The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases

Bananagram: an alternative to distal loopogram prior to colostomy closure for Hirschsprung disease

Background

This study aimed to investigate if mashed ripe bananas (bananagram) could be used to assess the integrity of the gut before transverse colostomy closure in patients with Hirschsprung disease (HSCR) in a low- and middle-income country tertiary-level hospital.

Methods

This is a prospective, single-center, hospital-based cohort study. A feeding tube tip was inserted about 5-8 cm through the distal loop, and 15 mL of mashed banana was introduced. The amount introduced and the spontaneous expulsion of mashed banana were measured. We also measured colonic transit time (CTT), input and expulsion ratio, color of the expulsed banana stream, size of the banana stream passed through the anus and clinical signs of bowel obstruction or perforation after the procedure.

Results

From January 2018 to June 2023, 266 HSCR patients with a transverse colostomy were included. The mean±standard deviation (SD) age was 26.45±6.41 months. The median CTT of mashed banana was 8 min (interquartile range (IQR): 4-13 min). The mean amount of mashed banana spontaneously expelled through the anus was 13.25±0.95 mL. More than 90% of patients expelled unchanged mashed bananas, and 9.4% expelled stool-banana mixtures. Banana stream was 0.3-1.5 cm in 257 patients and <0.3 cm in nine patients. These nine patients needed revision pull-through.

Conclusion

Bananagram can be performed at the bedside. It is easy to perform, cost-effective, available throughout the year and does not pose radiation hazards.

Machine learning prediction model of prolonged delay to loop ileostomy closure after rectal cancer surgery: a retrospective study

BACKGROUND

Delayed closure of a temporary ileostomy in patients with rectal cancer may cause psychological, physiological, and socioeconomic burdens to patients.

PURPOSE

This study aimed to develop and validate a machine learning-based model to predict the delayed ileostomy closure after surgery in patients with rectal cancer.

DESIGN

A retrospective study.

METHODS

LASSO regression was used for feature screening, and XGBoost was used for machine learning model construction. Model performance was assessed by receiver operating characteristic (ROC) curve analysis, calibration curve analysis, clinical decision curve analysis, sensitivity, specificity, accuracy, and F1 score. The SHAP method was used to interpretate the results of the machine learning model.

RESULTS

A total of 442 rectal cancer patients who received a loop ileostomy were included in this study, and 305 experienced delayed closure (69%). The XGBoost model area under the ROC curve (AUC) of the training set was 0.744 (95% confidence interval [CI]: 0.686-0.806) and of the test set was 0.809 (95% CI: 0.728-0.889). The importance of each variable, in descending order was body mass index (BMI), postoperative chemotherapy, distance from tumor to anal margin, depth of tumor infiltration, neoadjuvant chemoradiotherapy, and anastomotic stenosis. The importance of SHAP variables in the model from high to low was: 'BMI' 'postoperative chemotherapy' 'distance of the tumor from the anal verge' 'depth of tumor infiltration' 'neoadjuvant radiotherapy' 'anastomotic stenosis'.

CONCLUSION

The XGBoost machine learning model we constructed showed good performance in predicting delayed closure of loop ileostomy in rectal cancer patients. In addition, the SHAP method can help better understand the results of machine learning models.

Laparoscopic versus open ileostomy closure: a systematic review and meta-analysis of postoperative outcomes

PURPOSE

This study aims to compare laparoscopic versus open in ileostomy reversal techniques from multiple perspectives and to gain insight into the potential advantages and limitations of laparoscopic techniques and provide guidance on finding the best anastomosis for ileostomy reversal.

METHODS

This systematic review and meta-analysis has been pre-registered with PROSPERO. The registration number is CRD42025640754. A rigorous literature search was conducted across multiple databases, including Embase, PubMed, Cochrane Library, and China National Knowledge Infrastructure. The primary outcome measure was the incidence of overall postoperative complications, and the secondary outcomes included operative time, estimated blood loss, and the length hospital stay.

RESULTS

This research included 11 studies with a total of 867 cases, showing that the laparoscopic surgery group had a significantly lower overall complication rate compared to the open surgery group (OR = 0.40, 95% CI: 0.27-0.59, P < 0.00001). Further investigation of specific postoperative complications revealed that laparoscopic surgery significantly reduced the risk of bowel obstruction (OR = 0.39, 95% CI: 0.18-0.83, P = 0.01) and wound infection (OR = 0.41, 95% CI: 0.23-0.73, P = 0.003), with no significant difference observed for anastomotic leaks (OR = 0.40, 95% CI: 0.11-1.43, P = 0.16). Although laparoscopic surgery required a longer operative time (P = 0.002), it resulted in significantly shorter hospital stays (P < 0.00001) and did not increase estimated blood loss (P = 0.50). In addition, both extracorporeal laparoscopic surgery and intracorporeal laparoscopic surgery can effectively reduce the occurrence of postoperative complications and shorten the length of hospital stay compared with open surgery.

CONCLUSION

Laparoscopic-assisted ileostomy closure (both intracorporeal and extracorporeal techniques) demonstrates significant clinical benefits, including reduced postoperative complication rates, shortened hospitalization duration, and optimized recovery trajectories.

ETAD: a case series of endoscopic transanastomotic drainage of anastomotic leak by colonoscopy

BACKGROUND

Transanal drain placement is the preferred treatment for coloanal and low colorectal anastomotic leaks (AL). Endoscopic placement of double-pigtail stents (DPS) has been described sparingly in the colorectal literature for more proximal AL. Our objective was to investigate the efficacy of endoscopic transanastomotic drain (ETAD) placement in leaks after colorectal surgery.

METHODS

This is a case series of 12 patients who underwent ETAD placement for AL (12 patients) between May 2020 and July 2023. Patients with contained leaks were treated with ETAD if they were hemodynamically stable without peritonitis. Outcomes we evaluated included length of stay, need for readmission, need for reoperation, duration of drain placement, and reversal of diverting stomas.

RESULTS

Of the 12 patients, 5 were female and had a median age of 63. Indications for index surgery included diverticulitis (n = 9), inflammatory bowel disease (n = 1), rectal cancer (n = 1), and uncertain diagnosis (n = 1). 5 patients had stomas created (loop ileostomies,) at the index operation. Leaks were identified a median of 80 days (range 9-211) for diverted patients and a median of 15 days (range 5-18) for non-diverted patients. At the time of ETAD, three patients required readmission, four patients remained admitted from index operation, and five patients were treated as outpatients. All diverting loop ileostomies were reversed. The median duration of ETAD was 55 days (range 38-115 days). All were successfully managed with ETAD; no patients required revision of their anastomoses or new diverting stoma.

CONCLUSIONS

Endoscopic DPS placement into contained colorectal leaks was successful in promoting healing and avoiding reoperation in 100% of our patients. All ostomies but one have been reversed. Larger studies are necessary to evaluate safety and efficacy, long-term outcomes, and the appropriate patient population for consideration.

Enhanced recovery after surgery (ERAS) in stoma reversal surgery: a systematic review and meta-analysis

Stoma reversal surgery is known for relatively high complication rates. While Enhanced Recovery After Surgery (ERAS) protocols are extensively validated for colorectal surgery, their use in stoma reversal remains underexplored. This systematic review and meta-analysis evaluates clinical outcomes of stoma reversal surgery under ERAS protocols compared to standard care (SC) practices. Medline, EMBASE, and Cochrane Central databases were searched for studies that compared clinical outcomes of stoma reversal surgery under ERAS protocols versus SC practices. The endpoints of interest were length of stay (LOS), ileus, wound infection, anastomotic leak, time to first stool, overall, minor, and major postoperative complications, readmission rates, and reoperation rates. Mean difference (MD) was calculated for continuous variables and Odds Ratio (OR) for dichotomous variables. Statistical analysis was performed with R version 4.4.0. We included eight studies comprising 1322 patients. Among these, 603 (45.6%) followed an ERAS protocol, while 719 (54.4%) received SC practices. ERAS was associated with a significant decrease in LOS (MD -1.83; 95% CI -2.55 to -1.12; p < 0.01), wound infection (OR 0.47; 95% CI 0.23 to 0.97; p = 0.041), and time to first stool (MD -1.02; 95% CI -1.22 to -0.81; p < 0.01). No statistically significant difference was observed regarding ileus, anastomotic leak, overall, minor, and major postoperative complications, readmission rates, or reoperation rates. The implementation of ERAS protocols in stoma reversal procedures should be considered, as it was associated with a shorter length of hospital stay without increasing morbidity, and may even reduce complications such as wound infections.

The use of negative pressure wound therapy following stoma reversal: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Stoma reversal is a contaminated surgery with many patients experiencing significant wound complications that contribute to patient morbidity. It is believed that the use of prophylactic negative pressure wound therapy (NPWT) may enhance wound healing and help reduce the risk of developing surgical site infections (SSI). However, there is conflicting research regarding its effectiveness following stoma reversal. Our systematic review aims to evaluate the available randomized data to determine if the use of prophylactic NPWT after stoma reversal improves the duration of wound healing and reduces rates of postoperative complications.

METHODS

A comprehensive search of literature published up to January 2025 was conducted using the following databases: PubMed, Embase, Medline, and Cochrane Library. The included trials were randomized controlled trials that investigated the effect of NPWT following stoma reversal. The primary outcome was the time to complete wound healing. Secondary outcomes included the incidence of wound complications, SSI, hematomas, and the length of hospital stay.

RESULTS

Six randomised control trials were included, with 332 patients, of which 171 of these underwent NPWT. There was a significant reduction in time to complete wound healing (OR - 2.53, 95% CI - 3.82 to - 1.24, p = 0.0001, I2 = 45%) and wound healing at 42 days (OR 0.36, 95% CI 0.14 - 0.88, p = 0.03, I2 = 0%) in the NPWT group. There was no significant difference in any wound complications (OR 0.72, 95% CI 0.23-2.28, p = 0.58, I2 = 42%), SSI rates (OR 0.95, 95% CI 0.27-3.29, p = 0.94, I2 = 38%) or haematoma rates (OR 0.21, 95% CI 0.03-1.27, p = 0.09, I2 = 0%) between the groups. There was no significant difference in length of stay (OR - 0.02, 95% CI - 1.21-1.18, p = 0.98, I2 = 66%).

