Temporary ileostomy for ileal pouch-anal anastomosis. Function and complications

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Proximal intestinal diversion is associated with increased morbidity in patients undergoing elective colectomy for diverticular disease: an ACS-NSQIP study

BACKGROUND

Elective colectomy for diverticular disease is common. Some patients undergo primary resection with proximal diversion in an effort to limit morbidity associated with potential anastomotic leak.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried. All patients undergoing a single, elective resection for diverticular disease from 2005 to 2011 were analyzed. Thirty-day outcomes were reviewed. Factors predictive of undergoing diversion and the risk-adjusted odds of postoperative morbidity with and without proximal diversion were determined by multivariable logistic regression models.

RESULTS

Fifteen thousand six hundred two patients undergoing non-emergent, elective resection were identified, of whom 348 (2.2 %) underwent proximal diversion. Variables predictive for undergoing proximal diversion included age ≥65 years, BMI ≥30, current smoking status, corticosteroid use, and serum albumin <3.0 g/dL. Multivariable analysis demonstrated that diversion was associated with significantly increased risk of surgical site infection (OR = 1.68), deep venous thrombosis (OR = 5.27), acute renal failure (OR = 5.83), sepsis or septic shock (OR = 1.75), readmission (OR = 2.57), and prolonged length of stay (OR = 3.35).

CONCLUSIONS

Proximal diversion in the setting of elective segmental colectomy for diverticular disease is uncommon. A combination of preoperative factors and intraoperative factors drives the decision for diversion. Patients who undergo diversion experience increased postoperative morbidity. Surgeons should have a low index of suspicion for postoperative complications and be prepared to mitigate their effect on the patient's outcome.

Readmission for dehydration or renal failure after ileostomy creation

BACKGROUND

Ileostomy creation is a commonly performed operation in colorectal surgery; however, many patients develop complications such as dehydration postoperatively. Dehydration is often severe enough to warrant hospital readmission and may result in renal failure. The true incidence of this complication has not been well described.

OBJECTIVE

The aim of this study was to identify the rate of hospital readmission secondary to dehydration or renal failure within 30 days of ileostomy creation.

DESIGN

Retrospective review of all patients undergoing ileostomy creation from 2007 to 2011 in a single colorectal practice of 4 surgeons was performed. Charts were reviewed to identify patients readmitted for dehydration or renal failure within 30 days of operation. Data were then analyzed to identify predictors of readmission, dehydration, and renal failure. Subset analysis compared patients readmitted with simple dehydration versus patients with renal failure.

PATIENTS

Two hundred one patients undergoing colorectal operations that included ileostomy creation within a 4-year period at a single institution for a variety of indications were included.

MAIN OUTCOME MEASURES

The primary outcome measured was readmission for dehydration or renal failure.

RESULTS

We observed a 17% 30-day readmission rate for dehydration or renal failure following ileostomy creation. Age greater than 50 was identified as an independent predictor of readmission with renal failure, whereas IPAA was predictive of readmission for simple dehydration, but not renal failure. Patients admitted with renal failure had significantly longer hospital stays and median hospital charges after readmission in comparison with patients admitted with simple dehydration.

LIMITATIONS

This study was limited by its retrospective nature and its limited sample size.

CONCLUSION

Hospital readmission due to dehydration or renal failure following ileostomy creation is common, with age >50 being the strongest predictor for renal failure. Appropriate strategies to decrease dehydration and renal failure following ileostomy creation need to be investigated.

Comparison between Tube Ileostomy and Loop Ileostomy as a Diversion Procedure

Aim. Loop ileostomy has high complication rates and causes much patient inconvenience. This study was performed to compare the outcome of tube versus loop ileostomy in management of ileal perforations. Patients and Methods. From July 2008 to July 2011, all patients with ileal perforation on laparotomy where a defunctioning proximal protective loop ileostomy was considered advisable were chosen for study. Patients were randomly assigned to undergo either tube ileostomy or classical loop ileostomy as the diversion procedure. Tube ileostomy was constructed in the fashion of feeding jejunostomy, with postoperative saline irrigation. Results. A total of 60 diversion procedures were performed over the period with 30 for each of tube and loop ileostomy. Typhoid and tuberculosis formed the most common etiology for ileal perforation. The complication rate of tube ileostomy was 33%. Main complications related to tube ileostomy were peritubal leak, tube blockage. In patients with loop, overall complications in 53% majority were peristomal skin irritation and wound infection following ileostomy closure. Two patients developed obstruction following ileostomy closure which needed reoperation. Conclusions. Tube ileostomy is effective and feasible as a diversion procedure and has reduced morbidity. It can be used as an alternative to loop ileostomy.

Technical aspects of ileoanal pouch surgery

Ileal pouch-anal anastomosis has become the surgical procedure of choice for chronic ulcerative colitis. Since the initial description of the technique, various modifications have facilitated its evolution into a safe operation with excellent long-term outcomes. However, some aspects of the operation remain contentious. Our aim is to describe the technical aspects of ileal pouch-anal anastomosis and review the current literature in the areas of controversy.

Closure of Loop Ileostomies: Is Early Discharge Safe and Achievable?

A prospective audit of the complications associated with reversal of a loop ileostomy was carried out between March 2000 and March 2005. The complication rate, length of inpatient hospitalisation and re-admission rate were assessed in 100 patients, in a single clinical practice. The median (interquartile range) length of time between the primary procedure and closure was 133 days (120 – 270) days. Median length of inpatient stay was two days (one - three) days. The overall complication rate was 18 %. One patient had a post-operative leak leading to local abscess formation. This was drained surgically after initial failure with radiological drainage. A second patient had a late leak, three weeks after closure, leading to fistula formation. This patient required surgical resection of the anastomosis after failure of conservative management. Twelve patients were re-admitted with small bowel obstruction (12%), of whom 11 were managed conservatively, while one underwent further surgery. There was one post- operative death as a result of acute cardiac failure secondary to undiagnosed hypertensive cardiomyopathy.

