Management of the Difficult Stoma

Fecal ostomy creation is a commonly performed procedure with many indications. Better outcomes occur when preoperative patient education and stoma site marking are provided. Despite a seemingly simple operation, ostomy creation is often difficult and complications are common. Certain risk factors, particularly obesity, are strongly associated with stoma-related complications. The ability to optimize the ostomy and stoma in the operating room and to troubleshoot frequently encountered post-operative stoma-related issues are critical skills for surgeons and ostomy nurses alike.

Comparison of purse-string technique vs linear suture for skin closure after ileostomy reversal. A randomized controlled trial

BACKGROUND

Protective stoma after rectal surgery has been associated with important complications. The most common is surgical site infection (SSI) high rates after stoma reversal reported in literature. Our study compared the rate of SSI of two skin closure techniques, linear closure, and purse string closure.

METHODS

We carried out a single center, prospective, randomized controlled trial in the Department of Colorectal Surgery of Fondazione Policlinico Campus Bio-Medico of Rome between January 2018 through December 2021, to compare LC vs PS closure of ileostomy sites.

RESULTS

A total of 117 patients (53.84% male) with a mean age of 65.68 ± 14.33 years were finally evaluated in the study. 58 patients were included in the PS group and 59 patients in the LC one. There was a marked difference in the SSI rate between the two arms of the study: 3 of 58 patients in the purse-string arm versus 11 of 59 in the control arm (p = 0.043). The outcome of cosmesis was also higher in PS, with a statistical significance (mean ± DS 4,01 ± 0,73 for PS group vs mean ± DS 2,38 ± 0,72 for LC group, p < 0,001).

CONCLUSION

Our study demonstrated that the PS technique had a significantly lower incidence of stoma site SSI compared with LC technique. Our findings are in line with other randomized studies and suggest that PS closure could be considered as standard of care for wound closure after ileostomy reversal.

Clinical application of the B-type sutured ileostomy in robotic-assisted low anterior resection for rectal cancer: a propensity score matching analysis

Currently, there is no consensus on the position and method for temporary ileostomy in robotic-assisted low anterior resection for rectal cancer. Herein, this study introduced the B-type sutured ileostomy, a new temporary ileostomy technique, and compared it to the traditional one to assess its efficacy and safety. Between September 2020 and December 2022 in our centre, B-type sutured ileostomy was performed on 124 patients undergoing robotic-assisted low anterior resection for rectal cancer. A retrospective review of a prospectively collected database identified patients who underwent robotic-assisted low anterior resection for rectal cancer with a temporary ileostomy between January 2018 and December 2022. Patients who underwent B-type sutured ileostomy (B group) were matched in a 1:1 ratio with patients who underwent traditional ileostomy (Control group) using a propensity score based on age, sex, BMI, Comorbidity, American Society of Anesthesiologists (ASA) score, and Prior abdominal surgery history. Surgical and postoperative outcomes, health status, and stoma closure data were analyzed for both groups. ClinicalTrials.gov Identifier：NCT05915052.  The B group (n = 118) shows advantages compared to the Control group (n = 118) regarding total operation time (155.98 ± 21.63 min vs 168.92 ± 21.49 min, p = 0.001), postoperative body pain (81.92 ± 4.12 vs 78.41 ± 3.02, p = 0.001) and operation time of stoma closure (46.19 ± 11.30 min vs 57.88 ± 11.08 min, p = 0.025). The two groups had no other notable differences. The B-type sutured ileostomy is a safe and feasible option in robotic-assisted low anterior resection for rectal cancer. The B-type sutured ileostomy may offer advantages such as shorter overall surgical duration, lighter postoperative pain, and shorter second-stage ostomy incorporation surgery. However, attention should be directed towards the occurrence of stoma prolapse.

'Dumpling suture method' versus traditional suture method of protective loop ileostomy in laparoscopic anterior rectal resection with specimen extraction through stoma incision: a retrospective comparative cohort study

BACKGROUND

A diverting loop ileostomy (DLI) is performed in laparoscopic anterior rectal resection (LAR) surgery at high risk of anastomotic fistula. Minimally invasive surgery promotes postoperative recovery and cosmetics. To reduce abdominal trauma, specimen extraction through stoma incision (EXSI) is usually performed to avoid auxiliary abdominal incision with enlarged stomal incision. The traditional suture method (TSM) reduces the incision size by suturing the ends of the enlarged incision, leading to peristomal incisions and a higher risk of stomal complications. The study aimed to introduce the dumpling suture method (DSM) of PLI and compare this new method with TSM.

MATERIALS AND METHODS

The authors propose a novel stoma suture technique, which utilized a method of skin folding suture to reduce the enlarged incision size. A retrospective analysis was conducted on 71 consecutive patients with rectal cancer who underwent LAR-DLI with EXSI, and the intraoperative details and postoperative outcomes of the two groups were measured.

RESULTS

The DSM group showed a lower stomal complication rate (10.3 vs. 35.7%, P=0.016) than that of the TSM group. The scores of DET (Discoloration, Erosion, Tissue overgrowth), stomal pain, quality of life were all significantly lower in DSM group than in TSM group. In multivariate analysis, DSM was an independent protective factor for stoma-related complications. Operative time, time to first flatus, defecation and eat, nonstomal related postoperative complications were similar in both groups.

CONCLUSION

DSM utilizes a method of skin folding suture to reduce the enlarged incision size, which is safe and effective in reducing the incidence of peristomal skin infections and stomal complications. This procedure offers a novel suturing approach for loop ileostomy with enlarged incision, effectively reducing the postoperative trauma and incidence of stomal complications.

Is proctoscopy sufficient for the evaluation of colorectal anastomosis prior to ileostomy reversal? A nationwide retrospective analysis of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative group (SICO-CCN)

AIM

Several methods for assessing anastomotic integrity have been proposed, but the best is yet to be defined. The aim of this study was to compare the different methods to assess the integrity of colorectal anastomosis prior to ileostomy reversal.

METHOD

A retrospective cohort analysis on patients between 1 January 2010 and 31 December 2020 with a defunctioning stoma for middle and low rectal anterior resection was performed. A propensity score matching comparison between patients who underwent proctoscopy alone and patients who underwent proctoscopy plus any other preoperative method to assess the integrity of colorectal anastomosis prior to ileostomy reversal (transanal water-soluble contrast enema via conventional radiology, transanal water-soluble contrast enema via CT, and magnetic resonance) was performed.

RESULTS

The analysis involved 1045 patients from 26 Italian referral colorectal centres. The comparison between proctoscopy alone versus proctoscopy plus any other preoperative tool showed no significant differences in terms of stenoses (p = 0.217) or leakages (p = 0.103) prior to ileostomy reversal, as well as no differences in terms of misdiagnosed stenoses (p = 0.302) or leakages (p = 0.509). Interestingly, in the group that underwent proctoscopy and transanal water-soluble contrast enema the comparison between the two procedures demonstrated no significant differences in detecting stenoses (2 vs. 0, p = 0.98), while there was a significant difference in detecting leakages in favour of transanal water-soluble contrast enema via CT (3 vs. 12, p = 0.03).

CONCLUSIONS

We can confirm that proctoscopy alone should be considered sufficient prior to ileostomy reversal. However, in cases in which the results of proctoscopy are not completely clear or the surgeon remains suspicious of an anastomotic leakage, transanal water-soluble contrast enema via CT could guarantee its detection.

Novel Repair Technique for Oral and Anal Side Stoma Prolapse of a Loop Colostomy With the Stapled Modified Altemeier Method Using Indocyanine Green Fluorescence Imaging

BACKGROUND/AIM

Stoma prolapse is a common complication in the late phase after stoma creation. With advances in chemotherapy, a double-orifice colostomy or ileostomy and chemotherapy are used to treat primary unresectable colorectal cancer. Preoperative therapy with a double-orifice colostomy or ileostomy is performed to aid primary colorectal cancer miniaturization. Therefore, the number of stoma prolapses will likely increase in the future. Previous reports on the repair of stoma prolapse focused on unilateral stoma prolapse of loop colostomy, and there are no reports about the bilateral stoma prolapse of loop colostomy or ileostomy.

CASE REPORT

We report a novel repair technique for oral and anal side (bilateral) stoma prolapse of a loop colostomy with the stapled modified Altemeier method using indocyanine green (ICG) fluorescence imaging considering the distribution of marginal artery in preventing marginal artery injury which has considerable clinical significance.

CONCLUSION

Our novel technique for the oral and anal side prolapse of a loop colostomy is considered effective and safe.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Retrospective analysis of prospective database.

