Comparison of stapled versus handsewn loop ileostomy closure: a meta-analysis

Laparoscopic vs. open loop ileostomy reversal: a meta-analysis of randomized and non-randomized studies

PURPOSE

The present meta-analysis compares laparoscopic loop ileostomy reversal (LLIR) with open loop ileostomy reversal (OLIR) to evaluate the advantages of the laparoscopic technique compared to the traditional open technique in ileostomy reversal.

METHODS

Primary endpoints were hospital stay and overall complications. Secondary endpoints were operative time, EBL, readmission, medical complications, surgical complications, reoperation, wound infection, anastomotic leak, intestinal obstruction, and cost of the procedures. The included studies were also divided based on the type of anastomotic approach: extracorporeal laparoscopic loop ileostomy reversal (ELLIR) and intracorporeal laparoscopic loop ileostomy reversal (ILLIR).

RESULTS

In the analysis, 4 studies were included. Three hundred fifty-four patients were enrolled. As primary outcomes, a significant difference was found in hospital stay between the LLIR and OLIR groups (MD = -0.67, 95% CI -1.16 to -0.19, P = 0.007). The overall complications outcome resulted in favor of the LLIR group (RR = 0.64, 95% CI 0.43-0.95, P = 0.03). As secondary outcomes, the operative time was in favor of the OLIR group (MD = 19.18, 95% CI 10.20-28.16, P < 0.001). Surgical complications were lower in the LLIR group than in the OLIR group. No other differences between the secondary endpoints were found. Subgroup analysis showed a significant difference in hospital stay between the ILLIR and OLIR groups (MD = -0.92, 95% CI -1.55 to -0.30, P = 0.004). The overall complications outcome significantly favored the ILLIR group (RR = 0.38, 95% CI 0.15-0.96, P = 0.04).

CONCLUSION

Our meta-analysis shows an advantage in terms of shorter post-operative hospitalization and reduction of complications of LLIR compared to OLIR. The sub-group analysis shows that performing an extracorporeal anastomosis exposes the same risks of the open technique.

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.

A comparison of extracorporeal side to side or end to side anastomosis following a laparoscopic right hemicolectomy for colon cancer

Background

This study aimed to investigate whether an extracorporeal side‐to‐side (SS) or end‐to‐side (ES) stapled anastomosis impacts short‐term and long‐term outcomes after an oncological laparoscopic right hemicolectomy.

Methods

A retrospective cohort study of prospectively collected data from two Victorian tertiary referral hospitals was performed. Patients who underwent oncological resection for colorectal cancer between February 2010 and September 2020 were selected from the colorectal neoplasia database. Patients were divided into two groups depending on the type of stapled anastomosis: Group 1 (functional end‐to‐end/side‐to‐side (SS)); and Group 2 (end‐to‐side (ES)). Primary outcomes were anastomotic leak, postoperative ileus, mortality and morbidity, length of stay post‐surgery, readmission to hospital, and 30‐day mortality.

Results

This large case series of 1040 patients (SS = 625, ES = 415) demonstrated that the type of stapling technique impacted operative duration and postoperative ileus rates. Patients in the SS group had a faster operation of 108 min rather than 130 min in the ES group (p < 0.001). The SS group were more likely to experience a post‐operative ileus (p < 0.001) with no impact on length of stay (SS, 7 days versus ES, 7 days; p = 0.14). There were no differences between the two groups with respect to lymph node yield, lymph node ratio, anastomotic leaks, return to theatre, 30‐day mortality and 5‐year overall survival.

Discussion

The type of extracorporeal stapled anastomosis following an oncological laparoscopic right hemicolectomy has minimal impact on morbidity and survival outcomes; however, a side‐to‐side stapled anastomosis is more likely to be a faster operation with a higher postoperative ileus rate.

Double-layered hand-sewn anastomosis: a valuable resource for the colorectal surgeon

Hand-sewn anastomosis is an essential and fundamental skill for surgeons dealing with any gastrointestinal anastomosis. Despite the advances in minimally invasive surgery and stapling devices, there are still complex surgical circumstances when the surgeon’s surgical know-how are necessary. Therefore, a safe hand-sewn technique for bowel anastomosis is required to establish a tension-free, well-perfused, and sealed anastomosis that allows gastrointestinal continuity with no unexpected complications. We describe a step-by-step procedure for hand-sewn double-layered anastomosis that reflects these principles and is practical for small and large bowel anastomosis.

Short-term Outcomes of Day-Case Stoma Closure: A Prospective, Observational Study

BACKGROUND

Elective stoma closure is a common, standardized procedure in digestive surgery.

OBJECTIVE

This study aimed to evaluate the feasibility of day-case surgery for elective stoma closure.

DESIGN

This is a prospective, single-center, nonrandomized study of consecutive patients undergoing day-case elective stoma closure.

SETTING

This study was performed at a French tertiary hospital between January 2016 and June 2018.

PATIENTS

Elective stoma closure was performed by local incision with an ASA score of I, II, or stabilized III.

OUTCOME MEASURES

The primary end point was the day-case surgery success rate in the overall population (all patients having undergone elective stoma closure) and in the per protocol population (patients not fulfilling any of the preoperative or perioperative exclusion criteria). The secondary end points (in the per protocol population) were the overall morbidity rate (according to the Clavien-Dindo classification), the major morbidity rate (Clavien score ≥3), and day-case surgery quality criteria (unplanned consultation, unplanned hospitalization, and unplanned reoperation).

RESULTS

Between January 2016 and June 2018, 236 patients (the overall population; mean ± SD age: 54 ± 17; 120 men (51%)) underwent elective stoma closure. Fifty of these patients (21%) met all the inclusion criteria and constituted the per protocol population. The day-case surgery success rate was 17% (40 of 236 patients) in the overall population and 80% (40 of 50 patients) in the per protocol population. In the per protocol population, the overall morbidity rate was 30% and the major morbidity rate was 6%. Of the 40 patients with successful day-case surgery, the unplanned consultation rate and the unplanned hospitalization rate were both 32.5%. There were no unplanned reoperations.

LIMITATIONS

This was a single-center study.

CONCLUSION

In selected patients, day-case surgery for elective stoma closure is feasible and has acceptable complication and readmission rates. Day-case elective stoma closure can therefore be legitimately offered to selected patients. See Video Abstract at http://links.lww.com/DCR/B583.

