the predictive factors. METHODS The surgical database of Auckland City Hospital was searched for all patients aged ≥18 years with a new ileostomy formed between first January 2015 and first January 2019. Patient electronic medical records were reviewed to obtain data regarding the primary outcome of re-admissions within 60 days of discharge, as well as patient and operative variables. Multivariate regression analysis was performed to identify independent predictors of all-cause re-admissions and re-admissions with dehydration. RESULTS A total of 246 patients with 266 ileostomy formations were included. The 60-day re-admission rate was 29.3%, with dehydration present in 27.0% of these re-admissions. Renal impairment at discharge (odds ratio 2.819, 95% confidence interval 1.087-7.310) and the presence of at least one Clavien-Dindo 1 complication (odds ratio 2.268, 95% confidence interval 1.301-3.954) were independently associated with all-cause re-admission. The independent predictors of re-admission with dehydration were renal impairment at discharge, codeine prescribed on discharge, Charlson Comorbidity Index and body mass index. CONCLUSION Unplanned hospital re-admission following ileostomy formation is a significant issue in the New Zealand patient population. Some patient groups are at particularly high risk, such as those with renal impairment at discharge.
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Affiliation(s)
- Chen Liu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Sameer Bhat
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Ian Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
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12
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Ng ZQ, Levitt M, Platell C. The feasibility and safety of early ileostomy reversal: a systematic review and meta-analysis. ANZ J Surg 2020; 90:1580-1587. [PMID: 32597018 DOI: 10.1111/ans.16079] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent evidence supports the safety of early reversal of a temporary stoma, within 14 days of construction. The aim of this systematic review and meta-analysis was to evaluate the post-operative morbidity and overall feasibility of early stoma reversal. METHODS Medline and Cochrane databases were searched for studies up to June 2019 that investigated the outcomes of early stoma reversal (EC, defined as closure ≤14 days from the index operation) versus late stoma reversal (LC, ≥8 weeks from the index operation). Meta-analysis was performed on the respective rates of post-operative morbidity, anastomotic leak, wound infection, bleeding, sepsis, small bowel obstruction and ileus. RESULTS Nine studies were included (667 patients analysed). Meta-analysis showed no significant difference in the post-operative morbidity rate, anastomotic leak rate, rates of small bowel obstruction, bleeding and ileus between EC and LC. However, the wound infection rate was significantly higher after EC than LC; relative difference 0.10 (95% confidence interval 0.00-0.19, P = 0.047). The stoma-related complication rate was significantly higher after LC than EC; relative difference -0.28 (95% confidence interval -0.45 to -0.11, P = 0.001). CONCLUSION The concept of early stoma reversal is appealing, and this meta-analysis confirms the safety of early stoma closure with an associated reduction in stoma-related complications despite higher wound infection rates. However, the results need to be interpreted with caution due to the heterogeneity of the studies included, especially in respect of the definition of complications that were used. Further well-designed prospective studies are required prior to confident adoption of early stoma closure into clinical practice.
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Affiliation(s)
- Zi Qin Ng
- Colorectal Unit, Department of General Surgery, St John of God Subiaco Hospital, Perth, Western Australia, Australia
| | - Michael Levitt
- Colorectal Unit, Department of General Surgery, St John of God Subiaco Hospital, Perth, Western Australia, Australia
| | - Cameron Platell
- Colorectal Unit, Department of General Surgery, St John of God Subiaco Hospital, Perth, Western Australia, Australia.,School of Surgery, University of Western Australia, Perth, Western Australia, Australia
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13
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Garfinkle R, Savage P, Boutros M, Landry T, Reynier P, Morin N, Vasilevsky CA, Filion KB. Incidence and predictors of postoperative ileus after loop ileostomy closure: a systematic review and meta-analysis. Surg Endosc 2019; 33:2430-2443. [PMID: 31020433 DOI: 10.1007/s00464-019-06794-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/09/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Postoperative ileus (POI) is regarded as the most clinically significant morbidity following loop ileostomy closure; however, its incidence remains poorly understood. Our objective was therefore to determine the pooled incidence of POI after loop ileostomy closure and identify risk factors associated with its development. METHODS We systematically searched MEDLINE (via Ovid and PubMed), Embase, the Cochrane Library, Biosis Previews, and Scopus to identify studies reporting the incidence of POI in patients who underwent loop ileostomy closure. Two independent reviewers extracted data and appraised study quality. Cumulative incidence proportions were pooled across studies using a random-effects meta-analytic model. RESULTS Sixty-seven studies, including 9528 patients, met our inclusion criteria. The pooled estimate of POI was 8.0% (95% CI 6.9-9.3%; I2 = 74%). The estimated incidence varied by POI definition: studies with a robust definition of POI (n = 8) demonstrated the highest estimate of POI (12.4%, 95% CI 9.2-16.5%; I2 = 79%) while studies that did not report an explicit POI definition (n = 38) demonstrated the lowest estimate (6.7%, 95% CI 5.3-8.3%; I2 = 61%). Small bowel anastomosis technique (hand-sewn) and interval time from ileostomy creation to closure (longer time) were the factors most commonly associated with POI after loop ileostomy closure. However, most comparative studies were not powered to examine risk factors for POI. CONCLUSIONS POI is an important complication after loop ileostomy closure, and its incidence is dependent on its definition. More research aimed at studying this complication is required to better understand risk factors for POI after loop ileostomy closure.
