Early Closure Group Research Articles

A comparative study between early and conventional intestinal stoma closure in a tertiary care institute

Background: Little is known about ideal time for stoma closure. Therefore, the aim of this study is to compare early versus conventional stoma closure following bowel surgery in terms of quality of life (QoL), length of hospital stay (LoH), and postoperative complications. Methods: This randomized controlled trial was conducted at a medical college affiliated teaching hospital from May 2023 to June 2024. The 116 patients undergoing bowel surgery with temporary stoma creation were randomized into early closure (3 weeks post-surgery) and conventional closure (8-12 weeks post-surgery) groups. Primary outcome was anastomotic leak rate. Secondary outcomes included other postoperative complications, LoH, and QoL assessed using the EORTC QLQ-C30 questionnaire. Results: There was no significant difference in anastomotic leak rates between early (6.9%) and conventional (12.1%) closure groups. Overall complication rates were similar (56.9% early vs 50% conventional). LoH did not differ significantly between groups. QoL scores were significantly higher in the early closure group, with 100% of patients achieving considerable improvement (EORTC score 26-36) compared to 79.3% in the conventional group (p<0.05). Conclusions: Early stoma closure is safe and feasible in appropriately selected patients, with no increased risk of anastomotic leak or other complications. It significantly improves QoL compared to conventional closure timing, without prolonging hospital stay. These findings suggest that early stoma closure may be a beneficial option for suitable patients following bowel surgery.

Early vs Delayed Temporal Ileostomy Closure after Low Anterior Resection (LAR) in Patients with Rectal Cancer, A Cohort Study

Abstract Background The optimal timing for ileostomy closure remains controversial, most of the surgeons are closing ileostomy after 6-8 weeks, although ileostomy closure considered a simple procedure, it can cause significant morbidity; this study aims to clarify any relation between the post-closure complications rate and the time from its creation to the repair. Objective To compare between early ileostomy closure within 2 weeks and delayed ileostomy closure after 6 weeks regarding post closure complications (anastmotic leak – intra abdominal collection – intestinal obstruction –SSI),operative time, post operative hospital stay and quality of life improvement. Patients and Methods This is a A cohort study. Data was collected from departments of Ain Shams university hospitals as colorectal department and oncology department. Results The overall post-closure complications in our study was 37.5%, there was no significant difference between the overall complications rate for both early and late closure groups (35% and 40%) respectively (P value 0.534), The majority of the complications were intestinal obstruction, and superficial surgical site infection, there was significant association between the interval to ileostomy reversal and the intestinal obstruction, it was higher in the late closure group, in the other hand the surgical site infection complication found to be not significantly higher in the early closure group than the late closure group (25% Vs 15%) with (P value 0.428). Conclusion Our study revealed that the duration between the creation of protective ileostomy and its reversal was not a significant independent predictor of post-closure complications rate. Depending on whether a patient has mild pre-closure complications and appears tolerant of the psychological effect of his stoma, the ileostomy closure can be deferred safely for a real indication such as completing adjuvant chemotherapy without concern that the longer duration to closure will increase the postoperative complications rate. We sincerely hope that our effort adds to the body of evidence until a consensus regarding the ileostomy closure timing is reached.

Long-Term Functional Outcome After Early vs. Late Stoma Closure in Rectal Cancer Surgery: Sub-analysis of the Multicenter FORCE Trial

