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Liu J, Jiang M, Chen X, Ge Y, Zheng Z, Yang X, Zhou W, Zhang H, Zheng M, Luo B. Machine learning prediction model of prolonged delay to loop ileostomy closure after rectal cancer surgery: a retrospective study. World J Surg Oncol 2025; 23:185. [PMID: 40369609 PMCID: PMC12076957 DOI: 10.1186/s12957-025-03843-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2025] [Accepted: 05/02/2025] [Indexed: 05/16/2025] Open
Abstract
BACKGROUND Delayed closure of a temporary ileostomy in patients with rectal cancer may cause psychological, physiological, and socioeconomic burdens to patients. PURPOSE This study aimed to develop and validate a machine learning-based model to predict the delayed ileostomy closure after surgery in patients with rectal cancer. DESIGN A retrospective study. METHODS LASSO regression was used for feature screening, and XGBoost was used for machine learning model construction. Model performance was assessed by receiver operating characteristic (ROC) curve analysis, calibration curve analysis, clinical decision curve analysis, sensitivity, specificity, accuracy, and F1 score. The SHAP method was used to interpretate the results of the machine learning model. RESULTS A total of 442 rectal cancer patients who received a loop ileostomy were included in this study, and 305 experienced delayed closure (69%). The XGBoost model area under the ROC curve (AUC) of the training set was 0.744 (95% confidence interval [CI]: 0.686-0.806) and of the test set was 0.809 (95% CI: 0.728-0.889). The importance of each variable, in descending order was body mass index (BMI), postoperative chemotherapy, distance from tumor to anal margin, depth of tumor infiltration, neoadjuvant chemoradiotherapy, and anastomotic stenosis. The importance of SHAP variables in the model from high to low was: 'BMI' 'postoperative chemotherapy' 'distance of the tumor from the anal verge' 'depth of tumor infiltration' 'neoadjuvant radiotherapy' 'anastomotic stenosis'. CONCLUSION The XGBoost machine learning model we constructed showed good performance in predicting delayed closure of loop ileostomy in rectal cancer patients. In addition, the SHAP method can help better understand the results of machine learning models.
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Affiliation(s)
- Jianying Liu
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China
| | - Mengxiao Jiang
- Department of Urinary Surgery, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China
| | - Xiaoping Chen
- Department of Urinary Surgery, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China
| | - Yonglan Ge
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China
| | - Zongxin Zheng
- Department of Urinary Surgery, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China
| | - Xia Yang
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China
| | - Wenhao Zhou
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China
| | - Huiting Zhang
- Nursing Department of Huangpu Yard, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China.
| | - Meichun Zheng
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China.
| | - Baojia Luo
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, 510060, P.R. China.
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Li WB, Zhang Y, He RC, Li J, Kang N, An J. Assessing the Feasibility and Safety of Autologous Skin Flap-supported Loop Stomas. Surg Laparosc Endosc Percutan Tech 2025; 35:e1360. [PMID: 40065654 DOI: 10.1097/sle.0000000000001360] [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: 08/20/2024] [Accepted: 01/27/2025] [Indexed: 04/05/2025]
Abstract
PURPOSE To investigate the benefits of utilizing autologous flap-supported loop stomas in comparison to conventional rod-supported loop stomas regarding feasibility, safety, convenience, and satisfaction among doctors and patients. METHODS A retrospective analysis was conducted on the clinical data of 98 patients who underwent ileostomy at the Gastrointestinal Department of Shanxi Bethune Hospital Affiliated to Shanxi Medical University from July 2017 to January 2021. On the basis of the ileostomy methods used, the patients were categorized into 2 groups: the autologous flap loop ileostomy group (intervention group, 48 cases) and the traditional loop ileostomy group (traditional group, 50 cases). The analysis focused on assessing the quality of the stoma, short-term and long-term complications associated with postoperative stoma, and differences in feasibility, safety, convenience, and economic factors between the 2 groups. RESULTS The intervention group exhibited lower rates of short-term postoperative complications compared with the traditional group, especially in peristomal dermatitis ( P =0.002) and stoma leakage ( P =0.001). In addition, the frequency of stoma appliance replacement and the average cost within a 2-week period were also superior to those of the traditional group (all P <0.001). Long-term complications were not significantly different between the 2 groups ( P ≥ 0.05). Moreover, the intervention group had a shorter operating time ( P =0.01) and less blood loss ( P =0.006) than the traditional group for the ostomy closure surgery. CONCLUSIONS Autologous flap-supported loop stoma shows a notable decrease in postoperative stoma-related short-term complications, offering superior feasibility, safety, convenience, with favorable economic aspects as well.
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Affiliation(s)
- Wei-Bin Li
- Department of General Surgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
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Iqbal A, Rojas-Khalil Y, Waldon A, Parikh-Amin P, Garcia-Chavez HJ, Hartley BW, Keeling SS, Erstad DJ, Rosengart TK, Read TE. Two-Center Validation of a Novel Quality Improvement Protocol to Avoid Postileostomy Morbidity Using Home Intravenous Fluids and Structured Daily Calls. Dis Colon Rectum 2025; 68:457-465. [PMID: 40079659 DOI: 10.1097/dcr.0000000000003629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/15/2025]
Abstract
BACKGROUND New ileostomates have higher rates of dehydration and readmission compared to patients undergoing other colorectal procedures. OBJECTIVE We aimed to show the efficacy of a novel ileostomy-specific quality improvement protocol at an academic center with subsequent validation at another academic center. DESIGN Prospective cohort study. SETTING Baylor College of Medicine (Houston, TX) and University of Florida Health (Gainesville, Florida). PATIENTS Patients who underwent elective ileostomy creation were enrolled in 2 phases: phase I (efficacy phase) from 2011 to 2018 at the University of Florida and phase II (validation phase) from 2018 to 2024 at Baylor College of Medicine. INTERVENTIONS New ileostomates received an indwelling intravenous line postoperatively. After discharge, daily home visits and administration of intravenous fluid infusions were completed by a registered nurse, and daily phone calls were made for counseling and medication adjustment by an advanced practice provider. MAIN OUTCOME MEASURES Length of stay, readmission rate, complication rate, and cost of care. RESULTS A total of 600 patients were enrolled in the study. There was a significant improvement in postprotocol from preprotocol in hospital length of stay (University of Florida: 3 vs 8 days; Baylor College of Medicine: 2.1 vs 6.9 days, p < 0.01), readmission rates (University of Florida: 9% vs 56%; Baylor College of Medicine: 7% vs 40%, p < 0.01), cost of care (University of Florida: $19,700 vs $53,300; Baylor College of Medicine: $18,100 vs $47,856, p < 0.01), and complication rates (University of Florida: 19% vs 65%; Baylor College of Medicine: 17% vs 46%, p < 0.01). If readmitted, the length of stay and cost decreased by 81% and 83%, respectively. No line-related complication was noted. LIMITATIONS This study was not randomized. Resource and insurance limitations may be an impediment to protocol implementation for austere settings. CONCLUSIONS Implementation of a novel ileostomy-specific standardized protocol to avoid morbidity from dehydration by implementing home intravenous infusions in conjunction with comprehensive outpatient education and phone follow-up significantly improved the quality of care by decreasing the length of stay, readmissions, complications, and cost of care. These results were validated at another institution. See Video Abstract. VALIDACIN EN DOS CENTROS DE UN NOVEDOSO PROTOCOLO DE MEJORA DE LA CALIDAD PARA EVITAR LA MORBILIDAD POSILEOSTOMA MEDIANTE LQUIDOS INTRAVENOSOS A DOMICILIO Y LLAMADAS DIARIAS ESTRUCTURADAS ANTECEDENTES:Los nuevos ileostomizados presentan tasas más elevadas de deshidratación y reingreso en comparación con los pacientes sometidos a otros procedimientos colorrectales.OBJETIVO:Nuestro objetivo era demostrar la eficacia de un nuevo protocolo de mejora de la calidad específico para la ileostomía en un centro académico, con su posterior validación en otro centro académico.DISEÑO:Estudio de cohortes prospectivo.LUGAR:Baylor College of Medicine (Houston, Texas); University of Florida Health (Gainesville, Florida).PACIENTES:Los pacientes sometidos a creación electiva de ileostomía se inscribieron en dos fases; Fase I (fase de eficacia) de 2011 a 2018 en la Universidad de Florida y Fase II (fase de validación) de 2018 a 2024 en el Baylor College of Medicine.INTERVENCIONES:Los nuevos ileostomizados recibieron una vía intravenosa permanente en el postoperatorio. Después del alta, se completaron visitas domiciliarias diarias y administración de infusiones de líquidos intravenosos por parte de una enfermera registrada y llamadas telefónicas diarias para asesoramiento y ajuste de la medicación por parte de un Proveedor de Práctica Avanzada.PRINCIPALES MEDIDAS DE RESULTADO:Duración de la estancia, tasa de reingresos, tasa de complicaciones y costo de la atención.RESULTADOS:Un total de 600 pacientes participaron en el estudio. Hubo una mejora significativa en la duración de la estancia hospitalaria (Universidad de Florida: 3 frente a 8 días; Baylor College of Medicine: 2,1 frente a 6,9 días, p < 0,01), las tasas de readmisión (University of Florida: 9% frente a 56%; Baylor College of Medicine: 7% frente a 40%, p < 0,01), costo de la atención (Universidad de Florida: 19.700 $ frente a 53.300 $; Facultad de Medicina Baylor: 18.100 $ frente a 47.856 $, p < 0,01) y tasas de complicaciones (Universidad de Florida: 19% frente a 65%; Baylor College of Medicine: 17% frente a 46%, p < 0,01). En caso de reingreso, la duración de la estancia y el costo disminuyeron en un 81% y un 83%, respectivamente. No se observó ninguna complicación relacionada con la vía.LIMITACIONES:Este estudio no fue aleatorizado. Las limitaciones de recursos y seguros pueden ser un impedimento en la implementación del protocolo para entornos austeros.CONCLUSIONES:La aplicación de un novedoso protocolo estandarizado específico de la ileostomía para evitar la morbilidad por deshidratación, mediante la aplicación de infusiones intravenosas domiciliarias junto con una amplia educación ambulatoria y seguimiento telefónico, mejoró significativamente la calidad de la atención al disminuir la duración de la estancia, los reingresos, las complicaciones y el costo de la atención. Estos resultados se validaron en otra institución. (Traducción-Yesenia Rojas-Khalil).
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Affiliation(s)
- Atif Iqbal
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Ashley Waldon
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | | | | | | | - Derek J Erstad
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Todd K Rosengart
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Thomas E Read
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
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Ba MQ, Zheng WL, Zhang YL, Zhang LL, Chen JJ, Ma J, Huang JL. Construction of a nomogram prediction model for early postoperative stoma complications of colorectal cancer. World J Gastrointest Surg 2025; 17:100547. [PMID: 39872787 PMCID: PMC11757204 DOI: 10.4240/wjgs.v17.i1.100547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/28/2024] [Accepted: 10/25/2024] [Indexed: 12/27/2024] Open
Abstract
BACKGROUND Postoperative enterostomy is increasing in patients with colorectal cancer, but there is a lack of a model that can predict the probability of early complications. AIM To explore the factors influencing early postoperative stoma complications in colorectal cancer patients and to construct a nomogram prediction model for predicting the probability of these complications. METHODS A retrospective study of 462 patients who underwent postoperative ostomy for colorectal cancer in the Gastrointestinal Department of the Anhui Provincial Cancer Hospital. The patients' basic information, surgical details, pathological results, and preoperative inflammatory and nutritional indicators were reviewed. We used univariate and multivariate logistic regression to analyze the risk factors for early postoperative stoma complications in colorectal cancer patients and constructed a nomogram prediction model to predict the probability of these complications. RESULTS Binary logistic regression analysis revealed that diabetes [odds ratio (OR) = 3.088, 95% confidence interval (CI): 1.419-6.719], preoperative radiotherapy and chemotherapy (OR = 6.822, 95%CI: 2.171-21.433), stoma type (OR = 2.118, 95%CI: 1.151-3.898), Nutritional risk screening 2002 score (OR = 2.034, 95%CI: 1.082-3.822) and prognostic nutritional index (OR = 0.486, 95%CI: 0.254-0.927) were risk factors for early stoma complications after colorectal cancer surgery (P < 0.05). On the basis of these results, a prediction model was constructed and the area under the receiver operating characteristic curve was 0.740 (95%CI: 0.669-0.811). After internal validation, the area under the receiver operating characteristic curve of the validation group was 0.725 (95%CI: 0.631-0.820). The calibration curves for the modeling group and validation group are displayed. The predicted results have a good degree of overlap with the actual results. CONCLUSION A previous history of diabetes, preoperative radiotherapy and chemotherapy, stoma type, Nutritional risk screening 2002 score and prognostic nutritional index are risk factors for early stoma complications after colorectal cancer surgery. The nomogram prediction model constructed on the basis of the results of logistic regression analysis in this study can effectively predict the probability of early stomal complications after colorectal cancer surgery.