CONCLUSION

The use of NPWT after stoma reversal significantly reduces the time needed for complete wound healing while maintaining a comparable rate of wound complications and length of hospital stay. Therefore, NPWT may be valuable in optimizing postoperative recovery and enhancing patient outcomes.

Timing and morbidity of loop ileostomy closure after rectal cancer resection: a prospective observational multicentre snapshot study from Multidisciplinary Italian Study group for STOmas (MISSTO)

PURPOSE

Time to closure and morbidity are significant issues associated with ileostomy reversal after rectal cancer resection. This study aimed to investigate the rate, time, and morbidity associated with ileostomy closure procedure.

METHODS

Between February and December 2022, patients who underwent protective ileostomy after rectal cancer surgery across 45 Italian surgical centres were prospectively included. Data on ileostomy closure times, surgical methods, and complications were collected and analyzed. Both univariate and multivariate statistical tests were employed to assess stoma closure rates and the occurrence of post-operative complications.

RESULTS

A total of 287 patients participated in the study. Ileostomy closure was achieved in 241 patients, yielding overall and 6-month closure rates of 84% and 62%, respectively. The median time for ileostomy closure was 146 days. Direct sutures were used to close approximately 70% of skin defects, while purse-string sutures were applied in around 20%. The overall morbidity rate was 17%, with complications including skin suture dehiscence (7%), small bowel obstruction (6%), and anastomotic leakage (2%). Multivariate analysis revealed that an American Society of Anesthesiologists (ASA) score > 2 (p = 0.028), advanced age (p = 0.048), and previous stoma complications (p = 0.048) were independently linked to failure of stoma closure; hypertension (p = 0.036) was found to be a significant independent risk factor for post-operative complications.

CONCLUSION

This study demonstrated that a delay and a significant no-closure rate exist in ileostomy reversal after rectal cancer surgery. Post-operative complications remain high but can be prevented with adequate pre-operative assessment and post-operative care.

Laparoscopic intracorporeal anastomosis vs open anastomosis for ileostomy reversal in Crohn's disease: A single center retrospective study

BACKGROUND

There is an increased maturation of laparoscopic intracorporeal anastomosis techniques. However, research on its application for small bowel stoma reversal in patients with Crohn's disease (CD) is limited. Therefore, in this study, we compared the perioperative outcomes between laparoscopic intracorporeal ileostomy reversal (LIIR) and open ileostomy reversal (OIR).

AIM

To compare the safety, feasibility, bowel function recovery, and short- and long-term LIIR and OIR outcomes in patients with CD.

METHODS

This study included patients who underwent ileal reversal for CD between January 2021 and January 2023 at our institution. The baseline data, postoperative recovery, and complication indicators were retrospectively analyzed. Logistic regression analysis was conducted to explore factors that significantly influenced the development of enteral nutrition intolerance-related symptoms.

RESULTS

Notably, 15 of the 45 patients in this study underwent OIR, and the remaining 30 received LIIR. Notably, no statistically significant differences were found between the two groups regarding clinical baseline characteristics, operation time, intraoperative hemorrhage, anastomotic site, enterolysis range, first postoperative flatus, postoperative complications, reoperation rate, or incidence of postoperative enteral nutrition intolerance. Compared with the OIR group, the LIIR group had a shorter postoperative hospital stay (P = 0.045), lower incidence of enteral nutrition intolerance symptoms (P = 0.019), and earlier postoperative total enteral nutrition initiation (P = 0.033); however, it incurred higher total hospital costs (P = 0.038). Furthermore, multivariate logistic regression analysis revealed that the duration of surgery and anastomotic technique were independent risk factors for postoperative symptoms of enteral nutrition intolerance (P < 0.05).

CONCLUSION

Laparoscopic intracorporeal anastomosis for ileostomy reversal is safe and feasible. Patients who underwent this technique demonstrated improved tolerance to postoperative enteral nutrition and quicker resumption of total enteral nutrition.

Effectiveness of Subcutaneous Negative-Suction Drain on Surgical Site Infection After Ileostomy Reversal: A Propensity Score Matching Analysis

Background/Objective: Surgical site infection (SSI) is a leading common condition after ileostomy reversal (IR). However, evidence is unclear that subcutaneous negative-suction drainage (SND) reduces the incidence of SSI. This study aimed to investigate whether SND effectively reduced the incidence of SSI. Methods: We retrospectively analyzed the records of 531 patients who underwent IR at Incheon St. Mary's Hospital between June 2005 and December 2020. SND was classified into two groups based on its presence or absence. The estimated risk of SSI was calculated using the surgical risk calculator of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). After 1:1 propensity score matching (PSM) using the estimated risk of SSI, we analyzed the two group's postoperative outcomes, including SSI rates. Results: After PSM, there was no difference in demographics between the two groups; however, the reversal interval was longer in the SND group than in the no SND group (193.3 ± 151.6 vs. 151.5 ± 141.0 days, p = 0.005). The incidence of SSI was lower in the SND group than in the no SND group (5.2% vs. 13.0%, p = 0.013). Conclusions: SND insertion can reduce the incidence of SSI during IR. Therefore, SND insertion should be considered as a basic technique for reducing SSI after IR.

Reversal Surgery for Split Stoma with Peristomal Incision is Associated with Improved Postoperative Outcome in Patients with Crohn's Disease

BACKGROUND

Temporary stoma formation is common in Crohn's disease (CD), while stoma reversal is associated with postoperative morbidity. This study aimed to evaluate the postoperative outcomes of split stoma reversal, SSR (i.e., exteriorization of proximal and distal ends of the stoma through a small common opening) and end stoma closure, ESC (i.e., the proximal stump externalized, and distal end localized abdominally.

METHODS

Patients with CD who underwent stoma reversal surgeries between January 2017 and December 2021 were included. Demographic, clinical, and postoperative data were collected and analyzed to evaluate outcomes of reversal surgery.

RESULTS

A total of 255 patients who underwent stoma reversal surgeries met the inclusion criteria. SSR was superior to ESC in terms of operative time (80.0 vs. 120.0, p = 0.0004), intraoperative blood loss volume (20.0 vs. 100.0, p = 0.0002), incision length (3.0 vs. 15.0, p < 0.0001), surgical wound classification (0 vs. 8.3%, p = 0.04), postoperative hospital stay (7.0 vs. 9.0, p = 0.0007), hospital expense (45.6 vs. 54.2, p = 0.0003), and postoperative complications (23.8% vs. 44.3%, p = 0.0040). Although patients in the ESC group experienced more surgical recurrence than those in the SSR group (8.3% vs. 3.2%) during the follow-up, the Kaplan-Meier curve analysis revealed no statistical difference (p = 0.29).

CONCLUSIONS

The split stoma can be recommended when stoma construction is indicated in patients with Crohn's disease.

Defunctioning Ileostomy After Low Anterior Resection of Rectum: Morbidity Related to Fashioning and Closure

Background and Objectives: The aim of this study was to assess any predisposing factors to the morbidity of fashioning and reversal of diverting ileostomy in a prospective cohort of patients who have undergone TME and low colo-rectal or colo-anal anastomosis for rectal cancer. Materials and Methods: Consecutive patients with rectal cancer undergoing low anterior resection and a defunctioning loop ileostomy in three surgical units from 2016 to 2020 were included in the study and retrospectively analyzed. Results: One hundred eighty-two patients from three centres were included. Ileostomy-related mortality was 0.5%, attributed to renal failure.. Ileostomy-related morbidity was 46%. Postoperative ileus was seen in 37.4%, and dehydration in 18.8% of the patients. The readmission rate for ileostomy-related reasons was 15.4%. Stoma care was problematic in 15.7% or poor in 7% of the cases. Advanced age, male gender and obesity were independent risk factors for ileostomy-related morbidity. Ileostomy was reversed in 165 patients. The morbidity in 165 patients was 16%. Ileus was seen in 10.3%, anastomotic leak in 4.8% and wound infection in 12.7% of the cases. One patient died because of an anastomotic leak. No predisposing factors that affect the outcomes of ileostomy closure were identified. Conclusions: Diverting ileostomy-related morbidity is high. Life threatening dehydration and renal failure from ileus is more commonly seen in elderly, male and obese patients and should be anticipated. Ileostomy closure-related morbidity is low.

Ghost-ileostomy versus conventional loop ileostomy in patients undergoing low anterior resection for rectal cancer: results of a randomised controlled multicentre pilot trial (DRKS00013997)

PURPOSE

The objective of the current pilot trial was to evaluate whether ghost ileostomy is a safe alternative to the current standard of care in terms of a conventional loop ileostomy in patients undergoing low anterior resection with total mesorectal excision (LAR/TME) for rectal cancer.

METHODS

This randomized controlled pilot trial included patients undergoing LAR/TME, randomly assigning them to ghost ileostomy or conventional loop ileostomy intraoperatively. Follow-up spanned 6 months, evaluating the following endpoints: comprehensive complication index (CCI), postoperative morbidity, transformation of ghost ileostomy, presence of ostomy at 6 months, Wexner score, and quality of life (EORTC QLQ-C30 & CR29). Exploratory statistical analysis based on the intention-to-treat principle was conducted.

RESULTS

Recruiting 30 patients from May 2018 to September 2022, the trial was prematurely stopped due to slow recruitment. The mean CCI was comparable between groups at any point of time (at 6 months: 30.7 vs. 29.7, p = 0.889). There was no mortality and no need for creation of a terminal ostomy. Anastomotic leakage rates were similar in ghost ileostomy and loop ileostomy groups (p > 0.99). The ghost ileostomy was converted into a conventional loop ileostomy in 6 of 15 (40.0%) patients. Neither postoperative function, nor the overall quality of life showed significant differences.

CONCLUSION

Ghost ileostomy appears as a viable and safe option for selectively deciding ileostomy creation in LAR/TME for rectal cancer. However, challenges in patient selection, excluding those at high risk for anastomotic leakage, limit widespread application and call for optimization in future research.

TRIAL-REGISTRATION

German Clinical Trials Register ( https://drks.de/ ): DRKS00013997; date of registration: April 9th 2018.