PurposeThe aim of this study was to assess the effect of early stoma closure on bowel function after low anterior resection (LAR) for rectal cancer.MethodsPatients participating in the FORCE trial who underwent LAR with protective stoma were included in this study. Patients were subdivided into an early closure group (< 3 months) and late closure group (> 3 months). Endpoints of this study were the Wexner Incontinence, low anterior resection syndrome (LARS), EORTC QLQ-CR29, and fecal incontinence quality of life (FIQL) scores at 1 year.ResultsBetween 2017 and 2020, 38 patients had received a diverting stoma after LAR for rectal cancer and could be included. There was no significant difference in LARS (31 vs. 30, p = 0.63) and Wexner score (6.2 vs. 5.8, p = 0.77) between the early and late closure groups. Time to stoma closure in days was not a predictor for LARS (R2 = 0.001, F (1,36) = 0.049, p = 0.83) or Wexner score (R2 = 0.008, F (1,36) = 0.287, p = 0.60) after restored continuity. There was no significant difference between any of the FIQL domains of lifestyle, coping, depression, and embarrassment. In the EORTC QLQ-29, body image scored higher in the late closure group (21.3 vs. 1.6, p = 0.004).ConclusionTiming of stoma closure does not appear to affect long-term bowel function and quality of life, except for body image. To improve functional outcome, attention should be focused on other contributing factors.

Clinical Outcomes of Ileostomy Closure during versus after Adjuvant Chemotherapy in Patients with Rectal Cancer.

Protective ileostomy can effectively prevent severe anastomotic leakage after rectal cancer surgery; however, the optimal timing for ileostomy closure during adjuvant chemotherapy remains unclear. This study aimed to explore the safety and long-term outcomes of early ileostomy closure during adjuvant chemotherapy. Patients who underwent laparoscopic rectal cancer surgery combined with protective ileostomy and adjuvant chemotherapy between April 2017 and April 2021 were retrospectively evaluated. Patients were divided into an early closure group during chemotherapy (group A) and a late closure group after chemotherapy (group B). A total of 215 patients were included in this study, with 115 in group A and 100 in group B. There were no significant differences in demographic and clinical characteristics between the two groups. In group A, durations of stoma status (p < 0.001) and low anterior resection syndrome (LARS) (p < 0.001) were shorter, and rectal stenosis (p=0.036) and stoma-related complications (p=0.007), especially stoma stenosis (p=0.041), were less common. However, compliance with chemotherapy was worse (p=0.009). There were no significant differences in operative time, postoperative hospital stay, postoperative complications, incidence and severity of LARS, disease-free survival, or overall survival between groups. Early ileostomy closure can effectively reduce the duration of stoma status, duration of LARS, rectal stenosis, and stoma-related complications while not affecting surgical complications and oncological outcomes. Ileostomy closure should not be delayed because of adjuvant chemotherapy. However, follow-up should be strengthened to increase compliance and integrity with chemotherapy.

Outcomes of Early Versus Standard Closure of Diverting Ileostomy After Proctectomy: Meta-analysis and Meta-regression Analysis of Randomized Controlled Trials.

We aimed to compare outcomes of early and standard closure of diverting loop ileostomy (DLI) after proctectomy and determine risk factors for anastomotic leak (AL) and complications. Formation of DLI has been a routine practice after proctectomy to decrease the incidence and potential adverse sequela of AL. PubMed, Scopus, and Web of Science were searched for randomized controlled trials (RCTs) that compared outcomes of early versus standard closure of DLI after proctectomy. Main outcome measures were postoperative complications, AL, ileus, surgical site infection, reoperation, readmission, and hospital stay following DLI closure. Eleven RCTs (932 patients; 57% male) were included. Early closure group included 474 patients and standard closure 458 patients. Early closure was associated with higher odds of AL [odds ratio (OR): 2.315, P =0.013] and similar odds of complications (OR: 1.103, P =0.667), ileus (OR: 1.307, P =0.438), surgical site infection (OR: 1.668, P =0.079), reoperation (OR: 1.896, P =0.062), and readmission (OR: 3.431, P =0.206). Hospital stay was similar (weighted mean difference: 1.054, P =0.237). Early closure had higher odds of AL than standard closure when early closure was done ≤2 weeks (OR: 2.12, P =0.047) but not within 3 to 4 weeks (OR: 2.98, P =0.107). Factors significantly associated with complications after early closure were diabetes mellitus, smoking, and closure of DLI ≤2 weeks, whereas factors associated with AL were ≥ American Society of Anesthesiologists II classification and diabetes mellitus. Early closure of DLI after proctectomy has a higher risk of AL, particularly within 2 weeks of DLI formation. On the basis of this study, routine early ileostomy closure cannot be recommended.