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Affiliation(s)
- Ming-Qin Ba
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei 230031, Anhui Province, China
| | - Wen-Lin Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei 230031, Anhui Province, China
| | - Yu-Ling Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei 230031, Anhui Province, China
| | - Lin-Lin Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei 230031, Anhui Province, China
| | - Jing-Jing Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei 230031, Anhui Province, China
| | - Jie Ma
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei 230031, Anhui Province, China
| | - Jia-Li Huang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei 230031, Anhui Province, China
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Zhang X, Meng Q, Du J, Tian Z, Li Y, Yu B, Niu W. High output stoma after surgery for rectal cancer - a risk factor for low anterior resection syndrome? BMC Gastroenterol 2025; 25:32. [PMID: 39849372 PMCID: PMC11756101 DOI: 10.1186/s12876-025-03614-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2024] [Accepted: 01/15/2025] [Indexed: 01/25/2025] Open
Abstract
PURPOSE The relationship between high-output stoma (HOS) and low anterior resection syndrome (LARS) was previously unclear. This study investigated the association between HOS and major LARS in rectal cancer patients with preventive stoma. METHODS We conducted a retrospective analysis of 653 rectal cancer patients who underwent prophylactic ileostomy reversal after low anterior resection at the Fourth Hospital of Hebei Medical University between 2018 and 2021. Patients were categorized into HOS and non-HOS groups based on stoma output within 3 months before surgery. Major LARS was assessed using the LARS score. The association between HOS and major LARS was analyzed using multifactor logistic regression models, subgroup analyses, and smoothing curve fitting methods. RESULTS Among the 653 patients, 53 (8.1%) experienced HOS, and 81 (12.4%) developed major LARS after stoma closure. The HOS group exhibited a significantly higher risk of major LARS compared to the non-HOS group (P < 0.001). Multivariate logistic regression indicated that HOS was associated with a 210% increased risk of major LARS (OR: 3.10; 95% CI: 1.56, 6.14; P = 0.001). Subgroup analysis revealed that this association was more pronounced in older patients (age > 60), those without hypertension, with N0-N1 staging, a history of chemotherapy, and longer stoma closure intervals (Q3, Q4). CONCLUSION HOS is significantly associated with major LARS in rectal cancer patients, particularly in certain clinical subgroups. These findings suggest the need for careful management of HOS to potentially reduce LARS occurrence after stoma closure.
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Affiliation(s)
- Xuena Zhang
- Department of Nursing, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, China
| | - Qingyu Meng
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, China
| | - Jianna Du
- Department of Nursing, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, China
| | - Zhongtao Tian
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, China
| | - Yinju Li
- Department of Nursing, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, China
| | - Bin Yu
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, China
| | - Wenbo Niu
- Department of General Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, China.
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Ferrara F, Rizzo G, Bondurri A, Forni C, Anania G, Anastasi A, Baiocchi GL, Boccia L, Cassini D, Catarci M, Cestaro G, Cillara N, Cobellis F, De Luca R, De Nardi P, Deidda S, Delogu D, Fedi M, Giuffrida MC, Grossi U, Impellizzeri H, Langone A, Lauretta A, Lo Celso F, Maffioli A, Manigrasso M, Marafante C, Marano L, Marinello P, Massucco P, Merlini D, Morelli L, Mozzon M, Pafundi DP, Pata F, Pellino G, Peltrini R, Petrina A, Piazza D, Rabuini C, Resendiz A, Salmaso B, Santarelli M, Sena G, Siragusa L, Tamini N, Tondolo V, Tutino R, Vannelli A, Veltri M, Vincenti L, Parini D, MISSTO Snapshot Study Collaborative Group. Outcomes of loop ileostomy after rectal resection for cancer: A prospective observational multicenter snapshot study from Multidisciplinary Italian Study group for STOmas (MISSTO). Tech Coloproctol 2024; 29:16. [PMID: 39661237 DOI: 10.1007/s10151-024-03047-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 11/06/2024] [Indexed: 12/12/2024]
Abstract
BACKGROUND Diverting ileostomy is a common procedure in rectal cancer surgery, but it is sometimes associated with a nonnegligible rate of complications. The primary aim of this study was to analyze the incidence and types of stoma-related complications for ileostomy creation after rectal cancer resection. The secondary aims were to report the indications, the technical details, and the efficacy of stoma care provided by ostomy nurses. METHODS From 15 February to 31 December 2022, consecutive patients who underwent protective ileostomy after anterior rectal cancer resection were enrolled for prospective data collection at 45 Italian colorectal surgery centers. Univariate and multivariate analyses were performed to evaluate factors that influenced the occurrence of stoma-related complications. RESULTS In all, 287 patients were enrolled in the analysis. The short- and long-term postoperative stoma-related morbidity rates were 33.8% and 29.62%, respectively. The most frequent complications were dehydration (17.77%), peristomal skin dermatitis (13.59%), mucocutaneous separation (8.36%), and stoma retraction (4.18%). At the end of follow-up (median time 9 months), the overall stoma closure rate was 83.97% (241 patients), with a median time to stoma closure of 146 days (range 9-483 days). On multivariate analysis, the presence of a stoma nurse was a significant protective factor against stoma-related complications. CONCLUSIONS This study demonstrated that the creation of a protective ileostomy is associated to a nonnegligible rate of short-term and long-term postoperative stoma-related morbidity, higher than 25%. The most frequent complication is dehydration, and the presence of stoma-specialized nurses seems to be a protective factor for stoma-related complications. Moreover, more than 15% of protective stomas were not closed at the end of follow-up.
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Affiliation(s)
- F Ferrara
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), Unit of General and Oncologic Surgery, "Paolo Giaccone" Hospital, University of Palermo, Via Alfonso Giordano, 90127, Palermo, Italy.
| | - G Rizzo
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Rome, Italy
| | - A Bondurri
- Unit of General Surgery 1, Luigi Sacco University Hospital, ASST FBF-Sacco, Milan, Italy
| | - C Forni
- Nursing and Allied Profession Research Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - G Anania
- Unit of General Surgery 1, Arcispedale Sant'Anna, Ferrara, Italy
| | - A Anastasi
- Unit of General Surgery, San Giovanni Di Dio Hospital, Florence, Italy
| | - G L Baiocchi
- Unit of General Surgery, ASST Cremona, Cremona, Italy
| | - L Boccia
- Unit of General and Minimally Invasive Surgery, "Carlo Poma" Hospital, ASST Mantova, Mantova, Italy
| | - D Cassini
- Unit of General Surgery, Legnano Hospital, Legnano, Italy
| | - M Catarci
- Unit of General Surgery, Sandro Pertini Hospital, Rome, Italy
| | - G Cestaro
- Unit of General Surgery, San Antonio Abate Hospital, Gallarate, Italy
| | - N Cillara
- Unit of General Surgery, Santissima Trinità Hospital, Cagliari, Italy
| | - F Cobellis
- Unit of General Surgery, Casa Di Cura "Prof. Dott. Luigi Cobellis", Vallo Della Lucania, Italy
| | - R De Luca
- Department of Surgical Oncology, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - P De Nardi
- Unit of Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - S Deidda
- Unit of Coloproctology, Cagliari University Hospital, Cagliari, Italy
| | - D Delogu
- Unit of Surgical Pathology, Sassari University Hospital, Sassari, Italy
| | - M Fedi
- Unit of General Surgery, San Jacopo Hospital, Pistoia, Italy
| | - M C Giuffrida
- Unit of General and Oncologic Surgery, S. Croce E Carle Hospital, Cuneo, Italy
| | - U Grossi
- DiSCOG Department, Unit of General Surgery 2, Treviso Regional Hospital, University of Padova, Padua, Italy
| | - H Impellizzeri
- Unit of General Surgery, Pederzoli Hospital, Peschiera Del Garda, Italy
| | - A Langone
- Unit of General and Oncologic Surgery, S. Paolo Hospital, Savona, Italy
| | - A Lauretta
- Unit of Oncologic Surgery for Sarcomas, Rare and Multi-Visceral Tumors, CRO IRCCS, Aviano, Italy
| | - F Lo Celso
- Unit of General Surgery, Cattinara Hospital, Trieste, Italy
| | - A Maffioli
- Unit of General Surgery 1, Luigi Sacco University Hospital, ASST FBF-Sacco, Milan, Italy
| | - M Manigrasso
- Unit of Endoscopic Surgery, Federico II University Hospital, Naples, Italy
| | - C Marafante
- Unit of General Surgery, Ospedale Degli Infermi, Rivoli, Italy
| | - L Marano
- Unit of Surgical Oncology, Le Scotte University Hospital, University of Siena, Siena, Italy
| | - P Marinello
- Unit of General Surgery, Central Hospital, Bolzano, Italy
| | - P Massucco
- Unit of General and Oncologic Surgery, AO Ordine Mauriziano, Turin, Italy
| | - D Merlini
- Unit of General Surgery, Garbagnate Hospital, ASST Rhodense, Garbagnate Milanese, Italy
| | - L Morelli
- Unit of General Surgery, Pisa University Hospital, Pisa, Italy
| | - M Mozzon
- Unit of General Surgery, ASUFC Udine Hospital, Udine, Italy
| | - D P Pafundi
- Unit of General Surgery 2, Gemelli IRCCS University Hospital, Rome, Italy
| | - F Pata
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Cosenza, Italy
| | - G Pellino
- Unit of Colorectal Surgery, Luigi Vanvitelli University of Campania, Primo Policlinico, Naples, Italy
| | - R Peltrini
- Unit of General and Oncologic Surgery, Federico II University Hospital, Naples, Italy
| | - A Petrina
- Unit of General Surgery, Perugia University Hospital, Perugia, Italy
| | - D Piazza
- Unit of General and Oncologic Surgery, ARNAS Garibaldi, Catania, Italy
| | - C Rabuini
- Unit of General Surgery, Principe di Piemonte Hospital, Senigallia, Italy
| | - A Resendiz
- Unit of General Surgery, San Luigi Gonzaga Hospital, Turin, Italy
| | - B Salmaso
- Unit of General Surgery, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - M Santarelli
- Unit of General and Emergency Surgery, AOU Città Della Salute E Della Scienza, Turin, Italy
| | - G Sena
- Dipartimento Specialità Chirurgiche, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - L Siragusa
- UOSD Chirurgia Generale E Dell'apparato Digerente, Tor Vergata University Hospital, Rome, Italy
| | - N Tamini
- Unit of General Surgery, San Gerardo Hospital, Monza, Italy
| | - V Tondolo
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Rome, Italy
| | - R Tutino
- Unit of General and Emergency Surgery, Paolo Giaccone University Hospital, Palermo, Italy
| | - A Vannelli
- Unit of General Surgery, Valduce Hospital, Como, Italy
| | - M Veltri
- Unit of General Surgery, San Jacopo Hospital, Pistoia, Italy
| | - L Vincenti
- Unit of General Surgery, Azienda Ospedaliero Universitaria Consorziale Policlinico, Bari, Italy
| | - D Parini
- Unit of General Surgery, Santa Maria Della Misericordia Hospital, Rovigo, Italy
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Collaborators
Francesco Bagolini, Matteo Chiozza, Sabrina Pedon, Giuseppe Canonico, Carmela Martino, Elvira Adinolfi, Manuela Mastronardi, Massimo Petrella, Guido Mantovani, Annalisa Pascariello, Gianandrea Baldazzi, Marta Spalluto, Marco Della Sanità, Maria Sole Mattei, Michele Benedetti, Leonardo Montemurro, Corrado Bottini, Gianluca Grillone, Antonello Deserra, Alessandro Cannavera, Luigi Cobellis, Roberto Scola, Francesca Savastano, Gabriele Carbone, Francesco Denti, Luigi Zorcolo, Angelo Restivo, Luca Ippolito, Fabrizio Scognamillo, Antonio Giulio Marrosu, Sandro Giannessi, Virna Robustelli, Marco Stella, Enrico Gelarda, Danilo Donati, Diego Sasia, Marco Piccino, Alberto Brun Peressut, Rino Baldan, Creciun Mihail, Alessandro Vitali, Gianluigi Moretto, Raffaele Galleano, Omar Ghazouani, Sara Pollesel, Claudio Belluco, Nicolò Manzini, Fabio Porcelli, Alice Gabrieli, Andrea Micalef, Gloria Zaffaroni, Marco Milone, Giovanni Domenico De Palma, Sara Vertaldi, Ana Lavinia Apostu, Simone Lorenzo Birolo, Mauro Garino, Franco Roviello, Daniele Marrelli, Ludovico Carbone, Giacomo Bertelli, Antonio Frena, Federica Gonella, Marco Palisi, Federico Marin, Gregorio Franco, Niccolò Furbetta, Annalisa Comandatore, Cristina Folliero, Luca Amodio, Francesco Menegon Tasselli, Marco D'Ambrosio, Francesco Selvaggi, Biancamaria Iacone, Umberto Bracale, Roberto Ciaccarini, Michela Boncompagni, Davide Mascali, Caterina Piazza, Enrico Falzone, Rossella Reddavid, Maurizio Degiuli, Maurizio Luca, Diego Visconti, Alice Ferguglia, Chiara Piceni, Giorgio Ammerata, Giuseppe Sica, Andrea Martina Guida, Bruno Sensi, Lorenzo Ripamonti, Giulia Carlo, Paolina Venturelli, Gianfranco Cocorullo, Ada Della Valle, Andrea Romanzi, Maria Milanesi, Giovanni Tomasicchio, Nicola Paradiso, Ilaria Verriello,
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Liu Y, Li H, Wu JJ, Ye JH. Risk factors and risk prediction model for mucocutaneous separation in enterostomy patients: A single center experience. World J Clin Cases 2024; 12:6620-6628. [PMID: 39600483 PMCID: PMC11514340 DOI: 10.12998/wjcc.v12.i33.6620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 09/05/2024] [Accepted: 09/11/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Mucocutaneous separation (MCS) is a common postoperative complication in enterostomy patients, potentially leading to significant morbidity. Early identification of risk factors is crucial for preventing this condition. However, predictive models for MCS remain underdeveloped. AIM To construct a risk prediction model for MCS in enterostomy patients and assess its clinical predictive accuracy. METHODS A total of 492 patients who underwent enterostomy from January 2019 to March 2023 were included in the study. Patients were divided into two groups, the MCS group (n = 110), and the non-MCS (n = 382) based on the occurrence of MCS within the first 3 weeks after surgery. Univariate and multivariate analyses were used to identify the independent predictive factors of MCS and the model constructed. Receiver operating characteristic curve analysis was used to assess the model's performance. RESULTS The postoperative MCS incidence rate was 22.4%. Suture dislodgement (P < 0.0001), serum albumin level (P < 0.0001), body mass index (BMI) (P = 0.0006), hemoglobin level (P = 0.0409), intestinal rapture (P = 0.0043), incision infection (P < 0.0001), neoadjuvant therapy (P = 0.0432), stoma site (P = 0.0028) and elevated intra-abdominal pressure (P = 0.0395) were potential predictive factors of MCS. Suture dislodgement [P < 0.0001, OR: 28.0075 95%CI: (11.0901-82.1751)], serum albumin level (P = 0.0008, OR: 0.3504, 95%CI: [0.1902-0.6485]), BMI [P = 0.0045, OR: 2.1361, 95%CI: (1.2660-3.6235)], hemoglobin level [P = 0.0269, OR: 0.5164, 95%CI: (0.2881-0.9324)], intestinal rapture [P = 0.0351, OR: 3.0694, 95%CI: (1.0482-8.5558)], incision infection [P = 0.0179, OR: 0.2885, 95%CI: (0.0950-0.7624)] and neoadjuvant therapy [P = 0.0112, OR: 1.9769, 95%CI: (1.1718-3.3690)] were independent predictive factors and included in the model. The model had an area under the curve of 0.827 and good clinical utility on decision curve analysis. CONCLUSION The mucocutaneous separation prediction model constructed in this study has good predictive performance and can provide a reference for early warning of mucocutaneous separation in enterostomy patients.
