Risk factors for postoperative stoma outlet obstruction in ulcerative colitis

doi:10.4240/wjgs.v12.i12.507

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Study

World J Gastrointest Surg. Dec 27, 2020; 12(12): 507-519
Published online Dec 27, 2020. doi: 10.4240/wjgs.v12.i12.507

Table 1 Patient characteristics in the compared groups

	Overall (n = 148)	SOO (+) (n = 25)	SOO (-) (n = 123)	P value
Age¹(yr), (range)	48 (13-84)	50 (13-77)	48 (14-84)	0.614
Gender
Male	95 (64.2%)	18 (72.0%)	77 (62.6%)	0.372
Female	53 (35.8%)	7 (28.0%)	46 (37.4%)	0.372
Indication for surgery
Medical intractability	118 (79.7%)	16 (64.0%)	102 (82.9%)	0.032
Malignancy or dysplasia	30 (20.3%)	9 (36.0%)	21 (17.1%)	0.032
BMI¹(kg/m²), (range)	20.1 (11.7-36.1)	19.8 (14.8-25.5)	20.3 (11.7-36.1)	0.634
Mayo endoscopic score¹(range)	3 (0-3)	2 (0-3)	3 (0-3)	0.186
Extent of disease
Pancolitis	137 (92.6%)	24 (96.0%)	113 (91.9%)	0.691
Left-sided colitis	11 (7.4%)	1 (4.0%)	10 (8.1%)
Proctitis	0 (0.0%)	0 (0.0%)	0 (0.0%)
Disease duration¹, (mo), (range)	33 (0-413)	40.5 (3-336)	33 (0-413)	0.535
Disease severity
Mild	25 (16.9%)	6 (24.0%)	19 (15.4%)	0.341
Moderate	71 (48.0%)	14 (56.0%)	57 (46.3%)
Severe	38 (25.7%)	4 (16.0%)	34 (27.6%)
Fulminant	14 (9.5%)	1 (4.0%)	13 (10.6%)
Total glucocorticoid dose from onset of UC to surgery²
10000 mg or more	9 (7.3%)	2 (10.0%)	7 (6.7%)	0.637
Less than 10000 mg	115 (92.7%)	18 (90.0%)	97 (93.3%)	0.637
Total glucocorticoid dose 1 mo before surgery¹ (mg), (range)	0 (0-1720)	0 (0-765)	0 (0-1720)	0.026
Preoperative total protein level¹ (g/dL), (range)	6.4 (2.5-9.3)	6.8 (4.5-9.3)	6.3 (2.5-8.6)	0.048
Preoperative albumin level¹ (g/dL), (range)	3.2 (1.4-4.9)	3.6 (2.0-4.6)	3.1 (1.4-4.9)	0.203
Preoperative white blood cell count¹ (cells/μL), (range)	7455 (1850-20080)	7500 (2660-16670)	7450 (1850-20080)	0.543
Preoperative C-reactive protein level¹ (mg/dL), (range)	1.4 (0.0-32.4)	1.1 (0.0-8.8)	1.57 (0.0-32.4)	0.335
Onodera Prognostic Nutritional index¹ (range)	37.8 (15.9-57.5)	39.3 (29.2-56.9)	37.6 (15.9-57.5)	0.274

¹Variables are indicated by median.

²Variable is unknown in 24 patients. BMI: Body mass index; UC: Ulcerative colitis.

Table 2 Operative details and outcomes and computed tomography measurements in the compared groups

	Overall (n = 148)	SOO (+) (n = 25)	SOO (-) (n = 123)	P value
Surgical approach
Laparoscopy	146 (98.6%)	25 (100.0%)	121 (98.4%)	1.000
Open	2 (1.4%)	0 (0.0%)	2 (1.6%)	1.000
Site of stoma
Right	85 (57.4%)	10 (40.0%)	75 (61.0%)	0.053
Left	63 (42.6%)	15 (60.0%)	48 (39.0%)	0.053
Type of stoma
End	58 (39.2%)	3 (12.0%)	55 (44.7%)	0.002
Loop	90 (60.8%)	22 (88.0%)	68 (55.3%)	0.002
Operative time¹ (min), (range)	346 (208-631)	339 (234-595)	347 (208-631)	0.890
Intraoperative bleeding¹ (mL), (range)	73.5 (4-1316)	51 (5-811)	80 (4-1316)	0.310
Maximum stoma drainage volume¹ (mL), (range)	1800 (150-7800)	2300 (450-5230)	1690 (150-7800)	0.004
Days from surgery to maximum stoma drainage volume¹ (d), (range)	6 (1-22)	8 (2-21)	4 (1-22)	0.326
Adhesions below the ileostomy²
Yes	21 (22.8%)	7 (35.0%)	14 (19.4%)	0.123
None	71 (77.2%)	13 (65.0%)	58 (80.6%)	0.123
Rectus abdominal muscle thickness at umbilical level¹ (mm), (range)	9.6 (3.6-15.7)	10.4 (6.1-14.2)	9.6 (3.6-15.7)	0.189
Subcutaneous fat thickness at umbilical level¹ (mm), (range)	15.5 (2.4-52.3)	11.6 (6.6-36.0)	16.3 (2.4-52.3)	0.051

¹Variables are indicated by median.