Early vs. standard reversal ileostomy: a systematic review and meta-analysis.

BackgroundFormation of a defunctioning loop ileostomy is common after mid and low rectal resection. Historically, they were reversed between 3 and 6 months after initial resection. Recently, earlier closure (< 14 days) has been suggested by some current randomised controlled trials. The aim of this study was to investigate the effect of early stoma closure on surgical and patient outcomes.MethodsA systematic review of the current randomised controlled trial literature comparing early and standard ileostomy closure after rectal surgery was performed. Specifically, we examined surgical outcomes including; morbidity, mortality and quality of life.ResultsSix studies met the predefined criteria and were included in our analysis. 275 patients underwent early stoma closure compared with 259 patients having standard closure. Overall morbidity was similar between both groups (25.5% vs. 21.6%) (OR, 1.47; 95% CI 0.75–2.87). However, there tended to be more reoperations (8.4 vs. 4.2%) (OR, 2.02, 95% CI 0.99–4.14) and small bowel obstructions/postoperative ileus (9.3% vs. 4.4%) (OR 0.44, 95% CI 0.22–0.90) in the early closure group, but no difference across the other domains.ConclusionsEarly closure appears to be a feasible in highly selective cases after good perioperative counselling and shared decision-making. Further research on quality of life outcomes and long term benefits is necessary to help define which patients are suitable candidates for early closure.

Clinical outcomes of early closure versus conservative strategy after diagnosis with atrial septal defect: a nationwide population-based cohort study.

The long-term clinical benefits of atrial septal defect (ASD) closure remain controversial. We aimed to compare long-term clinical outcomes between patients who underwent early surgical closure after ASD diagnosis and those who did not. Using the Korean National Health Insurance Service database, we identified patients with isolated ASDs diagnosed between 1 January 2003 and 31 December 2006. The ASD patients who underwent closure surgery within 6 months after diagnosis were allocated to the early-closure group and the rest were allocated to the conservative-strategy group. The primary outcome was all-cause mortality. Secondary outcomes were atrial flutter/fibrillation (AFF) and ischaemic stroke. Among patients without a history of AFF or stroke, 1644 patients in the early-closure group were propensity score matched to 1644 patients in the conservative-strategy group and their median follow-up durations were 12.9 and 12.8 years, respectively. The early closure was associated with a significantly lower risk of mortality (hazard ratio, 0.55 [95% confidence interval, 0.43-0.70]). In an age-stratified analysis, significant mortality reductions in the early-closure group were found in patients aged 40 years or older. The risk of AFF was significantly higher in the early-closure group, which might be mainly ascribed to postoperative transient AFF, while there was no difference in ischaemic stroke between the 2 groups. Our data suggest that timely ASD closure without delay is necessary for ASD patients without previous history of clinical events, especially in patients aged 40 years or older.

Complications Following Early and Delayed Ileostomy Closure: An Interventional Study

