Ileostomy Reversal Research Articles

Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care in Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial

BackgroundPractices such as prolonged preoperative fasting, bowel preparation, delayed ambulation and resumption of orals result in morbidity in 15-20% of stoma reversal cases which can be improved by Enhanced Recovery After Surgery (ERAS) pathways. AimTo evaluate the safety, feasibility and efficacy of ERAS pathway in patients undergoing elective loop ileostomy or colostomy reversal surgery MethodsThis was an open-labeled, superiority randomized controlled trial in which patients undergoing loop ileostomy or colostomy reversal were randomized to standard or ERAS care. Patients with ASA class ≥3, needing laparotomy for stoma reversal, cardiac, renal and neurological illnesses were excluded. Components of ERAS protocol included pre-operative carbohydrate loading, avoidance of mechanical bowel preparation, goal directed fluid therapy, avoidance of long-acting opioid anesthetics or analgesics, avoidance of drains, urinary catheter or nasogastric tube, early mobilization and early enteral feeding. The primary outcome was length of stay (LOS) while the secondary outcomes were postoperative recovery and morbidity parameters. ResultsForty patients each were randomized to standard care and ERAS. Demographic and laboratory parameters between the two groups were comparable. ERAS group patients had significantly reduced LOS (5.3±0.3 vs 7 ± 2.6; mean difference: 1.73 ± 0.98; p=0.0008). Functional recovery was earlier in the ERAS group compared to the standard care group, such as early resolution of ileus (median-2 days; p<0.001), time to first stool (median-3 days; p=0.0002), time to the resumption of liquid diet (median-3 days; p<0.001) and solid diet (median-4 days; p<0.001). Surgical site infections (SSI) were significantly lesser in ERAS group (12.5% vs 32.5%; p=0.03) while postoperative nausea/vomiting (p=0.08), pulmonary complications (p=0.17) and urinary tract infections (p=0.56) were comparable in both groups. ConclusionERAS pathways are feasible, safe and significantly reduces LOS in patients undergoing elective loop ileostomy or colostomy reversal surgery.

Laparoscopic vs. open loop ileostomy reversal: a meta-analysis of randomized and non-randomized studies.

The present meta-analysis compares laparoscopic loop ileostomy reversal (LLIR) with open loop ileostomy reversal (OLIR) to evaluate the advantages of the laparoscopic technique compared to the traditional open technique in ileostomy reversal. Primary endpoints were hospital stay and overall complications. Secondary endpoints were operative time, EBL, readmission, medical complications, surgical complications, reoperation, wound infection, anastomotic leak, intestinal obstruction, and cost of the procedures. The included studies were also divided based on the type of anastomotic approach: extracorporeal laparoscopic loop ileostomy reversal (ELLIR) and intracorporeal laparoscopic loop ileostomy reversal (ILLIR). In the analysis, 4 studies were included. Three hundred fifty-four patients were enrolled. As primary outcomes, a significant difference was found in hospital stay between the LLIR and OLIR groups (MD = -0.67, 95% CI -1.16 to -0.19, P = 0.007). The overall complications outcome resulted in favor of the LLIR group (RR = 0.64, 95% CI 0.43-0.95, P = 0.03). As secondary outcomes, the operative time was in favor of the OLIR group (MD = 19.18, 95% CI 10.20-28.16, P < 0.001). Surgical complications were lower in the LLIR group than in the OLIR group. No other differences between the secondary endpoints were found.Subgroup analysis showed a significant difference in hospital stay between the ILLIR and OLIR groups (MD = -0.92, 95% CI -1.55 to -0.30, P = 0.004). The overall complications outcome significantly favored the ILLIR group (RR = 0.38, 95% CI 0.15-0.96, P = 0.04). Our meta-analysis shows an advantage in terms of shorter post-operative hospitalization and reduction of complications of LLIR compared to OLIR. The sub-group analysis shows that performing an extracorporeal anastomosis exposes the same risks of the open technique.