SETTINGS

Enhanced recovery colorectal surgery service.

PATIENTS

Patients who underwent new ileostomy before and after intervention.

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

Retrospective single-center study.

CONCLUSIONS

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

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

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

Quality of life amongst patients with diverting umbilical stomas in rectal surgery: a single centre prospective randomized controlled pilot study

BACKGROUND

The umbilical stoma (umbistoma) has been proposed as a viable alternative site for a temporary defunctioning stoma. Suggested advantages of the umbistoma include decreased number of surgical incisions required, improved cosmesis and ease of reversal surgery. This study aimed to assess the patient experience of umbilical loop ileostomies in rectal surgery, with the primary outcome being patient reported quality of life (QoL).

METHODS

A total of 20 patients undergoing laparoscopic rectal cancer surgery were randomly allocated to have a defunctioning ileostomy at a conventional site (right iliac fossa) or at the umbilicus. Patient-reported QoL was assessed at 6 weeks using the Stoma-QoL questionnaire. Secondary outcomes were number of stomas reversed, length of time awaiting stoma reversal surgery, duration of operative time for stoma reversal, length of hospital stay following stoma reversal and rate of parastomal or post reversal incisional hernias.

RESULTS

Patients who had an umbilical stoma scored significantly lower on the Stoma-QoL questionnaire compared to the conventional group, particularly on questions regarding feelings of tiredness, body insecurity and anxiety. No significant differences were observed between the two groups in relation to secondary outcomes.

CONCLUSION

There may be potential disadvantages to the umbilical stoma with negative impacts on body image and subsequent increased social anxiety. Patient selection and adequate counselling will be important when considering an umbilical stoma. Further larger scale prospective studies are required to further validate the feasibility and longer-term safety of umbilical stomas in both clinical outcomes as well as patient QoL.

Management of a Peristomal Abscess in a Patient With an Ileostomy: A Case Study

BACKGROUND

Peristomal abscess (PA) is an uncommon but challenging peristomal skin complication. The initial treatment of the PA usually includes incision and drainage of the abscess, resulting in a peristomal wound. The presence of the wound makes it difficult to maintain a seal between the ostomy skin barrier and the peristomal skin resulting in frequent removal and application of the skin barrier to prevent leakage and allow for daily wound care.

CASE

Ms T was a 52-year-old woman with an ileostomy resulting from a prior left hemicolectomy for colon cancer who developed a PA. Treatment of the PA was implemented, along with a modified 2-piece skin barrier that allowed access to the peristomal wound for daily dressing changes while maintaining a seal around the ostomy.

CONCLUSION

The modified 2-piece skin barrier technique proved a successful treatment for the management of the PA without frequent changes of the ostomy pouching system.

Timing and Complications of Intestinal Ostomy Takedown After Intestinal and Multivisceral Transplantation

BACKGROUND

Ileostomies are typically created at the time of intestinal and multivisceral transplantation to assist in graft monitoring with endoscopy and biopsies. Often, these ostomies are reversed with a takedown procedure once there is stable graft function, but data are limited on associated complications of the takedown procedure for patients with intestinal transplants.

METHODS

To assess complications associated with takedowns in this patient population, we performed a retrospective analysis of patients who had an intestinal transplant with elective ostomy takedown after transplant. No prisoners were used in the study and this manuscript is in compliance with the Helsinki Congress and the Declaration of Istanbul.

RESULTS

A total of 16 patients, 10 isolated patients with intestinal transplants and 6 patients with multivisceral transplants, were included in the study, and takedown occurred at a mean of (236.8 ± 117.1) days after transplant. Of the 16 patients, 5 patients (31%) had uncomplicated courses after takedown with no infection, no rejection, and no hospital readmission within 3 months of takedown. The rest of the patients (69%) developed either infection or rejection within 3 months of takedown, and 1 patient died of infection after ileostomy takedown.

CONCLUSION

This case series highlights the high risk of complications after ileostomy takedown for patients with intestinal transplants and contributes to the growing debate regarding the role of ileostomy creation and reversal in patients with intestinal transplants.

ILEOSTIM trial: a study protocol to evaluate the effectiveness of efferent loop stimulation before ileostomy reversal

PURPOSE

A protective loop ileostomy is the most useful method to reduce sequelae in the event of an anastomotic leakage (AL) after rectal cancer surgery. However, it requires an additional stoma reversal surgery with its own potential complications. Postoperative ileus (POI) remains the most common complication after ileostomy reversal, which leads to an increase in morbidity, length of hospital stay (LOS) and overall healthcare costs. Several retrospective studies carried out in this field have concluded that there are insufficient evidence-based recommendations about the routine application of preoperative bowel stimulation in clinical practice. Here we discuss whether stimulation of the efferent limb before ileostomy reversal might reduce POI and improve postoperative outcomes.

METHODS

This is a multicentre randomised controlled trial to determine whether mechanical stimulation of the efferent limb during the 2 weeks before the ileostomy reversal would help to reduce the development of POI after surgery. This study was registered on Clinicaltrials.gov (NCT05302557). Stimulation will consist of infusing a solution of 500 ml of saline chloride solution mixed with a thickening agent (Resource©, Nestlé Health Science; 6.4 g sachet) into the distal limb of the ileostomy loop. This will be performed within the 2 weeks before ileostomy reversal, in an outpatient clinic under the supervision of a trained stoma nurse.

CONCLUSION

The results of this study could provide some insights into the preoperative management of these patients.

Biologic use is not associated with postoperative complications in patients with Crohn's disease undergoing stoma reversion

PURPOSE

Stoma creation is a common procedure in patients with Crohn's disease (CD), and early prophylaxis with biologics is recommended for high-risk patients. However, the effect of biologic exposure on morbidity after stoma closure remains unknown. Therefore, this study aimed to investigate the impact of biologic use on the occurrence of complications in CD patients following stoma closure.

METHODS

Consecutive patients diagnosed with CD who underwent ileostomy reversal at a tertiary care centre between 1 January 2013 and 1 December 2021, were included in the study. The primary outcome was the occurrence of 90-day postoperative complications.

RESULTS

The study included 347 eligible patients who underwent ileostomy reversal. There was no significant difference in terms of infectious complications, overall complications or length of postoperative stay between the biologic and non-biologic groups. Multivariate logistic regression analysis identified several predictors of postoperative morbidity, including preoperative haemoglobin levels below 100 g/L, CRP levels above 10 mg/L, anastomotic site, ileostomy-related infectious complications and albumin levels below 35 g/L.

CONCLUSIONS

This study demonstrated that the use of biologics is not associated with adverse outcomes. However, such as high CRP levels, ileostomy-related infectious complications, hypoproteinemia, and hemoglobinemia, should be optimized prior to surgery to reduce postoperative morbidities.

Virtual Ileostomy as an Option for Complicated Colorectal Resections

When surgery requires a colorectal anastomosis, a diverting ostomy may be created to decrease the clinical impact of anastomotic failure. Unfortunately, diverting ileostomies are also associated with significant morbidity. Recent literature suggests that diverting ostomies are not necessary for the majority of patients undergoing colorectal anastomosis and that creation of a virtual ileostomy (VI) may spare patients the complications that accompany diverting ileostomy creation. We present 4 patients with complex medical histories who underwent colorectal resections with primary anastomoses and VI creation. None of these patients suffered anastomotic leak or required conversion of VI to defunctioning ileostomy and there were no major complications associated with VI creation. Our results, although limited by sample size, support the creation of a virtual ileostomy as a safe and effective alternative to diverting ileostomy creation at the time of colorectal anastomosis.

Peristomal Moisture-Associated Skin Damage Treatment: Use of Cyanoacrylate Liquid Skin Protectant: A Case Series

BACKGROUND

Despite recent advances in ostomy care, the incidence of stoma and peristomal skin complications including peristomal moisture-associated skin damage (MASD) remains as high as 80% of patients living with ostomies. We evaluated a cyanoacrylate liquid skin protectant (CLSP) for the treatment and healing of peristomal MASD in patients with an ileostomy, ileal conduit, or colostomy.

CASES

Five patients (24-85 years old) with peristomal MASD related to an ileostomy (n = 2), ileal conduit (n = 2), or colostomy (n = 1) were evaluated in this case study. All were treated with a CLSP in an attempt to reduce peristomal MASD caused by effluent leakage, which resulted in painful denudation of the peristomal skin. All patients received 1 to 2 applications of the CLSP prior to replacement of the pouching system. Prior to CLSP application, patients underwent assessment focusing on the causes of ostomy pouching system undermining and leakage. Interventions to prevent recurrent undermining and leakage, usually focused on modifications of the pouching system, were completed when indicated.