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Affiliation(s)
- Yun Liu
- Department of Reconstructive, Hand and Plastic Surgery, Zhejiang Chinese Medical University, Lishui Central Hospital, 289 Kuocang Road, Liandu District, Lishui 323000, Zhejiang Province, China
| | - Hong Li
- Department of Reconstructive, Hand and Plastic Surgery, Zhejiang Chinese Medical University, Lishui Central Hospital, 289 Kuocang Road, Liandu District, Lishui 323000, Zhejiang Province, China
| | - Jin-Jing Wu
- Department of Reconstructive, Hand and Plastic Surgery, Zhejiang Chinese Medical University, Lishui Central Hospital, 289 Kuocang Road, Liandu District, Lishui 323000, Zhejiang Province, China
| | - Jian-Hong Ye
- Department of Operation Room, Zhejiang Chinese Medical University, Lishui Central Hospital, 289 Kuocang Road, Liandu District, Lishui 323000, Zhejiang Province, China
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Khan MA, Niaz K, Asghar S, Yusufi MA, Nazir M, Muhammad Ali S, Ahmed A, Salahudeen AA, Kareem T. Surgical Site Infection After Stoma Reversal: A Comparison Between Linear and Purse-String Closure. Cureus 2023; 15:e50057. [PMID: 38186536 PMCID: PMC10769136 DOI: 10.7759/cureus.50057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Intestinal stomas are utilized for both benign and malignant conditions of the intestine to mitigate the risk of anastomotic leakage and re-exploration. However, stomas are associated with various complications, such as stoma necrosis, peri-stomal irritation, parastomal hernia, bleeding, bowel obstruction, and electrolyte abnormalities. Surgical site infection (SSI) is a significant source of morbidity following stoma reversal, leading to increased patient morbidity. The conventional method of stoma reversal involves closing the skin with non-absorbable sutures in a linear fashion, which is known as linear skin closure (LSC). Recently, a new method of skin closure using purse-string approximation (PSA) has been advocated, which allows healing by secondary intention. The rationale for this study is to compare the SSI associated with LSC and PSA after stoma reversal. OBJECTIVE This study aims to compare the frequency of SSI between LSC and PSA in stoma reversal. MATERIALS AND METHODS The study was conducted at the Department of General Surgery, Shifa International Hospitals Ltd. (SIH), Islamabad, Pakistan. The study is a randomized controlled clinical trial carried out between the 14th of March 2021 and the 22nd of November 2022. The sampling technique was non-probability consecutive random sampling. The sample size was calculated using the WHO sample size calculator by using the hypothesis test for two population proportions. The minimum sample size in each group was 40 patients. The total sample size was 80 patients. RESULTS The overall frequency of SSI in all the patients was 18/80 (22.5%). The frequency of SSI in Group 1 (LSC) was 6/40 (15.0%), and in Group 2 (PSA), it was 12/40 (30.0%). The frequency of SSI in Group 2 (PSA) was twice as high as in Group 1 (LSC); however, the p-value was calculated to be 0.108. Therefore, this difference was statistically insignificant. CONCLUSIONS While PSA has exhibited promise in reducing SSI rates and enhancing aesthetic outcomes and patient satisfaction, there is still enough data favoring LSC. Moreover, insufficient data is available for our population to make a definitive statement. Consequently, further research on this topic is warranted, preferably involving larger sample sizes and multicenter randomized controlled trials, to establish which technique is superior in SSI reduction.
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Affiliation(s)
- Muhammad Awais Khan
- Accident and Emergency, Frimley Health National Health Service (NHS) Foundation Trust, Surrey, GBR
| | - Khurram Niaz
- General Surgery, Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, PAK
| | - Shahzeb Asghar
- General Surgery, Multan Medical and Dental College, Multan, PAK
| | - Maaz A Yusufi
- General Surgery, University Hospitals Dorset National Health Service (NHS) Foundation Trust, Dorset, GBR
| | - Mohtamam Nazir
- General Surgery, Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, PAK
| | - Syed Muhammad Ali
- Surgery, Weill Cornell Medical School, Doha, QAT
- Acute Care Surgery, Hamad General Hospital, Doha, QAT
| | - Aryan Ahmed
- Acute Care Surgery, Hamad General Hospital, Doha, QAT
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9
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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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De Hous N, D'Urso A, Cadière GB, Cadière B, Rouanet P, Komen N, Lefevre JH. Evaluation of the SafeHeal Colovac+ anastomosis protection device after low anterior resection for rectal cancer: the safe anastomosis feasibility evaluation (SAFE) 2019 trial. Surg Endosc 2023; 37:7385-7392. [PMID: 37464064 DOI: 10.1007/s00464-023-10272-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/02/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Protective ileostomy (PI) is the current standard of care to protect the anastomosis after low anterior resection (LAR) for rectal cancer, but is associated with significant morbidity. Colovac is an anastomosis protection device designed to shield the anastomosis from fecal content. A second version (Colovac+) was developed to limit the migration risk during the implantation period. The objective of this clinical trial was to evaluate the preliminary efficacy and safety of the Colovac+. METHODS This was a prospective, multicenter, pilot study aiming to enroll 15 patients undergoing LAR with Colovac+ placement. After 10 days, a CT scan was performed to evaluate the anastomosis and the Colovac+ was retrieved endoscopically. During the 10-day implantation and 3-month follow-up period, we collected data regarding predefined efficacy and safety endpoints. The primary endpoint was the rate of major (Clavien-Dindo III-V) postoperative complications related to the Colovac+ or LAR procedure. RESULTS A total of 25 patients were included (68% male), of whom 15 were consecutively treated with the Colovac+ and Vacuum Loss Alert System. The Colovac+ was successfully implanted in all 15 patients. No major discomfort was reported during the implantation period. The endoscopic retrieval was performed in 14/15 (93%) patients. The overall major postoperative morbidity rate was 40%, but none of the reported complications were related to the Colovac+. A device migration occurred in 2 (13%) patients, but these were not associated with AL or stoma conversion. Overall, Colovac+ provided effective fecal diversion in all 15 patients and was able to avoid the PI in 11/15 (73%) patients. CONCLUSIONS Colovac+ provides a safe and effective protection of the anastomosis after LAR, and avoids the PI in the majority (73%) of patients. The improved design reduces the overall migration rate and limits the clinical impact of a migration.
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Affiliation(s)
- Nicolas De Hous
- Department of Abdominal Surgery, Antwerp University Hospital (UZA), Edegem, Belgium.
| | - Antonio D'Urso
- Department of General, Digestive and Endocrine Surgery, Centre Hospitalier Régional et Universitaire (CHRU), Strasbourg, France
| | - Guy-Bernard Cadière
- Department of Digestive Surgery, Centre Hospitalier Universitaire (CHU) Saint-Pierre, Brussels, Belgium
| | - Benjamin Cadière
- Department of Digestive Surgery, Centre Hospitalier Universitaire (CHU) Saint-Pierre, Brussels, Belgium
| | - Philippe Rouanet
- Department of Oncological Surgery, Institut du Cancer de Montpellier (ICM), Montpellier, France
| | - Niels Komen
- Department of Abdominal Surgery, Antwerp University Hospital (UZA), Edegem, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Edegem, Belgium
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Hôpital Saint-Antoine AP-HP, Sorbonne Université, Paris, France
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11
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Liu F, Wang LL, Liu XR, Li ZW, Peng D. Risk Factors for Radical Rectal Cancer Surgery with a Temporary Stoma Becoming a Permanent Stoma: A Pooling Up Analysis. J Laparoendosc Adv Surg Tech A 2023; 33:743-749. [PMID: 37099806 DOI: 10.1089/lap.2023.0119] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Purpose: The aim of this study was to find out the potential risk factors for the formation of a permanent stoma (PS) for rectal cancer patients with a temporary stoma (TS) after surgery. Methods: PubMed, Embase, and the Cochrane Library were searched for eligible studies until November 14, 2022. The patients were divided into the PS group and the TS group. Odds ratio (ORs) and 95% confidence intervals (CIs) were pooled up for describing dichotomous variables. Stata SE 16 was performed for data analysis. Results: After pooling up the data, a total of 14 studies involving 14,265 patients were included in this study. The outcomes showed that age (OR = 1.03, 95% CI = 0.96 to 1.10, I2 = 1.42%, P = .00 < .1), surgery type (P = .00 < .1), tumor stage (P = .00 < .1), preoperative chemoradiotherapy (P = .00 < .1), preoperative radiotherapy (P = .01 < .1), neoadjuvant therapy (P = .00 < .1), American Society of Anesthesiologists (ASA) score of ≥3 (P = .00 < .1), anastomotic leakage (P = .01 < .1), local recurrence (P = .00 < .1), and distant recurrence (P = .00 < .1) were associated with the patient with PS. However, sex (P = .15 > .1), previous abdominal surgery (P = .84 > .1), adjuvant chemotherapy (P = .87 > .1), and defunctioning stoma (P = .1) had little association with PS. Conclusion: Patients who were elderly, had advanced tumor stages, had a high ASA score, and underwent neoadjuvant therapy should be informed of the high risk of PS before surgery. Meanwhile, those who underwent rectal cancer surgery with a TS should beware of anastomotic leakage, local recurrences, and distant recurrences, which could increase the risk of PS.
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Affiliation(s)
- Fei Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lian-Lian Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xu-Rui Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zi-Wei Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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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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Denost Q, Sylla D, Fleming C, Maillou-Martinaud H, Preaubert-Hayes N, Benard A. A phase III randomized trial evaluating the quality of life impact of a tailored versus systematic use of defunctioning ileostomy following total mesorectal excision for rectal cancer-GRECCAR 17 trial protocol. Colorectal Dis 2023; 25:443-452. [PMID: 36413078 DOI: 10.1111/codi.16428] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/02/2022] [Accepted: 11/06/2022] [Indexed: 11/23/2022]
Abstract
AIM The systematic use of a defunctioning ileostomy for 2-3 months postoperatively to protect low colorectal anastomosis (<7 cm from the anal verge) has been the standard practice after total mesorectal excision (TME). However, stoma-related complications can occur in 20%-60% of cases, which may lead to prolonged inpatient care, urgent reoperation and long-term definitive stoma. A negative impact on quality of life (QoL) and increased healthcare expenses are also observed. Conversely, it has been reported that patients without a defunctioning stoma or following early stoma closure (days 8-12 after TME) have a better functional outcome than patients with systematic defunctioning stoma in situ for 2-3 months. METHOD The main objective of this trial is to compare the QoL impact of a tailored versus systematic use of a defunctioning stoma after TME for rectal cancer. The primary outcome is QoL at 12 months postoperatively using the European Organization for. Research and Treatment of Cancer QoL questionnaire QLQ-C30. Among 29 centres of the French GRECCAR network, 200 patients will be recruited over 18 months, with follow-up at 1, 4, 8 and 12 months postoperatively, in an open-label, randomized, two-parallel arm, phase III superiority clinical trial. The experimental arm (arm A) will undergo a tailored use of defunctioning stoma after TME based on a two-step process: (i) to perform or not a defunctioning stoma according to the personalized risk of anastomotic leak (defunctioning stoma only if modified anastomotic failure observed risk score ≥2) and (ii) if a stoma is fashioned, whether to perform an early stoma closure at days 8-12, according to clinical (fever), biochemical (C-reactive protein level on days 2 and 4 postoperatively) and radiological postoperative assessment (CT scan with retrograde contrast enema at days 7-8 postoperatively). The control arm (arm B) will undergo systematic use of a defunctioning stoma for 2-3 months after TME for all patients, in keeping with French national and international guidelines. Secondary outcomes will include comprehensive analysis of functional outcomes (including bowel, urinary and sexual function) again up to 12 months postoperatively and a cost analysis. Regular assessments of anastomotic leak rates in both arms (every 50 randomized patients) will be performed and an independent data monitoring committee will recommend trial cessation if this rate is excessive in arm A compared to arm B. CONCLUSION The GRECCAR 17 trial is the first randomized trial to assess a tailored, patient-specific approach to decisions regarding defunctioning stoma use and closure after TME according to personalized risk of anastomotic leak. The results of this trial will describe, for the first time, the QoL and morbidity impact of selective use of a defunctioning ileostomy and the potential health economic effect of such an approach.
