Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates

Risk factors for unplanned 31-day readmission after surgery for colorectal cancer patients: a meta-analysis

BACKGROUND

The high incidence of unplanned readmissions within 31 days after colorectal cancer surgery remains a significant challenge. However, the identified risk factors for these readmissions are inconsistent across the literature. This study aims to perform a comprehensive meta-analysis to estimate the incidence of unplanned readmissions and systematically identify the factors associated with this risk, providing robust evidence for targeted interventions to reduce readmission rates.

METHODS

This study was conducted in accordance with the PRISMA guidelines. All study steps, including study selection, data extraction, and quality assessment, were independently performed by two authors, with any disagreements resolved through consultation with a third author. A comprehensive search for published studies was conducted across the following databases up to January 2025: VIP Journal Database, Wanfang Data, CNKI, SinoMed, PubMed, Embase, Web of Science, and the Cochrane Library. Statistical analyses were performed using RevMan 5.4 and Stata 17.0, with a p-value of less than 0.05 considered statistically significant.

RESULTS

This meta-analysis identified several significant risk factors associated with unplanned readmission during this period (P < 0.05), including age (OR = 1.13), postoperative complications (OR = 1.87), tumor stage (TNM ≥ III) (OR = 2.01), tumor site in the rectum (OR = 1.64), stoma creation (OR = 1.70), Complicated diabetes (OR = 1.56), Charlson Comorbidity Index (CCI) (OR = 1.27), blood transfusion (BT) (OR = 1.24), Length of hospital stay (LOS) (OR = 1.65), and surgical approach (OR = 1.22). Notably, female (OR = 0.85) was identified as a protective factor against unplanned readmission.

CONCLUSION

The unplanned readmission rate within 31 days after colorectal cancer surgery was 11.73%. Current evidence suggests that age, postoperative complications, TNM ≥ III, tumor site in the rectum, stoma creation, complicated diabetes, Charlson Comorbidity Index (CCI), blood transfusion (BT), length of hospital stay (LOS), and surgical approach are significant risk factors for unplanned readmission. Conversely, female has been identified as a protective factor. To mitigate these risks and reduce readmission rates, healthcare professionals should implement targeted educational and clinical interventions.

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).

Defining Opportunities to Improve Perioperative Ostomy Care and Education

Objective

We sought to qualitatively identify opportunities to improve perioperative ostomy care and education.

Background

Patients with a new ostomy utilize ostomy care-related resources to manage their ostomy. Many patients experience ostomy-related issues after surgery.

Methods

In this qualitative study, patients who underwent the construction of a new ostomy, their caregivers, and healthcare professionals were purposively recruited for semistructured phone interviews. Interviews included questions about ostomy-related experiences, education, and resources in the perioperative phases of care. Interviews were transcribed and thematically coded using inductive content analysis with NVivo 12 Software. Focus groups of patients, caregivers, and healthcare professionals were conducted to validate themes.

Results

Overall, 53 interviews including 20 patients, 16 caregivers, and 17 healthcare professionals were conducted. The average age of patients and caregivers was 59 years, 69% were non-Hispanic White, 72% were female, and 39% had limited health literacy. Themes in the preoperative phase included "not knowing what to expect regarding an ostomy," "patient difficulty understanding their health condition," and "overwhelming amount of information regarding an ostomy." Inpatient phase themes included "not knowing the best ostomy supplies to use," "challenges with ostomy appliance application," and "lack of patient acceptance and maladjustment." Postdischarge themes included "difficulty obtaining supplies," "challenges caring for inflamed skin," "variability in the utility of home healthcare," "missing outpatient resources," and "limited information on hydration and diet management." Themes were subsequently validated in focus groups.

Conclusions

Patients, caregivers, and healthcare professionals reported key perioperative barriers to obtaining, understanding, and utilizing ostomy care-related resources and education. These findings inform the development of interventions to improve ostomy care and education.

Expedited discharge and risk of readmission after ostomy construction

BACKGROUND

Expedited discharge after surgery with construction of an ostomy may leave patients less prepared for home self-care, leading to increased hospital readmissions. We evaluated whether readmission rates were greater for patients with an expedited discharge (1-2 days) compared with nonexpedited discharge (3-5 days) after ostomy construction.

METHODS

A retrospective analysis of a prospective database of patients undergoing ostomy construction was performed using the American College of Surgeons National Safety and Quality Improvement Project data between years 2019 and 2020. Inclusion criteria included age >18 years, discharge to home, and postoperative length of stay 1-5 days. Patients were grouped into either expedited or nonexpedited discharge by postoperative length of stay. The primary outcome was 30-day postoperative readmission. Analysis included multivariable logistic regression models and partial effects analysis.

RESULTS

Of 13,628 patients included, 14.5% (n = 1,980) had an expedited discharge. Rates of 30-day readmission were 13.6% in the expedited group and 14.2% in the nonexpedited group (P = .51). Adjusting for patient and procedure factors, there was no significant difference in readmission rates between expedited and nonexpedited discharge groups (odds ratio, 1.08; 95% confidence interval, 0.94-1.25). In stratified analysis, there was no difference in readmission by discharge timing for any procedure type. The top 3 contributors to having an expedited discharge, as assessed by partial effects analysis, were procedure type, elective surgery, and pre-operative sepsis.

CONCLUSIONS

Early discharge within 1-2 days of ostomy construction was not associated with increased 30-day hospital readmissions. These findings support expedited discharges after ostomy construction in carefully selected, eligible patients.

Does Self-Compassion Expressive Writing Benefit People With an Ostomy? A Randomized Controlled Trial

PURPOSE

The purpose of this study was to investigate whether a self-compassion expressive writing activity could improve psychological well-being in people with an ostomy, as assessed by changes in body image distress, ostomy-specific quality of life (QOL), self-compassion, and dispositional disgust.

DESIGN

Randomized controlled trial design was used.

SUBJECTS AND SETTING

The sample comprised 175 English-speaking patients over 18 years of age with a fecal or urinary ostomy; all participants resided in Australia and New Zealand. All were recruited online between May and July 2019.

