1
|
Liu F, Luo XJ, Li ZW, Liu XY, Liu XR, Lv Q, Shu XP, Zhang W, Peng D. Early postoperative complications after transverse colostomy closure, a retrospective study. World J Gastrointest Surg 2024; 16:807-815. [PMID: 38577084 PMCID: PMC10989347 DOI: 10.4240/wjgs.v16.i3.807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/13/2024] [Accepted: 02/07/2024] [Indexed: 03/22/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Fei Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xiao-Juan Luo
- Endoscopy Center, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400012, China
| | - Zi-Wei Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xiao-Yu Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xu-Rui Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Quan Lv
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xin-Peng Shu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Wei Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| |
Collapse
|
2
|
Technical Considerations in Stoma Reversal. SEMINARS IN COLON AND RECTAL SURGERY 2023. [DOI: 10.1016/j.scrs.2023.100957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
|
3
|
Zhang Y, Liu C, Nistala KRY, Chong CS. Open versus laparoscopic Hartmann's procedure: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:2421-2430. [PMID: 36416926 DOI: 10.1007/s00384-022-04285-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Hartmann's procedure is traditionally performed in emergency situations where single-step procedures with immediate anastomosis may be unsafe. However, it can be associated with significant morbidity and low colostomy reversal rate. Whilst randomised controlled trials and a Cochrane review have reported strong evidence of laparoscopic over open colectomies, no such reviews have been performed for Hartmann's procedure. Hence, this paper aims to summarise the existing evidence to determine the efficacy of laparoscopic Hartmann's procedure over its open counterpart. METHODS Embase, Medline and Cochrane databases were searched from inception to 15 November 2020 for keywords relating to 'laparoscopy' and 'Hartmann' using strict inclusion and exclusion criteria. Odds ratio was estimated for dichotomous outcomes and weighted mean difference was estimated for continuous outcomes. RESULTS From the 836 articles yielded from the search strategy, 12 articles were selected for meta-analysis. Pooled analysis revealed that laparoscopic Hartmann's procedure (LHP) allows for a shorter length of stay, and a lower risk of overall surgical site infections and superficial surgical site infections. There was no significant difference in other outcomes. Single-arm analysis of LHP also showed an unprecedented high colostomy reversal rate of over 80%. CONCLUSION In clinically suitable patients, laparoscopic Hartmann's procedure has benefits over open Hartmann's procedure. Despite the selection bias of single-arm studies, LHP has reported a high stoma reversal rate of over 80%. Future well-controlled studies should be done to affirm the findings.
Collapse
Affiliation(s)
- Yingjia Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chunxi Liu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Choon Seng Chong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Division of Colorectal Surgery, Department of Surgery, University Surgical Cluster, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| |
Collapse
|
4
|
Archer V, Cloutier Z, Berg A, McKechnie T, Wiercioch W, Eskicioglu C. Short-stay compared to long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:2113-2124. [PMID: 36151483 DOI: 10.1007/s00384-022-04256-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 02/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Victoria Archer
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Zacharie Cloutier
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Annie Berg
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tyler McKechnie
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
5
|
Is length of the rectal stump predictive for postoperative outcome in Hartmann's reversal surgery? A multicenter experience of 105 consecutive cases. Int J Colorectal Dis 2022; 37:617-622. [PMID: 35091774 DOI: 10.1007/s00384-021-04090-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Although Hartmann's procedure is commonly performed, subsequent reversal is less frequent. The most common reasons for reversal surgery are advanced age, comorbidities, and perceived surgical difficulties. The main objective of this study was to investigate if the length of the rectal stump influences the outcome of Hartmann's reversal surgery. METHOD We conducted a retrospective case study analyzing data from 105 patients who underwent Hartmann's reversal procedure between 2007 and 2019 in two centers. We evaluated patient demographics, length of rectal stump, intraoperative surgical details, short-term and long-term outcomes. RESULTS From 2007 to 2019, 105 patients underwent Hartmann's reversal surgery. Short-term morbidity rate was 58% (61 patients), including 16% (17 patients) with severe postoperative complication (Clavien-Dindo ≥ 3). Anastomotic leakage rate was 2.9% (3 patients). Long-term complications were present in 41% (43 patients) of which abdominal wall defect was the most frequent complication. The mean length of the rectal stump was 15 cm. In almost 1 out of 5 patients (17%) the rectal stump was shorter than 10 cm. The three anastomotic leakages appeared in the long rectal stump group (3.6% vs. 0%, p = 0.273). The complication rate for patients with a short rectal stump was similar to those with a longer rectal stump (50% vs. 63%, p = 0.275). Smoking, high ASA score, obesity, and advanced age did not influence the outcomes of the reversal procedure either. CONCLUSION Length of the rectal stump is not a predictive factor for postoperative complications after Hartmann's reversal surgery.
Collapse
|
6
|
Li CK, Liang WW, Wang HM, Guo WT, Qin XS, Zhao J, Zhou WB, Li Y, Wang H, Huang RK. Gunsight sutures significantly reduce surgical-site infection after ileostomy reversal compared with linear sutures. Gastroenterol Rep (Oxf) 2021; 9:357-362. [PMID: 34567568 PMCID: PMC8460110 DOI: 10.1093/gastro/goaa075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/21/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022] Open
Abstract
Background Surgical-site infection (SSI) was one of the most common post-operative morbidities of ileostomy reversal. Although several skin-closure procedures had been developed to reduce the rate of SSI, the optimal procedure remains unclear. In this study, we compared the effect of two surgical techniques for wound closure following ileostomy reversal: gunsight suture (GS) and linear suture (LS). Methods A total of 233 patients who underwent loop ileostomy at the Sixth Affiliated Hospital of Sun Yat-sen University between January 2015 and December 2017 were enrolled into our study. These patients were divided into two groups: the LS group and the GS group. We compared the clinical characteristics between the two groups and analyzed the data using IBM SPSS to identify risk factors for SSI. Results Both groups successfully underwent surgery. The rate of SSI was significantly lower in the GS group (n = 2, 0.02%) than in the LS group (n = 16, 12.00%, P = 0.007). The length of hospital stay after the operation in the GS group was significantly shorter than that in the LS group (8.1 ± 3.2 vs 10.8 ± 5.4 days, P < 0.001). Multivariate analysis showed that GS was an independent protective risk factor for SSI (odds ratio = 0.212, P = 0.048). Conclusions Compared with the LS technique, the GS technique can significantly decrease the rate of SSI and shorten the length of hospital stay after surgery. The GS technique may be recommended for wound closure following ileostomy reversal.
Collapse
Affiliation(s)
- Chuang-Kun Li
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wei-Wen Liang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Huai-Ming Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wen-Tai Guo
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xiu-Sen Qin
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jie Zhao
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wen-Bin Zhou
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yang Li
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Hui Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Rong-Kang Huang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| |
Collapse
|
7
|
Laparoscopic Versus Open Hartmann Reversal: A Case-Control Study. Surg Res Pract 2021; 2021:4547537. [PMID: 33553574 PMCID: PMC7847322 DOI: 10.1155/2021/4547537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 01/07/2021] [Accepted: 01/16/2021] [Indexed: 12/13/2022] Open
Abstract
Background Laparoscopic reversal of Hartmann's procedure (LHR) offers reduced morbidity compared with open Hartmann's reversal (OHR). The aim of this study is to compare the outcome of laparoscopic versus open Hartmann reversal. Materials and Methods Thirty-four patients who underwent Hartmann reversal between January 2017 and July 2019 were evaluated. Patients underwent either LHR (n = 17) or OHR (n = 17). Variables such as numbers of patients, patient's age, sex, body mass index (BMI), comorbidities, ASA (American Society of Anesthesiology) score, indication for previous open sigmoid resection, mean operation time, rate of conversion to open surgery, length of hospital stay, mortality, and morbidity were retrospectively evaluated. Results The two groups of patients were homogeneous for gender, age, body mass index, cause of primary surgery, time to reversal, and comorbidities. In 97% of the cases, HP was done by open surgery. Our data revealed no difference in mean operation time (LHR: 180.5 ± 35.1 vs. OHR: 225.2 ± 48.4) and morbidity rate, although, in OHR group, there were more severe complications. Less intraoperative blood loss (LHR: 100 ± 40 mL vs. OHR: 450 ± 125 mL; p value <0.001), shorter time to flatus (LHR: 2.4 days vs. OHR: 3.6 days; p value <0.021), and shorter hospitalization (LHR: 4.4 vs. OHR: 11.2 days; p value <0.001) were observed in the LHR group. Mortality rate was null in both groups. Discussion. LHR is feasible and safe even for patients who received a primary open Hartmann's procedure. We suggest careful patient's selection allowing LHR procedures to highly skilled laparoscopy surgeons.