RESULTADOS A CORTO PLAZO DEL CIERRE DE ESTOMA AMBULATORIO UN ESTUDIO OBSERVACIONAL Y PROSPECTIVO

ANTECEDENTES:El cierre electivo de un estoma es un procedimiento común y estandarizado en cirugía digestiva.OBJETIVO:Evaluar la viabilidad de la cirugía ambulatoria para el cierre electivo de estomas.DISEÑO:Un estudio prospectivo, unicéntrico, no aleatorizado de pacientes consecutivos sometidos a cierre de estoma electivo ambulatorio.ESCENARIO:Un hospital terciario francés entre enero de 2016 y junio de 2018.PACIENTES:Cierre electivo de estoma realizado por incisión local con una puntuación de la American Society of Anesthesiologists de I, II o III estabilizado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue la tasa de éxito de la cirugía ambulatoria en la población general (todos los pacientes habiendo sido sometidos a cierre de estoma electivo) y en la población por protocolo (pacientes que no cumplían con ninguno de los criterios de exclusión preoperatorios o perioperatorios). Los resultados secundarios (en la población por protocolo) fueron la tasa de morbilidad general (según la clasificación de Clavien-Dindo), la tasa de morbilidad mayor (puntuación de Clavien ≥ 3) y los criterios de calidad de la cirugía ambulatoria (consulta no planificada, hospitalización no planificada y reoperación no planificada).RESULTADOS:Entre enero de 2016 y junio de 2018, 236 pacientes (la población general; edad media ± desviación estándar: 54 ± 17; 120 hombres (51%)) se sometieron al cierre electivo del estoma. Cincuenta de estos pacientes (21%) cumplieron todos los criterios de inclusión y constituyeron la población por protocolo. La tasa de éxito de la cirugía ambulatoria fue del 17% (40 de 236 pacientes) en la población general y del 80% (40 de 50 pacientes) en la población por protocolo. En la población por protocolo, la tasa de morbilidad general fue del 30% y la tasa de morbilidad mayor fue del 6%. De los 40 pacientes con cirugía ambulatoria exitosa, la tasa de consultas no planificadas y la tasa de hospitalización no planificada fueron ambas del 32.5%. No hubo reoperaciones no planificadas.LIMITACIONES:Este fue un estudio de un solo centro.CONCLUSIÓN:En pacientes seleccionados, la cirugía ambulatoria para el cierre electivo de estoma es factible y tiene tasas aceptables de complicaciones y reingreso. Por lo tanto, se puede ofrecer legítimamente el cierre electivo ambulatorio de estoma a pacientes seleccionados. Consulte Video Resumen en http://links.lww.com/DCR/B583.

Effects of anchoring sutures at diverting ileostomy after rectal cancer surgery on peritoneal adhesion at following ileostomy reversal

PURPOSE

During diverting ileostomy reversal for rectal cancer patients who underwent previous sphincter-saving surgery, the extent of adhesion formation around the ileostomy site affects operative and postoperative outcomes. Anchoring sutures placed at the time of the ileostomy procedure may reduce adhesions around the ileostomy. This study aimed to evaluate the effects of anchoring sutures on the degree of adhesion formation and the postoperative course at the time of ileostomy reversal.

METHODS

Patients who underwent sphincter-saving surgery with diverting ileostomy for rectal cancer between January 2013 and December 2017 were enrolled. Variables including the peritoneal dhesion index (PAI) score, operation time, the length of resected small bowel, operative complications, and postoperative hospital stay were collected prospectively and compared between the anchoring group (AG) and non-anchoring group (NAG).

RESULTS

A total of 90 patients were included in this study, with 60 and 30 patients in the AG and NAG, respectively. The AG had shorter mean operation time (46.88 ± 16.37 minutes vs. 61.53 ± 19.36 minutes, P = 0.001) and lower mean PAI score (3.02 ± 2.53 vs. 5.80 ± 2.60, P = 0.001), compared with the NAG. There was no significant difference in the incidence of postoperative complications between the AG and NAG (5.0% vs. 13.3%, respectively; P = 0.240).

CONCLUSION

Anchoring sutures at the formation of a diverting ileostomy could decrease the adhesion score and operation time at ileostomy reversal, thus may be effective in improving perioperative outcomes.

Development and in vivo Assessment of a Rapidly Collapsible Anastomotic Guide for Use in Anastomosis of the Small Intestine: A Pilot Study Using a Swine Model

Various conditions in human and veterinary medicine require intestinal resection and anastomosis, and complications from these procedures are frequent. A rapidly collapsible anastomotic guide was developed for small intestinal end-to-end anastomosis and was investigated in order to assess its utility to improve the anastomotic process and to potentially reduce complication rates. A complex manufacturing method for building a polymeric device was established utilizing biocompatible and biodegradable polyvinylpyrrolidone and polyurethane. This combination of polymers would result in rapid collapse of the material. The guide was designed as a hollow cylinder composed of overlaying shingles that separate following exposure to moisture. An in vivo study was performed using commercial pigs, with each pig receiving one standard handsewn anastomosis and one guide-facilitated anastomosis. Pigs were sacrificed after 13 days, at which time burst pressure, maximum luminal diameter, and presence of adhesions were assessed. Burst pressures were not statistically different between treatment groups, but in vivo anastomoses performed with the guide withstood 10% greater luminal burst pressure and maintained 17% larger luminal diameter than those performed using the standard handsewn technique alone. Surgeons commented that the addition of a guide eased the performance of the anastomosis. Hence, a rapidly collapsible anastomotic guide may be beneficial to the performance of intestinal anastomosis.

Protective Loop Ileostomy Closure Techniques: Comparison of Three Different Surgical Techniques

Objective

Anastomotic leaks can be very dangerous in colorectal cancers. Protective loop ileostomy is life-saving in low anterior rectal tumors to prevent pelvic sepsis. The aim of this study is to compare early morbidities for stapled, handsewn closure (end to end) or handsewn closure (anterior wall only) of loop ileostomy, and to further assess efficacy and safety for each technique. 

Methods

Patients who underwent loop ileostomy closure from January 2014 and December 2019 retrospectively were analyzed. Multivariate logistic regression was used to determine the effect of the potential risk factors on the rate of each complication. The patients were divided into three groups based on the anastomoses. The first group included patients who had handsewn anterior closure; the second group included patients who had side-to-side anastomosis using linear stapler, and the third group included patients who had end-to-end handsewn anastomosis. The primary endpoint of the study was the postoperative 30 days. IBM Statistical Package for the Social Sciences (SPSS), version 22.0 (SPSS Inc., Chicago, IL) was used for statistical analysis.

Results

A total of 198 patients underwent reversal. There was a statistical difference between the handsewn anterior wall and stapler anastomosis in terms of postoperative ileus and wound infection. The handsewn group was superior to anastomosis with stapler (p: 0.027 and p: 0.042, respectively). A statistical difference was found between handsewn anterior wall closure and handsewn end-to-end anastomosis in terms of postoperative ileus, wound infection, and postoperative hospital stay (p: 0.013, p: 0.037, and p: 0.046, respectively). When stapled anastomosis and handsewn end-to-end anastomosis techniques were compared, a statistical difference was found in terms of postoperative ileus risk (p: 0.043), but no significant difference was found in terms of postoperative wound infection and hospital stay.

