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Geisler BP, Cao KN, Ryschon AM, Alavi K, Komen N, Pietzsch JB. Cost associated with diverting ostomy after rectal cancer surgery: a transnational analysis. Surg Endosc 2023; 37:7759-7766. [PMID: 37580581 DOI: 10.1007/s00464-023-10300-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/12/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Diverting ileostomy and colostomy after total mesorectal excision reduces the risk of complications related to anastomotic leakages but is associated with a reduction in health-related quality of life and long-term economic consequences that are unknown. Our objective was to estimate the lifetime costs of stoma placement after rectal cancer resection in the U.S., England, and Germany. METHODS Input parameters were derived from quasi-systematic literature searches. Decision-analytic models with survival from colorectal cancer-adjusted life tables and country-specific stoma reversal proportions were created for the three countries to calculate lifetime costs. Main cost items were stoma maintenance costs and reimbursement for reversal procedures. Discounting was applied according to respective national guidelines. Sensitivity analysis was conducted to explore the impact of parameter uncertainty onto the results. RESULTS The cohort starting ages and median survival were 63 and 11.5 years for the U.S., 69 years and 8.5 years for England, and 71 and 6.5 years for Germany. Lifetime discounted stoma-related costs were $26,311, £9512, and €10,021, respectively. All three models were most sensitive to the proportion of ostomy reversal, age at baseline, and discount rate applied. CONCLUSION Conservative model-based projections suggest that stoma care leads to significant long-term costs. Efforts to reduce the number of patients who need to undergo a diverting ostomy could result in meaningful cost savings.
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Affiliation(s)
- Benjamin P Geisler
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Khoa N Cao
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Anne M Ryschon
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Karim Alavi
- Department of Surgery/Division of Colon and Rectal Surgery, UMass Memorial Health/UMass Chan Medical School, Worcester, MA, USA
| | - Niels Komen
- Department Abdominal Surgery, Universitair Ziekenhuis Antwerpen/ReSURG, Antwerp Surgical Training, Anatomy and Research Center, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Jan B Pietzsch
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA.
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Batistotti P, Montale A, Bruzzone M, Amato A, Binda GA. Protective ileostomy after low anterior resection for extraperitoneal rectal cancer: does the reversal surgery timing affect closure failure? Updates Surg 2023; 75:1811-1818. [PMID: 37428410 DOI: 10.1007/s13304-023-01573-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/22/2023] [Indexed: 07/11/2023]
Abstract
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.
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Affiliation(s)
- P Batistotti
- General Surgical Department, Ospedale Di Imperia, Via Sant'Agata 57, 18100, Imperia, Italy.
| | - A Montale
- Department of Gastroenterology and Digestive Endoscopy, E. O. Ospedali Galliera, Mura Delle Cappuccine 14, 16128, Genoa, Italy
| | - M Bruzzone
- Clinical Epidemiology Unit, IRCCS Ospedale San Martino, Largo Rosanna Benzi, 10, 16132, Genoa, Italy
| | - A Amato
- General Surgical Department, Ospedale Di Imperia, Via Sant'Agata 57, 18100, Imperia, Italy
| | - G A Binda
- General Surgery, Biomedical Institute, Genoa, Italy
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Tsai KY, You JF, Huang SH, Tsai TY, Hsieh PS, Lai CC, Tsai WS, Hung HY. Comparison of clinical outcomes of stoma reversal during versus after chemotherapy for rectal cancer patients. Langenbecks Arch Surg 2023; 408:274. [PMID: 37438486 DOI: 10.1007/s00423-023-03014-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE The optimal timing of stoma closure during or after adjuvant chemotherapy for rectal cancer patients undergoing sphincter-preserving surgery remains unknown. This study aimed to investigate the influence of clinical and oncological outcomes depending on the timing of stoma closure. METHODS Between January 2006 and December 2015, we enrolled 244 consecutive rectal cancer patients who underwent curative-intent sphincter-preserving surgery with diverting transverse colostomy and adjuvant chemotherapy. Patients with stoma closure during (During group) adjuvant chemotherapy were compared to those who had stoma closure after adjuvant chemotherapy (After group). RESULTS Parastomal hernia occurred more frequently in the after group than in the during group. (10% vs. 2.9%, p = 0.028). Overall, no significant difference was observed in overall survival (OS) or disease-free survival (DFS) between the two groups (p = 0.911 for OS, p = 0.505 for DFS). However, an inferior OS occurred if reopen surgery was performed within 30 days of stoma closure in the during group, as compared with the after group (p = 0.004). In addition, a marginally poor DFS was observed in the group of patients who received further operations due to 30-day stoma closure complications compared to the other patients (p = 0.07). CONCLUSIONS For rectal cancer patients who underwent sphincter-preserving surgery, attention should be given to avoid 30-day major complications after stoma reversal because patients who require reoperation during adjuvant chemotherapy may have poor long-term survival.
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Affiliation(s)
- Kun-Yu Tsai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan City, 33305, Taiwan
- Division of Colon and Rectal Surgery, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shu-Huan Huang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan City, 33305, Taiwan
| | - Tzong-Yun Tsai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan City, 33305, Taiwan
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Cheng-Chou Lai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Wen-Sy Tsai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Hsin-Yuan Hung
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan City, 33305, Taiwan.
- Division of Colon and Rectal Surgery, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.
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Panizza J, Swee YJS, Edmundson A, Clark D. Renal dysfunction occurs following ileostomy formation and is independent of readmission. ANZ J Surg 2023; 93:622-628. [PMID: 36621986 DOI: 10.1111/ans.18254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- John Panizza
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Yan Jing Sherrie Swee
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Aleks Edmundson
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - David Clark
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Tyler R, Foss H, Phelan L, Radley S, Geh I, Karandikar S. Impact of surgeon volume on 18-month unclosed ileostomy rate after restorative rectal cancer resection. Colorectal Dis 2023; 25:253-260. [PMID: 36222737 DOI: 10.1111/codi.16368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/03/2022] [Indexed: 02/08/2023]
Abstract
AIM The impact of surgeon volume on 18-month unclosed ileostomy rates after rectal cancer surgery has not been fully explored. The aim of this study was to describe the effect of surgeon volume and evaluate factors predictive of an unclosed ileostomy. METHOD Patients undergoing anterior resection with a diverting ileostomy for rectal cancer from March 2004 to October 2018 were identified from a prospectively maintained database. The unclosed ileostomy rate was determined by those with an unclosed ileostomy at 18 months. High- and low-volume surgeons (HVS and LVS, respectively) were classed as those performing five or more or fewer than five rectal cancer resections per year, respectively. Data on sex, age, American Society of Anesthesiologists grade, neoadjuvant chemoradiotherapy (CRT), tumour height, T-stage, anastomotic leak, surgical approach and adjuvant chemotherapy were also collected. Factors predictive of an unclosed ileostomy at 18 months were explored using a multivariate binary logistic regression analysis. RESULTS A total of 415 patients (62.4% male) with a median age of 67 were eligible for analysis. Of these, 115 (27.7%) had an unclosed ileostomy at 18 months. HVS had an unclosed ileostomy rate of 24.6% (72/292) compared with 34.9% (43/123) for LVS. Volume was associated with an unclosed ileostomy in univariable analysis (p = 0.032) but not in multivariate analysis (OR 1.75, 95% CI 0.92-3.32, p = 0.08). Independent factors predictive of an unclosed ileostomy were anastomotic leak (OR 10.41, 3.95-27.0, p < 0.01), adjuvant chemotherapy (OR 2.23, 1.24-3.96, p < 0.01) and neoadjuvant CRT (OR 2.16, 1.15-5.75, p = 0.01). CONCLUSION LVS were associated with a higher unclosed ileostomy at 18 months compared with HVS. This study adds further weight to the call for adoption of a minimum annual case threshold in rectal cancer surgery.
