Diverting Loop Ileostomy Research Articles

Surgical intervention for mechanical large bowel obstruction at a tertiary hospital: Which patients receive a stoma and how often are they reversed?

BackgroundThe surgical management of large bowel obstruction (LBO) is heterogeneous and influenced by multiple variables. The aim of this study was to analyze and compare the surgical interventions and outcomes of patients necessitating surgery for LBO. MethodsPatients with LBO between 2000 and 2017 were included. Main outcomes measures are intraoperative findings, operative management, post-operative outcomes and stoma closure rates. Results133 patients were included with predominately left-sided obstruction (82%). The most common etiology was colorectal cancer (44%) followed by extrinsic malignant compression (29%). The most common operation performed was fecal diversion without resection (46%). This group had significantly more stage 4 carcinoma, carcinomatosis and had the lowest stoma closure rate (16%).Eighty-six percent of the operated patients underwent fecal diversion, of these, 27% had stoma reversal at 6 months. Patients that had a resection and anastomosis with diverting loop ileostomy were most likely to undergo stoma reversal (p = 0.005) and had the lowest number of patients with stage-IV carcinoma. ConclusionsIn this single institution analysis, the management of LBO entails high operative and stoma rates, with less than 30% of patient undergoing stoma closure. Resection, anastomosis and DLI had the highest chance of stoma reversal.

Intra-amniotic Infection

Intra-amniotic Infection

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.

S1811 A Rare Case of Synchronous Squamous Cell Tumors of the Rectum: Diagnosis and Management

INTRODUCTION: Colorectal squamous cell carcinoma (SCC) is an extremely rare form of colon cancer, accounting for 0.1–0.2% of the cases. It has a female predominance, with a mean age of 57 years old at diagnosis. It is often diagnosed at an advanced stage. We present a case of two simultaneous SCC tumors of the rectum which were managed successfully with multidisciplinary approach. CASE DESCRIPTION/METHODS: A 65 year old female with remote history of left breast ductal carcinoma in situ, in remission after lumpectomy and adjuvant chemoradiation therapy several years ago, presented with intermittent hematochezia. She denied having any constitutional symptoms. Her previous colonoscopy was eight years prior and was unremarkable. There was no family history of gastrointestinal cancer. She rarely drank alcohol and did not smoke cigarettes. During rectal exam, a large mass was palpated in the rectum, without any palpable anal abnormalities. Labs showed normal CBC, LFTs and renal function. She underwent a colonoscopy which revealed an exophytic and friable 4 cm mass in the distal rectum. A separate subepithelial mass was seen at the rectosigmoid junction, with ulcerated mucosa overlying the lesion. The intervening rectum between the 2 distinct masses and the portion of the rectum distal to the rectal mass were both normal. Separate biopsies were taken of the two masses, and pathology revealed invasive, moderately differentiated squamous cell carcinoma with HPV positivity (Image 1). Imaging for staging did not reveal any metastases. The patient received neoadjuvant radiation and chemotherapy (Mitomycin C and 5-Fluorouracil). Post-treatment abdominal imaging showed significant response to therapy (Image 2). Subsequently, the patient underwent a laparoscopic hand assisted proctosigmoidectomy with colonic pouch anal anastomosis and diverting loop ileostomy. Pathology showed complete resolution of tumor at primary sites while carcinoma cells were found in one of the resected lymph nodes (Image 3). DISCUSSION: Colorectal SCC occurs mostly in the distal half of the colon, mainly at the rectosigmoid junction. While isolated colorectal SCCs are rare, our case is even more unique given the presence of synchronous colorectal SCC tumors. HPV infection is associated with colorectal SSC in past literature. To decrease the risk of SCC recurrence, neoadjuvant chemoradiation followed by surgical resection is the mainstay of treatment while recent evidence suggests that chemoradiation alone may be definitive therapy in some cases.Figure 1.: Colonoscopy showing submucosal mass with overlying ulcerated mucosa (arrow) at the rectosigmoid junction (A) and exophytic, friable mass seen in the distal rectum (B). Rectal mass biopsy H & E stain (20X) showing full thickness squamous atypia with lack of maturation consistent with squamous cell carcinoma (C) while diffuse nuclear p40 stain positivity (10X) supporting squamous origin (D) and strong p16 staining (10X) indicative of HPV-associated squamous cell carcinoma (E).Figure 2.: MRI abdomen showing submucosal mass (see arrow) at rectosigmoid junction with compression of lumen (A) and intraluminal mass (see arrow) in distal rectum (B). After chemotherapy and radiation, the mass at rectosigmoid has reduced to scar tissue with T2 hypointensity (C) while mass in distal rectum has completely resolved (D).Figure 3.: H & E stain (20X) showing no residual tumor identified in treated colon of patient with history of squamous cell carcinoma in (A) while treatment effect shown with numerous macrophages, few multinucleated giant cells (black arrow), lymphocytes and small vessel with hyaline changes (blue arrow) in B, and CD68 stain highlights macrophages within the area of treatment response (C). H & E stain (20X) showing lymph node with metastatic carcinoma showing treatment effect and viable tumor cells (arrows) within necrotic debris in lymph node in (E) while CK AE1/3 immunohistochemistry stain (20X) highlighting/confirming metastatic carcinoma with both viable tumor cells and necrotic cells expressing pancytokeratin.

