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Gouvas N, Manatakis D, Agalianos C, Dimitriou N, Baloyiannis I, Tzovaras G, Xynos E. Defunctioning Ileostomy After Low Anterior Resection of Rectum: Morbidity Related to Fashioning and Closure. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1864. [PMID: 39597049 PMCID: PMC11596492 DOI: 10.3390/medicina60111864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2024] [Revised: 09/21/2024] [Accepted: 11/06/2024] [Indexed: 11/29/2024]
Abstract
Background and Objectives: The aim of this study was to assess any predisposing factors to the morbidity of fashioning and reversal of diverting ileostomy in a prospective cohort of patients who have undergone TME and low colo-rectal or colo-anal anastomosis for rectal cancer. Materials and Methods: Consecutive patients with rectal cancer undergoing low anterior resection and a defunctioning loop ileostomy in three surgical units from 2016 to 2020 were included in the study and retrospectively analyzed. Results: One hundred eighty-two patients from three centres were included. Ileostomy-related mortality was 0.5%, attributed to renal failure.. Ileostomy-related morbidity was 46%. Postoperative ileus was seen in 37.4%, and dehydration in 18.8% of the patients. The readmission rate for ileostomy-related reasons was 15.4%. Stoma care was problematic in 15.7% or poor in 7% of the cases. Advanced age, male gender and obesity were independent risk factors for ileostomy-related morbidity. Ileostomy was reversed in 165 patients. The morbidity in 165 patients was 16%. Ileus was seen in 10.3%, anastomotic leak in 4.8% and wound infection in 12.7% of the cases. One patient died because of an anastomotic leak. No predisposing factors that affect the outcomes of ileostomy closure were identified. Conclusions: Diverting ileostomy-related morbidity is high. Life threatening dehydration and renal failure from ileus is more commonly seen in elderly, male and obese patients and should be anticipated. Ileostomy closure-related morbidity is low.
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Affiliation(s)
- Nikolaos Gouvas
- Department of General Surgery, Medical School, University of Cyprus, Nicosia 2404, Cyprus;
| | - Dimitrios Manatakis
- Department of General Surgery, Naval & Veterans Hospital, 11521 Athens, Greece;
| | - Christos Agalianos
- Department of General Surgery, Naval & Veterans Hospital, 73200 Chania, Greece;
| | - Nikoletta Dimitriou
- Department of General Surgery, Medical School, University of Cyprus, Nicosia 2404, Cyprus;
| | - Ioannis Baloyiannis
- Department of General Surgery, University Hospital of Larissa, 41334 Larisa, Greece; (I.B.); (G.T.)
| | - George Tzovaras
- Department of General Surgery, University Hospital of Larissa, 41334 Larisa, Greece; (I.B.); (G.T.)
| | - Evangelos Xynos
- Department of General Surgery, Creta Interclinic Hospital, 71304 Heraklion, Greece;
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Yang S, Tang G, Zhang Y, Wei Z, Du D. Meta-analysis: loop ileostomy versus colostomy to prevent complications of anterior resection for rectal cancer. Int J Colorectal Dis 2024; 39:68. [PMID: 38714581 PMCID: PMC11076370 DOI: 10.1007/s00384-024-04639-2] [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] [Accepted: 04/25/2024] [Indexed: 05/10/2024]
Abstract
PURPOSE Anastomotic leakage is a serious complication of colorectal cancer surgery, prolonging hospital stays and impacting patient prognosis. Preventive colostomy is required in patients at risk of anastomotic fistulas. However, it remains unclear whether the commonly used loop colostomy(LC) or loop ileostomy(LI) can reduce the complications of colorectal surgery. This study aims to compare perioperative morbidities associated with LC and LI following anterior rectal cancer resection, including LC and LI reversal. METHODS In this meta-analysis, the Embase, Web of Science, Scopus, PubMed, and Cochrane Library databases were searched for prospective cohort studies, retrospective cohort studies, and randomized controlled trials (RCTs) on perioperative morbidity during stoma development and reversal up to July 2023, The meta-analysis included 10 trials with 2036 individuals (2 RCTs and 8 cohorts). RESULTS No significant differences in morbidity, mortality, or stoma-related issues were found between the LI and LC groups after anterior resection surgery. However, patients in the LC group exhibited higher rates of stoma prolapse (RR: 0.39; 95%CI: 0.19-0.82; P = 0.01), retraction (RR: 0.45; 95%CI: 0.29-0.71; P < 0.01), surgical site infection (RR: 0.52; 95%CI: 0.27-1.00; P = 0.05) and incisional hernias (RR: 0.53; 95%CI: 0.32-0.89; P = 0.02) after stoma closure compared to those in the LI group. Conversely, the LI group showed higher rates of dehydration or electrolyte imbalances(RR: 2.98; 95%CI: 1.51-5.89; P < 0.01), high-output(RR: 6.17; 95%CI: 1.24-30.64; P = 0.03), and renal insufficiency post-surgery(RR: 2.51; 95%CI: 1.01-6.27; P = 0.05). CONCLUSION Our study strongly recommends a preventive LI for anterior resection due to rectal cancer. However, ileostomy is more likely to result in dehydration, renal insufficiency, and intestinal obstruction. More multicenter RCTs are needed to corroborate this.
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Affiliation(s)
- Shilai Yang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gang Tang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yudi Zhang
- College of Combination of Chinese and Western Medicine, Chongqing College of Traditional Chinese Medicine, No. 61, Puguobao Road, Bicheng Street, Bishan District, Chongqing, 402760, P.R. China
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Donglin Du
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Yang S, Lin Y, Zhong W, Xu W, Huang Z, Cai S, Chen W, Zhang B. Impact of ileostomy on postoperative wound complications in patients after laparoscopic rectal cancer surgery: A meta-analysis. Int Wound J 2024; 21:e14493. [PMID: 37989718 PMCID: PMC10898402 DOI: 10.1111/iwj.14493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 10/25/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023] Open
Abstract
To prevent anastomotic leakage and other postoperative complications after laparoscopic rectal cancer surgery, a protective ileostomy is often used. However, the necessity of performing ileostomy after laparoscopic rectal cancer remains controversial. The aim of this meta-analysis was to assess the benefit of ileostomy on wound infection after laparoscopic rectal cancer. The Cochrane Library, EMBASE, Web of Science, and PubMed were used to retrieve all related documents up to September 2023. Completion of the trial literature was submitted once the eligibility and exclusion criteria were met and the literature quality assessment was evaluated. This study compared the post-operative post-operative complications of an ileostomy with that of non-ileostomy in a laparoscope. We used Reman 5.3 to analyse meta-data. Controlled studies were evaluated with ROBINS-I. The meta-analyses included 525 studies, and 5 publications were chosen to statistically analyse the data according to the classification criteria. There was no statistically significant difference in the rate of postoperative wound infections among ostomate and nonostomate (odds ratio [OR], 1.79; 95% confidence interval [CI], 0.66, 4.84; p = 0.25). In 5 trials, the incidence of anastomotic leak was increased after surgery in nonostomate patients (OR, 0.26; 95% CI, 0.12, 0.57; p = 0.0009). Two studies reported no significant difference in the length of operation time when nonstomal compared to stomal operations in patients with rectal cancer (mean difference, 0.87; 95% CI, -2.99, 4.74; p = 0.66). No significant difference was found in the rate of wound infection and operation time after operation among the two groups, but the incidence of anastomosis leak increased after operation. Protective ileostomy after laparoscopic rectal cancer was effective in reducing the risk of anastomotic leakage in patients, and we found no additional risk of infection. We cautiously conclude that protective ileostomy is active and necessary for patients with a high risk of anastomotic leakage after surgery, which needs to be further confirmed by high-quality studies with larger samples.
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Affiliation(s)
- Shu Yang
- Department of Traditional Chinese MedicineThe Second Affiliated Hospital of Fujian Medical UniversityQuanzhouChina
| | - Yuting Lin
- Department of Traditional Chinese MedicineThe Second Affiliated Hospital of Fujian Medical UniversityQuanzhouChina
| | - Wenjin Zhong
- Department of Clinical LaboratoryThe Second Affiliated Hospital of Fujian Medical UniversityQuanzhouChina
| | - Wenji Xu
- Department of GastroenterologyThe Second Affiliated Hospital of Fujian Medical UniversityQuanzhouChina
| | - Zhongxin Huang
- Department of PathologyThe Second Affiliated Hospital of Fujian Medical UniversityQuanzhouChina
| | - Suqin Cai
- Department of PathologyThe Second Affiliated Hospital of Fujian Medical UniversityQuanzhouChina
| | - Wen Chen
- Department of Traditional Chinese MedicineThe Second Affiliated Hospital of Fujian Medical UniversityQuanzhouChina
| | - Baogen Zhang
- Department of Traditional Chinese MedicineThe Second Affiliated Hospital of Fujian Medical UniversityQuanzhouChina
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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: 3] [Impact Index Per Article: 1.5] [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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Keramati MR, Meshkati Yazd SM, Shahriarirad R, Ahmadi Tafti SM, Kazemeini A, Behboudi B, Fazeli MS, Keshvari A. Hand-sewn direct repair versus resection and hand-sewn anastomosis techniques for the reversal of diverting loop ileostomy after lower anterior rectal resection surgery: A randomized clinical trial. J Surg Oncol 2023; 127:798-805. [PMID: 36576493 DOI: 10.1002/jso.27185] [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: 09/02/2022] [Revised: 10/27/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Several techniques have been proposed for the closure of loop ileostomy. This is the first study comparing bowel function and outcomes of two different hand-sewn surgical techniques used for the closure of diverting protective loop ileostomy. METHOD In this prospective, randomized, double-blind clinical trial, 40 patients with a history of rectal cancer, low anterior resection, and diverting loop ileostomy who were candidates for ileostomy reversal were included and randomly assigned into two groups, hand-sewn direct repair of the ileal defect (group A) and resection and hand-sewn anastomosis of the ileum (group B). RESULTS The mean age of patients was 56.42 and 52.10 years in groups A and B, respectively. Regarding early postoperative period, group A developed earlier first gas passage (1.68 vs. 2.25 days, p = 0.041) and stool passage (2.10 vs. 2.80 days, p = 0.032). Group A also revealed shorter operating time (83.68 vs. 89.50 min, p = 0.040) and hospital stay (4.73 vs. 6.80 days, p = 0.001). None of the participants in both groups developed signs of bowel obstruction during the early and late postoperative follow-up period. CONCLUSIONS Direct hand-sewn repair for the closure of diverting loop ileostomy is a safe technique with better postoperative bowel function, oral diet tolerance, and less hospital stay compared to resection and hand-sewn anastomosis of the ileum.
