Retrospective study in a single unit: outcomes of delays in reversal of loop ileostomy
DOI:
https://doi.org/10.18203/2349-2902.isj20240566Keywords:
Loop ileostomy, Colorectal surgery, Reversal of ileostomyAbstract
Background: Formation of loop ileostomy is common after anterior resection to reduce the sequalae of an anastomosis leak. Delays to reversal of ileostomy is associated with complications.
Methods: Retrospective study between 1 July 2017 to 30 June 2023. Patients were included: >18 years old, loop ileostomy formed as part of anterior resection surgery (benign and malignant). Exclusion criteria: loop ileostomy performed during other colonic resections, patients with inflammatory bowel disease, de-functioning ileostomy for obstructions. Primary outcome measures included complications associated with delayed closure of loop ileostomy and readmissions after reversal surgery. Secondary measures included reasons for delay to surgery, complications prior to reversal surgery, and morbidity and mortality associated with it.
Results: 135 patients were included. 85.9% of patients experienced delays in reversal surgery. Those without delays in surgery had higher rate of stoma-related complications (p=0.002). Delays were due to a long waitlist (p<0.01) and adjuvant chemotherapy (p=0.598). There were no significant differences in the delays to surgery during COVID pandemic. Delays were associated with higher rate of wound infection (6.04%), post-operative ileus (12.07%), anastomotic leak (1.72%), and Clostridium difficile (C. diff) infection (3.45%). Handsewn end to end anastomosis was associated with higher proportion of post-operative ileus compared to the stapled side to side anastomosis group.
Conclusions: Reversal of ileostomy within 6 months of index surgery after adjuvant therapy could potentially reduce post-operative complications, and alleviate the burden on our healthcare system in the long run. A stapled side to side anastomosis should also be considered.
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References
Hüser N, Michalski CW, Erkan M, Schuster T, Rosenberg R, Kleeff J, et al. Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg. 2008;248(1):52-60.
Hajibandeh S, Hajibandeh S, Sarma DR, East J, Zaman S, Mankotia R, et al. Meta-analysis of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection: the dilemma remains. Int J Colorectal Disease. 2019;34(7):1151-9.
Dukes’ Club Research C. Factors impacting time to ileostomy closure after anterior resection: the UK closure of ileostomy timing cohort study (CLOSE-IT). Colorectal Disease. 2021;23(5):1109-19.
Massucco P, Fontana A, Mineccia M, Perotti S, Ciccone G, Galassi C, et al. Prospective, randomised, multicentre, open-label trial, designed to evaluate the best timing of closure of the temporary ileostomy (early versus late) in patients who underwent rectal cancer resection and with indication for adjuvant chemotherapy: the STOMAD (STOMa closure before or after ADjuvant therapy) randomised controlled trial. BMJ Open. 2021;11(2):e044692.
Barnard J, Milne T, Teo K, Weston M, Israel L, Peng SL. Causes and costs of delayed closure of ileostomies in rectal cancer patients in Australasian units. ANZ J Surg. 2023;93(3):636-42.
Keane C, Sharma P, Yuan L, Bissett I, O'Grady G. Impact of temporary ileostomy on long-term quality of life and bowel function: a systematic review and meta-analysis. ANZ Journal of Surgery. 2020;90(5):687-92.
Waterland P, Goonetilleke K, Naumann DN, Sutcliff M, Soliman F. Defunctioning Ileostomy Reversal Rates and Reasons for Delayed Reversal: Does Delay Impact on Complications of Ileostomy Reversal? A Study of 170 Defunctioning Ileostomies. J Clin Med Res. 2015;7(9):685-9.
Malik T, Lee MJ, Harikrishnan AB. The incidence of stoma related morbidity - a systematic review of randomised controlled trials. Ann R Coll Surg Engl. 2018;100(7):501-8.
Abdalla S, Scarpinata R. Early and Late Closure of Loop Ileostomies: A Retrospective Comparative Outcomes Analysis. Ostomy Wound Manage. 2018;64(12):30-5.
Rubio-Perez I, Leon M, Pastor D, Diaz Dominguez J, Cantero R. Increased postoperative complications after protective ileostomy closure delay: An institutional study. World J Gastrointest Surg. 2014;6(9):169-74.
Richards SJG, Udayasiri DK, Jones IT, Hastie IA, Chandra R, McCormick JJ, et al. Delayed ileostomy closure increases the odds of Clostridium difficile infection. Colorectal Dis. 2021;23(12):3213-9.
Khoo TW, Dudi-Venkata NN, Beh YZ, Bedrikovetski S, Kroon HM, Thomas ML, et al. Impact of timing of reversal of loop ileostomy on patient outcomes: a retrospective cohort study. Techn Coloproctol. 2021;25(11):1217-24.
Vaughan-Shaw PG, Gash K, Adams K, Vallance AE, Pilkington SA, Torkington J, et al. Protocol for a multicentre, dual prospective and retrospective cohort study investigating timing of ileostomy closure after anterior resection for rectal cancer: The CLOSurE of Ileostomy Timing (CLOSE-IT) study. BMJ Open. 2018;8(10):e023305.