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Affiliation(s)
- Quentin Denost
- Department of Colorectal Surgery, Hôpital Haut-Lévèque CHU, Bordeaux, France
| | - Dienabou Sylla
- Inserm, CIC1401-EC, Bordeaux, Service D'information Médicale CHU, Bordeaux, France
| | - Christina Fleming
- Department of Colorectal Surgery, Hôpital Haut-Lévèque CHU, Bordeaux, France
| | | | | | - Antoine Benard
- Inserm, CIC1401-EC, Bordeaux, Service D'information Médicale CHU, Bordeaux, France
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Thomas F, Menahem B, Lebreton G, Bouhier-Leporrier K, Dejardin O, Alves A. Permanent stoma after sphincter preservation for rectal cancer. A situation that occurs more often than you might think. Front Oncol 2023; 12:1056314. [PMID: 36776358 PMCID: PMC9909408 DOI: 10.3389/fonc.2022.1056314] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/16/2022] [Indexed: 01/27/2023] Open
Abstract
Objectives This study aimed: (i) to assess the cumulative incidence of permanent stoma (PS) after sphincter-preserving surgery (SPS) for rectal cancer (RC): (ii) to analyze associated risk factors for primary and secondary PS; and (iii) to compare the long-term survival of patients according to the stoma state. Methods We conducted a retrospective single-center cohort study based on a prospectively maintained database of SRC patients undergoing SPS from January 2007 to December 2017. Incidence of both primary (no reversal of defunctioning stoma) and secondary (created after closure of defunctioning stoma) PS were investigated. Associations between potential risk factors and PS were analyzed using a logistic regression model. Cumulative survival curve was drawn by Kaplan-Meier method. Results Of the 257 eligible patients, 43 patients (16.7%) had a PS (16 primary PS and 27 secondary PS) after a median follow-up of 4.8 years. In multivariate analysis, the independent risk factors for primary PS were severe post-operative complications (OR 3.66; 95% CI, 1.19-11.20, p=0.022), and old age (OR 1.11; 95% CI 1.04-1.18, p=0.001) and those for secondary PS were local recurrence (OR 38.07; 95% CI 11.07-130.9, p<0.0001), anastomotic leakage (OR 7.01; 95% CI, 2.23-22.04, p=0.009), and severe post-operative complications (OR 3.67; 95% CI, 1.22-11.04, p=0.02), respectively. Both overall survival (OS) and disease-free survival (DFS) were significantly lower in patients with a PS compared with patients with SPS (p < 0.01). Conclusions This present study suggests that one out of 6 patients has a PS, 5 years after rectal resection with SPS for SRC.
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Affiliation(s)
- Flavie Thomas
- Centre Hospitalier Universitaire de Caen, Caen, France
| | - Benjamin Menahem
- Centre Hospitalier Universitaire de Caen, Caen, France,*Correspondence: Benjamin Menahem,
| | - Gil Lebreton
- Centre Hospitalier Universitaire de Caen, Caen, France
| | | | - Olivier Dejardin
- Institut Nationale de la Recherche Medicale (INSERM) U1086 Unité de recherche Interdisciplinaire pour la Prévention et le Traitement des Cancers, Caen, France
| | - Arnaud Alves
- Centre Hospitalier Universitaire de Caen, Caen, France
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Shabunin AV, Bagatelija ZA, Kulushev VM, Hmylov LM, Maksimkin AI. [Prognostic factors of dehydration and renal damage in patients with formed preventive ileostomy during rectal resection for cancer]. Khirurgiia (Mosk) 2023:23-29. [PMID: 36583490 DOI: 10.17116/hirurgia202301123] [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: 12/31/2022]
Abstract
Despite the potential advantages of a preventive intestinal stoma after the formation of a low colon anastomosis during rectal resections, the formation of a preventive loop ileostomy is associated with a significant frequency of complications. OBJECTIVE To determine the potential prognostic factors of complications associated with ileostomy dysfunction in patients who have undergone rectal resection for cancer. MATERIAL AND METHODS We retrospectively analyzed patients over the age of 18 who underwent open and laparoscopic resection of the rectum with the formation of a preventive ileostomy from January 2015 to May 2022. To determine the influence of potential predictors on the frequency of complications associated with large ileostomy losses, a single-factor logistic regression analysis was used. Complications associated with large ileostomy losses were primarily water-electrolyte disorders, dehydration and acute renal failure, which required intensive therapy and re-hospitalization. RESULTS Of the 120 patients included in the study, 26 (21.7%) suffered complications associated with large losses of fluid and electrolytes in the stoma. In this group of patients, at least one repeated emergency hospitalization to a medical institution was required (average value 1.6). Factors associated with ileostomy dysfunction in a single-factor analysis were: the presence of signs of intestinal obstruction (OR=2.6; p=0.047), the development of postoperative complications (OR=3; p=0.024), steroid use (OR=4.3; p=0.010), smoking (OR=4.8; p=0.017) the average amount of discharge from the stoma at discharge is more than 1000 ml/24 h (OR=3.2; p=0.016) and the need for Loperamide at the time of discharge (OR=2.8; p=0.032). Multivariate logistic regression analysis revealed an independent risk factor for complications leading to re-hospitalization: ileostomy losses at discharge ≥1000 ml/24 h (OR=3.3 (1.18-9.37); p=0.023). CONCLUSION In our study, those patients whose ileostomy discharge exceeded 1000 ml/24 h at discharge were at increased risk of dehydration, hypokalemia, hypocalcemia, acute prerenal renal failure, which led to repeated hospitalization to correct these disorders, sometimes in the intensive care unit.
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Affiliation(s)
- A V Shabunin
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia.,Botkin Hospital, Moscow, Russia
| | - Z A Bagatelija
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia.,Botkin Hospital, Moscow, Russia
| | | | | | - A I Maksimkin
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
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16
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van Kessel CS, Mendes C, Young CJ. Peristomal Necrosis Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Case Report. J Wound Ostomy Continence Nurs 2022; 49:564-569. [PMID: 36417381 DOI: 10.1097/won.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Peristomal necrosis is a rare but challenging condition requiring multidisciplinary management involving surgical debridement and intensive WOC nurse management. CASE Mr T was a 56-year-old man who underwent cytoreductive surgery with intraperitoneal chemotherapy for a high-grade appendiceal neoplasm. As part of the procedure, an Abcarian stoma (end-ileostomy with a distal lumen from the transverse colon brought out flush with skin beside the proximal stoma) was created. Postoperatively there was leakage of effluent under the subcutaneous skin resulting in full-thickness necrosis of the peristomal area requiring surgical debridement. Consequently, a large peristomal skin defect occurred, resulting in difficulty achieving a good seal of the ostomy pouching system. To overcome these challenges, a multidisciplinary approach with WOC nurses, colorectal surgeons, and plastic surgeons was implemented. Initially, the defect was managed with a negative pressure wound therapy system, followed by a primary closure of the peristomal skin by the plastic surgeons. Mr T was discharged to home 58 days after his initial surgery; by that time, the peristomal skin was healed and he was able to manage ostomy pouching changes independently. Eight months later his ileostomy was successfully reversed. CONCLUSIONS Large peristomal defects are challenging but can be managed successfully via a multidisciplinary approach including WOC nurses, colorectal surgeons, and plastic surgeons.
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Affiliation(s)
- Charlotte S van Kessel
- Charlotte S. van Kessel, MD, PhD, MSc , Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Colleen Mendes, RN, STN, Department of Stomal Therapy, Royal Prince Alfred Hospital, Sydney, Australia
- Christopher J. Young, MD, MS, FRACS, FACS, FASCRS, Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Colleen Mendes
- Charlotte S. van Kessel, MD, PhD, MSc , Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Colleen Mendes, RN, STN, Department of Stomal Therapy, Royal Prince Alfred Hospital, Sydney, Australia
- Christopher J. Young, MD, MS, FRACS, FACS, FASCRS, Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christopher J Young
- Charlotte S. van Kessel, MD, PhD, MSc , Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Colleen Mendes, RN, STN, Department of Stomal Therapy, Royal Prince Alfred Hospital, Sydney, Australia
- Christopher J. Young, MD, MS, FRACS, FACS, FASCRS, Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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17
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Overall readmissions and readmissions related to dehydration after creation of an ileostomy: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:333-349. [PMID: 35192122 PMCID: PMC9018644 DOI: 10.1007/s10151-022-02580-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/18/2022] [Indexed: 12/19/2022]
Abstract
Background Hospital readmissions after creation of an ileostomy are common and come with a high clinical and financial burden. The aim of this review with pooled analysis was to determine the incidence of dehydration-related and all-cause readmissions after formation of an ileostomy, and the associated costs.
Methods A systematic literature search was conducted for studies reporting on dehydration-related and overall readmission rates after formation of a loop or end ileostomy between January 1990 and April 2021. Analyses were performed using R Statistical Software Version 3.6.1.
Results The search yielded 71 studies (n = 82,451 patients). The pooled incidence of readmissions due to dehydration was 6% (95% CI 0.04–0.09) within 30 days, with an all-cause readmission rate of 20% (CI 95% 0.18–0.23). Duration of readmissions for dehydration ranged from 2.5 to 9 days. Average costs of dehydration-related readmission were between $2750 and $5924 per patient. Other indications for readmission within 30 days were specified in 15 studies, with a pooled incidence of 5% (95% CI 0.02–0.14) for dehydration, 4% (95% CI 0.02–0.08) for stoma outlet problems, and 4% (95% CI 0.02–0.09) for infections. Conclusions One in five patients are readmitted with a stoma-related complication within 30 days of creation of an ileostomy. Dehydration is the leading cause for these readmissions, occurring in 6% of all patients within 30 days. This comes with high health care cost for a potentially avoidable cause. Better monitoring, patient awareness and preventive measures are required. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02580-6.
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18
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Calvo Espino P, Sánchez Movilla A, Alonso Sebastian I, García Schiever J, Varillas Delgado D, Sánchez Turrión V, López Monclús J. Incidence and risk factors of delayed development for stoma site incisional hernia after ileostomy closure in patients undergoing colorectal surgery with temporary ileostomy. Acta Chir Belg 2022; 122:41-47. [PMID: 33176613 DOI: 10.1080/00015458.2020.1846941] [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] [Indexed: 02/09/2023]
Abstract
BACKGROUND Stoma site incisional hernias after ileostomy closure are complex hernias that can be associated with abdominal pain, discomfort, and a diminished quality of life. The aim of this study was to determine the incidence of incisional hernia (IH) following temporary ileostomy reversal in patients undergoing colorectal surgery, and the risk factors associated with its development. METHODS This was a prospective, single-centre, cohort study of patients undergoing ileostomy reversal between January 2010 and December 2016. Comorbidities, operative characteristics, comparison between early and late ileostomy closure and postoperative complications were analysed. RESULTS A total of 202 consecutive patients were prospectively evaluated (median follow-up 46 months; range: 12-109). Stoma site incisional hernia occurred in 23% of patients (n = 47), diagnosed by physical examination or imaging tests. The reasons for the primary surgery were colorectal cancer (n = 141, 69.8%), inflammatory bowel disease (n = 14, 6.9%), emergency surgery (n = 35, 17.3%), and other conditions (n = 12, 5.9%). Secondary outcomes: a statistically significant risk factors for developing an IH was obesity (higher BMI) (OR 1.15, 95% CI: 1.05-1.26) p = .003). CONCLUSIONS 23% of patients developed surgical site IH, a higher BMI being the only risk factor found to be statistically significant in the development of an incisional hernia.
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Affiliation(s)
| | | | | | | | | | - Víctor Sánchez Turrión
- Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
- Universidad Autonoma de Madrid, Madrid, Spain
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19
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De Hous N, Khosrovani C, Lefevre JH, D'Urso A, Komen N. Evaluation of the SafeHeal Colovac+ Anastomosis Protection Device: A Preclinical Study. Surg Innov 2022; 29:390-397. [PMID: 35089103 DOI: 10.1177/15533506211051274] [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: 11/16/2022]
Abstract
BackgroundThe protective ostomy is the current standard of care to protect a low colorectal anastomosis from leakage, but exposes patients to complications requiring an alternative strategy. The Colovac+ is a vacuum-based intraluminal bypass device designed to shield the anastomosis from fecal content, preventing the clinical outcomes of anastomotic leakage. The objective of this study was to evaluate the preliminary efficacy, safety, and technical feasibility of the Colovac+ in a porcine model. Methods: Twelve pigs received a colorectal anastomosis with Colovac+ implantation. The device was left in situ for 10 days and then retrieved endoscopically. Six pigs were to be sacrificed immediately after device retrieval and the other 6 were to be sacrificed on day 38. Clinical, endoscopic, and histopathological examinations were performed to evaluate the following endpoints: prevention of contact between the anastomosis and fecal content, device migration, feasibility of the implantation and retrieval procedure, collateral damage to the colonic wall, colon healing after device retrieval, and systemic toxicity related to the device. Results: Eleven pigs completed the study. One pig died prematurely due to a surgical complication unrelated to the device (bladder damage with uroperitoneum). There was no evidence of contact between the anastomosis and fecal content, none of the pigs developed symptomatic anastomotic leakage, there were no significant device migrations, and there was no evidence of systemic toxicity. Colovac+ implantation was easily performed in all cases except 1 (due to an inappropriate lubricant). Colovac+ retrieval was achieved successfully in all cases. Postretrieval examinations on day 10 revealed ulcerations at the anchoring site in 4 cases indicating mechanical damage caused by the stent. However, in the recovery group, no ulcerations were observed on day 38, and the colonic wall had properly healed in all animals. Conclusions: The Colovac+ is a technically feasible, safe, and efficient device for the protection of a colorectal anastomosis in a porcine model. The device holds promise for clinical use and warrants further research.