²Variable is unknown in 56 patients.

Table 3 Multivariate analysis of risk factors associated with stoma outlet obstruction

Factor	Odds ratio	95%CI		P value
Factor	Odds ratio	Lower	Upper	P value
Malignancy or dysplasia	0.558	0.156	1.991	0.369
Total glucocorticoid dose 1 mo before surgery	0.998	0.995	1.001	0.244
Preoperative total protein level	1.220	0.686	2.168	0.499
Loop ileostomy	7.315	1.514	35.332	0.013
Maximum stoma drainage volume	1.000	1.000	1.001	0.035

Table 4 Patients characteristics in relation to stoma sidedness with ileal pouch-anal anastomosis

	Overall (n = 90)	Right side (n = 31)	Left side (n = 59)	P value
Age¹ (yr), (range)	41 (13-71)	41 (14-71)	41 (13-67)	0.690
Gender
Male	54 (60.0%)	17 (54.8%)	37 (62.7%)	0.469
Female	36 (40.0%)	14 (45.2%)	22 (37.3%)	0.469
Indication for surgery
Medical intractability	72 (80.0%)	26 (83.9%)	46 (78.0%)	0.506
Malignancy or dysplasia	18 (20.0%)	5 (16.1%)	13 (22.0%)	0.506
BMI¹ (kg/m²), (range)	19.8 (13.9-36.1)	21.8 (16.0-27.8)	19.3 (13.9-36.1)	0.023
Mayo endoscopic score¹(range)	3 (0-3)	3 (0-3)	3 (0-3)	0.878
Extent of disease
Pancolitis	84 (93.3%)	29 (93.5%)	55 (93.2%)	0.662
Left-sided colitis	6 (6.7%)	2 (6.5%)	4 (6.8%)
Proctitis	0	0	0
Disease duration¹ (mo), (range)	38 (1-336)	21 (1-252)	56 (1-336)	0.016
Disease severity
Mild	17 (18.9%)	6 (19.4%)	11 (18.6%)	0.471
Moderate	44 (48.9%)	12 (38.7%)	32 (54.2%)
Severe	21 (23.3%)	9 (29.0%)	12 (20.3%)
Fulminant	8 (8.9%)	4 (12.9%)	4 (6.8%)
Total glucocorticoid dose from onset of UC to surgery²
10000 mg or more	7 (9.3%)	2 (8.7%)	5 (9.4%)	0.644
Less than 10000 mg	69 (90.7%)	21 (91.3%)	48 (90.6%)	0.644
Total glucocorticoid dose 1 mo before surgery¹ (mg), (range)	0 (0-1000)	0 (0-595)	0 (0-1000)	0.955
Preoperative total protein level¹ (g/dL), (range)	6.45 (4.2-9.3)	6.4 (4.2-8.5)	6.45 (4.2-9.3)	0.919
Preoperative albumin level¹ (g/dL), (range)	3.45 (1.8-4.9)	3.6 (2.1-4.8)	3.4 (1.8-4.9)	0.586
Preoperative white blood cell count¹(cells/μL), (range)	7315 (2660-20080)	6120 (2660-10630)	8770 (2850-20080)	< 0.001
Preoperative C-reactive protein level¹ (mg/dL), (range)	0.78 (0.01-17.41)	0.48 (0.01-8.78)	1.06 (0.02-17.41)	0.155
Onodera Prognostic Nutritional index¹ (range)	41.4 (22.2-57.5)	39.6 (24.7-57.5)	42.0 (22.2-57.5)	0.977

¹Variables are indicated by median.

²Variable is unknown in 14 patients. BMI: Body mass index; UC: Ulcerative colitis.

Table 5 Operative details and outcomes and computed tomography measurements in relation to stoma sidedness with ileal pouch-anal anastomosis

