Creation Of Ileostomy Research Articles

Disparate potential for readmission prevention exists among inpatient and outpatient procedures in a minimally invasive surgery practice

BackgroundAdministrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability. MethodsA gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student’s t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher’s exact test. ResultsThere were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001). ConclusionThe use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies.

"Free-Floating Anus": A Flap-Free Approach for Definitive Excision of Circumferential Giant Condyloma Acuminata.

Giant condyloma acuminata (GCA), or Buschke-Löwenstein tumor, is a rare exophytic cauliflower-like growth in the anogenital region. The spectrum of treatment options is wide, ranging from the application of topical ointments to the performance of an abdominoperineal resection. Currently, wide local excision is the most common approach and may entail the creation of a protective loop ileostomy or implementation of flaps or grafts that facilitate closure. We describe a unique surgical approach for the management of circumferential GCA void of the use a protective loop ileostomy, flaps, or grafts. Our report highlights that the implementation of a radical, circumferential, wide excision resulting in "free-floating anus" and healing via secondary intention can ultimately lead to excellent functional and cosmetic results and therefore may be considered a minimally invasive surgical option for patients afflicted with a large, circumferential GCA.

Ghost Ileostomy Release Down-Our Initial Experience

Abstract Background Many publications describe the advantages of the creation of ghost ileostomy (GI) to prevent the need for formal covering ileostomy in more than 80% of carcinoma rectum patients. However, none of the papers describes exactly how to ultimately remove the GI in these 80% of patients in whom it doesn't need formal maturation. Aim To describe and evaluate the ghost ileostomy release down (GIRD) technique in terms of feasibility, complications, hospital stay, procedure time etc. in patients with low anterior resection/ultra-low anterior resection (LAR/uLAR) with GI for carcinoma rectum. Method The present was a prospective cohort study of patients with restorative colorectal resections with GI for carcinoma rectum, Postoperatively the patients were studied with respect to ease and feasibility of the release down of GI and its complications. The data was collected, analyzed and inference drawn. Results A total of 26 patients needed the GIRD and were included in the final statistical analysis of the study. The procedure was done between 7th to 16th postoperative days (POD) and was successful in all patients without the need of any additional surgical procedure. None of the patients required any local anesthetic injection or any extra analgesics. The average time taken for procedure was 5-minutes and none of the patients had any significant difficulty in GI release. There were no immediate postprocedure complications. Conclusion The GIRD technique is a simple, safe, and quick procedure done around the 10th POD that can easily be performed by the bedside of patient without the need of any anesthesia or additional analgesics.

Risk factors of acute renal failure in patients with protective ileostomy after rectal cancer surgery

BackgroundDespite the potential benefits of protective ileostomy in rectal surgery, diverting loop ileostomy construction is not free of specific medical consequences implying unplanned hospital readmissions. The most common reason for readmission in these patients is a dehydration with a prevalence of acute renal failure (ARF) of 20%. The objective of this study was to establish the predictive factors of ARF in patients with protective ileostomy after surgery for rectal cancer from a bicentric study.Methodswe conducted a bicentric retrospective cohort study to identify the risk factor of ARF. This study was carried out on 277 patients operated for rectal cancer with necessity of a protective ileostomy during the study period. ARF was measured at any endpoint between ileostomy creation and reversal. Multiple logistic regressions were performed to identify independent risk factors.ResultsA total of 277 patients were included, and 18% (n = 50) were readmitted for ARF. In multivariate logistic regression, increased age (OR 1.02, p = 0.01), Psychiatric diseases (OR 4.33, p = 0.014), Angiotensin II receptor blockers (OR 5.15, p < 0.001) and the ASA score ≥ 3 (OR 9.5, p < 0.001) were significantly associated with ARF.ConclusionAcute renal failure is a prevalent and significant event in the postoperative course of ileostomy patients. Patients at risk should be risk stratified before discharge and targeted for intensive preventive measures.

Rektal kanser cerrahisinde koruyucu ileostomi, koruyucu ileostomi gerçekten geçici mi?

