A Decalogue to Avoid Routine Ileostomy in Selected Patients With Border Line Risk to Develop Anastomotic Leakage After Minimally Invasive Low-Anterior Resection: A Pilot Study

Diverting ileostomy in benign colorectal surgery: the real clinical cost analysis

There are three types of complications stoma related: ones related to its construction, ones related to its function and related to closure. The aim of this study was to assess the risk of complications related to the stoma presence and to identificate variables related to complications. We conducted a retrospective study of patients who underwent sphincter-preserving elective surgery for benign condition between January 2013 and December 2020 at IRCCS Sacro Cuore Don Calabria Hospital in Negrar, Verona. Data were collected regarding demographics and complications associated with primary surgery, stoma closure and the interval period. Univariable and multivariable analysIs were conducted. A total of 446 (12.2%) diverting loop ileostomies were performed. At index procedure, 76 (17%) patients had complications and 34 patients had complications related to ileostomy creation. Twenty patients (4.4%) were re admitted before stoma closure for dehydration. One hundred and eighty-seven patients (41.9%) suffered from ileostomy management's problems. At univariate analysis, complications of having stoma are more frequent in elder patients (p = 0.013), ASA score > 2 (p = 0.02), IBD diagnosis (p = < 0.001) and patients who had ileostomy creation complications (p = 0.04). At stoma closure, 55 (12.3%) patients had complications. Forty-seven patients (10.5%) presented incisional hernia in the stoma closure site. Ileostomy closure complications are more common with ASA score > 2 (p = 0.01) and IBD diagnosis (p < 0.001). IBD was found an independent factor of poor outcome at the time of ileostomy creation and closure. Developing complications at the time of ileostomy creation is statistically related to develop complications during ileostomy maintenance at multivariable analysis A loop ileostomy is usually created to limit the potentially life-threatening consequenceS of anastomotic leakage, but it is not able to decrease the leak-related mortality, wound sepsis, postoperative bleeding and small bowel obstruction. Debate rises not only for its uncertain efficacy but also because of the significant morbidity related to stoma. The surgeon could use these data in order to tailor his surgical strategy to the patients and their disease.

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

AIM

The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR.

METHOD

Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed.

RESULTS

Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%).

CONCLUSION

The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Indocyanine green (ICG) fluorescence guide for the use and indications in general surgery: recommendations based on the descriptive review of the literature and the analysis of experience

Indocyanine Green is a fluorescent substance visible in near-infrared light. It is useful for the identification of anatomical structures (biliary tract, ureters, parathyroid, thoracic duct), the tissues vascularization (anastomosis in colorectal, esophageal, gastric, bariatric surgery, for plasties and flaps in abdominal wall surgery, liver resection, in strangulated hernias and in intestinal ischemia), for tumor identification (liver, pancreas, adrenal glands, implants of peritoneal carcinomatosis, retroperitoneal tumors and lymphomas) and sentinel node identification and lymphatic mapping in malignant tumors (stomach, breast, colon, rectum, esophagus and skin cancer). The evidence is very encouraging, although standardization of its use and randomized studies with higher number of patients are required to obtain definitive conclusions on its use in general surgery. The aim of this literature review is to provide a guide for the use of ICG fluorescence in general surgery procedures.

Ostomy closure rate during COVID-19 pandemic: an Italian multicentre observational study

