Time Of Stoma Closure Research Articles

The Timing of Stoma Closure in Infants with Necrotizing Enterocolitis: A Systematic Review and Meta-Analysis.

Aim Some infants with necrotizing enterocolitis (NEC) undergoing surgery require the formation of a stoma. The timing of stoma closure in these patients remains controversial. Our aim was to determine whether the different timing of closure had an impact on patient outcome. Methods Using a defined search strategy (PubMed, Embase, and Web of Science), two investigators (Q.L. and G.L.) independently identified studies comparing early stoma closure (ESC, before 8 weeks from stoma formation) versus late stoma closure (LSC, after 8 weeks) in infants with NEC. Outcome measures included the duration of parenteral nutrition, the length of hospital stay, and complications. Meta-analysis was performed using RevMan 5.3 (The Cochrane Collaboration, Copenhagen, Denmark). Data are expressed as mean ± standard deviation. Results Of the 505 articles screened, 6 articles met the inclusion criteria (280 infants). All studies but one were retrospective. The total duration on parenteral nutrition was similar in infants with ESC versus LSC, and the total length of hospital stay (pre- plus poststoma closure) was not influenced by the timing of stoma closure. Three studies (79 infants) reported similar complication rates after stoma closure between ESC (5/16, 31%) and LSC infants (13/63, 19%; p = 0.5). Conclusions This systematic review demonstrates that there is no difference between different timings for stoma closure in post-NEC infants. With the current supporting evidence, ESC seems to be as safe and feasible as LSC. Studies with a higher level of evidence are needed to confirm these conclusions.

End-loop Stoma versus the Traditional Two Separate Stomas after Intestinal Resection

Aim: To compare the technique of temporary partial intestinal anastomosis versus two separate stomas, following large bowel resection, in patients where the anastomosis is anticipated to have borderline margins with dubious viability. Patients and methods: Thirty patients underwent bowel resection, Group A (15 patients) had partially anastomosed end-loop stoma and Group B (15 patients had traditional two stomas technique. These operations were performed at the Ain Shams University Hospitals between November 2011 and October 2013. Patients with marked difference in the diameter between the cut ends of bowel loops after resection were added to the study. Bowel resection was performed because of conditions such as ischemic colitis, bowel mass and bowel injury. Results: Significant decrease in the intraoperative time was found where end loop stoma was constructed and also the operative time of stoma closure to regain bowel continuity in group A. As regard the complications, postoperatively, 1 of the patients of group A developed parastomal hernia and one patient of group B developed stoma necrosis which necessitated refashioning of the stoma. There were no major complications in group A. All patients were discharged between the 8th and 15th day after the procedure, and the stoma was closed 3 weeks to 12 weeks later. Conclusion: We believe that end-loop stoma is a simple, quick and safe technique with minimal stoma-related morbidity, and with simple and safe reversion. This technique can be considered as a useful option in the treatment of ischemic enteritis, and in the management of severe intestinal trauma.

Quality of Life and Timing of Stoma Closure in Patients With Rectal Cancer Undergoing Low Anterior Resection With Diverting Stoma

After low anterior resection for rectal cancer, creation of a diverting stoma is recommended. Data on the impact of a diverting stoma on quality of life are conflicting. Optimal timing of stoma closure in the setting of adjuvant chemotherapy is unclear. The purpose of this study was to investigate the impact of a diverting stoma on quality of life in patients undergoing rectal cancer resection before and after stoma closure. Furthermore, the study was conducted to look at the timing of stoma reversal and the potential influence of factors such as adjuvant chemotherapy. This was a longitudinal, observational, multicenter study. The study was conducted at 17 German colorectal centers. Patients with rectal cancer who planned for elective curative surgery with creation of temporary diverting stoma were included. This longitudinal observational study assessed quality of life at 3 occasions using European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core Questionnaire/Colorectal Cancer Module before cancer resection, before stoma closure, and 6 months after stoma closure. Furthermore, the timing of stoma closure and continence were evaluated. A total of 120 patients (64% men; mean age, 63.2 ± 11.5 years) were analyzed. Longitudinal global quality of life was not influenced by the presence of a stoma. Several functional and GI symptom scales were markedly impaired after stoma creation. Physical, role functioning, and sexual interest recovered after stoma closure. Social functioning stayed impaired (p < 0.0001). Median time to stoma closure was 5 months (range, 17 days to 18 months). A total of 3.4% of patients had very early stoma closure (within 30 days). Adjuvant chemotherapy delayed stoma closure (median, 5.6 vs 3.4 months without chemotherapy; p = 0.0001). The study was limited by its missing quality-of-life data for sexual function. The presence of a stoma had a negative impact on social functioning and GI symptoms. However, this had no clinically relevant influence on global quality of life. Time to stoma closure was nearly doubled when patients underwent adjuvant chemotherapy.