Conclusions

There was no significant difference in the rate of anastomotic leakage between the handsewn and stapled techniques. The rate of small-bowel obstruction was higher in the handsewn group. As a result, in this study, it was revealed that the handsewn anterior wall closure technique is the best among all ileostomy closure techniques.

Loop ileostomy closure: a retrospective comparison of three techniques

BACKGROUND

Loop ileostomy (LI) formation is a common practice for patients undergoing low anterior resection or restorative ileo-anal pouch surgery. Ileostomy closure can be performed using a stapled or hand-sewn technique, with or without resection. If hand-sewn, the closure can be one or two layers. Randomized controlled trials have not demonstrated one technique to be superior, and meta-analyses are limited by the heterogeneity of published studies. Our primary aim is to compare stapled ileostomy closure with single- and two-layer hand-sewn closures.

METHODS

This retrospective, single-centre cohort study included patients undergoing LI closure between January 1999 and April 2016. Patient demographics, anastomotic technique, operative time and patient outcomes were collected.

RESULTS

Our analysis included 244 patients (median age 67 years, 43.4% female). There were no significant differences in mean operative times (71.5, 73.1 and 88.5 min, for stapled, single- and two-layer hand-sewn closures, respectively, adjusted overall P = 0.262), or morbidity (21.5% versus 20.4% versus 17.6%, adjusted overall P = 0.934) between stapled or hand-sewn anastomoses, and no mortality. Once adjusting for age, sex, American College of Anaesthesiology grade, and consultant surgeon, the length of stay was different (overall P = 0.034), being similar between stapled and single-layer closures (4.2 versus 5.5 days, P = 0.105), but significantly different between stapled and two-layer closures (4.2 versus 8.3 days, P = 0.026).

CONCLUSION

Stapled and single-layered hand-sewn closures are similar in length of procedure, length of stay and complication rates. A two-layer, hand-sewn technique is associated with a significant increase in stay compared to a stapled ileostomy closure.

Outcome and Cost Analysis of Hand-Sewn and Stapled Anastomoses in the Reversal of Loop Ileostomy

Diverting loop ileostomies are common procedures for protecting high-risk anastomoses. There is little consensus on the most ideal technique both in terms of cost efficiency and outcome. Data for this study were collected from 101 patients who underwent loop ileostomy reversal between 2009 and 2014 at Morristown Medical Center. Of the 101 patients included in the review, 57 received a hand-sewn anastomosis (HS-A) and 44 received a stapled anastomosis (S-A). Average total hospital charges for stapled anastomoses were significantly greater than that for hand-sewn anastomoses, as were total operating room supply costs. When the total cost of the operation itself was considered, S-A cases were still found to be significantly greater than HS-A cases. Hospital room charges, total lab charges, pathology charges, and EKG/ECG charges were all greater for S-A cases than HS-A cases. Overall costs were greater for S-As than hand-sewn anastomoses and because of a lack of difference in procedure length, stapler supply costs were not offset. Complication rates and length of stay were also similar between the techniques. We found S-A cases to be more costly and have a greater cost/hour than HS-A cases.

Early Experience with Stapled Gastrointestinal Anastomoses in a Nigerian Hospital

Background:

Hand-sewn gastrointestinal anastomoses has been the traditional approach to gastrointestinal anastomosis in Nigeria while stapled anastomoses are infrequently performed in few centers.

Objectives:

To describe the outcome of our initial experience with stapled gastrointestinal anastomoses in a semi-urban patient population.

Patients and Methods:

Consecutive patients who had stapled gastrointestinal anastomoses between January 2011 and June 2014 in a Nigerian tertiary hospital were prospectively evaluated. Indications for operation, procedures performed and anastomoses constructed and postoperative outcome of each patient were documented.

Results:

Nineteen patients including seven males and 12 females had stapled anastomoses within the period. Their ages ranged between 41 and 68 (mean 52.5) years. Six (31.6%) Roux-en-Y gastrojejunostomies, 6 (31.6%) ileo-colic, 3 (15.8%) ileo-ileal, 2 (10.5%) colo-colic, and 2 (10.5%) colo-anal anastomoses were performed. Indications include antral gastric cancer in 4 (21.1%), right colon cancer 4 (21.1%), ileal perforations in 3 (15.8%) while 2 (10.5%) each had left colon cancer, common bile duct obstruction, rectal cancer and ruptured appendix. Mean duration of operation was 108 ± 46 min and mean duration of postoperative stay was 5 ± 2.6 days. No intraoperative complications were recorded and no anastomotic leakage occurred. At a median follow-up of 5 months no staple related stricture had occurred.

Conclusions:

Stapled gastrointestinal anastomoses are associated with a good outcome in our center. We propose a prospective, large-population randomized comparison of the technique with hand-sewn anastomoses.

Cost analysis of early versus delayed loop ileostomy closure: a case-matched study

BACKGROUND/AIMS

The optimal timing for the closure of loop ileostomies remains controversial. The aim of the current study was to investigate whether early ileostomy closure (EC) (<2 weeks post-formation) results in significant healthcare savings as against late closure (LC).

METHODS

Patients with available cost data that underwent EC between January 2008 and December 2012 were compared against matched patients undergoing LC during the same period. Direct hospital costs for the two groups were compared.

RESULTS

There were 42 EC patients and 61 LC patients. EC patients had significantly less ileostomy-related complications (p < 0.001) and hospital readmissions (p < 0.001). Operative time (p < 0.001) and operative cost (p = 0.002) were also both significantly less in the EC group. Community nursing costs favoured the LC group (p = 0.047). The EC group had an increased post-closure wound infection rate (p = 0.02). The mean total direct cost per patient was NZD 13,724 (SD NZD 3,736) for EC and NZD 16,728 (SD NZD 8,028) for LC. Representing an average costs saving of NZD 3,004 per patient favouring EC (p = 0.012).

CONCLUSION

Although EC increases the post-closure wound infection rate, EC reduces ileostomy complications, hospital readmissions and operative costs resulting in significant healthcare savings. In order to improve patient outcomes and make EC even more cost effective, efforts should be taken to reduce wound infections.

Hand suture versus stapler for closure of loop ileostomy--a systematic review and meta-analysis of randomized controlled trials

PURPOSE

The aims of this study are to compare the 30-day rate of bowel obstruction for stapled vs. handsewn closure of loop ileostomy, and to further assess efficacy and safety for each technique by secondary endpoints such as operative time, rates of anastomotic leakage, and other post-operative complications within 30 days.