S2275 All at Once: Dual Novel Diagnosis of Crohn’s Disease and Colonic Adenocarcinoma in a 22-Year-Old Man

INTRODUCTION: Colorectal cancer (CRC) is the third most commonly diagnosed cancer in the United States. Mucinous adenocarcinoma makes up 10-15% of all CRC and disproportionately affects younger adults. One study found that those aged 25 and younger who developed CRC present acutely and when compared to older adults, were diagnosed at a more advanced stage and carried a poorer prognosis.[1] Crohn’s disease frequently presents in ages 20-29 and can increase risk of CRC. CASE DESCRIPTION/METHODS: A 22 year old male with no significant past medical history presented to ED with intermittent abdominal pain, diarrhea and weight loss. Initial labs revealed leukocytosis, elevated CRP/ESR and positive fecal occult blood test. CT imaging revealed hepatic flexure stricture with dilation of the ascending colon and distal ileum with enlarged ileocolic lymph nodes (Figure 1). Colonoscopy revealed moderate stenosis at the hepatic flexure with significant inflammation and ulceration which prevented a pediatric colonscopy from traversing. Descending colon had scattered moderate inflammation. Two days following the colonoscopy, the patient developed a bowel perforation which required emergent exploratory laparotomy with open right hemicolectomy and diverting loop ileostomy. Surgical findings included terminal ileum perforation, dense stricture at the hepatic flexure with adherence to the underlying duodenum without fistula. Pathology report revealed adenocarcinoma in the ascending colon invading into the visceral peritoneal surface, with extensive lymphovascular invasion. The cancer was staged at G3pT4aN2a. The uninvolved terminal ileum revealed active inflammation consistent with Crohn’s disease. Genetic testing was only positive for polysomy of chromosome 17. He was ultimately diagnosed with mucinous adenocarcinoma with signet ring cell features in the setting of newly diagnosed Crohn’s disease (Figure 2). DISCUSSION: This is a rare case of advanced mucinous adenocarcinoma with signet ring features of the ascending colon in a 22-year-old with previously undiagnosed Crohn’s disease. This demonstrates the importance and difficulty of considering CRC in the differential when working up a young adult for GI symptoms as the newly diagnosed Crohn’s disease seemed to fit our patient’s presentation perfectly.Figure 1.: Stricture at the hepatic flexure with dilation of the ascending colon and distal ileum.Figure 2.: Signet ring cells.

S1844 Early Onset Colorectal Cancer (EOCRC) in a 43-Year-Old Woman: Current Guidelines Miss Patients at Risk for EOCRC

