Dehydration is the most common indication for readmission after diverting ileostomy creation

Angiotensin-Converting Enzyme Inhibitor (ACEI) and Angiotensin Receptor Blocker (ARB) Use are Associated With Increased Readmission After Ileostomy Creation

BackgroundHigh output is a common cause for readmission after new ileostomy creation. The loss of sodium leads to compensatory activation of the renin-angiotensin-aldosterone system (RAAS). Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are first-line therapy for hypertension in the United States. We hypothesized that concurrent use of ACEI/ARB increases the risk of readmission following new ileostomy creation due to the loss of this compensatory mechanism.MethodsPatients undergoing ileostomy creation between 2009-2022 at an integrated managed health care system were included in this retrospective study. Primary outcomes were hospital readmission and ED visit within 30-days. Additional variables included ACEI/ARB use, ileostomy type, Charlson Comorbidity Index, additional antihypertensives at discharge (furosemide, hydrochlorothiazide, spironolactone, amlodipine, nifedipine, and diltiazem), and readmission diagnosis. Descriptive and advanced statistical analysis was completed with SPSS.ResultsOf 540 patients, 41.9% were readmitted or visited an ED within 30 days. There was no difference in readmission or ED visit based on age, gender, or ileostomy type. Patients discharged with ACEI/ARB (37.4% vs 25.5%, P = .005) and additional antihypertensives (37.2% vs 17.3%, P = .006) were at a higher risk for readmission.ConclusionsInhibition of RAAS is associated with increased risk for hospital readmission. In patients with hypertension undergoing ileostomy creation, individualized care plans are needed with earlier antimotility agent use or intravenous rehydration plans.

Two-Center Validation of a Novel Quality Improvement Protocol to Avoid Postileostomy Morbidity Using Home Intravenous Fluids and Structured Daily Calls

BACKGROUND

New ileostomates have higher rates of dehydration and readmission compared to patients undergoing other colorectal procedures.

OBJECTIVE

We aimed to show the efficacy of a novel ileostomy-specific quality improvement protocol at an academic center with subsequent validation at another academic center.

DESIGN

Prospective cohort study.

SETTING

Baylor College of Medicine (Houston, TX) and University of Florida Health (Gainesville, Florida).

PATIENTS

Patients who underwent elective ileostomy creation were enrolled in 2 phases: phase I (efficacy phase) from 2011 to 2018 at the University of Florida and phase II (validation phase) from 2018 to 2024 at Baylor College of Medicine.

INTERVENTIONS

New ileostomates received an indwelling intravenous line postoperatively. After discharge, daily home visits and administration of intravenous fluid infusions were completed by a registered nurse, and daily phone calls were made for counseling and medication adjustment by an advanced practice provider.

MAIN OUTCOME MEASURES

Length of stay, readmission rate, complication rate, and cost of care.

RESULTS

A total of 600 patients were enrolled in the study. There was a significant improvement in postprotocol from preprotocol in hospital length of stay (University of Florida: 3 vs 8 days; Baylor College of Medicine: 2.1 vs 6.9 days, p < 0.01), readmission rates (University of Florida: 9% vs 56%; Baylor College of Medicine: 7% vs 40%, p < 0.01), cost of care (University of Florida: $19,700 vs $53,300; Baylor College of Medicine: $18,100 vs $47,856, p < 0.01), and complication rates (University of Florida: 19% vs 65%; Baylor College of Medicine: 17% vs 46%, p < 0.01). If readmitted, the length of stay and cost decreased by 81% and 83%, respectively. No line-related complication was noted.

LIMITATIONS

This study was not randomized. Resource and insurance limitations may be an impediment to protocol implementation for austere settings.

CONCLUSIONS

Implementation of a novel ileostomy-specific standardized protocol to avoid morbidity from dehydration by implementing home intravenous infusions in conjunction with comprehensive outpatient education and phone follow-up significantly improved the quality of care by decreasing the length of stay, readmissions, complications, and cost of care. These results were validated at another institution. See Video Abstract.

VALIDACIN EN DOS CENTROS DE UN NOVEDOSO PROTOCOLO DE MEJORA DE LA CALIDAD PARA EVITAR LA MORBILIDAD POSILEOSTOMA MEDIANTE LQUIDOS INTRAVENOSOS A DOMICILIO Y LLAMADAS DIARIAS ESTRUCTURADAS

ANTECEDENTES:Los nuevos ileostomizados presentan tasas más elevadas de deshidratación y reingreso en comparación con los pacientes sometidos a otros procedimientos colorrectales.OBJETIVO:Nuestro objetivo era demostrar la eficacia de un nuevo protocolo de mejora de la calidad específico para la ileostomía en un centro académico, con su posterior validación en otro centro académico.DISEÑO:Estudio de cohortes prospectivo.LUGAR:Baylor College of Medicine (Houston, Texas); University of Florida Health (Gainesville, Florida).PACIENTES:Los pacientes sometidos a creación electiva de ileostomía se inscribieron en dos fases; Fase I (fase de eficacia) de 2011 a 2018 en la Universidad de Florida y Fase II (fase de validación) de 2018 a 2024 en el Baylor College of Medicine.INTERVENCIONES:Los nuevos ileostomizados recibieron una vía intravenosa permanente en el postoperatorio. Después del alta, se completaron visitas domiciliarias diarias y administración de infusiones de líquidos intravenosos por parte de una enfermera registrada y llamadas telefónicas diarias para asesoramiento y ajuste de la medicación por parte de un Proveedor de Práctica Avanzada.PRINCIPALES MEDIDAS DE RESULTADO:Duración de la estancia, tasa de reingresos, tasa de complicaciones y costo de la atención.RESULTADOS:Un total de 600 pacientes participaron en el estudio. Hubo una mejora significativa en la duración de la estancia hospitalaria (Universidad de Florida: 3 frente a 8 días; Baylor College of Medicine: 2,1 frente a 6,9 días, p < 0,01), las tasas de readmisión (University of Florida: 9% frente a 56%; Baylor College of Medicine: 7% frente a 40%, p < 0,01), costo de la atención (Universidad de Florida: 19.700 $ frente a 53.300 $; Facultad de Medicina Baylor: 18.100 $ frente a 47.856 $, p < 0,01) y tasas de complicaciones (Universidad de Florida: 19% frente a 65%; Baylor College of Medicine: 17% frente a 46%, p < 0,01). En caso de reingreso, la duración de la estancia y el costo disminuyeron en un 81% y un 83%, respectivamente. No se observó ninguna complicación relacionada con la vía.LIMITACIONES:Este estudio no fue aleatorizado. Las limitaciones de recursos y seguros pueden ser un impedimento en la implementación del protocolo para entornos austeros.CONCLUSIONES:La aplicación de un novedoso protocolo estandarizado específico de la ileostomía para evitar la morbilidad por deshidratación, mediante la aplicación de infusiones intravenosas domiciliarias junto con una amplia educación ambulatoria y seguimiento telefónico, mejoró significativamente la calidad de la atención al disminuir la duración de la estancia, los reingresos, las complicaciones y el costo de la atención. Estos resultados se validaron en otra institución. (Traducción-Yesenia Rojas-Khalil).

CASTOMized project: a new comprehensive collaborative approach between case manager and stoma care nurse

BACKGROUND

The use of the Enhanced Recovery After Surgery (ERAS) care pathway is becoming more widespread in surgical specialties. However, the presence of an ostomy, and the patient's need to adapt quickly to living with a stoma, is described as the Achilles' heel of the ERAS pathways in colorectal surgery.

AIM

To investigate the efficacy of applying a new patient pathway within the ERAS protocol.

DESIGN

A retrospective observational study.

METHOD

The management of patients undergoing surgery for colorectal disease and stoma formation between January 2023 and December 2023 was reviewed. Two clinical nurse specialists collaborated to integrate interventions and pathways.

FINDINGS

Of the 99 colorectal cancer or inflammatory bowel disease patients included in the study, the stoma care and management for 96 (95.9%) of the group fully adhered to the pathway. A median hospital stay of 11 days was recorded, with an interquartile range of 9 days; 40% of patients were treated as emergency cases. Adherence to the ERAS protocol (nursing care items) was 98%. Most patients were discharged home (91%). Adherence to telephone follow-up decreased over time, but remained above 90%. In the immediate post-discharge period, the percentage of patients with a high-output stoma was established at 15%, with only 3 (3%) of these requiring re-admission.

CONCLUSION

The study highlights the benefits gained by entrusting advanced practice nurses with the integrated management of care pathways in ostomy patients.

High risk populations for unplanned healthcare utilization following ostomy construction

BACKGROUND

Patients with a new ostomy have high rates of unplanned healthcare utilization (UPHU). We used machine learning to assess which factors contributed the most to UPHU after ostomy construction.

METHODS

We retrospectively studied new ostomy patients between 2018 and 2021 ​at a single institution. The primary outcome was UPHU within 60 days of discharge. Factors that contributed the most to UPHU were assessed using a classification tree machine learning method.

