Low complication rate after stoma closure. Consultants attended 90% of the operations

Early postoperative complications after transverse colostomy closure, a retrospective study

BACKGROUND

Ostomy is a common surgery usually performed to protect patients from clinical symptoms caused by distal anastomotic leakage after colorectal cancer (CRC) surgery and perforation or to relieve intestinal obstruction.

AIM

To analyze the complications after transverse colostomy closure.

METHODS

Patients who underwent transverse colostomy closure from Jan 2015 to Jan 2022 were retrospectively enrolled in a single clinical center. The differences between the complication group and the no complication group were compared. Logistic regression analyses were conducted to find independent factors for overall complications or incision infection.

RESULTS

A total of 102 patients who underwent transverse colostomy closure were enrolled in the current study. Seventy (68.6%) patients underwent transverse colostomy because of CRC related causes. Postoperative complications occurred in 30 (29.4%) patients and the most frequent complication occurring after transverse colostomy closure was incision infection (46.7%). The complication group had longer hospital stays (P < 0.01). However, no potential risk factors were identified for overall complications and incision infection.

CONCLUSION

The most frequent complication occurring after transverse colostomy closure surgery in our center was incision infection. The operation time, interval from transverse colostomy to reversal, and method of anastomosis might have no impact on the postoperative complications. Surgeons should pay more attention to aseptic techniques.

Laparoscopic vs. open loop ileostomy reversal: a meta-analysis of randomized and non-randomized studies

PURPOSE

The present meta-analysis compares laparoscopic loop ileostomy reversal (LLIR) with open loop ileostomy reversal (OLIR) to evaluate the advantages of the laparoscopic technique compared to the traditional open technique in ileostomy reversal.

METHODS

Primary endpoints were hospital stay and overall complications. Secondary endpoints were operative time, EBL, readmission, medical complications, surgical complications, reoperation, wound infection, anastomotic leak, intestinal obstruction, and cost of the procedures. The included studies were also divided based on the type of anastomotic approach: extracorporeal laparoscopic loop ileostomy reversal (ELLIR) and intracorporeal laparoscopic loop ileostomy reversal (ILLIR).

RESULTS

In the analysis, 4 studies were included. Three hundred fifty-four patients were enrolled. As primary outcomes, a significant difference was found in hospital stay between the LLIR and OLIR groups (MD = -0.67, 95% CI -1.16 to -0.19, P = 0.007). The overall complications outcome resulted in favor of the LLIR group (RR = 0.64, 95% CI 0.43-0.95, P = 0.03). As secondary outcomes, the operative time was in favor of the OLIR group (MD = 19.18, 95% CI 10.20-28.16, P < 0.001). Surgical complications were lower in the LLIR group than in the OLIR group. No other differences between the secondary endpoints were found. Subgroup analysis showed a significant difference in hospital stay between the ILLIR and OLIR groups (MD = -0.92, 95% CI -1.55 to -0.30, P = 0.004). The overall complications outcome significantly favored the ILLIR group (RR = 0.38, 95% CI 0.15-0.96, P = 0.04).

CONCLUSION

Our meta-analysis shows an advantage in terms of shorter post-operative hospitalization and reduction of complications of LLIR compared to OLIR. The sub-group analysis shows that performing an extracorporeal anastomosis exposes the same risks of the open technique.

Comparison of modified gunsight suture technique and traditional interrupted suture in enterostomy closure

BACKGROUND

Prophylactic enterostomy surgery is a common surgical approach used to reduce the risk of anastomotic leakage in patients who have undergone partial intestinal resection due to trauma or tumors. However, the traditional interrupted suturing technique used in enterostomy closure surgery has several issues, including longer surgical incisions and higher incision tension, which can increase the risk of postoperative complications. To address these issues, scholars have proposed the use of a "gunsight suture" technique. This technique involves using a gunsight incision instead of a traditional linear incision, leaving a gap in the center for the drainage of blood and fluid to reduce the risk of infection. Building on this technique, we propose an improved gunsight suture technique. A drainage tube is placed at the lowest point of the incision and close the gap in the center of the gunsight suture, which theoretically facilitates early postoperative mobility and reduces the burden of dressing changes, thereby reducing the risk of postoperative complications.

AIM

To compare the effectiveness of improved gunsight suture technique with traditional interrupted suture in closing intestinal stomas.

METHODS

In this study, a retrospective, single-center case analysis was conducted on 270 patients who underwent prophylactic ileostomy closure surgery at the Department of Colorectal Surgery of Qilu Hospital from April 2017 to December 2021. The patients were divided into two groups: 135 patients received sutures using the improved gunsight method, while the remaining 135 patients were sutured with the traditional interrupted suture method. We collected data on a variety of parameters, such as operation time, postoperative pain score, body temperature, length of hospital stays, laboratory indicators, incidence of incisional complications, number of wound dressing changes, and hospitalization costs. Non-parametric tests and chi-square tests were utilized for data analysis.

