Morbidity after closure of a defunctioning loop ileostomy

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

Randomized controlled trial.

SETTINGS

Two high-volume colorectal surgery centers.

PATIENTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

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

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

ILEOSTIM trial: a study protocol to evaluate the effectiveness of efferent loop stimulation before ileostomy reversal

PURPOSE

A protective loop ileostomy is the most useful method to reduce sequelae in the event of an anastomotic leakage (AL) after rectal cancer surgery. However, it requires an additional stoma reversal surgery with its own potential complications. Postoperative ileus (POI) remains the most common complication after ileostomy reversal, which leads to an increase in morbidity, length of hospital stay (LOS) and overall healthcare costs. Several retrospective studies carried out in this field have concluded that there are insufficient evidence-based recommendations about the routine application of preoperative bowel stimulation in clinical practice. Here we discuss whether stimulation of the efferent limb before ileostomy reversal might reduce POI and improve postoperative outcomes.

METHODS

This is a multicentre randomised controlled trial to determine whether mechanical stimulation of the efferent limb during the 2 weeks before the ileostomy reversal would help to reduce the development of POI after surgery. This study was registered on Clinicaltrials.gov (NCT05302557). Stimulation will consist of infusing a solution of 500 ml of saline chloride solution mixed with a thickening agent (Resource©, Nestlé Health Science; 6.4 g sachet) into the distal limb of the ileostomy loop. This will be performed within the 2 weeks before ileostomy reversal, in an outpatient clinic under the supervision of a trained stoma nurse.

CONCLUSION

The results of this study could provide some insights into the preoperative management of these patients.

Cyanoacrylate in Colorectal Surgery: Is It Safe?

Anastomotic leakage (AL) of a gastrointestinal (GI) anastomosis continues to be an important complication in GI surgery. Since its introduction more than 60 years ago, Cyanoacrylate (CA) has gained popularity in colorectal surgery to provide "prophylaxis" against AL. However, although in surgical practice it is increasingly used, evidence on humans is still lacking. The aim of this study is to analyze in humans the safety of CA to seal colorectal anastomosis. All consecutive patients from Jannuary 2022 through December 2022 who underwent minimally invasive colorectal surgery were retrospectively analyzed from a prospectively maintained database. Inclusion criteria were a histological diagnosis of cancer, a totally minimally invasive procedure, and the absence of intraoperative complications. 103 patients were included in the study; N-butyl cyanoacrylate with metacryloxisulfolane (Glubran 2®) was used to seal colorectal anastomosis, no adverse reactions to CA or postoperative complications related to inflammation and adhesions occurred; and only one case of AL (0.9%) was recorded. We can consider this study an important proof of concept on the safety of CA to seal colorectal anastomosis. It opens the possibility of starting prospective and comparative studies in humans to evaluate the effectiveness of CA in preventing colorectal AL.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Can physiological stimulation prior to ileostomy closure reduce postoperative ileus? A prospective multicenter pilot study

BACKGROUND

The aim of this study was to assess the impact of ileostomy closure following preoperative physiological stimulation (PPS) on postoperative ileus (POI) in patients with loop ileostomy after low anterior resection for rectal cancer.

METHODS

Patients who underwent ileostomy closure between January 2017 and February 2020 in two tertiary referral centers were prospectively included. PPS stimulation was compared to standard treatment. Stimulation was carried out daily during the 15 days prior to ileostomy closure by the patient's self-instillation of 200 ml of fecal contents from the ileostomy bag via the efferent loop, using a rectal catheter. Standard treatment (ST) consisted of observation. Outcomes measures were POI, morbidity, stimulation feasibility, and predictors to ileus.

RESULTS

A total of 58 patients were included [42 males and 16 females, median age 67 (43-85) years]. PPS was used in 24 patients, who completed the entire stimulation process, and ST in 34 patients. No differences in preoperative factors were found between the two groups. POI was significantly lower in the PPS group (4.2%) vs the ST group (32.4%); p < 0.01, OR: 0.05 (CI 95% 0.01-0.65). The PPS group had a shorter time to restoration of bowel function (1 day vs 3 days) p = 0.02 and a shorter time to tolerance of liquids (1 day vs 2 days), p = 0.04. Age (p = 0.01), open approach at index surgery, p = 0.03, adjuvant capecitabine (p = 0.01). and previous abdominal surgeries (p = 0.02) were associated with POI in the multivariate analysis. C-reactive-protein values on the 3rd (p = 0.02) and 5th (p < 0.01) postoperative day were also associated with POI.

CONCLUSIONS

PPS for patients who underwent ileostomy closure after low anterior resection for rectal cancer is feasible and might reduce POI.

Negative-pressure wound therapy after stoma reversal in colorectal surgery: a randomized controlled trial

Background

Stoma-reversal surgery is associated with high postoperative morbidity, including wound complications and surgical-site infections (SSIs). This study aims to assess whether the application of negative-pressure wound therapy (NPWT) can improve wound healing compared with conventional wound dressing.

Methods

This was a single-centre, superiority, open-label, parallel, individually randomized controlled trial. Patients undergoing stoma reversal were randomized (1 : 1) to receive NPWT or conventional wound dressing. The primary endpoint of the study was the rate of wound complications and SSIs after stoma closure. The secondary endpoints were postoperative wound pain, rate of wound healing after 30 days from stoma closure, and wound aesthetic satisfaction.

