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Rethinking postoperative care: same-day ileostomy closure discharge improves patient outcomes. J Gastrointest Surg 2024; 28:667-671. [PMID: 38704204 DOI: 10.1016/j.gassur.2024.02.017] [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: 12/16/2023] [Revised: 01/19/2024] [Accepted: 02/07/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND The evolution of enhanced recovery pathways (ERPs) in colon and rectal surgery has led to the development of same-day discharge (SDD) procedures for selected patients. Early discharge after diverting loop ileostomy (DLI) closure was first described in 2003. However, its widespread adoption remains limited, with SDD accounting for only 3.2% of all DLI closures in 2005-2006, according to the American College of Surgeons National Surgical Quality Improvement Program database, and rising to just 4.1% by 2016. This study aimed to compare the outcomes of SDD DLI closure with those of DLI closure after the standard ERP. METHODS A retrospective case-matched study compared 125 patients undergoing SDD DLI closure with 250 patients undergoing DLI closure after the standard ERP based on age (±1 year), sex, American Society of Anesthesiologists score, body mass index, surgery date (±2 months), underlying disease, and hospital site. The primary outcome was comparative 30-day complication rates. RESULTS Patients in the traditional ERP group received more intraoperative fluids (1221.1 ± 416.6 vs 1039.0 ± 368.3 mL, P < .001) but had similar estimated blood loss. Ten patients (8%) in the SDD-ERP group failed SDD. The 30-day postoperative complication rate was significantly lower in the SDD group (14.8%) than the standard ERP group (25.7%, P = .025). This difference was primarily driven by a lower incidence of ileus in the SDD group (9.6% vs 14.8%, P = .034). There were no significant differences in readmission rate (9.6% of SDD-ERP vs 9.2% of standard ERP, P = .900) and reoperation rates (3.2% of SDD-ERP vs 2.4% of standard ERP, P = .650). CONCLUSION SDD ileostomy closure is a safe, feasible, and effective procedure associated with fewer complications than the present study's standard ERP. This could represent a new standard of care. Further prospective trials are required to confirm the findings of this study.
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Comparison of purse-string technique vs linear suture for skin closure after ileostomy reversal. A randomized controlled trial. Langenbecks Arch Surg 2024; 409:141. [PMID: 38676785 DOI: 10.1007/s00423-024-03332-w] [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: 11/18/2023] [Accepted: 04/23/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Protective stoma after rectal surgery has been associated with important complications. The most common is surgical site infection (SSI) high rates after stoma reversal reported in literature. Our study compared the rate of SSI of two skin closure techniques, linear closure, and purse string closure. METHODS We carried out a single center, prospective, randomized controlled trial in the Department of Colorectal Surgery of Fondazione Policlinico Campus Bio-Medico of Rome between January 2018 through December 2021, to compare LC vs PS closure of ileostomy sites. RESULTS A total of 117 patients (53.84% male) with a mean age of 65.68 ± 14.33 years were finally evaluated in the study. 58 patients were included in the PS group and 59 patients in the LC one. There was a marked difference in the SSI rate between the two arms of the study: 3 of 58 patients in the purse-string arm versus 11 of 59 in the control arm (p = 0.043). The outcome of cosmesis was also higher in PS, with a statistical significance (mean ± DS 4,01 ± 0,73 for PS group vs mean ± DS 2,38 ± 0,72 for LC group, p < 0,001). CONCLUSION Our study demonstrated that the PS technique had a significantly lower incidence of stoma site SSI compared with LC technique. Our findings are in line with other randomized studies and suggest that PS closure could be considered as standard of care for wound closure after ileostomy reversal.
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ILEOSTIM trial: a study protocol to evaluate the effectiveness of efferent loop stimulation before ileostomy reversal. Tech Coloproctol 2023; 27:1251-1256. [PMID: 37106220 PMCID: PMC10638139 DOI: 10.1007/s10151-023-02807-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE A protective loop ileostomy is the most useful method to reduce sequelae in the event of an anastomotic leakage (AL) after rectal cancer surgery. However, it requires an additional stoma reversal surgery with its own potential complications. Postoperative ileus (POI) remains the most common complication after ileostomy reversal, which leads to an increase in morbidity, length of hospital stay (LOS) and overall healthcare costs. Several retrospective studies carried out in this field have concluded that there are insufficient evidence-based recommendations about the routine application of preoperative bowel stimulation in clinical practice. Here we discuss whether stimulation of the efferent limb before ileostomy reversal might reduce POI and improve postoperative outcomes. METHODS This is a multicentre randomised controlled trial to determine whether mechanical stimulation of the efferent limb during the 2 weeks before the ileostomy reversal would help to reduce the development of POI after surgery. This study was registered on Clinicaltrials.gov (NCT05302557). Stimulation will consist of infusing a solution of 500 ml of saline chloride solution mixed with a thickening agent (Resource©, Nestlé Health Science; 6.4 g sachet) into the distal limb of the ileostomy loop. This will be performed within the 2 weeks before ileostomy reversal, in an outpatient clinic under the supervision of a trained stoma nurse. CONCLUSION The results of this study could provide some insights into the preoperative management of these patients.
