Creation Of Diverting Ileostomy Research Articles

Risk Factors Associated with the Development of Colorectal Anastomotic Strictures Prior to Diverting Loop Ileostomy Reversal.

Anastomotic strictures represent a major source of morbidity in colorectal surgery with an incidence reported up to 30%. Despite this, the mechanism by which strictures develop remains unclear. This study aims to determine the incidence of colorectal anastomotic strictures and associated risk factors among a series of diverted patients. A retrospective chart review was conducted of 142 patients over a 7-year period at a single institution after colorectal resection with anastomosis and diverting ileostomy creation re-examined with postoperative endoscopy. One patient was removed due to anastomotic tumor recurrence. Patient and technical factors were examined for significance using chi-square analysis. Logistic regression was used to perform multivariate analysis to estimate odds ratio (OR) and 95% confidence intervals (CI). Among 141 patients, 14.1% (20 patients) developed strictures detected on endoscopy. Strictures were observed in a greater percentage of women than men (21.2% vs 8%, P = .025). 30.6% of patients who underwent resections for diverticulitis developed strictures while those with neoplastic lesions and other indications had stricture rates of 6.8% and 17.6%, respectively (P = .002). Anastomoses performed during a colostomy reversal were associated with a higher stricture rate (OR 4.23, 95% CI 1.37-13.40, P = .012). Anastomoses performed with a 28/29mm EEA circular stapler demonstrated a significantly higher stricture rate versus a 31/33mm stapler (OR 7.21, 95% CI 1.23-155.58, P = .045). Our data reveal that female sex, history of diverticulitis, anastomoses performed in the setting of colostomy reversal, and smaller stapler size are associated with a higher rate of anastomotic stricture.

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.

Morbidity and costs of diverting ileostomy in transanal total mesorectal excision with primary anastomosis for rectal cancer.

The role of diverting ileostomy is debated in rectal cancer surgery with primary anastomosis. The aim of this study was to evaluate the associated morbidity and hospital costs of diversion after sphincter saving TaTME surgery. All patients undergoing TaTME with primary anastomosis for rectal cancer between January 2012 and December 2019 in a single centre in the Netherlands were included. Patients with diverting ileostomy creation during primary surgery were compared with those without ileostomy. Outcomes included length of hospital stay, anastomotic leakage rates and total hospital costs at 1year. One hundred and one patients were included in the ileostomy group, and 46 patients were in the non-ileostomy group. The number of female patients was 31 (30.7%) in the ileostomy group and 21 (45.7%) in the non-ileostomy group Mean age was 64.5 ± 11.1years in the ileostomy group and 62.6 ± 10.7years in the non-ileostomy group The anastomotic leakage rate was 21.7% in the non-ileostomy group and 15.8% in the ileostomy group (p = 0.385). The grade of leakage and number of anastomotic takedowns did not differ between groups. Mean costs at 1year after surgery was €26,500.13 in the ileostomy group and €16,852.61 in the non-ileostomy group. The main cost driver was longer total length of hospital stay at 1year (mean 12.4 ± 13.3days vs 20.6 ± 12.6days, p = 0.000). Morbidity and associated costs after diverting ileostomy are high. The incidence and morbidity of anastomotic leakage was not reduced by creation of an ileostomy. Omission of a diverting ileostomy after TaTME could possibly result in a reduction in treatment associated morbidity and costs.

Risk factors and management of stoma-related obstruction after laparoscopic colorectal surgery with diverting ileostomy