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Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Paul Savage
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.,Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Tara Landry
- Medical Libraries, McGill University Health Center, Montreal, QC, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada. .,Department of Medicine, McGill University, Montreal, QC, Canada.
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14
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Cost analysis in a randomized trial of early closure of a temporary ileostomy after rectal resection for cancer (EASY trial). Surg Endosc 2019; 34:69-76. [PMID: 30911920 PMCID: PMC6946724 DOI: 10.1007/s00464-019-06732-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 03/06/2019] [Indexed: 12/31/2022]
Abstract
Background Hospital costs associated with the treatment of rectal cancer are considerable and the formation of a temporary stoma accounts for additional costs. Results from the EASY trial showed that early closure of a temporary ileostomy was associated with significantly fewer postoperative complications but no difference in health-related quality of life up to 12 months after rectal resection. The aim of the present study was to perform a cost analysis within the framework of the EASY trial. Methods Early closure (8–13 days) of a temporary stoma was compared to late closure (> 12 weeks) in the randomized controlled trial EASY (NCT01287637). The study period and follow-up was 12 months after rectal resection. Inclusion of participants was made after index surgery. Exclusion criteria were diabetes mellitus, steroid treatment, signs of postoperative complications or anastomotic leakage. Clinical effectiveness and resource use were derived from the trial and unit costs from Swedish sources. Costs were calculated for the year 2016 and analysed from the perspective of the healthcare sector. Results Fifty-five patients underwent early closure, and 57 late closure in eight Swedish and Danish hospitals between 2011 and 2014. The difference in mean cost per patient was 4060 US dollar (95% confidence interval 1121; 6999, p value < 0.01) in favour of early closure. A sensitivity analysis, taking protocol-driven examinations into account, resulted in an overall difference in mean cost per patient of $3608, in favour of early closure (95% confidence interval 668; 6549, p value 0.02). The predominant cost factors were reoperations, readmissions and endoscopic examinations. Conclusions The significant cost reduction in this study, together with results of safety and efficacy from the randomized controlled trial, supports the routine use of early closure of a temporary ileostomy after rectal resection for cancer in selected patients without signs of anastomotic leakage. Clinical trial Registered at clinicaltrials.gov, clinical trials identifier NCT01287637.
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15
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Early Closure of Defunctioning Loop Ileostomy: Is It Beneficial for the Patient? A Meta-analysis. World J Surg 2018; 42:3171-3178. [DOI: 10.1007/s00268-018-4603-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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16
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Does a Defunctioning Stoma Impair Anorectal Function After Low Anterior Resection of the Rectum for Cancer? A 12-Year Follow-up of a Randomized Multicenter Trial. Dis Colon Rectum 2017; 60:800-806. [PMID: 28682965 DOI: 10.1097/dcr.0000000000000818] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anorectal function after low anterior resection of the rectum for cancer is often impaired, and long-term outcome has not frequently been reported. OBJECTIVE We evaluated anorectal function 12 years after rectal resection with regard to whether patients had a defunctioning temporary stoma at the initial rectal resection. DESIGN An exploratory cross-sectional investigation of a previously randomized study population. SETTINGS Twenty-one Swedish hospitals performing rectal cancer surgery during a 5-year period participated in the trial. PATIENTS Patients operated on with low anterior resection for cancer were included. INTERVENTIONS Patients were randomly assigned to receive or not receive a temporary defunctioning stoma. MAIN OUTCOME MEASURES We evaluated anorectal function 12 years after low anterior resection in patients who were initially randomly assigned to temporary stoma or not, by means of using the low anterior resection syndrome score questionnaire, which assesses incontinence for flatus, incontinence for liquid stools, defecation frequency, clustering, and urgency. Self-perceived health status was evaluated by the EQ-5D-3L questionnaire. RESULTS Eighty-nine percent (87/98) of the patients responded to the questionnaires, including 46 with and 41 without an initial temporary stoma. Patient demography was comparable between the groups. No differences regarding major, minor, and no low anterior resection syndrome categories were found between the groups. The stoma group had increased incontinence for flatus (p = 0.03) and liquid stools (p = 0.005) and worse overall low anterior resection syndrome score (p = 0.04) but no differences regarding frequency, clustering, and urgency. LIMITATIONS The study was limited by its sample size (n = 98) based on a previously randomized trial population (n = 234). CONCLUSIONS After low anterior resection for cancer, the incidence of the categories major, minor, and no low anterior resection syndrome were comparable in the stoma and the no-stoma groups. Incontinence for flatus and liquid stools was more commonly reported by patients who were randomly assigned to temporary stoma, as compared with those without, which may indicate an association between temporary stoma and impaired anorectal function. See Video Abstract at http://links.lww.com/DCR/A413.