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Stapled side-to-side anastomosis for ileostomy reversal: a simple and reproducible technique with video. Langenbecks Arch Surg 2023; 408:238. [PMID: 37335357 DOI: 10.1007/s00423-023-02987-1] [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: 07/12/2022] [Accepted: 06/14/2023] [Indexed: 06/21/2023]
Abstract
INTRODUCTION Protective diverting ileostomy is commonly performed in rectal surgery to avoid septic complications of low colorectal anastomosis. Ileostomy closure usually occurs three months after the surgery and can be realized in two ways: hand sewn or stapled. Existing randomized studies comparing the two techniques showed no difference in terms of complications. METHODS Our study describes the standard technique of ileostomy reversal as done in Bordeaux University Hospital in 10 steps individually illustrated and with an explicative video. We also collected data concerning the 50 last patients who underwent an ileostomy reversal in our center from June 2021 to June 2022. RESULTS Mean duration of the ileostomy closure was 46.8 minutes, and the mean total hospital stay was 4.66 days. Five of 50 (10%) patients had a post-operative bowel obstruction, 2/50 (4%) patients had a post-operative bleeding, 1/50 (2%) patient had a wound infection, and there was no anastomotic leakage observed. CONCLUSION Stapled side-to-side anastomosis is a rapid, simple, and reproducible technique for ileostomy reversal. There are no more complications compared to hand-sewn anastomosis. It engenders an additional cost compensated by the gain in operating time which altogether saves money.
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A retrospective analysis of early discharge following minimally invasive colectomy in an enhanced recovery pathway. Surg Endosc 2022; 37:2756-2764. [PMID: 36471062 PMCID: PMC9734303 DOI: 10.1007/s00464-022-09777-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is increasing evidence to support discharge prior to gastrointestinal recovery following colorectal surgery. Furthermore, many patients are discharged early despite being excluded from an ambulatory colectomy pathway. The objective of this study was to determine the outcomes of patients discharged early following laparoscopic colectomy in an enhanced recovery pathway (ERP). METHODS A retrospective review of all adult patients undergoing elective laparoscopic colectomy at a single university-affiliated colorectal referral center (08/2017-06/2021) was performed. Patients were included if they had undergone elective laparoscopic colectomy or ileostomy closure and excluded if they had been enrolled in an ambulatory colectomy pathway. Patients were then divided into three groups: LOS =1 day, LOS 2-3 days, and LOS 4+ days. The main outcomes were 30-day emergency room (ER) visits and readmissions. Reasons for inpatient stay per post-operative day (POD) were also recorded. RESULTS A total of 497 patients were included [LOS1 n = 63 (13%), LOS2-3 n = 284 (57%), and LOS4+ n = 150 (30%)]. There were no differences in patient characteristics, diagnosis, or procedure between the groups. Patients were discharged with gastrointestinal recovery (GI-3) in 54% LOS1 vs. 98% LOS2-3 vs. 100% LOS4+ (p<0.001). Shorter procedure duration, transversus abdominus plane block, and lower opioid requirements were associated with shorter LOS (p<0.001). The absence of flatus was the most common reason to keep patients hospitalized: 61% on POD1, 21% on POD2, and 8% on POD3 (p<0.001). There were no differences in 30-day emergency visits, or readmission between the groups. In the LOS1 group, there were no differences in outcomes between patients with full return of bowel function at discharge compared to those without. CONCLUSION Discharge on POD1 was not associated with increased emergency department use, complications, or readmissions. Importantly, full return of bowel function at discharge did not affect outcomes. There may be potential to expand eligibility criteria for ambulatory colectomy protocol.