METHODS

Following completion of a baseline questionnaire, participants were randomly assigned to complete either an online self-compassion expressive writing exercise (intervention group; n = 88; 50.29%) or a control expressive writing exercise (n = 87; 49.71%). Online questionnaires were completed 1-week and 1-month following completion of either expressive writing task. Intent-to-treat repeated-measure ANOVA analyses assessed benefits to self-compassion, body image distress, and ostomy-specific quality of life. Dispositional disgust sensitivity and propensity, as assessed by baseline scores on the Dispositional Disgust Sensitivity and Propensity Scale (DPSS), were assessed as moderators.

RESULTS

Analyses revealed that younger people with an ostomy had poorer self-compassion, greater body image distress, and poorer ostomy-specific QOL than older people, and those who had lived with their ostomy for longer had lower body image distress and greater QOL. There were no significant main effects of writing condition on primary measures; however, individuals in the intervention condition with low dispositional disgust had greater self-compassion, greater ostomy-specific QOL, and lower body image distress than those with high dispositional disgust.

CONCLUSION

Although expressive writing is a pragmatic and accessible intervention, our findings suggested that it was of benefit only to people with low dispositional disgust. Further work is required to establish an effective psychological tool for this under-researched population.

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.

Beyond the Operating Room: A Narrative Review of Enhanced Recovery Strategies in Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols have significantly transformed the management of patients undergoing colorectal surgery. This comprehensive review explores the key components and benefits of ERAS in colorectal procedures, focusing on preoperative, perioperative, and postoperative strategies aimed at improving patient outcomes. These strategies include preoperative patient education, multimodal analgesia, minimally invasive surgical techniques, and early mobilization. ERAS protocols reduce postoperative complications, shorten hospital stays, and enhance overall recovery, leading to better patient satisfaction and decreased healthcare costs. However, challenges such as patient adherence and managing high-risk patients remain critical areas for further research. Additionally, future research should focus on refining ERAS protocols, integrating novel technologies such as minimally invasive techniques, and evaluating long-term outcomes to further enhance the recovery process.

Management of complications in patients with an ileostomy: an umbrella review of systematic reviews for the EndOTrial Consortium

BACKGROUND

Standardized clinical care processes for patients with Crohn's disease (CD) and a permanent ileostomy (PI) are lacking. The EndOTrial consortium aims to address this gap by developing pathways for care.

METHODS

In this umbrella review, we searched major databases for relevant systematic reviews (SRs) or scoping reviews (ScR) published until January 5, 2024. Screening, data extraction, and quality appraisal (AMSTAR 2) were performed by two independent reviewers.

RESULTS

Of 1349 screened papers, 22 reviews met our inclusion criteria, including 20 SRs (eight with meta-analysis) and 2 ScRs. None exclusively focused on PI. Furthermore, nine reviews did not mention patients with inflammatory bowel disease (IBD), and only two reviews included patients with high-output ileostomy, highlighting a large evidence gap. The identified reviews covered six categories with nine types of interventions, including ostomy care pathways, peristomal skin care, patient education, clinical management of high-output stoma, management and prevention of postoperative ileus, dietary and nutritional support, nursing and supporting care, telemedicine, and self-management interventions. Most SRs including nursing interventions for stoma care highlighted nurses' role in a variety of standard and specialized treatments. Notably, none of the reviews exclusively examined disease recurrence, stoma pouching systems or adhesives, behavioral interventions, or mental health in patients living with ileostomy.

CONCLUSIONS

Evidence for best practice interventions to treat complications and improve quality of life in patients living with an ileostomy for CD is limited and heterogeneous. These results outline the need for standardized clinical care processes and pathways tailored to the unique needs of this patient population.

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.

Management of adult intestinal stomas: The 2023 French guidelines

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Better stoma care using the Stoma App: does it help? A first randomized double-blind clinical trial on the effect of mobile healthcare on quality of life in stoma patients

BACKGROUND

Receiving a stoma significantly impacts patients' quality of life. Coping with this new situation can be difficult, which may result in a variety of physical and psychosocial problems. It is essential to provide adequate guidance to help patients cope with their stoma, as this positively influences self-efficacy in return. Higher self-efficacy reduces psychosocial problems increasing patient's quality of life. This study investigates whether a new mobile application, the Stoma App, improves quality of life. And if personalized guidance, timed support, and peer contact offered as an in-app surplus makes a difference.

METHODS

A double-blind, randomized controlled trial was conducted between March 2021 and April 2023. Patients aged > 18 years undergoing ileostomy or colostomy surgery, in possession of a compatible smartphone were included. The intervention group received the full version of the app containing personalized and time guidance, peer support, and generic (non-personalized) stoma-related information. The control group received a restricted version with only generic information. Primary outcome was stoma quality of life. Secondary outcomes included psychological adaption, complications, re-admittance, reoperations, and length of hospital stay.

RESULTS

The intervention version of the app was used by 96 patients and the control version by 112 patients. After correction for confounding, the intervention group reported a significant 3.1-point improvement in stoma-related quality of life one month postoperatively (p = 0.038). On secondary outcomes, no significant improvements could be retrieved of the intervention group.

CONCLUSION

The Stoma App improves the quality of life of stoma patients. Peer support and personalized guidance are of significant importance in building self-efficacy. It is to be recommended to implement Stoma app-freely available software qualifying as a medical device-in standard stoma care pathways for the benefits of both patients and healthcare providers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Retrospective analysis of prospective database.

SETTINGS

Enhanced recovery colorectal surgery service.

PATIENTS

Patients who underwent new ileostomy before and after intervention.

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

Retrospective single-center study.

CONCLUSIONS

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

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

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

Developing and validation of a smartphone app for post-discharge early follow-up after colorectal cancer surgeries

Background

Colorectal surgeries are complex procedures associated with high rates of complications and hospital readmission.

Objective

This study aimed to develop an electronic post-discharge follow-up plan to remotely monitor patients' symptoms in the postoperative period of colorectal surgeries and evaluate the outcomes of emergency department visits and the rate of severe complications within 15 days after hospital discharge.

Design

We developed a digital tool capable of remotely assessing symptoms that could indicate complications related to colorectal surgical procedures and directing early management. This project was divided into two stages. The first was platform development with an algorithm for identifying symptoms and directing conduct, and the second was clinical validation of the program and evaluation of patient's experience. Patients who underwent elective oncological colorectal surgery were invited to participate in this study. We used commercial software (CleverCare) that was adjusted according to the clinical algorithm developed in this study, predicting complications and directing conduct with minimal human intervention using a Chatbot with Natural Language Processing (NPL) and artificial intelligence.