RESULTS

Among 318 patients, 30.8 ​% of patients had an UPHU event. The classification tree identified diabetes mellitus as the most important factor associated with UPHU: 56 ​% of diabetics had UPHU. Smoking history was the next most important factor: 77 ​% of diabetics who smoked had UPHU. Patients who had diabetes, smoked, and had chronic kidney disease had the highest UPHU rate at 86 ​%.

DISCUSSION

Unplanned healthcare utilization after ostomy construction is highest among patients with diabetes, smoking history, and chronic kidney disease.

Defunctioning Ileostomy After Low Anterior Resection of Rectum: Morbidity Related to Fashioning and Closure

Background and Objectives: The aim of this study was to assess any predisposing factors to the morbidity of fashioning and reversal of diverting ileostomy in a prospective cohort of patients who have undergone TME and low colo-rectal or colo-anal anastomosis for rectal cancer. Materials and Methods: Consecutive patients with rectal cancer undergoing low anterior resection and a defunctioning loop ileostomy in three surgical units from 2016 to 2020 were included in the study and retrospectively analyzed. Results: One hundred eighty-two patients from three centres were included. Ileostomy-related mortality was 0.5%, attributed to renal failure.. Ileostomy-related morbidity was 46%. Postoperative ileus was seen in 37.4%, and dehydration in 18.8% of the patients. The readmission rate for ileostomy-related reasons was 15.4%. Stoma care was problematic in 15.7% or poor in 7% of the cases. Advanced age, male gender and obesity were independent risk factors for ileostomy-related morbidity. Ileostomy was reversed in 165 patients. The morbidity in 165 patients was 16%. Ileus was seen in 10.3%, anastomotic leak in 4.8% and wound infection in 12.7% of the cases. One patient died because of an anastomotic leak. No predisposing factors that affect the outcomes of ileostomy closure were identified. Conclusions: Diverting ileostomy-related morbidity is high. Life threatening dehydration and renal failure from ileus is more commonly seen in elderly, male and obese patients and should be anticipated. Ileostomy closure-related morbidity is low.

The Readability, Understandability, and Suitability of Online Resources for Ostomy Care

PURPOSE

the purpose of this study was to evaluate the content, readability, understandability, and suitability of online resources for patient specific ostomy care.

DESIGN

Retrospective cohort study.

SUBJECT AND SETTING

Online websites for ostomy care designed for patients.

METHODS

Ostomy care websites designed for patients were identified by querying three online search engines. Content areas were established following assessment of all websites by two reviewers. Readability of each website was determined using the Flesch Reading Ease Test and the Simple Measure of Gobbledygook (SMOG) index. Understandability was measured using the Patient Education Materials Assessment Tool (PEMAT), and suitability was determined using the Suitability Assessment of Materials (SAM). Chi-Square and rank sum tests were used to compare these measures across website type and by number of content areas.

RESULTS

Twenty-three websites met inclusion criteria; 26.1% were for-profit, 13% were government, 26.1% were academic, and 34.8% were non-profit. Nineteen content areas were identified including themes related to pouching, bathing, physical activity, managing output, lifestyle, mental health, and eating. The median number of content areas covered was 8.5 [interquartile range (IQR) 4-13]. The most common content areas were changing/emptying a pouching system (82.6% of websites), preventing/managing peristomal skin irritation (78.3%), eating (60.9%), and odor management (60.9%). Less than 27% of websites had content on irrigation, blockage/constipation, and body image. Readability scores using the Flesch Reading Ease (mean 58, IQR 54.7-69.5) and SMOG Index (mean 9.1, IQR 7.6-9.9) correlated to a high-school or "fairly difficult" reading level. The mean PEMAT measuring understandability was 80 (IQR 78.9-84.0). The mean SAM score checking for suitability (literacy demand, graphics, layout and type, learning stimulation and motivation and cultural appropriateness) was 55% (IQR 48.4%-61.3%), indicating "adequate material." A greater number of content areas on the websites were associated with worse readability (SMOG and Flesch Reading Ease scores) than websites presenting fewer content areas (P = .001 & P < .001, respectively).

CONCLUSIONS

We found significant variability in the content, readability, understandability, and suitability of online materials for ostomy care. Websites with more content areas were associated with worse readability.

When Is Diversion Indicated After Right-Sided Colon Resections?

INTRODUCTION

Ileocolonic anastomoses have a low anastomotic leak (AL) risk, resulting in infrequent diverting loop ileostomy use. Identifying patients who warrant diverting loop ileostomy with right-sided resection is challenging due to this low incidence of AL. Therefore, a multicenter database was used to develop an AL risk score to help inform when diversion should be strongly considered after right-sided resections.

MATERIALS AND METHODS

Patients undergoing elective right-sided resections within the 2012-2020 American College of Surgeons National Surgical Quality Improvement Program-targeted colectomy participant user files were identified. Multivariable logistic regression identified AL risk factors that were then converted to point values to develop an AL risk score. The developed AL risk score was then assessed for visual correspondence and analyzed for internal validity.

RESULTS

42,176 patients underwent right-sided resection without diversion, and the incidence of AL was 2.4%. The risk calculator exhibited excellent calibration and fair discrimination. Strong visual correspondence was observed for predicted and actual AL rates within the 95% confidence interval for nine of ten risk score deciles.

CONCLUSIONS

An internally validated AL risk score for elective ileocolic resections was developed. Most patients had scores that categorized them at a low risk of AL. The diversion after elective right-sided resections should be reserved for extreme cases.

Body Fluid Collection Devices for Ostomy Patients: A Review

Background/Objectives: Abdominal ostomy surgery has a severe impact on individuals' daily lives. These procedures are typically indicated for conditions such as cancer, inflammatory bowel disease, or traumatic injuries. They involve creating an artificial opening, denominated the stoma, in the abdominal area to divert feces or urine, establishing a connection between the affected organs and the body's exterior. Thus, specialized products to collect the body fluids are required, being effective and tailored products crucial to enhance the quality of life of such patients. Methods: This paper presents a review of fecal fluid collection devices and advanced technologies designed to assist patients with ostomies. The study aims to identify the known bags/devices and evaluate their attributed performance in enhancing the population's physical and social quality of life. This review is based on a systematic search conducted between 20 February and 2 March 2024, in the PubMed, Scopus, Web of Science, Google Scholar, and Google Patents databases. Articles published within the last eight years from this period were included in the analysis. Results: The devices found in the study were classified as passive, requiring active monitoring by the user, and active, providing automated assistance. Three main categories were identified, reflecting the most significant concerns of patients: (1) devices that control fluid leakage, reducing peristomal dermatological problems; (2) devices that minimize odors and noise, reducing social embarrassment; and (3) devices that monitor fluid volume, helping with electrolyte balance, especially in patients with ileostomies. Conclusions: This study revealed that the existing devices meet primary collection and disposal needs. However, introducing smart devices could offer greater control and confidence to users, providing real-time information on gas pressure, stool texture, and accumulated volume. Thus, overall, the development of advanced technologies can significantly improve patients' quality of life, restore social confidence, and enable a more effective management of the condition by sharing information with medical teams.

Preoperative risk factors for ileostomy-associated kidney injury in colorectal tumor surgery following ileostomy formation

PURPOSE

Diverting ileostomy is related to postoperative high-output stoma (HOS) leading to kidney injury. The purpose of our study was to clarify the risk factors for ileostomy-associated kidney injury, which is kidney injury starting after the first operation to ileostomy closure after colorectal tumor surgery with diverting ileostomy.

METHODS

Between January 2013 and December 2020, 442 patients who underwent colorectal tumor surgery (cancer, neuroendocrine tumor, and leiomyosarcoma) following diverting ileostomy formation were included. We used the KDIGO (Kidney Disease Improving Global Outcomes) guidelines, which defines the acute kidney injury (AKI) to classify patients with ileostomy-associated kidney injury. The definition of AKI was (i) serum creatinine (sCr) ≥ 0.3 mg/dL or (ii) sCr ≥1.5-fold the preoperative level. Multivariate analyses were performed to identify the independent risk factors for kidney injury.

RESULTS

Kidney injury developed in 99/442 eligible patients (22.4%). Patients in the kidney injury group were older age, male sex, high American Society of Anesthesiologists Physical Status Classification System (ASA-PS) score, hypertension, cardiovascular diseases, diabetes. The preoperative hemoglobin, albumin, prognostic nutritional index (PNI), and creatinine clearance (CCr) were lower, and the maximum wound length was more extended than the non-kidney injury group. The median highest daily stoma output was significantly higher in the kidney injury group. The postoperative white blood cell (WBC) and C-reactive protein (CRP) levels were also high in the kidney injury group. The univariate analysis showed older age, male sex, high ASA-PS score, hypertension, cardiovascular diseases, and diabetes were the risk factors for kidney injury. The multivariate analysis revealed that age 70 or older, ASA-PS III/IV, hypertension, and HOS ≥2000 ml/day were independent risk factors for kidney injury.