During the corona virus disease 2019 (COVID-19) pandemic, most of the surgical procedures were performed for emergencies or oncologic reasons to the detriment of the remaining elective procedures for benign conditions. Ileostomy or colostomy creation are sequelae of oncologic or emergency colorectal surgery, but their closure does not fall within the definition of oncologic or emergency surgery. The aim of this retrospective multicentre observational study is to report the impact of COVID-19 pandemic on the ostomy closure rate in Italy. Data regarding ileostomy and colostomy creation and closure from 24 Italian centres, during the study period (March 2020–February 2021) and during the control period (March 2019–February 2020) were collected. Three hospitals (12.5%) were COVID free. The number of colostomies and ileostomies created and closed in the same period was lower ( -18.8% and -30%, respectively) in the study period in comparison to the control period (p = 0.1915 and p = 0.0001, respectively), such as the ostomies closed in the analysed periods but created before (colostomy -36.2% and ileostomy -7.4%, p = 0.2211 and p = 0.1319, respectively). Overall, a 19.5% reduction in ostomies closed occurred in the study period. Based on the present study, a reduction in ostomy closure rate occurred in Italy between March 2020 and February 2021. During the pandemic, the need to change the clinical practice probably prolonged deterioration of quality of life in patients with ostomies, increasing number of stomas that will never be closed, and related management costs, even if these issues have not been investigated in this study.

Complications after bowel resection for inflammatory bowel disease associated cancer. A systematic literature review

INTRODUCTION

Inflammatory bowel disease (IBD) associated colorectal cancer represents the 1-2% of all patients affected by colorectal carcinoma, but it is frequent responsible for death in these patients. Aim of this systematic review was to report the complications after bowel resection in patients with IBD associated cancer.

EVIDENCE ACQUISITION

A systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The search was carried out in PubMed, Embase, Cochrane and Web of Science databases. A total of 54,084 articles were found. Of these 38,954 were eliminated because were duplicates between the searches. Of the remaining 15,130 articles, 14,888 were excluded after screening title and abstract.

EVIDENCE SYNTHESIS

Two-hundred-forty-two articles were fully analyzed, and 239 further articles were excluded. Finally, three articles were included for a total of 63 patients. Overall, 38 early postoperative complications (60.3%) were observed. Of these, anastomotic leakage occurred in 13 patients (20.6%). The indication for surgery was ulcerative colitis in 52 patients (82.5%), Crohn's disease in 8 patients (12.7%) and indeterminate colitis in 3 patients (4.8%). Intraoperative complications, readmission and postoperative mortality were not observed.

CONCLUSIONS

Complication rate after bowel resection for IBD associated cancer is not different from complication rate after colorectal surgery for other diseases. Given the high probability of developing a cancer and the time correlated occurrence of malignancy in IBD patients, it should be debated if a surgical resection should be performed as soon as dysplasia is detected in IBD patients or earlier in their life.

Comprehensive testing of colorectal anastomosis: results of prospective observational cohort study

BACKGROUND

Anastomotic leakage remains one of the most threatening complications in colorectal surgery. Intraoperative testing of anastomosis may reduce the postoperative anastomotic leakage rates. This study aimed to investigate a novel comprehensive intraoperative colorectal anastomosis testing technique to detect the failure of the anastomosis construction and to reduce the risk of postoperative leak.

METHODS

This multi-centre prospective cohort pilot study included 60 patients who underwent colorectal resection with an anastomosis at or below 15 cm from the anal verge. Comprehensive trimodal testing consisted of indocyanine green fluorescence angiography, tension testing, air-leak, and methylene blue leak tests to evaluate the perfusion, tension, and mechanical integrity of the anastomosis.

RESULTS

Ten (16.7%) patients developed an anastomotic leakage. Trimodal test was positive in 16 (26.6%) patients and the operative plan was changed for all of them. Diverting ileostomy was performed in 14 (87.5%) patients. However, two (12.5%) patients still developed clinically significant anastomotic leakage (Grade B). Forty-four (73.4%) patients had a negative trimodal test, preventive ileostomy was performed in 19 (43.2%), and five (11.4%) patients had clinically significant anastomotic leakage (Grade B and C).

CONCLUSION

Trimodal testing identifies anastomoses with initial technical failure where reinforcement of anastomosis or diversion can lead to an acceptable rate of anastomotic leakage. Identification of well-performed anastomosis could allow a reduction of ileostomy rate by two-fold. However, anastomotic leakage rate remains high in technically well-performed anastomoses.