Results

We planned three Interim Analyses to evaluate the outcomes of complications, referrals to the Emergency Department (ED), ED visits, adherence, and patient satisfaction. After each analysis, specialists validated the changes before implementation. A total of 92 eligible participants agreed to participate in the study. The ability to detect complications increased with each adjustment phase, and after the third and last phase, the digital solution identified 3(4.8%) real complications, with a sensitivity of 75%, specificity of 83%, accuracy of 82%, positive predictive value of 27%, and negative predictive value of 97%. Complete adherence to the monitoring program was 83.7% with an NPS score of 94 in the last evaluation phase.

Conclusion

The digital platform is safe with high adherence rates and good patient acceptance.

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.

Complications and Healthcare Costs Associated With the First Year Following Colostomy and Ileostomy Formation: A Retrospective Study

PURPOSE

The purpose of this study was to evaluate clinical and economic outcomes during the first year following ostomy formation.

DESIGN

Single-center retrospective audit.

SUBJECTS AND SETTING

The sample comprised 200 patients who underwent surgery leading to ileostomy or colostomy at a large English National Health Service (NHS) Trust.

METHODS

Clinical complications, medicine prescriptions, and interactions with healthcare services were reported over 12 months postsurgery, and interactions with the NHS were matched to the closest NHS unit cost to determine mean patient cost.

RESULTS

The most common ostomy-related surgical site complications were high output (35.0%; n = 70), followed by moderate/severe peristomal skin complications (24.5%; n = 49) and bleeding (23.5%; n = 47). Ostomy management-related complications included general difficulties with ostomy management (50.0%; n = 100) and leakage-related mild peristomal skin issues (48.5%; n = 97). Clinical complication rates were highest in the first quarter following ostomy formation, except parastomal hernia, which increased in incidence over time. Ileostomy patients more frequently experienced high output, acute renal failure, and ostomy management-related complications and had increased length of inpatient admission. However, healthcare resource use was high in both groups, with a median of 13 inpatient admission days and 12 outpatient contacts overall within the first year. Mean cost per patient was £20,444.60 (US $26,018.41); 90.5% of these costs were attributed to ostomy-related factors.

CONCLUSIONS

Patients are likely to experience at least one clinical complication following intestinal ostomy formation and have multiple interactions with the NHS. While a number of complications are more frequent in patients with ileostomies, both groups experienced considerable costs within the first year following surgery associated with ostomy management and recovery.

Nurse specialist and ostomy patient: Competence and skills in the care pathway. A scoping review

AIMS AND OBJECTIVES

To summarise the evidence published to date regarding nursing core competence in stoma care of any type of ostomy throughout the patient's ostomy surgery candidate care pathway from preoperative to follow-up.

BACKGROUND

Nurses should play a key role in all ostomy patient care pathways to help them to adapt to the new physics and psychological conditions from the preoperative phases to the prevention of tardive stomal complications.

DESIGN

Scoping review.

METHODS

This scoping review was conducted following the methodological framework proposed by Arskey and O'Malley, following the Preferred Reporting Item for Systematic Review and Meta-analysis for Scoping Review. PRISMA-ScR Checklist is included in the manuscript. The following databases were queried: PubMed, EMBASE and CINAHL, from August to October 2022.

RESULTS

The search strategy in the consulted databases identified 3144 studies. Different types of ostomies were found and investigated: tracheostomy, gastrostomy, jejunostomy, ileostomy, colostomy and urostomy. The results of the included studies helped address the objective that allowed the ostomatherapy skills to be broken down into the different periods of the care pathway.

CONCLUSION

Caring for an ostomy patient requires advanced skills and a trusting relationship. The skills outlined in this research suggest how essential the stoma care nurse specialist is in these patients' care.

Predicting Colorectal Surgery Readmission Risk: a Surgery-Specific Predictive Model

Most current predictive models for risk of readmission were primarily designed from non-surgical patients and often utilize administrative data alone. Models built upon comprehensive data sources specific to colorectal surgery may be key to implementing interventions aimed at reducing readmissions. This study aimed to develop a predictive model for risk of 30-day readmission specific to colorectal surgery patients including administrative, clinical, laboratory, and socioeconomic status (SES) data. Patients admitted to the colorectal surgery service who underwent surgery and were discharged from an academic tertiary hospital between 2017 and 2019 were included. A total of 1549 patients met eligibility criteria for this retrospective split-sample cohort study. The 30-day readmission rate of the cohort was 19.62%. A multivariable logistic regression was developed (C=0.70, 95% CI 0.61-0.73), which outperformed two internationally used readmission risk prediction indices (C=0.58, 95% CI 0.52-0.65) and (C=0.60, 95% CI 0.53-0.66). Tailored surgery-specific readmission models with comprehensive data sources outperform the most used readmission indices in predicting 30-day readmission in colorectal surgery patients. Model performance is improved by using more comprehensive datasets that include administrative and socioeconomic details about a patient, as well as clinical information used for decision-making around the time of discharge.

Predictors of Hospital Readmission in Patients Undergoing Creation of an Intestinal Ostomy

PURPOSE

The purpose of this study was to identify predictors of 30- and 60-day hospital readmission in patients undergoing ileostomy or colostomy creation.

DESIGN

A retrospective, cohort study.

SAMPLE AND SETTING

The study sample comprised 258 patients who underwent ileostomy or colostomy creation from 2018 to 2021 in a suburban teaching hospital in the northeastern United States. The mean age of participants was 62.8 (SD 15.8) years; half were female and half were male. Slightly more than half 50.3% (n = 130) and 49.2% (n =127) underwent ileostomy surgery.

METHODS

Data were abstracted from the electronic medical record and included the following variable categories: demographic factors, ostomy- and surgical-related factors, and ostomy- and surgical-related complications. Study outcome measures were readmission within 30 and 60 days from the index hospital admission discharge date. Predictors of hospital readmission were analyzed using bivariate testing, followed by multivariate analysis.

