Early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resections: an integrated systematic review and meta-analysis of published randomized controlled trials

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Ileostomy versus colostomy: impact on functional outcomes after total mesorectal excision for rectal cancer

AIM

Even if a defunctioning stoma mitigates the serious consequences of anastomotic leakage after total mesorectal excision (TME) for rectal cancer, the presence of a temporary stoma or having a stoma for a prolonged period of time may also be a determining factor for further morbidities and poor bowel function. The aim of this study was to evaluate the impact of diverting stomas on clinical and functional outcomes after TME, comparing ileostomy or colostomy effects.

METHODS

All consecutive patients who underwent TME for rectal cancer between March 2017 and December 2020 in three Italian referral centres were enrolled in the present study. For every patient sex, age, stage of the tumour, neoadjuvant therapy, surgical technique, anastomotic technique, the presence of a diverting stoma, perioperative complications and functional postoperative status were recorded. Considering the diverting stoma, the kind of stoma, length of time before closure and stoma related complications were evaluated.

RESULTS

During the study period 416 consecutive patients (63% men) were included. Preoperative neoadjuvant therapy was performed in 79%. A minimally invasive approach was performed in >95% of patients. Temporary stoma was performed during the operation in 387 patients (93%) (ileostomy 71%, colostomy 21%). The stoma was closed in 84% of patients. The median time from surgery to stoma closure was 145 days. No difference was found between ileostomy and colostomy in overall morbidity after stoma creation and closure. Moreover, increased postoperative functional disturbance seemed to be significantly proportional to the attending time for closure for ileostomy.

CONCLUSION

The presence of a defunctioning stoma seems to have a negative impact on functional bowel activity, especially for delayed closure for ileostomy. This should be considered when the kind of stoma (ileostomy vs. colostomy) is selected for each patient.

A novel nomogram to predict low anterior resection syndrome (LARS) after ileostomy reversal for rectal cancer patients

BACKGROUND AND AIM

Low anterior resection syndrome (LARS) in patients undergoing low or ultra-low anterior resection (LAR) is a common problem and significantly impacts the quality of life. Patients with an ileostomy after LAR are more likely to develop LARS. However, there hasn't been a model predicting LARS occurrence in these patients. This study aims to construct a nomogram to predict the probability of LARS occurrence in patients with temporary ileostomy and guide preventive strategies before reversal.

METHODS

168 patients undergoing LAR with ileostomy from one center were enrolled as the training cohort, and 134 patients of the same inclusion criteria from another center were enrolled as the validation cohort. The training cohort was screened for risk factors for major LARS using univariate and multivariate logistic regression. The nomogram was constructed using the filtered variables, the ROC curve was used to describe the model's discrimination, and the calibration was used to describe the accuracy.

RESULTS

The optimal cut-off value for stoma closure time was 128 days. Three risk factors were identified using logistic regression analysis: preoperative radiotherapy (OR = 3.038, [95%CI 1.75-5.015], P = 0.005), stoma closure time (OR = 2.298, [95%CI 1.088-4.858], P = 0.029) and pN stage (OR = 1.739, [95%CI 1.235-3.980], P = 0.001). A nomogram was constructed based on these three variables and showed good performance predicting major LARS after stoma reversal. The area under the curve (AUC) was 0.827 in the training group and 0.821 in the validation group; The calibration curve suggested good precision in both groups.

CONCLUSIONS

This novel nomogram can accurately predict the probability of major LARS occurrence after ileostomy reversal for rectal cancer patients. This model can help screen ileostomy patients with high risks and guide individualized preventive strategies before stoma reversal.

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

AIM

The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR.

METHOD

Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed.

RESULTS

Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%).

CONCLUSION

The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Morbidity of Temporary Loop Ileostomy in Patients with Colorectal Cancer

Leakage of low colorectal anastomoses after total mesorectal excision is a dreaded complication. Hence, an ileostomy is commonly performed during anterior resection especially in patients who have received neoadjuvant radiation. The aim of this study was to quantify the temporary loop ileostomy-related benefits as well as morbidity in patients with colorectal cancer. We did a retrospective study including all patients who underwent anterior resection with diversion ileostomy for biopsy-proven rectal carcinoma at our institute from 1 Jan 2016 to 31 Dec 2017 with follow-up of 2 years. A total of 104 patients were included in the study. In our series, 6.7% patients had an anastomotic dehiscence which precluded patients from stoma reversal. 12.5% of the patients had a stoma-related complication. 5.7% patients had complications following a stoma reversal. Eighty percent of the patients who developed clinically evident dehiscence in the immediate postoperative period were managed conservatively because of the presence of stoma. We did not have any mortality related to the stoma. 18.3% patients did not have their stomas reversed. The stoma non-reversal due to anastomotic dehiscence or stricture could be attributed to in 7.7% patients. 3.8% had to have their ileostomies converted to a permanent colostomy due to either a rectovaginal fistula or dehiscence or stricture. The complications associated with ileostomy are not insignificant. In our study, the tumor location in lower rectum was the only significant factor for non-reversal. We have to objectively identify patients who are at low risk for leakage and avoid ileostomy in them, and also try to minimize the morbidity of ileostomy by methods like early closure.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