Results

Between June 2019 and January 2021, 50 patients were allocated to the NPWT group (all received NPWT, 49 were analysed); 50 patients were allocated to the conventional wound dressing group (48 received the treatment, 45 were analysed). No significant difference was found in wound-complication rate (10 per cent NPWT versus 16 per cent controls; odds ratio 0.61 (95 per cent c.i. 0.18 to 2.10), P = 0.542) and incisional SSI rate (8 per cent NPWT versus 7 per cent controls; odds ratio 1.24 (95 per cent c.i. 0.26 to 5.99), P = 1.000). The NPWT group showed less pain, higher aesthetic satisfaction (P < 0.0001), and a higher proportion of wound healing (92 versus 78 per cent; P = 0.081) compared with the control group.

Conclusion

NPWT does not reduce the incidence of SSI after stoma-reversal surgery compared with conventional wound dressing. However, NPWT improved the healing of uninfected wounds, reduced wound pain and led to better aesthetic outcomes.

Registration number: NCT037812016 (clinicaltrials.gov).

Outcomes of diverting loop ileostomy reversal in the elderly: a case-control study

BACKGROUND

Although diverting loop ileostomy (DLI) reversal is considered to be a relatively simple procedure, it is not immune from major morbidity. We aimed to compare outcomes of DLI reversal between elderly and non-elderly patients.

METHODS

Retrospective review of all patients who underwent DLI reversal at a single tertiary medical centre between 2010 and 2020. The elderly group consisted of patients 70 or older compared to a control group of those younger than 70 years.

RESULTS

During the study period, 307 patients underwent DLI reversal. Of these, 76 patients were in the elderly group (mean age 75.6) and 231 in the control group (mean age 55.3). The groups were comparable in terms of mean time interval between the creation of the ileostomy and reversal (242 versus 255 days, respectively, P = 0.5), choice between stapled and hand-sewn anastomoses (97.4% stapled anastomosis versus 93.1%, P = 0.086), median post-operative length of stay (5 days in both, P = 0.086), rates of post-operative complications (26.3% versus 26.8%, P = 0.99), severe complications (5.3% versus 6.9%, P = 0.81) and 30-day readmission rates (13.2% versus 10.8%, P = 0.58). Multivariate analysis found the time interval between the creation of the stoma and its reversal to be the only significant risk factor for major post-operative morbidity. Age was not found to be correlated with post-operative morbidity.

CONCLUSION

The outcomes of loop ileostomy reversal in elderly patients are similar to non-elderly patients. Efforts should be made to decrease the time interval between the creation of the stoma and its reversal as this is a significant risk factor for major post-operative morbidity.

Risk factors for postoperative ileus following loop ileostomy closure

Objectives

The most common intra-abdominal complication following loop ileostomy closure (LIC) is postoperative ileus (POI). The aim of the study was to determine the risk factors of POI development following LIC and make recommendations for its prevention.

Material and Methods

In this study, patients having undergone LIC with peristomal incision following distal colorectal surgery were included. Clavien-Dindo classification was used to evaluate postoperative complications. POI and postoperative leakage were defined based on clinical and radiological criteria. The Centers for Disease Control and Prevention 2017 criteria were used to diagnose surgical site infection (SSI). Postoperative bleeding was diagnosed one day after surgery if there was a >2 g/dL or ≥15% decrease in the hemoglobin level.

Results

Seventy-nine patients were included into the study. In nine of the patients POI developed, six had SSI, five had postoperative bleeding, and two had anastomosis leakage. In the univariate analysis; age <60 years (p= 0.02), presence of comorbidity (p= 0.007), using an open technique in the first surgery (p= 0.02), performing total colectomy in the first surgery (p= 0.048), performing hand-sewn anastomosis of LIC (p= 0.01), and postoperative blood transfusion (p= 0.04) were found to be risk factors for POI. Performing hand-sewn anastomosis of LIC (p= 0.03) and using an open technique in the first surgery (p= 0.03) were found to be independent variables for POI risk.

Conclusion

Using an open technique in the first surgery and performing a hand-sewn anastomosis of LIC may increase POI.

Predictors of complications from stoma closure in elective colorectal surgery: an assessment from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP)

BACKGROUND

There is significant morbidity after diverting ileostomy closure, so identifying predictors of complications could be of great benefit. The aim of our study was to evaluate the incidence and risk factors for postoperative morbidity after elective ileostomy closure.

METHODS

The ACS-NSQIP dataset was evaluated for elective ileostomy closures from 1/1/2015 to 12/31/2016. Demographic characteristics, operative, and postoperative outcomes were evaluated. The primary outcome was 30-day major morbidity (Clavien class III and greater). Secondary outcomes were rates and predictors of major morbidity, superficial site infection (SSI), reoperation, and readmission from multivariate logistic regression modeling.

RESULTS

We retrospectively evaluated 1885 patients. The median operative time was 65 (IQR 50-90) minutes and median length of stay was 3 (IQR 2-5) days. Major morbidity was recorded in 6.7%, including mortality (1.0%), deep/organ space SSI (2.6%), dehiscence (0.8%), reintubation (0.5%), sepsis (1.7%), septic shock (0.8%), and reoperation (3.7%). Readmission was recorded in 9.7% and 6.2% had SSI. Multivariate logistic regression showed male sex (OR 1.584; 95% CI 1.068-2.347; p = 0.022) and longer operative time (OR 1.004; 95% CI 1.001-1.007; p = 0.009) were among those variables associated with increased odds of major morbidity. Dyspnea (OR 2.431; 95% CI 1.139-5.094; p = 0.021) and longer operative time (OR 1.003; 95% CI 1.001-1.007; p = 0.034) were among the independent risk factors for SSI. Male sex (OR 2.246; 95% CI 1.297-3.892; p = 0.004, chronic obstructive pulmonary disease (OR 2.959; 95% CI 1.153-7.591; p = 0.024), and longer operative time (OR 1.005; 95% CI 1.001-1.009; p = 0.011) were associated with increased odds of reoperation. Chronic obstructive pulmonary disease (OR 2.578; 95% CI 1.338-4.968; p = 0.005), wound infection (OR 2.680; 95% CI 1.043-6.890; p = 0.041), and inflammatory bowel disease (OR 2.565; 95% CI 1.203-5.463; p = 0.015) were associated with increased odds of readmission.

