The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy Surgery

The effectiveness of the educational program on knowledge and caring performance of parents of children with colostomy: a clinical trial study

BACKGROUND

Colostomy is an important emergency procedure to save children's lives. It is necessary to use a suitable educational program to improve the knowledge and caring performance of parents. Therefore, this study was conducted with the aim of determining the effectiveness of the educational program on the knowledge and caring performance of parents of children with colostomy.

METHODS

This clinical trial study was conducted on 78 parents of children with colostomy. The patients were randomly divided into 39 test groups and 39 control groups using the 4 block method. The data were collected with demographic information questionnaire and parents' knowledge and care performance questionnaire. Collected data were analyzed using SPSS25, employing descriptive (including frequency, percentage, mean, and standard deviation) and inferential (including paired t-test, independent t-test, chi-square, and analysis of covariance) statistics.

RESULTS

There is no difference between the control and test groups with demographic characteristics. There was a significant difference between the average score of parental care knowledge after the intervention in the control and test groups (P < 0.001). There was a significant difference between the average score of parental care performance after the intervention in the control and test groups (P < 0.001).

CONCLUSIONS

The educational program can be used as an effective way to increase the knowledge and care performance of parents of children with colostomy and to control complications caused by colostomy.

TRIAL REGISTRATION

IRCT20230507058110N1, 2023-05-13.

Extraperitoneal Colostomy Versus Transperitoneal Colostomy After Laparoscopic Abdominoperineal Resection for Rectal Cancer: A Systematic Review and Meta-analysis

PURPOSE

This study aimed to compare extraperitoneal colostomy (EPC) with transperitoneal colostomy (TPC) after laparoscopic abdominoperineal resection (APR) for rectal cancer regarding postoperative complications.

METHOD

A literature search was performed on PubMed, Ovid, and Cochrane Databases for studies comparing EPC with TPC after laparoscopic APR for rectal cancer. The last search was performed on June 4, 2024. The primary outcome was the incidence of parastomal hernia. The Review Manager (version 5.3) was used for data analysis.

RESULTS

A total of 9 studies with 1002 patients were included in this meta-analysis. Among the enrolled literatures, one was randomized clinical trials, and others were retrospectively case-control designed. EPC showed significant efficiency in preventing parastomal hernia (P<0.001, OR=0.16, 95% CI: 0.09-0.28, I2=0%). Besides, the results indicated that the EPC group was associated with significantly less incidence of stoma retraction (P=0.02, OR=0.23, 95% CI: 0.06-0.81, I2=0%), stoma prolapse (P=0.002, OR=0.18, 95% CI: 0.06-0.54, I2=0%), and total stoma-related complications (P<0.001, OR=0.50, 95% CI: 0.33-0.74, I2=26%). In addition, no significant difference was observed between the 2 groups in terms of the total operative time or the time for colostomy creation.

CONCLUSION

Current data demonstrated the significant efficiency of EPC in preventing parastomal hernia after laparoscopic APR for rectal cancer. Besides, the clinical safety and feasibility of EPC were also indicated. The EPC procedure could be widely recommended for permanent colostomy in clinical practice.

Identifying Strategies for Home Management of Ostomy Care: Content Analysis of YouTube

BACKGROUND

The social media platform YouTube is a recognized educational resource for health information, but few studies have explored its value for conveying the lived experience of individuals managing chronic health conditions and end users' interactions with medical device technology. Our study explores self-care strategies and end user needs of people living with a stoma because patient education and engagement in ostomy self-care are essential for avoiding ostomy-related complications. Ostomy surgery creates a stoma (an opening) in the abdomen to alter the route of excreta from digestive and urinary organs into a detachable external pouching system. After hospital discharge, people who have undergone ostomies perform critical self-care tasks including frequent ostomy appliance changes and stomal and peristomal skin maintenance.

OBJECTIVE

The purpose of this study was to systematically assess YouTube videos narrated by people who have undergone ostomies about their ostomy self-care in home (nonhospital) settings with a focus on identifying end user needs and different strategies used by people who have undergone ostomies during critical self-care tasks.

METHODS

Using predefined search terms and clear inclusion and exclusion criteria, we identified YouTube videos depicting narrators who have undergone ostomies and their ostomy self-care in home settings. Using a consensus coding approach among 3 independent reviewers, all videos were analyzed to collect metadata, data of narrators who have undergone ostomies, and specific content data.

RESULTS

There were 65 user-generated YouTube videos that met the inclusion and exclusion criteria. These videos were posted by 28 unique content creators representing a broad range of ages who used a variety of supplies. The common challenges discussed were peristomal skin complications, inadequate appliance adhesion and subsequent leakage, and supplies-related challenges. Narrators who have undergone ostomies discussed various expert tricks and tips to successfully combat these challenges.