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Affiliation(s)
- Mohammad Reza Keramati
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mostafa Meshkati Yazd
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Mohsen Ahmadi Tafti
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Kazemeini
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Behboudi
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sadegh Fazeli
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Keshvari
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Tyler R, Foss H, Phelan L, Radley S, Geh I, Karandikar S. Impact of surgeon volume on 18-month unclosed ileostomy rate after restorative rectal cancer resection. Colorectal Dis 2023; 25:253-260. [PMID: 36222737 DOI: 10.1111/codi.16368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/03/2022] [Indexed: 02/08/2023]
Abstract
AIM The impact of surgeon volume on 18-month unclosed ileostomy rates after rectal cancer surgery has not been fully explored. The aim of this study was to describe the effect of surgeon volume and evaluate factors predictive of an unclosed ileostomy. METHOD Patients undergoing anterior resection with a diverting ileostomy for rectal cancer from March 2004 to October 2018 were identified from a prospectively maintained database. The unclosed ileostomy rate was determined by those with an unclosed ileostomy at 18 months. High- and low-volume surgeons (HVS and LVS, respectively) were classed as those performing five or more or fewer than five rectal cancer resections per year, respectively. Data on sex, age, American Society of Anesthesiologists grade, neoadjuvant chemoradiotherapy (CRT), tumour height, T-stage, anastomotic leak, surgical approach and adjuvant chemotherapy were also collected. Factors predictive of an unclosed ileostomy at 18 months were explored using a multivariate binary logistic regression analysis. RESULTS A total of 415 patients (62.4% male) with a median age of 67 were eligible for analysis. Of these, 115 (27.7%) had an unclosed ileostomy at 18 months. HVS had an unclosed ileostomy rate of 24.6% (72/292) compared with 34.9% (43/123) for LVS. Volume was associated with an unclosed ileostomy in univariable analysis (p = 0.032) but not in multivariate analysis (OR 1.75, 95% CI 0.92-3.32, p = 0.08). Independent factors predictive of an unclosed ileostomy were anastomotic leak (OR 10.41, 3.95-27.0, p < 0.01), adjuvant chemotherapy (OR 2.23, 1.24-3.96, p < 0.01) and neoadjuvant CRT (OR 2.16, 1.15-5.75, p = 0.01). CONCLUSION LVS were associated with a higher unclosed ileostomy at 18 months compared with HVS. This study adds further weight to the call for adoption of a minimum annual case threshold in rectal cancer surgery.
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Affiliation(s)
| | - Helen Foss
- Birmingham Heartlands Hospital, Birmingham, UK
| | - Liam Phelan
- Birmingham Heartlands Hospital, Birmingham, UK
| | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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A diversion stoma after anterior resection for rectal cancer. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract108920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
This review covers the problem of forming a diverting stoma during resections of the rectum with primary anastomosis. The incidence of rectal cancer tends to increase, and surgical resection remains the main method of treatment. Anastomotic leakage significantly increases the postoperative mortality. The most effective way to prevent severe complications is the formation of a diverting stoma. However, the indications, the choice of a specific technique and the timing of the stoma elimination are not clearly defined. This review discusses the state of the problem, special attention is paid to the choice of the level of stoma formation (ileostomy or transversostomy).
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Comparison of postoperative complication rates between a novel endoluminal balloon-assisted drainage and diverting stoma after low rectal cancer. Clin Transl Oncol 2022; 24:1347-1353. [PMID: 35029803 DOI: 10.1007/s12094-021-02775-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
Abstract
AIM To introduce a novel endo-luminal balloon-assisted drainage (EBAD) and compare postoperative complication rates between EBAD and diverting stoma (DS) groups. METHODS The single center prospective non-random cohort study included a total of 163 patients in convenience patients with rectal cancer between January 2019 and January 2021. Out of 163 patients, 83 underwent DS and 80 EBAD. Primary endpoints were postoperative complication rate. RESULTS The total number of complications was 28 in the DS group vs. 22 in the EBAD group (P = 0.388). 18 patients (21.7%) in the DS group and 14 patients (17.5%) in the EBAD group developed postoperative complication (P = 0.501). There were no differences identified for anastomotic leak rates between the two groups (P = 0.677). The rate of the pelvic abscess was lower in the EBAD group (1/80, 1.3%) than in the DS group (4/83, 4.8%) but with no statistical significance (P = 0.386). Compared with the DS group, the median operative time was shorter in the EBAD group (225 vs. 173.5 min, P < 0.001). Regarding incomplete small bowel obstruction, a higher prevalence was observed in the DS group compared to the EBAD group (7.2% vs 2.5%, P = 0.301). 7 patients (11.3%) in the DS group developed a para-stomal hernia, while no patient suffered a catheter-related complication. The median postoperative hospital stay was shorter in the DS groups than in the EBAD group (7 vs 8 days, P = 0.009). The median residence time of endo-luminal balloon-assisted drainage was 5.41 days. The median average and total volume of drainage were 51.57 ml/day and 255 ml, respectively. CONCLUSION EBAD is feasible and safe with similar postoperative complications when compared with a DS. EBAD may replace DS after rectum resection.
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Aker M, Askari A, Rabie M, Aly M, Adegbola S, Patel K, Currow C, Nunn R, Hadjittofi C, Rankin A, Halai S, Elsamani K, Bondje S, Mohamed I, Lee J, Wong J, Robertson-Waters E, Uddin A, Hollingshead J. Management of anastomotic leaks after elective colorectal resections: The East of England experience. A retrospective cohort. Int J Surg 2021; 96:106167. [PMID: 34752951 DOI: 10.1016/j.ijsu.2021.106167] [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: 08/10/2021] [Revised: 10/26/2021] [Accepted: 10/31/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Colorectal anastomotic leaks (AL) are associated with high morbidity and mortality. Management of AL and its intra-operative decision making is often difficult. The aim of this multi-centre study is to explore different management strategies, including different surgical options, and analyse rates and patterns of failure of initial management. METHODS All consecutive patients who had a confirmed AL after elective colorectal resections from 1st January 2014 to 31st December 2019 were included at seven hospitals across the East of England Region. Morbidity (length of stay, and failures) and mortality were compared across the different management strategies, and survival analyses were performed (Clinicaltrials.gov ID: NCT05000580). RESULTS Across all seven hospitals, a total of 3391 elective resection were done during the study period. 201 (5.9%) consecutive patients with confirmed AL were included. The initial treatment was conservative in 102(50.7%). 19 patients (9.5%) had a radiological procedure, 80 (39.8%) of patients required surgery as an initial treatment post AL. Of those who initially did not have a surgical intervention (n = 121), 10% (n = 12/121) eventually required laparotomy, 2 additional patients required transanal drainage. Ultimately 45.8% (n = 92/201) of the whole population eventually required a laparotomy. Patients managed conservatively had a shorter LOS when compared to either radiological drainage or surgical patients. Patients with a defunctioning stoma are more likely to have a successful conservative management and shorter LOS. 90-day mortality across the entire population was 8.1%. There were no significant differences in mortality or long-terms survival between the different initial treatment modalities or whether the leak was right or left sided. CONCLUSION Despite initial conservative, antibiotic and radiological intervention being successful in the majority of patients, two out of five patients will still require a laparotomy and over a quarter of patients will have an end stoma.
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Affiliation(s)
- Medhat Aker
- Surgical Trainees of East of England Research (STEER) Collaborative, United Kingdom Colorectal Consultant, West Hertfordshire Hospitals NHS Trust, United Kingdom Department of general surgery, Ainshams University, Egypt
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Zelga P, Kluska P, Zelga M, Piasecka-Zelga J, Dziki A. Patient-Related Factors Associated With Stoma and Peristomal Complications Following Fecal Ostomy Surgery: A Scoping Review. J Wound Ostomy Continence Nurs 2021; 48:415-430. [PMID: 34495932 DOI: 10.1097/won.0000000000000796] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE Ostomy creation is often an integral part of the surgical management of various diseases including colorectal malignancies and inflammatory bowel disease. Stoma and peristomal complications may occur in up to 70% of patients following ostomy surgery. The aim of this scoping literature review was to synthesize evidence on the risk factors for developing complications following creation of a fecal ostomy. DESIGN Scoping literature review. SEARCH STRATEGY Two independent researchers completed a search of the online bibliographic databases PubMed, MEDLINE, Cochrane, Google Scholar, and EMBASE for all articles published between January 1980 and December 2018. The search comprised multiple elements including systematic literature reviews with meta-analysis of pooled findings, randomized controlled trials, cohort studies, observational studies, other types of review articles, and multiple case reports. We screened 307 unique titles and abstracts; 68 articles met our eligibility criteria for inclusion. The methodological rigor of study quality included in our scoping review was variable. FINDINGS/CONCLUSIONS We identified 6 risk factors associated with an increased likelihood of stoma or peristomal complications (1) age more than 65 years; (2) female sex; (3) body mass index more than 25; (4) diabetes mellitus as a comorbid condition; (5) abdominal malignancy as the underlying reason for ostomy surgery; and (6) lack of preoperative stoma site marking and WOC/ostomy nurse specialist care prior to stoma surgery. We also found evidence that persons with a colostomy are at a higher risk for prolapse and parastomal hernia. IMPLICATIONS Health care professionals should consider these risk factors when caring for patients undergoing fecal ostomy surgery and manage modifiable factors whenever possible. For example, preoperative stoma site marking by an ostomy nurse or surgeon familiar with this task, along with careful perioperative ostomy care and education of the patient by an ostomy nurse specialist, are essential to reduce the risk of modifiable risk factors related to creation of a fecal ostomy.
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Affiliation(s)
- Piotr Zelga
- Piotr Zelga, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Piotr Kluska, MD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Marta Zelga, MD, Department of Pediatric Surgery, Urology and Transplantology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
- Joanna Piasecka-Zelga, PhD, Research Laboratory for Medicine and Veterinary Products in the GMP Quality System, Nofer Institute of Occupational Medicine, Lodz, Poland
- Adam Dziki, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - Piotr Kluska
- Piotr Zelga, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Piotr Kluska, MD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Marta Zelga, MD, Department of Pediatric Surgery, Urology and Transplantology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
- Joanna Piasecka-Zelga, PhD, Research Laboratory for Medicine and Veterinary Products in the GMP Quality System, Nofer Institute of Occupational Medicine, Lodz, Poland
- Adam Dziki, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - Marta Zelga
- Piotr Zelga, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Piotr Kluska, MD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Marta Zelga, MD, Department of Pediatric Surgery, Urology and Transplantology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
- Joanna Piasecka-Zelga, PhD, Research Laboratory for Medicine and Veterinary Products in the GMP Quality System, Nofer Institute of Occupational Medicine, Lodz, Poland
- Adam Dziki, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - Joanna Piasecka-Zelga
- Piotr Zelga, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Piotr Kluska, MD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Marta Zelga, MD, Department of Pediatric Surgery, Urology and Transplantology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
- Joanna Piasecka-Zelga, PhD, Research Laboratory for Medicine and Veterinary Products in the GMP Quality System, Nofer Institute of Occupational Medicine, Lodz, Poland
- Adam Dziki, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - Adam Dziki
- Piotr Zelga, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Piotr Kluska, MD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
- Marta Zelga, MD, Department of Pediatric Surgery, Urology and Transplantology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
- Joanna Piasecka-Zelga, PhD, Research Laboratory for Medicine and Veterinary Products in the GMP Quality System, Nofer Institute of Occupational Medicine, Lodz, Poland
- Adam Dziki, MD, PhD, Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
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Park SS, Kim MJ, Lee DE, Park SC, Han KS, Hong CW, Sohn DK, Chang HJ, Oh JH. Diverting ileostomy itself may not increase the rate of postoperative readmission related to dehydration after low anterior resection. Ann Surg Treat Res 2021; 101:111-119. [PMID: 34386460 PMCID: PMC8331557 DOI: 10.4174/astr.2021.101.2.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/21/2021] [Accepted: 06/16/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was performed to evaluate the risk of readmission in the first year after low anterior resection (LAR) for patients with rectal cancer and to identify the contributing factors for readmission related to dehydration specifically. Methods This was a retrospective analysis of 570 patients who underwent LAR for rectal cancer at National Cancer Center, Republic of Korea. A diverting loop ileostomy was performed in 357 (62.6%) of these patients. Readmission was defined as an unplanned visit to the emergency room or admission to the ward. The reasons for readmission were reviewed and compared between the ileostomy (n = 357) and no-ileostomy (n = 213) groups. The risk factors for readmission and readmission due to dehydration were analyzed using multivariable logistic and Cox proportional hazard model. Results Dehydration was the most common cause of readmission in both groups (ileostomy group, 6.7%, and no-ileostomy group, 4.7%, P = 0.323). On multivariable analysis, risk factors for readmission were an estimated intraoperative blood loss of ≥400 mL (odds ratio [OR], 1.757; 95% confidence interval [CI], 1.058-2.918; P = 0.029), and postoperative chemotherapy (OR, 2.914; 95% CI, 1.824-4.653; P < 0.001). On multivariable analysis, postoperative chemotherapy, and not a diverting loop ileostomy, was an independent risk factor for dehydration-related readmission (OR, 5.102; 95% CI, 1.772-14.688; P = 0.003). Conclusion The most common cause of readmission after LAR for rectal cancer was dehydration, as reported previously. Postoperative chemotherapy, not the creation of a diverting ileostomy, was identified as the risk factor associated with readmission related to dehydration.