CONCLUSIONS

Elective stoma closure has significant risk of morbidity. Patients with longer operative times were at increased risk for major morbidity, overall SSI, and reoperation. From the analysis, factors specifically associated with major morbidity, overall infectious complications, readmissions, and reoperations were identified. This information can be used to prospectively prepare for these high-risk patients, potentially improving postoperative outcomes.

Loop ileostomy closure: a retrospective comparison of three techniques

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Significant morbidity is associated with proximal fecal diversion among high-risk patients who undergo colectomy: A NSQIP analysis

BACKGROUND

The value of proximal fecal diversion for patients undergoing colectomies is an ongoing debate. Previous studies have shown a benefit in decreased anastomotic leak rates and mitigation of the morbidity of a leak, especially in high-risk populations. However, more recent data suggests increased morbidity with fecal diversion, creating a complication with an unknown degree of anastomotic leak reduction. Therefore, we aimed to determine the impact on morbidity of a diverting loop ileostomy (DLI) in patients with a high risk of anastomotic leak.

METHODS

The ACS-NSQIP database was queried (via CPT code) for adult patients (age ≥18 years) who underwent a colectomy only or colectomy with ileostomy (CWI) between Jan 2013 and Dec 2016. We compared thirty-day outcomes between a 3:1 propensity-matched colectomy only group to patients who had a CWI. We used risk factors for anastomotic leak as a basis of our propensity match which included preoperative smoking, steroid use, preoperative weight loss, preoperative transfusion, hypoalbuminemia, and leukocytosis; intraoperative match variables included indication for surgery, wound class, duration of operation, primary CPT code, elective vs. emergent, and inpatient vs. outpatient surgery.

RESULTS

We identified 39,588 patients from the NSQIP database who had a colectomy only or a CWI. The colectomy only group was older (age 63 vs 52 years p < 0.001), overweight (BMI 34 vs 26.7, p < 0.001), more likely to be diabetic (16% vs 9.5%, p < 0.001) and hypertensive (49.3% vs 31.4%). However, the CWI group had higher steroid use (36.8% vs 10%, p < 0.001), preoperative sepsis (13.2% vs 2.5%, p < 0.001), smoking rate (25.7% vs 15.4%, p < 0.001), and preoperative weight loss (12.5% vs 4.9%, p < 0.001). Our propensity analysis matched 2274 colectomy only patients and 758 CWI patients. Baseline demographics were similar between groups. While the mortality rate was similar between groups (1.5% vs 1.8%, p = 0.8), CWI patients had longer length of stay (median 8 vs 7 days, p < 0.001), higher renal injury rates (3.2% vs 0.9%, p < 0.001), higher readmission rates (18.8% vs 11%, p < 0.001) and higher overall NSQIP morbidity (44.5% vs 37.6%, p = 0.001). The anastomotic leak rate was 3.8% in the CWI group and 5.1% in the colectomy only group (p = 0.09).

CONCLUSIONS

Significant thirty-day morbidity exists with a diverting ileostomy among high-risk colectomy patients with minimal benefit in anastomotic leak rates.

A new technique of completely diverted tube ileostomy for the protection of colorectal anastomosis: a pilot study

AIM

This study was designed to evaluate a new technique for a completely diverting tube ileostomy achieved through temporary occlusion of the distal ileum using a flexible rubber strip.

METHODS

This prospective interventional study was conducted in one centre. Patients who underwent colorectal resections with a primary anastomosis and who were deemed as requiring a defunctioning stoma were included in the study. After completion of resection and anastomosis, the tube ileostomy was fashioned by inserting a reinforced (spiral) endotracheal tube with an inner diameter of 7.5 mm into the ileum. To provide complete faecal diversion, temporary occlusion of the distal ileum was performed using a flexible rubber strip. The primary outcome of this study was the incidence of complete diversion achieved using this method.

RESULTS

Fifty consecutive patients underwent a diverted tube ileostomy using the technique described above. Defaecation before removal of the strip did not occur in any of the patients inferring that complete diversion was observed in all patients (100%). The tube was removed at postoperative week 3. After tube removal, the resulting enterocutaneous fistulas closed spontaneously in a median of 6 (2-30) days.

CONCLUSION

The diverting tube ileostomy technique using an easily removable rubber strip to defunction the colorectal anastomosis is a safe and effective method that precludes the need to fashion a stoma.

Prediction model and web-based risk calculator for postoperative ileus after loop ileostomy closure

Background

Postoperative ileus (POI) is a significant complication after loop ileostomy closure given both its frequency and impact on the patient. The purpose of this study was to develop and externally validate a prediction model for POI after loop ileostomy closure.