Introduction: Ileostomy is used frequently now-a-days for various surgical conditions. Patients with ileostomies face several problems like physiological, psychological and social problems. Moreover, a stoma can also lead to different complications. Surgeries for reversal of stomas can also lead to different complications, leading to increased morbidity and mortality. Aim: To find significant differences, if any, in morbidity and mortality between patients of early and delayed ileostomy closure. Materials and Methods: In this interventional study, 100 patients were recruited into two groups of i.e., 40 in early ileostomy closure group and 60 in the delayed ileostomy closure group. Their baseline characteristics were compared to find out the comparability between the two groups. The patients were followed-up over a period of time to find out complications such as skin excoriation, wound dehiscence, wound infection, anastomotic leakage, faecal fistula etc. Student’s t-test was applied for continuous variables and for discrete variables, Chi-square test was applied to find out whether there was any statistically significant difference between the two groups. A p-value&lt;0.05 was considered significant. Results: Out of total 40 patients, in the early closure group 5 (12.5%) of patients closure group developed skin excoriation, whereas 10 (25%) developed wound infection and 10% of the patients developed incisional hernia. Skin excoriation amongst delayed closure group was noticed in 21 (35%), wound infection in 6 (10%) and Incisional hernia in 1 (1.7%) patient. Skin excoriation was significantly less among early closure group with an OR of 0.27 (0.09-0.78). Duration of stay in the hospital was significantly less among the early closure group (24.92±5.12) days compared to the delayed closure group (41.43±12.29) days (p&lt;0.001). One patient expired due to sepsis after on 13th postoperative day, who was in the delayed closure group. Conclusion: Skin excoriation was significantly less amongst the patients of the early ileostomy group. Hence, early ileostomy closure can reduce the complications of ileostomy and the duration of carrying the ileostomy.

Identity Formation Patterns and Online Activities in Adolescence

ABSTRACT Online activities can provide a wide range of opportunities for young people in dealing with age-related transitions and developmental tasks, such as forming their identity. This study aimed to unravel the associations between adolescent identity formation and online activities, internet skills, and risks. Using a nationally representative sample of Lithuanian adolescents (N = 549, mean age 15.5 years, 46.6% girls), we examined how adolescents, who were classified into distinct identity statuses (achievement, early closure, moratorium, searching moratorium, and diffusion) across two identity domains central to the adolescent experience (educational and interpersonal identity), differ in their pattern of online activities, skills, and risks. The findings highlighted that adolescents in the achievement and searching moratorium statuses could be characterized by a richness of online experiences. Those in the searching moratorium status also had the lowest level of online risks. In contrast, those in the moratorium and diffusion statuses showed lower diversity and richness of online activities. Adolescents in the diffusion status group also had low internet skills. Adolescents in the early closure group showed a mixed profile of online activities.

Safety of early ileostomy closure: a systematic review and meta-analysis of randomized controlled trials.

Patients with a defunctioning ileostomy after rectal resection experience substantial ileostomy-related morbidity and decreased quality of life. Early reversal of the defunctioning ileostomy has been proposed as a method of mitigating these problems. We aimed to evaluate the safety of early ileostomy closure within 6 weeks. Randomized controlled trials investigating the safety of early ileostomy closure were identified through a systematic search and review of the current literature. Meta-analysis of the extracted outcome data was performed, and the methodological quality of the individual studies was assessed. The search identified six eligible studies yielding a total of 528 patients, with 269 in the early closure (EC) group and 259 in the standard closure (SC) group. Major complications in the EC group was 5.2% compared with 3.6% in the SC group (RR = 1.12, 95% CI 0.33-3.79). Anastomotic leakage in the EC group was 3.3% compared with 3.5% in the SC group (RR = 0.89, 95% CI 0.29-2.75). The meta-analysis resulted in no statistically significant differences between the groups in any of the primary or secondary outcomes. This review was not able to discern a statistically significant difference in postoperative complications when comparing early and standard ileostomy closure. The current literature indicates that early ileostomy closure is not associated with higher complication rates in patients with an uncomplicated postoperative course and radiologically verified intact distal anastomosis after index surgery.

Early and Late Closure of Loop Ileostomies: A Retrospective Comparative Outcomes Analysis