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Affiliation(s)
| | - Helen Foss
- Birmingham Heartlands Hospital, Birmingham, UK
| | - Liam Phelan
- Birmingham Heartlands Hospital, Birmingham, UK
| | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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Impact of timing of reversal of loop ileostomy on patient outcomes: a retrospective cohort study. Tech Coloproctol 2021; 25:1217-1224. [PMID: 34499279 DOI: 10.1007/s10151-021-02516-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Diverting loop ileostomies (DLIs) are ideally reversed 6-12 weeks after the index operation. However, reversal surgery is frequently delayed in a real-world setting, with potential implications on patient's quality of life and postoperative complications. The aim of this study was to investigate the impact of timing of the reversal on patient outcomes at a tertiary referral hospital. METHODS Consecutive patients who underwent elective reversal of loop ileostomy (RLI) between January 2007 and January 2019 were included. The primary outcomes were incidence of postoperative ileus (POI) and 30-day postoperative complications. RESULTS Of 251 eligible patients, 158 (63%) were men, the median age was 64 years (range 23-88 years), and the most common index operation was an ultra-low anterior resection in 106 (42%). The median time to reversal for the entire cohort was 7.4 months (range 1-28). RLI was performed within 6 months after the index surgery in 89 patients (35%, early group), 6-12 months in 120 (48%, middle group) and after more than 12 months in 42 (17%, late group) patients. A significantly lower incidence of postoperative ileus (13.5% vs. 25.8% vs. 38.1%, p = 0.006), and 30-day postoperative complications (29.2% vs 41.7% vs. 57.1%, p = 0.011) were seen in the early group compared to the middle and late groups, respectively. There was no difference in the return to theater, length of hospital stay, and readmission rate between groups. CONCLUSION Delayed RLI is associated with increased risk of postoperative complications.
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Clinical Outcomes of Ileostomy Closure before Adjuvant Chemotherapy after Rectal Cancer Surgery: An Observational Study from a Chinese Center. Gastroenterol Res Pract 2021; 2021:5592721. [PMID: 34335738 PMCID: PMC8294951 DOI: 10.1155/2021/5592721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background The optimal timing of temporary ileostomy closure with respect to the time of adjuvant chemotherapy following sphincter-saving surgery for rectal cancer remains unclear. The aim of this study is to investigate the clinical and oncological outcomes of ileostomy closure before, during, and after adjuvant chemotherapy following curative rectal cancer resection. Methods Patients diagnosed with rectal adenocarcinoma who underwent low anterior resection and temporary loop ileostomy during May 2015 and September 2019 were retrospectively evaluated. Patients undergoing ileostomy closure before adjuvant chemotherapy (Group I) were compared to patients undergoing closure during (Group II) and after (Group III) adjuvant chemotherapy. Results A total of 225 patients were evaluated for eligibility, and 132 were finally selected and divided into 3 groups (24 in Group I, 53 in Group II, and 55 in Group III). No significant differences were observed in operative time, postoperative hospital stay, postoperative complications, total adjuvant chemotherapy cycles, and low anterior resection syndrome scores among the three groups. There was no significant difference in disease-free survival (p = 0.834) and overall survival (p = 0.462) between the three groups. Conclusion Temporary ileostomy closure before adjuvant chemotherapy following curative rectal cancer resection can achieve a clinical and oncological safety level equal to stoma closure during or after chemotherapy in selected patients.
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Podda M, Sylla P, Baiocchi G, Adamina M, Agnoletti V, Agresta F, Ansaloni L, Arezzo A, Avenia N, Biffl W, Biondi A, Bui S, Campanile FC, Carcoforo P, Commisso C, Crucitti A, De'Angelis N, De'Angelis GL, De Filippo M, De Simone B, Di Saverio S, Ercolani G, Fraga GP, Gabrielli F, Gaiani F, Guerrieri M, Guttadauro A, Kluger Y, Leppaniemi AK, Loffredo A, Meschi T, Moore EE, Ortenzi M, Pata F, Parini D, Pisanu A, Poggioli G, Polistena A, Puzziello A, Rondelli F, Sartelli M, Smart N, Sugrue ME, Tejedor P, Vacante M, Coccolini F, Davies J, Catena F. Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
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Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Gianluca Baiocchi
- ASST Cremona, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michel Adamina
- Department of Colorectal Surgery, Cantonal Hospital of Winterthur, Winterthur - University of Basel, Basel, Switzerland
| | | | - Ferdinando Agresta
- Department of General Surgery, Vittorio Veneto Hospital, AULSS2 Trevigiana del Veneto, Vittorio Veneto, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nicola Avenia
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Antonio Biondi
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Simona Bui
- Department of Medical Oncology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Fabio C Campanile
- Department of Surgery, ASL VT - Ospedale "San Giovanni Decollato - Andosilla", Civita Castellana, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudia Commisso
- Department of Radiology, University Hospital of Parma, Parma, Italy
| | - Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital and Catholic University, Rome, Italy
| | - Nicola De'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Gian Luigi De'Angelis
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | | | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | - Federica Gaiani
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari K Leppaniemi
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andrea Loffredo
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma Geriatric-Rehabilitation Department, Parma University Hospital, Parma, Italy
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | | | | | - Dario Parini
- Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Polistena
- Dipartimento di Chirurgia Pietro Valdoni Policlinico Umberto I, Sapienza Università degli Studi di Roma, Rome, Italy
| | - Alessandro Puzziello
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Fabio Rondelli
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | | | | | - Michael E Sugrue
- Letterkenny University Hospital and CPM sEUBP Interreg Project, Letterkenny, Ireland
| | | | - Marco Vacante
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Jørgensen JB, Erichsen R, Pedersen BG, Laurberg S, Iversen LH. Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study. BJS Open 2020; 4:1162-1171. [PMID: 33022143 PMCID: PMC7709365 DOI: 10.1002/bjs5.50340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/09/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Data on stoma reversal following restorative rectal resection (RRR) with a diverting stoma are conflicting. This study investigated a Danish population-based cohort of patients undergoing RRR to evaluate factors predictive of stoma reversal during 3 years of follow-up. METHODS Patients from national registries with rectal cancer undergoing RRR or Hartmann's procedure with curative intent between May 2001 and April 2012 were included. Patients with a diverting stoma were followed from the time of primary rectal cancer resection to date of stoma reversal, death, emigration, or end of 3-year follow-up. The cumulative incidence proportion (CIP) of stoma reversal at 1 and 3 years was calculated, treating death as a competing risk. Factors predictive of stoma reversal were explored using Cox regression analysis. RESULTS Of 6859 patients included, 35·7, 41·9 and 22·4 per cent respectively had a RRR with a diverting stoma, RRR without a stoma, and Hartmann's procedure with an end-colostomy. In patients with a diverting stoma, the CIP of stoma reversal was 70·3 (95 per cent c.i. 68·4 to 72·1) per cent after 1 year, and 74·3 (72·5 to 76·0) per cent after 3 years. Neoadjuvant treatment (hazard ratio (HR) 0·75, 95 per cent c.i. 0·66 to 0·85), blood loss greater than 300 ml (HR 0·86, 0·76 to 0·97), anastomotic leak (HR 0·41, 0·33 to 0·50), T3 category (HR 0·63, 0·47 to 0·83), T4 category (HR 0·62, 0·42 to 0·90) and UICC stage IV (HR 0·57, 0·41 to 0·80) were possible predictors of delayed stoma reversal. CONCLUSION In one-quarter of the patients the diverting stoma had not been reversed 3 years after the intended RRR procedure.