METHODS

A systematic literature search (MEDLINE, The Cochrane Library, EMBASE and ISI Web of Science) was performed to identify randomized controlled trials (RCTs) comparing stapled and handsewn closure of loop ileostomy after low anterior resection. Random effects meta-analyses were calculated and presented as risk ratio (RR) and mean difference (MD) with corresponding 95 % confidence intervals.

RESULTS

Forty publications were retrieved and 4 RCTs (649 patients) were included. There was methodological and clinical heterogeneity of included trials, but statistical heterogeneity was low for most endpoints. Stapler use significantly reduced the rate of bowel obstruction compared to hand-sewn closure (RR 0.53 [0.32, 0.88]; P = 0.01). The operation time was significantly lower for stapling compared to hand suture (MD -15.5 min [-18.4, 12.6]; P < 0.001). All other secondary outcomes did not show significant differences.

CONCLUSIONS

This meta-analysis shows superiority of stapled closure of loop ileostomy compared to handsewn closure in terms of bowel obstruction rate and mean operation time. Other relevant complications such as anastomotic leakage are equivalent. Even so, both techniques are options with opposing advantages and disadvantages.

Comparing methods of ileostomy closure constructed in colorectal surgery in Turkey

INTRODUCTION

Stoma construction is a life saver method for emergent and elective operations in colorectal surgery. However, they are associated with high rates of morbidity and mortality.

AIM

To compare the operative findings, early postoperative complications, and costs of stapled and hand-sewn closures in loop ileostomies that are constructed in emergent and elective colorectal surgery.

MATERIAL AND METHODS

The data of 68 patients requiring loop ileostomies during colorectal surgery were retrospectively evaluated. SPSS (version 20) was used for data analysis.

RESULTS

The study group consisted of 44 men and 24 women with a mean age of 55.5 years. The ileostomy closures were performed with hand-sewn method in 36 patients (group 1) and stapled method in 32 patients (group 2). The mean operation time was 75.4 min in group 1 and 46.7 min in group 2 (p < 0.001). Early postoperative complications were wound infection (8.8%), small bowel obstruction (6.06%), and anastomotic leakage (2.9%). Total costs, flatulence and faeces outlet time, oral feeding starting time, time of hospital stay, and early postoperative complications were lower in the stapled group.

CONCLUSIONS

Morbidity and mortality rates of stoma construction and its closure are still considerable. Lower anastomotic leakage rate, complication rate, and costs and shorter operative times in the stapled group make this method preferable.

Demonstrating the benefits of transversus abdominis plane blocks on patient outcomes in laparoscopic colorectal surgery: review of 200 consecutive cases

BACKGROUND

Quality improvement in colorectal surgery (CRS) requires implementation of tools to improve patient and financial outcomes, and assessment of results. Our objective was to evaluate the durability of transversus abdominis plane (TAP) blocks and a standardized enhanced recovery protocol (ERP) on a large series of laparoscopic colorectal resections.

STUDY DESIGN

Two hundred consecutive laparoscopic CRS patients received TAP blocks under laparoscopic guidance at the end of their operation. All were managed with a standardized ERP. Demographic, perioperative, and postoperative outcomes variables were analyzed. The main outcomes measures were length of stay (LOS), readmission, reoperation, morbidity, and mortality rates.

RESULTS

Of 200 cases, 194 were elective and 6 emergent. The main diagnosis was colorectal cancer (45%). The mean patient age was 61.2 years, mean body mass index was 29.2 kg/m(2), and the majority (63%) were American Society of Anesthesiologists (ASA) class III. The main procedure performed was a segmental colectomy (64%). Mean operative time was 181 minutes. Nine cases (4.5%) were converted to open. The median LOS was 2 days (range 1 to 8 days). Twenty-one percent were discharged by postoperative day (POD) 1, 41% by POD 2, and 77% by POD 3. By POD 7, 99% were discharged. Twelve percent (n = 24) had complications, and 6.5% (n = 13) were readmitted. There were 3 unplanned reoperations and no mortalities. Comparing the first and second groups of 100 consecutive patients further tested the consistency of the TAP block benefit. With comparable demographics, there were no significant differences in readmission, complication, or reoperation rates over the entire series.

CONCLUSIONS

Adding TAP blocks to an ERP facilitated shorter LOS with low readmission and reoperation rates when compared to previously published series. The effect appears durable and consistent in a large case series. Transversus abdominis plane blocks may be an efficient, cost-effective method for improving laparoscopic CRS results.

Feasibility and safety of a fold-over diverting ileostomy reversal after rectal cancer surgery: case-matched comparison to the resection technique

PURPOSE

Compared to the stapling technique, the fold-over technique (FO) has the benefit of avoiding the sacrifice of the bowel segment. The aim of this study was to compare short-term outcomes between the FO and a conventional resection.

METHODS

Between June 2008 and March 2012, a total of 242 patients who underwent a diverting ileostomy reversal after rectal cancer surgery were selected. Among them, 29 patients underwent the FO. Using propensity scores to adjust for body mass index, previous abdominal surgery history, rectal cancer surgery type (open vs. minimally invasive), and reason for ileostomy (protective aim vs. leakage management), we created a well-balanced cohort by matching each patient who underwent the FO, as the study group, with two patients who underwent a stapled or a hand-sewn technique with bowel resection (RE), as the control group (FO : RE = 1 : 2). Morbidity and perioperative recovery were compared between the two groups.

RESULTS

Twenty-four and forty-eight patients were allocated to the FO and the RE groups, respectively. The mean operation time was 91 ± 26 minutes in the FO group and 97 ± 34 minutes in the RE group (P = 0.494). The overall morbidity rates were not different between the two groups (12.5% in FO vs. 14.6% in RE, P = 1.000). The rate of postoperative ileus was similar between the two groups (8.3% in FO vs. 12.5% in RE, P = 0.710). Although time to resumption of soft diet was shorter in the FO group than in the RE group, the lengths of hospital stay were not different.

CONCLUSION

The FO and the conventional resection have similar short-term clinical outcomes for diverting ileostomy reversal.

Meta-analysis of handsewn versus stapled reversal of loop ileostomy

BACKGROUND

The morbidity associated with closure of loop ileostomy (LI) may be attributed to the various surgical techniques employed for the closure. The purpose of this review was to review the hand-sutured (HS) versus the stapled anastomosis (SA) techniques, used in the reversal of LI.

METHODS

The MEDLINE, PubMed, CINHAL, Cochrane library and Web of Knowledge databases were searched for randomized controlled trials (RCTs) and case-control trials (CCTs), evaluating HS and SA in reversal of LI. Data extraction with risk of bias assessment was followed by subgroup and pooled data meta-analysis where applicable per outcome.