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Affiliation(s)
- Nicolas De Hous
- Department of Abdominal Surgery, 60202Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Charam Khosrovani
- Department of Digestive Surgery, Elsan-Fontvert Clinic, Sorgues, France
| | - Jérémie H Lefevre
- Department of Digestive Surgery, 37117Saint-Antoine Hospital AP-HP, Sorbonne University, Paris, France
| | - Antonio D'Urso
- Department of General, Digestive, and Endocrine Surgery, 36604Strasbourg University Hospital, Strasbourg, France
| | - Niels Komen
- Department of Abdominal Surgery, 60202Antwerp University Hospital, University of Antwerp, Edegem, Belgium.,Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), 60202University of Antwerp, Edegem, Belgium
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20
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Pei W, Cui H, Liu Z, Zhao F, Zhu X, Li L, Jing C, Xu T, Peng L, Zhuo H, Chen Y, Zhang J. One-stitch method vs. traditional method of protective loop ileostomy for rectal cancer: the impact of BMI obesity. J Cancer Res Clin Oncol 2021; 147:2709-2719. [PMID: 33606093 DOI: 10.1007/s00432-021-03556-z] [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: 07/31/2020] [Accepted: 02/04/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Protective loop ileostomy is an effective diversion measure often used to reduce the risk of anastomotic leakage. The purpose of the present study was to evaluate the surgical outcomes of the one-stitch method (OM) of protective loop ileostomy in laparoscopic low anterior resection for BMI obesity patients with rectal cancer compared with the traditional method (TM). METHODS The patients diagnosed as rectal adenocarcinoma cases by preoperative pathology were included in this retrospective study. The subjects underwent protective loop ileostomy in laparoscopic low anterior resection from January 2016 to June 2019 in the Shandong Provincial Hospital affiliated to Shandong University. The data of loop ileostomy and stoma closure operation were retrieved from the medical cases system of the hospital. RESULTS 242 patients were included in the present study. In the BMI obese cohort, the OM group showed a shorter operative time both in the loop ileostomy (232.5 vs. 250.0 min, p = 0.04) and stoma closure operation (102.5 vs. 115.0 min, p = 0.001) and a lower peristomal adhesion extent (p = 0.02) and a shorter median postoperative stay (6 vs. 7 days, p = 0.03) during stoma closure operation than that of the TM group. In the TM group, obese cases showed a higher operative time of stoma closure operation (115.0 vs. 95.0, p < 0.001), a higher parastomal hernia rate (p = 0.04), a higher peristomal adhesion extent (p = 0.005) and a longer postoperative stay of stoma closure operation (p = 0.02) compared with the non-obese cases, while in the OM group, no significant differences were observed between the obese and non-obese cases in terms of the above-mentioned factors. CONCLUSIONS The OM exhibited more advantages than TM, notably in BMI obesity patients.
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Affiliation(s)
- Wenting Pei
- Department of Pediatric Hematology-Oncology, Qilu Children's Hospital of Shandong University, Jinan, 250000, Shandong, China
| | - Huaiping Cui
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China
| | - Zhenjun Liu
- Department of Gastrointestinal Surgery, Feicheng Hospital Affiliated to Shandong First Medical University, FeiCheng People's Hospital, Feicheng, 271600, Shandong, China
| | - Feng Zhao
- Department of General Surgery, People's Hospital of Lingcheng District, Lingcheng District, Dezhou, 253500, Shandong, China
| | - Xuezhang Zhu
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China
| | - Leping Li
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Changqing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Tao Xu
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Lipan Peng
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Hongqing Zhuo
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Yuezhi Chen
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Jizhun Zhang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China.
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China.
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21
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Baloyiannis I, Perivoliotis K, Vederaki S, Koukoulis G, Symeonidis D, Tzovaras G. Current evidence regarding the role of adjuvant chemotherapy in rectal cancer patients with pathologic complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:1395-1406. [PMID: 33772323 DOI: 10.1007/s00384-021-03915-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this meta-analysis was to investigate the role of adjuvant chemotherapy (AC) in rectal cancer patients with pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) and curative resection. METHODS This study was completed in accordance to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic scholar databases (Medline, Web of Science, Scopus) were screened for eligible articles. The level of evidence (LoE) was assessed using the GRADE methodology. RESULTS Overall, 23 non-randomized studies and 17,406 patients were included in the present meta-analysis. Pooled comparisons confirmed that AC improved overall survival (HR: 0.68, p=0.0003), but not disease-free (p=0.22) and recurrence-free survival (p=0.39). However, the LoE for all outcomes was characterized as "very low," due to the absence of RCTs. CONCLUSIONS Considering the study limitations and the lack of randomized studies, further high-quality RCTs are required to confirm the findings of our study.
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Affiliation(s)
- Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | | | - Styliani Vederaki
- Faculty of Medicine, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | - Georgios Koukoulis
- Faculty of Medicine, University of Thessaly, Mezourlo, 41110, Larissa, Greece
- Department of Surgery, Koutlimbaneio and Triantafylleio General Hospital of Larissa, Larissa, Greece
| | - Dimitrios Symeonidis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
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22
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Kim NE, Hall JF. Risk Factors for Readmission after Ileostomy Creation: an NSQIP Database Study. J Gastrointest Surg 2021; 25:1010-1018. [PMID: 32207078 DOI: 10.1007/s11605-020-04549-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/13/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ileostomy creation is associated with excess readmissions following colorectal surgery. This study identifies risk factors for readmission in patients undergoing ileostomy creation and identifies areas of clinical intervention to reduce readmission. METHODS We used the NSQIP dataset including colectomy specific data to include 39,380 patients who underwent ileostomy creation between 2012 and 2017. We conducted univariate and multivariable analysis to identify predictors of surgery-related 30-day readmissions. Our multivariate model included surgery type (total abdominal colectomy, partial colectomy, enterectomy, or pelvic dissection), gender, age, race, ethnicity, preoperative renal failure, dialysis, transfusion, ascites, ventilator dependence, diabetes, ASA class, functional status, emergency case, SSI, wound disruption, postoperative renal insufficiency, postoperative sepsis, discharge destination, and wound class. RESULTS A total of 5718 (14.52%) patients were readmitted within 30 days. After multivariate analysis, factors associated with readmission were gender, age, Hispanic ethnicity, dialysis, transfusion, ventilator dependence, diabetes, emergency case, SSI, postoperative renal insufficiency, postoperative sepsis, and discharge to a skilled facility. Patients who had enterectomy and partial colectomies were less likely to be readmitted than patients who had a pelvic procedure. Patients with postoperative renal insufficiency or renal failure were much more likely to be readmitted. CONCLUSION Factors associated with readmission included the type of procedure and postoperative complications such as SSI, sepsis, and renal failure. Efforts to reduce readmission should focus on patients undergoing concomitant pelvic procedures as well as avoidance and management of common complications in this group of patients.
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Affiliation(s)
- Na Eun Kim
- General Surgery Department, Boston Medical Center, 88 East Newton C515, Boston, MA, 02118, USA.
| | - Jason F Hall
- Colon & Rectal Surgery and Colorectal Surgery Department, Boston Medical Center, Boston, MA, USA
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23
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Maeda S, Ouchi A, Komori K, Kinoshita T, Oshiro T, Ito S, Abe T, Shimizu Y. Risk factors for peristomal skin disorders associated with temporary ileostomy construction. Surg Today 2021; 51:1152-1157. [PMID: 33569690 DOI: 10.1007/s00595-020-02209-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/13/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Skin disorders are the most common stoma-related complications after temporary diverting loop ileostomy with proctectomy. The aim of the present study was to investigate risk factors for skin disorders associated with temporary ileostomy construction. METHODS A total of 185 consecutive patients who underwent curative proctectomy with temporary diverting loop ileostomy for rectal malignancies at a single comprehensive cancer center between 2013 and 2018 were collected and analyzed. RESULTS The most frequent stoma-related complications were skin disorders (n = 62, 33.5%), followed by mucocutaneous separation (n = 38, 20.5%) and high-output stoma (n = 34, 18.4%). Patients with skin disorders had a higher median body mass index (BMI; 22.4 vs. 21.3 kg/m2, P = 0.002) and lower stoma height (16 vs. 20 mm, P < 0.001) than those without skin disorders. According to a multivariable logistic regression analysis, independent predictors of skin disorders included overweight (median BMI ≥ 25 kg/m2 [odds ratio = 3.6, 95% confidence interval: 1.5-8.6], P = 0.004) and lower stomal height (median stoma height < 20 mm [odds ratio = 3.2, 95% confidence interval: 1.6-6.3], P < 0.001). CONCLUSION Overweight and lower stoma height are correlated with the presence of skin disorders. Construction of a well-elevated stoma can reduce skin disorders associated with temporary ileostomy construction.
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Affiliation(s)
- Shingo Maeda
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Akira Ouchi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan.
| | - Koji Komori
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Takashi Kinoshita
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Taihei Oshiro
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Seiji Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Tetsuya Abe
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
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De Hous N, Lefevre JH, D'Urso A, Van den Broeck S, Komen N. Intraluminal bypass devices as an alternative to protective ostomy for prevention of colorectal anastomotic leakage: a systematic review of the literature. Colorectal Dis 2020; 22:1496-1505. [PMID: 32268451 DOI: 10.1111/codi.15055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
AIM Anastomotic leakage (AL) is the most important complication of colorectal surgery, leading to high morbidity and mortality. Protective ostomy, the current standard of care for protecting a colorectal anastomosis, has important drawbacks that require the creation of an alternative strategy. Over the past 30 years, several intraluminal bypass devices, designed to shield the anastomosis from the faecal stream, have been developed. The aim of this literature review was to create an updated overview of the devices available and their effectiveness in preventing AL, and to investigate whether they could serve as an alternative to protective ostomy in the future. METHOD A systematic review of the literature on intraluminal bypass devices used for preventing colorectal AL was performed. The MEDLINE and Cochrane Library databases were searched, and articles were marked as relevant if an intraluminal bypass device was studied in an animal or human population. RESULTS The database search yielded 24 relevant articles related to 10 intraluminal bypass devices protecting a colorectal anastomosis. These articles included experimental animal studies, preclinical (pilot) studies, as well as retrospective and prospective clinical studies. Each device was assessed with regard to surgical technique, effectiveness and device-related complications. CONCLUSION Intraluminal bypass devices show promise in preventing AL and its clinical consequences. However, there is insufficient high-level evidence to draw firm conclusions. There is a need for randomized controlled trials that directly compare these devices with the protective ostomy.
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Affiliation(s)
- N De Hous
- Department of Abdominal Surgery, University Hospital of Antwerp, University of Antwerp, Edegem, Belgium
| | - J H Lefevre
- Department of Digestive Surgery, Saint-Antoine Hospital, Sorbonne University, Paris, France
| | - A D'Urso
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - S Van den Broeck
- Department of Abdominal Surgery, University Hospital of Antwerp, University of Antwerp, Edegem, Belgium
| | - N Komen
- Department of Abdominal Surgery, University Hospital of Antwerp, University of Antwerp, Edegem, Belgium
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25
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Liu C, Bhat S, O'Grady G, Bissett I. Re-admissions after ileostomy formation: a retrospective analysis from a New Zealand tertiary centre. ANZ J Surg 2020; 90:1621-1626. [PMID: 32808425 DOI: 10.1111/ans.16076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ileostomy formation is a commonly performed procedure in colorectal surgery. The morbidity associated with ileostomies is substantial, particularly for unplanned hospital re-admissions and re-admissions with dehydration. Studies of post-ileostomy re-admissions from an Australasian institution are currently lacking. This retrospective study aimed to quantify the 60-day re-admission rate after ileostomy formation in a New Zealand tertiary centre and to determine the predictive factors. METHODS The surgical database of Auckland City Hospital was searched for all patients aged ≥18 years with a new ileostomy formed between first January 2015 and first January 2019. Patient electronic medical records were reviewed to obtain data regarding the primary outcome of re-admissions within 60 days of discharge, as well as patient and operative variables. Multivariate regression analysis was performed to identify independent predictors of all-cause re-admissions and re-admissions with dehydration. RESULTS A total of 246 patients with 266 ileostomy formations were included. The 60-day re-admission rate was 29.3%, with dehydration present in 27.0% of these re-admissions. Renal impairment at discharge (odds ratio 2.819, 95% confidence interval 1.087-7.310) and the presence of at least one Clavien-Dindo 1 complication (odds ratio 2.268, 95% confidence interval 1.301-3.954) were independently associated with all-cause re-admission. The independent predictors of re-admission with dehydration were renal impairment at discharge, codeine prescribed on discharge, Charlson Comorbidity Index and body mass index. CONCLUSION Unplanned hospital re-admission following ileostomy formation is a significant issue in the New Zealand patient population. Some patient groups are at particularly high risk, such as those with renal impairment at discharge.
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Affiliation(s)
- Chen Liu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Sameer Bhat
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Ian Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Chen Y, Pei W, Wang Q, Wang W, Xu T, Jing C, Li L, Zhang J. One-stitch versus traditional method of protective loop ileostomy in laparoscopic low anterior rectal resection: A retrospective comparative study. Int J Surg 2020; 80:117-123. [PMID: 32650118 DOI: 10.1016/j.ijsu.2020.06.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/08/2020] [Accepted: 06/16/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Protective loop ileostomy is widely performed during rectal resection surgery. The study aimed to introduce the one-stitch method (OM) of protective loop ileostomy in laparoscopic low anterior resection and compare this new method with the traditional method (TM). MATERIALS AND METHODS A retrospective analysis was conducted on 109 patients with pathologically diagnosed adenocarcinoma of the rectum from January 2017 to December 2018 in the study centre, and the intraoperative details and postoperative outcomes of the two groups were measured. RESULTS A total of 95 patients were included: 54 underwent protective loop ileostomy with the TM, while 41 underwent surgery utilizing the OM. Univariate analysis demonstrated that the operative times of resection and closure were significantly shorter (resection, 200.0 vs. 227.5 min, P = 0.028; closure, 70.0 vs. 92.5 min, P = 0.018) and the peristomal adhesions during closure were milder (P = 0.007) in the OM group than in the TM group. The postoperative complications were similar in both groups. In multivariate analysis, the OM (OR 0.352, 95% CI = 0.155-0.799, P = 0.013) was a significant factor influencing the operative time of resection. The peristomal adhesion extent was the only independent risk factor for the stoma closure time (mild, OR 0.036, 95% CI = 0.010-0.129, P < 0.001; moderate, OR 0.128, 95% CI = 0.033-0.494, P = 0.003). No significant predictive factor of peristomal adhesion extent was identified in multivariable analysis. CONCLUSION The OM of protective loop ileostomy in laparoscopic low anterior resection was time-saving, simple and easy to popularize and did not lead to more postoperative complications than the TM.
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Affiliation(s)
- Yuezhi Chen
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Wenting Pei
- Qilu Children's Hospital of Shandong University, Jinan, Shandong, 250000, China
| | - Qiang Wang
- Department of Personnel Office, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Personnel Office, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Wenchen Wang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Tao Xu
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Changqing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Leping Li
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Jizhun Zhang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China.