Complications associated with loop ileostomy reversal delayed greater than twelve months

Diverting loop ileostomy is performed after colectomy to allow for anastomotic healing, and prevention of pelvic sepsis when an anastomotic leak occurs. There is no consensus on the optimal timing of ileostomy closure, and there is limited data on complications associated with ileostomy closure greater than 12 months after creation. The aim of this study is to investigate outcomes of delayed loop ileostomy closure greater than 12 months after creation. Patients undergoing loop ileostomy closure between 2013 and 2023 at Carilion Medical Center, in Roanoke, VA were reviewed. Cohorts compared were defined as Control Group (closure < 4 months) and Delayed Group (closure > 12 months). Demographics and outcomes were compared. Statistical comparisons were performed using either Wilcoxon rank sum test, Pearson's Chi-squared test or Fisher's exact test. Statistical modeling included binary logistic regression for 30-day readmissions and a generalized linear modeling for days till bowel function returns. Adjusted odds ratios, confidence intervals, and p-values were calculated. There were 135 patients in the Control Group and 19 patients in the Delayed Group. Demographics were similar between the groups except for a higher percentage of patients with diabetes, renal failure and history of cancer in Delayed Group (all p < 0.05). Operative time was longer for Delayed loop ileostomy closure (p < 0.05). Patients in the Delayed Group demonstrated a higher hospital readmission rate within 30 days (p < 0.05). Both groups had similar return of bowel function on post-operative day 2, similar length of stay, and similar rates of postoperative ileus (p = NS). Delayed loop ileostomy closure more than 12 months after creation does not delay return of bowel function but may lead to higher hospital readmission rates within 30 days.

Temporary diverting loop ileostomy in Crohn's disease surgery; indications and outcome

INTRODUCTION

Crohn's disease can present with complex surgical pathologies, posing a significant risk of morbidity and mortality for patients. The implementation of a loop ileostomy for selected patients may help minimize associated risks.

METHODS

In this retrospective cohort study, we investigated the utilization of temporary fecal diversion through the creation of a loop ileostomy in Crohn's surgery. Closure of all ostomies involved a hand-sewn single-layer technique. We then conducted bivariate analysis on 30-day outcomes for closures, focusing on favorable recovery defined as the restoration of bowel continuity without the occurrence of two challenges in recovery: newly developed organ dysfunction or the necessity for reoperation.

RESULTS

In total, 168 patients were included. The median age of the patients was 38 years (IQR 27-51). The most common indication for a loop ostomy was peritonitis (49%). After ileostomy closure, 163 patients (97%) achieved favorable recovery, while five encountered challenges; four (2.4%) underwent abdominal surgery, and one (0.6%) developed acute renal failure requiring dialysis. Two patients (1.2%) had a re-creation of ileostomy. Patients encountering challenges were older (56 [IQR 41-61] vs. 37 [IQR 27-50]; p 0.039) and more often required secondary intention wound healing (40% vs. 6.7%; p 0.049) and postoperative parenteral nutrition following their index surgery (83% vs. 26%; p 0.006).

CONCLUSION

Selectively staging the Crohn's disease operations with a loop ileostomy is a reliable practice with low morbidity and high restoration rates of bowel continuity. Our hand-sewn single-layer technique proves effective in achieving successful surgical recovery.

Predictors of complications after prophylactic ileostomy reversal for rectal cancer: A retrospective study

BACKGROUND

Previous studies have analyzed the risk factors for complications after ileostomy reversal for rectal cancer (RC), but there were significant differences in the reported risk factors for complications after stoma reversal. No studies have analyzed the risk factors for stoma-related complications and overall postoperative complications separately.

AIM

To analyze the risk factors for overall complications and stoma-related complications after ileostomy reversal for patients with RC.

METHODS

This was a retrospective study of 439 patients who underwent ileostomy reversal at a clinical center and were followed up between September 2012 and September 2022. Continuous variables are expressed as the mean ± SD and were analyzed with independent-sample t tests, while frequency variables are expressed as n (%), and the χ2 test or Fisher's exact test was used. Univariate and multivariate logistic regression analyses were used to identify predictors of overall complications and stoma-related complications.

RESULTS

The overall complication rate after ileostomy reversal was 11.4%. Patients with lower preoperative albumin concentration (P < 0.01), greater blood loss (P = 0.017), and longer operative times (P < 0.01) were more likely to experience postoperative complications. The incidence of stoma-related complications was 6.4%. Analysis of the study showed that a higher body mass index (BMI) (P < 0.01), preoperative comorbid hypertension (P = 0.049), time from primary surgery to ileostomy reversal (P < 0.01) and longer operation time (P = 0.010) were more likely to result in stoma-related complications postoperatively. Multivariate logistic regression analysis revealed that a lower preoperative albumin level (P < 0.01, OR = 0.888, 95%CI: 0.828-0.958) was an independent risk factor for overall complications. Moreover, multivariate analysis revealed that BMI (P < 0.01, OR = 1.176, 95%CI: 1.041-1.330) and time from primary surgery to ileostomy reversal (P < 0.01, OR = 1.140, 95%CI: 1.038-1.252) were independent risk factors for stoma-related complications after stoma reversal.

CONCLUSION

The preoperative albumin level was a predictor of overall complications. Preoperative BMI and the time from primary surgery to ileostomy reversal were predictors of stoma-related complications.

Comparison of purse-string technique vs linear suture for skin closure after ileostomy reversal. A randomized controlled trial

BACKGROUND

Protective stoma after rectal surgery has been associated with important complications. The most common is surgical site infection (SSI) high rates after stoma reversal reported in literature. Our study compared the rate of SSI of two skin closure techniques, linear closure, and purse string closure.

METHODS

We carried out a single center, prospective, randomized controlled trial in the Department of Colorectal Surgery of Fondazione Policlinico Campus Bio-Medico of Rome between January 2018 through December 2021, to compare LC vs PS closure of ileostomy sites.

RESULTS

A total of 117 patients (53.84% male) with a mean age of 65.68 ± 14.33 years were finally evaluated in the study. 58 patients were included in the PS group and 59 patients in the LC one. There was a marked difference in the SSI rate between the two arms of the study: 3 of 58 patients in the purse-string arm versus 11 of 59 in the control arm (p = 0.043). The outcome of cosmesis was also higher in PS, with a statistical significance (mean ± DS 4,01 ± 0,73 for PS group vs mean ± DS 2,38 ± 0,72 for LC group, p < 0,001).

CONCLUSION

Our study demonstrated that the PS technique had a significantly lower incidence of stoma site SSI compared with LC technique. Our findings are in line with other randomized studies and suggest that PS closure could be considered as standard of care for wound closure after ileostomy reversal.

Early postoperative complications after transverse colostomy closure, a retrospective study

BACKGROUND

Ostomy is a common surgery usually performed to protect patients from clinical symptoms caused by distal anastomotic leakage after colorectal cancer (CRC) surgery and perforation or to relieve intestinal obstruction.

AIM

To analyze the complications after transverse colostomy closure.

METHODS

Patients who underwent transverse colostomy closure from Jan 2015 to Jan 2022 were retrospectively enrolled in a single clinical center. The differences between the complication group and the no complication group were compared. Logistic regression analyses were conducted to find independent factors for overall complications or incision infection.

RESULTS

A total of 102 patients who underwent transverse colostomy closure were enrolled in the current study. Seventy (68.6%) patients underwent transverse colostomy because of CRC related causes. Postoperative complications occurred in 30 (29.4%) patients and the most frequent complication occurring after transverse colostomy closure was incision infection (46.7%). The complication group had longer hospital stays (P < 0.01). However, no potential risk factors were identified for overall complications and incision infection.

CONCLUSION

The most frequent complication occurring after transverse colostomy closure surgery in our center was incision infection. The operation time, interval from transverse colostomy to reversal, and method of anastomosis might have no impact on the postoperative complications. Surgeons should pay more attention to aseptic techniques.

Clinical Outcomes of Ileostomy Closure during versus after Adjuvant Chemotherapy in Patients with Rectal Cancer

Background

Protective ileostomy can effectively prevent severe anastomotic leakage after rectal cancer surgery; however, the optimal timing for ileostomy closure during adjuvant chemotherapy remains unclear. This study aimed to explore the safety and long-term outcomes of early ileostomy closure during adjuvant chemotherapy.

Method

Patients who underwent laparoscopic rectal cancer surgery combined with protective ileostomy and adjuvant chemotherapy between April 2017 and April 2021 were retrospectively evaluated. Patients were divided into an early closure group during chemotherapy (group A) and a late closure group after chemotherapy (group B).

Results

A total of 215 patients were included in this study, with 115 in group A and 100 in group B. There were no significant differences in demographic and clinical characteristics between the two groups. In group A, durations of stoma status (p < 0.001) and low anterior resection syndrome (LARS) (p < 0.001) were shorter, and rectal stenosis (p=0.036) and stoma-related complications (p=0.007), especially stoma stenosis (p=0.041), were less common. However, compliance with chemotherapy was worse (p=0.009). There were no significant differences in operative time, postoperative hospital stay, postoperative complications, incidence and severity of LARS, disease-free survival, or overall survival between groups.

Conclusion

Early ileostomy closure can effectively reduce the duration of stoma status, duration of LARS, rectal stenosis, and stoma-related complications while not affecting surgical complications and oncological outcomes. Ileostomy closure should not be delayed because of adjuvant chemotherapy. However, follow-up should be strengthened to increase compliance and integrity with chemotherapy.

Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium

PURPOSE

Anastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes.

METHODS

This is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did or did not receive DLI during LAR. Secondary outcomes included risk factors for AL, receipt of adjuvant therapy, 3-year overall survival, and 3-year recurrence.

RESULTS

Of 815 patients, 38 (4.7%) suffered AL after LAR. Patients with AL were more likely to be male, have unintentional preoperative weight loss, and are less likely to undergo DLI. On multivariable analysis, DLI remained protective against AL (p < 0.001). Diverted patients were less likely to undergo future surgical procedures including additional ostomy creation, completion proctectomy, or pelvic washout for AL. Subgroup analysis of 456 patients with locally advanced disease showed that DLI was correlated with increased receipt of adjuvant therapy for patients with and without AL on univariate analysis (SHR:1.59; [95% CI 1.19-2.14]; p = 0.002), but significance was not met in multivariate models.

CONCLUSION

Lack of DLI and preoperative weight loss was associated with anastomotic leak. Fecal diversion may improve the timely initiation of adjuvant oncologic therapy. The long-term outcomes following routine diverting stomas warrant further study.