RESULTS

Four RCTs (HS: 321, SA: 328) and 10 CCTs (HS: 2808, SA: 1044) were identified, with a total of 4508 patients. Regardless of subgroup analysis, no difference was seen between the two techniques with regard to anastomotic leaks (P = 0.24, odds ratio (OR): 1.37, 95% confidence interval (CI): 0.81-2.29) or re-operation. The stapled group showed a significantly lower rate of conservatively managed small bowel obstruction (SBO)/ ileus at 30 days (P < 0.001, OR: 2.27, 95% CI: 1.59-2.96) (P < 0.001) and SBO during combined short- and long-term follow-up (P < 0.001). The SA also showed significant shorter operative time (P = 0.02; WMD 11.52 min), time to first bowel opening (P < 0.001; WMD 0.52 days) and length of hospital stay (P = 0.03; WMD 0.70 days).

CONCLUSION

The stapled technique offers an advantage in terms of lower post-operative subacute SBO rates, a faster operative technique and shorter hospitalization times. These perceived benefits make it potentially superior to HS for the reversal of LI.

[Ileostomy closure in a colorectal surgery unit. Comparative analysis of different techniques]

INTRODUCTION

The objective of this study is to assess whether the results of loop ileostomy closure in terms of morbidity and hospital stay are influenced by the type of anastomosis and suture used.

METHOD

All patients who underwent loop ileostomy closure were reviewed. A retrospective cohort study comparing morbidity and hospital stay according to the type of anastomosis (TT/LL) and the type of suture (hand sewn/mechanical) was performed.

RESULTS

From January 2003 to November 2011 a total of 167 loop ileostomy closures were analized. The groups were: type of anastomosis (TT 95/LL 72) and type of suture (manual 105/stapled 62). In 76% of the observed population the underlying disease was cancer. Mortality occurred in one case. The stratified morbidity analysis by type of complications showed no significant differences between the groups in terms of local (7.4% TT, LL 8.3%, 6.7% hand sewn, stapled 9.7%), general (TT 9.5%, 16.7% LL, hand sewn 6.7%, 6.5% stapled) and surgical (TT 15.8%, 19.4% LL, hand sewn 17.1%, 17.7% stapled) complications, nor in the rate of reoperations (TT 6.3%, 6.9% LL, hand sewn 6.7%, 6.5% stapled) and hospital stay in days (TT 7.8, 8 LL, hand sewn 8.6, stapled 6.7) CONCLUSIONS: Closure of loop ileostomy can be performed regardless of the type of suture or anastomosis used, with the same rate of morbidity and hospital stay.

A systematic review of systematic reviews and panoramic meta-analysis: staples versus sutures for surgical procedures

Objective

To systematically evaluate the evidence across surgical specialties as to whether staples or sutures better improve patient and provider level outcomes.

Design

A systematic review of systematic reviews and panoramic meta-analysis of pooled estimates.

Results

Eleven systematic reviews, including 13,661 observations, met the inclusion criteria. In orthopaedic surgery sutures were found to be preferable, and for appendicial stump sutures were protective against both surgical site infection and post surgical complications. However, staples were protective against leak in ilecolic anastomosis. For all other surgery types the evidence was inconclusive with wider confidence intervals including the possibly of preferential outcomes for surgical site infection or post surgical complication for either staples or sutures. Whilst reviews showed substantial variation in mean differences in operating time (I² 94%) there was clear evidence of a reduction in average operating time across all surgery types. Few reviews reported on length of stay, but the three reviews that did (I² 0%, including 950 observations) showed a non significant reduction in length of stay, but showed evidence of publication bias (P-value for Egger test 0.05).

Conclusions

Evidence across surgical specialties indicates that wound closure with staples reduces the mean operating time. Despite including several thousand observations, no clear evidence of superiority emerged for either staples or sutures with respect to surgical site infection, post surgical complications, or length of stay.

Randomized clinical trial of the benefit of laparoscopy with closure of loop ileostomy

Background

The aim was to compare reversal and laparoscopy with standard reversal of loop ileostomy in terms of hospital stay and morbidity in a randomized study.

Methods

Patients having reversal of a loop ileostomy were randomized to either standard reversal of ileostomy or reversal and laparoscopy. Strict discharge criteria were applied: toleration of two meals without nausea and vomiting, passing a bowel motion, and attaining adequate pain control with oral analgesia. Morbidity and cost were also compared between the two groups.

Results

A total of 74 patients (reversal and laparoscopy 40, standard reversal 34) with a median age of 61 years underwent loop ileostomy reversal; there were 45 men (61 per cent). Ileostomy was most commonly carried out after laparoscopic low anterior resection (36 patients). Median length of stay, based on discharge criteria, was significantly shorter in the reversal and laparoscopy group than in the standard group: 4 (interquartile range 3–4) versus 5 (4–6) days (P = 0·003). The overall morbidity rate was also lower in patients who had ileostomy reversal and laparoscopy: 10 versus 32 per cent (P = 0·023). The median cost per patient was lower in the reversal and laparoscopy group: €3450 (interquartile range 2766–3450) versus €4527 (3843–7263) (P = 0·015). There was no statistically significant difference in American Society of Anesthesiologists fitness grade or time to reversal between the two groups.

Conclusion

Reversal of loop ileostomy with laparoscopy was associated with a shorter hospital stay, lower morbidity and reduced cost compared with the standard technique. Registration number: ISRCTN46101203 (http://www.controlled-trials.com).

Radical cystectomy with W-shaped orthotopic ileal neobladder constructed with non-absorbable titanium staples-long term follow-up

PURPOSES

We retrospectively assessed our experience with the W-shaped orthotopic ileal pouch, which was constructed with non-absorbable titanium staples. For these purpose, we discuss the results of bladder capacity, urinary continence and early and long-term postoperative complications.

MATERIALS AND METHODS

We included in the study 17 patients who underwent radical cystoprostatectomy followed by construction of an orthotopic W-shaped ileal pouch between October 2000 and November 2009. A 65-70 cm segment of ileum was isolated and prearranged into a W-configuration, leaving two 10 cm intact segments on both sides of the ileal fragment. In our technique we entirely anatomized all adjacent limbs in order to create a sphere-shaped pouch. The ureters were directly anastomized to both intact segments of the ileal division. All our patients underwent pouchscopy 6 months after operation and annually.

RESULTS

Mean operative time for neobladder reconstruction and ureteral anastomoses was 87 ± 7.67 minutes. In one patient a leak from the ileo-ileal anastomosis was confirmed on the 3rd day after operation. In 2 cases unilateral stricture of the ureteral-neobladder anastomosis was documented. Staple lines were mostly covered with ileal mucosa after 6 months. The mean functional bladder capacity was 340 ± 27.6 mL and 375 ± 43.4 mL at 6 and 12 months, respectively. First-year daytime and nighttime continence was good and acceptable in 90% and 78% of patients, while it increased to 95% during the 2nd year.