Collapse
|
8
|
Mohamedahmed AYY, Stonelake S, Zaman S, Hajibandeh S. Closure of stoma site with or without prophylactic mesh reinforcement: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:1477-1488. [PMID: 32588121 DOI: 10.1007/s00384-020-03681-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 02/04/2023]
Abstract
AIMS To evaluate comparative outcomes of the closure of temporary stoma site with or without prophylactic mesh reinforcement METHODS: A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Studies comparing the reversal of stoma with and without prophylactic mesh reinforcement were included. Stoma site incisional hernia (SSIH), surgical site infection (SSI), operative time, seroma formation, haematoma formation, bowel obstruction, anastomosis leak, length of hospital stay (LOS) and secondary operation to repair the SSIH were the evaluated outcome parameters. RESULTS Six comparative studies reporting a total of 1683 patients who underwent closure of stoma with (n = 669) or without (n = 1014) prophylactic mesh reinforcement were included. Use of mesh was associated with a significantly lower risk of SSIH (OR 0.22, P = 0.003) and need for surgical intervention to repair SSIH (OR 0.32, P = 0.04) compared with no use of mesh. However, it was associated with significantly longer operative time (MD 47.78, P = 0.02). There was no significant difference in SSI (OR 1.09, P = 0.59), bowel obstruction (OR 1.11, P = 0.74), seroma formation (OR 2.86, P = 0.19), anastomosis leak (OR 1.60, P = 0.15), haematoma formation (OR 1.25, P = 0.75) or LOS (MD - 0.45, P = 0.31) between two groups. CONCLUSION Prophylactic mesh reinforcement during the closure of temporary stoma may significantly reduce the risk of SSIH and surgical intervention to repair the hernia without increasing the risk of SSI or other morbidities. However, it may increase the procedure time. Future higher-quality randomised evidence is required.
Collapse
Affiliation(s)
- Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Stephen Stonelake
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| |
Collapse
|
9
|
Pizza F, D’Antonio D, Arcopinto M, Dell’Isola C, Marvaso A. Safety and efficacy of prophylactic resorbable biosynthetic mesh in loop-ileostomy reversal: a case–control study. Updates Surg 2020; 72:103-108. [DOI: 10.1007/s13304-020-00702-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 01/02/2020] [Indexed: 12/19/2022]
|
10
|
Lorenz A, Kogler P, Kafka-Ritsch R, Öfner D, Perathoner A. Incisional hernia at the site of stoma reversal-incidence and risk factors in a retrospective observational analysis. Int J Colorectal Dis 2019; 34:1179-1187. [PMID: 31065787 DOI: 10.1007/s00384-019-03310-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The closure of a stoma site has a high incidence of incisional hernia (IH) development, reaching 30% in some studies. Location and defect size in the abdominal wall depend on the type of stoma formed, most commonly a loop ileostomy or terminal sigmoid colostomy. METHODS The retrospective single-centre study includes all consecutive patients who underwent stoma reversal between 2010 and 2016 at the Department of Visceral, Transplant and Thoracic Surgery in Innsbruck. Patient characteristics and follow-up examinations were evaluated for IH at both the stoma reversal site and at any other surgical access sites. RESULTS A total of 181 patients (49% female, 51% male) had a stoma reversal operation. A parastomal hernia was present in 5% (n = 9). Follow-up data was available for 140 patients (77%). A postoperative IH at the stoma reversal site developed in 15.7% (n = 22) and in 18.6% (n = 26) at other surgical wounds to the abdominal wall during a median follow-up of 136 weeks. The combination of a preoperative parastomal hernia and a postoperative IH was observed in 2.8% (n = 5). Parastomal herniation, male sex, body mass index over 25, arterial hypertension and concomitant ventral hernia were associated with IH formation at the stoma reversal. CONCLUSION The rate of IH at the stoma reversal site was lower than expected from the literature, whereas the rate of IH at other surgical wounds to the abdominal wall was within the expected range.
Collapse
Affiliation(s)
- Andreas Lorenz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Pamela Kogler
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Alexander Perathoner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| |
Collapse
|
11
|
Garfinkle R, Savage P, Boutros M, Landry T, Reynier P, Morin N, Vasilevsky CA, Filion KB. Incidence and predictors of postoperative ileus after loop ileostomy closure: a systematic review and meta-analysis. Surg Endosc 2019; 33:2430-2443. [PMID: 31020433 DOI: 10.1007/s00464-019-06794-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/09/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Postoperative ileus (POI) is regarded as the most clinically significant morbidity following loop ileostomy closure; however, its incidence remains poorly understood. Our objective was therefore to determine the pooled incidence of POI after loop ileostomy closure and identify risk factors associated with its development. METHODS We systematically searched MEDLINE (via Ovid and PubMed), Embase, the Cochrane Library, Biosis Previews, and Scopus to identify studies reporting the incidence of POI in patients who underwent loop ileostomy closure. Two independent reviewers extracted data and appraised study quality. Cumulative incidence proportions were pooled across studies using a random-effects meta-analytic model. RESULTS Sixty-seven studies, including 9528 patients, met our inclusion criteria. The pooled estimate of POI was 8.0% (95% CI 6.9-9.3%; I2 = 74%). The estimated incidence varied by POI definition: studies with a robust definition of POI (n = 8) demonstrated the highest estimate of POI (12.4%, 95% CI 9.2-16.5%; I2 = 79%) while studies that did not report an explicit POI definition (n = 38) demonstrated the lowest estimate (6.7%, 95% CI 5.3-8.3%; I2 = 61%). Small bowel anastomosis technique (hand-sewn) and interval time from ileostomy creation to closure (longer time) were the factors most commonly associated with POI after loop ileostomy closure. However, most comparative studies were not powered to examine risk factors for POI. CONCLUSIONS POI is an important complication after loop ileostomy closure, and its incidence is dependent on its definition. More research aimed at studying this complication is required to better understand risk factors for POI after loop ileostomy closure.
Collapse
Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Paul Savage
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.,Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Tara Landry
- Medical Libraries, McGill University Health Center, Montreal, QC, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada. .,Department of Medicine, McGill University, Montreal, QC, Canada.