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Risk factor for the development of surgical site infection following ileostomy reversal: a single-center report. Updates Surg 2022; 74:1675-1682. [PMID: 36002762 DOI: 10.1007/s13304-022-01335-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/09/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Postoperative surgical site infection (SSI) is not uncommon in patients with ileostomy reversal. The appropriate index to predict the postoperative SSI in these individuals remains unclear. The aim of this study is to evaluate the risk factor for SSI after ileostomy reversal. METHODS A consecutive cohort of 201 patients who underwent elective ileostomy reversal between January 2015 and January 2020 were retrospectively analyzed. Patients were divided into two groups: SSI group and non-SSI group. Univariate and multivariate analyses were conducted to identify risk factors for postoperative SSI. RESULTS Postoperative SSI occurred in 37 (18.4%) patients. Compared with the non-SSI group, patients in SSI group had higher incidence of nutrition risk (56.77% vs 39.02%, P = 0.049), higher C-reactive protein (CRP) level (10.81 ± 16.49 vs 4.86 ± 4.14 mg/L, P < 0.001), and longer postoperative hospital stay (13.08 ± 3.71 vs 7.47 ± 2.38 days, P < 0.001). By analyzing the receiver-operating characteristic (ROC) curve, CRP have the value in predicting the occurrence of SSI. The areas under the ROC curves of CRP for SSI was 0.671 (95% confidence interval 0.568-0.774, P = 0.001) with an optimal diagnostic cut-off value of 8.0 mg/L. By the univariate and multivariate analyses, preoperative C-reactive protein (CRP) ≥ 8 mg/L(P < 0.001) and conventional linear closure method (P = 0.004) were independent risk factors for postoperative SSI. CONCLUSIONS Preoperative CRP levels can be served as a predictive index for postoperative SSI after stoma reversal. Purse-string closure technique is the treatment of choice to minimize stoma site SSI in patients with stoma reversal.
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Early vs. standard reversal ileostomy: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:851-862. [PMID: 35596904 PMCID: PMC9123394 DOI: 10.1007/s10151-022-02629-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/24/2022] [Indexed: 11/28/2022]
Abstract
Background Formation of a defunctioning loop ileostomy is common after mid and low rectal resection. Historically, they were reversed between 3 and 6 months after initial resection. Recently, earlier closure (< 14 days) has been suggested by some current randomised controlled trials. The aim of this study was to investigate the effect of early stoma closure on surgical and patient outcomes. Methods A systematic review of the current randomised controlled trial literature comparing early and standard ileostomy closure after rectal surgery was performed. Specifically, we examined surgical outcomes including; morbidity, mortality and quality of life. Results Six studies met the predefined criteria and were included in our analysis. 275 patients underwent early stoma closure compared with 259 patients having standard closure. Overall morbidity was similar between both groups (25.5% vs. 21.6%) (OR, 1.47; 95% CI 0.75–2.87). However, there tended to be more reoperations (8.4 vs. 4.2%) (OR, 2.02, 95% CI 0.99–4.14) and small bowel obstructions/postoperative ileus (9.3% vs. 4.4%) (OR 0.44, 95% CI 0.22–0.90) in the early closure group, but no difference across the other domains. Conclusions Early closure appears to be a feasible in highly selective cases after good perioperative counselling and shared decision-making. Further research on quality of life outcomes and long term benefits is necessary to help define which patients are suitable candidates for early closure.
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Comparison between Wound Closure Methods in the Reversal of Diverting Ileostomy. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:109-117. [PMID: 35342168 DOI: 10.4166/kjg.2021.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/13/2021] [Accepted: 12/19/2021] [Indexed: 11/03/2022]
Abstract
Background/Aims The objective of this study was to determine the more appropriate wound-closure method by comparing the effectiveness of two methods in a group of patients who underwent ileostomy repair. Methods The study conducted after obtaining the approval of the Institutional Review Board (IRB) included 58 patients ≥19 years of age who underwent ileostomy at the Department of Surgery at the Presbyterian Medical Center. This was a retrospective, single-center trial. Patients who underwent ileostomy closure between January 2011 and September 2017 were assigned to the primary wound-closure (PC, n=25) group and the purse-string wound-closure (PSC, n=33) group. Post-repair complications, such as wound infection, delayed healing, and patient satisfaction related to wound management, were investigated and compared according to the wound-closure method. Results The PSC group had a significantly lower surgical site infection rate than the PC group (0% vs. 44%, p<0.001). The wound-healing period was also significantly different between the PC and PSC groups (mean 27.18 days vs. 20.96 days, p=0.023). However, the postoperative wound-healing delay of >30 days was not significantly different (39% vs. 20%, p=0.114). In addition, there were no significant differences in the response to questionnaires on patient satisfaction between the two groups. Conclusions PSC has a lower surgical site infection rate and the wound-healing delay was not very different from that of PC. Therefore, if patients are at risk of wound infection, such as in severe wound contamination, long operating time, and immunocompromised conditions, we should consider PSC as a wound closure method of choice.
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Laparoscopic vs open surgery in ileostomy reversal in Crohn’s disease: A retrospective study. World J Gastrointest Surg 2021; 13:1414-1422. [PMID: 34950430 PMCID: PMC8649567 DOI: 10.4240/wjgs.v13.i11.1414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/23/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although minimally invasive surgery is becoming more commonly applied for ileostomy reversal (IR), there have been relatively few studies of IR for patients with Crohn's disease (CD). It is therefore important to evaluate the potential benefits and risks of laparoscopy for patients with CD.
AIM To compare the safety, feasibility, and short-term and long-term outcomes of laparoscopic IR (LIR) vs open IR (OIR) for the treatment of CD.