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Evaluation of negative-pressure wound therapy for surgical site infections after ileostomy closure in colorectal cancer patients: a prospective multicenter study. Surg Today 2020; 50:1687-1693. [PMID: 32638132 DOI: 10.1007/s00595-020-02068-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/05/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Surgical site infection (SSI) occurs at a high rate after ileostomy closure. The effect of preventive negative-pressure wound therapy (NPWT) on SSI development in closed wounds remains controversial. We conducted a prospective multicenter study to evaluate the usefulness of preventive NPWT for SSI after ileostomy closure. METHODS From January 2018 to November 2018, 50 patients who underwent closure of ileostomy created after surgery for colorectal cancer participated in this study. An NPWT device was applied to each wound immediately after surgery and then treatment was continued for 3 days. The primary endpoint was 30-day SSI, and the secondary endpoints were the incidence of seroma, hematoma, and adverse events related to NPWT. RESULTS No patients developed SSI, seroma, or hematoma. Adverse events that may have been causally linked with NPWT were contact dermatitis in two patients and wound pain in one patient, and there were no cases of discontinuation or decompression of NPWT. CONCLUSION The use of NPWT following ileostomy closure may be useful for reducing the development of SSI in colorectal cancer patients. This is a prospective multicenter pilot study and we are planning a comparative study based on these successful results. TRAIL REGISTRATION Registration number: UMIN000032053 ( https://www.umin.ac.jp/ ).
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Development of a Risk Score to Predict Anastomotic Leak After Left-Sided Colectomy: Which Patients Warrant Diversion? J Gastrointest Surg 2020; 24:132-143. [PMID: 31250368 PMCID: PMC8687042 DOI: 10.1007/s11605-019-04293-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/02/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anastomotic leak is a feared complication after left-sided colectomy, but its risk can potentially be reduced with the use of a diverting ostomy. However, an ostomy has its own associated negative sequelae; therefore, it is critical to appropriately identify patients to divert. This is difficult in practice since many risk factors for anastomotic leak exist and outside factors bias this decision. We aimed to develop and validate a risk score to predict an individual's risk of anastomotic leak and aid in the decision. METHODS The American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted PUF was queried from 2012 to 2016 for patients undergoing elective left-sided resection for malignancy, benign neoplasm, or diverticular disease. Multivariable logistic regression identified predictors of anastomotic leak in non-diverted patients, and a risk score was developed and validated. RESULTS 38,475 patients underwent resection with an overall anastomotic leak rate of 3%. Independent risk factors for anastomotic leak included younger age, male sex, tobacco use, and omission of combined bowel preparation. A risk score incorporating independent predictors demonstrated excellent calibration. There was strong visual correspondence between predicted and observed anastomotic leak rates. 3960 patients underwent resection with diversion, yet over half of these patients had a predicted leak rate of less than 4%. CONCLUSION A novel risk score can be used to stratify patients according to anastomotic leak risk after elective left-sided resection. Intraoperative calculation of scores for patients can help guide surgical decision-making in both diverting the highest risk patients and avoiding diversion in low-risk patients.
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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: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [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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Tamura K, Matsuda K, Yokoyama S, Iwamoto H, Mizumoto Y, Murakami D, Nakamura Y, Yamaue H. 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] [MESH Headings] [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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Affiliation(s)
- Koichi Tamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Kenji Matsuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Shozo Yokoyama
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Hiromitsu Iwamoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Yuki Mizumoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Daisuke Murakami
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Yuki Nakamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan.
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Beeken RJ, Haviland JS, Taylor C, Campbell A, Fisher A, Grimmett C, Ozakinci G, Slater S, Wilson I, Hubbard G. Smoking, alcohol consumption, diet and physical activity following stoma formation surgery, stoma-related concerns, and desire for lifestyle advice: a United Kingdom survey. BMC Public Health 2019; 19:574. [PMID: 31092219 PMCID: PMC6518630 DOI: 10.1186/s12889-019-6913-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 04/29/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Adherence to smoking, alcohol consumption, diet and physical activity (PA) guidelines may improve outcomes for people with a stoma. A better understanding of these behaviours following stoma formation surgery and their experiences and attitudes towards receiving lifestyle advice, could help identify specific gaps and inform interventions going forward. The aim of this study was to describe changes in current lifestyle following stoma formation and to explore concerns, desire for lifestyle information, advice and support among people who have or have had a stoma. METHODS A sample of adults who currently had or in the past had a stoma for treatment for any medical condition was recruited online through relevant charities and companies, and invited to complete a cross-sectional, online survey. Consenting participants (n = 425) provided demographic information and completed brief, validated questionnaires about their lifestyle, alongside questions around their concerns regarding permanent stoma and experiences of lifestyle information and advice. Responses were summarised using descriptive statistics, and associations between reported concerns about stoma and changes in health behaviours were explored. RESULTS Most respondents (93%) still had a stoma at the time of completing the survey. The majority (80%) had not consumed at least 5 portions of fruit and vegetables on the previous day and 20% reported they had not participated in at least 30 min of physical activity on any day in the previous week. Most respondents were non-smokers (84%) and did not exceed recommendations for alcohol intake (60%). Most (56%) felt their PA had decreased following stoma formation. Frequencies of concerns about a permanent stoma were high, and appeared to be associated with reported decreases in PA. Of those reporting nausea, 40% felt their diet had worsened since having their stoma. A large proportion of respondents had not received PA (42%) or dietary (30%) advice, and of these > 90% would have liked guidance. CONCLUSIONS Few respondents to this survey were eating the recommended amount of fruit and vegetables, and most reported a decrease in their PA following stoma surgery. Lifestyle advice would be welcomed by this population, which professionals should take into account when addressing stoma- related concerns.
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Affiliation(s)
| | - Joanne S. Haviland
- Institute of Cancer Research Clinical Trials and Statistics Unit, Division of Clinical Studies, The Institute of Cancer Research, London, UK
| | - Claire Taylor
- St Mark’s Hospital, London North West NHS Healthcare, Harrow, UK
| | | | - Abigail Fisher
- Research Department of Behavioural Science and Health, University College London, London, UK
| | | | - Gozde Ozakinci
- School of Medicine, University of St Andrews, St Andrews, Scotland, UK
| | - Sarah Slater
- Beatson West of Scotland Cancer Centre, Glasgow, Scotland, UK
| | - Iseult Wilson
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, UK
| | - Gill Hubbard
- Department of Nursing, University of the Highlands and Islands, Inverness, UK
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Systematic review and meta-analysis of incisional hernia post-reversal of ileostomy. Hernia 2019; 24:9-21. [PMID: 31073963 DOI: 10.1007/s10029-019-01961-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/28/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Incisional hernia following closure of loop ileostomy is a common problem. Assessment of the proportion of this complication is limited by small sample size and inconsistent reporting. The aim of this review was to provide an estimate of the proportion of incisional hernia following closure of loop ileostomy according to clinical and radiological diagnostic criteria and to investigate the association of bibliometric and study quality parameters with reported proportion. METHODS A systematic review of PubMed, Embase, CENTRAL, ISRCTN Registry and Open Grey from 2000 onwards was performed according to PRISMA standards. Reporting on the type of stoma and mesh reinforcement after closure was mandatory for inclusion, whereas studies on paediatric populations were excluded. Fixed effect or random effects models were used to calculate pooled proportion estimates. Meta-regression models were formed to explore potential heterogeneity. RESULTS 42 studies with 7166 patients were included. The pooled estimate of the proportion of incisional hernia after ileostomy closure was 6.1% (95% confidence interval, CI 4.4-8.3%). Proportion estimates for higher quality studies and studies reporting on incisional hernia as primary outcome were 9.0% (95% CI 6.3-12.7%) and 13.1% (95% CI 8.8-19.1%). Significant between-study heterogeneity was identified (P < 0.001, I2 = 87%) and the likelihood of publication bias was high (P = 0.028). Mixed effects regression showed that both year of publication (P = 0.034, Q = 4.484, df = 1.000) and defining hernia as a primary outcome (Q = 20.298, P < 0.001) were related to effect size. Method of follow-up and quality of the studies affected the proportion. CONCLUSION The proportion of incisional hernia at ileostomy closure site is estimated at 6.1%. Reporting incisional hernia as primary or secondary outcome, the method of diagnosis, the year of publication and methodological quality are associated with reported proportion.
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Flor-Lorente B, Sánchez-Guillén L, Pellino G, Frasson M, García-Granero Á, Ponce M, Domingo S, Paya V, García-Granero E. "Virtual ileostomy" combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report. Langenbecks Arch Surg 2019; 404:375-383. [PMID: 30919049 DOI: 10.1007/s00423-019-01776-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/08/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Despite the benefits of a loop ileostomy after total mesorectal excision (TME), it carries a significant associated morbidity. A "virtual ileostomy" (VI) has been proposed to avoid ileostomies in low-risk patients, which could then be converted into a real ileostomy (RI) in the event of anastomotic leak (AL). The aim of the present study is to evaluate safety and efficacy of VI associated with early endoscopy in patients undergoing rectal surgery with anastomosis to detect subclinical AL prior to the onset of clinical symptoms for sepsis. METHODS This is a single-center, retrospective study of a consecutive series of patients undergoing elective or emergent colorectal surgery with low or ultralow colorectal or ileorectal anastomosis between September 2015 and September 2016. RESULTS We included 44 consecutive, unselected patients. Eight patients (18.2%) required conversion into RI and one required terminal colostomy because of AL, of whom 44.4% were asymptomatic and AL was detected with early endoscopy. Fashioning of RI was not associated with further morbidity. All patients with AL converted into RI (n = 8/9) (88.9%), had adequate healed anastomosis, and later underwent stoma closure with no complications. A stoma was avoided in 79.6% of VI. Endoscopy was associated with 55% sensitivity and 100% specificity, with a global accuracy of 88%. CONCLUSIONS The combination of VI with early postoperative endoscopy could avoid unnecessary ileostomies in patients with low or ultralow anastomoses and reveal AL before the onset of symptoms, thus reducing associated morbidity.
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Affiliation(s)
- Blas Flor-Lorente
- Colorectal Unit, Hospital Universitario y Politécnico La Fe, Valencia Hospital La Fe, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - Luis Sánchez-Guillén
- Colorectal Unit, Hospital Universitario y Politécnico La Fe, Valencia Hospital La Fe, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain.
| | - Gianluca Pellino
- Colorectal Unit, Hospital Universitario y Politécnico La Fe, Valencia Hospital La Fe, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - Matteo Frasson
- Colorectal Unit, Hospital Universitario y Politécnico La Fe, Valencia Hospital La Fe, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - Álvaro García-Granero
- Colorectal Unit, Hospital Universitario y Politécnico La Fe, Valencia Hospital La Fe, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - Marta Ponce
- Digestive Medicine, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Santiago Domingo
- Gynecologic Oncology Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Vicente Paya
- Gynecologic Oncology Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Eduardo García-Granero
- Colorectal Unit, Hospital Universitario y Politécnico La Fe, Valencia Hospital La Fe, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
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Ileostomy versus fecal diversion device to protect anastomosis after rectal surgery: a randomized clinical trial. Int J Colorectal Dis 2019; 34:811-819. [PMID: 30740632 DOI: 10.1007/s00384-019-03255-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Patients with rectal anastomosis commonly experience various ileostomy-related complications. This study aimed to elucidate the usefulness of a fecal diversion device (FDD) as an alternative to ileostomy for protecting rectal anastomosis. METHODS Patients with rectal anastomosis were randomly assigned to the ileostomy and FDD groups except in cases of emergency surgery. The primary endpoint was the clinical safety and effectiveness of FDD. The mean operation time, delay of diet advancement, length of hospital stay, FDD and stoma durations, and anastomotic leakage (AL) management methods were compared. RESULTS A total of 54 patients were enrolled in this study. No cases of mortality occurred. Overall morbidity was similar between groups (P = 0.551). Six patients (22.2%) in the FDD group and nine (29.0%) in the stoma group (P = 0.555) had AL. The mean total hospital stay was 16.4 ± 6.7 and 23.4 ± 8.7 days in the FDD and stoma groups, respectively (P = 0.002). The mean total hospital cost was 12,726.8 ± 3422.8 USD and 17,954.9 ± 9040.3 USD in the FDD and stoma groups, respectively (P = 0.008). The mean FDD and stoma durations were 21.6 ± 6.1 days and 114.9 ± 41.3 days, respectively (P < 0.0001). CONCLUSIONS This study demonstrated FDD safety and effectiveness. We identified the possibility of FDD as an alternative technique to conventional stoma procedures.
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Garfinkle R, Savage P, Boutros M, Landry T, Reynier P, Morin N, Vasilevsky CA, Filion KB. Incidence and predictors of postoperative ileus after loop ileostomy closure: a systematic review and meta-analysis. Surg Endosc 2019; 33:2430-2443. [PMID: 31020433 DOI: 10.1007/s00464-019-06794-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/09/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Postoperative ileus (POI) is regarded as the most clinically significant morbidity following loop ileostomy closure; however, its incidence remains poorly understood. Our objective was therefore to determine the pooled incidence of POI after loop ileostomy closure and identify risk factors associated with its development. METHODS We systematically searched MEDLINE (via Ovid and PubMed), Embase, the Cochrane Library, Biosis Previews, and Scopus to identify studies reporting the incidence of POI in patients who underwent loop ileostomy closure. Two independent reviewers extracted data and appraised study quality. Cumulative incidence proportions were pooled across studies using a random-effects meta-analytic model. RESULTS Sixty-seven studies, including 9528 patients, met our inclusion criteria. The pooled estimate of POI was 8.0% (95% CI 6.9-9.3%; I2 = 74%). The estimated incidence varied by POI definition: studies with a robust definition of POI (n = 8) demonstrated the highest estimate of POI (12.4%, 95% CI 9.2-16.5%; I2 = 79%) while studies that did not report an explicit POI definition (n = 38) demonstrated the lowest estimate (6.7%, 95% CI 5.3-8.3%; I2 = 61%). Small bowel anastomosis technique (hand-sewn) and interval time from ileostomy creation to closure (longer time) were the factors most commonly associated with POI after loop ileostomy closure. However, most comparative studies were not powered to examine risk factors for POI. CONCLUSIONS POI is an important complication after loop ileostomy closure, and its incidence is dependent on its definition. More research aimed at studying this complication is required to better understand risk factors for POI after loop ileostomy closure.
