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Hu J, Zhang X, Sun J, Hu H, Tang C, Ba L, Xu Q. Supportive Care Needs of Patients With Temporary Ostomy in Enhanced Recovery After Surgery: A Mixed-Methods Study. J Nurs Res 2024; 32:e329. [PMID: 38727228 DOI: 10.1097/jnr.0000000000000610] [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: 05/31/2024] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS), a global surgical quality improvement initiative, reduces the length of stay in the hospital. Temporary stoma care for rectal cancer is complex, and patients require prolonged care services to adjust to the stoma. The shorter stay durations in the new model challenge the conventional care pathways and create new patient needs. PURPOSE This study was designed to explore the supportive care needs of patients under the new surgical model to provide a reference for the design of ERAS nursing care plans. METHODS A convergent parallel mixed-methods design was used in this study. Patients with temporary stomas for rectal cancer were recruited using a convenience sampling method in gastrointestinal surgery wards and wound & stoma clinics in two public tertiary care hospitals in China. Standardized questionnaires were administered to 140 patients to collect quantitative data, and semistructured interviews were conducted individually with 13 patients to collect qualitative data. The questionnaire data were analyzed using descriptive statistics, and the interview data were analyzed using thematic analysis. RESULTS "Health system and information needs" and "care and support needs" were identified in both the qualitative and quantitative analyses as the most significant unmet needs of the participants. In addition, the qualitative analysis identified receiving focused stoma care instructions and easily understandable information as essential to fulfilling health system and information needs. Care and support needs included access to continued postdischarge services and attention from medical professionals. CONCLUSION/IMPLICATIONS FOR PRACTICE The participants in this study experienced a variety of unmet supportive care needs under the ERAS protocol, with gaps particularly notable in two categories: "health system and information needs" and "care and support needs." Increased perioperative care and shorter hospital stays under the ERAS protocol reduce opportunities for patients to receive targeted instruction and shift much of the ostomy education and care workload out of the hospital, requiring greater attention from clinical nurses to ensure quality of care.
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Affiliation(s)
- Jieman Hu
- PhD, RN, Lecturer, School of Nursing, Nanjing Medical University, Nanjing, China
| | - Xiuling Zhang
- BSN, RN, Department of Gastrointestinal Colorectal and Anal Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jianan Sun
- MS, RN, Department of Gastrointestinal Colorectal and Anal Surgery, The First Hospital of Jilin University, Changchun, China
| | - Haiyan Hu
- BSN, RN, Head Nurse, Department of Gastrointestinal Colorectal and Anal Surgery, The First Hospital of Jilin University, Changchun, China
| | - Chulei Tang
- PhD, RN, Lecturer, School of Nursing, Nanjing Medical University, Nanjing, China
| | - Lei Ba
- PhD, Associate Professor, National Health Commission Contraceptives Adverse Reaction Surveillance Center, Jiangsu Health Development Research Center, Nanjing, China
| | - Qin Xu
- MS, RN, Professor, School of Nursing, Nanjing Medical University, Nanjing, China
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Yang S, Tang G, Zhang Y, Wei Z, Du D. Meta-analysis: loop ileostomy versus colostomy to prevent complications of anterior resection for rectal cancer. Int J Colorectal Dis 2024; 39:68. [PMID: 38714581 PMCID: PMC11076370 DOI: 10.1007/s00384-024-04639-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/10/2024]
Abstract
PURPOSE Anastomotic leakage is a serious complication of colorectal cancer surgery, prolonging hospital stays and impacting patient prognosis. Preventive colostomy is required in patients at risk of anastomotic fistulas. However, it remains unclear whether the commonly used loop colostomy(LC) or loop ileostomy(LI) can reduce the complications of colorectal surgery. This study aims to compare perioperative morbidities associated with LC and LI following anterior rectal cancer resection, including LC and LI reversal. METHODS In this meta-analysis, the Embase, Web of Science, Scopus, PubMed, and Cochrane Library databases were searched for prospective cohort studies, retrospective cohort studies, and randomized controlled trials (RCTs) on perioperative morbidity during stoma development and reversal up to July 2023, The meta-analysis included 10 trials with 2036 individuals (2 RCTs and 8 cohorts). RESULTS No significant differences in morbidity, mortality, or stoma-related issues were found between the LI and LC groups after anterior resection surgery. However, patients in the LC group exhibited higher rates of stoma prolapse (RR: 0.39; 95%CI: 0.19-0.82; P = 0.01), retraction (RR: 0.45; 95%CI: 0.29-0.71; P < 0.01), surgical site infection (RR: 0.52; 95%CI: 0.27-1.00; P = 0.05) and incisional hernias (RR: 0.53; 95%CI: 0.32-0.89; P = 0.02) after stoma closure compared to those in the LI group. Conversely, the LI group showed higher rates of dehydration or electrolyte imbalances(RR: 2.98; 95%CI: 1.51-5.89; P < 0.01), high-output(RR: 6.17; 95%CI: 1.24-30.64; P = 0.03), and renal insufficiency post-surgery(RR: 2.51; 95%CI: 1.01-6.27; P = 0.05). CONCLUSION Our study strongly recommends a preventive LI for anterior resection due to rectal cancer. However, ileostomy is more likely to result in dehydration, renal insufficiency, and intestinal obstruction. More multicenter RCTs are needed to corroborate this.
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Affiliation(s)
- Shilai Yang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gang Tang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yudi Zhang
- College of Combination of Chinese and Western Medicine, Chongqing College of Traditional Chinese Medicine, No. 61, Puguobao Road, Bicheng Street, Bishan District, Chongqing, 402760, P.R. China
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Donglin Du
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Wang YJ, Lin KH, Kang JC, Hu JM, Chen CY, Pu TW. Benefits of laparoscopy-assisted ileostomy in colorectal cancer patients with bowel obstruction. World J Clin Cases 2023; 11:5660-5665. [PMID: 37727726 PMCID: PMC10505990 DOI: 10.12998/wjcc.v11.i24.5660] [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: 06/13/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Ileostomies are commonly performed after colon and rectal surgeries. Laparoscopy-assisted ileostomy with adhesion lysis may have potential benefits over conventional open surgery. AIM To compare the outcomes of laparoscopy-assisted and conventional ileostomies. METHODS Data from 48 consecutive patients who underwent ileostomy at our institution between May 2021 and May 2022 were retrospectively analyzed. The groups comprised 26 and 22 patients who underwent laparoscopic ileostomy (laparoscopic group) and conventional ileostomy (conventional group), respectively, performed by a single surgeon. Patient demographics, operative characteristics, postoperative outcomes, and 30-d morbidities and mortality rates were analyzed. RESULTS The two groups had comparable mean ages, sex distributions, American Society of Anesthesiologists scores, and body mass indices. However, the laparoscopic group showed similar operative time, better visualization for adhesion lysis, and lower visual analog scale scores than the conventional group. CONCLUSION Laparoscopy-assisted ileostomy is a safe and efficient method that produces lower visual analog scale scores, better intraoperative visualization for effective adhesion lysis, and similar operative time compared with conventional ileostomy.
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Affiliation(s)
- Yi-Jie Wang
- Department of Surgery, Tri Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Kuan-Hsun Lin
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Jung-Cheng Kang
- Division of Colon and Rectal Surgery, Department of Surgery, Taiwan Adventist Hospital, Taipei 105, Taiwan
| | - Je-Ming Hu
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Chao-Yang Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Ta-Wei Pu
- Division of Colon and Rectal Surgery, Department of Surgery, Songshan branch, Tri-Service General Hospital, National Defense Medical Center, Taipei 105, Taiwan
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Ge Z, Zhao X, Liu Z, Yang G, Wu Q, Wang X, Zhang X, Cheng Z, Wang K. Complications of preventive loop ileostomy versus colostomy: a meta-analysis, trial sequential analysis, and systematic review. BMC Surg 2023; 23:235. [PMID: 37568176 PMCID: PMC10422751 DOI: 10.1186/s12893-023-02129-w] [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: 02/25/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Preventive colostomy is required for colorectal surgery, and the incidence of complications associated with ileostomy and colostomy remains controversial. This study aimed to compare the incidence of postoperative complications between ileostomy and colostomy procedures. METHODS Data analysis was conducted on 30 studies, and meta-analysis and trial sequential analysis (TSA) were performed on five studies. The basic indicators, such as stoma prolapse, leak, wound infection, ileus, and a series of other indicators, were compared. RESULTS No statistically significant differences were observed with complications other than stoma prolapse. Meta-analysis and TSA showed that the incidence of ileostomy prolapse was lower than that of colostomy prolapse, and the difference was statistically significant. Apart from the four complications listed above, the general data analysis showed differences in incidence between the two groups. The incidence of skin irritation, parastomal hernia, dehydration, pneumonia, and urinary tract infections was higher with ileostomy than with colostomy. In contrast, the incidence of parastomal fistula, stenosis, hemorrhage, and enterocutaneous fistula was higher with colostomy than with ileostomy. CONCLUSIONS There were differences in the incidence of ileostomy and colostomy complications in the selected studies, with a low incidence of ileostomy prolapse. PROSPERO REGISTRATION NUMBER CRD42022303133.
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Affiliation(s)
- Zheng Ge
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Xiang Zhao
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Zitian Liu
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Guangwei Yang
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Qunzheng Wu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xiaoyang Wang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xiang Zhang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Zhiqiang Cheng
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China.
| | - Kexin Wang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Martellucci J, Balestri R, Brusciano L, Iacopini V, Puccini M, Docimo L, Cianchi F, Buccianti P, Prosperi P. Ileostomy versus colostomy: impact on functional outcomes after total mesorectal excision for rectal cancer. Colorectal Dis 2023; 25:1686-1693. [PMID: 37461265 DOI: 10.1111/codi.16657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 05/06/2023] [Accepted: 06/01/2023] [Indexed: 08/17/2023]
Abstract
AIM Even if a defunctioning stoma mitigates the serious consequences of anastomotic leakage after total mesorectal excision (TME) for rectal cancer, the presence of a temporary stoma or having a stoma for a prolonged period of time may also be a determining factor for further morbidities and poor bowel function. The aim of this study was to evaluate the impact of diverting stomas on clinical and functional outcomes after TME, comparing ileostomy or colostomy effects. METHODS All consecutive patients who underwent TME for rectal cancer between March 2017 and December 2020 in three Italian referral centres were enrolled in the present study. For every patient sex, age, stage of the tumour, neoadjuvant therapy, surgical technique, anastomotic technique, the presence of a diverting stoma, perioperative complications and functional postoperative status were recorded. Considering the diverting stoma, the kind of stoma, length of time before closure and stoma related complications were evaluated. RESULTS During the study period 416 consecutive patients (63% men) were included. Preoperative neoadjuvant therapy was performed in 79%. A minimally invasive approach was performed in >95% of patients. Temporary stoma was performed during the operation in 387 patients (93%) (ileostomy 71%, colostomy 21%). The stoma was closed in 84% of patients. The median time from surgery to stoma closure was 145 days. No difference was found between ileostomy and colostomy in overall morbidity after stoma creation and closure. Moreover, increased postoperative functional disturbance seemed to be significantly proportional to the attending time for closure for ileostomy. CONCLUSION The presence of a defunctioning stoma seems to have a negative impact on functional bowel activity, especially for delayed closure for ileostomy. This should be considered when the kind of stoma (ileostomy vs. colostomy) is selected for each patient.
