Advertisement

Early ileostomy reversal after minimally invasive surgery and ERAS program for mid and low rectal cancer

  • Corrado Pedrazzani
  • Federica Secci
  • Eduardo Fernandes
  • Ivans Jelovskijs
  • Giulia Turri
  • Cristian Conti
  • Andrea Ruzzenente
  • Alfredo Guglielmi
Original Article

Abstract

Diverting loop ileostomy following low anterior resection (LAR) is known to decrease quality of life and prolongs the return back to patients’ baseline activity. The aim of this retrospective study was to explore feasibility and safety of an early ileostomy reversal strategy in a cohort of patients undergoing minimally invasive LAR within an enhanced recovery after surgery (ERAS) program. Prospectively collected data from 15 patients who underwent minimally invasive LAR and diverting ileostomy at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust between September 2015 and December 2016 were retrospectively analyzed. Of 15 patients, 10 patients underwent laparoscopic LAR and 5 patients a robot-assisted procedure. Post-operative complications were observed in 5 patients. Four patients suffered Clavien-Dindo grade 1 or 2 complications, and one patient required redo surgery due to bowel obstruction at the ileostomy site (grade 3b). Following ileostomy reversal, 10 out of 15 patients experienced complications. Two patients required redo surgery for bowel obstruction (grade 3b), whilst eight patients suffered grade 1 or 2 complications, being surgical site infection the most frequently observed (6 cases). Despite that, 80% of patients had their ileostomy reversed within 30 days and median time from initial surgery to ileostomy reversal was 22 days (range 10–150). Early ileostomy closure after minimally invasive LAR and ERAS program is feasible although it carries non-negligible risk of severe complications which, however, does not hinder its accomplishment.

Keywords

Rectal cancer Low anterior resection Laparoscopic surgery Robotic surgery Ileostomy closure 

Notes

Acknowledgements

Drs. Corrado Pedrazzani and Alfredo Guglielmi want to thank Dr. Lidia Biondani for the valuable help in the management of patients with ostomy and for cooperating in this study.

Compliance with ethical standards

Conflict of interest

Drs. Corrado Pedrazzani, Federica Secci, Eduardo Fernandes, Ivans Jelovskijs, Guido Mantovani, Cristian Conti, Enrico Lazzarini, Giulia Turri, and Alfredo Guglielmi have no conflicts of interest or financial ties to disclose.

Research involving human participants and/or animals

The research has complied with all National and institutional policies on the use of human subjects.

Informed consent

Informed consent was obtained from all patients, and the study was approved by the local ethic committee.