Aim: This single-center retrospective study aimed to evaluate the rate of protective ileostomy closure in patients with rectosigmoid junction/rectal cancer and to investigate the factors that prevent ileostomy reversal.&#x0D; Material and Method: Patients with rectal cancer treated with/without neoadjuvant chemoradiotherapy were included in this study. All were treated with anterior rectal resection and temporary protective ileostomy creation. Decision for ileostomy closure was brought upon predefined ileostomy closure protocol.&#x0D; Results: Total number of 115 patients (17 with rectosigmoid junction and 98 with rectal cancer) were operated. Neoadjuvant chemoradiotherapy was conducted in 90 of them. Ileostomy closure rate was 73.9%. Mean time for stoma closure in patients with chemoradiotherapy conduction was 227.8 days, while in the rest, time was shorter (168.3 days), without statistical difference. Multivariate analysis revealed that endoscopic examination of the anastomosis during its creation was independent prognostic factor that affected ileostomy closure.&#x0D; Conclusion: More than one quarter of the patients with protective ileostomy experienced non-closure of their stoma due to various events after index rectal cancer surgery. Endoscopic examination of the anastomosis during its creation presented as independent factor affecting ileostomy closure.

Operative management of anastomotic leak after sigmoid colectomy for left-sided diverticular disease: Ileostomy creation may be as safe as colostomy creation.

The management of anastomotic leak after sigmoid colectomy for diverticular disease has not been well defined. Specifically, there is a lack of literature on optimal types of reoperations for leaks. The aim of this study was to describe and compare reoperative approaches and their postoperative outcomes. We performed a retrospective cohort study using the NSQIP Colectomy Module (2012-2019) and single-institution chart review. Patients with diverticular disease who underwent elective sigmoid colectomy were included. Primary outcomes were anastomotic leak requiring reoperation and management of anastomotic leak. Of 37,471 patients who underwent sigmoid colectomy for diverticular disease, 1003 (2.7%) suffered an anastomotic leak, of whom 583 underwent reoperation. Of the 572 patients who were not initially diverted and underwent reoperation for leak, 302 (52.8%) were managed with stoma creation - 200 (35.0%) with colostomy and 102 (17.8%) with ileostomy. The remaining 47.2% underwent colectomy with reanastomosis, suturing of large bowel, and drainage. There were no differences in length of stay, readmission, or mortality between patients who underwent ileostomy or colostomy at reoperation (p > 0.05). Single-institution analysis demonstrated that 100% of patients with ileostomies underwent subsequent ileostomy closure, compared to 60% of patients with colostomies. In patients who suffer anastomotic leaks after sigmoid colectomy for diverticular disease and undergo reoperations, ileostomy at the time of reoperation appears to be safe, with comparable results to colostomy. Ileostomies were more frequently closed than colostomies. When faced with a colorectal anastomotic leak, ileostomy creation may be considered.

Early Closure of a Temporary Ileostomy in Patients with Rectal Cancer

Introduction: Rectal cancer is a common malignancy affecting millions of individuals worldwide. Surgery is the primary treatment modality, and for many patients, the creation of a temporary ileostomy is required to protect the anastomosis and allow for healing. Objectives: The main objective of the study is to find the safety and feasibility of early ileostomy closure within four to eight weeks of the initial surgery compared to traditional closure time frames of six to twelve months and to examine the potential benefits of early ileostomy closure, including reductions in morbidity, improved quality of life, and decreased healthcare costs. Material and methods: This multicenter study was conducted in Surgical Department Lady Reading hospital Peshawar during 1st January 2020 to 30th June 2020. Data on patient demographics, medical history, surgical procedures, and postoperative outcomes were collected using medical records and standardized data collection forms. Patient-reported outcomes, such as quality of life and stoma-related complications, may also have been assessed using validated instruments. Results: Demographic data of the 60 patients included in the study showed a median age of 62 years (range: 42-84 years) and a male-to-female ratio of 1:1.3. The majority of patients (70%) had an American Society of Anesthesiologists (ASA) physical status of 2 or 3, indicating mild to moderate systemic disease. The median body mass index (BMI) was 25 kg/m² (range: 18-35 kg/m²), with 30% of patients classified as overweight (BMI 25-29.9 kg/m²) and 13% classified as obese (BMI ≥ 30 kg/m²). Practical implication: This article will helps to support the safety and efficacy of early closure of temporary ileostomy in patients with rectal cancer. Conclusion: In conclusion, this study provides evidence to support the safety and efficacy of early closure of temporary ileostomy in patients with rectal cancer. The results indicate that there were no significant differences in the incidence of complications between early closure and traditional closure groups. Keywords: Temporary, Ileostomy, Patients, Rectal, Cancer