Temporary Tube Stoma versus Conventional Loop Stoma for the Protection of a Low Anastomosis in Colorectal Surgery: A Systematic Review and Meta-analysis

The aim of this systematic review is to evaluate and compare the efficacy and safety of temporary tube stoma and conventional loop stoma for the protection of a low anastomosis in colorectal cancer. A systematic literature search was performed using PubMed, EMBASE, Science Citation Index, and Cochrane Central Register of Controlled Trails. Primary outcome measures were anastomotic leakage rate, the reoperation rate for anastomotic leakage, and stoma-related complications. Secondary outcome measures were operation time, length of hospital stay, time to stoma closure, and permanent stoma rate. Four studies were carried out and 642 patients (332 with temporary tube stoma and 310 with conventional loop stoma) met the inclusion criteria. The incidences of anastomotic leakage and reoperation rate were statistically similar in tube stoma and loop stoma groups. In comparison with conventional loop stoma, temporary tube stoma was associated with a significantly less stoma-related complications (odds ratio = 0.20; 95% confidence interval [CI]: 0.08-0.50), and shorter operation and hospital stay time (weighted mean difference = -47.28 minutes, 95% CI: -74.68 to -19.88; and weighted mean difference = -5.22 days, 95% CI: -10.32 to -0.13, respectively). Time to stoma closure was significantly shorter in the temporary tube stoma groups (weighted mean difference = -114.58 days, 95% CI: -148.38 to -80.77). Patients receiving temporary tube stoma had lower rates of stoma-related complications, shorter operation and hospital stay time, and stoma closure time. Tube can be easily removed without second surgery in most cases. Therefore, temporary tube stoma is a feasible and effective alternative to conventional loop stoma for the protection of a low colorectal anastomosis.

When is the best time for temporary stoma closure in laparoscopic sphincter-saving surgery for rectal cancer? A study of 259 consecutive patients.

There is no consensus regarding the best timing for temporary stoma closure after proctectomy for rectal cancer, especially if the patient requires adjuvant chemotherapy. This study aimed to assess whether the timing of stoma closure could influence postoperative morbidity. Patients with rectal cancer undergoing laparoscopic proctectomy with temporary stoma were included and divided into three groups according to the delay of stoma closure after proctectomy: ≤60 days (Group A), 61-90 days (Group B), and >90 days (Group C). From 2008 to 2013, 259 patients (146 men, median age 61 years) were divided into Groups A (n = 65), B (n = 115), and C (n = 79). At the time of stoma closure, seven (11%) patients received adjuvant chemotherapy in Group A versus 42 (37%) in Group B (p = 0.0002) and 24 (30%) in Group C (p = 0.004), and peristomal hernia was noted in four patients (6%) in Group A versus 14 (12%) in Group B and 21 (27%) in Group C (p < 0.0001). Although overall postoperative morbidity was similar between groups, anastomotic leakage (at the stoma closure site) was noted in one patient in Group A versus zero in Group B versus four in Group C (p = 0.03). Median hospital stay was 5 days in Group A versus 6 in Group B versus 6 in Group C (p = 0.004). Our results suggested that timing of temporary stoma closure can influence postoperative morbidity. Best results were obtained if stoma closure was performed before 90 days, even during adjuvant chemotherapy. There is no benefit in delaying stoma closure after completion of adjuvant chemotherapy.

Completely diverted tube ileostomy compared with loop ileostomy for protection of low colorectal anastomosis: a pilot study

The study was designed to evaluate a new completely diverted tube ileostomy (CDTI) with a reversible single-row stapled occlusion of the distal limb to defunction a low colorectal anastomosis, and to compare it with a loop ileostomy (LI). From September 2010 to August 2012, 95 patients with rectal cancer who underwent elective low anterior resections were recruited into the study. They received either a CDTI or a LI. Demographics, clinical features and operative data were recorded. Fifty-four patients (56%) had a CDTI and 41 (44%) a LI. There were no significant differences in patient demographics and clinical characteristics. Anastomotic dehiscence occurred in three (5.6%) patients in the CDTI group and two (4.9%) in the LI group (not significant) and no patient developed faecal peritonitis. In the CDTI group, the distal ileum spontaneously recanalized from the stapler occlusion with an average anastomosis exclusion time of 27.9 (14-70) days. The CDTI tube was removed on day 33 (20-75) and the subsequent stoma closure time was 12.3 (6-30) days. The CDTI procedure is a safe and effective technique for defunctioning an elective low colorectal anastomosis and avoids a formal stoma.