References

  1. 1.
    Hüser N, Michalski CW, Erkan M, Schuster T, Rosenberg R, Kleeff J, Friess H (2008) Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 248:52–60.  https://doi.org/10.1097/SLA.0b013e318176bf65 (Review) CrossRefPubMedGoogle Scholar
  2. 2.
    Tan WS, Tang CL, Shi L, Eu KW (2009) Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 96:462–472.  https://doi.org/10.1002/bjs.6594 (Review) CrossRefPubMedGoogle Scholar
  3. 3.
    Snijders HS, van Leersum NJ, Henneman D, de Vries AC, Tollenaar RA, Stiggelbout AM, Wouters MW, Dekker JW (2015) Optimal treatment strategy in rectal cancer surgery: should we be cowboys or chickens? Ann Surg Oncol 22:3582–3589.  https://doi.org/10.1245/s10434-015-4385-7 CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Zhang W, Lou Z, Liu Q, Meng R, Gong H, Hao L, Liu P, Sun G, Ma J, Zhang W (2017) Multicenter analysis of risk factors for anastomotic leakage after middle and low rectal cancer resection without diverting stoma: a retrospective study of 319 consecutive patients. Int J Colorectal Dis.  https://doi.org/10.1007/s00384-017-2875-8 CrossRefGoogle Scholar
  5. 5.
    Herrle F, Sandra-Petrescu F, Weiss C, Post S, Runkel N, Kienle P (2016) Quality of life and timing of stoma closure in patients with rectal cancer undergoing low anterior resection with diverting stoma: a multicenter longitudinal observational study. Dis Colon Rectum 59:281–290.  https://doi.org/10.1097/DCR.0000000000000545 CrossRefPubMedGoogle Scholar
  6. 6.
    Frouws MA, Snijders HS, Malm SH, Liefers GJ, Van de Velde CJH, Neijenhuis PA, Kroon HM (2017) Clinical relevance of a grading system for anastomotic leakage after low anterior resection: analysis from a national cohort database. Dis Colon Rectum 60:706–713.  https://doi.org/10.1097/DCR.0000000000000800 CrossRefPubMedGoogle Scholar
  7. 7.
    Borstlap WAA, Westerduin E, Aukema TS, Bemelman WA, Tanis PJ, Dutch Snapshot Research Group (2017) anastomotic leakage and chronic presacral sinus formation after low anterior resection: results from a large cross-sectional study. Ann Surg.  https://doi.org/10.1097/sla.0000000000002429 CrossRefGoogle Scholar
  8. 8.
    Chude GG, Rayate NV, Patris V, Koshariya M, Jagad R, Kawamoto J, Lygidakis NJ (2008) Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology 55:1562–1567PubMedGoogle Scholar
  9. 9.
    Chow A, Tilney HS, Paraskeva P, Jeyarajah S, Zacharakis E, Purkayastha S (2009) The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Colorectal Dis 24:711–723.  https://doi.org/10.1007/s00384-009-0660-z (Review) CrossRefPubMedGoogle Scholar
  10. 10.
    Robertson JP, Puckett J, Vather R, Jaung R, Bissett I (2015) Early closure of temporary loop ileostomies: a systematic review. Ostomy Wound Manag 61:50–57Google Scholar
  11. 11.
    Li W, Stocchi L, Cherla D, Liu G, Agostinelli A, Delaney CP, Steele SR, Gorgun E (2017) Factors associated with hospital readmission following diverting ileostomy creation. Tech Coloproctol. https://doi.org/10.1007/s10151-017-1667-zCrossRefGoogle Scholar
  12. 12.
    Silva MA, Ratnayake G, Deen KI (2003) Quality of life of stoma patients: temporary ileostomy versus colostomy. World J Surg 27:421–424CrossRefGoogle Scholar
  13. 13.
    Brown H, Randle J (2005) Living with a stoma: a review of the literature. J Clin Nurs 14:74–81 (Review) CrossRefGoogle Scholar
  14. 14.
    Neuman HB, Park J, Fuzesi S, Temple LK (2012) Rectal cancer patients’ quality of life with a temporary stoma: shifting perspectives. Dis Colon Rectum 55:1117–1124.  https://doi.org/10.1097/DCR.0b013e3182686213 CrossRefPubMedGoogle Scholar
  15. 15.
    Verweij NM, Hamaker ME, Zimmerman DD, van Loon YT, van den Bos F, Pronk A, Borel Rinkes IH, Schiphorst AH (2016) The impact of an ostomy on older colorectal cancer patients: a cross-sectional survey. Int J Colorectal Dis 32:89–94.  https://doi.org/10.1007/s00384-016-2665-8 CrossRefPubMedGoogle Scholar