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Affiliation(s)
- J. B. Jørgensen
- Departments of SurgeryAarhusDenmark
- Department of SurgeryRanders Regional HospitalRandersDenmark
| | - R. Erichsen
- Clinical EpidemiologyAarhusDenmark
- Department of SurgeryRanders Regional HospitalRandersDenmark
| | | | | | - L. H. Iversen
- Departments of SurgeryAarhusDenmark
- Danish Colorectal Cancer GroupCopenhagenDenmark
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Zhuang CL, Zhang FM, Wang Z, Jiang X, Wang F, Liu ZC. Precision functional sphincter-preserving surgery (PPS) for ultralow rectal cancer: a natural orifice specimen extraction (NOSE) surgery technique. Surg Endosc 2020; 35:476-485. [PMID: 32989539 DOI: 10.1007/s00464-020-07989-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients with ultralow rectal cancer, surgical resection of the tumor without impairing sphincter function remains a technical challenge. The purpose of this study was to describe a new technique of transanal natural orifice specimen extraction (NOSE) surgery using our independently developed devices, aiming to achieve precise cancer resection and preserve sphincter function in patients with ultralow rectal cancer. METHODS Precision functional sphincter-preserving surgery (PPS) was performed on nineteen patients with ultralow rectal cancer between June 2019 and April 2020. With the help of our independently developed devices, surgeons directly and accurately removed the lower edge of the tumor and retained healthy rectal tissue on the nontumorous side. Hand-sewn anastomosis with a mattress suture was used to achieve sturdy anastomosis. Preoperative baseline characteristics, operative details, 90-day postoperative complications, costs, and anal function score at 6 months after surgery were documented. RESULTS Nineteen ultralow rectal cancer patients with a median distance to the dentate line of 2.0 cm successfully underwent PPS without serious postoperative complications. Six out of nineteen patients (31.6%) received a prophylactic stoma. The average cost was 62164.1 yuan. At 6 months after surgery, the average Wexner anal function score and the average Vaizey score were both 3 points. CONCLUSIONS PPS can be employed to precisely resect rectal tumors and preserve sphincter function in ultralow rectal cancer patients. The use of our devices enhanced surgical efficiency, reduced the need for prophylactic stoma, reduced surgery-related costs, and prevented abdominal surgical incisions.
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Affiliation(s)
- Cheng-Le Zhuang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Feng-Min Zhang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Zheng Wang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Xun Jiang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Feng Wang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China
| | - Zhong-Chen Liu
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai, 200072, China.
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11
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Zhang L, Zheng W, Cui J, Wu YL, Xu TL, Zhang HZ. Risk factors for nonclosure of defunctioning stoma and stoma-related complications among low rectal cancer patients after sphincter-preserving surgery. Chronic Dis Transl Med 2020; 6:188-197. [PMID: 32908969 PMCID: PMC7451586 DOI: 10.1016/j.cdtm.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Indexed: 12/15/2022] Open
Abstract
Background Defunctioning stoma is widely used to reduce anastomotic complications in rectal cancer surgery. However, the complications of stoma and stoma reversal surgery should not be underestimated. Furthermore, in some patients, stoma reversal failed. Here, we investigated the complications of defunctioning stoma surgery and subsequent reversal surgery and identify risk factors associated with the failure of getting stoma reversed. Methods In total, 154 patients who simultaneously underwent low anterior resection and defunctioning stoma were reviewed. Patients were divided into two groups according to whether their stoma got reversed or not. The reasons that patients received defunctioning stoma and experienced stoma-related complications and the risk factors for failing to get stoma reversed were analysed. Results The mean follow-up time was 47.54 (range 4.0–164.0) months. During follow-up, 19.5% of the patients suffered stoma-related long-term complications. Only 79 (51.3%) patients had their stomas reversed. The morbidity of complications after reversal surgery was 45.6%, and these mainly consisted of incision-related complications. Multivariate analyses showed that pre-treatment comorbidity (HR = 3.17, 95% CI 1.27–7.96, P = 0.014), postoperative TNM stage (HR = 2.55, 95% CI 1.05–6.18, P = 0.038), neoadjuvant therapy (HR = 2.75, 95% CI 1.07–7.05, P = 0.036), anastomosis-related complications (HR = 4.52, 95% CI 1.81–11.29, P = 0.001), and disease recurrence (HR = 24.83, 95% CI 2.90–213.06, P = 0.003) were significant independent risk factors for a defunctioning stoma to be permanent. Conclusions Defunctioning stoma is an effective method to reduce symptomatic anastomotic leakage, but the stoma itself and its reversal procedure are associated with high morbidity of complications, and many defunctioning stomas eventually become permanent. Therefore, surgeons should carefully assess preoperatively and perform defunctioning stomas in very high risk patients. In addition, doctors should perform stoma reversal surgery more actively to prevent temporary stomas from becoming permanent.
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Affiliation(s)
- Lin Zhang
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Wei Zheng
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Jian Cui
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Yun-Long Wu
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Tian-Lei Xu
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Hai-Zeng Zhang
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
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12
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Gadan S, Lindgren R, Floodeen H, Matthiessen P. Reversal of defunctioning stoma following rectal cancer surgery: are we getting better? A population-based single centre experience. ANZ J Surg 2019; 89:403-407. [PMID: 30806006 DOI: 10.1111/ans.14990] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/28/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND The aim was to assess factors influencing the timing of defunctioning stoma (DS) reversal following low anterior resection of rectum for cancer (LAR). METHODS All patients operated with LAR and a primary DS during a 9-year period were included. Reversal later than 120 days after LAR was considered as delayed. A DS not reversed within 2 years was considered as permanent. RESULTS In the present study, median age at LAR was 67 years, 45% were females, median body mass index was 25, 87% had American Society of Anesthesiologists class I or II, 64% had pre-operative radiotherapy, and 3% had cancer stage IV. A total of 79% (92/116) underwent stoma reversal, whereof 25% (23/92) were reversed within 120 days. The most common health-related reasons for delayed stoma reversal were adjuvant chemotherapy in 38%, symptomatic anastomotic leakage in 16% and other post-operative adverse events in 13%. In 35% delayed stoma reversal was because of low priority within the healthcare system. A total of 18% (20/110) never had their DS reversed (n = 11) or had their DS converted to a permanent end colostomy (n = 9). Major risk factors for permanent stoma were stage IV cancer in 55%, and symptomatic anastomotic leakage in 30%. CONCLUSION One fourth of the patients had their defunctioning stoma reversed within 120 days. The most common identifiable medical reasons for delayed stoma reversal were adjuvant chemotherapy and symptomatic anastomotic leakage, while in one out of three patients it was because of low priority by the healthcare provider.