CONCLUSIONS

Surgeons should consider diverting colostomy creation for patients with risk factors such as age 70 or older, ASA-PS III/IV, and hypertension.

How to dramatically reduce dehydration-related readmission in patients undergoing restorative surgery with diverting ileostomy for ulcerative colitis

BACKGROUND

Patients affected by ulcerative colitis (UC) often require surgery, involving two or three-stage procedures, including ileostomy creation. While ileostomy has some advantages, it can lead to complications, such as dehydration. The aim of this study was to evaluate the impact of a new individualized stoma-therapeutic-care-pathway (STCP) on dehydration-related readmissions. Secondary endpoints were stoma-related complications.

METHODS

The study compares two series of consecutive patients with UC undergoing diverting ileostomy during restorative ileo-pouch-anal-anastomosis. The STCP group consists of patients enrolled from January 2020 to December 2021 who followed the pathway. The older group was selected from 2015 to 2017 (control group). Clinical data were collected, including patient characteristics, hospital stay, complications, and readmissions. The study was approved by the local institutional review board.

RESULTS

Overall, 30-day dehydration-related readmission occurred in one (1.4%) versus nine (15.3%) patients in the STCP group versus control group, respectively (p = 0.005). In-hospital peristomal skin complications were significantly lower in STCP group (6 patients, 8.5%) versus control (35, 59.3%), as well as ostomy complications that occurred in 5 (7%) patients in the STCP group versus 8 (13.5%) in the control group (both p < 0.001). Ostomy complications reduced significantly in the STCP group after discharge (two patients, 2.8% versus eight, 13.5%), p = 0.001, and after 30-days (three patients, 4.2% versus five, 8.5%).

CONCLUSIONS

This study underscores the effectiveness of STCP in reducing dehydration-related readmissions and stoma-related complications in patients with UC undergoing stoma creation. It emphasizes the significance of patient education, close follow-up, and multidisciplinary care. Further research and standardized stoma education are essential.

Local excision vs. proctectomy in patients with ypT0-1 rectal cancer following neoadjuvant therapy: a propensity score matched analysis of the National Cancer Database

BACKGROUND

We aimed to evaluate outcomes of organ preservation by local excision (LE) compared to proctectomy following neoadjuvant therapy for rectal cancer.

METHODS

This retrospective observational study using the National Cancer Database (NCDB) included patients with locally advanced non-metastatic rectal cancer (ypT0-1 tumors) treated with neoadjuvant therapy between 2004 and 2019. Outcomes of patients who underwent LE or proctectomy were compared. 1:1 propensity score matching including patient demographics, clinical and therapeutic factors was used to minimize selection bias. Main outcome was overall survival (OS).

RESULTS

11,256 of 318,548 patients were included, 526 (4.6%) of whom underwent LE. After matching, mean 5-year OS was similar between the groups (54.1 vs. 54.2 months; p = 0.881). Positive resection margins (1.2% vs. 0.6%; p = 0.45), pathologic T stage (p = 0.07), 30-day mortality (0.6% vs. 0.6%; p = 1), and 90-day mortality (1.5% vs. 1.2%; p = 0.75) were comparable between the groups. Length of stay (1 vs. 6 days; p < 0.001) and 30-day readmission rate (5.3% vs. 10.3%; p = 0.02) were lower in LE patients. Multivariate analysis of predictors of OS demonstrated male sex (HR 1.38, 95% CI 1.08-1.77; p = 0.009), higher Charlson score (HR 1.52, 95% CI 1.29-1.79; p < 0.001), poorly differentiated carcinoma (HR 1.61, 95% CI 1.08-2.39; p = 0.02), mucinous carcinoma (HR 3.53, 95% CI 1.72-7.24; p < 0.001), and pathological T1 (HR 1.45, 95% CI 1.14-1.84; p = 0.002) were independent predictors of increased mortality. LE did not correlate with worse OS (HR 0.91, 95% CI 0.42-1.97; p = 0.82).

CONCLUSION

Our findings show no overall significant survival difference between LE and total mesorectal excision, including ypT1 tumors. Moreover, patients with poorly differentiated or mucinous adenocarcinomas generally had poorer outcomes, regardless of surgical method.

Reducing dehydration-induced readmissions post-colorectal surgery: the impact of a prevention bundle

INTRODUCTION

Ileostomy, frequently created after colorectal resections, hinders the physiologic function of the colon and can lead to dehydration and acute kidney injury due to high stoma outputs. This study aimed to evaluate the effectiveness of preventive measures on ileostomy-induced dehydration and related readmissions in a high-volume unit.

METHODS

In this prospective cohort study at a high-volume colorectal surgery department in Turkiye, the Prospective Ileostomy-induced Dehydration Prevention Bundle Project (PIDBP) was assessed from March 2021 to March 2022. The study enrolled patients undergoing colorectal surgery with ileostomy and involved comprehensive inpatient stoma care, education, and a structured post-discharge follow-up. The follow-up included the "Hydration follow-up scale" to monitor ileostomy output and related complications. The primary outcome was the readmission rate due to dehydration-related complications. The patients receiving the bundle intervention were compared with patients treated in the preceding year, focusing on the effectiveness of interventions such as dietary adjustments, fluid therapy, and pharmacological management.

RESULTS

In the study, 104 patients were analyzed, divided into 54 pre-bundle and 50 bundle group patients, with no significant differences in patient characteristics. While the overall readmission rate due to dehydration was 12.5%, a significant reduction in dehydration-related readmissions was observed in the bundle group compared to the pre-bundle group (2% vs. 22%, p = 0.002). Univariate analysis identified high stoma output (> 800 ml/24 h) (p < 0.001), chronic renal failure (CRF) (p = 0.01), postoperative ileus (p = 0.03), higher ASA status (p = 0.04), extended hospital stays (p = 0.03), and small bowel resections (especially in J-pouch patients) (p < 0.001) as significant predictors of readmission. Multivariate analysis revealed that the mean ileostomy output before discharge was the sole significant predictor of dehydration-related readmission (OR 1.01), with an optimal cutoff of 877.5 ml/day identified with an area under the curve (AUC) of 0.947, demonstrating high sensitivity (92.3%) and specificity (86.8%) in predicting readmission risk.

CONCLUSION

The Prospective Ileostomy-induced Dehydration Prevention Bundle Project significantly reduced readmission rates after colorectal surgery.

Diverting ileostomy in benign colorectal surgery: the real clinical cost analysis

There are three types of complications stoma related: ones related to its construction, ones related to its function and related to closure. The aim of this study was to assess the risk of complications related to the stoma presence and to identificate variables related to complications. We conducted a retrospective study of patients who underwent sphincter-preserving elective surgery for benign condition between January 2013 and December 2020 at IRCCS Sacro Cuore Don Calabria Hospital in Negrar, Verona. Data were collected regarding demographics and complications associated with primary surgery, stoma closure and the interval period. Univariable and multivariable analysIs were conducted. A total of 446 (12.2%) diverting loop ileostomies were performed. At index procedure, 76 (17%) patients had complications and 34 patients had complications related to ileostomy creation. Twenty patients (4.4%) were re admitted before stoma closure for dehydration. One hundred and eighty-seven patients (41.9%) suffered from ileostomy management's problems. At univariate analysis, complications of having stoma are more frequent in elder patients (p = 0.013), ASA score > 2 (p = 0.02), IBD diagnosis (p = < 0.001) and patients who had ileostomy creation complications (p = 0.04). At stoma closure, 55 (12.3%) patients had complications. Forty-seven patients (10.5%) presented incisional hernia in the stoma closure site. Ileostomy closure complications are more common with ASA score > 2 (p = 0.01) and IBD diagnosis (p < 0.001). IBD was found an independent factor of poor outcome at the time of ileostomy creation and closure. Developing complications at the time of ileostomy creation is statistically related to develop complications during ileostomy maintenance at multivariable analysis A loop ileostomy is usually created to limit the potentially life-threatening consequenceS of anastomotic leakage, but it is not able to decrease the leak-related mortality, wound sepsis, postoperative bleeding and small bowel obstruction. Debate rises not only for its uncertain efficacy but also because of the significant morbidity related to stoma. The surgeon could use these data in order to tailor his surgical strategy to the patients and their disease.

Patient-centred stoma care support: ileostomy patients

Stoma patients require continuous support throughout their entire journey with a stoma. Although many Stoma Care Services across the UK offer patient follow-up pathways, there is not one unified pathway. Patients may not be prepared for life with a stoma because, depending on their stoma type, they will have specific needs, and if patients and healthcare professionals are not prepared to manage these stoma-specific needs, complications and hospital readmissions may occur, worsening patients' outcomes and quality of life. Ileostomy patients are known to be more likely to experience complications, including hospital readmissions, and therefore, special care should be taken when preparing these patients for life with a stoma. They should be informed and educated to prevent complications, and if this is not always possible, thye should at least be able to recognise and manage early signs and symptoms of complications. This will empower them to self-care and know when to seek medical attention.