INTRODUCTION: The incidence of colorectal cancer (CRC) among individuals less than 50 years old is increasing and is estimated to double by 2030. Risk factors for early onset CRC (EOCRC), outside of hereditary CRC syndromes or personal history of IBD, are not well understood. We present a case of EOCRC in a 43-year-old woman. CASE DESCRIPTION/METHODS: The patient presented with six months of worsening hematochezia, abdominal pain, and constipation. Her past medical history included cervical dysplasia status post loop electrosurgical excision and thyroid follicular adenoma status post thyroid lobectomy. Her family history was significant for CRC in her father, diagnosed at age 80. CT abdomen/pelvis showed circumferential rectal wall thickening and prominent perirectal lymph nodes. Colonoscopy revealed a partially obstructing 3cm rectal tumor with associated severe stenosis that was only traversed with an EGD scope. Pathology showed colonic mucosa with high-grade dysplasia. A staging CT chest did not reveal metastases. Her clinical picture was suspicious for colorectal cancer and colorectal surgery recommended neoadjuvant chemotherapy followed by low anterior resection with diverting loop ileostomy. DISCUSSION: This patient's presentation was typical of EOCRC, which tends to present with left-sided disease and in patients older than 40 years. Her risk factor was a family history of CRC in her father; although, he was diagnosed at age 80 at an index colonoscopy. A family history of CRC, even in second- or third-degree relatives, has been associated with increased risk. Some studies have suggested that BMI, tobacco use, coronary artery disease, hypertension, stroke, diabetes, and socioeconomic status are risk factors for EOCRC. Other research indicates that combinations of age, male sex, personal history of IBD, or African American or Asian race are risk factors. Our current U.S. Preventive Services Task Force guidelines do not account for EOCRC. It is difficult to balance the cost effectiveness of initiating the American Cancer Society qualified recommendation to start screening at age 45 versus increasing screening rates and diagnostic colonoscopy completion rates among patients over age 50. As evidenced by our patient, simply lowering the screening age may not be an effective intervention to capture EOCRC phenotypes. Further research is needed to improve understanding of the associated biological and environmental risk factors to improve early identification of individuals at high risk for EOCRC.Figure 1.: Partially-obstructing rectal tumor prior to biopsy.

S3359 Adult Isolated Hypoganglionosis in the Anorectal Canal

INTRODUCTION: Hirschsprung's disease (HD) is a congenital bowel innervation disorder characterized by the absence of ganglion cells in myenteric and submucosal plexus in the distal. The term ‘‘Variant HD’’ has been used to describe a heterogeneous group of intestinal innervation disorders with clinical presentation that resembles HD despite the presence of ganglionic cells seen on rectal biopsy. Isolated hypoganglionosis is a rare entity that present with persistent bowel symptoms similar to those with classical HD, however has resected bowel histopathological findings of reduced number of nerve cells in the myenteric ganglia. CASE DESCRIPTION/METHODS: We present a case report of a 19-year-old male who was diagnosed with isolated hypoganglionosis following a long history of fecal impaction and constipation since childhood. Patient presented to our institution with complaints of distended abdomen at 19 years of age. CT imaging demonstrated a massively distended rectosigmoid colon filled with abundant fecal material (Figure 1). An abdominal series revealed stool scattered throughout his colon and a dilated, saccular appearing rectum. A water soluble contrast enema exhibited a short segment (approximately 8 cm) narrowing of bowel in the region of the rectum with dilated upstream sigmoid colon (Figure 2). The remainder of the visualized bowel including proximal sigmoid, descending, transverse, ascending colon and cecum were of normal caliber. This imaging pattern was compatible with Hirschsprung's disease. The patient then underwent a laparoscopic-assisted proctosigmoidectomy with a stapled end to end coloanal anastomosis and a diverting loop ileostomy. Though the surgical pathology demonstrated the presence of ganglion cells in the sigmoid colon and rectum, the anorectal canal showed presence of rare ganglion cells (Figure 3). On follow up, the patient underwent another water soluble contrast enema that confirmed an intact anastomosis and he subsequently underwent successful ileostomy closure two months later. One week after closure, the patient had recovered well, reporting daily bowel movements with good evacuation control and no fecal incontinence. DISCUSSION: To our knowledge, this is the first case of adult HD variant, isolated hypoganglionosis, with histology demonstrating hypoganglionosis in the anorectal canal and no evidence of agangliosis in the rectum and sigmoid colon. Following removal of the remnant hypoganglionic intestinal segment, our patient’s bowel motility significantly improved.Figure 1.: Routine CT abdomen and pelvis with intravenous and oral contrast was performed on admission with axial images and coronal reformations (A and B, respectively). These images demonstrated marked sigmoid colonic fecal loading and dilation (white arrows), compatible with a chronic obstructive process such as Hirschsprung's disease.Figure 2.: Water soluble enema study was performed. (A) This study showed a short segment (8 cm) narrowing of the distal rectum (solid white arrow) with upstream dilatation of the proximal rectum (dashed white arrow). (B) The AP view demonstrates massive upstream dilation of the rectum and sigmoid colon.Figure 3.: H&E stain of anorectal canal (A) and sigmoid rectal area (B). Arrows indicate ganglion cells, which were rare in the anorectal canal region. Inserts show the higher magnification of the circled area. Bar = 50 um.