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Affiliation(s)
- Sung Sil Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Min Jung Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong-Eun Lee
- Biostatistics Collaboration Team, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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12
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Yellinek S, Krizzuk D, Gilshtein H, Moreno-Djadou T, de Sousa CAB, Qureshi S, Wexner SD. Early postoperative outcomes of diverting loop ileostomy closure surgery following laparoscopic versus open colorectal surgery. Surg Endosc 2021; 35:2509-2514. [PMID: 32458288 DOI: 10.1007/s00464-020-07662-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although diverting loop ileostomy (DLI) formation reduces the consequences of anastomotic leak and may also decrease the incidence of this severe complication, DLI closure can result in significant complications. The laparoscopic approach in colorectal surgery has numerous benefits, including reduced length of stay (LOS), less wound infection, and better cosmesis. The aim of this study was to determine whether a laparoscopic approach at the time of the ileostomy creation has a beneficial effect on the outcomes of ileostomy closure. METHODS A retrospective analysis of an IRB-approved prospective database was performed for all patients who underwent DLI closure between 2010 and 2017. Patients' demographics, operative reports, and postoperative course were reviewed. Statistical analyses were performed using SPSS software and included descriptive statistics, Chi-square for categorical variables, and Student's t tests for continuous variables. Skewed variables were compared using the non-parametric Mann-Whitney U test. Regression analysis for overall complications and LOS were preformed to further assess the impact of laparoscopy. RESULTS We identified 795 patients (363 females) who underwent DLI reversal surgery. The surgical approach in the index operation was laparoscopy in 65% of patients. Conversion to laparotomy at the ileostomy closure occurred in 6.1% of patients. The overall complication rate was lower and the LOS was shorter for patients who underwent DLI closure following laparoscopic surgery. Laparoscopy at the index operation was also associated with a lower incidence of postoperative ileus and a lower estimated blood loss (EBL) at the time of DLI reversal. Multivariate regression analysis found laparoscopy to have significant benefits compared to laparotomy for overall complications and for LOS. CONCLUSION Ileostomy closure following laparoscopic colorectal surgery offers benefits including reductions in LOS and overall complications.
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Affiliation(s)
- Shlomo Yellinek
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Dimitri Krizzuk
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Hayim Gilshtein
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Teresa Moreno-Djadou
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | | | - Sana Qureshi
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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13
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Alekseev MV, Shelygin YA, Rybakov EG. [Risk factors associated with non-closure of defunctioning stoma in patients with rectal cancer: univariate and multivariate analysis]. Khirurgiia (Mosk) 2021:40-47. [PMID: 33570353 DOI: 10.17116/hirurgia202102140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify the risk factors associated with non-closure of defunctioning stoma in patients with rectal cancer. MATERIAL AND METHODS A retrospective analysis included patients who underwent surgical treatment at the Ryzhikh National Medical Research Centre of Coloproctology for the period from March 2017 to August 2019. Inclusion criterion was anterior or low anterior resection followed by anastomosis and preventive stoma. Univariate and multivariate analysis enrolled 28 factors for identifying the risk factors of non-closure of defunctioning stoma. RESULTS There were 246 patients with rectal cancer. Intraoperative fluorescence angiography was applied in 145 cases to assess blood supply within the anastomosis and reduce the risk of anastomotic leakage. According to multivariate analysis, only two factors had significant influence on non-closure of preventive stoma - any grade of anastomotic leakage (OR 6.5; 95% CI 2.2-18.8, p=0.001) and rectal cancer stage IV (OR 7.2; 95% CI 1.9-27.6, p=0.004). CONCLUSION According to our data, permanent stoma is observed in 15% of patients.
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Affiliation(s)
- M V Alekseev
- Ryzhikh National Medical Research Centre of Coloproctology, Moscow, Russia.,Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - Yu A Shelygin
- Ryzhikh National Medical Research Centre of Coloproctology, Moscow, Russia.,Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - E G Rybakov
- Ryzhikh National Medical Research Centre of Coloproctology, Moscow, Russia
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14
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Du R, Zhou J, Tong G, Chang Y, Li D, Wang F, Ding X, Zhang Q, Wang W, Wang L, Wang D. Postoperative morbidity and mortality after anterior resection with preventive diverting loop ileostomy versus loop colostomy for rectal cancer: A updated systematic review and meta-analysis. Eur J Surg Oncol 2021; 47:1514-1525. [PMID: 33622575 DOI: 10.1016/j.ejso.2021.01.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/07/2021] [Accepted: 01/29/2021] [Indexed: 12/24/2022] Open
Abstract
The purpose of this meta-analysis was to evaluate the perioperative morbidity after anterior resection with diverting loop ileostomy (LI) versus colostomy (LC) and its reversal for rectal cancer. The studies on the application of loop ileostomy versus loop colostomy in anterior resection published from January 2000 to January 2020 were searched in the databases of Pubmed, Embase, Cochrane library, and Clinical trials. All randomized controlled trials (RCTs) and cohort studies were included according to inclusion criteria. Eight studies (2 RCTs and 6 cohort studies) totaling 1451 patients (821 LI and 630 LC) were included in the meta-analysis. The morbidity related to stoma formation and closure did not demonstrate significant differences. Significantly more LCs were complicated by stoma prolapse & retraction (OR:0.26,95%CI:0.11-0.60,P = 0.001), parastomal hernia (OR = 0.52,95%CI:0.30-0.88, P = 0.01), surgical site infection (SSI) (OR = 0.24,95%CI:0.11-0.49,P < 0.0001) and incisional hernias (OR = 0.39,95%CI:0.19-0.83,P = 0.01) than by LIs. Patients with LI demonstrated significantly more complications related to the stoma, such as dehydration (OR = 0.52,95%CI:0.30-0.88, P = 0.01) and ileus (OR = 2.23,95%CI:1.12-4.43, P = 0.02) than patients with LC. While after the subgroup analysis of different publication years, LI could reduce the risk of the morbidity after stoma formation in previous years group (P = 0.04) with a lower heterogeneity (I2 = 37%); LC could reduce the incidence of parastomal dermatitis in recent years group (P < 0.0001) without heterogeneity in each subgroup (I2 = 0%). Cumulative meta-analysis detected significant turning points in dehydration, SSI, and ileus. This meta-analysis recommends diverting LI in the anterior resection for rectal cancer, but there is a risk of dehydration, irritant dermatitis, and ileus.
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Affiliation(s)
- Rui Du
- Graduate School, Dalian Medical University, West Section of Lvshun South Road No. 9, Dalian 116044, China
| | - Jiajie Zhou
- Graduate School, Dalian Medical University, West Section of Lvshun South Road No. 9, Dalian 116044, China
| | - Guifan Tong
- Graduate School, Dalian Medical University, West Section of Lvshun South Road No. 9, Dalian 116044, China
| | - Yue Chang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Boyang Lake Road No. 10, Tianjin 301617, China
| | - Dongliang Li
- Clinical Medical College, Yangzhou University, Huaihai Road No.7, Yangzhou 225001, China
| | - Feng Wang
- Graduate School, Dalian Medical University, West Section of Lvshun South Road No. 9, Dalian 116044, China
| | - Xu Ding
- Clinical Medical College, Yangzhou University, Huaihai Road No.7, Yangzhou 225001, China
| | - Qi Zhang
- Clinical Medical College, Yangzhou University, Huaihai Road No.7, Yangzhou 225001, China
| | - Wei Wang
- Clinical Medical College of Yangzhou University, General Surgery Institute of Yangzhou-Yangzhou University, Northern Jiangsu People's Hospital, Nantong Road No.98, Yangzhou 225001, China
| | - Liuhua Wang
- Clinical Medical College of Yangzhou University, General Surgery Institute of Yangzhou-Yangzhou University, Northern Jiangsu People's Hospital, Nantong Road No.98, Yangzhou 225001, China
| | - Daorong Wang
- Clinical Medical College of Yangzhou University, General Surgery Institute of Yangzhou-Yangzhou University, Northern Jiangsu People's Hospital, Nantong Road No.98, Yangzhou 225001, China.
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15
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Zhang L, Zheng W, Cui J, Wu YL, Xu TL, Zhang HZ. Risk factors for nonclosure of defunctioning stoma and stoma-related complications among low rectal cancer patients after sphincter-preserving surgery. Chronic Dis Transl Med 2020; 6:188-197. [PMID: 32908969 PMCID: PMC7451586 DOI: 10.1016/j.cdtm.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Indexed: 12/15/2022] Open
Abstract
Background Defunctioning stoma is widely used to reduce anastomotic complications in rectal cancer surgery. However, the complications of stoma and stoma reversal surgery should not be underestimated. Furthermore, in some patients, stoma reversal failed. Here, we investigated the complications of defunctioning stoma surgery and subsequent reversal surgery and identify risk factors associated with the failure of getting stoma reversed. Methods In total, 154 patients who simultaneously underwent low anterior resection and defunctioning stoma were reviewed. Patients were divided into two groups according to whether their stoma got reversed or not. The reasons that patients received defunctioning stoma and experienced stoma-related complications and the risk factors for failing to get stoma reversed were analysed. Results The mean follow-up time was 47.54 (range 4.0–164.0) months. During follow-up, 19.5% of the patients suffered stoma-related long-term complications. Only 79 (51.3%) patients had their stomas reversed. The morbidity of complications after reversal surgery was 45.6%, and these mainly consisted of incision-related complications. Multivariate analyses showed that pre-treatment comorbidity (HR = 3.17, 95% CI 1.27–7.96, P = 0.014), postoperative TNM stage (HR = 2.55, 95% CI 1.05–6.18, P = 0.038), neoadjuvant therapy (HR = 2.75, 95% CI 1.07–7.05, P = 0.036), anastomosis-related complications (HR = 4.52, 95% CI 1.81–11.29, P = 0.001), and disease recurrence (HR = 24.83, 95% CI 2.90–213.06, P = 0.003) were significant independent risk factors for a defunctioning stoma to be permanent. Conclusions Defunctioning stoma is an effective method to reduce symptomatic anastomotic leakage, but the stoma itself and its reversal procedure are associated with high morbidity of complications, and many defunctioning stomas eventually become permanent. Therefore, surgeons should carefully assess preoperatively and perform defunctioning stomas in very high risk patients. In addition, doctors should perform stoma reversal surgery more actively to prevent temporary stomas from becoming permanent.