Impact of pandemic and socioeconomic influences on decision-making for emergency ostomy procedures: Key factors affecting hospital visit decisions

Emergency surgeries are linked with increased morbidity and reduced life expectancy, often associated with low socioeconomic status, limited access to healthcare, and delayed hospital admissions. While the influence of socioeconomic status on elective surgery outcomes is well-established, its impact on emergency surgeries, including ostomy creation and closure, is less clear. This study aimed to explore how the pandemic and socioeconomic status affect emergency ostomy procedures, seeking to determine which has a greater effect. It emphasizes the importance of considering socioeconomic factors in patient care pathways for ostomy procedures. A total of 542 patients who underwent emergency ostomy formation between 2016 and 2022 were retrospectively analyzed and divided into pre-pandemic and pandemic periods. The pre-pandemic and pandemic periods were compared between themselves and against each other. Demographic data (age and sex), comorbidities, socioeconomic status, etiology of the primary disease, type of surgery, stoma type, length of hospital stay, ostomy closure time, and postoperative complications were retrospectively analyzed for all patients. In total, 290 (53%) patients underwent surgery during the pandemic period, whereas 252 (47%) underwent surgery during the pre-pandemic period. Emergency surgery was performed for malignancy in 366 (67%) patients. The number of days patients underwent ostomy closure was significantly higher in the low-income group (P = .038, 95% CI: 293,2, 386-945). The risk of failure of stoma closure was 3-fold (95% CI: 1.8-5.2) in patients with metastasis. The risk of mortality was 12.4-fold (95% CI: 6.5-23.7) when there was failure of stoma closure. When compared to pandemic period, the mortality risk was 6.3-fold (95% CI: 3.9-10.2) in pre-pandemic period. Pandemic patients had a shorter hospital stay than before the pandemic (P = .044). A high socioeconomic status was significantly associated with early hospital admission for ostomy closure, and lower probability of mortality. More metastases and perforations were observed during the pandemic period and mortality was increased during pandemic and in patients without ostomy closure. The socioeconomic status lost its effect in cases of emergency ostomy creation and had no impact on length of hospital stay in either the pre-pandemic or pandemic period.

Meta-analysis: loop ileostomy versus colostomy to prevent complications of anterior resection for rectal cancer

PURPOSE

Anastomotic leakage is a serious complication of colorectal cancer surgery, prolonging hospital stays and impacting patient prognosis. Preventive colostomy is required in patients at risk of anastomotic fistulas. However, it remains unclear whether the commonly used loop colostomy(LC) or loop ileostomy(LI) can reduce the complications of colorectal surgery. This study aims to compare perioperative morbidities associated with LC and LI following anterior rectal cancer resection, including LC and LI reversal.

METHODS

In this meta-analysis, the Embase, Web of Science, Scopus, PubMed, and Cochrane Library databases were searched for prospective cohort studies, retrospective cohort studies, and randomized controlled trials (RCTs) on perioperative morbidity during stoma development and reversal up to July 2023, The meta-analysis included 10 trials with 2036 individuals (2 RCTs and 8 cohorts).

RESULTS

No significant differences in morbidity, mortality, or stoma-related issues were found between the LI and LC groups after anterior resection surgery. However, patients in the LC group exhibited higher rates of stoma prolapse (RR: 0.39; 95%CI: 0.19-0.82; P = 0.01), retraction (RR: 0.45; 95%CI: 0.29-0.71; P < 0.01), surgical site infection (RR: 0.52; 95%CI: 0.27-1.00; P = 0.05) and incisional hernias (RR: 0.53; 95%CI: 0.32-0.89; P = 0.02) after stoma closure compared to those in the LI group. Conversely, the LI group showed higher rates of dehydration or electrolyte imbalances(RR: 2.98; 95%CI: 1.51-5.89; P < 0.01), high-output(RR: 6.17; 95%CI: 1.24-30.64; P = 0.03), and renal insufficiency post-surgery(RR: 2.51; 95%CI: 1.01-6.27; P = 0.05).

CONCLUSION

Our study strongly recommends a preventive LI for anterior resection due to rectal cancer. However, ileostomy is more likely to result in dehydration, renal insufficiency, and intestinal obstruction. More multicenter RCTs are needed to corroborate this.

Preoperative use of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and diuretics increases the risk of dehydration after ileostomy formation: population-based cohort study

BACKGROUND

Readmission rates following ileostomy formation are high. Dehydration and consecutive renal failure are common causes of readmission, potentially pronounced by drugs affecting the homeostasis. The aim of the study was to assess the risk of dehydration after ileostomy formation in patients treated with angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB) or diuretics.

METHOD

This nationwide population-based cohort study used data derived from the Colorectal Cancer Data Base of several Swedish healthcare registers. The study included all patients operated on with elective anterior resection and temporary ileostomy for rectal cancer clinically staged I-III in Sweden in 2007-2016. Exposure was at least two dispensations of ACEI, ARB or diuretics within 1 year prior to surgery. Outcome was 90-day readmission due to dehydration including acute renal failure.

RESULTS

In total, 3252 patients were included with 1173 (36.1%) exposed to ACEI, ARB or diuretics. The cumulative incidence for 90-day readmission due to dehydration was 29.0% (151 of 520) for exposed versus 13.8% (98 of 712) for unexposed. The proportion of readmissions due to any reason was 44.3% (520 of 1173) for exposed compared to 34.2% (712 of 2079) for unexposed. The incidence rate ratio for readmission due to dehydration was 2.83 (95% c.i. 2.21 to 3.63, P < 0.001). The hazard rate ratio was 2.45 (95% c.i. 1.83 to 3.27, P < 0.001) after adjusting for age, gender and comorbidity.

CONCLUSION

Medication with ACEI, ARB or diuretics defines a vulnerable patient group with increased risk of readmission due to dehydration after ileostomy formation.

Metabolic and Nutritional Issues after Lower Digestive Tract Surgery: The Important Role of the Dietitian in a Multidisciplinary Setting

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure.

Nutritional Considerations in Colorectal Surgery in Diverting Ileostomy Patients: A Review

Colorectal surgery often results in a temporary or permanent ileostomy construction. The general nutritional status and intake of patients with an ileostomy have not received much attention and scientific evidence is lacking. Nutritional complications associated with ileostomy formation and colonic exclusion include fluid (dehydration) and electrolyte abnormalities (mainly hyponatremia), impaired renal function occurring from plasma volume depletion, and reduced energy absorption due to the role of the large bowel in energy assimilation. People with ileostomies frequently avoid specific foods, due to concerns of possible malfunction or food blockages of their stoma, which may produce a negative effect on their overall dietary intake and nutritional status. The present article reviews the existing literature on nutritional considerations for those with an ileostomy and discusses measures to optimize overall nutritional status of this category of patients.

Influence of Preoperative Educational Intervention for Patients Undergoing Fecal Ostomy Surgery: A Comparison Cohort Study

PURPOSE

This aim of this study was to compare the impact on hospital stay and short-term overall complications prior to and following the introduction of an outpatient preoperative ostomy education program to an existing inpatient ostomy education program.

DESIGN

A comparison cohort study.

SUBJECTS AND SETTING

One hundred thirty-eight consecutive patients undergoing ostomy surgery were included. One group (n = 65, 47%) was given an experimental preoperative ostomy education intervention, along with standard care including a postoperative educational intervention during the initial hospital course. A second group (n = 73, 53%) received the same standardized education in the postoperative period. Data were collected from a single tertiary center located in Seville, Spain, during a 12-month period between July 2014 and June 2015.

METHODS

Data were collected in 2 phases. Data from participants undergoing postoperative (standard) education were collected retrospectively. Data for the group receiving preoperative education were collective prospectively. Outcome variables were postoperative length of stay, surgical complications (severity was assessed by the Clavien-Dindo grading system), subsequent interventions, and readmission rates.

RESULTS

Analysis indicated no differences between the average length of postoperative hospital stay (12.32 days in the preoperative education group vs 12.76 days in the postoperative education group, P = .401). In contrast, overall complications, mortality, and readmission rates were significantly higher in the preoperative education program group (P = .027, P = .047, and P = .046, respectively).

CONCLUSIONS

Delivering a standardized educational intervention during the preoperative period versus postoperative education delivery during the ostomy surgery hospital course did not reduce length of stay. Analysis indicated that overall complications, mortality, and readmission rates were significantly higher in the preoperative education program group but we hypothesize that intervening factors may have influenced these outcomes.

Protective ileostomy after low anterior resection for extraperitoneal rectal cancer: does the reversal surgery timing affect closure failure?