CONCLUSIONS

This study used a novel approach to gain insights about end user interactions with medical devices while performing ostomy self-care, which are difficult to gain using traditional behavioral techniques. The analysis revealed that people who have undergone ostomies are willing to share their personal experience with ostomy self-care on the web and that these videos are viewed by the public. User-generated videos demonstrated a variety of supplies used, end user needs, and different strategies for performing ostomy self-care. Future research should examine how these findings connect to YouTube ostomy self-care content generated by health care professionals and organizations and to guidelines for ostomy self-care.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Aging Disparities in Ostomy Surgery

INTRODUCTION

Little is known about the association between age and fecal ostomy surgery trends over time. We aim to 1) determine the rate of fecal ostomy operations over time and 2) compare rates of colostomy formation between patients older and younger than 65 y.

MATERIALS AND METHODS

Retrospective multi-institutional cohort study of patients ≥18 y who underwent colorectal resection between 2003 and 2014 using the Nationwide Inpatient Sample database. Patients were identified using International Classification of Diseases, 9th edition Procedural Codes. A difference-in-difference analysis was performed to evaluate the differences in colostomy formation between age groups.

RESULTS

Out of 819,441 adult patients who underwent major colorectal resection, 136,840 (16.6%) required ostomy formation. Median age was 63 y (interquartile range 51-74), 50% were female. Overall, 82,606 (10.0%) patients underwent a colostomy formation and 54,234 (6.6%) an ileostomy formation. Rates of colostomy formation decreased (13.2%-7.1% in <65 and 14.0%-7.2% in ≥65). Incidence of ileostomy formation increased for both age groups (6.1%-9.9% in <65 and 3.8%-6.3% in ≥65). The difference-in-difference analysis showed that the decline in colostomy formation was less pronounced among the older adult cohort (odds ratio 0.49, 95% confidence interval 0.47-0.50) than those <65 (odds ratio 0.42, 95% confidence interval 0.41-0.44).

CONCLUSIONS

Incidence of colostomy formation decreased in both groups over the study period. In contrast, the decline in colostomy formation was slower among older adults. This highlights a significant change in surgical trends across the United States with increasing rates of ileostomy use. Appropriate resource allocation and support are vital to the recovery of this growing surgical patient population.

Challenges faced by patients undergoing fecal ostomy surgery: a qualitative study of colorectal cancer patient perspectives

BACKGROUND

Education and support for ostomy are instrumental in surgical recovery and adaptation. This study aimed to evaluate (i) the challenges faced by fecal ostomy patients with colorectal cancer and (ii) the resources necessary for recovery.

METHODS

This study recruited patients 21 to 90 days after scheduled fecal ostomy surgery for locally advanced or metastatic colorectal cancer from a single tertiary academic center. This study conducted 1:1 semistructured interviews until thematic saturation using hybrid deductive-inductive coding.

RESULTS

This study interviewed 20 patients (80% male; mean age of 59.7 years). Several major themes emerged, including challenges in (i) practical ostomy management, (ii) emotional distress, (iii) adaptation to daily life, and (iv) provider relationships. The participants faced ostomy care challenges owing to peristomal skin issues, leaks, and difficulty ordering supplies. Many participants noted significant distress or anxiety related to embarrassment caused by leaks, odors, or noise. This distress led participants to fear going out in public, embarrassment from the ostomy, and anxiety about their daily activities (eg, returning to work and relationships). When adapting to life with an ostomy, several participants noted that anxiety affected their ability to care for the ostomy and resume their daily activities, leading to social isolation. Patients reported challenges with provider relationships and a lack of anticipatory guidance from the surgical team preoperatively, including insufficient education on practical management, ordering of ostomy supplies, ensuring adequate hydration, and maintaining proper nutrition.

CONCLUSION

Patients with colorectal cancer who require fecal ostomy face several challenges related to ostomy. Interventions that address practical management, navigating distress, adaptation, and provider education are needed to provide tailored education and support.