RESULTS

There were no statistically significant differences in general patient information between the two groups, including the interval between the first surgery and the stoma closure [132 (105, 184) d vs 134 (109, 181) d, P = 0.63], gender ratio (0.64 vs 0.69, P = 0.44), age [62 (52, 68) years vs 60 (52, 68) years, P = 0.33], preoperative body mass index (BMI) [23.83 (21.60, 25.95) kg/m² vs 23.12 (20.94, 25.06) kg/m², P = 0.17]. The incidence of incision infection in the improved gunsight suture group tended to be lower than that in the traditional interrupted suture group [ (n = 2/135, 1.4%) vs (n = 10/135, 7.4%), P < 0.05], and the postoperative hospital stay in the improved gunsight suture group was significantly shorter than that in the traditional interrupted suture group [5 (4, 7) d vs 7 (6, 8) d, P < 0.05]. Additionally, the surgical cost in the modified gunsight suture group was slightly lower than that in the traditional suture group [4840 (4330, 5138) yuan vs 4980 (4726, 5221) yuan, P > 0.05], but there was no significant difference in the total hospitalization cost between the two groups.

CONCLUSION

In stoma closure surgery, the improved gunsight technique can reduce the incision infection rate, shorten the postoperative hospital stay, reduce wound tension, and provide better wound cosmetic effects compared to traditional interrupted suture.

Journey for patients following ileostomy creation is not straightforward

BACKGROUND

An ileostomy is usually created to avert systemic sepsis in a patient with a tenuous anastomosis. However, what is often not reported are the numerous issues facing these patients subsequently, ranging from readmissions, non-reversal of the stoma, and complications from the closure. This study was performed to identify these issues among patients following creation of an ileostomy.

METHODS

We conducted a retrospective analysis of consecutive patients who had an ileostomy created from January 2011 to December 2016 at two institutions. Statistical analysis was performed to identify risk factors associated with readmissions and ileostomy non-reversal.

RESULTS

In total, 193 patients had an ileostomy created during the study period. Twenty-six (13.5%) patients developed stoma-related complications requiring readmission. The most common cause of readmission (9.3%) was due to dehydration and acute kidney injury secondary to high stoma output. One hundred thirty (67.4%) patients had their ileostomy reversed. On multivariate analysis, only stomas created during an ultra-low anterior resection were associated with reversal (OR 2.88 [95% CI, 1.24-6.68]; p = 0.014). Among the patients who underwent ileostomy reversal, seven (3.6%) patients developed complications from their ileostomy reversal. Four patients (2.1%) suffered from an anastomotic leak which required repeat surgical intervention with one mortality from the ensuing sepsis.

CONCLUSION

Almost half of the patients who had an Ileostomy had an undesirable outcome, including readmissions, non-reversal, and post-operative complications following closure. Patients need to be properly counselled about the risks involved prior to the index operation.

Anastomotic Leakage After Stoma Reversal Combined with Incisional Hernia Repair

BACKGROUND

Stoma reversal in patients with an incisional hernia represents a clinical dilemma, as it remains unknown whether hernia repair should be concomitantly employed. We aimed at examining postoperative complications and mortality in patients undergoing stoma reversal with or without concomitant hernia repair.

METHODS

This study included all patients subjected to stoma reversal between 2010 and 2016 at our institution. Patients were grouped according to conductance of concomitant incisional hernia repair or not. The primary outcome was anastomotic leak (AL). Secondary outcomes were surgical site occurrences (SSO), overall surgical complications, 90-day mortality and overall survival.

RESULTS

In total, 142 patients were included of whom 18 (13%) underwent concomitant hernia repair. The incidence of AL was significantly higher in patients subjected to concomitant hernia repair (four out of 18 [22.2%]) compared with patients undergoing stoma reversal alone (three out of 124 [2.4%], P = 0.002). Additional variables associated with AL were duration of surgery (P < 0.001) and ischemic heart disease (P = 0.039). Twenty-two patients (15.5%) developed a SSO: eight (44.4%) in the hernia repair group and 14 (11.3%) in the non-hernia repair group (P < 0.001). In the multivariable analysis, concomitant hernia repair remained significantly associated with development of postoperative complications (OR = 5.92, 95% CI = 1.54-25.96, P = 0.012).

CONCLUSIONS

Compared with stoma reversal alone, incisional hernia repair concomitant with stoma reversal was associated with a higher incidence of AL and other complications.

Systematic review and meta-analysis of incisional hernia post-reversal of ileostomy

PURPOSE

Incisional hernia following closure of loop ileostomy is a common problem. Assessment of the proportion of this complication is limited by small sample size and inconsistent reporting. The aim of this review was to provide an estimate of the proportion of incisional hernia following closure of loop ileostomy according to clinical and radiological diagnostic criteria and to investigate the association of bibliometric and study quality parameters with reported proportion.

