Closure Of Diverting Ileostomy Research Articles

Conformal sphincteric resection for ultra-low rectal cancer located below the dentate line: A pilot report.

Sphincter-sparing surgery can be achieved in most cases of low rectal cancer with the development of intersphincteric resection. However, abdominoperineal resection is still inevitable for patients with tumours located below the dentate line. To address this, we have developed a procedure called conformal sphincteric resection (CSR) in which the corresponding part of the subcutaneous portion of the external anal sphincter and the perianal skin on the tumour side is removed to achieve a safe distal resection margin and lateral resection margin while the dentate line and the internal anal sphincter on the tumour-free side are preserved as much as possible, to achieve sphincter preservation without compromising oncological safety and functional acceptability, and to render tumour location no longer a contraindication for sphincter-sparing surgery. This is the first study to describe the concept, indication and surgical procedure of CSR and to report its preliminary surgical, oncological and functional results. This is a retrospective, single-centre, single-arm pilot study conducted at Huashan Hospital, Fudan University. Demographic, clinicopathological, oncological and functional follow-up data were collected from 20 consecutive patients with rectal tumours located below the dentate line who underwent laparoscopic CSR by the same surgical team from June 2018 to March 2022. The mean distance of the tumour's lower edge from the anal verge was 13.1 ± 6.0 mm. The mean distal resection margin was 10.6 ± 4.3 mm. All circumferential resection margins were negative. There were no instances of perioperative mortality. The complication rate was 25% but all were Clavien-Dindo Grade I. Among the 20 cases, 17 were diagnosed with adenocarcinoma, one with squamous cell carcinoma and two with adenoma featuring high-grade intraepithelial neoplasia. Pathological TNM staging revealed two, seven, five, five and one case(s) in Stages 0, I, II, III and IV, respectively. The median follow-up period was 20 months (interquartile range 22 months), with no withdrawals. The overall and disease-free survival rates were both 95%. The mean Wexner incontinence score and low anterior resection syndrome score recorded 18 months following diverting ileostomy closure were 6.3 ± 3.8 and 27.3 ± 3.6, respectively. This study has proposed the CSR procedure for the first time, which is a technically feasible, oncologically safe and functionally acceptable procedure for carefully selected patients with rectal tumours located below the dentate line.

The evaluation of postoperative bowel dysfunction in Japanese patients with rectal cancer.

The present study assessed postoperative bowel dysfunction in Japanese patients with rectal cancer, including patients who underwent preoperative radiotherapy (RT). A total of 277 rectal cancer patients who underwent primary resection were included in the analyses. A questionnaire survey was administered using the low anterior resection syndrome (LARS) score and Wexner score. Scores were determined one year after rectal surgery or diverting ileostomy closure. The LARS score was categorized as minor LARS (21-29) and major LARS (30-42). The proportions of patients with minor and major LARS were significantly larger and Wexner scores significantly higher in patients with distal tumors and a lower anastomosis level than in those with proximal tumors and a higher anastomosis level. Among the patients with lower rectal cancer, the proportions with minor and major LARS were similar between those with and without preoperative RT. The Wexner scores in patients with preoperative RT were significantly higher than in patients without RT. A distal tumor location and lower anastomosis level were independent risk factors of major LARS in multivariate analyses. A distal tumor location, low anastomosis level, and preoperative RT might be associated with postoperative bowel dysfunction in rectal cancer patients.

Safety, efficacy, and operability of a newly developed absorbable adhesion barrier (GM142) in patients with primary rectal cancer scheduled for diverting ileostomy during laparoscopic surgery: Randomized controlled trial.