CONCLUSIONS

For these 5 patients, complete resolution of peristomal MASD was observed at 2 to 8 days following CLSP treatment. More severe peristomal MASD cases required 7 to 8 days for complete resolution while less severe peristomal MASD resolved within 2 to 3 days. Patients showed less frequent pouching system changes, healing of peristomal skin, and reduced peristomal MASD associated with the CLSP treatment and addressing underlying etiology. On a pain scale of 0 to 10, patients reported less pain with an average of more than 7 out of 10 prior to the CLSP treatment and less than 4 out of 10 after treatment.

Cost benefit analysis and pathology review of ileostomy and colostomy specimens processed over a 20-year period

Rising healthcare costs have been linked to overtreatment and overuse of available resources. Identifying and eliminating low-value services is vital for reducing such costs. At many institutions, including ours, all ileostomy and colostomy specimens are sent for pathological evaluation. It is estimated that approximately 120,000 ileostomy/colostomy procedures are done every year, and at least 1 million patients have stomas at any given time in North America. Hence, we decided to analyze the pathological findings and cost-benefit of undertaking the pathological evaluation of these colostomy and ileostomy specimens. The pathology database of our department was searched for all ileostomy and colostomy specimens received between 2000 and 2020, resulting in a total of 2762 cases (1944 ileostomy and 818 colostomy). We performed a cost-benefit analysis and pathologic review of these cases. The results of our study show that 99.38% of these specimens did not show any significant pathological abnormality, and non-neoplastic pathologic findings accounted for 99.63% of cases. Less than 1% of our cases showed any clinically significant pathological findings. All 10 cases that showed a neoplastic or malignant diagnosis showed some abnormal finding that was appreciated at the time of gross examination. We conclude that microscopic evaluation of ileostomy and colostomy specimens incurs significant costs and provides no clear value or relevant information for patient care. The results of our study provide support for ileostomy and colostomy specimens to be triaged by gross-only pathological examination in the first instance for the vast majority of cases.

Wound Infection After Ileostomy Closure: An Interim Analysis of a Prospective Randomized Study Comparing Primary Versus Circumferential Subcuticular Closure Techniques

Background: Circumferential subcuticular wound approximation (CSWA) of round shaped skin wounds after ileostomy take down is believed to lower the rates of surgical site infection (SSI). We performed this randomized trial to compare the rates of SSI and other short-term outcomes among primary linear skin closure (PC) and CSWA groups of patients. Patients and Methods: All patients undergoing ileostomy reversal during the study period were randomly assigned to either PC or CSWA. The primary outcome was the incidence of SSI as assessed by ASEPSIS scoring system. The secondary outcomes included healing time, length of post-operative hospital stay, and patients' satisfaction regarding cosmetic outcome, expectations, pain, time of healing, wound care, and activity on a five-point Likert scale. Results: Thirty-one patients (PC = 15; CSWA = 16) underwent ileostomy reversal during the study period. There was no SSI in the PC group whereas three patients developed SSI in the CSWA group but the result was not statistically significant (p = 0.23). The scores for time of healing (p < 0.001), wound care (p = 0.007), and activity (p < 0.001) were significantly better for PC compared with CSWA whereas there was no significant difference in the scores for cosmetic outcome, expectations, and pain. Healing time was shorter in the PC group (6.7 vs. 34.2 days; p < 0.001) whereas the post-operative length of stay was comparable (6.3 vs. 7 days; p = 0.27). Conclusions: Although there was no difference in the incidence of SSI among the two groups, the PC group fared better in terms of mean time to healing and requirement of wound care.

Cost associated with diverting ostomy after rectal cancer surgery: a transnational analysis

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.

The Role of Ileostomy in the Prevention and Treatment of Anastomotic Leakage after Elective Rectal Cancer Surgery - A Retrospective Analysis of Specific Risk Factors, Outcomes, and Complications

Background: The objective of this paper is to highlight the role and place of ileostomy from the perspective of the risk of anastomotic leakage (AL). Materials and method: This was a retrospective study of 74 (46.54%) low and ultra-low anterior resections from 159 cases of rectal cancer operated on in a seven-year interval (2015 - 2021). The cases were divided into two groups: Group A with protective ileostomy (47 cases = 63.51%) and Group B without protective ileostomy (27 cases = 35.49%). Results: The type of anastomosis was low colorectal for 15 cases and ileorectal for two cases, both in Group A, with either mechanical or manual sutures. Continuous loop ileostomy was the only fecal diversion procedure used for protection. The ileostomy-specific complications recorded in Group A were peristomal skin lesions (8 cases), early peristomal hernia (2 cases), and severe dehydration with acute renal-insufficency (7 cases). The closure of the ileostomy was performed in 42 cases (89.36%), with the time between the primary operation and the closure being 4.28 months on average, with limits between 12 days and 10 months. AL treatment was conservative in 13 (76.47%) cases and surgical in four cases, with the types of operations performed at reintervention being take-down of the anastomosis + left terminal colostomy + ileostomy closure in three cases (2 in Group A and 1 in Group B) and terminal ileostomy in one case in Group A. Conclusions: To reduce its specific complications, ileostomy should be performed in well-selected patients. Those with risk factors for leakage include males, the elderly, and those having important comorbidities, neoadjuvant chemoradiotherapy, low tumors below 5 cm from the anal verge, or complete circumferential stenosis and peritumoral inflammatory infiltrate.

Analysis of abdominal adhesion using the ileostomy model

Abdominal adhesion occurs commonly in clinical practice, causing unfavorable symptoms and readmission. The ileostomy operation is a common surgical procedure and we utilized this model to evaluate abdominal adhesion. Adhesion grade score was calculated in 35 patients (Cohort 1) and subjected to correlation and receiver operating characteristic analysis. Then 98 consecutive patients (Cohort 2) who underwent ileostomy and ileostomy closure were included into a retrospective study. Logistic regression analysis was performed, and the risk of small bowel obstruction was also assessed. The time of ileostomy closure correlated with adhesion grade score in Cohort 1, justifying its use as an indicator of abdominal adhesion. All patients in Cohort 2 were then divided into the high- and low-adhesion group. A multi-variable logistic regression analysis indicated that type of surgery and peritoneum suture during ileostomy were significant factors affecting the risk of abdominal adhesion. Abdominal adhesion had the trend to prolong the length of stay postoperatively without increasing the risk of bowel obstruction. Nine patients suffered bowel obstruction, and age older than 65 significantly increased the risk. We proposed the ileostomy procedure to be a model of abdominal adhesion, and the operative time of ileostomy closure could be used as an alternative of adhesion score. Type of surgery and peritoneum suture may be risk factors of abdominal adhesion. Older age increased the risk of small bowel obstruction after ileostomy surgery.

Evaluation of the SafeHeal Colovac+ anastomosis protection device after low anterior resection for rectal cancer: the safe anastomosis feasibility evaluation (SAFE) 2019 trial

BACKGROUND

Protective ileostomy (PI) is the current standard of care to protect the anastomosis after low anterior resection (LAR) for rectal cancer, but is associated with significant morbidity. Colovac is an anastomosis protection device designed to shield the anastomosis from fecal content. A second version (Colovac+) was developed to limit the migration risk during the implantation period. The objective of this clinical trial was to evaluate the preliminary efficacy and safety of the Colovac+.

METHODS

This was a prospective, multicenter, pilot study aiming to enroll 15 patients undergoing LAR with Colovac+ placement. After 10 days, a CT scan was performed to evaluate the anastomosis and the Colovac+ was retrieved endoscopically. During the 10-day implantation and 3-month follow-up period, we collected data regarding predefined efficacy and safety endpoints. The primary endpoint was the rate of major (Clavien-Dindo III-V) postoperative complications related to the Colovac+ or LAR procedure.

RESULTS

A total of 25 patients were included (68% male), of whom 15 were consecutively treated with the Colovac+ and Vacuum Loss Alert System. The Colovac+ was successfully implanted in all 15 patients. No major discomfort was reported during the implantation period. The endoscopic retrieval was performed in 14/15 (93%) patients. The overall major postoperative morbidity rate was 40%, but none of the reported complications were related to the Colovac+. A device migration occurred in 2 (13%) patients, but these were not associated with AL or stoma conversion. Overall, Colovac+ provided effective fecal diversion in all 15 patients and was able to avoid the PI in 11/15 (73%) patients.