S2321 Use of a Lumen-Apposing Metal Stent for a Colo-Colonic Stricture in the Time of COVID-19

INTRODUCTION: Anastomotic strictures are a known complication of colon resections. Risk factors include neoadjuvant chemo-radiation, anastomotic leak, diverting stoma and stapled anastomosis. Endoscopic balloon dilation is the first line intervention for anastomotic strictures but often requires several treatment sessions and associated healthcare system exposure. We describe a case of a colorectal anastomotic stricture treated with a lumen apposing metal stent (LAMS) with the purpose of decreasing frequency of endoscopic therapy during the initial outbreak of COVID-19. CASE DESCRIPTION/METHODS: A 51 year old female presented for management of a colo-colonic anastomotic stricture. She underwent a low anterior resection for stage III rectal cancer, complicated by an anastomotic leak requiring a diverting loop ileostomy. She then completed adjuvant XRT and FOLFOX therapy. She presented for evaluation 6 months after the creation of her loop ileostomy to consider reversal. During endoscopy, a severe stricture was found which could not be traversed even with a 15 Fr gastroscope. Initial dilation to 10mm with a balloon dilator was successful. One week later, the stricture was improved but still severe. A 15 mm by 10 mm LAMS was placed with the intent of decreasing the number of required procedures and healthcare system exposure during the initial outbreak of COVID-19. The stent was removed 6 weeks later, and the underlying stricture was markedly improved to a diameter of 15 mm, easily traversable with a gastroscope. The patient did not experience any complications while the stent was in place and was able to proceed with planning for ostomy reversal. DISCUSSION: Endoscopic balloon dilation is the initial intervention for anastomotic strictures. Serial balloon dilations usually require multiple procedures to achieve a durable response. With the uncertainty caused by the recent outbreak of COVID-19, many physicians and patients are looking for ways to decrease exposure to healthcare centers. Although LAMS are approved for the management of pancreatic fluid collections, they have been described as an alternative therapy for luminal GI strictures. This case demonstrates early adoption of LAMS with successful luminal dilation of an anastomotic stricture during the COVID-19 pandemic in an effort to decrease healthcare exposure and PPE use during an unprecedented time.Figure 1.: Colo-colonic anastomotic stricture prior to dilation.Figure 2.: LAMS 6 weeks after initial placement.Figure 3.: Stricture after LAMS removal.

Modified two-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review and meta-analysis of observational research

Restorative proctocolectomy (RPC) is performed for patients with refractory ulcerative colitis (UC). This operation is performed in 2 or 3 stages and involves forming a diverting loop ileostomy thought to protect patients from complications related to anastomotic leak. However, some advocate for a modified 2-stage approach, consisting of subtotal colectomy followed by completion proctectomy and ileal pouch anal anastomosis without diverting ileostomy. We present a systematic review and meta-analysis comparing postoperative complication rates between modified 2-stage and traditional RPC with ileal pouch anal anastomosis. Records were sourced from PubMed/Embase databases. Studies comparing postoperative complications following RPC for ulcerative colitis (UC) were selected according to PRISMA guidelines comparing modified 2-stage (exposure), classic 2-stage, and 3-stage approaches (comparators). The primary outcome measure was safety as measured by postoperative complication rates. We employed random effects meta-analysis. We included ten observational studies including 1727 patients (38% modified 2-stage). Among pediatric patients, modified 2-stage approaches had higher rates of anastomotic leak than 3-stage approaches (p = 0.03). Among adult cohorts with lower preoperative biologic use rates, modified 2-stage approaches had lower leak rates than classic 2-stage approaches (p < 0.001). The modified 2-stage approach may be safe for adult patients who otherwise require a 3-stage approach while reducing costs and length of stay. Pediatric patients may benefit from lower leak rates when receiving 3-stage compared with modified 2-stage approaches, especially when on biologics. The modified 2-stage approach may be safer than the classic 2-stage approach for adult patients with lower biologic exposure.

Robotic neo‐rectopexy: a technique for repair of neo‐rectal prolapse following transanal total mesorectal excision – a video vignette

As TaTME is gaining popularity for the treatment of low rectal cancers, certain complications are becoming more prevalent. A unique complication is neo-rectal prolapse, which can lead to a significantly poor quality of life (1). We present the case of a 48 year-old male with invasive rectal adenocarcinoma (T3N0) who received neoadjuvant chemoradiation and subsequently underwent a robotic low anterior resection and transanal total mesorectal excision (TaTME) with a handsewn coloanal anastomosis and a diverting loop ileostomy.