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Affiliation(s)
- Jacopo Martellucci
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | | | - Luigi Brusciano
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Veronica Iacopini
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | - Marco Puccini
- General Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - Ludovico Docimo
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Fabio Cianchi
- Digestive Surgery, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Piero Buccianti
- General Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - Paolo Prosperi
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
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Omar M, Tarek A, Abdeslam B, Amouzou EGYO, Abdelmalek O, Khalid AT, Hicham EB, Ouadii M, Khalid M, Amine RM, Bachir BE, Emmanuel B. Risk factors of acute renal failure in patients with protective ileostomy after rectal cancer surgery. BMC Surg 2023; 23:107. [PMID: 37118719 PMCID: PMC10148495 DOI: 10.1186/s12893-023-02016-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/25/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Despite the potential benefits of protective ileostomy in rectal surgery, diverting loop ileostomy construction is not free of specific medical consequences implying unplanned hospital readmissions. The most common reason for readmission in these patients is a dehydration with a prevalence of acute renal failure (ARF) of 20%. The objective of this study was to establish the predictive factors of ARF in patients with protective ileostomy after surgery for rectal cancer from a bicentric study. METHODS we conducted a bicentric retrospective cohort study to identify the risk factor of ARF. This study was carried out on 277 patients operated for rectal cancer with necessity of a protective ileostomy during the study period. ARF was measured at any endpoint between ileostomy creation and reversal. Multiple logistic regressions were performed to identify independent risk factors. RESULTS A total of 277 patients were included, and 18% (n = 50) were readmitted for ARF. In multivariate logistic regression, increased age (OR 1.02, p = 0.01), Psychiatric diseases (OR 4.33, p = 0.014), Angiotensin II receptor blockers (OR 5.15, p < 0.001) and the ASA score ≥ 3 (OR 9.5, p < 0.001) were significantly associated with ARF. CONCLUSION Acute renal failure is a prevalent and significant event in the postoperative course of ileostomy patients. Patients at risk should be risk stratified before discharge and targeted for intensive preventive measures.
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Affiliation(s)
- Marghich Omar
- Department of Visceral Surgery, University Hospital Hassan 2, Fes, Morocco.
| | - Anis Tarek
- Department of Visceral Surgery, University Hospital Hassan 2, Fes, Morocco
| | - Bouassria Abdeslam
- Department of Visceral Surgery, University Hospital Hassan 2, Fes, Morocco
| | | | | | - Ait Taleb Khalid
- Department of Visceral Surgery, University Hospital Hassan 2, Fes, Morocco
| | | | - Mouaqit Ouadii
- Department of Visceral Surgery, University Hospital Hassan 2, Fes, Morocco
| | - Mazaz Khalid
- Department of Visceral Surgery, University Hospital Hassan 2, Fes, Morocco
| | - Rahili Mohamed Amine
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Benjelloun El Bachir
- Faculty of Medicine, Pharmacy and Dental Medicine, Sidi Mohamed Ben Abdellah University, Fes, Morocco
| | - Benizri Emmanuel
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
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7
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Brisinda G, Chiarello MM, Pepe G, Cariati M, Fico V, Mirco P, Bianchi V. Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors. World J Clin Cases 2022; 10:13321-13336. [PMID: 36683625 PMCID: PMC9850997 DOI: 10.12998/wjcc.v10.i36.13321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/08/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) after restorative surgery for rectal cancer (RC) is associated with significant morbidity and mortality.
AIM To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study.
METHODS To identify risk factors for AL, a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed. Clinical, demographic and operative features, intraoperative outcomes and oncological characteristics were evaluated.
RESULTS The incidence of AL was 10.4%, with a mean time interval of 6.2 ± 2.1 d. Overall mortality was 0.8%. Mortality was higher in patients with AL (4.9%) than in patients without leak (0.4%, P = 0.009). Poor bowel preparation, blood transfusion, median age, prognostic nutritional index < 40 points, tumor diameter and intraoperative blood loss were identified as risk factors for AL. Location of anastomosis, number of stapler cartridges used to divide the rectum, diameter of circular stapler, level of vascular section, T and N status and stage of disease were also correlated to AL in our patients. The diverting ileostomy did not reduce the leak rate, while the use of the transanastomic tube significantly did.
CONCLUSION Clinical, surgical and pathological factors are associated with an increased risk of AL. It adversely affects the morbidity and mortality of RC patients.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Department of Surgery, Università Cattolica S Cuore, Rome 00168, Italy
| | | | - Gilda Pepe
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Maria Cariati
- Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Paolo Mirco
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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Mathew AP, M S, K C, Muralee M, Wagh M. Morbidity of Temporary Loop Ileostomy in Patients with Colorectal Cancer. Indian J Surg Oncol 2022; 13:468-473. [PMID: 36187539 PMCID: PMC9515269 DOI: 10.1007/s13193-022-01501-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 01/11/2022] [Indexed: 11/28/2022] Open
Abstract
Leakage of low colorectal anastomoses after total mesorectal excision is a dreaded complication. Hence, an ileostomy is commonly performed during anterior resection especially in patients who have received neoadjuvant radiation. The aim of this study was to quantify the temporary loop ileostomy-related benefits as well as morbidity in patients with colorectal cancer. We did a retrospective study including all patients who underwent anterior resection with diversion ileostomy for biopsy-proven rectal carcinoma at our institute from 1 Jan 2016 to 31 Dec 2017 with follow-up of 2 years. A total of 104 patients were included in the study. In our series, 6.7% patients had an anastomotic dehiscence which precluded patients from stoma reversal. 12.5% of the patients had a stoma-related complication. 5.7% patients had complications following a stoma reversal. Eighty percent of the patients who developed clinically evident dehiscence in the immediate postoperative period were managed conservatively because of the presence of stoma. We did not have any mortality related to the stoma. 18.3% patients did not have their stomas reversed. The stoma non-reversal due to anastomotic dehiscence or stricture could be attributed to in 7.7% patients. 3.8% had to have their ileostomies converted to a permanent colostomy due to either a rectovaginal fistula or dehiscence or stricture. The complications associated with ileostomy are not insignificant. In our study, the tumor location in lower rectum was the only significant factor for non-reversal. We have to objectively identify patients who are at low risk for leakage and avoid ileostomy in them, and also try to minimize the morbidity of ileostomy by methods like early closure.
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Affiliation(s)
- Arun Peter Mathew
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
| | - Srinidhi M
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
| | - Chandramohan K
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
| | - Madhu Muralee
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
| | - Mira Wagh
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
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Chiarello MM, Bianchi V, Fransvea P, Brisinda G. Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery. World J Gastroenterol 2022; 28:3747-3752. [PMID: 36161042 PMCID: PMC9372806 DOI: 10.3748/wjg.v28.i28.3747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/13/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leakage (AL) has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure. An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication. Despite AL continues to be a dreadful compli-cation after colorectal surgery, there has been no consensus on its management. However, based on patient’s presentation and timing of the AL, there has been a gradual shift to a more conservative management, keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak. A nonoperative management is usually preferred in these patients. There are several treatment options, also for patients without a stoma who do not require a reoperation for a contained pelvic leak, including recently developed endoscopic procedures, such as clip placement or endoluminal vacuum-assisted therapy. More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.
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Affiliation(s)
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, taly
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, taly
| | - Giuseppe Brisinda
- Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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10
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Huang SH, Tsai KY, Tsai TY, You JF, Yeh CY, Hsieh PS, Tang R, Chiang JM, Tsai WS. Preoperative risk stratification of permanent stoma in patients with non-metastatic mid and low rectal cancer undergoing curative resection and a temporary stoma. Langenbecks Arch Surg 2022; 407:1991-1999. [DOI: 10.1007/s00423-022-02503-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
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Abstract
Management of the acute anastomotic leak is complex and patient-specific. Clinically stable patients often benefit from a nonoperative approach utilizing antibiotics with or without percutaneous drainage. Clinically unstable patients or nonresponders to conservative management require operative intervention. Surgical management is dictated by the degree of contamination and inflammation but includes drainage with proximal diversion, anastomotic resection with end-stoma creation, or reanastomosis with proximal diversion. Newer therapies, including colorectal stenting, vacuum-assisted rectal drainage, and endoscopic clipping, have also been described.