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Affiliation(s)
- Lin Zhang
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Wei Zheng
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Jian Cui
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Yun-Long Wu
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Tian-Lei Xu
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Hai-Zeng Zhang
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
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16
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Loop ileostomy versus loop colostomy as temporary deviation after anterior resection for rectal cancer. Langenbecks Arch Surg 2020; 405:1147-1153. [DOI: 10.1007/s00423-020-01940-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022]
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17
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Shiraishi T, Nishizawa Y, Ikeda K, Tsukada Y, Sasaki T, Ito M. Risk factors for parastomal hernia of loop stoma and relationships with other stoma complications in laparoscopic surgery era. BMC Surg 2020; 20:141. [PMID: 32571293 PMCID: PMC7310075 DOI: 10.1186/s12893-020-00802-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 06/18/2020] [Indexed: 12/01/2022] Open
Abstract
Background Laparoscopic approach is now a widespread technique used worldwide, but there are few recent studies on risk factors for parastomal hernia. Therefore, this study was performed to analyze the incidence of parastomal hernia in laparoscopic and open surgery in which a loop stoma was created and was intended to be temporary, and to determine risk factors for parastomal hernia formation. Associations between parastomal hernia and other stoma-related complications were also analyzed. Methods A retrospective analysis of patient and surgical characteristics was performed in 153 consecutive patients who underwent a temporary diverting loop ileostomy or colostomy after surgery related to malignant diseases at our hospital from January to December 2016. Results Parastomal hernia developed in 77 cases (50.3%), including 39 (25.5%) diagnosed by physical examination and 38 (24.8%) detected by CT alone. On multivariate analysis, a stoma not passing through the middle of the rectus abdominis muscle was the only independent risk factor for parastomal hernia formation (p = 0.005) during the median follow-up of 245.0 days. When we analyzed the factors that were associated with a stoma not passing through the middle of the rectus abdominis muscle, the only independent factor associated with this misplacement of the stoma was a laparoscopic approach (p = 0.012). An analysis of stoma-related complications showed that peristomal skin disorders were significantly associated with parastomal hernia (p = 0.049). Conclusions This study showed that a stoma that is not formed through the middle of the rectus abdominis muscle is a risk factor for parastomal hernia formation, and that a laparoscopic approach is associated with this risk factor. Moreover, parastomal hernia is significantly associated with peristomal skin disorders.
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Affiliation(s)
- Takuya Shiraishi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.,Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Agostinho N, Hamilton AE, Young CJ. Could it be an anastomotic leak? A pelvic abscess of unknown aetiology. ANZ J Surg 2019; 90:1169-1171. [PMID: 31578785 DOI: 10.1111/ans.15443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/21/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Nelson Agostinho
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Auerilius E Hamilton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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19
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Vergara-Fernández O, Trejo-Avila M, Santes O, Solórzano-Vicuña D, Salgado-Nesme N. Predictors of dehydration and acute renal failure in patients with diverting loop ileostomy creation after colorectal surgery. World J Clin Cases 2019; 7:1805-1813. [PMID: 31417926 PMCID: PMC6692275 DOI: 10.12998/wjcc.v7.i14.1805] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/17/2019] [Accepted: 06/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Despite the potential benefits of fecal diversion after low pelvic anastomosis in colorectal surgery, diverting loop ileostomy construction is related to significant rates of complications.
AIM To determine potential predictors of high output related complications in patients with diverting loop ileostomy creation after colorectal surgery.
METHODS Patients who underwent open and laparoscopic colorectal surgery requiring a diverting loop ileostomy from January 2010 to March 2018 were retrospectively analyzed. We included patients older than 18 years, who underwent colorectal surgery with primary low pelvic anastomosis, and with the creation of a diverting loop ileostomy, at elective or emergency settings for the treatment of benign or malignant conditions. Univariate and multivariate logistic regression analysis was used to determine the effect of the potential predictors on the rate of high output related complications. The high output related complications were dehydration and acute renal failure that required visits to the emergency department and hospitalizations.
RESULTS Of the 102 patients included in the study, 23.5% (n = 24) suffered high output related complications. In this group of patients at least one visit to the emergency department (mean 1.6), and at least one readmission to the hospital was needed. The factors associated with high-output ileostomy, in the univariate analysis, were: urgent surgical intervention (OR = 2.6; P = 0.047), the development of postoperative complications (OR = 3; P = 0.024), have ulcerative colitis (OR = 4.8; P = 0.017), use of steroids (OR = 4.3; P = 0.010), mean output at discharge greater than 1000 mL/24 h (OR = 3.2; P = 0.016), and use of loperamide at discharge (OR = 2.8; P = 0.032). Multivariate logistic regression analysis identified two independent risk factors for high output related complications: ulcerative colitis [OR = 7.6 (95%CI: 1.81-31.95); P = 0.006], and ileostomy output at discharge ≥ 1000 mL/24 h [OR = 3.3 (1.18-9.37); P = 0.023].
CONCLUSION In our study, patients with ulcerative colitis and those with an ileostomy output above 1000 mL/24 h at discharge, were at increased risk of high output related complications.
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Affiliation(s)
- Omar Vergara-Fernández
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
| | - Mario Trejo-Avila
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
| | - Oscar Santes
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
| | - Danilo Solórzano-Vicuña
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
| | - Noel Salgado-Nesme
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City 14080, Mexico
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20
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Defunctioning loop ileostomy for rectal anastomoses: predictors of stoma outlet obstruction. Int J Colorectal Dis 2019; 34:1141-1145. [PMID: 31055627 DOI: 10.1007/s00384-019-03308-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Creation of defunctioning loop ileostomy is a standard procedure in laparoscopic lower rectal surgery. Stoma-related obstruction sometimes occurs, but its cause has not been fully analyzed. This study aims to assess stoma obstructive complications and clarify the risk factors of stoma-related obstructions. METHODS Two hundred and thirty consecutive patients who underwent laparoscopic rectal cancer surgery with defunctioning loop ileostomy between April 2007 and December 2017 were recruited, numbering 230. We statistically examined the frequency and risk factor of stoma outlet obstruction. RESULTS Postoperative stoma-related complications developed in 41 patients (17.8%) overall, and there was no 30-day mortality. Stoma outlet obstructions occurred in 16 patients (7.0%) during postoperative course. Thick subcutaneous fat at the stoma-marking site (vertical distance ≥ 20 mm) and body mass index (≥ 22.2) were significantly associated with the risk of stoma outlet obstruction in univariate analysis. Thick subcutaneous fat was a significant predictive factor of stoma outlet obstruction according to multivariate analysis (odds ratio 3.80). CONCLUSIONS This report investigates significant predictors of stoma outlet obstruction in laparoscopic rectal cancer surgery for the first time. In laparoscopic procedure, stoma outlet obstruction should be particularly considered in obese patients who have especially thick subcutaneous fat of the abdominal wall.
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Efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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The influence of diverting loop ileostomy vs. colostomy on postoperative morbidity in restorative anterior resection for rectal cancer: a systematic review and meta-analysis. Langenbecks Arch Surg 2019; 404:129-139. [PMID: 30747281 DOI: 10.1007/s00423-019-01758-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/29/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND The aim of this systematic review and meta-analysis was to evaluate the morbidity of loop ileostomy (LI) and loop colostomy (LC) creation in restorative anterior resection for rectal cancer as well as the morbidity of their reversal. METHODS PubMed, EMBASE, MEDLINE via Ovid, and Cochrane Library were systematically searched for records published from 1980 to 2017 by three independent researchers. The primary endpoint was overall morbidity after stoma creation and reversal. Mantel-Haenszel odds ratio (OR) was used to compare categorical variables. Clinical significance was evaluated using numbers needed to treat (NNT). RESULTS Six studies (two randomized controlled trials and four observational studies) totaling 1063 patients (666 LI and 397 LC) were included in the meta-analysis. Overall morbidity rate after both stoma creation and closure was 15.6% in LI vs. 20.4% in LC [OR(95%CI) = 0.67 (0.29, 1.58); p = 0.36] [NNT(95%CI) = 21 (> 10.4 to benefit, > 2430.2 to harm)]. Morbidity rate after stoma creation was both statistically and clinically significantly lower after LI [18.2% vs. 30.6%; OR(95%CI) = 0.42 (0.25, 0.70); p = 0.001; NNT(95%CI) = 9 (4.7, 29.3)]. Dehydration rate was 3.1% (8/259) in LI vs. 0% (0/168) in LC. The difference was not statistically or clinically significant [OR(95%CI) = 3.00 (0.74, 12.22); p = 0.13; NNT (95%CI) = 33 (19.2, 101.9)]. Ileus rates after stoma closure were significantly higher in LI as compared to LC [5.2% vs. 1.7%; OR(95%CI) = 2.65 (1.13, 6.18); p = 0.02]. CONCLUSIONS This meta-analysis found no difference between LI and LC in overall morbidity after stoma creation and closure. Morbidity rates following the creation of LI were significantly decreased at the cost of a risk for dehydration.
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The application of defunctioning stomas after low anterior resection of rectal cancer. Surg Today 2018; 49:451-459. [DOI: 10.1007/s00595-018-1736-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/29/2018] [Indexed: 02/07/2023]
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Emmanuel A, Chohda E, Lapa C, Miles A, Haji A, Ellul J. Defunctioning Stomas Result in Significantly More Short-Term Complications Following Low Anterior Resection for Rectal Cancer. World J Surg 2018; 42:3755-3764. [PMID: 29777268 PMCID: PMC6182750 DOI: 10.1007/s00268-018-4672-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Studies suggest that defunctioning stomas reduce the rate of anastomotic leakage and urgent reoperations after anterior resection. Although the magnitude of benefit appears to be limited, there has been a trend in recent years towards routinely creating defunctioning stomas. However, little is known about post-operative complication rates in patients with and without a defunctioning stoma. We compared overall short-term post-operative complications after low anterior resection in patients managed with a defunctioning stoma to those managed without a stoma. METHODS A retrospective cohort study of patients undergoing elective low anterior resection of the rectum for rectal cancer. The primary outcome was overall 90-day post-operative complications. RESULTS Two hundred and three patients met the inclusion criteria for low anterior resection. One hundred and forty (69%) had a primary defunctioning stoma created. 45% received neoadjuvant radiotherapy. Patients with a defunctioning stoma had significantly more complications (57.1 vs 34.9%, p = 0.003), were more likely to suffer multiple complications (17.9 vs 3.2%, p < 0.004) and had longer hospital stays (13.0 vs 6.9 days, p = 0.005) than those without a stoma. 19% experienced a stoma-related complication, 56% still had a stoma 1 year after their surgery, and 26% were left with a stoma at their last follow-up. Anastomotic leak rates were similar but there was a significantly higher reoperation rate among patients managed without a defunctioning stoma. CONCLUSION Patients selected to have a defunctioning stoma had an absolute increase of 22% in overall post-operative complications compared to those managed without a stoma. These findings support the more selective use of defunctioning stomas. STUDY REGISTRATION Registered at www.researchregistry.com (UIN: researchregistry3412).