Purse-string skin closure versus linear skin closure in people undergoing stoma reversal

BACKGROUND

Stoma reversal is associated with a relatively high risk of surgical site infection (SSI), occurring in up to 40% of cases. This may be explained by the presence of microorganisms around the stoma site, and possible contamination with the intestinal contents during the open-end manipulation of the bowel, making the stoma closure site a clean-contaminated wound. The conventional technique for stoma reversal is linear skin closure (LSC). The purse-string skin closure (PSSC) technique (circumferential skin approximation) creates a small opening in the centre of the wound, enabling free drainage of contaminants and serous fluid. This could decrease the risk of SSI compared with LSC.

OBJECTIVES

To assess the effects of purse-string skin closure compared with linear skin closure in people undergoing stoma reversal.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and three trials registers on 21 December 2022. We also checked references, searched for citations, and contacted study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing PSSC and LSC techniques in people undergoing closure of stoma (loop ileostomy, end ileostomy, loop colostomy, or end colostomy) created for any indication.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible studies, extracted data, evaluated the methodological quality of the included studies, and conducted the analyses. The most clinically relevant outcomes were SSI, participant satisfaction, incisional hernia, and operative time. We calculated odds ratios (ORs) for dichotomous data and mean differences (MDs) for continuous data, each with its corresponding 95% confidence interval (CI). We used the GRADE approach to rate the certainty of the evidence.

MAIN RESULTS

Nine RCTs involving 757 participants were eligible for inclusion. Eight studies recruited only adults (aged 18 years and older), and one study included people aged 12 years and older. The participants underwent elective reversal of either ileostomy (82%) or colostomy (18%). We considered all studies at high risk of performance and detection bias (lack of blinding) and four studies at unclear risk of selection bias related to random sequence generation. PSSC compared with LSC likely reduces the risk of SSI (OR 0.17, 95% CI 0.09 to 0.29; I2 = 0%; 9 studies, 757 participants; moderate-certainty evidence). The anticipated absolute risk of SSI is 52 per 1000 people who have PSSC and 243 per 1000 people who have LSC. The likelihood of being very satisfied or satisfied with stoma closure may be higher amongst people who have PSSC compared with people who have LSC (100% vs 89%; OR 20.11, 95% CI 1.09 to 369.88; 2 studies, 122 participants; low-certainty evidence). The results of the analysis suggest that PSSC compared with LSC may have little or no effect on the risk of incisional hernia (OR 0.51, 95% CI 0.07 to 3.70; I2 = 49%; 4 studies, 297 participants; very low-certainty evidence) and operative time (MD -2.67 minutes, 95% CI -8.56 to 3.22; I2 = 65%; 6 studies, 460 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

PSSC compared with LSC likely reduces the risk of SSI in people undergoing reversal of stoma. People who have PSSC may be more satisfied with the result compared with people who have LSC. There may be little or no difference between the skin closure techniques in terms of incisional hernia and operative time, though the evidence for these two outcomes is very uncertain.

Loop Ileostomy Closure as a 23-Hour Stay Procedure With Preoperative Efferent Limb Enteral Stimulation: A Randomized Controlled Trial

BACKGROUND

Loop ileostomy closure is a common procedure in colorectal surgery. Often seen as a simple operation associated with a low complication rate, it still leads to lengthy hospitalizations. Reducing postoperative complications and ileus rates could lead to a shorter length of stay and even ambulatory surgery.

OBJECTIVES

This study aimed to assess the safety and feasibility of ileostomy closure performed in a 23-hour hospitalization setting using a standardized enhanced recovery pathway.

DESIGN

Randomized controlled trial.

SETTINGS

Two high-volume colorectal surgery centers.

PATIENTS

Healthy adults undergoing elective ileostomy closure from July 2019 to January 2022.

INTERVENTION

All patients were enrolled in a standardized enhanced recovery pathway specific to ileostomy closure, including daily irrigation of efferent limb with a nutritional formula for 7 days before surgery. Patients were randomly allocated to either conventional hospitalization (n = 23) or a 23-hour stay (n = 24).

MAIN OUTCOME MEASURES

Primary outcome was total length of stay and secondary outcomes were 30-day rates of readmission, postoperative ileus, surgical site infections, and postoperative morbidity and mortality.

RESULTS

A total of 47 patients were ultimately randomly allocated. Patients in the 23-hour hospitalization arm had a shorter median length of stay (1 vs 2 days, p = 0.02) and similar rates of readmission (4% vs 13%, p = 0.35), postoperative ileus (none in both arms), surgical site infection (0% vs 4%, p = 0.49), postoperative morbidity (21% vs 22%, p = 1.00), and mortality (none in both arms).

LIMITATIONS

Due to coronavirus disease 2019, access to surgical beds was greatly limited, leading to a shift toward ambulatory surgery for ileostomy closure. The study was terminated early, which affected its statistical power.

CONCLUSION

Loop ileostomy closures as 23-hour stay procedures are feasible and safe. Ileus rate might be reduced by preoperative intestinal stimulation with nutritional formula through the stoma's efferent limb, although specific randomized controlled trials are needed to confirm this association. See Video Abstract .

CIERRE DE ILEOSTOMA EN ASA COMO PROCEDIMIENTO AMBULATORIO DE HORAS CON ESTMULO PREOPERATORIO ENTERAL EFERENTE ESTUDIO ALEATORIO CONTROLADO

ANTECEDENTES:El cierre de la ileostomía en asa es un procedimiento común en la cirugía colorrectal. A menudo vista como una operación simple asociada con bajas tasas de complicaciones, aún conduce a largas hospitalizaciones. La reducción de las complicaciones postoperatorias y las tasas de íleo podría conducir a una estadía hospitalaria más corta o incluso a una cirugía ambulatoria.OBJETIVOS:El presente estudio pretende evaluar la seguridad y la viabilidad del cierre de ileostomía realizadas en un entorno de hospitalización de 23 horas utilizando una vía de recuperación mejorada y estandarizada.DISEÑO:Estudio aleatorio controladoAJUSTES:Dos centros de cirugía colorrectal de gran volúmenPACIENTES:Adultos sanos sometidos a cierre electivo de ileostomía, desde Julio de 2019 hasta Enero de 2022.INTERVENCIÓN:Todos los pacientes fueron inscritos en una vía de recuperación mejorada y estandarizada específica para el cierre de la ileostomía, incluyendo la irrigación diaria de la extremidad eferente del intestino asociada a una fórmula nutricional durante 7 días previos a la cirugía. Los pacientes fueron asignados aleatoriamente en hospitalización convencional (n = 23) o a una estadía de 23 horas (n = 24).PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la duración total de la estadía hospitalaria y los resultados secundarios fueron las tasas de reingreso a los 30 días, el íleo postoperatorio, las infecciones de la herida quirúrgica, la morbilidad y mortalidad postoperatorias.RESULTADOS:Finalmente fueron randomizados un total de 47 pacientes. Aquellos que se encontraban en el grupo de hospitalización de 23 horas tuvieron una estadía media más corta (1 día versus 2 días, p = 0,02) y tasas similares de reingreso (4% vs 13%, p = 0,35), de íleo postoperatorio (ninguno en ambos brazos), de infección del sitio quirúrgico (0 vs 4%, p = 0,49), de morbilidad postoperatoria (21% vs 22%, p > 0,99) y de mortalidad (ninguna en ambos brazos).LIMITACIONES:Debido a la pandemia SARS CoV-2, el acceso a las camas quirúrgicas fue muy limitado, lo que llevó a un cambio hacia la cirugía ambulatoria para el cierre de ileostomías. El estudio finalizó anticipadamente, lo que afectó su poder estadístico.CONCLUSIÓN:Los cierres de ileostomía en asa como procedimientos de estadía de 23 horas son factibles y seguros. La tasa de íleo podría reducirse mediante la estimulación intestinal preoperatoria a través de la rama eferente del estoma asociada a fórmulas nutricionales, por lo que se necesitan estudios randomizados específicos para confirmar esta asociación. (Traducción-Dr. Xavier Delgadillo ).

Transanal Total Mesorectal Excision With Delayed Coloanal Anastomosis (TaTME-DCAA) Versus Laparoscopic Total Mesorectal Excision (LTME) and Robotic Total Mesorectal Excision (RTME) for Low Rectal Cancer: A Propensity Score-Matched Analysis of Short-term Outcomes, Bowel Function, and Cost

INTRODUCTION

Total mesorectal excision (TME) with delayed coloanal anastomosis (DCAA) is surgical option for low rectal cancer, replacing conventional immediate coloanal anastomosis (ICAA) with bowel diversion. This study aimed to assess the outcomes of transanal TME (TaTME) with DCAA versus laparoscopic TME (LTME) with ICAA versus robotic TME (RTME) with ICAA.

METHODS

This was a retrospective propensity score-matched analysis of patients who underwent elective TaTME-DCAA between November 2021 and June 2022. Patients were propensity-score matched in a ratio of 1:3 to patients who underwent LTME-ICAA and RTME-ICAA from January 2019 to December 2020. Outcome measures were histopathologic results, postoperative morbidity, function, and inpatient costs.

RESULTS

Twelve patients in the TaTME-DCAA group were compared with 36 patients in the LTME-ICAA and RTME-ICAA groups each after propensity score matching. Histopathologic results and postoperative morbidity rates were statistically similar. Overall stoma-related complication rates in the ICAA groups were 11%. Median total length of hospital stays for TME plus stoma reversal surgery was similar across all techniques (10 vs. 10 vs. 9 days; P =0.532). Despite a significantly shorter duration of follow-up, bowel function after TaTME-DCAA was comparable to that of LTME-ICAA and RTME-ICAA. Overall median inpatient costs of TaTME-DCAA were comparable to LTME-ICAA and significantly cheaper than RTME-ICAA ($31,087 vs. $29,927 vs. $36,750; P =0.002).

CONCLUSIONS

TaTME with DCAA is a feasible and safe technique compared with other minimally invasive methods of TME, while avoiding bowel diversion and stoma-related complications, as well as comparing favorably in terms of overall hospitalization costs.

Factors affecting timing of loop ileostomy closure: a regional centre's experience with 106 patients

INTRODUCTION

The burden of defunctioning ileostomy is significant with up to two thirds of patients reporting stoma-related morbidity. While timely reversal is safe and cost-effective, the time to reversal in regional Australian hospitals is not well described in professional publications. We aim to assess the current timeliness of ileostomy closure and identify possible reasons for delaying closure.

