Temporary Fecal Diversion Research Articles

Morbidity of Loop Ileostomy Closure after Restorative Proctocolectomy for Ulcerative Colitis and Familial Adenomatous Polyposis: a Systematic Review

BackgroundTemporary loop ileostomy is a routine procedure to reduce the morbidity of restorative proctocolectomy. However, morbidity of ileostomy closure could reduce the benefit of this concept. The objective of this systematic review was to assess the risks of ileostomy closure after restorative proctocolectomy for ulcerative colitis or familial adenomatous polyposis. Materials and MethodsPublications in English or German language reporting morbidity of ileostomy closure after restorative proctocolectomy were identified by Medline search. Two hundred thirty-two publications were screened, 143 were assessed in full-text, and finally 26 studies (reporting 2146 ileostomy closures) fulfilled the eligibility criteria. Weighted means for overall morbidity and mortality of ileostomy closure, rate of redo operations, anastomotic dehiscence, bowel obstruction, wound infection, and late complications were calculated. ResultsOverall morbidity of ileostomy closure was 16.5 %, there was no mortality. Redo operations for complications were necessary in 3.0 %. Anastomotic dehiscence occurred in 2.0 %. Postoperative bowel obstruction developed in 7.6 %, with 2.9 % of patients requiring laparotomy for this complication. Wound infection rate was 4.0 %. Hernia or bowel obstruction as late complications developed in 1.9 and 9.4 %, respectively. ConclusionThe considerable morbidity of ileostomy reversal reduces the overall benefit of temporary fecal diversion. However, ileostomy creation is still recommended, as it effectively reduces the risk of pouch-related septic complications.

Spontaneous Healing of a Rectovaginal Fistula Developing after Laparoscopic Segmental Bowel Resection for Intestinal Deep Infiltrating Endometriosis

The surgical treatment of intestinal deep infiltrating endometriosis has an associated risk of major complications such as dehiscence of the intestinal anastomosis, pelvic abscess, and rectovaginal fistula. The management of postoperative rectovaginal fistula frequently requires a reoperation and the construction of a stoma for temporary fecal diversion. In this paper we describe a 27-year-old woman undergoing laparoscopic treatment of deep infiltrating endometriosis (extramucosal cystectomy, resection of the uterosacral ligaments, resection of the posterior vaginal fornix, and segmental bowel resection) complicated by a rectovaginal fistula, which healed spontaneously with nonsurgical conservative treatment.

Comunicazione orale: Robot-assisted rectal resection with total mesorectal excision

Comunicazione orale: Robot-assisted rectal resection with total mesorectal excision

Morbidity and Mortality after the Closure of a Protective Loop Ileostomy: Analysis of Possible Predictors

A diverting loop ileostomy is often created to protect distal colorectal, coloanal and ileoanal anastomoses. Ileostomy closure is associated with somewhat morbidity and mortality. The aim of this study was to determine the morbidity and morbidity related factors of ileostomy closure. Prospectively recorded data of 255 patients who underwent diverting loop ileostomy between October 2000 and May 2011 were analyzed retrospectively. The study consisted of 139 male and 116 female patients with a median age of 54 years (range 17-79) who underwent ileostomy closure. The morbidity rate of ileostomy closure was 18.4% (47 patients) and the mortality rate was 1.2% (3 patients). When patients with morbidity and without morbidity were compared in terms of gender; age, American Society of Anesthesiology Score, primary pathology, surgeon factor; setting of ileostomy creation and time to stoma closure, only American Society of Anesthesiology Score was found as a predictor for morbidities. Closure of loop ileostomy is a simple procedure with low morbidity and a small but significant risk of mortality. Surgeons must consider the known risks in conjunction with the overall benefit/risk analysis before deciding between a temporary fecal diversion and a discontinuous colonic resection.