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Affiliation(s)
- Andrew Emmanuel
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Ezzat Chohda
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Christo Lapa
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Andrew Miles
- Department of Colorectal Surgery, Hampshire Hospitals NHS Foundation Trust, Wessex, UK
| | - Amyn Haji
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Joe Ellul
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
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25
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Lambrichts DPV, de Smet GHJ, van der Bogt RD, Kroese LF, Menon AG, Jeekel J, Kleinrensink GJ, Lange JF. Incidence, risk factors and prevention of stoma site incisional hernias: a systematic review and meta-analysis. Colorectal Dis 2018; 20:O288-O303. [PMID: 30092621 DOI: 10.1111/codi.14369] [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: 05/08/2018] [Accepted: 07/16/2018] [Indexed: 12/14/2022]
Abstract
AIM Stoma reversal might lead to a stoma site incisional hernia. Recently, prophylactic mesh reinforcement of the stoma site has gained increased attention, supporting the need for accurate data on the incidence of and risk factors for stoma site incisional hernia and to identify high-risk patients. The aim of this study was to assess incidence, risk factors and prevention of stoma site incisional hernias. METHOD Embase, MEDLINE, Web of Science, Cochrane and Google Scholar databases were searched. Studies reporting the incidence of stoma site incisional hernia after stoma reversal were included. Study quality was assessed with the Newcastle-Ottawa Scale and Cochrane risk of bias tool. Data on incidence, risk factors and prophylactic mesh reinforcement were extracted. RESULTS Of 1440 articles found, 33 studies comprising 4679 reversals were included. The overall incidence of incisional hernia was 6.5% [range 0%-38%, median follow-up 27.5 (17.54-36) months]. Eleven studies assessed stoma site incisional hernia as the primary end-point, showing an incidence of 17.7% [range 1.7%-36.1%, median follow-up 28 (15.25-51.70) months]. Body mass index, diabetes and surgery for malignant disease were found to be independent risk factors, as derived from eight studies. Two retrospective comparative cohort studies showed significantly lower rates of stoma site incisional hernia with prophylactic mesh reinforcement compared with nonmesh controls [6.4% vs 36.1% (P = 0.001); 3% vs 19% (P = 0.04)]. CONCLUSION Stoma site incisional hernia should not be underestimated as a long-term problem. Body mass index, diabetes and malignancy seem to be potential risk factors. Currently, limited data are available on the outcomes of prophylactic mesh reinforcement to prevent stoma site incisional hernia.
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Affiliation(s)
- D P V Lambrichts
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - G H J de Smet
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - R D van der Bogt
- Department of Gastroenterology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - L F Kroese
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A G Menon
- Department of Surgery, IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands
| | - J Jeekel
- Department of Neuroscience, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - G-J Kleinrensink
- Department of Neuroscience, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Surgery, IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands
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26
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Gavriilidis P, Azoulay D, Taflampas P. Loop transverse colostomy versus loop ileostomy for defunctioning of colorectal anastomosis: a systematic review, updated conventional meta-analysis, and cumulative meta-analysis. Surg Today 2018; 49:108-117. [PMID: 30151626 DOI: 10.1007/s00595-018-1708-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/19/2018] [Indexed: 01/07/2023]
Abstract
Defunctioning of colorectal anastomosis either with loop transverse colostomy or ileostomy was evaluated using updated and cumulative meta-analyses. Studies were identified by a systematic search of Embase, PubMed, Cochrane Library, and Google Scholar databases and were selected as per the PRISMA checklist. Both randomised control trials (RCTs) and retrospective studies were included. A sensitivity analysis was performed, and a cumulative meta-analysis was performed to monitor evidence over time. Significantly more male patients underwent loop ileostomy than transverse colostomy [odds ratio (OR) = 0.59 (95% confidence interval (CI) 0.39, 0.90), p < 0.001, I2 = 48%]. Significantly more colostomies were complicated by stoma prolapse than by ileostomies [OR = 6.32 (95% CI 2.78, 14.35), p < 0.001, I2 = 0%). Patients with ileostomy demonstrated a significantly higher complication rate of high-output stoma than patients with colostomies [Peto OR = 0.16 (95% CI 0.04, 0.55), p = 0.004, I2 = 0%]. Patients with colostomies demonstrated significantly more complications related to stoma reversal, such as wound infections and incisional hernias, than patients with ileostomies [OR = 3.45 (95% CI 2.00, 5.95), p < 0.001, I2 = 0%; OR = 4.80 (95% CI 1.85, 12.44), p < 0.001, I2 = 0%, respectively]. Overall complications related to stoma formation and closure did not demonstrate significant differences; however, their I2 values were 82% and 76%, respectively, suggesting high heterogeneity, which may have influenced the results. A subgroup analysis of RCTs showed no discrepancies when compared to the whole sample. In the cumulative meta-analysis, the effect size of each study was non-significant for the entire period. The demonstrated significant differences did not translate in favour of ileostomy when the overall complications of stoma formation and reversal were evaluated. Confounding factors and underpowered samples may have influenced the results. Future multicentre RCTs with homogeneous populations and adequate power may demonstrate more conclusive evidence regarding the superiority of one procedure over the other.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of General and Colorectal Surgery, Northern Lincolnshire and Goole, Diana, Princess of Wales Hospital, Scartho Road, Grimsby, DN33 2BA, UK. .,Department of Surgery, Henri Mondor University Hospital, 94010, Créteil, France.
| | - Daniel Azoulay
- Department of Surgery, Henri Mondor University Hospital, 94010, Créteil, France
| | - Panos Taflampas
- Department of General and Colorectal Surgery, Northern Lincolnshire and Goole, Diana, Princess of Wales Hospital, Scartho Road, Grimsby, DN33 2BA, UK
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27
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Pisarska M, Gajewska N, Małczak P, Wysocki M, Witowski J, Torbicz G, Major P, Mizera M, Dembiński M, Migaczewski M, Budzyński A, Pędziwiatr M. Defunctioning ileostomy reduces leakage rate in rectal cancer surgery - systematic review and meta-analysis. Oncotarget 2018; 9:20816-20825. [PMID: 29755692 PMCID: PMC5945534 DOI: 10.18632/oncotarget.25015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 03/08/2018] [Indexed: 12/11/2022] Open
Abstract
Objectives The role of a defunctioning ileostomy in every anterior rectal resection with total mesorectal excision (TME) is still controversial. In this study, we aimed to review the current literature to determine the impact of ileostomy creation on postoperative outcomes in patients undergoing anterior rectal resection with TME. Methods MEDLINE, Embase and Cochrane Library were searched for eligible studies. We analyzed data up to October 2017. Eligible studies had to compare patients with vs. without a defunctioning ileostomy in rectal cancer surgery and comprise data on anastomotic leakage in both groups. The primary outcome was anastomotic leakage. Secondary outcomes included the complication rate, mortality, reoperation rate, length of hospital stay and 30-day readmission. Results Initial search yielded 1,966 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. Leakage rate (RR = 0.43, 95% CI 0.28-0.67) and the number of reoperations (RR = 0.62, 95% CI 0.40-0.94) were significantly lower in the defunctioning stoma group. Morbidity was significantly higher in the stoma group (RR = 1.32, 95% CI 1.05–1.65). Analysis of mortality, length of hospital stay and readmission rate did not show any significant differences. Conclusion A defunctioning ileostomy may decrease the anastomotic leakage rate, additionally significantly reducing the risk of reoperations but it may also increase the overall complication rate. The presence of the protective stoma has no effect on mortality, length of hospital stay and readmission rate.
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Affiliation(s)
- Magdalena Pisarska
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Natalia Gajewska
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Małczak
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Wysocki
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Jan Witowski
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Grzegorz Torbicz
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Major
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Magdalena Mizera
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Dembiński
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Migaczewski
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Andrzej Budzyński
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
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28
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Blok RD, Stam R, Westerduin E, Borstlap WAA, Hompes R, Bemelman WA, Tanis PJ. Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer. Eur J Surg Oncol 2018; 44:1220-1225. [PMID: 29685761 DOI: 10.1016/j.ejso.2018.03.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 02/26/2018] [Accepted: 03/31/2018] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The need for routine diverting ileostomy following restorative total mesorectal excision (TME) is increasingly debated as the benefits might not outweigh the disadvantages. This study evaluated an institutional shift from routine (RD) to highly selective diversion (HSD) after TME surgery for rectal cancer. MATERIALS AND METHODS Patients having TME with primary anastomosis and HSD for low or mid rectal cancer between December 2014 and March 2017 were compared with a historical control group with RD in the preceding period since January 2011. HSD was introduced in conjunction with uptake of transanal TME. RESULTS In the RD group, 45/50 patients (90%) had a primary diverting stoma, and 3/40 patients (8%) in the HSD group. Anastomotic leakage occurred in 10 (20%) and three (8%) cases after a median follow-up of 36 and 19 months after RD and HSD, respectively. There was no postoperative mortality. An unintentional stoma beyond 1 year postoperative was present in six and two patients, respectively. One-year stoma-related readmission and reoperation rate (including reversal) after RD were 84% and 86%, respectively. Corresponding percentages were significantly lower after HSD (17% and 17%; P < 0.001). Total hospital stay within one year was median 11 days (IQR 8-19) versus 5 days (IQR 4-11), respectively (P < 0.001). CONCLUSION This single institutional comparative cohort study shows that highly selective defunctioning of a low anastomosis in rectal cancer patients did not adversely affect incidence or consequences of anastomotic leakage with a substantial decrease in 1-year readmission and reintervention rate, leading to an overall significantly reduced hospital stay.