452 Impact of COVID-19 on the closure of temporary ileostomies following colorectal surgery

Abstract Aims Temporary defunctioning ileostomies are created in emergency general surgery and elective colorectal surgery with the aim of reversal in the near future. Ileostomies come with associated morbidity. There is a nationwide delay to closure of ileostomies in the UK for a variety of reasons and Covid-19 has had a further significant impact on surgical waiting lists. We aim to assess the length of delay to reversal of ileostomy and whether there is greater morbidity associated with delayed reversal. Methods All reversal of ileostomy patients referred to the National Waiting Times Centre over a one year period between November 2021 and November 2022 we included. Demographics and details of index surgery were collected, as well as reversal peri-operative details, complications and length of stay. Results Twenty-three patients underwent reversal of ileostomy. Mean age 60.4 years. Mean number of days from index procedure to reversal was 648 days (range 99 – 2136). Reasons for delay were; adjuvant chemotherapy (n=6), waiting list/Covid-19 delays (n=13), patient preference/no reason documented (n=4). There were 7 end ileostomies who underwent laparotomy and 16 loop ileostomies reversed. Mean length of stay was 7.04 days (range 2-19 days). 7 patients had ileus following reversal, 3 had an anastomotic leak requiring return to theatre, 1 returned to theatre for bleeding and 1 developed Clostridium difficile. Conclusion Half of this cohort of patients who were referred as ‘long-waiters’ to the National Waiting Times Hospital developed a complication following reversal of ileostomy. This cohort of patients waited on average 377 days longer than pre-Covid-19 waits (Close-IT).

Risk factors for surgical site infections and trends in skin closure technique after diverting loop ileostomy reversal: A multi-institutional analysis

BackgroundSurgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique. MethodsA retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary ​+ ​drain, or purse-string closure. The primary outcome was SSI at the former DLI site. ResultsA SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure ​+ ​drain, and 2.7% for purse-string closure (p ​= ​0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p ​< ​0.0001). ConclusionsThis study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time.

Standardized digital solution with surgical procedure manager (SPM®)-an opportunity for maximizing patient safety and efficiency in ileostomy reversal?

Standardization and digitalization are getting more and more essential in surgery. Surgical procedure manager (SPM®) is a freestanding computer serving as a digital supporter in the operating room. SPM® navigates step-by-step through surgery by providing a checklist for each individual step. This was a single center, retrospective study at the Department for General and Visceral Surgery at Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin. Patients who underwent ileostomy reversal without SPM® in the period of January 2017 until December 2017 were compared to patients who were operated with SPM® in the period of June 2018 until July 2020. Explorative analysis and multiple logistic regression were performed. Overall, 214 patients underwent ileostomy reversal: 95 patients without SPM® vs. 119 patients with SPM®. Ileostomy reversal was performed by head of department/attendings in 34.1%, by fellows in 28.5% and by residents in 37.4%; p = 0.91. Postoperative intraabdominal abscess emerged more often in patients without SPM®: ten (10.5%) patients vs. four (3.4%) patients; p = 0.035. Multiple logistic regression showed a risk reduction for intraabdominal abscess {Odds ratio (OR) 0.19 [95% confidence interval (CI) 0.05-0.71]; p = 0.014} and for bowel perforation [OR 0.09 (95% CI 0.01-0.93); p = 0.043] in the group with use of SPM® in ileostomy reversal. SPM® may reduce postoperative complications in ileostomy reversal such as intraabdominal abscess and bowel perforation. SPM® may contribute to patient safety.

Stapled side-to-side anastomosis for ileostomy reversal: a simple and reproducible technique with video.

Protective diverting ileostomy is commonly performed in rectal surgery to avoid septic complications of low colorectal anastomosis. Ileostomy closure usually occurs three months after the surgery and can be realized in two ways: hand sewn or stapled. Existing randomized studies comparing the two techniques showed no difference in terms of complications. Our study describes the standard technique of ileostomy reversal as done in Bordeaux University Hospital in 10 steps individually illustrated and with an explicative video. We also collected data concerning the 50 last patients who underwent an ileostomy reversal in our center from June 2021 to June 2022. Mean duration of the ileostomy closure was 46.8 minutes, and the mean total hospital stay was 4.66 days. Five of 50 (10%) patients had a post-operative bowel obstruction, 2/50 (4%) patients had a post-operative bleeding, 1/50 (2%) patient had a wound infection, and there was no anastomotic leakage observed. Stapled side-to-side anastomosis is a rapid, simple, and reproducible technique for ileostomy reversal. There are no more complications compared to hand-sewn anastomosis. It engenders an additional cost compensated by the gain in operating time which altogether saves money.