Retrospective research was conducted to compare outcomes between patients who had early (<6 months) or late (>6 months) loop ileostomy closure. Records of patients >18 years of age who underwent circumstomal reversal of a loop ileostomy over a period of 5 years in 1 hospital's colorectal unit were abstracted and analyzed. Data from patients who had a planned or conversion to laparotomy, a concurrent bowel resection, reversal of double-barrel small bowel and colonic stomas, or closure of an end ileostomy or patients whose records were incomplete were excluded. Demographic information, American Society of Anesthesiologists (ASA) grade, primary operation indication, surgery and inpatient dates, readmission within 30 days of discharge, reasons for readmission, complication type, and Clavien-Dindo classification were extracted and compared between early and late closure groups using independent-sample t test and Fisher's exact test. Among the 75 study participants, 25 had an early closure (mean age 68.6 [range 26 - 93] years, mean time since primary surgery 3.8 months) and 50 had a late closure procedure (mean age 71.6 [range 46 - 93] years, mean time since primary surgery 12.8 months). Gender distribution, ASA grades, primary surgery indication, and total number of readmissions were similar between the 2 groups. Hospital length of stay was significantly shorter (5.5 days vs 9.4 days; P = .01) and average number of complications was significantly lower (0.33 vs 0.61; P = .04) in the early closure group. Rates of postoperative ileus, anastomotic bleed, and wound-related complications were not significantly different. Hospital length of stay and average number of postoperative complications following circumstomal loop ileostomy closure were significantly lower in the early than in the late closure group. Additional studies are warranted to help guide practice.

Early Closure of Defunctioning Loop Ileostomy: Is It Beneficial for the Patient? A Meta-analysis.

To perform a meta-analysis to answer the question, whether early closure (EC) of defunctioning loop ileostomy may be beneficial for patient as compared with late closure (LC) without exceeding the risk of surgical-related morbidity. Medline and the Cochrane Trials Register were searched for trials published up to November 2016 comparing EC (defined as ≤14days from the index operation in which the ileostomy was performed) versus LC for stoma closure after rectal surgery. Meta-analysis was performed using Review Manager 5.0. Inclusion criteria MAIN OUTCOME MEASURES: Overall morbidity rate, anastomotic leakage rate, and wound infection rate within 90days after elective surgery. Six studies were included and analyzed, yielding 570 patients (252 in EC group and 318 in LC). Meta-analysis showed no significant difference in the overall morbidity rate between the EC and LC groups (OR 0.63; 95% CI, 0.22-1.78; P = 0.38). Despite a significant higher wound infection rate of stoma site (OR 3.83; 95% CI 2.14-6.86; P < 0.00001), meta-analysis showed no significant difference in the anastomotic leakage rate between the EC and LC groups (OR 0.63; 95% CI 0.22-1.78; P = 0.38). Moreover, both stoma-related complications (OR 0.46; 95% CI 0.24-0.86; P = 0.02) and small bowel obstruction rates (OR 0.11; 95% CI 0.06-0.20; P < 0.00001) were significantly lower in the EC group than in the LC group, respectively. Heterogeneity of the studies CONCLUSION: This meta-analysis suggests that EC of a defunctioning loop ileostomy is effective and safe in careful selected patients without increasing overall postoperative complications. This promising strategy should be proposed in patients in order to reduce stoma-related complications.

Meta-analysis of early versus late closure of a temporary ileostomy after proctectomy