P344 Diverting ileostomy in Inflammatory Bowel Disease's surgery: the real clinical cost analysis

Abstract Background A loop ileostomy does not prevent an anastomotic leak and it is not risk-free, but it can decrease the clinical impact of dehiscence. Inflammatory bowel disease condition is more complex than other benign situations candidated to colorectal surgery. The aim of our study was to assess the risk of complications related to the stoma presence and to identificate variables related with complications in a series of IBD’s patients undergoing various colorectal surgeries along with primary diverting stoma. Methods We conducted a retrospective study of patients who underwent sphincter-preserving elective surgery for IBD between January 2014 to December 2020 at IRCCS Sacro Cuore Don Calabria Hospital. Data were collected regarding baseline demographics, operative techniques and complications. Ileostomy-related complications were separated into three categories: complications related to stoma creation at the time of index surgery within 30 days; complications of having an ileostomy; complications of ileostomy closure. Results Fifty-six diverting loop ileostomies were performed and included in our study (table 1). Seventeen patients (30%) at index procedures had the following complications: 5 had anastomotic leak or pelvic abscess (8.9%), 3 had bowel obstruction (5.4%) and 7 (12.5%) bleeding requiring transfusion. Two patients had complications related to ileostomy creation: 1 had prolapse (1.8%) and 1 rotation with obstruction (1.8%). Seven patients (12.5%) required reoperation. Seven patients (12.5%) were readmitted within 30 days after index surgery for dehydratation. Twenty-four patients (42.1%) suffered during the same time from ileostomy management’s problems. Eighteen patients (32.1%) at stoma closure had the following complications: 6 had anastomotic leak or pelvic abscess (10.7%), 7 had SSI (12.5%), 5 had bowel obstruction (8.9%) and 2 bleeding requiring transfusions (3.6%). Nine patients (16%) required reoperation. At univariate analysis complications of ileostomy status are more frequent in male (p=0.01) and in patients who had ileostomy creation complications (p=0.04). Ileostomy closure complications are more common in male patients (p=0.005). Complications at the time of ileostomy creation were found at multivariate analysis statistically related to complications during ileostomy maintenance. Conclusion Ileostomy alone cannot mitigate the overall high rate of complications expected in IBD’s patients, also in consideration of potential problems stoma it-self related. Even if our study is retrospective and presents a small court, when resection is necessary despite patient's conditions we propose to resect without anastomosis at the time of index procedure and restore the bowel continuity only after patient's status optimization.

P420 Safety &amp; feasibility of targeted mesenteric approaches to ileocolic resection and anastomosis in Crohn’s Disease

Abstract Background More than 80% of patients with Crohn's disease (CD) require surgical intervention during their lifetime. High rates of disease recurrence often necessitate repeat surgery. Recurrence is typically observed at or immediately proximal to the anastomosis, raising the question of whether surgical techniques have the potential to decrease recurrence rates. In addition, the mesentery has recently been implicated in the pathophysiology of CD, and several techniques have been developed to reduce its influence on recurrence. We aimed to describe the short-term safety and feasibility of these approaches. Methods This is a comparative retrospective single-center cohort study of consecutive CD patients undergoing primary or redo ileocolic resection with mesenteric excision and exclusion (MEE), extended mesenteric excision (EME) only, or Kono-S anastomosis (KSA) only from 2015-2022. Patients undergoing both EME plus KSA were considered to have MEE. Patients' characteristics, perioperative data, and short-to-midterm outcomes were collected. Univariate analysis was performed. Results A total of 186 patients underwent MEE (n=46), EME (n=66), or KSA (n=74). All three groups had comparable (p&amp;gt;0.05) risk factors in terms of mean age at diagnosis and surgery (25.4 and 37.5 years old, respectively), preoperative biologics (63.4%) and corticosteroids (22.6%), smoking, and associated perianal disease. However, the MEE group had more penetrating disease compared to the other groups (MEE 50.0% vs. EME 34.8% vs. KSA 20.4%; p&amp;lt;0.01). Overall there were no differences (p&amp;gt;0.05) in rates of emergency surgery (4.8%), ileostomy creation (14%), and laparoscopy (64.5%) Table 1. Estimated blood loss and length of stay were also comparable between groups (p&amp;gt;0.05). Operative time in the MEE group was longer (median: 187, range: 67-360 minutes) compared to the other two groups (KSA: 170 (56-487); EME: 152 (63-436, p&amp;lt;0.01). Post-operatively, the groups had similar lengths of stay (4 days), rates of readmissions (9.1%) and major postoperative complications (6.5%). After a median overall follow-up of 8 months (0-86), endoscopic (18.8%) and surgical recurrences (1.1%) did not differ between groups (p&amp;gt;0.05) Table 2. Conclusion Targeting the mesentery with novel surgical approaches to ileocolic Crohn's disease was observed to be safe and feasible on short-term follow-up. Long-term follow-up is needed to assess the impact of these techniques on post-operative anastomotic disease recurrence.