Risk factors for postoperative ileus after diverting loop ileostomy closure

BACKGROUND

Postoperative ileus is one of the most common complications after diverting loop ileostomy closure. Some reports have investigated the risk factors for postoperative complications or ileus after ileostomy closure; however, these studies did not evaluate the index surgery sufficiently. In this study, we evaluated the risk factors, including the details of the index surgery, for ileus after diverting ileostomy closure.

METHODS

This was a retrospective study of patients who underwent ileostomy closure following index surgery for rectal cancer. Patients who developed postoperative ileus [POI (+)] and patients who did not [POI (-)] after ileostomy closure were compared.

RESULTS

Sixty-eight patients were evaluated and were divided into two groups: POI (+) (n = 11) and POI (-) (n = 57), and the groups were compared. There were no significant differences in the details of the index surgery, operative procedure, transanal total mesorectal excision, lateral lymph node dissection, operating time, or blood loss. The incidence of Clavien-Dindo grade ≥ III complications and adjuvant chemotherapy after index surgery were significantly higher in the POI (+) group.

CONCLUSIONS

The incidence of Clavien-Dindo grade ≥ III complications and adjuvant chemotherapy after index surgery may increase the risk of postoperative ileus after ileostomy closure.

Early versus delayed defunctioning ileostomy closure after low anterior resection for rectal cancer: a meta-analysis and trial sequential analysis of safety and functional outcomes

PURPOSE

We performed a systematic review and meta-analysis with trial sequential analysis (TSA) to answer whether early closure of defunctioning ileostomy may be suitable after low anterior resection.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, up to October 2021, for RCTs comparing early closure (EC ≤ 30 days) and delayed closure (DC ≥ 60 days) of defunctioning ileostomy. The risk ratio (RR) with 95% CI was calculated for dichotomous variables and the mean difference (MD) with 95% CI for continuous variables. The GRADE methodology was implemented for assessing Quality of Evidence (QoE). TSA was implemented to address the risk of random error associated with sparse data and/or multiple testing.

RESULTS

Seven RCTs were included for quantitative synthesis. 599 patients were allocated to either EC (n = 306) or DC (n = 293). EC was associated with a higher rate of wound complications compared to DC (RR 2.56; 95% CI 1.33 to 4.93; P = 0.005; I2 = 0%, QoE High), a lower incidence of postoperative small bowel obstruction (RR 0.46; 95% CI 0.24 to 0.89; P = 0.02; I2 = 0%, QoE moderate), and a lower rate of stoma-related complications (RR 0.26; 95% CI 0.16 to 0.42; P < 0.00001; I2 = 0%, QoE moderate). The rate of minor low anterior resection syndrome (LARS) (RR 1.13; 95% CI 0.55 to 2.33; P = 0.74; I2 = 0%, QoE low) and major LARS (RR 0.80; 95% CI 0.59 to 1.09; P = 0.16; I2 = 0%, QoE low) did not differ between the two groups. TSA demonstrated inconclusive evidence with insufficient sample sizes to detect the observed effects.

CONCLUSION

EC may confer some advantages compared with a DC. However, TSA advocated a cautious interpretation of the results.

PROSPERO REGISTER ID

CRD42021276557.

Timing of Closure of a Protective Loop-Ileostomy Can Be Crucial for Restoration of a Functional Digestion

Introduction

Protective loop-ileostomy is one of the most common interventions in abdominal surgery to provide an alternative intestinal outlet until sufficient healing of a distal anastomosis has occurred. However, closure of a loop-ileostomy is also associated with complications. Thus, knowledge of the optimal time interval between primary and secondary surgery is crucial.

Methods

Data from 409 patients were retrospectively analyzed regarding complications and risk factors in closure-associated morbidity and mortality. A modified Clavien-Dindo classification of surgical complications was used to evaluate the severity of complications.

Results

A total of 96 (23.5%) patients suffered from postoperative complications after the closure of the loop-ileostomy. Early closure within 150 days from enterostomy (n = 229) was associated with less complications (p < 0.001^**). Looking at the severity of complications, there were significantly more (p = 0.014^*) mild postoperative complications in the late closure group (>150 days). Dysfunctional digestive problems—either (sub-) ileus (p = 0.004^*), diarrhea or stool incontinence (p = 0.003^*)—were the most frequent complications associated with late closure. Finally, we could validate in a multivariate analysis that “time to closure” (p = 0.002^*) is independently associated with the development of complications after closure of a protective loop-ileostomy.