AimThe aim of this study was to compare the outcomes of GM142, a newly developed gelatin film with a concave and convex structure to a commercially available conventional film, hyaluronate‐carboxymethylcellulose.MethodsPatients with primary rectal cancer who were scheduled for diverting ileostomy during laparoscopic surgery were eligible for this study. Patients were randomized before surgery and an antiadhesion film was applied under the umbilical incision. The primary outcome was the incidence of adhesion under the midline incision confirmed by second‐look surgery for diverting ileostomy closure. The secondary outcomes were the adhesion severity score, the extent of adhesion score, the presence of intestinal obstruction, and the success of all patching.ResultsA total of 146 patients were enrolled. A total of 123 patients were included in the full analysis set. The primary outcome of “no adhesion” was observed in 66.1% in the GM142 group and 55.7% in the conventional film group. The noninferiority of GM142 to conventional film was confirmed (P = .0005). The secondary outcomes were similar between the groups. For the safety evaluation, there were no safety concerns regarding allergic reactions to gelatin or increased gelatin‐specific IgE antibody titers.ConclusionsThe noninferiority of GM142 to conventional film was shown. GM142 showed no major safety issues. The clinical safety profiles of GM142 suggested certain physiological benefits of the gelatin film as an adhesion barrier.

Outcomes of robotic partial excision of the levator ani muscle for locally advanced low rectal cancer invading the ipsilateral pelvic floor at the anorectal ring level.

The purpose of this study is to evaluate partial excision of the levator ani muscle (PELM) enables preservation of anal sphincter function although levator ani muscle (LAM) was invaded. Functional outcomes and oncologic outcomes of 23 consecutive patients who underwent robotic PELM for low rectal cancer at the anorectal ring level invading or abutting the ipsilateral LAM are analysed. Secured resection margins were achieved, especially for the circumferential resection margin. During a median follow-up of 44months, the 3-year local recurrence rate was 14.4%. Among patients who underwent diverting ileostomy closure, mean Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores were 68.3±11.9 and 10.7±5.3, respectively, at 1year after closure. PELM is a sphincter-preserving alternative to abdominoperineal resection (APR) or extralevator APR for low rectal cancer invading the ipsilateral LAM at the level of the anorectal ring.

Prophylactic negative-pressure wound therapy after ileostomy reversal for the prevention of wound healing complications in colorectal cancer patients: a randomized controlled trial

BackgroundThe aim of this study was to assess the usefulness of protective negative-pressure wound therapy (NPWT) in the reduction of wound healing complications (WHC) and surgical site infections (SSI) after diverting ileostomy closure in patients who underwent surgery for colorectal cancer.MethodsIn this prospective randomized clinical trial in a tertiary academic surgical center, patients who had colorectal cancer surgery with protective loop ileostomy and were scheduled to undergo ileostomy closure with primary wound closure from January 2016 to December 2018 were randomized to be treated with or without NPWT. The primary endpoint was the incidence of WHC. Secondary endpoints were incidence of SSI, length of postoperative hospital stay (LOS), and length of complete wound healing (CWH) time.ResultsWe enrolled 35 patients NPWT (24 males [68.6%]; mean age 61.6 ± 11.3 years), with NPWT and 36 patients (20 males [55.6%]; mean age 62.4 ± 11.3 years) with only primary wound closure (control group). WHC was observed in 11 patients (30.6%) in the control group and 3 (8.57%) in the NPWT group (p = 0.020). Patients in the NPWT group had a significantly lower incidence of SSI (2 [5.71%] vs. 8 [22.2%] in the control group; p = 0.046) as well as significantly shorter median CWH (7 [7–7] days vs. 7 [7–15.5] days, p = 0.030). There was no difference in median LOS between groups (3 [2.5–5] days in the control group vs. 4 [2–4] days in the NPWT group; p = 0.072).ConclusionsProphylactic postoperative NPWT after diverting ileostomy closure in colorectal cancer patients reduces the incidence of WRC and SSI.Clinical trial registrationclinicaltrials.gov (NCT04088162).

Predictors of complications from stoma closure in elective colorectal surgery: an assessment from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP).

