Morbidity related to defunctioning ileostomy closure after ileal pouch-anal anastomosis and low colonic anastomosis

Purpose  

Defunctioning ileostomies are widely performed in order to prevent or treat anastomotic leakage after colorectal surgery. The aim of the present study was to determine morbidity related to stoma closure and to identify predictive factors of a complicated postoperative course.     

Morbidity related to defunctioning loop ileostomy in low anterior resection

Aim

A defunctioning loop ileostomy in low anterior resection reduces the incidence and morbidity of an anastomotic leakage, but complications related to the stoma may occur. We explored stoma-associated complications during the stoma period and after stoma reversal.

Methods

A retrospective analysis of rectal cancer patients operated with low anterior resection and a defunctioning loop ileostomy at Helsingborg Hospital and Malm? University Hospital from January 2007 to June 2009 was undertaken.

Results

Ninety-two patients were included, of whom 82 (89?%) underwent stoma reversal. The median stoma period was 6.2?±?3.2?months. Sixty-six percent of the patients suffered from minor or major stoma-associated morbidity. The complication rate was significantly related to the stoma time (p?<?0.01). Twenty-nine percent (27/92) had at least one episode of dehydration, leading to readmittance in half of the cases. Elderly patients were more prone to develop dehydration. Dehydration most commonly occurred early in the postoperative period (mean, 5.8?weeks). The mean hospital stay for stoma reversal was 6.5?±?4.0?days. Forty percent (33/82) had some complication associated with the reversal.

Conclusion

This study indicates high morbidity associated with defunctioning loop ileostomy. Our data suggest that the stoma time should be limited to reduce complications. Monitoring and early stoma reversal should be considered in elderly patients. Furthermore, stoma reversal is not uneventful, and more studies are needed to address how to minimize complications.     

Short-term outcomes of local correction of stoma prolapse with a stapler device

Background

The aim of the present study was to classify the short-term outcomes of local correction of stoma prolapse with a stapler device.

Methods

The medical records of 11 patients undergoing local correction of stoma prolapse using a stapler device were retrospectively reviewed.

Results

No mortality or morbidity was observed after the surgery. Median operative time was 35 min (range 15–75 min), and blood loss was minimal. Median duration of follow-up was 12 months (range 6–55 months). One of the 11 patients had a recurrent stoma prolapse.

Conclusions

This technique can be a feasible, safe and minimally invasive correction procedure for stoma prolapse.     

Focused preoperative patient stoma education, prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the enhanced recovery programme

Purpose  

Stoma formation is a well-known cause for delayed discharge following colorectal surgery. This has been addressed by the enhanced recovery programme (ERP) preoperatively through stoma counselling sessions. These aim to promote independent stoma management post-operatively, thus expediting hospital discharge. We compared the numbers of patients with prolonged hospital stay secondary to delayed independent stoma management prior to and following the introduction of an enhanced recovery programme with preoperative stoma education.     

Parastomal hernia: is prevention better than cure? Use of preperitoneal polypropylene mesh at the time of stoma formation

Background  

This is a prospective study of prophylactic mesh placement in the preperitoneal space at the time of stoma formation to prevent parastomal hernia.     

Meta-analysis of randomized trials comparing endoscopic stenting and surgical decompression for colorectal cancer obstruction

Purpose

Surgical decompression is the traditional treatment for acute colorectal cancer obstruction. In recent years, colorectal stenting has been used to relieve the obstruction. This study used meta-analytic techniques to compare colonic stenting versus surgical decompression for colorectal cancer obstruction.

Methods

A comprehensive search of several databases was conducted. The search identified 321 potential abstracts and titles of which eight randomized trials involving 353 patients were retrieved in full text. A meta-analysis of the studies included was carried out to identify the differences in outcomes between the two procedures.

Results

The pooled analysis showed no significant differences for mortality (odds ratio (OR) 0.91) and morbidity (OR 2.05) rates between the two strategies while the permanent stoma creation rate was significantly higher in the surgical group as compared to the stent group (OR 3.12). By comparing surgery and colonic stenting in studies which analyzed the use of stenting as a “bridge to surgery,” the pooled analysis showed that primary anastomosis was more frequent in the stent group as compared to the surgical group (OR 0.42), and the stoma creation was more frequent in the surgical group as compared to the stent group (OR 2.36).