Current approach to loop ileostomy closure: a nationwide survey on behalf of the Italian Society of ColoRectal Surgery (SICCR)

Compared to standardized minimally invasive colorectal procedures, there is considerable perioperative heterogeneity in loop ileostomy reversal. This study aimed to investigate the current perioperative practice and technical variations of loop ileostomy reversal following rectal cancer surgery. A nationwide online survey was conducted among members of the Italian Society of ColoRectal Surgery (SICCR). A link to the questionnaire was sent via mail. The survey consisted of 31 questions concerning the main procedural steps and application of the ERAS protocol after loop ileostomy reversal. Overall, 219 participants completed the survey. One respondent in four used a combination of water-soluble contrast studies (WSCS) and digital rectal examination to assess the integrity of the anastomosis before ileostomy closure. Conversely, 17.8% of them used either only WSCS or only endoscopy. Surgeons routinely perform hand-sewn or stapled anastomoses in 45.2% and 54.8% of the cases, respectively. Side-to-side antiperistaltic stapled anastomosis was the most performed anastomosis (36%). Most surgeons declared that they have never used prostheses for abdominal wall closure (64%), whereas 35% preferred retromuscular mesh placement in selected cases only. Forty-six respondents (66.7%) reported using interrupted stitches for skin closure, while 65 (29.7%) a purse-string suture. Furthermore, skin approximation at the stoma site using open methods was significantly more common among surgeons with greater experience in ileostomy reversal (p = 0.031). Overall, a good compliance with the ERAS protocol was found. However, colorectal surgeons were significantly more likely to follow the ERAS pathway than general surgeons (p < 0.05). Surgeons use different anastomotic techniques for ileostomy reversal after rectal cancer surgery. Based on current evidence, purse-string skin closure and ERAS pathway should be implemented, while the role of mesh prophylactic strategy needs to be explored further.

Development of a novel nomogram for the prediction of surgical site infection risk after loop ileostomy closure

BACKGROUND

A postoperative surgical site infection (SSI) is a prevalent complication after loop ileostomy closure. There are few studies on the risk factors and the development of predictive models for postoperative SSIs. The aim of this study was to develop and validate a nomogram model capable of accurately predicting the occurrence of postoperative SSIs.

METHODS

This retrospective analysis examined the clinical data of 369 patients who underwent loop ileostomy closure at a local hospital from January 2015 to March 2022. A logistic regression model was used to identify the potential risk factors for a postoperative SSI after loop ileostomy closure. A nomogram was established using independent risk factors, and the prediction performance of the model was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC).

RESULTS

Forty-eight (13.0%) developed postoperative SSIs after loop ileostomy closure. Multivariate logistic regression analysis revealed that a body mass index (BMI) > 25 kg/m2, diabetes, linear skin closure (LSC), and a prolonged operative time were independent risk factors for SSIs, whereas the presence of a subcutaneous drainage tube was identified as an independent protective factor. The nomogram models constructed using these variables achieved AUCs of 0.833 and 0.823 on the training set and validation set, respectively. The calibration curves demonstrated excellent consistency.

CONCLUSION

The nomogram developed using clinical data from patients who underwent loop ileostomy closure demonstrates a robust predictive capability, offering valuable guidance to clinicians in assessing the risk of postoperative SSIs.

Catastrophic outcome following misidentification of bowel anatomy during Hartmann's reversal: A case report and technical considerations

BACKGROUND

Reversal of Hartmann's procedure is a complex surgery with potential complications. This case report describes a rare and severe complication following an attempted reversal.

CASE PRESENTATION

A 53-year-old male who had undergone a Hartmann's procedure for non-metastatic sigmoid colon cancer presented with bowel obstruction 10 days after attempted reversal surgery at another hospital. Imaging studies suggested an entero-colic fistula. Emergency laparotomy revealed dense adhesions and multiple bowel injuries. The procedure was terminated, and controlled fistulae were created.

MANAGEMENT AND OUTCOME

The patient required two months of intensive care. A subsequent surgery excised the fistulae and restored intestinal continuity, leaving the patient with an end colostomy and approximately 120 cm of ileum.

CONCLUSION

This case highlights the potential risks of Hartmann's reversal and emphasizes the importance of proper patient selection, timing, and surgical expertise. It underscores the need for thorough preoperative evaluation and preparation when attempting such complex surgeries.

Same-day Ileostomy Closure Discharge Reduces Costs Without Compromising Outcomes: An Economic Analysis

OBJECTIVE

This study aims to assess the costs of a same-day discharge (SDD) enhanced recovery pathway for diverting loop ileostomy (DLI) closure compared with a standard institutional enhanced recovery protocol.

BACKGROUND

Every year, 50,155 patients in the United States undergo temporary stoma reversal. While ambulatory stoma closure has shown promise, widespread adoption remains slow. This study builds on previous research, focusing on the costs of a novel SDD protocol introduced in 2020.