The utilization of an absorbable mesh after ostomy reversal does not decrease incisional hernia rates

BackgroundPostoperative ostomy reversal hernias are common and can create strain on the healthcare system.There is little literature evaluating the utilization of absorbable mesh following ostomy reversal. The effect on subsequent hernia rates at our institution has not been evaluated. We examine if the addition of absorbable mesh decreases the postoperative hernia rate in our patient population. MethodsWe performed a retrospective review of all ileostomy and colostomy reversals. Patients were divided into two groups based on whether an absorbable mesh was used at ostomy closure or not. ResultsHernia recurrence rates were lower in the group that had mesh reinforcement (8.96%) vs the group that did not receive a mesh (14.8%) though this was not statistically significant (p = 0.233). ConclusionProphylactic use of an absorbable biosynthetic mesh did not alter the rate of incisional hernia rates following ostomy reversal in our cohort of patients.

P-021 DELAYED ENTEROCUTANEOUS FISTULA AND ENCAPSULATING MESH INFECTION AFTER COMPOSITE MESH REPAIR OF AN ABDOMINAL MIDLINE INCISIONAL HERNIA - COMPLICATIONS 12 YEARS LATER

Abstract Aim Mesh infection is a well-recognised complication of incisional hernia repair, however, is usually encountered within months after mesh insertion. Only a few cases have been published where an enterocutaneous fistula has presented many years after mesh repair of an incisional hernia. Here we describe a complicated case of enterocutaneous fistula and mesh infection 12 years after the primary surgery. Material &amp; Methods A 44 year-old gentleman presented acutely with a worsening 4 month history of an umbilical discharging sinus with associated fever, intermittent abdominal pain and nausea. There was also an associated hard lump and skin erythema. He previously had a laparotomy, small bowel resection for tuberculosis and ileostomy formation 13 years ago, followed by ileostomy reversal and intraperitoneal incisional hernia repair with composite mesh 1 year later. Results Cross-sectional imaging showed a large volume of gas within the mesh with underlying small bowel and collection within anterior abdominal wall, suggesting an enterocutaneous fistula. The patient initially underwent ultrasound guided aspiration of the collection followed by nutritional optimisation prior to another laparotomy, mesh excision and small bowel resection. The mesh was found to have a thick biofilm initially thought to be encased in mycobacterium but further testing was negative for this. Conclusions Delayed mesh infection over more than a decade after mesh insertion is rare. It is likely that pre-existing risk factors such as previous TB and small bowel resection with adhesions increased the risk of enterocutaneous fistulation.

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.

ILEOSTIM trial: a study protocol to evaluate the effectiveness of efferent loop stimulation before ileostomy reversal

PurposeA protective loop ileostomy is the most useful method to reduce sequelae in the event of an anastomotic leakage (AL) after rectal cancer surgery. However, it requires an additional stoma reversal surgery with its own potential complications. Postoperative ileus (POI) remains the most common complication after ileostomy reversal, which leads to an increase in morbidity, length of hospital stay (LOS) and overall healthcare costs. Several retrospective studies carried out in this field have concluded that there are insufficient evidence-based recommendations about the routine application of preoperative bowel stimulation in clinical practice. Here we discuss whether stimulation of the efferent limb before ileostomy reversal might reduce POI and improve postoperative outcomes.MethodsThis is a multicentre randomised controlled trial to determine whether mechanical stimulation of the efferent limb during the 2 weeks before the ileostomy reversal would help to reduce the development of POI after surgery. This study was registered on Clinicaltrials.gov (NCT05302557). Stimulation will consist of infusing a solution of 500 ml of saline chloride solution mixed with a thickening agent (Resource©, Nestlé Health Science; 6.4 g sachet) into the distal limb of the ileostomy loop. This will be performed within the 2 weeks before ileostomy reversal, in an outpatient clinic under the supervision of a trained stoma nurse.ConclusionThe results of this study could provide some insights into the preoperative management of these patients.

Cost-Effectiveness Analysis of REBYOTA™ (Fecal Microbiota, Live-jslm [FMBL]) Versus Standard of Care for the Prevention of Recurrent Clostridioides difficile Infection in the USA.