BackgroundStoma-related obstruction (SRO) is defined as small bowel obstruction occurring around the limbs of diverting ileostomy (DI). This study was aimed to investigate the incidence, risk factors, and management of SRO after laparoscopic colorectal surgery with DI creation. MethodsThis study included 155 patients who underwent laparoscopic colorectal surgery with DI creation for rectal cancer (n = 138), ulcerative colitis (UC) (n = 14), and familial adenomatous polyposis (FAP) (n = 3) between 2011 and 2019. Univariate and multivariate analyses were performed to identify the risk factors of SRO. ResultsThe incidence of SRO was 7.7% (n = 12), and it was significantly lower (P < 0.01) in patients with lower anterior resection or intersphincteric resection (4.3%) than in those with ileal-pouch anal anastomosis (IPAA) (35.2%). The multivariate analysis revealed that IPAA was independently associated with the development of SRO (P = 0.001; odds ratio, 9.4; 95% confidence interval, 2.5–35.4). Eleven of 12 patients (92%) with SRO required trans-stomal tube decompression, and 8 of those (67%) underwent early stoma closure. ConclusionIPAA was an independent risk factor of SRO in laparoscopic colorectal surgery with DI creation. Early stoma closure was needed in most cases of SRO.

When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn's disease?

The aims of this study were to determine risk factors for morbidity associated with laparoscopic ileocolic resection (LICR) for Crohn's disease (CD) and whether the addition of a diverting ileostomy is associated with reduced morbidity. Patients undergoing LICR for primary CD at our institution from 2005 to 2015 included in a prospectively maintained database were assessed. The decision to perform a diverting ileostomy was left at the discretion of the operating surgeon. Demographics, disease-related, and treatment-related variables were evaluated using univariate and multivariate analyses as possible factors associated with diverting ileostomy creation and 30-day perioperative septic complications (anastomotic leaks and/or abscess). Use of any immunosuppressive medication was defined as use of steroids, biologics, and immunomodulators either alone or in combination. For 409 patients, mortality was nil, overall morbidity rate was 40.6%, conversion rate 9.3%, and septic morbidity rate 7.6%. A diverting stoma was created in 22% of cases and was independently associated with BMI < 18.5kg/m2 (P = 0.001), low serum albumin levels (P = 0.006), and longer operative time (P = 0.003). Use of any immunosuppressive medication was the only variable independently associated with septic complications, both in the overall population (OR 2.7, P = 0.036) and in the subgroup of undiverted patients (OR 3.1, P = 0.031). There was no association between septic morbidity and ileostomy creation, anastomotic configuration, penetrating disease, combined procedures (other resection or strictureplasty), BMI, albumin levels, and operative times. LICR is safe in selected cases of complex penetrating disease, including when combined procedures are necessary. Our data are unable to prove that a diverting stoma is associated with reduced morbidity.

Discussion of: Individual surgeon practice is the most important factor influencing diverting ileostomy creation for patients undergoing sigmoid colectomy for diverticulitis

Discussion of: Individual surgeon practice is the most important factor influencing diverting ileostomy creation for patients undergoing sigmoid colectomy for diverticulitis

Use of an ACE inhibitor or angiotensin receptor blocker is a major risk factor for dehydration requiring readmission in the setting of a new ileostomy.

Diverting ileostomies help prevent major complications related to anastomoses after colorectal resection but can cause metabolic derangement and hypovolemia, leading to readmission. This paper aims to determine whether angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use increased the risk of readmission, or readmission specifically for dehydration after new ileostomy creation. Retrospective analysis of patients undergoing diverting ileostomy at a tertiary-care hospital, 2009-2015. Primary outcome was 60-day readmission for dehydration; secondary outcomes included 60-day readmission for any cause, or for infection obstruction. Ninety-nine patients underwent diverting ileostomy creation, 59% with a primary diagnosis of colorectal cancer. The 60-day readmission rate was 36% (n = 36). Of readmitted patients, 39% (n = 14) were admitted for dehydration. Other readmission reasons were infection (33%) and obstruction (3%). The majority (64%, n = 9) of patients readmitted for dehydration were taking either an ACEi or an ARB. Compared to patients not readmitted for dehydration, those who were readmitted for dehydration were more likely to be on an ACEi or an ARB (11/85, 13% vs. 9/14, 64%). After controlling for covariates, ACEi or ARB use was significantly associated with risk of readmission (p < 0.0001, odds ratio = 13.56, 95% confidence interval 3.54-51.92,). No other diuretic agent was statistically associated with readmission for dehydration. ACEi and ARB use is a significant risk factor for readmission for dehydration following diverting ileostomy creation. Consideration should be given to withholding these medications after ileostomy creation to reduce this risk.