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Affiliation(s)
- Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - William Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
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Closure of Temporary Ileostomy 2 Versus 12 Weeks After Rectal Resection for Cancer: A Word of Caution From a Prospective, Randomized Controlled Multicenter Trial. Dis Colon Rectum 2021; 64:1398-1406. [PMID: 34343161 PMCID: PMC8492188 DOI: 10.1097/dcr.0000000000002182] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The optimum timing for temporary ileostomy closure after low anterior resection is still open. OBJECTIVE This trial aimed to compare early (2 wk) versus late (12 wk) stoma closure. DESIGN The study included 2 parallel groups in a multicenter, randomized controlled clinical trial. SETTINGS The study was conducted at 3 Swiss hospitals. PATIENTS Patients undergoing low anterior resection and temporary ileostomy for cancer were included. INTERVENTIONS Patients were randomly allocated to early or late stoma closure. Before closure, colonic anastomosis was examined for integrity. MAIN OUTCOME MEASURES The primary efficacy outcome was the Gastrointestinal Quality of Life Index 6 weeks after resection. Secondary end points included safety (morbidity), feasibility, and quality of life 4 months after low anterior resection. RESULTS The trial was stopped for safety concerns after 71 patients were randomly assigned to early closure (37 patients) or late closure (34 patients). There were comparable baseline data between the groups. No difference in quality of life occurred 6 weeks (mean Gastrointestinal Quality of Life Index: 99.8 vs 106.0; p = 0.139) and 4 months (108.6 vs 107.1; p = 0.904) after index surgery. Intraoperative tendency of oozing (visual analog scale: 35.8 vs 19.3; p = 0.011), adhesions (visual analog scale: 61.3 vs 46.2; p = 0.034), leak of colonic anastomosis (19% vs 0%; p = 0.012), leak of colonic or ileal anastomosis (24% vs 0%; p = 0.002), and reintervention (16% vs 0%; p = 0.026) were significantly higher after early closure. The concept of early closure failed in 10 patients (27% vs 0% in the late closure group (95% CI for the difference, 9.4%-44.4%)). LIMITATIONS The trial was prematurely stopped because of safety issues. The aimed group size was not reached. CONCLUSIONS Early stoma closure does not provide better quality of life up to 4 months after low anterior resection but is afflicted with significantly adverse feasibility and higher morbidity when compared with late closure. See Video Abstract at http://links.lww.com/DCR/B665. CIERRE DE LA ILEOSTOMA TEMPORAL VERSUS SEMANAS POSTERIOR A LA RESECCIN RECTAL POR CNCER UNA ADVERTENCIA DE UN ESTUDIO MULTICNTRICO CONTROLADO RANDOMIZADO PROSPECTIVO ANTECEDENTES:El momento óptimo para el cierre temporal de la ileostomía posterior a la resección anterior baja es aun controversial.OBJETIVO:Este estudio tuvo como objetivo comparar el cierre del estoma temprano (2 semanas) versus tardío (12 semanas).DISEÑO:Estudio clínico controlado, randomizado, multicéntrico, de dos grupos paralelos.ENTORNO CLINICO:El estudio se llevó a cabo en 3 hospitales suizos.PACIENTES:Se incluyeron pacientes sometidos a resección anterior baja e ileostomía temporal por cáncer.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente al cierre del estoma temprano o tardío. Antes del cierre, se examinó la integridad de la anastomosis colónica.PRINCIPALES MEDIDAS DE VALORACION:El principal resultado de eficacia fue el Índice de Calidad de Vida Gastrointestinal 6 semanas después de la resección. Los criterios secundarios incluyeron la seguridad (morbilidad), factibilidad y calidad de vida 4 meses posterior a la resección anterior baja.RESULTADOS:El estudio se detuvo por motivos de seguridad después de que 71 pacientes fueron asignados aleatoriamente a cierre temprano (37 pacientes) o cierre tardío (34 pacientes). Hubo datos de referencia comparables entre los grupos. No se produjeron diferencias en la calidad de vida 6 semanas (índice de calidad de vida gastrointestinal, media 99,8 vs. 106; p = 0,139) y 4 meses (108,6 vs 107,1, p = 0,904) después de la cirugía inicial. Tendencia intraoperatoria de supuración (escala analógica visual 35,8 vs 19,3, p = 0,011), adherencias (escala analógica visual 61,3 vs 46,2, p = 0,034), fuga de anastomosis colónica (19% vs 0%, p = 0,012), fuga de anastomosis colónica o ileal (24% vs 0%, p = 0,002) y reintervención (16% vs 0%, p = 0,026) fueron significativamente mayores después del cierre temprano. El concepto de cierre temprano fracasó en 10 pacientes (27% vs ninguno en el grupo de cierre tardío (intervalo de confianza del 95% para la diferencia: 9,4% a 44,4%)).LIMITACIONES:El estudio se detuvo prematuramente debido a problemas de seguridad. No se alcanzó el tamaño del grupo previsto.CONCLUSIÓN:El cierre temprano del estoma no proporciona una mejor calidad de vida hasta 4 meses posterior a una resección anterior baja, esto se ve afectado por efectos adversos significativos durante su realización y una mayor morbilidad en comparación con el cierre tardío. Consulte Video Resumen en http://links.lww.com/DCR/B665.
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Ahmad NZ, Abbas MH, Khan SU, Parvaiz A. A meta-analysis of the role of diverting ileostomy after rectal cancer surgery. Int J Colorectal Dis 2021; 36:445-455. [PMID: 33064212 DOI: 10.1007/s00384-020-03771-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leak is a feared complication of rectal cancer surgery. A diverting stoma is believed to act as a safety mechanism against this undesirable outcome. This meta-analysis aimed to examine the role of loop ileostomy in the prevention of this complication. METHODS The Medline, Embase and Cochrane databases were searched for randomized controlled trials (RCTs) comparing anastomotic complications after rectal cancer surgery in the presence or absence of diverting ileostomy. The need for reoperation and postoperative complications were also analysed. The length of hospital stay, intraoperative blood loss and operating time were analysed as secondary endpoints. RESULTS A significantly higher number of anastomotic leaks was detected in patients with no diverting ileostomies than in those with diversion (odds ratio (OR) 0.292 and 95% confidence interval (CI) 0.177-0.481), and more patients required reoperations in this group (OR 0.219 and 95% CI 0.114-0.422). The rate of complications other than anastomotic leak was significantly higher in patients with diverting ileostomies than in those without (OR 3.337 and 95% CI of 1.570-7.093). The operating time was longer in the ileostomy group than in the no ileostomy group (P 0.001), but no significant differences in the intraoperative blood loss or postoperative hospital stay length were observed between the two groups(P 0.199 and 0.191 respectively). CONCLUSION A lower leak rate in the presence of diverting ileostomy is supported by relatively weak evidence. While mitigating the consequences of leakage, diverting ileostomies lead to numerous other complications. High-quality RCTs are needed before routine ileostomy diversions can be recommended after rectal cancer surgery.
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Affiliation(s)
- Nasir Zaheer Ahmad
- Department of Surgery, University Hospital Limerick, St Nessan's Rd, Dooradoyle, Co, Limerick, V94 F858, Republic of Ireland.
| | - Muhammad Hasan Abbas
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | - Saad Ullah Khan
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | - Amjad Parvaiz
- Faculty of Health Sciences, University of Portsmouth, Portsmouth, UK.,Colorectal Department, Poole NHS Trust, Poole, UK
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Du R, Zhou J, Tong G, Chang Y, Li D, Wang F, Ding X, Zhang Q, Wang W, Wang L, Wang D. Postoperative morbidity and mortality after anterior resection with preventive diverting loop ileostomy versus loop colostomy for rectal cancer: A updated systematic review and meta-analysis. Eur J Surg Oncol 2021; 47:1514-1525. [PMID: 33622575 DOI: 10.1016/j.ejso.2021.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/07/2021] [Accepted: 01/29/2021] [Indexed: 12/24/2022] Open
Abstract
The purpose of this meta-analysis was to evaluate the perioperative morbidity after anterior resection with diverting loop ileostomy (LI) versus colostomy (LC) and its reversal for rectal cancer. The studies on the application of loop ileostomy versus loop colostomy in anterior resection published from January 2000 to January 2020 were searched in the databases of Pubmed, Embase, Cochrane library, and Clinical trials. All randomized controlled trials (RCTs) and cohort studies were included according to inclusion criteria. Eight studies (2 RCTs and 6 cohort studies) totaling 1451 patients (821 LI and 630 LC) were included in the meta-analysis. The morbidity related to stoma formation and closure did not demonstrate significant differences. Significantly more LCs were complicated by stoma prolapse & retraction (OR:0.26,95%CI:0.11-0.60,P = 0.001), parastomal hernia (OR = 0.52,95%CI:0.30-0.88, P = 0.01), surgical site infection (SSI) (OR = 0.24,95%CI:0.11-0.49,P < 0.0001) and incisional hernias (OR = 0.39,95%CI:0.19-0.83,P = 0.01) than by LIs. Patients with LI demonstrated significantly more complications related to the stoma, such as dehydration (OR = 0.52,95%CI:0.30-0.88, P = 0.01) and ileus (OR = 2.23,95%CI:1.12-4.43, P = 0.02) than patients with LC. While after the subgroup analysis of different publication years, LI could reduce the risk of the morbidity after stoma formation in previous years group (P = 0.04) with a lower heterogeneity (I2 = 37%); LC could reduce the incidence of parastomal dermatitis in recent years group (P < 0.0001) without heterogeneity in each subgroup (I2 = 0%). Cumulative meta-analysis detected significant turning points in dehydration, SSI, and ileus. This meta-analysis recommends diverting LI in the anterior resection for rectal cancer, but there is a risk of dehydration, irritant dermatitis, and ileus.
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Affiliation(s)
- Rui Du
- Graduate School, Dalian Medical University, West Section of Lvshun South Road No. 9, Dalian 116044, China
| | - Jiajie Zhou
- Graduate School, Dalian Medical University, West Section of Lvshun South Road No. 9, Dalian 116044, China
| | - Guifan Tong
- Graduate School, Dalian Medical University, West Section of Lvshun South Road No. 9, Dalian 116044, China
| | - Yue Chang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Boyang Lake Road No. 10, Tianjin 301617, China
| | - Dongliang Li
- Clinical Medical College, Yangzhou University, Huaihai Road No.7, Yangzhou 225001, China
| | - Feng Wang
- Graduate School, Dalian Medical University, West Section of Lvshun South Road No. 9, Dalian 116044, China
| | - Xu Ding
- Clinical Medical College, Yangzhou University, Huaihai Road No.7, Yangzhou 225001, China
| | - Qi Zhang
- Clinical Medical College, Yangzhou University, Huaihai Road No.7, Yangzhou 225001, China
| | - Wei Wang
- Clinical Medical College of Yangzhou University, General Surgery Institute of Yangzhou-Yangzhou University, Northern Jiangsu People's Hospital, Nantong Road No.98, Yangzhou 225001, China
| | - Liuhua Wang
- Clinical Medical College of Yangzhou University, General Surgery Institute of Yangzhou-Yangzhou University, Northern Jiangsu People's Hospital, Nantong Road No.98, Yangzhou 225001, China
| | - Daorong Wang
- Clinical Medical College of Yangzhou University, General Surgery Institute of Yangzhou-Yangzhou University, Northern Jiangsu People's Hospital, Nantong Road No.98, Yangzhou 225001, China.
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Endoscopic vacuum therapy for in- and outpatient treatment of colorectal defects. Surg Endosc 2020; 35:6687-6695. [PMID: 33259019 PMCID: PMC8599392 DOI: 10.1007/s00464-020-08172-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/15/2020] [Indexed: 12/11/2022]
Abstract
Background Evidence for endoscopic vacuum therapy (EVT) for colorectal defects is still based on small patient series from various institutions, employing different treatment algorithms and methods. As EVT was invented at our institution 20 years ago, the aim was to report the efficacy and safety of EVT for colorectal defects as well as to analyze factors associated with efficacy, therapy duration, and outpatient treatment. Methods Cohort study with analysis of prospectively collected data of patients receiving EVT for colorectal defects at a tertiary referral center in Germany (n = 281). Results The majority of patients had malignant disease (83%) and an American Society of Anesthesiologists classification of III/IV (81%). Most frequent indications for EVT were anastomotic leakage after sigmoid or rectal resection (67%) followed by rectal stump leakage (20%). EVT was successful in 256 out of 281 patients (91%). EVT following multi-visceral resection (P = 0.037) and recent surgical revision after primary surgery (P = 0.009) were risk factors for EVT failure. EVT-associated adverse events occurred in 27 patients (10%). Median treatment duration was 25 days. Previous chemo-radiation (P = 0.006) was associated with a significant longer duration of EVT. Outpatient treatment was conducted in 49% of patients with a median hospital stay reduction of 15 days and 98% treatment success. Younger patient age (P = 0.044) was associated with the possibility of outpatient treatment. Restoration of intestinal continuity was achieved in 60% of patients where technically possible with a 12-month rate of 52%. Conclusions In patients with colorectal defects, EVT appears to be a safe and effective, minimally invasive option for in- and outpatient treatment.
