Complication rates of ostomy surgery are high and vary significantly between hospitals

Ostomy continence devices: a systematic review of the literature and meta-analysis

AIM

Colostomy complication rates range widely from 10% to 70%. The psychological burden on patients, leading to lifestyle changes and decreased quality of life (QoL), is one of the largest factors. The aim of this work was to assess the history and efficacy of ostomy continence devices in improving continence and QoL.

METHOD

In this PRISMA-compliant systematic review and meta-analysis, we searched PubMed, Scopus, Google Scholar and clinicaltrials.gov for studies on continence devices for all ostomies up to April 2023. Primary outcomes were continence and improvement in QoL. Secondary outcomes were leakage, patient's device preference and complications. Risk of Bias 2 and the revised tool to assess risk of bias in non-randomized studies of interventions (ROBINS-1) were used to assess risk of bias. Certainty of evidence was graded using GRADE.

RESULTS

Twenty-two studies assessed devices from 1978 to 2022. The two main types identified were ball-valve devices and plug systems. Conseal and Vitala were the two main devices with significant evidence allowing for pooled analyses. Conseal, the only currently marketed device, had a pooled rate of continence of 67.4%, QoL improvement was 74.9%, patient preference over a traditional appliance was 69.1%, leakage was 10.1% and complications was 13.7%. Since 2011, five studies have investigated experimental devices on both human and animal models.

CONCLUSION

Ostomy continence has been a long-standing goal without a consistently reliable solution. We propose that selective and short-term usage of continence devices may lead to improved continence and QoL in ostomy patients. Further research is needed to develop a reliable daily device for ostomy continence. Future investigation should include the needs of ileostomates.

Risk factors for early ostomy complications in emergency and elective colorectal surgery: A single-center retrospective cohort study

BACKGROUND AND AIMS

The clinical significance of early ostomy complications has been emphasized worldwide, and the current evidence concerning the impact of emergency or elective surgery on ostomy complications is limited. This study aimed to investigate the effect of elective and emergency colorectal surgery on early ostomy complications and the risk factors associated with specific complications.

METHODS

A mandatory colorectal recording system for consecutive ostomy patients between 2012 and 2020 was reviewed retrospectively. Patient socio-demographics, ostomy-related variables, and early period ostomy complications were retrieved from the patient records. The chi-square test, t-test, analysis of variance (ANOVA), and logistic regression were used to analyze the data.

RESULTS

The study cohort included 872 patients. At least one or more complications developed in 573 (65.7%) patients, 356 (63.6%) in the emergency group, and 217 (69.6%) in the elective group. When comparing emergency surgery to elective surgery, necrosis (7.4% versus 3.4%, p = 0.009), mucocutaneous separation (37.2% versus 27.1%, p = 0.002), and bleeding (6.1% versus 2.1%, p = 0.003) were more prevalent. Peristomal irritant contact dermatitis (PICD) (37.3% versus 26%, p < 0.001) was more common in elective surgery. Risk factors for PICD were comorbidity (p = 0.003), malignant disease (p = 0.047), and loop ostomy (p < 0.001) in elective surgery; female sex (p = 0.025), neo-adjuvant therapy (p = 0.024), and ileostomy (p = 0.006) in emergency surgery. The height of the ostomy (less than 10 mm) was a modifiable risk factor for mucocutaneous separation in both elective surgery (p < 0.001) and emergency surgery (p = 0.045).

CONCLUSION

Early ostomy complications were more likely to occur after emergency colorectal surgery than in an elective setting. Patient- and ostomy-related risk factors for complications differed between elective and emergency surgeries.

Validation of Urostomy Parastomal Herniation Incisional Prevention Strategies

OBJECTIVE

To evaluate simulated parastomal herniation forces in in vitro abdominal fascial models. Our group previously illustrated how incision type may play a consequential role in bowel herniation force generated across an incision using several abdominal fascia models. We sought to (1) Confirm findings in fresh human tissue, (2) Assess correlation between herniation force and incision size, and (3) Determine whether incision type impacts drainage in a simulated ex vivo ileal conduit.

MATERIALS AND METHODS

Axial tension force (N) of herniation was measured using our previously published protocol, pulling a Foley catheter balloon 3.8 cm diameter affixed to a dynamometer through silicone/fascial incisions ranging 3-5.8 cm. We simulated ileal conduits using bovine small intestine with stoma matured through human fascia using 3.0 cm linear or cruciate incisions. The conduit's caudal end was catheterized and filled at 20 mL/min. Drainage was measured by pad weight change. Two-sided α < 0.05 was used to reject the null hypothesis.

RESULTS

Mean (±SD) herniation forces in fresh human fascia varied significantly across linear longitudinal, linear transverse, and cruciate incisions (20.9 ± 3.7, 23.3 ± 8.8, and 8.9 ± 3.8 N, respectively [P = .011]). Fresh human fascial linear incisions 3 cm in diameter had a herniation force of 22.1 ± 6.3 vs 3.5 ± 0.7 N for 5.8 cm incisions when herniating a 3.8 cm balloon (P = .002). All observations were similar in silicone. In simulated ileal conduit, mean drainage: 70.8 ± 3.6 vs 82.1 ± 9.7 mL (linear vs cruciate) after 100 mL instilled, respectively (P = .05).

CONCLUSION

This ex vivo study further suggests incision type has predictable influence on herniation force. These data support standardization of urostomy construction techniques and evaluating the clinical impact of stomal maturation techniques on parastomal hernia rates.

Outcomes of Total Joint Arthroplasty Subsequent to Ostomy: A Case Series

Background

Ostomy surgery is associated with a high rate of postoperative complications and poses several theoretical concerns for subsequent total joint arthroplasty (TJA). There is concern that ostomy may negatively impact nutrition or increase risk of known gastrointestinal (GI) complications such as obstruction, constipation, or diarrhea, particularly with the use of postoperative opioids. There is also concern that the open nature of the ostomy may increase the risk of infection. This case series reports outcomes and assesses the risk associated with TJA in patients with previous surgical history of intestinal ostomy.

Methods

This is an institutional review board-approved retrospective case series of patients with surgical history of ostomy who underwent total hip or total knee arthroplasty. Cohort consisted of 14 cases in 10 patients and was examined to report individual TJA and ostomy procedural details and outcomes.

Results

Of the 14 cases, none required GI clearance or prophylaxis outside of standard perioperative antibiotics prior to TJA surgeries, and all TJAs resulted in good outcomes. Four cases (29%) had a complication, although only 2 of these were GI complications and none were life-threatening or required further surgery. The first of the 2 experienced increased ostomy output, and symptoms were resolved promptly with rehydration. The second experienced decreased ostomy output, and symptoms were resolved promptly with changes in prn pain medications. Other complications were postoperative urinary tract infection and syncopal episode.

Conclusions

TJA can be performed safely in the setting of ostomy with major consideration being risk of diarrhea or constipation during postoperative period.

Evaluation of the Use, Reasons, and Satisfaction with the Complementary Medicine among Patients Living with a Permanent Ostomy

Patients living with a permanent ostomy encounter many physical, psychological, and social challenges due to the loss of function of a part of their body. Today, as the use of alternative therapies increases, some of these patients are seeking complementary medicine to relieve the symptoms and complications of their disease. Therefore, the present study aimed to determine the use of, reasons for, and satisfaction with the complementary medicine among patients living with a permanent ostomy. This descriptive cross-sectional study was conducted on 100 patients living with a permanent ostomy who were referred to ostomy clinics in southeastern Iran. The census method was used for sampling. The research tool included a complementary medicine questionnaire. SPSS-25 was used for data analysis. The results showed that in physical methods, most of the participants used herbal medicines (83%), aromatherapy (79%), vitamin supplements (76%), and diet (66%). In mental methods, most of the participants used prayer/recourse/vow (91%) and music therapy (75%) (every day to several times a year). People with university education (p < 0.001), higher incomes (p = 0.002), and history of addiction (p = 0.048) used more methods of complementary medicine. Fifty-three point four of the participants used herbal medicines to reduce physical complications, 46.6% used them to improve anxiety and stress induced by ostomy, and between 66 and 80% was completely satisfied with the use of various types of complementary medicine. The study results showed that the frequency of complementary medicine use among patients living with a permanent ostomy varied from a few days to several years. Considering the use of complementary medicine by these patients, educational programs, and interventions are necessary to increase the general awareness of ostomy patients about the types of complementary and alternative medicine (CAM) and the effects of these methods.

