Predisposing Factors for High Output Stoma in Patients With a Diverting Loop Ileostomy After Colorectal Surgeries

High output stoma after surgery for rectal cancer - a risk factor for low anterior resection syndrome?

PURPOSE

The relationship between high-output stoma (HOS) and low anterior resection syndrome (LARS) was previously unclear. This study investigated the association between HOS and major LARS in rectal cancer patients with preventive stoma.

METHODS

We conducted a retrospective analysis of 653 rectal cancer patients who underwent prophylactic ileostomy reversal after low anterior resection at the Fourth Hospital of Hebei Medical University between 2018 and 2021. Patients were categorized into HOS and non-HOS groups based on stoma output within 3 months before surgery. Major LARS was assessed using the LARS score. The association between HOS and major LARS was analyzed using multifactor logistic regression models, subgroup analyses, and smoothing curve fitting methods.

RESULTS

Among the 653 patients, 53 (8.1%) experienced HOS, and 81 (12.4%) developed major LARS after stoma closure. The HOS group exhibited a significantly higher risk of major LARS compared to the non-HOS group (P < 0.001). Multivariate logistic regression indicated that HOS was associated with a 210% increased risk of major LARS (OR: 3.10; 95% CI: 1.56, 6.14; P = 0.001). Subgroup analysis revealed that this association was more pronounced in older patients (age > 60), those without hypertension, with N0-N1 staging, a history of chemotherapy, and longer stoma closure intervals (Q3, Q4).

CONCLUSION

HOS is significantly associated with major LARS in rectal cancer patients, particularly in certain clinical subgroups. These findings suggest the need for careful management of HOS to potentially reduce LARS occurrence after stoma closure.

The Frequency of Stoma-Related Readmissions After Emergency and Elective Ileostomy Formation: The Leicester Experience

Background Approximately 9,000 patients undergo ileostomy formation each year in England. This includes those formed in both the elective and emergency settings. Recent studies have indicated a stoma-related complication rate of up to 83%.The aim of the current study was to ascertain the most common indications for ileostomy formation and to determine whether there were differences in the complication rates depending on whether the surgery occurred in the emergency or elective setting. Methods The study was a retrospective audit conducted at the University Hospitals of Leicester. Inclusion criteria were patients who underwent ileostomy formation between January 1 and December 31, 2023. Results The study cohort comprised 97 patients. Eleven of 44 (25.0%) patients in the emergency cohort had stoma-related complications, with their main reasons being high output stomas and bowel obstruction, which is higher compared to the elective patient cohort which had a complication rate of 5/53 (9.4%), with their main reasons being parastomal hernias and stoma prolapse. Ileostomies formed as a result of colorectal malignancy also led to a higher complication rate. Conclusion Our study suggests that ileostomies formed in the emergency setting as well as those formed due to colorectal malignancies had a higher rate of stoma-related complications. Stoma-related complications continue to be a common presentation to the emergency department.

[Morphological predictors of water-electrolyte disorders in patients with preventive ileostomy after rectal resection for cancer]

OBJECTIVE

To analyze morphological changes in wall of functioning and non-functioning small intestine in patients with preventive ileostomy and to determine histological predictors of water-electrolyte disorders.

MATERIAL AND METHODS

We prospectively analyzed 57 patients >18 years old who underwent rectal resection with preventive ileostomy between January 2022 and November 2023. Anthropometric data included gender, age, body mass index, ECOG and ASA classes. Complications associated with large losses through ileostomy were water-electrolyte disorders, dehydration and acute renal failure with repeated hospitalization. Morphological analysis implied intraoperative full-layer biopsy of small intestine on anterior abdominal wall (ileostomy). Intraoperative biopsy of efferent and afferent loops was also carried out. Tissue samples were examined by light microscopy. We analyzed mean height of mucous membrane villi and depth of crypts, as well as their ratio. Fibrosis and swelling of submucosa were evaluated too. The results were analyzed in the SPSS Statistics 20 software.

RESULTS

Mean height of intestinal villi <465 microns (p=0.028), ratio of their height to crypt depth <4.38 (p=0.034) and submucosal fibrosis (p=0.031) significantly affected malabsorption and readmission of patients. The risk of readmission was 11.5 and 5.5 times higher in univariate analysis. Multivariate analysis revealed in-hospital dehydration with resumption of infusion therapy as a predictor of readmission (p=0.046).

CONCLUSION

Ileostomy is a certain stress for the patient's body. Not every patient is able for adaptation. One of the adaptation mechanisms is hypertrophy of mucous membrane villi involved in digestion. This mechanism is less pronounced in patients with repeated hospitalizations. Preoperative morphological examination of ileum mucosa may be an additional objective predictor of possible complications of preventive ileostomy.

Knowledge, attitudes, practices and associated factors regarding high output stoma of ileostomy among colorectal surgical nurses: a multicentre cross-sectional study

PURPOSE

High output stoma(HOS) is one of the most common complications after ileostomy, leading to fluid and electrolyte disturbances and renal dysfunction, and increasing the risk of readmission. Routine health education for HOS should be provided, and nurses, as the primary educators, should have adequate knowledge and skills in this area. However, there is a paucity of research on the knowledge and practice of HOS management. This study used the Knowledge, Attitude and Behavioural Practice Model to assess the management of HOS by colorectal surgery nurses and to explore the factors that influence it.

METHOD

Using a multi-centre, cross-sectional study design, 398 colorectal surgery nurses from 6 hospitals in 6 cities in 6 provinces were surveyed using a structured electronic questionnaire to assess general information and knowledge, attitudes and management practices and training needs related to HOS of ileostomy.

RESULTS

Colorectal surgery nurses' knowledge and practice of HOS was low. The presence or absence of training is an important factor influencing nurses' knowledge, attitudes and practice, with most nurses having no training and stoma specialist nurses scoring relatively high on knowledge and practice.

CONCLUSIONS

Nurses play a very important role in the management of HOS, but this study shows that the current level of knowledge and practice of HOS among colorectal surgery nurses is concerning, and whether or not they have received training is the most critical influencing factor; therefore, training related to HOS is urgently needed.

Obstructive and secretory complications of diverting ileostomy

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

A review of chyme reinfusion: new tech solutions for age old problems

High-output double enterostomies (DES) and enteroatmospheric fistulae (EAF) are associated with significant morbidity, including infection, malnutrition, and prolonged hospital admissions. Management is complex and has remained a challenging surgical problem for many decades in both adult and paediatric patient populations. Chyme reinfusion (CR) from the proximal to distal DES or EAF limb is a potential therapeutic solution which has been shown to be safe and beneficial; however, early methods have involved the manual handling of chyme, which is labour intensive and poorly tolerated by both patients and staff. Over the past four decades, there has been growing interest in the application and development of medical device technology to improve the effectiveness and user-friendliness of CR. New Zealand (NZ) has been at the forefront of innovation in this field, with exciting translational research projects in both adults and neonates (funded and enabled by the NZ MedTech CORE). This narrative review provides a summary of the evolution of CR technology globally, synthesises the extant clinical evidence and highlights future directions.