// Xiaozhun Huang 1, * , Chunling Wang 2, * , Zhangkan Huang 1 , Houhong Zhou 1 , Han Li 1 , Fengxiang Shi 3 , Longde Du 4 , Xianni Ke 5 , Biao Zheng 1 , Shuisheng Zhang 6 and Xu Che 6 1 Department of Abdominal Surgery, National Cancer Center/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen 518116, China 2 Department of Hepatology, Huizhou Municipal Central Hospital, Huizhou 516000, China 3 Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China 4 Department of Thoracic Surgery, National Cancer Center/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen 518116, China 5 Department of Medical Oncology, National Cancer Center/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen 518116, China 6 Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China * These authors have contributed equally to this work Correspondence to: Xu Che, email: drchexu@126.com Shuisheng Zhang, email: thelifeofwater@126.com Keywords: temporary ileostomy; early closure; late closure; complication; hospital stay Received: November 08, 2017 Accepted: January 03, 2018 Published: January 08, 2018 ABSTRACT Background: A temporary ileostomy is frequently constructed to reduce the risk of symptomatic anastomotic leakage. An ostomy is a heavy burden on both patient and society, and early closure is therefore desirable to counteract increased morbidity. The optimal time for stoma closure has been investigated in some studies, although it remains controversial. Methods: We conducted a literature search of PubMed, Wiley, Web of Science, and the Cochrane Library to identify studies published till 2017 that focused on perioperative complications and details related to early( 4weeks) closure of temporary ileostomies after proctectomy. Results: Six studies (three randomized controlled trials, two prospective non-randomized trials, and one retrospective trial) satisfied our inclusion criteria, and the outcomes of 767 patients (356 early closures and 411 late closures) were analyzed. There was a significantly lower prevalence of skin irritation ( p =0.0002) in the early group, but no worse morbidity outcomes were observed between the early and late closure groups. Hospital stay length after an ileostomy closure was not prolonged following early closure, suggesting that the increased wound infection risk did not significantly delay discharge. Also, the overall hospital stay length, when time since admission for the original operation was included in the late closure group, showed no significantly longer duration in the early closure group ( p = 0.02). Conclusions: We found that early closure of a temporary ileostomy after proctectomy was feasible in selected patients, with some advantages and disadvantages that need to be weighed by the patient and surgeon.

Early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resections: an integrated systematic review and meta‐analysis of published randomized controlled trials

The objective of this study was to evaluate the surgical outcomes and feasibility of early loop defunctioning ileostomy closure, within 2weeks of index surgery, in patients undergoing distal colorectal resection. A systematic review of the literature on published randomized controlled trials reporting the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection using the principles of meta-analysis on RevMan 5.4 statistical software was undertaken. Four randomized, controlled trials on 446 patients evaluating the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing low colorectal resection were analysed. There were 176 patients in the early closure group and 270 patients in the delayed closure group. The risk of anastomotic leak [risk ratio 0.37 (CI: 0.10-1.42), P=0.15], anastomotic stenosis [risk ratio 4.79 (CI: 0.23-98.47), P=0.31] and postoperative complications [risk ratio 0.75 (CI: 0.48-1.16), P=0.19] was similar in both groups. In addition, there was no significant difference between the groups with regard to the duration of operation [standardized mean difference -0.49 (CI: -01.09, -0.12), P=0.12] and length of hospitalization [standardized mean difference -0.04 (CI: -0.25, -0.18), P=0.75]. Early closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection is feasible with comparable outcomes to delayed closure.

Effectiveness between early and late temporary ileostomy closure in patients with rectal cancer: A prospective study

A temporary stoma is often used in rectal cancer surgery to protect a distal anastomosis, which remains a major concern after rectal cancer surgery, particularly after low anterior resection. The temporary stoma is scheduled for closure. However, the optimal time of closure of the protecting stoma remains unclear because of sparse studies and data. We aimed to detect the efficacy between early and late temporary ileostomy closure in patients with rectal cancer during or after neoadjuvant chemoradiotherapy. We conducted a prospective, 2-group design between early and late ileostomy closure group in patients after rectal cancer surgery with temporary stoma. Participants were recruited in a teaching hospital in Guangzhou, China. A total of 161 patients confirmed diagnosis of rectal cancer underwent curative surgery and temporary ileostomy. Participants with temporary ileostomy received closure surgery after 1 (early) or 6 (late) months were assessed by clinical parameters and quality of life. Patients in late closure group received more adjuvant chemotherapy cycles but with comparable incidence of stoma closure–related complications and length of hospital stay compared to early closure group. Participants in late closure group with standardized postoperative chemotherapy might have a better prognosis compared with those in early closure group. An increased emphasis should be given to choose the optimal closure time of patients with rectal cancer having temporary ileostomy. Colorectal nurses could provide support to physician for observation of prognosis of different closure time.

