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Loop Ileostomy Reversal After Colon and Rectal Surgery a Single Institutional 5-Year Experience in 944 Patients

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Loop Ileostomy Reversal After Colon and Rectal Surgery a Single Institutional 5-Year Experience in 944 Patients ORIGINAL ARTICLE Loop Ileostomy Reversal After Colon and Rectal Surgery A Single Institutional 5-Year Experience in 944 Patients Gaetano Luglio, MD; Rajesh Pendlimari, MBBS; Stefan D. Holubar, MD; Robert R. Cima, MD, MA; Heidi Nelson, MD Background: Diverting loop ileostomy is used to miti- American Society of Anesthesiologists class III or IV. In- gate the sequelae of anastomotic dehiscence. dications for the initial operation were ulcerative colitis (49.5%), rectal cancer (27.5%), diverticular disease (6.8%), Objective: To report the rate of complications after il- and other (16.1%). Anastomotic technique for reversal eostomy reversal using standardized definitions to aid phy- was sutured fold-over in 466 patients (49.4%), stapled sicians who are deciding whether to divert anastomo- in 315 (33.4%), and handsewn end to end in 163 (17.3%). ses. After reversal, the mean time to first bowel movement, tolerance of soft diet, and discharge from hospital was Methods: Patients who underwent diverting loop ileos- 2.6, 3.7, and 5.2 days, respectively. Handsewn cases had tomy closure from January 1, 2005, through February 28, longer operative times and longer times to bowel move- 2010, were identified using a prospective database. Peri- ment, soft diet, and discharge. Overall, complications oc- operative variables and 30-day outcomes were re- curred in 203 patients (21.5%), including 45 patients viewed. Complications were graded according to the Cla- (4.8%) who experienced a major complication; there were vien-Dindo Classification, in which grade III, IV, or V no deaths within 30 days. represents major complications. Univariate analysis as- sessed the relationship between operative variables and Conclusion: Ileostomy closure is associated with a low surgical outcomes. rate of major grade III and IV complications and should be reserved for patients who have a predicted postop- Results: A total of 944 patients underwent reversal: 43.1% erative major complication rate of 5% or more without were women, the mean age was 47.2 years, the mean body diversion. mass index (calculated as weight in kilograms divided by height in meters squared) was 25.7, and 18.5% were Arch Surg. 2011;146(10):1191-1196 HE NEED FOR FECAL DIVER- as anterior resection, in which surgeons sion in colorectal surgery is must individualize the decision regard- highly variable and influ- ing fecal diversion because the leak rates enced not only by the site are highly variable (3%-23%).11-20 In such of the anastomosis but also cases, risk adjustments often are made by preoperative and intraoperative risk fac- at the time of surgery. Telem and col- T 21 tors. For some procedures, such as ul- leagues describe a model of 5 intraop- tralow anterior resection, coloanal anas- erative risk factors and propose that proxi- tomosis, or ileal pouch anal anastomosis, mal diversion should be considered for the risk of anastomotic leak is high enough patients with 3 or more intraoperative risk factors. Taken together, the current lit- erature provides baseline leak rates for spe- See Invited Critique cific procedures and provides risk adjust- at end of article ment models that allow surgeons to estimate the anastomotic leak rate for a Author Affiliations: Division of (13% for ileal pouch anal anastomosis and given procedure in a given patient. What Colon and Rectal Surgery, Mayo 11% for coloanal anastomosis)1,2 to war- is missing are more precise data on rates Clinic, Rochester, Minnesota rant routine fecal diversion, whereas for (Drs Luglio, Pendlimari, Cima, of serious and/or major long-term com- and Nelson); and others (eg, right, left, and sigmoid resec- plications that can occur as a result of sec- Dartmouth-Hitchcock Medical tions), the risk is sufficiently low (1%- ondary stoma reversal procedures; that is, Center, Lebanon, New 7%) that fecal diversion is rarely indi- events that would counterbalance the ben- Hampshire (Dr Holubar). cated.3-10 There are other procedures, such efits of diversion. We know that the cre- ARCH SURG/ VOL 146 (NO. 10), OCT 2011 WWW.ARCHSURG.COM 1191 ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 ation of stomas can cause transient problems with high tions (grade III, IV, or V) after ileostomy reversal. The second- stoma output and dehydration as well as local stoma com- ary end point was an evaluation of the differences in short- plications, such as prolapse and hernias.22,23 What we do term outcomes between the various ileostomy reversal not know are the rates of major complications from stoma techniques using univariate analysis. The software JMP 8.0 (SAS reversal using standardized tools to quantitate the com- Institute Inc, Cary, North Carolina) was used for all descrip- tive and comparative statistical analyses. plication severity. We, therefore, studied a large prospec- Our practice approach is, in general, to reverse diverting il- tive