| |
Collapse
|
12
|
Sier MF, Wisselink DD, Ubbink DT, Oostenbroek RJ, Veldink GJ, Lamme B, van Duijvendijk P, van Geloven AAW, Eijsbouts QAJ, Bemelman WA. Randomized clinical trial of intracutaneously versus transcutaneously sutured ileostomy to prevent stoma-related complications (ISI trial). Br J Surg 2018; 105:637-644. [PMID: 29493785 PMCID: PMC5947256 DOI: 10.1002/bjs.10750] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 09/27/2017] [Accepted: 10/03/2017] [Indexed: 11/16/2022]
Abstract
Background Ileostomy construction is a common procedure but can be associated with morbidity. The stoma is commonly secured to the skin using transcutaneous sutures. It is hypothesized that intracutaneous sutures result in a tighter adherence of the peristomal skin to the stoma plate to prevent faecal leakage. The study aimed to compare the effect of intracutaneous versus transcutaneous suturing of ileostomies on faecal leakage and quality of life. Methods This randomized trial was undertaken in 11 hospitals in the Netherlands. Patients scheduled to receive an ileostomy for any reason were randomized to intracutaneous or transcutaneous suturing (IC and TC groups respectively). The primary outcome was faecal leakage. Secondary outcomes were stoma‐related quality of life and costs of stoma‐related materials and reinterventions. Results Between April 2011 and February 2016, 339 patients were randomized to the IC (170) or TC (169) group. Leakage rates were higher in the IC than in the TC group (52·4 versus 41·4 per cent respectively; risk difference 11·0 (95 per cent c.i. 0·3 to 21·2) per cent). Skin irritation rates were high (78·2 versus 72·2 per cent), but did not differ significantly between the groups (risk difference 6·1 (95 per cent c.i. –3·2 to 15·10) per cent). There were no significant differences in quality of life or costs between the groups. Conclusion Intracutaneous suturing of an ileostomy is associated with more peristomal leakage than transcutaneous suturing. Overall stoma‐related complications did not differ between the two techniques. Registration number: NTR2369 (
http://www.trialregister.nl). More leaks with intracutaneous
Collapse
Affiliation(s)
- M F Sier
- Department of Surgery, University Medical Centre Leiden, Leiden, The Netherlands
| | - D D Wisselink
- Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - D T Ubbink
- Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - R J Oostenbroek
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - G J Veldink
- Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - B Lamme
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | | | - Q A J Eijsbouts
- Department of Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
13
|
Sureshkumar S, Jubel K, Ali MS, Vijayakumar C, Amaranathan A, Sundaramoorthy S, Palanivel C. Comparing Surgical Site Infection and Scar Cosmesis Between Conventional Linear Skin Closure Versus Purse-string Skin Closure in Stoma Reversal - A Randomized Controlled Trial. Cureus 2018; 10:e2181. [PMID: 29657907 PMCID: PMC5896871 DOI: 10.7759/cureus.2181] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Introduction Stoma closure is one of the most frequently performed surgeries. The common complications are surgical site infection (SSI) and poor scar cosmesis. Purse-string sutures are expected to have less incidence of SSI due to the free drainage of secretions from the wound and possibly the early detection of a wound infection. Compared to the conventional linear closure, the purse-string closure technique is expected to have less wound infection, improved scar cosmesis, and good patient satisfaction because of a smaller size scar. Hence, a well-structured study is required to substantiate the advantage of this technique. Methodology This randomized control trial was carried out for two years in a tertiary care centre in Southern India. Patients with various stoma reversals, including colostomy, as well as ileostomy reversal, were included in the study. Patients were divided into Group I - conventional linear skin suturing (n = 40) and Group II - purse-string closure (n = 40). After the closure of rectus muscle, the skin is closed using the purse-string method (subcuticular) in the experimental group. Results Both the groups were comparable with respect to age, gender, body mass index (BMI), the presence of co-morbidities, and indication for surgery. Stomal procedures were done (26.3%) for malignant cases. The difference in mean hospital days for both groups were statistically insignificant (11.95 vs. 9.9; p = 0.927). The incidence of SSI between the groups were statistically significant (17 vs. 3; p = 0.003). The mean Patient and Observer Scar Assessment Scoring (POSAS) scores between the groups (65.30 vs. 83.40; p = 0.012) were statistically significant. This proved significant improvement in scar cosmesis in purse-string skin closure. At one month postoperative, the purse-string group had better patient satisfaction (3.08 vs. 4.48; p = 0.001), which was evidenced by a mean Likert 3 scale score. The mean visual analogue scale (VAS) score did not show any significant difference in pain between the groups. Conclusion Purse-string skin closure for stoma reversal had significantly less incidence of SSI. The duration of antibiotic therapy was also less in purse-string skin closure patients as compared to linear skin closure patients. Purse-string skin closures significantly improved the scar outcome and patient satisfaction.
Collapse
Affiliation(s)
- Sathasivam Sureshkumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kunnathoor Jubel
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | | | - Chellappa Vijayakumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Anandhi Amaranathan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sudharsanan Sundaramoorthy
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Chinnakali Palanivel
- Preventive Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| |
Collapse
|
14
|
Sier MF, Oostenbroek RJ, Dijkgraaf MGW, Veldink GJ, Bemelman WA, Pronk A, Spillenaar-Bilgen EJ, Kelder W, Hoff C, Ubbink DT. Home visits as part of a new care pathway (iAID) to improve quality of care and quality of life in ostomy patients: a cluster-randomized stepped-wedge trial. Colorectal Dis 2017; 19:739-749. [PMID: 28192627 DOI: 10.1111/codi.13630] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 12/12/2016] [Indexed: 12/13/2022]
Abstract
AIM Morbidity in patients with an ostomy is high. A new care pathway, including perioperative home visits by enterostomal therapists, was studied to assess whether more elaborate education and closer guidance could reduce stoma-related complications and improve quality of life (QoL), at acceptable cost. METHOD Patients requiring an ileostomy or colostomy, for any inflammatory or malignant bowel disease, were included in a 15-centre cluster-randomized 'stepped-wedge' study. Primary outcomes were stoma-related complications and QoL, measured using the Stoma-QOL, 3 months after surgery. Secondary outcomes included costs of care. RESULTS The standard pathway (SP) was followed by 113 patients and the new pathway (NP) by 105 patients. Although the overall number of stoma-related complications was similar in both groups (SP 156, NP 150), the proportion of patients experiencing one or more stoma-related complications was significantly higher in the NP (72% vs 84%, risk difference 12%; 95% CI: 0.3-23.3%). Although in the NP more patients had stoma-related complications, QoL scores were significantly better (P < 0.001). In the SP more patients required extra care at home for their ostomy than in the NP (60.6% vs 33.7%, respectively; risk difference 26.9%, 95% CI: 13.5-40.4%). Stoma revision was done more often in the SP (n = 11) than in the NP (n = 2). Total costs in the SP did not differ significantly from the NP. CONCLUSION The NP did not reduce the number of stoma-related complications but did lead to improved quality of care and life, against similar costs. Based on these results the NP, including perioperative home visits by an enterostomal therapist, can be recommended.
Collapse
Affiliation(s)
- M F Sier
- Department of Surgery, University Medical Centre Leiden, Leiden, The Netherlands
| | - R J Oostenbroek
- Department of Surgery, Albert Schweitzer Hospital Dordrecht, Dordrecht, The Netherlands
| | - M G W Dijkgraaf
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - G J Veldink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - A Pronk
- Department of Surgery, Diakonessen Hospital Utrecht, Utrecht, The Netherlands
| | | | - W Kelder
- Department of Surgery, Martini Hospital Groningen, Groningen, The Netherlands
| | - C Hoff
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - D T Ubbink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | |
Collapse
|
15
|
Laparoscopically Assisted Reversal of Hartmann's Procedure for Perforated Diverticulitis. Int Surg 2017. [DOI: 10.9738/intsurg-d-16-00125.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to retrospectively review the clinical outcomes of laparoscopically assisted and open surgical reversal of Hartmann's procedure (HR). We reviewed all patients undergoing laparoscopic or open HR at Tri-Service General Hospital, Taipei, Taiwan, between January 2002 and January 2010. A total of 34 perforated diverticulitis patients initially treated by exploratory laparotomy with Hartmann's procedure were enrolled and divided into 2 groups: laparoscopic and open HR. Data relative to patient age at the time of HR, sex, body mass index, operative time, longest incision length, estimated blood loss, intraoperative complications, postoperative complications, time to bowel function return, duration of hospitalization, and length of follow-up were reviewed. The median colostomy closure period was significantly higher in the laparoscopic group than in the open group (P = 0.011). The median longest incision length, estimated blood loss, time to first oral intake, and hospital stay were significantly lower in the laparoscopic group compared with the open group. Laparoscopic HR may be a technically safe, feasible approach that provides better cosmesis, less blood loss, and faster recovery compared with open HR.
Collapse
|
16
|
Abstract
Temporary stomas are frequently used in the management of diverticulitis, colorectal cancer, and inflammatory bowel disease. These temporary stomas are used to try to mitigate septic complications from anastomotic leaks and to avoid the need for reoperation. Once acute medical conditions have improved and after the anastomosis has been proven to be healed, stomas can be reversed. Contrast enemas, digital rectal examination, and endoscopic evaluation are used to evaluate the anastomosis prior to reversal. Stoma reversal is associated with complications including anastomotic leak, postoperative ileus, bowel obstruction, enterocutaneous fistula, and, most commonly, surgical site infection. Furthermore, many stomas, which were intended to be temporary, may not be reversed due to postoperative complications, adjuvant therapy, or prohibitive comorbidities.