Surgical management of ulcerative colitis

Surgery is the only curative option in the treatment of ulcerative colitis. Despite advances in the medical management surgery is required in about a third of patients. In the acute setting surgery is indicated when medical treatment fails to improve an episode of acute severe colitis. The intervention of choice is a staged colectomy with end ileostomy and preservation of the rectal stump in the first instance. Indications for elective surgery are failure of medical therapy and malignant transformation. The surgical options include conventional proctectomy with ileostomy or a Kock's continent ileostomy and colectomy with an ileorectal anastomosis. The current gold standard is restorative proctocolectomy with ileal pouch-anal anastomosis. Most frequently the technique includes a J pouch with a stapled anastomosis and temporary faecal diversion with a loop ileostomy. Laparoscopic pouch surgery is a feasible and safe option with an excellent cosmetic result. Although the morbidity remains significant after surgery, the quality of life is good with a satisfactory long-term functional outcome.

Laparoscopic loop ileostomy with a single-port stab incision technique

Loop ileostomy is an effective means of temporary fecal diversion. It is technically easy to create and manage. Moreover, ileostomy closure does not require a formal laparotomy. With the advent of laparoscopy, many of these loop ileostomies are being performed with laparoscopic assistance. Studies have proved the beneficial effects of laparoscopically created loop ileostomy for fecal diversion. Techniques for performing laparoscopic loop ileostomy have been described using two or more 10- to 12-mm ports with Hassan's technique at the umbilical site for pneumoperitoneum creation. We describe a modified technique, wherein pneumoperitoneum is created using a 10-mm port at the site of the future ileostomy, and a second 5-mm port is placed under vision at the umbilical site. This procedure requires minimal intervention and a reduced pneumoperitoneum time. Since the umbilical port site is 5 mm, it does not require closure, and it also reduces the chances of port-site hernia, formation, patient discomfort and scarring. Because intervention is minimally invasive, operative time is reduced, and there is less of chance postoperative ileus and adhesion formation.

Preliminary report of a new technique for temporary faecal diversion after extraperitoneal colorectal anastomosis

Loop ileostomy is a suitable procedure for transitory faecal diversion after colorectal or coloanal anastomosis. We describe here an easy alternative technique for ileostomy construction that does not require reintervention for the closure. In twenty patients undergoing anterior resection of the extraperitoneal rectum with colorectal and/or coloanal anastomosis, loop ileostomy was performed using a modified jejunotomy tube inflated with 10 ml of normal saline. The tube was deflated on the eighth post-operative day and removed on day 11 after a radiological contrast enema of the anastomosis. Radiological control carried out on day 11 evidenced a premature dislocation of the jejunostomy tube in 1 patient, thus the tube was correctly removed without any complications. In another patient a delayed closure of the ileo cutaneous fistula was recorded that required simple medication over 15 days in the out patient clinic. No signs of anastomotic leakage, either clinical or radiological were evidenced. We have described here a safe alternative technique for loop ileostomy with negligible complications related to construction as demonstrated in our results.

Loop ileostomy versus loop transverse colostomy for temporary fecal diversion after colorectal anastomosis

Background: Leakage from low colorectal anastomosis could be reduced by using covering stoma to divert fecal stream. Controversy is still present as to whether loop ileostomy (LI) or loop transverse colostomy (LTC) is the optimal method of defunctioning such anastomosis. Methods: Patients requiring defunctioning following anterior resection or emergency left colonic resection were randomized to receive either LI or LTC. Comparison was made between both groups regarding efficacy & complications. The minimum follow up after stoma closure was 3 months (mean 10 months). Results: Between January 2007 and April 2009, 62 patients were randomized into 2 groups (LI 32, LTC 30). There were no significant differences in the mortality, postoperative leakage, stoma prolapse, parastomal hernia, parastomal fistula, incisional hernia, postoperative bowel obstruction, or skin irritation. However, there were significant difference in favour of LI including less evidence of wound infection, less hospital stay, less stomal retraction or necrosis, less time for creation of stoma, less time of bowel transiet and better patient adaptation, while dehydration and time of closure was in favour of LTC. Conclusion: In this randomized study, both methods appear to provide satisfactory protection method for the low colorectal anastomosis, but LI in general was associated with little complications specially wound infection & stoma related complications, which favours it as a covering stoma.