Individual surgeon practice is the most important factor influencing diverting loop ileostomy creation for patients undergoing sigmoid colectomy for diverticulitis

BackgroundTo identify factors associated with diverting ileostomy creation (DLI) in patients undergoing sigmoid colectomy for diverticular disease in a high volume colorectal unit and to obtain information for better preoperative patient counseling. MethodsPatients who underwent sigmoid colectomy with colorectal anastomosis with or without DLI for diverticulitis between 01/1994-12/2014 were identified. Preoperative characteristics, surgeon practice year, individual surgeon and postoperative outcomes were compared between patients with DLI or not. Results1320 patients were identified and DLI was created in 204 (15.4%) patients. DLI creation was associated with older age (p < 0.001), female gender (p = 0.01), higher ASA-class (p < 0.001), hypertension (p = 0.01), DM(p < 0.001), renal comorbidities (p < 0.001), preoperative steroid use (p = 0.03), preoperative anemia (p = 0.004), and open surgery (p < 0.001). While ileostomy creation rates did not vary over the years during the study period or with increased surgeons' experience, surgeon identity had significant impact on ileostomy creation (Rate range 6.8–60.7%, p < 0.001). Multivariate logistic regression analysis revealed that individual surgeon, open approach, preoperative steroid use, and disease-related factors remained independently associated with DLI creation. ConclusionIndividual surgeon's practice affects the rate of diverting ileostomy creation in patients undergoing sigmoid colectomy for diverticular disease.

Factors associated with hospital readmission following diverting ileostomy creation.

The creation of a diverting loop ileostomy is associated with the risk of readmission due to stoma-related complications. We hypothesized that the assessment of our institution-specific readmissions following ileostomy creation would help identifying at-risk groups which should be the focus of future preventative strategies. Patients who underwent loop ileostomy formation from 2009 to 2013 were reviewed. We evaluated readmissions within 30days after discharge following loop ileostomy construction. Possible associations between readmission and demographic, disease-related and treatment-related factors were assessed using univariate and multivariate analyses. Out of 1267 patients undergoing loop ileostomy construction, 163 patients (12.9%) were readmitted. The main causes of readmissions were organ/space infections (43, 3.4%), small bowel obstruction/ileus (42, 3.3%) and dehydration (38, 3%). Independent factors associated with overall readmission were cardiovascular (OR=2.0) and renal comorbidity (OR=2.9), preoperative chemo/radiotherapy (OR=4.0), laparoscopic approach (OR=1.7) and longer operative time (OR=1.2). Cancer diagnosis was associated with reduced readmission rates (OR=0.2). Independent factors associated with readmission due to dehydration were chemo/radiotherapy (OR=4.7) and laparoscopic approach (OR=2.6). Dehydration associated with diverting ileostomy creation was relevant as an individual cause of readmission, but its overall incidence was relatively rare. Dedicated strategies to prevent dehydration should be directed to patients who received chemoradiotherapy and/or laparoscopic surgery.

The effects of preoperative oral antibiotic use on the development of surgical site infection after elective colorectal resections: A retrospective cohort analysis in consecutively operated 90 patients

PurposeThe influence of oral antibiotic use together with mechanical bowel preparation (MBP) on surgical site infection (SSI) rate, length of hospital stay and total hospital costs in patients undergoing elective colorectal surgery were evaluated in this study. MethodsData from 90 consecutive patients undergoing elective colorectal resection between October 2006 and September 2009 was analyzed retrospectively. All patients received MBP. Patients in group A were given oral antibiotics (a total 480 mg of gentamycin, 4 gr of metronidazole in two divided doses and 2 mg of bisacodyl PO), whereas patients in group B received no oral antibiotics. Exclusion criteria were emergent operations, laparoscopic operations, preoperative chemoradiotherapy, intraoperative colonoscopy prior to the creation of an anastomosis or antibiotic use within the previous 10 days. SSI, length of hospital stays and total hospital charges were evaluated. ResultsPatients in both study groups, group A (n = 45) and group B (n = 45), were similar in terms of age, BMI, diverting ileostomy creation, localization and stage of the disease. Patients receiving oral antibiotics demonstrated a lower rate of wound infections (36% vs. 71%, p < 0.001), shorter hospital stay (8.1 ± 2.4 days vs. 14.2 ± 10.9 days, respectively, p < 0.001) and similar rates for anastomotic leakage (2% vs. 11%, p = 0.20). The mean ± SD total hospital charges were significantly lower in Group A (2.699 ± 0.892$) than that in Group B (4.411 ± 4.995$, p = 0.029). ConclusionPreoperative oral antibiotic use with MBP may provide faster recovery with less SSI and hospital charges.