Thus early discharge following closure of a loop ileostomy, can be achieved with an acceptably low serious complication rate.

Morbidity and mortality after closure of loop ileostomy

BACKGROUND

A temporary loop ileostomy is commonly used to protect low pelvic anastomoses. Closure is associated with morbidity and mortality. This study investigated patterns of complications after loop ileostomy closure and factors associated with morbidity and mortality.

METHOD

A review was performed of patients who underwent loop ileostomy closure between 1999 and 2005.

RESULTS

Three hundred and twenty-five patients underwent closure of loop ileostomy. Reasons for primary surgery were: anterior resection for cancer (n = 160, 49%), ileal pouch-anal anastomosis (n = 114, 35%), diverticular disease (n = 25, 8%), Crohn's colitis (n = 4, 1%) and other conditions (n = 22, 7%). Overall mortality was 2.5% (n = 8) and morbidity was 22.8% (n = 74). Thirty-two patients (10%) developed small bowel obstruction, of whom seven required operative intervention. Overall, the re-operation rate in this series was 28 patients (8.6%). Thirteen (4%) patients had an anastomotic leak of whom 12 patients had re-operation. Preoperative anaemia was significantly associated with leakage (Hb < 11 g/dl; n = 65, P = 0.033). The leakage rate was lower after a stapled anastomosis than a hand-sutured anastomosis (4/203 vs 9/122; P = 0.039). Hypo-albuminaemia (albumin < 34 g/l) was significantly associated with mortality (n = 46, P < 0.001).

CONCLUSIONS

Loop ileostomy closure is associated with morbidity and mortality. Anaemia and hypo-albuminaemia may be associated with poor outcome.

Re: Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer Br J Surg (Br J Surg 2009; 96: 462-472)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Ileostomy or colostomy for temporary decompression of colorectal anastomosis. Systematic review and meta-analysis

PURPOSE

The controversy regarding whether loop ileostomy or loop transverse colostomy is a better method for temporary decompression of colorectal anastomosis motivated this review.

METHODS

Five randomized trials were included, with 334 patients: 168 in the loop ileostomy group and 166 in the loop transverse colostomy group. The outcomes analyzed were: 1. Mortality; 2. Wound infection; 3. Time of stoma formation; 4. Time of stoma closure; 5. Time interval between stoma formation and closure; 6. Stoma prolapse; 7. Stoma retraction; 8. Parastomal hernia; 9. Parastomal fistula; 10. Stenosis; 11. Necrosis; 12. Skin irritation; 13. Ileus; 14. Bowel leakage; 15. Reoperation; 16. Patient adaptation; 17. Length of hospital stay; 18. Colorectal anastomotic dehiscence; 19. Incisional hernia; 20. Postoperative bowel obstruction.

RESULTS

Stoma prolapse was statistically significant (p = 0.00001), but with statistical heterogeneity; the sensitive analysis was applied, excluding the trials that included emergency surgery, and this showed: p = 0.02, with I2 = 0% for the heterogeneity test.

CONCLUSIONS

The outcomes reported were not statistically or clinically significant except for stoma prolapse. Better evidence for making the choice between loop ileostomy or loop colostomy requires large-scale randomized controlled trials.

Emergency subtotal colectomy for lower gastrointestinal haemorrhage: over-utilised or under-estimated?

INTRODUCTION

A minority of patients with unlocalised massive lower gastrointestinal bleeding (LGIB) will require treatment with emergency subtotal colectomy (STC).

METHODS

To determine the outcome of STC in this high-risk group, we retrospectively reviewed the histopathology reports and case records of all subtotal colectomies performed for LGIB over a 8-year period.

RESULTS

Fifty-eight patients (mean age: 71 years; male to female ratio, 1 : 1) underwent emergency surgery for unlocalised LGIB, 45% of which were massive on admission, and unresponsive to resuscitation. The remainder had persistent or recurrent bleeding during the index hospitalisation. The hospitalisation for colectomy represented the first for LGIB for 56% of the study group, while 38% were on at least their third such admission. All but three patients underwent preoperative rigid proctosigmoidoscopy. Fifty-five of the 58 patients were treated with STC and primary ileorectal anastomosis. The major causes of bleeding were diverticular disease only (68%), angiodysplasia only (12%) and both diseases (12%). Overall mortality was 17%, with the main contributor being sepsis resulting from anastomotic leak. Non-fatal complications occurred in 20%, resulting in a mean postoperative length of stay of 13 days. All patients were doing well on their first follow-up visit with a mean number of four stools per day after 1 month.

CONCLUSION

While emergency STC is an effective and definitive method of treating unlocalised massive LGIB, its associated morbidity and mortality may limit its usefulness.

Closure of loop ileostomy after low anterior rectal resection and restorative proctocolectomy

OBJECTIVE

Low pelvic anastomoses are associated with a high leak rate. Loop ileostomies are commonly performed during ileoanal and coloanal anastomoses. This study was undertaken to review our experience with loop ileostomy closure after low anterior rectal resection and restorative proctocolectomy.

PATIENTS AND METHODS

One hundred sixty five patients undergoing loop ileostomy closure at a single institution after coloanal and ileoanal anastomoses for rectal carcinoma (n = 148) ulcerative colitis (n = 9) and FAP (n = 8) from January 2003 to December 2006. Fecal diversion was maintained for a mean 13,5 weeks.

RESULTS

Of the 165 patients, 100 were male and 65 female with mean age 59 (range 23-83 years). Overall, complication rate was 10,9 per cent. The common complication were sub occlusion six patients, occlusion three patients, wound infection eight patients and abdominal sepsis one patient. Complications required operative management in four cases. There was no mortality related to ileostomy.

CONCLUSION

The study shown that ileostomy closure is a safe and effective with generally minor complications and should be considered as a safe alterative for fecal diversion.