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Affiliation(s)
- Soran Gadan
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Rickard Lindgren
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Hannah Floodeen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Peter Matthiessen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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13
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da-Fonseca LM, Buzatti KCDLR, Castro LL, Lacerda Filho A, Correia MITD, da-Silva RG. Factors preventing restoration of bowel continuity in patients with rectal cancer submitted to anterior rectal resection and protective ileostomy. Rev Col Bras Cir 2019; 45:e1998. [PMID: 30624520 DOI: 10.1590/0100-6991e-20181998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/25/2018] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE to evaluate the factors associated with non-closure of protective ileostomy after anterior resection of the rectum with total mesorectum excision for rectal cancer, the morbidity associated with the closure of ileostomies and the rate of permanent ileostomy in patients with rectal adenocarcinoma. METHODS we conducted a retrospective study with 174 consecutive patients diagnosed with rectal tumors, of whom 92 underwent anterior resection of the rectum with coloanal or colorectal anastomosis and protective ileostomy, with curative intent. We carried out a multivariate analysis to determine the factors associated with definite permanence of the stoma, as well as studied the morbidity of patients who underwent bowel continuity restoration. RESULTS In the 84-month follow-up period, 54 of the 92 patients evaluated (58.7%) had the ileostomy closed and 38 (41.3%) remained with the stoma. Among the 62 patients who had the ileostomy closed, 11 (17.7%) presented some type of postoperative complication: three had ileal anastomosis dehiscence, five had intestinal obstruction, two had surgical wound infection, and one, pneumonia. Eight of these patients required a new stoma. CONCLUSION according to the multivariate analysis, the factors associated with stoma permanence were anastomotic fistula, presence of metastases and closure of the ileostomy during chemotherapy.
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Affiliation(s)
- Leonardo Maciel da-Fonseca
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Coloproctologia, Belo Horizonte, MG, Brasil
| | - Kelly Cristine de Lacerda Rodrigues Buzatti
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Coloproctologia, Belo Horizonte, MG, Brasil
| | - Luísa Lima Castro
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte, MG, Brasil
| | - Antônio Lacerda Filho
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Coloproctologia, Belo Horizonte, MG, Brasil
| | - Maria Isabel Toulson Davisson Correia
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Nutrição, Belo Horizonte, MG, Brasil
| | - Rodrigo Gomes da-Silva
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Coloproctologia, Belo Horizonte, MG, Brasil
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14
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15
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Pisarska M, Gajewska N, Małczak P, Wysocki M, Witowski J, Torbicz G, Major P, Mizera M, Dembiński M, Migaczewski M, Budzyński A, Pędziwiatr M. Defunctioning ileostomy reduces leakage rate in rectal cancer surgery - systematic review and meta-analysis. Oncotarget 2018; 9:20816-20825. [PMID: 29755692 PMCID: PMC5945534 DOI: 10.18632/oncotarget.25015] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 03/08/2018] [Indexed: 12/11/2022] Open
Abstract
Objectives The role of a defunctioning ileostomy in every anterior rectal resection with total mesorectal excision (TME) is still controversial. In this study, we aimed to review the current literature to determine the impact of ileostomy creation on postoperative outcomes in patients undergoing anterior rectal resection with TME. Methods MEDLINE, Embase and Cochrane Library were searched for eligible studies. We analyzed data up to October 2017. Eligible studies had to compare patients with vs. without a defunctioning ileostomy in rectal cancer surgery and comprise data on anastomotic leakage in both groups. The primary outcome was anastomotic leakage. Secondary outcomes included the complication rate, mortality, reoperation rate, length of hospital stay and 30-day readmission. Results Initial search yielded 1,966 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. Leakage rate (RR = 0.43, 95% CI 0.28-0.67) and the number of reoperations (RR = 0.62, 95% CI 0.40-0.94) were significantly lower in the defunctioning stoma group. Morbidity was significantly higher in the stoma group (RR = 1.32, 95% CI 1.05–1.65). Analysis of mortality, length of hospital stay and readmission rate did not show any significant differences. Conclusion A defunctioning ileostomy may decrease the anastomotic leakage rate, additionally significantly reducing the risk of reoperations but it may also increase the overall complication rate. The presence of the protective stoma has no effect on mortality, length of hospital stay and readmission rate.
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Affiliation(s)
- Magdalena Pisarska
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Natalia Gajewska
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Małczak
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Wysocki
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Jan Witowski
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Grzegorz Torbicz
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Major
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Magdalena Mizera
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Dembiński
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Migaczewski
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Andrzej Budzyński
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
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16
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Liu L, Huang Q, Wang J, Chen Q, Lin R, Ge B. Protection of low rectal anastomosis with a new tube ileostomy using a biofragmentable anastomosis ring: A retrospective study. Medicine (Baltimore) 2016; 95:e5345. [PMID: 27828857 PMCID: PMC5106063 DOI: 10.1097/md.0000000000005345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A temporarily defunctioning stoma, while effective at reducing symptomatic anastomotic leakage after low anterior resection (LAR) of rectal cancer, and its subsequent closure, is associated with significant morbidity. Here, we devised a new tube ileostomy using a biofragmentable anastomosis ring (TIB) with no need for reversal.This is a retrospective cohort study. From June 2011 to March 2015, TIBs were performed on 31 consecutive patients with mid- or low-rectal cancer who underwent elective laparoscopic LARs. From January 2008 to May 2011, 25 similarly diseased patients underwent elective laparoscopic LARs and conventional loop ileostomy (LI) and were included as controls. All of the anastomotic sites were within 6 cm of the anal verge. Demographic, clinical feature, and operative data were recorded.The demographic features of both groups were similar. The TIB mean surgical duration was significantly lower than in the LI group (215 ± 28 vs 245 ± 54 min, P = 0.010). Because of readmission for stoma closure, the total hospital stay of the LI group was longer than that of the TIB group (38.1 ± 26.5 vs 19.1 ± 7.9 days, respectively, P = 0.002). Ileal content was completely diverted by TIB for 13.7 ± 2.1 (range, 10-19) days postoperatively. The drainage tube was removed on postoperative day 27.8 ± 6.9 (range, 20-44), and the mean continued duration of the discharge tract, before fistula healing, was 4.5 ± 1.9 (range, 2-10) days. Postoperative complications of the 2 modalities were not significant. In the TIB group, 1 rectovaginal fistula occurred 30 days postsurgery. In the LI group, 1 rectovaginal fistula occurred 3 months after stoma closure. Both complications were treated with transverse colostomy. No major TIB associated complications were observed in the present study.TIB is a safe, feasible, effective, but time-limited diversion technique, which may reduce symptomatic anastomosis leakage after LAR for rectal cancer.