Loop ileostomy is commonly performed after LAR with TME to temporarily protect the anastomosis. Usually, defunctioning stoma is closed after 1-6 months, although sometimes it becomes definitive de facto. The aim of this study is to investigate the long-term risk of no-reversal of protective ileostomy after LAR for middle-low rectal cancer and the predictive risk factors. A retrospective analysis of a consecutive cohort of patients who underwent curative LAR with covering ileostomy for extraperitoneal rectal cancer in two colorectal units was performed. A different policy for scheduling stoma closure was applied between centers. All the data were collected through an electronic database (Microsoft Excel®). Descriptive statistical analysis was performed using Fisher's exact and Student's t test. Multivariate logistic regression analysis was conducted. Two-hundred twenty-two patients were analysed: reversal procedure was carried out in 193 patients, in 29 cases stoma was never closed. The mean interval time from index surgery was 4.9 months (Center1: 3 vs. Center2: 7.8). At the univariate analysis, mean age and tumor stage were significantly higher in the "no-reversal" group. Unclosed ostomies were significantly lower in Center 1 than Center 2 (8% vs. 19.6%). At the multivariate analysis female gender, anastomotic leakage and Center 2 had significant higher risk of unclosed ileostomy. Currently, no clinical recommendations have been established and the policy of scheduling stoma reversal is variable. Our study suggests that an established protocol could avoid closure delay, decreasing permanent stomas. Consequently, ileostomy closure should be weighed as standardized step in cancer therapeutic pathway.

Endometriosis with colonic and rectal involvement: surgical approach and outcomes in 142 patients

PURPOSE

Endometriosis involving the colon and/or rectum (CRE) is operatively managed using various methods. We aimed to determine if a more limited excision is associated with 30-day complications, symptom improvement, and/or recurrence.

METHODS

This is a retrospective review of consecutive cases of patients who underwent surgical management of CRE between 2010 and 2018. Primary outcomes were the associations between risk factors and symptom improvement, 30-day complications, and time to recurrence. Multivariable logistic regression assessed the independent risk factors.

RESULTS

Of 2681 endometriosis cases, 142 [5.3% of total, mean age 35.4 (31.0; 39.0) years, 73.9% stage IV] underwent CRE excision (superficial partial = 66.9%, segmental = 27.5%, full thickness = 1.41%). Minor complications (14.8%) were associated with blood loss [150 (112; 288) vs. 100 (50.0; 200) mls, p = 0.046], Sigmoid involvement [45.5% vs. 12.2%, HR 5.89 (1.4; 22.5), p = 0.01], stoma formation [52.6% vs. 8.9%, HR 10.9 (3.65; 34.1), p < 0.001], and segmental resection [38.5% vs. 5.8%, HR 9.75 (3.54; 30.4), p < 0.001]. Superficial, partial-thickness resections were associated with decreased risk [(4.2% vs. 36.2%), HR 0.08 (0.02; 0.24), p < 0.001]. Factors associated with major complications (8.5%) were blood loss [250 (100; 400) vs. 100 (50.0; 200) mls, p = 0.03], open surgery [31.6% vs. 4.9%, HR 8.74 (2.36; 32.9), p = 0.001], stoma formation [42% vs. 3.3%, HR 20.3 (5.41; 90.0), p < 0.001], and segmental colectomy [28.2% vs. 0.9%, HR 34.6 (6.25; 876), p < 0.001]. Partial-thickness resection was associated with decreased risk ([.05% vs. 23.4%, HR 8.74 (2.36; 32.9), p < 0.001]. 19.1% experienced recurrence. Open surgery [5.2% vs. 21.3%, HR 0.14 (0.02; 1.05), p = 0.027] and superficial partial thickness excision [23.4% vs. 10.6%, HR 2.86 (1.08; 7.59), p = 0.027] were associated. Segmental resection was associated with decreased recurrence risk [7.6% vs. 23.5%, HR 0.27 (0.08; 0.91), p = 0.024].

CONCLUSION

Limiting resection to partial-thickness or full-thickness disc excision compared to bowel resection may improve complications but increase recurrence risk.

Moving towards in pouch diagnostics for ostomy patients: exploiting the versatility of laser induced graphene sensors

The development of a 3D printed sensor for direct incorporation within stoma pouches is described. Laser induced graphene scribed on either side of polyimide film served as the basis of a 2 electrode configuration that could be integrated within a disposable pouch sensor for the periodic monitoring of ileostomy fluid pH. The graphene sensors were characterised using electron microscopy, Raman spectroscopy, DekTak profilometry with the electrochemical properties investigated using both cyclic and square wave voltammetry. Adsorbed riboflavin was employed as a biocompatible redox probe for the voltammetric measurement of pH. The variation in peak position with pH was found to be linear over pH 3-8 with a sub Nernstian response (43 mV/pH). The adsorbed probe was found to be reversible and exhibited minimal leaching through repeated scanning. The performance of the system was assessed in a heterogeneous bacterial fermentation mixture simulating ileostomy fluid with the pH recorded before and after 96 h incubation. The peak profile in the bacterial medium provided an unambiguous signal free from interference with the calculated pH before and after incubation (pH 5.3 to 3.66) in good agreement with that obtained with commercial pH probes.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s10853-023-08881-x.

Defunctioning stoma in anterior resection for rectal cancer does not impact anastomotic leakage: a national population-based cohort study

BACKGROUND

Anterior resection (AR) is considered the gold standard for curative cancer treatment in the middle and upper rectum. The goal of the sphincter-preserving procedure, such as AR, is vulnerable to anastomotic leak (AL) complications. Defunctioning stoma (DS) became the protective measure against AL. Often a defunctioning loop-ileostomy is used, which is associated with substantial morbidity. However, not much is known if the routine use of DS reduces the overall incidence of AL.

METHODS

Elective patients subjected to AR in 2007-2009 and 2016-18 were recruited from the Swedish colorectal cancer registry (SCRCR). Patient characteristics, including DS status and occurrence of AL, were analyzed. In addition, independent risk factors for AL were investigated by multivariable regression.

RESULTS

The statistical increase of DS from 71.6% in 2007-2009 to 76.7% in 2016-2018 did not impact the incidence of AL (9.2% and 8.2%), respectively. DLI was constructed in more than 35% of high-located tumors ≥ 11 cm from the anal verge. Multivariable analysis showed that male gender, ASA 3-4, BMI > 30 kg/m², and neoadjuvant therapy were independent risk factors for AL.

CONCLUSION

Routine DS did not decrease overall AL after AR. A selective decision algorithm for DS construction is needed to protect from AL and mitigate DS morbidities.

Impact of ileostomy in the adjuvant treatment and outcome of colon cancer

BACKGROUND

After tumor resection, a preventive diverting loop ileostomy creation is a routine surgical procedure to prevent anastomotic leakage and infections and to preclude secondary surgeries. Despite its benefits, several studies have proposed potential complications that extend the disease course by impairing the feasibility of adjuvant chemotherapy and adherence.

PURPOSE

The aim of this study was to evaluate the impact of ileostomy complications on the adherence to adjuvant treatment and overall survival (OS) of colon cancer (CC) patients.

METHODS

Retrospective, observational study. Patients diagnosed with colon adenocarcinoma were treated between January 2010 and December 2020 at the National Cancer Institute in Mexico.

STATISTICAL ANALYSIS

χ² and t-test, Kaplan-Meier, log-rank, and Cox regression. Statistical significance differences were assessed when p was bilaterally < 0.05.

RESULTS

The most frequent complications of loop-derived ileostomy were hydro-electrolytic dehydration (50%), acute kidney injury (AKI) (26%), grade 1-2 diarrhea (28%), and grade 3-4 diarrhea (21%) (p = 0.001). Patients with complete chemotherapy did not reach the median OS. In contrast, the median OS for patients with non-complete chemotherapy was 56 months (p = 0.023). Additionally, 5-year OS reached to 100% in the early restitution group, 85% in the late restitution group, and 60% in the non-restitution group (p = 0.016). Finally, AKI (p = 0.029; 95% confidence interval (CI) 3.348 [1.133-9.895]), complete chemotherapy (p = 0.028; 95% CI 0.376 [0.105-0.940]), and reversed ileostomy (p = 0.001; 95% CI 0.125 [0.038-0.407]) remained as predictors of overall survival for patients with CC treated with a loop ileostomy.

CONCLUSIONS

Our results emphasize the early stoma reversal restitution as a safe and feasible alternative to prevent severe complications related to ileostomies which improve chemotherapy adherence and overall survival of colon cancer patients. This is one of the pioneer studies analyzing the impact of ileostomy on treatment adherence and outcome of Latin American patients with colon cancer.

TRIAL REGISTRATION

Retrospective study No. 2021/045, in April 2021.

Risk factors of acute renal failure in patients with protective ileostomy after rectal cancer surgery

BACKGROUND

Despite the potential benefits of protective ileostomy in rectal surgery, diverting loop ileostomy construction is not free of specific medical consequences implying unplanned hospital readmissions. The most common reason for readmission in these patients is a dehydration with a prevalence of acute renal failure (ARF) of 20%. The objective of this study was to establish the predictive factors of ARF in patients with protective ileostomy after surgery for rectal cancer from a bicentric study.