METHODS

A retrospective case-control study was conducted at Mayo Clinic, Rochester, Minnesota, and Mayo Clinic, Jacksonville, Florida, comparing patients undergoing SDD DLI closure from August 2020 to February 2023 to those in a matched cohort receiving standard inpatient enhanced recovery protocol. Patients were matched based on age, sex, american society of anesthesiologists score, surgery period, and hospital. Primary outcomes included direct hospitalization and additional costs in the 30 days postdischarge.

RESULTS

The SDD group (n = 118) demonstrated a significant reduction in median index episode hospitalization and 30-day postoperative costs compared with the inpatient group (n = 236), with savings of $4827 per patient. Complication rates were similar, and so were readmission and reoperation rates.

CONCLUSIONS

Implementation of the SDD for DLI closure is associated with substantial cost savings without compromising patient outcomes. The study advocates for a shift towards SDD protocols, offering economic benefits and potential improvements in health care resource utilization.

Characteristics of Interventional Trials for Patients Living With Intestinal Stoma Registered in ClinicalTrials.gov With a Focus on Inflammatory Bowel Disease

BACKGROUND

This systematic review was performed to characterize the landscape of research conducted in patients with intestinal stoma (IS) and highlight unmet needs for clinical research in Crohn's disease (CD) and IS.

METHODS

We searched ClinicalTrials.gov from inception to May 25, 2022, to identify clinical trials assessing interventions in patients with an IS, as well as those with an IS and CD. Studies were grouped according to type of intervention. We excluded observational studies with no treatment arm.

RESULTS

A total of 253 studies were included in the final analysis. Most studies investigated devices (n = 122 [48.2%]), or surgical procedures (n = 63 [24.9%]), followed by behavioral interventions (n = 30 [11.8%]), drugs (n = 20 [7.9%]), dietary interventions (n = 2 [0.8%]), skin care products (n = 2 0.8%]), and others (n = 14 [5.5%]). A total of 50.9% (n = 129) of studies had completed recruitment, enrolling 11 116 participants. Only 6 studies (surgery: n = 3; physiological studies: n = 2; drugs: n = 1) exclusively included patients with inflammatory bowel disease (IBD), and 16 studies commented that patients with IBD were excluded in their eligibility criteria. No study assessed efficacy of drugs in patients with CD and IS. Approximately one-quarter of studies (n = 65 of 253) included quality of life as an outcome measure.

CONCLUSION

There is a paucity of research in IBD patients with IS, with the majority focusing on devices and surgical procedures. There have been no drug trials evaluating efficacy in patients with CD and IS. There is an urgent need to identify barriers to enrollment and develop eligibility and outcome measures that enable the inclusion of patients with CD with stoma into clinical trials.

Enhancing pediatric stoma care: Analyzing YouTube videos for pediatric stoma pouch changing techniques

PURPOSE

The purpose of this study was to evaluate the quality, content, and reliability of YouTube videos that address ostomy bag change techniques in children. As digital platforms are increasingly used for health-related information, especially for those caring for pediatric ostomy patients, this study aims to identify the strengths and limitations of available online resources.

DESIGN

A descriptive, retrospective, and cross-sectional research design was used to evaluate YouTube videos focused on pediatric ostomy bag change techniques.

SUBJECTS AND SETTING

The study included a total of 33 YouTube videos identified through searches conducted between May 3 and May 30, 2024. Videos included infants, children, and adolescents and were selected based on their relevance to pediatric double pouch ostomy care.

METHODS

Videos were scored using the modified DISCERN score and the Global Quality Scale (GQS) to assess video quality and reliability. A checklist based on established ostomy care guidelines was used for content analysis and identification of common procedural errors. The view rates, video/likes ratio, and popularity of the videos were calculated as the video power index. Data were analyzed using SPSS 27 and statistical significance was determined with a p-value of less than 0.05.

RESULTS

The analysis showed that 54.5 % of the videos were uploaded by independent publishers and 45.5 % by healthcare institutions. Videos aimed at caregivers were the most common (66.7 %). The mean number of views was 24,026.57, with a mean modified DISCERN score of 2.53 and a GQS score of 2.80. There was also a positive correlation between video length and quality scores. Significant differences in video quality were found between those published by healthcare organizations and independent publishers, with healthcare organization videos generally scoring higher. The most common errors in the videos included inadequate stoma coverage and improper disposal procedures.

CONCLUSIONS

The study shows that there is significant variability in the quality and reliability of YouTube videos on how to change an ostomy pouch in children. Compared to videos produced by independent publishers, videos produced by healthcare institutions had higher quality and reliability. The findings underscore the need for improved educational resources and quality control in digital platforms in order to better support the caregivers of pediatric ostomy patients.