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Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Paul Savage
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.,Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Tara Landry
- Medical Libraries, McGill University Health Center, Montreal, QC, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada. .,Department of Medicine, McGill University, Montreal, QC, Canada.
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Predicting the Risk of Readmission From Dehydration After Ileostomy Formation: The Dehydration Readmission After Ileostomy Prediction Score. Dis Colon Rectum 2018; 61:1410-1417. [PMID: 30303886 PMCID: PMC6219896 DOI: 10.1097/dcr.0000000000001217] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND All-cause readmission rates in patients undergoing ileostomy formation are as high as 20% to 30%. Dehydration is a leading cause. No predictive model for dehydration readmission has been described. OBJECTIVE The purpose of this study was to develop and validate the Dehydration Readmission After Ileostomy Prediction scoring system to predict the risk of readmission for dehydration after ileostomy formation. DESIGN Patients who underwent ileostomy formation were identified using the American College of Surgeons National Surgical Quality Improvement Program data set (2012-2015). Predictors for dehydration were identified using multivariable logistic regression analysis and translated into a point scoring system based on corresponding β-coefficients using 2012-2014 data (derivation). Model discrimination was assessed with receiver operating characteristic curves using 2015 data (validation). SETTINGS This study used the American College of Surgeons National Surgical Quality Improvement Program. PATIENTS A total of 8064 (derivation) and 3467 patients (validation) were included from the American College of Surgeons National Surgical Quality Improvement Program. MAIN OUTCOME MEASURES Dehydration readmission within 30 days of operation was measured. RESULTS A total of 8064 patients were in the derivation sample, with 2.9% (20.1% overall) readmitted for dehydration. Twenty-five variables were queried, and 7 predictors were identified with points assigned: ASA class III (4 points), female sex (5 points), IPAA (4 points), age ≥65 years (5 points), shortened length of stay (5 points), ASA class I to II with IBD (7 points), and hypertension (9 points). A 39-point, 5-tier risk category scoring system was developed. The model performed well in derivation (area under curve = 0.71) and validation samples (area under curve = 0.74) and passed the Hosmer-Lemeshow goodness-of-fit test. LIMITATIONS Limitations of this study pertained to those of the American College of Surgeons National Surgical Quality Improvement Program, including a lack of generalizability, lack of ileostomy-specific variables, and inability to capture multiple readmission International Classification of Diseases, 9/10 edition, codes. CONCLUSIONS The Dehydration Readmission After Ileostomy Prediction score is a validated scoring system that identifies patients at risk for dehydration readmission after ileostomy formation. It is a specific approach to optimize patient factors, implement interventions, and prevent readmissions. See Video Abstract at http://links.lww.com/DCR/A746.
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The 2017 European Society of Coloproctology (ESCP) collaborating group. Safety of primary anastomosis following emergency left sided colorectal resection: an international, multi-centre prospective audit. Colorectal Dis 2018; 20 Suppl 6:47-57. [PMID: 30255647 DOI: 10.1111/codi.14373] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Some evidence suggests that primary anastomosis following left sided colorectal resection in the emergency setting may be safe in selected patients, and confer favourable outcomes to permanent enterostomy. The aim of this study was to compare the major postoperative complication rate in patients undergoing end stoma vs primary anastomosis following emergency left sided colorectal resection. METHODS A pre-planned analysis of the European Society of Coloproctology 2017 audit. Adult patients (> 16 years) who underwent emergency (unplanned, within 24 h of hospital admission) left sided colonic or rectal resection were included. The primary endpoint was the 30-day major complication rate (Clavien-Dindo grade 3 to 5). RESULTS From 591 patients, 455 (77%) received an end stoma, 103 a primary anastomosis (17%) and 33 primary anastomosis with defunctioning stoma (6%). In multivariable models, anastomosis was associated with a similar major complication rate to end stoma (adjusted odds ratio for end stoma 1.52, 95%CI 0.83-2.79, P = 0.173). Although a defunctioning stoma was not associated with reduced anastomotic leak (12% defunctioned [4/33] vs 13% not defunctioned [13/97], adjusted odds ratio 2.19, 95%CI 0.43-11.02, P = 0.343), it was associated with less severe complications (75% [3/4] with defunctioning stoma, 86.7% anastomosis only [13/15]), a lower mortality rate (0% [0/4] vs 20% [3/15]), and fewer reoperations (50% [2/4] vs 73% [11/15]) when a leak did occur. CONCLUSIONS Primary anastomosis in selected patients appears safe after left sided emergency colorectal resection. A defunctioning stoma might mitigate against risk of subsequent complications.
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Cuyle PJ, Engelen A, Moons V, Tollens T, Carton S. Lanreotide in the prevention and management of high-output ileostomy after colorectal cancer surgery. J Drug Assess 2018; 7:28-33. [PMID: 29888099 PMCID: PMC5990955 DOI: 10.1080/21556660.2018.1467916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/22/2018] [Indexed: 12/11/2022] Open
Abstract
Objective: Patients with stage III and high-risk stage II colorectal cancer (CRC) are advised to initiate adjuvant treatment as soon as feasible and certainly before 8 to 12 weeks after resection of the tumor. A protective ileostomy is often constructed during surgery to protect a primary anastomosis “at risk”, especially in rectal cancer surgery. However, up to 17% of patients with a stoma suffer from high output, a major complication that can prevent adjuvant treatment implementation or completion. To avoid delay or cancellation of adjuvant therapy after CRC resection, effective strategies must be implemented to successfully treat and/or prevent high-output stoma (HOS). Methods: We report two clinical case reports clearly demonstrating the impact and management of HOS in this setting. A review of the available literature and ongoing clinical studies is provided. Results: The clinical cases describe patients with advanced stage CRC and focus on the different strategies for HOS management, presenting their outcome and how each strategy affects the implementation of adjuvant treatment. The patient population with the highest risk of developing HOS is described, along with the rationale for using somatostatin analogs, such as lanreotide, to treat and prevent high output. Conclusion: In patients with CRC and protective ileostomies after primary resection, HOS could be treated with somatostatin analogs in combination with dietary recommendations and Saint Mark's solution. The role of this therapeutic approach as a preventive strategy in patients at high risk of developing HOS, deserves further exploration in a prospective randomized clinical trial.
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Affiliation(s)
- Pieter-Jan Cuyle
- Department of Gastroenterology/Digestive Oncology, Imelda General Hospital, Bonheiden, Belgium
| | - Anke Engelen
- Department of Gastroenterology/Digestive Oncology, Imelda General Hospital, Bonheiden, Belgium
| | - Veerle Moons
- Department of Gastroenterology/Digestive Oncology, Imelda General Hospital, Bonheiden, Belgium
| | - Tim Tollens
- Department of Abdominal Surgery, Imelda General Hospital, Bonheiden, Belgium
| | - Saskia Carton
- Department of Gastroenterology/Digestive Oncology, Imelda General Hospital, Bonheiden, Belgium
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Song O, Kim KH, Lee SY, Kim CH, Kim YJ, Kim HR. Risk factors of stoma re-creation after closure of diverting ileostomy in patients with rectal cancer who underwent low anterior resection or intersphincteric resection with loop ileostomy. Ann Surg Treat Res 2018; 94:203-208. [PMID: 29629355 PMCID: PMC5880978 DOI: 10.4174/astr.2018.94.4.203] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/18/2017] [Accepted: 08/03/2017] [Indexed: 12/17/2022] Open
Abstract
Purpose The aim of this study was to identify the risk factors of stoma re-creation after closure of diverting ileostomy in patients with rectal cancer who underwent low anterior resection (LAR) or intersphincteric resection (ISR) with loop ileostomy. Methods We retrospectively reviewed 520 consecutive patients with rectal cancer who underwent LAR or ISR with loop ileostomy from January 2005 to December 2014 at Chonnam National University Hwasun Hospital. Risk factors for stoma re-creation after ileostomy closure were evaluated. Results Among 520 patients with rectal cancer who underwent LAR or ISR with loop ileostomy, 458 patients underwent stoma closure. Among these patients, 45 (9.8%) underwent stoma re-creation. The median period between primary surgery and stoma closure was 5.5 months (range, 0.5–78.3 months), and the median period between closure and re-creation was 6.8 months (range, 0–71.5 months). Stoma re-creation was performed because of anastomosis-related complications (26, 57.8%), local recurrence (15, 33.3%), and anal sphincter dysfunction (3, 6.7%). Multivariate analysis showed that independent risk factors for stoma re-creation were anastomotic leakage (odds ratio [OR], 4.258; 95% confidence interval [CI], 1.814–9.993), postoperative radiotherapy (OR, 3.947; 95% CI, 1.624–9.594), and ISR (OR, 3.293; 95% CI, 1.462–7.417). Conclusion Anastomotic leakage, postoperative radiotherapy, and ISR were independent risk factors for stoma re-creation after closure of ileostomy in patients with rectal cancer.
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Affiliation(s)
- Ook Song
- Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Kyung Hwan Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Soo Young Lee
- Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Young Jin Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyeong Rok Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
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Stafford C, Francone TD, Marcello PW, Roberts PL, Ricciardi R. Is Diversion with Ileostomy Non-inferior to Hartmann Resection for Left-sided Colorectal Anastomotic Leak? J Gastrointest Surg 2018; 22:503-507. [PMID: 29119532 DOI: 10.1007/s11605-017-3612-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 10/17/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of left-sided colorectal anastomotic leaks often requires fecal stream diversion for prevention of further septic complications. To manage anastomotic leak, it is unclear if diverting ileostomy provides similar outcomes to Hartmann resection with colostomy. METHODS We identified all patients who developed anastomotic leak following left-sided colorectal resections from 1/2012 through 12/2014 using the American College of Surgeons National Surgical Quality Improvement Program. Then, we examined the risk of mortality and abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection. RESULTS There were 1745 patients who experienced an anastomotic leak in a cohort of 63,748 patients (3.7%). Two hundred thirty-five patients had a reoperation for anastomotic leak involving the formation of a diverting ileostomy (n = 77) or Hartmann resection (n = 158). There was no difference in mortality or abdominal reoperation in patients treated with diverting ileostomy (3.9, 7.8%) versus Hartmann resection (3.8, 6.3%) (p = 0.8). CONCLUSION There was no difference in the outcomes of mortality or need for second abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection for left-sided colorectal anastomotic leak. Thus, select patients with left-sided colorectal anastomotic leaks may be safely managed with diverting ileostomy.
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Affiliation(s)
- Caitlin Stafford
- Section of Colon & Rectal Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA
| | - Todd D Francone
- Section of Colon & Rectal Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA
| | - Peter W Marcello
- Department of Colon & Rectal Surgery, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Patricia L Roberts
- Department of Colon & Rectal Surgery, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Rocco Ricciardi
- Section of Colon & Rectal Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA.
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Bhama AR, Batool F, Collins SD, Ferraro J, Cleary RK. Risk Factors for Postoperative Complications Following Diverting Loop Ileostomy Takedown. J Gastrointest Surg 2017; 21:2048-2055. [PMID: 28971302 DOI: 10.1007/s11605-017-3567-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 08/27/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Diverting loop ileostomies are frequently created to divert the fecal stream in an effort to protect downstream anastomoses. These are later reversed to restore intestinal continuity. The goal of this study is to evaluate risk factors for postoperative complications following diverting loop ileostomy takedown. MATERIALS AND METHODS Patients who underwent diverting loop ileostomy takedown between January 1, 2010 and April 28, 2015 were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified and a hierarchical logistic regression model was used to identify risk factors for postoperative complications. RESULTS 1,737 patients met the inclusion criteria. Rates of postoperative complications were generally low. Mean length of stay (LOS) was 5.6 (± 4.5) days. Outcomes of interest were the following: overall morbidity, serious morbidity, extended LOS, SSI, UTI, pneumonia, readmission, reoperation, and mortality. Risk factors for these outcomes included the following: ASA class, bleeding disorder, prolonged operative time, race, tobacco use, gender, steroid use, peripheral vascular disease, weight loss, and functional status. CONCLUSIONS Diverting loop ileostomy takedown has a complication rate of approximately 20%. Higher ASA class, longer operative times, history of bleeding disorder, and functional status were identified as risk factors for most complications.
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Affiliation(s)
- Anuradha R Bhama
- Division of Colon and Rectal Surgery, Department of Surgery, St. Joseph Mercy Health System - Ann Arbor, Ann Arbor, MI, 48106, USA.
| | - Farwa Batool
- Division of Colon and Rectal Surgery, Department of Surgery, St. Joseph Mercy Health System - Ann Arbor, Ann Arbor, MI, 48106, USA
| | - Stacey D Collins
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI, 48104, USA
| | - Jane Ferraro
- Division of Colon and Rectal Surgery, Department of Surgery, St. Joseph Mercy Health System - Ann Arbor, Ann Arbor, MI, 48106, USA
| | - Robert K Cleary
- Division of Colon and Rectal Surgery, Department of Surgery, St. Joseph Mercy Health System - Ann Arbor, Ann Arbor, MI, 48106, USA
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Miura T, Sakamoto Y, Morohashi H, Yoshida T, Sato K, Hakamada K. Risk factor for permanent stoma and incontinence quality of life after sphincter-preserving surgery for low rectal cancer without a diverting stoma. Ann Gastroenterol Surg 2017; 2:79-86. [PMID: 29863122 PMCID: PMC5868869 DOI: 10.1002/ags3.12033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 07/13/2017] [Indexed: 12/13/2022] Open
Abstract
The goal of the present study was to evaluate permanent stoma formation and defecation function in long-term follow up after surgery for low rectal cancer without a diverting stoma. Subjects were 275 patients who underwent sphincter-preserving surgery for low rectal cancer between 2000 and 2012. Clinical outcomes were evaluated and defecation function was assessed based on a questionnaire survey, using Wexner and modified fecal incontinence quality of life (mFIQL) scores. Incidence of anastomotic leakage was 21.8%, and surgery-related death as a result of anastomotic leakage occurred in one male patient. Median follow-up period was 4.9 years and permanent stoma formation rate was 16.7%. Anastomotic leakage was an independent predictor of permanent stoma formation (odds ratio [OR] 5.86, P<0.001). Age <65 years (OR 1.99, P=0.001) and male gender (OR 4.36, P=0.026) were independent predictors of anastomotic leakage. A permanent stoma was formed as a result of poor healing of anastomotic leakage in 29.6% of males, but in no females. Defecation function was surveyed in 27 and 116 patients with and without anastomotic leakage, respectively. These groups had no significant differences in median follow-up period (63.5 vs 63 months), Wexner scores (quartile) (6 (2.5-9) vs 6 (3-11)), and mFIQL scores (26.1 (4.8-64.2) vs 23.8 (5.9-60.7). Defecation function associated with anastomotic leakage showed no significant dependence on gender or resection procedure. Sphincter-preserving surgery without a diverting stoma may be indicated for females with low rectal cancer. In this procedure, male gender is a risk factor for anastomotic leakage and subsequent formation of a permanent stoma in one in three patients.