Enteric nervous system abnormalities are present in human necrotizing enterocolitis: potential neurotransplantation therapy

IntroductionIntestinal dysmotility following human necrotizing enterocolitis suggests that the enteric nervous system is injured during the disease. We examined human intestinal specimens to characterize the enteric nervous system injury that occurs in necrotizing enterocolitis, and then used an animal model of experimental necrotizing enterocolitis to determine whether transplantation of neural stem cells can protect the enteric nervous system from injury.MethodsHuman intestinal specimens resected from patients with necrotizing enterocolitis (n = 18), from control patients with bowel atresia (n = 8), and from necrotizing enterocolitis and control patients undergoing stoma closure several months later (n = 14 and n = 6 respectively) were subjected to histologic examination, immunohistochemistry, and real-time reverse-transcription polymerase chain reaction to examine the myenteric plexus structure and neurotransmitter expression. In addition, experimental necrotizing enterocolitis was induced in newborn rat pups and neurotransplantation was performed by administration of fluorescently labeled neural stem cells, with subsequent visualization of transplanted cells and determination of intestinal integrity and intestinal motility.ResultsThere was significant enteric nervous system damage with increased enteric nervous system apoptosis, and decreased neuronal nitric oxide synthase expression in myenteric ganglia from human intestine resected for necrotizing enterocolitis compared with control intestine. Structural and functional abnormalities persisted months later at the time of stoma closure. Similar abnormalities were identified in rat pups exposed to experimental necrotizing enterocolitis. Pups receiving neural stem cell transplantation had improved enteric nervous system and intestinal integrity, differentiation of transplanted neural stem cells into functional neurons, significantly improved intestinal transit, and significantly decreased mortality compared with control pups.ConclusionsSignificant injury to the enteric nervous system occurs in both human and experimental necrotizing enterocolitis. Neural stem cell transplantation may represent a novel future therapy for patients with necrotizing enterocolitis.

Stapled ileostomy closure results in reduction of postoperative morbidity

Loop ileostomy is widely employed as a defunctioning procedure for left-sided colonic anastomoses. Closure of the stoma carries a risk of morbidity and even mortality. The aim of this prospective trial was to evaluate the ability of stapled stoma closure to decrease the rates of perioperative morbidity. One hundred and nineteen patients (mean age 56.2 +/- 5.4 years) underwent two-stage operations for rectal carcinoma with protective loop ileostomy between 2005 and 2008. All patients were randomly divided into two groups: 56 patients had conventional ileostomy takedown, while in the other 63, a functional end-to-end anastomosis was created using a linear stapler. Groups were comparable in terms of age, gender, body mass index, and other parameters. Mean time of stoma closure using functional end-to-end anastomosis was 68 +/- 7, when compared to 92 +/- 11 min (P = 0.01) for conventional stoma closure. The overall morbidity rate after ileostomy closure using a stapler was 3.2%: one patient (1.6%) developed a wound infection and self-limited bleeding from the anastomotic line, while another patient (1.6%) had an ileal obstruction caused by adhesions and required additional intervention. Conventional ileostomy closure resulted in a 14.3% morbidity rate: six patients (10.7%) had prolonged ileus, 2 (3.6%) had small bowel obstruction, and 2 (3.6%) had wound infections (P = 0.04). Functional end-to-end anastomosis reduces operating time and morbidity compared to conventional ileostomy takedown.