METHODS

A retrospective analysis of loop ileostomies created and reversed in Launceston General Hospital for both rectal cancer surgery and other benign indications was undertaken. Patients with loop ileostomy created between 2010 and 2020 were included. Clinical data of timing of events, complications, readmission and stoma follow-up were recorded; and analysed using multivariate regression analyses to identify clinically relevant risk factors for delayed closure.

RESULTS

A total of 123 patients underwent loop-ileostomy formation during the study period, of which 106 patients (86.2%) were reversed. Median time to closure was 8.5 months (IQR 5.2-12.4) for patients with rectal cancers, compared to 5.2 months (IQR 3.6-9.3) for patients who did not have rectal cancer, with a difference of 3.4 months (95% CI 0.9, 5.9; P = 0.008). Adjuvant chemotherapy and unexpected readmission to hospital were associated with delayed reversal (P = 0.0081 and P = 0.0005, respectively).

CONCLUSION

Stoma reversal is often scheduled 3-6 months after creation. More than two-thirds of patients experienced delays due to changing clinical concerns and non-clinical factors, such as unexpected delays at each stage of surgical planning. Early placement on the waiting list and better-coordinated follow-ups may expedite reversal surgery and reduce associated morbidities.

Single-Centre Retrospective Audit of Clostridium difficile Infections Post Ileostomy Reversal

Background Clostridium difficile (C. difficile) infection can have serious implications on patient outcomes, especially post ileostomy reversal. The symptoms can range from asymptomatic/mild to severe, with significant morbidity or mortality. Thus far, no study has been published to determine the role and impact of preoperative C. difficile testing prior to ileostomy reversal. The aim of this audit was to identify risk factors for the development of post-ileostomy reversal C. difficile infection and provide further improvements and direction for future research. Methods All patients undergoing ileostomy reversal at the General Surgery Department at Sir Charles Gairdner Hospital, a tertiary centre in Perth, Western Australia, were retrospectively identified between January 2019 and June 2021. Demographics and key data points, such as specific types of antibiotic usage, were extracted from patient notes and analysed using IBM SPSS Statistics for Windows, version 27 (released 2020; IBM Corp., Armonk, New York, United States). Results Sixty-nine patients were identified in the audit period, with 8.70% of patients testing positive for C. difficile infection post ileostomy reversal. At the index ileostomy formation operation, postoperative use of quinolone antibiotics was statistically associated with an increased risk of developing C. difficile on ileostomy reversal (odds ratio (OR) = 15.25, confidence interval (CI) 95%, p = 0.035). Intraoperative nitroimidazole use was statistically associated with a reduced risk of C. difficile infection on ileostomy reversal (OR = 0.16, CI 95%, p = 0.045). Patients who had diverticulitis as their underlying disease pathology were 10 times more likely to develop C. difficile infection post ileostomy reversal, although this finding was not statistically significant in our study. Conclusion Several risk factors were identified, such as the use of quinolone antibiotics or having underlying diverticulitis as causes for ileostomy formation. The results from this audit provides further direction in designing further research studies into the role and impact of C. difficile testing and treatment in the perioperative period around ileostomy reversal.

Effect of Negative Pressure Wound Therapy on Surgical Site Infections following Stoma Reversal in Colorectal Surgery: A Meta-Analysis

BACKGROUND

Surgical site infections (SSI) are common complications after surgery, which cause other complications and increase medical costs. However, the effect of negative-pressure wound therapy (NPWT) for the prevention of SSI at stoma reversal remains inconclusive, with controversial results. This meta-analysis aimed to evaluate the safety and efficacy of NPWT following stoma reversal in colorectal surgery to prevent SSI and other wound complications.

METHODS

We conducted a systematic search of the PubMed, EMBASE, and Cochrane Library databases for articles published up to July 2022 and identified relevant studies reporting the NPWT administration following stoma reversal in colorectal surgery compared with non-pressure dressing. The primary outcome was the incidence of SSI, and the secondary outcomes were hematoma, seroma, and length of hospital stay (LOS).

RESULTS

Nine studies were included in the meta-analysis, with 825 patients with (n = 310) or without (n = 515) NPWT. Pooled SSI rate was lower in the NPWT group than in the non-pressure dressing group (OR = 0.50; 95% CI: 0.29, 0.84; P = 0.01). There was no significant effect on hematoma (OR = 0.21; 95% CI: 0.03, 1.27; P = 0.09), seroma (OR = 0.26; 95% CI: 0.05, 1.28; P = 0.1) and LOS (MD = -0.16, 95% CI: -0.83, 0.51; P = 0.64).

CONCLUSION

The use of NPWT following stoma reversal in colorectal surgery reduced the incidence of SSI. However, this conclusion needs to be interpreted with caution, and further studies should be conducted to confirm in higher-quality RCTs.

Defining the safety of early ileostomy closure after ileal pouch anal anastomosis

PURPOSE

The safety of early ileostomy reversal after ileal pouch anal anastomosis (IPAA) has not been established. Our hypothesis was that ileostomy reversal before 8 weeks is associated with negative outcomes.

METHODS

This was a retrospective cohort study from a prospectively maintained institutional database. Patients who underwent primary IPAA with ileostomy reversal between 2000 and 2021 from a Pouch Registry were stratified on the basis of timing of reversal. Those reversed before 8 weeks (early) and those reversed from 8 weeks to 116 days (routine) were compared. The primary outcome was overall complications according to timing and reason for closure.

RESULTS

Ileostomy reversal was performed early in 92 patients and routinely in 1908. Median time to closure was 49 days in the early group and 93 days in the routine group. Reasons for early reversal were stoma-related morbidity in 43.3% (n = 39) and scheduled closure in 56.7% (n = 51). The complication rate in the early group was 17.4% versus 11% in the routine group (p = 0.085). When early patients were stratified according to reason for reversal, those reversed early for stoma-related morbidity had an increased complication rate compared to the routine group (25.6% vs. 11%, p = 0.006). Patients undergoing scheduled reversal in the early group did not have increased complications (11.8% vs. 11%, p = 0.9). There was a higher likelihood of pouch anastomotic leak when reversal was performed early for stoma complications compared to routinely (OR 5.13, 95% CI 1.01-16.57, p = 0.049).

CONCLUSIONS

Early closure is safe but could be delayed in stoma morbidity as patients may experience increased complications.

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

BACKGROUND AND AIMS

Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients.

METHODS

Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement.

RESULTS

In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting.

CONCLUSIONS

By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.

Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care in Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial

BACKGROUND

Practices such as prolonged preoperative fasting, bowel preparation, delayed ambulation and resumption of orals result in morbidity in 15-20% of stoma reversal cases which can be improved by Enhanced Recovery After Surgery (ERAS) pathways.

AIM

To evaluate the safety, feasibility and efficacy of ERAS pathway in patients undergoing elective loop ileostomy or colostomy reversal surgery METHODS: This was an open-labeled, superiority randomized controlled trial in which patients undergoing loop ileostomy or colostomy reversal were randomized to standard or ERAS care. Patients with ASA class ≥3, needing laparotomy for stoma reversal, cardiac, renal and neurological illnesses were excluded. Components of ERAS protocol included pre-operative carbohydrate loading, avoidance of mechanical bowel preparation, goal directed fluid therapy, avoidance of long-acting opioid anesthetics or analgesics, avoidance of drains, urinary catheter or nasogastric tube, early mobilization and early enteral feeding. The primary outcome was length of stay (LOS) while the secondary outcomes were postoperative recovery and morbidity parameters.

RESULTS

Forty patients each were randomized to standard care and ERAS. Demographic and laboratory parameters between the two groups were comparable. ERAS group patients had significantly reduced LOS (5.3 ± 0.3 vs 7 ± 2.6; mean difference: 1.73 ± 0.98; p=0.0008). Functional recovery was earlier in the ERAS group compared to the standard care group, such as early resolution of ileus (median-2 days; p<0.001), time to first stool (median-3 days; p=0.0002), time to the resumption of liquid diet (median-3 days; p<0.001) and solid diet (median-4 days; p<0.001). Surgical site infections (SSI) were significantly lesser in ERAS group (12.5% vs 32.5%; p=0.03) while postoperative nausea/vomiting (p=0.08), pulmonary complications (p=0.17) and urinary tract infections (p=0.56) were comparable in both groups.

CONCLUSION

ERAS pathways are feasible, safe and significantly reduces LOS in patients undergoing elective loop ileostomy or colostomy reversal surgery.

Decreasing rates of colectomy for benign neoplasms: A nationwide analysis

BACKGROUND

Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms.

METHODS

All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups.

RESULTS

Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001).

CONCLUSIONS

The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.

Protective ileostomy after low anterior resection for extraperitoneal rectal cancer: does the reversal surgery timing affect closure failure?

Loop ileostomy is commonly performed after LAR with TME to temporarily protect the anastomosis. Usually, defunctioning stoma is closed after 1-6 months, although sometimes it becomes definitive de facto. The aim of this study is to investigate the long-term risk of no-reversal of protective ileostomy after LAR for middle-low rectal cancer and the predictive risk factors. A retrospective analysis of a consecutive cohort of patients who underwent curative LAR with covering ileostomy for extraperitoneal rectal cancer in two colorectal units was performed. A different policy for scheduling stoma closure was applied between centers. All the data were collected through an electronic database (Microsoft Excel®). Descriptive statistical analysis was performed using Fisher's exact and Student's t test. Multivariate logistic regression analysis was conducted. Two-hundred twenty-two patients were analysed: reversal procedure was carried out in 193 patients, in 29 cases stoma was never closed. The mean interval time from index surgery was 4.9 months (Center1: 3 vs. Center2: 7.8). At the univariate analysis, mean age and tumor stage were significantly higher in the "no-reversal" group. Unclosed ostomies were significantly lower in Center 1 than Center 2 (8% vs. 19.6%). At the multivariate analysis female gender, anastomotic leakage and Center 2 had significant higher risk of unclosed ileostomy. Currently, no clinical recommendations have been established and the policy of scheduling stoma reversal is variable. Our study suggests that an established protocol could avoid closure delay, decreasing permanent stomas. Consequently, ileostomy closure should be weighed as standardized step in cancer therapeutic pathway.