Conclusion

Late closure (>150 days) of a loop-ileostomy is an independent risk factor in post-closure complications in a multivariate analysis. Nevertheless, circumstances of disease and therapy need to be considered when scheduling the closure procedure.

Improving the time to ileostomy closure following an anterior resection for rectal cancer in the UK

AIM

Delayed closure of ileostomy following an anterior resection for rectal cancer in the UK is common. The aims of this study were (i) to investigate the variation in patient pathways between hospitals, (ii) to identify the key learning points from units with the shortest time to closure and (iii) to develop guidance for a pathway to minimize delay in ileostomy closure.

METHOD

This was a mixed methods study. Thirty-eight colorectal units in the UK completed a short online survey. Nine colorectal units in Wales filled in an additional, expanded version of the survey. Semi-structured interviews were performed with clinicians from the six best performing units in terms of timely ileostomy closure. The optimal pathway suggested is based on the best evidence available and the Association of Coloproctology of Great Britain and Ireland guidelines.

RESULTS

Qualitative analysis revealed that 5% of units (n = 2) have a local target time for ileostomy closure. Of all units, 90% (n = 34) would consider implementing a pathway if guidelines were developed. In-depth interviews highlighted the importance of a multidisciplinary approach, a dedicated coordinator to facilitate timely booking, and consensus on whether closure should be performed before or after adjuvant chemotherapy.

CONCLUSION

There is a lack of national guidance in timing of contrast studies and ileostomy closure. Key aspects to consider are better information at consent regarding stoma closure timing, a dedicated person to track patients and the planning of contrast studies at discharge from initial surgery. With a dedicated approach closure of ileostomy within 10-12 weeks is feasible for most units.

[Nursing interventions in stoma reversal: an integrative reviewIntervenções de enfermagem na inversão do estoma intestinal: uma revisão integrativa]

Introduction

Intestinal stomas have a significant impact on people's quality of life. However, these should be reversed after gastrointestinal transit has been restored or the initial inflammatory response has gone. In addition, patients may refuse to reverse them due to a lack of information and guidance from healthcare professionals. Therefore, it is important to identify nursing interventions in caring for patients with stoma reversal.

Materials and Methods

An integrative literature review was conducted in WOS, PubMed, Scopus, SciELO and Cochrane databases published between 2015 and 2020. 36 articles were selected based on inclusion and exclusion criteria with their methodological analysis.

Results

The following nursing interventions were identified: preoperative assessment, bowel preparation and follow-up of comorbidities in the preoperative period; prophylaxis, skin preparation, surgical technique and abdominal wall closure in the intraoperative period; surgical wound care, quality of life and education in the postoperative period.

Discussion

It is essential to reflect on reversal time, surgical technique and the importance of nursing interventions.

Conclusions

Nursing plays an important role in stoma reversal not only because of physical care and education provided, but also the interventions applicable to social and emotional contexts affecting the patient's lifestyle.

Extended duration of faecal diversion is associated with increased ileus upon loop ileostomy reversal

AIM

The timing of ileostomy reversal has been the subject of controversy, with researchers investigating the safety of early versus late stoma closure. Anecdotally, a longer duration of faecal diversion is associated with a greater incidence of postoperative ileus. We sought to investigate the association between duration of diversion and postoperative ileus.

METHOD

We conducted an institutional retrospective cohort study on 173 patients undergoing ileostomy closure between 2012 and 2018. Our primary outcome was ileus; secondary outcomes included postoperative complications and descriptive factors. We investigated the association between duration of diversion and ileus using several analyses to ensure that time was treated appropriately as a continuous, nonlinear variable.

RESULTS

In all, 20.2% of patients had an ileus. Multivariate analysis did not identify a significant association between any independent predictors and ileus, although there was a trend towards increased risk of ileus with increasing duration of diversion. When treated as a categorical variable, a duration of diversion >328 days independently increased the odds of ileus (OR = 3.25, P = 0.033). Duration of diversion was associated with days to first flatus and to first diet (P = 0.025 and P = 0.004, respectively). When patients received nasogastric intubation, the mean duration of intubation was 3.2 days.

CONCLUSION

Greater duration of diversion was associated with a trend towards increased risk of ileus; this risk tripled when diversion lasted more than 328 days.

Impact of a defunctioning ileostomy and time to stoma closure on bowel function after low anterior resection for rectal cancer: a systematic review and meta-analysis

BACKGROUND

Impaired bowel function after low anterior resection (LAR) for rectal cancer is a frequent problem with a major impact on quality of life. The aim of this study was to assess the impact of a defunctioning ileostomy, and time to ileostomy closure on bowel function after LAR for rectal cancer.