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Frailty assessment can predict textbook outcomes in senior adults after minimally invasive colorectal cancer surgery

AimColorectal cancer (CRC) surgery can be associated with suboptimal outcomes in older patients. The aim was to identify the correlation between frailty and surgical variables with the achievement of Textbook Outcome (TO), a composite measure of the ideal postoperative course, by older patients with CRC. MethodAll consecutive patients ≥70years who underwent elective CRC-surgery between January 2017 and November 2021 were analyzed from a prospective database. To obtain a TO, all the following must be achieved: 90-day survival, Clavien-Dindo (CD) < 3, no reintervention, no readmission, no discharge to rehabilitation facility, no changes in the living situation and length of stay (LOS) ≤5days/≤14days for colon and rectal surgery respectively. Frailty and surgical variables were related to the achievement of TO. ResultsFour-hundred-twenty-one consecutive patients had surgery (97.7% minimally invasive), 24.9% for rectal cancer, median age 80 years (range 70–92), median LOS of 4 days (range 1–96). Overall, 288/421 patients (68.4%) achieved a TO. CD 3–4 complications rate was 6.4%, 90-day mortality rate was 2.9%.At univariate analysis, frailty and surgical variables (ileostomy creation, p = 0.045) were related to. However, multivariate analysis showed that only frailty measures such as flemish Triage Risk Screening Tool≥2 (OR 1.97, 95%CI: 1.23–3.16; p = 0.005); Charlson Index>6 (OR 1.61, 95%CI: 1.03–2.51; p = 0.036) or Timed-Up-and-Go>20 s (OR 2.06, 95%CI: 1.01–4.19; p = 0.048) independently predicted an increased risk of not achieving a TO. ConclusionThe association between frailty and comprehensive surgical outcomes offers objective data for guiding family counseling, managing expectations and discussing the possible loss of independence with patients and caregivers.

S2228 A Segmental Colitis Associated With Diverticulosis versus Inflammatory Bowel Disease: A Diagnostic Dilemma Despite Total Proctocolectomy

Introduction: Patients with diverticular disease can develop segmental colitis associated with diverticulosis (SCAD). It can range from mild inflammatory changes to chronic active inflammation that mimics inflammatory bowel disease (IBD). SCAD usually presents a more benign outcome, with a low rate of complications. Here, we present a complex case in which a diagnosis was still unclear till the final stage of the management. Case Description/Methods: A 60-year-old female was admitted for hypovolemic shock. She was resuscitated, and the GI was consulted for the management of IBD. She was recently diagnosed with ulcerative colitis about 2 months ago. She has abdominal pain in the right lower side, and examination revealed mild abdominal tenderness. She was already on prednisone 60 mg daily for 2 weeks and infliximab maintenance dose (completed 2 doses) and mesalamine from the last admission. She has had 3 colonoscopies in the past. The first colonoscopy 6 months ago showed a normal rectum, unable to traverse the sigmoid colon due to stricture and diverticulosis. The biopsy showed a normal rectum and a very focal area of cryptitis. The last colonoscopy 2 months ago showed a severely inflamed ulcerated mucosa in the sigmoid colon (Figure, left). Colon biopsy showed mild acute cryptitis and distorted and branched crypts. No crypt abscesses or granulomas were seen. On this admission, CT enterography showed pancolitis. Serology for Crohn's disease (CD) was negative, including ASCA IgA and ASCA IgG. The strong differential diagnosis was SCAD vs.IBD. The decision was to continue with the medical treatment (i.e., completion of steroid course, infliximab, and follow the response) and was discharged. The patient again presented with a shock one month after this admission. Unfortunately, she had colonic perforation and had total proctocolectomy with ileostomy creation. Pathology of surgical specimens revealed mild chronic active colitis and severe diverticular disease with associated transmural inflammation (Figure, right). Ileum excision showed no significant pathologic changes unlikely to be CD. The patient was doing well till the last follow-up. Discussion: This is a unique case where the diagnosis of SCAD vs. IBD was unclear regardless of the availability of serology, endoscopic, surgery, and histopathological examinations. In this complex case, we suggest a multidisciplinary team approach to improve patient-centered care.Figure 1.: Left: colonoscopy showing inflamed ulcerated mucosa in the sigmoid colon. Right: Pathology shows mild chronic active colitis and severe diverticular disease.