The timing of enterostomy reversal after necrotizing enterocolitis

Background/Purpose Newborns undergoing surgery for necrotizing enterocolitis (NEC) often require a stoma. The study purpose is to determine if the timing of stoma closure impacts the postoperative course. Methods After obtaining institutional review board approval, records of patients with NEC who received a stoma between 2003 and 2007 at 2 pediatric institutions were reviewed. Data collected included time interval between stoma creation and closure, indication for closure, postoperative complications, time to feeds, and length of neonatal intensive care unit and hospital stays. For analysis purposes, patients were divided in 2 groups: 1, stoma closed within 10 weeks; and 2, stoma closed more than 10 weeks after construction. Results There were 37 patients: 13 in group 1 and 24 in group 2. Group 1 babies were ventilated longer postoperation (7.69 vs 1.08 days, P = .0006). They required total parenteral nutrition for more days (51.62 vs 16.30 days, P = .0486). Group 1 patients took longer to reach full po (19.08 vs 7.86 days, P = .027), and they had a longer length of stay postreversal (113.08 vs 31.32 days, P = .0373). No differences were observed in survival rates or anastomotic complications. Conclusion The timing of stoma reversal significantly impacts the postoperative course after NEC. Unless seriously indicated, stoma closure should be deferred until at least 10 weeks postcreation.

Ileostomy or colostomy for temporary decompression of colorectal anastomosis: systematic review and meta-analysis

The controversy regarding whether loop ileostomy or loop transverse colostomy is a better method for temporary decompression of colorectal anastomosis motivated this review. Five randomized trials were included, with 334 patients: 168 in the loop ileostomy group and 166 in the loop transverse colostomy group. The outcomes analyzed were: 1. Mortality; 2. Wound infection; 3. Time of stoma formation; 4. Time of stoma closure; 5. Time interval between stoma formation and closure; 6. Stoma prolapse; 7. Stoma retraction; 8. Parastomal hernia; 9. Parastomal fistula; 10. Stenosis; 11. Necrosis; 12. Skin irritation; 13. Ileus; 14. Bowel leakage; 15. Reoperation; 16. Patient adaptation; 17. Length of hospital stay; 18. Colorectal anastomotic dehiscence; 19. Incisional hernia; 20. Postoperative bowel obstruction. Stoma prolapse was statistically significant (p = 0.00001), but with statistical heterogeneity; the sensitive analysis was applied, excluding the trials that included emergency surgery, and this showed: p = 0.02, with I2 = 0% for the heterogeneity test. The outcomes reported were not statistically or clinically significant except for stoma prolapse. Better evidence for making the choice between loop ileostomy or loop colostomy requires large-scale randomized controlled trials.

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.

Intestinal cytokine gene expression in infants with acute necrotizing enterocolitis: Interleukin-11 mRNA expression inversely correlates with extent of disease

Background/Purpose: The authors have shown previously that surgical specimens from infants with acute necrotizing enterocolitis (NEC) show upregulation of inducible nitric oxide (NO) synthase (iNOS) and interferon-γ mRNA. However, the contribution of other inflammatory cytokines such as interleukin-8 (IL-8), IL-11, and IL-12 has not been defined. Likewise, the role of GTP-cyclohydrolase, the rate-limiting enzyme in tetrahydrobiopterin synthesis, and thus NO production by iNOS is unclear. In this study, the authors sought to further define the pattern of cytokine expression seen in infants with acute NEC. Methods: The authors measured intestinal cytokine mRNA expression by semiquantitative reverse transcriptase polymerase chain reaction in 21 infants with histologically confirmed NEC, 18 with other inflammatory conditions, and in 9 patients without intestinal inflammation. Guanosine triphosphate-cyclohydrolase (GTP-CH) activity was measured by specific enzyme assay. Univariate exact logistic regression analysis was performed to identify predictors of outcome. Results: IL-8 and IL-11 mRNA were upregulated in patients with acute NEC compared with those with other inflammatory conditions or those without disease; these levels returned to baseline at the time of stoma closure. Increased IL-11 mRNA decreased the likelihood of pan-necrosis (odds ratio, 0.93; P =.002). Increased IL-12 levels (but not IL-8) seemed to protect against pan-necrosis (odds ratio, 0.70; P =.06). Conclusions: Local upregulation of IL-11 may represent an adaptive response designed to limit the extent of intestinal damage in NEC. Decreased IL-12 levels may contribute to the pathogenesis of NEC by allowing bacteria to escape host defenses. J Pediatr Surg 36:1122-1129. Copyright © 2001 by W.B. Saunders Company.

Morphologic changes of the anal sphincter musculature during and after temporary stool deviation.