"Scarless" and no-stoma surgery for low rectal cancer: the laparoscopic pull-through delayed "high" colo-anal anastomosis.

Despite recent improvements in surgical technique, low rectal anastomoses for rectal cancer still carry a not negligible incidence of anastomotic leakage and pelvic related morbidity. The Turnball-Cutait delayed colo-anal anastomosis, also referred as pull-through procedure was introduced with the aim to reduce the surgical anastomotic related complications and overcome the need of diverting ileostomy creation. Recently, this technique regained popularity as a viable option not only as salvage procedure after anastomotic failure or in case of hostile pelvis but also as first choice option in case of low rectal cancer. We report our experience with a personal technique for delayed "high" colo-anal anastomosis and its combination with a minimally invasive approach in order to reduce surgical morbidity, avoid the need for stoma creation and minimize the impact of surgery. Between 2011 and 2015, eight consecutive patients were operated for low rectal cancer by the described technique by a minimally invasive approach. The procedure was successfully completed in all cases. Post-operative major morbidity and 60days mortality were nihil. There was no need for stoma creation or service laparotomy resulting in a virtually "scarless" surgery. Mean cumulative hospital stay (combining the two stages of the procedure) was 7, 6days (range 7-9). The proposed technique by combining the advantage of a minimally invasive approach to those of a delayed "high" colo-anal anastomoses can be considered a viable option for the surgical treatment of low rectal cancer.

Dehydration Is the Most Common Indication for Readmission After Diverting Ileostomy Creation

Early readmission after discharge from the hospital is an undesirable outcome. Ileostomies are commonly used to prevent symptomatic anastomotic complications in colorectal resections. The aim of this study was to identify factors predictive of readmission after colectomy/proctectomy and diverting loop ileostomy. This study is a retrospective review. Patients were included who underwent colon and rectal resections with ileostomy at our institution. Sex, age, type of disease, comorbidities, elective vs urgent procedure, type of ileostomy, operative method, steroid use, ASA score, and the use of diuretics were evaluated as potential factors for readmission. The primary outcomes measured were the need for readmission and the presence of dehydration (ostomy output ≥1500 mL over 24 hours and a blood urea nitrogen/creatinine level ≥20, or physical findings of dehydration). Six hundred three loop ileostomies were created mostly in white (95.3%), male (55.6%) patients undergoing colon or rectal resections. IBD was the most common indication at 50.9%, with rectal cancer at 16.1%, and other at 31.0%. The 60-day readmission rate was 16.9% (n = 102) with the most common cause dehydration (n = 44, 43.1%). Regression analysis demonstrated that the laparoscopic approach (p = 0.02), lack of epidural anesthesia (p = 0.004), preoperative use of steroids (p = 0.04), and postoperative use of diuretics (p = 0.0001) were highly predictive for readmission. Furthermore, regression analysis for readmission for dehydration identified the use of postoperative diuretics as the sole risk factor (p = 0.0001). This study is limited by the retrospective analysis of data, and it does not capture patients that were treated at home or in clinic. Readmission after colon or rectal resection with diverting loop ileostomy was high at 16.9%. Dehydration was the major cause for readmission. Patients receiving diuretics are at increased risk for readmission for dehydration. High-risk patients should be treated more cautiously as inpatients and closely monitored in the outpatient setting to help reduce dehydration and readmission.