RESULTS

Within 30 days of the index hospitalization, 49 patients were readmitted (19%), and 17 patients were readmitted (6.6%) within 60 days. For readmissions within 30 days, anatomical location of the stoma in the ileum and transverse colon as compared to descending/sigmoid colon stomas emerged as significant predictors (odds ratio [OR] 2.2; P = .036; confidence interval [CI] 1.05-4.85; OR 4.5; P = .036; CI 1.17-18.53, respectively). Within 60 days, length of the index hospitalization from 15 to 21 days as compared to shorter lengths of hospitalization emerged as the only significant predictor at this timeframe (OR 6.62; P = .018, CI 1.37-31.84).

CONCLUSIONS

These factors provide a basis for identifying patients at higher risk for hospital readmission following ileostomy or colostomy surgery. For patients at higher risk for readmission following ostomy surgery, heightened surveillance and management in the immediate postoperative period may be necessary to avert potential complications.

Home to Stay: A Randomized Controlled Trial Evaluating the Effect of a Postdischarge Mobile App to Reduce 30-Day Readmission Following Elective Colorectal Surgery

OBJECTIVE

A randomized controlled trial was conducted to evaluate the effect of a postdischarge app on 30-day readmissions and patient-reported outcomes following colorectal surgery.

BACKGROUND

Patients undergoing colorectal surgery are particularly vulnerable during their transition from hospital-to-home. There has been increasing interest in e-health to provide cost-effective transitional care. An integrated discharge monitoring program using a mobile app platform was developed to support patients after surgery.

METHODS

A 2 arm, superiority randomized control trial was conducted at an academic tertiary care center with patients undergoing elective colorectal surgery. The intervention group received usual postoperative care and postdischarge monitoring with the app. The primary outcome was 30-day readmissions following hospital discharge.

RESULTS

Two hundred eighty-two participants were randomized. The majority were young, had inflammatory bowel disease and underwent laparoscopic surgery. Intention to treat analysis showed no difference between groups for 30-day readmission (14.8% vs 17.6%, P =0.55), ER visits (25.0% vs 28.8%, P =0.49), primary care visits (12.5% vs 8.8%, P =0.34) or unplanned healthcare visits (34.4% vs 35.2%, P =0.89). All patient reported outcomes were significantly improved with median scores higher with the app for satisfaction [9, interquartile range (IQR): 8-10 vs 8, IQR: 7-9, P =0.001], well-being (7, IQR: 6-8 vs 6, IQR: 5-7, P =0.001) and significantly lower for anxiety (3, IQR: 2-5 vs 5, IQR: 3-6, P =0.001).

CONCLUSIONS

Although the app did not show a significant reduction in 30-day readmission or ER visits, it did lead to significant improvements in patient-reported outcomes. The app may be an important tool to support patients following colorectal surgery.

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.

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.

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.

Diagnosis, Treatment, and Prevention of Ileostomy Complications: An Updated Review

An ileostomy is associated with multiple complications that may frequently or persistently affect the life of ostomates. All healthcare professionals should have knowledge of the diagnosis, treatment, and prevention of ileostomy complications. Peristomal dermatitis is caused by watery and highly alkaline effluent. Skin protective products are typically used for local treatment. Ischemia/necrosis occurs due to insufficient arterial blood supply. Retraction is seen in patients with a bulky mesentery and occurs following ischemia. Convex stoma appliances can be used for skin protection against fecal leakage. Small bowel obstruction (SBO) is common and occurs only at the stoma site. Trans-stomal decompression is most effective in these cases. High output stoma (HOS) is defined as a condition when the output exceeds 1,000- 2,000 ml/day, lasting for one to three days. Treatment includes intravenous fluid and electrolyte resuscitation followed by restriction of hypotonic fluid and the use of antimotility (and antisecretory) drugs. Stomal prolapse is a full-thickness protrusion of an inverted bowel. Manual reduction is attempted initially, whereas emergency bowel resection may be needed for incarcerated cases. A parastomal hernia (PSH) is an incisional hernia of the stoma site. Surgery is considered in cases of incarceration, but most cases are manageable with non-surgical treatment.

[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.

Home to Stay: A randomized controlled trial protocol to assess use of a mobile app to reduce readmissions following colorectal surgery

AIM

Patients undergoing colorectal surgery face high rates of emergency room visits and readmission to hospital. These unplanned hospital visits lead to both increased patient anxiety and health care costs. The aim of this study is to evaluate the use of mobile application to support patients undergoing colorectal surgery following discharge from hospital.

METHOD

This study is a randomized controlled trial in which the control group will receive standard follow-up care following discharge after surgery and the intervention group will receive standard follow-up care in addition to the mobile application. The primary outcome is the proportion of patients with unplanned hospital visits within 30 days of discharge. The secondary outcomes are patient-reported outcomes on validated scales evaluating their quality of recovery following discharge. A sample size of 670 subjects is planned. For the primary outcome, the control and intervention groups will be compared using a generalized linear model to account for clustering of patients within centres. For the secondary outcomes, the overall scores on the Quality of Recovery 15 and Patient Activation Measure will be analysed using a linear regression model.

RESULTS

It is expected that the results of this study will show that the mobile app will lead to significant improvements in unplanned hospital visits as well as improved quality of recovery for patients.

CONCLUSION

If the trial is successful, the mobile app can be easily adopted more widely into clinical practice to support patients at home following surgery.

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.

Early discharge after colorectal cancer resection: trends and impact on patient outcomes

BACKGROUND

Implementation of early discharge in colorectal surgery has been effective in improving patient satisfaction and reducing healthcare costs. Readmission rates following early discharge among colorectal cancer patients are believed to be low, however, remain understudied. The objectives of this study were: (i) to describe trends in early post-operative discharge and the associated hospitalization costs; (ii) to explore patient outcomes and resource utilization following early discharge; and (ii) to identify predictors of readmission following early discharge.

METHODS

This was a retrospective cohort study using the Nationwide Readmissions Database. Adult patients admitted with a primary colorectal neoplasm who underwent colectomy or proctectomy between 2010 and 2017 were identified using ICD-9/10 codes. The exposure of interest was early post-operative discharge defined as ≤ 3 days from surgery. Main outcome measures were 30-day readmissions, post-operative complication rates, LOS and cost.