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Affiliation(s)
| | | | | | | | | | - Bujun Ge
- Department of General Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- Correspondence: Bujun Ge, Department of General Surgery, Tongji Hospital, Tongji University School of Medicine, 389 XinCun Road, Shanghai 200065, China (e-mail: )
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17
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De Palma GD, Luglio G. Quality of life in rectal cancer surgery: What do the patient ask? World J Gastrointest Surg 2015; 7:349-355. [PMID: 26730279 PMCID: PMC4691714 DOI: 10.4240/wjgs.v7.i12.349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/13/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision (TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques (pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.
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18
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Waterland P, Goonetilleke K, Naumann DN, Sutcliff M, Soliman F. Defunctioning Ileostomy Reversal Rates and Reasons for Delayed Reversal: Does Delay Impact on Complications of Ileostomy Reversal? A Study of 170 Defunctioning Ileostomies. J Clin Med Res 2015; 7:685-9. [PMID: 26251682 PMCID: PMC4522985 DOI: 10.14740/jocmr2150w] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 12/21/2022] Open
Abstract
Background Temporary defunctioning ileostomy can reduce the consequences of anastomotic leak following low anterior resection. However, some patients never have their ileostomy reversed and in other cases the time to reversal of ileostomy can be delayed. The aim of this study was to identify the ileostomy closure rate following anterior resection, time to closure of ileostomy, reasons for delay in reversal and whether delay was associated with an increased complication rate. Methods Data were collected retrospectively on consecutive patients undergoing defunctioning ileostomy following anterior resection for rectal cancer, between January 2009 and August 2013. Data were collected on reversal of ileostomy rates, time to reversal, reasons for delayed reversal (defined as > 6 months) and complications following reversal. Results One hundred seventy patients were studied (median age 69 years, range 41 - 90 years), of whom 117 (69%) were male. One hundred twenty-seven (75%) patients had their ileostomies reversed. Median time to reversal was 6 months (range 1 - 42). In 63 patients who had delayed reversal, reasons were adjuvant chemotherapy (22, 35%), medical illness (14, 22%), anastomotic leak (9, 14%), and others (4, 7%). Postoperative complications occurred in 33 patients (26%). There was no postoperative mortality. Univariate analysis showed that delayed reversal was associated with an increased rate of complications and longer length of hospital stay following reversal (P < 0.05). Conclusions One in four defunctioning ileostomies are not closed following anterior resection in our unit. Of those that are closed, approximately 50% have delayed closure beyond 6 months which is associated with increased risk of complications following their ileostomy reversal.
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Affiliation(s)
- Peter Waterland
- Department of Colorectal Surgery, Worcester Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK
| | - Kolitha Goonetilleke
- Department of General Surgery, Good Hope Hospital, Rectory Road, Sutton Coldfield, West Midlands B75 7RR, UK
| | - David N Naumann
- Department of General Surgery, Good Hope Hospital, Rectory Road, Sutton Coldfield, West Midlands B75 7RR, UK
| | - Mathew Sutcliff
- Department of General Surgery, Good Hope Hospital, Rectory Road, Sutton Coldfield, West Midlands B75 7RR, UK
| | - Faris Soliman
- Department of General Surgery, Good Hope Hospital, Rectory Road, Sutton Coldfield, West Midlands B75 7RR, UK
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19
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Robertson J, Linkhorn H, Vather R, Jaung R, Bissett IP. Cost analysis of early versus delayed loop ileostomy closure: a case-matched study. Dig Surg 2015; 32:166-72. [PMID: 25833332 DOI: 10.1159/000375324] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 01/14/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS The optimal timing for the closure of loop ileostomies remains controversial. The aim of the current study was to investigate whether early ileostomy closure (EC) (<2 weeks post-formation) results in significant healthcare savings as against late closure (LC). METHODS Patients with available cost data that underwent EC between January 2008 and December 2012 were compared against matched patients undergoing LC during the same period. Direct hospital costs for the two groups were compared. RESULTS There were 42 EC patients and 61 LC patients. EC patients had significantly less ileostomy-related complications (p < 0.001) and hospital readmissions (p < 0.001). Operative time (p < 0.001) and operative cost (p = 0.002) were also both significantly less in the EC group. Community nursing costs favoured the LC group (p = 0.047). The EC group had an increased post-closure wound infection rate (p = 0.02). The mean total direct cost per patient was NZD 13,724 (SD NZD 3,736) for EC and NZD 16,728 (SD NZD 8,028) for LC. Representing an average costs saving of NZD 3,004 per patient favouring EC (p = 0.012). CONCLUSION Although EC increases the post-closure wound infection rate, EC reduces ileostomy complications, hospital readmissions and operative costs resulting in significant healthcare savings. In order to improve patient outcomes and make EC even more cost effective, efforts should be taken to reduce wound infections.
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Affiliation(s)
- Jason Robertson
- Department of Surgery, University of Auckland, Auckland, New Zealand
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20
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Kye BH, Kim HJ, Kim JG, Cho HM. Is it safe the reversal of a diverting stoma during adjuvant chemotherapy in elderly rectal cancer patients? Int J Surg 2014; 12:1337-41. [PMID: 25448655 DOI: 10.1016/j.ijsu.2014.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 10/07/2014] [Accepted: 10/20/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The aim of this study was to investigate the clinical outcomes between 2 groups of elderly rectal cancer patients according to the time duration after which their diverting stoma can be reversed. METHODS We recruited 124 patients who were ≥65 years old and had undergone diverting stoma after rectal cancer surgery. In Group 1, the reversal of the stoma was predominantly performed after the sixth adjuvant chemotherapy. In Group 2, the reversal was predominantly performed after the third adjuvant chemotherapy. RESULTS The mean duration for which patients had a stoma was 28.6 ± 9.9 weeks in Group 1 and 17.1 ± 7.4 weeks in Group 2. The interval between stoma formation and stoma formation-related complications was slightly longer in Group 1 than in Group 2 (13.5 ± 9.7 vs. 8.0 ± 4.9 weeks, p = 0.075). There were 16 stoma-related complications in Group 1 (23.2%) and 10 in Group 2 (18.2%) (p = 0.516). There were 6 stoma closure-related complications in Group 1 (8.8%) and 6 in Group 2 (10.9%) (p = 0.766). DISCUSSION This study shows that stoma closure during adjuvant chemotherapy is no more harmful than stoma closure after termination of adjuvant chemotherapy. CONCLUSION It may be possible to limit the duration of diverting stoma following rectal cancer surgery, even if patients are elderly and undergoing adjuvant chemotherapy.
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Affiliation(s)
- Bong-Hyeon Kye
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93-6, Ji-dong, Paldal-gu, Suwon-si, Gyeonggi-do 442-723, Republic of Korea
| | - Hyung-Jin Kim
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93-6, Ji-dong, Paldal-gu, Suwon-si, Gyeonggi-do 442-723, Republic of Korea
| | - Jun-Gi Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul 137-701, Republic of Korea
| | - Hyeon-Min Cho
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93-6, Ji-dong, Paldal-gu, Suwon-si, Gyeonggi-do 442-723, Republic of Korea.
