Modified Approach for Extraperitoneal Colostomy Creation in Laparoscopic Abdominoperineal Resection.

BACKGROUND: Parastomal hernia is a major long-term complication after abdominoperineal resection. Extraperitoneal colostomy has been proposed as an effective step for parastomal hernia prevention, but it has not been widely used as it is technically demanding and time-consuming. We proposed a modified approach for extraperitoneal colostomy creation by entering the extraperitoneal space through the arcuate line of the posterior rectus sheath. OBJECTIVE: To evaluate the safety, difficulty, and efficacy of long-term parastomal hernia prevention of the modified approach for extraperitoneal colostomy creation compared with the conventional transperitoneal colostomy approach. DESIGN: This was a retrospective evaluation of a surgical and video database. SETTINGS: This was a single-institution retrospective study. PATIENTS: Clinical data of 74 patients who underwent laparoscopic abdominoperineal resection surgery from January 2019 to January 2020 in the Department of General Surgery, Qilu Hospital of Shandong University, were retrospectively reviewed. MAIN OUTCOME MEASURES: Baseline characteristics, time required for colostomy creation (from skin incision to colostomy maturation), perioperative complications, and long-term colostomy-related complications were compared. RESULTS: Baseline characteristics did not differ between the 2 approaches. The BMI level ranged from 19.5 to 29.4 for patients undergoing extraperitoneal approach. Time required for colostomy creation median [interquartile range], (22 [21-25] minutes for extraperitoneal vs 23 [21-25] minutes for transperitoneal, p = 0.861) were comparable between the 2 approaches. The cumulative incidence of parastomal hernia was significantly greater with transperitoneal colostomy than extraperitoneal colostomy at 2 and 3 years postoperatively (16.2% vs 0%, p = 0.025, and 21.6% vs 0%, p = 0.005). The remaining perioperative complications and long-term colostomy-related complications did not differ between the 2 approaches. LIMITATIONS: This study is limited by its retrospective design and small sample size. CONCLUSIONS: The modified approach for extraperitoneal colostomy creation is safe, technically simple, and effective for long-term parastomal hernia prevention in patients with a BMI of 19.5 to 29.4.

The Effect of a Temporary Stoma on Long-term Functional Outcomes Following Surgery for Rectal Cancer.

BACKGROUND: Patients with rectal cancer may undergo surgical resection with or without a temporary stoma. OBJECTIVE: This study primarily aimed to compare long-term functional outcomes between patients with and without a temporary stoma after surgery for rectal cancer. The secondary aim was to investigate the effect of time to stoma reversal on functional outcomes. DESIGN: This was a multicenter, cross-sectional study. SETTINGS: This study was conducted at 7 Dutch hospitals. PATIENTS: Included were patients who had undergone rectal cancer surgery (2009-2015). Excluded were deceased patients, who were deceased, had a permanent stoma, or had intellectual disability. MAIN OUTCOME MEASURES: Functional outcomes were measured using the Rome IV criteria for constipation and fecal incontinence and the low anterior resection syndrome score. RESULTS: Of 656 patients, 32% received a temporary ileostomy and 20% a temporary colostomy (86% response). Follow-up was at 56 (interquartile range, 38.5-79) months. Patients who had a temporary ileostomy experienced less constipation, more fecal incontinence, and more major low anterior resection syndrome than those without a temporary stoma. Patients who had a temporary colostomy experienced more major low anterior resection syndrome than those without a temporary stoma. A temporary ileostomy or colostomy was not associated with constipation or fecal incontinence after correction for confounding factors (eg, anastomotic height, anastomotic leakage, radiotherapy). Time to stoma reversal was not associated with constipation, fecal incontinence, or major low anterior resection syndrome. LIMITATIONS: Cross-sectional design. CONCLUSIONS: Although patients with a temporary ileostomy or colostomy have worse functional outcomes in the long term, it seems that the reason for creating a temporary stoma, rather than the stoma itself, underlies this phenomenon. Time to reversal of a temporary stoma does not influence functional outcomes. See Video Abstract . EL EFECTO DEL ESTOMA TEMPORAL SOBRE LOS RESULTADOS FUNCIONALES A LARGO PLAZO DESPUS DE LA CIRUGA POR CNCER DE RECTO: ANTECEDENTES:Los pacientes con cáncer de recto pueden someterse a resección quirúrgica con o sin un estoma temporal.OBJETIVO:El objetivo principal de este estudio fue comparar los resultados funcionales a largo plazo entre pacientes con y sin estoma temporal después de cirugía por cáncer de recto. El objetivo secundario fue investigar el efecto del tiempo transcurrido hasta la reversión del estoma sobre los resultados funcionales.DISEÑO:Este fue un estudio transversal multicéntrico.ESCENARIO:Este estudio se llevó a cabo en siete hospitales holandeses.PACIENTES:Se incluyeron pacientes sometidos a cirugía de cáncer de recto (2009-2015). Se excluyeron pacientes fallecidos, pacientes con estoma permanente o discapacidad intelectual.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados funcionales se midieron utilizando los criterios de Roma IV para el estreñimiento y la incontinencia fecal y la puntuación del síndrome de resección anterior baja (LARS).RESULTADOS:De 656 pacientes, el 32% recibió una ileostomía temporal y el 20% una colostomía temporal (respuesta del 86%). El seguimiento fue de 56.0 (RIQ 38.5-79.0) meses. Los pacientes a los que se les realizó una ileostomía temporal experimentaron menos estreñimiento, más incontinencia fecal y más LARS mayor que los pacientes sin un estoma temporal. Los pacientes que tuvieron una colostomía temporal experimentaron más LARS mayor que los pacientes sin un estoma temporal. Una ileostomía o colostomía temporal no se asoció con estreñimiento o incontinencia fecal después de la corrección de factores de confusión (p. ej., altura anastomótica, fuga anastomótica, radioterapia). El tiempo hasta la reversión del estoma no se asoció con estreñimiento, incontinencia fecal o LARS mayor.LIMITACIONES:El presente estudio está limitado por su diseño transversal.CONCLUSIONES:Aunque los pacientes con una ileostomía o colostomía temporal tienen peores resultados funcionales a largo plazo, parece que la razón para crear un estoma temporal, más que el estoma en sí, se asocia a este fenómeno. El tiempo hasta la reversión de un estoma temporal no influye en los resultados funcionales. (Traducción-Dr. Jorge Silva Velazco ).