Healing Peristomal Wounds Around Retracted Stomas with Negative-Pressure Wound Therapy: A Case Series

ABSTRACT

One method for treating a retracted stoma is a vacuum dressing that cleans the wound and protects against intestinal leakage. This case series describes the use of an integrated, single-use negative-pressure wound therapy (NPWT) dressing to treat retracted stomas as an alternative to other noninvasive remedies. The report includes seven patients who were hospitalized in the authors' surgical department from 2019 to 2020. All patients developed severe peristomal infection that failed to respond to local treatment with proper ostomy appliances or specialist dressings. After cleaning each wound and removing necrotic lesions, the authors applied a single-use hydrofiber NPWT dressing to each patient. The dressing was changed every 2 to 5 days, depending on the effects of the therapy. The stoma orifice was covered with a bag with two-piece ostomy systems. The peristomal wound healed in all cases, and leakage was eliminated. The mean time of treatment was 14 days (range, 10-21 days), and the vacuum dressings were changed an average of four times (range, 3-7 times). None of the patients required a stoma translocation or other additional surgery. Three patients received systemic IV antibiotic therapy to treat general infection. Single-use NPWT dressings protect peristomal wounds from bowel leakage and do not hinder the application of stoma bags. This system, similar to standard NPWT devices, effectively protects infected stomas from retraction.

An eHealth symptom and complication management program for cancer patients with newly created ostomies and their caregivers (Alliance): a pilot feasibility randomized trial

BACKGROUND

Cancer patients with newly created ostomies face complications that reduce quality of life (QOL) and increase morbidity and mortality. This proof-of-concept study examined the feasibility, usability, acceptability, and initial efficacy of an eHealth program titled the "Patient Reported Outcomes-Informed Symptom Management System" (PRISMS) during post-ostomy creation care transition.

METHODS

We conducted a 2-arm pilot randomized controlled trial among 23 patients who received surgical treatment with curative intent for bladder and colorectal cancer and their caregivers. After assessing QOL, general symptoms, and caregiver burden at baseline, participants were randomly assigned to PRISMS (n = 16 dyads) or usual care (UC) (n = 7 dyads). After a 60-day intervention period, participants completed a follow-up survey and post-exit interview. We used descriptive statistics and t-tests to analyze the data.

RESULTS

We achieved an 86.21% recruitment rate and a 73.91% retention rate. Among the PRISMS participants who used the system and biometric devices (n = 14, 87.50%), 46.43% used the devices for ≥ 50 days during the study period. Participants reported PRISMS as useful and acceptable. Compared to their UC counterparts, PRISMS patient social well-being scores decreased over time and had an increased trend of physical and emotional well-being; PRISMS caregivers experienced a greater decrease in caregiver burden.

CONCLUSIONS

PRISMS recruitment and retention rates were comparable to existing family-based intervention studies. PRISMS is a useful and acceptable multilevel intervention with the potential to improve the health outcomes of cancer patients needing ostomy care and their caregivers during post-surgery care transition. A sufficiently powered RCT is needed to test its effects.

TRIAL REGISTRATION

ClinicalTrial.gov ID: NCT04492007. Registration date: 30/07/2020.

Comparison of Simulated Outcomes of Colorectal Cancer Surgery at the Highest-Performing vs Chosen Local Hospitals

IMPORTANCE

Variation in outcomes across hospitals adversely affects surgical patients. The use of high-quality hospitals varies by population, which may contribute to surgical disparities.

OBJECTIVE

To simulate the implications of data-driven hospital selection for social welfare among patients who underwent colorectal cancer surgery.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation used the hospital inpatient file from the Florida Agency for Health Care Administration. Surgical outcomes of patients who were treated between January 1, 2016, and December 31, 2018 (training cohort), were used to estimate hospital performance. Costs and benefits of care at alternative hospitals were assessed in patients who were treated between January 1, 2019, and December 31, 2019 (testing cohort). The cohorts comprised patients 18 years or older who underwent elective colorectal resection for benign or malignant neoplasms. Data were analyzed from March to October 2022.

EXPOSURES

Using hierarchical logistic regression, we estimated the implications of hospital selection for in-hospital mortality risk in patients in the training cohort. These estimates were applied to patients in the testing cohort using bayesian simulations to compare outcomes at each patient's highest-performing and chosen local hospitals. Analyses were stratified by race and ethnicity to evaluate the potential implications for equity.

MAIN OUTCOMES AND MEASURES

The primary outcome was the mean patient-level change in social welfare, a composite measure balancing the value of reduced mortality with associated costs of care at higher-performing hospitals.

RESULTS

A total of 21 098 patients (mean [SD] age, 67.3 [12.0] years; 10 782 males [51.1%]; 2232 Black [10.6%] and 18 866 White [89.4%] individuals) who were treated at 178 hospitals were included. A higher-quality local hospital was identified for 3057 of 5000 patients (61.1%) in the testing cohort. Selecting the highest-performing hospital was associated with a 26.5% (95% CI, 24.5%-29.0%) relative reduction and 0.24% (95% CI, 0.23%-0.25%) absolute reduction in mortality risk. A mean amount of $1953 (95% CI, $1744-$2162) was gained in social welfare per patient treated. Simulated reassignment to a higher-quality local hospital was associated with a 23.5% (95% CI, 19.3%-32.9%) relative reduction and 0.26% (95% CI, 0.21%-0.30%) absolute reduction in mortality risk for Black patients, with $2427 (95% CI, $1697-$3158) gained in social welfare.

CONCLUSIONS AND RELEVANCE

In this economic evaluation, using procedure-specific hospital performance as the primary factor in the selection of a local hospital for colorectal cancer surgery was associated with improved outcomes for both patients and society. Surgical outcomes data can be used to transform care and guide policy in colorectal cancer.

Physicians perceive that ostomates have decreased quality of life but not overall health: An international survey of physicians

AIM

The aim of this work was to evaluate physicians' perceptions of ostomates' quality of life (QoL) and comfort of care among an international sample of physicians caring for ostomates.

METHOD

This was a cross-sectional survey study. We conducted a survey of primary care physicians (PCP), gastroenterologists (GI), and general surgeons (GS) from three continents using the SERMO online physician platform. We piloted the survey for content, clarity and domain development using a pilot sample of physicians from each speciality before use. We summarized responses to questions related to physician comfort of ostomate care with descriptive statistics. We conducted multiple logistic regression with the primary outcome of physician perception of ostomate QoL.

RESULTS

A total of 617 physicians (PCP 264, GI 176, GS 177) completed the survey representing North America, Europe and Australia similarly. The average age was 46 years and 21% were women. Ninety per cent of physicians care for an ostomate at least once per month. Eighty eight per cent had access to enterostomal nurses. Eighty two per cent of physicians believed that ostomates have decreased QoL. Forty seven per cent believed that ostomates have decreased overall health. Almost half of respondents answered incorrectly to a 'bogus question' citing fake clinical evidence supporting a negative impact of ostomies on social relationships. Increased physician comfort in ostomy care (OR 1.30, p = 0.04) and US-based physicians (OR 1.75, p = 0.01) were associated with increased odds of answering that ostomates have no decreased QoL.

CONCLUSION

Among a diverse international sample, most physicians believe that ostomates have decreased QoL but not overall health. Physician implicit bias, physician comfort and geographical variability account for these findings. Targeted efforts to increase physician comfort in ostomate care and establish universal best practices is needed.

Risk factors associated with readmission within 30 days following stoma surgery: Development of a 'traffic light' prediction model

AIM

Patients undergoing stoma surgery have a higher risk for early readmission. Some patients may benefit from closer postdischarge surveillance to provide early detection of complications and timely intervention. However, there is a paucity of validated tools to identify those at higher risk of readmission. Here, we aim to determine the independent risk factors associated with readmission within 30 days of discharge following stoma surgery, attempt to validate previous predictive models and develop a novel prediction tool.

METHOD

A retrospective review of 423 patients who underwent ileostomy or colostomy stoma formation at a UK tertiary colorectal centre between 2019 and 2021. Univariate, multivariate and logistic regression analyses were used to analyse a large number of demographics and risk factors and the association with readmission.

RESULTS

This study cohort included 220 ileostomy and 203 colostomy patients. Of these, 87 (20.6%) were readmitted within 30 days of discharge following index surgery. A large number of demographics were evaluated for association with readmission. Readmission was associated with chronic heart failure (p < 0.05), postoperative stoma-specific complications (bleeding, p = 0.02; high-output stoma, p = 0.01) and those with a loop ileostomy (34.0% vs. 18.6%; p = 0.01). A previous predictive model was ineffective in this cohort, therefore a simplified 'traffic light' risk scoring system was developed and found to have improved discrimination.

CONCLUSION

Readmission following stoma formation is associated with key variables that could provide the means to triage, risk score and potentially predict readmissions. We found that a novel and simplified scoring system may provide improved prediction.

A systematic review and meta-analysis on the effectiveness of web-based psychosocial interventions among patients with colorectal cancer

AIMS

To synthesize the effectiveness of web-based psychosocial interventions on self-efficacy, anxiety, depression, quality of life (QoL), non-specific psychological and cancer-specific distress among patients with colorectal cancer (CRC).