CONCLUSIONS

The long term follow-up shows that non-absorbable titanium staples can be safely used for creation of an orthotopic ileal neobladder. However, these data should be further validated in a larger series of patients.

Systematic review and meta-analysis of published, randomized, controlled trials comparing suture anastomosis to stapled anastomosis for ileostomy closure

The objective of this article is to systematically analyze the randomized, controlled trials comparing the effectiveness of suture anastomosis (SUA) versus stapled anastomosis (STA) in patients undergoing ileostomy closure. Randomized, controlled trials comparing the effectiveness of SUA versus STA in patients undergoing ileostomy closure were analyzed using RevMan(®), and combined outcomes were expressed as odds risk ratio (OR) and standardized mean difference (SMD). Four randomized, controlled trials that recruited 645 patients were retrieved from electronic databases. There were 327 patients in the STA group and 318 patients in the SUA group. There was significant heterogeneity among included trials. Operative time (SMD -1.02; 95 % CI -1.89, -0.15; z = 2.29; p < 0.02) was shorter following STA compared to SUA. In addition, risk of small bowel obstruction (OR 0.54; 95 % confidence interval (CI), 0.30, 0.95; z = 2.13; p < 0.03) was lower in the STA group. Risk of anastomotic leak (OR 0.87; 95 % CI 0.12, 6.33; z = 0.14; p = 0.89), surgical site infection, reoperation and readmission were similar following STA and SUA in patients undergoing ileostomy closure. Length of hospital stay was also similar between STA and SUA groups. In ileostomy closure, STA was associated with shorter operative time and lower risk of postoperative small bowel obstruction. However, STA and SUA were similar in terms of anastomotic leak, surgical site infection, readmission, reoperations and length of hospital stay.

HAnd Suture Versus STApling for Closure of Loop Ileostomy (HASTA Trial): results of a multicenter randomized trial (DRKS00000040)

OBJECTIVES

The objective of the HASTA trial was to compare hand suture versus stapling loop ileostomy closure in a randomized controlled trial.

BACKGROUND

Bowel obstruction is one of the main and the clinically and economically most relevant complication following closure of loop ileostomy after low anterior resection. The best surgical technique for closure of loop ileostomy has not been defined yet.

METHODS

HASTA trial is a multicenter pragmatic randomized controlled surgical trial with 2 parallel groups to compare hand suture versus stapling for closure of loop ileostomy. The primary endpoint was the rate of bowel obstruction within 30 days after ileostomy closure.

RESULTS

A total of 337 randomized patients undergoing closure of loop ileostomy after low anterior resection because of rectal cancer in 27 centers were included. The overall rate of postoperative ileus after ileostomy closure was 13.4%. Seventeen of 165 (10.3%) patients in the stapler group and 27 of 163 (16.6%) in the hand suture group developed bowel obstruction within 30 days postoperatively [odds ratio (OR) = 1.72; 95% confidence interval (CI): 0.89-3.31 = 0.10]. Duration of surgical intervention was significantly shorter in the stapler group (15 minutes; P < 0.001). Multivariable analysis of potential risk factors did not reveal any significant correlation with development of postoperative ileus. Rate of anastomotic leakage (stapler: 3.0%, hand suture: 1.8%, P = 0.48) did not differ significantly as well as all other secondary endpoints.

CONCLUSIONS

Hand-sewn anastomosis versus stapler ileo-ileostomy for ileostomy closure are equally effective in terms of postoperative bowel obstruction, with stapler anastomosis leading to a shorter operation time. Postoperative ileus after ileostomy reversal remains a relevant complication.

Stapled vs hand suture closure of loop ileostomy: a meta-analysis

AIM

Loop ileostomies are widely used in colorectal surgery to reduce the consequences of distal anastomotic failure. The optimal surgical technique for their closure has yet not been defined. A meta-analysis was performed to compare the outcome after stapled or hand sutured ileostomy closure.

METHOD

An electronic literature search of EMBASE, PubMed and the Cochrane Library was undertaken to identify studies reporting stapled and hand sutured ileostomy closure. End-points included postoperative small bowel obstruction (SBO), anastomotic leakage, wound infection, overall postoperative complications, operation time, hospital stay and surgery-related cost.

RESULTS

Fourteen studies including 5084 patients were identified. Meta-analysis showed that stapled closure was associated with a lower rate of SBO overall (OR = 0.56, P < 0.00001) and early (within 30 days of closure) SBO (OR = 0.51, P < 0.00001). This difference persisted for direct ileostomy closure (OR = 0.62, P = 0.02) or closure with bowel resection and hand sewn anastomosis (OR = 0.44, P < 0.00001). Stapled closure required a shorter inpatient stay (mean difference -1.22, P < 0.0001) and operating time (mean difference -11.21, P = 0.01). No significant difference was noted between the two techniques in terms of anastomotic leakage, wound infection, overall complications or cost.

CONCLUSION

Stapled side-to-side anastomosis is associated with fewer complications, especially SBO, than hand sewn ileostomy closure by direct suture or resection and anastomosis. It is quicker to perform and associated with fewer postoperative bowel obstructions.

Bowel anastomoses: The theory, the practice and the evidence base

Since the introduction of stapling instruments in the 1970s various studies have compared the results of sutured and stapled bowel anastomoses. A literature search was performed from 1960 to 2010 and articles relating to small bowel, colonic and colorectal anastomotic techniques were reviewed. References from these articles were also reviewed, and relevant articles obtained. Either a stapled or sutured gastrointestinal tract anastomosis is acceptable in most situations. The available evidence suggests that in the following situations, however, particular anastomotic techniques may result in fewer complications: A stapled side-to-side ileocolic anastomosis is preferable following a right hemicolectomy for cancer. A stapled side-to-side anastomosis is likely also preferable after an ileocolic resection for Crohn’s disease. Colorectal anastomoses can be sutured or stapled with similar results, although the incidence of strictures is higher following stapled anastomoses. Following reversal of loop ileostomy there is some evidence to suggest that a stapled side-to-side anastomosis or sutured enterotomy closure (rather than spout resection and sutured anastomosis) results in fewer complications. Non-randomised data has indicated that small bowel anastomoses are best sutured in the trauma patient. This article reviews the theory, practice and evidence base behind the various gastrointestinal anastomoses to help the practising general surgeon make evidence based operative decisions.

Low complication rate after stoma closure. Consultants attended 90% of the operations

AIM

To evaluate complications after stoma closure.

METHOD

Using a retrospective review of 997 medical records, data were collected from all patients undergoing stoma closure at the Department of Surgery P, Aarhus University Hospital, Denmark, from 1996 to 2010. Patient data after Hartmann reversal and loop-ileostomy closure were compared. Data regarding the grade of the operating surgeon and assistant were extracted.