A selective approach to restorative proctocolectomy without ileostomy: a single centre experience

OBJECTIVE

A single surgeon series on complications and functional outcomes following restorative proctocolectomy (RPC) is presented.

METHOD

An ethically-approved database was used to collect data on all patients undergoing RPC at a single institution. Patient demographics, operative details, complications and functional outcomes were assessed. The impact of ileostomy omission on outcomes was also assessed.

RESULTS

Two hundred patients undergoing RPC between 1987 and 2006 were included. There were 122 (61.0%) males and the mean age at surgery was 37.6 years. A J pouch was constructed in 199 (99.5%) patients and an ileostomy omitted in 160 (80.0%). Since adopting a selective policy after the 36th consecutive patient in the series, only 9 (5.5%) patients have had an ileostomy constructed at the time of pouch construction. Complications occurred in 112 (56.3%) patients, with anastomotic stricture (20.6%) and pouchitis (28.6%) being the most common. Anastomotic stricture was more common in those patients receiving an ileostomy (43.6%vs 15.0%, P < 0.001), as were pouch-cutaneous fistulae (5.1%vs 0.6%, P = 0.039) and pelvic sepsis (15.4%vs 5.0%, P = 0.023). Functional outcomes were good, with median 24-h stool frequency of five motions at 1 year. There was increased urgency to defaecate which in part may be due to a significant decline in the use of antidiarrhoeal medication during follow up.

CONCLUSIONS

Selective omission of a covering ileostomy in most cases can produce good results following RPC with no increase in the risk of septic complications or pouch failure, and a decreased risk of anastomotic stricture, with maintenance of good function in the majority.

The outcome of loop ileostomy closure: a prospective study

BACKGROUND

The use of a loop ileostomy is an effective method to protect pelvic anastomoses, although there is some debate as to the routine use of a stoma. A second operation is required to close the stoma, with potential complications.

OBJECTIVE

The aim of this study was to assess prospectively the morbidity of closure of loop ileostomy.

METHOD

All patients scheduled for loop ileostomy closure over a 12-month period were included. The patient demographics, operative technique, complications and length of stay were recorded prospectively.

RESULTS

Fifty consecutive patients (28 males and 22 females) with a median age (interquartile range, IQR) of 56 (42-73) years underwent closure of loop ileostomy, at a median time (IQR) of 29 (18-48) weeks after formation. Twelve patients (24%) developed complications: six (12%) had intestinal obstruction of which one required a laparotomy, four (8%) had wound infections of which one required re-operation, one (2%) had an ileal anastomotic leak and subsequently died and one (2%) died from a myocardial infarction. The median length (IQR) of hospital stay was 8 (7-10) days.

CONCLUSION

We have demonstrated that a quarter of patients develop complications after loop ileostomy closure. The majority of these are minor. Methods to reduce the number of complications, such as optimum time for closure and distal limb irrigation techniques, need to be studied.

Ileostomy or colostomy for temporary decompression of colorectal anastomosis

BACKGROUND

The use of loop ileostomy or loop transverse colostomy represents an important issue in colorectal surgery. Despite a slight preference for a loop ileostomy as a temporary stoma, the best form for temporary decompression of colorectal anastomosis still remains controversial.

OBJECTIVES

To assess the evidence in the use of loop ileostomy compared with loop transverse colostomy for temporary decompression of colorectal anastomosis, comparing the safety and effectiveness.

SEARCH STRATEGY

We identified randomised controlled trials from MEDLINE, EMBASE, Lilacs, and the Cochrane Central Register of Controlled Trials. Further, by hand-searching relevant medical journals and proceedings from major gastroenterological congresses. We did not limit the seaches regarding date and language.

SELECTION CRITERIA

We assessed all randomised clinical trials, that met the objectives and reported major outcomes: 1. Mortality; 2. Wound infection; 3. Time of formation of stoma; 4. Time of closure of stoma; 5. Time interval between formation and closure of stoma; 6. Stoma prolapse; 7. Stoma retraction; 8. Parastomal hernia; 9. Parastomal fistula; 10. Stenosis; 11. Necrosis; 12. Skin irritation; 13. Ileus; 14. Bowel leakage; 15. Reoperation; 16. Patient adaptation; 17. Length of hospital stay; 18. Colorectal anastomotic dehiscence; 19. Incisional hernia; 20. Postoperative bowel obstruction.

DATA COLLECTION AND ANALYSIS

Details of the randomisation, blinding, whether an intention-to-treat analysis was done, and the number of patients lost to follow-up was recorded. For data analysis the relative risk and risk difference were used with corresponding 95% confidence interval; fixed effect was used for all outcomes unless incisional hernia (random effect model). Statistical heterogeneity in the results of the meta-analysis was assessed by inspection of graphical presentation (funnel plot) and by calculating a test of heterogeneity.

MAIN RESULTS

Five trials were included with 334 patients: 168 to loop ileostomy group and 166 to loop transverse colostomy group. The continuous outcomes could not be measured because of the lack of the data. The outcomes stoma prolapse had statistical significant difference: p=0.00001, but with statistical heterogeneity, p=0,001. When the sensitive analysis was applied excluding the trials that included emergencies surgeries, the result had a discreet difference: p = 0.02 and Test for heterogeneity: chi-square = 0.78, df = 2, p = 0.68, I(2)=0%.

AUTHORS' CONCLUSIONS

The best available evidence for decompression of colorectal anastomosis, either use of loop ileostomy or loop colostomy, could not be clarified from this review. So far, the results in terms of occurrence of postoperative stoma prolapse support the choice of loop ileostomy as a technique for fecal diversion for colorectal anastomosis, but large scale RCT's is needed to verify this.

Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited

Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g. <5 rectal polyps) can be identified where ileorectal anastomosis (IRA) might be reasonable. We feel that the risk of rectal cancer after IRA means that IPAA should be recommended for the vast majority of FAP patients. We accept that in some very selected cases, based on clinical and genetics data (and perhaps influenced by patient choice regarding female fecundity), a stepwise surgical strategy with a primary IPA followed at a later age by a secondary proctectomy with IPAA could be proposed.

Colon and rectal injuries

PURPOSE

This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature.

METHODS

Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers.

RESULTS

A total of 203 articles were considered relevant.

CONCLUSIONS

The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.

Ileostomy rod--is it a bridge too far?

OBJECTIVE

Defunctioning loop ileostomies are used commonly to protect low colorectal anastomoses and thereby reducing the serious complications of leakage. However, they are associated with specific complications such as retraction. Traditionally, a supporting rod is placed as a bridge to support both limbs of the stoma in the hope of reducing the incidence of stomal retraction. There is little evidence in the published literature to support this practice. The aim of this study was to determine whether using an ileostomy rod would reduce the incidence of stomal retraction.

METHOD

A prospective, randomised controlled trial was performed in 60 consecutive patients who required a defunctioning loop ileostomy. Patients were allocated to either a 'bridge' or 'bridge-less' protocol. All the patients were assessed by dedicated stoma nurses for at least 3 months and until their stomas were closed. Their postoperative symptoms, including stoma activity and retraction rate, were recorded.

RESULTS

Between May 2001 and June 2004, 57 patients completed the study (28 bridge; 29 bridge-less). There were no significant differences in the retraction rate between the groups. No clinical anastomotic leakage was recorded and none of the patients required early closure.

CONCLUSIONS

If a loop ileostomy is constructed properly, stomal retraction is uncommon and routine use of a bridge is unnecessary.

Transanal stent in anterior resection does not prevent anastomotic leakage

OBJECTIVE

A defunctioning transanal stent may theoretically reduce the leakage rate after anterior rectal resection. We present a randomized open study with the aim of comparing the leakage rate after anterior resection with a loop ileostomy, a transanal stent, both or neither.

PATIENTS AND METHODS

Randomized open trial of 194 patients operated in 11 hospitals during September 2000 to September 2003 with anterior resection for a mobile rectal tumour, 115 men and 79 women, median age 68 years (range 37-90 years). The surgeon decided upon the use of a protective ileostomy, and after completion of the operation the patients were randomized in two groups with and without a transanal stent.

RESULTS

A clinically significant leakage was diagnosed in 25 patients (13%). No significant difference was found 17 of 98 patients with a stent and 8 of 96 without (P = 0.09), or in 9 of 44 ileostomy patients with a stent and in 3 of 45 without (P = 0.07). Several leaks over a short time led to an interim analysis after inclusion of 194 of 448 planned patients. The analysis showed no significant protective effect of the stent, and more leakages in the stent group, although not statistically significant. On this basis it was decided to discontinue the study prematurely for ethical reasons.

CONCLUSION

Decompression of the anastomosis with a transanal stent does not reduce the risk of anastomotic leakage after anterior resection.

The effect on morbidity of mesentery lengthening techniques and the use of a covering stoma after ileoanal pouch surgery

PURPOSE

A tension-free anastomosis in a restorative proctocolectomy requires sufficient length of small-bowel mesentery. To ensure adequate length, it has been proposed that the superior mesenteric artery be divided and the right colon marginal vascular arcade be preserved. This study was designed to evaluate the influence of mesenteric lengthening techniques on the need for a stoma and on early outcomes after restorative proctocolectomy.

METHODS

Records of patients who had a restorative proctocolectomy between January 1998 and October 2003 were reviewed. Patient and disease characteristics, operative techniques and findings, the need for a stoma, and postoperative complications were recorded.

RESULTS

In one patient a restorative proctocolectomy was not possible. The remaining 220 patients were divided into two groups: Group A (inflammatory bowel disease; n = 123) and Group B (noninflammatory bowel disease; n = 97). Sixty-nine patients (31.4 percent) had major comorbidities. A lengthening technique was performed in 120 patients (54.5 percent) by dividing the ileocecal artery (n = 37) or the superior mesenteric artery (n = 88); 5 patients had only the marginal vascular arcade preserved. An ileostomy was not required in 116 patients (52.7 percent). In multivariate analysis, in Group B the only surgical variable influencing the need for an ileostomy was preservation of the marginal vascular arcade (50 vs. 14.7 percent; P < 0.0005). Complications occurred in 41 patients (18.6 percent), more frequently for those in Group A and for patients receiving steroids (23.6 vs. 12.4 percent, P = 0.012; 10.4 vs. 6.8 percent, P = 0.0172).

CONCLUSIONS

The use of mesentery lengthening techniques allows a restorative proctocolectomy to be performed in almost all patients without increasing morbidity and may reduce the number of covering stomas. Because division of the ileocecal and/or superior mesenteric arteries may be required, preservation of the marginal vascular arcade is essential whenever possible.

Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision

BACKGROUND

The aim of this study was to compare loop ileostomy and loop transverse colostomy as the preferred mode of faecal diversion following low anterior resection with total mesorectal excision for rectal cancer.

METHODS

Patients who required proximal diversion after low anterior resection with total mesorectal excision were randomized to have either a loop ileostomy or a loop transverse colostomy. Postoperative morbidity, stoma-related problems and morbidity following closure were compared.

RESULTS

From April 1999 to November 2000, 42 patients had a loop ileostomy and 38 had a loop transverse colostomy constructed following low anterior resection. Postoperative intestinal obstruction and prolonged ileus occurred more commonly in patients with an ileostomy (P = 0.037). There was no difference in time to resumption of diet, length of hospital stay following stoma closure and incidence of stoma-related complications after discharge from hospital. A total of seven patients had intestinal obstruction from the time of stoma creation to stoma closure (six following ileostomy and one following colostomy; P = 0.01).

CONCLUSION

Intestinal obstruction and ileus are more common after loop ileostomy than loop colostomy. Loop transverse colostomy should be recommended as the preferred method of proximal faecal diversion.