CONCLUSIONS

Colovac+ provides a safe and effective protection of the anastomosis after LAR, and avoids the PI in the majority (73%) of patients. The improved design reduces the overall migration rate and limits the clinical impact of a migration.

Complications of preventive loop ileostomy versus colostomy: a meta-analysis, trial sequential analysis, and systematic review

BACKGROUND

Preventive colostomy is required for colorectal surgery, and the incidence of complications associated with ileostomy and colostomy remains controversial. This study aimed to compare the incidence of postoperative complications between ileostomy and colostomy procedures.

METHODS

Data analysis was conducted on 30 studies, and meta-analysis and trial sequential analysis (TSA) were performed on five studies. The basic indicators, such as stoma prolapse, leak, wound infection, ileus, and a series of other indicators, were compared.

RESULTS

No statistically significant differences were observed with complications other than stoma prolapse. Meta-analysis and TSA showed that the incidence of ileostomy prolapse was lower than that of colostomy prolapse, and the difference was statistically significant. Apart from the four complications listed above, the general data analysis showed differences in incidence between the two groups. The incidence of skin irritation, parastomal hernia, dehydration, pneumonia, and urinary tract infections was higher with ileostomy than with colostomy. In contrast, the incidence of parastomal fistula, stenosis, hemorrhage, and enterocutaneous fistula was higher with colostomy than with ileostomy.

CONCLUSIONS

There were differences in the incidence of ileostomy and colostomy complications in the selected studies, with a low incidence of ileostomy prolapse.

PROSPERO REGISTRATION NUMBER

CRD42022303133.

Reconstruction, oversewing, or taking the anastomosis down - which surgical intervention is most potent in the treatment of anastomotic leaks following colorectal resections?

PURPOSE

Anastomotic leak (AL) following colorectal resections can be treated interventionally. However, most cases require surgical intervention. Thus, several surgical techniques are available, which intend to affect the further course positively. The aim of this retrospective analysis is to determine which surgical technique proves to have the biggest potential in reducing the morbidity and mortality as well as to minimize the need of re-interventions after AL.

METHODS

All patients with a history of AL following colorectal resection between 2008 and 2020 were analyzed. Patient's outcomes following surgical treatment of AL, including morbidity and mortality, clinical and para-clinical (laboratory examinations, ultrasound, and CT-scan) detection of AL recurrence, re-intervention rate, and the length of hospital stay were documented and correlated with the surgical technique used (e.g. simply over-sewing the AL, over-sewing the AL with the construction of a protective ileostomy, resection and reconstruction of the anastomosis, peritoneal lavage and transanal drainage, or taking the anastomosis down and constructing an end stoma).

RESULTS

A total of 2,724 colorectal resections were documented. Grade C AL occurred in 92 (4.4% AL occurrence-rate) and 31 (7.2% AL occurrence-rate) cases following colon and rectal resections, respectively. The anastomosis was not preservable in 52 and 17 cases following colon and rectal resections, respectively. Therefore, the anastomosis had been taken down and an end-stoma had been constructed. Over-sewing the AL with the construction of a protective ileostomy had the highest anastomosis preservation rate (14 of 18 cases) and lowest re-intervention rate (mean value of 1.5 re-interventions) following colon and rectal resections (7 of 9 cases; mean value, 1.5 re-interventions).

CONCLUSION

In cases where an AL is preservable, over-sewing the anastomosis and constructing a protective ileostomy has the greatest potential for positive short-term outcomes following colorectal resections.

Short-term outcome of diverting loop ileostomy reversals performed by residents: a retrospective cohort prognostic factor study

AIM

The reversal of diverting loop ileostomy (DLI) is one of surgical trainees' first procedures. Complications of DLI reversal can cause life-threatening complications and increase patient morbidity. This study compared DLI reversals performed by surgical trainees with those by attending surgeons.

METHOD

This retrospective cohort study was performed at a single primary care center on 300 patients undergoing DLI reversal. The primary outcome was morbidity, according to the Clavien-Dindo classification (CDC), with special attention paid to the surgeon's level of training. The secondary endpoint was postoperative intestinal motility dysfunction.

RESULTS

Surgical trainees had significantly longer operation times (p < 0.001) than attending surgeons. Univariate analyses revealed no influence on the level of training for postoperative morbidity. First bowel movement later than 3 days after surgery was a significant risk factor for CDC [Formula: see text] 3 (OR, 4.348; 96% CI, 1670-11.321; p = 0.003). Independent risk factors for surgical site infections (SSIs) were an elevated BMI (OR, 1.162; 95% CI, 1.043-1.1294; p = 0.007) and a delayed bowel movement (OR, 3.973; 95% CI, 1.300-12.138; p = 0.015). For postoperative intestinal motility dysfunction, an independent risk factor was a primary malignant disease (OR, 1.980; 95% CI, 1.120-3.500; p = 0.019), and side-to-side stapled anastomosis was a protective factor (OR, 0.337; 95% CI 0.155-0.733; p = 0.006).

CONCLUSION

Even though surgical trainees needed significantly more time to perform the surgery, the level of surgical training was not a risk factor for increased postoperative morbidity. Instead, delayed first bowel movement was predictive of SSI.

Impact of a diverting ileostomy in total mesorectal excision with primary anastomosis for rectal cancer

BACKGROUND

The role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity.

METHODS

Patients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity.

RESULTS

In 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424-4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%.

CONCLUSIONS

The stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

Single-centre experience of loop ileostomy closure: a retrospective comparison of conventional-linear closure and purse-string closure on surgical-site-infection rates

BACKGROUND

The closure of ileostomy is associated with significant morbidity, the most common being surgical site infection (SSI), ranging up to 41%. This study compared the stoma site SSI rates after either the conventional-linear closure (CLC) or purse-string closure (PSC).

METHODS

The study conducted a single-centre retrospective cohort study of elective loop-ileostomy closures from June 2015 to January 2021. Patient demographics, surgical techniques and outcomes, including SSI rates, were analysed using SPSS ver.27.

RESULTS

Hundred and six patients underwent loop-ileostomy closure, 91.5% (n = 97) had CLC of which 67% (n = 65) were stapled. Male patients comprise 67.9%, with a median age of 62. The median BMI was 27. The median surgical time, LOS and interval time to closure were 66 min, 4.5 days and 5.5 months, respectively. The SSI rate was 19.6% (n = 19) for CLC and 11.1% (n = 1) for PSC. The SSI rate was significantly reduced to 3.7% (P < 0.001) in CLC when the site was washed with betadine. Multivariate logistic regression controlled for statistically insignificant confounders showed that stoma site betadine wash was significantly and independently associated with reduced SSI risk (P = 0.026). Other significant factors which reduced SSI risk were prophylactic antibiotic therapy (P = 0.004), operative time < 60 min (P = 0.021), and having the closure done >3 months post the formation surgery (P = 0.040).

CONCLUSIONS

This study found that stoma SSI risk was independently and significantly reduced when CLC stapled site was washed with betadine. This low-cost intervention that significantly reduced skin closure site SSI rates is readily available and can easily be adopted into clinical practice.

Renal dysfunction occurs following ileostomy formation and is independent of readmission

BACKGROUND

Ileostomy formation may be permanent or intended as temporary to defunction a high-risk pelvic anastomosis to reduce the risk of septic consequences of anastomotic leak. However, these procedures have a high rate of readmission, most commonly due to dehydration and associated with acute kidney injury (AKI).

METHODS

A single centre retrospective cohort study of patients who underwent ileostomy formation from 2015 to 2020 and analysed in two groups: those who needed readmission within 60 days and those who did not. Data collected included demographics and renal function and electrolytes at baseline (ileostomy formation) and at elective ileostomy closure.

RESULTS

A total of 171 patients were included in the analysis, with a readmission rate 38% within 60 days of discharge. There was a significant increase in creatinine from baseline blood tests compared to date of elective ileostomy closure in both the readmission and no readmission arms. There was a significant decrease in eGFR from baseline blood tests compared with date of ileostomy closure in both readmission and no readmission arms. There was no significant difference in creatinine or eGFR between readmission and no readmission arms at date of ileostomy closure. Baseline serum sodium levels were lower in the readmission arm compared to no readmission arm.

CONCLUSION

Ileostomy formation is associated with a deterioration in renal function, which occurs independent of whether the patient requires readmission to hospital. Low serum sodium may be used as a predictor for patients with an increased risk of readmission.