METHODS The baseline characteristics, operative data, and short-term (30-d) and long-term outcomes of patients with CD who underwent LIR and OIR at our institution between January 2017 and January 2020 were retrieved from an electronic database and retrospectively reviewed.
RESULTS Of the 60 patients enrolled in this study, LIR was performed for 48 and OIR for 12. There were no statistically significant differences in baseline characteristics, operation time, intraoperative blood loss, days to flatus and soft diet, postoperative complications, hospitalization time, readmission rate within 30 d, length of hospitalization, hospitalization costs, or reoperation rate after IR between the two groups. However, patients in the LIR group more frequently required lysis of adhesions as compared to those in the OIR group (87.5% vs 41.7%, respectively, P < 0.05). Notably, following exclusion of patients who underwent enterectomy plus IR, OIR was more advantageous in terms of postoperative recovery of gastrointestinal function and hospitalization costs.
CONCLUSION The safety and feasibility of LIR for the treatment of CD are comparable to those of OIR with no increase in intraoperative or postoperative complications.
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Less is more-the best test for anastomotic leaks in rectal cancer patients prior to ileostomy reversal. Int J Colorectal Dis 2021; 36:2387-2398. [PMID: 34251505 PMCID: PMC8505329 DOI: 10.1007/s00384-021-03963-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE No clear consensus exists on how to routinely assess the integrity of the colorectal anastomosis prior to ileostomy reversal. The objective of this study was to evaluate the accuracy of contrast enema, endoscopic procedures, and digital rectal examination in rectal cancer patients in this setting. METHODS A systematic literature search was performed. Studies assessing at least one index test for which a 2 × 2 table was calculable were included. Hierarchical summary receiver operating characteristic curves were calculated and used for test comparison. Paired data were used where parameters could not be calculated. Methodological quality was assessed with the QUADAS-2 tool. RESULTS Two prospective and 11 retrospective studies comprising 1903 patients were eligible for inclusion. Paired data analysis showed equal or better results for sensitivity and specificity of both endoscopic procedures and digital rectal examination compared to contrast enema. Subgroup analysis of contrast enema according to methodological quality revealed that studies with higher methodological quality reported poorer sensitivity for equal specificity and vice versa. No case was described where a contrast enema revealed an anastomotic leak that was overseen in digital rectal examination or endoscopic procedures. CONCLUSIONS Endoscopy and digital rectal examination appear to be the best diagnostic tests to assess the integrity of the colorectal anastomosis prior to ileostomy reversal. Accuracy measures of contrast enema are overestimated by studies with lower methodological quality. Synopsis of existing evidence and risk-benefit considerations justifies omission of contrast enema in favor of endoscopic and clinical assessment. TRIAL REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019107771.
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Abstract
PURPOSE This study investigates whether contrast enema (CE) and flexible endoscopy (FE) should be performed routinely after low anterior resection (LAR) before ileostomy reversal. Additionally, the impact of previous anastomotic leakage (AL) on diagnostic test accuracy (DTA) was assessed. METHODS This is a retrospective analysis of prospectively collected tertiary care data of two centers. Consecutive rectal cancer patients undergoing LAR with loop ileostomy formation were included. Before ileostomy reversal, all patients were assessed by CE and FE. DTA of FE and CE for asymptomatic AL in patients who had previously suffered from clinically relevant AL (group 1) compared with those without apparent AL after LAR (group 0) were assessed separately. RESULTS Two hundred ninety-three patients were included in the analysis, 86 in group 1 and 207 in group 0. Overall sensitivity for detection of asymptomatic AL was 76% (FE) and 60% (CE). Specificity was 100% for both tests. DTA of FE was equal or superior to CE in all subgroups. Prevalence of asymptomatic AL at the time of testing was 1.4% in group 0 and 25.6% in group 1. CONCLUSION Flexible endoscopy is the more accurate diagnostic test for the detection of asymptomatic anastomotic leaks prior to ileostomy reversal. Contrast enema showed no gain of information. In the group without complications after the initial rectal resection, 104 must be tested to find one leak prior to reversal. In those patients, routine diagnostic testing additional to digital rectal examination may be questioned.