S2877 Weight Loss Utilizing Endoscopic Sleeve Gastroplasty (ESG), Benefit for Ostomy Reversal in Obese Patient With Ulcerative Colitis (UC)

Introduction: Over the last thirty years, the prevalence of both obesity and inflammatory bowel disease has increased globally. Surgical management in ulcerative colitis (UC) is reserved for medically refractory UC, most typically in a three-stage pattern: initial removal of the colon and creation of an end ileostomy, followed by removal of the rectum and construction of ileal pouch anal anastomosis and diverting ileostomy, followed by reversal of the ileostomy. Proctectomy is particularly difficult in obese patients due to increased visceral adiposity, thickened abdominal wall, adhesions, and reduced mobility secondary to bulky mesentery. Patients with Body Mass Index (BMI) greater than 30 are found to have greater risk for complications in comparison to normal BMI counterparts. Endoscopic sleeve gastroplasty (ESG) is a newer, minimally invasive procedure for the treatment of obesity which endoscopically reduces gastric volume through an endoscopic suturing system. We present a novel case where ESG was used as a tool for weight loss in a patient who encountered delayed ostomy reversal due to morbid obesity. Case Description/Methods: A 39-year-old man with medical history significant for morbid obesity and medically refractory UC became a candidate for proctocolectomy with an ileal pouch anal anastomosis. However, given the patient’s obesity, there was concern of the J-pouch-end ileostomy being unable to reach the patient’s pelvis. Patient underwent a da Vinci assisted laparoscopic subtotal colectomy with end ileostomy in order to preserve the rectum for a potential J-pouch after his weight loss. Post subtotal colectomy and end ileostomy, patient was referred for endoscopic sleeve gastroplasty due to additional weight gain post-op due to symptom mediated inactivity, thereby further delaying his ostomy reversal and placement of ileoanal J-pouch. Patient underwent endoscopic sleeve gastrectomy (ESG) with effective weight loss, anatomically allowing successful ostomy reversal, completion proctectomy, and J-tube construction. (Figure) Discussion: Future studies are required to determine whether ESG weight loss should be an integral initial step of medical management of IBD in obese patients to inevitably avoid surgical intervention. In summary, ESG may be a pivotal modality as a tool for weight loss in patients with UC and morbid obesity who may encounter delayed proctectomy and ostomy reversal, overall helping contribute to decreased surgical morbidity, complications, and faster improvement in overall quality of life.Figure 1.: Clinical management and BMI over patient's clinical course.

Decreasing Readmissions After Ileostomy Creation Through a Perioperative Quality Improvement Program.