[Techniques in prophylactic ileostomy reversal]

In order to prevent and reduce the severity of anastomotic leakage after low rectal cancer surgery, prophylactic ileostomy is often performed by the clinician simultaneously. There are many controversies about prophylactic ileostomy in medicine, such as ileostomy indications, ileostomy complications, ileostomy reversal time, ileostomy reversal method and technique. Based on relevant literature and our own experience, we discussed the timing, method and complications of ileostomy reversal in this article to improve the diagnosis and treatment of ileostomy reversal as well as the life quality of the patients after ileostomy reversal.

Clinical and surgical factors for successful stoma reversal in patients with Crohn's disease-results of a retrospective cohort study

PURPOSE

Despite the wide range of medical and interventional therapy options available, some patients with Crohn's disease (CD) need an ileostomy or colostomy. The aim of this study was to identify clinical, surgical and drug-related predictors of successful stoma reversal in CD patients.

METHODS

A retrospective medical record analysis of surgical department logs, hospital discharge letters and patient reports from outpatient departments was performed for all CD patients who underwent a first ostomy surgery.

RESULTS

Our study analysed a total of 149 patients (76 women, 73 men, median age at first stoma of 34 years after a median CD duration of 9 years), with a median follow-up of 78.4 (IQR 88.6) months after first ostomy surgery. Of these patients, 73 (49%) underwent stoma reversal after a median of 11.7 months (IQR 15.7 months) of whom 17 (23.3%) needed a second stoma. In multivariant analysis, Montreal A1 classification (HR 2.07; 95% confidence interval 1.23-3.47; p = 0.006), a primary laparotomy (HR 2.30; 95% confidence interval 1.20-4.41; p = 0.012) and the absence of perianal/rectal CD activity (HR 3.00; 95% confidence interval 1.86-4.86; p < 0.001) emerged as independent predictors of a shorter time to stoma reversal. Introduction or switch of biological therapy after first stoma was not associated with successful reversal of the stoma (OR 4.6 95% confidence interval 1.45-14.66; p = 0.01). Laboratory parameters had no influence.

CONCLUSION

Clinical and surgical features-rather than medication or laboratory findings-were found to be predictors of successful stoma reversal in CD patients. Future studies focusing on the definition of a Standard Operation Procedure for emergency and elective CD surgery are warranted.

Nutritional and Educational Intervention to Recover a Healthy Eating Pattern Reducing Clinical Ileostomy-Related Complications

The aim of this study was to evaluate a diet intervention implemented by our hospital in order to determinate its capacity to improve the eating pattern of patients with an ileostomy, facilitating the implementation new eating-related behaviors, reducing doubt and dissatisfaction and other complications. The study was conducted with a quasi-experimental design in a tertiary level hospital. The elaboration and implementation of a nutritional intervention consisting of a Mediterranean-diet-based set of menus duly modified that was reinforced by specific counseling at the reintroduction of oral diet, hospital discharge and first follow-up appointment. Descriptive, bivariate and multivariate analyses were performed. The protocol was approved by the competent Ethics Committee. The patients of the intervention group considered that the diet facilitated eating five or more meals a day and diminished doubt and concerns related to eating pattern. Most patients (86%) had a favorable experience regarding weight recovery and a significant reduction of all-cause readmissions and readmission with dehydration (p = 0.015 and p < 0.001, respectively). The intervention helped an effective self-management of eating pattern by patients who had a physical improvement related to hydration status, which, together with an improvement in weight regain, decreased the probability of readmissions.

Safety and Feasibility of Temporary Ileostomy in Older Patients: A Retrospective Study

BACKGROUND

Temporary ileostomy reduces the incidence of severe anastomotic leakage and postoperative mortality. However, little is known about ileostomy-related complications in older adults.

PURPOSE

To clarify the safety and feasibility of temporary ileostomy for rectal cancer in older patients.

METHODS

Data were collected from a prospectively created database and complemented by secondary chart review for consecutive patients with rectal malignancy who underwent curative proctectomy with diverting loop ileostomy between 2013 and 2018. Ileostomy construction and closure were compared between two groups (defined as elderly and non-elderly patients). Data for 22 patients who were 75 years of age and older (elderly group) and 160 patients who were younger than 75 years (non-elderly group) were analyzed.

RESULTS

The median maximum fecal output was significantly higher in the non-elderly group compared with the elderly group. No significant differences were observed between the two groups in postoperative intravenous hydration, creatinine ratio, and ileostomy-related complication rate. Although the elderly group had a higher rate of early stoma closure, the causes were not related to those complications.

CONCLUSION

Temporary ileostomy was a safe and feasible procedure in this population of older patients with rectal malignancies.

Feasibility and advantages analyses of wedge resection without mesentery detached approach applied to closure of loop ileostomy

OBJECTIVES

To evaluate the feasibility and advantages of wedge resection plus transverse suture without mesentery detached approach applied to loop ileostomy closure by analyzing the surgical data and the incidence of postoperative complications of patients undergoing this procedure.

METHODS

We performed a retrospective analysis of the hospitalization data of patients who underwent ileostomy closure surgery and met the research standards from January 2017 to April 2021 in Guangxi Medical University Cancer Hospital; all surgeries were performed by the same surgeon. The perioperative data were statistically analyzed by grouping.

RESULTS

In total, 65 patients were enrolled in this study, with 12 in the wedge resection group, 35 in the stapler group, and 18 in the hand suture group. There was no significant difference in operation time between the wedge resection group and stapler group (P > 0.05), but both groups had shorter operation time than that in the hand suture group (P < 0.05). The postoperative exhaustion time of wedge resection group was earlier than that of the others, and cost of surgical consumables in the wedge resection group was significantly lower than that in the stapler group, all with statistically significant differences (P < 0.05). By contrast, there were no statistically significant differences in postoperative complication incidences among the three groups.

CONCLUSIONS

The wedge resection plus transverse suture without mesentery detached approach is safe and easy for closure of loop ileostomy in selected patients, and the intestinal motility recovers rapidly postoperatively. It costs less surgical consumables, and is particularly suitable for the currently implemented Diagnosis-Related Groups payment method.

A technique for constructing diverting loop ileostomy to prevent outlet obstruction after rectal resection and total colectomy: a retrospective single-center study

PURPOSE

Preventing outlet obstruction associated with a diverting stoma is important. Previously, we constructed a diverting loop ileostomy with the proximal limb of the small intestine on the caudal side, namely the oral inferior (OI) method. However, to address the issue of twisting and stenosis of the small intestine, we recently constructed a diverting loop ileostomy with the proximal limb on the cranial side, namely the oral superior (OS) method. We compared the incidence of outlet obstruction between the two methods.

METHODS

The subjects of this retrospective study were 133 patients who underwent colorectal resection or total colectomy, with D2 or more lymph node dissection and diverting loop ileostomy construction, between April, 2001 and December, 2018, at our hospital. The OI method was performed in 54 patients and the OS method was performed in 79 patients.

RESULTS

In the OS group, a history of laparotomy, neoadjuvant therapy, clinical stage III, and the use of anti-adhesion materials were more common, whereas blood loss and the incidence of outlet obstruction were significantly lower. Multivariate analysis identified only OS placement as a significant factor for reducing the incidence of outlet obstruction.

CONCLUSION

When constructing a diverting loop ileostomy, placing the proximal limb on the cranial side is important.

Small Bowel Crohn's Disease Recurrence is Common After Total Proctocolectomy for Crohn's Colitis

BACKGROUND

Surgical intervention for Crohn's disease involving the colon is often a total proctocolectomy with end ileostomy. There are limited data regarding postoperative small bowel recurrence rates in the recent era.

OBJECTIVE

The purpose of this study was to determine the rate of small bowel Crohn's disease recurrence following total proctocolectomy and secondarily define risk factors for disease recurrence.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at four hospitals within a single healthcare system.

PATIENTS

Patients were those with Crohn's disease undergoing total proctocolectomy with end ileostomy between 2009-2019.

MAIN OUTCOME MEASURES

Main outcome measures were clinical, endoscopic, radiographic, and/or surgical Crohn's disease recurrence.

RESULTS

In total, 193 patients were included with a median follow-up of 1.8 years (IQR 0.4-4.6). Overall, 74.6% (n = 144) of patients had been previously exposed to biologic therapy, and 51.3% (n = 99) had a history of small bowel Crohn's disease. Postoperatively, 14.5% (n = 28) of patients received biologic therapy. Crohn's disease recurrence occurred in 23.3% (n = 45) of patients with an estimated median 5-year recurrence rate of 40.8% (95% CI' 30.2-51.4). Surgical recurrence occurred in 8.8% (n = 17) of patients with an estimated median 5-year recurrence rate of 16.9% (95% CI' 8.5-25.3). On multivariable analysis, prior small bowel surgery for Crohn's disease (HR 2.61; 95% CI' 1.42-4.81) and Crohn's diagnosis at age <18 years (HR 2.56; 95% CI' 1.40-4.71) were associated with Crohn's recurrence. In patients without prior small bowel Crohn's disease, 14.9% (n = 14) had Crohn's recurrence with an estimated 5-year overall recurrence rate of 31.1% (95% CI' 13.3-45.3) and 5-year surgical recurrence rate of 5.7% (95% CI' 0.0-12.0).