Diabetic Foot Ulcer: Close Wound Early

SAN DIEGO — Early wound closure prior to hospital discharge after surgical debridement of infected diabetic foot ulcers yields higher ulcer healing rates and a shorter time to healing, compared with various nonclosure wound management methods, according to a propensity-matched study reported at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.Shey-Ying Chen, MD, presented a retrospective comparison between 179 diabetic foot ulcer (DFU) patients with early wound closure after surgical debridement and an equal number of matched controls treated with various nonclosure techniques, including negative pressure wound therapy and the repeated application of moist dressings.During 1 year of follow-up post-discharge, ulcer healing occurred in 75% of the early wound closure group, compared with 66% of the nonclosure patients. Readmission for further treatment of the index ulcer occurred in 33% of the early closure group and 52% of the nonclosure group.Ulcer healing was significantly less likely in patients with peripheral vascular disease, with an OR of 0.62; neuropathy, with an OR of 0.53; and methicillin-resistant Staphylococcus aureus wound infection, with an OR of 0.59, he said.Bruce Jancin is with the Denver bureau of Frontline Medical News. SAN DIEGO — Early wound closure prior to hospital discharge after surgical debridement of infected diabetic foot ulcers yields higher ulcer healing rates and a shorter time to healing, compared with various nonclosure wound management methods, according to a propensity-matched study reported at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. Shey-Ying Chen, MD, presented a retrospective comparison between 179 diabetic foot ulcer (DFU) patients with early wound closure after surgical debridement and an equal number of matched controls treated with various nonclosure techniques, including negative pressure wound therapy and the repeated application of moist dressings. During 1 year of follow-up post-discharge, ulcer healing occurred in 75% of the early wound closure group, compared with 66% of the nonclosure patients. Readmission for further treatment of the index ulcer occurred in 33% of the early closure group and 52% of the nonclosure group. Ulcer healing was significantly less likely in patients with peripheral vascular disease, with an OR of 0.62; neuropathy, with an OR of 0.53; and methicillin-resistant Staphylococcus aureus wound infection, with an OR of 0.59, he said. Bruce Jancin is with the Denver bureau of Frontline Medical News.

Patent ductus arteriosus in preterm infants: Benefits of early surgical closure

Patent ductus arteriosus in preterm neonates leads to significant morbidity. Surgery is indicated when pharmacological treatment fails or is contraindicated, but the optimal timing remains unclear. We retrospectively studied all 41 preterm neonates with symptomatic ductus arteriosus who underwent ligation between 1988 and 2009. We compared early complications rates and late neurological outcomes of patients operated on before 21 days of age with these operated on later. The median gestational age at birth was 26 weeks (range 23-31 weeks) and median weight at birth was 930 g (range 510-1500 g); 34 (82.9%) received pharmacological treatment before surgery. Fourteen (34.1%) patients underwent surgical closure before 21 days of age and 27 (65.9%) after 21 days. The 2 groups did not differ significantly in gestational age and weight at birth, but those operated on after 21 days received significantly more pharmacological treatment cycles. Patients in the early closure group had shorter intubation times: median 23 days (range 13-35 days) vs. 43 days (range 27-84 days; p < 0.001) and shorter neonatal intensive care unit stay: median 44 days (range 31-66 days) vs. 76 days (range 41-97 days; p < 0.001), with significantly lower rates of bronchopulmonary dysplasia, intraventricular hemorrhage, and acute renal failure, and significantly better neurological outcomes. Performing early ligation of symptomatic ductus arteriosus after unsuccessful pharmacological therapy in preterm neonates might lower complication rates and improve neurological outcome. Prospective randomized studies are needed to determine the optimal treatment.