METHODS

We performed a systematic review based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Comprehensive literature searches were conducted using PubMed, Embase and Cochrane databases for articles published from 1989 up to August 2019. Analysis was performed using Review Manager (version 5.3) using a random-effects model.

RESULTS

The search yielded 11 studies (1400 patients) that reported on functional outcome after LAR with at least 1 year follow-up, except for one study. Five scales were used: the Low Anterior Resection Syndrome (LARS) score, the Wexner score, the Memorial Sloan Kettering Cancer Centre Bowel Function Instrument, the Fecal Incontinence Quality of Life scale, and the Hallbook questionnaire. Based on seven studies, major LARS occurred more often in the ileostomy group (OR 2.84, 95% CI, 1.70-4.75, p < 0.0001: I2 = 60%, X2 = 0.02). Based on six studies, a longer time to stoma closure increased the risk of major LARS with a mean difference in time to closure of 2.39 months (95% CI, 1.28-3.51, p < 0.0001: I2 = 21%, X2 = 0.28) in the major vs. no LARS group. Other scoring systems could not be pooled, but presence of an ileostomy predicted poorer bowel function except with the Hallbook questionnaire.

CONCLUSIONS

The risk of developing major LARS seems higher with a defunctioning ileostomy. A prolonged time to ileostomy closure seems to reinforce the negative effect on bowel function; therefore, early reversal should be an important part of the patient pathway.

Diversion Colitis and Probiotic Stimulation: Effects of Bowel Stimulation Prior to Ileostomy Closure

Background: Diversion colitis is a non-specific inflammation of a defunctionalised segment of the colon after a temporary stoma has been performed. This inflammation is associated with a change in the colonic flora. Aim: To evaluate the efficacy and safety of preoperative stimulation of the efferent loop with probiotics prior to closure of the protective ileostomy in patients operated on colorectal carcinoma and its effect on diversion colitis. A prospective, randomised, double-blind, controlled study is carried out. Methods: Patients who underwent surgery for colorectal carcinoma with protective ileostomy pending reconstructive surgery and with diversion colitis as diagnosis are included. Randomised and divided into two groups. Histological and endoscopic changes were evaluated after stimulation, after restorative surgery and during the short-term follow-up after surgery. Results: Patients in CG were distributed according to the endoscopic index of severity in pre-stimulation/post-stimulation as follows: severe n = 9/9 (25.7%), moderate n = 23/23 (65.7%), and mild n = 3/3 (8.6%); compared to the distribution in SG, severe n = 9/0 (26.5/0%), moderate n = 23/3 (67.6/8.8%), mild n = 2/19 (5.9/55.9%) and normal colonoscopy in 0/12 patients (0/35.3%). Conclusion: Probiotic stimulation of the efferent loop is a safe and effective method, managing to reduce both macroscopic and microscopic colitis, as well as a decrease in symptoms in the short term after reconstructive surgery.

Increased risk of complications in smokers undergoing reversal of diverting ileostomy

BACKGROUND

Diverting ileostomy (DI) is utilised in rectal cancer surgery to mitigate the effects of anastomotic leak. The aim of this study was to assess the clinical risk factors associated with post-operative complications of DI reversal.

METHODS

A single-centre retrospective analysis of patients who underwent surgical resection for rectal cancer and subsequent DI reversal between January 2012 and December 2020 was undertaken. Medical records were reviewed to extract clinical, operative and pathologic details and post-operative complications according to the Clavien-Dindo classification. Univariate and multivariable analyses were undertaken to assess risk factors associated with post-operative complications of DI reversal.

RESULTS

One hundred and twenty-six adult patients who underwent DI reversal were included of which 49 had a post-operative complication (39%). The most common complication was prolonged post-operative ileus, which occurred in 24 patients (19%). On multivariable analysis smoking was significantly associated with overall complications (odds ratio [OR] = 5.60, 95% confidence interval [CI] 1.90-16.52, p = 0.0018), and high Clavien-Dindo (2-5) category complications (OR = 4.60, 95% CI 1.81-11.68, p = 0.0013). In addition, patients who received adjuvant chemotherapy were less likely to have a reversal of DI complication (OR = 0.43, 95% CI 0.19-0.94, p = 0.0342) and less likely to have a high Clavien-Dindo (2-5) category complication (OR = 0.44, 95% CI 0.20-0.93, p = 0.0311).