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Affiliation(s)
- R D Blok
- Department of Surgery, Academic Medical Centre, University of Amsterdam, G4, Post box 22660, 1105 AZ Amsterdam, The Netherlands; LEXOR, Oncode Institute and Cancer Center Amsterdam, Academic Medical Centre, University of Amsterdam, F0, Post box 22660, 1105 AZ Amsterdam, The Netherlands.
| | - R Stam
- Department of Surgery, Academic Medical Centre, University of Amsterdam, G4, Post box 22660, 1105 AZ Amsterdam, The Netherlands
| | - E Westerduin
- Department of Surgery, Academic Medical Centre, University of Amsterdam, G4, Post box 22660, 1105 AZ Amsterdam, The Netherlands
| | - W A A Borstlap
- Department of Surgery, Academic Medical Centre, University of Amsterdam, G4, Post box 22660, 1105 AZ Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Academic Medical Centre, University of Amsterdam, G4, Post box 22660, 1105 AZ Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, University of Amsterdam, G4, Post box 22660, 1105 AZ Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Centre, University of Amsterdam, G4, Post box 22660, 1105 AZ Amsterdam, The Netherlands
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29
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Nelson T, Pranavi AR, Sureshkumar S, Sreenath GS, Kate V. Early versus conventional stoma closure following bowel surgery: A randomized controlled trial. Saudi J Gastroenterol 2018; 24:52-58. [PMID: 29451185 PMCID: PMC5848326 DOI: 10.4103/sjg.sjg_445_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND/AIM To compare early stoma closure with conventional stoma closure following defunctioning diversion stoma surgery with respect to the frequency of complications, health-related quality of life (QoL), and length of hospitalization (LoH). PATIENTS AND METHODS This study was designed as a prospective parallel-arm randomized controlled trial. Patients who underwent temporary stoma following bowel surgery between February 2014 and November 2015 were included. The rate of complications (medical and surgical) following early and conventional stoma closure was assessed. Health-related QoL and LoH were also measured. RESULTS One hundred patients were included, with 50 cases in each group. Postoperative complications including laparostoma (6% vs. 2%;P = 0.307), wound infection (32% vs. 18%; P = 0.106), intra-abdominal collection (14% vs. 18%; P = 0.585), anastomotic leak (4%vs. 8%;P = 0.400), and medical complications were comparable (22% vs. 32%;P = 0.257). The length of hospital stay, overall mortality and morbidity (64% vs. 44%; P = 0.05) were similar across the two groups. There was a significant reduction in the cost towards stoma care (96% vs. 2%; P = 0.001) in the early stoma closure group. Patients in the early stoma closure group also had a significantly better QoL. CONCLUSION Early stoma closure does not carry an increased risk of postoperative complications, reduces cost towards stoma care, and leads to better a QoL.
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Affiliation(s)
- Thirugnanasambandam Nelson
- Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Amuda R. Pranavi
- Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sathasivam Sureshkumar
- Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Gubbi S. Sreenath
- Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vikram Kate
- Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India,Address for correspondence: Dr. Vikram Kate, Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. E-mail:
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30
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Arezzo A, Bini R, Lo Secco G, Verra M, Passera R. The role of stents in the management of colorectal complications: a systematic review. Surg Endosc 2017; 31:2720-2730. [PMID: 27815744 DOI: 10.1007/s00464-016-5315-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/25/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Complications in colorectal surgery include a wide range of clinical conditions, which increase mortality, morbidity, hospital stay and costs. In some cases, the placement of a self-expanding metal stent may represent a possible therapeutic strategy, avoiding further surgery. METHODS In order to verify the feasibility and safety of the technique, we reviewed the medical literature, between January 1997 and 2015, selecting 32 studies. Inclusion criteria were based on Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations. RESULTS The estimated rate of early success was 73.3% (95% CI 66.3-79.3), raising from 25 to 68% in the time frame 1997-2007. The rate of early complications was 31.4% (95% CI 25.3-38.3%), progressively decreasing from 75 to 43% up to 2009. The rate of surgery for acute complication was 9.3% (95% CI 6.0-14.2%), reduced on time course from 25 to 9%. The rate of closure of dehiscence was 74.5% (95% CI 62.8-83.5%), while the rate of long-lasting success was 57.3% (95% CI 50.3-64.0%). CONCLUSIONS Endoscopic stenting in the early postoperative management of anastomotic complications after colorectal surgery should be considered in patients with minimal risk for sepsis, as a safe and often effective alternative to surgery. However, in order to establish the safety and efficacy of this technique, prospective studies involving a larger cohort of patients are required.
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Affiliation(s)
- Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy.
| | - Roberto Bini
- Department of Surgical Sciences, San Giovanni Bosco Hospital, Turin, Italy
| | - Giacomo Lo Secco
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
| | - Mauro Verra
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Turin, Italy
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31
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Sheetz K, Hemmila MR, Duby A, Krapohl G, Morris A, Campbell DA, Hendren S. Results of a statewide survey of surgeons' care practices for emergency Hartmann's procedure. J Surg Res 2016; 205:108-14. [PMID: 27621006 DOI: 10.1016/j.jss.2016.05.017] [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: 03/30/2016] [Revised: 05/04/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency general surgery is associated with high morbidity and mortality but has seldom been targeted for practice improvement. The goal of this study was to determine whether perioperative practices vary among surgeons for emergency Hartmann's procedures and whether perioperative care practices are associated with hospitals' complication rates. MATERIALS AND METHODS We conducted a survey of surgeons at 27 Michigan hospitals. Questionnaires focused on preoperative, intraoperative, and postoperative care practices. Hospitals were divided into quartiles of risk-adjusted complication rates. Responses of surgeons at hospitals with the lowest complication rates were compared to those with the highest, to determine whether there were systematic differences. Qualitative content analysis was performed for open-ended questions. RESULTS A total of 106 surgeons returned questionnaires (response rate 49%). We identified variation in use of bowel preparation, ostomy site marking, rectal stump management, ostomy protrusion, skin closure method, antibiotics duration, and ambulation/physical therapy practices. Surgeons from hospitals with low complication rates were more likely to use a clean instrument tray during wound closure (61% versus 11%, P = 0.001) and reported greater use of laparoscopic lavage without resection for emergency diverticulitis cases (31% versus 6%, P = 0.05). Surgeons in the lower complication rate hospitals listed more modifiable care factors in their open-ended responses to questions about reasons for complications. CONCLUSIONS Surgeons' practices vary for emergency Hartmann's procedure. This study serves as a proof of concept that studying surgeons' practices is feasible within a quality collaborative setting. Such data can be used to generate testable hypotheses for performance improvement aimed in high-risk, emergency surgery.
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Affiliation(s)
- Kyle Sheetz
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan.
| | - Mark R Hemmila
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
| | - Ashley Duby
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Greta Krapohl
- Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
| | - Arden Morris
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
| | - Darrell A Campbell
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
| | - Samantha Hendren
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; Michigan Surgical Quality Collaborative, Ann Arbor, Michigan
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32
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Jongen AC, Bosmans JW, Kartal S, Lubbers T, Sosef M, Slooter GD, Stoot JH, van Schooten FJ, Bouvy ND, Derikx JP. Predictive Factors for Anastomotic Leakage After Colorectal Surgery: Study Protocol for a Prospective Observational Study (REVEAL Study). JMIR Res Protoc 2016; 5:e90. [PMID: 27282451 PMCID: PMC4919551 DOI: 10.2196/resprot.5477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/07/2016] [Accepted: 02/07/2016] [Indexed: 12/28/2022] Open
Abstract
Background Anastomotic leakage (AL) remains the most important complication following colorectal surgery, and is associated with high morbidity and mortality rates. Previous research has focused on identifying risk factors and potential biomarkers for AL, but the sensitivity of these tests remains poor. Objective This prospective multicenter observational study aims at combining multiple parameters to establish a diagnostic algorithm for colorectal AL. Methods This study aims to include 588 patients undergoing surgery for colorectal carcinoma. Patients will be eligible for inclusion when surgery includes the construction of a colorectal anastomosis. Patient characteristics will be collected upon consented inclusion, and buccal swabs, breath, stool, and blood samples will be obtained prior to surgery. These samples will allow for the collection of information regarding patients’ inflammatory status, genetic predisposition, and intestinal microbiota. Additionally, breath and blood samples will be taken postoperatively and patients will be strictly observed during their in-hospital stay, and the period shortly thereafter. Results This study has been open for inclusion since August 2015. Conclusions An estimated 8-10% of patients will develop AL following surgery, and they will be compared to non-leakage patients. The objectives of this study are twofold. The primary aim is to establish and validate a diagnostic algorithm for the pre-operative prediction of the risk of AL development using a combination of inflammatory, immune-related, and genetic parameters. Previously established risk factors and novel parameters will be incorporated into this algorithm, which will aid in the recognition of patients who are at risk for AL. Based on these results, recommendations can be made regarding the construction of an anastomosis or deviating stoma, and possible preventive strategies. Furthermore, we aim to develop a new algorithm for the post-operative diagnosis of AL at an earlier stage, which will positively reflect on short-term survival rates. Trial Registration Clinicaltrials.gov: NCT02347735; https://clinicaltrials.gov/ct2/show/NCT02347735 (archived by WebCite at http://www.webcitation.org/6hm6rxCsA)
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Affiliation(s)
- Audrey Chm Jongen
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.
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33
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Kang HT, Bahk HJ, Shim JY, Kim NK. Management of long-term colorectal cancer survivors in Korea. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2016. [DOI: 10.5124/jkma.2016.59.4.276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Hee-Taik Kang
- Department of Family Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hyun Jung Bahk
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Yong Shim
- Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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34
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Blumetti J, Abcarian H. Management of low colorectal anastomotic leak: Preserving the anastomosis. World J Gastrointest Surg 2015; 7:378-383. [PMID: 26730283 PMCID: PMC4691718 DOI: 10.4240/wjgs.v7.i12.378] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/05/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy (Hartmann’s procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.
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Adam N, Rahbar S, Skinner R. Outcomes of Colostomy Reversal in a Public Safety Net Hospital: The End or Beginning of a New Problem? Am Surg 2015. [DOI: 10.1177/000313481508101034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Colostomy reversals can be technically challenging and linked to significant morbidity. There is sparse evidence that evaluates outcomes after colostomy reversals performed by acute care surgeons. We performed a review of 61 colostomy reversals from January 2011 to January 2014. Colostomies for acute diverticulitis were predominate, n = 32 (52%). Traumatic colorectal injuries were n = 15, 25 per cent. Colorectal cancer was n = 8, 13 per cent. Sigmoid volvulus accounted for n = 2 cases. Abdominal sepsis from adhesions was n = 3. A rectal foreign body was for n = 1 case. The time to reversal was 360 ± 506 days. Completion of reversals was successful in 90 per cent of cases and protecting stoma use was in n = 12, (22%). Surgical site infections occurred in n = 20, patients (32%). Surgical site infections were prevalent in obese patients, (55%). Anastomotic leaks (ALs) occurred at 12 per cent, and were prevalent in obese, [obese (22%) vs nonobese (8%), P = 0.1]. The majority of AL n = 6, (85%) were in acute diverticulitis and trauma. There were no ALs in cases with protective diversion. No deaths occurred. The elective nature of colostomy reversals does not imply low morbidity. Obesity and major inflammatory processes were associated with major surgical complications. These data suggest that protective stomas should be applied liberally, particularly in high-risk cases.
