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EXPERIENCE WITH EARLY VERSUS ROUTINE ENTERIC STOMA CLOSURES: A COMPARATIVE STUDY.

Byline: Nadeem Ali Shah, Ainul Hadi, Mussarat Hussain, Mohammad Kalim, Tahira Mehreen, Inayat Shah and Juweria Abid

ABSTRACT

Objectives: To compare the outcome of enteric stoma closure within two, four and eight weeks of its formation.

Methodology: A total of 283 patients with loop enteric stomas were considered for the study in the Department of Surgery, Lady Reading Hospital, Peshawar, from March 2000 to March 2005. They were divided into group A, B (intervention groups) and C (control group) in which stoma were closed at 2, 4 and 8 weeks of its formation respectively. Resection of stoma with end to end anastomosis of the gut was done in a single layer interrupted extra mucosal technique using 3/0 PDS. Results in term of successful healing or complication were recorded and analyzed. Follow up was arranged at 30th and 90th day of discharge from hospital.

Results: Healing of stoma was achieved in 84.38% of patients in group A, 93.18% in group B and 95.16% in group C. Commonest complication was anastomotic leak that responded to conservative management in 3.13% of patients in Group A, 6.81% in group B and 2.42% in group C. Anastomotic leak needing re-exteriorization was found in 6.25% of patients in group A, none in group B and 1.45% in group C. There was no mortality in any of the three groups.

Conclusion: Early stoma closure, preferably during the same admission is a safe, cost effective and an attractive technique.

Key Words: Enteric stoma, Ileo-colostomy, Colostomy, Early stoma closure, Anastomosis, Anastomotic leak

INTRODUCTION

Temporary diverting stomas are made to protect distal gut repairs or injuries for different gut pathologies. However, it is associated with well-recognized morbidity, cost and unproven need for a delay in its closure1. "When is the best time to close this stoma" is a debatable issue among surgeons. In the absence of major intra-abdominal sepsis, malnutrition or major wound problems, early stoma closure can be safely carried out2,3. The concept of early stoma closure is attractive and is readily accepted by the patient4. Early closure is however more technically demanding and is associated with greater blood loss5. Ileostomy/colostomy is a high medical priority in this era of stringent financial budgeting and every attempt should be made to close it as early as possible. This is especially needed if complication like leak around the appliance, skin excoriation, prolapse and problems with its high output occurs6.

In developing countries, poor nutrition and problems with the unreliable supply of stoma collecting appliances (i.e. colostomy bags) is a very tempting reason for its early closure7. This study aims to find out the safety of early stoma closure.

METHODOLOGY

This study is conducted in the surgical wards of Lady Reading Hospital from march 2008 to march 2014.A total number of 293 patients (203 male and 90 female), who had exteriorization of enteric stomas for different reasons were considered for closure and the study. Their ages ranged from 13 years to 75 years with a mean age of 35 years.

They were divided into group A and B (intervention groups) and C (control group), in which the stomas were closed at 2, 4 and 8 weeks of its formation respectively. Only loop stomas were considered for the study. The randomization sequence was obtained by a threecard test in which the patient picked up one of three envelopes. Each envelope contained one card that had written either Group A, B or C. The three groups were similar with respect to pre-operative demographics. The commonest cause of stoma formation in all the three groups was fire arm injuries. Results in term of success and complications were recorded and analyzed. Exclusion criteria included patients who needed a permanent stoma, patients with inflammatory bowel disease, major intra-abdominal sepsis or wound infection, poor nutritional state or patient with polytrauma and abdominal tuberculosis. 10 patients did not give consent to be included in the study and were excluded.

The level of stoma were classified roughly as proximal (within the proximal 25cm of small gut), middle and distal (within the distal 25cm of small gut) including ileo-colic (comprising the distal ileum and any part of the colon) and colostomy.