database to more precisely quantitate the risk of ma- eostomy no less than 12 weeks after the primary operation. Gen- jor (grades III-V) postoperative complications following eral surgery residents and colorectal surgery fellows operated loop ileostomy reversal using the Clavien-Dindo classi- under the guidance of attending physicians during all proce- fication system. dures. Three main closure techniques were used. The FO tech- nique was performed leaving the mesenteric side of the small METHODS bowel intact and closing the small bowel enterotomy in a trans- verse fashion, using a double-layer technique with absorbable This study was approved by the Mayo Clinic Institutional Re- or slowly absorbable suture material. view Board. A prospective colorectal divisional database was The ST technique, which is typically used after a limited used to identify all patients from January 1, 2005, through Feb- small-bowel resection, used a linear stapler (75 or 100 mm), ruary 28, 2010, who underwent loop ileostomy reversal. Pa- approximating the antimesenteric border of the ileum, fol- tients who underwent concurrent abdominal procedures at the lowed by a reload of the stapler, according to surgeon prefer- time of ileostomy reversal were excluded. Baseline character- ence. The EE technique was performed when a small-bowel re- istics included age, sex, body mass index (calculated as weight section was considered necessary, and handsewn EE was in kilograms divided by height in meters squared), American constructed in a standard double-layer fashion using absorb- Society of Anesthesiologists status, and the primary diagnosis. able or slowly absorbable suture material. These techniques were Operative data included operative time (in minutes), type of performed either by local site incision—that is, when only an incision (local site or midline), presence of parastomal hernia, elliptical or circular incision was made around the stoma to per- and ileostomy reversal technique as follows: sutured fold-over form the closure—or by a midline incision as needed, either closure of the small bowel without resection (FO), resection before or during attempted reversal via the local site. with stapled closure with side-to-side anastomosis (ST), and resection with handsewn end-to-end anastomosis (EE). Op- RESULTS erative data at the time of ileostomy construction included the mode of surgery (minimally invasive surgery or open lapa- rotomy) and use of adhesion barrier material. Minimally inva- During the 5-year study period, 944 patients who un- sive surgery techniques included laparoscopic-assisted sur- derwent reversal of loop ileostomy were included: 466 gery, hand-assisted laparoscopic surgery, and robotic-assisted (49.4%) by FO technique, 315 (33.4%) by ST tech- laparoscopic surgery. nique, and 163 (17.3%) by EE technique. Patient demo- Short-term (30-day) postoperative outcomes included days graphic characteristics are shown in Table 1. The mean to bowel movement, days to tolerate soft diet, and postopera- age and body mass index were 47.2 years and 25.7, re- tive length of hospital stay. Overall morbidity, reoperation, and spectively. Age and body mass index were slightly lower readmission rates were identified. Overall morbidity included in the FO subgroup, but the 3 subgroups had similar pre- both surgical and medical complications, which were retro- spectively graded using the Clavien-Dindo staging system.24,25 operative American Society of Anesthesiologists physi- The overall morbidity is reflective of the number of patients cal status. The most common primary diagnoses were ul- who had at least 1 complication; that is, patients who had at cerative colitis (49.5%), rectal cancer (27.5%), and least 1 complication were counted only once, and only their diverticular disease (6.8%); primary diagnoses were sig- highest-grade complication was counted. In the present study, nificantly different among the subgroups. major complications were defined as those of grade III or higher Operative variables are presented in Table 2. The over- (ie, grade III, IV, or V—those requiring at least endoscopic, ra- all mean (SD) operative time for ileostomy reversal was diographic, or surgical intervention). 98(35) minutes, and the EE technique took longer than In addition to the standard Clavien-Dindo classification, the the others. The local site was used as the sole incision in following surgical complications were described: ileus/partial 96.5% of the patients, and a significantly higher propor- small-bowel obstruction (defined as the inability to tolerate oral feedings after eating a regular diet and/or 5 or more days of noth- tion of the FO operations were performed through the ing to eat or drink or radiologic evidence of dilated small bowel, local site. Parastomal hernia was identified during ileos- not requiring reoperation), small-bowel obstruction requiring tomy closure in 4.2% of the patients. At the time of il- reoperation, volvulus requiring reoperation, anastomotic leak eostomy construction, a minimally invasive surgery tech- (confirmed at abdominal exploration or abdominal imaging), nique was used in 51.9% of patients.
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