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Affiliation(s)
- Nadir Adam
- Department of Surgery, Kern Medical Center, Bakersfield, California
| | - Shahrzad Rahbar
- Department of Surgery, Kern Medical Center, Bakersfield, California
| | - Ruby Skinner
- Department of Surgery, Kern Medical Center, Bakersfield, California
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Geng HZ, Nasier D, Liu B, Gao H, Xu YK. Meta-analysis of elective surgical complications related to defunctioning loop ileostomy compared with loop colostomy after low anterior resection for rectal carcinoma. Ann R Coll Surg Engl 2015; 97:494-501. [PMID: 26274752 PMCID: PMC5210131 DOI: 10.1308/003588415x14181254789240] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2014] [Indexed: 01/11/2023] Open
Abstract
Introduction Defunctioning loop ileostomy (LI) and loop colostomy (LC) are used widely to protect/treat anastomotic leakage after colorectal surgery. However, it is not known which surgical approach has a lower prevalence of surgical complications after low anterior resection for rectal carcinoma (LARRC). Methods We conducted a literature search of PubMed, MEDLINE, Ovid, Embase and Cochrane databases to identify studies published between 1966 and 2013 focusing on elective surgical complications related to defunctioning LI and LC undertaken to protect a distal rectal anastomosis after LARRC. Results Five studies (two randomized controlled trials, one prospective non-randomized trial, and two retrospective trials) satisfied the inclusion criteria. Outcomes of 1,025 patients (652 LI and 373 LC) were analyzed. After the construction of a LI or LC, there was a significantly lower prevalence of sepsis (p=0.04), prolapse (p=0.03), and parastomal hernia (p=0.02) in LI patients than in LC patients. Also, the prevalence of overall complications was significantly lower in those who received LIs compared with those who received LCs (p<0.0001). After closure of defunctioning loops, there were significantly fewer wound infections (p=0.006) and incisional hernias (p=0.007) in LI patients than in LC patients, but there was no significant difference between the two groups in terms of overall complications. Conclusions The results of this meta-analysis show that a defunctioning LI may be superior to LC with respect to a lower prevalence of surgical complications after LARRC.
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Affiliation(s)
- Hong Zhi Geng
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Dilidan Nasier
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Bing Liu
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Hua Gao
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Yi Ke Xu
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
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Arezzo A, Verra M, Passera R, Bullano A, Rapetti L, Morino M. Long-term efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. Dig Liver Dis 2015; 47:342-5. [PMID: 25563812 DOI: 10.1016/j.dld.2014.12.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 10/29/2014] [Accepted: 12/03/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anastomotic leaks are a severe complication after colorectal surgery. We aimed to evaluate the long-term efficacy of endoscopic vacuum therapy for their treatment. METHODS Retrospective review of a series of post-surgical colorectal leaks treated with endoscopic vacuum therapy, with minimum follow-up of 1 year. Generalized peritonitis or haemodynamic instability was considered contraindication to endoscopic treatment. RESULTS Endoscopic vacuum therapy was applied in 14 patients with colorectal leak, in 2 cases complicated by recto-vaginal fistula. Overall success rate was 79%, favoured by early beginning of treatment (90%) and presence of a stoma (100%) and no preoperative radiotherapy (86%). Median duration of treatment was 12.5 sessions (range 4-40). Median time for complete healing was 40.5 days (range 8-114), for a median cost of treatment of 3125 Euros. No complication related to endoscopic vacuum therapy was observed. Further surgery was required in 3 cases. CONCLUSION Endoscopic vacuum therapy is a safe treatment for post-surgical leaks, with high success rates.
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Affiliation(s)
- Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Italy.
| | - Mauro Verra
- Department of Surgical Sciences, University of Torino, Italy
| | - Roberto Passera
- Department of Surgical Sciences, University of Torino, Italy
| | - Alberto Bullano
- Department of Surgical Sciences, University of Torino, Italy
| | - Lisa Rapetti
- Department of Surgical Sciences, University of Torino, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Italy
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Riss S, Chandrakumaran K, Dayal S, Cecil T, Mohamed F, Moran B. Risk of definitive stoma after surgery for peritoneal malignancy in 958 patients: Comparative study between complete cytoreductive surgery and maximal tumor debulking. Eur J Surg Oncol 2015; 41:392-5. [DOI: 10.1016/j.ejso.2014.09.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/09/2014] [Accepted: 09/01/2014] [Indexed: 12/11/2022] Open
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Lee CM, Huh JW, Park YA, Cho YB, Kim HC, Yun SH, Lee WY, Chun HK. Risk factors of permanent stomas in patients with rectal cancer after low anterior resection with temporary stomas. Yonsei Med J 2015; 56:447-53. [PMID: 25683994 PMCID: PMC4329357 DOI: 10.3349/ymj.2015.56.2.447] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim of this study was to identify risk factors influencing permanent stomas after low anterior resection with temporary stomas for rectal cancer. MATERIALS AND METHODS A total of 2528 consecutive rectal cancer patients who had undergone low anterior resection were retrospectively reviewed. Risk factors for permanent stomas were evaluated among these patients. RESULTS Among 2528 cases of rectal cancer, a total of 231 patients had a temporary diverting stoma. Among these cases, 217 (93.9%) received a stoma reversal. The median period between primary surgery and stoma reversal was 7.5 months. The temporary and permanent stoma groups consisted of 203 and 28 patients, respectively. Multivariate analysis showed that independent risk factors for permanent stomas were anastomotic-related complications (p=0.001) and local recurrence (p=0.001). The 5-year overall survival for the temporary and permanent stoma groups were 87.0% and 70.5%, respectively (p<0.001). CONCLUSION Rectal cancer patients who have temporary stomas after low anterior resection with local recurrence and anastomotic-related complications may be at increased risk for permanent stoma.
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Affiliation(s)
- Chul Min Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
BACKGROUND AND OBJECTIVE Most surgeons suggest the use of fecal diversion in patients undergoing low anterior resections of rectal tumors at high risk for anastomotic leakage. We describe an exploratory study to evaluate the efficacy and safety of a new diversion method called a spontaneously closing cannula ileostomy, which was designed to protect rectal anastomoses in patients at high risk for anastomotic leakage. The outcomes of patients treated with cannula ileostomy were compared to those of patients treated with loop ileostomy. MAIN OUTCOME MEASURES Outcomes included the rates of anastomotic leakage, reoperation and other complications, as well as length of hospital stay and cost. DESIGN AND PATIENTS From January 2011 to December 2012, 294 patients undergoing low colorectal or coloanal anastomosis were treated with ileum diversion using cannula ileostomy or traditional loop ileostomy. Demographics, clinical features, and operational data were recorded. RESULTS The anastomotic leakage rates were 8.1% (12/149) in the cannula ileostomy group and 8.3% (12/145) in the loop ileostomy group (p = 1.0). The reoperation rate was 3% (4/149) in patients treated with a cannula ileostomy and 3.4% (5/145) in those who underwent a loop ileostomy (p = 0.75). The median length of the hospital stay was 8.6 days in the cannula ileostomy group and 17.1 days (p < 0.01) in the loop ileostomy group, including time for the initial and reversal operations. In the cannula ileostomy group, the median time to defecation from the anus was 16.5 days after the operation. During the follow-up period, 13 patients in the loop ileostomy group retained their stoma, as compared to 2 in the cannula ileostomy group (p < 0.01). LIMITATIONS This study was a nonrandomized design and lacked contrast enema data to identify anastomotic leaks. CONCLUSIONS Cannula ileostomy is a safe and effective diverting technique that protects low colorectal and coloanal anastomoses. Patients receiving a cannula ileostomy had shorter hospital stays and lower rates of permanent stoma than those receiving a loop ileostomy.
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Abstract
BACKGROUND Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement. OBJECTIVE The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement. DESIGN This was a retrospective cohort study. SETTINGS The study took place within the 34-hospital Michigan Surgical Quality Collaborative. PATIENTS Patients included were those undergoing ostomy creation surgery between 2006 and 2011. MAIN OUTCOME MEASURES We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type). RESULTS A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4-43.9) to 60.8% (95% CI, 48.9-72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals. LIMITATIONS This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes. CONCLUSIONS Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.
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de Miguel Velasco M, Jiménez Escovar F, Parajó Calvo A. Estado actual de la prevención y tratamiento de las complicaciones de los estomas. Revisión de conjunto. Cir Esp 2014; 92:149-56. [DOI: 10.1016/j.ciresp.2013.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 08/14/2013] [Accepted: 09/15/2013] [Indexed: 12/31/2022]
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Hanju H, Jiahe X, Caizhao L, Sen L, Jianjiang L. Use of cannula ileostomy to protect a low colorectal anastomosis in patients having preoperative neoadjuvant chemoradiotherapy. Colorectal Dis 2014; 16:O117-22. [PMID: 24128335 DOI: 10.1111/codi.12456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 07/19/2013] [Indexed: 12/12/2022]
Abstract
AIM This study evaluated the efficacy and safety of ileal diversion, using a tracheal cannula, to protect from a low colorectal anastomosis in patients treated with neoadjuvant chemoradiotherapy. METHOD Fifty patients who presented with rectal cancer and who had accepted neoadjuvant chemoradiotherapy were included. All underwent a low anterior resection with ileal diversion by either tracheal cannula ileostomy (n = 28) or conventional loop ileostomy (n = 22). Demographics, clinical features and operation data were recorded. RESULTS Two patients developed anastomotic dehiscence after completion of the cannula ileostomy but neither patient required any further operation. There was no difference in anastomotic dehiscence, peritonitis or requirement for further surgery in patients treated with cannula ileostomy and loop ileostomy. CONCLUSION Cannula ileostomy is a safe, quick, effective and convenient means of intestinal diversion after low anterior resection. Its obvious advantage over loop ileostomy is a reduced overall hospital stay and avoidance of the need to close the stoma.
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Affiliation(s)
- H Hanju
- Department of Colorectal Surgery, First Affiliated Hospital, Zhejiang University, Zhejiang, China
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Bakker IS, Snijders HS, Wouters MW, Havenga K, Tollenaar RAEM, Wiggers T, Dekker JWT. High complication rate after low anterior resection for mid and high rectal cancer; results of a population-based study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2014; 40:692-8. [PMID: 24655803 DOI: 10.1016/j.ejso.2014.02.234] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 01/17/2014] [Accepted: 02/18/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Surgical resection is the cornerstone of treatment for rectal cancer patients. Treatment options consist of a primary anastomosis, anastomosis with defunctioning stoma or end-colostomy with closure of the distal rectal stump. This study aimed to compare postoperative outcome of these three surgical options. METHODS Data was derived from the national database of the Dutch Surgical Colorectal Audit. Mid and high rectal cancer patients who underwent rectal cancer resection between January 2011 and December 2012 were included. Endpoints were postoperative complications including anastomotic leakage, reinterventions, hospital stay and mortality within 30 days postoperative. RESULTS In total, 2585 patients were included. Twenty-five per cent of all patients received a primary anastomosis; 51% an anastomosis with defunctioning stoma, and 24% an end-colostomy. More than one third of patients developed postoperative complications, the lowest rate being in the primary anastomosis group. Anastomotic leakage rates were 12% in patients with a primary anastomosis, and 9% in patients with an anastomosis with defunctioning stoma (p < 0.05). Multivariate analysis showed more postoperative complications, prolonged hospital stay, and increased mortality rates in patients with a defunctioning stoma or end-colostomy. The latter had proportionally less invasive reinterventions when compared to the other two groups. CONCLUSIONS Patients with a primary anastomosis had the best postoperative outcome. A defunctioning stoma leads to a lower anastomotic leakage rate, though is associated with higher rates of complications, prolonged hospital stay and mortality. The decision to create a defunctioning stoma should be focus of future studies.