Methods

The model was developed and validated according to the TRIPOD checklist for prediction model development and validation. The development cohort included consecutive patients who underwent loop ileostomy closure in two teaching hospitals in Montreal, Canada. Candidate variables considered for inclusion in the model were chosen a priori based on subject knowledge. The final prediction model, which modelled the 30-day cumulative incidence of POI using logistic regression, was selected using the highest area under the receiver operating characteristic curve (AUC) criterion. Model calibration was assessed using the Hosmer–Lemeshow goodness-of-fit test. The model was then validated externally in an independent cohort of similar patients from the University of British Columbia.

Results

The development cohort included 531 patients, in whom the incidence of POI was 16·8 per cent. The final model included five variables: age, ASA fitness grade, underlying pathology/treatment, interval between ileostomy creation and closure, and duration of surgery for ileostomy closure (AUC 0·68, 95 per cent c.i. 0·61 to 0·74). The model demonstrated good calibration (P = 0·142). The validation cohort consisted of 216 patients, and the incidence of POI was 15·7 per cent. On external validation, the model maintained good discrimination (AUC 0·72, 0·63 to 0·81) and calibration (P = 0·538).

Conclusion

A prediction model was developed for POI after loop ileostomy closure and included five variables. The model maintained good performance on external validation.

Systematic review and meta-analysis of incisional hernia post-reversal of ileostomy

PURPOSE

Incisional hernia following closure of loop ileostomy is a common problem. Assessment of the proportion of this complication is limited by small sample size and inconsistent reporting. The aim of this review was to provide an estimate of the proportion of incisional hernia following closure of loop ileostomy according to clinical and radiological diagnostic criteria and to investigate the association of bibliometric and study quality parameters with reported proportion.

METHODS

A systematic review of PubMed, Embase, CENTRAL, ISRCTN Registry and Open Grey from 2000 onwards was performed according to PRISMA standards. Reporting on the type of stoma and mesh reinforcement after closure was mandatory for inclusion, whereas studies on paediatric populations were excluded. Fixed effect or random effects models were used to calculate pooled proportion estimates. Meta-regression models were formed to explore potential heterogeneity.

RESULTS

42 studies with 7166 patients were included. The pooled estimate of the proportion of incisional hernia after ileostomy closure was 6.1% (95% confidence interval, CI 4.4-8.3%). Proportion estimates for higher quality studies and studies reporting on incisional hernia as primary outcome were 9.0% (95% CI 6.3-12.7%) and 13.1% (95% CI 8.8-19.1%). Significant between-study heterogeneity was identified (P < 0.001, I² = 87%) and the likelihood of publication bias was high (P = 0.028). Mixed effects regression showed that both year of publication (P = 0.034, Q = 4.484, df = 1.000) and defining hernia as a primary outcome (Q = 20.298, P < 0.001) were related to effect size. Method of follow-up and quality of the studies affected the proportion.

CONCLUSION

The proportion of incisional hernia at ileostomy closure site is estimated at 6.1%. Reporting incisional hernia as primary or secondary outcome, the method of diagnosis, the year of publication and methodological quality are associated with reported proportion.

Incidence and predictors of postoperative ileus after loop ileostomy closure: a systematic review and meta-analysis

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.

Stringent fluid management might help to prevent postoperative ileus after loop ileostomy closure

PURPOSE

The present study aimed to analyze the impact of perioperative fluid management on postoperative ileus (POI) after loop ileostomy closure.

METHODS

Consecutive loop ileostomy closures over a 6-year period (May 2011-May 2017) were included. Main outcomes were POI, defined as time to first stool beyond POD 3, and postoperative complications of any grade. Critical fluid management-related thresholds including postoperative weight gain were identified through receiver operator characteristics (ROC) analysis and tested in a multivariable analysis.

RESULTS

Of 238 included patients, 33 (14%) presented with POI; overall complications occurred in 91 patients (38%). 1.7 L IV fluids at postoperative day (POD) 0 was determined a critical threshold for POI (area under ROC curve (AUROC), 0.64), yielding a negative predictive value (NPV) of 93%. Further, a critical cutoff for a postoperative weight gain of 1.2 kg at POD 2 was identified (AUROC, 0.65; NPV, 95%). Multivariable analysis confirmed POD 0 fluids of > 1.7 L (OR, 4.7; 95% CI, 1.4-15.3; p = 0.01) and POD 2 weight gain of > 1.2 kg (OR, 3.1; 95% CI, 1-9.4; p = 0.046) as independent predictors for POI.

CONCLUSIONS

Perioperative fluid administration of > 1.7 L and POD 2 weight gain of > 1.2 kg represent critical thresholds for POI after loop ileostomy closure.

Incidence, risk factors and prevention of stoma site incisional hernias: a systematic review and meta-analysis

AIM

Stoma reversal might lead to a stoma site incisional hernia. Recently, prophylactic mesh reinforcement of the stoma site has gained increased attention, supporting the need for accurate data on the incidence of and risk factors for stoma site incisional hernia and to identify high-risk patients. The aim of this study was to assess incidence, risk factors and prevention of stoma site incisional hernias.

METHOD

Embase, MEDLINE, Web of Science, Cochrane and Google Scholar databases were searched. Studies reporting the incidence of stoma site incisional hernia after stoma reversal were included. Study quality was assessed with the Newcastle-Ottawa Scale and Cochrane risk of bias tool. Data on incidence, risk factors and prophylactic mesh reinforcement were extracted.