Collapse
Affiliation(s)
- Karen L Sherman
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| |
Collapse
|
17
|
Comparison of Short-term Outcomes After Laparoscopic Versus Open Hartmann Reversal: A Case-matched Study. Surg Laparosc Endosc Percutan Tech 2017; 26:e75-9. [PMID: 27403621 DOI: 10.1097/sle.0000000000000299] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE The aim of this study is to compare short-term outcomes of laparoscopic versus open Hartmann reversal. MATERIALS AND METHODS Patients who underwent Hartmann reversal between January 2005 and September 2014 were identified and matched for age, sex, body mass index, American Society of Anesthesiologists score, and creation of diverting ileostomy to open counterparts. Patient characteristics and postoperative outcomes (30 d) were evaluated. RESULTS Eighteen patients with laparoscopic Hartmann reversal were matched to 18 open patients. There were no differences between laparoscopic versus open groups in terms of operative time (157.7±52.2 vs. 151.5±49.3 min, P>0.05) or overall complication rates [6 (33.3%) vs. 6 (33.3%) (P>0.05)]. No anastomotic leaks or mortality occurred in either group. However, the laparoscopic group was associated with significantly decreased estimated blood loss (114±103 vs. 217±125 mL, P<0.05), faster return of bowel function (3.2±0.6 vs. 4±0.6 d, P<0.05), and reduced hospital stay (5.4±3.1 vs. 8.3±4.8 d, P<0.05). CONCLUSIONS Laparoscopic Hartmann reversal can be safely performed with better short-term outcomes in carefully selected patients.
Collapse
|
18
|
Doud AN, Levine EA, Fino NF, Stewart JH, Shen P, Votanopoulos KI. Stoma Creation and Reversal After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2015; 23:503-10. [PMID: 26077915 DOI: 10.1245/s10434-015-4674-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC) often includes stoma creation. We evaluated the indications, morbidity, and mortality associated with stoma creation and reversal after CRS/HIPEC. METHODS Retrospective analysis of a prospective database of 1149 CRS-HIPEC procedures was performed. Patient demographics, type of malignancy, comorbidities, Clavien-graded morbidity, mortality, indications for stoma creation, and outcomes of subsequent reversal were abstracted. RESULTS Sixteen percent (186/1149) of CRS/HIPEC procedures included stoma creation, whereas 1.1 % (11/963) of patients without initial stoma creation developed anastomotic leaks requiring stoma. Patients who required a stoma had worse preoperative performance status (ECOG 0/1: 77.2 vs. 86.1 %, p = 0.002), greater burden of disease (PCI 17.6 vs. 12.9, p < 0.0001), and were more likely to have R2 resections (74.5 vs. 48.8 %, p < 0.0001) than those without stoma creation. Stomas were intended to be permanent in 17.5 % (35/199). Of 164 patients with potentially reversible ostomies, only 26.2 % (43/164) underwent reversal. Disease progression (43/164, 26.2 %) and death (40/164, 24.3 %) most commonly precluded reversal. After reversal, 27.9 % (12/43) suffered a Clavien I/II morbidity, 27.9 % (12/43) suffered Clavien III/IV morbidity, and 30-day mortality was 4.7 % (2/43). Anastomotic leak occurred after 9 % (3/33) of ileostomy and 10 % (1/10) of colostomy reversals. CONCLUSIONS Stomas are more common among CRS/HIPEC patients with a high burden of disease and poor functional status. Reversal is uncommon and is associated with significant major morbidity. Preoperative counseling for those with high disease burden and poor functional status should include the risk of permanent stoma.
Collapse
Affiliation(s)
- Andrea N Doud
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA.
| | - Edward A Levine
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA
| | - Nora F Fino
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, USA
| | - John H Stewart
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA
| | - Perry Shen
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA
| | - Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, 27157, USA.
| |
Collapse
|
19
|
Richards CH, Roxburgh CSD. Surgical outcome in patients undergoing reversal of Hartmann's procedures: a multicentre study. Colorectal Dis 2015; 17:242-9. [PMID: 25331720 DOI: 10.1111/codi.12807] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/18/2014] [Indexed: 12/12/2022]
Abstract
AIM Recent evidence has suggested that a laparoscopic rather than an open approach to reversal of Hartmann's procedure (ROH) may be associated with fewer complications. Much of the data for comparison are historical or based on small case series. The aims of this study were to determine the morbidity and mortality of ROH in 10 hospitals in the modern era and to identify risk factors for complications. METHOD A multicentre study of patients undergoing ROH (2007-2013) was performed. Data were collected retrospectively from perioperative health databases and casenotes where appropriate on patient demographics, laboratory investigations and operative details. Complications were classified as minor (I-II) or major (III-IV) based on the Clavien-Dindo criteria. Risk factors for complications were assessed by multivariate analysis with calculation of OR with 95% CI. RESULTS Ten hospitals in Scotland provided data on 252 patients undergoing ROH. Most operations were open (85%) with 15% started laparoscopically (conversion rate 64%). In the postoperative period, 35 (14%) patients had a major complication, including anastomotic leakage in 10 (4%) and postoperative death in one (0.4%). Patients with a complication stayed significantly longer in hospital (12 days vs 7 days, P < 0.001). On multivariate analysis, a wound complication after the original Hartmann's procedure (OR = 3.85, 95% CI: 1.08-13.75, P = 0.038) was associated with any complication after ROH, but only American Society of Anesthesiologists (ASA) grade (OR = 3.35, 95% CI: 1.38-8.09, P = 0.007) was independently associated with the development of a major complication. CONCLUSION ROH has a low postoperative mortality but significant morbidity. Most operations are still performed by open surgery, and in those attempted laparoscopically, the conversion rate is high.
Collapse
Affiliation(s)
- C H Richards
- Specialty trainee (StR) in General Surgery, Raigmore Hospital, NHS Highland, Inverness, UK
| | | | | |
Collapse
|
20
|
Walklett CL, Yeomans NP. A retrospective case note review of laparoscopic versus open reversal of Hartmann's procedure. Ann R Coll Surg Engl 2014; 96:539-42. [PMID: 25245735 DOI: 10.1308/003588414x14055925058238] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION First described in 1921, Hartmann's procedure is the gold standard treatment for complicated sigmoid diverticular disease. It is also used commonly for other causes of perforation of the large bowel. However, the reversal rate in the UK is much lower than in comparable countries, at only 18-22%. Furthermore, laparoscopic reversal (LRH) is used far less frequently than open reversal (ORH) despite evidence that a laparoscopic technique reduces patient morbidity and decreases patient recovery time. METHODS This retrospective case note review undertook an analysis of all the patients who had undergone Hartmann's procedure at two centres in Leeds Teaching Hospitals NHS Trust between February 2007 and February 2012. Out of 305 patients, 235 were identified and included in the analysis. Comparisons were then drawn between LRH and ORH groups. RESULTS The reversal rate was 21%. Three-quarters (76%) were performed using an open technique, 20% were laparoscopic and 5% were converted to an open procedure. The mean hospital stay was longer for the ORH group (9.82 days, standard deviation [SD]: 5.85 days, 95% confidence interval [CI]: 2.99 days) than for the LRH group (7.29 days, SD: 4.65 days, 95% CI: 11.58 days) p=0.006). Seven ORH patients (21%) were reoperated but only one LRH patient (13%) had a reoperation at six months. Five factors were found to have a significant effect on the likelihood of reversal of Hartmann's procedure. CONCLUSIONS The overall reversal rate for Hartmann's procedure remains low. Shorter hospital stays, lower 6-month reoperation rates and reduced 30-day complication rates are associated with LRH when compared with ORH.
Collapse
|
21
|
Laparoscopic reversal of Hartmann's procedure. Updates Surg 2014; 66:277-81. [PMID: 25262377 DOI: 10.1007/s13304-014-0268-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 09/20/2014] [Indexed: 12/18/2022]
Abstract
Reestablishing continuity after a Hartmann's procedure is considered a major surgical procedure with high morbidity/mortality. The aim of this study was to assess the short-/long-term outcome of laparoscopic restoration of bowel continuity after HP. A prospectively collected database of colorectal laparoscopic procedures (>800) performed between June 2005 and June 2013 was used to identify 20 consecutive patients who had undergone laparoscopic reversal of Hartmann's procedure (LHR). Median age was 65.4. Ten patients (50 %) had undergone surgery for perforated diverticulitis, 3 (15 %) for cancer, and 7 (35 %) for other reasons (volvulus, posttraumatic perforation, and sigmoid perforation from foreign body). Previous HP had been performed laparoscopically in only 3 patients. Median operative time was 162.5 min. All the procedures were completed laparoscopically. Intraoperative complication rate was nil. Post-operative mortality and morbidity were respectively 0 and 10 % (1 pneumonia, 1 bowel obstruction from post-anastomotic stenosis which required resection and redo of the anastomosis). Median time to first flatus was 3 days, to normal diet 5 days. Median hospital stay was 9 days without readmissions. We followed up the patients for a median of 44 months: when asked, all 20 (100 %) said they would undergo the operation (LHR) again; 3 (15 %) had been re-operated of laparoscopic mesh repair for incisional hernia. When performed by experienced surgeons, LHR is a feasible, safe, reproducible operation, which allows early return of bowel function, early discharge and fast return to work for the patient. It has a low morbidity rate.