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies.

BACKGROUND: The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence. OBJECTIVE: To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction. DATA SOURCES: A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023. STUDY SELECTION: Randomized controlled trials and propensity score-matched studies. INTERVENTIONS: Emergency colonic resection, self-expanding metallic stent, and decompressing stoma. MAIN OUTCOME MEASURES: Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates. RESULTS: Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively. LIMITATIONS: There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction. CONCLUSIONS: This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Pull-Through for Hirschsprung's Disease: Insights for Limited-Resource Settings From Mbarara.

INTRODUCTION: In many resource-limited settings, patients with Hirschsprung's Disease (HD) undergo initial diverting colostomy, followed by pull-through, and finally, colostomy closure. This approach allows for decompression of dilated and thickened bowel and improved patient nutritional status. However, this three-stage approach prolongs treatment duration, with significant stoma morbidity, costs, and impact on quality of life. Our aim was to determine whether pull-through for HD can safely be performed with simultaneous stoma closure, reducing treatment approach from three to two stages. METHODS: Children with HD and diverting colostomy were prospectively followed as they underwent pull-through with simultaneous stoma closure. Their in-hospital course and 3-mo outpatient course were assessed for postoperative complications. Patients with total colonic HD, redo pull-through, and residual dilated colon were excluded from the study. RESULTS: Of the 20 children, 17 were male (n = 17, 85%). All patients had rectosigmoid HD. The median weight, age at colostomy formation, and age at pull-through were 11.05 kg (interquartile range [IQR] 10-12.75), 0.9 y (IQR 0.25-2.8), and 2.08 y (IQR 1.28-2.75), respectively. Mean duration with colostomy before pull-through was 1.1 y (standard deviation 1.51). Median hospital length of stay was 6 d (IQR 5-7). Early complications included anastomotic leak (n = 1), perianal skin excoriation (n = 2), surgical site skin infection (n = 3), and fascial dehiscence (n = 1). Longer-term complications included stricture (n = 1, 5%) and enterocolitis (n = 2, 10%). CONCLUSIONS: In this small case series, we have demonstrated that pull-through with simultaneous stoma closure can be safely performed in resource-constrained settings. Further studies are needed to understand the quality of life and economic impact of this change in management for HD patients.

Primary Repair Versus Resection for AAST Grade I and II Colon Injuries: Does the Type of Repair Matter?