Dansac Invent convex in the management of flush ileostomy

This article examines the use of the Dansac Invent convex drainable stoma appliance. A review of the literature highlights the indications for use of convexity and discusses the potential contraindications. A short case study describes the use of convex appliances in a patient with a flush, high-output ileostomy.

Comparison of loop versus end ileostomy for fecal diversion after restorative proctocolectomy for ulcerative colitis

BACKGROUND

The goal of this study was to compare the benefits versus complications of temporary loop ileostomies and end ileostomies in a consecutive series of patients undergoing colectomy and ileal pouch-anal anastomosis for ulcerative colitis.

STUDY DESIGN

A retrospective review was performed of all patients undergoing restorative proctocolectomy with diverting ileostomy for ulcerative colitis at the UCLA Medical Center during a 4-year period. An end ileostomy (EI) was used for 38 patients and a loop ileostomy (LI) for 39. All patients had a J pouch, with all EI patients having a hand-sewn ileoanal anastomosis, and 33 LI patients having a double-stapled anal anastomosis. EI closure was performed through a laparotomy, and LI closure was performed through a periileostomy incision.

RESULTS

The mean operative time for EI closure was 157 minutes, and for LI closure was 103 minutes. The wound infection rate after EI closure was 5.3% and after LI was 10.3%. For EI patients, 2 of 38 patients required reoperation, compared with 5 of 39 for LI. The mean hospital stay after EI closure was 6.7 days, and after LI closure was 7.1 days. Peristomal skin irritation was more severe, more prolonged, and occurred in more than twice as many LI as EI patients. Home ostomy nurse care was necessary for a mean of two visits for EI patients and five visits for LI patients. The cost ofostomy supplies and care was more than double for LI patients compared with those with EI. Patient satisfaction and ability to resume physical and social activities early after ileostomy construction were much more favorable for EI than LI patients.

CONCLUSIONS

The benefit of shorter operating time for LI closure compared with EI closure is often outweighed by the complications and costs of LI stomal care and patient dissatisfaction. EI should be considered more frequently for temporary ileal diversion after restorative proctocolectomy.

Stapled versus sutured closure of loop ileostomy: a randomized controlled trial

OBJECTIVE

To compare the outcome after conventional sutured loop ileostomy closure with stapled ileostomy closure.

SUMMARY BACKGROUND DATA

A defunctioning loop ileostomy is now widely used in colorectal surgery. Subsequent closure may be associated with early complications, particularly bowel obstruction. The results of a preliminary nonrandomized study suggested that there was no significant difference in the rate of complications between sutured and stapled closure of loop ileostomy.

METHODS

One hundred forty-one consecutive patients who underwent loop ileostomy between 1993 and 1998 were randomized before surgery to either sutured or stapled loop ileostomy closure. Seventy-one patients had stapled closure and 70 had sutured closure.

RESULTS

Both groups were comparable in terms of age, sex, original operation, duration after original operation, and level of operating surgeon. Postoperative bowel obstruction occurred in 10/70 (14%) patients after sutured closure compared with 2/71 (3%) patients after stapled closure. Subgroup analysis of ileostomy closure in patients having an ileal pouch showed no significant difference in bowel obstruction between stapled and sutured closure (2/30 vs. 7/29). The incidence of other complications, readmissions, and reoperations did not differ between the two groups. The stapled closure was only 4 minutes quicker than sutured closure. The mean total hospital stay tended to be shorter after the stapled closure than the sutured closure, but this did not reach statistical significance.

CONCLUSIONS

Bowel obstruction occurred less frequently after stapled closure, but the mean hospital stay and readmission and reoperation rate did not significantly differ between the two groups.

Complications of abdominal stoma surgery

PURPOSE

This study was undertaken to review and summarize the complications of ileostomy and colostomy creation and subsequent closure.

METHODS

The English-language medical literature for at least the past 15 years was reviewed comprehensively.

RESULTS

Complications of surgery for the creation of end, loop, and "end loop" stomas are presented. Technical factors, which might influence complication rates, are discussed. Optimal management of ostomy complications is presented, especially for peristomal hernias. Similarly, techniques and complications for stoma closure are analyzed.

CONCLUSIONS

Stoma creation is not a trivial undertaking; careful surgical technique minimizes complications (which are relatively frequent), and promotes good ostomy function. Peristomal hernias are difficult to cure permanently. The morbidity of ileostomy and colostomy closure is also appreciable.

The morbidity of defunctioning stomata

BACKGROUND

The choice of a defunctioning stoma in restorative resection of rectal carcinoma is unclear. Traditionally, the loop colostomy has been preferred.

METHODS

All patients with either a defunctioning loop ileostomy or colostomy treated by a single surgeon (MS) were studied. The morbidity of stoma construction and closure, as well as problems experienced in the intervening period, were entered on a database.

RESULTS

No significant difference in the morbidity of closure was noted when loop ileostomy was compared to loop colostomy. Although a trend favouring loop ileostomy was noted when interval morbidity was examined, this difference was not statistically significant.

CONCLUSIONS

Loop colostomy and ileostomy are both effective in defunctioning the distal colon following a restorative resection for rectal carcinoma. There is some morbidity associated with both but when a stoma is constructed, loop ileostomy is preferable. The loop ileostomy is generally easier to manage and is not associated with a greater rate of complications (in its construction and closure) than the loop colostomy.