Interventions for Adjunctive Care in Patients With Inflammatory Bowel Disease and Permanent Ileostomy: A Systematic Review

Background

The evidence for the management of patients with Crohn's disease (CD) and permanent ileostomy (PI) is limited. We aimed to summarize the interventional studies related to the provision of adjunctive ostomy care in this population.

Methods

MEDLINE, Embase, and Cochrane CENTRAL were searched from inception to January 5, 2024. Eligible studies were non-randomized or randomized controlled trials (RCTs), or comparative cohort studies predominantly recruiting participants with CD and/or ulcerative colitis (UC) with PI assessing interventions for the management of high stoma output, disease recurrence, peristomal skin care, pouching systems, behavioral interventions, mental health support, and diet.

Results

Out of 3217 records, 6 were eligible and all were RCTs (n = 95). Out of these, 5 adopted a crossover design, and 1 study was a double-blind parallel-group RCT. All except 1 were published more than 20 years ago (1976-2003). Two studies exclusively included patients with UC, one included CD, and the remaining included both UC and CD. Four studies assessed pharmacological interventions (loperamide, 5-aminosalysilate [5-ASA], azodisal sodium, and budesonide), one assessed oral supplement with different osmolarities, and one assessed dietary intervention (unrefined vs refined carbohydrate). A decrease in ileostomy output was the primary outcome of interest in 4 studies. None of the studies assessed interventions for peristomal skin care, quality of life, stoma pouching systems, behavioral interventions, mental health, or CD recurrence.

Conclusions

This study highlights that the evidence base to inform care for patients with IBD and PI is almost non-existent. There is an urgent need for focused research in this area to inform evidence-based treatment decisions.

Management of the Difficult Stoma

Fecal ostomy creation is a commonly performed procedure with many indications. Better outcomes occur when preoperative patient education and stoma site marking are provided. Despite a seemingly simple operation, ostomy creation is often difficult and complications are common. Certain risk factors, particularly obesity, are strongly associated with stoma-related complications. The ability to optimize the ostomy and stoma in the operating room and to troubleshoot frequently encountered post-operative stoma-related issues are critical skills for surgeons and ostomy nurses alike.

Rethinking postoperative care: same-day ileostomy closure discharge improves patient outcomes

BACKGROUND

The evolution of enhanced recovery pathways (ERPs) in colon and rectal surgery has led to the development of same-day discharge (SDD) procedures for selected patients. Early discharge after diverting loop ileostomy (DLI) closure was first described in 2003. However, its widespread adoption remains limited, with SDD accounting for only 3.2% of all DLI closures in 2005-2006, according to the American College of Surgeons National Surgical Quality Improvement Program database, and rising to just 4.1% by 2016. This study aimed to compare the outcomes of SDD DLI closure with those of DLI closure after the standard ERP.

METHODS

A retrospective case-matched study compared 125 patients undergoing SDD DLI closure with 250 patients undergoing DLI closure after the standard ERP based on age (±1 year), sex, American Society of Anesthesiologists score, body mass index, surgery date (±2 months), underlying disease, and hospital site. The primary outcome was comparative 30-day complication rates.

RESULTS

Patients in the traditional ERP group received more intraoperative fluids (1221.1 ± 416.6 vs 1039.0 ± 368.3 mL, P < .001) but had similar estimated blood loss. Ten patients (8%) in the SDD-ERP group failed SDD. The 30-day postoperative complication rate was significantly lower in the SDD group (14.8%) than the standard ERP group (25.7%, P = .025). This difference was primarily driven by a lower incidence of ileus in the SDD group (9.6% vs 14.8%, P = .034). There were no significant differences in readmission rate (9.6% of SDD-ERP vs 9.2% of standard ERP, P = .900) and reoperation rates (3.2% of SDD-ERP vs 2.4% of standard ERP, P = .650).

CONCLUSION

SDD ileostomy closure is a safe, feasible, and effective procedure associated with fewer complications than the present study's standard ERP. This could represent a new standard of care. Further prospective trials are required to confirm the findings of this study.

Management of adult intestinal stomas: The 2023 French guidelines

AIM

Digestive stoma are frequently performed. The last French guidelines have been published twenty years ago. Our aim was to update French clinical practice guidelines for the perioperative management of digestive stoma and stoma-related complications.

METHODS

A systematic literature review of French and English articles published between January 2000 and May 2022 was performed. Only digestive stoma for fecal evacuation in adults were considered. Stoma in children, urinary stoma, digestive stoma for enteral nutrition, and rare stoma (Koch, perineal) were not included.