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Risk factors for postoperative ileus following loop ileostomy closure. Turk J Surg 2020; 36:333-339. [PMID: 33778391 DOI: 10.47717/turkjsurg.2020.4911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/03/2020] [Indexed: 02/04/2023]
Abstract
Objectives The most common intra-abdominal complication following loop ileostomy closure (LIC) is postoperative ileus (POI). The aim of the study was to determine the risk factors of POI development following LIC and make recommendations for its prevention. Material and Methods In this study, patients having undergone LIC with peristomal incision following distal colorectal surgery were included. Clavien-Dindo classification was used to evaluate postoperative complications. POI and postoperative leakage were defined based on clinical and radiological criteria. The Centers for Disease Control and Prevention 2017 criteria were used to diagnose surgical site infection (SSI). Postoperative bleeding was diagnosed one day after surgery if there was a >2 g/dL or ≥15% decrease in the hemoglobin level. Results Seventy-nine patients were included into the study. In nine of the patients POI developed, six had SSI, five had postoperative bleeding, and two had anastomosis leakage. In the univariate analysis; age <60 years (p= 0.02), presence of comorbidity (p= 0.007), using an open technique in the first surgery (p= 0.02), performing total colectomy in the first surgery (p= 0.048), performing hand-sewn anastomosis of LIC (p= 0.01), and postoperative blood transfusion (p= 0.04) were found to be risk factors for POI. Performing hand-sewn anastomosis of LIC (p= 0.03) and using an open technique in the first surgery (p= 0.03) were found to be independent variables for POI risk. Conclusion Using an open technique in the first surgery and performing a hand-sewn anastomosis of LIC may increase POI.
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Pouchogram Prior to Ileostomy Reversal after Ileal Pouch-Anal Anastomosis in Pediatric Patients: Is it Useful in the Setting of Routine EUA? J Pediatr Surg 2020; 55:1499-1502. [PMID: 31706610 DOI: 10.1016/j.jpedsurg.2019.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/07/2019] [Accepted: 09/04/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine if there is a role for routine pouchogram before ileostomy reversal after IPAA in pediatric patients. METHODS The medical records of pediatric patients who underwent pouchogram between 2007 and 2017 prior to ileostomy reversal after IPAA at two affiliated hospitals were reviewed for concordance between exam under anesthesia (EUA) and pouchogram findings, management of abnormal pouchogram findings, and short and long-term outcomes after ileostomy reversal. Clinical notes were used to find patient-reported symptoms at the time of pouchogram. RESULTS Sixty patients (57% female) underwent pouchogram before planned ileostomy reversal. The median time from IPAA formation to pouchogram was 60.5 days (IQR: 46-77) and median follow-up was 4 years (IQR: 1-6). Fifty-seven patients (95%) were asymptomatic prior to reversal. Of the 40 asymptomatic patients with a normal EUA, pouchogram detected one stricture (3%), but reversal proceeded as planned. In the 16 patients with strictures on EUA, pouchogram only detected six (40%). One of 50 (2%) asymptomatic patients with normal pouchogram had anastomotic dehiscence found on EUA. Despite normal pouchogram and EUA, four asymptomatic patients required subsequent diversion for pouch-related complications between 13 and 60 months after ileostomy reversal. Three patients had pelvic pain prior to pouchogram; associated symptoms included perineal pain (n = 1) hematochezia (n = 1), and tenesmus (n = 1). EUA and pouchogram were concordant in two patients (n = 1 anastomotic complication, n = 1 pouch septum) and ileostomy reversal was delayed. In the remaining symptomatic patient, pouchogram detected an anastomotic leak where EUA detected only a stricture, and this prompted a delay in reversal. Long term, none of these patients required diversion or excision of their pouch. CONCLUSION Routine pouchogram in asymptomatic pediatric patients does not change management and can be omitted, thereby sparing patients discomfort and unnecessary radiation exposure. Pouchogram may have diagnostic value in symptomatic patients. LEVEL OF EVIDENCE III. TYPE OF STUDY Study of Diagnostic Test.
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Clostridium difficile Infection After Ileostomy Reversal. Ann Coloproctol 2020; 37:S4-S6. [PMID: 32178491 PMCID: PMC8359696 DOI: 10.3393/ac.2019.09.24] [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: 08/25/2019] [Accepted: 09/24/2019] [Indexed: 11/03/2022] Open
Abstract
Clostridium difficile infection (CDI) after ileostomy reversal is rare, with few reports available in the available literature describing this condition. The diagnosis of CDI after ileostomy reversal is challenging because symptoms such as diarrhea observed in these patients can occur frequently after surgery. However, CDI can be fatal, so early diagnosis and prompt treatment are important. We discuss 2 patients with positive C. difficile toxin assay results on stool cultures performed after ileostomy reversal. Clinical progression differed between these patients: one patient who presented with severe CDI and shock was successfully treated following a prolonged intensive care unit stay for the management of vital signs and underwent hemodialysis, while another patient showed symptoms of mild colitis but we could not confirm whether diarrhea was associated with CDI or with the usual postoperative state. To our knowledge, these represent 2 of just a few cases reported in the literature describing CDI after ileostomy reversal.