LIMITATIONS

The study was limited by its retrospective design and lack of consistent follow-up on all patients.

CONCLUSIONS

Greater than one third of patients who underwent total proctocolectomy for Crohn's disease were estimated to have small bowel Crohn's recurrence at 5 years after surgery. Patients with a history of small bowel surgery for Crohn's and diagnosis at any early age may benefit from more intensive postoperative surveillance and consideration for early medical prophylaxis. See Video Abstract at http://links.lww.com/DCR/B762.

RECURRENCIA FRECUENTE DE LA ENFERMEDAD DE CROHN DEL INTESTINO DELGADO DESPUS DE LA PROCTOCOLECTOMA TOTAL POR COLITIS DE CROHN

ANTECEDENTES:La cirugia para la enfermedad de Crohn que involucra el colon es a menudo una proctocolectomía total con ileostomía terminal. Hay datos limitados con respecto a las tasas de recurrencia posoperatoria de la enfermedad de Crohn del intestino delgado en la actualidad.OBJETIVO:Buscamos determinar la tasa de recurrencia de la enfermedad de Crohn del intestino delgado después de la proctocolectomía total y, en segundo lugar, definir los factores de riesgo de recurrencia de la enfermedad.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Cuatro hospitales de un mismo sistema sanitario.PACIENTES:Pacientes con enfermedad de Crohn sometidos a proctocolectomía total con ileostomía terminal entre 2009-2019.PRINCIPALES MEDIDAS DE VALORACIÓN:Recurrencia clínica, endoscópica, radiográfica y / o quirúrgica de la enfermedad de Crohn.RESULTADOS:Se incluyeron 193 pacientes con un seguimiento promedio de 1,8 años (IQR 0,4-4,6). El 74,6% (n = 144) de los pacientes habían recibido previamente terapia biológica y el 51,3% (n = 99) tenían antecedentes de enfermedad de Crohn del intestino delgado. Después de la operación, el 14,5% (n = 28) de los pacientes recibieron terapia biológica. La recurrencia de la enfermedad de Crohn ocurrió en el 23,3% (n = 45) de los pacientes con una tasa de recurrencia media estimada a los 5 años del 40,8% (IC del 95%: 30,2-51,4). La recidiva quirúrgica se produjo en el 8,8% (n = 17) de los pacientes con una tasa de recidiva media estimada a los 5 años del 16,9% (IC del 95%: 8,5-25,3). En el análisis multivariable, la cirugía previa del intestino delgado para la enfermedad de Crohn (HR 2,61, IC del 95%: 1,42-4,81) y el diagnóstico de Crohn a la edad <18 (HR 2,56, IC del 95%: 1,40-4,71) se asociaron con la recurrencia de Crohn. En pacientes sin enfermedad previa de Crohn del intestino delgado, el 14,9% (n = 14) tuvo recurrencia de Crohn con una tasa de recurrencia general estimada a 5 años del 31,1% (IC del 95%: 13,3-45,3) y una tasa de recurrencia quirúrgica a 5 años del 5,7% (IC del 95%: 0,0-12,0).LIMITACIONES:Diseño retrospectivo, falta de seguimiento constante de todos los pacientes.CONCLUSIONES:Se estimó que más de un tercio de los pacientes que se sometieron a proctocolectomía total tenían recurrencia de Crohn del intestino delgado a los 5 años después de la cirugía. Los pacientes con antecedentes de cirugía por enfermedad de Crohn del intestino delgado y diagnóstico a una edad temprana pueden beneficiarse de una vigilancia posoperatoria más intensiva y la consideración de una profilaxis médica temprana. Consulte Video Resumen en http://links.lww.com/DCR/B762. (Traducción- Dr. Ingrid Melo).

The "Phillips" Ileostomy Correction Technique for Prolapsed Stoma

INTRODUCTION

Stoma prolapse is a common complication associated with ostomy creation, causing leakage, obstruction, and sometimes incarceration. Sometimes ileostomy prolapse cannot be treated with resection and alternative methods must be applied. We propose a new surgical revisional technique for ileostomy prolapse.

TECHNIQUE

Under general anesthesia, the prolapsed stoma is dissected and freed from the fascia and skin. The bowel is everted to create a nipple of 2-3 cm and subsequently fixed with a 3-row linear stapler, creating a "Phillips ileostomy." The ileostomy is then sutured to the skin with 3-0 full thickness stitches.

RESULTS

In our center, 3 patients were treated in a day surgery setting, and no complication occurred. One patient reported a prolapse recurrence after 6 months and was successfully treated with the same technique with no recurrence at 1 year.

CONCLUSIONS

The 3-row stapler fixation of prolapsed ileostomy is simple to perform, preserves the bowel, and can be performed in the day surgery setting.

Surgical Infection Society Guidelines for Total Abdominal Colectomy versus Diverting Loop Ileostomy with Antegrade Intra-Colonic Lavage for the Surgical Management of Severe or Fulminant, Non-Perforated Clostridioides difficile Colitis

Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery. Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for summarizing the current SIS recommendations for total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for severe or fulminant, non-perforated C. difficile colitis. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Severe infection was defined as laboratory diagnosis of C. difficile infection with leukocytosis (white blood cell count of ≥15,000 cells/mL) or elevated creatinine (serum creatinine level >1.5 mg/dL). Fulminant infection was defined as laboratory diagnosis of C. difficile infection with hypotension or shock, ileus, or megacolon. Perforation was defined as complete disruption of the colon wall. Total abdominal colectomy was defined as resection of the ascending, transverse, descending, and sigmoid colon with end ileostomy. For the purpose of the guideline, the terms subtotal colectomy, total abdominal colectomy, and rectal-sparing total colectomy were used interchangeably. Diverting loop ileostomy with antegrade enema was defined as creation of both a diverting loop ileostomy with intra-operative colonic lavage and post-operative antegrade vancomycin unless otherwise specified. Evaluation of the published evidence was performed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that total abdominal colectomy be the procedure of choice for definitive therapy of severe or fulminant, non-perforated C. difficile colitis. In select patients, colon preservation using diverting loop ileostomy with intra-colonic vancomycin may be associated with higher rates of ostomy reversal and restoration of gastrointestinal continuity but may lead to development of recurrent C. difficile colitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations regarding use of total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for adults with severe or fulminant, non-perforated C. difficile infection.

Achieving stomal continence with an ileal pouch and a percutaneous implant

In this study, a soft-tissue-anchored, percutaneous port used as a mechanical continence-preserving valve in reservoir ileo- and urostomies was functionally and morphologically evaluated in eight dogs. During follow-up, the skin failed to attach to the implant, but the intestine inside the stoma port appeared to be attached to the mesh. After reaching adequate reservoir volume, the urostomies were rendered continent by attaching a lid to the implant. The experiments were ended at different time intervals due to implant-related adverse events. In only one case did the histological evaluation reveal integration at both the implant-intestine and implant-skin interfaces, with a low degree of inflammation and the absence of bacterial colonisation. In the remaining cases, integration was not obtained and instead mucosal downgrowth and biofilm formation were observed. The skin-implant junction was characterised by the absence of direct contact between the epidermis and the implant. Varying degrees of epidermal downgrowth, granulation tissue formation, inflammatory cell infiltration and bacterial growth and biofilm formation were prominent findings. In contrast, the subcutaneously located anchor part of the titanium port was well integrated and encapsulated by fibrous tissue. These results demonstrate the opportunity to achieve integration between a soft-tissue-anchored titanium port, skin and intestine. However, predictable long-term function could not be achieved in these animal models due to implant- and non-implant-related adverse events. Unless barriers at both the implant-skin and implant-intestine junctions are created, epidermal and mucosal downward migration and biofilm formation will jeopardise implant performance.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Combined stoma reversal and liver resection for rectal metastatic cancer: A single center retrospective analysis

GOAL OF THE STUDY

Concomitant liver metastases are discovered at the time of diagnosis in 25% of patients with colorectal cancers. The appropriate time to restore digestive continuity after stoma creation during rectal surgery has not yet been established. The objective of this study is to assess the morbidity of stoma reversal during the secondary hepatectomy procedure.