Conclusion

Our study suggested that, in patients with acute colorectal cancer obstruction, stent placement improved several outcomes, such as primary anastomosis, stoma formation, and permanent stoma, while it failed to show an improvement in mortality and morbidity risk.     

Ileoscopy via Stoma After Diverting Ileostomy: A Safe and Effective Tool to Evaluate for Crohn’s Recurrence of Neoterminal Ileum

Background  

Recurrence of Crohn’s disease (CD) most commonly occurs in the neoterminal ileum near the stoma after fecal diverting ileostomy. Methods used to assess CD recurrence include small bowel series, ileostomy injection, computed tomography (CT) enterography, and capsule endoscopy. Retrograde ileoscopy via stoma is also a valuable tool for recognition of CD recurrence; however, this technique has not been formally studied.     

The effect of peri-stomal infiltration with bupivacaine/epinephrine on post-operative pain, nausea and ease of surgery in reversal of loop ileostomies

Purpose  

Evidence to support the routine use of local anaesthetic in the reversal of loop ileostomy is equivocal. This randomized control study looked at the use of peri-operative infiltration of stoma with 0.25% bupivacaine with 1/200,000 epinephrine on the ease of surgery and its effect on post-operative pain and nausea.     

Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure?

Background

Adhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm®) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the lenght of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm.

Methods

Twenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured.

Results

All 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p=0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p=0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p=0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively).

Conclusions

When consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.     

Preliminary experience with umbilical stoma in transumbilical single-port colorectal surgery

Background

The umbilicus, an embryological natural orifice, is increasingly used as the only access route during single-incision laparoscopic surgery (SILS) for colorectal disease. As a part of some of these procedures, a temporary, diverting ostomy could be exteriorized through the umbilicus itself. Theoretical advantages include better preservation of the abdominal wall and potentially superior cosmetic results. The aim of the present study was to evaluate our preliminary experience in SILS colorectal resection with umbilical stoma (u-stoma).

Methods

We retrospectively reviewed all colorectal patients operated using SILS for benign or malignant disease at Paris Poissy Medical Center. Patients were selected for consideration of u-stoma with our stoma therapists.

Results

Between January 2010 and December 2016, 234 patients underwent colorectal SILS procedures. In 74 patients (31.6%), an ileostomy (n = 41) or a colostomy (n = 33) was fashioned. Of these, 20 (27% of all ostomies) were umbilical stomas. The 20 u-stoma patients, 10 men and 10 women, received either a loop ileostomy (n = 14) or an end (n = 4) or loop (n = 2) colostomy. The mean age was 52 years (range 29–81 years). There was no mortality. Operative stoma-related morbidity occurred in only 5% of patients (n = 1: ileal torsion volvulus). Median follow-up after stoma formation was 30 months (range 12–59 months). Adjustment to the stoma and quality of life were satisfactory as estimated by both the patient and the stoma therapist. All stomas were reversed. At a median follow-up of 27.5 months (range 7–55 months) after stoma reversal, two patients had reoperation for incisional hernia.

Conclusion

This preliminary experience showed that u-stoma is a feasible and safe alternative to more conventional ostomy after SILS.

     

Management and outcome of colorectal anastomotic leaks

Purpose

Anastomotic leak is a devastating complication of an intestinal anastomosis. Optimal management and outcome is not routinely described, and much of our knowledge relies upon historical data. We wished to examine the management and outcome of anastomotic leaks on a colorectal surgery unit in the twenty-first century.

Method

A retrospective audit of all patients who had a colorectal anastomotic leak between January 2002 and December 2008 in a large university teaching hospital. Data collected included patient characteristics, primary diagnosis, mode of diagnosis and time to diagnosis of anastomotic leak, inpatient management, morbidity and mortality, permanent stoma rate, use of hospital resources.