Gustafsson CP, Gunnarsson U, Dahlstrand U, Lindforss U. Loop-ileostomy reversal-patient-related characteristics influencing time to closure. Int J Colorectal Dis. 2018;33(5):593-600.
Chand M, Nash GF, Talbot RW. Timely closure of loop ileostomy following anterior resection for rectal cancer. Eur J Cancer Care. 2008;17(6):611-5.
El-Hussuna A, Lauritsen M, Bülow S. Relatively high incidence of complications after loop ileostomy reversal. Dan Med J. 2012;59(10):A4517.
Farag S, Rehman S, Sains P, Baig MK, Sajid MS. Early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resections: an integrated systematic review and meta-analysis of published randomized controlled trials. Colorectal Disease. 2017;19(12):1050-7.
Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305(22):2335-42.
Menahem B, Lubrano J, Vallois A, Alves A. Early Closure of Defunctioning Loop Ileostomy: Is It Beneficial for the Patient? A Meta-analysis. World J Surg. 2018;42(10):3171-8.
Kuryba AJ, Scott NA, Hill J, Van Der Meulen JH, Walker K. Determinants of stoma reversal in rectal cancer patients who had an anterior resection between 2009 and 2012 in the English National Health Service. Colorectal Dis. 2016;18(6):O199-O205.
Turner GA, Clifford KA, Holloway R, Woodfield JC, Thompson‐Fawcett M. The impact of prolonged delay to loop ileostomy closure on postoperative morbidity and hospital stay: A retrospective cohort study. Colorectal Disease. 2022;24(7):854-61.
Lasithiotakis K, Aghahoseini A, Alexander D. Is Early Reversal of Defunctioning Ileostomy a Shorter, Easier and Less Expensive Operation? World J Surg. 2016;40(7):1737-40.
Beamish EL, Johnson J, Shih B, Killick R, Dondelinger F, McGoran C, et al. 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. Gut Microbes. 2023;15(1).
Winslet MC, Drolc Z, Allan A, Keighley MR. Assessment of the defunctioning efficiency of the loop ileostomy. Dis Colon Rectum. 1991;34(8):699-703.
Beamish EL, Johnson J, Shaw EJ, Scott NA, Bhowmick A, Rigby RJ. Loop ileostomy-mediated fecal stream diversion is associated with microbial dysbiosis. Gut Microbes. 2017;8(5):467-78.
Löffler T, Rossion I, Bruckner T, Diener MK, Koch M, von Frankenberg M, et al. HAnd Suture Versus STApling for Closure of Loop Ileostomy (HASTA Trial): results of a multicenter randomized trial (DRKS00000040). Ann Surg. 2012;256(5):828-35.
Rodríguez-Padilla Á, Morales-Martín G, Pérez-Quintero R, Gómez-Salgado J, Balongo-García R, Ruiz-Frutos C. Postoperative Ileus after Stimulation with Probiotics before Ileostomy Closure. Nutrients. 2021;13(2).
Leffler DA, Lamont JT. Clostridium difficile infection. N Engl J Med. 2015;372(16):1539-48.
Garfinkle R, Savage P, Boutros M, Landry T, Reynier P, Morin N, et al. Incidence and predictors of postoperative ileus after loop ileostomy closure: a systematic review and meta-analysis. Surg Endosc. 2019;33(8):2430-43.
Sajid MS, Craciunas L, Baig MK, Sains P. Systematic review and meta-analysis of published, randomized, controlled trials comparing suture anastomosis to stapled anastomosis for ileostomy closure. Tech Coloproctol. 2013;17(6):631-9.
Gong J, Guo Z, Li Y, Gu L, Zhu W, Li J, et al. Stapled vs hand suture closure of loop ileostomy: a meta-analysis. Colorectal Dis. 2013;15(10):e561-8.
Hasegawa H, Radley S, Morton DG, Keighley MR. Stapled versus sutured closure of loop ileostomy: a randomized controlled trial. Ann Surg. 2000;231(2):202-4.
Löffler T, Rossion I, Gooßen K, Saure D, Weitz J, Ulrich A, et al. Hand suture versus stapler for closure of loop ileostomy--a systematic review and meta-analysis of randomized controlled trials. Langenbecks Arch Surg. 2015;400(2):193-205.
Leung TT, MacLean AR, Buie WD, Dixon E. Comparison of stapled versus handsewn loop ileostomy closure: a meta-analysis. J Gastrointest Surg. 2008;12(5):939-44.
Alves A, Panis Y, Lelong B, Dousset B, Benoist S, Vicaut E. Randomized clinical trial of early versus delayed temporary stoma closure after proctectomy. Br J Surg. 2008;95(6):693-8.
Ellebæk MB, Perdawood SK, Steenstrup S, Khalaf S, Kundal J, Möller S, et al. Early versus late reversal of diverting loop ileostomy in rectal cancer surgery: a multicentre randomized controlled trial. Sci Rep. 2023;13(1):5818.
Hindenburg T, Rosenberg J. Closing a temporary ileostomy within two weeks. Dan Med Bull. 2010;57(6):A4157.