METHODS

A systematic review of PubMed, Embase, CENTRAL, ISRCTN Registry and Open Grey from 2000 onwards was performed according to PRISMA standards. Reporting on the type of stoma and mesh reinforcement after closure was mandatory for inclusion, whereas studies on paediatric populations were excluded. Fixed effect or random effects models were used to calculate pooled proportion estimates. Meta-regression models were formed to explore potential heterogeneity.

RESULTS

42 studies with 7166 patients were included. The pooled estimate of the proportion of incisional hernia after ileostomy closure was 6.1% (95% confidence interval, CI 4.4-8.3%). Proportion estimates for higher quality studies and studies reporting on incisional hernia as primary outcome were 9.0% (95% CI 6.3-12.7%) and 13.1% (95% CI 8.8-19.1%). Significant between-study heterogeneity was identified (P < 0.001, I² = 87%) and the likelihood of publication bias was high (P = 0.028). Mixed effects regression showed that both year of publication (P = 0.034, Q = 4.484, df = 1.000) and defining hernia as a primary outcome (Q = 20.298, P < 0.001) were related to effect size. Method of follow-up and quality of the studies affected the proportion.

CONCLUSION

The proportion of incisional hernia at ileostomy closure site is estimated at 6.1%. Reporting incisional hernia as primary or secondary outcome, the method of diagnosis, the year of publication and methodological quality are associated with reported proportion.

Laparoscopic Versus Open Loop Ileostomy Reversal: Is there an Advantage to a Minimally Invasive Approach?

BACKGROUND

Ileostomy reversals are commonly performed procedures after colon and rectal operations. Laparoscopic ileostomy reversal (LIR) with lysis of adhesions has potential benefits over conventional open surgery. The aim of this study was to compare outcomes of laparoscopic and open ileostomy reversal.

METHODS

133 consecutive patients undergoing ileostomy reversal at our institution between June 2009 and August 2013 were analyzed using a retrospective database. The group comprised 53 laparoscopic cases and 80 open cases, performed by four surgeons at a single center. The data were analyzed for patient demographics, operative characteristics, postoperative outcomes, and 30-day morbidity and mortality.

RESULTS

The two groups had comparable mean age, gender distribution, ASA scores, and BMI. The laparoscopic group had a significantly longer duration of surgery compared to the open reversal group (109 versus 93 min, p < 0.05). However, this group underwent more lysis of adhesions (60.4 % versus 26.3 %, p < 0.01) as well as concurrent stoma site mesh reinforcement (32.1 % versus 6.3 %, p < 0.01). In the laparoscopy group, 20.7 % of patients underwent intra-corporeal ileo-ileal anastomosis. There were no significant differences between the laparoscopic and open groups with regard to estimated blood loss (31 versus 40 ml, respectively) or mean length of stay (5.3 vs. 5.7 days, respectively). The rates of overall 30-day morbidity (16.9 % for laparoscopic vs. 21.3 % for open) as well as rates of specific complications were equivalent between groups. 30-day mortalities were not noted in either group.

CONCLUSION

LIR is safe and effective with low perioperative morbidity and mortality. The use of laparoscopy as an option in terms of concomitant hernia repair and lysis of adhesions may be considered in selected patients.

Systematic Review of Adverse Effects: A Further Step towards Modernization of Acupuncture in China

As a further step towards the modernization of acupuncture, the objective of this review was to figure out the frequency and severity of adverse complications and events in acupuncture treatment reported from 1980 to 2013 in China. All first-hand case reports of acupuncture-related complications and adverse events that could be identified in the scientific literature were reviewed and classified according to the type of complication and adverse event, circumstance of the event, and long-term patient outcome. The selected case reports were published between 1980 and 2013 in 3 databases. Relevant papers were collected and analyzed by 2 reviewers. Over the 33 years, 182 incidents were identified in 133 relevant papers. Internal organ, tissue, or nerve injury is the main complications of acupuncture especially for pneumothorax and central nervous system injury. Adverse effects also included syncope, infections, hemorrhage, allergy, burn, aphonia, hysteria, cough, thirst, fever, somnolence, and broken needles. Qualifying training of acupuncturists should be systemized and the clinical acupuncture operations should be standardized in order to effectively prevent the occurrence of acupuncture accidents, enhance the influence of acupuncture, and further popularize acupuncture to the rest of the world.