Geographical Variation in the Use of Diverting Loop Ileostomy in Australia and New Zealand Colorectal Surgeons.

PurposeAnastomotic leak (AL) after a low pelvic anastomosis is a devastating complication, with short- and long-term morbidity and increased mortality. Surgeons may employ various adjuncts in an attempt to reduce AL rates or mitigate their impact. These include the use of temporary diverting ileostomy (TDI), transanal or rectal tubes and pelvic drains. This questionnaire evaluates the preferences and routine use of these adjuncts in Australasian colorectal surgeons.MethodsA cross-sectional survey was administered to Australian and New Zealand colorectal surgeons on September 20, 2018. The study survey consisted of 15 questions exploring basic demographics and the number of rectal resections and ileal pouches performed in 12 months, along with the surgeon’s preference for the use of diverting stomas, rectal tubes, and pelvic drains.ResultsThere were 90 respondents to the survey (31.6%). Surgeons in Western Australia (71.4%) were more likely to use a mandatory TDI in colorectal extraperitoneal anastomoses than surgeons in Queensland (14.3%). South Australian surgeons are more likely to employ a mandatory TDI (100%) for ileal pouches than Queensland surgeons (42.9%). Rectal tubes are not commonly utilized (40.0% never use them), and pelvic drains are (45.6% in all cases). Surgeons consider a median AL rate of 15% was felt to justify the use of a TDI in low pelvic anastomoses and a median AL rate of 10% for ileal pouchesConclusionThere is considerable geographical variation in colorectal surgical practice throughout Australia and New Zealand. While surgeons interrogate the same literature, there are presumably other factors that see translation into variations in clinical practice.

Revisiting the Value of Drains After Low Anterior Resection for Rectal Cancer: a Multi-institutional Analysis of 996 Patients

BackgroundIntraoperative pelvic drains are often placed during low anterior resection (LAR) to evacuate postoperative fluid collections and identify/control potential anastomotic leaks. Our aim was to assess the validity of this practice. MethodsPatients from the US Rectal Cancer Consortium (2007–2017) who underwent curative-intent LAR for a primary rectal cancer were included. Patients were categorized as receiving a closed suction drain intraoperatively or not. Primary outcomes were superficial surgical site infection (SSI), deep SSI, intraabdominal abscess, anastomotic leak, and need for secondary drain placement. Three subgroup analyses were conducted in patients who received neoadjuvant chemoradiation, had a diverting loop ileostomy (DLI), and had low anastomoses < 6 cm from the anal verge. ResultsOf 996 patients 67% (n = 551) received a drain. Drain patients were more likely to be male (64 vs 54%), have a smoking history (25 vs 19%), have received neoadjuvant chemoradiation (73 vs 61%), have low tumors (56 vs 36%), and have received a DLI (80 vs 71%) (all p < 0.05). Drains were associated with an increased anastomotic leak rate (14 vs 8%, p = 0.041), although there was no difference in the need for a secondary drainage procedure to control the leak (82 vs 88%, p = 0.924). These findings persisted in all subset analyses. Drains were not associated with increased superficial SSI, deep SSI, or intraabdominal abscess in the entire cohort or each subset analysis. Reoperation (12 vs 10%, p = 0.478) and readmission rates (28 vs 31%, p = 0.511) were similar. ConclusionsAlthough not associated with increased infectious complications, intraoperatively placed pelvic drains after low anterior resection for rectal cancer are associated with an increase in anastomotic leak rate and no reduction in the need for secondary drain placement or reoperation. Routine drainage appears to be unnecessary.

Full robotic Hartmann's reversal: technical aspects and preliminary experience.

Laparoscopic Hartmann's reversal (HR) is a major abdominal operation that is associated with considerable morbidity and mortality. The robotic approach, with its intrinsic advantages, could potentially overcome the technical complexity of laparoscopy. The aim of this study was to evaluate the short-term results of a series of 24 robotic HR cases. The data from 24 patients who underwent robotic HR between September 2016 and July 2019 at two different institutions were prospectively collected and retrospectively analysed. A full robotic single-docking reversal procedure with intracorporeal anastomosis was performed in all patients. The mean age and body mass index of the patients were 69years and 26kg/m2 , respectively. Of the patients, 58% were ≥70years old and 42% had comorbidities (mean Charlson Comorbidity Index 3). The mean operating time was 240min. There were no cases of conversion to the open or laparoscopic approach. No diverting loop ileostomies were constructed. The mean length of hospital stay was 6days. Minor complications were recorded in three patients. Neither major complications nor 30-day readmissions were registered. Robotic HR is a feasible and safe procedure. The robotic approach has low rates of major complications and conversion and could potentially increase the number of patients undergoing HR.

