Early postoperative complications after transverse colostomy closure, a retrospective study

Abstract

BACKGROUND

Ostomy is a common surgery usually performed to protect patients from clinical symptoms caused by distal anastomotic leakage after colorectal cancer (CRC) surgery and perforation or to relieve intestinal obstruction.

AIM

To analyze the complications after transverse colostomy closure.

METHODS

Patients who underwent transverse colostomy closure from Jan 2015 to Jan 2022 were retrospectively enrolled in a single clinical center. The differences between the complication group and the no complication group were compared. Logistic regression analyses were conducted to find independent factors for overall complications or incision infection.

RESULTS

A total of 102 patients who underwent transverse colostomy closure were enrolled in the current study. Seventy (68.6%) patients underwent transverse colostomy because of CRC related causes. Postoperative complications occurred in 30 (29.4%) patients and the most frequent complication occurring after transverse colostomy closure was incision infection (46.7%). The complication group had longer hospital stays (P < 0.01). However, no potential risk factors were identified for overall complications and incision infection.

CONCLUSION

The most frequent complication occurring after transverse colostomy closure surgery in our center was incision infection. The operation time, interval from transverse colostomy to reversal, and method of anastomosis might have no impact on the postoperative complications. Surgeons should pay more attention to aseptic techniques.

Key Words: Transverse colostomy closure; Surgery; Complications; A single clinical centre; Risk factors

Core Tip: The current study was conducted to analyze the complications after transverse colostomy closure. A total of 102 patients who underwent transverse colostomy closure were enrolled in the current study. The complication group had longer hospital stay. However, no potential risk factor was identified for overall complications and incision infection. The most frequent complication occurring after transverse colostomy closure surgery in our center was incision infection. Operation time, interval from transverse colostomy to reversal and methods of anastomosis might have no impact on the postoperative complications. Surgeons should pay more attention to aseptic techniques.

INTRODUCTION

Ostomy is a common surgery usually performed to protect patients from clinical symptoms caused by distal anastomotic leakage after colorectal cancer (CRC) surgery and perforation or to relieve intestinal obstruction[1-3]. Given the convenience and validity of preventing anastomotic leakage, some experts have also suggested performing prophylactic ostomy[4-7]. A temporary stoma was usually recommended to be reversed at nearly 3 months after primary surgery[8,9]. However, several studies have reported a high rate of complications after ostomy closure, especially surgical site infections, with the highest rate reaching 40%[10]. Postoperative complications can lengthen hospital stays and cause heavy financial burdens, and severe complications can lead to death[11,12]. For better management of complications, several risk factors for complications have been reported, such as the interval from ostomy to reversal, operation time, blood transfusion and stapled anastomosis[13-17].

Previous studies have compared the incidence of postoperative complications between ileostomy and colostomy closure and found that patients who underwent colostomy closure were more likely to suffer from complications[18-20]. Most studies reporting complications after colostomy closure were conducted at the end of the last century, and the sample sizes were relatively small[21-23]. Furthermore, which factors, such as the time to stoma closure, affect the incidence of complications remains controversial[24-26].

Currently, colostomy, especially transverse colostomy, is still a commonly used type of ostomy. As a result, the purpose of the current study was to analyse complications after transverse colostomy closure and identify relevant risk factors for complications.

MATERIALS AND METHODS

Patients

Patients who underwent transverse colostomy closure surgery from Jan 2015 to Jan 2022 at a single clinical centre were retrospectively enrolled. The ethics committee of the First Affiliated Hospital of Chongqing Medical University approved this study (number K2024-008-01), and the data used in this study were obtained from public databases. No informed consent was needed. This study was conducted in accordance with the World Medical Association Declaration of Helsinki.

Inclusion and exclusion criteria

Patients who underwent transverse colostomy closure surgery for different diseases were included in this study (n = 140). The exclusion criteria were as follows: (1) Incomplete clinical records (n = 15); and (2) patients who had distant metastasis (n = 22); and 102 patients enrolled in this study (Figure 1).

Figure 1 Flow chart of patient selection.

Surgical procedure

The skin and subcutaneous tissue were first incised along the stoma margin, after which the colon was dissociated from the abdominal wall, the scar tissue around the stoma margin was removed, and the bowel was trimmed. Next, the two ends of the stoma were anastomosed with an anastomosis. Finally, the abdominal wall incision was sutured intermittently with silk threads (Figure 2).

Figure 2 Surgery procedure. A: Image of transverse loop stoma; B: Surgical site after transverse colostomy closure.