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[Efficacy comparison of purse-string vs. linear closure of the wound following stoma reversal: systematic review and meta-analysis]. ZHONGHUA WEI CHANG WAI KE ZA ZHI = CHINESE JOURNAL OF GASTROINTESTINAL SURGERY 2019; 22:1188-1195. [PMID: 31874537 DOI: 10.3760/cma.j.issn.1671-0274.2019.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Objective: To compare the efficacy of purse-string skin closure (PSC) and linear skin closure (LSC) in stoma reversal. Methods: Randomized controlled trials (RCT) comparing the use of PSC and LSC during stoma reversal were searched from Embase, PubMed, Web of Science, CNKI net, Wanfang database, VIP Chinese Science and Technology Journal Database. Literature inclusion criteria: (1) randomized controlled trials about comparing PSC and LSC in stoma reversal published publicly; only including English literature; (2) patients undergoing stoma (ileostomy or colostomy) reversal without limitation of age, sex and ethnicity; (3) PSC group receiving the suture of the dermis layer of the skin by purse-string suture, and forming a pore channel in the center of the skin after tightening and knotting, in order to achieve the purpose of secondary healing; the LSC group receiving the suture of the skin with conventional simple interrupted suture; (4) the enrolled literatures needed to include at least one of the following outcome indicators: the primary outcome was the incidence of SSI; the secondary outcome included the operation time, incisional hernia, hospital stay and patient satisfaction. Literature exclusion criteria: (1) duplicate published studies, incomplete studies, reviews, case reports, unpublished literature, retrospective studies, non-RCT. The search time ended on November 15, 2018. The basic information and important outcome indicators of the included articles were extracted. The Cochrane bias risk assessment tool was used to evaluate the quality of the selected literatures. Patient satisfaction was assessed using the following scales: (1) the patient and observer scar assessment scale (POSAS); (2) the body image questionnaire (BIQ); (3) Likert scale; (4) short form 36 (SF-36), version 2; (5) visual analog scale (VAS). Meta-analysis was performed using Review manager 5.3 software provided by the Cochrane Collaboration. Results: A total of 9 randomized controlled trials were included, involving 806 patients with 411 cases in the PSC group and 395 cases in the LSC group. Baseline data such as age, gender, body mass index (BMI), underlying disease, and anesthesia grading were not significantly different between the two groups (all P>0.05). The quality of these nine randomized controlled trials was high. Because the evaluation methods for these studies are not uniform, it is impossible to conduct a meta-analysis of patient satisfaction. However, from the summary results of various studies, the postoperative satisfaction of the purse-string suture group was better than that of the linear suture group. The meta-analysis showed that there was significant difference in postoperative SSI incidence between the PSC group and the LSC group [OR=0.14, 95%CI: 0.08-0.24, P<0.00001], while there were no significant differences in incidence of incisional hernia [OR=0.66, 95%CI: 0.24-1.82, P=0.42], operation time [MD=0.61, 95%CI: -3.17-4.38, P=0.75], and hospital stay [MD=-0.26, 95%CI: -0.82-0.30, P=0.37]. Conclusions: PSC can be used for closure of the wound following stoma reversal. Compared with LSC, PSC can significantly reduce the incidence of SSI, and increase patients' satisfaction.
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Resting vector volume measured before ileostomy reversal may be a predictor of major fecal incontinence in patients with mid or low rectal cancer: a longitudinal cohort study using a prospective clinical database. Int J Colorectal Dis 2019; 34:1079-1086. [PMID: 30997602 DOI: 10.1007/s00384-019-03293-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Despite a high incidence of fecal incontinence following sphincter-preservation surgery (SPS), there are no definitive factors measured before ileostomy reversal that predict fecal incontinence. We investigated whether vector volume anorectal manometry before ileostomy reversal predicts major fecal incontinence following SPS in patients with mid or low rectal cancer. METHODS This longitudinal prospective cohort study comprised 173 patients who underwent vector volume anorectal manometry before ileostomy reversal. The Fecal Incontinence Severity Index was measured 1 year after the primary SPS and classified as major incontinence (FISI score ≥ 25) or continent/minor incontinence (FISI score < 25). Multivariable logistic regression analysis was used to identify predictors of major incontinence. RESULTS Ninety-two patients (53.1%) had major incontinence. Although tumor stage, location, and neoadjuvant chemoradiotherapy were comparable, the major incontinence group had lower resting pressure (28.4 vs. 34.3 mmHg, P = 0.027), greater asymmetry at rest (39.1% vs. 34.1%, P = 0.002) and squeezing (34.2% vs. 31.4%, P = 0.046), shorter sphincter length (3.3 vs. 3.7 cm, P = 0.034), and lower resting vector volume (143,601 vs. 278,922 mmHg2 mm, P < 0.001) compared with the continent/minor incontinence group. Resting vector volume was the only independent predictor of major incontinence (odds ratio = 0.675 per 100,000 mmHg2 mm, 95% confidence interval, 0.532-0.823; P = 0.006). CONCLUSIONS This study revealed that resting vector volume before ileostomy reversal may predict major fecal incontinence. We suggest that the physiology of the anorectum should be discussed with patients before ileostomy reversal in patients at high risk of fecal incontinence.