The use of an ileostomy connector to diminish the frequency of defecation prior to ileostomy closure in patients with a pelvic pouch

A new method for allowing stool passage into the pelvic pouch before ileostomy closure to verify the defecation state and diminish stool frequency is reported herein. This was accomplished by fitting an ileostomy connector connecting the proximal and distal openings of the diverting loop stoma. The ileostomy connector was initially in place for 6 h a day, the length of time being gradually increased until it was able to be left in for 24 h a day over a 3-month period. The calculated daily frequency of stools decreased from 24 to 6 or 7 times, and the mean daily frequency immediately after ileostomy closure was 6.5 times. Physiological study also showed an improvement, with squeeze pressure increasing from 35 cmH2O to 116 cmH2O and the maximum tolerated volume increasing from 35 ml before, to 90 ml 3 months following the use of an ileostomy connector. Thus, we conclude that an ileostomy connector may be useful to predict postoperative functional outcome and its complications, and to diminish the frequency of defecation before ileostomy closure in patients with a covering loop stoma.

Clinical and physiological aspects of ileal pouch-anal anastomosis

Proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for severe chronic ulcerative colitis and familial polyposis coli because the entire colonic mucosa is removed while anal function can be preserved and the necessity for permanent ileostomy is eliminated. Long-term functional results are generally gratifying, as defecation frequency and degree of incontinence are acceptable in most patients. Pouchitis, however, a non-specific inflammation of the ileal reservoir, is a major long-term complication occurring in a considerable number of patients. The etiology of pouchitis is unknown. Since pouchitis occurs more frequently or even exclusively in ulcerative colitis patients it is assumed that pouchitis is a novel manifestation of inflammatory bowel disease. However, bacterial overgrowth in the ileal pouch may also play a pathogenetic role. Chronic inflammation and villous atrophy of varying severity is found in virtually all pouches. Acute inflammatory changes and ulceration are associated with pouchitis.

Loop ileostomy fixation: a simple technique to minimise the risk of stomal volvulus

Turnbull's "loop" ileostomies is a routinely performed procedure in the management of a variety of colorectal problems. Mechanical and functional complications occur with both permanent and temporary ileostomies, however they are more common with the loop than with the end (Brooke) variety. With the advent of restorative proctocolectomy with pouch formation, and the documented benefit of simultaneous temporary faecal diversion, the incidence of such complications will rise. Bowel obstruction, requiring laparotomy in the interval before stoma closure, is more commonly associated with the loop ileostomy. A loop stoma is routinely brought out directly through the abdominal wall, with little or no fixation or closure of the lateral space. However, anti-mesenteric fixation, as described here, minimises the risk of volvulus by widening the attachment of the adjacent ileum to the parities, creating a broader fulcrum. Since adopting this simple technique, we report no complications in over 30 loop ileostomies, "fixed" by this technique and followed up for a minimum of 4 years. Where applicable, no difficulty was encountered with stoma closure, either by a transverse single layer serosubmucosal technique, or as a minimal resection with end to end anastomosis (sewn or stapled), following bowel mobilisation. This technique should minimise the frequency of obstructive events, and we recommend it's routine use.

Loop ileostomy for temporary fecal diversion

The aim of this study was to prospectively assess the morbidity of creating and closing loop ileostomies in a consecutive series of patients having an ileoanal pouch procedure. Between 1983 and 1991, 203 patients had loop ileostomies created for temporary fecal diversion after an ileoanal pouch procedure. There was one death as a result of liver failure. One patient developed a persistent pouch-vaginal fistula that resulted in pouch excision. The remaining 201 patients had their ileostomies closed at a mean time of 10 weeks after the primary procedure. Only 7% needed surgery to correct ileostomy-related problems. After ileostomy closure, complications were noted in only 2% of patients. Loop ileostomy is easy to create and provides highly effective fecal diversion, which decreases the incidence of and mitigates the serious sequelae of pouch sepsis. Closure is simple, does not require a laparotomy, and is associated with few complications. Our experience with loop ileostomy for temporary fecal diversion after an ileoanal pouch procedure has been favorable. The loop ileostomy may be the stoma of choice for most clinical situations in which temporary fecal diversion is indicated.

Fat-induced ileal brake in humans: a dose-dependent phenomenon correlated to the plasma levels of peptide YY

BACKGROUND

Upper gastrointestinal motility is regulated by the presence of nutrients in the distal gut. The present study evaluated whether lipid-induced ileal brake on gastric emptying (1) can be elicited by low fat concentrations; (2) is a dose-dependent phenomenon; and (3) is related to gastrointestinal peptide release.

METHODS

Seven patients were studied in the defunctionalized stage of total colectomy, on three separate occasions. On each study day, patients ate a meal labeled in the solid component; 30 minutes later, one of the following solutions was randomly infused into the ileal pouch: 0.9% saline, 2% oleic acid, and 20% oleic acid. Plasma concentrations of peptide YY (PYY), enteroglucagon, neurotensin, and motilin were measured.

RESULTS

Both oleic acid solutions slowed gastric emptying compared with saline (P < 0.001), the effect being dose dependent (P < 0.001). Ileal infusions did not modify neurotensin and enteroglucagon levels but induced a dose-dependent increase of PYY (P < 0.01) and a borderline decrease of motilin (P = 0.05) levels. Slower rates of gastric emptying were related to increased plasma concentrations of PYY (r = 0.615; P < 0.05).

CONCLUSIONS

This study shows that (1) the ileal brake on gastric emptying can be evoked by low doses of lipids in the distal ileum; (2) the delay of gastric emptying is related to the release of PYY; and (3) both phenomena are dose dependent.

Fistula complicating restorative proctocolectomy

Twenty-seven patients developed a fistula after 168 restorative proctocolectomies. Thirteen fistulas were enterocutaneous (two with communication to the bladder); their origins were from the pouch (three patients), the ileoanal anastomosis (three), the pouch appendage (three), a previous loop ileostomy (two) and iatrogenic small bowel injury (two). Two patients had Crohn's disease. The pouch was removed in four patients, one of whom died from chronic small bowel obstruction; the remaining nine have satisfactory pouch function after fistula excision. Ten pouch-vaginal fistulas occurred, all from the ileoanal anastomosis; four were extrasphincteric. Four of these patients had underlying Crohn's disease. Only two patients, with Crohn's disease and indeterminate colitis, required pouch excision; the remainder have good pouch function after treatment of the fistula. There were three pouch-perineal fistulas, all from the ileoanal anastomosis; these were successfully managed by seton fistulotomy. There was one pouch-vesical fistula, successfully treated by excision of the fistula and pouch appendage.