Diverticulitis: An update from the age old Paradigm

Colostomy takedown is an under-appreciated and challenging operation. Restoration of bowel continuity is not performed in up to 50% of patients after their initial surgery for diverticulitis. It is essential to wait six months after the initial operation to minimize the risk of enterotomies and other complications. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Open necrosectomy combined with continuous positive drainage and prophylactic diverting loop ileostomy for late infected pancreatic necrosis: a retrospective cohort study

BackgroundTo evaluate an innovative open necrosectomy strategy with continuous positive drainage and prophylactic diverting loop ileostomy for the management of late infected pancreatic necrosis (LIPN).MethodsConsecutive patients were divided into open necrosectomy (ON) group (n = 23), open necrosectomy with colonic segment resection (ON+CSR) group (n = 8) and open necrosectomy with prophylactic diverting loop ileostomy (ON+PDLI) group (n = 11). Continuous positive drainage (CPD) via double-lumen irrigation–suction tube (DLIST) was performed in ON+PDLI group. The primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. The secondary endpoints were duration of hospitalization, cost, time interval between open surgery and total enteral nutrition (TEN).ResultsThe recovery time of organ function in ON+PDLI group was shorter than that in other two groups. Colonic complications occurred in 13 patients (56.5%) in the ON group and 3 patients (27.3%) in the ON+PDLI group (p = 0.11). The length of stay in the ON+PDLI group was shorter than the ON group (p = 0.001). The hospitalization cost in the ON+PDLI group was less than the ON group (p = 0.0052).ConclusionON+PDLI can avoid the intestinal dysfunction, re-ileostomy, the resection of innocent colon and reduce the intraoperative trauma. Despite being of colonic complications before or during operation, CPD + PDLI may show superior effectiveness, safety, and convenience in LIPN.

Diverting loop ileostomy versus total abdominal colectomy for clostridioides difficile colitis: outcomes beyond the index admission

Diverting loop ileostomy (DLI) and colonic lavage has emerged as a valid alternative to total abdominal colectomy (TAC) for the surgical management of Clostridioides difficile colitis (CDC). However, little data are available on outcomes beyond the index admission. The objective of this study was to compare post-discharge outcomes between patients who underwent DLI and TAC for CDC. Adult patients who underwent DLI or TAC for CDC between 2011 and 2016 were identified from the Nationwide Readmissions Database, and only discharges between January and September in each calendar year were included to allow for a 90-day follow-up period for all cases. Ninety-day overall in-hospital mortality (index admission mortality plus 90-day post-discharge mortality) and 90-day unplanned readmissions were compared. To assess 6-month ileostomy reversal rates, the cohort was then truncated to exclude discharges after June in each calendar year. Multivariate regression was used to adjust for patient demographics and disease severity. In total, 2070 patients were discharged between January and September of each included year: 1486 (71.8%) TAC compared to 584 (28.2%) DLI. Overall in-hospital mortality was higher among patients who underwent TAC (34.5% vs. 27.7%, p = 0.004); however, this association did not remain on multivariate regression (OR 1.14, 95% CI 0.91-1.43). Among the 1434 patients who were discharged alive, the 90-day unplanned readmission rate was similar in both groups (TAC: 26.1% vs. DLI: 23.1%, p = 0.26). After truncating the cohort to those patients discharged alive between January and June of each included year (n = 1016), patients who underwent DLI had a significantly greater 6-month ileostomy reversal rate (26.4% vs. 8.3%, p < 0.001). DLI was independently associated with higher odds of 6-month ileostomy reversal (OR 2.68, 95% CI 1.80-4.00). In the surgical management of CDC, DLI is associated with equivalent mortality and unplanned readmission, but greater likelihood of 6-month ileostomy reversal, compared to TAC.