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21
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Pérez Domínguez L, García Martínez MT, Cáceres Alvarado N, Toscano Novella A, Higuero Grosso AP, Casal Núñez JE. Morbidity and mortality of temporary diverting ileostomies in rectal cancer surgery. Cir Esp 2014; 92:604-8. [PMID: 24969349 DOI: 10.1016/j.ciresp.2013.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 12/04/2013] [Accepted: 12/08/2013] [Indexed: 11/28/2022]
Abstract
INTRODUCTION A temporary diverting ileostomy is frequently used to reduce the consequences of a distal anastomotic leakage after total mesorectal excision in rectal cancer surgery. This surgical technique is associated with high morbidity and a not negligible mortality. The aim of this study is to evaluate the morbidity and mortality rate associated with an ileostomy and its posterior closure. MATERIAL AND METHODS Between 2001 and 2012, 96 patients with temporary diverting ileostomy were retrospectively analyzed. Morbidity and mortality were analyzed before and after the stoma closure. The studied variables included age, sex, comorbidities, time to bowel continuity restoration and adjuvant chemotherapy. RESULTS In 5 patients the stoma was permanent and another 5 died. The morbidity and mortality rates associated with the stoma while it was present were 21 and 1% respectively. We performed a stoma closure in 86 patients, 57% of whom had previously received adjuvant therapy. There was no postoperative mortality after closure and the morbidity rate was 24%. The average time between initial surgery and restoration of intestinal continuity was 152.2 days. This interval was significantly higher in patients who had received adjuvant therapy. No statistically significant difference was found between the variables analyzed and complications. CONCLUSIONS Diverting ileostomy is associated with low mortality and high morbidity rates before and after closure. Adjuvant chemotherapy significantly delays bowel continuity restoration, although in this study did not influence in the rate of complications.
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Affiliation(s)
- Lucinda Pérez Domínguez
- Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España.
| | - María Teresa García Martínez
- Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - Nieves Cáceres Alvarado
- Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - Angeles Toscano Novella
- Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - Antonio Pedro Higuero Grosso
- Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - José Enrique Casal Núñez
- Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
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Chiu A, Chan HT, Brown CJ, Raval MJ, Phang PT. Failing to reverse a diverting stoma after lower anterior resection of rectal cancer. Am J Surg 2014; 207:708-11; discussion 711. [PMID: 24791631 DOI: 10.1016/j.amjsurg.2013.12.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 12/13/2013] [Accepted: 12/15/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND A diverting stoma is an accepted adjunct to low anterior resection (LAR) for rectal cancer. However, some patients do not undergo a subsequent procedure to have the stoma reversed. We aim to determine incidence and risk factors for nonclosure of the diverting stoma. METHODS This is a retrospective study of stage I to III rectal cancer patients at a single institution having LAR with curative intent and a diverting stoma. RESULTS We studied 162 patients. Prevalence of nonclosure of the temporary stoma was 14.5% within 13 months of the index surgery. On a multivariate linear regression model, nonclosure was associated with anastomotic leak (odds ratio 9.89, 2.31 to 43.93, P < .001) and age older than 65 (odds ratio 2.76, 1.08 to 7.48, P < .036). CONCLUSIONS Prevalence of nonclosure of a diverting stoma after LAR for rectal cancer is substantial (14.5%). Patients should be counselled regarding this risk with particular attention to potential risk factors.
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Affiliation(s)
- Andrew Chiu
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Hong T Chan
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Carl J Brown
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Manoj J Raval
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - P Terry Phang
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.
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Tulchinsky H, Shacham-Shmueli E, Klausner JM, Inbar M, Geva R. Should a loop ileostomy closure in rectal cancer patients be done during or after adjuvant chemotherapy? J Surg Oncol 2014; 109:266-269. [DOI: 10.1002/jso.23493] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Hagit Tulchinsky
- Proctology Unit, Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Division of Surgery, Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Einat Shacham-Shmueli
- Department of Oncology, Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Joseph M. Klausner
- Division of Surgery, Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Moshe Inbar
- Department of Oncology, Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Ravit Geva
- Department of Oncology, Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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Vallribera Valls F, Villanueva Figueredo B, Jiménez Gómez LM, Espín Bassany E, Sánchez Martinez JL, Martí Gallostra M, Armengol Carrasco M. [Ileostomy closure in a colorectal surgery unit. Comparative analysis of different techniques]. Cir Esp 2014; 92:182-7. [PMID: 24412284 DOI: 10.1016/j.ciresp.2013.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 04/25/2013] [Accepted: 04/28/2013] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The objective of this study is to assess whether the results of loop ileostomy closure in terms of morbidity and hospital stay are influenced by the type of anastomosis and suture used. METHOD All patients who underwent loop ileostomy closure were reviewed. A retrospective cohort study comparing morbidity and hospital stay according to the type of anastomosis (TT/LL) and the type of suture (hand sewn/mechanical) was performed. RESULTS From January 2003 to November 2011 a total of 167 loop ileostomy closures were analized. The groups were: type of anastomosis (TT 95/LL 72) and type of suture (manual 105/stapled 62). In 76% of the observed population the underlying disease was cancer. Mortality occurred in one case. The stratified morbidity analysis by type of complications showed no significant differences between the groups in terms of local (7.4% TT, LL 8.3%, 6.7% hand sewn, stapled 9.7%), general (TT 9.5%, 16.7% LL, hand sewn 6.7%, 6.5% stapled) and surgical (TT 15.8%, 19.4% LL, hand sewn 17.1%, 17.7% stapled) complications, nor in the rate of reoperations (TT 6.3%, 6.9% LL, hand sewn 6.7%, 6.5% stapled) and hospital stay in days (TT 7.8, 8 LL, hand sewn 8.6, stapled 6.7) CONCLUSIONS: Closure of loop ileostomy can be performed regardless of the type of suture or anastomosis used, with the same rate of morbidity and hospital stay.
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Affiliation(s)
- Francesc Vallribera Valls
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - Borja Villanueva Figueredo
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España.
| | - Luis Miguel Jiménez Gómez
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - Eloi Espín Bassany
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - José Luis Sánchez Martinez
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - Marc Martí Gallostra
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
| | - Manuel Armengol Carrasco
- Servicio de Coloproctología, Unidad de Cirugía General y del Aparato Digestivo, Hospital Vall d'Hebrón, Barcelona, España
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Floodeen H, Lindgren R, Matthiessen P. When are defunctioning stomas in rectal cancer surgery really reversed? Results from a population-based single center experience. Scand J Surg 2013; 102:246-50. [PMID: 24056133 DOI: 10.1177/1457496913489086] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS This study assessed the timing of reversal of defunctioning stoma following low anterior resection of the rectum for cancer and risk factors for a defunctioning stoma becoming permanent in patients who were not reversed. MATERIAL AND METHODS Patients who underwent low anterior resection with defunctioning stoma during a 12-year period were assessed with regard to timing of stoma reversal. Delayed reversal was defined as >4 months after low anterior resection. Patients with a defunctioning stoma that was never reversed were assessed regarding risk factors for permanent stoma. RESULTS A total of 134 patients were analyzed. Of 106 stoma reversals, 19% were reversed within 4 months of low anterior resection, while 81% were reversed later than 4 months. In 58% of these patients, the delay was to due to low medical priority given to this procedure. The other main reasons for delayed stoma reversal were nonsurgical complications (20%), symptomatic anastomotic leakage following low anterior resection (12%), and postoperative adjuvant chemotherapy (10%). Of all patients, 21% (28/134) ended up with a permanent stoma. Risk factors for a defunctioning stoma becoming permanent were stage IV cancer (P < 0.001) and symptomatic anastomotic leakage following low anterior resection (P < 0.001). CONCLUSION Four in five patients experienced a delayed stoma reversal, in a majority because of the low priority given to this surgical procedure.