Collapse
|
22
|
de'Angelis N, Felli E, Azoulay D, Brunetti F. Robotic-assisted reversal of Hartmann's procedure for diverticulitis. J Robot Surg 2014; 8:381-3. [PMID: 25419246 PMCID: PMC4236621 DOI: 10.1007/s11701-014-0458-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 02/25/2014] [Indexed: 02/01/2023]
Abstract
The minimally invasive laparoscopic approach for the reversal of Hartmann's procedure (HP) has been shown to be a safe and feasible approach associated with low morbidity and fast recovery. Robotic surgery has not yet been described for HP reversal. We report the case of an 84-year-old man originally operated on in an emergency setting by conventional HP for complicated diverticulitis who underwent a robotic-assisted HP reversal. The surgical procedure and the post-operative follow-up were uneventful, with low post-operative pain, early return to bowel function, and discharge at day 3. The robotic surgery appeared to be a safe, feasible, and valuable approach for HP reversal.
Collapse
Affiliation(s)
- Nicola de'Angelis
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris Est, UPEC, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Emanuele Felli
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris Est, UPEC, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Daniel Azoulay
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris Est, UPEC, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Francesco Brunetti
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris Est, UPEC, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| |
Collapse
|
23
|
Causey MW, Rivadeneira DE, Steele SR. Historical and current trends in colon trauma. Clin Colon Rectal Surg 2013; 25:189-99. [PMID: 24294119 DOI: 10.1055/s-0032-1329389] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The authors discuss the evolution of the evaluation and management of colonic trauma, as well as the debate regarding primary repair versus fecal diversion. Their evidence-based review covers diagnosis, management, surgical approaches, and perioperative care of patients with colon-related trauma. The management of traumatic colon injuries has evolved significantly over the past 50 years; here the authors describe a practical approach to the treatment and management of traumatic injuries to the colon based on the most current research. However, management of traumatic colon injuries remains a challenge and continues to be associated with significant morbidity. Familiarity with the different methods to the approach and management of colonic injuries will allow surgeons to minimize unnecessary complications and mortality.
Collapse
Affiliation(s)
- Marlin Wayne Causey
- Department of Surgery, Uniformed Services University of the Health Sciences (USUHS), Madigan Healthcare System, Fort Lewis, Washington
| | | | | |
Collapse
|
24
|
Alizai PH, Schulze-Hagen M, Klink CD, Ulmer F, Roeth AA, Neumann UP, Jansen M, Rosch R. Primary anastomosis with a defunctioning stoma versus Hartmann's procedure for perforated diverticulitis--a comparison of stoma reversal rates. Int J Colorectal Dis 2013; 28:1681-8. [PMID: 23913315 DOI: 10.1007/s00384-013-1753-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The ideal treatment of patients with perforated diverticulitis is still controversial. Hartmann's procedure has been the treatment of choice for decades, but primary anastomosis with a defunctioning stoma has become an accepted alternative. The aim of this study was to evaluate the stoma reversal rates after these two surgical strategies. METHODS A retrospective review of the data from patients with perforated sigmoid diverticulitis between 2002 and 2011 undergoing a Hartmann's procedure (HP) versus a primary anastomosis with a defunctioning stoma (PA) was performed. Additionally, patients were contacted by mail or telephone in March 2012 using a standardized questionnaire. RESULTS A total of 98 patients were identified: 72 undergoing HP and 26 patients receiving PA. The median follow-up time was 63 months (range 4-118). Whilst 85 % of patients with PA have had their stoma reversed, only 58 % of patients with an HP had a stoma reversal (p = 0.046). The median period until stoma reversal was significantly longer for HP (19 weeks) than for PA (12 weeks; p = 0.03). The 30-day mortality for PA was 12 % as opposed to 25 % for HP (p = 0.167). According to the Clavien-Dindo classification, surgical complications occurred significantly less frequently in patients with PA (p = 0.014). CONCLUSION The stoma reversal rates for PA are significantly higher than for HP. Thus, depending on the overall clinical situation, primary resection and anastomosis with a proximal defunctioning stoma might be the optimal procedure for selected patients with perforated diverticular disease.
Collapse
Affiliation(s)
- P H Alizai
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany,
| | | | | | | | | | | | | | | |
Collapse
|
25
|
de’Angelis N, Brunetti F, Memeo R, Batista da Costa J, Schneck AS, Carra MC, Azoulay D. Comparison between open and laparoscopic reversal of Hartmann’s procedure for diverticulitis. World J Gastrointest Surg 2013; 5:245-251. [PMID: 23983906 PMCID: PMC3753438 DOI: 10.4240/wjgs.v5.i8.245] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 06/29/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the open and laparoscopic Hartmann’s reversal in patients first treated for complicated diverticulitis.
METHODS: Forty-six consecutive patients with diverticular disease were included in this retrospective, single-center study of a prospectively maintained colorectal surgery database. All patients underwent conventional Hartmann’s procedures for acute complicated diverticulitis. Other indications for Hartmann’s procedures were excluded. Patients underwent open (OHR) or laparoscopic Hartmann’s reversal (LHR) between 2000 and 2010, and received the same pre- and post-operative protocols of cares. Operative variables, length of stay, short- (at 1 mo) and long-term (at 1 and 3 years) post-operative complications, and surgery-related costs were compared between groups.
RESULTS: The OHR group consisted of 18 patients (13 males, mean age ± SD, 61.4 ± 12.8 years), and the LHR group comprised 28 patients (16 males, mean age 54.9 ± 14.4 years). The mean operative time and the estimated blood loss were higher in the OHR group (235.8 ± 43.6 min vs 171.1 ± 27.4 min; and 301.1 ± 54.6 mL vs 225 ± 38.6 mL respectively, P = 0.001). Bowel function returned in an average of 4.3 ± 1.7 d in the OHR group, and 3 ± 1.3 d in the LHR group (P = 0.01). The length of hospital stay was significantly longer in the OHR group (11.2 ± 5.3 d vs 6.7 ± 1.9 d, P < 0.001). The 1 mo complication rate was 33.3% in the OHR (6 wound infections) and 3.6% in the LHR group (1 hemorrhage) (P = 0.004). At 12 mo, the complication rate remained significantly higher in the OHR group (27.8% vs 10.7%, P = 0.03). The anastomotic leak and mortality rates were nil. At 3 years, no patient required re-intervention for surgical complications. The OHR procedure had significantly higher costs (+56%) compared to the LHR procedure, when combining the surgery-related costs and the length of hospital stay.
CONCLUSION: LHR appears to be a safe and feasible procedure that is associated with reduced hospitality stays, complication rates, and costs compared to OHR.
Collapse
|
26
|
Randomized clinical trial of intestinal ostomy takedown comparing pursestring wound closure vs conventional closure to eliminate the risk of wound infection. Dis Colon Rectum 2013; 56:205-11. [PMID: 23303149 DOI: 10.1097/dcr.0b013e31827888f6] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The use of temporary stomas has been demonstrated to reduce septic complications, especially in high-risk anastomosis; therefore, it is necessary to reduce the number of complications secondary to ostomy takedowns, namely wound infection, anastomotic leaks, and intestinal obstruction. OBJECTIVE To compare the rates of superficial wound infection and patient satisfaction after pursestring closure of ostomy wound vs conventional linear closure. DESIGN Patients undergoing colostomy or ileostomy closure between January 2010 and February 2011 were randomly assigned to linear closure (n = 30) or pursestring closure (n = 31) of their ostomy wound. Wound infection within 30 days of surgery was defined as the presence of purulent discharge, pain, erythema, warmth, or positive culture for bacteria. Patient satisfaction, healing time, difficulty managing the wound, and limitation of activities were analyzed with the Likert questionnaire. RESULTS The infection rate for the control group was 36.6% (n = 11) vs 0% in the pursestring closure group (p < 0.0001). Healing time was 5.9 weeks in the linear closure group and 3.8 weeks in the pursestring group (p = 0.0002). Seventy percent of the patients with pursestring closure were very satisfied in comparison with 20% in the other group (p = 0.0001). LIMITATIONS This study was limited by the heterogeneity in the type of stoma in both groups. CONCLUSION The pursestring method resulted in the absence of infection after ostomy wound closure (shorter healing time and improved patient satisfaction).