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

Six databases (PubMed, PsycINFO, Embase, Scopus, CINAHL and CNKI) were searched from inception to December 2021.

REVIEW METHODS

Experimental/quasi-experimental studies involving patients with CRC for the improvement of aforementioned outcomes were included. Two reviewers screened and extracted the data, and assessed studies' methodological quality using risk of bias tools. Meta-analyses and narrative syntheses were performed.

RESULTS

Nineteen studies consisting of 1386 participants were identified. Cognitive-behavioural therapy delivered online was the most common trialled web-based psychosocial intervention. Meta-analyses revealed no positive effect for self-efficacy (standardized mean difference 0.93, 95% CI: 0.52 to 1.35, p < .01) and minimal benefit for QoL (mean difference [MD] 2.83, 95% CI: -0.31 to 5.98, p = .08) but significant positive effects for anxiety (MD -2.23, 95% CI: -3.31 to -1.14, p < .01) and depression (MD -2.84, 95% CI: -4.09 to -1.59, p < .01) among CRC survivors in the intervention group as compared with the control group. Narrative synthesis suggested possible benefits in reducing distress.

CONCLUSION

Web-based psychosocial interventions are promising alternatives to conventional delivery methods in reducing patients' anxiety, depression and distress. However, evidence on self-efficacy and QoL remains inconsistent. More adequately powered, well-designed trials with targeted and theory-based interventions are required to ascertain findings.

IMPACT

By highlighting the potential of web-based psychosocial interventions in reducing anxiety and depression among CRC survivors, this review has put forth beneficial information supporting the use and acceptance of web-based care delivery in light of COVID-19 restrictions and nationwide lockdowns. Meanwhile, the paucity of empirical support reflects the necessity of more extensive research to test and improve other health outcomes. PROSPERO registration number: CRD42021261396.

Reducing New Ileostomy Readmissions in a Rural Health Care Setting: A Quality Improvement Initiative

BACKGROUND

Readmission after ileostomy creation continues to be a major cause of morbidity with rates ranging from 15% to 30% due to dehydration and obstruction. Rural environments pose an added risk of readmission due to larger travel distances and lack of consistent home health services.

OBJECTIVE

This study aimed to reduce ileostomy-related readmission rates in a rural academic medical center.

DESIGN

This is a rapid cycle quality improvement study.

SETTING

This single-center study was conducted in a rural academic medical center.

PATIENTS

Colorectal surgery patients receiving a new ileostomy were included in this study.

INTERVENTIONS

Improvement initiatives were identified through Plan-Do-Study-Act cycles (enhanced team continuity, standardized rehydration, nursing/staff education).

MAIN OUTCOME MEASURES

Thirty-day readmission, average length of stay, and average time to readmission served as main outcome measures.

RESULTS

Roughly equal rates of ileostomy were created in each time point, consistent with a tertiary care colorectal practice. The preimplementation readmission rate was 29%. Over the course of the entire quality improvement initiative, re-admission rates decreased by more than 50% (29% to 14%). PDSA cycle 1, which involved integrating a service-specific physician assistant to the team, allowed for greater continuity of care and had the most dramatic effect, decreasing rates by 27.5% (29% to 21%). Standardization of oral rehydration therapy and the implementation of a patient-directed intake/output sheet during PDSA cycle 2 resulted in further improvement in readmission rates (21% to 15%). Finally, implementation of nurse and physician assistant (PA)-driven patient education on fiber supplementation resulted in an additional yet nominal decrease in readmissions (15% to 14%). Latency to readmission also significantly increased throughout the study period.

LIMITATIONS

This study was limited by its small sample size in a single-center study.

CONCLUSION

Implementation of initiatives targeting enhanced team continuity, the standardization of rehydration therapies, and improved patient education decreased readmission rates in patients with new ileostomies. Rural centers, where outpatient resources are not as readily available or accessible, stand to benefit the most from these types of targeted interventions to decrease readmission rates. See Video Abstract at http://links.lww.com/DCR/B771.

REDUCCIN EN LAS READMISIONES POR ILEOSTOMAS NE MEDIOS DE ATENCIN MDICA RURAL INICIATIVA DE MEJORA EN LA CALIDAD

ANTECEDENTES:La readmisión después de la creación de una ileostomía sigue siendo una de las principales causas de morbilidad con tasas que oscilan entre el 15% y el 30% debido a la deshidratación y la oclusión. Un entorno rurale presenta un riesgo adicional de readmisión debido a las mayores distancias de viaje y la falta de servicios de salud domiciliarios adecuados.OBJETIVO:Reducir las tasas de reingreso por ileostomía en un centro médico académico rural.DISEÑO:Estudio de mejoría de la calidad de ciclo rápido.AJUSTE:Estudio unicéntrico en una unidad de servicio médico académico rural.PACIENTES:Pacientes de cirugía colorrectal a quienes se les confeccionó una ileostomía.INTERVENCIONES:Iniciativas de mejoría identificadas a través de los ciclos Planificar-Hacer-Estudiar-Actuar (Continuidad del equipo mejorada, rehidratación estandarizada, educación de enfermería / personal).PRINCIPALES MEDIDAS DE RESULTADO:30 días de readmisión, duración media de la estadía hospitalaria, tiempo medio de reingreso.RESULTADOS:Se crearon tasas aproximadamente iguales de ileostomías un momento dado de tiempo, subsecuentes en la práctica colorrectal de atención terciaria. La tasa de readmisión previa a la implementación del estudio fue del 29%. En el transcurso de toda la iniciativa de mejoría en la calidad, las tasas de readmisión disminuyeron en más del 50% (29% a 14%). El ciclo 1 de PDSA, que implicó la integración en el equipo de un asistente médico específico, lo que permitió una mayor continuidad en la atención y tuvo el mayor efecto disminuyendo las tasas en un 27,5% (29% a 21%). La estandarización de una terapia de rehidratación oral y la implementación de una hoja de ingresos / perdidas dirigida al paciente durante el ciclo 2 de PDSA resultó en una mejoría adicional en las tasas de readmisión (21% a 15%). Finalmente, la implementación de la educación del paciente impulsada por enfermeras y AF sobre el consumo suplementario de dietas con fibra dio como resultado una disminución adicional, aunque nominal, de las readmisiones (15% a 14%). La latencia hasta la readmisión también aumentó significativamente durante el período de estudio.LIMITACIONES:Estudio de un solo centro con un muestreo de pequeño tamaño.CONCLUSIONES:La implementación de iniciativas dirigidas a mejorar la continuidad en el equipo, la estandarización de las terapias de rehidratación y la mejoría en la información de los pacientes disminuyeron las tasas de readmisión en todos aquellas personas con nuevas ileostomías. Los centros rurales, donde los recursos para pacientes ambulatorios no están tan fácilmente disponibles o accesibles, son los que más beneficiaron de este tipo de intervenciones específicas para reducir las tasas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B771. (Traducción-Dr. Xavier Delgadillo).

Stoma-Related Complications: A Single-Center Experience and Literature Review

Introduction: The creation of an abdominal stoma is a common procedure performed by surgeons as a part of the treatment for benign and malignant conditions in general surgery. Stoma formation is simple, but sometimes the associated postoperative complications have an impact on the patients’ physical and psychological state. The majority of complications do not require reoperation, but when it is indicated, we have to assess the most appropriate option for the patient.

Material and Methods: We conducted a retrospective study in a single surgical center, the Department of Surgery, Mureș County Hospital, Târgu Mureș, Romania, using data from patients who have been admitted under elective conditions for stoma-related complications between 2005 and 2019.

Results: A total number of 877 ostomies (653 colostomies and 224 ileostomies) were performed, and 157 patients (17.9%) developed some type of stoma complication and required surgical intervention. The mean age was 64.5 ± 2.1 years, with a male-female ratio of 1.3 to 1. The leading comorbidities included cardiovascular disease (52.2% of cases), obesity (22.2%), and diabetes (18.4%). Parastomal hernia was the most frequent complication (47.5% of cases), followed by stoma prolapse (23.4%), parastomal stenosis (20.3%), and parastomal infection (8.2%). There was an association between age and the type of complication: parastomal hernia, stoma prolapse, and stenosis were more frequent in the elderly; parastomal infection was more prevalent in young patients. A longer hospital stay was observed in case of parastomal hernia.

Conclusions: Stoma formation is associated with significant morbidity. Typically, the complications appear in the elderly. Conservative treatment is essential, but some of the late complications, such as parastomal hernia, stoma stenosis, stoma prolapse, and parastomal infection, require a surgical solution. Parastomal hernias are the most common complications, frequently associated with comorbidities and prolonged hospitalization.