BackgroundThere is significant morbidity after diverting ileostomy closure, so identifying predictors of complications could be of great benefit. The aim of our study was to evaluate the incidence and risk factors for postoperative morbidity after elective ileostomy closure.MethodsThe ACS-NSQIP dataset was evaluated for elective ileostomy closures from 1/1/2015 to 12/31/2016. Demographic characteristics, operative, and postoperative outcomes were evaluated. The primary outcome was 30-day major morbidity (Clavien class III and greater). Secondary outcomes were rates and predictors of major morbidity, superficial site infection (SSI), reoperation, and readmission from multivariate logistic regression modeling.ResultsWe retrospectively evaluated 1885 patients. The median operative time was 65 (IQR 50–90) minutes and median length of stay was 3 (IQR 2–5) days. Major morbidity was recorded in 6.7%, including mortality (1.0%), deep/organ space SSI (2.6%), dehiscence (0.8%), reintubation (0.5%), sepsis (1.7%), septic shock (0.8%), and reoperation (3.7%). Readmission was recorded in 9.7% and 6.2% had SSI. Multivariate logistic regression showed male sex (OR 1.584; 95% CI 1.068–2.347; p = 0.022) and longer operative time (OR 1.004; 95% CI 1.001–1.007; p = 0.009) were among those variables associated with increased odds of major morbidity. Dyspnea (OR 2.431; 95% CI 1.139–5.094; p = 0.021) and longer operative time (OR 1.003; 95% CI 1.001–1.007; p = 0.034) were among the independent risk factors for SSI. Male sex (OR 2.246; 95% CI 1.297–3.892; p = 0.004, chronic obstructive pulmonary disease (OR 2.959; 95% CI 1.153–7.591; p = 0.024), and longer operative time (OR 1.005; 95% CI 1.001–1.009; p = 0.011) were associated with increased odds of reoperation. Chronic obstructive pulmonary disease (OR 2.578; 95% CI 1.338–4.968; p = 0.005), wound infection (OR 2.680; 95% CI 1.043–6.890; p = 0.041), and inflammatory bowel disease (OR 2.565; 95% CI 1.203–5.463; p = 0.015) were associated with increased odds of readmission.ConclusionsElective stoma closure has significant risk of morbidity. Patients with longer operative times were at increased risk for major morbidity, overall SSI, and reoperation. From the analysis, factors specifically associated with major morbidity, overall infectious complications, readmissions, and reoperations were identified. This information can be used to prospectively prepare for these high-risk patients, potentially improving postoperative outcomes.Electronic supplementary materialThe online version of this article (10.1007/s10151-020-02307-5) contains supplementary material, which is available to authorized users.

Risk factors for complications after diverting ileostomy closure in patients who have undergone rectal cancer surgery.

To clarify the risk factors for complications after diverting ileostomy closure in patients who have undergone rectal cancer surgery. The study group comprised 240 patients who underwent a diverting ileostomy at the time of lower anterior resection or internal anal sphincter resection, in our department, between 2004 and 2015. Univariate and multivariate analyses of 18 variables were performed to establish which of these are risk factors for postoperative complications. The most common complications were intestinal obstruction and wound infection. Univariate analysis showed that an age of 72years or older (p = 0.0028), an interval between surgery and closure of 6months or longer (p = 0.0049), and an operation time of 145min or longer (p = 0.0293) were significant risk factors for postoperative complications. Multivariate analysis showed that age (odds ratio, 3.4236; p = 0.0025), the interval between surgery and closure (odds ratio, 3.4780; p = 0.0039), and operation time (odds 2.5179; p = 0.0260) were independent risk factors. Age, interval between surgery and closure, and operation time were independent risk factors for postoperative complications after diverting ileostomy closure. Thus, temporary ileostomy closure should be performed within 6 months after surgery for rectal cancer.

Novel anal sphincter saving procedure with partial excision of levator-ani muscle in rectal cancer invading ipsilateral pelvic floor

PurposeTumors at the level of the anorectal junction had required total levator-ani muscle excision to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle and intact external sphincter, en bloc resection of rectum with levator-ani muscle including tumor would be possible. This hemilevator excision (HLE) technique enables preserving the anal sphincter function while obtaining oncologic clearance and avoiding permanent colostomy in those patients. This study aimed to evaluate the surgical outcomes and feasibility of HLE.MethodsData on 13 consecutive patients who underwent HLE for pathologically proven low rectal cancer were retrospectively collected. All 13 patients presented low rectal cancer at the anorectal ring level that was suspected to invade or abut to the ipsilateral side of the levator-ani muscle.ResultsA secure resection margin was achieved in all cases, and anastomotic leakage occurred in 2 patients. During follow-up, 3 patients experienced tumor recurrence (2 systemic and 1 local). Among 6 patients who underwent diverting ileostomy closure after the index operation, 2 complained of fecal incontinence. The other 4 patients without fecal incontinence showed <10 times of bowel movement per day. Accessing their incontinence scale, mean Wexner score was 9.4.ConclusionHLE is a novel sphincter-preserving technique that can be a treatment option for low rectal cancer invading ipsilateral levator-ani muscle, which has been an indication for abdominoperineal resection (APR) or extralevator APR. However, the long-term oncologic and functional outcomes of this procedure still need to be assessed to confirm its validity.