大腸癌手術における一時的ループイレオストミーの造設と閉鎖についての検討

目的: 大腸癌手術における一時的ループイレオストミーの安全性について検討した．方法: 1995∼2007年にループイレオストミーを造設，閉鎖した39例を対象とした．結果: covering stomaとして造設したものが20例，縫合不全後に造設したものが19例であった．ロッドを使用せず丸く高いストーマを造設した．ストーマ径は平均縦30mm横30mm高さ26mmであった．造設後ストーマ周囲皮膚障害が3例，ストーマの潰瘍が2例，イレウスが2例発生したが，ストーマの脱落，脱出，ヘルニア，ハイアウトプットストーマはなかった．ストーマの閉鎖法は機能的端々吻合が24例，手縫い端々吻合が15例であった．手縫い群で5例の吻合部小腸閉塞と，再手術を要した縫合不全が1例に発生した．結語: 大腸癌手術における一時的ループイレオストミーの造設と閉鎖は，重篤な合併症も少なく安全な手技であった．機能的端々吻合は，閉鎖後の小腸閉塞が無く安全であった．

Risk of Fecal Diversion in Complicated Perianal Crohn’s Disease

The purpose of the study was to determine the overall risk of a permanent stoma in patients with complicated perianal Crohn’s disease, and to identify risk factors predicting stoma carriage. A total of 102 consecutive patients presented with the first manifestation of complicated perianal Crohn’s disease in our outpatient department between 1992 and 1995. Ninety-seven patients (95%) could be followed up at a median of 16 years after first diagnosis of Crohn’s disease. Patients were sent a standardized questionnaire and patient charts were reviewed with respect to the recurrence of perianal abscesses or fistulas and surgical treatment, including fecal diversion. Factors predictive of permanent stoma carriage were determined by univariate and multivariate analysis. Thirty of 97 patients (31%) with complicated perianal Crohn’s disease eventually required a permanent stoma. The median time from first diagnosis of Crohn’s disease to permanent fecal diversion was 8.5 years (range 0–23 years). Temporary fecal diversion became necessary in 51 of 97 patients (53%), but could be successfully removed in 24 of 51 patients (47%). Increased rates of permanent fecal diversion were observed in 54% of patients with complex perianal fistulas and in 54% of patients with rectovaginal fistulas, as well as in patients that had undergone subtotal colon resection (60%), left-sided colon resection (83%), or rectal resection (92%). An increased risk for permanent stoma carriage was identified by multivariate analysis for complex perianal fistulas (odds ratio [OR] 5; 95% confidence interval [CI] 2–18), temporary fecal diversion (OR 8; 95% CI 2–35), fecal incontinence (OR 21, 95% CI 3–165), or rectal resection (OR 30; 95% CI 3–179). Local drainage, setons, and temporary stoma for deep and complicated fistulas in Crohn’s disease, followed by a rectal advancement flap, may result in closing of the stoma in 47% of the time. The risk of permanent fecal diversion was substantial in patients with complicated perianal Crohn’s disease, with patients requiring a colorectal resection or suffering from fecal incontinence carrying a particularly high risk for permanent fecal diversion. In contrast, patients with perianal Crohn’s disease who required surgery for small bowel disease or a segmental colon resection carried no risk of a permanent stoma.

Should ileoanal pouch surgery be staged for patients with mucosal ulcerative colitis on immunosuppressives?

Much debate has revolved around whether patients with mucosal ulcerative colitis (MUC) receiving immunosuppression should be weaned off immunosuppressives before undergoing ileal pouch surgery. Therefore, the aim of this study was to assess the affect of immunosuppressive drugs on postoperative complications after ileoanal pouch surgery. A retrospective medical record review of patients with MUC who underwent ileal pouch surgery while taking immunosuppressive drugs such as azathioprine, 6-mercaptopurine (6-MP), methotrexate, and cyclosporin A was performed. Postoperative complications in the study group were compared to three matched groups: patients with MUC who had ileoanal pouch surgery while taking systemic steroids, patients with MUC not receiving any immunosuppressive drugs, and patients with familial adenomatous polyposis. Twenty-two patients with MUC who underwent ileoanal pouch surgery while taking immunosuppressive drugs were identified from a prospectively entered database of patients who had this surgery between 1988 and 2005. All but two patients underwent temporary fecal diversion. Fifteen patients were taking 6-MP or azathioprine; six were on cyclosporine A, and one both on azathioprine and cyclosporine A. Fifteen patients were also taking steroids at the time of ileoanal pouch surgery. Early (within 30 days of surgery) and late complications occurred in 36 and 50% of the study group patients, respectively, but did not significantly differ from a matched group of patients with MUC who did not take immunosuppressive drugs. Patients with familial adenomatous polyposis had a significantly lower long-term complication rate. This retrospective case-matched study suggests that the use of immunosuppressive drugs and cyclosporine A may not be associated with an increased rate of complications after ileoanal pouch surgery.