Data collection

The clinical characteristics included age, sex, body mass index, smoking status, drinking status, hypertension, type 2 diabetes mellitus (T2DM), preoperative haemoglobin, preoperative albumin, interval from transverse colostomy to reversal, method of anastomosis, operation time, blood loss, hospital stay, cause of transverse colostomy and complications were obtained from the electronic medical record system. Postoperative complications were classified on the basis of the Clavien-Dindo classification[27].

Statistical analysis

Continuous variables are expressed as the mean ± SD, and an independent sample t test was used to compare the differences between the complication group and the no complication group. Categorical variables are expressed as absolute values and percentages, and the chi-square test or Fisher’s exact test was used. Logistic regression analyses were also conducted to identify independent factors for overall complications and incisional infection. The data were analysed using SPSS (version 22.0) statistical software. A bilateral P value < 0.05 was considered to indicate statistical significance.

RESULTS

Baseline characteristics of included patients

A total of 102 patients who underwent colostomy closure surgery were enrolled in the current study. The average age of those patients was 57.7 years. Sixty-one (59.8%) patients were males, and 40 (40.2%) patients were females. Postoperative complications occurred in 30 (29.4%) patients. More information is provided in Table 1.

Table 1 Clinical characteristics, n (%).

Characteristics	No. (n = 102)
Age, yr	57.7 ± 12.7
Sex
Male	61 (59.8)
Female	41 (40.2)
BMI, kg/m2	22.4 ± 3.2
Smoking	42 (41.2)
Drinking	36 (35.3)
Hypertension	21 (20.6)
T2DM	9 (8.8)
Pre-operative hemoglobin, g/L	129.6 ± 17.4
Pre-operative albumin, g/L	42.4 ± 4.4
Interval from transverse colostomy to reversal, month	7.3 ± 4.5
Methods of anastomosis
End-to-end anastomosis	25 (24.5)
End-to-side anastomosis	27 (26.5)
Side-to side anastomosis	50 (49.0)
Operation time	132.8 ± 64.0
Blood loss	43.8 ± 46.7
Hospital stay	9.4 ± 9.7
Complications	30 (29.4)

Variables are expressed as the mean ± SD, n (%). BMI: Body mass index; T2DM: Type 2 diabetes mellitus.

In terms of the causes of transverse colostomy, 70 (68.6%) patients underwent surgery because of CRC-related causes, including anastomotic leakage after CRC surgery (32.4%), prophylactic transverse colostomy after CRC surgery (29.4%), and obstruction of CRC (3.9%). Other related causes involved perforation because of trauma (15.7%), obstruction (6.8%) and so on (Table 2).

Table 2 The causes of transverse colostomy, n (%).

Characteristics	No. (n = 102)
CRC related causes	70 (68.6)
Perforation of CRC	1 (1.0)
Obstruction of CRC	4 (3.9)
Anastomotic leakage after CRC surgery	33 (32.4)
Prophylactic transverse colostomy after CRC surgery	30 (29.4)
Rectovaginal fistula after CRC surgery	1 (1.0)
Anastomotic bleeding after CRC surgery	1 (1.0)
Other related causes	32 (31.4)
Colorectal benign tumors	3 (2.9)
Perforation because of trauma	16 (15.7)
Rectovesical fistula	6 (5.9)
Obstruction	7 (6.8)

CRC: Colorectal cancer.

The most frequent complication occurring after colostomy closure surgery was incision infection (46.7%), followed by pulmonary infection (13.3%), ileus (13.3%), anastomotic leakage (10%), abdominal infection (10%), and bleeding (6.7%). Moreover, 4 (13.3%) patients had complications ≥ grade III (requiring surgical, endoscopic or radiological intervention), including severe ileus (6.6%) and anastomotic leakage (6.6%; Table 3).

Table 3 Complications of the included patients, n (%).

Characteristics	No. (n = 30)
Grade I-II complications	26 (86.7)
Pulmonary infection	4 (13.3)
Abdominal infection	3 (10.0)
Incision infection	14 (46.7)
Anastomotic leakage	1 (3.3)
Ileus	2 (6.7)
Bleeding	2 (6.7)
≥ Grade III complications	4 (13.3)
Anastomotic leakage	2 (6.7)
Ileus	2 (6.7)

Comparison between the complication group and the no complication group

The complication group had longer hospital stays (P < 0.01). However, there were no differences in terms of the method of anastomosis (P = 0.63), preoperative haemoglobin concentration (P = 0.32), preoperative albumin concentration (P = 0.17), operation time (P = 0.69), blood loss (P = 0.61) or other characteristics (P > 0.05; Table 4).