CONCLUSION

Smokers who have undergone surgical resection of rectal cancer have a significantly increased risk of post-operative complications after DI reversal. In these patients, the importance of smoking cessation must be emphasised. The decreased complication rate observed in patients who received adjuvant chemotherapy was an unexpected finding.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Loop ileostomy in rectal cancer surgery: factors predicting reversal and stoma related morbidity

PURPOSE

Loop ileostomy is performed in rectal cancer surgery to decrease the impact of anastomotic leak but it is associated with a significant complication rate. This study aimed to analyze the morbidity related to diverting ileostomy and to identify factors predictive of complications related to stoma management and reversal, as well as conversion into a permanent ileostomy.

METHODS

A retrospective study was conducted on 112 patients submitted to oncological rectal resection and defunctioning ileostomy in a Portuguese colorectal unit between March 2012 and March 2019.

RESULTS

Loop ileostomy was responsible for 13% of index surgery morbidity and 15% of patients' readmissions due to high output, stoma stenosis and parastomal hernia. Ileostomy was reversed in 89% cases with 7% Clavien-Dindo ≥ IIIb complications. An association was established between diabetes and higher stoma management morbidity (OR: 3.28 [95% CI: 1.039-10.426]. p = 0.041). Likewise, diabetes (OR: 0.17 [95% CI: 0.038; 6.90], p=0.015), oncological disease stage ≥ III (OR: 0.10 [95% CI: 0.005; 0.656], p=0.047) and index rectal surgery morbidity (OR: 0.23 [95% CI: 0.052; 0.955], p=0.041) were associated with less ileostomy closure. Complications of the index surgery also related to higher stoma reversal morbidity (OR: 5.11 [95% CI: 1.665; 16.346], p=0.005).

CONCLUSIONS

Diabetes and complications of index rectal surgery were identified as predictive of ileostomy morbidity, closure rate and associated complications. It is essential to adjust treatment decisions to patient's morbidity risk and adopt a more selective approach concerning the use of an ileostomy.

Predictors of hernia after loop ileostomy closure: a single-center retrospective review

PURPOSE

Our aims were to determine the rate of incisional hernia after closure of a loop ileostomy (LI) and to identify any perioperative risk factors that may be associated with hernia development.

METHODS

We performed an IRB-approved retrospective review that included consecutive patients who underwent LI closure from January 1, 2012, to December 31, 2014. The primary outcome was identification of hernia on physical exam or by abdominal imaging. A stepwise logistic regression analysis was used to determine predictors of ileostomy site hernia.

RESULTS

A total of 243 consecutive patients had LI closure during the study timeframe. The overall rate of hernia formation was 11.9% (29/243). The median time to discovery of the hernia was 16.4 (range, 2.2-55.9) months with a median follow-up time of 49 months. Although LI performed in conjunction with sigmoidectomy for diverticulitis consisted of only 19% of ileostomy cases, 62% of hernias were (18/29) identified in this cohort. Rates of hernia formation increased with respect to body mass index (underweight 0%; normal 4.6%; overweight 13.8%; obese 21%). The multivariable model identified increased BMI (underweight/normal weight versus overweight: OR 4.13, 95% CI 1.06-16.04; underweight/normal weight versus obese: OR 8.74, 95% CI 2.17-35.23) and surgical indication (reference variable: diverticulitis; rectal cancer: OR 0.21, 95% CI 0.06-0.76; Crohn's/ulcerative colitis: OR 0.06, 95% CI 0.01-0.53; other: OR 0.15, 95% CI 0.04-0.64) as significant predictors of ileostomy site hernia.

CONCLUSION

The development of a hernia at the site of LI closure was influenced mostly by BMI, surgical indication, and operative time.

Early versus late closure of temporary ileostomy after rectal cancer surgery: a meta-analysis

The complications caused by early closure (EC) or late closure (LC) after temporary ileostomy in rectal cancer patients have not been compared systematically. We conducted this meta-analysis to explore the details surrounding this issue, based on a search of PubMed, ScienceDirect, Scopus, Web of Science, Ovid MEDLINE, the Cochrane Library, Embase, and Google Scholar. The comparative indices included total complications, severe complications, and various individual complications before or after closure. Four randomized-controlled trials (RCTs), including the EASY trial, were analyzed, involving a collective total of 324 patients. EC tended to result in more postoperative complications than LC for rectal cancer patients with temporary ileostomy. This difference was mainly embodied in wound complications. Nevertheless, LC resulted in more complications than EC before closure, such as leakage outside the appliance bag and skin irritation. There was no obvious difference in severe postoperative complications or medical complications. With fewer overall and wound-related complications, LC tended to be more suitable than EC for rectal cancer patients with a temporary ileostomy; however, the complications before closure should also be considered.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The feasibility and safety of early ileostomy reversal: a systematic review and meta-analysis

BACKGROUND

Recent evidence supports the safety of early reversal of a temporary stoma, within 14 days of construction. The aim of this systematic review and meta-analysis was to evaluate the post-operative morbidity and overall feasibility of early stoma reversal.