Temporary loop ileostomy for restorative proctocolectomy

The aim of a defunctioning ileostomy after restorative proctocolectomy is to mitigate the consequences of pelvic sepsis, should it occur. However, there are complications related to the ileostomy itself. Of 310 patients (174 male and 136 female; mean age 33.2 years) who underwent restorative proctocolectomy between 1976 and 1990, 296 had a covering ileostomy and 14 did not. The stoma has been closed in 263 (88.9 per cent) at a median interval from formation of 12.0 weeks. Ileostomy-related complications before closure occurred in 17 patients (5.7 per cent). Laparotomy for obstruction due to the ileostomy was required in seven patients (2.4 per cent). Retraction requiring revision occurred in three patients (1.0 per cent), an abscess behind the stoma in one (0.3 per cent) and miscellaneous appliance problems in seven (2.4 per cent). Following closure, 59 patients overall (22.4 per cent) developed an ileostomy-related complication. There were 30 cases of small bowel obstruction, treated conservatively in 19 (7.2 per cent) and by laparotomy in 11 (4.2 per cent). Peritonitis requiring laparotomy occurred in three patients (1.1 per cent) and two (0.8 per cent) developed an enterocutaneous fistula. There were 14 (5.3 per cent) wound infections and 16 (6.1 per cent) other miscellaneous problems. Significant complications associated with a temporary ileostomy were less frequent in this series than in some other reports. Obstruction was the most common complication and fistula was rare.

Loop ileostomy is a safe option for fecal diversion

This study was undertaken to prospectively assess all morbidity and mortality associated with temporary loop ileostomy. Eighty-three consecutive patients of a median age of 45 years required temporary fecal diversion after either ileoanal or low colorectal anastomosis (n = 72), for perianal Crohn's disease (n = 5), or for other reasons (n = 6). All loop ileostomies were supported with a rod, and fecal diversion was maintained for a mean of 10 weeks. To date, 67 patients have had re-establishment of intestinal continuity. Stoma closure was affected through a parastomal incision in 64 patients; in three, a laparotomy was required. The closure was stapled side to side in 49 patients, while a hand-sewn anastomosis was done in the other 18 patients; all skin wounds were left open. The mean length of surgery for ileostomy closure was 56 minutes, and the mean hospital stay was five days. Nine patients (10.8 percent) developed 10 complications, nine of which required hospitalization. Specifically, four patients developed dehydration and electrolyte abnormalities secondary to high stoma output, and two had anastomotic leaks that spontaneously healed following conservative management. One patient developed a superficial wound infection that spontaneously drained itself. One patient developed a partial small bowel obstruction that resolved without surgery after a four-day hospitalization. One stoma retracted after supporting rod removal and prompted premature closure. There was no stomal ischemia, hemorrhage, prolapse, or mortality in this series. Thus, loop ileostomy is a safe way to achieve fecal diversion.

A more functional loop ileostomy rod

The use of a flat Jackson-Pratt drain for a loop ileostomy rod is described. It elevates the loop, prevents its retraction into the abdomen, and can be cut to precisely the size of the stoma, thereby alleviating the problem of skin excoriation from a poorly fitting appliance.

Continuing evolution of the pelvic pouch procedure

The results of the pelvic pouch procedure were reviewed to assess the surgical complication rate and outcome of patients who had had the procedure performed with a stapled ileo-anal anastomosis with and without a defunctioning ileostomy. Between December 1982 and March 1992, 483 patients underwent a pelvic pouch (PP) procedure. Patients were divided into three groups: group I consisted of 325 patients (178 men and boys and 147 women and girls) who underwent a PP procedure with a handsewn ileoanal anastomosis (IAA) with a defunctioning loop ileostomy. In group II, there were 87 patients (47 men and boys and 40 women and girls) who had a stapled IAA with a defunctioning ileostomy. Group III patients consisted of 71 patients (43 men and boys and 28 women and girls) who had a stapled IAA with no covering ileostomy. Assessment was made of the IAA leak rate, the surgical complications, the reoperation rate, and functional outcome. Early surgical complications included 40 (12%) IAA leaks in group I patients compared with only six (7%) leaks in group II patients who had a stapled IAA (p < 0.05). In group III patients, who had a stapled IAA but no covering ileostomy, there were 13 leaks (18%). Eleven of these 13 leaks healed spontaneously with tube drainage; one patient remains with a rectal tube in place 6 weeks after operation, and only one patient has required a reoperation (defunctioning ileostomy). Functionally, all patients with a healed IAA after a leak have had an excellent result comparable to those without a leak. Patients who were male, older than age 40, on steroids, and had had a true one-stage PP procedure, had a greater risk of developing an IAA leak. In two patients, there was intraoperative difficulty, and one of these patients had an IAA leak after operation. Disease activity at the resection margin and patient weight did not affect the leak rate. Our results suggest that the IAA leak rate is significantly reduced in patients with a stapled IAA with an ileostomy compared with those with a handsewn IAA. Omission of the defunctioning ileostomy is associated with a higher IAA leak rate, but spontaneous healing occurs in almost all patients without impairment of functional results. In patients in whom the ileostomy is omitted, the IAA leak rate is greatest in male patients who have undergone a true one-stage PP procedure, are on steroids, and are older than age 40.