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Vilz TO, v. Websky M, Kalff JC, Stoffels B. Intestinale Stomata. COLOPROCTOLOGY 2020. [DOI: 10.1007/s00053-020-00503-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wilhelm P, Rolinger J, Falch C, Kirschniak A, Reisenauer C. Therapy of pessary-induced rectovaginal fistula and pelvic organ prolapse in elderly patients by vaginal approach and modified LeFort colpocleisis: a case series. Arch Gynecol Obstet 2020; 302:283-287. [PMID: 32449060 DOI: 10.1007/s00404-020-05602-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Pelvic organ prolapse (POP) presents a common benign condition in women associated with reduced quality of life (QoL). The use of pessaries is considered a first-line treatment of POP. However, pessaries can cause perforations into adjacent organs resulting in fistulas. We present a series of three cases of rectovaginal fistulas (RVF) due to pessary perforation. METHODS Three consecutive cases of pessary-induced RVF in patients with POP stage IV were assessed between September 2016 and September 2019. Consensus for therapeutic strategy was reached by an interdisciplinary board. RESULTS The RVF were located in the posterior vaginal wall and had a diameter of up to 60 mm. In one of three patients, a two-step approach was chosen with the ostomy being performed at the same time as fistula closure and modified LeFort colpocleisis. It was followed by ostomy closure 3 months later. In two patients, a three-step approach was chosen with the ostomy performed separately due to a local tissue inflammation around RVF. Neither fistula nor POP recurrences have occurred so far. CONCLUSION Combined temporary gastrointestinal diversion, RVF closure and POP therapy can be performed as a two- or three-stage approach. Lack of evidence and standardized algorithms in RVF therapy make further clinical studies essential. We encourage the preoperative assessment of any case of complex rectovaginal fistula by an interdisciplinary board for determining an individualized treatment.
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Affiliation(s)
- Peter Wilhelm
- Department of Surgery and Transplantation, University Hospital Tuebingen, Tübingen, Germany
| | - Jens Rolinger
- Department of Surgery and Transplantation, University Hospital Tuebingen, Tübingen, Germany
| | - Claudius Falch
- Department of Surgery and Transplantation, University Hospital Tuebingen, Tübingen, Germany
| | - Andreas Kirschniak
- Department of Surgery and Transplantation, University Hospital Tuebingen, Tübingen, Germany
| | - Christl Reisenauer
- Department of Obstetrics and Gynecology, University Hospital Tuebingen, Calwerstrasse 7, 72076, Tübingen, Germany.
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Kitaguchi D, Enomoto T, Ohara Y, Owada Y, Hisakura K, Akashi Y, Takahashi K, Ogawa K, Shimomura O, Oda T. Exploring optimal examination to detect occult anastomotic leakage after rectal resection in patients with diverting stoma. BMC Surg 2020; 20:53. [PMID: 32192490 PMCID: PMC7081590 DOI: 10.1186/s12893-020-00706-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background When considering “early stoma closure”, both standardized inclusion/exclusion criteria and standardized methods to assess anastomosis are necessary to reduce the risk of occult anastomotic leakage (AL). However, in the immediate postoperative period, neither have the incidence and risk factors of occult AL in patients with diverting stoma (DS) been clarified nor have methods to assess anastomosis been standardized. The aim of this study was to elucidate the incidence and risk factors of occult AL in patients who had undergone rectal resection with DS and to evaluate the significance of computed tomography (CT) following water-soluble contrast enema (CE) to detect occult anastomotic leakage. Methods This was a single institutional prospective observational study of patients who had undergone rectal resection with the selective use of DS between May and October 2019. Fifteen patients had undergone CE and CT to assess for AL on postoperative day (POD) 7, and CT was performed just after CE. Univariate analysis was performed to assess the relationship between preoperative variables and the incidence of occult AL on POD 7. Results The incidence of occult AL on postoperative day 7 was 6 of 15 (40%). Hand-sewn anastomosis, compared with stapled anastomosis, was a significant risk factor. Five more cases with occult AL that could not be detected with CE could be detected on CT following CE; CE alone had a 33% false-negative radiological result rate. Conclusions Hand-sewn anastomosis appeared to be a risk factor for occult AL, and CE alone had a high false-negative radiological result rate. When considering the introduction of early stoma closure, stapled anastomosis and CT following CE could be an appropriate inclusion criterion and preoperative examination, respectively.
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Affiliation(s)
- Daichi Kitaguchi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Katsuji Hisakura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Osamu Shimomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Abstract
An intestinal stoma (greek στὁμα, stoma: mouth, opening) is a surgically created opening of a gut section through the abdominal wall, which serves as an artificial intestinal exit for excretion of feces (synonym preternatural anus). A stoma of the gastrointestinal (GI) tract is often surgically created at the distal small intestine (ileostomy) and the colon (colostomy). Temporary or permanent deviation of fecal excretion may be required to treat various pathological conditions (e.g. congenital anomalies, ileus, inflammatory bowel diseases, posttraumatic, diverticulitis, colorectal malignancy). The creation of an end vs. a loop stoma is technically different. To achieve sufficient patient satisfaction close collaboration between surgeons, professional stoma care with guidance and training as well as support from self-help groups are required. In this way serious stoma-related complications can be avoided.
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Tsujinaka S, Tan KY, Miyakura Y, Fukano R, Oshima M, Konishi F, Rikiyama T. Current Management of Intestinal Stomas and Their Complications. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:25-33. [PMID: 32002473 PMCID: PMC6989127 DOI: 10.23922/jarc.2019-032] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/30/2019] [Indexed: 12/14/2022]
Abstract
Inappropriate stoma site, improper management of stoma, and stoma complications lead to diminished quality of life of ostomates. Healthcare professionals involved in stoma creation and/or care should have the fundamental and updated knowledge of the management of stomas and their complications. This review article consists of the following major sections: principles of perioperative patient management, early complications, and late complications. In the “principles of perioperative patient management” section, the current concepts and trends in preoperative education, stoma site marking, postoperative education, and patient educational resources are discussed. In the “early complications” section, we have focused on the etiology and current management of ischemia/necrosis, fluid and electrolyte imbalances, mucocutaneous separation, and retraction. In the “late complications” section, we have focused on the etiology and current management of parastomal hernia, stoma prolapse, parastomal varices, and pyoderma gangrenosum. Pre- and postoperative patient education facilitates the patient's independence in stoma care and resumption of normal activities. Healthcare providers should have basic skills and updated knowledge on the management of stomas and complications of stomas, to act as the first crisis manager for ostomates.
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Affiliation(s)
- Shingo Tsujinaka
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kok-Yang Tan
- Department of Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Yasuyuki Miyakura
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Rieko Fukano
- Department of Nursing, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsuko Oshima
- Department of Nursing, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Fumio Konishi
- Department of Surgery, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Italian guidelines for the surgical management of enteral stomas in adults. Tech Coloproctol 2019; 23:1037-1056. [DOI: 10.1007/s10151-019-02099-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
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Ambe PC, Kurz NR, Nitschke C, Odeh SF, Möslein G, Zirngibl H. Intestinal Ostomy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:182-187. [PMID: 29607805 DOI: 10.3238/arztebl.2018.0182] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 07/25/2017] [Accepted: 11/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND About 100 000 ostomy carriers are estimated to live in Germany today. The creation of an ostomy represents a major life event that can be associated with impaired quality of life. Optimal ostomy creation and proper ostomy care are crucially important determinants of the success of treatment and of the patients' quality of life. METHODS This article is based on pertinent publications retrieved by a selective search in PubMed, GoogleScholar, and Scopus, and on the authors' experience. RESULTS Intestinal stomata can be created using either the small or the large bowel. More than 75% of all stomata are placed as part of the treatment of colorectal cancer. The incidence of stoma-related complications is reported to be 10-70%. Skin irritation, erosion, and ulceration are the most common early complications, with a combined incidence of 25-34%, while stoma prolapse is the most common late complication, with an incidence of 8-75%. Most early complications can be managed conservatively, while most late complications require surgical revision. In 19% of cases, an ostomy that was initially planned to be temporary becomes permanent. Inappropriate stoma location and inadequate ostomy care are the most common causes of early complications. Both surgical and patient-related factors influence late complications. CONCLUSION Every step from the planning of a stoma to its postoperative care should be discussed with the patient in detail. Preoperative marking is essential for an optimal stoma site. Optimal patient management with the involvement of an ostomy nurse increases ostomy acceptance, reduces ostomy-related complications, and improves the quality of life of ostomy carriers.
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Affiliation(s)
- Peter C Ambe
- Department of; Visceral, Minimally Invasive, and Oncological Surgery, Marien Hospital Düsseldorf; Department of General and Visceral Surgery, Chair of Surgery II, Helios University Hospital Wuppertal, University of Witten/Herdecke Helios University Hospital Wuppertal, University of Witten/Herdecke; Center for Hereditary Gastrointestinal Tumors, Chair of Surgery II, Helios; University Hospital Wuppertal, University of Witten/Herdecke
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Shalaby M, Thabet W, Morshed M, Farid M, Sileri P. Preventive strategies for anastomotic leakage after colorectal resections: A review. World J Meta-Anal 2019; 7:389-398. [DOI: 10.13105/wjma.v7.i8.389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 08/31/2019] [Accepted: 09/03/2019] [Indexed: 02/06/2023] Open
Abstract
Anastomosis is a crucial step in radical cancer surgery. Despite being a daily practice in gastrointestinal surgery, anastomotic leakage (AL) stands as a frequent postoperative complication. Because of increased morbidity, mortality, combined with longer hospital stay, the rate of re-intervention, and poor oncological outcomes, AL is considered the most feared and life-threatening complication after colorectal resections. Furthermore, poor functional outcomes with a higher rate of a permeant stoma in 56% of patients this could negatively affect the patient’s quality of life. This a narrative review which will cover intraoperative anastomotic integrity assessment and preventive measures in order to reduce AL. Although the most important prerequisites for the creation of anastomosis is well-perfused and tension-free anastomosis, surgeons have proposed several preventive measures, which were assumed to reduce the incidence of AL, including antibiotic prophylaxis, intraoperative air leak test, omental pedicle flap, defunctioning stoma, pelvic drain insertion, stapled anastomosis, and general surgical technique. However, lack of clear evidence of which preventive measures is superior over the other combined with the fact that the decision remains based on the surgeon’s choice. Despite the advances in surgical techniques, AL remains a serious health problem associated with increased morbidity, mortality with additional cost. Many preventative measures were employed with no clear evidence supporting the superiority of stapled anastomosis over hand-Sewn anastomosis, coating of the anastomosis, or pelvic drain. Defunctioning stoma, when justified it could decrease the leakage-related complications and the incidence of reoperation. MBP combined with oral antibiotics still recommended.