  16. 16.
    Pakkastie TE, Ovaska JT, Pekkala ES, Luukkonen PE, Järvinen HJ (1997) A randomised study of colostomies in low colorectal anastomoses. Eur J Surg 163:929–933PubMedGoogle Scholar
  17. 17.
    Park JS, Choi GS, Lim KH, Jang YS, Jun SH (2010) Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes. Ann Surg Oncol 17:3195–3202.  https://doi.org/10.1245/s10434-010-1162-5 CrossRefPubMedGoogle Scholar
  18. 18.
    Pedrazzani C, Menestrina N, Moro M, Brazzo G, Mantovani G, Polati E, Guglielmi A (2016) Local wound infiltration plus transversus abdominis plane (TAP) block versus local wound infiltration in laparoscopic colorectal surgery and ERAS program. Surg Endosc 30:5117–5125CrossRefGoogle Scholar
  19. 19.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefGoogle Scholar
  20. 20.
    Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Büchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147:339–351.  https://doi.org/10.1016/j.surg.2009.10.012 (Review) CrossRefPubMedGoogle Scholar
  21. 21.
    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for prevention of surgical site infection. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 20:250–278CrossRefGoogle Scholar
  22. 22.
    Delaney CP, Kehlet H, Senagore AJ, Bauer AJ, Beart R, Billingham R, Coleman RL, Dozois EJ, Leslie JB, Marks J, Megibow AJ, Michelassi F, Steinbrook RA, On behalf of the Postoperative Ileus Management Council (PIMC) (2006) Postoperative ileus: profiles, risk factors and definitions. A framework for optimizing surgical outcomes in patients undergoing major abdominal and colorectal surgery. Clinical consensus update in general surgery. http://www.clinicalwebcasts.com/pdfs/GenSurg_WEB.pdf. Accessed 12 Dec 2013
  23. 23.
    Bakx R, Busch OR, van Geldere D, Bemelman WA, Slors JF, van Lanschot JJ (2003) Feasibility of early closure of loop ileostomies: a pilot study. Dis Colon Rectum 46:1680–1684CrossRefGoogle Scholar
  24. 24.
    Alves A, Panis Y, Lelong B, Dousset B, Benoist S, Vicaut E (2008) Randomized clinical trial of early versus delayed temporary stoma closure after proctectomy. Br J Surg 95:693–698.  https://doi.org/10.1002/bjs.6212 CrossRefPubMedGoogle Scholar
  25. 25.
    Kim MJ, Kim YS, Park SC, Sohn DK, Kim DY, Chang HJ, Oh JH (2016) Risk factors for permanent stoma after rectal cancer surgery with temporary ileostomy. Surgery 159:721–727.  https://doi.org/10.1016/j.surg.2015.09.011 CrossRefPubMedGoogle Scholar
  26. 26.
    Weise WJ, Serrano FA, Fought J, Gennari FJ (2008) Acute electrolyte and acid-base disorders in patients with ileostomies: a case series. Am J Kidney Dis 52:494–500.  https://doi.org/10.1053/j.ajkd.2008.04.015 CrossRefPubMedGoogle Scholar
  27. 27.
    Zhou MW, Wang ZH, Chen ZY, Xiang JB, Gu XD (2017) Advantages of early preventive ileostomy closure after total mesorectal excision surgery for rectal cancer: an institutional retrospective study of 123 consecutive patients. Dig Surg 34:305–311.  https://doi.org/10.1159/000452676 CrossRefPubMedGoogle Scholar
  28. 28.
    Robertson I, Leung E, Hughes D, Spiers M, Donnelly L, Mackenzie I, Macdonald A (2005) Prospective analysis of stoma-related complications. Colorectal Dis 7:279–285CrossRefGoogle Scholar
  29. 29.
    Poskus E, Kildusis E, Smolskas E, Ambrazevicius M, Strupas K (2014) Complications after loop ileostomy closure: a retrospective analysis of 132 patients. Viszeralmedizin 30:276–280.  https://doi.org/10.1159/000366218 CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Sier MF, van Gelder L, Ubbink DT, Bemelman WA, Oostenbroek RJ (2015) Factors affecting timing of closure and non-reversal of temporary ileostomies. Int J Colorectal Dis 30:1185–1192.  https://doi.org/10.1007/s00384-015-2253-3 CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Rubio-Perez I, Leon M, Pastor D, Diaz Dominguez J, Cantero R (2014) Increased post-operative complications after protective ileostomy closure delay: an institutional study. World J Gastrointest Surg 27(6):169–174.  https://doi.org/10.4240/wjgs.v6.i9.169 CrossRefGoogle Scholar