Readmission after ileostomy creation in patients undergoing colorectal surgery creates a significant burden on health care cost and patient quality of care, with a 30-day readmission rate of 40%. This study aimed to evaluate the implementation of our perioperative quality improvement program, Decreasing Readmissions After Ileostomy Creation. Perioperative interventions were administered to patients who underwent ileostomy creation. A single tertiary care academic center. Eighty patients participated in this program from February 2020 to January 2021. The primary outcomes measured were 30-day readmission rates and causes of readmission, which were compared to a historical national database. Descriptive statistics were used to evaluate the effectiveness of this quality improvement program. Eighty patients were enrolled in this prospective quality improvement program. The mean age was 52 (±15.06) years. The most common indication for patients undergoing creation of an ileostomy was colorectal cancer (40%; n = 32). The overall 30-day readmission rate was 8.75% (n = 7) throughout the study period, which was significantly lower than historical cohort data (20.10%; p = 0.01). Among the 7 readmitted patients, 3 (3.75%) were readmitted due to dehydration. The most significant associated risk factor for all-cause readmission was urgent/emergent operative status, which was associated with an increased risk of readmission ( p = 0.01). The 3 readmitted patients with dehydration had a mean Dehydration Readmission After Ileostomy Prediction risk score of 11.71 points, compared to 9.59 points in nondehydrated patients, who did not require readmission ( p = 0.38). This study is limited by its small sample size (N = 80). The Decreasing Readmissions After Ileostomy Creation program has been successful in reducing both the all-cause readmission rate and readmission due to dehydration both within an academic tertiary care referral center and in comparison with historical readmission rates. See Video Abstract at http://links.lww.com/DCR/B894 . ANTECEDENTES:La readmisión después de la creación de una ileostomía en pacientes de cirugía colorrectal crea una carga significativa sobre el costo de la atención médica y la calidad de la atención del paciente, con una tasa de readmisión a los 30 días que llega al 40%.OBJETIVO:Este estudio tiene como objetivo evaluar la implementación de nuestro programa de mejora de la calidad perioperatoria que disminuyen los reingresos después de la creación de ileostomía.DISEÑO:Se administraron intervenciones perioperatorias a pacientes que se sometieron a la creación de una ileostomía.AJUSTE:Se trataba de un único centro académico de atención terciaria.PACIENTES:Participaron 80 pacientes en este programa desde febrero de 2020 hasta enero de 2021.PRINCIPALES MEDIDAS DE RESULTADO:Los principales resultados medidos fueron las tasas de reingreso a los 30 días y las causas de reingreso, que se compararon con una base de datos histórica nacional. Se utilizaron estadísticas descriptivas para evaluar la eficacia de este programa de mejora de la calidad.RESULTADOS:Ochenta pacientes se inscribieron en este programa prospectivo de mejora de la calidad. La edad media fue de 52 (± 15,06) años. La indicación más común para los pacientes que se sometieron a la creación de una ileostomía fue el cáncer colorrectal (40%, n = 32). La tasa general de reingreso a los 30 días fue del 8,75% (n = 7) durante todo el período de estudio, lo que fue significativamente más bajo que los datos históricos de la cohorte (20,10%, p = 0,01). Entre los 7 pacientes readmitidos, tres (3,75%) fueron readmitidos por deshidratación. El factor de riesgo asociado más significativo para la readmisión por todas las causas fue el estado operatorio urgente / emergencia, que se asoció con un mayor riesgo de readmisión (p = 0,01). Los tres pacientes readmitidos con deshidratación tuvieron una puntuación de riesgo promedio de readmisión por deshidratación después de la predicción de ileostomía de 11,71 puntos, en comparación con los pacientes no deshidratados, que no requirieron readmisión (media, 9,59 puntos, p = 0,38).LIMITACIONES:Este estudio está limitado por su pequeño tamaño de muestra (n = 80).CONCLUSIONES:El programa de disminución de las readmisiones después de la creación de una ileostomía ha logrado reducir tanto la tasa de readmisión por todas las causas como la readmisión por deshidratación, tanto dentro de un centro académico de referencia de atención terciaria como en comparación con las tasas históricas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B894 . (Traducción-Dr Yolanda Colorado ).

Ileostomy closure

Introduction: Faecal diversion is an effective procedure to protect bowel anastomosis at high risk for leak. Loop ileostomy is more or less acceptable method for faecal diversion. Some concerns still exist regarding the risk for a significant morbidity and complications associated to ileostomy creation itself and moreover to its closure. Surgical expertise and closure techniques are considered potential factors influencing mortality. Aim of the study is to present a single institutional experience with ileostomy closures, in a high-volume training hospital, where ileostomy reversal is mainly performed by young surgeons. Methods: A retrospective study was done to evaluate data of patients who underwent loop ileostomy and ileostomy closure between June 2017 to June 2021 at Dhiraj Hospital Sumandeep Vidyapeeth , Pipariya , vadodara. Ileostomy closure was always done in hand-sewn fashion, performing either a direct closure (DC) or a resection plus end-to-end anastomosis (EEA). Postoperative morbidity was graded according to Clavien-Dindo classification. Outcomes after both methods were compared by Fisher’s exact test and Wilcoxon rank-sum test. Results: Hundred and four patients were included. Ileostomy reversal was performed by EEA in 86 patients (82.69%) and by DC in 18 patients (17.30%). Surgery was performed with a peristomal access in 93 cases (89.42%).