RESULTS

Of 1440 articles found, 33 studies comprising 4679 reversals were included. The overall incidence of incisional hernia was 6.5% [range 0%-38%, median follow-up 27.5 (17.54-36) months]. Eleven studies assessed stoma site incisional hernia as the primary end-point, showing an incidence of 17.7% [range 1.7%-36.1%, median follow-up 28 (15.25-51.70) months]. Body mass index, diabetes and surgery for malignant disease were found to be independent risk factors, as derived from eight studies. Two retrospective comparative cohort studies showed significantly lower rates of stoma site incisional hernia with prophylactic mesh reinforcement compared with nonmesh controls [6.4% vs 36.1% (P = 0.001); 3% vs 19% (P = 0.04)].

CONCLUSION

Stoma site incisional hernia should not be underestimated as a long-term problem. Body mass index, diabetes and malignancy seem to be potential risk factors. Currently, limited data are available on the outcomes of prophylactic mesh reinforcement to prevent stoma site incisional hernia.

Risk Factors for Postoperative Complications Following Diverting Loop Ileostomy Takedown

INTRODUCTION

Diverting loop ileostomies are frequently created to divert the fecal stream in an effort to protect downstream anastomoses. These are later reversed to restore intestinal continuity. The goal of this study is to evaluate risk factors for postoperative complications following diverting loop ileostomy takedown.

MATERIALS AND METHODS

Patients who underwent diverting loop ileostomy takedown between January 1, 2010 and April 28, 2015 were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified and a hierarchical logistic regression model was used to identify risk factors for postoperative complications.

RESULTS

1,737 patients met the inclusion criteria. Rates of postoperative complications were generally low. Mean length of stay (LOS) was 5.6 (± 4.5) days. Outcomes of interest were the following: overall morbidity, serious morbidity, extended LOS, SSI, UTI, pneumonia, readmission, reoperation, and mortality. Risk factors for these outcomes included the following: ASA class, bleeding disorder, prolonged operative time, race, tobacco use, gender, steroid use, peripheral vascular disease, weight loss, and functional status.

CONCLUSIONS

Diverting loop ileostomy takedown has a complication rate of approximately 20%. Higher ASA class, longer operative times, history of bleeding disorder, and functional status were identified as risk factors for most complications.

Study protocol evaluating the use of bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicenter randomized controlled trial

AIM

Postoperative ileus is the most commonly observed morbidity following ileostomy closure. Studies have demonstrated that the defunctionalized bowel of a loop ileostomy undergoes a series of functional and structural changes, such as atrophy of the intestinal villi and muscular layers, which may contribute to ileus. A single-centre study in Spain demonstrated that preoperative bowel stimulation via the distal limb of the loop ileostomy decreased postoperative ileus, length of stay and time to gastrointestinal function.

METHOD

A multicentre randomized controlled trial involving patients from Canadian institutions was designed to evaluate the effect of preoperative bowel stimulation before ileostomy closure on postoperative ileus. Stimulation will include canalizing the distal limb of the ileostomy loop with an 18Fr Foley catheter and infusing it with a solution of 500 ml of normal saline mixed with 30 g of a thickening agent (Nestle^© Thicken-Up^© ). This will be performed 10 times over the 3 weeks before ileostomy closure in an outpatient clinic setting by a trained Enterostomal Therapy nurse. Surgeons and the treating surgical team will be blinded to their patient's group allocation. Data regarding patient demographics, and operative and postoperative variables, will be collected prospectively. Primary outcome will be postoperative ileus, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, that either requires nasogastric tube insertion or is associated with two of the following on or after post-operative day 3: nausea/vomiting; abdominal distension; and the absence of flatus. Secondary outcomes will include length of stay, time to tolerating a regular diet, time to first passage of flatus or stool and overall morbidity. A cost analysis will be performed to compare the costs of conventional care with conventional care plus preoperative stimulation.

DISCUSSION

This manuscript discusses the potential benefits of preoperative bowel stimulation in improving postoperative outcomes and outlines our protocol for the first multicenter study to evaluate preoperative bowel stimulation before ileostomy closure. The results of this study could have considerable implications for the care of patients undergoing ileostomy closure.

Loop ileostomy-mediated fecal stream diversion is associated with microbial dysbiosis

Loop ileostomy is an effective procedure to protect downstream intestinal anastomoses. Ileostomy reversal surgery is often performed within 12 months of formation but is associated with substantial morbidity due to severe post-surgical complications. Distal ileum is deprived of enteral nutrition and rendered inactive, often becoming atrophied and fibrotic. This study aimed to investigate the microbial and morphological changes that occur in the defunctioned ileum following loop ileostomy-mediated fecal stream diversion. Functional and defunctioned ileal resection tissue was obtained at the time of loop-ileostomy closure. Intrapatient comparisons, including histological assessment of morphology and epithelial cell proliferation, were performed on paired samples using the functional limb as control. Mucosal-associated microflora was quantified via determination of 16S rRNA gene copy number using qPCR analysis. DGGE with Sanger sequencing and qPCR methods profiled microflora to genus and phylum level, respectively. Reduced villous height and proliferation confirmed atrophy of the defunctioned ileum. DGGE analysis revealed that the microflora within defunctioned ileum is less diverse and convergence between defunctioned microbiota profiles was observed. Candidate Genera, notably Clostridia and Streptococcus, reduced in relative terms in defunctioned ileum. We conclude that Ileostomy-associated nutrient deprivation results in dysbiosis and impaired intestinal renewal in the defunctioned ileum. Altered host-microbial interactions at the mucosal surface likely contribute to the deterioration in homeostasis and thus may underpin numerous postoperative complications. Strategies to sustain the microflora before reanastomosis should be investigated.

Reversal of loop ileostomy under an Enhanced Recovery Programme - Is the stapled anastomosis technique still better than the handsewn technique?