RESULTS

In total, 342,242 patients were identified, and of those, 51,977 patients (15.2%) had early discharges. During the study period, the proportion of early discharges significantly increased (R2 = 0.94), from 9.9 to 23.4%, while readmission rates in this group remained unchanged (mean 7.3% ± 0.5). Complications that required bounceback readmission (within 7 days) after early discharge, rather than during index admission, were an independent predictor of longer overall LOS (ß = 0.044, p < 0.001) and higher hospitalization costs (ß = 0.031, p < 0.001). On multiple logistic regression, factors independently associated with bounceback readmission following early discharge were: male gender (OR = 1.47, 95%CI 1.33-1.63); open surgery (OR = 1.37, 95%CI 1.23-1.52); presence of stoma (OR = 1.51, 95%CI 1.22-1.87); transfer to facility or discharge with home health service (OR = 1.53, 95%CI 1.34-1.75); and Medicare/Medicaid insurance (OR = 1.34, 95%CI 1.14-1.57), among others.

CONCLUSION

Early post-operative discharge of colorectal cancer patients is increasing despite a lack of improvement in readmission rates and an overall increase in hospitalization costs. Premature discharge of select patients may result in readmissions due to critical complications related to surgery resulting in increased resource utilization.

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).

Empowering New Ostomy Patients Through a Novel Inpatient Group Education Class: A Quality Improvement Project

PURPOSE

A quality improvement project was undertaken that evaluated the results of a group inpatient ostomy education class designed to reinforce information provided by the WOC nurse. A secondary goal was to provide emotional support during the immediate postoperative period following ostomy surgery.

PARTICIPANTS AND SETTING

Participants were inpatients undergoing fecal ostomies (ileostomies, jejunostomies, or colostomies) and their families. This project took place in an inpatient colorectal unit at the project hospital in Northeast, Ohio.

APPROACH

The Plan, Do, Check, Act process was used to guide the quality improvement. Using feedback from postoperative patients, a multidisciplinary team designed an inpatient group ostomy class with education targeting patient-identified needs. Educational content was created with feedback from postoperative patients. The 1-hour class was offered twice weekly and was facilitated by a dietician, a pharmacist, and an RN. Content included general postoperative discharge information, appliance self-care, nutrition guidelines, medications, and resources for support.

OUTCOMES

From 2016 to 2019, more than 1500 patients and family members participated in the educational offerings. During this time, length of hospital stay for ostomy patients decreased from 7.299 to 5.938 days. Readmission rates for patients undergoing fecal ostomies declined from 12.9% to a postclass rate of 11.2%. Written/verbal feedback from class attendees, physicians, and nurses was positive.

IMPLICATIONS FOR PRACTICE

Project outcomes validated the need for a structured, ongoing inpatient, postoperative, group education for ostomy patients during the immediate postoperative period. Next steps will be to resume the class as it was paused due to COVID-19 restrictions, to continue to revise content, and to implement supplementary materials such as DVDs and online resources.

Systematic Review of Ostomy Care Pathways

OBJECTIVE

To evaluate if ostomy care pathways improve outcomes for adults anticipating or living with an ostomy.

DATA SOURCES

In this systematic review, the authors searched the MEDLINE, CINAHL, Cochrane Central, and EMBASE databases.

STUDY SELECTION

Studies were included if they met the following criteria: written in English, targeted adults anticipating or currently living with an ostomy, evaluated the impact of two or more components of an ostomy care pathway, and included one or more of the pertinent outcomes (patient satisfaction, hospital length of stay, hospital readmission rates, and staff satisfaction).

DATA EXTRACTION

Details recorded included design, setting, descriptions of intervention and control groups, patient characteristics, outcomes, data collection tools, effect size, and potential harms.

DATA SYNTHESIS

Of 5,298 total records, 11 met the inclusion criteria: 2 randomized controlled trials and 9 nonrandomized studies. The overall quality of the studies was low. Of the four studies that examined patient satisfaction, all studies reported improvement or positive satisfaction rates. Of the six studies that evaluated hospital length of stay, five noted a decrease in length of stay. Of the eight studies that evaluated hospital readmission rates, five found a reduction in hospital readmission rates. No studies reported on staff satisfaction.

CONCLUSIONS

Ostomy care pathways included preoperative education and counseling, postoperative education and discharge planning, and outpatient home visits and telephone follow-ups. Ostomy care pathways may contribute to patient satisfaction and decrease both hospital length of stay and hospital readmission rates. However, higher-quality literature is needed to be confident in the effectiveness of ostomy care pathways.

Ostomy and Continent Diversion Patient Bill of Rights: Research Validation of Standards of Care

An estimated 725,000 to 1 million people are living with an ostomy or continent diversion in the United States, and approximately 100,000 ostomy surgeries are performed each year in the United States. As a result of ostomy surgery, bodily waste is rerouted from its usual path because of malfunctioning parts of the urinary or digestive system. An ostomy can be temporary or permanent. The ostomy community is an underserved population of patients. United Ostomy Associations of America, Inc (UOAA), is a nonprofit organization dedicated to promoting quality of life for people with ostomies and continent diversions through information, support, advocacy, and collaboration. Over the years, UOAA has received hundreds of stories from people who have received inadequate care. In the United States, patients receiving medical care have certain health rights. For ostomy and continent diversion patients, these rights are known as the "You Matter! Know What to Expect and Know Your Rights-Ostomy and Continent Diversion Patient Bill of Rights" (PBOR). These rights define and provide a guide to patients and health care professionals as to what the best practices are when receiving and providing high-quality ostomy care during all phases of the surgical experience. This includes preoperative to postoperative care and throughout the life span when living with an ostomy or continent diversion. In 2020, the National Quality Forum released "The Care We Need: Driving Better Health Outcomes for People and Communities," a National Quality Task Force report that provides a road map where every person in every community can expect to consistently and predictably receive high-quality care by 2030 (thecareweneed.org). One of the core strategic objectives this report stated is to ensure appropriate, safe, and accessible care. Actionable opportunities to drive change include accelerating adoption of leading practices. The adoption of the PBOR best practices will drive the health care quality improvement change needed for the ostomy and continent diversion population. There are concerns in the ostomy and continent diversion communities among patients and health care professionals that the standards of care outlined in the PBOR are not occurring across the United States in all health care settings. There are further concerns stated by health care professionals that the patient-centered recommendations outlined in the PBOR need to be strengthened by being supported with available published health care evidence. The work of this task force was to bring together members of UOAA's Advocacy Committee, members of the Wound, Ostomy, and Continence Nurses Society (WOCN Society) Public Policy and Advocacy Committee, and representatives from surgical organizations and industry to create a systemic change by validating through evidence the Ostomy and Continent Diversion PBOR. Through the work of the task force, each component of the PBOR has been substantiated as evidence-based. Thus, this article validates the PBOR as a guideline for high-quality standards of ostomy care. We show that when patients receive the standards of care as outlined in the PBOR, there is improved quality of care. We can now recognize that until every ostomy or continent diversion patient receives these health care rights, in all health care settings, will they truly be realized and respected as human rights in the United States and thus people living with an ostomy or continent diversion will receive "the care they need."