Results

Thirty patients (16 male, 14 female), with a median age of 60?years (range 25?C84?years), had an anastomotic leak. The median time to presentation of clinically suspected leaks was 12?days (range 3?C56?days). Fourteen patients required reoperation, with ten needing the anastomosis take down. Average hospital stay was 40?days. The permanent stoma rate following a rectal anastomotic leak was 27% and 57.1% from a colonic leak. Overall mortality in this series was 27%. Mortality was higher after leak from a colonic anastomosis than after leak from a rectal anastomosis (43.8% vs. 7.1%, respectively).

Conclusions

Anastomotic leaks are not detected until late in the post-operative period and are associated with a high mortality. Demand on hospital resources is high. In this series, patients who leaked after a colonic anastomosis had a higher mortality and permanent stoma rate than after leaks from a rectal anastomosis.     

Diverting stoma in rectal cancer surgery. A retrospective study of 329 patients from Japanese cancer centers

Background  

A diverting stoma (DS) has been constructed for many patients with low anterior resection (LAR), but it is still controversial whether DS can prevent anastomotic leakages. The aim of this study was to investigate the risk factors of anastomotic leakage including DS construction, and to evaluate the clinical course affected by DS according to the necessity of urgent abdominal reoperation for anastomotic leakage.     

Current use of diverting stoma in anterior resection for cancer: population-based cohort study of total and partial mesorectal excision

Purpose

A diverting stoma is commonly used to reduce the risk of anastomotic leakage when performing total mesorectal excision (TME) in anterior resection for rectal cancer. The purpose of this study was to evaluate the impact of fecal diversion in relation to partial mesorectal excision (PME).

Methods

A retrospective analysis was undertaken on a national cohort, originally created to study the impact of central arterial ligation on patients with increased cardiovascular risk. Some 741 patients operated with anterior resection for rectal cancer during the years 2007 through 2010 were followed up for 53 months. Multivariate logistic regression was used to evaluate the impact of diverting stoma on the risk of anastomotic leakage and permanent stoma, expressed as odds ratios (ORs) and 95 % confidence intervals (CIs).

Results

The risk of anastomotic leakage was increased in TME surgery when not using a diverting stoma (OR 5.1; 95 % CI 2.2–11.6), while the corresponding risk increase in PME patients was modest (OR 1.8; 95 % CI 0.8–4.0). At study completion or death, 26 and 13 % of TME and PME patients, respectively, had a permanent stoma. A diverting stoma was a statistically significant risk factor for a permanent stoma in PME patients (OR 4.7; 95 % CI 2.5–9.0), while less important in TME patients (OR 1.8; 95 % CI 0.6–5.5).

Conclusion

The benefit of a diverting stoma concerning anastomotic leakage in this patient group seems doubtful. Moreover, the diverting stoma itself may contribute to the high rate of permanent stomas.

     

A sustaining rod increases necrosis of loop ileostomies: a randomized controlled trial

Purpose

Defunctioning loop ileostomies (LI) are commonly used in colorectal surgery to reduce the potentially detrimental consequences of anastomotic leakages. However, stoma-related morbidity is high with up to 75% of patients having local complications. The aim of this study was to investigate the effect of a sustaining rod on the local complication rate.

Methods

In this prospective, multi-center, randomized controlled trial, subjects were allocated to either a rod or a rod-less protocol (NCT00959738). The primary outcome was local morbidity as measured by a stoma specific morbidity score (SSMS) during the first 3 months postoperatively.

Results

Between August 2008 and July 2014, a total of 122 patients were enrolled in the study, of which 78 (63.8%) completed the study [44 (56.4%) rod, 34 (43.6%) rod-less]. There was no significant difference in the SSMS between the two groups. The incidence of necrosis or partial necrosis, however, was significantly increased in the rod group: 13 (29.5%) vs. 1 (2.9%) in the rod-less group (p < 0.01). The retraction rate did not differ significantly between the groups: two (4.5%) in the rod vs. five (14.7%) in the rod-less group (p = 0.13). High body mass index (BMI > 26) was associated with an odds ratio of 5 (p < 0.01) for severe stoma complications.

Conclusions

A rod-less technique for loop ileostomies reduces the risk of stomal necrosis, with a high BMI being an independent risk factor for stomal complications.