Patients were fully hydrated and their Hemoglobin (Hb) and serum albumin levels were corrected before surgery. Distal loop study was done in all cases and then the distal gut was washed with 2-3 liters of anti-grade N/saline solution to clean it from remaining barium. Patients were kept on fluid diet for 48 hours and a laxative was added before 24 hours to clean the proximal gut in all patients. The stoma was mobilized, ends resected and end-to-end single layer, extra-mucosal, interrupted closure done using 3/0 PDS. The defect in abdominal wall at the stoma site was left open in group A and B for five days and closed after words if there were no complications. In control group C it was closed primarily.

All patient groups were continued on I/V plabolyte TDS, I/V ceftriaxone 1Gram BD, I/V metronidazole TDS and effective N/G suction for 72 hours. All patients were allowed sips orally if they have passed flatus and there were no abdominal distention, tachycardia or fever. They were discharged usually on 7th post-operative day if there were no complications. They were asked to come for follow up on 30th and 90th day of discharge. Data was collected on a standard proforma made for this study and was maintained for entries till 90 post-operative day for further data entry. Results were tabulated as shown in the results.

RESULTS

A total of 283 patients were considered for the study. The number of patients in group A was 32(11.31%), group B 44(15.55%) and control group 207(73.14%). The level of stoma and its closure time are shown in table 1. The causes for stoma formation are shown in table 2.

In group A successful closure was achieved in 28 patients (84.38%), in group B in 40 patients (93.18%) and in control group it was in 197 patients (95.16%). The incidence of Anastomotic leak that responded to conservative management in group A was 1 patient (3.13%), in group B 3 patients (6.81%) and in control group 5 patients (2.42%). Anastomotic leak needing re exteriorization in group A was 2 patients (6.25%), none in group B and 3 patients (1.45%) in group C.

The incidence of intestinal obstruction and peritonitis needing laparotomy in group A was 1 patient (3.13%), group B none and control group C 1 patient (0.48%). There was no mortality in any of the three groups. Complications are shown in table 3.

DISCUSSION

The idea of early closure of enteric stoma sparked from a decision to close an unmanageable jejunostomy at 2 weeks of its formation. The first to question the timing of stoma closure was Boyden who in 1995 objected the closure of colostomy for diverticulitis related stomas at 3 to 9 month of its formation8. The reported overall complication rate of stoma closure at conventional timing of 2-3 months is between 12 to 20% with a 30 day mortality of 7%9-11.

Early closure reduces stoma related morbidity, improves quality of life and still protects the purpose for which it is served9-12. However when a complicated stoma, i.e. the one with gangrene, stenosis, prolapse or skin excoriation were closed, its post-operative course was not smooth13.

An uncomplicated stoma can be closed as early as at 11th day of its formation with no morbidity and mortality9-14.

The results of various studies comparing early vs. late closure show no difference in complication rate2-6. On the other hand some finds that the complication rate of colic and ileocolic stoma closure is not related to the timing of closure15. Loop ileostomies should in particular be closed early if adjuvant chemotherapy is being planned for a distal disease process16. However some authors advocate that the cutoff value for increased risk of developing post-operative complications is 8 weeks, below which the risk of such occurrence is significantly higher with sensitivity rate of 88%17,18.

Table 1: Distribution of patients in various groups

Site of stoma###Group A###Group B###Group C###Total

Proximal###10(31.25%)###6(13.63%)###10(4.83%)###26(9.19%)

Middle###2(6.25%)###16(36.36%)###40(19.32%)###58(20.5%)

Distal###10(31.25%)###10(22.72%)###112(54.11%)###132(46.64%)

Colostomy###10(31.25%)###12(27.27%)###45(21.74%)###67(23.67%)