RESULTS

Out of 997 patients, 700 (70.6%) had a loop-ileostomy closure and 172 (17.4%) had a Hartmann reversal. Postoperative mortality was 0.5%. Seven patients required re-operation (0.7%). Morbidity was registered in 31.9% of the patients, with 131 (13.1%) having early complications and 187 (18.8%) having late complications. Wound infection was the most frequent early complication, which occurred in 31 patients (3.1%). Only 10 patients (1%) had an anastomotic leak. Incisional hernia was the most frequent late complication, occurring in 92 patients (9.3%). A consultant attended 90% of the operations. Junior surgeons never performed stoma closure without supervision. Body mass index was significantly associated with the development of incisional hernia. Hartmann reversal was associated with higher rates of complications compared with loop-ileostomy closure. In patients with Hartmann reversal, stapled anastomosis was associated with stricture in 12 out of 95 cases (12.6%), whereas hand-sewn anastomosis was not associated with stricture (0 out of 64 patients; 0%; P < 0.05).

CONCLUSION

Stoma closure is associated with low rates of leakage. A favourable case mix and high degree of consultant attendance may explain the good results.

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

PURPOSE

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

METHODS

A consecutive series of 138 patients were retrospectively analyzed after stoma reversal. Data collection included general demographics and surgery-related aspects. Morbidity related to stoma closure was retrieved from our prospectively collected registry of complications.

RESULTS

In 74 of 138 patients, defunctioning ileostomy was performed after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The remaining ileostomies (n = 64) were constructed after a low colorectal or coloanal anastomosis. A total of 46 complications were recorded in 28 patients resulting in an overall complication rate of 20.3%. Anastomotic leakage rate was 4.3%, and reoperation rate was 8.0%. The number of complications according to the Clavien-Dindo classification was 5 for grade I (10.9%), 26 for grade II (56.5%), 13 for grade III (28.3%), 1 for grade IV (2.2%), and 1 for grade V (2.2%). Multivariate analysis revealed a significantly higher ASA score in the complicated group (P = 0.015, odds ratio 2.6, 95% confidence interval 1.2-5.6).

CONCLUSIONS

Closure of a defunctioning ileostomy is associated with 20% morbidity and a reoperation rate of 8%. There is an urgent need for criteria on which a more selective use of a defunctioning ileostomy after low colonic anastomosis or IPAA can be based given its associated morbidity.

Perioperative morbidity of radical cystectomy: A review

A systematic review of the literature on perioperative morbidity (POM) was done using Medline software with a combination of keywords like mortality, morbidity, and complications. In addition, we review the analysis of our hospital data of 261 Radical cystectomies (RCs) performed in an 11-year period and our latest clinical pathway for RC. Age range in our series was 50 to 81 years with 240 males and 21 females. RCs were performed by intraperitoneal method in 172 patients and by our extraperitoneal (EP) method in 89 patients. Urinary diversion was ileal conduit in 159 patients and neobladder in 102 patients. Blood loss ranged between 500 and 1500 ccs. Postoperative mortality occurred in eight patients (3%). Among the other early post-op complications, major urinary leak was seen in nine and minor in 11, requiring PCN in five patients and reoperation in four patients. Bowel leak or obstruction was seen in six and four patients, respectively, requiring reoperation in six patients. EP RC in our series showed some benefit in reduction of POM. The mortality of RC has declined but the POM still ranges from 11 to 68%, as reported in 23 series (1999-2008) comprising of 14 076 patients. Various risk factors leading to POM and some corrective measures are discussed in detail. However, most of these series are retrospective and lack standard complication reporting, which limits the comparison of outcomes. Various modifications in open surgical technique and laparoscopic and Robotic approaches are aimed at reduction in mortality and POM of RC.

Morbidity after closure of a defunctioning loop ileostomy

PURPOSE

A low pelvic anastomosis is associated with a substantial risk of leakage. A defunctioning stoma (DS) reduces the clinical anastomotic leak rate and the need for re-operation, but stoma closure has its own risk of morbidity and mortality. This study aims to audit morbidity and mortality after loop ileostomy (LI) closure.

PATIENTS AND METHODS

The medical records of 197 consecutive patients who underwent closure of a defunctioning LI between August 2003 and July 2008 were reviewed. Postoperative morbidity and mortality were recorded.

RESULTS

Transverse closure of the enterotomy was performed in 149 patients (75.6%), segmental enterectomy with hand-sewn end-to-end anastomosis in 26 (13.2%) and stapled side-to-side anastomosis in 22 (11.2%). Overall postoperative morbidity and mortality were 32.0% and 0.5%, respectively. The surgical complication rate was 30.5%, including prolonged ileus (11.2%), small bowel obstruction (4.1%), anastomotic leak (3.0%) and wound infection (4.6%). Surgical complications were more frequent in male patients (p = 0.005). Prolonged ileus was more frequent when the interval to stoma reversal exceeded 12 weeks (14.3% versus 3.5% ; p = 0.02). The incidence of complications was not influenced by the closure technique. Nineteen patients (9.6%) required re-operation for anastomotic leak (n = 8), wound infection (n = 1), small bowel obstruction (n = 3) and incisional herniation (n = 7).

CONCLUSION

LI closure is associated with clinically relevant morbidity and mortality. This association should be taken into account in the context of a routine DS policy and should be part of the patient's information.

Short-term outcome of infliximab and other medications on patients with inflammatory bowel disease undergoing ileostomy reversal

AIM

We evaluated the impact of immunosuppressive drugs on the short-term outcome following loop ileostomy closure in patients with inflammatory bowel disease.

METHOD

Data on 249 patients with inflammatory bowel disease, who underwent loop ileostomy closure from 2001 to 2008, were retrospectively reviewed from a prospectively maintained database. Patients were distributed among groups according to the inflammatory bowel disease drugs used. Comorbidity, diagnosis, intra-operative and postoperative morbidity and length of stay data were analysed. Patients in group (INF) were receiving infliximab with or without other immunosuppressive agents (28), patients in group (S) were receiving only steroids (72) and those, in group III (S&I) were on steroids plus immunosuppressive agents, other than infliximab (35). Patients in group (ND) had not received any immunosuppressive agents for 2 months and served as the control group (114).

RESULTS

Postoperative complication rates (wound infection, hernia, obstruction, intra-abdominal abscess, leakage, enterocutaneous fistula and sepsis) occured in 4.0, 12.0, 14 and 17.0% of patients in the four groups (P > 0.05). Reoperation was needed in 3.0% (2) of patients in group S, 6.0% (2) in S&I and 3.0% (3) in C groups, and the mean hospital stay was 4.6 (± 2.1), 5.6 (± 4.6), 5.2 (± 4.7) and 5.2 (± 6) days in groups INF, S, S&I and ND, respectively. There was no mortality.