METHODS

Medline and Cochrane databases were searched for studies up to June 2019 that investigated the outcomes of early stoma reversal (EC, defined as closure ≤14 days from the index operation) versus late stoma reversal (LC, ≥8 weeks from the index operation). Meta-analysis was performed on the respective rates of post-operative morbidity, anastomotic leak, wound infection, bleeding, sepsis, small bowel obstruction and ileus.

RESULTS

Nine studies were included (667 patients analysed). Meta-analysis showed no significant difference in the post-operative morbidity rate, anastomotic leak rate, rates of small bowel obstruction, bleeding and ileus between EC and LC. However, the wound infection rate was significantly higher after EC than LC; relative difference 0.10 (95% confidence interval 0.00-0.19, P = 0.047). The stoma-related complication rate was significantly higher after LC than EC; relative difference -0.28 (95% confidence interval -0.45 to -0.11, P = 0.001).

CONCLUSION

The concept of early stoma reversal is appealing, and this meta-analysis confirms the safety of early stoma closure with an associated reduction in stoma-related complications despite higher wound infection rates. However, the results need to be interpreted with caution due to the heterogeneity of the studies included, especially in respect of the definition of complications that were used. Further well-designed prospective studies are required prior to confident adoption of early stoma closure into clinical practice.

Early Versus Routine Stoma Closure in Patients With Colorectal Resection: A Meta-Analysis of 7 Randomized Controlled Trials

Background. A substantial proportion of patients undergoing colorectal surgery receive a temporary stoma, and the timing for stoma closure remains unclear. The aim of this study was to evaluate the safety and feasibility of early stoma closure (ESC) compared with routine stoma closure (RSC) after colorectal surgery. Methods. We comprehensively searched PubMed, Embase, and the Cochrane Library for randomized controlled trials that compared ESC and RSC after colorectal surgery. Results. A total of 7 randomized controlled trials with 814 enrolled patients were identified for this meta-analysis. There were no significant differences between the ESC and RSC groups regarding the complications of stoma closure (26.8% and 16.6%, respectively; odds ratio [OR]: 1.30; 95% confidence interval [CI]: 0.89-1.90; P = .17). A subgroup analysis was conducted by Clavien-Dindo grade of complication, and no significant difference was observed in any subgroup ( P > .05). However, the ESC group had a significantly higher risk of wound complications than the RSC group (17.6% and 7.8%, respectively; OR: 2.61; 95% CI: 1.43-4.76; P = .002), and the RSC group had more cases of small bowel obstruction than the ESC group (3.1% and 8.4%, respectively; OR: 0.37; 95% CI: 0.15-0.87; P = .02). Conclusions. ESC is a safe and effective therapeutic approach in patients who have undergone colorectal surgery; it is associated with a reduced risk of bowel obstruction but a higher risk of wound complications.

Early renal dysfunction after temporary ileostomy construction

PURPOSE

Loop ileostomy is often used to prevent complications after colorectal surgery, but it has been reported to cause renal impairment. This study aimed to evaluate the changes in the renal function after ileostomy and to compare these with the renal function after low anterior resection without ileostomy (low-ANT).

METHODS

The subjects included 58 patients who underwent ileostomy construction and closure for rectal cancer. The estimated glomerular filtration rate (eGFR) was calculated at specific time points after the index surgery. In addition, we conducted a case-matched study on 147 patients who underwent low-ANT.

RESULTS

The eGFR was significantly lower at 1 month after ileostomy than at the time of ileostomy construction (78.8 vs. 84.0, p < 0.0001) and did not improve after ileostomy closure. The only risk factor for a reduced eGFR was preoperative chemotherapy or chemoradiotherapy. In the case-matched study, 36 patients were allocated for each of the two groups. The number of ileostomy patients with a reduced eGFR was significantly increased 1 month after the index surgery (p = 0.005).

CONCLUSIONS

The eGFR began to decrease at one month after ileostomy construction and did not improve after ileostomy closure.

Investigating Risk Factors for Complications after Ileostomy Reversal in Low Anterior Rectal Resection Patients: An Observational Study