Collapse
|
27
|
Mirbagheri N, Dark J, Skinner S. Factors predicting stomal wound closure infection rates. Tech Coloproctol 2012; 17:215-20. [PMID: 23076288 DOI: 10.1007/s10151-012-0908-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 09/19/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND Stoma closure is associated with high wound infection rates. The aim of this study was to evaluate risk factors for infection rates in such wounds, with particular emphasis on assessing the importance of the stomal wound closure technique. METHODS A retrospective analysis of 142 patients who had undergone ileostomy or colostomy closure between 2002 and 2011 was performed. Postoperative outcome as measured by wound infection rate was recorded. Three different closure techniques were identified: primary closure (PC), primary closure with penrose drain (PCP) and purse-string circumferential wound approximation technique (PSC). Other factors such as age, sex, ASA score, type of prophylactic antibiotics used, diabetes, smoking and obesity were also analysed. All other techniques were excluded. RESULTS Our series consisted of 142 stomal closures (90 ileostomy and 52 colostomy closures). The patients had a median age of 63.5 years with an interquartile range of 50.1-73.2 years. The overall wound infection rate was 10.7%. PC, PCP and PSC were associated with wound infection rates of 17.9, 10.5 and 3.6%, respectively. Compared to PSC, PC and PCP were associated with significantly higher wound infection rates (p = 0.027 and p = 0.068, respectively). Obesity was a significant risk factor for wound infection (p = 0.024). Use of triple-agent antibiotics prophylactically had a protective effect on the infection rate (p = 0.012). CONCLUSIONS To reduce stomal wound closure infection rates, we recommend institution of closure techniques other than PC with or without a drain. Risk factors such as obesity should be addressed, and prophylactic triple antibiotics should be administered.
Collapse
Affiliation(s)
- N Mirbagheri
- Department of Surgery, Frankston Hospital, Hastings Road, Frankston, VIC, Australia.
| | | | | |
Collapse
|
28
|
Amlong CA, Schroeder KM, Andrei AC, Han S, Donnelly MJ. The analgesic efficacy of transversus abdominis plane blocks in ileostomy takedowns: a retrospective analysis. J Clin Anesth 2012; 24:373-7. [DOI: 10.1016/j.jclinane.2011.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 09/28/2011] [Accepted: 10/09/2011] [Indexed: 10/28/2022]
|
29
|
Resection and primary anastomosis with proximal diversion instead of Hartmann's: evolving the management of diverticulitis using NSQIP data. J Trauma Acute Care Surg 2012; 72:807-14; quiz 1124. [PMID: 22491590 DOI: 10.1097/ta.0b013e31824ef90b] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The emergency surgical treatment of acute diverticulitis with feculent or purulent peritonitis has traditionally been the Hartmann's procedure (HP). Debate continues over whether primary resection with anastomosis and proximal diversion may be performed in the setting of a high-risk anastomosis in complicated diverticular disease. In contrast to a loop ileostomy takedown, the morbidity of a Hartmann's reversal is preventative for many patients, leaving them with a permanent stoma. Our study compared the surgical outcomes of patients with perforated diverticulitis who underwent a HP to primary anastomosis with proximal diversion (PAPD). METHODS The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2009 to identify all cases of perforated diverticulitis classified as contaminated or dirty/infected. Patients were stratified into HP or PAPD, and logistic regression models were created to control for patient demographics, comorbidities, perioperative risk, and illness severity to determine the impact of surgical procedure on outcome. RESULTS There were 2,018 patients meeting the inclusion criteria of which 340 (17%) underwent PAPD and the remainder underwent HP. Significant independent predictors of infectious outcomes were alcohol use, preoperative sepsis, and operative time. There was no significant difference in risk of infectious complications, return to the operating room, prolonged ventilator use, death, or hospital length of stay between the two procedures. When considering only dirty/infected cases, the mortality risk was twofold greater when PAPD was performed. CONCLUSION The treatment of acute diverticulitis in the setting of contamination can be safely treated with resection, primary anastomosis, and proximal diversion as opposed to a HP in certain circumstances. Given the decreased morbidity of subsequent loop ileostomy takedown compared with a Hartmann's reversal, this procedure should be given consideration in the management of acute, perforated diverticulitis but may not be warranted in cases of feculent peritonitis.
Collapse
|
30
|
Abstract
BACKGROUND The supposed optimal treatment of perforated diverticulitis with generalized peritonitis has changed several times during the last century, but at present is still unclear. METHODS/RESULTS The first cases of complicated perforated diverticulitis of the colon were reported in the beginning of the twentieth century. At that time the first therapeutic guidelines were postulated in which an initial nonresectional procedure was provided to be the safest plan of management. After many years in which resection had become standard practice, today, one century later, again (laparoscopic) nonresectional surgery is presented as a safe and promising alternative in treatment of complicated perforated diverticulitis. The question rises what had happened to close the circle? CONCLUSIONS This paper includes a historic summary of changing patterns in surgical strategies in perforated diverticulitis complicated by generalized peritonitis.
Collapse
|
31
|
Conventional and laparoscopic reversal of the Hartmann procedure: a review of literature. J Gastrointest Surg 2010; 14:743-52. [PMID: 19936852 PMCID: PMC2836249 DOI: 10.1007/s11605-009-1084-3] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 10/26/2009] [Indexed: 01/31/2023]
Abstract
PURPOSE The aim of this study was to provide a systematic overview on both laparoscopic and conventional Hartmann reversal. Furthermore, the Hartmann procedure is reevaluated in the light of new emerging alternatives. METHODS Medline, Ovid, EMBASE, and Cochrane database were searched for studies reporting on outcomes after Hartmann reversal. RESULTS Thirty-five studies were included in this review of which 30 were retrospective. A total of 6,249 patients with a mean age of 60 years underwent Hartmann reversal. Two thirds of patients were classified as American Society of Anesthesiologists (ASA) I-II. The mean reversal rate after a Hartmann procedure was 44%, and mean time interval between Hartmann procedure and Hartmann reversal was 7.5 months. The most frequent reported reasons for renouncing Hartmann reversal were high ASA classification and patients' refusal. The overall morbidity rate ranged from 3% to 50% (mean 16.3%) and mortality rate from 0% to 7.1% (mean 1%). Patients treated laparoscopically had a shorter hospital stay (6.9 vs. 10.7 days) and appeared to have lower mean morbidity rates compared to conventional surgery (12.2% vs. 20.3%). CONCLUSION Hartmann reversal carries a high risk on perioperative morbidity and mortality. The mean reversal rate is considerably low (44%). Laparoscopic reversal compares favorably to conventional; however, high level evidence is needed to determine whether it is superior.
Collapse
|
32
|
The effect of peri-stomal infiltration with bupivacaine/epinephrine on post-operative pain, nausea and ease of surgery in reversal of loop ileostomies. Int J Colorectal Dis 2009; 24:1435-9. [PMID: 19680668 DOI: 10.1007/s00384-009-0788-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE Evidence to support the routine use of local anaesthetic in the reversal of loop ileostomy is equivocal. This randomized control study looked at the use of peri-operative infiltration of stoma with 0.25% bupivacaine with 1/200,000 epinephrine on the ease of surgery and its effect on post-operative pain and nausea. METHODS Sixty patients were randomized to receive peri-stomal infiltration with either 0.25% bupivacaine with 1/200,000 epinephrine or normal saline. The surgeon graded the surgery as straightforward, intermediate or difficult, and the time for the operation was also recorded. Post-operatively, analgesia was provided via PCA for 24 h. Post-operative pain and nausea scores and total morphine usage median (inter-quartile range) were compared using the Mann-Whitney U test with p < 0.05 considered significant. RESULTS There was no difference between the local anaesthetic groups and controls with respect to opiate consumption (p = 0.4), post-operative pain (p = 0.72) or nausea (p = 0.78). Shorter total anaesthetic and operative times were noted in study group, but this was not significant (p = 0.55). However, surgery was found to be easier in the local anaesthetic group (p = 0.0046). CONCLUSION Peri-stomal infiltration with 0.25% bupivacaine with 1/200,000 epinephrine does not impact on post-operative pain and nausea scores or opiate analgesia use. However, its use is recommended as an aid to dissection in surgery.