Table 4 Comparison between the complication group and the no complication group, n (%).

Characteristics	Complications (n = 30)	No complications (n = 72)	P value
Age, yr	58.3 ± 11.3	57.5 ± 13.3	0.756
Sex			0.677
Male	17 (56.7)	44 (61.1)
Female	13 (43.3)	28 (38.9)
BMI, kg/m2	22.3 ± 2.9	22.4 ± 3.3	0.85
Smoking	12 (40.0)	30 (41.7)	0.876
Drinking	13 (43.3)	23 (31.9)	0.273
Hypertension	6 (20.0)	15 (20.8)	0.924
T2DM	2 (6.7)	7 (9.7)	1
Pre-operative hemoglobin, g/L	126.9 ± 20.0	130.7 ± 16.2	0.322
Pre-operative albumin, g/L	41.5 ± 4.1	42.8 ± 4.5	0.174
Interval from transverse colostomy to reversal, month	7.8 ± 6.2	7.1 ± 3.6	0.452
Methods of anastomosis			0.633
End-to-end anastomosis	8 (26.7)	27 (37.5)
End-to-side anastomosis	6 (20.0)	21 (29.7)
Side-to side anastomosis	16 (53.3)	24 (33.3)
Operation time	133.0 ± 57.3	132.7 ± 67.0	0.979
Blood loss	47.4 ± 54.9	42.3 ± 43.1	0.617
Hospital stay	15.4 ± 16.0	6.9 ± 2.7	< 0.01a

^aP value < 0.05.

Variables are expressed as the mean ± SD, n (%). BMI: Body mass index; T2DM: Type 2 diabetes mellitus.

Logistic regression of overall complications and incisional infection

Univariate logistic regression analysis was also conducted to identify potential risk factors for overall complications and incision infection. However, no potential risk factors were identified in this study (P > 0.05; Table 5).

Table 5 Univariate logistic regression analysis of overall complications and incision infection.

Risk factors	Univariate analysis of overall complications		Univariate analysis of incision infection
	OR (95%CI)	P value	OR (95%CI)	P value
Age, yr	1.005 (0.972-1.040)	0.754	0.977 (0.935-1.021)	0.296
Sex (male/female)	1.202 (0.507-2.850)	0.677	0.802 (0.248-2.593)	0.713
BMI, Kg/m2	0.987 (0.862-1.129)	0.848	0.988 (0.827-1.182)	0.898
Hypertension (yes/no)	0.950 (0.329-2.742)	0.924	1.061 (0.267-4.206)	0.933
T2DM (yes/no)	0.663 (0.130-3.394)	0.622	0.769 (0.089-6.669)	0.812
Smoking (yes/no)	0.933 (0.392-2.223)	0.876	2.118 (0.676-6.636)	0.198
Drinking (yes/no)	1.629 (0.679-3.911)	0.275	2.034 (0.652-6.349)	0.221
Pre-operative hemoglobin, g/L	0.988 (0.964-1.012)	0.320	0.989 (0.958-1.021)	0.509
Pre-operative albumin, g/L	0.934 (0.847-1.031)	0.175	0.957 (0.843-1.086)	0.494
Operation time, min	1.000 (0.993-1.007)	0.979	0.995 (0.984-1.007)	0.413
Blood loss, mL	1.002 (0.993-1.011)	0.614	0.995 (0.980-1.010)	0.528
Interval from transverse colostomy to reversal, month	1.035 (0.946-1.133)	0.454	1.033 (0.926-1.153)	0.562
Methods of anastomosis (Side-to side/end-to-side/end-to-end)	1.046 (0.622-1.761)	0.864	1.664 (0.734-3.774)	0.223

OR: Odds ratio; BMI: Body mass index; T2DM: Type 2 diabetes mellitus.

DISCUSSION

In this study, a total of 102 patients who underwent transverse colostomy closure surgery were enrolled. Postoperative complications occurred in 30 (29.4%) patients. The most frequent complication occurring after colostomy closure surgery was incision infection, with an incidence of 13.7%. The complication group had longer hospital stays than did the no complication group. Furthermore, logistic regression analyses included factors such as operation time, interval from transverse colostomy to reversal, and method of anastomosis; however, no potential risk factors were identified for overall complications or incision infection.

