Randomized clinical trial of intracutaneously versus transcutaneously sutured ileostomy to prevent stoma-related complications (ISI trial)

Background

Ileostomy construction is a common procedure but can be associated with morbidity. The stoma is commonly secured to the skin using transcutaneous sutures. It is hypothesized that intracutaneous sutures result in a tighter adherence of the peristomal skin to the stoma plate to prevent faecal leakage. The study aimed to compare the effect of intracutaneous versus transcutaneous suturing of ileostomies on faecal leakage and quality of life.

Methods

This randomized trial was undertaken in 11 hospitals in the Netherlands. Patients scheduled to receive an ileostomy for any reason were randomized to intracutaneous or transcutaneous suturing (IC and TC groups respectively). The primary outcome was faecal leakage. Secondary outcomes were stoma‐related quality of life and costs of stoma‐related materials and reinterventions.

Results

Between April 2011 and February 2016, 339 patients were randomized to the IC (170) or TC (169) group. Leakage rates were higher in the IC than in the TC group (52·4 versus 41·4 per cent respectively; risk difference 11·0 (95 per cent c.i. 0·3 to 21·2) per cent). Skin irritation rates were high (78·2 versus 72·2 per cent), but did not differ significantly between the groups (risk difference 6·1 (95 per cent c.i. –3·2 to 15·10) per cent). There were no significant differences in quality of life or costs between the groups.

Conclusion

Intracutaneous suturing of an ileostomy is associated with more peristomal leakage than transcutaneous suturing. Overall stoma‐related complications did not differ between the two techniques. Registration number: NTR2369 ( http://www.trialregister.nl).

More leaks with intracutaneous

Home visits as part of a new care pathway (iAID) to improve quality of care and quality of life in ostomy patients: a cluster-randomized stepped-wedge trial

AIM

Morbidity in patients with an ostomy is high. A new care pathway, including perioperative home visits by enterostomal therapists, was studied to assess whether more elaborate education and closer guidance could reduce stoma-related complications and improve quality of life (QoL), at acceptable cost.

METHOD

Patients requiring an ileostomy or colostomy, for any inflammatory or malignant bowel disease, were included in a 15-centre cluster-randomized 'stepped-wedge' study. Primary outcomes were stoma-related complications and QoL, measured using the Stoma-QOL, 3 months after surgery. Secondary outcomes included costs of care.

RESULTS

The standard pathway (SP) was followed by 113 patients and the new pathway (NP) by 105 patients. Although the overall number of stoma-related complications was similar in both groups (SP 156, NP 150), the proportion of patients experiencing one or more stoma-related complications was significantly higher in the NP (72% vs 84%, risk difference 12%; 95% CI: 0.3-23.3%). Although in the NP more patients had stoma-related complications, QoL scores were significantly better (P < 0.001). In the SP more patients required extra care at home for their ostomy than in the NP (60.6% vs 33.7%, respectively; risk difference 26.9%, 95% CI: 13.5-40.4%). Stoma revision was done more often in the SP (n = 11) than in the NP (n = 2). Total costs in the SP did not differ significantly from the NP.

CONCLUSION

The NP did not reduce the number of stoma-related complications but did lead to improved quality of care and life, against similar costs. Based on these results the NP, including perioperative home visits by an enterostomal therapist, can be recommended.

Factors affecting timing of closure and non-reversal of temporary ileostomies

BACKGROUND

Although stoma closure is considered a simple surgical intervention, the interval between construction and reversal is often prolonged, and some ileostomies may never be reversed. We evaluated possible predictors for non-reversal and prolonged interval between construction and reversal.

MATERIAL AND METHODS

In a cohort study of ileostomy patients treated in a large teaching hospital, we collected data from the surgical complication and enterostomal therapists' registries between January 2001 and December 2011. Parameters responsible for morbidity, mortality, length of stay and time interval between construction and reversal were analysed.

RESULTS

Of 485 intentionally temporary ileostomies, 359 were reversed after a median of 5.6 months (IQR 3.8-8.9 months), while 126 (26%) remained permanent. End ileostomy and intra-abdominal abscess independently delayed reversal. Age, end ileostomy, higher body mass index and preoperative radiotherapy were independent factors for non-reversal. Median duration of hospitalisation for reversal was 7.0 days (5-13 days). Morbidity and mortality were 31 and 0.9%, respectively. In 20 patients (5.5%), re-ileostomy was necessary.

CONCLUSIONS

A substantial number of ileostomies that are intended to be temporary will never be reversed. If reversed, the interval between construction and reversal is longer than anticipated, while morbidity after reversal and duration of hospitalisation are considerable. Besides a temporary ileostomy, there are two other options: no diversion or a permanent colostomy. Shared decision-making is to be preferred in these situations.

Shrinkage of abdominal aortic aneurysm after successful endovascular repair: results from single center study

AIM

In the literature, the behavior of the aneurysm sac after endovascular grafting has been the subject of significant speculation. It has been suggested that shrinkage of the abdominal aortic aneurysm (AAA) is different for various endografts. This study was undertaken to evaluate endograft-specific differences in aneurysm sac shrinkage and to evaluate other factors that may influence AAA shrinkage.

METHODS

Forty patients with an AAA treated with endovascular grafts with a complete 18 months follow-up and complete CT angiography (CTA) follow-up were available for analysis. All patients with a persistent endoleak, endograft migration or any other reason for intervention or conversion were excluded from this analysis. Shrinkage was defined as a reduction in the AAA diameter of 5 mm or more. Chi-squared tests were used to test whether shrinkage was different for the kind of stent graft used (Gore Excluder vs Cook-Zenith), preexistent AAA diameter (<65 mm vs =or>65 mm), and AAA status (ruptured vs non-ruptured) (two-sided; a= 0.05).

RESULTS

At 18 months after treatment, shrinkage was observed in 14 patients (52%) of the 27 patients treated with a Gore Excluder endograft and in 8 patients (62%) of the 13 patients treated with a Cook Zenith endograft (P=0.74). In 31 patients with a diameter <65 mm, shrinkage was observed in 19 patients (61%) whereas of the 9 patients with a diameter =or>65 mm, shrinkage was observed in 3 patients (33%) (P=0.253). Of the 34 patients with a non-ruptured AAA, shrinkage was observed in 18 patients (53%) versus of the 6 patients with a ruptured AAA shrinkage was observed in 4 patients (66%) (P=0.673).

CONCLUSIONS

From this study can be concluded that the influence of the endograft on shrinkage of the AAA sac might be less prominent than suggested in the literature. Furthermore, our study shows that other factors such as preexistent AAA diameter may influence AAA shrinkage after endovascular repair.