PATIENTS AND METHODS

This was a single-center retrospective case-control study including patients who underwent ileostomy or colostomy reversal by a direct approach (REVERSAL group) compared to those who did not undergo stoma reversal (NON-REVERSAL group) during hepatic resection of rectal cancer metastasis between 2004 and 2016. Peri-operative data were collected. The primary outcome measure was the comprehensive complication index (CCI). The secondary outcomes were overall mortality, liver-related morbidity, duration of hospital stay and occurrence of gastrointestinal leaks. Statistical analysis was carried out using SPSS 23.0 software.

RESULTS

Thirty liver resections were included; 14 in the REVERSAL group (female/male=11/19, age=60 years). No statistically significant difference was observed in the CCI scores (15 vs. 20.8; P=0.6). Complications occurred in 9 (64%) and 8 (50%) patients in the REVERSAL and NON-REVERSAL groups, respectively (P=0.48). No gastro-intestinal leaks or post-operative mortality occurred.

CONCLUSION

Stoma reversal during hepatectomy for liver metastasis from a primary rectal cancer represents a safe alternative since post-operative outcome was not associated with additional morbidity in this series.

Long term remission after ileorectal anastomosis in Crohn's colitis

BACKGROUND

Crohn's disease represents a heterogeneous entity, but its location tends to be relatively stable overtime. For extensive refractory Crohn's colitis, ileorectal anastomosis after colectomy is an engaging option, since the necessity of a permanent ileostomy is avoided.

AIMS

In our study, the long-term outcome of two groups of patients with Crohn's colitis who underwent colectomy and ileorectal anastomosis was compared. The first group had isolated colonic Crohn's disease without rectal involvement and perianal disease, while the second group included patients who had rectal and/or ileal involvement, with or without perianal disease.

METHODS

Between 1996 and 2016, in a single IBD tertiary center, 80 patients with a history of colectomy and ileorectal anastomosis for refractory Crohn's colitis were retrospectively identified.

RESULTS

Recurrence of disease was diagnosed in 57/64 of patients with Crohn's colitis with rectal and/or ileal and/or perianal involvement compared with 1/16 of patients with isolated Crohn's colitis without rectal and perianal disease in a median time of recurrence of 2 years (IQR 1-6 years, minimum to maximum, 1-18 years, p < 0.001). Only 6 patients (7,5%) underwent definitive end ileostomy without proctectomy (1 in the noIRP group and 5 in the IRP group).

CONCLUSION

Our data suggest that colectomy with ileorectal anastomosis may represent a curative option in patients with refractory isolated colitis without rectal and perianal involvement.

Comparison of the clinical outcomes of skin bridge loop ileostomy and traditional loop ileostomy in patients with low rectal cancer

To compare the clinical results of patients with low rectal cancer who underwent skin bridge loop ileostomy and traditional loop ileostomy, and provide clinical evidence for choosing a better ostomy method. We retrospectively collected data of 118 patients with rectal cancer who underwent low anterior resection and loop ileostomy. To investigate the patients characteristics, postoperative stoma-related complications and the frequency of exchanged ostomy bags. The differences of these indicators between the two groups of patients who underwent skin bridge loop ileostomy and traditional loop ileostomy were compared. The Visual Analog Scale (VAS) score of the skin bridge loop ileostomy group was lower than that of the traditional ileostomy loop group (P < 0.05). The skin bridge group had a lower Discoloration, Erosion, Tissue overgrowth (DET) score and incidence of mucocutaneous separation than the traditional group at the 1st and 2nd weeks after operation (P < 0.05). The average number of weekly exchanged ostomy bags was significantly less in the skin bridge group than in the traditional group within 4 weeks after surgery (P < 0.05). Our experience demonstrates that the skin bridge loop ileostomy may significantly reduce early postoperative stoma-related complications, the frequency of exchanged ostomy bags and patients' medical costs after discharge.

One-stitch method vs. traditional method of protective loop ileostomy for rectal cancer: the impact of BMI obesity

PURPOSE

Protective loop ileostomy is an effective diversion measure often used to reduce the risk of anastomotic leakage. The purpose of the present study was to evaluate the surgical outcomes of the one-stitch method (OM) of protective loop ileostomy in laparoscopic low anterior resection for BMI obesity patients with rectal cancer compared with the traditional method (TM).

METHODS

The patients diagnosed as rectal adenocarcinoma cases by preoperative pathology were included in this retrospective study. The subjects underwent protective loop ileostomy in laparoscopic low anterior resection from January 2016 to June 2019 in the Shandong Provincial Hospital affiliated to Shandong University. The data of loop ileostomy and stoma closure operation were retrieved from the medical cases system of the hospital.

RESULTS

242 patients were included in the present study. In the BMI obese cohort, the OM group showed a shorter operative time both in the loop ileostomy (232.5 vs. 250.0 min, p = 0.04) and stoma closure operation (102.5 vs. 115.0 min, p = 0.001) and a lower peristomal adhesion extent (p = 0.02) and a shorter median postoperative stay (6 vs. 7 days, p = 0.03) during stoma closure operation than that of the TM group. In the TM group, obese cases showed a higher operative time of stoma closure operation (115.0 vs. 95.0, p < 0.001), a higher parastomal hernia rate (p = 0.04), a higher peristomal adhesion extent (p = 0.005) and a longer postoperative stay of stoma closure operation (p = 0.02) compared with the non-obese cases, while in the OM group, no significant differences were observed between the obese and non-obese cases in terms of the above-mentioned factors.

CONCLUSIONS

The OM exhibited more advantages than TM, notably in BMI obesity patients.

Postoperative Ileus after Stimulation with Probiotics before Ileostomy Closure

Loop ileostomy closure after colorectal surgery is often associated with Postoperative ileus, with an incidence between 13-20%. The aim of this study is to evaluate the efficacy and safety of preoperative stimulation of the efferent loop with probiotics prior to ileostomy closure in patients operated on for colorectal carcinoma. For this, a prospective, randomized, double-blind, controlled study is designed. All patients who underwent surgery for colorectal carcinoma with loop ileostomy were included. Randomized and divided into two groups, 34 cases and 35 controls were included in the study. Postoperative ileus, the need for nasogastric tube insertion, the time required to begin tolerating a diet, restoration of bowel function, and duration of hospital stay were evaluated. The incidence of Postoperative ileus was similar in both groups, 9/34 patients stimulated with probiotics and 10/35 in the control group (CG) with a p = 0.192. The comparative analysis showed a direct relationship between Postoperative ileus after oncological surgery and Postoperative ileus after reconstruction surgery, independently of stimulation. Postoperative ileus after closure ileostomy is independent of stimulation of the ileostomy with probiotics through the efferent loop. There seem to be a relationship between Postoperative ileus after reconstruction and the previous existence of Postoperative ileus after colorectal cancer surgery.

Thirty years of the health care service for ostomy patients in Juiz de Fora and surroundings

OBJECTIVE

to establish the epidemiological profile of ostomized patients treated at the Health Care Service for Ostomy Patients in Juiz de Fora and region (SASPO/JF) and to quantify the pathologies that led to the stoma as well as the ostomy-related complications.

METHOD

a retrospective study was carried out with the analysis of 496 medical records of patients registered at HCSOP/JF over 30 years and who remained in at the service in June 2018. The following variables were considered: age, sex, pathology that led to the stoma, type, time, location and complications of stomas.

RESULTS

53.43% were male patients and 46.57% female. The average age was 56.24 years among men and 58.40 years among women. Eight patients had two types of ostomies simultaneously and a total of 504 ostomies were as follows: 340 colostomies (67.46%), 117 ileostomies (23.21%) and 47 urostomies (9.33%). Additionally, 47.65% of the colostomies and 76.92% of the ileostomies were temporary, while all urostomies were permanent. In 70.24% of cases, the reason for making the stoma was malignancy. There were 277 stomas with one or more complications (54.96%).

CONCLUSIONS

most of the ostomized patients were over 50 years old and the main diagnosis that led to the stoma was malignancy. Ileostomies had a higher percentage of complications than colostomies and urostomies and, for all types of stomas, the most frequent complication was dermatitis.