Pouch volvulus-why adhesions are not always the enemy.

Minimally invasive approaches to proctocolectomy with ileal pouch anal anastomosis have become the standard of care with one benefit being the reduced risk of adhesion-related complications. However, a lack of pouch adherence to the pelvis can lead to increased mobility as well as volvulization, placing pouch viability at risk. We aimed to describe our institutional experience with pouch volvulus. Patients who presented with pouch volvulus from 1983 to 2020 were identified through a search of our pelvic pouch registry and enterprise-wide electronic medical record. Pouch volvulus was defined as a reducible rotation of the J-pouch on its mesenteric axis with evidence of a properly oriented ileo-anal anastomosis. Patients with 'twisted pouches' were excluded. In total, 5760 patients underwent ileal pouch anal anastomosis from 1983 to 2020. Six patients (five women) were identified with a diagnosis of 'pouch volvulus' consistent with our definition. The six pouches were constructed utilizing laparoscopic techniques and the mean time from construction to volvulus was 2.36 years. All patients underwent urgent surgery, with a paucity of adhesions noted in five. Reduction and pouch pexy was performed in three and pouch excision in three, with immediate pouch reconstruction in two and end ileostomy creation in one. At a median follow-up of 9months, pouch survival was 50%. Pelvic pouches constructed using minimally invasive techniques may be at risk of volvulus due to reduced adhesion development. A high index of suspicion is warranted in pouch patients with obstructive symptomatology. CT imaging may be diagnostic, and prompt surgical intervention may facilitate pouch salvage.

New Use of an Absorbable Adhesion Barrier (INTERCEED) for Temporary Diverting Ileostomy in Minimally Invasive Rectal Surgery

Abstract Objectives Sometimes, severe adhesion occurs between the rectus abdominis muscle and the ileal intestinal limbs after temporary diverting ileostomy. This can make ileostomy reversal difficult. The aim of the present study is to assess whether absorbable adhesion barrier made of oxidized regenerated cellulose (INTERCEED) could contribute to improved surgical outcomes in stoma reversal. Methods This was a single-institutional retrospective study. A total of 36 consecutive patients who underwent ileostomy reversal by a single surgeon were retrospectively reviewed. INTERCEED was inserted between the ileal limbs and the rectus abdominis muscle at the time of ileostomy creation in 12 patients. Surgical outcomes of the ileostomy reversal were compared between patients treated with and without INTERCEED. Results The degree of adhesion formation between the ileal limbs and the rectus abdominis muscles, operating time, and estimated blood loss were significantly reduced in patients treated with INTERCEED compared with those treated by the conventional approach. None of the patients in the INTERCEED group had postoperative complications after the initial surgery and ileostomy reversal. Conclusions INTERCEED is suitable for insertion between the ileal limbs and the rectus abdominis muscles because of its softness and flexibility. The use of INTERCEED for diverting ileostomy contributes to reduced adhesion formation, operative time, and blood loss in patients, and further research is needed to confirm our results.

Association Between Advanced T Stage and Thick Rectus Abdominis Muscle and Outlet Obstruction and High-Output Stoma After Ileostomy in Patients With Rectal Cancer

Objective This study aimed to identify factors associated with outlet obstruction and high-output stoma (HOS) after ileostomy creation. Summary of background data Ileostomy creation is effective in preventing leakage among patients undergoing low anterior resection for rectal cancer. However, major complications such as outlet obstruction and HOS can occur after surgery. Moreover, these complications cannot be prevented. Methods This retrospective study included 34 patients with rectal cancer who underwent low anterior resection and ileostomy creation at Okayama University Hospital from January 2015 to December 2018. Then, the risk factors associated with outlet obstruction and HOS were analyzed. Results Of 34 patients, 7 (21%) experienced outlet obstruction. In a multivariate logistic regression analysis, advanced T stage (P = 0.10), ileostomy with a short horizontal diameter (P = 0.01), and thick rectus abdominis (RA) muscle (P = 0.0005) were considered independent risk factors for outlet obstruction. There was a significant correlation between outlet obstruction and HOS (P = 0.03). Meanwhile, the independent risk factors of HOS were advanced T stage (P = 0.03) and thick RA muscle (P = 0.04). Conclusions Thick RA muscle and advanced T stage were the common risk factors of outlet obstruction and HOS. Therefore, in high-risk patients, these complications can be prevented by choosing an appropriate ileostomy location according to RA muscle thickness and by preventing tubing into the ileostomy.