Comparison of modified gunsight suture technique and traditional interrupted suture in enterostomy closure

BACKGROUND

Prophylactic enterostomy surgery is a common surgical approach used to reduce the risk of anastomotic leakage in patients who have undergone partial intestinal resection due to trauma or tumors. However, the traditional interrupted suturing technique used in enterostomy closure surgery has several issues, including longer surgical incisions and higher incision tension, which can increase the risk of postoperative complications. To address these issues, scholars have proposed the use of a "gunsight suture" technique. This technique involves using a gunsight incision instead of a traditional linear incision, leaving a gap in the center for the drainage of blood and fluid to reduce the risk of infection. Building on this technique, we propose an improved gunsight suture technique. A drainage tube is placed at the lowest point of the incision and close the gap in the center of the gunsight suture, which theoretically facilitates early postoperative mobility and reduces the burden of dressing changes, thereby reducing the risk of postoperative complications.

AIM

To compare the effectiveness of improved gunsight suture technique with traditional interrupted suture in closing intestinal stomas.

METHODS

In this study, a retrospective, single-center case analysis was conducted on 270 patients who underwent prophylactic ileostomy closure surgery at the Department of Colorectal Surgery of Qilu Hospital from April 2017 to December 2021. The patients were divided into two groups: 135 patients received sutures using the improved gunsight method, while the remaining 135 patients were sutured with the traditional interrupted suture method. We collected data on a variety of parameters, such as operation time, postoperative pain score, body temperature, length of hospital stays, laboratory indicators, incidence of incisional complications, number of wound dressing changes, and hospitalization costs. Non-parametric tests and chi-square tests were utilized for data analysis.

RESULTS

There were no statistically significant differences in general patient information between the two groups, including the interval between the first surgery and the stoma closure [132 (105, 184) d vs 134 (109, 181) d, P = 0.63], gender ratio (0.64 vs 0.69, P = 0.44), age [62 (52, 68) years vs 60 (52, 68) years, P = 0.33], preoperative body mass index (BMI) [23.83 (21.60, 25.95) kg/m² vs 23.12 (20.94, 25.06) kg/m², P = 0.17]. The incidence of incision infection in the improved gunsight suture group tended to be lower than that in the traditional interrupted suture group [ (n = 2/135, 1.4%) vs (n = 10/135, 7.4%), P < 0.05], and the postoperative hospital stay in the improved gunsight suture group was significantly shorter than that in the traditional interrupted suture group [5 (4, 7) d vs 7 (6, 8) d, P < 0.05]. Additionally, the surgical cost in the modified gunsight suture group was slightly lower than that in the traditional suture group [4840 (4330, 5138) yuan vs 4980 (4726, 5221) yuan, P > 0.05], but there was no significant difference in the total hospitalization cost between the two groups.

CONCLUSION

In stoma closure surgery, the improved gunsight technique can reduce the incision infection rate, shorten the postoperative hospital stay, reduce wound tension, and provide better wound cosmetic effects compared to traditional interrupted suture.

Risk Factors for Radical Rectal Cancer Surgery with a Temporary Stoma Becoming a Permanent Stoma: A Pooling Up Analysis

Purpose: The aim of this study was to find out the potential risk factors for the formation of a permanent stoma (PS) for rectal cancer patients with a temporary stoma (TS) after surgery. Methods: PubMed, Embase, and the Cochrane Library were searched for eligible studies until November 14, 2022. The patients were divided into the PS group and the TS group. Odds ratio (ORs) and 95% confidence intervals (CIs) were pooled up for describing dichotomous variables. Stata SE 16 was performed for data analysis. Results: After pooling up the data, a total of 14 studies involving 14,265 patients were included in this study. The outcomes showed that age (OR = 1.03, 95% CI = 0.96 to 1.10, I2 = 1.42%, P = .00 < .1), surgery type (P = .00 < .1), tumor stage (P = .00 < .1), preoperative chemoradiotherapy (P = .00 < .1), preoperative radiotherapy (P = .01 < .1), neoadjuvant therapy (P = .00 < .1), American Society of Anesthesiologists (ASA) score of ≥3 (P = .00 < .1), anastomotic leakage (P = .01 < .1), local recurrence (P = .00 < .1), and distant recurrence (P = .00 < .1) were associated with the patient with PS. However, sex (P = .15 > .1), previous abdominal surgery (P = .84 > .1), adjuvant chemotherapy (P = .87 > .1), and defunctioning stoma (P = .1) had little association with PS. Conclusion: Patients who were elderly, had advanced tumor stages, had a high ASA score, and underwent neoadjuvant therapy should be informed of the high risk of PS before surgery. Meanwhile, those who underwent rectal cancer surgery with a TS should beware of anastomotic leakage, local recurrences, and distant recurrences, which could increase the risk of PS.

Comparison of clinical outcomes of stoma reversal during versus after chemotherapy for rectal cancer patients

PURPOSE

The optimal timing of stoma closure during or after adjuvant chemotherapy for rectal cancer patients undergoing sphincter-preserving surgery remains unknown. This study aimed to investigate the influence of clinical and oncological outcomes depending on the timing of stoma closure.

METHODS

Between January 2006 and December 2015, we enrolled 244 consecutive rectal cancer patients who underwent curative-intent sphincter-preserving surgery with diverting transverse colostomy and adjuvant chemotherapy. Patients with stoma closure during (During group) adjuvant chemotherapy were compared to those who had stoma closure after adjuvant chemotherapy (After group).

RESULTS

Parastomal hernia occurred more frequently in the after group than in the during group. (10% vs. 2.9%, p = 0.028). Overall, no significant difference was observed in overall survival (OS) or disease-free survival (DFS) between the two groups (p = 0.911 for OS, p = 0.505 for DFS). However, an inferior OS occurred if reopen surgery was performed within 30 days of stoma closure in the during group, as compared with the after group (p = 0.004). In addition, a marginally poor DFS was observed in the group of patients who received further operations due to 30-day stoma closure complications compared to the other patients (p = 0.07).

CONCLUSIONS

For rectal cancer patients who underwent sphincter-preserving surgery, attention should be given to avoid 30-day major complications after stoma reversal because patients who require reoperation during adjuvant chemotherapy may have poor long-term survival.

Defunctioning stoma in anterior resection for rectal cancer does not impact anastomotic leakage: a national population-based cohort study

BACKGROUND

Anterior resection (AR) is considered the gold standard for curative cancer treatment in the middle and upper rectum. The goal of the sphincter-preserving procedure, such as AR, is vulnerable to anastomotic leak (AL) complications. Defunctioning stoma (DS) became the protective measure against AL. Often a defunctioning loop-ileostomy is used, which is associated with substantial morbidity. However, not much is known if the routine use of DS reduces the overall incidence of AL.

METHODS

Elective patients subjected to AR in 2007-2009 and 2016-18 were recruited from the Swedish colorectal cancer registry (SCRCR). Patient characteristics, including DS status and occurrence of AL, were analyzed. In addition, independent risk factors for AL were investigated by multivariable regression.

RESULTS

The statistical increase of DS from 71.6% in 2007-2009 to 76.7% in 2016-2018 did not impact the incidence of AL (9.2% and 8.2%), respectively. DLI was constructed in more than 35% of high-located tumors ≥ 11 cm from the anal verge. Multivariable analysis showed that male gender, ASA 3-4, BMI > 30 kg/m², and neoadjuvant therapy were independent risk factors for AL.

CONCLUSION

Routine DS did not decrease overall AL after AR. A selective decision algorithm for DS construction is needed to protect from AL and mitigate DS morbidities.

Laparoscopic versus open loop ileostomy reversal: A systematic review and meta-analysis

Background

Loop ileostomies (LIs) are used for temporary fecal diversion to protect downstream colorectal anastomoses. Standard operative approach for LI reversal has been through an open technique. Recently, laparoscopic LI reversal has been employed and studied. The aim of this systematic review was to compare laparoscopic and open LI reversal.

Methods

Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared rate of postoperative morbidity and/or length of stay (LOS) in patients undergoing laparoscopic or open LI reversal. Pairwise meta-analyses using inverse variance random effects was performed. The Grading of Recommendations, Assessment, Development, and Evidence (GRADE) approach was conducted to assess quality of evidence.

Results

From 410 citations, four observational studies with 213 patients undergoing laparoscopic LI reversal and 176 patients undergoing open LI reversal met inclusion. Patients in the laparoscopic group had significantly shorter LOS (MD -0.39, 95%CI -0.73 to -0.04, p = 0.03). Laparoscopic and open LI reversal were comparable in postoperative morbidity, aside from a decrease of superficial surgical site infection (sSSI) with the use of laparoscopy (OR 0.22, 95%CI 0.07 to 0.71, p = 0.01). Operative time was not significantly different between groups (MD 11.91, 95%CI -1.87 to 25.70, p = 0.09). The GRADE quality of evidence was low to very low.

Conclusions

This review presents low quality evidence that laparoscopic LI reversal is a feasible approach that may reduce postoperative LOS and sSSI compared to open LI reversal without increasing operative time. Future prospective comparative studies are required to confirm the findings of the present review.

Short-term outcome of diverting loop ileostomy reversals performed by residents: a retrospective cohort prognostic factor study

AIM

The reversal of diverting loop ileostomy (DLI) is one of surgical trainees' first procedures. Complications of DLI reversal can cause life-threatening complications and increase patient morbidity. This study compared DLI reversals performed by surgical trainees with those by attending surgeons.

METHOD

This retrospective cohort study was performed at a single primary care center on 300 patients undergoing DLI reversal. The primary outcome was morbidity, according to the Clavien-Dindo classification (CDC), with special attention paid to the surgeon's level of training. The secondary endpoint was postoperative intestinal motility dysfunction.

RESULTS

Surgical trainees had significantly longer operation times (p < 0.001) than attending surgeons. Univariate analyses revealed no influence on the level of training for postoperative morbidity. First bowel movement later than 3 days after surgery was a significant risk factor for CDC [Formula: see text] 3 (OR, 4.348; 96% CI, 1670-11.321; p = 0.003). Independent risk factors for surgical site infections (SSIs) were an elevated BMI (OR, 1.162; 95% CI, 1.043-1.1294; p = 0.007) and a delayed bowel movement (OR, 3.973; 95% CI, 1.300-12.138; p = 0.015). For postoperative intestinal motility dysfunction, an independent risk factor was a primary malignant disease (OR, 1.980; 95% CI, 1.120-3.500; p = 0.019), and side-to-side stapled anastomosis was a protective factor (OR, 0.337; 95% CI 0.155-0.733; p = 0.006).