RESULTS

Guidelines include the surgical landmarks to create digestive stoma (ideal location, mucocutaneous anastomosis, utility of support rods, use of prophylactic mesh), the perioperative clinical practice guidelines (patient education, preoperative ostomy site marking, postoperative equipment, prescriptions, and follow-up), the management of early stoma-related complications (difficulties for nursing, high output, stoma necrosis, retraction, abscess and peristomal skin complications), and the management of late stoma-related complications (stoma prolapse, parastomal hernia, stoma stenosis, late stoma retraction). A level of evidence was assigned to each statement.

CONCLUSION

These guidelines will be very useful in clinical practice, and allow to delete some outdated dogma.

Gastrointestinal Ostomies in Children: A Primer for the Pediatrician

Despite the advancement of medical therapies in the care of the preterm neonate, in the management of short bowel syndrome and the control of pediatric inflammatory bowel disease, the need to create fecal ostomies remains a common, advantageous treatment option for many medically complex children.

Disparate potential for readmission prevention exists among inpatient and outpatient procedures in a minimally invasive surgery practice

BACKGROUND

Administrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability.

METHODS

A gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student's t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher's exact test.

RESULTS

There were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001).

CONCLUSION

The use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies.

Modified Approach for Extraperitoneal Colostomy Creation in Laparoscopic Abdominoperineal Resection

BACKGROUND

Parastomal hernia is a major long-term complication after abdominoperineal resection. Extraperitoneal colostomy has been proposed as an effective step for parastomal hernia prevention, but it has not been widely used as it is technically demanding and time-consuming. We proposed a modified approach for extraperitoneal colostomy creation by entering the extraperitoneal space through the arcuate line of the posterior rectus sheath.

OBJECTIVE

To evaluate the safety, difficulty, and efficacy of long-term parastomal hernia prevention of the modified approach for extraperitoneal colostomy creation compared with the conventional transperitoneal colostomy approach.

DESIGN

This was a retrospective evaluation of a surgical and video database.

SETTINGS

This was a single-institution retrospective study.

PATIENTS

Clinical data of 74 patients who underwent laparoscopic abdominoperineal resection surgery from January 2019 to January 2020 in the Department of General Surgery, Qilu Hospital of Shandong University, were retrospectively reviewed.

MAIN OUTCOME MEASURES

Baseline characteristics, time required for colostomy creation (from skin incision to colostomy maturation), perioperative complications, and long-term colostomy-related complications were compared.

RESULTS

Baseline characteristics did not differ between the 2 approaches. The BMI level ranged from 19.5 to 29.4 for patients undergoing extraperitoneal approach. Time required for colostomy creation median [interquartile range], (22 [21-25] minutes for extraperitoneal vs 23 [21-25] minutes for transperitoneal, p = 0.861) were comparable between the 2 approaches. The cumulative incidence of parastomal hernia was significantly greater with transperitoneal colostomy than extraperitoneal colostomy at 2 and 3 years postoperatively (16.2% vs 0%, p = 0.025, and 21.6% vs 0%, p = 0.005). The remaining perioperative complications and long-term colostomy-related complications did not differ between the 2 approaches.

LIMITATIONS

This study is limited by its retrospective design and small sample size.

CONCLUSIONS

The modified approach for extraperitoneal colostomy creation is safe, technically simple, and effective for long-term parastomal hernia prevention in patients with a BMI of 19.5 to 29.4.

Postoperative Oral Rehydration and Regimented Follow-up Decrease Readmissions After Colorectal Surgery That Includes Ileostomies

BACKGROUND

Ileostomies constitute 15% to 43% of readmissions after colorectal surgery, often due to dehydration and acute kidney injury. Prior institutional interventions decreased readmissions but not among patients who underwent new ileostomies.

OBJECTIVE

To evaluate readmissions among patients who underwent new ileostomies after postoperative oral rehydration solution and standardized clinic visits.

DESIGN

Retrospective analysis of prospective database.

SETTINGS

Enhanced recovery colorectal surgery service.

PATIENTS

Patients who underwent new ileostomy before and after intervention.

INTERVENTIONS

Postoperative oral rehydration solution and postdischarge clinic visits with review of inputs/outputs, antimotility and appliance needs, and trained nurse reeducation 4 to 7 days after discharge, 30 days postoperatively, and every 1 to 2 weeks thereafter as needed.

MAIN OUTCOME MEASURES

Readmission rate due to dehydration/acute kidney injury (primary), emergency department visits, and readmission rates overall and for specific diagnoses. Analysis used univariate and weighted techniques.