METHODS

we conducted a bicentric retrospective cohort study to identify the risk factor of ARF. This study was carried out on 277 patients operated for rectal cancer with necessity of a protective ileostomy during the study period. ARF was measured at any endpoint between ileostomy creation and reversal. Multiple logistic regressions were performed to identify independent risk factors.

RESULTS

A total of 277 patients were included, and 18% (n = 50) were readmitted for ARF. In multivariate logistic regression, increased age (OR 1.02, p = 0.01), Psychiatric diseases (OR 4.33, p = 0.014), Angiotensin II receptor blockers (OR 5.15, p < 0.001) and the ASA score ≥ 3 (OR 9.5, p < 0.001) were significantly associated with ARF.

CONCLUSION

Acute renal failure is a prevalent and significant event in the postoperative course of ileostomy patients. Patients at risk should be risk stratified before discharge and targeted for intensive preventive measures.

Frailty assessment can predict textbook outcomes in senior adults after minimally invasive colorectal cancer surgery

AIM

Colorectal cancer (CRC) surgery can be associated with suboptimal outcomes in older patients. The aim was to identify the correlation between frailty and surgical variables with the achievement of Textbook Outcome (TO), a composite measure of the ideal postoperative course, by older patients with CRC.

METHOD

All consecutive patients ≥70years who underwent elective CRC-surgery between January 2017 and November 2021 were analyzed from a prospective database. To obtain a TO, all the following must be achieved: 90-day survival, Clavien-Dindo (CD) < 3, no reintervention, no readmission, no discharge to rehabilitation facility, no changes in the living situation and length of stay (LOS) ≤5days/≤14days for colon and rectal surgery respectively. Frailty and surgical variables were related to the achievement of TO.

RESULTS

Four-hundred-twenty-one consecutive patients had surgery (97.7% minimally invasive), 24.9% for rectal cancer, median age 80 years (range 70-92), median LOS of 4 days (range 1-96). Overall, 288/421 patients (68.4%) achieved a TO. CD 3-4 complications rate was 6.4%, 90-day mortality rate was 2.9%. At univariate analysis, frailty and surgical variables (ileostomy creation, p = 0.045) were related to. However, multivariate analysis showed that only frailty measures such as flemish Triage Risk Screening Tool≥2 (OR 1.97, 95%CI: 1.23-3.16; p = 0.005); Charlson Index>6 (OR 1.61, 95%CI: 1.03-2.51; p = 0.036) or Timed-Up-and-Go>20 s (OR 2.06, 95%CI: 1.01-4.19; p = 0.048) independently predicted an increased risk of not achieving a TO.

CONCLUSION

The association between frailty and comprehensive surgical outcomes offers objective data for guiding family counseling, managing expectations and discussing the possible loss of independence with patients and caregivers.

Deterioration in renal function after stoma creation: a retrospective review from a Middle Eastern tertiary care center

BACKGROUND

Stomas are associated with multiple complications including dehydration which ultimately affects renal function. These complications begin with changes in the estimated glomerular filtration rate (GFR).

OBJECTIVES

Evaluate changes in GFR after stoma creation by stoma type and identify how different types of stoma affect GFR.

DESIGN

Retrospective, analytical cohort SETTING: Tertiary care center in Saudi Arabia PATIENTS AND METHODS: The colorectal surgery database was reviewed for all adult patients who underwent stoma creation (permanent and temporary ileostomies and colostomies) or reversal in 2000-2015. GFR was estimated at the first encounter, before the index surgery, at the time of stoma reversal, and upon the last follow-up. Patients with renal impairment, including low GFR before stoma creation, patients who had a temporary stoma converted to a permanent stoma, and patients who died with a stoma were excluded. We studied the association of several demographic and clinical factors on changes in GFR by univariate and multivariate analysis.

MAIN OUTCOME MEASURES

Estimated GFR at the last clinic visit for the permanent stoma group and at stoma closure for the temporary stoma group.

SAMPLE SIZE

394 patients (149 ileostomates, 245 colostomates) RESULTS: Thirty-three (8.4%) of the 394 patients had a low GFR: 11 (7.4%) in the ileostomy group and 22 (9%) in the colostomy group (P= .579). The rate of readmissions with ileostomies was higher (11.4%) than with colostomies (3.3%) (P≤.001). The number of temporary ileostomies (n=9, 7.0%) differed from temporary colostomies (n=2, 1.9%) but the difference was not statistically significant (P=.06). In the multivariate analysis, stoma permanency, hypertension, chemotherapy and nephrotoxic drugs were risk factors associated with low GFR.

CONCLUSION

Ileostomies were not associated with a high rate of renal function deterioration in comparison to colostomies, but had a significantly higher rate of readmission due to dehydration and electrolytes imbalance possibly due to the hot climate in Saudi Arabia.

LIMITATIONS

Retrospective nature and limited sample size which may have resulted in a type 2 statistical error.

CONFLICTS OF INTEREST

None.

Renal dysfunction occurs following ileostomy formation and is independent of readmission

BACKGROUND

Ileostomy formation may be permanent or intended as temporary to defunction a high-risk pelvic anastomosis to reduce the risk of septic consequences of anastomotic leak. However, these procedures have a high rate of readmission, most commonly due to dehydration and associated with acute kidney injury (AKI).

METHODS

A single centre retrospective cohort study of patients who underwent ileostomy formation from 2015 to 2020 and analysed in two groups: those who needed readmission within 60 days and those who did not. Data collected included demographics and renal function and electrolytes at baseline (ileostomy formation) and at elective ileostomy closure.

RESULTS

A total of 171 patients were included in the analysis, with a readmission rate 38% within 60 days of discharge. There was a significant increase in creatinine from baseline blood tests compared to date of elective ileostomy closure in both the readmission and no readmission arms. There was a significant decrease in eGFR from baseline blood tests compared with date of ileostomy closure in both readmission and no readmission arms. There was no significant difference in creatinine or eGFR between readmission and no readmission arms at date of ileostomy closure. Baseline serum sodium levels were lower in the readmission arm compared to no readmission arm.

CONCLUSION

Ileostomy formation is associated with a deterioration in renal function, which occurs independent of whether the patient requires readmission to hospital. Low serum sodium may be used as a predictor for patients with an increased risk of readmission.

Readmission with acute kidney injury following ileostomy: patterns and predictors of a common phenomenon

PURPOSE

Ileostomy is associated with various complications, often necessitating rehospitalization. High-output ileostomy is common and may lead to acute kidney injury (AKI). Here we describe the temporal pattern of readmission with AKI following ileostomy formation and identify risk factors.

METHODS

Patients that underwent formation of ileostomy between 2008 and 2021 were included in this study. Readmission with AKI with high output ileostomy was defined as readmission with serum creatinine > 1.5-fold compared to the level at discharge or latest baseline (at least stage-1 AKI according to Kidney Disease: Improving Global Outcome (KDIGO) criteria), accompanied by ileostomy output > 1000 ml in 24 h. Patient characteristics and perioperative course were assessed to identify predictors for readmission with AKI.

RESULTS

Of 1191 patients who underwent ileostomy, 198 (16.6%) were readmitted with a high output stoma and AKI. The mean time to readmission with AKI was 98.97 ± 156.36 days. Eighty-six patients (43.4%) had early readmission (within 30 days), and 66 (33%) were readmitted after more than 90 days. Over 90% of patients had more than one readmission, and 110 patients (55%) had 5 or more. Patient-related predictors for readmission with AKI were age > 65, body mass index > 30 kg/m2, and hypertension. Factors related to the postoperative course were AKI with creatinine > 2 mg/dl, postoperative hemoglobin < 8 g/dl or blood transfusion, albumin < 20 g/dl, high output stoma and need for loperamide, and length of hospital stay > 20 days. Factors related to early versus late readmissions and multiple readmissions were also analyzed.

CONCLUSIONS

Readmission with AKI following ileostomy formation is a consequential event with distinct risk factors. Acknowledging these risk factors is the foundation for designing interventions aiming to reduce frequency of AKI readmissions in predisposed patient populations.

Nutritional Issues Faced by Patients with Intestinal Stoma: A Narrative Review

The incidences of colorectal cancer and inflammatory bowel diseases are increasing in the developed countries of Western Europe and North America, and consequently, the prevalence rate of temporary or permanent stomas has increased in recent years. Nevertheless, the amount of research in the nutrition field in the case of patients with stoma is rather limited. This review article aims to assess the impact of nutrition on an intestinal stoma and possible sequelae resolved with nutritional therapy. The research analyses conducted thus far indicate a significantly increased risk of developing malnutrition, vitamin deficiency (especially group B), and an increased number of discharges from the stoma and its relevance with abnormalities found in electrolyte concentrations.