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Affiliation(s)
- Mostafa Shalaby
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
- Department of General Surgery UOC C, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome 00133, Italy
| | - Waleed Thabet
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
| | - Mosaad Morshed
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
| | - Mohamed Farid
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
| | - Pierpaolo Sileri
- Department of General Surgery UOC C, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome 00133, Italy
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Indications for and complications of intestinal stomas in the children and adults at a tertiary care hospital in a resource-limited setting: a Tanzanian experience. BMC Gastroenterol 2019; 19:157. [PMID: 31462228 PMCID: PMC6714288 DOI: 10.1186/s12876-019-1070-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 08/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An intestinal stoma, though a life-saving procedure on the care of many gastrointestinal conditions, carries significant number of complications. This study describes the common indications, complications, and management of stomas and identifies the factors that are associated with these complications in a tertiary care hospital in Tanzania. METHODS A cross-sectional study of patients with intestinal stomas was conducted at Bugando Medical Centre (BMC) between July 2016 and June 2017. Ethical approval to conduct the study was obtained from relevant authority before the commencement of the study. RESULTS A total of 167 patients (M: F = 1.2:1) were enrolled in the study. The mean age at diagnosis was 0.6 ± 1.4 years for children and mean age for adults was 36.7 ± 15.8 years. Anorectal malformation (110, 89.4%) was the most common indication for intestinal stoma formation in children, while bowel perforation (14, 31.8%) was the main indications in adults. The sigmoid colon (137, 82.0%) was the most common anatomical site for stoma formation followed by the ileum (18, 10.8%). Stoma prolapse (18, 41.9%) was the most frequent complication of a stoma, whereas, surgical site infection (9, 34.6%) was the most frequent complication after stoma closure. Thirty five (26.7.%) of the children developed stomal complications, while only 8 (22.2%) of the adults developed complications. The level of training of operating surgeon and timing of surgery were the main predictors of stoma-related complications (p < 0.034 and 0.013), whereas the level of training of the operating surgeon and the type of stoma closure were significantly associated with the complications related to stoma closure (p < 0.001). CONCLUSION The intestinal stomas performed at BMC are associated with various complications, which in turn, become a burden to the patients. The insights observed in the current study may apply to other tertiary hospitals in Tanzania and Africa at large. We suggest that the keystones for improvement and control in the formation and complications of intestinal stomas are the following; colostomy formation should rarely be done in transverse colon, the procedure should be carried out by senior doctors (specialist) or junior doctors under close and direct supervision of the specialists, using proper meticulous techniques, and the need to determine and/or improve techniques for early detection of complications.
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van den Hil LCL, van Steensel S, Schreinemacher MHF, Bouvy ND. Prophylactic mesh placement to avoid incisional hernias after stoma reversal: a systematic review and meta-analysis. Hernia 2019; 23:733-741. [PMID: 31302788 PMCID: PMC6661031 DOI: 10.1007/s10029-019-01996-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/20/2019] [Indexed: 12/13/2022]
Abstract
Purpose To provide an overview of the available literature on prevention of incisional hernias after stoma reversal, with the use of prophylactic meshes. Methods A literature search of Pubmed, MEDLINE and EMBASE was performed. Search terms for stoma, enterostomy, mesh, prophylaxis and hernia were used. Search was updated to December 31th 2018. No time limitations were used, while English, Geman, Dutch and French were used as language restrictions. The primary outcome was the incidence of incisional hernia formation after stoma reversal. Secondary outcomes were mesh-related complications. Data on study design, sample size, patient characteristics, stoma and mesh characteristics, duration of follow-up and outcomes were extracted from the included articles. Results A number of 241 articles were identified and three studies with 536 patients were included. A prophylactic mesh was placed in 168 patients to prevent incisional hernias after stoma reversal. Follow-up ranged from 10 to 21 months. The risk of incisional hernia in case of prophylactic mesh placement was significantly lower in comparison to no mesh placement (OR 0.10, 95% CI 0.04–0.27, p < 0.001, I2 = 0%, CI 0–91.40%). No differences in surgical site infections were detected between the groups. Conclusions The use of a prophylactic mesh seems to reduce the risk on incisional hernias after stoma reversal and therefore mesh reinforcement should be considered after stoma reversal. Electronic supplementary material The online version of this article (10.1007/s10029-019-01996-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- L C L van den Hil
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands.
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands.
- Department of General Surgery, Maastricht University Medical Centre, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - S van Steensel
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
| | - M H F Schreinemacher
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
| | - N D Bouvy
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
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26
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The influence of diverting loop ileostomy vs. colostomy on postoperative morbidity in restorative anterior resection for rectal cancer: a systematic review and meta-analysis. Langenbecks Arch Surg 2019; 404:129-139. [PMID: 30747281 DOI: 10.1007/s00423-019-01758-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/29/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND The aim of this systematic review and meta-analysis was to evaluate the morbidity of loop ileostomy (LI) and loop colostomy (LC) creation in restorative anterior resection for rectal cancer as well as the morbidity of their reversal. METHODS PubMed, EMBASE, MEDLINE via Ovid, and Cochrane Library were systematically searched for records published from 1980 to 2017 by three independent researchers. The primary endpoint was overall morbidity after stoma creation and reversal. Mantel-Haenszel odds ratio (OR) was used to compare categorical variables. Clinical significance was evaluated using numbers needed to treat (NNT). RESULTS Six studies (two randomized controlled trials and four observational studies) totaling 1063 patients (666 LI and 397 LC) were included in the meta-analysis. Overall morbidity rate after both stoma creation and closure was 15.6% in LI vs. 20.4% in LC [OR(95%CI) = 0.67 (0.29, 1.58); p = 0.36] [NNT(95%CI) = 21 (> 10.4 to benefit, > 2430.2 to harm)]. Morbidity rate after stoma creation was both statistically and clinically significantly lower after LI [18.2% vs. 30.6%; OR(95%CI) = 0.42 (0.25, 0.70); p = 0.001; NNT(95%CI) = 9 (4.7, 29.3)]. Dehydration rate was 3.1% (8/259) in LI vs. 0% (0/168) in LC. The difference was not statistically or clinically significant [OR(95%CI) = 3.00 (0.74, 12.22); p = 0.13; NNT (95%CI) = 33 (19.2, 101.9)]. Ileus rates after stoma closure were significantly higher in LI as compared to LC [5.2% vs. 1.7%; OR(95%CI) = 2.65 (1.13, 6.18); p = 0.02]. CONCLUSIONS This meta-analysis found no difference between LI and LC in overall morbidity after stoma creation and closure. Morbidity rates following the creation of LI were significantly decreased at the cost of a risk for dehydration.
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Shalaby M, Emile S, Elfeki H, Sakr A, Wexner SD, Sileri P. Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage. BJS Open 2018; 3:153-160. [PMID: 30957061 PMCID: PMC6433422 DOI: 10.1002/bjs5.50124] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 12/17/2022] Open
Abstract
Background Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leakage. The aim of this study was to evaluate the safety and efficacy of EVT in the treatment of anastomotic leakage and rectal stump insufficiency after Hartmann's procedure. Methods A systematic search of MEDLINE, Scopus and Cochrane databases was performed using search terms related to EVT and anastomotic leakage or rectal stump insufficiency in line with the PRISMA checklist. Observational studies, RCTs and case series studies published to July 2017 were included. Primary outcomes of the review were the success of EVT, defined as complete or partial healing of the anastomotic defect and associated cavity, and the rate of stoma reversal after EVT. Secondary outcomes included the duration of treatment to complete healing, complications of treatment and the need for further intervention. A meta-analysis was conducted. The potential effect of clinical confounders on the failure of EVT was investigated using the random-effects meta-regression model. Results Of 476 articles identified, 17 studies reporting on 276 patients were ultimately included. The weighted mean rate of success was 85·3 (95 per cent c.i. 80·1 to 90·5) per cent, with a median duration from inception of EVT to complete healing of 47 (range 40-105) days. The weighted mean rate of stoma reversal across the studies was 75·9 (64·6 to 87·2) per cent. Twenty-five patients (9·1 per cent) required additional interventions after EVT. Thirty-eight patients (13·8 per cent) developed complications. The weighted mean complication rate across the studies was 11·1 (6·0 to 16·2) per cent. Variables significantly associated with failure included preoperative radiotherapy, absence of diverting stoma, complications and male sex. Conclusion EVT is associated with a high rate of complete healing of anastomotic leakage and stoma reversal. It is an effective option in appropriately selected patients with anastomotic leakage.
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Affiliation(s)
- M Shalaby
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt.,Department of General Surgery Rome Tor Vergata University Rome Italy
| | - S Emile
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt
| | - H Elfeki
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt.,Department of Surgery, Colorectal Surgery Unit Aarhus University Aarhus Denmark
| | - A Sakr
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt
| | - S D Wexner
- Department of Colorectal Surgery Cleveland Clinic Florida Weston Florida USA
| | - P Sileri
- Department of General Surgery Rome Tor Vergata University Rome Italy
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28
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The application of defunctioning stomas after low anterior resection of rectal cancer. Surg Today 2018; 49:451-459. [DOI: 10.1007/s00595-018-1736-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/29/2018] [Indexed: 02/07/2023]
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Splenic flexure mobilization in rectal cancer surgery: do we always need it? Updates Surg 2018; 71:505-513. [PMID: 30406931 DOI: 10.1007/s13304-018-0603-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/30/2018] [Indexed: 01/20/2023]
Abstract
Splenic flexure (SFM) in rectal cancer surgery is a crucial step which may increase the difficulty of the operation. The aim of this retrospective single-center study is to demonstrate if the selective omission of SFM during anterior rectal resection can reduce the complexity of the operation, without affecting post-operative and oncologic outcomes. Data of 112 consecutive rectal resections for cancer from March 2010 to March 2017 were analyzed and divided into two groups: SFM and No-SFM. A sub-analysis was then performed for laparoscopy and traditional cases. Post-operative and oncologic outcomes, including overall (OS) and cancer-related survival (CRS), were analyzed and compared. SFM was performed in 42% of cases and laparoscopy was used in 73.2%. Operative time resulted significantly lower in the No-SFM group (190 vs. 225 min, p = 0.01). In laparoscopy in the No-SFM group, operative time and post-operative stay were significantly lower (205.5 vs. 222.5 min, p = 0.04; 9 vs. 10 days, p = 0.01). Most of the open resections were performed without SFM (35.4% vs. 14.9%, p = 0.02). No statistical significant differences were found in OS and CRS in the two groups. We support the hypothesis that every surgeon should carry out an accurate intra-operative evaluation to perform a selective SFM. When possible, SFM can be safely avoided with no additional risks in terms of post-operative and oncologic outcomes.
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Reichert M, Weber C, Pons-Kühnemann J, Hecker M, Padberg W, Hecker A. Protective loop ileostomy increases the risk for prolonged postoperative paralytic ileus after open oncologic rectal resection. Int J Colorectal Dis 2018; 33:1551-1557. [PMID: 30112664 DOI: 10.1007/s00384-018-3142-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Postoperative gut dysmotility is a physiologic and frequent temporary reaction after major abdominal surgery. If paralysis merges into a prolonged ileus state, it causes significant morbidity and subsequently worse outcome and discomfort for the patients. Pathophysiology of pathologic prolonged postoperative paralytic ileus remains multifactorial. METHODS We present a retrospective single-center analysis of patients, who underwent a primary open oncologic anterior rectal resection with primary anastomosis with or without defunctioning loop ileostomy during a 43-month period of observation. Primary endpoint was the rate of prolonged postoperative paralytic ileus, defined by the intravenous administration of neostigmine. Confounders for regression analysis were assessed by univariate analysis and correlations between confounders were examined. Odds ratio for prolonged postoperative paralytic ileus in patients with defunctioning loop ileostomy was estimated by a logistic regression model. RESULTS Of 101 patients (62 male), 62 (61.39%) received defunctioning loop ileostomy. In univariate analysis, male gender and patients with ileostomy showed more frequently prolonged paralysis by tendency (both p = 0.07). Logistic regression analysis proves the influence of a defunctioning ileostomy on the development of prolonged postoperative paralytic ileus after oncologic rectal resection (p = 0.047). Odds ratio for prolonged postoperative paralytic ileus in patients with ileostomy was 4.96 [95% CI 1.02-24.03]. CONCLUSIONS Although the construction of defunctioning loop ileostomies during rectal resection is a safe, uncomplicated surgical procedure, they can cause significant postoperative morbidity for the patients. High fluid and electrolyte loss are well-known complications, but herewith we raise the evidence for prolonged gut paralysis in patients with defunctioning loop ileostomy.