Recurrent Clostridioides difficile infection (rCDI) is common and associated with considerable clinical and economic consequences. REBYOTA™ (fecal microbiota, live-jslm [FMBL]) is a microbiota-based live biotherapeutic approved for the prevention of rCDI following antibiotic treatment for rCDI. We sought to evaluate cost-effectiveness of FMBL compared to standard of care (SOC) from a US third-party payer perspective among patients with one or more (≥ 1) recurrences. A Markov model with a lifetime time horizon was developed. The model population included adult patients who had ≥ 1 recurrence after a primary CDI episode and had completed ≥ 1 round of antibiotics, or had ≥ 2 severe CDI episodes resulting in hospitalization within the last year. The model consisted of six health states with an 8-week model cycle: rCDI, absence of CDI after recurrence, colectomy, ileostomy, ileostomy reversal, and death. Drug costs and rCDI-related medical costs were estimated in 2022 US dollars and discounted at 3% annually. Deterministic sensitivity analyses were performed. Compared to SOC, FMBL at $9000/course resulted in an incremental cost-effectiveness ratio (ICER) of $18,727 per quality-adjusted life year (QALY) gained. The incremental cost was $5336 (FMBL $79,236, SOC $73,900) and the incremental effectiveness was 0.285QALYs (FMBL 10.346, SOC 10.061). The cumulative drug acquisition and administration costs for the FMBL and SOC arms were $24,245 and $16,876, while rCDI-related medical costs for FMBL and SOC were $54,991 and $57,024, respectively. The ICER in the subgroup of patients at first recurrence was $13,727 per QALY gained. FMBL remained cost-effective across all sensitivity analyses. FMBL was found to be cost-effective compared to SOC for the prevention of rCDI with more benefits among patients at first recurrence, with an ICER far below the payer ICER threshold of $100,000. Patients treated with FMBL experienced higher total QALYs and reduced healthcare resource utilization, including reduced hospitalizations.

Short-term outcome of diverting loop ileostomy reversals performed by residents: a retrospective cohort prognostic factor study

AimThe reversal of diverting loop ileostomy (DLI) is one of surgical trainees’ first procedures. Complications of DLI reversal can cause life-threatening complications and increase patient morbidity. This study compared DLI reversals performed by surgical trainees with those by attending surgeons.MethodThis retrospective cohort study was performed at a single primary care center on 300 patients undergoing DLI reversal. The primary outcome was morbidity, according to the Clavien-Dindo classification (CDC), with special attention paid to the surgeon’s level of training. The secondary endpoint was postoperative intestinal motility dysfunction.ResultsSurgical trainees had significantly longer operation times (p < 0.001) than attending surgeons. Univariate analyses revealed no influence on the level of training for postoperative morbidity. First bowel movement later than 3 days after surgery was a significant risk factor for CDC ≥\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\ge$$\\end{document} 3 (OR, 4.348; 96% CI, 1670–11.321; p = 0.003). Independent risk factors for surgical site infections (SSIs) were an elevated BMI (OR, 1.162; 95% CI, 1.043–1.1294; p = 0.007) and a delayed bowel movement (OR, 3.973; 95% CI, 1.300–12.138; p = 0.015). For postoperative intestinal motility dysfunction, an independent risk factor was a primary malignant disease (OR, 1.980; 95% CI, 1.120–3.500; p = 0.019), and side-to-side stapled anastomosis was a protective factor (OR, 0.337; 95% CI 0.155–0.733; p = 0.006).ConclusionEven though surgical trainees needed significantly more time to perform the surgery, the level of surgical training was not a risk factor for increased postoperative morbidity. Instead, delayed first bowel movement was predictive of SSI.

Delay in loop ileostomy reversal surgery does not impact upon post-operative clinical outcomes. Complications are associated with an increased loss of microflora in the defunctioned intestine

ABSTRACT Loop ileostomy is a common surgical procedure to allow downstream tissue healing, with the aim of re-joining the bowel approximately 12 months later. The reversal procedure is associated with a substantial morbidity up to 40%. Our previous research demonstrated that defunctioned ileum becomes atrophied, with extensive microbial dysbiosis. This study sought to investigate the potential influence of delaying ileostomy reversal surgery upon both clinical and pathological outcomes. Post-operative clinical data was recorded, including routine blood test results, duration of hospital stay, length of time with stoma and incidence of post-operative complications. We measured ileal fibrosis and atrophy and assessed whether these, or dysbiosis, were impacted by the length of time a stoma was in place, or were linked to clinical outcomes. Associations between clinical data were investigated using scatterplot matrix analysis and t-tests. We found no differences in time between ileostomy formation and reversal in patients experiencing complications vs. individuals with no complications. Furthermore, there were no correlations between days with stoma and pathological measures, such as atrophy or fibrosis, and no ongoing increases in collagen production at the time of reversal surgery. This data suggests that the length of time a stoma is in place does not impact on the likelihood of complications. The incidence of complications is associated with increased loss of microbiota in the defunctioned ileum, but importantly, the decrease in bacteria is not linked to time with stoma. Microbiota diversity in the functional and defunctioned limb correlated within an individual, and was not significantly different between those who experienced complications following surgery vs. those that didn’t. Microbiota diversity was also not significantly impacted through delay (>365 days) in stoma reversal. We propose that methods to restore intestinal microbiota numbers, and not necessarily their composition, prior to reversal should be explored to improve the clinical outcomes of ileostomy reversal surgery.