Management of postoperative complications after laparoscopic left hemicolectomy - an approach in modern times after incorporation of indocyanine green (ICG) and full mobilization of the splenic flexure

BACKGROUND

Aim is to report our experience in the management of complications after laparoscopic left hemicolectomy (LLH) after the incorporation in our clinical practice of intraoperative indocyanine green (ICG) fluorescence angiography (FA).

METHODS

In our last period after incorporation of ICG-FA, 277 unselected consecutive patients underwent laparoscopic colorectal surgery with this technology. Ninety-seven (35%) right hemicolectomy, 19 segmental resection of the splenic flexure (6.9%), 54 anterior resection of the rectum (19.5%) and 107 LLH (38.6%) were performed. Complications were graded according to Clavien-Dindo classification, and anastomotic leakages (AL) were graded according to Clavien-Dindo classification and to International Study Group of Rectal Cancer (ISGRC) classification.

RESULTS

Eight surgical and one medical complications (8.4%) were observed. Two AL occurred (1.9%). One drained spontaneously by drainage placed intraoperatively (Clavien-Dindo I, ISGRC A) and one treated by laparoscopic peritoneal lavage, leakage suture and ileostomy (Clavien-Dindo III-b, ISGRC C). Other complications were: wound infection (Clavien-Dindo II)(2); postoperative anemia caused by rectorrhagia (Clavien-Dindo II)(2); pelvic abscess between bladder and uterus (Clavien-Dindo III-a)(1); hemoperitoneum secondary to inferior mesenteric artery bleeding treated with peritoneal lavage and hemostasis (Clavien-Dindo III-b)(1); atrial fibrillation (Clavien- Dindo II)(1). All complications have been resolved.

CONCLUSIONS

The complication rate after LLH after the incorporation of ICG-FA is low, since the number of AL have dramatically decreased in comparison to our previous experience. The management of these patients proved to be safe and effective due to in all cases the complication has been resolved. Further studies are required to standardize the management of these patients.

Ghost ileostomy versus conventional loop ileostomy in patients undergoing low anterior resection for rectal cancer (DRKS00013997): protocol for a randomised controlled trial

INTRODUCTION

Anastomotic leakage is the most important complication in colorectal surgery occurring in up to 20% after low anterior rectal resection. Therefore, a diverting ileostomy is usually created during low anterior resection to protect the anastomosis or rather to diminish the consequences in case of anastomotic leakage. The so-called virtual or ghost ileostomy is a pre-stage ostomy that can be easily exteriorised, if anastomotic leakage is suspected, in order to avoid the severe consequences of anastomotic leakage. On the other hand, an actual ileostomy can be avoided in patients, who do not develop anastomotic leakage.

METHODS AND ANALYSIS

The GHOST trial is a randomised controlled pilot trial comparing ghost ileostomy with conventional loop ileostomy in patients undergoing low anterior resection with total mesorectal excision for rectal cancer. After screening for eligibility and obtaining informed consent, a total of 60 adult patients are included in the trial. Patients are intraoperatively randomised to the trial groups in a 1:1 ratio after assuring that none of the intraoperative exclusion criteria are present. The main outcome parameter is the comprehensive complication index as a measure of safety. Further outcomes include specific complications, stoma-related complications, complications of ileostomy closure, frequency of transformation of ghost ileostomy into conventional ileostomy, frequency of terminal ostomy creation, proportion of patients with an ostomy at 6 months after index surgery, anorectal function (Wexner score) and quality of life assessed by the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and CR29 questionnaires. Follow-up for each individual patient will be 6 months.

ETHICS AND DISSEMINATION

The GHOST trial has been approved by the Medical Ethics Committee of Heidelberg University (reference number S-694/2017). If the intervention proves to be safe, loop ileostomy could be spared in a large proportion of patients, thus also avoiding stoma-related complications and a second operation (ileostomy closure) with its inherent complications in these patients.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00013997); Universal Trial Number: U1111-1208-9742.