Randomized trial of loop ileostomy in restorative proctocolectomy

A randomized controlled trial was performed to assess the role of loop ileostomy in totally stapled restorative proctocolectomy. Entry criteria included all patients who were not on corticosteroids in whom on-table testing revealed a watertight pouch with intact ileoanal anastomosis. Of 59 patients undergoing restorative proctocolectomy over 36 months, 45 were eligible and were randomized to loop ileostomy (n = 23) or no ileostomy (n = 22). The age and diagnosis of the groups were similar. There were no deaths; two ileoanal anastomotic leaks occurred, one in each group. Ileoanal stenosis occurred in five patients with and one without an ileostomy. The incidences of wound and pelvic sepsis, bowel obstruction and pouchitis were similar. Twelve patients (52 per cent) developed ileostomy-related complications. The median total hospital stay was 23 (range 13-75) days with ileostomy and 13 (range 7-119) days without (P < 0.001). This study indicates that there is a low risk of pelvic sepsis which is not increased by avoiding a protective ileostomy. Loop ileostomy was associated with a high incidence of complications.

Complications of surgical excision of rectum

Surgical excision of all or part of the rectum remains a formidable technical challenge for the surgeon and a source of substantial morbidity and mortality for the patient. Most complications are avoidable by meticulous attention to the technical details in the performance of the operation. However, even in the best of circumstances, these procedures are accompanied by complications. An understanding of the mechanisms of these complications combined with a realistic approach to their diagnosis and solution will minimize the impact on ultimate results.

Ileal pouch-anal anastomosis without ileostomy

Thirty-seven patients underwent construction of a J-ileal pouch-anal anastomosis (IPAA) without temporary diverting ileostomy for chronic ulcerative colitis (CUC) (20 patients), familial adenomatous polyposis (FAP) (15 patients), indeterminate colitis (1 patient) and nonhereditary polyposis coli (1 patient) between 1981 and 1990. Seven of 20 CUC patients (35 percent) were on steroids at the time of hospital admission. The postoperative course of these patients was compared with that of a group of patients undergoing IPAA with ileostomy during that same time period and matched for age, sex, diagnosis, date of surgery, and steroid use. Eight patients (22 percent) in the group without ileostomy and four patients (11 percent) with ileostomy experienced one or more postoperative pouch-related complications. Complications requiring reoperation in patients without ileostomy occurred more frequently in patients either taking steroids or having previous pelvic radiation therapy. Functional results in patients undergoing one-stage procedures after a mean of 28 postoperative months were comparable to those in patients having staged procedures. Surgeons' criteria for a one-stage procedure in these patients should include absolute lack of tension on the anastomosis, good blood supply to the terminal ileum, good general health, and absence of recent intake of steroids at the time of surgery. We conclude that J-pouch construction with IPAA can be safely performed without diverting ileostomy, provided that these selection factors are taken into account.

Comparison of morbidity and function after colectomy with ileorectal anastomosis or restorative proctocolectomy for familial adenomatous polyposis

Restorative proctocolectomy with an ileal reservoir (RPC) should prevent colorectal cancer in patients with familial adenomatous polyposis. Until this is confirmed its role compared with total colectomy and ileorectal anastomosis (IRA) will depend on the relative morbidity and postoperative bowel function after the two procedures. This was analysed in 99 patients (37 RPC, 62 IRA) operated on between 1977 and 1989. Morbidity was greater after RPC with subsequent ileostomy closure (median hospital stay, 24 versus 11 days; complications, 60 versus 21 per cent; reoperation, 29 versus 3 per cent; return to normal activity; 31 versus 14 weeks). There was little difference in bowel function; after IRA median frequency was 3/24 h and urgency (unable to wait 15 min) occurred in 50 per cent, compared with 4.5/24h and 17 per cent after RPC. Night evacuation occurred in 10 and 43 per cent respectively. IRA was performed in younger patients (median 19 versus 31 years) who had fewer bowel motions before operation (2 versus 5/24 h). The greater morbidity of RPC suggests that it should be restricted to patients at higher risk of developing later rectal cancer, including those unavailable for follow-up and those with large or confluent rectal polyps or with curable colon cancer at the initial colectomy.

Complications following closure of loop ileostomy

The morbidity and mortality of 50 patients undergoing closure of loop ileostomy was reviewed. The patients had a mean age of 57.9 years and significant intercurrent disease. There were no in-hospital deaths or anastomotic leakage at the site of closure. Small bowel obstruction occurred in 12% of patients, all of whom responded to conservative treatment. The wound infection rate was 14%, but the development of a wound infection did not result in a significantly longer hospital stay. We conclude that, when a careful technique of sharp dissection is used, closure of a loop ileostomy is associated with an acceptably low incidence of complications even in elderly and often unwell patients.

Loop ileostomy after ileal pouch-anal anastomosis--is it necessary?

Construction of a loop ileostomy is usually advised in patients having an ileal pouch-anal anastomosis to minimize the complication of chronic pelvic sepsis. Formation and closure of a loop ileostomy was associated with a 41 percent and 30 percent complication rate, respectively, in a prospective series of 34 patients. This morbidity must now be assessed in relation to the benefits of avoiding temporary fecal diversion in restorative proctocolectomy.

Comparison of restorative proctocolectomy with and without covering ileostomy in ulcerative colitis

The experience of restorative proctocolectomy for ulcerative colitis is reported in 16 consecutive patients with no covering ileostomy (group 2) in comparison with 15 patients with a covering stoma (group 1); in each group a J pouch was constructed. All patients had pre- and postoperative clinical and manometric evaluations of the functional result up to 12 months. There were no deaths or permanent failures. The number of early complications was four in each group. Re-ileostomy was needed in one patient of group 1, and an ileostomy was constructed in three patients of group 2. At 1 year after operation the functional results did not differ between groups 1 and 2 in terms of daily frequency of defaecation (mean 5.6 and 5.4 in 24 h respectively), or in terms of anal basal or maximal squeeze pressures. There was a significant (P less than 0.01) saving in total hospital stay (median 11 days) and in operating theatre time (mean 41 min) in patients with no covering ileostomy. It is concluded that a covering ileostomy may be unnecessary in restorative proctocolectomy, at least in suitable cases with no technical difficulty at the time of operation.