Prolonged diversion after ileal pouch-anal anastomosis: Is it safe to wait?

Diverting loop ileostomy reversal (DLI-R) is routinely performed from 2-6months following ileal pouch-anal anastomosis (IPAA). The safety of delayed reversal after IPAA is not well-defined. The aim of this study was to determine if prolonged diversion is associated with adverse outcomes compared to routine closure. Adult patients undergoing primary IPAA with DLI from 2000 to 2021 were included in this retrospective cohort study from our institutional database. Patients were stratified into tertiles based on timing of reversal: Routine (56-116 days), Delayed (117-180 days), or Prolonged (>6months). Univariate analysis compared categorical variables between groups. Patients reversed at <8 weeks were excluded. In total, 2615 patients underwent DLI-R following IPAA (3-stage 61%, 2-stage 39%; mean age 39.9 years). DLI-R was performed as Routine, Delayed and Prolonged in 1908 (72.9%), 426 (16.4%) and 281 (10.8%), respectively. Overall, DLI-R related complications occurred in 12.4% (n=324). The complication rate in the Routine group was 11% (n=210), in the Delayed group was 12.2% (n=52) and in the Prolonged group was 22.1% (n=62). Reasons for prolonged diversion in the Prolonged group were complications at the time of IPAA in 207 (73.9%) or patient preference/scheduling in 73 (26.1%). DLI-R >6months after IPAA due to complications had higher rates of overall complications following ileostomy reversal (OR 2.6, 95% CI 1.85-3.72, p < 0.001) whereas when DLI-R was delayed due to preference/scheduling outcomes were not different than the Routine group (p=0.28). Prolonged time to ileostomy reversal after IPAA is probably safe without increased risk of complications when due to patient preference.

Impact of chemotherapy on surgical outcomes in ileostomy reversal: a propensity score matching study from a single centre.

In patients with chemotherapy, there is no consensus on the timing of ileostomy closure. Ileostomy reversal could improve the quality of life and minimise the long-term adverse events of delayed closure. In this study, we evaluated the impact of chemotherapy on ileostomy closure and searched for the predictive factors for complications. We retrospectively analysed 212 patients with rectal cancer who underwent ileostomy closure surgery during and without chemotherapy and were consecutively enrolled between 2010 and 2016. As a result of the heterogeneity of the two groups, propensity score matching (PSM) was performed with a 1:1 PSM cohort. A total of 162 patients were included in the analysis. The overall stoma closure-related complications (12.4% vs. 11.1%, p = 1.00) and major complications (2.5% vs. 6.2%, p = 0.44) were not significantly different between the two groups. Multivariate analysis demonstrated that chronic kidney disease and bevacizumab use are risk factors for major complications. Patients with oral or intravenous chemotherapy can safely have ileostomy closure with an adequate time delay from chemotherapy. When patients use bevacizumab, major complications related to ileostomy closure should still be cautioned.

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.

Emergent Subtotal Colectomies Have Higher Leak Rates in Subsequent J-Pouch Stages

PurposeThe most common surgery for ulcerative colitis (UC) is the staged restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). On occasion, an emergent first-stage subtotal colectomy must be performed. The purpose of this study was to compare rates of postoperative complications in three-stage IPAA patients who underwent emergent vs non-emergent first-stage subtotal colectomies in the subsequent staged procedures. MethodsThis was a retrospective chart review conducted at a single tertiary care inflammatory bowel disease (IBD) center. All UC or IBD-Unspecified patients who underwent a three-stage IPAA between 2008 and 2017 were identified. Emergent surgery was defined as that performed on an inpatient who had perforation, toxic megacolon, uncontrolled hemorrhage, or septic shock. The primary outcomes were the presence of anastomotic leak, obstruction, bleeding, and the need for reoperation for each within a 6-month postoperative period of the second (RPC with IPAA and DLI) and third surgical stages (ileostomy reversal). ResultsA total of 342 patients underwent a three-stage IPAA, of which 30 (9.4%) had emergent first-stage operations. Patients who underwent an emergent STC were more likely to have a post-operative anastomotic leak and need an additional procedure following the subsequent second and third-staged operations on both univariate and multivariate analysis (p < 0.05). No difference was found for obstruction, wound infection, intra-abdominal abscess, or bleeding (p > 0.05). ConclusionThree-stage IPAA patients with emergent first-stage subtotal colectomies were more likely to have a post-operative anastomotic leak and need an additional procedure for a leak following the subsequent second- and third-stage operations.