Diverting Loop Ileostomy for Clostridium Difficile Colitis: A Systematic Review and Meta-analysis

Diverting loop ileostomy (DLI) with colonic lavage has been proposed as an alternative to total abdominal colectomy (TAC) for fulminant Clostridium difficile infection (CDI). Controversy exists regarding the mortality benefit and outcomes of this surgical approach. We conducted a MEDLINE database search for articles between 1999 and 2019 pertaining to DLI for the surgical treatment of CDI. Five articles met the inclusion criteria. Four studies were retrospective and one was a prospective matched cohort study. 3683 patients were included in the 5 studies; 733 patients (20%) underwent DLI, while 2950 patients (80%) underwent TAC. The only shared outcome measure across all 5 studies was mortality. The overall mortality rate for the entire cohort undergoing both procedures was 30.3%. There was no statistically significant difference in pooled mortality between DLI and TAC (OR: .73; 95% CI, .45-1.2; P = .22). Reporting of other postoperative outcomes was variable. Fulminant CDI remains a life-threatening condition with high mortality. Loop ileostomy may be a viable surgical alternative to total colectomy with similar mortality; however, further work is needed to determine specific patient characteristics that warrant routine use of DLI.

Total Neoadjuvant Therapy vs Standard Therapy in Locally Advanced Rectal Cancer: A Systematic Review and Meta-analysis

Importance

Standard therapy for locally advanced rectal cancer includes concurrent chemoradiotherapy followed by surgery and adjuvant chemotherapy (CRT plus A). An alternative strategy known as total neoadjuvant therapy (TNT) involves administration of CRT plus neoadjuvant chemotherapy before surgery with the goal of delivering uninterrupted systemic therapy to eradicate micrometastases. A comparison of these 2 approaches has not been systematically reviewed previously.

Objective

To determine the differences in rates of pathologic complete response (PCR), disease-free and overall survival, sphincter-preserving surgery, and ileostomy between patients receiving TNT vs standard CRT plus A.

Data Sources

MEDLINE (via PubMed) and Embase (via OVID) were searched from inception through July 1, 2020, for the following terms: anal/anorectal neoplasms OR anal/anorectal cancer AND total neoadjuvant treatment OR total neoadjuvant therapy. Only studies in English were included.

Study Selection

Randomized clinical trials or prospective/retrospective cohort studies comparing outcomes in patients with locally advanced rectal cancer who received TNT vs CRT plus A.

Data Extraction and Synthesis

Data regarding the first author, publication year, location, sample size, and rates of PCR, sphincter-preserving surgery, ileostomy, and disease-free and overall survival were extracted using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and pooled using a random-effects model.

Main Outcomes and Measures

Rates of PCR, sphincter-preserving surgery, ileostomy, and disease-free and overall survival.

Results

After reviewing 2165 reports, 7 unique studies including a total of 2416 unique patients, of whom 1206 received TNT, were selected. The median age for the patients receiving TNT ranged from 57 to 69 years, with 58% to 73% being male. The pooled prevalence of PCR was 29.9% (range, 17.2%-38.5%) in the TNT group and 14.9% (range, 4.2%-21.3%) in the CRT plus A group. Total neoadjuvant therapy was associated with a higher chance of achieving a PCR (odds ratio [OR], 2.44; 95% CI, 1.99-2.98). No statistically significant difference in the proportion of sphincter-preserving surgery (OR, 1.06; 95% CI, 0.73-1.54) or ileostomy (OR, 1.05; 95% CI, 0.76-1.46) between recipients of TNT and CRT plus A was observed. Only 3 studies presented data on disease-free survival, and pooled analysis showed significantly higher odds of improved disease-free survival in patients who received TNT (OR, 2.07; 95% CI, 1.20-3.56; I2 = 49%). Data on overall survival were not consistently reported.

Conclusions and Relevance

The findings of this systematic review and meta-analysis suggest that TNT is a promising strategy in locally advanced rectal cancer, with superior rates of PCR compared with standard therapy. However, the long-term effect on disease recurrence and overall survival needs to be explored in future studies.

Fertility Impact of Initial Operation Type for Female Ulcerative Colitis Patients

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is the mainstay of surgical treatment for patients with ulcerative colitis (UC) but is associated with an increased risk of infertility. We developed a simulation model examining the impact of initial surgical procedure on quality-adjusted life-years (QALYs) and fertility end points.

METHODS

A patient-level state transition model was used to analyze outcomes by surgical approach strategy for females of childbearing age. Initial surgical options included IPAA, rectal-sparing colectomy with end ileostomy (RCEI), and ileorectal anastomosis (IRA). The primary outcome examined was QALYs, whereas secondary outcomes included UC and fertility-associated end points.

RESULTS

IPAA resulted in higher QALYs for patients aged 20-30 years, as compared with RCEI. For patients aged 35 years, RCEI resulted in higher QALYs (7.54 RCEI vs 7.53 IPAA) and was associated with a 28% higher rate of childbirth, a 14-month decrease in time to childbirth, and a 77% reduction in in vitro fertilization utilization. When accounting for the decreased infertility risk associated with laparoscopic IPAA, IPAA resulted in higher QALYs (7.57) even for patients aged 35 years.

CONCLUSIONS

Despite an increased risk of infertility, our model results suggest that IPAA may be the optimal surgical strategy for female UC patients aged 20-30 years who desire children. For patients aged 35 years, RCEI should additionally be considered, as QALYs for RCEI and IPAA were similar. These quantitative data can be used by patients and providers to help develop an individualized approach to surgical management choice.

Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on pouchitis in ulcerative colitis. Part 2: Treatment

Pouchitis treatment is a complex entity that requires a close medical and surgical relationship. The elective treatment for acute pouchitis is antibiotics. After a first episode of pouchitis it is recommended prophylaxis therapy with a probiotic mix, nevertheless it is not clear the use of this formulation for preventing a first episode of pouchitis after surgery. First-line treatment for chronic pouchitis is an antibiotic combination. The next step in treatment should be oral budesonide. Selected cases of severe, chronic refractory pouchitis may benefit from biologic agents, and anti-TNF α should be recommended as the first option, leaving the new biologicals for multi-refractory patients. Permanent ileostomy may be an option in severe refractory cases to medical treatment.

Complications Following the Use of Biologic Mesh in Ileostomy Closure: A Retrospective, Comparative Study

Prophylactic placement of mesh in the abdominal wall during ileostomy closure can decrease the rate of hernia formation. However, few studies have evaluated the safety of biologic mesh in ileostomy closure.

PURPOSE

This study aimed to investigate the safety of biologic mesh in ileostomy closure, specifically the need to remove the mesh due to infection. The rate of surgical site infection (SSI), incisional hernia, surgical site occurrence ([SSO] including seroma and hematoma), and wound pain between primary closure and mesh closure groups also were investigated.

METHODS

Using a retrospective study design, data from all consecutive patients who underwent ileostomy closure from January 2015 to June 2016 at the Hanyang University Hospital, Seoul, Republic of Korea, were analyzed. Patients with stage IV colorectal cancer, who were older than 85 years, or who experienced intestinal perforation during the procedure were excluded. Demographic (age, sex, body mass index [BMI], underlying disease) and clinical characteristics as well as SSI, SSO, length of hospital stay, use of additional analgesics, white blood cell count, C-reactive protein, and visual analog scale (VAS) pain scores (noted on days 1, 3, 5, and 14) were abstracted and compared. Clinical and surgical variables were compared using the Mann-Whitney U test, the χ2-test, or Fisher's exact test, depending on the nature of the data.

RESULTS

Of the 38 patients who underwent ileostomy closure, 33 (18 [54.5%] who received primary closure and 15 [45.5%] who received mesh closure) were included for analysis. Patient, surgical, and clinical characteristics were not significantly different, but the mean age of the primary closure group was significantly higher than that of the mesh closure group (71 ± 9 vs. 62 ± 10 years old; P = .014). The median follow-up duration was 25 months (interquartile range 18.0-31.5 months). Six (6) complications were observed in 5 patients in the primary closure group, and 8 complications in 5 patients were noted in the mesh closure group (27.8% vs. 33.3%; P = 1.000). None of the cases required removal of the biologic mesh due to mesh-related infectious complication. Two (2) SSIs occurred in the primary closure group (11.1% vs. 0%; P = .489). Three (3) patients experienced a postoperative incisional hernia (9.1%) - 1 in the primary closure group and 2 in the mesh closure group (5.6% vs. 13.3%; P = .579). No statistically significant differences in pain or length of hospitalization were noted.

CONCLUSION

No mesh-related infectious complications required biologic mesh removal, and no significant differences were noted in SSI, incisional hernia, and wound pain between the primary closure and mesh closure groups. Although not significantly different, the higher rates of hernia and SSOs in the mesh group require further study.