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Affiliation(s)
- H Floodeen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
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26
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Do older Americans undergo stoma reversal following low anterior resection for rectal cancer? J Surg Res 2012; 183:238-45. [PMID: 23298948 DOI: 10.1016/j.jss.2012.11.057] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/21/2012] [Accepted: 11/30/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE For low-lying rectal cancers, proximal diversion can reduce anastomotic leak after sphincter-preserving surgery; however, evidence suggests that such temporary diversions are often not reversed. We aimed to evaluate nonreversal and delayed stoma reversal in elderly patients undergoing low anterior resection (LAR). DESIGN SEER-Medicare-linked analysis from 1991-2007. SETTINGS AND PARTICIPANTS A total of 1179 primary stage I-III rectal cancer patients over age 66 who underwent LAR with synchronous diverting stoma. MAIN OUTCOME MEASURES (1) Stoma creation and reversal rates; (2) time to reversal; (3) characteristics associated with reversal and shorter time to reversal. RESULTS Within 18 mo of LAR, 51% of patients (603/1179) underwent stoma reversal. Stoma reversal was associated with age <80 y (P < 0.0001), male sex (P = 0.018), fewer comorbidities (P = 0.017), higher income (quartile 4 versus 1; P = 0.002), early tumor stage (1 versus 3; P < 0.001), neoadjuvant radiation (P < 0.0001), rectal tumor location (versus rectosigmoid; P = 0.001), more recent diagnosis (P = 0.021), and shorter length of stay on LAR admission (P = 0.021). Median time to reversal was 126 d (interquartile range: 79-249). Longer time to reversal was associated with older age (P = 0.031), presence of comorbidities (P = 0.014), more advanced tumor stage (P = 0.007), positive lymph nodes (P = 0.009), receipt of adjuvant radiation therapy (P = 0.008), more recent diagnosis (P = 0.004), and longer length of stay on LAR admission (P < 0.0001). CONCLUSIONS Half of elderly rectal cancer patients who undergo LAR with temporary stoma have not undergone stoma reversal by 18 mo. Identifiable risk factors predict both nonreversal and longer time to reversal. These results help inform preoperative discussions and promote realistic expectations for elderly rectal cancer patients.
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27
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Memon S, Heriot AG, Atkin CE, Lynch AC. Facilitated early ileostomy closure after rectal cancer surgery: a case-matched study. Tech Coloproctol 2012; 16:285-90. [DOI: 10.1007/s10151-012-0843-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 04/30/2012] [Indexed: 10/28/2022]
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Abstract
PURPOSE The purpose of the study was to examine time to reversal of a temporary ostomy, reasons for delayed closure, and patient satisfaction with the scheduling of their closure and related hospital care. DESIGN Cross-sectional, descriptive study. SUBJECTS AND SETTING The target population comprised patients who underwent creation of a temporary ostomy and reversal surgery within one National Health System Hospital Trust in the United Kingdom. The population served by this Trust are ethnically and socioeconomically diverse, predominantly living in urban areas around Greater London. Sixty-one persons who met inclusion criteria were identified. METHODS A two-step analytical process was undertaken. First, a literature review examining incidence and causes of delayed stoma closure was undertaken. Second, a postal survey of all patients who had had their stoma closed in 2009 was conducted. Respondents were allowed 2 weeks to complete and return the questionnaire. INSTRUMENT The survey instrument was developed locally and subjected to content validation using ostomy patients, surgical and nursing colleagues. It consisted of 9 questions querying time from original surgery to closure, reasons for delaying closure surgery beyond 12 weeks, and satisfaction with care. RESULTS Twenty-seven patients returned their questionnaires, indicating they consented to participate; a response rate of 44%. Half of the respondents (n = 14 [52%]) underwent closure surgery within 6 months of stoma formation; the remaining 48% waited more than 6 months (median: 6.5 months, range: 1.5-26 months). Thirteen patients (48%) reported a delay in receiving their stoma closure; the main reason cited was the need for a course of adjuvant postoperative chemotherapy. Three quarters of respondents (22 [74%]) were satisfied with the overall care they received. CONCLUSION Findings from this study suggest that stoma closure may be associated with fewest complications if performed before 12 weeks.
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Courtier R, Parés D, Silva CA, Gil MJ, Pascual M, Alonso S, Pera M, Grande L. [Clinical results of loop ileostomy closures in rectal cancer surgical patients. Effect of chemotherapy in the waiting period]. Cir Esp 2011; 88:308-13. [PMID: 20889147 DOI: 10.1016/j.ciresp.2010.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 07/23/2010] [Accepted: 08/20/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The introduction of sphincter preservation surgery in rectal cancer has led to an increase in the number of low resections protected with a loop ileostomy. This requires subsequent closure of the stoma, a surgical procedure which is not devoid of morbidity or mortality. The aims of the study were to analyse the clinical results of the passage reconstruction surgery and to find out the interval between both surgeries, as well as the role chemotherapy plays in this. PATIENTS AND METHOD The prospective data of patients previously operated on for rectal cancer were used retrospectively with those whose ileostomy was closed between May 2004 and September 2008. Data associated to chemotherapy indication, interval between surgeries and complications were collected and analysed. RESULTS A total of 54 consecutive patients with a mean age of 66 years were analysed. The mean interval between surgeries was 178 days, being significantly less in the patient group that did not receive chemotherapy (p=0.008). The post-operative stay was 6.3 days (SD=4.1). Mortality due to respiratory failure was 1.8% and the morbidity was 22.2%, with 7.4% requiring further surgery. CONCLUSIONS The mortality and morbidity of ileostomy closures are not inconsiderable, although its advantages in the protection of the stoma justify its use. The ileostomy construction interval appears to be significantly affected by post-operative chemotherapy.
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Affiliation(s)
- Ricardo Courtier
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario del Mar, Universitat Autònoma de Barcelona, Barcelona, España.
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Miccini M, Bonapasta SA, Gregori M, Barillari P, Tocchi A. Ghost ileostomy: real and potential advantages. Am J Surg 2010; 200:e55-7. [DOI: 10.1016/j.amjsurg.2009.12.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 12/11/2009] [Accepted: 12/14/2009] [Indexed: 11/26/2022]
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Taylor C, Morgan L. Quality of life following reversal of temporary stoma after rectal cancer treatment. Eur J Oncol Nurs 2010; 15:59-66. [PMID: 20667779 DOI: 10.1016/j.ejon.2010.06.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 06/01/2010] [Accepted: 06/04/2010] [Indexed: 11/24/2022]
Abstract
PURPOSE An examination of quality of life outcomes following reversal of a temporary stoma after rectal cancer treatment. METHOD An extensive search of the literature was conducted. Studies selected examine the consequences of stoma reversal on individual's lives. Methodological issues and implications for nursing practice are also considered. RESULTS It is clear that after stoma reversal, there is often a temporary alteration in bowel function, impacting on individuals' physical, social and psychological health for several months. There is possibility of permanent difficulties for some, significantly affecting their quality of life if left untreated. These effects can lead to more negative post-operative experiences than expected. CONCLUSION This review prompts discussion about how to provide appropriate support for patients following stoma reversal but also optimal pre-operative preparation, to foster realistic expectations and subsequent adaptation. It is suggested that nursing support should be targeted to the first few months post-reversal when bowel symptoms tend to be most troublesome.