Influence of temporary faecal diversion on long-term survival after curative surgery for colorectal cancer.

Experimental carcinogenesis is enhanced at colorectal anastomoses, inhibited by proximal faecal diversion and promoted by the closure of a defunctioning stoma. The clinical relevance of these observations was investigated in a retrospective study of curative restorative resection for colorectal carcinoma. The 5-year disease-free survival rate (95 per cent confidence interval) in 122 patients with a temporary stoma (50.4 (41.1-59.7) per cent) was significantly reduced (P < 0.01) compared with that in 218 with no stoma (66.8 (59.4-73.5) per cent). In patients with Dukes B tumours early stoma closure (within 3 months of resection) was associated with a worse survival (P < 0.005) and a higher tumour recurrence rate (P < 0.05) than in those with no stoma. Survival rates after late stoma closure were no different from those in patients with no stoma. Multivariate analysis revealed Dukes stage (P < 0.0001), tumour differentiation (P = 0.02) and timing of stoma closure (P = 0.02) as independent predictors of survival. In curative surgery for colorectal cancer temporary faecal diversion confers a survival disadvantage that can be prevented by delayed closure of the stoma.

Loop ileostomy as temporary faecal diversion following total mesorectal excision

Aim: Anastomotic leakage following low anterior resection with total mesorectal excision carries a significant morbidity and mortality. Both loop ileostomy and loop transverse colostomy are common options of temporary faecal diversion to reduce the severity of anastomotic leakage. We use loop ileostomy routinely because of its ease of construction and closure, and low complication rate. Here, we reviewed our result of loop ileostomy.Methods: We reviewed the medical records of all patients who had temporary loop ileostomy constructed following low anterior resection with total mesorectal excision for CA rectum, from 1.1999 to 12.2003. Stoma related morbidity pre and post–closure of loop ileostomy were recorded.Results: Eighty‐eight patients had loop ileostomy constructed and later closed from 1.1999 to 12.2003. Seventeen of them required small bowel resection during closure of the loop ileostomy. Three patients (3.4%) had skin excoriation and one patient (1.1%) had prolonged ileus after the construction of ileostomy (3.4%). After closure of ileostomy, two patients (2.2%) had wound infection and two patients (2.2%) had anastomotic leakage. Six patients (6.8%) developed intestinal obstruction later. Post‐closure intestinal obstruction and anastomotic leakage were found to be associated with small bowel resection during the closure of ileostomy (P=0.042).Conclusion: Loop ileostomy and its closure are associated with low complication rates. We therefore continue to advocate the use of loop ileostomy as a temporary diversion procedure after total mesorectal excision.