A multidimensional learning curve analysis of totally laparoscopic ileostomy reversal using a single surgeon' s experience.

Recently, totally laparoscopic ileostomy reversal (TLAP) has received increasing attention and exhibited promising short-term outcomes. The aim of this study was to detail the learning process of the TLAP technique. Based on our initial experience with TLAP from 2018, a total of 65 TLAP cases were enrolled. Demographics and perioperative parameters were assessed using cumulative sum (CUSUM), moving average, and risk-adjusted CUSUM (RA-CUSUM) analyses. The overall mean operative time (OT) was 94 min and the median postoperative hospitalization period was 4 days, and there was an estimated 10.77% incidence rate of perioperative complications. Three unique phases of the learning curve were derived from CUSUM analysis, and the mean OT of phase I (1-24 cases) was 108.5 min, that of phase II (25-39 cases) was 92 min, and that of phase III (40-65 cases) was 80 min, respectively. There was no significant difference in perioperative complications between these 3 phases. Similarly, moving average analysis indicated that the operation time was reduced significantly after the 20th case and reached a steady state after the 36th case. Furthermore, complication-based CUSUM and RA-CUSUM analyses indicated an acceptable range of complication rates during the whole learning period. Our data demonstrated 3 distinct phases of the learning curve of TLAP. For an experienced surgeon, surgical competence in TLAP can be grasped at around 25 cases with satisfactory short-term outcomes.

Day-case loop ileostomy reversal based on the community hospital joined enhanced recovery after surgery (CHJ-ERAS) program in China: Safe and feasible

BackgroundThis study was performed to determine the feasibility of Day-case loop ileostomy reversal (DLIR) in China based on the community hospital joined enhanced recovery after surgery (CHJ-ERAS) program. MethodPatients who underwent loop ileostomy were enrolled in the CHJ-ERAS program for DLIR after rigorous evaluation. The primary outcome was the results of short-term follow-ups. ResultsFrom August 2017 to April 2022, 216 patients have been enrolled in the CHJ-ERAS program for DLIR. After DLIR, 14 patients (14/216, 6.5%) have recorded 17 episodes of postoperative complications within 1 month after surgery, including 10 readmission and 2 reoperation. Compared with in-patient loop ileostomy reversal, DLIR based on CHJ-ERAS did not increase the postoperative complications and reoperations. ConclusionThe CMJ-ERAS program for DLIR in our center is a safe and feasible alternative option for inpatient LIR and an acceptable transitional approach for the development of day-case DLIR in developing countries.

A novel nomogram to predict low anterior resection syndrome (LARS) after ileostomy reversal for rectal cancer patients.

Low anterior resection syndrome (LARS) in patients undergoing low or ultra-low anterior resection (LAR) is a common problem and significantly impacts the quality of life. Patients with an ileostomy after LAR are more likely to develop LARS. However, there hasn't been a model predicting LARS occurrence in these patients. This study aims to construct a nomogram to predict the probability of LARS occurrence in patients with temporary ileostomy and guide preventive strategies before reversal. 168 patients undergoing LAR with ileostomy from one center were enrolled as the training cohort, and 134 patients of the same inclusion criteria from another center were enrolled as the validation cohort. The training cohort was screened for risk factors for major LARS using univariate and multivariate logistic regression. The nomogram was constructed using the filtered variables, the ROC curve was used to describe the model's discrimination, and the calibration was used to describe the accuracy. The optimal cut-off value for stoma closure time was 128 days. Three risk factors were identified using logistic regression analysis: preoperative radiotherapy (OR=3.038, [95%CI 1.75-5.015], P=0.005), stoma closure time (OR=2.298, [95%CI 1.088-4.858], P=0.029) and pN stage (OR=1.739, [95%CI 1.235-3.980], P=0.001). A nomogram was constructed based on these three variables and showed good performance predicting major LARS after stoma reversal. The area under the curve (AUC) was 0.827 in the training group and 0.821 in the validation group; The calibration curve suggested good precision in both groups. This novel nomogram can accurately predict the probability of major LARS occurrence after ileostomy reversal for rectal cancer patients. This model can help screen ileostomy patients with high risks and guide individualized preventive strategies before stoma reversal.