Previous studies have reported complications after transverse colostomy closure surgery. Aston and Everett[24] enrolled 100 patients who had a temporary transverse loop colostomy closed between 1969 and 1982; they found that the most frequent complication was faecal fistula (10%) and stressed that closing the stoma within 3 wk was as safe as closing it within 8 wk. Henry and Everett[21] reported that fistula formation at the site of closure was the most frequent complication. However, with the development of surgical techniques and clinical management, the incidence of complications in recent years has changed. Pokorny et al[16] and Rullier et al[18] reported that wound infection was the most frequent complication, with incidences of 9.0% and 8.9%, respectively, which was in accordance with our studies. In our study, the incidence of incision infection was 13.7%. Although incisional infection after transverse colostomy closure is usually not life-threatening, it increases the cost of hospitalization and pain of patients. Gonzalez et al[28] reported that age, operation time, and cardiac risk factors were found to be independent risk factors for surgical site infection; however, our study did not identify any risk factors, possibly because of the relatively small sample size. More measures should be taken to decrease the incidence of incision infection, including better management of T2DM, purse-string skin closure, an open incision, and a large surgeon volume[26,29,30].

Although the complication group had longer hospital stays, no significant differences were found in terms of the method of anastomosis, operation time or other characteristics, and no risk factors were found. These findings prompted us to further investigate the possible reasons for complications, such as the experience of surgeons and surgical techniques.

The interval from ostomy to reversal was the most common risk factor for postoperative complications, but this topic remains controversial. In 2019, Krebs et al[25] reported that the time to stoma closure was an independent risk factor for complications after diverting stoma closure, and the optimal cut-off was 240 d[25]. Conversely, a meta-analysis of 7 randomized controlled trials demonstrated that early stoma closure (4 wk) was as safe as routine surgery (8 wk)[31]. Pokorny et al[16] and Aston and Everett[24] reported that the interval was not an independent predictor of complications. Because stoma closure was performed at different times, the conclusions might vary. Our study showed that the interval (ranging from 1.2-14 months) from transverse colostomy closure to reversal did not seem to influence the incidence of complications. The conclusion above might indicate that the time to perform transverse colostomy closure should be individualized and adjusted for various reasons, such as chemotherapy, primary disease, and complications after primary surgery.

To our knowledge, this is the first study to analyse postoperative complications and predictors, especially for patients who underwent transverse colostomy closure. Although several studies have reported complications after stoma closure and relevant risk factors, they did not separate ileostomy closure from colostomy closure. Because of the greater incidence of complications after colostomy closure than after ileostomy, the current study was necessary.

Some limitations of our study should be considered. First, the retrospective nature of the single-centre study indicated unavoidable selection bias. Second, only 102 patients were enrolled in this study, which was a small sample size. Moreover, additional parameters need to be included to identify risk factors. Thus, further multicentre prospective studies with large sample sizes are needed.

CONCLUSION

In conclusion, the most frequent complication occurring after colostomy closure surgery was incision infection. The operation time, interval from transverse colostomy to reversal, and method of anastomosis might have no impact on postoperative complications.

ARTICLE HIGHLIGHTS

Research background

Previous studies comparing the incidence of postoperative complications in patients with ileostomy and colostomy closure have found that patients undergoing colostomy closure are more likely to experience complications. Most of the studies reporting post-colonostomy complications were conducted at the end of the last century with relatively small sample sizes.

Research motivation

At present, colostomy, especially transverse colostomy, is still a common type of colostomy.

Research objectives

The aim of this study was to analyze complications after transverse colostomy closure and to identify risk factors associated with complications.

Research methods

This article used a retrospective study method to include 102 patients at a single clinical centre. The differences between the complication group and the no complication group were compared. Logistic regression analyses were conducted to find independent factors for overall complications or incision infection.

Research results

A total of 102 patients who underwent transverse colostomy closure were enrolled in the current study. Seventy (68.6%) patients underwent transverse colostomy because of colorectal cancer related causes. Postoperative complications occurred in 30 (29.4%) patients and the most frequent complication occurring after transverse colostomy closure was incision infection (46.7%). The complication group had longer hospital stays (P < 0.01). However, no potential risk factors were identified for overall complications and incision infection.

Research conclusions

Finally, we found that the most common complication after colostomy closure was wound infection. Operation time, time interval between transverse colostomy and reversal, and anastomosis method had no effect on postoperative complications.

Research perspectives

The study will conduct to analyze the overall survival after transverse colostomy closure.