INTRODUCTION

Recent literature suggests that stapled anastomotic (SA) technique for the reversal of loop ileostomy (LI) may be beneficial in terms of early recovery and reduced incidence of small bowel obstruction when compared to the handsewn anastomosis (HA). Enhanced Recovery Programme (ERP) after colorectal procedures has demonstrated a reduction in some aspects of surgical morbidity. The aim of this study was to investigate the outcomes of patients undergoing reversal of LI within an ERP programme and compare the HA to the SA in relation to clinical outcomes.

MATERIAL AND METHODS

All adult patients undergoing elective reversal of loop ileostomy between January 2008 and December 2012 without any additional procedures, were included in our study. Adherence to ERP modules and 30 day postoperative complications were assessed via retrospective review of patient case notes.

RESULTS

One hundred and eight patients had an ileostomy reversal; 61 in the SA and 47 in the HA group. There were no demographic differences between the two groups. ERP module compliance was satisfactory (>80%) in 11 of the 14 modules with no difference in individual module compliance between the two groups. The operating times were found to be comparable (p = 0.35). Overall mortality (p = 0.44), anastomotic leak rates (p = 1.00), intra-abdominal collections (p = 0.65), small bowel obstruction (p = 1.00), reoperation rates (p = 0.65), ileus (p = 0.14) and other significant complications (Clavien-Dindo > 2) (p = 0.08) were similar between the two groups. A significantly longer total length of hospital stay (TLOS) was found in the SA group (median 3 Vs 4 days, p = 0.009).

CONCLUSION

Reversal of LI under an ERP appears to potentially neutralise the suggested SA benefits in terms of postoperative complications without any additional negative implications. Other non-operative factors may have a potential effect on outcomes such as the TLOS.

Complications after Loop Ileostomy Closure: A Retrospective Analysis of 132 Patients

BACKGROUND

Closure of a loop ileostomy is a relatively simple procedure although many studies have demonstrated high morbidity rates following it. Methods to reduce the number of complications, such as timing of closure or different surgical closure techniques, are investigated. The aim of this study was to evaluate the experience of the Abdominal Surgery Center at Vilnius University Hospital (VUH) 'Santariskiu klinikos' to review the complications after closure of loop ileostomy and to identify potential risk factors for postoperative complications.

METHODS

Data from 132 patients who underwent closure of loop ileostomy from 2003 to 2013 at the Abdominal Surgery Center of VUH were collected, including demographics, causes of ileostomy formation, additional diseases, time from creation to closure of ileostomy, anastomotic technique, duration of the operation, postoperative complications, and hospital stay after surgery. The operations were performed by 15 surgeons with varying experience assisted by surgical residents. Experience in ileostomy closure was defined by the number of procedures performed.

RESULTS

Complications occurred in 24 patients (18.2%), with 20 of them having surgical complications: bowel obstruction (9 (6.8%)), wound infection (4 (3.0%)), peritonitis due to anastomotic leak (3 (2.3%)), intra-abdominal abscess (2 (1.5%)), anastomotic leak with enterocutaneous fistula (1 (0.76%)), and bleeding (1 (0.76%)). 4 patients had non-surgical complications: postoperative diarrhea (2 (1.5%)), urinary retention (1 (0.76%)), and deep vein thrombosis (1 (0.76%)). Most complications were classified as group II according to the Clavien-Dindo classification. 2 patients died (1.5%). The anastomotic technique used did not affect the outcome. The experience of the surgeon as judged by the frequency of the procedure was the main factor affecting postoperative morbidity significantly (p = 0.03).

CONCLUSION

Our study revealed that the rate of postoperative complications and a smooth postoperative course after the closure of ileostomy was influenced by surgical experience.

Tube ileostomy for faecal diversion in elective distal colorectal anastomosis: a systematic review and pooled analysis

AIM

Tube ileostomy may be an alternative technique to loop ileostomy for protection of distal anastomosis, but its evidence base has not yet been established. This systematic review aims to evaluate the use of tube ileostomy and compare the outcomes associated with it.

METHOD

A systematic literature search of MEDLINE, EMBASE, Web of Science and the Cochrane database was conducted. Studies reporting on elective left-sided/colorectal anastomosis were included. Studies which reported on emergent surgery, small bowel anastomosis or tube ileostomy as a bridging procedure were excluded. The intra-operative technique, postoperative management and complications were assessed. Outcome measures included anastomotic leak, reoperation and complications related to the stoma or tube ileostomy.

RESULTS

Seven studies met the inclusion criteria. Three were case series with 101 patients and four were nonrandomized comparative studies with 665 patients. Pooled analyses of three comparative studies, comparing tube ileostomy (n = 278) with loop ileostomy (n = 254), revealed no significant differences in anastomotic leak rates (pooled OR 0.85, 95% CI 0.41-1.75; I(2) = 0%, P = 0.43).

CONCLUSION

There is a re-emergence of interest in the use of tube ileostomy to defunction a distal anastomosis. Pooled analyses of studies comparing tube ileostomy with loop ileostomy do not show statistically significant differences in anastomotic leak rates. Further refinement of this technique and randomized controlled studies are necessary for this technique to be routinely taken up by surgeons.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Morbidity of loop ileostomy closure after restorative proctocolectomy for ulcerative colitis and familial adenomatous polyposis: a systematic review

BACKGROUND

Temporary loop ileostomy is a routine procedure to reduce the morbidity of restorative proctocolectomy. However, morbidity of ileostomy closure could reduce the benefit of this concept. The objective of this systematic review was to assess the risks of ileostomy closure after restorative proctocolectomy for ulcerative colitis or familial adenomatous polyposis.