INTRODUCTION: The management of traumatic colon injuries has evolved over the past two decades. Recent evidence suggests that primary repair or resection over colostomy may decrease morbidity and mortality. Data comparing patients undergoing primary repair versus resection are lacking. We sought to compare the outcomes of patients undergoing primary repair versus resection for low-grade colon injuries. METHODS: A retrospective review of all patients who presented with American Association for the Surgery of Trauma grade I and II traumatic colon injuries to our Level I trauma center between 2011 and 2021 was performed. Patients were further dichotomized based on whether they underwent primary repair or resection with anastomosis. Outcome measures included length of stay data, infectious complications, and mortality. RESULTS: A total of 120 patients met inclusion criteria. The majority of patients (76.7%) were male, and the average age was 35.6 ± 13.1 y. Most patients also underwent primary repair (80.8%). There were no statistically significant differences between the groups in arrival physiology or in injury severity score. Length of stay data including hospital length of stay, intensive care unit length of stay, and ventilator days were similar between groups. Postoperative complications including pneumonia, surgical site infections, fascial dehiscence, the development of enterocutaneous fistulas, and unplanned returns to the operating room were also all found to be similar between groups. The group who underwent resection with anastomosis did demonstrate a higher rate of intra-abdominal abscess development (3.1% versus 26.1%, P < 0001). Mortality between both groups was not found to be statistically significant (7.2% versus 4.3%, P = 0.4) CONCLUSIONS: For low-grade (American Association for the Surgery of Trauma I and II) traumatic colon injuries, patients undergoing primary repair demonstrated a decreased rate of intra-abdominal abscess development when compared to patients who underwent resection with anastomosis.

From burden to relief: The economic and quality-of-life advantages of pseudo continent perineal colostomy in ultra-low rectal cancer patients.

BACKGROUND AND OBJECTIVE: Pseudo Continent Perineal Colostomy (PCPC) is an alternative technique to left iliac colostomy (LIC) after abdominoperineal resection for ultra low rectal cancer (ULRC). It allows placing the stoma in the perineum to preserve patients' body image. However, concerns about its impact on quality of life and management costs have limited its adoption. We aimed to compare the early outcomes and financial burden of PCPC and LIC in ULRC patients in Morocco, a low-middle-income country. METHODS: From January 2018 to December 2019, all patients who underwent abdomino-perineal resection (APR) with LIC or PCPC were prospectively enrolled. For each patient, baseline characteristics, and in hospital and 90 days morbidity with a focus on perineal complications were reported. Quality of life (QOL) was assessed using the validated EORTC-C30 and CR29 questionnaires. Financial burden to patients was reported using declarative out-of-pocket costs (OOPC) analysis. RESULTS: Among 49 patients who underwent APR, 33 received PCPC and 16 received definitive LIC. Similar rates of early perineal complications were observed between the two groups (p = 0.49). Readmission rate at POD90 was higher in the LIC-group due to perineal sepsis (p = 0.09). QOL analysis at 6 months revealed that patients with PCPC had a higher global health status (p = 0.006), a better physical functioning and reported fewer symptoms of flatulence and fecal incontinence (p = 0.001). Patients with a LIC reported more financial difficulties with higher median OOPC of stoma management up to €23 versus €0 per month for PCPC (p = 0.0024). PCPC was the only predictive factor of improved patient reported outcomes. CONCLUSIONS: PCPC is a cost-effective alternative to the standard definitive colostomy without alteration of the QOL or additional perineal complications during the first 6 months following the surgery. These findings may help convince surgeons to offer this option to patients refusing definitive LIC.

Operative trends following the adoption of nonoperative management of rectal cancer.

BACKGROUND: Differentiating clinical near-complete and complete responses (cCR) after neoadjuvant therapy (NT) is challenging in rectal cancer patients. We hypothesized that magnetic resonance imaging staging limitations for low rectal cancers may increase the proportion of abdominoperineal resection (APR) with permanent colostomy for those without a cCR. METHODS: Single institution retrospective analysis of rectal cancer cases before and after adoption of nonoperative "watch and wait" (W&W) pathway. APR as a percentage of rectal resections was the primary outcome. RESULTS: There were 76 total mesorectal excisions (TME) in the pre-W&W group and 98 in the post-W&W group. NT was significantly more common in the post-W&W group. There was no significant difference in the APR primary outcome (pre-W&W APR 33.3% vs. post-W&W APR 26.5%, p = 0.482). APR patients had fewer complete TME grades (69.2% vs. 46.2%) and more pathologic complete responses (0% vs. 26.9%) in the post-W&W period. The cCR rate for patients with nonoperative management was 51.4% (n = 37) and 13.5% (n = 5) had regrowths, all of whom underwent salvage surgery. CONCLUSION: APR for those without a cCR to NT has not increased in the nonoperative management era. Balancing the pathologic complete response rate may require restaging some patients with clinical near-complete responses.