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Affiliation(s)
- Takuya Miura
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Yoshiyuki Sakamoto
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Hajime Morohashi
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Tatsuya Yoshida
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Kentaro Sato
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
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Factors associated with hospital readmission following diverting ileostomy creation. Tech Coloproctol 2017; 21:641-648. [DOI: 10.1007/s10151-017-1667-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 07/08/2017] [Indexed: 12/24/2022]
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Predictors of High-Output Stoma After Low Anterior Resection With Diverting Ileostomy for Rectal Cancer. Int Surg 2017. [DOI: 10.9738/intsurg-d-17-00121.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background:
The aim of this study was to identify predictors of high-output stoma (HOS) after low anterior resection (LAR) with diverting ileostomy for rectal cancer.
Methods:
The medical records of 60 patients who underwent LAR with diverting ileostomy for rectal cancer between 2012 and 2015 were reviewed. HOS was defined as ileostomy output greater than 1500 mL per 24 hours. Patient and surgical characteristics and patient laboratory data were examined to assess for predictors of HOS using univariate and multivariate logistic regression.
Results:
The incidence of HOS was 43.3% (26/60). In univariate analysis, age ≥ 70 years, diabetes mellitus (DM), preoperative albumin level ≤ 4.0 g/dL, and preoperative serum hemoglobin level ≤ 12 g/dL were significantly associated with HOS. Multivariate analysis identified DM (odds ratio, 9.74; 95% confidence interval, 1.86–77.3) as an independent predictor of HOS.
Conclusions:
DM might be a predictor of HOS in patients undergoing LAR with diverting ileostomy for rectal cancer.
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Clinical Relevance of a Grading System for Anastomotic Leakage After Low Anterior Resection: Analysis From a National Cohort Database. Dis Colon Rectum 2017; 60:706-713. [PMID: 28594720 DOI: 10.1097/dcr.0000000000000800] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leakage is a severe complication after low anterior resection for rectal cancer. With a global increase in registration initiatives, adapting uniform definitions and grading systems is highly relevant. OBJECTIVE This study aimed to provide clinical parameters to categorize anastomotic leakage into subcategories according to the International Study Group of Rectal Cancer. DESIGN All of the patients who underwent a low anterior resection in the Netherlands with primary anastomosis were included using the population-based Dutch Surgical Colorectal Audit. SETTINGS Data were derived from the Dutch Surgical Colorectal Audit. MAIN OUTCOME MEASURES The development of grade B anastomotic leakage (requiring invasive treatment but no surgery) versus grade C anastomotic leakage (requiring reoperation) was measured. RESULTS Overall, 4287 patients underwent low anterior resection with primary anastomosis. A total of 159 patients (4%) were diagnosed with grade B anastomotic leakage versus 259 (6%) with grade C. Hospital stay and intensive care unit visits were significantly higher in patients with grade C anastomotic leakage compared with patients with grade B leakage. Mortality in patients with grade C leakage was higher compared with grade B leakage, although nonsignificant (5.8% vs 2.5%; p = 0.12). Multivariate analysis showed that patients with diverting stomas (n = 2866) had a decreased risk of developing grade C leakage compared with grade B (OR = 0.17 (95% CI, 0.10-0.29)). Male patients had an increased risk of developing grade C anastomotic leakage, and patients receiving neoadjuvant treatment before surgery had an increased risk of developing grade B anastomotic leakage. LIMITATIONS Some possibly relevant variables, such as smoking and nutritional status, were not recorded in the database. CONCLUSIONS Anastomotic leakage after low anterior resection for rectal cancer was a frequent observed complication in this cohort. Differences in clinical outcome suggest that grade B and C leakage should be considered separate entities in future registrations. In patients with a diverting stoma, the chances of experiencing grade C anastomotic leakage were reduced. See Video Abstract at http://links.lww.com/DCR/A315.
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Belkin N, Bordeianou LG, Shellito PC, Hawkins AT. Morbidity Associated with Diverting Loop Ileostomies: Weighing Diversion in Rectosigmoid Resection. Am Surg 2017. [DOI: 10.1177/000313481708300739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Anterior resection with primary anastomosis is the procedure of choice for patients with rectosigmoid cancers with good sphincter function. Surgeons may perform an associated diverting loop ileostomy (DLI) to minimize the likelihood and/or the severity of an anastomotic leak. To examine the morbidity of DLIs, we performed a review of a prospectively maintained database. Participants included all patients at the Massachusetts General Hospital who underwent anterior resection from January 2013 to July 2015 for rectosigmoid cancers and who subsequently underwent adjuvant chemotherapy. The primary outcome was time to start of adjuvant chemotherapy. Secondary outcomes included length of hospitalization, perioperative complications, and 60-day postoperative complications. Inclusion criteria were met in 57 patients and DLI was performed in 21 (37%). The DLI group had higher estimated blood loss (431.7 vs 192.1 mL, P = 0.03) and a longer operation time (3.7 vs 2.3 hours, P = 0.0007). The DLI group took over a week longer to start adjuvant chemotherapy than the non-DLI group (median time to chemo: 43 vs 34 days, P = 0.002). Postoperatively, DLI was associated with a longer hospitalization (6.7 vs 3.1 days, P = 0.0003), more perioperative complications (57.1% vs 13.9%, P = 0.0006), and more 60-day read-missions or emergency department visits (38.1% vs 5.6%, P = 0.002). Ostomies are associated with appreciable morbidity. In turn, they do not eliminate postoperative complications. Surgeons should closely consider ostomy morbidity in rectosigmoid resection and institute a proactive approach toward identification and prevention of complications.
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Affiliation(s)
| | - Liliana G. Bordeianou
- Colorectal Surgery Program, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paul C. Shellito
- Colorectal Surgery Program, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexander T. Hawkins
- Division of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
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Steinhagen E, Colwell J, Cannon LM. Intestinal Stomas-Postoperative Stoma Care and Peristomal Skin Complications. Clin Colon Rectal Surg 2017; 30:184-192. [PMID: 28684936 DOI: 10.1055/s-0037-1598159] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intestinal stomas are necessary for several colon and rectal conditions and represent a major change in the new ostomate's daily life. Though dehydration is the most frequent etiology requiring readmission, irritant contact dermatitis and a host of other peristomal skin conditions are more common complications for ostomates. Wound, ostomy, and continence nurses are invaluable resources to both ostomy patients and providers. A few simple interventions can prevent or resolve most common peristomal complications. Good stoma care is possible in a resource-poor environment.
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Affiliation(s)
- Emily Steinhagen
- Division of Colon and Rectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Janice Colwell
- Section of Colon and Rectal Surgery, Department of General Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Lisa M Cannon
- Section of Colon and Rectal Surgery, Department of General Surgery, University of Chicago Medicine, Chicago, Illinois
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Iqbal A, Raza A, Huang E, Goldstein L, Hughes SJ, Tan SA. Cost Effectiveness of a Novel Attempt to Reduce Readmission after Ileostomy Creation. JSLS 2017; 21:JSLS.2016.00082. [PMID: 28144122 PMCID: PMC5266511 DOI: 10.4293/jsls.2016.00082] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background and Objectives: Dehydration is a common complication after ileostomy creation and is the most frequent reason for postoperative readmission to the hospital. We sought to determine the clinical and economic impact of an outpatient intervention to decrease readmissions for dehydration after ileostomy creation. Methods: All new ileostomates from 09/2011 through 10/2012 at the University of Florida were enrolled to receive an ileostomy education and management protocol and a daily telephone call for 3 weeks after discharge. Counseling and medication adjustments were provided, with a satisfaction survey at the end. Outcomes of these patients were compared to those in a historical control cohort. A cost analysis was conducted to calculate the savings to the hospital. Results: Thirty-eight patients were enrolled. All patients required telephone counseling, and the mean satisfaction score rating was 4.69, on a scale of 1 to 5. The readmission rate for dehydration within 30 days of discharge decreased significantly from 65% before intervention to 16% (5/32 patients) after intervention (P = .002). The length of readmission hospital stay decreased from a mean of 4.2 days before the introduction of the intervention to 3 days after. Cost analysis revealed that the actual total hospital cost of dehydration-specific readmission decreased from $88,858 to $25,037, a saving of $63,821. Conclusion: A standardized ileostomy pathway with comprehensive patient education and outpatient telephone follow-up is cost effective, has a positive influence on patient satisfaction, and reduces dehydration-related readmission rates.
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Affiliation(s)
| | - Ahsan Raza
- Ahsan Raza, MD, Department of Surgery, University of Florida, P. O. Box 100109, Gainesville, Florida, USA
| | - Emina Huang
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lindsey Goldstein
- Ahsan Raza, MD, Department of Surgery, University of Florida, P. O. Box 100109, Gainesville, Florida, USA
| | - Steven J Hughes
- Ahsan Raza, MD, Department of Surgery, University of Florida, P. O. Box 100109, Gainesville, Florida, USA
| | - Sanda A Tan
- Ahsan Raza, MD, Department of Surgery, University of Florida, P. O. Box 100109, Gainesville, Florida, USA
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Shaffer VO, Owi T, Kumarusamy MA, Sullivan PS, Srinivasan JK, Maithel SK, Staley CA, Sweeney JF, Esper G. Decreasing Hospital Readmission in Ileostomy Patients: Results of Novel Pilot Program. J Am Coll Surg 2017; 224:425-430. [PMID: 28232058 DOI: 10.1016/j.jamcollsurg.2016.12.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nearly 30% of patients with newly formed ileostomies require hospital readmission from severe dehydration or associated complications. This contributes to significant morbidity and rising healthcare costs associated with this procedure. Our aim was to design and pilot a novel program to decrease readmissions in this patient population. STUDY DESIGN An agreement was established with Visiting Nurse Health System (VNHS) in March 2015 that incorporated regular home visits with clinical triggers to institute surgeon-supervised corrective measures aimed at preventing patient decompensation associated with hospital readmissions. Thirty-day readmission data for patients managed with and without VNHS support for 10.5 months before and after implementation of this new program were collected. RESULTS Of 833 patients with small bowel procedures, 162 were ileostomies with 47 in the VNHS and 115 in the non-VNHS group. Before program implementation, VNHS (n = 24) and non-VNHS patients (n = 54) had similar readmission rates (20.8% vs 16.7%). After implementation, VNHS patients (n = 23) had a 58% reduction in hospital readmission (8.7%) and non-VNHS patient hospital readmissions (n = 61) increased slightly (24.5%). Total cost of readmissions per patient in the cohort decreased by >80% in the pilot VNHS group. CONCLUSIONS Implementation of a novel program reduced the 30-day readmission rate by 58% and cost of readmissions per patient by >80% in a high risk for readmission patient population with newly created ileostomies. Future efforts will expand this program to a greater number of patients, both institutionally and systemically, to reduce the readmission-rate and healthcare costs for this high-risk patient population.
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Affiliation(s)
| | - Tari Owi
- Emory Healthcare Brain Health Center, Atlanta, GA
| | | | | | | | - Shishir K Maithel
- Department of Surgery, Emory University, Atlanta, GA; Winship Cancer Institute, Atlanta, GA
| | - Charles A Staley
- Department of Surgery, Emory University, Atlanta, GA; Winship Cancer Institute, Atlanta, GA
| | | | - Greg Esper
- Department of Neurology, Office of Quality and Project Management, Emory University, Atlanta, GA
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Shwaartz C, Fields AC, Prigoff JG, Aalberg JJ, Divino CM. Should patients With obstructing colorectal cancer have proximal diversion? Am J Surg 2016; 213:742-747. [PMID: 27742029 DOI: 10.1016/j.amjsurg.2016.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 08/05/2016] [Accepted: 08/08/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Up to 20% of patients with colorectal cancer present with obstruction. The goal of this study was to compare the short-term outcomes of patients with obstructing colon cancer who underwent resection and primary anastomosis with or without proximal diversion. METHODS The American College of Surgeons' National Surgical Quality Improvement Program Procedure Targeted Colectomy databases from 2012 to 2014 were reviewed. Patients undergoing colorectal resection with or without diverting ostomy for obstructing colorectal cancer were analyzed. Propensity score-matched cohorts of diverted and nondiverted patients were created accounting for patient characteristics. The primary outcomes were 30-day mortality, postoperative complications, and readmission. RESULTS There were 2,323 patients (92%) with no proximal diversion and 204 patients (8%) with proximal diversion. In univariate analysis, patients with colorectal resection with diversion were significantly more likely to have any complication (P = .001), sepsis (P = .01), and blood transfusion (P = .001). Diversion patients were also significantly more likely to be readmitted to the hospital within 30 days of the index procedure (P = .02). Proximal diversion was associated with any complication (P = .01), failure to wean off ventilator (P = .05), and longer length of stay (P = .01) in matched cohorts. CONCLUSIONS Proximal diversion in the setting of obstructive colorectal cancer is associated with higher rates of any complication, deep wound infection, sepsis, and readmission. Surgeons who perform a primary anastomosis with diversion for obstructing colorectal cancer should take into account the significant risk for postoperative complications.
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Affiliation(s)
- Chaya Shwaartz
- Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adam C Fields
- Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jake G Prigoff
- Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey J Aalberg
- Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Celia M Divino
- Division of General Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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