CONCLUSION

Even though surgical trainees needed significantly more time to perform the surgery, the level of surgical training was not a risk factor for increased postoperative morbidity. Instead, delayed first bowel movement was predictive of SSI.

Early versus late reversal of diverting loop ileostomy in rectal cancer surgery: a multicentre randomized controlled trial

Diverting loop ileostomy has become routine in low anterior resection (LAR) for rectal cancer. The optimal time for stoma reversal is controversial. The aim of the present study was to compare the results after planned early (within 8-12 days) versus late (> 3 months) stoma reversal. The primary outcomes were morbidity and mortality, as measured by the Comprehensive Complication Index (CCI) within 30 days after stoma reversal, and the secondary outcomes were morbidity and mortality within 90 days after LAR. This was a multicentre trial including all patients scheduled for anterior low resection for rectal cancer with curative intent. Inclusion period was from April 2011 to December 2018. All patients were randomized 1:1 prior to surgery. Among 257 consecutive and eligible patients, a total of 214 patients were randomized: 107 patients to early stoma reversal and 107 to late reversal. A total of 68 patients were excluded for various reasons, and 146 patients completed the study, with 77 in the early reversal group and 69 in the late reversal group. The patients were asked to complete the Gastrointestinal Quality of Life Index before surgery (baseline) and at 6 and 12 months after LAR. Ostomy-related complications were evaluated by dedicated ostomy staff using the validated DET score. ClinicalTrials Identifier: NCT01865071. Fifty-three patients (69%) in the early reversal group and 60 patients (87%) in the late reversal group received the intended treatment. There were no significant differences in CCI within 90 days after index surgery with the LAR and within 30 days after stoma reversal between the two groups. There were no differences in patient-reported quality of life but significantly more stoma-related complications in the late reversal group. A total of 5 patients experienced anastomotic leakage (AL) after stoma reversal, 4 in the early reversal group and one in the late reversal group. Early and late stoma reversal showed similar outcomes in terms of overall complications and quality of life. The risk of developing anastomotic leakage after early ostomy reversal is a concern.

Hand-sewn direct repair versus resection and hand-sewn anastomosis techniques for the reversal of diverting loop ileostomy after lower anterior rectal resection surgery: A randomized clinical trial

INTRODUCTION

Several techniques have been proposed for the closure of loop ileostomy. This is the first study comparing bowel function and outcomes of two different hand-sewn surgical techniques used for the closure of diverting protective loop ileostomy.

METHOD

In this prospective, randomized, double-blind clinical trial, 40 patients with a history of rectal cancer, low anterior resection, and diverting loop ileostomy who were candidates for ileostomy reversal were included and randomly assigned into two groups, hand-sewn direct repair of the ileal defect (group A) and resection and hand-sewn anastomosis of the ileum (group B).

RESULTS

The mean age of patients was 56.42 and 52.10 years in groups A and B, respectively. Regarding early postoperative period, group A developed earlier first gas passage (1.68 vs. 2.25 days, p = 0.041) and stool passage (2.10 vs. 2.80 days, p = 0.032). Group A also revealed shorter operating time (83.68 vs. 89.50 min, p = 0.040) and hospital stay (4.73 vs. 6.80 days, p = 0.001). None of the participants in both groups developed signs of bowel obstruction during the early and late postoperative follow-up period.

CONCLUSIONS

Direct hand-sewn repair for the closure of diverting loop ileostomy is a safe technique with better postoperative bowel function, oral diet tolerance, and less hospital stay compared to resection and hand-sewn anastomosis of the ileum.

Impact of a diverting ileostomy in total mesorectal excision with primary anastomosis for rectal cancer

BACKGROUND

The role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity.

METHODS

Patients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity.

RESULTS

In 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424-4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%.

CONCLUSIONS

The stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

A multidimensional learning curve analysis of totally laparoscopic ileostomy reversal using a single surgeon' s experience

Purpose

Recently, totally laparoscopic ileostomy reversal (TLAP) has received increasing attention and exhibited promising short-term outcomes. The aim of this study was to detail the learning process of the TLAP technique.

Methods

Based on our initial experience with TLAP from 2018, a total of 65 TLAP cases were enrolled. Demographics and perioperative parameters were assessed using cumulative sum (CUSUM), moving average, and risk-adjusted CUSUM (RA-CUSUM) analyses.

Results

The overall mean operative time (OT) was 94 min and the median postoperative hospitalization period was 4 days, and there was an estimated 10.77% incidence rate of perioperative complications. Three unique phases of the learning curve were derived from CUSUM analysis, and the mean OT of phase I (1-24 cases) was 108.5 min, that of phase II (25-39 cases) was 92 min, and that of phase III (40-65 cases) was 80 min, respectively. There was no significant difference in perioperative complications between these 3 phases. Similarly, moving average analysis indicated that the operation time was reduced significantly after the 20th case and reached a steady state after the 36th case. Furthermore, complication-based CUSUM and RA-CUSUM analyses indicated an acceptable range of complication rates during the whole learning period.

Conclusion

Our data demonstrated 3 distinct phases of the learning curve of TLAP. For an experienced surgeon, surgical competence in TLAP can be grasped at around 25 cases with satisfactory short-term outcomes.

Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis

Anastomotic leakage (AL) is the most fearsome complication in low rectal resection. The temporary diverting stoma (DS) is recommended to prevent AL, but it may cause relevant morbidity and needs a second surgical procedure to be closed. Therefore, the use of a transanal drainage tube (TDT) has been proposed as an alternative. We performed a systematic review and meta-analysis concerning the peri-operative outcomes in patients undergoing elective anterior rectal resection (ARR) with TDT alone or DS alone. Six studies were meta-analyzed, including a total of 735 patients. The meta-analysis showed that the incidences of AL, surgery-related complications, infective complications, and 30-day reoperation after ARR with low colorectal or coloanal anastomosis did not differ significantly between patients undergoing positioning of TDT and those undergoing DS. Furthermore, overall complications were significantly rarer in patients undergoing TDT. A meta-analysis of the randomized control trial (RCT) and no-RCT subgroups did not detect any statistically significant differences in any outcomes. These results suggest that it might be reasonable to employ a TDT in place of a DS to protect low colorectal and coloanal anastomosis, with consequent considerable advantages in terms of the short- and long-term post-operative outcomes. However, more well-designed RCTs are needed to definitively assess this issue.

The role of transanal tube after low anterior resection in patients with rectal cancer treated with neoadjuvant chemoradiotherapy: A propensity score-matched study

BACKGROUND

The protective efficacy of transanal tube for anastomosis was compared with that of diverting stoma in patients with rectal cancer treated with neoadjuvant chemoradiotherapy.

METHODS

We included consecutive patients with rectal cancer treated with neoadjuvant chemoradiotherapy and curative surgery from January 2013 to December 2019. The patients were grouped into transanal tube or diverting stoma, according to the protection methods they received. Propensity score-matching with 1:1 ratio was done. The primary outcome was the incidence of anastomotic leakage.

RESULTS

Of the 656 eligible patients, 207 (31.6%) and 385 (58.7%) patients were grouped into transanal tube and diverting stoma, respectively, and 64 (9.7%) patients who did not undergo either transanal tube or diverting stoma were excluded. After matching, the incidence of anastomotic leakage was 9.7% and 10.6% in diverting stoma and transanal tube, respectively (P = .871). The overall morbidity was 23.2% and 15.0% in diverting stoma and transanal tube, respectively (P = .045). In the multivariate analysis, tumor size >2.5 cm and level of anastomosis <4 cm were significant risk factors for anastomotic leakage. In a subgroup analysis for patients with the level of anastomosis >4 cm, the incidence of anastomotic leakage was not significantly different between the transanal tube and diverting stoma groups. However, for patients with a level of anastomosis <4 cm, the incidence of grade C anastomotic leakage was significantly greater in the transanal tube than in the diverting stoma group (2.5% vs 9.9%, P = .040).

CONCLUSION

The protective efficacy of transanal tube may be comparable to diverting stoma, especially for those with a level of anastomosis >4 cm.

Rectal stimulation with prebiotics and probiotics before ileostomy reversal: a study protocol for a randomized controlled trial

BACKGROUND

Ileostomy closure is associated with a high rate of postoperative morbidity, and adynamic ileus is the most common complication, with an incidence of up to 32%. This complication is associated with delayed initiation of oral diet intake, abdominal distention, prolonged hospital stay, and more significant patient discomfort. The present study aims to evaluate the rectal stimulus with prebiotics and probiotics before ileostomy reversal.

METHODS

This is a protocol study for an open-label randomized controlled clinical trial. Ethical approval was received (CAAE: 56551722.6.0000.0071). The following criteria will be used for inclusion: adult patients with rectal cancer stages cT3/4Nx or cTxN+ that underwent loop protection ileostomy, patients treated with neoadjuvant chemoradiotherapy, and patients who underwent laparoscopic or robotic total mesorectal excision. Patients will be randomized to one of two groups. The intervention group (with rectal stimulus): the patients will apply 500 ml of saline solution with 6 g of Simbioflora® rectally, once a day, for 15 days before ileostomy closure. The control group (without rectal stimulation): the patients will close the ileostomy with no previous rectal stimulus. The primary outcomes will be the adynamic ileus (need for postoperative nasogastric tube insertion; nausea/vomiting; or intolerance to oral feedings within the first 72 h) and intestinal transit (time to first evacuation/flatus).

RESULTS

The patient's enrollment starts in January 2023. We expect to finish in July 2025.

DISCUSSION

The findings of this randomized clinical study may have important implications for managing patients undergoing ileostomy reversal.

TRIAL REGISTRATION

This study is registered in the Brazilian Trial Registry (ReBEC) under RBR-366n64w. Registration date: 19/07/2022.

Satisfactory short-term outcomes of totally laparoscopic ileostomy reversal compared to open surgery in colorectal cancer patients

Background

Recently, totally laparoscopic (TLAP) surgery has suggested its potential on ileostomy reversal. This study aimed to compare the short-term outcomes between TLAP and traditional open ileostomy reversal.

Patients and methods

From September 2016 to September 2021, 107 eligible patients underwent TLAP (n = 48) or open (n = 59) loop ileostomy reversal were retrospectively enrolled. Surgical parameters, postoperative recovery and complications were identified and compared between TLAP technique vs. open surgery.