Modified Primary Anastomosis Using an Intestinal Internal Drainage Tube for Crohn's Disease: A Pilot Study

PURPOSE

Surgical treatment is an important part of the management of Crohn's disease (CD). However, the current recommended staged procedures require two operations, with long hospital stays and high costs, while traditional primary anastomosis has a high risk of complications. Therefore, the aim of this study was to compare the clinical efficacy and safety of modified primary anastomosis using intestinal internal drainage tubes for CD.

METHODS

In this study, emergency and nonemergency CD patients were included separately. Then, the patients were divided into three subgroups: patients with intestinal internal drainage tubes (modified primary anastomosis), staged procedures, and traditional primary anastomosis. The main outcomes were the number of hospitalizations, length and cost of the first hospital stay, length and cost of total hospital stays, and complications.

RESULTS

The outcomes of the three subgroups of emergency CD patients were not significantly different. For nonemergency CD patients, patients with intestinal internal drainage tubes had shorter total hospital stays and fewer hospitalizations compared with the staged procedures subgroup, while no significant differences in any outcomes were observed between the modified and traditional primary anastomosis subgroups.

CONCLUSIONS

For emergency CD patients, no significant advantage in terms of the main outcomes was observed for modified primary anastomosis. For nonemergency CD patients, modified primary anastomosis reduced the length of total hospital stays and hospitalizations compared with staged procedures. The placement of intestinal internal drainage tubes allows some patients who cannot undergo primary anastomosis to undergo it, which is a modification of traditional primary anastomosis.

Application and evaluation of transitory protective stoma in ovarian cancer surgery

Ovarian cancer is the most fatal of all female reproductive cancers. The fatality rate of OC is the highest among gynecological malignant tumors, and cytoreductive surgery is a common surgical procedure for patients with advanced ovarian cancer. To achieve satisfactory tumor reduction, intraoperative bowel surgery is often involved. Intestinal anastomosis is the traditional way to restore intestinal continuity, but the higher rate of postoperative complications still cannot be ignored. Transitory protective stoma can reduce the severity of postoperative complications and traumatic stress reaction and provide the opportunity for conservative treatment. But there are also many problems, such as stoma-related complications and the impact on social psychology. Therefore, it is essential to select appropriate patients according to the indications for the transitory protective stoma, and a customized postoperative care plan is needed specifically for the stoma population.

Patient and surgeon preferences for early ileostomy closure following restorative proctectomy for rectal cancer: why aren't we doing it?

BACKGROUND

Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC.

METHODS

A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively.

RESULTS

Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients.

CONCLUSIONS

Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.

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.

Characterising nationwide reasons for unplanned hospital readmission after colorectal cancer surgery

BACKGROUND

Readmissions after colorectal cancer surgery are common, despite advancements in surgical care, and have a significant impact on both individual patients and overall healthcare costs. The aim of this study was to determine the 30-and 90 days readmission rate after colorectal cancer surgery, and to investigate the risk factors and clinical reasons for unplanned readmissions.

METHOD

A multicenter, population-based study including all patients discharged after index colorectal cancer resection from 2010 to 2020 in Aotearoa New Zealand (AoNZ) was completed. The Ministry of Health National Minimum Dataset was used. Rates of readmission at 30 days and 90 days were calculated. Mixed-effect logistic regression models were built to investigate factors associated with unplanned readmission. Reasons for readmission were described.

RESULTS

Data were obtained on 16,885 patients. Unplanned 30-day and 90-day hospital readmission rates were 15.1% and 23.7% respectively. The main readmission risk factors were comorbidities, advanced disease, and postoperative complications. Hospital level variation was not present. Despite risk adjustment, R² value of models was low (30 days: 4.3%, 90 days: 5.2%). The most common reasons for readmission were gastrointestinal causes (32.1%) and wound complications (14.4%). Rates of readmission did not improve over the 11 years study period (p = 0.876).

CONCLUSION

Readmissions following colorectal resections in AoNZ are higher than other comparable healthcare systems and rates have remained constant over time. While patient comorbidities and postoperative complications are associated with readmission, the explanatory value of these variables is poor. To reduce unplanned readmissions, efforts should be focused on prevention and early detection of post-discharge complications.

[Prognostic factors of dehydration and renal damage in patients with formed preventive ileostomy during rectal resection for cancer]

Despite the potential advantages of a preventive intestinal stoma after the formation of a low colon anastomosis during rectal resections, the formation of a preventive loop ileostomy is associated with a significant frequency of complications.

OBJECTIVE

To determine the potential prognostic factors of complications associated with ileostomy dysfunction in patients who have undergone rectal resection for cancer.

MATERIAL AND METHODS

We retrospectively analyzed patients over the age of 18 who underwent open and laparoscopic resection of the rectum with the formation of a preventive ileostomy from January 2015 to May 2022. To determine the influence of potential predictors on the frequency of complications associated with large ileostomy losses, a single-factor logistic regression analysis was used. Complications associated with large ileostomy losses were primarily water-electrolyte disorders, dehydration and acute renal failure, which required intensive therapy and re-hospitalization.

RESULTS

Of the 120 patients included in the study, 26 (21.7%) suffered complications associated with large losses of fluid and electrolytes in the stoma. In this group of patients, at least one repeated emergency hospitalization to a medical institution was required (average value 1.6). Factors associated with ileostomy dysfunction in a single-factor analysis were: the presence of signs of intestinal obstruction (OR=2.6; p=0.047), the development of postoperative complications (OR=3; p=0.024), steroid use (OR=4.3; p=0.010), smoking (OR=4.8; p=0.017) the average amount of discharge from the stoma at discharge is more than 1000 ml/24 h (OR=3.2; p=0.016) and the need for Loperamide at the time of discharge (OR=2.8; p=0.032). Multivariate logistic regression analysis revealed an independent risk factor for complications leading to re-hospitalization: ileostomy losses at discharge ≥1000 ml/24 h (OR=3.3 (1.18-9.37); p=0.023).

CONCLUSION

In our study, those patients whose ileostomy discharge exceeded 1000 ml/24 h at discharge were at increased risk of dehydration, hypokalemia, hypocalcemia, acute prerenal renal failure, which led to repeated hospitalization to correct these disorders, sometimes in the intensive care unit.

Obstructive and secretory complications of diverting ileostomy

This review aimed to highlight the etiology, diagnosis, treatment, and prevention of obstructive and secretory complications associated with diverting ileostomy (DI). Obstructive complications at the stoma site are termed stoma outlet obstruction (SOO) or stoma-related obstruction (SRO). The incidence of SOO/SRO is 5.4%-27.3%, and the risk factors are multifactorial; however, the configuration of the stoma limb and the thickness of the rectus abdominis muscle (RAM) may be of particular concern. Trans-stomal tube decompression is initially attempted with a success rate of 33%-86%. A thick RAM may carry the risk of recurrence. Surgical refinement, including a wider incision of the anterior sheath and adequate stoma limb length, avoids tension and immobility and may decrease SOO/SRO. Secretory complications of DI are termed high output stoma (HOS). Persistent HOS lead to water and sodium depletion, and secondary hyperaldosteronism, resulting in electrolyte imbalances, such as hypomagnesemia. The incidence of HOS is 14%-24%, with an output of 1000-2000 mL/d lasting up to three days. Treatment of HOS is commenced after excluding postoperative complications or enteritis and includes fluid intake restriction, antimotility and antisecretory drug therapies, and magnesium supplementation. Intensive monitoring and surveillance programs have been successful in decreasing readmissions for dehydration.

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.

Nutritional and Educational Intervention to Recover a Healthy Eating Pattern Reducing Clinical Ileostomy-Related Complications

The aim of this study was to evaluate a diet intervention implemented by our hospital in order to determinate its capacity to improve the eating pattern of patients with an ileostomy, facilitating the implementation new eating-related behaviors, reducing doubt and dissatisfaction and other complications. The study was conducted with a quasi-experimental design in a tertiary level hospital. The elaboration and implementation of a nutritional intervention consisting of a Mediterranean-diet-based set of menus duly modified that was reinforced by specific counseling at the reintroduction of oral diet, hospital discharge and first follow-up appointment. Descriptive, bivariate and multivariate analyses were performed. The protocol was approved by the competent Ethics Committee. The patients of the intervention group considered that the diet facilitated eating five or more meals a day and diminished doubt and concerns related to eating pattern. Most patients (86%) had a favorable experience regarding weight recovery and a significant reduction of all-cause readmissions and readmission with dehydration (p = 0.015 and p < 0.001, respectively). The intervention helped an effective self-management of eating pattern by patients who had a physical improvement related to hydration status, which, together with an improvement in weight regain, decreased the probability of readmissions.

Decreasing Readmissions After Ileostomy Creation Through a Perioperative Quality Improvement Program

BACKGROUND

Readmission after ileostomy creation in patients undergoing colorectal surgery creates a significant burden on health care cost and patient quality of care, with a 30-day readmission rate of 40%.