RESULTS

A total of 312 patients (199 preintervention; 113 postintervention) were included, with a mean age of 59.0 years. Patients were predominantly White (94.9%) and evenly split between men and women. The most common diagnosis was diverticulitis (43.3%). The most common procedure was high anterior resection (38.8%), followed by low anterior resection (16.35%). Patient and procedure characteristics were well matched between groups. Multivariate analysis demonstrated that readmission rate due to dehydration/acute kidney injury significantly decreased between pre- and postintervention study groups (45.7% vs 16.5%, p = 0.039). Emergency department visits due to dehydration/acute kidney injury (12.0% vs 1.7%, p < 0.001) and readmissions from all causes (24.33% vs 10.6%, p = 0.005) also significantly decreased. Other complications were not significantly different between groups. Average stoma output 24 hours before (776 vs 625 mL, p = 0.005) and after (993 vs 890 mL, p = 0.025) discharge was significantly decreased in the postintervention group.

LIMITATIONS

Retrospective single-center study.

CONCLUSIONS

An oral rehydration solution and frequent standardized postdischarge visits led by trained nursing staff decreased readmissions and emergency department visits among patients who underwent new ileostomies after colorectal surgery. See Video Abstract .

LA REHIDRATACIN ORAL POSOPERATORIA Y EL SEGUIMIENTO REGLAMENTADO REDUCEN LOS REINGRESOS EN PACIENTES DE CIRUGA COLORRECTAL CON ILEOSTOMAS

ANTECEDENTES:Las ileostomías constituyen del 15 al 43% de los reingresos después de la cirugía colorrectal, a menudo debido a la deshidratación y la lesión renal aguda. Las intervenciones institucionales previas redujeron los reingresos, pero no entre los pacientes con nuevas ileostomías.OBJETIVO:Evaluar los reingresos entre pacientes con nuevas ileostomías después del uso de solución de rehidratación oral postoperatoria y visitas clínicas estandarizadas.DISEÑO:Análisis retrospectivo de base de datos prospectiva.AJUSTES:Servicio de cirugía colorrectal de recuperación mejorada.PACIENTES:Pacientes con ileostomía nueva antes y después de la intervención.INTERVENCIÓN(ES):Solución de rehidratación oral posoperatoria y visitas clínicas posteriores al alta con revisión de entradas/salidas, antimotilidad y necesidades de aparatos, y reeducación de enfermeras capacitadas 4-7 días después del alta, 30 días después de la operación y cada 1-2 semanas después, según sea necesario.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de readmisión debido a deshidratación/lesión renal aguda (primaria), tasa de urgencias y de readmisión en general y para diagnósticos específicos. El análisis utilizó técnicas univariadas y ponderadas.RESULTADOS:Se incluyeron un total de 312 pacientes (199 preintervención; 113 postintervención), con una edad media de 59,0 años. Los pacientes eran predominantemente blancos (94,9%) y se dividieron equitativamente entre hombres y mujeres. El diagnóstico más frecuente fue diverticulitis (43,3%). El procedimiento más común fue la resección anterior alta (38,8 %) seguida de la resección anterior baja (16,35 %). Las características del paciente y del procedimiento coincidieron bien entre los grupos. El análisis multivariante demostró que la tasa de reingreso debido a deshidratación/lesión renal aguda disminuyó significativamente entre los grupos de estudio antes y después de la intervención (45,7 % frente a 16,5 %, p = 0,039). Las visitas a urgencias por deshidratación/insuficiencia renal aguda (12,0 % frente a 1,7 %, p < 0,001) y los reingresos por todas las causas (24,33 % frente a 10,6 %, p = 0,005) también disminuyeron significativamente. Otras complicaciones no fueron significativamente diferentes entre los grupos. El gasto medio del estoma 24 horas antes (776 ml frente a 625 ml, p = 0,005) y después (993 ml frente a 890 ml, p = 0,025) del alta disminuyó significativamente en el grupo posterior a la intervención.LIMITACIONES:Estudio retrospectivo de centro único.CONCLUSIONES:Una solución de rehidratación oral y frecuentes visitas estandarizadas posteriores al alta dirigidas por personal de enfermería capacitado redujeron los reingresos y las visitas al servicio de urgencias entre los pacientes con nuevas ileostomías después de la cirugía colorrectal. ( Traducción-Dr. Yolanda Colorado ).

Efficacy of laparoscopic surgery for loop colostomy: a propensity-score-matched analysis

PURPOSE

Colostomy is a common procedure for fecal diversion, but the optimal colostomy approach is unclear in terms of surgical outcomes and stoma-related complications. The purpose of this study was to examine the efficacy and feasibility of laparoscopic loop colostomy.