Stoma-related complications and emergencies

Stoma creations are common procedures in surgical specialties. They can be created either as a temporary or a permanent measure. Despite advancements in surgical technique and stoma care, complications are common. Patients experiencing stoma-related complications often present to the emergency department. Emergency physicians are not expected to be stoma experts, yet they are often the first point of contact for patients experiencing stoma-related complications. Accordingly, emergency physicians should be familiar with the types of stomas and complications and emergencies associated with them so that they can appropriately address the problems related to stomas. This article will provide a review of emergencies and complications associated with ileostomies, colostomies, and urostomies.

Marginalization in the Medical Encounter: Ostomy Patients Experience of Perceived Stigmatizing Sentiments from Medical Clinicians

Introduction

Ostomy¹ stigma negatively impacts the health of people with an ostomy and contributes to a lower quality of life and health outcomes.

Objective

To assess whether participants experience perceived stigmatizing sentiments (SS) from medical clinicians at the time of their ostomy procedure.

Methods

Using a nonprobability sample of 312 persons with an ostomy, we conducted a retrospective descriptive study. We measured SS as patients’ self-reports of verbal and non-verbal communication from clinicians that were perceived to be negative and may contribute to ostomy stigma. We used thematic analyses to analyze open-ended written comments.

Results

Findings indicate that ostomy patients experience stigmatizing sentiments from their medical clinician before and after surgery. Sixteen percent of patients reported a SS, such as clinicians stating feelings of disgust, showing visible signs of disgust, or treating patients negatively regarding the ostomy.

Conclusion

The perceived treatment that this patient cohort experienced in healthcare likely contributes to ostomy stigmatization and may impact ostomy patients’ psychosocial adjustment. Future research should examine the specific consequences of perceived stigmatizing sentiments from medical clinicians.

Comparison of surgical outcomes for colostomy closure performed by acute care surgeons versus a dedicated colorectal surgery service

BACKGROUND

Despite colostomy closure being a common procedure, it remains highly morbid. Previous literature suggests that complication rates, including surgical site infections, intra-abdominal abscess, and anastomotic failures, reach as high as 50%. With the creation of a dedicated colorectal service, colostomy reversals have been largely migrated from the acute care surgery services. This study analyzes the differences in outcomes in colostomy closures performed between colorectal surgeons and acute care surgeons.

METHODS

We retrospectively analyzed our experience with 127 colostomy closures performed in our hospital system by acute care surgeons and colorectal surgeons from 2016 through 2020. Demographic data, operative data, and outcomes such as abscess formation, anastomotic leak, and readmission were analyzed. Multivariate regression analysis was performed for intraabdominal abscesses and anastomotic leaks.

RESULTS

In total, 71 colostomy closures were performed by colorectal surgeons (56%) and 56 by acute care surgeons (43%). The majority of colostomy reversals were after Hartmann's procedure for perforated diverticulitis. No differences in demographics were identified, except for a shorter interval to closure in the acute care surgeons group (10.0 vs 7.2 months; P = .049). Two (3.6%) acute care surgeon patients required colorectal surgeon consultation during the definitive repair. Regression analysis identified body mass index (odds ratio 2.43; P = .001), male gender (odds ratio -2.39; P = .18), and colorectal surgeons (odds ratio -2.28; P = .025) as significant risk factors for anastomotic leak.

CONCLUSION

Analysis of the current series identified female gender and increased body mass index as higher risk, while procedures performed by colorectal surgeons were at decreased risk for anastomotic leak. Our study identified colostomy reversals performed by a dedicated colorectal service decreased the rate of anastomotic leak.

Interactive Training Program Improves Surgeon and Pathologist Comfort Level With Total Mesorectal Excision Grading for Rectal Cancer

BACKGROUND

Total mesorectal excision for rectal cancer has been shown to decrease local recurrence and improve survival, and specimen grading is recommended as a best practice. However, specimen grading remains underutilized in the United States potentially because of the lack of surgeon and pathologist training in the technique.

OBJECTIVE

This study aimed to determine whether an interactive webinar improves physician comfort with mesorectal grading.

DESIGN

To test the effect of the program, participants completed a survey before and after participating.

SETTINGS

Twelve Michigan Surgical Quality Collaborative hospitals volunteered to participate in a Total Mesorectal Excision Project.

PARTICIPANTS

Total mesorectal excision grading training program participants were surgeons, surgery residents, pathologists, and pathology assistants from 12 hospitals.

MAIN OUTCOME MEASURES

Comfort with grading total mesorectal excision specimens was our main outcome measure. Prewebinar surveys also measured familiarity, previous experience, and training in grade assignment, as well as interest in the training program. Postwebinar surveys measured webinar relevance and effectiveness as well as participant intention to use content in practice.

RESULTS

A total of 34 participants completed the prewebinar survey and 28 participants completed the postwebinar survey. The postwebinar overall median comfort level with specimen grading of 3.64 was significantly higher than the prewebinar overall median comfort level of 2.94 (95% CI, 3.32-3.96 versus 95% CI 2.56-3.32; p = 0.007). When evaluated separately, both surgeons and pathologists reported significantly higher comfort levels with total mesorectal excision grading after the webinar.

LIMITATIONS

Six participants did not complete the postwebinar survey. Surgery residents and pathology assistants were analyzed with practicing surgeons and pathologists. The pre- and postwebinar surveys were deidentified, so paired analysis was not possible.

CONCLUSIONS

Our total mesorectal excision grading training program improved the comfort level of both surgeons and pathologists with specimen grading. Survey results also demonstrate that providers are interested in receiving training in rectal cancer specimen grading. See Video Abstract at http://links.lww.com/DCR/B766.PROGRAMA DE ENTRENAMIENTO INTERACTIVO MEJORA EL NIVEL DE COMODIDAD DEL CIRUJANO Y DEL PATÓLOGO CON LA CLASIFICACIÓN DE LA ESCISIÓN TOTAL DEL MESORRECTO PARA EL CÁNCER DE RECTO.

ANTECEDENTES

Se ha demostrado que la escisión total del mesorrecto para el cáncer de recto disminuye la recurrencia local y mejora la supervivencia, y se recomienda la clasificación de la muestra como buena práctica de rutina. Sin embargo, sigue siendo poco utilizado en los Estados Unidos debido principalmente a la falta de formación en la técnica de cirujanos y patólogos.

OBJETIVO

Determinar si un seminario interactivo en línea mejora la comodidad del médico con la clasificación mesorrectal.

DISEO

Para probar el efecto del programa, los participantes completaron una encuesta antes y después de haber participado de la misma.

MARCO

Doce hospitales en cooperación sobre la calidad quirúrgica de Michigan se ofrecieron como voluntarios para participar en el proyecto de Escisión Total de Mesorrecto.

PARTICIPANTES

Los participantes del programa de entrenamiento en la clasificación de escisión total de mesorrecto fueron cirujanos, residentes de cirugía, patólogos y asistentes de patología de doce hospitales.

PRINCIPALES RESULTADOS MEDIDOS

La comodidad con la clasificación de las muestras de escisión total de mesorrecto fue nuestro principal resultado de medición. Las encuestas previas al seminario en línea también midieron la familiaridad, la experiencia y entrenamiento previo en la clasificación, así como el interés en el programa de entrenamiento. Las encuestas posteriores midieron la relevancia y la eficacia del seminario web, así como la intención de los participantes de utilizar en la practica el contenido.

RESULTADOS

Un total de 34 participantes completaron la encuesta previa, y 28 de ellos la completaron con posterioridad al seminario en línea.La mediana del nivel de comodidad general, posterior al seminario en línea, con respecto a la clasificación de la pieza de 3,64 fue significativamente mayor con respecto al valor de 2,94 previo al seminario (IC del 95%: 3,32 - 3,96 versus IC 2,56 - 3,32, respectivamente; valor de p = 0,007).Cuando fueron evaluados de manera separada, tanto los cirujanos como los patólogos reportaron niveles de comodidad significativamente más altos con la clasificación de escisión total de mesorrecto (TME) después del seminario en línea.

LIMITACIONES

Seis participantes no completaron la encuesta posterior al seminario en línea. Los residentes de cirugía y los asistentes de patología fueron analizados conjuntamente con los cirujanos y patólogos en ejercicio, respectivamente. Las encuestas previas y posteriores al seminario en línea fueron anónimas, anulándose la identificación, por lo que no fue posible realizar un análisis por pares.

CONCLUSIONES

Nuestro programa de entrenamiento en la clasificación de escisión total de mesorrecto mejoró el nivel de comodidad tanto de los cirujanos como de los patólogos con la clasificación de las muestras. Los resultados de la encuesta también demuestran que el personal involucrado está interesado en recibir capacitación en la clasificación de muestras de cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B766. (Traducción-Dr Osvaldo Gauto).