Risk factors associated with portomesenteric venous thrombosis in patients undergoing restorative proctocolectomy for medically refractory ulcerative colitis.

Data on risk factors for portomesenteric venous thrombosis (PMVT) following abdominal surgery for ulcerative colitis (UC) are limited. The aim of this study was to investigate factors associated with PMVT after surgical treatment for UC. Patients who underwent restorative proctocolectomy (RPC) and ileal pouch-anal anastomosis (IPAA) including diverting ileostomy closure for medically refractory UC were identified from a prospectively maintained database. Patient-related, disease-related and treatment-related variables were collected. Univariable and multivariable analyses were performed to assess factors associated with PMVT. Of the 521 patients completing surgical treatment for UC between 2006 and 2012, symptomatic PMVT occurred in 36 (7%), which resulted in a significantly increased hospital stay (P < 0.001). Patients developing PMVT were younger (P = 0.014), had a lower preoperative albumin level (P = 0.037) and were more likely to have been taking steroids within 1 month before surgery (P = 0.006). The combined incidence of PMVT was comparable between patients having a three-stage and two-stage management (6% vs. 8%, P = 0.43), but the relative incidence of PMVT after RPC + IPAA was 8%, significantly higher than the 4% after total abdominal colectomy (TAC) (P = 0.005) and the 2% after subsequent completion proctectomy (CP) + IPAA (P = 0.038). Multivariate analysis confirmed that RPC + IPAA was associated with a significantly greater risk of PMVT than CP + IPAA (OR = 4.9, P = 0.003) or TAC (OR = 3.5, P = 0.011). Preoperative steroid use was an independent factor for PMVT (OR = 5.8, P = 0.006). Steroid use 1 month before surgery is associated with an increased risk of PMVT. A staged restorative proctocolectomy does not increase the overall incidence of PMVT.

Colorectal Congress in St. Gallen, Switzerland

December. Snow. Frozen trees. Cars slowly proceeding in the darkness like metal ghosts. This is what I found arriving to St. Gallen, 1 h from Zurich, where Professor Jochen Lange had organized the fourth European Colorectal Congress, helped by his staff including the charming and skilled Judith Balzien. This outstanding Meeting has become a ‘‘must’’ in the field, hosting the best specialists in the field for 3 days and being attended by over 1,200 people from all countries, mostly Europe, but also United States and Japan. Complications and Liver metastases were the topics of the St. Gallen European Colorectal Congress 2010. ‘‘What do volume and learning curves tell us?’’, ‘‘Which are the preventable causes of failure during colorectal cancer surgery?’’, P. Quirke, R.J. Heald, and H. Kehlet tried to reply to these questions. L. Pahlman discussed on the bowel preparation in colorectal surgery and E. Rullier reported his experience on risk factors for anastomotic leakage after resection for rectal cancer, whereas R. Madoff, the Editor of DCR, explained how to treat postoperative leakages and abscesses. Again, N. Mortensen reported on the Oxford experience on anastomotic leaks stating that his complication has become very rare, but there was disagreement in the audience, W.A. Bemelman reported on Endo-Sponge treatment for anastomotic leakage. T. Holm, from Sweden, talked about the ‘‘Anterior Resection Syndrome’’ which may affect many patients with fecal incontinence and urgency, especially after long course preoperative radiotherapy, and may be treated with sacral neuromodulation and bulking agents’ injection, and possibly prevented constructing a J-pouch above the anastomosis. N.S. Williams and V.W. Fazio reported their experience on parastomal hernias and coloanal anastomosis, whereas the Spanish Dutch M.A. Cuesta impressed the audience saying that one out of 200 patients dies following a diverting ileostomy closure after anterior resection for rectal cancer. The chairman, S.D. Wexner, asked the audience how many would routinely ‘‘protect’’ a very low anastomosis: almost everybody raised his hand. The author of the present report gave a talk on postoperative complications after PPH and STARR, including rectal perforations following stapled hemorrhoidopexy, and chronic proctalgia after stapled rectal resection. The chairman A. Herold recommended more selective indications to surgery in case of obstructed defecation. R. J. Nicholls reported the St. Mark’s experience with ileo-anal reservoir and ‘‘re-do’’ pouch, whereas S.D. Wexner stressed the need for an adequate prevention of postoperative adhesions, a major cause of morbidity and expenses. ‘‘Seprafilm’’ might be the right answer, provided that it does not increase the risk of suture dehiscences. A Consultant Corner, brilliantly chaired by H. Abcarian, the Iranian–U.S. surgeon, ended the complications session. ‘‘Portal vein embolisation’’, ‘‘Surgical options in patients with peritoneal seeding’’, ‘‘Stereotactic body radiation’’, ‘‘Radio-frequency ablation’’, and ‘‘Regional chemotherapy’’ were some of the topics of the session Liver metastases, presented by M.A. Choti, P.H. Sugarbaker, A. Mendez Romero, N.E. Kemeny, and E.K. Abdalea. A number of Satellyte Symposia were also organized, among them the one on the VAAFT, the video-assisted The congress sessions are also available online at the following address: www.docAcademy.ch.