  32. 32.
    Van Westreenen HL, Visser A, Tanis PJ, Bemelman WA (2012) Morbidity related to defunctioning ileostomy closure after ileal pouch-anal anastomosis and low colonic anastomosis. Int J Colorectal Dis 27:49–54.  https://doi.org/10.1007/s00384-011-1276-7 CrossRefPubMedGoogle Scholar
  33. 33.
    Mennigen R, Sewald W, Senninger N, Rijcken E (2014) Morbidity of loop ileostomy closure after restorative proctocolectomy for ulcerative colitis and familial adenomatous polyposis: a systematic review. J Gastrointest Surg 18:2192–2200.  https://doi.org/10.1007/s11605-014-2660-8 Review CrossRefPubMedGoogle Scholar
  34. 34.
    Waterland P, Goonetilleke K, Naumann DN, Sutcliff M, Soliman F (2015) 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 7:685–689.  https://doi.org/10.14740/jocmr2150w CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Phatak UR, Kao LS, You YN, Rodriguez-Bigas MA, Skibber JM, Feig BW, Nguyen S, Cantor SB, Chang GJ (2014) Impact of ileostomy-related complications on the multidisciplinary treatment of rectal cancer. Ann Surg Oncol 21:507–512.  https://doi.org/10.1245/s10434-013-3287-9 CrossRefPubMedGoogle Scholar
  36. 36.
    Yin TC, Tsai HL, Yang PF, Su WC, Ma CJ, Huang CW, Huang MY, Huang CM, Wang JY (2017) Early closure of defunctioning stoma increases complications related to stoma closure after concurrent chemoradiotherapy and low anterior resection in patients with rectal cancer. World J Surg Oncol 15:80.  https://doi.org/10.1186/s12957-017-1149-9 CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Jordi-Galais P, Turrin N, Tresallet C, Nguyen-Thanh Q, Chigot JP, Menegaux F (2003) Early closure of temporary stoma of the small bowel. Gastroenterol Clin Biol 27:697–699 (French) PubMedGoogle Scholar
  38. 38.
    Danielsen AK, Park J, Jansen JE, Bock D, Skullman S, Wedin A, Marinez AC, Haglind E, Angenete E, Rosenberg J (2017) Early closure of a temporary ileostomy in patients with rectal cancer: a multicenter randomized controlled trial. Ann Surg 265:284–290.  https://doi.org/10.1097/SLA.0000000000001829 CrossRefPubMedGoogle Scholar
  39. 39.
    Hindenburg T, Rosenberg J (2010) Closing a temporary ileostomy within two weeks. Dan Med Bull 57:A4157 (Review) PubMedGoogle Scholar
  40. 40.
    Perdawid SK, Andersen OB (2011) Acceptable results of early closure of loop ileostomy to protect low rectal anastomosis. Dan Med Bull 58:A4280PubMedGoogle Scholar
  41. 41.
    Omundsen M, Hayes J, Collinson R, Merrie A, Parry B, Bissett I (2012) Early ileostomy closure: is there a downside? ANZ J Surg 82:352–354.  https://doi.org/10.1111/j.1445-2197.2012.06033.x CrossRefPubMedGoogle Scholar
  42. 42.
    Rathnayake MM, Kumarage SK, Wijesuriya SR, Munasinghe BN, Ariyaratne MH, Deen KI (2008) Complications of loop ileostomy and ileostomy closure and their implications for extended enterostomal therapy: a prospective clinical study. Int J Nurs Stud 45:1118–1121 Epub 2007 Dec 21 CrossRefGoogle Scholar

Copyright information

© Italian Society of Surgery (SIC) 2018

Authors and Affiliations

  1. 1.Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona Hospital TrustUniversity of VeronaVeronaItaly
  2. 2.Division of Minimally Invasive, General and Robotic SurgeryUniversity of Illinois at ChicagoChicagoUSA
  3. 3.Clinic of Surgical Oncology, Latvia Oncology Center, Riga Eastern University HospitalRiga Stradin UniversityRigaLatvia

Personalised recommendations