A Theory-Based, Multidisciplinary Approach to Cocreate a Patient-Centric Digital Solution to Enhance Perioperative Health Outcomes Among Colorectal Cancer Patients and Their Family Caregivers: Development and Evaluation Study

Background

Elective colorectal cancer (CRC) surgeries offer enhanced surgical outcomes but demand high self-efficacy in prehabilitation and competency in self-care and disease management postsurgery. Conventional strategies to meet perioperative needs have not been pragmatic, and there remains a pressing need for novel technologies that could improve health outcomes.

Objective

The aim of this paper was to describe the development of a smartphone-based interactive CRC self-management enhancement psychosocial program (iCanManage) in order to improve health outcomes among patients who undergo elective CRC surgeries and their family caregivers.

Methods

A multidisciplinary international team comprising physicians, specialist nurses, a psychologist, software engineers, academic researchers, cancer survivors, patient ambassadors, and ostomy care medical equipment suppliers was formed to facilitate the development of this patient-centric digital solution. The process occurred in several stages: (1) review of current practice through clinic visits and on-site observations; (2) review of literature and findings from preliminary studies; (3) content development grounded in an underpinning theory; (4) integration of support services; and (5) optimizing user experience through improving interface aesthetics and customization. In our study, 5 participants with CRC performed preliminary assessments on the quality of the developed solution using the 20-item user version of the Mobile App Rating Scale (uMARS), which had good psychometric properties.

Results

Based on the collected uMARS data, the smartphone app was rated highly for functionality, aesthetics, information quality, and perceived impact, and moderately for engagement and subjective quality. Several limiting factors such as poor agility in the adoption of digital technology and low eHealth literacy were identified despite efforts to promote engagement and ensure ease of use of the mobile app. To overcome such barriers, additional app-training sessions, an instruction manual, and regular telephone calls will be incorporated into the iCanManage program during the trial period.

Conclusions

This form of multidisciplinary collaboration is advantageous as it can potentially streamline existing care paths and allow the delivery of more holistic care to the CRC population during the perioperative period. Should the program be found to be effective and sustainable, hospitals adopting this digital solution may achieve better resource allocation and reduce overall health care costs in the long run.

Trial Registration

ClinicalTrials.gov NCT04159363; https://clinicaltrials.gov/ct2/show/NCT04159363

Case Report of a Novel Technique for Fecal Diversion

An estimated 100,000 individuals within the United States experience operations that result in a colostomy or ileostomy each year. Ostomy formation is used in surgery for operations involving several pathologies involving the small intestine or colon. Evidence shows that loop ileostomy or loop colostomy for fecal diversion effectively reduce the complications of anastomotic dehiscence. Anastomotic leak can cause significant morbidity and mortality. The role of temporary fecal diversion though a loop ileostomy or colostomy is vital in protecting tenuous anastomoses in the pelvis, immunocompromised patients, or those who are septic.⁴ We present a case of a patient with a perforated colon cancer who required an innovative technique for fecal diversion.

Patient-Related Factors Associated With Stoma and Peristomal Complications Following Fecal Ostomy Surgery: A Scoping Review

PURPOSE

Ostomy creation is often an integral part of the surgical management of various diseases including colorectal malignancies and inflammatory bowel disease. Stoma and peristomal complications may occur in up to 70% of patients following ostomy surgery. The aim of this scoping literature review was to synthesize evidence on the risk factors for developing complications following creation of a fecal ostomy.

DESIGN

Scoping literature review.

SEARCH STRATEGY

Two independent researchers completed a search of the online bibliographic databases PubMed, MEDLINE, Cochrane, Google Scholar, and EMBASE for all articles published between January 1980 and December 2018. The search comprised multiple elements including systematic literature reviews with meta-analysis of pooled findings, randomized controlled trials, cohort studies, observational studies, other types of review articles, and multiple case reports. We screened 307 unique titles and abstracts; 68 articles met our eligibility criteria for inclusion. The methodological rigor of study quality included in our scoping review was variable.

FINDINGS/CONCLUSIONS

We identified 6 risk factors associated with an increased likelihood of stoma or peristomal complications (1) age more than 65 years; (2) female sex; (3) body mass index more than 25; (4) diabetes mellitus as a comorbid condition; (5) abdominal malignancy as the underlying reason for ostomy surgery; and (6) lack of preoperative stoma site marking and WOC/ostomy nurse specialist care prior to stoma surgery. We also found evidence that persons with a colostomy are at a higher risk for prolapse and parastomal hernia.

IMPLICATIONS

Health care professionals should consider these risk factors when caring for patients undergoing fecal ostomy surgery and manage modifiable factors whenever possible. For example, preoperative stoma site marking by an ostomy nurse or surgeon familiar with this task, along with careful perioperative ostomy care and education of the patient by an ostomy nurse specialist, are essential to reduce the risk of modifiable risk factors related to creation of a fecal ostomy.

High recurrence rate after posterior component separation and keyhole mesh reconstruction for complex parastomal hernia: A case series study

AIM

This study aimed to describe the results of complex parastomal hernia repair after posterior component separation and keyhole reconstruction.

METHOD

We conducted a retrospective review of a prospectively sustained database in one single complex abdominal wall referral centre. We analysed the data of patients who underwent the posterior component separation technique using modified transversus abdominis release for complex parastomal hernia and retromuscular keyhole mesh repair from February 2014 to January 2017. Demographic data, hernia characteristics, operative details and outcomes were analysed. The primary outcome measured was the recurrence rate during the follow-up.

RESULTS

Twenty patients were included in this study. Among the patients who underwent surgery for parastomal hernia, 17 patients had a colostomy (85%) and three patients had a ureteroileostomy after the Bricker procedure (15%). The mean body mass index was 33.2 kg/m² (range 25-47). Twelve patients had an expected associated risk according to the Carolinas equation for determining associated risk classification of >60%. Sixty per cent of our patients had contaminated or dirty/infected wounds. The overall complication rate was 60%. Surgical site infection was observed in 25% of the cases. The mortality rate in our study group was 5% (n = 1). We found clinical or radiological evidence of parastomal hernia recurrence in nine out of 20 (45%) patients during follow-up. No hernia recurrence was detected in the concomitant incisional hernias.

CONCLUSIONS

Although posterior component separation in the form of modified transversus abdominis muscle release allows abdominal wall reconstruction, keyhole mesh configuration at the stoma site does not offer satisfactory results in terms of long-term recurrence rate at the parastomal defect.

Caregiver contribution to self-care and its associated variables among caregivers of ostomy patients: Results of a cross-sectional study

AIMS AND OBJECTIVES

To describe caregiver contribution (CC) to ostomy self-care and identify its associated variables among caregivers of ostomy patients.

BACKGROUND

Self-care is essential for ostomy patients, but it can be difficult to perform. In these cases, caregivers play a key role in promoting self-care behaviours. So far, the CC to ostomy self-care has not been investigated thoroughly.

DESIGN

This is a cross-sectional and multicentre study conducted at seven outpatient clinics of two Italian regions.

METHODS

We recruited 252 caregivers between February 2017-May 2018. The Caregiver Contribution to Ostomy Self-Care Index (CC-OSCI) was used to measure CC to ostomy self-care. Three multivariable linear regression models were fitted to identify variables associated with CC dimensions (maintenance, monitoring and management). The STROBE checklist was used to report the present study.

RESULTS

The sample (mean age = 58.73, SD = 13.98) was mostly female (80.60%), unemployed (58.70%) and resided with the patient (81.00%). Caregivers being employed and those declaring more hours of contribution per week were associated with a significantly lower contribution to self-care maintenance. Caregivers with lower levels of education and those residing with the patient were less likely to contribute to CC to self-care monitoring. Spousal caregivers and those with higher preparedness contributed significantly lower to CC to self-care management.

CONCLUSIONS

We found a variety of sociodemographic factors associated with CC to ostomy self-care.

RELEVANCE TO CLINICAL PRACTICE

Sociodemographic variables associated with CC to ostomy self-care can help clinicians develop more tailored educational interventions for caregivers who find their contribution challenging.

The correlation between emotional intelligence and self-esteem in patients with intestinal stoma: A descriptive-correlational study

Aim

Patients with intestinal stoma would experience some periods of psychological disorders such as self‐esteem disturbances. Self‐esteem is one of the most important factors affecting the patient's mental health. It is suggested that factors such as emotional intelligence could be related to self‐esteem. This study seeks to determine the correlation between emotional intelligence and self‐esteem in patients with an ostomy.

Design

This was a descriptive‐correlational study.

