Abstract
PurposePrevious institutional analysis of ileostomy closure revealed substantial morbidity. This subsequent study aimed at determining if a change in clinical practice resulted in reduced complication rates.MethodsBetween June 2004 and January 2014, all consecutive adult patients undergoing ileostomy closure were retrospectively identified. Postoperative outcome after change in clinical practice consisting of routine participation of a colorectal surgeon, stapled side-to-side anastomosis and increased clinical awareness (cohort B) was compared with our previously published historical control group (cohort A). The primary outcome was major morbidity, defined as Clavien-Dindo grade three or higher. Independent risk factors of major morbidity were identified using multivariable analysis.ResultsIn total, 165 patients underwent ileostomy closure in cohort A, and 144 patients in cohort B. At baseline, more primary diverting ileostomies were present in cohort A (94 vs. 82 %; p = 0.001) with a similar rate of loop and end-ileostomy between the two cohorts (p = 0.331). A significant increase in colorectal surgeon participation (89 vs. 53 %; p < 0.001) and stapled side-to-side anastomosis was observed (63 vs. 16 %; p < 0.001). The major morbidity rate was 11 % in cohort A, which significantly reduced to 4 % in cohort B (p = 0.03). Surgery being performed or supervised by a colorectal surgeon (odds ratio [OR] 0.28, 95 % CI 0.11–0.67) and loop-ileostomy compared to end-ileostomy (OR 0.18, 95 % CI 0.07–0.52) were independently associated with lower major morbidity.ConclusionIleostomy closure appears to be more complex surgery then generally considered, especially end-ileostomy closure. Postoperative outcome could be significantly improved by a change in surgical practice.Electronic supplementary materialThe online version of this article (doi:10.1007/s00384-015-2478-1) contains supplementary material, which is available to authorized users.
Highlights
Defunctioning ileostomies are constructed for several reasons, but mostly to protect a low colorectal, colo-anal or an ileal pouch-anal anastomosis (IPAA)
The aim of this study was to evaluate if these changes in practice and increased awareness of the associated risks of the procedure led to a reduced major morbidity after ileostomy closure
Patients in the cohort A were more often classified as grade III according to the American Society of Anaesthesiologists (ASA) (18.2 vs 7.6 %; p = 0.024)
Summary
Defunctioning ileostomies are constructed for several reasons, but mostly to protect a low colorectal, colo-anal or an ileal pouch-anal anastomosis (IPAA). There is still debate about the value of routine diversion of such anastomoses, a defunctioning ileostomy has been reported to significantly reduce clinical anastomotic leakage rates and mitigate its consequences [1]. In patients who develop leakage of a nondiverted anastomosis, a secondary defunctioning ileostomy can be constructed if breakdown of the anastomosis is not indicated. Less frequent indications for diverting ileostomy are inflammatory bowel disease, intestinal ischemia, oncological diseases, functional problems or surgical complications other than distal leaking anastomosis. A defunctioning ileostomy has clear advantages, stoma-related morbidity should be taken into account as well. Closure of a defunctioning ileostomy can result in substantial morbidity, with a reported complication rate of 17 % in a
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