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Affiliation(s)
- I S Bakker
- University Medical Center Groningen, Department of Abdominal Surgery, University of Groningen, Groningen, The Netherlands.
| | - H S Snijders
- Leiden University Medical Center, Department of Surgery, Leiden, The Netherlands
| | - M W Wouters
- Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Department of Surgical Oncology, Amsterdam, The Netherlands
| | - K Havenga
- University Medical Center Groningen, Department of Abdominal Surgery, University of Groningen, Groningen, The Netherlands
| | - R A E M Tollenaar
- Leiden University Medical Center, Department of Surgery, Leiden, The Netherlands
| | - T Wiggers
- University Medical Center Groningen, Department of Abdominal Surgery, University of Groningen, Groningen, The Netherlands
| | - J W T Dekker
- Reinier de Graaf Hospital, Department of Surgery, Delft, The Netherlands
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Nguyen MT, Phatak UR, Li LT, Hicks SC, Moffett JM, Arita NA, Berger RL, Kao LS, Liang MK. Review of stoma site and midline incisional hernias after stoma reversal. J Surg Res 2014; 190:504-9. [PMID: 24560428 DOI: 10.1016/j.jss.2014.01.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 01/24/2014] [Accepted: 01/24/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND The incidence of incisional hernias after stoma reversal is not well reported. The aim of this study was to systematically review the literature reporting data on incisional hernias after stoma reversal. We evaluated both the incidence of stoma site and midline incisional hernias. METHODS A systematic review identified studies published between January 1, 1980, and December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies were excluded. Assessment of risk of bias, detection method, and essential study-specific characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done. RESULTS Sixteen studies were included in the analysis; 1613 patients had 1613 stomas formed. Fifteen studies assessed stoma site hernias and five studies assessed midline incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3% (range 0%-33.9%) and for midline incisional hernias was 44.1% (range 8.7%-58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two. CONCLUSION Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed.
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Affiliation(s)
- Mylan T Nguyen
- Department of General Surgery, University of Texas Health Science Center at Houston, Houston, Texas; Department of General Surgery, Baylor College of Medicine, Houston, Texas
| | - Uma R Phatak
- Department of General Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Linda T Li
- Department of General Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Jennifer M Moffett
- Department of General Surgery, Baylor College of Medicine, Houston, Texas
| | - Nestor A Arita
- Department of General Surgery, Baylor College of Medicine, Houston, Texas
| | - Rachel L Berger
- Department of General Surgery, Baylor College of Medicine, Houston, Texas
| | - Lillian S Kao
- Department of General Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Mike K Liang
- Department of General Surgery, University of Texas Health Science Center at Houston, Houston, Texas.
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Floodeen H, Lindgren R, Matthiessen P. When are defunctioning stomas in rectal cancer surgery really reversed? Results from a population-based single center experience. Scand J Surg 2013; 102:246-50. [PMID: 24056133 DOI: 10.1177/1457496913489086] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS This study assessed the timing of reversal of defunctioning stoma following low anterior resection of the rectum for cancer and risk factors for a defunctioning stoma becoming permanent in patients who were not reversed. MATERIAL AND METHODS Patients who underwent low anterior resection with defunctioning stoma during a 12-year period were assessed with regard to timing of stoma reversal. Delayed reversal was defined as >4 months after low anterior resection. Patients with a defunctioning stoma that was never reversed were assessed regarding risk factors for permanent stoma. RESULTS A total of 134 patients were analyzed. Of 106 stoma reversals, 19% were reversed within 4 months of low anterior resection, while 81% were reversed later than 4 months. In 58% of these patients, the delay was to due to low medical priority given to this procedure. The other main reasons for delayed stoma reversal were nonsurgical complications (20%), symptomatic anastomotic leakage following low anterior resection (12%), and postoperative adjuvant chemotherapy (10%). Of all patients, 21% (28/134) ended up with a permanent stoma. Risk factors for a defunctioning stoma becoming permanent were stage IV cancer (P < 0.001) and symptomatic anastomotic leakage following low anterior resection (P < 0.001). CONCLUSION Four in five patients experienced a delayed stoma reversal, in a majority because of the low priority given to this surgical procedure.
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Affiliation(s)
- H Floodeen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
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Baek SJ, Kim J, Kwak J, Kim SH. Can trans-anal reinforcing sutures after double stapling in lower anterior resection reduce the need for a temporary diverting ostomy? World J Gastroenterol 2013; 19:5309-5313. [PMID: 23983434 PMCID: PMC3752565 DOI: 10.3748/wjg.v19.i32.5309] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/17/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate trans-anal reinforcing sutures in low anterior resection using the double-stapled anastomosis technique for primary rectal cancers performed at a single institution.
METHODS: The data of patients who received trans-anal reinforcing sutures were compared with those of patients who did not receive them after low anterior resection. Patients who underwent laparoscopic low anterior resection and the double-stapled anastomosis technique for primary rectal cancer between January 2008 and December 2011 were included in this study. Patients with no anastomosis, a hand-sewn anastomosis, high anterior resection, or preoperative chemoradiation were excluded. The primary outcomes measured were the incidence of postoperative anastomotic complications and placement of a diverting ileostomy.
RESULTS: Among 110 patients, the rate of placement of a diverting ileostomy was significantly lower in the suture group (SG) compared with the non-suture control group (CG) [SG, n = 6 (12.8%); CG, n = 19 (30.2%), P = 0.031]. No significant difference was observed in the rate of anastomotic leakage [SG, n = 3 (6.4%); CG, n = 5 (7.9%)].
CONCLUSION: Trans-anal reinforcing sutures may reduce the need for diverting ileostomy. A randomized prospective study with a larger population should be performed in the future to demonstrate the efficacy of trans-anal reinforcing sutures.
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Sajid MS, Craciunas L, Baig MK, Sains P. Systematic review and meta-analysis of published, randomized, controlled trials comparing suture anastomosis to stapled anastomosis for ileostomy closure. Tech Coloproctol 2013; 17:631-9. [PMID: 23681301 DOI: 10.1007/s10151-013-1027-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 05/03/2013] [Indexed: 12/12/2022]
Abstract
The objective of this article is to systematically analyze the randomized, controlled trials comparing the effectiveness of suture anastomosis (SUA) versus stapled anastomosis (STA) in patients undergoing ileostomy closure. Randomized, controlled trials comparing the effectiveness of SUA versus STA in patients undergoing ileostomy closure were analyzed using RevMan(®), and combined outcomes were expressed as odds risk ratio (OR) and standardized mean difference (SMD). Four randomized, controlled trials that recruited 645 patients were retrieved from electronic databases. There were 327 patients in the STA group and 318 patients in the SUA group. There was significant heterogeneity among included trials. Operative time (SMD -1.02; 95 % CI -1.89, -0.15; z = 2.29; p < 0.02) was shorter following STA compared to SUA. In addition, risk of small bowel obstruction (OR 0.54; 95 % confidence interval (CI), 0.30, 0.95; z = 2.13; p < 0.03) was lower in the STA group. Risk of anastomotic leak (OR 0.87; 95 % CI 0.12, 6.33; z = 0.14; p = 0.89), surgical site infection, reoperation and readmission were similar following STA and SUA in patients undergoing ileostomy closure. Length of hospital stay was also similar between STA and SUA groups. In ileostomy closure, STA was associated with shorter operative time and lower risk of postoperative small bowel obstruction. However, STA and SUA were similar in terms of anastomotic leak, surgical site infection, readmission, reoperations and length of hospital stay.
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Affiliation(s)
- M S Sajid
- Department of General and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex, BN11 2DH, UK,
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Anastomotic leak is not associated with oncologic outcome in patients undergoing low anterior resection for rectal cancer. Ann Surg 2013; 256:1034-8. [PMID: 22584695 DOI: 10.1097/sla.0b013e318257d2c1] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine the association between anastomotic leak and oncologic outcome after anterior resection, stratifying for defunctioning stoma. BACKGROUND It has been hypothesized that anastomotic leak predisposes rectal cancer patients to local recurrence. Many have a defunctioning stoma to reduce risk of clinically significant leakage. METHODS The records of patients undergoing low anterior resection (1991-2010) for rectal adenocarcinoma (≤15 cm from anal verge) were retrospectively analyzed using a prospectively collected colorectal database. Data (age, gender, stage, defunctioning stoma, neoadjuvant treatment, distance from anal verge, anastomotic leak) were collected. Clinical leakage was defined as anastomotic complication requiring intervention or interventional radiology within 60 days of surgery. Estimated local recurrence, overall survival, and disease-specific survival were compared using log-rank method and Cox regression analysis. RESULTS 1127 patients were included, with 5.6-year median follow-up. The incidence of clinical anastomotic leak was 3.5%. Sixteen of 677 with defunctioning stoma (2.2%) developed clinical leak; 24 of 450 without stoma (6.3%) developed leak (P = 0.005). There were no perioperative deaths among patients with clinical leakage. When stratified for defunctioning stoma, there was no association between clinical leak and local recurrence, disease-free survival, or overall survival. On multivariable analysis, when controlling for neoadjuvant therapy, distance of tumor from anal verge, defunctioning stoma, and pathologic stage, clinical leak was not associated with time to local recurrence, disease-free survival, or overall survival. CONCLUSIONS In this cohort, anastomotic leakage was not associated with risk of local recurrence. Defunctioning stoma was associated with lower incidence of clinical leakage but not with difference in oncologic outcome. Careful patient selection for defunctioning stoma helps reduce risk of clinically significant anastomotic leak.
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Do older Americans undergo stoma reversal following low anterior resection for rectal cancer? J Surg Res 2012; 183:238-45. [PMID: 23298948 DOI: 10.1016/j.jss.2012.11.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/21/2012] [Accepted: 11/30/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE For low-lying rectal cancers, proximal diversion can reduce anastomotic leak after sphincter-preserving surgery; however, evidence suggests that such temporary diversions are often not reversed. We aimed to evaluate nonreversal and delayed stoma reversal in elderly patients undergoing low anterior resection (LAR). DESIGN SEER-Medicare-linked analysis from 1991-2007. SETTINGS AND PARTICIPANTS A total of 1179 primary stage I-III rectal cancer patients over age 66 who underwent LAR with synchronous diverting stoma. MAIN OUTCOME MEASURES (1) Stoma creation and reversal rates; (2) time to reversal; (3) characteristics associated with reversal and shorter time to reversal. RESULTS Within 18 mo of LAR, 51% of patients (603/1179) underwent stoma reversal. Stoma reversal was associated with age <80 y (P < 0.0001), male sex (P = 0.018), fewer comorbidities (P = 0.017), higher income (quartile 4 versus 1; P = 0.002), early tumor stage (1 versus 3; P < 0.001), neoadjuvant radiation (P < 0.0001), rectal tumor location (versus rectosigmoid; P = 0.001), more recent diagnosis (P = 0.021), and shorter length of stay on LAR admission (P = 0.021). Median time to reversal was 126 d (interquartile range: 79-249). Longer time to reversal was associated with older age (P = 0.031), presence of comorbidities (P = 0.014), more advanced tumor stage (P = 0.007), positive lymph nodes (P = 0.009), receipt of adjuvant radiation therapy (P = 0.008), more recent diagnosis (P = 0.004), and longer length of stay on LAR admission (P < 0.0001). CONCLUSIONS Half of elderly rectal cancer patients who undergo LAR with temporary stoma have not undergone stoma reversal by 18 mo. Identifiable risk factors predict both nonreversal and longer time to reversal. These results help inform preoperative discussions and promote realistic expectations for elderly rectal cancer patients.
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