Introduction: Defunctioning ileostomy has been widely used in patients undergoing low anterior rectal resection to reduce the rate of postoperative leakage. It is still not clear whether interval between primary procedure and ileostomy reversal has an impact on treatment outcomes. Methods: In our prospective observational study we reviewed 164 consecutive cases of patients who underwent total mesorectal excision with primary anastomosis. Univariate and multivariate regression models were used to search for risk factors for prolonged length of stay and complications after defunctioning ileostomy reversal. Receiver operating characteristic curves were utilized to set cut-off points for prolonged length of stay and perioperative morbidity. Results: In total, 132 patients were included in the statistical analysis. The median interval between primary procedure and defunctioning ileostomy reversal was 134 (range: 17-754) days, while median length of stay was 5 days (4-6 interquartile range (IQR)). Prolonged length of stay cut-off was established at 6 days. Regression models revealed that interval between primary surgery and stoma closure as well as complications after primary procedure are risk factors for complications after defunctioning ileostomy reversal. Prolonged length of stay has been found to be related primarily to interval between primary surgery and stoma closure. Conclusions: In our study interval between primary surgery and stoma closure along with complication occurrence after primary procedure are risk factors for perioperative morbidity and prolonged length of stay (LOS) after ileostomy reversal. The effort should be made to minimize the interval to ileostomy reversal. However, randomized studies are necessary to avoid the bias which appears in this observational study and confirm our findings.

[Early ileostomy closure in patients with rectal cancer. Primary results of the randomized controlled multicenter trial]

AIM

To evaluate safety of early closure of ileostomy in patients with rectal cancer after primary surgery.

MATERIAL AND METHODS

The trial included patients from several medical centers without signs of anastomotic leakage. CT-proctography or rectoscopy were performed in 8 days after primary surgery to confirm integrity of the anastomoses. Exclusion criteria were factors affecting normal tissue regeneration (diabetes mellitus, steroid drugs prescription, etc.). Patients with intact anastomoses and no exclusion criteria were randomized into 2 groups: group 1 (n=31) with early closure of ileostomy (in 8-13 days after surgery) and group 2 (n=34) with delayed closure (after 12 weeks). All data were analyzed.

RESULTS

Postoperative morbidity was similar in both groups (6.45% vs. 5.88%, p=0.08). However, less duration of reconstructive surgery was noted in group 1 (50 (27-126) min vs. 71 min (31-134). This value was 1.42 times less in the main group (95% CI 1.30-1.52; p=0.02).

CONCLUSION

Early closure of ileostomy in patients after surgery for rectal cancer is feasible and does not result increased postoperative morbidity. This approach may be considered as an alternative to delayed closure. However, further researches devoted to analysis of ileostomy-associated complications and quality of life are necessary.

Ileostomy versus fecal diversion device to protect anastomosis after rectal surgery: a randomized clinical trial

PURPOSE

Patients with rectal anastomosis commonly experience various ileostomy-related complications. This study aimed to elucidate the usefulness of a fecal diversion device (FDD) as an alternative to ileostomy for protecting rectal anastomosis.

METHODS

Patients with rectal anastomosis were randomly assigned to the ileostomy and FDD groups except in cases of emergency surgery. The primary endpoint was the clinical safety and effectiveness of FDD. The mean operation time, delay of diet advancement, length of hospital stay, FDD and stoma durations, and anastomotic leakage (AL) management methods were compared.

RESULTS

A total of 54 patients were enrolled in this study. No cases of mortality occurred. Overall morbidity was similar between groups (P = 0.551). Six patients (22.2%) in the FDD group and nine (29.0%) in the stoma group (P = 0.555) had AL. The mean total hospital stay was 16.4 ± 6.7 and 23.4 ± 8.7 days in the FDD and stoma groups, respectively (P = 0.002). The mean total hospital cost was 12,726.8 ± 3422.8 USD and 17,954.9 ± 9040.3 USD in the FDD and stoma groups, respectively (P = 0.008). The mean FDD and stoma durations were 21.6 ± 6.1 days and 114.9 ± 41.3 days, respectively (P < 0.0001).

CONCLUSIONS

This study demonstrated FDD safety and effectiveness. We identified the possibility of FDD as an alternative technique to conventional stoma procedures.

Defunctioning ileostomy and mechanical bowel preparation may contribute to development of low anterior resection syndrome

INTRODUCTION

Laparoscopic surgery is an approved technique in colorectal cancer treatment. Functional and quality-of-life studies have revealed significant changes in faecal continence.

AIM

To assess the incidence and risk factors of low anterior resection syndrome (LARS) in patients undergoing rectal resections for cancer.

MATERIAL AND METHODS

We enrolled patients undergoing rectal resections in a general surgery department of a university hospital. The primary outcomes were the Jorge-Wexner scale and the LARS score 6 months after the end of treatment. The secondary outcomes were the risk factors for LARS development.