METHODS

This retrospective cohort study included patients who underwent loop colostomy at Shizuoka Cancer Center in Japan between April 2010 and March 2022. Patients were divided into two groups based on surgical approach: the laparoscopic (LAP) and open (OPEN) groups. Surgical outcomes and the incidences of stoma-related complications such as stomal prolapse (SP), parastomal hernia (PSH), and skin disorders (SD) were compared with and without propensity score matching.

RESULTS

Of the 388 eligible patients, 180 (46%) were in the LAP group and 208 (54%) were in the OPEN group. The male-to-female ratio was 5.5:4.5 in the Lap group and was 5.3:4.7 in the OPEN group, respectively. The median age was 68 years (range, 31-88 years) in the LAP group and 65 years (range, 23-93 years) in the OPEN group, respectively. The LAP group, compared with the OPEN group, had a shorter operative time and lower incidences of surgical site infection (3.9% versus 16.3%, respectively; p < 0.01) and SD (11.7% versus 24.5%, respectively; p < 0.01). There was no significant difference between the LAP and OPEN groups in the incidence of SP (17.3% versus 17.3%, respectively) or PSH (8.9% versus 6.7%, respectively). After propensity score matching, the incidences of surgical site infection and SD were significantly lower in the LAP group than in the OPEN group, while there were no significant differences in the operative time or the incidences of SP and PSH.

CONCLUSION

Our results suggest that laparoscopic surgery could be beneficial and feasible in loop colostomy.

Risk factors for surgical site infections and trends in skin closure technique after diverting loop ileostomy reversal: A multi-institutional analysis

BACKGROUND

Surgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique.

METHODS

A retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary ​+ ​drain, or purse-string closure. The primary outcome was SSI at the former DLI site.

RESULTS

A SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure ​+ ​drain, and 2.7% for purse-string closure (p ​= ​0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p ​< ​0.0001).

CONCLUSIONS

This study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time.

AGA Clinical Practice Update on Management of Ostomies: Commentary

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding the management of patients with an enteral stoma.

METHODS

This CPU was commissioned and approved by the AGA Institute Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of a multidisciplinary group of authors composed of gastroenterologists, a colorectal surgeon, a wound ostomy and continence nurse, and ostomate.

Practical Considerations of Perioperative Assessment and Optimization in Major Colorectal Surgery

Successful outcomes after colorectal surgery result not only from technique in the operating room, but also from optimization of the patient prior to surgery. This article will discuss the role of preoperative assessment and optimization in the colorectal surgery patient. Through discussion of the various clinical models, readers will understand the range of options available for optimization. This study will also present information on how to design a preoperative clinic and the barriers to success.

Major renal morbidity following elective rectal cancer resection by the type of diverting ostomy

AIM

Patients with rectal cancer often undergo faecal diversion, yet the existing literature cursorily reports renal sequelae by the type of ostomy. We aimed to determine whether the presence of an ileostomy or colostomy was associated with postoperative renal morbidity.

METHODS

We identified patients with rectal cancer undergoing elective resection with primary anastomosis without diversion, with an ileostomy and with a colostomy by 21 possible procedures in the colectomy- and proctectomy-specific National Surgical Quality Improvement Program files. The odds of major renal events (renal failure [dialysis initiated] or progressive renal insufficiency [>2 mg/dl increase in creatinine without dialysis]), progressive renal insufficiency alone and readmissions were assessed using propensity score weighting and logistic regression.

RESULTS

Of 15 075 patients (63.7% Stage II-III, 85.7% creatinine values obtained ≤30 days preoperatively), 37.7% were not diverted, 39.5% had an ileostomy and 22.9% a colostomy. Compared to non-diverted patients, diversion was associated with major renal events (ileostomy, odds ratio [OR] 2.1, 95% confidence interval [CI] 1.6-2.9; colostomy, OR 1.8, 95% CI 1.3-2.5), progressive renal insufficiency (ileostomy, OR 2.5, 95% CI 1.7-3.5; colostomy, OR 2.0, 95% CI 1.4-2.9), readmissions for renal failure (ileostomy, OR 3.2, 95% CI 2.1-5.0; colostomy, OR 2.5, 95% CI 1.6-4.1) and readmissions for fluid/electrolyte abnormalities (ileostomy, OR 2.3, 95% CI 1.6-3.3; colostomy, OR 1.8, 95% CI 1.2-2.6).

CONCLUSION

Diverting ostomies after elective rectal cancer resection are strongly associated with renal morbidity. The decision to divert is complex, and it is unclear whether select patients may benefit from a colostomy from a renal perspective.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.