Surgical Audit of Patients with Ileal Perforations Requiring Ileostomy in a Tertiary Care Hospital in India

Introduction. Ileal perforation peritonitis is a frequently encountered surgical emergency in the developing countries. The choice of a procedure for source control depends on the patient condition as well as the surgeon preference. Material and Methods. This was a prospective observational study including 41 patients presenting with perforation peritonitis due to ileal perforation and managed with ileostomy. Demographic profile and operative findings in terms of number of perforations, site, and size of perforation along with histopathological findings of all the cases were recorded. Results. The majority of patients were male. Pain abdomen and fever were the most common presenting complaints. Body mass index of the patients was in the range of 15.4–25.3 while comorbidities were present in 43% cases. Mean duration of preoperative resuscitation was 14.73 + 13.77 hours. Operative findings showed that 78% patients had a single perforation; most perforations were 0.6–1 cm in size and within 15 cm proximal to ileocecal junction. Mesenteric lymphadenopathy was seen in 29.2% patients. On histopathological examination, nonspecific perforations followed by typhoid and tubercular perforations respectively were the most common. Conclusion. Patients with ileal perforations are routinely seen in surgical emergencies and their demography, clinical profile, and intraoperative findings may guide the choice of procedure to be performed.

Stapled vs hand suture closure of loop ileostomy: a meta-analysis

AIM

Loop ileostomies are widely used in colorectal surgery to reduce the consequences of distal anastomotic failure. The optimal surgical technique for their closure has yet not been defined. A meta-analysis was performed to compare the outcome after stapled or hand sutured ileostomy closure.

METHOD

An electronic literature search of EMBASE, PubMed and the Cochrane Library was undertaken to identify studies reporting stapled and hand sutured ileostomy closure. End-points included postoperative small bowel obstruction (SBO), anastomotic leakage, wound infection, overall postoperative complications, operation time, hospital stay and surgery-related cost.

RESULTS

Fourteen studies including 5084 patients were identified. Meta-analysis showed that stapled closure was associated with a lower rate of SBO overall (OR = 0.56, P < 0.00001) and early (within 30 days of closure) SBO (OR = 0.51, P < 0.00001). This difference persisted for direct ileostomy closure (OR = 0.62, P = 0.02) or closure with bowel resection and hand sewn anastomosis (OR = 0.44, P < 0.00001). Stapled closure required a shorter inpatient stay (mean difference -1.22, P < 0.0001) and operating time (mean difference -11.21, P = 0.01). No significant difference was noted between the two techniques in terms of anastomotic leakage, wound infection, overall complications or cost.

CONCLUSION

Stapled side-to-side anastomosis is associated with fewer complications, especially SBO, than hand sewn ileostomy closure by direct suture or resection and anastomosis. It is quicker to perform and associated with fewer postoperative bowel obstructions.

Abdominal wall closure after a stomal reversal procedure

The closure of a temporary stoma involves 2 different surgical procedures: the stoma reversal procedure and the abdominal wall reconstruction of the stoma site. The management of the abdominal wall has different areas that should be analyzed such us how to avoid surgical site infection (SSI), the technique to be used in case of a concomitant hernia at the stoma site or to prevent an incisional hernia in the future, how to deal with the incision when the stoma reversal procedure is performed by laparoscopy and how to close the skin at the stoma site. The aim of this paper is to analyze these aspects in relation to abdominal wall reconstruction during a stoma reversal procedure.

Management of anastomotic leakage in a nationwide cohort of colonic cancer patients

BACKGROUND

The mortality associated with anastomotic leakage (AL) after colonic cancer surgery is high and management often results in permanent fecal diversion. Preservation of bowel continuity in combination with proximal loop diversion (salvage) may reduce the number of permanent ostomies without jeopardizing safety.

STUDY DESIGN

This nationwide study used prospective data from the database of the Danish Colorectal Cancer Group, the National Patient Registry, and patient files. Patients with AL requiring surgery (grade C) were categorized according to the type of surgical treatment as anastomotic takedown with an end-ostomy or salvage. Thirty-day mortality, long-term mortality, and permanent ostomy rates were analyzed using multivariable logistic and Cox regression analyses.

RESULTS

Anastomotic leakage occurred in 593 of 9,333 patients (6.4%), of whom 507 with grade C were included. Takedown and salvage were undertaken in 433 (85.4%) and 74 (14.6%) patients, respectively. Salvage was performed more frequently for Hinchey I-II or minor anastomotic defects and resulted in increased likelihood of stoma reversal (adjusted hazard ratio 3.24, 95% CI 2.04 to 5.16, p < 0.001), corresponding to a risk of permanent fecal diversion of 16.8%, compared with 54.5% after takedown. Adjusted mortality rates were comparable between the groups. A second episode of AL after stoma reversal occurred more frequently in patients with end-ileostomies (10 of 64) than in patients with end-colostomies (1 of 64) or loop-ileostomies (3 of 36), p = 0.017.

CONCLUSIONS

Patients with Hinchey I-II and small anastomotic defect were safely managed by anastomotic salvage, which reduced the risk of permanent fecal diversion. Anastomotic salvage is a viable option for this subset of patients.