Damage-control laparotomy in nontrauma patients

The principle of damage-control laparotomy (DCL) in trauma is well established. The DCL concept can be applied in emergency general surgery when an abbreviated laparotomy is performed at the initial stage. Subsequent definitive management and abdominal closure are achieved when the patient is stabilized. In this study, we report our experience with DCL in acute general surgical nontrauma patients. A retrospective review was performed of all nontrauma patients who underwent DCL at Auckland City Hospital from January 2008 to December 2010. Data including indications and outcome were collected and analyzed. Forty-two nontrauma patients underwent DCL in the 3-year period. The median age was 66 years. There were 22 males and 20 females. The most common primary indications for DCL were bowel ischemia (13 patients), bleeding (13 patients), and peritonitis (10 patients). Majority of patients had an American Society of Anesthesiologists score of 3 or 4. Overall, 24 patients (57%) underwent closure of the fascia within 7 days, 7 patients were closed after more than 7 days, and 11 patients could not undergo primary closure at all. The main complications after DCL were sepsis (14 patients) and intra-abdominal collections (10 patients). There were significantly fewer postoperative complications in patients undergoing early closure. The medium length of stay in intensive care as well as in hospital was significantly less in the early closure group. However, postoperative respiratory failure was more common in those with early closure (5 vs. 0). The mortality rate overall was 19%, with no significant difference regarding timing of abdominal closure. The DCL principle is often applied to the critically ill surgical patients in the nontrauma setting. This group of critical surgical patients has a high morbidity and mortality. However, early abdominal closure should be performed where possible to prevent complications. It is unclear whether patients with early closure were going to have a better outcome regardless, and prospective studies are needed to address. Therapeutic/care management, level V.

Early ileostomy closure: is there a downside?

A loop ileostomy is a common adjunct to formation of a low colorectal anastomosis. However, it is not without significant physical and psychological morbidity, and financial cost. Feasibility of early closure during the index admission has previously been reported. This pilot study examines the safety of early closure compared with traditional timing. A retrospective audit of consecutive ileostomy closures performed in a tertiary colorectal unit from January 2008 to January 2010. Demographic data, treatment data and complications were collected by a single investigator from a prospective clinical audit database and hospital records. Patients undergoing early closure (within 10 days of the index operation) were compared with the traditional timing group. A total of 93 patients underwent closure of loop ileostomy during the study period (44 female; 49 male). Median patient age was 61 years. Nineteen patients (20%) underwent early closure. There were six wound infections in the early closure group (32%), and five in the traditional timing group (7%) (P = 0.01). There was no significant difference in other complications between the two groups. There was a significantly shorter overall hospital stay in the early closure group with a median stay of 14 days (range 10-26), and in the traditional timing group a median stay of 17 days (range 7-80) (P = 0.05). Seven patients (9%) in the traditional timing group had ileostomy-related complications. Early ileostomy closure appears to be associated with an increased wound infection rate but otherwise appears to be a safe alternative to traditional closure in selected patients and may reduce overall hospital stay.

Late vs early ostomy closure for necrotizing enterocolitis: analysis of adhesion formation, resource consumption, and costs

BackgroundSurgeons prefer to close ostomies at least 6 weeks after the primary operation because of the anticipated postoperative abdominal adhesions. Limited data support this habit. Our aim was to evaluate adhesion formation—together with an analysis of resource consumption and costs—in patients with necrotizing enterocolitis who underwent early closure (EC), compared with a group of patients who underwent late closure (LC). MethodsChart reviews and cost analyses were performed on all patients with necrotizing enterocolitis undergoing ostomy closure from 1997 to 2009. Operative reports were independently scored for adhesions by 2 surgeons. ResultsThirteen patients underwent EC (median, 39 days; range, 32-40), whereas 62 patients underwent LC (median, 94 days; range, 54-150). Adhesion formation in the EC group (10/13 patients, or 77%) was not significantly different (P = 1.000) from the LC group (47/59 patients, or 80%). No differences were found in the costs of hospital stay, surgical interventions, and outpatient clinic visits. ConclusionsOstomy closure within 6 weeks of the initial procedure was not associated with more adhesions or with changes in direct medical costs. Therefore, after stabilization of the patient, ostomy closure can be considered within 6 weeks during the same admission as the initial laparotomy.