RESULTS

Fifty-six patients were included; 15 (26%) developed major LARS and 10 (18%) had minor LARS at 6 months. In univariate analysis the risk factors were: preoperative radiotherapy (p < 0.001, OR = 11.9, 95% CI: 2.98-47.48); shorter distance of the tumour from the anal verge (p = 0.001, OR = 0.69, 95% CI: 0.55-0.86); bowel preparation (p = 0.01, OR = 6.27, 95% CI: 1.51-26.07); low anterior rectal resection (p = 0.01, OR = 17.07, 95% CI: 1.86-156.83); and protective ileostomy (p = 0.001, OR = 15.97, 95% CI: 4.07-61.92). The risk factors for a higher Jorge-Wexner score in univariate analysis were greater diameter of tumour (p = 0.035), radiotherapy (p = 0.001), shorter distance from the anal verge (p = 0.002), bowel preparation (p = 0.042), low anterior rectal (LAR) (p = 0.01), ileostomy (p = 0.001), perioperative complications (p = 0.032), and readmission within 30 days (p = 0.034). In the multivariate analysis, readmissions and perioperative complications were significant.

CONCLUSIONS

In addition to typically described risk factors, two new ones have been identified. Mechanical bowel preparation and defunctioning ileostomy may also contribute to LARS development. However, due to the limitations of this study our observations require further confirmation in future trials.

Does Wound Irrigation with Clorhexidine Gluconate Reduce the Surgical Site Infection Rate in Closure of Temporary Loop Ileostomy? A Prospective Clinical Study

BACKGROUND

The aim of this study was to investigate the effect of irrigating the surgical site with 0.05% chlorhexidine gluconate (CHG) on surgical site infection (SSI) in temporary loop ileostomy closure.

METHODS

In this observational cohort, patients who underwent diverting loop ileostomy and elective ileostomy closure for any reason between September 2014 and July 2016 were enrolled. Irrigation of the surgical site with 0.05% CHG or saline were compared regarding post-operative incision complications. Infection risk was estimated by the National Nosocomial Infection Surveillance System (NNIS) and Study of the Effect of Nosocomial Infection Control (SENIC) scores. Post-operative follow-up was performed by a surgeon blinded to the treatment. Diagnosis of SSI was recorded according to the Guidelines for Prevention of Surgical Site Infection. Wound healing was evaluated by the Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of the deep tissues, Isolation of bacteria, and the duration of inpatient Stay (ASEPSIS) score.

RESULTS

There were 122 patients meeting the inclusion criteria: 60 in the saline (control) and 62 in the CHG (study) group. The mean age was 56.5 ± 13.5 (standard deviation [SD]); 74 patients were male. The groups were similar regarding age, sex, indication for ileostomy, neoadjuvant therapies, and SENIC and ASEPSIS scores. The overall SSI rate was 18%: 19 patients (31.6%) in the control group and 3 (4.8%) patients in the study group (p < 0.001). The mean ASEPSIS score was higher in the control group (12.8 ± 17.7) than in the study group (3.7 ± 7.8) (p < 0.001). Patients in the control group had significantly higher rates of seroma (13.3% vs 1.6%; p = 0.014) and incision dehiscence (31.6% and 4.8%; p = 0.001). Time to healing was 9.9 ± 5.1 days in the control group and 7.3 ± 5.3 days in the study group (p = 0.007).

CONCLUSIONS

Irrigation of the incision with 0.05% CHG reduces the SSI rate compared with saline irrigation. There is a need for randomized and wider trials to clarify the effect and standards of incision irrigation.

Physiotherapy and Anterior Resection Syndrome (PARiS) trial: feasibility study protocol

INTRODUCTION

Rectal cancer affects more than 600 patients per year in Wales, with a 5-year survival rate of around 60%. A recent report demonstrated that 19% of patients with bowel cancer had difficulty controlling their bowels after surgery, and these patients were twice as likely to report lower quality of life than those who had control. Nearly all patients will experience bowel dysfunction initially following surgery and up to 25% will experience severe bowel dysfunction on a long-term basis. The aim of this study is to test the feasibility of introducing a simple intervention in an attempt to improve bowel function following surgery for rectal cancer. We propose the introduction of an educational session from specialist nurses and physiotherapists prior to surgery and a subsequent physiotherapy programme for 3 months to teach patients how to strengthen their pelvic floor.

METHODS AND ANALYSIS

All patients with rectal cancer planned to receive an anterior resection will be approached for the study. The study will take place in three centres over 12 months, and we expect to recruit 40 patients. The primary outcome measure is the proportion of eligible patients approached who consent to and attend the educational session. The secondary outcomes include patient compliance to the pelvic floor rehabilitation programme (assessed by patient paper or electronic diary), the acceptability of the intervention to the patient (assessed using qualitative interviews) and preoperative and postoperative pelvic floor tone (assessed using the Oxford Grading System and the International Continence Society Grading System), patient bowel function and patient quality of life (assessed using validated questionnaires).

ETHICS AND DISSEMINATION

Ethics approval was granted. This feasibility study is in progress. If patients find the intervention acceptable, the next stage would be a trial comparing outcomes after anterior resection in those who have and do not have physiotherapy.

TRIAL REGISTRATION NUMBER

ISRCTN77383505; Pre-results.