Methods

This study was conducted on 155 patients with intestinal stoma referring to the selected hospitals affiliated to Iran University of Medical Sciences and Iranian Ostomy Association in 2018. The patients were selected using convenience sampling method. The study tools included demographic characteristics form, Rosenberg self‐esteem scale and Schutte emotional intelligence questionnaire. Data analysis was performed in SPSS v.16 using descriptive and inferential statistics, including variance analysis and independent t test.

Results

Participants included 79 women and 76 men with the most frequency of age between 50–70 years old. 52.26% of the cases had cancer and 45.81% of the cases had inflammatory bowel disease and other related diseases. Pearson correlation coefficient results showed a positive and significant correlation between total emotional intelligence and self‐esteem (r = .56) (p = <.001).

The Lived Experiences of Persons With Ostomies Attending a Support Group: A Qualitative Study

PURPOSE

The purpose of this study was to describe the lived experiences of patients with ostomies participating in a support group.

DESIGN

Qualitative, descriptive, phenomenological study.

SUBJECT AND SETTING

Fifteen adults with different types of ostomies were recruited from support groups in the state of Georgia.

METHODS

Semistructured interviews were digitally audio-recorded and transcribed verbatim. Analyses of data were performed using Parse's 5-step thematic analysis.

RESULTS

Four major themes and 10 subthemes emerged from the interviews: (1) theme 1-support group gives hope and changes lives, with 2 subthemes of increased knowledge and provided new knowledge and allows open communication; (2) theme 2-changes in body image had 2 subthemes, some things are different and everyone is the same; (3) theme 3-I am not alone resulted in 4 subthemes of feeling of belonging, willingness to be helped, being supported, and developing lifelong relationships; and (4) theme 4-being independent manifested 2 subthemes including confidence in rejoining society, and building confidence and decreased shame.

CONCLUSION

We found that participation in an ostomy support group allowed individuals with ostomies to function at more advanced levels than they were before participating in the support group. The lived experiences were characterized by hope, willingness to live fully again, participating in different activities, and making new friends. Participants shared their positive experiences with others who were experiencing the same problems they once experienced. These findings add to and support the body of knowledge related to the interactions between nurses and individuals with ostomies as well as the care needed to ensure a safe discharge from the acute care facility. New knowledge gained may help in the improvement of the education provided during hospitalization. Providing this information will equip patients and families with a better understanding of and methods to care for their new ostomies and develop an acceptance of their new health status.

Correlation between self-efficacy and self-esteem in patients with an intestinal stoma

BACKGROUND

Patients with an intestinal stoma experience psychological difficulties, including disturbances in self-efficacy and self-esteem. There is evidence that they are interdependent.

AIM

This study aimed to determine the correlation between self-efficacy and self-esteem in patients with an intestinal stoma.

METHODS

A descriptive-correlational study was conducted with 155 patients with an intestinal stoma. Participants were selected using convenience sampling. Data were collected using demographic questions, the stoma self-efficacy scale and the Rosenberg self-esteem scale, and analysed using descriptive and analytical statistics.

FINDINGS

Seventy-nine men and 76 women took part; the 50-70 years age group had the highest proportion of participants. Regarding diagnosis, 52.26% had cancer and 45.81% had inflammatory bowel disease or related conditions. Pearson's correlation coefficient indicated a positive, significant correlation between total self-efficacy and its dimensions with self-esteem (P<0.001; r=0.54).

CONCLUSION

Self-efficacy is positively correlated with self-esteem in patients with an intestinal stoma. It is recommended that educational interventions are planned and implemented to boost self-esteem and self-efficacy in these patients.

Case report of surgical management of a locally invasive colostomy adenocarcinoma

INTRODUCTION

This case report involves the presentation and management of a locally invasive adenocarcinoma at the site of a colostomy in a patient with multiple comorbidities and anatomic constraints.

PRESENTATION OF CASE

63 year-old woman with a complicated medical and surgical history, including imperforate anus and permanent colostomy, who presented with a fungating mass at the site of her colostomy. Evaluation revealed a locally invasive adenocarcinoma requiring surgical management for symptom control and oncologic treatment.

DISCUSSION

Due to the patient's medical comorbidities, body habitus, prior surgery, prior radiation and locally invasive cancer, there were numerous physiologic and anatomic issues that required a multi-disciplinary approach. Specifically, consideration of the patient's prior radiation to the left chest, history of cystectomy and ileal conduit, history of prior colon resection, as well as her short stature and severe kyphosis required input from urology, plastic surgery and colorectal surgery for operative planning. The patient's chronic renal insufficiency, recurrent urinary tract infections and history of thromboembolic disease further complicated her perioperative management. Oncologic resection with wide local excision at the skin and abdominal wall were performed with mass closure of the midline and peristomal abdominoplasty, using mesh underlay. The patient's postoperative course was complicated by gastric outlet obstruction and recurrent urosepsis.

CONCLUSIONS

Patients with chronic colostomies require colon cancer screening similar to their non-stoma peers, in accordance with national guidelines. Oncologic resection of cancers involving colostomies is feasible, but may require multi-disciplinary planning to manage complicated anatomic concerns.

Parastomal Hernia Repair Outcomes: A Nine-Year Experience

Parastomal hernias (PHs) frequently complicate enterostomy creation. Decision for PH repair (PHR) is driven by patient symptoms due to the frequency of complications and recurrences. The European Hernia Society (EHS) PH classification is based on the PH defect size and the presence/ absence of concomitant incisional hernia. The aim of this study was to evaluate PHR outcomes based on EHS classification. An Institutional Review Board–approved retrospective review of a prospective database between 2009 and 2017 was performed. Patient demographics, enterostomy type, EHS classification, operative technique, and clinical outcomes (postoperative complications, 30-day readmission, and PH recurrence) were obtained. Cases were analyzed by EHS classifications I and II (SmallPH) versus III and IV (LargePH). Sixty-two patients underwent PHR (35: SmallPH, 27: LargePH). Patient groups (SmallPH vs LargePH) were similar based on American Society of Anesthesiologists Class III and obesity. Hernia recurrence was seen in 26 per cent of repairs with no difference between groups. The median recurrence-free survival was 3.9 years. There was no difference in superficial SSI, deep SSI, nonwound complications, or readmission between SmallPH and LargePH. Both small and large PHs experience similar outcomes after repair. Strategies to improve outcomes should be developed and implemented universally across all EHS PH classes.

National Study of Immediate and Delayed Readmissions After Colostomy Creation

BACKGROUND

Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy.

METHODS

The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission.

RESULTS

Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively.

CONCLUSIONS

Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.

Reduction in surgical stoma rates in Crohn's disease: a population-based time trend analysis

AIM

Trends in surgical rates for Crohn's disease (CD) in the biological era are controversial. We aim to assess modern trends in the formation rates of surgical stomas.

METHOD

Population-based surveillance in the Calgary Health Zone (CHZ), Canada, was conducted between 1 April 2002 and 31 March 2011, using the Discharge Abstract Database to identify adult patients with CD admitted to hospital and treated with surgical stoma formation (n = 545). Annual stoma incidence was calculated by dividing the number of incident stomas by the prevalence of CD in the CHZ. Time trend analysis of the stoma-formation rate was performed, expressed as annual percentage change (APC) with 95% CI. Stoma-formation rates were stratified according to procedure (emergency vs elective) and duration of stoma [temporary (reversed within 2 years of formation) vs permanent].

RESULTS

The overall rate of stoma formation between 2002 and 2011 showed a downwards trend, of a mean of 5.2% (95% CI: -8.5 to -1.8) per year, from a rate of 2.30 stomas/100 person-years (PY) in 2002 to 1.51 stomas/100 PY in 2011. The rate of emergency stoma formation decreased significantly from 2002 to 2011 (mean APC = -9.4%; 95% CI: -15.6 to -2.8), while the rate of elective ostomies essentially showed no change (mean APC = -0.9%; 95% CI: -5.3 to 3.8). The rate of temporary stoma formation decreased significantly, by 4.6% (95% CI: -7.3 to -1.8) per year, while permanent stoma formation was stable (APC = 1.0%; 95% CI: -4.0 to +6.3).

CONCLUSION

A reduction in the overall rate of stoma formation in CD has been driven by fewer emergency stomas, although rates of permanent stoma have remained stable.

Ostomy Management: A Model of Interdisciplinary Care

This article provides an overview of key palliative care considerations for management of patients with wounds and ostomies. Ostomy formation is indicated for a variety of intestinal conditions. Specifics of ostomy management, impact on quality of life, and patient perspectives can be complicated. Wound ostomy and continence nursing professionals play a central role in the successful management of this patient population.

Assessment of the Value of Comorbidity Indices for Risk Adjustment in Colorectal Surgery Patients

BACKGROUND AND PURPOSE

Comorbidity indices (CIs) are widely used in retrospective studies. We investigated the value of commonly used CIs in risk adjustment for postoperative complications after colorectal surgery.