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Affiliation(s)
- Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany.
| | - Christian Weber
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Jörn Pons-Kühnemann
- Medical Statistics, Institute of Medical Informatics, Justus-Liebig-University of Giessen, Rudolf-Buchheim Strasse 6, 35392, Giessen, Germany
| | - Matthias Hecker
- Department of Pulmonary and Critical Care Medicine, University Hospital of Giessen, Klinikstrasse 33, 35392, Giessen, Germany
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
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Pisano M, Zorcolo L, Merli C, Cimbanassi S, Poiasina E, Ceresoli M, Agresta F, Allievi N, Bellanova G, Coccolini F, Coy C, Fugazzola P, Martinez CA, Montori G, Paolillo C, Penachim TJ, Pereira B, Reis T, Restivo A, Rezende-Neto J, Sartelli M, Valentino M, Abu-Zidan FM, Ashkenazi I, Bala M, Chiara O, De' Angelis N, Deidda S, De Simone B, Di Saverio S, Finotti E, Kenji I, Moore E, Wexner S, Biffl W, Coimbra R, Guttadauro A, Leppäniemi A, Maier R, Magnone S, Mefire AC, Peitzmann A, Sakakushev B, Sugrue M, Viale P, Weber D, Kashuk J, Fraga GP, Kluger I, Catena F, Ansaloni L. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg 2018; 13:36. [PMID: 30123315 PMCID: PMC6090779 DOI: 10.1186/s13017-018-0192-3] [Citation(s) in RCA: 147] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/28/2018] [Indexed: 02/07/2023] Open
Abstract
ᅟ Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC). Methods The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017. Results CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted. With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value. Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required. Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation. Conclusions The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.
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Affiliation(s)
- Michele Pisano
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Luigi Zorcolo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Cecilia Merli
- Unit of Emergency Medicine Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | | | - Elia Poiasina
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Marco Ceresoli
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | | | - Niccolò Allievi
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | - Federico Coccolini
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | - Claudio Coy
- 9Colorectal Unit, Campinas State University, Campinas, SP Brazil
| | - Paola Fugazzola
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | | | - Ciro Paolillo
- Emergency Department Udine Healthcare and University Integrated Trust, Udine, Italy
| | | | - Bruno Pereira
- 14Department of Surgery, University of Campinas, Campinas, Brazil
| | - Tarcisio Reis
- Oncology Surgery and Intensive Care, Oswaldo Cruz Hospital, Recife, Brazil
| | - Angelo Restivo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Joao Rezende-Neto
- 16Department of Surgery Division of General Surgery, University of Toronto, Toronto, Canada
| | | | - Massimo Valentino
- 18Radiology Unit Emergency Department, S. Antonio Abate Hospital, Tolmezzo, UD Italy
| | - Fikri M Abu-Zidan
- 19Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Miklosh Bala
- 21Trauma and Acute Care Surgery Unit Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | | | - Nicola De' Angelis
- 22Unit of Digestive Surgery, HPB Surgery and Liver Transplant Henri Mondor Hospital, Créteil, France
| | - Simona Deidda
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Belinda De Simone
- Department of General and Emergency Surgery Cannes' Hospital Cannes, Cedex, Cannes, France
| | | | - Elena Finotti
- Department of General Surgery ULSS5 del Veneto, Adria, (RO) Italy
| | - Inaba Kenji
- 25Division of Trauma & Critical Care University of Southern California, Los Angeles, USA
| | - Ernest Moore
- 26Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO USA
| | - Steven Wexner
- Digestive Disease Center, Department of Colorectal Surgery Cleveland Clinic Florida, Tallahassee, USA
| | - Walter Biffl
- 28Acute Care Surgery The Queen's Medical Center, Honolulu, HI USA
| | - Raul Coimbra
- 29Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Health Sciences, San Diego, USA
| | - Angelo Guttadauro
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | - Ari Leppäniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Stefano Magnone
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Alain Chicom Mefire
- 32Department of Surgery and Obs/Gyn, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Andrew Peitzmann
- 33Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Boris Sakakushev
- 34General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Dieter Weber
- 37Trauma and General Surgeon, Royal Perth Hospital, Perth, Australia
| | - Jeffry Kashuk
- 38Surgery and Critical Care Assuta Medical Centers, Tel Aviv, Israel
| | - Gustavo P Fraga
- 39Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Ioran Kluger
- 40Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
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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: 0.5] [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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Yu X, Wang QX, Xiao WW, Chang H, Zeng ZF, Lu ZH, Wu XJ, Chen G, Pan ZZ, Wan DS, Ding PR, Gao YH. Neoadjuvant oxaliplatin and capecitabine combined with bevacizumab plus radiotherapy for locally advanced rectal cancer: results of a single-institute phase II study. Cancer Commun (Lond) 2018; 38:24. [PMID: 29784042 PMCID: PMC5993137 DOI: 10.1186/s40880-018-0294-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/05/2018] [Indexed: 01/22/2023] Open
Abstract
Background Neoadjuvant chemoradiotherapy followed by surgery is recommended as the standard of care for locally advanced rectal cancer, reducing local recurrence but not distant metastasis. Intensified systemic therapy is warranted to reduce the risk of distant metastasis. The present study aimed to evaluate the safety and efficacy of neoadjuvant oxaliplatin and capecitabine (XELOX) combined with bevacizumab plus radiotherapy for locally advanced rectal cancer. Methods Patients with stages II to III rectal cancer received one cycle of induction chemotherapy and concurrent chemoradiotherapy with XELOX plus bevacizumab. Surgery was performed 6–8 weeks after completion of radiotherapy, and postoperative chemotherapy with three cycles of XELOX and two cycles of capecitabine were given. The primary endpoints were pathologic complete response (pCR) rate and safety, and the secondary endpoints were 3-year overall survival and progression-free survival. Results Forty-five patients were enrolled between February 2013 and April 2015. All completed the neoadjuvant therapy. Seven patients (15.6%) refused subsequent surgical therapy for personal reasons, and the other 38 patients received radical resection, with a sphincter preservation rate of 84.2% and a pCR rate of 39.5%. Toxicity was acceptable, with grades 3–4 hematological toxicity and diarrhea observed in six and two patients, respectively. Incidence of anastomotic leak that required surgical intervention was 13.3%. After a median follow-up period of 37 months, five patients developed disease progression and two died of cancer. The 3-year overall survival rate and 3-year progression-free survival rate were 95.3% and 88.6%, respectively. Conclusions The addition of bevacizumab to neoadjuvant chemoradiotherapy resulted in a satisfying pCR rate and 3-year survival, but also may increase the risk of anastomotic leak, thus this regimen is not suitable to be considered for regular recommendation for locally advanced rectal cancer. Trial registration Clinicaltrials.govidentifierNCT01818973
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Affiliation(s)
- Xin Yu
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - Qiao-Xuan Wang
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - Wei-Wei Xiao
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - Hui Chang
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - Zhi-Fan Zeng
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - Zhen-Hai Lu
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - Xiao-Jun Wu
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - Gong Chen
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - Zhi-Zhong Pan
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - De-Sen Wan
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China
| | - Pei-Rong Ding
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China.
| | - Yuan-Hong Gao
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China. .,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Rd East, Guangzhou, 510060, P. R. China.
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Harries RL, Torkington J. Stomal Closure: Strategies to Prevent Incisional Hernia. Front Surg 2018; 5:28. [PMID: 29670882 PMCID: PMC5893847 DOI: 10.3389/fsurg.2018.00028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 03/13/2018] [Indexed: 12/18/2022] Open
Abstract
Incisional hernias following ostomy reversal occur frequently. Incisional hernias at the site of a previous stoma closure can cause significant morbidity, impaired quality of life, lead to life-threatening hernia incarceration or strangulation and result in a significant financial burden on health care systems Despite this, the evidence base on the subject is limited. Many recognised risk factors for the development of incisional hernia following ostomy reversal are related to patient factors such as age, malignancy, diabetes, COPD, hypertension and obesity, and are not easily correctable. There is a limited amount of evidence to suggest that prophylactic mesh reinforcement may be of benefit to reduce the post stoma closure incisional hernia rate but a further large scale randomised controlled trial is due to report in the near future. There appears to be weak evidence to suggest that surgeons should favour circular, or "purse-string" closure of the skin following stoma closure in order to reduce the risk of SSI, which in turn may reduce incisional hernia formation. There remains the need for further evidence in relation to suture technique, skin closure techniques, mechanical bowel preparation and oral antibiotic prescription focusing on incisional hernia development as an outcome measure. Within this review, we discuss in detail the evidence base for the risk factors for the development of, and the strategies to prevent ostomy reversal site incisional hernias.
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Affiliation(s)
- Rhiannon L Harries
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Jared Torkington
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, United Kingdom
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Amelung FJ, de Guerre LEVM, Consten ECJ, Kist JW, Verheijen PM, Broeders IAMJ, Draaisma WA. Incidence of and risk factors for stoma-site incisional herniation after reversal. BJS Open 2018; 2:128-134. [PMID: 29951636 PMCID: PMC5989939 DOI: 10.1002/bjs5.48] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/13/2017] [Indexed: 01/04/2023] Open
Abstract
Background Stoma reversal is often considered a straightforward procedure with low short‐term complication rates. The aim of this study was to determine the rate of incisional hernia following stoma reversal and identify risk factors for its development. Methods This was an observational study of consecutive patients who underwent stoma reversal between 2009 and 2015 at a teaching hospital. Patients followed for at least 12 months were eligible. The primary outcome was the development of incisional hernia at the previous stoma site. Independent risk factors were assessed using multivariable logistic regression analysis. Results After a median follow‐up of 24 (range 12–89) months, 110 of 318 included patients (34·6 per cent) developed an incisional hernia at the previous stoma site. In 85 (77·3 per cent) the hernia was symptomatic, and 72 patients (65·5 per cent) underwent surgical correction. Higher BMI (odds ratio (OR) 1·12, 95 per cent c.i. 1·04 to 1·21), stoma prolapse (OR 3·27, 1·04 to 10·27), parastomal hernia (OR 5·08, 1·30 to 19·85) and hypertension (OR 2·52, 1·14 to 5·54) were identified as independent risk factors for the development of incisional hernia at the previous stoma site. In addition, the risk of incisional hernia was greater in patients with underlying malignant disease who had undergone a colostomy than in those who had had an ileostomy (OR 5·05, 2·28 to 11·23). Conclusion Incisional hernia of the previous stoma site was common and frequently required surgical correction. Higher BMI, reversal of colostomy in patients with an underlying malignancy, stoma prolapse, parastomal hernia and hypertension were identified as independent risk factors.