S‐III‐02 Construction and Management of Loop Ileostomy

Aim: The aim of this study was to determine the morbidity associated with both construction and reversal of loop ileostomies. Methods: Thirty‐three patients who had loop ileostomies constructed and 31 of these same patients who had their loop ileostomies reversed between 1994 and 2001 were reviewed.The loop ileostomies were constructed in round‐shaped (2.5∼3 cm in diameter) like a end ileostomy and everted to produce a 2∼3 cm stoma without a rod Results: The average size of ileostomies was 28 × 29 × 25(hight)mm. Five patients had complications arising from ileostomy construction including 4 parastomal irritation, 1 ileus, and 1 stomal ulcer. All complications improved with conservative management. Mean time to ileostomy reversal was 78 days. Of 31 patients who had loop ileostomies reversed, 10 patients had staple closure (functional end‐to‐end anastomosis with ENDO GIA 45). Nine patients had complications associated with reversal including 6 small bowel obstruction due to anastomotic stenosis(anastomotic edema), 1 leakage and 2 SIRS. Of these 9 patients, 2 required surgical intervention. One patient suffered leakage required reanastomosis, one for SIRS required reconstruction of loop ileostomy. Of 6 patients developed small bowel obstruction, 3 required long intestinal tube decompression. All patients improved with conservative management. 10 patients who had their loop ileostomies closed by functional end‐to‐end anastomosis had no bowel obstruction and other complications. Conclusions: Defunctioning loop ileostomy is associated with low morbidity. We recommend a defunctioning ileostomy as the procedure of choice for temporary fecal diversion, and functional end‐to‐end anastomosis in reversal of ileostomies.

Laparoscopy-assisted loop ileostomy: an acceptable option for temporary fecal diversion after anorectal surgery.

Temporary fecal diversion may be desired after many anorectal procedures. The aim of this study was to describe a technique for laparoscopy-assisted creation of a loop ileostomy in patients undergoing anorectal and perineal surgery and to relate short-term outcomes. A retrospective review of the medical records of 53 consecutive patients who underwent laparoscopy-assisted creation of a loop ileostomy as an adjunct to anorectal or perineal surgery between 1993 and 1999 was performed. Data were obtained for age of the patient, previous abdominal surgical procedures, anorectal or perineal surgical procedure performed, American Society of Anesthesiology scores, operative times for both creation and takedown of the ileostomy, and postoperative return of bowel function. The average duration of operation for laparoscopy-assisted creation of the loop ileostomy was 47 (range, 28-75) minutes, with no conversions to laparotomy. All patients were able to tolerate a regular diet on the first postoperative day. Closure was accomplished 69 (range, 63-96) days later with an average operative time of 52 (range, 35-90) minutes. One patient developed ileus after takedown of his stoma. The other 52 patients were able to tolerate a regular diet by the second postoperative day. Laparoscopy-assisted creation of a loop ileostomy is an effective method for temporary fecal diversion in patients undergoing anorectal surgery.

Fournier's gangrene: diagnostic approach and therapeutic challenge.

To identify the prognostic variables and to assess the role of aggressive management in patients with Fournier's gangrene. Retrospective study. University hospital, Greece. 11 patients (9 men and 2 women) with Fournier's gangrene admitted between April 1986 and December 2000. Early aggressive debridements. Postoperative course, hospital stay, outcome, morbidity, and mortality. The mean age was 65 years (range 17-90) and the mean (SD) duration of hospital stay was 35 (8) days (range 8-62). The aetiology was identified in 8 patients and idiopathic in 3. Predisposing factors (diabetes, n = 4; heart failure, agranulocytosis, and alcohol misuse, n = 1 each) were identified in 6 patients. All patients except one had raised serum glucose concentrations and low serum albumin values. On admission the white cell count was >15 x 10(9)/L in 10, serum sodium <135 mmol/L, mean (SD) serum creatinine 124 (27) micromol/L, and C-reactive protein >150 mg/L was found in all patients. 3/9 male patients required partial excision of the scrotum. Temporary faecal diversion was done for 3 patients. A mean of 3 aggressive repeated debridements (range: 3-6) were required. Nine patients survived and two patients died. Rapid and accurate diagnosis remains the key to achieving a successful outcome. Abnormal laboratory variables on admission may suggest the diagnosis. Early, repeated, aggressive debridement is essential for a successful outcome.

Proctectomy and coloanal anastomosis for rectal cancer.

Fueled by a greater understanding of pelvic physiology along with an improved comprehension of rectal cancer spread, we are now able to offer most patients restoration of intestinal continuity following oncologic proctectomy. Coloanal or ultralow colorectal anastomosis can be performed in most patients with midrectal cancers, provided that anal sphincter function is not impaired preoperatively. Functional results may be improved by construction of a colonic pouch with pouch-anal anastomosis. Temporary fecal diversion, usually with a diverting loop ileostomy, may be prudent, especially in patients undergoing neoadjuvant chemoradiation.