	Overall (n = 90)	Right side (n = 31)	Left side (n = 59)	P value
Surgical approach
Laparoscopy	89 (98.9%)	30 (96.8%)	59 (100%)	0.344
Open	1 (1.1%)	1 (3.2%)	0	0.344
Operative time¹ (min), (range)	346 (222-631)	347 (227-487)	339 (222-631)	0.393
Intraoperative bleeding¹ (mL), (range)	61.5 (5-741)	52 (5-337)	63 (5-741)	0.959
Maximum stoma drainage volume¹ (mL), (range)	2000 (150-5230)	1900 (150-4600)	2000 (400-5230)	0.577
Days from surgery to maximum stoma drainage volume¹ (d), (range)	6 (1-21)	6 (1-21)	6 (1-14)	0.051
Rectus abdominal muscle thickness at umbilical level¹ (mm), (range)	9.8 (5.7-15.7)	10.65 (6.3-13.6)	9.5 (5.7-15.7)	0.228
Subcutaneous fat thickness at umbilical level¹ (mm), (range)	15.7 (2.9-52.3)	16.9 (7.2-42.5)	13.8 (2.9-52.3)	0.058
Stoma outlet obstruction
Yes	22 (24.4%)	8 (25.8%)	14 (23.7%)	0.827
None	68 (75.6%)	23 (74.2%)	45 (76.3%)	0.827
Distance from pouch to stoma (cm), (range)	30 (30-50)	30 (30-50)	40 (30-50)	< 0.001
IPAA dehiscence
Yes	6 (6.7%)	0	6 (10.2%)	0.072
None	84 (93.3%)	31 (100%)	53 (89.8%)	0.072
Postoperative complications (Clavien-Dindo classification)
Grade 1 or less	47 (52.2%)	15 (48.4%)	32 (54.2%)	0.598
Grade 2 or higher	43 (47.8%)	16 (51.6%)	27 (45.8%)	0.598

¹Variables are indicated by median.

Table 6 Patient characteristics in the stoma outlet obstruction group

	sSOO (n = 18)	rSOO (n = 7)	P value
Age¹ (yr), (range)	50.5 (13-77)	50 (16-71)	0.745
Gender
Male	6 (33.3%)	6 (85.7%)	0.337
Female	12 (66.7%)	1 (14.3%)	0.337
Indication for surgery
Medical intractability	12 (66.7%)	4 (57.1%)	0.499
Malignancy or dysplasia	6 (33.3%)	3 (42.9%)	0.499
BMI¹ (kg/m²), (range)	18.9 (14.8-25.5)	21.8 (19.0-24.2)	0.158
Mayo endoscopic score¹(range)	2 (0-3)	2 (0-3)	0.657
Extent of disease
Pancolitis	17 (94.4%)	7 (100.0%)	0.720
Left-sided colitis	1 (5.6%)	0 (0.0%)
Proctitis	0 (0.0%)	0 (0.0%)
Disease duration¹ (mo), (range)	40.5 (3-336)	49 (15-108)	0.923
Disease severity
Mild	5 (27.8%)	1 (14.3%)	0.141
Moderate	11 (61.1%)	3 (42.9%)
Severe	1 (5.6%)	3 (42.9%)
Fulminant	1 (5.6%)	0 (0.0%)
Total glucocorticoid dose from onset of UC to surgery²
10000 mg or more	1	1	0.521
Less than 10000 mg	13	5	0.521
Total glucocorticoid dose 1 mo before surgery¹ (mg), (range)	0 (0-765)	0 (0-280)	0.745
Preoperative total protein level¹ (g/dL), (range)	6.8 (4.8-9.3)	6.8 (4.5-8.1)	0.745
Preoperative albumin level¹ (g/dL), (range)	3.5 (2.0-4.6)	4.2 (2.3-4.6)	0.657

¹Variables are indicated by median.

²Variable is unknown in 5 patients.

Table 7 Operative details and outcomes and computed tomography measurements in the stoma outlet obstruction group

	sSOO (n = 18)	rSOO (n = 7)	P value
Surgical approach
Laparoscopy	18 (100.0%)	7 (100.0%)
Open	0 (0.0%)	0 (0.0%)
Site of stoma
Right	6 (33.3%)	4 (57.1%)	0.261
Left	12 (66.7%)	3 (42.9%)	0.261
Type of stoma
End	3 (16.7%)	0 (0.0%)	0.355
Loop	15 (83.3%)	7 (100.0%)	0.355
Operative time¹ (min), (range)	333 (234-595)	345 (258-441)	0.929
Intraoperative bleeding¹ (mL), (range)	56.5 (5-811)	51 (20-78)	0.495
Maximum stoma drainage volume¹ (mL), (range)	2250 (450-5230)	2660 (800-4600)	0.492
Rectus abdominal muscle thickness at umbilical level¹(mm), (range)	9.3 (6.1-13.3)	12.7 (8.9-14.2)	0.006
Subcutaneous fat thickness at umbilical level¹ (mm), (range)	11.5 (6.6-36.0)	11.6 (7.3-20.4)	0.836

¹Variables are indicated by median.

Table 8 Multivariate analysis of the risk factors for repeated stoma outlet obstruction

Factor	Odds ratio	95%CI		P value
Factor	Odds ratio	Lower	Upper	P value
Rectus abdominal muscle thickness at umbilical level	2.249	1.176	4.300	0.014

Citation: Kitahara T, Sato Y, Oshiro T, Matsunaga R, Nagashima M, Okazumi S. Risk factors for postoperative stoma outlet obstruction in ulcerative colitis. World J Gastrointest Surg 2020; 12(12): 507-519
URL: https://www.wjgnet.com/1948-9366/full/v12/i12/507.htm
DOI: https://dx.doi.org/10.4240/wjgs.v12.i12.507