     

The nutritional impact of diverting stoma-related complications in elderly rectal cancer patients

Purpose

Diverting stomas following rectal cancer surgery can affect patients' quality of life, and their complications may negatively affect patients' long-term outcomes and quality of life. The purpose of this study is to investigate the relationship between diverting stoma-related complications and nutritional status.

Methods

In a retrospective study of 114 patients aged 65 years and older who underwent diverting loop ileostomy following rectal cancer surgery between June 2004 and March 2011, we analyzed retrospectively diverting stoma-related complications and nutrition status for the following time periods: before stoma construction, before stoma closure, and after stoma closure.

Results

Complications related to the diverting stoma developed in 24 (21.1 %) patients and complications related to stoma closure in 11 (9.6 %) patients. Nutritional screening performed prior to stoma closure showed that patients who experienced stoma formation-related complications had lower albumin levels (P?=?0.016) and lower total lymphocytes (P?=?<0.0001). Body weight loss was more severe in patients with stoma-related complication (P?=?0.036).

Conclusions

Diverting stoma-related complications may affect patient's nutritional status. Stoma closure operation and proper nutritional support may be important for avoiding complications and improving patients' long-term outcomes and quality of life.     

The fate of preserved sphincter in rectal cancer patients

Purpose

Sphincter-saving surgery is widely accepted operative modality to treat rectal cancer. It often requires temporary diverting stoma to avoid the complications of anastomotic failure. This study investigates the cumulative failure rate in sphincter preservation for rectal cancer and the risk factors associated with the permanent stoma.

Methods

A retrospective study on 358 patients diagnosed with primary rectal cancer from 2009 to 2013 was conducted at a single institute. Three hundred and thirty-one out of 358 patients with rectal cancer located within 12 cm from the anal verge, who underwent sphincter-preserving surgery, were included in this study. The cumulative rate for permanent stoma was calculated. Univariate and multivariate analysis were performed, comparing the patients with stoma to the ones without.

Results

Temporary diverting stoma was created in 223 (82%) patients. After median follow-up of 42 months, 18 patients (6.6%) persistently used temporary stoma or required re-creation of stoma. Univariate analysis revealed that BMI, tumor location below 4 cm from the anal verge, coloanal anastomosis, anastomotic leakage, and local recurrence were significantly associated with persistent use or re-formation of stoma. Multivariate analysis showed that anastomotic leakage (OR 50.3; 95% CI, 10.1–250.1; p?<?0.0001) and local recurrence (OR 11.3; 95% CI, 1.61–78.5; p?=?0.015) were the independent risk factors.

Conclusion

Patients with anastomotic leakage and local recurrence are at high risk for permanent stoma. Not only should patients be fully informed of possible failure in sphincter preservation preoperatively, but also patient-oriented decision should be made on patient-tailored surgical plan.

     

Outcomes of support rod usage in loop stoma formation

Aim

Traditionally, support rods have been used when creating loop stomas in the hope of preventing retraction. However, their effectiveness has not been clearly established. This study aimed to investigate the rate of stoma rod usage and its impact on stoma retraction and complication rates.

Method

A prospective cohort of 515 consecutive patients who underwent loop ileostomy/colostomy formation at a tertiary referral colorectal unit in Sydney, Australia were studied. Mortality and unplanned return to theatre rates were calculated. The primary outcome measure of interest was stoma retraction, occurring within 30 days of surgery. Secondary outcome measures included early stoma complications. The 10-year temporal trends for rod usage, stoma retraction, and complications were examined.

Results

Mortality occurred in 23 patients (4.1 %) and unplanned return to theatre in 4 patients (0.8 %). Stoma retraction occurred in four patients (0.78 %), all without rods. However, the rate of retraction was similar, irrespective of whether rods were used (P?=?0.12). There was a significant decline in the use of rods during the study period (P?<?0.001) but this was not associated with an increase in stoma retraction rates. Early complications occurred in 94/432 patients (21.8 %) and were more likely to occur in patients with rods (64/223 versus 30/209 without rods, P?<?0.001).