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Affiliation(s)
- Claire Taylor
- Burdett Institute of Gastrointestinal Nursing, Kings College, London, UK.
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David GG, Slavin JP, Willmott S, Corless DJ, Khan AU, Selvasekar CR. Loop ileostomy following anterior resection: is it really temporary? Colorectal Dis 2010; 12:428-32. [PMID: 19226365 DOI: 10.1111/j.1463-1318.2009.01815.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis if anastomotic dehiscence occurs following low colorectal anastomosis. Although it has been suggested that a loop ileostomy should be reversed within 12 weeks of formation, this is often not the case. We set out to analyse the use of loop ileostomy following elective anterior resection in England and to identify factors associated with non and delayed reversal. METHOD Hospital episode statistics for the years 2001-2006 were obtained from the Department of Health. Patients undergoing elective anterior resection with a loop ileostomy for a primary diagnosis of rectal or recto-sigmoid cancer between April 2001 and March 2003 were identified as the study cohort. This cohort was followed until March 2006 to identify patients undergoing reversal of an ileostomy in an English NHS Hospital. RESULTS A total of 6582 patients had an elective anterior resection between April 2001 and March 2003, of which 964 (14.6%) also had an ileostomy. Seven hundred and two (75.1%) patients were reversed before March 2006. Advancing age and comorbidity were statistically related to nonreversal. Median time to reversal was 207 days (Interquartile range 119-321.5 days). Postoperative chemotherapy and comorbidity significantly delayed reversal. CONCLUSIONS One in four loop ileostomies performed to defunction an elective anterior resection is not reversed, and in the presence of significant comorbidity one in three is not reversed. Only 12% is reversed within 12 weeks.
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Affiliation(s)
- G G David
- Leighton Research Unit, Department of General Surgery, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, UK
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Saha AK, Tapping CR, Foley GT, Baker RP, Sagar PM, Burke DA, Sue-Ling HM, Finan PJ. Morbidity and mortality after closure of loop ileostomy. Colorectal Dis 2009; 11:866-71. [PMID: 19175627 DOI: 10.1111/j.1463-1318.2008.01708.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND A temporary loop ileostomy is commonly used to protect low pelvic anastomoses. Closure is associated with morbidity and mortality. This study investigated patterns of complications after loop ileostomy closure and factors associated with morbidity and mortality. METHOD A review was performed of patients who underwent loop ileostomy closure between 1999 and 2005. RESULTS Three hundred and twenty-five patients underwent closure of loop ileostomy. Reasons for primary surgery were: anterior resection for cancer (n = 160, 49%), ileal pouch-anal anastomosis (n = 114, 35%), diverticular disease (n = 25, 8%), Crohn's colitis (n = 4, 1%) and other conditions (n = 22, 7%). Overall mortality was 2.5% (n = 8) and morbidity was 22.8% (n = 74). Thirty-two patients (10%) developed small bowel obstruction, of whom seven required operative intervention. Overall, the re-operation rate in this series was 28 patients (8.6%). Thirteen (4%) patients had an anastomotic leak of whom 12 patients had re-operation. Preoperative anaemia was significantly associated with leakage (Hb < 11 g/dl; n = 65, P = 0.033). The leakage rate was lower after a stapled anastomosis than a hand-sutured anastomosis (4/203 vs 9/122; P = 0.039). Hypo-albuminaemia (albumin < 34 g/l) was significantly associated with mortality (n = 46, P < 0.001). CONCLUSIONS Loop ileostomy closure is associated with morbidity and mortality. Anaemia and hypo-albuminaemia may be associated with poor outcome.
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Affiliation(s)
- A K Saha
- The John Goligher Colorectal Unit, Research Room D156, D Floor, Clarendon Wing, Leads General Infirmary, Great George Street, Leeds LS1 3EX, UK.
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Abstract
INTRODUCTION Hartmann's procedure is widely used in the management of complicated diverticular disease and for colorectal cancer. Very little national data are available about the reasons for performing this procedure and the reversal rate. METHOD Hospital episode statistics data were obtained from The Department of Health and exported to an Access database for analysis. A cohort of patients who underwent a Hartmann's procedure between April 2001 and March 2002 were identified and followed until April 2006 to identify patients undergoing reversal of Hartmann's. RESULTS Approximately 3950 Hartmann's procedures were performed between April 2001 and March 2002, 2853 as an emergency and 1097 as an elective procedure. Most emergency Hartmann's were performed for benign disease (2067, 72.5%) whereas a majority of the elective Hartmann's were performed for cancer (756, 68.9%). Seven hundred and thirty six (23.3%) of these patients underwent reversal during the study period. The median time interval between a Hartmann's procedure and reversal was 284.5 days (interquartile range 181-468.25). CONCLUSION This study represents the single largest cohort in whom outcome after Hartmann's procedure has been studied. A majority of Hartmann's are performed as an emergency for benign diseases and most of them are not reversed.
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Affiliation(s)
- G G David
- Leighton Research Unit, Department of General Surgery, Mid Cheshire Hospitals NHS Trust, Leighton Hospital, Crewe, UK
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Liver resections combined with closure of loop ileostomies: a retrospective analysis. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2008; 2008:501397. [PMID: 19096524 PMCID: PMC2599919 DOI: 10.1155/2008/501397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 10/30/2008] [Indexed: 12/31/2022]
Abstract
Background.
The management of patients with colorectal liver metastases and loop ileostomies remains controversial. This study was performed to assess the outcome of combined liver resection and loop ileostomy closure. Methods. Analysis of prospectively collected perioperative data, including morbidity and mortality, of 283 consecutive hepatectomies for colorectal liver metastases was undertaken. Consecutive liver resections were performed from 1996 to 2006 in one centre by a single surgeon (NDK). Fourteen of these patients had combined liver resection and ileostomy closure. Case-matched analysis was undertaken.
Results.
Six (2.2%) patients died in the hepatectomy only group and none died in the combined group. There was no difference in operative blood loss between the two groups (0.09). Perioperative morbidity was 36% in the combined group and 23% in the hepatectomy alone group (P = 0.33). Mean hospital stay was 14 days in the combined group and 11 days in the hepatectomy only group (P = 0.046). Case-matched analysis showed a significant increase in hospital stay (P = 0.03) and complications (P = 0.049) in the combined group.
Conclusion.
In patients with CRLM, combined liver resection and closure of ileostomy may be associated with a higher operative morbidity and a prolonged hospital stay.
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Flikier-Zelkowicz B, Codina-Cazador A, Farrés-Coll R, Olivet-Pujol F, Martín-Grillo A, Pujadas-de Palol M. Morbilidad y mortalidad en relación con el cierre de ileostomías derivativas en la cirugía del cáncer de recto. Cir Esp 2008; 84:16-9. [DOI: 10.1016/s0009-739x(08)70598-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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