Total###32###44###207###283

Table 2: Reasons for stoma formation in various groups

Reasons for stoma formation###Group A###Group B###Group C###Total

Fire arm injuries###17(6.01%)###19(6.71%)###149(52.65%)###185

Covering stoma for distal repairs###8(2.83%)###12(4.24%)###22(7.77%)###42

Resection-exteriorization of gut gan-###5(1.77%)###10(0.35%)###30(10.6%)###45

grene/volvulus

Exteriorized other gut perforations###2(0.71%)###3(1.06%)###6(2.12%)###11

Total###32###44###207###283

Table 3: Outcome of surgery in all the groups

Complications###Group A###Group B###Group C

Successful Cases###27(84.38%)###41(93.18%)###197(95.16%)

Anastomotic Leak Managed Conservatively###1(3.13)###3(6.81%)###5(2.42%)

Anastomotic Leak that needed Re-exteriorization###2(6.25%)###0###3(1.45%)

Intestinal Obstruction that needed Laparotomy###1(3.13%)###0###1(0.48%)

Peritonitis that needed Laparotomy###1(3.13%)###0###1(0.48%)

Closure of colic or ileo-colic stoma can be associated with a significant complication rate and even mortality and should not be considered a minor procedure10. According to some authors the results of closure is considered to be dependent on timing and technique of closure10.

Generally speaking a delay of at least 2-3 months between stoma formation and closure is recommended if the risk factors for a complicated stoma are present such as advance age, Diabetes, hypo-albuminemia, steroid dependence, tuberculosis, peritonitis or complications following primary intervention as well as high injury severity score. Otherwise, stoma closure earlier than 3 months carries no additional morbidity or mortality20.

In our study successful healing of anastomosis was achieved in 27(84.38%), 41(93.18%) and 197(95.16%) of patients in group A, B and C respectively.

The commonest complication in all the three groups was anastomotic leak found in 3(9.37%), 3(6.81%) and 8(3.86%) respectively. The reported incidence of fecal fistula in literature for early and late closure is far higher than what we have found23. This is probably because of our technique of excising the edematous and infected end of stoma before end to end anastomosis is carried out. Other complications like intestinal obstruction and peritonitis were negligible.

We had no mortality in this series and this is very encouraging if compared to work done by others21-23. The concept of so called same admission small/large gut stoma closure is not a new one and has been reported in the literature since long22-24.

Early stoma closure is based on sound principles of collagen synthesis at the margins of gut and wound, which is in proliferative phase at seven to eleven days24. This ensures better anastomotic and wound healing.

The rationale behind routine closure of small and large gut stoma at 2-3 months is to achieve an optimal nutritional state, allow healing of distal repairs and subsidence of infection and inflamation24. In our experience if the distal loop studies are normal and patient is otherwise fit and in good health, early closure of stoma is an attractive option that is welcomed by the patient and his attendants. This not only saves patient from the demoralizing effects of a stoma but also reduce the financial burden on him that he sustains in term of purchasing the collecting appliances, readmissions for complications of stoma and its closure and loss of an early return to his job. Further multicenter trials are needed to confirm our results.

CONCLUSION

Early stoma closure, preferably during the same admission is a safe, cost effective and an attractive technique.

REFERENCES

1. Nelken N, Lewis F. the influence of injury severity on complication rate after primary closure of colostomy for penetrating colon trauma. Ann Surg 1989; 209: 439-47

2. Danielsen AK, Park J, Jansen JE, Bock D, Skullman S, Wedin A, et al. Early closure of a temporary ileostomy in patients with rectal cancer: a multicenter randomized controlled trial. Ann Surg 2016 Jun 17. [Epub ahead of print]

3. Livingston DH, Miller FB, Richardson JD. Are the risk of colostomy closure exaggerated? Am J Surg 1989;158: 17-20.

4. Lewis A, Weeden D. Early closure of transverse loop colostomies. Ann R Coll Surg Engl 1982;64: 57-58.

5. Mosdell DM, Doberneck RC. morbidity and mortality of ostomy closure. Am J Surg 1991; 162: 633-66.

6. Danielsen AK1, Correa-Marinez A, Angenete E, Skullmann S, Haglind E, Rosenberg J; Early closure of temporary ileostomy-the EASY trial: protocol for a randomised controlled trial. Br Med J Open. 2011; 1: 162. Edwards DP, Chisholm EM, Donaldson DR. Closure of transverse loop colostomy and loop Ileostomy. Ann R Coll Surg Engl 1998; 80: 33-5.