MATERIALS AND METHODS

Publications in English or German language reporting morbidity of ileostomy closure after restorative proctocolectomy were identified by Medline search. Two hundred thirty-two publications were screened, 143 were assessed in full-text, and finally 26 studies (reporting 2146 ileostomy closures) fulfilled the eligibility criteria. Weighted means for overall morbidity and mortality of ileostomy closure, rate of redo operations, anastomotic dehiscence, bowel obstruction, wound infection, and late complications were calculated.

RESULTS

Overall morbidity of ileostomy closure was 16.5 %, there was no mortality. Redo operations for complications were necessary in 3.0 %. Anastomotic dehiscence occurred in 2.0 %. Postoperative bowel obstruction developed in 7.6 %, with 2.9 % of patients requiring laparotomy for this complication. Wound infection rate was 4.0 %. Hernia or bowel obstruction as late complications developed in 1.9 and 9.4 %, respectively.

CONCLUSION

The considerable morbidity of ileostomy reversal reduces the overall benefit of temporary fecal diversion. However, ileostomy creation is still recommended, as it effectively reduces the risk of pouch-related septic complications.

Stimulation of the efferent limb before ileostomy closure: a randomized clinical trial

BACKGROUND

Postoperative ileus is the most common complication after ileostomy closure with an increase in morbidity, hospital stay, and health care costs.

OBJECTIVE

The aim of this study is to assess the utility of a new technique for reducing postoperative ileus after protective ileostomy closure.

DESIGN

This is a prospective randomized study registered at ClinicalTrials.gov (NCT01881594). Patients were randomly assigned to undergo either stimulation through the efferent limb of the ileostomy before surgery or nonstimulation before surgery.

SETTING

This study was conducted at the Department of Surgery of the Virgen de la Arrixaca Clinical University Hospital (Murcia).

PATIENTS

Seventy patients underwent surgery for ileostomy closure. In 35 patients, during the 2 weeks before surgery, daily stimulation of the defunctionalized stomal segment was performed by using a thick solution (500 mL of physiological saline associated with 30 g of thickening agent, Nestle Resource, Vevey, Switzerland). In the other 35 patients, stimulation was not performed before surgery.

MAIN OUTCOME MEASURES

The primary outcome was postoperative ileus. The secondary outcomes included time to tolerating a diet and postoperative stay.

RESULTS

Both groups of patients were homogenous for demographic data, characteristics of the first rectal cancer operation, and intersurgery periods. After ileostomy closure, the stimulated group of patients had an earlier return to oral tolerance (1.06 vs 2.57 days; p = 0.007) and passage of flatus or stool (1.14 vs 2.85 days; p <0.001) than the nonstimulated group of patients. The incidence of postoperative ileus (2.85% vs 20%; p = 0.024) and hospital stay (2.49 vs 4.61 days; p = 0.002) was also lower in the stimulated patients.

LIMITATIONS

Small numbers of patients means that no definitive statements can be made regarding the effectiveness of this technique.

CONCLUSIONS

Stimulation of the efferent limb of the ileostomy before closure is a safe technique that reduces postoperative ileus and fosters early intestinal transit and oral tolerance with a shorter postoperative hospital stay.

Meta-analysis of handsewn versus stapled reversal of loop ileostomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Abdominal wall closure after a stomal reversal procedure

The closure of a temporary stoma involves 2 different surgical procedures: the stoma reversal procedure and the abdominal wall reconstruction of the stoma site. The management of the abdominal wall has different areas that should be analyzed such us how to avoid surgical site infection (SSI), the technique to be used in case of a concomitant hernia at the stoma site or to prevent an incisional hernia in the future, how to deal with the incision when the stoma reversal procedure is performed by laparoscopy and how to close the skin at the stoma site. The aim of this paper is to analyze these aspects in relation to abdominal wall reconstruction during a stoma reversal procedure.

Review of stoma site and midline incisional hernias after stoma reversal

BACKGROUND

The incidence of incisional hernias after stoma reversal is not well reported. The aim of this study was to systematically review the literature reporting data on incisional hernias after stoma reversal. We evaluated both the incidence of stoma site and midline incisional hernias.

METHODS

A systematic review identified studies published between January 1, 1980, and December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies were excluded. Assessment of risk of bias, detection method, and essential study-specific characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done.

RESULTS

Sixteen studies were included in the analysis; 1613 patients had 1613 stomas formed. Fifteen studies assessed stoma site hernias and five studies assessed midline incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3% (range 0%-33.9%) and for midline incisional hernias was 44.1% (range 8.7%-58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two.

CONCLUSION

Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed.

Pilot study evaluating the efficacy of AlloMEM™ for prevention of intraperitoneal adhesions and peritoneal regeneration after loop ileostomy

OBJECTIVE

This study was designed to evaluate the feasibility of AlloMEM™, a novel lyophililzed human peritoneal membrane, at peritoneal reconstitution, and decreasing adhesion formation after temporary loop ileostomy.

METHODS

In a pilot study, ten patients had AlloMEM™ used during elective formation of a temporary diverting loop ileostomy for benign or malignant colorectal disease. A blinded investigator and the operating surgeon analyzed the change in adhesion formation and peritoneal remodelling using ileostomy mobilization time and a 5-point adhesion scale grading intra-abdominally and at the subcutaneous and fascial levels.