Collapse
|
33
|
Kashuk JL, Cothren CC, Moore EE, Johnson JL, Biffl WL, Barnett CC. Primary repair of civilian colon injuries is safe in the damage control scenario. Surgery 2009; 146:663-8; discussion 668-70. [DOI: 10.1016/j.surg.2009.06.042] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 06/06/2009] [Indexed: 11/16/2022]
|
34
|
Saha AK, Tapping CR, Foley GT, Baker RP, Sagar PM, Burke DA, Sue-Ling HM, Finan PJ. Morbidity and mortality after closure of loop ileostomy. Colorectal Dis 2009; 11:866-71. [PMID: 19175627 DOI: 10.1111/j.1463-1318.2008.01708.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND A temporary loop ileostomy is commonly used to protect low pelvic anastomoses. Closure is associated with morbidity and mortality. This study investigated patterns of complications after loop ileostomy closure and factors associated with morbidity and mortality. METHOD A review was performed of patients who underwent loop ileostomy closure between 1999 and 2005. RESULTS Three hundred and twenty-five patients underwent closure of loop ileostomy. Reasons for primary surgery were: anterior resection for cancer (n = 160, 49%), ileal pouch-anal anastomosis (n = 114, 35%), diverticular disease (n = 25, 8%), Crohn's colitis (n = 4, 1%) and other conditions (n = 22, 7%). Overall mortality was 2.5% (n = 8) and morbidity was 22.8% (n = 74). Thirty-two patients (10%) developed small bowel obstruction, of whom seven required operative intervention. Overall, the re-operation rate in this series was 28 patients (8.6%). Thirteen (4%) patients had an anastomotic leak of whom 12 patients had re-operation. Preoperative anaemia was significantly associated with leakage (Hb < 11 g/dl; n = 65, P = 0.033). The leakage rate was lower after a stapled anastomosis than a hand-sutured anastomosis (4/203 vs 9/122; P = 0.039). Hypo-albuminaemia (albumin < 34 g/l) was significantly associated with mortality (n = 46, P < 0.001). CONCLUSIONS Loop ileostomy closure is associated with morbidity and mortality. Anaemia and hypo-albuminaemia may be associated with poor outcome.
Collapse
Affiliation(s)
- A K Saha
- The John Goligher Colorectal Unit, Research Room D156, D Floor, Clarendon Wing, Leads General Infirmary, Great George Street, Leeds LS1 3EX, UK.
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Vermeulen J, Coene PPLO, Van Hout NM, van der Harst E, Gosselink MP, Mannaerts GHH, Weidema WF, Lange JF. Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? Colorectal Dis 2009; 11:619-24. [PMID: 18727727 DOI: 10.1111/j.1463-1318.2008.01667.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis. METHOD All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal. RESULTS Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037). CONCLUSIONS Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis.
Collapse
Affiliation(s)
- J Vermeulen
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
36
|
The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Colorectal Dis 2009; 24:711-23. [PMID: 19221766 DOI: 10.1007/s00384-009-0660-z] [Citation(s) in RCA: 263] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2009] [Indexed: 02/04/2023]
Abstract
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.
Collapse
|
37
|
Outcomes of Primary Repair and Primary Anastomosis in War-Related Colon Injuries. ACTA ACUST UNITED AC 2009; 66:1286-91; discussion 1291-3. [DOI: 10.1097/ta.0b013e31819ea3fc] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
38
|
Mansfield SD, Jensen C, Phair AS, Kelly OT, Kelly SB. Complications of loop ileostomy closure: a retrospective cohort analysis of 123 patients. World J Surg 2009; 32:2101-6. [PMID: 18563482 DOI: 10.1007/s00268-008-9669-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Loop ileostomies are often formed in order to defunction distal anastomoses. The aim of this study was to review the complications following closure of loop ileostomies. METHODS This is a retrospective case note analysis of all loop ileostomy closures performed in the Northumbria Healthcare NHS Trust (population over 500,000) over a 5-year period between 2001 and 2005. RESULTS A total of 123 case records were reviewed. Complications occurred in 41 patients (33.3%), with 9 patients (7.3%) requiring further intervention. There were 4 (3.3%) postoperative deaths. Complications were more common in patients with increased comorbidity (p = 0.0007) and postoperative death was more frequent among the elderly (p = 0.0006). Postoperative death was more common in those patients who had their stomas created during surgery (elective or emergency) for diverticular disease (3 patients, p = 0.006). Patients with diverticular disease had significantly higher comorbidity and peritoneal contamination at the time of primary surgery. Ileostomy reversal after anterior resection for cancer was associated with a lower complication rate than the rest of the cohort (26%, p = 0.0003) but there was no significant difference in mortality. Neither the grade of the surgeon, the case volume, or the anastomotic technique affected postoperative morbidity. Reoperation was more common in patients whose closure procedure took less time (p = 0.002) and in those who had a shorter wait from creation to reversal of the stoma (p < 0.0001). CONCLUSIONS Reversal of loop ileostomy may be associated with significant morbidity and mortality. Increasing the delay from creation to closure may result in fewer complications.There is an increased risk in older patients with more comorbidity, particularly when the primary procedure is for diverticular disease with significant peritoneal contamination.
Collapse
Affiliation(s)
- S D Mansfield
- Department of General Surgery, North Tyneside General Hospital, Rake Lane, North Shields, Tyne and Wear, NE29 8NH, UK.
| | | | | | | | | |
Collapse
|
39
|
GonzÁLez QH, RodrÍGuez-Zentner HA, Moreno-Berber JM, Vergara-FernÁNdez O, De LeÓN HÉCTC, Jonguitud LA, Ramos R, Moreno-LÓPez JA. Laparoscopic versus Open Total Mesorectal Excision: A Nonrandomized Comparative Prospective Trial in a Tertiary Center in Mexico City. Am Surg 2009. [DOI: 10.1177/000313480907500107] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Because definitive long-term results are not yet available, the oncologic safety of laparoscopic surgery in rectal cancer remains controversial. Laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME). However, few prospective randomized studies have been performed. The main purpose of our study was to evaluate whether relevant differences in safety and efficacy exist after elective LTME for the treatment of rectal cancer compared with OTME in a tertiary referral medical center. This comparative nonrandomized prospective study analyzes data in 56 patients with middle and lower rectal cancer treated with low anterior resection or abdominoperineal resection from November 2005 to November 2007. Follow-up was determined through office charts or direct patient contact. Statistical analysis was performed using χ2 test and Student's t test. Twenty-eight patients underwent LTME and 28 patients were in the OTME group. No conversion was required in the LTME group. Mean operating time was shorter in the laparoscopic group (LTME) (181.3 vs 206.1 min, P < 0.002). Less intraoperative blood loss and fewer postoperative complications were seen in the LTME group. Return of bowel motility was observed earlier after laparoscopic surgery. There was no 30-day mortality and the overall morbidity was 17 per cent in the LTME group versus 32 per cent in the OTME group. The mean number of harvested lymph nodes was greater in the laparoscopic group than in the OTME group (12.1 ± 2 vs 9.3 ± 3). Mean follow-up time was 12 months (range 9-24 months). No local recurrence was found. LTME is a feasible procedure with acceptable postoperative morbidity and low mortality, however it is technically demanding. This series confirms its safety, although oncologic results are at present comparable with the OTME published series with the limitation of a short follow-up period. Further randomized studies are necessary to evaluate long-term clinical outcome.