Methicillin-resistant Staphylococcus aureus enterocolitis in a 16-month-old boy: a case report

BackgroundMethicillin-resistant Staphylococcus aureus enterocolitis is a rare disease that typically affects immunocompromised adults. Most cases of pediatric enterocolitis are caused by Gram-negative bacteria, Gram-positive Clostridiodes difficile, or viruses. This is the first published case report of a toddler with methicillin-resistant Staphylococcus aureus enterocolitis.Case presentationA 16-month-old non-Hispanic White boy with no past medical or psychosocial history initially presented to the emergency room with abdominal pain and emesis. Past family history was pertinent only for his father having a history of constipation. He was diagnosed with intussusception and underwent successful contrast reduction on hospital day 0. The following day, the patient had recurrent symptoms and a repeat contrast enema showed no evidence of recurrent intussusception. A computed tomography scan was obtained, which was concerning for possible recurrence with compromised bowel. He was taken to the operating room for operative reduction and underwent an ileocecetomy with primary handsewn end-to-end anastomosis. His postoperative course was complicated by an anastomotic leak on hospital day 6 necessitating reoperation and creation of an end ileostomy with mucous fistula. He received intravenous metronidazole, ceftriaxone, and ceftazidime antibiotics during his hospital course. On postoperative day 12, the patient developed a sudden increase in ileostomy output, and stool cultures were obtained. His symptoms persisted despite diet modifications, stopping antibiotics, and initiating loperamide. Three days later, stool cultures resulted negative for Escherichia coli, Salmonella, Shigella, Campylobacter species, and Clostridiodes difficile but were positive for methicillin-resistant Staphylococcus aureus. The patient was started on a 10-day course of oral vancomycin and discharged home in good condition 4 days later. After 12 weeks, the patient underwent reversal of the ostomy and is doing well at the 1 month postoperative follow-up, now 5 months from his initial surgery.ConclusionsTo our knowledge, this is the first published report of a toddler being diagnosed with methicillin-resistant Staphylococcus aureus enterocolitis. Because methicillin-resistant Staphylococcus aureus enterocolitis is rare and has overlapping symptoms with more common gastrointestinal pathologies, it is often misdiagnosed. When a patient presents with diarrhea or high ostomy output along with fecal cultures negative for Clostridiodes difficile and other common pathogenic agents, methicillin-resistant Staphylococcus aureus should be considered.

Robotic pyelolithotomy in a solitary pelvic kidney complicated with fulminant Clostridium difficile: a case report

BackgroundRobotic-assisted surgeries have gradually become the standard of care for many procedures, especially in the field of urology. Despite the widespread use of robotic assistance in surgeries, data on its postoperative complications are extremely limited. We detail a rare presentation of fulminant Clostridium difficile colitis requiring surgical intervention in a patient with a solitary ectopic pelvic kidney who underwent a robotic-assisted pyelolithotomy. Highlights of the most recent management recommendations for C. difficile infection are also presented.Case presentationA 26-year-old Caucasian woman who underwent a robot-assisted pyelolithotomy of a pelvic kidney developed tachycardia, leukocytosis, and severe diarrhea 2 days following surgery. Because of her long history of antibiotic use, her severe symptoms were concerning for C. difficile colitis. This was confirmed by a C. difficile toxin test and a computed tomography scan. She was given recommended antibiotics, but her condition progressively deteriorated. The patient developed fulminant colitis and toxic megacolon, for which she underwent an exploratory laparotomy with subtotal abdominal colectomy and ileostomy creation on the twelfth day of her hospitalization. She fully recovered and was discharged 3 weeks after her subtotal colectomy.ConclusionAlthough robotic surgeries have been shown to have several advantages, risk of postsurgical complications remains. We present a rare case of fulminant C. difficile colitis that complicated a robotic-assisted pyelolithotomy. Active prevention, early detection, and optimization of management are essential to preventing unfavorable outcomes.