RESULTS

The mean body mass index was 31 [standard deviation (SD) 5.6], and 40 % of patients had previous abdominal surgery. Ileostomies were reversed after a mean 14 weeks (SD 6.0). The mean ileostomy mobilization time was 27.2 min (SD 12.0). From baseline to ileostomy reversal, there were significant increases in adhesions at the subcutaneous (p = 0.0002) and fascial levels (p = 0.0024). The increased subcutaneous adhesions were associated with improved peritoneal remodeling. There was no significant increase in adhesions from baseline to ileostomy reversal at the intra-abdominal points (p = 0.9393) or around the ileostomy site (p = 0.6128). The median hospital length of stay was 2.6 days (range, 2-3). A single adverse event related to product packaging led to redesign of the packaging process.

CONCLUSIONS

Use of AlloMEM™ in ileostomy closures suggested improvement in adhesions around the fascia and promotion of peritoneal remodeling. AlloMEM™ was safe, feasible, and easy to use in this pilot study. Comparative research is needed to assess the outcomes with this novel product.

Closure of defunctioning loop ileostomy is associated with considerable morbidity

AIM

An elective defunctioning ileostomy is commonly employed to attenuate the morbidity that may arise from distal anastomotic leakage. The magnitude of risk associated with subsequent ileostomy closure is difficult to estimate as many of the data arise from small series. This study looked at the rate of complications and predictive factors in a large series of patients.

METHODS

The National Surgical Quality Improvement Program database was queried for patients who had an elective closure of ileostomy between 2005 and 2010. Patient demographics, preoperative risk factors and operative variables were recorded. The primary outcome was occurrence of major (mortality, sepsis, return to the operating room, renal failure, major cardiac, neurological or respiratory episode) or minor (wound infection, urinary tract infection) complications within 30 days. Univariate and multivariate regression was used to evaluate the effect of these clinical factors on the complication rate.

RESULTS

In total, 5401 patients underwent closure of ileostomy, of whom 502 (9.3%) patients had major complications. The incidence of minor complications was 8.4% (452 patients). There were 32 (0.6%) deaths. American Society of Anesthesiologists grade, functional status, prolonged operative time, history of chronic obstructive pulmonary disease, dialysis and disseminated cancer were independent predictors of major complications. There was no significant increase in complication rates in patients over the age of 80. Major complications were associated with a significant increase in postoperative stay (13.9 vs 4.7 days, P < 0.0001).

CONCLUSION

Closure of ileostomy is associated with a significant complication rate. It may use as many resources as the primary surgery and is not a minor follow-up operation.

Tissue adhesives in gastrointestinal anastomosis: a systematic review

BACKGROUND

Anastomotic leakage in gastrointestinal (GI) surgery remains a major problem. Although numerous studies have been undertaken on the role of tissue adhesives as GI anastomotic sealants, no clear overview has been presented. This systematic review aims to provide a clear overview of recent experimental and clinical research on the sealing of different levels of GI anastomosis with tissue adhesives.

METHODS

We searched MEDLINE and Embase databases for clinical and experimental articles published after 2000. We included articles only if these addressed a tissue adhesive applied around a GI anastomosis to prevent anastomotic leakage or decrease leakage-related complications. We categorized results according to level of anastomosis, category of tissue adhesive, and level of evidence.

RESULTS

We included 48 studies: three on esophageal anastomosis, 13 on gastric anastomosis, four on pancreatic anastomosis, eight on small intestinal anastomosis, and 20 on colorectal anastomosis; 15 of the studies were on humans.

CONCLUSIONS

Research on ileal and gastric/bariatric anastomosis reveals promising results for fibrin glue sealing for specific clinical indications. Sealing of pancreatico-enteric anastomosis does not seem to be useful for high-risk patients; however, research in this field is limited. Ileal anastomotic sealing was promising in every included study, and calls for clinical evaluation. For colorectal anastomoses, sealing with fibrin glue sealing seems to have more positive results than with cyanoacrylate. Further research should concentrate on the clinical evaluation of promising experimental results as well as on new types of tissue adhesives. This research field would benefit from a systematic experimental approach with comparable methodology.

Loop ileostomies in colorectal cancer patients--morbidity and risk factors for nonreversal

BACKGROUND

In colorectal cancer patients, loop ileostomies are used to protect an anastomosis, in salvage surgery after a complication, and as a palliative measure. The aim of this study was to identify complications to the ileostomy, time until reversal, and risk factors for nonclosure or a permanent stoma.

MATERIAL AND METHODS

Consecutive patients who received a loop ileostomy with the diagnosis of colorectal cancer at index surgery in four hospitals in Region Västra Götaland, Sweden, from January 1, 2007 until February 28, 2010 were retrospectively studied. Demography, events during index surgery, complications related to the ileostomy and technique, and complications during closure were registered.

RESULTS

A total of 262 patients received a loop ileostomy. Loop iliostomies were constructed during emergency surgery in 15% of patients. Forty-three percent had complications related to the ileostomy; most common were high-volume output and leakage of stomal output. Morbidity after closure was high, at 28%, and mortality was 1%. Eighty-six percent had their stoma closed, median time 178 (3-700) d. Risk factors for nonreversal were postoperative complications to index surgery and advanced cancer disease. Eleven percent received a secondary stoma, and at the end of the study 23% had a permanent stoma.

CONCLUSIONS

The morbidity related to loop ileostomies and loop ileostomy closure is considerable. One in five patients will have a permanent stoma, and our conclusion is that for emergency patients with advanced disease another type of stoma should be chosen, if possible, to reduce the morbidity.