Risk factors for parastomal hernia of loop stoma and relationships with other stoma complications in laparoscopic surgery era

BackgroundLaparoscopic approach is now a widespread technique used worldwide, but there are few recent studies on risk factors for parastomal hernia. Therefore, this study was performed to analyze the incidence of parastomal hernia in laparoscopic and open surgery in which a loop stoma was created and was intended to be temporary, and to determine risk factors for parastomal hernia formation. Associations between parastomal hernia and other stoma-related complications were also analyzed.MethodsA retrospective analysis of patient and surgical characteristics was performed in 153 consecutive patients who underwent a temporary diverting loop ileostomy or colostomy after surgery related to malignant diseases at our hospital from January to December 2016.ResultsParastomal hernia developed in 77 cases (50.3%), including 39 (25.5%) diagnosed by physical examination and 38 (24.8%) detected by CT alone. On multivariate analysis, a stoma not passing through the middle of the rectus abdominis muscle was the only independent risk factor for parastomal hernia formation (p = 0.005) during the median follow-up of 245.0 days. When we analyzed the factors that were associated with a stoma not passing through the middle of the rectus abdominis muscle, the only independent factor associated with this misplacement of the stoma was a laparoscopic approach (p = 0.012). An analysis of stoma-related complications showed that peristomal skin disorders were significantly associated with parastomal hernia (p = 0.049).ConclusionsThis study showed that a stoma that is not formed through the middle of the rectus abdominis muscle is a risk factor for parastomal hernia formation, and that a laparoscopic approach is associated with this risk factor. Moreover, parastomal hernia is significantly associated with peristomal skin disorders.

A systematic review and meta-analysis of diverting loop ileostomy versus total abdominal colectomy for the treatment of Clostridium difficile colitis.

Clostridium difficile is an increasingly common source of in-patient morbidity and mortality. We aim to assess the effects of diverting loop ileostomy (DLI) versus total abdominal colectomy (TAC) for Clostridium difficile colitis (CDC), in terms of mortality and morbidity. Systematic literature search was performed using PubMed, Embase, Cochrane, and Web of Science databases for randomized and non-randomized studies comparing DLI and TAC for fulminant CDC. Meta-analysis was carried out for mortality and postoperative complications. Five non-randomized studies qualified for inclusion in the quantitative synthesis. In total, 3683 patients were allocated to DLI (n = 733) or TAC (n = 2950). The overall mortality was equivalent (OR 0.73; 95% CI 0.45-1.20; P = 0.22). Regarding secondary outcomes, the pooled analysis revealed the following equivalent rates of postoperative events: thromboembolism (OR 0.45; 95% CI 0.14-1.43; P = 0.18), acute renal failure (OR 1.71; 95% CI 0.91-3.23; P = 0.10), surgical site infection (OR 0.95; 95% CI 0.11-8.59; P = 0.97), pneumonia (OR 0.98; 95% CI 0.36-2.66; P = 0.97), urinary tract infection (OR 0.81; 95% CI 0.26-2.52; P = 0.72), and reoperation (OR 0.95; 95% CI 0.50-1.82; P = 0.78). The ostomy reversal rate was significantly higher in DLI (OR 12.55; 95% CI 3.31-47.55; P = 0.0002). The overall morbidity and mortality rates between DLI and TAC for the treatment of CDC seemed to be equivalent. Evidence from a randomized controlled trial is needed to clarify the timing and understand the impact of DLI for CDC.

Stoma closure and reinforcement (SCAR): A study protocol for a pilot trial

A quality metric for centers performing rectal cancer surgery is a high percentage of sphincter sparing procedures. These procedures often involve temporary bowel diversion to minimize the complications of an anastomotic leak. The most common strategy is a diverting loop ileostomy which is then closed after completion of adjuvant therapy or the patient recovers from surgery. Loop ileostomy is not without complications and the closure is complicated by a one in three chance of incisional hernia development. Strategies to prevent this problem have been designed using a variety of techniques with and without mesh placement. This proposed pilot study will test the safety and efficacy of a novel stoma closure technique involving permanent mesh in the retro rectus position during ileostomy closure. The study will prospectively follow 20 patients undergoing ileostomy closure using this technique and evaluate for safety of the procedure, quality of life, and feasibility for a larger randomized controlled trial. Patients will be followed post procedurally and evaluated for 30-day complications, as well as followed up with routine cancer surveillance computed tomography every 6 months in which the presence of stoma site incisional hernias will be evaluated. The results of this pilot study will inform the design of a multiple center, blinded randomized controlled trial to evaluate the utility of permanent mesh placement to decrease the incidence of prior stoma site incisional hernias.

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.