METHODS

Patients undergoing colectomy without stoma for colonic neoplasia at a single institution from 2009 to 2014 were included. Four CIs were calculated or obtained for each patient, using administrative data: Charlson-Deyo (CCI-D), Charlson-Romano (CCI-R), Elixhauser Comorbidity Score, and American Society of Anesthesiologists classification. Outcomes of interest in the 90-day postoperative period were any surgical complication, surgical site infection (SSI), Clavien-Dindo (CD) grade 3 or higher complication, anastomotic leak or abscess, and nonroutine discharge. Base models were created for each outcome based on significant bivariate associations. Logistic regression models were constructed for each outcome using base models alone, and each index as an additional covariate. Models were also compared using the DeLong and Clarke-Pearson method for receiver operating characteristic (ROC) curves, with the CCI-D as the reference.

RESULTS

Overall, 1813 patients were included. Postoperative complications were reported in 756 (42%) patients. Only 9% of patients had a CD grade 3 or higher complication, and 22.8% of patients developed an SSI. Multivariable modeling showed equivalent performance of the base model and the base model augmented by the CIs for all outcomes. The ROC curves for the four indices were also similar.

CONCLUSIONS

The inclusion of CIs added little to the base models, and all CIs performed similarly well. Our study suggests that CIs do not adequately risk-adjust for complications after colorectal surgery.

Iatrogenic Colonic Perforations: Changing the Paradigm

PURPOSE

The purpose of our study was to investigate the clinical outcomes of colonoscopic perforations in patients.

MATERIALS AND METHODS

We retrospectively studied patients with perforations secondary to diagnostic/therapeutic colonoscopy between 2009 and 2015 at the Pontevedra Hospital Complex. We analyzed age, closure method, length of hospitalization, and long-term progress.

RESULTS

Of the 34 perforations detected, 67.6% occurred in patients aged below 75 years. Most perforations occurred in the descending colon (55%). Perforations occurred in 55.9% of outpatients and 45% of inpatients. Diagnostic and therapeutic colonoscopies caused perforations in 20.6% and 79.4% of patients, respectively. Conservative treatment alone was performed in 5.9%, complete or partial endoscopic closure in 14.7%, and surgery in 79.4% of patients. Patients treated only conservatively or with concomitant endoscopic closure showed no mortality. The mortality rate was 14.8% in those treated surgically, and 55% of these patients required a subsequent ostomy.

CONCLUSIONS

Conservative management with antibiotics and parenteral nutrition concomitant with complete/partial endoscopic closure effectively treats perforations, provided intraprocedural diagnosis is possible with immediate administration of antibiotics after the procedure. Nevertheless, studies with larger number of patients and statistical analysis are necessary in the near future.

Comparison of Outcomes Between Total Abdominal and Partial Colectomy for the Management of Severe, Complicated Clostridium Difficile Infection

BACKGROUND

Patients with severe, complicated Clostridium difficile infection (CDI) may ultimately require a colectomy. Although associated with high morbidity and mortality, a total colectomy has been the mainstay of surgical treatment. However, small studies have suggested partial colectomy may provide equivalent outcomes. We compared the outcomes of partial and total colectomy for CDI in a nationwide database.

STUDY DESIGN

We performed a retrospective study using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP). Patients with a primary diagnosis of Clostridium difficile colitis from 2007 to 2015, who underwent a total abdominal or partial colectomy, were analyzed. Postoperative mortality rate, complications, and length of stay were evaluated. Logistic regression controlling for patient and clinical factors evaluated the impact of type of operation performed.

RESULTS

There were 733 colectomies for CDI, of which 151 (20.6%) were partial colectomies. Patients with a partial colectomy had a slightly higher 30-day mortality rate (37.1%) compared with total abdominal colectomy patients (34.7%, p = 0.58). However, logistic regression controlling for patient factors demonstrated no statistically significant difference for partial colectomy in 30-day mortality (odds ratio [OR] 1.21, 95% CI 0.76 to 1.96) or complication rate (OR 0.92, 95% CI 0.51 to 1.62) compared with total colectomy. There was no difference in days to surgery (4.6 partial vs 5.0 total, p = 0.70). Total abdominal colectomy trended toward a longer postoperative stay (18.0 vs 15.1 days for partial, p = 0.08).

CONCLUSIONS

In a national database, a significant percentage of operations for CDI are partial colectomies. There were no significant differences found in mortality or complications between partial and total colectomy for severe complicated CDI.

Cost-effectiveness of a Ceramide-Infused Skin Barrier Versus a Standard Barrier: Findings From a Long-Term Cost-effectiveness Analysis

PURPOSE

To assess the cost-effectiveness of a ceramide-infused skin barrier (CIB) versus other skin barriers (standard of care) among patients who have undergone ostomy creation.

DESIGN

Cost-effectiveness analysis, based on a decision-analytic model that was estimated using data from the ADVOCATE (A Study Determining Variances in Ostomy Skin Conditions And The Economic Impact) trial, which investigated stoma-related healthcare costs over 12 weeks among patients who recently underwent fecal ostomy, and from other sources.

SUBJECTS AND SETTING

Analysis was based on a hypothetical cohort of 1000 patients who recently underwent fecal ostomy; over a 1-year period, 500 patients were assumed to use CIB and 500 were assumed to use standard of care.

METHODS

We adapted a previous economic model to estimate expected 1-year costs and outcomes among persons with a new ostomy assumed to use CIB versus standard of care. Outcomes of interest included peristomal skin complications (PSCs) (up to 2 during the 1-year period of interest) and quality-adjusted life days (QALDs); QALDs vary from 1, indicating a day of perfect health to 0, indicating a day with the lowest possible health (deceased). Subjects were assigned QALDs on a daily basis, with the value of the QALD on any given day based on whether the patient was experiencing a PSC. Costs included those related to skin barriers, ostomy accessories, and care of PSCs. The incremental cost-effectiveness of CIB versus standard of care was estimated as the incremental cost per PSC averted and QALD gained, respectively; net monetary benefit of CIB was also estimated. All analyses were run using the perspective of an Australian payer.

RESULTS

On a per-patient basis, use of CIB was expected over a 1-year period to result in 0.16 fewer PSCs, an additional 0.35 QALDs, and a savings of A$180 (Australian dollars, US $137) in healthcare costs all versus standard of care. Management with CIB provided a net monetary benefit (calculated as the product of maximum willingness to pay for 1 QALD times additional QALDs with CIB less the incremental cost of CIB) of A$228 (US $174). Probabilistic sensitivity analysis was also completed; it revealed that 97% of model runs resulted in fewer expected PSCs with CIB; 92% of these runs resulted in lower expected costs with CIB.

CONCLUSIONS

Findings suggest that the CIB is a cost-effective skin barrier for persons living with an ostomy.

The Impact of Early Involvement in a Postdischarge Support Program for Ostomy Surgery Patients on Preventable Healthcare Utilization

PURPOSE:

To evaluate the impact of a postdischarge ostomy support program as an adjunct to nurse-led ostomy care on preventable healthcare utilization.

DESIGN:

A cross-sectional study.

SUBJECTS AND SETTING:

A postdischarge support program offered by an ostomy product's manufacturer provides persons living with an ostomy with patient-centered and easily accessible assistance. Individuals who underwent ostomy surgery within 18 months prior to the survey date were selected from an ostomy patient database maintained by the ostomy patient support program provider. Of 7026 surveys sent to program enrollees, 493 (7%) responded, compared with 225 (5%) out of 4149 surveys sent to individuals in a comparison group. The 2 groups were similar in demographics. A majority of the survey respondents were female (60% of program enrollees vs 55% of respondents in the comparison group). Among the program enrollees, 44% had colostomy, 43% had ileostomy, 10% had urostomy, and 4% had at least 2 types of ostomy surgery compared with 52%, 32%, 12%, and 4% of the respondents in a comparison group, respectively.

METHODS:

The study compared hospital readmission and emergency room (ER) visit rates attributable to ostomy complications between program enrollees and respondents in the comparison group. The event rates were measured in 2 study periods: within the first month of discharge and after the first month of discharge. Eligible individuals received an online survey that included the following domains: characteristics of ostomy surgery; readmissions and ER visits within the first month or after the first month of discharge, including reasons for preventable events; and level of health care access. Multivariate logistic regressions controlling for covariates were applied to investigate associations between program enrollment and ostomy-related readmission or ER visit rates.

RESULTS:

Logistic regression analyses showed that, when compared with respondents in the comparison group, program enrollees had a significantly lower likelihood of being readmitted and visiting the ER due to ostomy complications after the first month of hospital discharge and up to 18 months postdischarge (odds ratio [OR] = 0.45; 95% confidence interval [CI], 0.27-0.73; and OR = 0.37; 95% CI, 0.22-0.64, respectively).