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Impact of surgical proficiency levels on postoperative morbidity: a single centre analysis of 558 ileostomy reversals. Int J Colorectal Dis 2018. [PMID: 29536237 DOI: 10.1007/s00384-018-3026-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Defunctioning ileostomies reduce the consequences of distal anastomotic leakage following bowel resections. Ileostomy reversal in itself, however, is associated with appreciable morbidity (3-40%) and mortality (0-4%). Despite being a common teaching procedure, there is limited information on the impact of surgical proficiency levels on postoperative outcome. METHODS Adult patients undergoing closure of a defunctioning ileostomy between September 2008 and January 2017 were identified from a surgical administrative database that was collected prospectively (n = 558). Baseline characteristics (age, ASA score, BMI, health care insurance coverage) and closure techniques were recorded. Operation time, rate of bowel resection, postoperative complications ranked by Clavien-Dindo classification and length of stay were analysed with respect to proficiency levels (residents vs. consultants). RESULTS Two hundred three ileostomy reversals were performed by residents; 355 ileostomies were closed by consultants. Operation time was considerably shorter in the consultant group (p < 0.001). Major postoperative complication rates however were not different among the groups when adjusted for possible confounders (p = 0.948). The rate of anastomotic leakage was 3% and the overall major morbidity rate was 11%. CONCLUSION Operation time rather than surgical outcome and overall morbidity were affected by surgical proficiency levels. Therefore, ileostomy reversal can be considered an appropriate teaching operation for young general surgery trainees.
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Abstract
BACKGROUND Individual trials comparing hand-sewn with stapled closure of loop ileostomy show different outcomes due to lack of statistical power. A systematic review, with a pooled analysis of results, might provide a more definitive answer. This review aimed to compare hand-sewn with stapled anastomotic technique for closure of a loop ileostomy and looked at the effect of bowel resection on the complication rates. METHODOLOGY Relevant studies were identified from MEDLINE, EMBASE and the Cochrane database. All randomised clinical trials, prospective and retrospective studies comparing hand-sewn with stapled closure of loop ileostomy were included. RESULTS Of the 4,917 patients in 15 identified studies, 3,406 had hand-sewn and 1,511 stapled anastomosis. There was no difference in the rate of anastomotic leak between the hand-sewn (2.93%, 55/1,877) and the stapled group (2.08%, 25/1,202) (OR 0.81, 95% CI 0.43-1.54, p = 0.52, I2 = 33%). The rate of small-bowel obstruction was higher in the hand-sewn group (7.03%, 231/3,284) compared to the stapled group (5.58%, 73/1,308; OR 0.69, 95% CI 0.51-0.92, p = 0.01, I2 = 0%). There was no difference in the incidence of anastomotic leak and small-bowel obstruction in the hand-sewn anastomosis between patients with or without bowel resection. CONCLUSIONS There was no significant difference in the rate of anastomotic leakage between the hand-sewn and stapled techniques. The rate of small-bowel obstruction was higher in the hand-sewn group. Performance of bowel resection does not significantly increase the incidence of anastomotic leak or small-bowel obstruction.
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Risk Factors for Postoperative Complications Following Diverting Loop Ileostomy Takedown. J Gastrointest Surg 2017; 21:2048-2055. [PMID: 28971302 DOI: 10.1007/s11605-017-3567-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 08/27/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Diverting loop ileostomies are frequently created to divert the fecal stream in an effort to protect downstream anastomoses. These are later reversed to restore intestinal continuity. The goal of this study is to evaluate risk factors for postoperative complications following diverting loop ileostomy takedown. MATERIALS AND METHODS Patients who underwent diverting loop ileostomy takedown between January 1, 2010 and April 28, 2015 were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified and a hierarchical logistic regression model was used to identify risk factors for postoperative complications. RESULTS 1,737 patients met the inclusion criteria. Rates of postoperative complications were generally low. Mean length of stay (LOS) was 5.6 (± 4.5) days. Outcomes of interest were the following: overall morbidity, serious morbidity, extended LOS, SSI, UTI, pneumonia, readmission, reoperation, and mortality. Risk factors for these outcomes included the following: ASA class, bleeding disorder, prolonged operative time, race, tobacco use, gender, steroid use, peripheral vascular disease, weight loss, and functional status. CONCLUSIONS Diverting loop ileostomy takedown has a complication rate of approximately 20%. Higher ASA class, longer operative times, history of bleeding disorder, and functional status were identified as risk factors for most complications.