CONCLUSION

There were no significantly increased postoperative complications after ileostomy closure in patients who received infliximab or other immunosuppressive medications compared with patients who did not.

Revisiting stapled and handsewn loop ileostomy closures: a large retrospective series

OBJECTIVE

To compare the surgical outcomes of stapled and handsewn closures in loop ileostomies.

METHODS

The data of 225 patients requiring loop ileostomies from 2002 to 2007 were retrospectively evaluated. The patients underwent partial small-bowel resections and either handsewn or stapled anastomoses for the ileostomy closures. They were followed up postoperatively with routine surgical examinations.

RESULTS

The study group consisted of 124 men and 101 women with a mean age of 49.12 years. The ileostomy closure was performed with handsewn in 129 patients and with stapled in 96 patients. The mean time to the first postoperative flatus was 2.426 days in the handsewn group and 2.052 days in the stapled group (p <0.05). The mean time to the first postoperative defecation was 3.202 days in the handsewn group and 2.667 days in the stapled group (p <0.05). The mean duration of patient hospital stay was 8.581 days for the handsewn group and 6.063 days for the stapled group (p <0.05).

CONCLUSIONS

Patients who underwent ileostomy closure with stapled recovered faster in the postoperative period and required shorter hospital stays than those whose closures were performed with handsewn. In our opinion, stapled should be considered the gold standard for loop ileostomy closures.

Robot-assisted laparoscopic intracorporeal hand-sewn bowel anastomosis during pediatric bladder reconstructive surgery

Bowel anastomosis performed during robot-assisted laparoscopic surgery in both adult and pediatric populations has typically been performed using endoscopic staplers or with exteriorization of the bowel. In the pediatric population, no articles have been published that explore the possibility of a completely intracorporeal hand-sewn anastomosis during robot-assisted laparoscopic surgery. We report our series of six children who were undergoing robot-assisted laparoscopic intracorporeal hand-sewn bowel anastomosis during bladder reconstructive surgery for neurogenic bladder. The postoperative course was uncomplicated with regard to the bowel anastomosis, demonstrating the feasibility of the technique in experienced hands.

Complications of loop ileostomy closure in patients with rectal tumor

BACKGROUND

Loop ileostomy is customary after very low rectal anastomosis to reduce the rate of pelvic sepsis that can result from anastomotic leakage. To evaluate complications of stoma closure is important to maximize the benefit of making the defunctioning stoma. The aim of this study was to examine possible risk factors associated with complications, especially wound infections, after loop ileostomy closure in patients with rectal tumor.

METHODS

Data from 125 consecutive patients who underwent an elective closure of loop ileostomy after primary rectal tumor resection from January 2005 and October 2009 at a single institution were prospectively collected. Nineteen independent clinical variables were examined by univariate and multivariate analyses.

RESULTS

Postoperative complications developed in 21 (16.8%) patients, including 20 (16%) wound infections, 1 (0.8%) ileus, and 1 (0.8%) anastomotic bleeding. There was no postoperative mortality. Risk factors for wound infection included male gender (odds ratio = 5.30; 95% confidence interval 1.14-24.8; p = 0.0339) and surgical site infection (SSI) after primary surgery (odds ratio = 5.00; 95% confidence interval 1.24-20.1; p = 0.0234). Mean length of postoperative hospital stay was significantly longer in patients with complications than in patients without them (14.0 versus 11.0 days; p = 0.0078).

CONCLUSIONS

The present study showed that most complications associated with ileostomy closure in a homogeneous group of patients with rectal tumor were wound infections. Male gender and SSI after primary surgery were independent risk factors for the development of wound infections. Surgeons should be aware of such high-risk patients, and techniques other than primary closure might need to be considered in high-risk patients to reduce wound infections.

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

BACKGROUND AND AIMS

Loop ileostomies are used currently in surgical practice to reduce the consequences of distal anastomotic failure following colorectal resection. It is often assumed that reversal of a loop ileostomy is a simple and safe procedure. However, many studies have demonstrated high morbidity rates following loop ileostomy closure. The aims of this systematic review were to examine all the existing evidence in the literature on morbidity and mortality following closure of loop ileostomy.

METHOD

A literature search of Ovid, Embase, the Cochrane database, Google Scholar and Medline using Pubmed as the search engine was used to identify studies reporting on the morbidity of loop ileostomy closure (latest at June 15th 2008), was performed. Outcomes of interest included demographics, the details regarding the original indication for operation, operative and hospital-related outcomes, post-operative bowel-related complications, and other surgical and medical complications.

RESULTS

Forty-eight studies from 18 countries satisfied the inclusion criteria. Outcomes of a total of 6,107 patients were analysed. Overall morbidity following closure of loop ileostomy was found to be 17.3% with a mortality rate of 0.4%. 3.7% of patients required a laparotomy at the time of ileostomy closure. The most common post-operative complications included small bowel obstruction (7.2%) and wound sepsis (5.0%).

CONCLUSION

The consequences of anastomotic leakage following colorectal resection are severe. However, the consequences of stoma reversal are often underestimated. Surgeons should adopt a selective strategy regarding the use of defunctioning ileostomy, and counsel patients further prior to the original surgery. In this way, patients at low risk may be spared the morbidity of stoma reversal.

Standardized postoperative pathway: accelerating recovery after ileostomy closure

PURPOSE

In this study we evaluated the outcome of a standardized enhanced recovery program in patients undergoing ileostomy closure.

METHODS

Forty-two patients underwent ileostomy closure by a single surgeon and were managed by a standardized postoperative care pathway. On the first postoperative day, patients received oral analgesia and a soft diet. Discharge was based on standard criteria previously published for laparoscopic colectomy patients. Results were recorded prospectively in an Institutional Review Board-approved database, including demographics, operative time, blood loss, complications, length of stay, and readmission data.

RESULTS

The median operative time and blood loss were 60 minutes and 17.5 mL, respectively, and median hospital stay was 2 days. Twenty-nine patients (69 percent) were discharged by postoperative Day 2. The complication rate was 23.8 percent; complications included prolonged postoperative ileus (n = 3), early postoperative small-bowel obstruction (n = 1), mortality not related to ileostomy closure (n = 1), minor bleeding (n = 1), wound infection (n = 1), incisional hernia (n = 1), diarrhea (n = 1), dehydration (n = 1). The 30-day readmission rate was 9.5 percent (n = 4). Two patients had reoperation within 30 days for small-bowel obstruction and a wound infection.

CONCLUSIONS

Ileostomy closure patients managed with postoperative care pathways can have a short hospital stay with acceptable morbidity and readmission rates.