The value of diverting loop ileostomy on the high-risk colon and rectal anastomosis

Introduction The need for diverting loop ileostomies to protect high-risk anastomoses has been questioned recently by several authors. This study was designed to evaluate the potential benefits and complications of diverting loop ileostomies in a high-risk anastomosis population. Methods Ninety-four consecutive patients undergoing diverting loop ileostomy were evaluated from a prospective database between 2003 and 2006. Criteria for diversion were: anastomosis less than 5 cm from the anal verge, previous pelvic radiation therapy, obstruction, and infection. Data regarding patient demographics, underlying pathology, anastomotic problems, and ileostomy-related problems were gathered. Results Indications for surgery were malignancy (n = 40), ulcerative colitis (n = 37), acute diverticulitis (n = 12), perirectal fistulas (n = 3), and familial polyposis (n = 2). There were 5 anastomotic complications. One required permanent stoma and 4 required delay in diverting ileostomy closure but no other intervention. Ileostomy-related problems were limited to minor stoma and pouch complaints requiring stoma nurse evaluation (n = 23), dehydration requiring outpatient (n = 8) or inpatient (n = 4) intravenous fluids, stricture at stoma closure site (n = 2), and bleeding at stoma closure site (n = 1). Four stoma site hernias (4.3%) have been identified to date. Conclusion The use of diverting loop ileostomy in patients undergoing colon and rectal surgery with high-risk anastomoses is beneficial. Their selected use has resulted in a 1% anastomotic loss rate with an acceptably low rate of complications related to the ileostomy.

Hand-Sewn Coloanal Anastomosis for Distal Rectal Cancer: Long-Term Clinical Outcomes

As the oncologic safety of coloanal anastomosis (CAA) has been proved by many other authors, the incidence of CAA following ultralow anterior resection has increased. The purpose of this study is to evaluate the functional outcome and complications of patients who underwent ultralow anterior resection and CAA for distal rectal cancer. Fifty-seven patients underwent CAA following ultralow anterior resection between July 1997 and November 2003. Forty-four patients, who were followed up more than 6 months after diverting ileostomy closure, were evaluated for recurrence, complications, and functional outcomes. The mean follow-up period was 36.3 +/- 22.8 months (range, 8-83 months). The complications were multiple fistula (n = 3), fistula with anal stenosis (n=1), local recurrence with anal stenosis (n = 1), and anal stenosis (n = 7). Anal incontinence (Kirwan grade III) was noted in 14 patients, and bowel movements were observed more than six times per day in 16 patients. Overall recurrence occurred in six patients (13.6%). The 5-year survival rate was 85.3%, and the disease-free 5-year survival rate was 73.3%. Although CAA in patients with rectal cancer provides excellent long-term survival, a low risk of recurrence, and tolerable function, complications and poor functional outcomes of CAA do occur. Therefore, the choice of this method should be considered carefully.