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The safety and feasibility of early discharge following ileostomy reversal: a National Surgical Quality Improvement Program analysis. J Surg Res 2017; 217:247-251. [PMID: 28711368 DOI: 10.1016/j.jss.2017.06.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/23/2017] [Accepted: 06/16/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study aimed to compare 30-day clinical outcomes following routine ileostomy reversal between patients that underwent early discharge (<24 h) and standard discharge (postoperative day [POD] 2 or 3). METHODS A retrospective cohort analysis was conducted between 2005 and 2014 using the American College of Surgeons National Surgical Quality Improvement Program data set. All patients undergoing ileostomy reversal who were discharged on POD 0 or 1 (early discharge group [EDG]) versus POD 2 or 3 (standard discharge group [SDG]) were identified. The primary outcome was the 30-day adverse event rate. The secondary outcome was the 30-day readmission rate. A multivariate analysis was performed to determine the adjusted effect of early discharge as well as the predictors of adverse events and readmissions. RESULTS The study population consisted of 355 and 5805 patients in the EDG and SDG, respectively. There were 19 (5.4%) 30-day adverse events in the EDG and 341 (5.8%) in the SDG. The EDG had 17 (4.8%) 30-day readmissions and the SDG had 294 (5.1%). The adjusted odds ratio for 30-day adverse events in the EDG was 0.95 (P = 0.83), and for 30-day readmissions, it was 1.01 (P = 0.96). Higher BMI, longer operative time, ASA ≥3, chronic steroid use along with a history of bleeding disorder were significant predictors for adverse events and readmissions. CONCLUSIONS Select patients discharged within 24 h of ileostomy reversal did not have a significantly higher rate of adverse events or readmissions compared to patients discharged on POD 2 or 3 following uncomplicated surgery. Predictors of adverse events and readmissions can guide the selection of patients suitable for early discharge.
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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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Abstract
INTRODUCTION The Barcelona technique for bowel anastomosis is not well described in the currently available literature, but it saves steps when compared to conventional stapled anastomoses. In short, the proximal and distal ends of a resection margin are approximated, small enterotomies made, a stapler is passed into both lumens creating a common channel, and lastly, this same stapler is used to create the anastomosis and amputate the specimen. We report on this technique with ileostomy reversal in terms of cost and complications. MATERIALS AND METHODS Review of ileostomy reversals (2006-2014) by a single surgical oncologist. RESULTS Thirty patients had surgery using the Barcelona technique. Median age was 58 years, and median postoperative surgical stay was 3 days. The majority of patients had rectal cancer initially treated with low anterior resection and diverting loop ileostomy (80 %). One patient had a wound infection (3 %), and there were no anastomotic leaks, intra-abdominal abscesses, or strictures. This technique required fewer stapler loads saving $510 in charges per case. CONCLUSIONS The Barcelona technique is safe and effective for ileostomy reversal. There are reduced costs related to equipment as compared to the conventional technique and thus the use of this method can result in significant medical cost savings.
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Conventional Linear versus Purse-string Skin Closure after Loop Ileostomy Reversal: Comparison of Wound Infection Rates and Operative Outcomes. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2011; 27:58-63. [PMID: 21602963 PMCID: PMC3092076 DOI: 10.3393/jksc.2011.27.2.58] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 01/30/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE Wound infection after an ileostomy reversal is a common problem. To reduce wound-related complications, purse-string skin closure was introduced as an alternative to conventional linear skin closure. This study is designed to compare wound infection rates and operative outcomes between linear and purse-string skin closure after a loop ileostomy reversal. METHODS Between December 2002 and October 2010, a total of 48 consecutive patients undergoing a loop ileostomy reversal were enrolled. Outcomes were compared between linear skin closure (group L, n = 30) and purse string closure (group P, n = 18). The operative technique for linear skin closure consisted of an elliptical incision around the stoma, with mobilization, and anastomosis of the ileum. The rectus fascia was repaired with interrupted sutures. Skin closure was performed with vertical mattress interrupted sutures. Purse-string skin closure consisted of a circumstomal incision around the ileostomy using the same procedures as used for the ileum. Fascial closure was identical to linear closure, but the circumstomal skin incision was approximated using a purse-string subcuticular suture (2-0 Polysorb). RESULTS Between group L and P, there were no differences of age, gender, body mass index, and American Society of Anesthesiologists (ASA) scores. Original indication for ileostomy was 23 cases of malignancy (76.7%) in group L, and 13 cases of malignancy (77.2%) in group P. The median time duration from ileostomy to reversal was 4.0 months (range, 0.6 to 55.7 months) in group L and 4.1 months (range, 2.2 to 43.9 months) in group P. The median operative time was 103 minutes (range, 45 to 260 minutes) in group L and 100 minutes (range, 30 to 185 minutes) in group P. The median hospital stay was 11 days (range, 5 to 4 days) in group L and 7 days (range, 4 to 14 days) in group P (P < 0.001). Wound infection was found in 5 cases (16.7%) in group L and in one case (5.6%) in group L (P = 0.26). CONCLUSION Based on this study, purse-string skin closure after a loop ileostomy reversal showed comparable outcomes, in terms of wound infection rates, to those of linear skin closure. Thus, purse-string skin closure could be a good alternative to the conventional linear closure.
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