7. Boyden AM. The surgical treatment of diverticulitis of colon. Ann Surg 1950;132: 94-109.

8. Makela JT, Turku PH, Laitinen ST. Analysis of late stomal complications following ostomy surgery. Ann Chir Gynaecol 1997;86: 305-10.

9. Freund HR, Raniel J, Muggia-Sulam M. Factors affecting the morbidity of colostomy closure: a retrospective study. Dis Colon rectum 1982; 25: 712-5.

10. Garber HI, Morris DM, Eisenstat TE, Coker DD, Annous MO. Factors influencing the morbidity of colostomy closure. Dis Colon Rectum 1982; 25: 462-70.

11. Bakx R, Busch OR, van Geldere D, Bemelman WA, Slors JF, van Lanschot JJ. Feasibility of early closure of loop ileostomies: a pilot study. Dis Colon Rectum 2003; 46: 1680-4.

12. Bakx R, Busch ORC, Bemelman WA, Veldink GJ, Slors JFM, van Lanschot JJ. Morbidity of temporary loop ileostomies. Dig Surg 2004; 21: 277-81.

13. Menegaux F, Jordi-Galais P, Turrin N, Chigot JP. Closure of small bowel stoma on post operative day 10. Eur J Surg 2002; 168: 713-15

14. Alves A1, 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: 693-8.

15. Musemeche CA, Kosloki Am, Ricketts RR. Enterostomy in nectrotizing enterocolitis: an analysis of techniques and timing of closure. J Pediatr Surg 1987; 22: 497-83.

16. Lordon JT, Heywood R, Shirol S, Edwards DP. Following anterior resection of rectal cancer, de-functioning Ileostomy closure may be significantly delayed by adjuvant chemotherapy retrospective study. Colorectal Dis 2007; 9: 420-22.

17. Kuijpers JH. [Gastrointestinal surgery and gastroenterology] Stoma and stomal surgery. Ned Tijdschr Geneeskd 2001; 145: 1144-8.

18. Perez RO, Habr-Gama A, Seid VE, Proscurshim I, Sousa AH, Kiss DR, et al. Loop Ileostomy morbidity: timing of closure matters. Dis colon Rectum 2006; 49: 1539-45.

19. Maurer CA, Schilling MK. Rekonstruktionszeitpunkt nach stomaanlage im Darmtrakt. Acta Chir Aust 2001; 33: 284-7.

20. Worni M, Witschi A, Gloor B, Candinas D, Laffer UT, Kuehni CE. Early closure of ileostomy is associated with less postoperative nausea and vomiting. Dig Surg 2011; 28: 417-23.

21. Thal ER, Yeary EC. Morbidity of colostomy closure following colon trauma. J Trauma 1980; 20: 287-91.

22. Renz BM, Feliciano DV, Sherman R. same admission colostomy closures (SACC). A new approach to rectal wound: A prospective study. Ann Surg 1993; 218: 279-92.

23. Aston CM. Everett WG. Comparison of early and late closure of transverse loop colostomies. Ann R Coll Surg Eng 1984; 66: 331-3.

24. Forester DW, Spence VA, Walker WF. Colonic mucosalsubmucosal blood flow and the incidence of fecal fistula formation following colostomy closure. Br J Surg 1981; 68: 541-4.

25. Geoghegan JG, Rosenburg IL. Experience with early anastomosis after Hartmann procedure. Ann R Coll Surg Engl 1991; 73: 80-2.

26. Blomquist P, Jiborn H, Zederfieldt B. Effect of diverting colostomy on collagen metabolism in the colonic wall. Studies in rat. Am J Surg 1985; 149: 330-3.
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Publication:Journal of Postgraduate Medical Institute
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2016
Words:2884
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