Assessment of the importance of ostomy patients' understanding of dietary and lifestyle recommendations

OBJECTIVE

the objective of our study was to evaluate the level of understanding of ostomy patients regarding lifestyle, diet, and high output stoma (HOS) management recommendations provided by healthcare professionals.

METHOD

a prospective study to follow up ostomy patients at nutritional consultations was designed. The follow-up process was performed 7-10 days after hospital discharge and again one month later. At the first visit, patients were instructed in the detection and management of HOS. At the second visit, the level of understanding of the training received was assessed using an evaluation questionnaire. A descriptive analysis of the answers to each of the questionnaire's items was performed. Fisher's exact test was used to evaluate differences in the level of understanding recorded with the questionnaire.

RESULTS

a total of 35 patients were recruited; 71.4 % did not provide correct answers to all the questions. There were no significant differences in the correctness of the answers to the questionnaire according to education level.

CONCLUSIONS

many patients do not adequately understand the information provided by healthcare professionals and this could have a negative impact on the incidence of clinical complications.

Ileostomy Patients Using Patient Engagement Technology Experience Decreased Length of Stay

Patients who undergo colorectal surgery, particularly, construction of a new ileostomy, are known to have longer length of stay (LOS) and increased readmissions. With the increased availability of patient engagement technology (PET), we hypothesized that because PET facilitates education before and after surgery, ileostomy patients who used PET would have decreased LOS without increasing readmissions. Variables were obtained from the National Surgical Quality Improvement Program (NSQIP) database for patients undergoing ileostomy construction. Study patients were categorized into three groups: pre-PET (patients prior to PET), non-PET (patients who did not use PET), and PET users (patients who used PET). Univariate analysis of patient and surgical characteristics, LOS, ED visits, and readmissions and multivariable modeling of potential predictors of LOS were performed. There were 106 patients in the pre-PET, 51 in the PET, and 108 in the non-PET and cohorts were similar except pre-op diagnosis. Length of stay was lower for the PET cohort (p = 0.0001), with no significant difference in readmission or ED visits. On multivariable analysis, we identified the PET cohort as an independent predictor of shorter LOS relative to non-PET and pre-PET (p = 0.007 and p = 0.02, respectively). Similarly, patients had significantly shorter LOS who had a diagnosis of neoplasm as compared to IBD (p = 0.03). Hypertension requiring medication (p = 0.001) and Black race relative to White race (p = 0.002) were independent predictors of longer LOS. In this study of ileostomy patients, we have shown that use of PET is an independent predictor of decreased LOS without increased ED visits or readmissions.

Overall readmissions and readmissions related to dehydration after creation of an ileostomy: a systematic review and meta-analysis

Background

Hospital readmissions after creation of an ileostomy are common and come with a high clinical and financial burden. The aim of this review with pooled analysis was to determine the incidence of dehydration-related and all-cause readmissions after formation of an ileostomy, and the associated costs.

Methods

A systematic literature search was conducted for studies reporting on dehydration-related and overall readmission rates after formation of a loop or end ileostomy between January 1990 and April 2021. Analyses were performed using R Statistical Software Version 3.6.1.

Results

The search yielded 71 studies (n = 82,451 patients). The pooled incidence of readmissions due to dehydration was 6% (95% CI 0.04–0.09) within 30 days, with an all-cause readmission rate of 20% (CI 95% 0.18–0.23). Duration of readmissions for dehydration ranged from 2.5 to 9 days. Average costs of dehydration-related readmission were between $2750 and $5924 per patient. Other indications for readmission within 30 days were specified in 15 studies, with a pooled incidence of 5% (95% CI 0.02–0.14) for dehydration, 4% (95% CI 0.02–0.08) for stoma outlet problems, and 4% (95% CI 0.02–0.09) for infections.

Conclusions

One in five patients are readmitted with a stoma-related complication within 30 days of creation of an ileostomy. Dehydration is the leading cause for these readmissions, occurring in 6% of all patients within 30 days. This comes with high health care cost for a potentially avoidable cause. Better monitoring, patient awareness and preventive measures are required.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02580-6.

Nursing Interventions to Promote Self-Care in a Candidate for a Bowel Elimination Ostomy: Scoping Review

Objectives: To identify nursing interventions, their characteristics, and outcomes for promoting self-care in candidates for a bowel elimination ostomy. Materials and methods: A scoping review was carried out based on the Joanna Briggs Institute’s recommendations. For this, studies published in Portuguese, English, and Spanish on the Web of Science, CINAHL, and Scopus databases and without a time limit were selected on November 9, 2020. Results: Of 2248 articles identified, 41 were included in this review. We identified 20 nursing interventions associated with the self-care of patients with an ostomy; most of them have gaps in their content, method, and frequency or dosing. More than 30 indicators were identified to assess the impact of nursing interventions; however, most of them were indirect assessments. Conclusion: There is scarce evidence regarding the different aspects that must be involved in nursing interventions for patients with a stoma. Moreover, there is no standardization in methods, frequency, or dosing of intervention. It is urgent to define the content, method, and frequency of nursing interventions necessary to promote self-care in patients with a bowel elimination ostomy and to use assessment tools that directly measure stoma self-care competence.