Results

The operation time and estimated blood loss showed no obvious difference between TLAP and open group. However, TLAP reversal significantly decreased the incision length (4.5cm vs. 6cm, P < 0.001). Furthermore, patients underwent TLAP surgery showed quicker first ground activities (1 day vs. 2 days, P < 0.001), faster first flatus passage (2 days vs. 3 days, P = 0.004) and shorter postoperative stay (5 days vs. 7 days, P = 0.007). More importantly, postoperative complications were significantly reduced after TLAP reversal (3 cases vs. 10 cases, P = 0.026). Further logistic regression analyses also indicated the TLAP technique was associated with lower incidence of complications (OR=3.316, CI, 1.118-9.835; P = 0.031).

Conclusions

TLAP surgery is competitive in promoting postoperative recovery as well as reducing complications compared to the traditional open ileostomy reversal.

Postoperative Morbidity Following Loop Ileostomy Reversal after Primary Elective or Urgent Surgery: A Retrospective Study with 145 Patients

Temporary loop ileostomy is usually performed to protect distal anastomosis or to treat urgent surgical cases. The aim of this study is to evaluate whether, after primary urgent stoma construction, patients undergoing ileostomy reversal have different postoperative outcomes compared with patients who have protective stoma performed in an elective setting. A retrospective observational study was conducted including patients who underwent ileostomy reversal. Baseline patient characteristics and perioperative outcomes were collected in a single database. The overall morbidity rate during recovery was fixed as a primary outcome. Between 2011 and 2021, the complete data records of 145 patients were evaluated. After ileostomy reversal, the postoperative morbidity rate did not differ between groups (14.4% vs. 11.5%, p = 0.790). Even considering each complication, such as ileus, small bowel obstruction, bleeding and wound infection, no significant difference was detected. Similarly, the time to first flatus was 2.25 ± 1.24 vs. 2.1 ± 0.99 (p = 0.379) and the length of hospital stay was 5.43 ± 3.03 vs. 5.84 ± 5.15 (p = 0.568). The only significant factor associated with postoperative complications on logistic regression analysis was the presence of comorbidities (OR 4.49; 95% CI 1.19-29.4, p = 0.05). In the present cohort of patients, there was no difference in the postoperative complication rate after stoma closure following elective or urgent indication for surgery.

Patient and surgeon preferences for early ileostomy closure following restorative proctectomy for rectal cancer: why aren't we doing it?

BACKGROUND

Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC.

METHODS

A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively.

RESULTS

Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients.

CONCLUSIONS

Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.

The Colorectal Anastomosis: A Timeless Challenge

Colorectal anastomosis is a sophisticated problem that demands an elaborate discussion and an elegant solution. "Those who forget the past are condemned to repeat it." George Santayana, Life of Reason , 1905.

Short-stay compared to long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis

PURPOSE

Short-stay admissions, with lengths of stay less than 24 h, are used for various surgeries without increasing adverse events. However, it is unclear if short-stay admissions would be safe for loop ileostomy reversals. This review aimed to compare outcomes between short (≤24 hours) and long (>24 hours) admissions for adults undergoing loop ileostomy reversals.

METHODS

Medline, Embase, CINAHL, Web of Science, and the Cochrane Library were systematically searched for studies comparing short- to long-stay admissions in adults undergoing loop ileostomy reversals. Meta-analyses were conducted for mortality, reoperation, readmission, and non-reoperative complications. Quality of evidence was assessed with grading of recommendations, assessment, development, and evaluations (GRADE) guidelines.

RESULTS

Four observational studies enrolling 24,628 patients were included. Moderate certainty evidence suggests there is no difference in readmissions between short- and long-stay admissions (relative risk (RR) 0.98, 95% CI 0.75 to 1.28, p 0.86). Low certainty evidence demonstrates that short stays may reduce non-reoperative complications (RR 0.44, 95% CI 0.31 to 0.62, p < 0.01). Very low certainty evidence demonstrates that there is no difference in reoperations between short and long stays (RR 1.14, 95% CI 0.26 to 5.04, p 0.87).

CONCLUSIONS

Moderate certainty evidence demonstrates that there is no difference in readmission rates between short- and long-stay admissions for loop ileostomy reversals. Less robust evidence suggests equivalence in reoperations and a decrease in non-reoperative complications. Future prospective trials are required to evaluate the feasibility and efficacy of short-stay admissions.

TRIAL REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307381 Prospero (CRD42022307381), January 30, 2022.

From Formation to Closure: Aggregate Morbidity and Mortality Associated With Defunctioning Loop Ileostomies

BACKGROUND

Defunctioning loop ileostomies are used commonly, but there are significant morbidities.

OBJECTIVE

This study aimed to describe the morbidity and mortality associated with the formation and closure of defunctioning loop ileostomies.

DESIGN

This descriptive study is based on electronic health records and claims data.

SETTINGS

This study was conducted at academic and community hospitals in Ontario, Canada.

PATIENTS

Adult patients who had a low anterior resection with concurrent defunctioning loop ileostomy from 2002 to 2014 were included.

MAIN OUTCOME MEASURES

Outcomes of interest included 30-day major complications, acute kidney injury, transfusion, and deep space infection. The rate of ileostomy reversal and the percentage of permanent ostomies were also collected.

RESULTS

The cohort consists of 4658 patients who underwent low anterior resection with concurrent defunctioning loop ileostomy. The 30-day, 90-day, and 1-year mortality rates of these patients were 1.2%, 2.2%, and 5.1%. The rate of reoperation was 5.5%, the rate of hospital readmission was 13.4%, the rate of major complications was 28.5%, the rate of deep organ/space infection requiring percutaneous intervention was 5.2%, and the rate of acute kidney injury requiring hospitalization was 10.4%. Eighty-six percent had their ileostomy reversed, leaving 13.2% with a permanent ostomy. After ileostomy reversal, 30-day and 90-day mortality rates were 0.6% and 0.9%. The rate of major complications was 10.3%, bowel obstruction 7%, ventral hernia 10.5%, deep space infection 1.7%, and repeat operation 2.3%.

LIMITATIONS

This study is based on electronic health records and claims data and, thus, the accuracy of results depends on the accuracy of data administration' which can be variable across institutions.

CONCLUSIONS

Morbidity and mortality of defunctioning loop ileostomies are significant. One in 8 patients will have a permanent ostomy. See Video Abstract at http://links.lww.com/DCR/B810 .

DESDE LA FORMACIN HASTA EL CIERRE AGREGADA MORBILIDAD Y MORTALIDAD ASOCIADA CON LAS ILEOSTOMAS EN ASA DERIVATIVA

ANTECEDENTES:Las ileostomías en asa derivativa se utilizan con frecuencia, pero existen morbilidades importantes.OBJETIVO:Describir la morbilidad y mortalidad asociadas con la formación y cierre de ileostomías en asa derivativa.DISEÑO:Estudio descriptivo basado en historias clínicas electrónicas y datos de reclamaciones.ENTORNO CLINICO:Hospitales académicos y comunitarios en Ontario, Canadá.PACIENTES:Pacientes adultos sometidos a resección anterior baja con concurrente ileostomía en asa derivativa de 2002 a 2014.PRINCIPALES MEDIDAS DE VALORACION:Los resultados de interés incluyeron complicaciones mayores a los 30 días, lesión renal aguda, transfusión e infección del espacio profundo. También se recolectó la tasa de reversión de la ileostomía y el porcentaje de ostomías permanentes.RESULTADOS:La cohorte consistió de 4658 pacientes sometidos a resección anterior baja con concurrente ileostomía en asa derivativa. La mortalidad de estos pacientes, a treinta días, 90 días y un año, fue del 1,2%, 2,2% y 5,1%, respectivamente. La tasa de reintervención fue del 5,5%, el reingreso hospitalario fue del 13,4%, la complicación mayor fue del 28,5%, la infección profunda de órganos / espacios que requirieron intervención percutánea fue del 5,2%, y la lesión renal aguda que requirió hospitalización fue del 10,4%. Ochenta y seis por ciento tuvieron reversión de su ileostomía, dejando al 13.2% con una ostomía permanente. Después de la reversión de la ileostomía, la mortalidad a los 30 días y 90 días fue de 0,6% y 0,9%, respectivamente. La tasa de complicaciones mayores fue del 10,3%, obstrucción intestinal del 7%, hernia ventral del 10,5%, infección del espacio profundo del 1,7% y reintervención del 2,3%.LIMITACIONES:El estudio se basa en registros médicos electrónicos y datos de reclamos y, por lo tanto, la precisión de los resultados depende de la precisión en la administración de datos, que pueden variar entre instituciones.CONCLUSIONES:La morbilidad y la mortalidad de las ileostomías en asa derivativa son significativas. Uno de cada 8 pacientes tendrá una ostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/B810 . (Traducción-Dr. Fidel Ruiz Healy ).

Management of a traumatic anorectal full-thickness laceration: a case report

The rectum is the least frequently injured organ in trauma, with an incidence of about 1% to 3% in trauma cases involving civilians. Most rectal injuries are caused by gunshot wounds, blunt force trauma, and stab wounds. A 46-year-old male patient was crushed between two vehicles while he was working. He was hemodynamically unstable, and the Focused Assessment with Sonography for Trauma showed hemoperitoneum and hemoretroperitoneum; therefore, damage control surgery with pelvic packing was performed. A subsequent whole-body computed tomography scan showed a displaced pelvic bone and sacrum fracture. There was evidence of an anorectal full-thickness laceration and urethral laceration. In second-look surgery performed 48 hours later, the pelvis was stabilized with external fixators, and it was decided to proceed with loop sigmoid colostomy. A tractioned rectal probe with an internal balloon was positioned in order to approach the flaps of the rectal wall laceration. On postoperative day 13, a radiological examination with endoluminal contrast injected from the stoma after removal of the balloon was performed and showed no evidence of extraluminal leak. Rectosigmoidoscopy, rectal manometry, anal sphincter electromyography, and trans-stomic transit examinations showed normal findings, indicating that it was appropriate to proceed with the closure of the colostomy. The postoperative course was uneventful. The optimal management for extraperitoneal penetrating rectal injuries continues to evolve. Primary repair with fecal diversion is the mainstay of treatment, and a conservative approach to rectal lacerations with an internal balloon in a rectal probe could provide a possibility for healing with a lower risk of complications.