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Affiliation(s)
- F J Amelung
- Department of Surgery Meander Medical Centre Amersfoort The Netherlands
| | - L E V M de Guerre
- Department of Surgery Meander Medical Centre Amersfoort The Netherlands
| | - E C J Consten
- Department of Surgery Meander Medical Centre Amersfoort The Netherlands
| | - J W Kist
- Department of Radiology Meander Medical Centre Amersfoort The Netherlands
| | - P M Verheijen
- Department of Surgery Meander Medical Centre Amersfoort The Netherlands
| | - I A M J Broeders
- Department of Surgery Meander Medical Centre Amersfoort The Netherlands
| | - W A Draaisma
- Department of Surgery Meander Medical Centre Amersfoort The Netherlands
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Uchima Y, Aomatsu N, Miyamoto H, Okada T, Kurihara S, Hirakawa T, Iwauchi T, Morimoto J, Yamagata S, Nakazawa K, Takeuchi K. Efficacy and Safety of Transanal Tube Drainage for Prevention of Anastomotic Leakage Following Laparoscopic Low Anterior Resection for Rectal Cancers. ACTA ACUST UNITED AC 2018. [DOI: 10.4236/jct.2018.97045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Zindel J, Gygax C, Studer P, Kauper M, Candinas D, Banz V, Brügger LE. A sustaining rod increases necrosis of loop ileostomies: a randomized controlled trial. Int J Colorectal Dis 2017; 32:875-881. [PMID: 28417196 DOI: 10.1007/s00384-017-2813-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Joel Zindel
- Inselspital, University Hospital Bern and University of Bern, CH-3010, Bern, Switzerland
| | - Chantal Gygax
- Inselspital, University Hospital Bern and University of Bern, CH-3010, Bern, Switzerland
| | - Peter Studer
- Inselspital, University Hospital Bern and University of Bern, CH-3010, Bern, Switzerland
| | - Melanie Kauper
- Department of Visceral Surgery, Kantonsspital Luzern, CH-6000 Luzern and Spital Tafers, CH-1712, Tafers, Switzerland
| | - Daniel Candinas
- Inselspital, University Hospital Bern and University of Bern, CH-3010, Bern, Switzerland
| | - Vanessa Banz
- Inselspital, University Hospital Bern and University of Bern, CH-3010, Bern, Switzerland
| | - Lukas E Brügger
- Inselspital, University Hospital Bern and University of Bern, CH-3010, Bern, Switzerland.
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Abstract
The use of temporary fecal diversion is of great importance to tenuous anastomosis, immunosuppressed patient, or actively infected patient. Its use protects newly constructed intestinal anastomoses from being the culprit of pelvic sepsis or systemic illness. Thus, potential morbidity and mortality can be averted. However, its appropriate or optimal use is often debated. We herein discuss the evidence for when to best use a diverting stoma for colorectal, coloanal, and ileoanal anastomoses. We also discuss the importance of considering a temporary diverting stoma in the setting of high-dose immunosuppression (e.g., transplant patients or inflammatory bowel disease), active infection, or upon creation of ileal pouch-anal anastomosis. Lastly, we discuss the advantages and disadvantages of a loop ileostomy versus colostomy for temporary diversion of fecal contents.
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Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
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Yin TC, Tsai HL, Yang PF, Su WC, Ma CJ, Huang CW, Huang MY, Huang CM, Wang JY. Early closure of defunctioning stoma increases complications related to stoma closure after concurrent chemoradiotherapy and low anterior resection in patients with rectal cancer. World J Surg Oncol 2017; 15:80. [PMID: 28399874 PMCID: PMC5387334 DOI: 10.1186/s12957-017-1149-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/05/2017] [Indexed: 12/14/2022] Open
Abstract
Background After a low anterior resection, creating a defunctioning stoma is vital for securing the anastomosis in low-lying rectal cancer patients receiving concurrent chemoradiotherapy. Although it decreases the complication and reoperation rates associated with anastomotic leakage, the complications that arise before and after stoma closure should be carefully evaluated and managed. Methods This study enrolled 95 rectal cancer patients who received neoadjuvant concurrent chemoradiotherapy and low anterior resection with anastomosis of the bowel between July 2010 and November 2012. A defunctioning stoma was created in 63 patients during low anterior resection and in another three patients after anastomotic leakage. Results The total complication rate from stoma creation to closure was 36.4%. Ileostomy led to greater renal insufficiency than colostomy did and significantly increased the readmission rate (all p < 0.05). The complication rate related to stoma closure was 36.0%. Patients with ileostomy had an increased risk of developing complications (p = 0.017), and early closure of the defunctioning stoma yielded a higher incidence of morbidity (p = 0.006). Multivariate analysis revealed that a time to closure of ≤109 days was an independent risk factor for developing complications (p = 0.007). Conclusions The optimal timing of stoma reversal is at least 109 days after stoma construction in rectal cancer patients receiving concurrent chemoradiotherapy and low anterior resection.
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Affiliation(s)
- Tzu-Chieh Yin
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Surgery, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiang-Lin Tsai
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung, 807, Taiwan.,Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ping-Fu Yang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Surgery, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chih Su
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung, 807, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Jen Ma
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung, 807, Taiwan
| | - Ming-Yii Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chun-Ming Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung, 807, Taiwan. .,Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Research Center for Natural Products and Drug Development, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Wen Y, Jabir MA, Keating M, Althans AR, Brady JT, Champagne BJ, Delaney CP, Steele SR. Alvimopan in the setting of colorectal resection with an ostomy: To use or not to use? Surg Endosc 2016; 31:3483-3488. [PMID: 27928668 DOI: 10.1007/s00464-016-5373-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 11/21/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated. METHODS A retrospective review (2010-2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence of POI and other postoperative complications. RESULTS There were equal numbers of laparoscopic (N = 18) and open resections (N = 40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N = 37) or colostomy (N = 21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4-7) versus control 6 (4.75-9.25) days, P = 0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P = 0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P = 0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P = 0.26), but the readmission rate within 30 days was higher in the alvimopan group (19 vs. 13.8%, P = 0.45). Neither of these differences reached statistically significance. CONCLUSION The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.
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Affiliation(s)
- Yuxiang Wen
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Murad A Jabir
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Michael Keating
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Alison R Althans
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Justin T Brady
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA.
| | - Bradley J Champagne
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
| | - Conor P Delaney
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44016, USA
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Braumann C, Müller V, Knies M, Aufmesser B, Schwenk W, Koplin G. Quality of life and need for care in patients with an ostomy: a survey of 2647 patients of the Berlin OStomy-Study (BOSS). Langenbecks Arch Surg 2016; 401:1191-1201. [PMID: 27659022 DOI: 10.1007/s00423-016-1507-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/30/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although ostomies are sometimes necessary, it is unclear which type of ostomy is advantageous for quality of life (QoL). In an observational study of 2647 patients, QoL after colostomy (CS) and small bowel stoma (SBS) formation was evaluated. METHODS The European Organisation for Research and Treatment of Cancer (EORTC)-QLQ-C30 and CR-38 questionnaires were used. Patient characteristics, retrospective information about the ostomy and previous treatments, and current stoma-related complications were recorded. All questionnaires were distributed and collected by stoma therapists at the homecare company PubliCare®. RESULTS In all, 1790 patients had a CS, and 756 had an SBS. The mean Global Health Score (mGHS-a general QoL indicator) was 52.33 in CS and 49.40 in SBS patients (p = 0.004), but the effect size (Cohen's d) was 0.1. In SBS patients, all functional scores were lower and most of the symptom scores were higher. CONCLUSIONS QoL differed significantly for CS and SBS patients, but the effect size was marginal. The care of certain patient groups, particularly (female) patients who receive emergency surgeries, must be improved. More professional education and guidance are necessary for a larger proportion of patients. This survey provided reference data for quality of life in patients with an ostomy.
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Affiliation(s)
- Chris Braumann
- Department of General- and Visceral Surgery St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Verena Müller
- Department of General, Visceral, Vascular and Thoracic Surgery, Charité - University Medicine Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
- Department of General, Visceral and Transplantation Surgery, Charité - University Medicine Berlin, Campus Virchow, Berlin, Germany
| | - Moritz Knies
- Department of General, Visceral, Vascular and Thoracic Surgery, Charité - University Medicine Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
- Department of General, Visceral and Transplantation Surgery, Charité - University Medicine Berlin, Campus Virchow, Berlin, Germany
| | - Birgit Aufmesser
- Department of General, Visceral, Vascular and Thoracic Surgery, Charité - University Medicine Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
- Department of General, Visceral and Transplantation Surgery, Charité - University Medicine Berlin, Campus Virchow, Berlin, Germany
| | - Wolfgang Schwenk
- Department of General and Visceral Surgery, MIS, Asklepios Klinik Altona, Hamburg, Germany
| | - Gerold Koplin
- Department of General, Visceral, Vascular and Thoracic Surgery, Charité - University Medicine Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany.
- Department of General, Visceral and Transplantation Surgery, Charité - University Medicine Berlin, Campus Virchow, Berlin, Germany.
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Jongen AC, Bosmans JW, Kartal S, Lubbers T, Sosef M, Slooter GD, Stoot JH, van Schooten FJ, Bouvy ND, Derikx JP. Predictive Factors for Anastomotic Leakage After Colorectal Surgery: Study Protocol for a Prospective Observational Study (REVEAL Study). JMIR Res Protoc 2016; 5:e90. [PMID: 27282451 PMCID: PMC4919551 DOI: 10.2196/resprot.5477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/07/2016] [Accepted: 02/07/2016] [Indexed: 12/28/2022] Open
Abstract
Background Anastomotic leakage (AL) remains the most important complication following colorectal surgery, and is associated with high morbidity and mortality rates. Previous research has focused on identifying risk factors and potential biomarkers for AL, but the sensitivity of these tests remains poor. Objective This prospective multicenter observational study aims at combining multiple parameters to establish a diagnostic algorithm for colorectal AL. Methods This study aims to include 588 patients undergoing surgery for colorectal carcinoma. Patients will be eligible for inclusion when surgery includes the construction of a colorectal anastomosis. Patient characteristics will be collected upon consented inclusion, and buccal swabs, breath, stool, and blood samples will be obtained prior to surgery. These samples will allow for the collection of information regarding patients’ inflammatory status, genetic predisposition, and intestinal microbiota. Additionally, breath and blood samples will be taken postoperatively and patients will be strictly observed during their in-hospital stay, and the period shortly thereafter. Results This study has been open for inclusion since August 2015. Conclusions An estimated 8-10% of patients will develop AL following surgery, and they will be compared to non-leakage patients. The objectives of this study are twofold. The primary aim is to establish and validate a diagnostic algorithm for the pre-operative prediction of the risk of AL development using a combination of inflammatory, immune-related, and genetic parameters. Previously established risk factors and novel parameters will be incorporated into this algorithm, which will aid in the recognition of patients who are at risk for AL. Based on these results, recommendations can be made regarding the construction of an anastomosis or deviating stoma, and possible preventive strategies. Furthermore, we aim to develop a new algorithm for the post-operative diagnosis of AL at an earlier stage, which will positively reflect on short-term survival rates. Trial Registration Clinicaltrials.gov: NCT02347735; https://clinicaltrials.gov/ct2/show/NCT02347735 (archived by WebCite at http://www.webcitation.org/6hm6rxCsA)
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Affiliation(s)
- Audrey Chm Jongen
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.