Temporary stool deviation, using a stoma, is a well-known surgical principle to protect low colorectal or coloanal anastomoses. The purpose of this study was to evaluate any morphologic changes with regard to the anal sphincter muscles during and after temporary ileostomy. Forty-four patients with rectal carcinomas were studied prospectively. All patients underwent low anterior resection. Reconstruction was performed using either a coloanal pouch or a straight end-to-end anastomosis. A protective stoma was fashioned in all 44 patients (ileostomy n=41; colostomy n=3). Stoma closure was carried out after a median of 85 days (41-330 days). Using a standard protocol, anal-sphincter thickness [m. puborectalis, external anal sphincter (EAS) and internal anal (IAS) sphincter] was assessed by means of endoanal ultrasonography preoperatively, at the time of stoma closure, and every 3 months thereafter for 1 year. The diameter of the puborectal muscle decreased from a median preoperative value of 6.3 mm to 5.7 mm at the time of stoma closure (P=0.03). After 3 months, 6.2 mm was measured. This value remained stable for the complete follow-up period. Similar results were recorded for the EAS. The IAS thickness remained stable throughout the study period, measuring between 2.1 mm and 2.4 mm. Temporary stool deviation does lead to morphologic changes of the anal sphincter. While the smooth muscle remains unchanged, the striated counterpart undergoes atrophic transformation. However, after passage reconstruction, i.e., stoma closure, a rapid regeneration of the voluntary muscles is observed.

The role of inflammatory cytokines and nitric oxide in the pathogenesis of necrotizing enterocolitis

Purpose: The role of inflammatory cytokines in the pathogenesis of necrotizing enterocolitis (NEC) is still undefined. Elevated levels of interleukin (IL)-6 and tumor necrosis factor (TNF)-α have been measured in infants with NEC, while elevated levels of nitric oxide (NO) have been reported in newborn infants with clinical sepsis. However, the cellular source of the NO or cytokines is unknown. The authors hypothesized that local intestinal production of NO induced by cytokines may contribute to the pathogenesis of bowel necrosis in NEC by inducing apoptosis (programmed cell death) or necrosis of the enterocytes. We examined the levels of inflammatory cytokines and NO in the intestine of infants undergoing surgical resection for NEC, and the cellular localization of human inducible NO synthase (NOS-2) in the inflamed gut. Methods: We compared 15 patients undergoing bowel resection for NEC, with six infants (of similar age) undergoing intestinal resection for ileal atresia or stricture, meconium peritonitis, intussusception, or cecal perforation (control). Diagnosis of NEC was confirmed histologically. Representative segments of the surgical specimen were examined for messenger RNA (mRNA) for NOS-2 by Northern blotting and in situ hybridization. Cytokine mRNA was measured by polymerase chain reaction (PCR) because mRNA could not be detected by Northern blotting. The site of NO production was determined by in situ hybridization and immunohistochemistry. Apoptosis was measured using in situ DNA strand break extension (TUNEL). Nitrotyrosine immunoreactivity was assessed to determine if NO mediates cellular injury via peroxynitrite formation. Results: Messenger RNA for NOS-2 was detected in nearly all patients with NEC except for one infant who underwent proximal diverting jejunostomy alone, and who did not have histological evidence of NEC at that site. NOS-2 mRNA was detected less frequently in control patients. In situ hybridization and immunohistochemistry showed that the enterocytes were the predominant source of NOS-2 activity in the intestine of NEC patients. Extensive apoptosis was seen in enterocytes in the apical villi of infants with NEC, and correlated with nitrotyrosine staining. NOS-2 activity was markedly diminished at the time of stoma closure, but remained elevated in infants who died from progressive disease. PCR showed variable cytokine mRNA expression in the intestine. Transforming growth factor (TGF)-β expression was nearly identical in NEC and control. However, interferon (IFN)-γ was present in 9 of 10 NEC, but only in one of six control patients. Conclusion: The data show that NO is produced in large quantity by enterocytes in the intestinal wall of infants with NEC and leads to apoptosis of enterocytes in apical villi through peroxynitrite formation.

Colostomy closure.

One hundred and forty-seven colostomies were closed in 146 patients at Wellington Hospital between 1 January 1978 and 1 January 1987. The majority of stomata were formed in patients with colorectal cancer. At least one additional significant procedure was undertaken at the time of stoma closure in 10 patients. The overall complication rate was highest in those patients undergoing closure of a sigmoid end-colostomy (50%). Three complications resulted in death (2%). Twenty-four patients (16.3%) developed wound infections. Five patients developed 'leaks' (3.4%). The use of prophylactic antibiotics appeared to reduce the rate of infection significantly. The highest rates of wound infection and leakage occurred in patients in whom drains were used. Wound infections increased hospital stay. Thirty-one non-bowel or wound-related complications occurred in 25 patients.