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Li W, Ozuner G. Does the timing of loop ileostomy closure affect outcome: A case-matched study. Int J Surg 2017; 43:52-55. [DOI: 10.1016/j.ijsu.2017.05.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 04/18/2017] [Accepted: 05/15/2017] [Indexed: 11/17/2022]
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Lasithiotakis K, Aghahoseini A, Alexander D. Is Early Reversal of Defunctioning Ileostomy a Shorter, Easier and Less Expensive Operation? World J Surg 2017; 40:1737-40. [PMID: 26908242 DOI: 10.1007/s00268-016-3448-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND A defunctioning loop ileostomy mitigates the consequences of anastomotic leak from low rectal anastomosis but it is associated with significant morbidity. In this study, the outcome of early reversal of defunctioning ileostomy during the same admission with the primary operation was assessed. METHODS This randomized study was carried out at York Teaching Hospital during the period 2003-2007. All patients with defunctioning ileostomy were considered for an early second operation if they had an uneventful recovery and were in good general condition. Patients on steroids, at high cardiorespiratory risk and those experiencing any postoperative complication were excluded. Eligible patients with satisfactory gastrografin enema on postoperative day 6 were randomized to early versus late reversal at 6-8 weeks. Outcome measures were ease of closure as assessed by a visual analog scale by the operating surgeon, all postoperative complications, duration of the operation, total length of hospital stay and associated costs. RESULTS Thirty-nine consecutive patients were assessed for eligibility and finally 26 were included in the study. Sixteen patients underwent early reversal. The median(interquartile range (IQR)) age was 62(22) years. Early reversal was significantly superior in terms of ease of abdominal wall closure, ease of reversal (p < 0.01 each), duration of the operation (median(IQR) 20(13) vs. 40(9) min, p < 0.01) and costs of stoma care (median(IQR) 27(9) vs. 311(108) £, p < 0.01). There were no major (grade III/IV) complications in either group. Total length of hospital stay was similar between groups. CONCLUSION In carefully selected patients, early reversal of defunctioning ileostomy is feasible, technically easier and has shorter operative time which can also lead to significant cost savings.
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Affiliation(s)
- Konstantinos Lasithiotakis
- Department of General Surgery, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York, North Yorkshire, YO31 8HE, UK.
| | - Assad Aghahoseini
- Department of General Surgery, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York, North Yorkshire, YO31 8HE, UK
| | - David Alexander
- Department of General Surgery, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York, North Yorkshire, YO31 8HE, UK
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Floodeen H, Hallböök O, Hagberg L, Matthiessen P. Costs and resource use following defunctioning stoma in low anterior resection for cancer – A long-term analysis of a randomized multicenter trial. Eur J Surg Oncol 2017; 43:330-336. [DOI: 10.1016/j.ejso.2016.12.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/06/2016] [Indexed: 01/14/2023] Open
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20
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Massarweh NN, Artinyan A, Chang GJ. Neoadjuvant treatment for rectal cancer-A value-based proposition. J Surg Oncol 2016; 114:304-10. [DOI: 10.1002/jso.24267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 04/05/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Nader N. Massarweh
- VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety; Michael E DeBakey VA Medical Center; Houston Texas
- Division of Surgical Oncology; Michael E DeBakey Department of Surgery; Baylor College of Medicine; Houston Texas
| | - Avo Artinyan
- Division of Surgical Oncology; Michael E DeBakey Department of Surgery; Baylor College of Medicine; Houston Texas
| | - George J. Chang
- Departments of Surgical Oncology and Health Services Research; The University of Texas MD Anderson Cancer Center Houston; Houston Texas
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