Conclusions

Stoma retraction is a rare complication and its incidence is not significantly affected by the use of support rods. Further, complications are common post-operatively, and the rate appears higher when rods are used. The routine use of rods warrants judicious application.

What does this paper add to the literature?

It remains unclear whether support rods prevent stoma retraction. This study, the largest to date, confirms that stoma retraction is a rare complication and is not significantly affected by the use of rods. Consequently, routine rod usage cannot be recommended, particularly as it is associated with increased stoma complications.

     

Sigmoid resection with primary anastomosis and ileostomy versus laparoscopic lavage in purulent peritonitis from perforated diverticulitis: outcome analysis in a prospective cohort of 40 consecutive patients

Purpose

This prospective study aimed to compare outcomes after laparoscopic peritoneal lavage (LPL) and sigmoid resection with primary colorectal anastomosis (RPA).

Methods

From June 2010 to June 2015, 40 patients presenting with Hinchey III peritonitis from perforated diverticulitis underwent LPL or RPA. Patients with Hinchey II or IV peritonitis and patients who underwent an upfront Hartmann procedure were excluded. Primary endpoint was overall 30-day or in-hospital postoperative morbidity after surgical treatment of peritonitis.

Results

Twenty-five patients underwent RPA and 15 LPL. Overall postoperative morbidity and mortality rates were not significantly different after RPA and LPL (40 vs 67 %, p = 0.19; 4 vs 6.7 %, p = 1, respectively). Intra-abdominal morbidity and reoperation rates were significantly higher after LPL compared to RPA (53 vs 12 %, p < 0.01; 40 vs 4 %, p = 0.02, respectively). Multivariate analysis showed that LPL (p = 0.028, HR = 18.936, CI 95 % = 1.369–261.886) was associated with an increased risk of postoperative intra-abdominal septic morbidity. Among 6 patients who underwent reoperation after LPL, 4 had a Hartmann procedure. All surviving patients who had a procedure requiring stoma creation underwent stoma reversal after a median delay of 92 days after LPL and 72 days after RPA (p = 0.07).

Conclusion

LPL for perforated diverticulitis is associated with a high risk of inadequate intra-abdominal sepsis control requiring a Hartmann procedure in up to 25 % of patients. RPA appears to be safer and more effective. It may represent the best option in this context.

     

Reversal of Hartmann’s procedure following acute diverticulitis: is timing everything?

Background  

Patients who undergo a Hartmann’s procedure may not be offered a reversal due to concerns over the morbidity of the second procedure. The aims of this study were to examine the morbidity post reversal of Hartmann’s procedure.     

Primary anastomosis with a defunctioning stoma versus Hartmann's procedure for perforated diverticulitis—a comparison of stoma reversal rates

Purpose

The ideal treatment of patients with perforated diverticulitis is still controversial. Hartmann's procedure has been the treatment of choice for decades, but primary anastomosis with a defunctioning stoma has become an accepted alternative. The aim of this study was to evaluate the stoma reversal rates after these two surgical strategies.

Methods

A retrospective review of the data from patients with perforated sigmoid diverticulitis between 2002 and 2011 undergoing a Hartmann's procedure (HP) versus a primary anastomosis with a defunctioning stoma (PA) was performed. Additionally, patients were contacted by mail or telephone in March 2012 using a standardized questionnaire.

Results

A total of 98 patients were identified: 72 undergoing HP and 26 patients receiving PA. The median follow-up time was 63 months (range 4–118). Whilst 85 % of patients with PA have had their stoma reversed, only 58 % of patients with an HP had a stoma reversal (p?=?0.046). The median period until stoma reversal was significantly longer for HP (19 weeks) than for PA (12 weeks; p?=?0.03). The 30-day mortality for PA was 12 % as opposed to 25 % for HP (p?=?0.167). According to the Clavien–Dindo classification, surgical complications occurred significantly less frequently in patients with PA (p?=?0.014).

Conclusion

The stoma reversal rates for PA are significantly higher than for HP. Thus, depending on the overall clinical situation, primary resection and anastomosis with a proximal defunctioning stoma might be the optimal procedure for selected patients with perforated diverticular disease.