Preventable Emergency Department Visits After Colorectal Surgery

BACKGROUND

The emergency department plays a common and critical role in the treatment of postoperative patients. However, many quality improvement databases fail to record these interactions. As such, our understanding of the prevalence and etiology of postoperative emergency department visits in contemporary colorectal surgery is limited. Visits with potentially preventable etiologies represent a significant target for quality improvement, particularly in the current era of rapidly evolving postoperative and ambulatory care patterns.

OBJECTIVE

We aimed to characterize postoperative emergency department visits and identify factors associated with these visits for potential intervention.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at an academic medical center.

PATIENTS

Consecutive patients undergoing colectomy or proctectomy within the division of colorectal surgery at an academic medical center between 2014 and 2018 were included.

MAIN OUTCOME MEASURES

Frequency and indication for emergency department visits, as well as clinical and sociodemographic factors associated with emergency department visits in the postoperative period, were included measures.

RESULTS

From the 1763 individual operations, there were 207 emergency department visits from 199 patients (11%) within 30 days of discharge. Two thirds of emergency department visits led to readmission. Median (interquartile range) time to presentation was 8 days (4-16 d). Median time in the emergency department was 7.8 hours (6.0-10.1 h). One third of visits were identified as potentially preventable, most commonly for pain (17%) and stoma complications (excluding dehydration; 13%). A primary language other than English was associated with any postoperative emergency department visit risk ratio of 2.7 (95% CI, 1.3-5.3), as well as a preventable visit risk ratio of 3.6 (95% CI, 1.7-8.0).

LIMITATIONS

This was a single-center study and a retrospective review.

CONCLUSIONS

One third of emergency department visits after colorectal surgery are potentially preventable. Special attention should be directed toward those patients who do not speak English as a primary language. See Video Abstract at http://links.lww.com/DCR/B648.

SE PUEDEN EVITAR LAS VISITAS AL SERVICIO DE URGENCIA DESPUS DE UNA CIRUGA COLORECTAL

ANTECEDENTES:Las unidades de emergencia tienen un rol fundamental en el periodo posterior a una cirugía. Sin embargo muchos de los registros en las bases de datos de estas secciones no son de buena calidad. Por esto analizar la prevalencia y etiología de las visitas postoperatorias en cirugía colorectal resulta ser bastante limitada. Para lograr una mejoría en la calidad es fundamental analizar las causas potencialmente evitables, especialmente al considerer la rapida evolucion de los parametros de medición actuales.OBJETIVO:Nuestro objetivo es caracterizar las visitas postoperatorias al servicio de urgencias e identificar los factores asociados potencialmente evitables.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Centro médico académico, 2014-2018.PACIENTES:Pacientes consecutivos sometidos a colectomía o proctectomía dentro de la división de cirugía colorrectal en un centro médico académico entre 2014 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:Frecuencia e indicación de las visitas al servicio de urgencias en el period postoperatorio: factores clínicos y sociodemográficos.RESULTADOS:De 1763 operaciones individuales, hubo 207 visitas al departamento de emergencias de 199 pacientes (11%) en los 30 días posteriores al alta. Dos tercios de las visitas al servicio de urgencias dieron lugar a readmisiones. La mediana [rango intercuartílico] de tiempo hasta la presentación fue de 8 [4-16] días. La mediana de tiempo en el servicio de urgencias fue de 7,8 [6-10,1] horas. Un tercio de las visitas se identificaron como potencialmente evitables, más comúnmente dolor (17%) y complicaciones del estoma (excluida la deshidratación) (13%). En los pacientes con poco manejo del inglés se asoció con una mayor frecuencia razón de visitas al departamento de emergencias posoperatorias [IC del 95%] 2,7 [1,3-5,3], así como opetancialmente evitables con un RR de 3,6 [1,7-8,0].LIMITACIONES:Estudio de un solo centro y revisión retrospectiva.CONCLUSIÓN:Al menos un tercio de las visitas al servicio de urgencias después de una cirugía colorrectal son potencialmente evitables. Se debe prestar especial atención a los pacientes que no hablan inglés como idioma materno. Consulte Video Resumen en http://links.lww.com/DCR/B648.

Colorectal: Management of Postoperative Complications in Colorectal Surgery

The complications encountered in colorectal surgery can be categorized into early and late. The most consequential early complication is anastomotic leak, which can be managed with percutaneous drainage or reoperation, depending on the patient's clinical status. Other early complications include anastomotic bleeding, surgical site infection, ileus, postoperative urinary retention, and stoma-related complications. Most stoma-related complications can be managed without reoperation. Late complications, such as bowel dysfunction, sexual dysfunction, and anastomotic stricture, are usually managed expectantly and should be discussed in the preoperative setting. There is growing interest in prevention of postoperative outcomes with preoperative nutritional supplementation and prehabilitation.

Algorithmic approaches to ostomy management: An integrative review

Objective

The aim of this review is to describe approaches to ostomy management utilizing algorithmic approaches found within the literature.

Design

An integrative review approach was used based on a modified Cooper's five‐stage research review framework.

Data Sources

Systematic searches occurred using the CINAHL and MEDLINE databases searching for peer‐reviewed, English publications.

Review Methods

There were 640 articles identified through the review process, 608 of which were excluded based on title and abstract review. The remaining 12 articles were assessed in full text after which two studies were removed as duplicates and six studies were excluded based on inclusion/exclusion criteria. Four studies were included in this synthesis. Studies were critically analysed using a critical appraisal tool developed for both qualitative and quantitative study assessments.

Results

Utilizing inductive content analysis, included literature was presented within two categories: validation of ostomy algorithms and implementation of ostomy algorithms in practice. Four themes emerged from these categories including the following: algorithm validation, identifying underlying causes, focus on accessories and large‐scale implementation.

Conclusion

No currently available validated algorithms published in full were found during this literature review. Current literature demonstrates the potential benefit for ostomy management algorithms to standardize and improve ostomy patient care.

Impact

This study sought to determine the availability and supporting research of ostomy management algorithms which may assist in standardizing and improving ostomy care. This review has demonstrated a lack of available ostomy management algorithms. Given the potential benefit of ostomy algorithms identified within the literature, further studies should be completed to develop, validate and test new ostomy management algorithms.

Dietary management for people with an ileostomy: a scoping review

OBJECTIVE

The objective of this review was to identify and map the evidence for oral dietary management of ileostomies.