Techniques and complications of ileostomy takedown

Objective: We use a loop ileostomy for temporary fecal diversion because of ease of technical construction and assumed low complication rate. Here, we review our complications of loop ileostomy and takedown using three techniques of closure.Methods: We reviewed charts of all patients who had temporary ileostomies constructed during 1987 to 1995 (n = 366). Ileostomy takedown was performed in 339 patients using one of three closure techniques: enterotomy suture (65%), resection with handsewn anastomosis (20%), and stapled anastomosis (15%). Complications were recorded for pre-takedown and 30-day post-takedown intervals.Results: Overall complication rate was 28%. Pre-takedown complications occurred in 21 patients (5.7%), including small bowel obstruction (2.5%) and dehydration/electrolyte derangement (2.2%). Post-takedown complications occurred in 83 patients (24.5%), including wound infection (14.2%), small bowel obstruction (5%), anastomotic leak (2.9%), and 1 death from a cardiac event. Post-takedown obstruction was higher for closure using resection with sutured anastomosis (12%) compared with enterotomy suture (2.3%), P ≤0.003. Stapled anastomosis had an intermediate rate of obstruction (7.7%). Anastomotic leak was similar between closure techniques.Conclusions: Loop ileostomy and takedown are associated with low rates of serious complications (5% or less). As such, we continue to advocate use of loop ileostomy as a diversion procedure. Closure by enterotomy suture is preferred over resection. However, if resection is required, closure by stapled anastomosis is preferred over suture anastomosis.

Defunctioning loop ileostomy: a prospective audit

Background: Defunctioning loop ileostomies are uncommonly used forms of fecal diversion. The aim of this study was to determine the morbidity associated with both construction and reversal of loop ileostomies. Study Design: An analysis was performed of all patients who underwent loop ileostomy construction or reversal between 1990 and 1997, with data being collected prospectively. Results: One-hundred-two patients, (43 male, 59 female) with a mean age of 38 years (range 13 to 81 years) had loop ileostomies constructed. Indications for ileostomy construction included inflammatory bowel disease (76 patients), ultralow anterior resection for carcinoma (16 patients), or miscellaneous reasons (10 patients). Nine patients (9%) had complications arising from ileostomy construction including 4 parastomal infections, 3 high output ileostomies, 1 small-bowel obstruction, and 1 ileostomy stenosis in the early postoperative period. Only the stricture required surgical intervention. All other complications improved with conservative management. Mean time to ileostomy reversal was 120 days. Three patients (4%) had complications associated with reversal. All of these complications required surgical intervention, 2 for small bowel obstruction, and 1 for small bowel perforation. Currently 84 patients have had their ileostomy reversed, and 12 patients have had their loop ileostomy converted to a permanent stoma for reasons not related to the loop ileostomy itself. Conclusions: Defunctioning loop ileostomy is associated with low morbidity. We recommend a defunctioning ileostomy as the procedure of choice for temporary fecal diversion.

Posterior sagittal resection for rectal aganglionosis: Preliminary results of a new approach

Background: There is no general agreement about how patients who have short-segment Hirschsprung's disease should be treated. Methods: Ten patients with Hirschsprung's disease, seven with rectal and three with rectosigmoidal aganglionosis, were operated on through a posterior sagittal incision. In nine patients, a primary rectal resection and coloanal anastomosis was performed. In one patient, a longitudinal posterior myectomy of the rectum was performed as a primary procedure, but the procedure was eventually converted to a rectal resection and coloanal anastomosis through the same incision. Results: One early and one late anastomotic complication occurred. Both were successfully treated with a temporary fecal diversion (left-sided colostomy for 6 to 8 weeks). The functional results as evaluated with anorectal manometry were similar to a group of Hirschsprung's patients treated with transabdominal pull-through resection and coloanal anastomosis. Conclusion: This approach might prove to be a useful alternative both to the transabdominal resection and the posterior longitudinal rectal myectomy in Hirschsprung's disease with rectal aganglionosis.