CONCLUSIONS:

Findings suggest that enrolling patients in the postdischarge ostomy support program provides an effective approach to reducing preventable healthcare utilization.

Racial Disparities After Stoma Construction Exist in Time to Closure After 1 Year but Not in Overall Stoma Reversal Rates

INTRODUCTION

Conflicting data exist on racial disparities in stoma reversal (SR) rates. Our aim was to investigate the role of race in SR rates, and time to closure, in a longitudinal, racially diverse database.

METHODS

All adult patients (>18 years) who received an ileostomy or colostomy from 1999 to 2016 at a single institution were identified. Primary outcomes were SR rates and time to closure. Failure to reverse and time to closure was modeled using Cox regression. Kaplan-Meier survival curves, stratified by race, were generated for time to closure and hazard ratios (HRs) calculated.

RESULTS

Of 770 patients with stomas, 65.6% of patients underwent SR; 76.6% were white and 23.4% were black. On adjusted analysis, race did not predict overall SR rates or time to closure if performed less than 1 year. Instead, significant predictors for failure in SR included age, insurance status, end colostomy/ileostomy, and loop colostomy (p < 0.05). Predictors of delay in time to closure included insurance, end colostomy/ileostomy, and loop colostomy (p < 0.05). In patients who underwent reversal after 1 year, black race was an independent predictor of time to closure (HR 0.21, 95% CI 0.07-0.63, p < 0.05).

CONCLUSION

SR rates were equal between black and white patients. Disparities in time to closure existed only for black patients if reversed more than 1 year after index stoma construction. While equitable outcomes were achieved for most patients, further investigation is necessary to understand stoma disparities after 1 year.

Assessing trends in laparoscopic colostomy reversal and evaluating outcomes when compared to open procedures

BACKGROUND

Laparoscopic colostomy reversal has emerged as a viable option for Hartmann's reversal but the trends in national adoption and postoperative complications are unknown. This study evaluates the practice trends for laparoscopic colostomy and compares complications, length of stay, and operative times between laparoscopic and open colostomy reversal.

METHODS

All patients who had open or laparoscopic colostomy reversal surgery (current procedure codes: 44227 and 44626) between 2005 and 2014 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Data collected included patient demographics, comorbid conditions, postsurgical diagnosis, and estimated probabilities of morbidity and mortality. Univariate and multivariate unconditional logistic regression models and linear regression models were employed to evaluate the associations between various outcomes and surgical specialties.

RESULTS

The reported volume of both open and laparoscopic colostomy reversal surgeries increased over time, but the percentage of open reversal surgery decreased from 100% in 2005 to 74.2% in 2014. The average annual increase in percentage of laparoscopic colostomy reversal surgery was 2.87%. The complication rates of open colostomy reversal surgery were significantly higher than the rates of laparoscopic colostomy reversal surgery (P < 0.0001). Although there were fluctuations, the complication rates remained constant over the 9-year study period for both open and laparoscopic colostomy reversal surgeries. The total hospital length of stay among patients who had laparoscopic colostomy reversal surgery was shorter compared to patients who had open colostomy reversal surgery [mean change (MC) = -1.77 days, P < 0.0001]. Similarly, a shorter operation time was also observed for patients who had laparoscopic colostomy reversal surgery (MC = -26.48 min, P < 0.0001).

CONCLUSION

Based on the NSQIP database, laparoscopic colostomy reversal is increasing steadily year over year from 2005 to 2014 in NSQIP participating hospitals. Overall complication rates and length of stay are significantly lower and sustained throughout the study period for laparoscopic reversal.

Prevention of parastomal hernia in the emergency setting

AIM

This study assessed safety and efficacy associated with hernia prophylaxis using a retromuscular slowly resorbable synthetic mesh for stoma reinforcement.

METHOD

This was a cohort study with a historic reference group. The study took place in a high-volume surgical department. During a 2-year period (July 2012-July 2014), we included 109 patients undergoing emergency surgery with formation of ileostomy or colostomy. All patients received a retromuscular slowly resorbable synthetic mesh (TIGR®, Novus Scientific) at the stoma site. The reference group included 117 patients who underwent emergency stoma formation without a prophylactic mesh in the 2-year period prior to July 2012. The primary endpoint was effect on prevention of parastomal hernia within 1 year. Secondary endpoints were 30-day and 1-year complications including mortality.

RESULTS

The operative field was contaminated or dirty in 48% of the procedures. Operative time was significantly longer in the mesh group. The cumulative incidences of parastomal hernia at 1 year for the control and the mesh group were 8 and 7% (p = 0.424), respectively. The postoperative 30-day and 1-year rate of complications, reoperations and mortality were not different between the two groups. No patients underwent removal of the mesh and no clinical mesh infections were seen.

CONCLUSION

Use of a resorbable synthetic mesh during emergency ostomy formation showed no significant preventive effect on formation of parastomal hernia after 1 year. Although surgery was often conducted in a severely contaminated field, the procedure was without significantly increased complication rate.

Characterization of Readmission by Day of Rehospitalization After Colorectal Surgery

BACKGROUND

Factors associated with readmission stratified by the day of postdischarge rehospitalization after colorectal surgery have not been characterized previously.

OBJECTIVE

The purpose of this study was to identify factors leading to readmission on a day-to-day basis after discharge from colorectal surgery.

DESIGN

This was a retrospective analysis of patients readmitted within 30-days after colorectal surgery. Reasons and factors associated with readmission each day after discharge were evaluated. Early readmitted patients (day 0-5 postdischarge) were compared with those readmitted later (day 6-29 postdischarge).

SETTINGS

The study was conducted at a tertiary center.

PATIENTS

Patients included those who had undergone primary colorectal resection from the American College of Surgeons National Surgical Quality Improvement Program (2012-2013).

MAIN OUTCOME MEASURES

The study intended to identify factors associated with any early versus late hospital readmission and to evaluate diagnoses for unplanned readmissions on a day-to-day basis after discharge.

RESULTS

For 69,222 elective colorectal procedures, 7476 patients (10.8%) were readmitted to the hospital within 30 days. Early (median, 3 days) and late (median, 11 days) readmissions were 3278 (43.8%) and 4198 (56.2%). Except for sex, patient demographics were similar between groups. Neurologic comorbidity; wound disruption; sepsis or septic shock; unplanned reintubation and reoperation; anastomotic leak and ileus; and neurological, cardiovascular, and pulmonary complications were significantly higher in the early readmission, whereas disseminated malignancy, stoma creation, and renal/urological complications were significantly higher in the late readmission group. On multivariable analysis, early readmission was significantly associated with male patients, wound disruption, sepsis or septic shock, reoperation, reintubation, and postoperative neurological complications. Disseminated malignancy, ostomy creation, and postoperative renal dysfunction/urological infection were associated with delayed readmission.

LIMITATIONS

Thirty-day readmissions and reasons for unplanned rehospitalizations were evaluated.

CONCLUSIONS

Differing factors are associated with early versus late readmission after colorectal resection. These data suggest that early readmission is intricately related to patient and operative complexity and hence may be inevitable, whereas delayed hospital presentation is associated with identifiable perioperative predictors at the time of discharge and hence more likely to be targetable.

Results of a statewide survey of surgeons' care practices for emergency Hartmann's procedure

BACKGROUND

Emergency general surgery is associated with high morbidity and mortality but has seldom been targeted for practice improvement. The goal of this study was to determine whether perioperative practices vary among surgeons for emergency Hartmann's procedures and whether perioperative care practices are associated with hospitals' complication rates.

MATERIALS AND METHODS

We conducted a survey of surgeons at 27 Michigan hospitals. Questionnaires focused on preoperative, intraoperative, and postoperative care practices. Hospitals were divided into quartiles of risk-adjusted complication rates. Responses of surgeons at hospitals with the lowest complication rates were compared to those with the highest, to determine whether there were systematic differences. Qualitative content analysis was performed for open-ended questions.

RESULTS

A total of 106 surgeons returned questionnaires (response rate 49%). We identified variation in use of bowel preparation, ostomy site marking, rectal stump management, ostomy protrusion, skin closure method, antibiotics duration, and ambulation/physical therapy practices. Surgeons from hospitals with low complication rates were more likely to use a clean instrument tray during wound closure (61% versus 11%, P = 0.001) and reported greater use of laparoscopic lavage without resection for emergency diverticulitis cases (31% versus 6%, P = 0.05). Surgeons in the lower complication rate hospitals listed more modifiable care factors in their open-ended responses to questions about reasons for complications.

CONCLUSIONS

Surgeons' practices vary for emergency Hartmann's procedure. This study serves as a proof of concept that studying surgeons' practices is feasible within a quality collaborative setting. Such data can be used to generate testable hypotheses for performance improvement aimed in high-risk, emergency surgery.