Collapse
Affiliation(s)
- QuintÍN H. GonzÁLez
- From the Department of Surgery, Division of Colorectal Surgery, Instituto Nacional de Ciencias Medicas y Nutrición “Dr. Salvador Zubirán”, Mexico City, Mexico
| | - Homero A. RodrÍGuez-Zentner
- From the Department of Surgery, Division of Colorectal Surgery, Instituto Nacional de Ciencias Medicas y Nutrición “Dr. Salvador Zubirán”, Mexico City, Mexico
| | - J. Manuel Moreno-Berber
- From the Department of Surgery, Division of Colorectal Surgery, Instituto Nacional de Ciencias Medicas y Nutrición “Dr. Salvador Zubirán”, Mexico City, Mexico
| | - Omar Vergara-FernÁNdez
- From the Department of Surgery, Division of Colorectal Surgery, Instituto Nacional de Ciencias Medicas y Nutrición “Dr. Salvador Zubirán”, Mexico City, Mexico
| | - HÉCtor Tapia-Cid De LeÓN
- From the Department of Surgery, Division of Colorectal Surgery, Instituto Nacional de Ciencias Medicas y Nutrición “Dr. Salvador Zubirán”, Mexico City, Mexico
| | - Luis A. Jonguitud
- From the Department of Surgery, Division of Colorectal Surgery, Instituto Nacional de Ciencias Medicas y Nutrición “Dr. Salvador Zubirán”, Mexico City, Mexico
| | - Roberto Ramos
- From the Department of Surgery, Division of Colorectal Surgery, Instituto Nacional de Ciencias Medicas y Nutrición “Dr. Salvador Zubirán”, Mexico City, Mexico
| | - J. AndrÉS Moreno-LÓPez
- From the Department of Surgery, Division of Colorectal Surgery, Instituto Nacional de Ciencias Medicas y Nutrición “Dr. Salvador Zubirán”, Mexico City, Mexico
| |
Collapse
|
40
|
Joh YG, Lindsetmo RO, Stulberg J, Obias V, Champagne B, Delaney CP. Standardized postoperative pathway: accelerating recovery after ileostomy closure. Dis Colon Rectum 2008; 51:1786-9. [PMID: 18575937 DOI: 10.1007/s10350-008-9399-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 04/21/2008] [Accepted: 05/03/2008] [Indexed: 02/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Yong-Geul Joh
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | | | | | | | | | | |
Collapse
|
41
|
Martínez JL, Luque-de-León E, Andrade P. Factors related to anastomotic dehiscence and mortality after terminal stomal closure in the management of patients with severe secondary peritonitis. J Gastrointest Surg 2008; 12:2110-8. [PMID: 18923877 DOI: 10.1007/s11605-008-0714-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 09/18/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Management of severe secondary peritonitis (SSP) may require intestinal resections and bowel exteriorization due to an unacceptable high risk for anastomotic dehiscence (AD). Bowel exteriorization can be achieved through loop or terminal stomas. There are no studies addressing the fate of these latter. Our aim was to determine factors associated with AD and mortality in patients submitted to restoration of intestinal continuity after creation of terminal stomas as part of their operative management for SSP. PATIENTS AND METHODS We analyzed prospectively collected databases on all consecutive patients with SSP submitted to restoration of intestinal continuity after having had terminal ileostomies (TI) or terminal colostomies (TC) as part of their operative management during a 30-month period. Several patient and disease and operative variables were evaluated as factors related to AD and mortality in this group of patients. Univariate statistical comparisons were made using Student's t test for continuous variables and chi-square test when categorical variables were compared. Multivariate analyses were also performed. RESULTS A total of 72 male patients and 36 female patients were included in the study; 54 had TI and 54 had TC. Median number of operations performed as part of their management for SSP (prior to stomal closure) was 2 (range, 1-15). A total of 76 (70%) had had diffuse peritonitis, and 39 (36%) required management with an open abdomen (26 of them with a skin-only closure technique). Median time interval between stomal creation and closure was 190 days (range, 14-2,192). Stapled and hand-sewn anastomoses were done in 24 and 84 patients, respectively. AD occurred in 11 patients (10%). Univariate analyses disclosed age > or = 50 years (p < 0.05), high American Society of Anesthesiologists (ASA) score (> or = 3; p < 0.01), history of chronic renal failure (p < 0.04), history of diffuse peritonitis (p < 0.05), management with an open abdomen (p < 0.05), and lower preoperative hemoglobin values (p < 0.05) as risk factors for AD. Only age > or = 50 years prevailed after multivariate analyses. A total of seven patients died (6%). Factors associated with mortality were age > or = 65 years (p < 0.02), high ASA score (> or = 3; p < 0.01), preoperative use of total parenteral nutrition (p < 0.02), lower preoperative hemoglobin values (p < 0.05), time interval between stomal creation and closure < 3 months (p < 0.01), AD (p < 0.02), and need for reoperation after stomal closure (p < 0.02). After multivariate analyses, time interval between stomal creation and closure < 3 months and need for reoperation were the only ones that prevailed as independent risk factors for mortality (p < 0.05). CONCLUSIONS Although several variables were related to AD and mortality, waiting at least >3 months before attempting restoration of intestinal continuity seems to be the best approach and a practical recommendation in this group of challenging patients.
Collapse
Affiliation(s)
- José L Martínez
- Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades-Centro Médico Nacional Siglo XXI (IMSS), Av. Cuauhtémoc 330 3er piso, Colonia Doctores, Delegación Cuauhtémoc, México City, México.
| | | | | |
Collapse
|
42
|
Kaiser AM, Israelit S, Klaristenfeld D, Selvindoss P, Vukasin P, Ault G, Beart RW. Morbidity of ostomy takedown. J Gastrointest Surg 2008; 12:437-41. [PMID: 18095033 DOI: 10.1007/s11605-007-0457-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2007] [Accepted: 11/30/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE Creation of a temporary ostomy is a surgical tool to divert stool from a more distal area of concern (anastomosis, inflammation, etc). To provide a true benefit, the morbidity/mortality from the ostomy takedown itself should be minimal. The aim of our study was therefore to evaluate our own experience and determine the complications and mortality of stoma closure in relation to the type and location of the respective ostomy. METHODS Patients undergoing an elective takedown of a temporary ostomy at our teaching institution between January 1999 and July 2005 were included in our analysis, and the medical records were retrospectively reviewed. Excluded were only patients with relevant chart deficiencies and nonelective stoma revisions/takedowns. Data collected included general demographics; the type and location of the stoma; the operative technique; and the type, timing, and impact of complications. Perioperative morbidity was defined as complications occurring within 30 days from the operation. RESULTS 156 patients (median age 45 years, range 18-85) were included in the analysis: 31 loop and 59 end colostomy reversals and 56 loop and 10 end ileostomy takedowns. Mean follow-up was 6 months. The overall mortality rate was low (0.65%, 1/156 patients). However, the morbidity rate was 36.5% (57 patients), with 6 (3.8%) systemic complications and 51 (32.7%) local complications. Minor would infection (34 patients, 21.8%) and postoperative ileus (9 patients, 5.7%) were the most common surgery-related complications, but they generally resolved with conservative management. Anastomotic leak and formation/persistence of an enterocutaneous fistula (6 patients, 3.8%) were the most serious local complications and required reintervention in all of the patients. Closure of a loop colostomy accounted for half and Hartmann reversals for one third of these complications, as opposed to ileostomy takedowns, which accounted for only one sixth (1.8% absolute risk). CONCLUSION Takedown of a temporary ostomy has a low mortality but a nonnegligible morbidity. The stoma location (large vs. small bowel) has a higher impact than the type of stoma construction (end vs. loop) on the incidence and severity of complications.
Collapse
Affiliation(s)
- Andreas M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033, USA.
| | | | | | | | | | | | | |
Collapse
|
43
|
Armendáriz-Rubio P, de Miguel Velasco M, Ortiz Hurtado H. [Comparison of colostomies and ileostomies as diverting stomas after low anterior resection]. Cir Esp 2007; 81:115-20. [PMID: 17349233 DOI: 10.1016/s0009-739x(07)71280-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate two procedures (transverse colostomy and ileostomy) as diverting stomas after low anterior resection to determine whether one is superior to the other. MATERIAL AND METHOD A literature review was performed to compare both stomas from construction to closure. RESULTS Distinguishing between the complications specific to stoma construction from those caused by anterior resection is difficult. While the stoma is in place, transverse colostomy seems to be better tolerated. Colostomy closure seems to have more septic complications, although the real frequency of bowel obstruction after ileostomy closure remains to be determined. CONCLUSIONS Given the characteristics of previous studies, the superiority of one diverting stoma over the other cannot be established. Ileostomy seems better tolerated by patients and is associated with a lower complication rate after closure (bowel obstruction remains to be evaluated). Randomized prospective studies with a larger number of patients are required to determine which of these procedures is superior.
Collapse
Affiliation(s)
- Pedro Armendáriz-Rubio
- Sección de Coloproctologia, Servicio de Cirugía General y del Aparato Digestivo, Hospital Virgen del Camino, Pamplona, Navarra, España.
| | | | | |
Collapse
|
44
|
Abstract
PURPOSE This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature. METHODS Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers. RESULTS A total of 203 articles were considered relevant. CONCLUSIONS The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.
Collapse
Affiliation(s)
- Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan 48106, USA.
| | | | | |
Collapse
|