Comparison of stapled versus handsewn loop ileostomy closure

“The purpose of this study was to compare the rates of small bowel obstruction, anastomotic complications, and wound infections between stapled and handsewn closures of loop ileostomies. The diverting loop ileostomy is a commonly used stoma, often employed to diminish the consequences of an anastomotic leak in low colorectal anastomoses, ileal pouch-anal anastomoses, and in situations where reversible patient factors increase the risk of an anastomotic dehiscence. They are also used to divert the fecal stream in the event of an anastomotic leak and, occasionally, in severe fistulizing perianal disease.”

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The surgical management of purulent peritonitis from perforated diverticulitis

Oberkofler CE, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012 Nov; 256(5):819-26; discussion 826-7.

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Results: Patient demographics were equally distributed in both groups (Hinchey III: 76% vs 75% and Hinchey IV: 24% vs 25%, for HP vs PA, respectively). The overall complication rate for both resection and stoma reversal operations was comparable (80% vs 84%, P = 0.813). Although the outcome after the initial colon resection did not show any significant differences (mortality 13% vs 9% and morbidity 67% vs 75% in HP vs PA), the stoma reversal rate after PA with diverting ileostomy was higher (90% vs 57%, P = 0.005) and serious complications (Grades IIIb-IV: 0% vs 20%, P = 0.046), operating time (73 minutes vs 183 minutes, P < 0.001), hospital stay (6 days vs 9 days, P = 0.016), and lower in-hospital costs (US $16,717 vs US $24,014) were significantly reduced in the PA group.

Conclusions: This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis.

Thornell A, et al. Laparoscopic Lavage for Perforated Diverticulitis With Purulent Peritonitis: A Randomized Trial. Ann Intern Med. 2016 Feb 2;164(3):137-45.

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LL vs Hartmann

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Considerations in stoma reversal

Sherman KL, Wexner SD. Considerations in Stoma Reversal. Clin Colon Rectal Surg. 2017 Jul;30(3):172-177.

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Temporary stomas are frequently used in the management of diverticulitis, colorectal cancer, and inflammatory bowel disease. These temporary stomas are used to try to mitigate septic complications from anastomotic leaks and to avoid the need for reoperation. Once acute medical conditions have improved and after the anastomosis has been proven to be healed, stomas can be reversed. Contrast enemas, digital rectal examination, and endoscopic evaluation are used to evaluate the anastomosis prior to reversal. Stoma reversal is associated with complications including anastomotic leak, postoperative ileus, bowel obstruction, enterocutaneous fistula, and, most commonly, surgical site infection. Furthermore, many stomas, which were intended to be temporary, may not be reversed due to postoperative complications, adjuvant therapy, or prohibitive comorbidities.

Decreasing hospital readmission in ileostomy patients: Results of novel pilot program

Shaffer VO, Owi T, Kumarusamy MA, Sullivan PS, Srinivasan JK, Maithel SK, Staley CA, Sweeney JF, Esper G. Decreasing Hospital Readmission in Ileostomy Patients: Results of Novel Pilot Program. J Am Coll Surg. 2017 Apr;224(4):425-430.

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BACKGROUND: Nearly 30% of patients with newly formed ileostomies require hospital readmission from severe dehydration or associated complications. This contributes to significant morbidity and rising healthcare costs associated with this procedure. Our aim was to design and pilot a novel program to decrease readmissions in this patient population.

STUDY DESIGN: An agreement was established with Visiting Nurse Health System (VNHS) in March 2015 that incorporated regular home visits with clinical triggers to institute surgeon-supervised corrective measures aimed at preventing patient decompensation associated with hospital readmissions. Thirty-day readmission data for patients managed with and without VNHS support for 10.5 months before and after implementation of this new program were collected.

RESULTS: Of 833 patients with small bowel procedures, 162 were ileostomies with 47 in the VNHS and 115 in the non-VNHS group. Before program implementation, VNHS (n = 24) and non-VNHS patients (n = 54) had similar readmission rates (20.8% vs 16.7%). After implementation, VNHS patients (n = 23) had a 58% reduction in hospital readmission (8.7%) and non-VNHS patient hospital readmissions (n = 61) increased slightly (24.5%). Total cost of readmissions per patient in the cohort decreased by >80% in the pilot VNHS group.

CONCLUSIONS: Implementation of a novel program reduced the 30-day readmission rate by 58% and cost of readmissions per patient by >80% in a high risk for readmission patient population with newly created ileostomies. Future efforts will expand this program to a greater number of patients, both institutionally and systemically, to reduce the readmission-rate and healthcare costs for this high-risk patient population.

Pathogenesis of diversion colitis

This week’s discussions included the causes of diversion colitis.

Tominaga K, et al. Diversion colitis and pouchitis: A mini-review. World J Gastroenterol. 2018 Apr 28;24(16):1734-1747.

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“The basic mechanisms underlying diversion colitis are still unclear. Glotzer hypothesized that it might be the result of bacterial overgrowth, the presence of harmful bacteria, nutritional deficiencies, toxins, or disturbance in the symbiotic relationship between luminal bacteria and the mucosal layer[2]. Reportedly, concentrations of carbohydrate-fermenting anaerobic bacteria and pathogenic bacteria are reduced in de-functioned colons[5,23,53] and these reports indicate that the overgrowth of anaerobic bacteria or a pathogenic bacterium is unlikely to be an important etiological factor. On the other hand, there is an increase of nitrate-reducing bacteria in patients with diversion colitis[7] and nitrate-reducing bacteria produce nitric oxide (NO) which plays a protective role in low concentrations, but at higher levels it becomes toxic to the colonic tissue[54]. Thus, it has been suggested that increases in nitrate-reducing bacteria may result in toxic levels of NO, leading to the diversion colitis.” (Tominaga, 2018, p. 1739)

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