INTRODUCTION

Dietary advice is commonly provided for ileostomy management but can be inconsistent, conflicting, and inadequate. There is a lack of high-quality research investigating dietary management of ileostomies. This scoping review highlights gaps in the literature that need addressing to inform practice, and identifies dietary strategies and outcomes to be investigated in future studies.

INCLUSION CRITERIA

Evidence relating to the use of oral dietary strategies to manage complications and nutritional consequences associated with having an ileostomy was included. Evidence included all types of original research (ie, quantitative and qualitative methodologies, expert opinion articles, and consensus guidelines).

METHODS

This review followed JBI methodology for scoping reviews. A pre-determined search of 13 databases, including MEDLINE, Embase, and Web of Science, was conducted in August 2019. The search was not limited by date, but during screening, expert opinion evidence was limited to 2008 onward. Data extraction was carried out by two reviewers for each study/article using a database tool designed specifically for this review. Results are presented using a combination of tabular summaries and narrative reports.

RESULTS

Thirty-one research studies were included: 11 experimental (including four crossover randomized controlled trials), three pre-post design, 13 observational (12 cross-sectional, one longitudinal), and four qualitative. Forty-four expert opinion articles/guidelines were also included. In experimental studies, nine nutrient modifications and 34 individual foods/drinks were investigated. In pre-post studies, 10 nutrient modifications, 80 foods/drinks, and 11 eating-related behaviors were investigated. In observational studies, eight nutrient modifications, 94 foods/drinks, and five eating-related behaviors were reported. In qualitative studies, two nutrient modifications, 17 foods/drinks, and one eating-related behavior were reported. In expert opinion articles/guidelines, recommendations relating to 51 nutrient modifications, 339 foods/drinks, and 23 eating-related behaviors were reported. Although large numbers of individual foods and drinks were suggested to be associated with outcomes relating to ileostomy management, findings from observational studies showed these were generally reported by <50% of people with an ileostomy. The most common nutrients reported in association with outcomes related to ileostomy management were fiber, fat, and alcohol. Across most outcomes and studies/expert opinion, low fiber and low fat were suggested to be beneficial, while alcohol was detrimental. Other nutrient associations frequently reported in expert opinion (but with minimal attention in research studies) included negative consequences of caffeinated drinks and positive effects of white starchy carbohydrates on stoma output. Output volume and consistency were the most commonly reported outcomes relating to ileostomy management across all study types. Flatulence and odor were also common outcomes in observational studies.

CONCLUSIONS

This review found an abundance of literature, particularly expert opinion, reporting on dietary management for people with an ileostomy. However, this literature was highly heterogeneous in terms of dietary strategies and outcomes reported. It is likely that most dietary advice provided in practice is based on expert opinion with some supported by limited research. High-quality research investigating the effect of the dietary strategies identified in this review on commonly associated outcomes relating to ileostomy management is needed to improve evidence-based advice.

Impact of a nutrition consultation on the rate of high output stoma-related readmission: an ambispective cohort study

The aims of this study were to assess the impact of a follow-up nutrition consultation for ostomy patients on the rate of high output stoma (HOS)-related readmissions, as well as on the detection of poor nutritional status and their management, and to determine the associated economic impact. A single-centre ambispective cohort study was conducted in which all adult patients undergoing intestinal resection and stoma creation were recruited. Two nutrition consultations were established for early follow-up after hospital discharge and patients were prospectively included. Additionally, a retrospective search was carried out to include a control group. In both groups, a 12-month follow-up was conducted to record readmissions associated with high output stoma. A multivariate logistic regression was performed. Statistical significance level was established at p < 0.05. 170 patients were recruited, 85 patients in each cohort. Demographic data and clinical characteristics were recorded. A significant difference was observed in HOS-related readmissions, with readmission rates of 28.6% vs 10.3% in the retrospective and prospective cohort, respectively. At the first follow-up consultation, 50.5% of patients presented some degree of protein-calorie malnutrition. A statistically significant improvement in nutritional status was observed in the second evaluation. The intervention carried out resulted in a total saving of €24,175. Early follow-up of patients after discharge resulted in a significant reduction in the rate of HOS-related readmissions and allowed to identify a high percentage of patients with malnutrition. The cost analysis showed the process to be a cost-effective improvement.

New Ileostomy Formation and Subsequent Community-onset Acute and Chronic Kidney Disease: A Population-based Cohort Study

OBJECTIVE

The aim of this study was to examine relationships between ileostomy formation and subsequent kidney disease.

SUMMARY AND BACKGROUND DATA

Colonic absorptive capacity loss from ileostomy formation can cause volume depletion and could result in kidney disease.

METHODS

We conducted a population-based cohort study comparing patients who underwent ileostomy formation with or without bowel resection (ileostomy group) to patients who underwent bowel resection without ileostomy formation (reference group). Adjusted odds ratios (aORs) for community-onset acute kidney injury (AKI) within 3 months and new-onset chronic kidney disease (CKD) within 1 year following hospital discharge were determined.

RESULTS

Among 19,889 patients, 4136 comprised the ileostomy group and 15,753 comprised the reference group; 1350 patients experienced community-onset AKI and 464 developed new-onset CKD. The aOR for community-onset AKI with ileostomy formation was 4.08 [95% confidence interval (CI) = 3.62-4.61] for any stage AKI, 7.08 (95% CI = 5.66-8.85) for stage ≥2 injury, and 7.67 (95% CI = 5.06-11.63) for stage 3 injuries. Community-onset AKI modified associations between ileostomy formation and new-onset CKD (P = 0.002). Odds of new-onset CKD were increased in the ileostomy group relative to the reference group for patients both with (aOR = 4.99; 95% CI = 3.42-7.28) and without (aOR = 2.45; 95% CI = 1.85-2.23) previous community-onset AKI episodes. In analyses comparing patients that underwent ileostomy formation and subsequent reversal within 1 year to the reference group without ileostomy, the relationship with new-onset CKD was attenuated for patients both with (aOR = 2.49; 95% CI = 1.50-4.12) and without (aOR = 0.97; 95% CI = 0.67-1.40) previous community-onset AKI episodes.

CONCLUSIONS

Ileostomy formation is strongly associated with subsequent kidney disease. Vigilance for this complication and new strategies for prevention and treatment are necessary.