OBJECTIVE

This study aimed to evaluate the implementation of our perioperative quality improvement program, Decreasing Readmissions After Ileostomy Creation.

DESIGN

Perioperative interventions were administered to patients who underwent ileostomy creation.

SETTINGS

A single tertiary care academic center.

PATIENTS

Eighty patients participated in this program from February 2020 to January 2021.

MAIN OUTCOME MEASURES

The primary outcomes measured were 30-day readmission rates and causes of readmission, which were compared to a historical national database. Descriptive statistics were used to evaluate the effectiveness of this quality improvement program.

RESULTS

Eighty patients were enrolled in this prospective quality improvement program. The mean age was 52 (±15.06) years. The most common indication for patients undergoing creation of an ileostomy was colorectal cancer (40%; n = 32). The overall 30-day readmission rate was 8.75% (n = 7) throughout the study period, which was significantly lower than historical cohort data (20.10%; p = 0.01). Among the 7 readmitted patients, 3 (3.75%) were readmitted due to dehydration. The most significant associated risk factor for all-cause readmission was urgent/emergent operative status, which was associated with an increased risk of readmission ( p = 0.01). The 3 readmitted patients with dehydration had a mean Dehydration Readmission After Ileostomy Prediction risk score of 11.71 points, compared to 9.59 points in nondehydrated patients, who did not require readmission ( p = 0.38).

LIMITATIONS

This study is limited by its small sample size (N = 80).

CONCLUSIONS

The Decreasing Readmissions After Ileostomy Creation program has been successful in reducing both the all-cause readmission rate and readmission due to dehydration both within an academic tertiary care referral center and in comparison with historical readmission rates. See Video Abstract at http://links.lww.com/DCR/B894 .

DISMINUCIN DE LA READMISIN DESPUS DE LA CREACIN DE UNA ILEOSTOMA MEDIANTE UN PROGRAMA DE MEJORA DE LA CALIDAD PERIOPERATORIA

ANTECEDENTES:La readmisión después de la creación de una ileostomía en pacientes de cirugía colorrectal crea una carga significativa sobre el costo de la atención médica y la calidad de la atención del paciente, con una tasa de readmisión a los 30 días que llega al 40%.OBJETIVO:Este estudio tiene como objetivo evaluar la implementación de nuestro programa de mejora de la calidad perioperatoria que disminuyen los reingresos después de la creación de ileostomía.DISEÑO:Se administraron intervenciones perioperatorias a pacientes que se sometieron a la creación de una ileostomía.AJUSTE:Se trataba de un único centro académico de atención terciaria.PACIENTES:Participaron 80 pacientes en este programa desde febrero de 2020 hasta enero de 2021.PRINCIPALES MEDIDAS DE RESULTADO:Los principales resultados medidos fueron las tasas de reingreso a los 30 días y las causas de reingreso, que se compararon con una base de datos histórica nacional. Se utilizaron estadísticas descriptivas para evaluar la eficacia de este programa de mejora de la calidad.RESULTADOS:Ochenta pacientes se inscribieron en este programa prospectivo de mejora de la calidad. La edad media fue de 52 (± 15,06) años. La indicación más común para los pacientes que se sometieron a la creación de una ileostomía fue el cáncer colorrectal (40%, n = 32). La tasa general de reingreso a los 30 días fue del 8,75% (n = 7) durante todo el período de estudio, lo que fue significativamente más bajo que los datos históricos de la cohorte (20,10%, p = 0,01). Entre los 7 pacientes readmitidos, tres (3,75%) fueron readmitidos por deshidratación. El factor de riesgo asociado más significativo para la readmisión por todas las causas fue el estado operatorio urgente / emergencia, que se asoció con un mayor riesgo de readmisión (p = 0,01). Los tres pacientes readmitidos con deshidratación tuvieron una puntuación de riesgo promedio de readmisión por deshidratación después de la predicción de ileostomía de 11,71 puntos, en comparación con los pacientes no deshidratados, que no requirieron readmisión (media, 9,59 puntos, p = 0,38).LIMITACIONES:Este estudio está limitado por su pequeño tamaño de muestra (n = 80).CONCLUSIONES:El programa de disminución de las readmisiones después de la creación de una ileostomía ha logrado reducir tanto la tasa de readmisión por todas las causas como la readmisión por deshidratación, tanto dentro de un centro académico de referencia de atención terciaria como en comparación con las tasas históricas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B894 . (Traducción-Dr Yolanda Colorado ).

Diverting ileostomy is a risk factor for renal impairment during CAPOX therapy

PURPOSE

Temporary ileostomy is sometimes created after colorectal surgery and may cause renal impairment. However, the impact of ileostomy on renal function during adjuvant chemotherapy for colorectal cancer (CRC) remains unknown. The aim of the present study was to examine the effects of ileostomy on renal function during adjuvant chemotherapy.

METHODS

We examined 184 patients who received adjuvant CAPOX therapy (capecitabine and oxaliplatin) for CRC with or without ileostomy between January 2011 and December 2020 at the University of Tokyo Hospital. Clinicopathological factors, including renal function, were retrospectively reviewed in association with temporary ileostomy. Factors associated with reductions in the estimated glomerular filtration rate (eGFR) during CAPOX therapy were analyzed.

RESULTS

Eighteen patients (10%) underwent temporary ileostomy. The maximum decrease in eGFR during CAPOX therapy was significantly higher in patients with than in those without ileostomy (- 16.1 vs. - 5.6 mL/min/1.73m², p = 0.003). A multivariate analysis identified ileostomy as one of factors independently associated with reductions in eGFR during CAPOX therapy (p = 0.003). The cumulative number of readmission due to dehydration was also higher in patients with ileostomy (33% vs. 1%, p < 0.001).

CONCLUSIONS

Ileostomy significantly reduced eGFR during adjuvant CAPOX therapy. Therefore, renal function needs to be monitored during CAPOX therapy, particularly in patients with ileostomy.

The impact of prolonged delay to loop ileostomy closure on postoperative morbidity and hospital stay: A retrospective cohort study

AIM

There is increasing evidence that delayed loop ileostomy closure is associated with an increase in postoperative morbidity. In the context of a publicly funded health service with constrained theatre access, we review the impact of delay in loop ileostomy closure.

METHOD

A retrospective cohort study of patients undergoing loop ileostomy closure at the Dunedin Public Hospital between 2000-2017 was performed. Cases and complications were identified from the prospectively maintained Otago Clinical Audit database. Patient demographics, ASA score, indications for ileostomy, reasons for delay in closure, length of stay (LOS) after ileostomy closure and complications were collected. LOS and overall complication rate were assessed using univariable and multivariable analyses.

RESULTS

A total of 292 patients were included in the study, of whom 74 (25.3%) were waiting for longer than 12 months for ileostomy closure. The overall complication rate was 21.5%. This was 8% up to 90 days, 20% between 90-360 days, 28% between 360-720 days and 54% after 720 days. Delay was associated with an increased risk of any complication (RR 1.06 for every 30 days with stoma, p < 0.001), including Ileus (OR [95% CI] 1.06 [1.00-1.11], p = 0.024). Overall mean LOS was 5.9 days (range 1-63), being 4.6 days up to 180 days, 5.6 between 180-720 days and 8.7 after 720 days. LOS significantly increased with increasing stoma duration (p = 0.04).

CONCLUSION

Increasing time with loop ileostomy is detrimental for patients, being associated with an increase in complication rates, and is detrimental for hospitals due to increased length of stay. Resources should be allocated for timely closure of loop ileostomies.

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).

Ostomy closure rate during COVID-19 pandemic: an Italian multicentre observational study

During the corona virus disease 2019 (COVID-19) pandemic, most of the surgical procedures were performed for emergencies or oncologic reasons to the detriment of the remaining elective procedures for benign conditions. Ileostomy or colostomy creation are sequelae of oncologic or emergency colorectal surgery, but their closure does not fall within the definition of oncologic or emergency surgery. The aim of this retrospective multicentre observational study is to report the impact of COVID-19 pandemic on the ostomy closure rate in Italy. Data regarding ileostomy and colostomy creation and closure from 24 Italian centres, during the study period (March 2020-February 2021) and during the control period (March 2019-February 2020) were collected. Three hospitals (12.5%) were COVID free. The number of colostomies and ileostomies created and closed in the same period was lower ( -18.8% and -30%, respectively) in the study period in comparison to the control period (p = 0.1915 and p = 0.0001, respectively), such as the ostomies closed in the analysed periods but created before (colostomy -36.2% and ileostomy -7.4%, p = 0.2211 and p = 0.1319, respectively). Overall, a 19.5% reduction in ostomies closed occurred in the study period. Based on the present study, a reduction in ostomy closure rate occurred in Italy between March 2020 and February 2021. During the pandemic, the need to change the clinical practice probably prolonged deterioration of quality of life in patients with ostomies, increasing number of stomas that will never be closed, and related management costs, even if these issues have not been investigated in this study.