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Wang S, Zhang Z, Liu M, Li S, Jiang C. Efficacy of transanal tube placement after anterior resection for rectal cancer: a systematic review and meta-analysis. World J Surg Oncol 2016; 14:92. [PMID: 27030245 PMCID: PMC4815125 DOI: 10.1186/s12957-016-0854-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 03/24/2016] [Indexed: 12/21/2022] Open
Abstract
Background Anastomotic leakage is a serious complication that can occur after anterior resection of the rectum. There is a question regarding whether the placement of a transanal tube can decrease the rate of anastomotic leakage. The aim of this systematic review and meta-analysis was to evaluate the efficacy of transanal tube placement after anterior resection. Methods We searched three major databases (PubMed, Embase, and the Cochrane Library) up until January 2015 for studies evaluating the benefit of transanal tubes after anterior resection for rectal cancer. The primary outcome measure was the rate of clinical anastomotic leakage. Secondary outcome was the rate of reoperation. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were obtained using random effects models. Results One randomized controlled trial and three observational studies involving 909 patients met inclusion criteria. Clinical anastomotic leakage occurred in 3.49 % (14 of 401) of patients with transanal tubes and 12.01 % (61 of 508) of patients without transanal tubes. Meta-analysis of the studies showed a lower risk of anastomotic leakage (RR, 0.32; 95 % CI 0.18–0.58) and reoperation related to leakage (RR, 0.19; 95 % CI 0.08–0.46) when the transanal tube was placed. Conclusions While studies are few and mostly observational, the data to date indicate that placement of a transanal tube decreases the rate of clinical anastomotic leakage and reoperation related to leakage. More studies are needed to confirm these findings.
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Affiliation(s)
- Shuanhu Wang
- Department of Gastrointestinal surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, China.
| | - Zongbing Zhang
- Department of Gastrointestinal surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, China
| | - Mulin Liu
- Department of Gastrointestinal surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, China
| | - Shiqing Li
- Department of Gastrointestinal surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, China
| | - Congqiao Jiang
- Department of Gastrointestinal surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, China
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Geng HZ, Nasier D, Liu B, Gao H, Xu YK. Meta-analysis of elective surgical complications related to defunctioning loop ileostomy compared with loop colostomy after low anterior resection for rectal carcinoma. Ann R Coll Surg Engl 2015; 97:494-501. [PMID: 26274752 PMCID: PMC5210131 DOI: 10.1308/003588415x14181254789240] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2014] [Indexed: 01/11/2023] Open
Abstract
Introduction Defunctioning loop ileostomy (LI) and loop colostomy (LC) are used widely to protect/treat anastomotic leakage after colorectal surgery. However, it is not known which surgical approach has a lower prevalence of surgical complications after low anterior resection for rectal carcinoma (LARRC). Methods We conducted a literature search of PubMed, MEDLINE, Ovid, Embase and Cochrane databases to identify studies published between 1966 and 2013 focusing on elective surgical complications related to defunctioning LI and LC undertaken to protect a distal rectal anastomosis after LARRC. Results Five studies (two randomized controlled trials, one prospective non-randomized trial, and two retrospective trials) satisfied the inclusion criteria. Outcomes of 1,025 patients (652 LI and 373 LC) were analyzed. After the construction of a LI or LC, there was a significantly lower prevalence of sepsis (p=0.04), prolapse (p=0.03), and parastomal hernia (p=0.02) in LI patients than in LC patients. Also, the prevalence of overall complications was significantly lower in those who received LIs compared with those who received LCs (p<0.0001). After closure of defunctioning loops, there were significantly fewer wound infections (p=0.006) and incisional hernias (p=0.007) in LI patients than in LC patients, but there was no significant difference between the two groups in terms of overall complications. Conclusions The results of this meta-analysis show that a defunctioning LI may be superior to LC with respect to a lower prevalence of surgical complications after LARRC.
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Affiliation(s)
- Hong Zhi Geng
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Dilidan Nasier
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Bing Liu
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Hua Gao
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Yi Ke Xu
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
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Inglin RA, Eberli D, Brügger LE, Sulser T, Williams NS, Candinas D. Current aspects and future prospects of total anorectal reconstruction--a critical and comprehensive review of the literature. Int J Colorectal Dis 2015; 30:293-302. [PMID: 25403563 DOI: 10.1007/s00384-014-2065-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Many rectal cancer patients undergo abdominoperineal excision worldwide every year. Various procedures to restore perineal (pseudo-) continence, referred to as total anorectal reconstruction, have been proposed. The best technique, however, has not yet been defined. In this study, the different reconstruction techniques with regard to morbidity, functional outcome and quality of life were analysed. Technical and timing issues (i.e. whether the definitive procedure should be performed synchronously or be delayed), oncological safety, economical aspects as well as possible future improvements are further discussed. METHODS A MEDLINE and EMBASE search was conducted to identify the pertinent multilingual literature between 1989 and 2013. All publications meeting the defined inclusion/exclusion criteria were eligible for analysis. RESULTS Dynamic graciloplasty, artificial bowel sphincter, circular smooth muscle cuff or gluteoplasty result in median resting and squeezing neo-anal pressures that equate to the measurements found in incontinent patients. However, quality of life was generally stated to be good by patients who had undergone the procedures, despite imperfect continence, faecal evacuation problems and a considerable associated morbidity. Many patients developed an alternative perception for the urge to defecate that decisively improved functional outcome. Theoretical calculations suggested cost-effectiveness of total anorectal reconstruction compared well to life with a permanent colostomy. CONCLUSIONS Many patients would be highly motivated to have their abdominal replaced by a functional perineal colostomy. Given the considerable morbidity and questionable functional outcome of current reconstruction technique improvements are required. Tissue engineering might be an option to design an anatomically and physiologically matured, and customised continence organ.
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Affiliation(s)
- Roman A Inglin
- Department of Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Freiburgstrasse 10, CH-3010, Bern, Switzerland,
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Diverting ileostomy in colorectal surgery: when is it necessary? Langenbecks Arch Surg 2015; 400:145-52. [PMID: 25633276 DOI: 10.1007/s00423-015-1275-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 01/19/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice. METHODS Retrospective and prospective articles spanning the past 50 years were reviewed to identify the definition of an anastomotic leak (AL), evaluate risk factors for AL, and assess methods of evaluation of the anastomosis. We then pooled the evidence for and against fecal diversion, the incidence and consequences of stomal complications, and the evidence comparing loop ileostomy vs. loop colostomy as the optimal method of fecal diversion. RESULTS Evidence shows that despite the fact that fecal diversion does not decrease postoperative mortality, it does significantly decrease the risk of anastomotic leak and the need for urgent reoperation when a leak does occur. Diverting stomas are a low-risk surgical procedure from a technical standpoint but carry substantial postoperative morbidity that can greatly hamper patients' quality of life and recovery. High-risk patients such as those with low colorectal anastomoses (<10 cm from anal verge), colo-anal anastomoses, technically difficult resections, malnutrition, and male patients seem to reap the greatest benefit from fecal diversion. CONCLUSIONS Fecal diversion is recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. It is most beneficial when used selectively in high-risk patients with low pelvic anastomoses that are at an increased risk for AL. New tools are needed to identify patients at high risk for anastomotic failure after anterior resection.
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Abstract
The construction of an intestinal stoma is fraught with complications and should not be considered a trivial undertaking. Serious complications requiring immediate reoperations can occur, as can minor problems that will subject the patient to daily and nightly distress. Intestinal stomas undoubtedly will dramatically change lifestyles; patients will experience physiologic and psychologic detriment with stoma-related problems, however minor they may seem. Common complications include poor stoma siting, high output, skin irritation, ischemia, retraction, parastomal hernia (PH), and prolapse. Surgeons should be cognizant of these complications before, during, and after stoma creation, and adequate measures should be taken to avoid them. In this review, the authors highlight these often seen problems and discuss management and prevention strategies.
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Affiliation(s)
- Michael Kwiatt
- Division of Colon and Rectal Surgery, Department of Surgery, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Michitaka Kawata
- Division of Colon and Rectal Surgery, Department of Surgery, Cooper Medical School of Rowan University, Camden, New Jersey
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Early protective ileostomy closure following stoma formation with a dual-sided absorbable adhesive barrier. Eur Surg 2014. [DOI: 10.1007/s10353-014-0266-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Devaraj B, Cologne KG. Role of fecal diversion in colorectal anastomotic failure: Where are we now? SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Moirangthem G. Laparoscopic Colorectal Surgery: An Update (with Special Reference to Indian Scenario). J Clin Diagn Res 2014; 8:NE01-6. [PMID: 24959478 PMCID: PMC4064916 DOI: 10.7860/jcdr/2014/8269.4285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/05/2014] [Indexed: 01/22/2023]
Abstract
Laparoscopic cholecystectomy, being already declared as gold standard technique, laparoscopic surgery has advanced far and wide, touching almost every corner of the abdomen. This advancement has gradually expanded to colorectal surgery which is done for malignant diseases as well. However, laparoscopic colorectal surgery has not been accepted as quickly as was laparoscopic cholecystectomy. This is because of its steep learning curve, concerns with oncological outcomes, lack of randomized control trials (RCTs) and initial reports on high port site recurrences which occurred after curative resections. But all these initial concerns have been overcome by doing a series of RCTs globally, in the past decade, that revealed that laparoscopic colorectal surgery for malignant disease offered short term benefits without compromising on oncological principles of radicality of resection, tumour resection margins and completeness of lymph node harvesting as compared to those of open surgery. Favourable post-operative results with respect to less blood loss, less pain, lesser surgical site infections, lesser requirement of analgesics, early return of bowel function and shorter hospital stay in patients who underwent laparoscopic colorectal resections were obtained in studies done on individual series, including those done in India and more recently, in large trials. An update on recent studies done on laparoscopic colorectal surgery by reviewing many RCTs and individual series, including our experiences, was made, to support the advantages of this procedure which were obtained when it was carried out by skilled hands.
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Affiliation(s)
- G.S. Moirangthem
- Professor and Head, Department of Surgery & Gastrointestinal and Minimal Access Surgery Unit, Regional Institute of Medical Sciences, Imphal, India
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