Similar success rate in proximal and distal colonic stent placement: a retrospective multi-center study.

OBJECTIVES: Stenting of malignant colon obstruction is used as a bridge to surgery or as an alternative to surgical colostomy in a palliative setting. Current guidelines recommend stent placement as the first line of treatment in colonic obstruction in both curative and palliative settings. However, it is unclear whether the location of the malignant obstruction influences the outcome of the stenting procedure. The goal of this study was to compare the outcomes of colonic stents between proximal and distal colonic strictures with regard to technical and clinical success and the risk of adverse events. METHODS: A multi-center retrospective cohort was composed of patients who underwent a colonic stent placement at two tertiary hospitals between 2013 and 2021. The technical and clinical outcome, stent type used, duration of post-procedural hospital stay and complications were noted. RESULTS: A total of 148 patients who underwent colonic stenting were identified. 41 patients underwent stent placement in the proximal colon and 107 patients underwent a distal stent placement. There was no difference in technical success (100% vs 96.3%, p = 0.209), clinical success (97.0% vs 89.6%, p = 0.199) or complications (24.4% vs 37.4%, p = 0,135). CONCLUSION: Technical success and clinical success rates are high and do not differ between stent locations. There is no significant difference in complication rates between proximal and distal colonic stents.

Low Hartmann's procedure versus abdominoperineal resection for rectal cancer, a propensity score matching cohort study.

BACKGROUND: This study aimed to compare low Hartmann's procedure (LHP) with abdominoperineal resection (APR) for rectal cancer (RC) regarding postoperative complications. METHOD: RC patients receiving radical LHP or APR from 2015 to 2019 in our center were retrospectively enrolled. Patients' demographic and surgical information was collected and analyzed. Propensity score matching (PSM) was used to balance the baseline information. The primary outcome was the incidence of major complications. All the statistical analysis was performed by SPSS 22.0 and R. RESULTS: 342 individuals were primarily included and 134 remained after PSM with a 1:2 ratio (50 in LHP and 84 in APR). Patients in the LHP group were associated with higher tumor height (P < 0.001). No significant difference was observed between the two groups for the incidence of major complications (6.0% vs. 1.2%, P = 0.290), and severe pelvic abscess (2% vs. 0%, P = 0.373). However, the occurrence rate of minor complications was significantly higher in the LHP group (52% vs. 21.4%, P < 0.001), and the difference mainly lay in abdominal wound infection (10% vs. 0%, P = 0.006) and bowel obstruction (16% vs. 4.8%, P = 0.028). LHP was not the independent risk factor of pelvic abscess in the multivariate analysis. CONCLUSION: Our data demonstrated a comparable incidence of major complications between LHP and APR. LHP was still a reliable alternative in selected RC patients when primary anastomosis was not recommended.

Meta-analysis: loop ileostomy versus colostomy to prevent complications of anterior resection for rectal cancer.

PURPOSE: Anastomotic leakage is a serious complication of colorectal cancer surgery, prolonging hospital stays and impacting patient prognosis. Preventive colostomy is required in patients at risk of anastomotic fistulas. However, it remains unclear whether the commonly used loop colostomy(LC) or loop ileostomy(LI) can reduce the complications of colorectal surgery. This study aims to compare perioperative morbidities associated with LC and LI following anterior rectal cancer resection, including LC and LI reversal. METHODS: In this meta-analysis, the Embase, Web of Science, Scopus, PubMed, and Cochrane Library databases were searched for prospective cohort studies, retrospective cohort studies, and randomized controlled trials (RCTs) on perioperative morbidity during stoma development and reversal up to July 2023, The meta-analysis included 10 trials with 2036 individuals (2 RCTs and 8 cohorts). RESULTS: No significant differences in morbidity, mortality, or stoma-related issues were found between the LI and LC groups after anterior resection surgery. However, patients in the LC group exhibited higher rates of stoma prolapse (RR: 0.39; 95%CI: 0.19-0.82; P = 0.01), retraction (RR: 0.45; 95%CI: 0.29-0.71; P < 0.01), surgical site infection (RR: 0.52; 95%CI: 0.27-1.00; P = 0.05) and incisional hernias (RR: 0.53; 95%CI: 0.32-0.89; P = 0.02) after stoma closure compared to those in the LI group. Conversely, the LI group showed higher rates of dehydration or electrolyte imbalances(RR: 2.98; 95%CI: 1.51-5.89; P < 0.01), high-output(RR: 6.17; 95%CI: 1.24-30.64; P = 0.03), and renal insufficiency post-surgery(RR: 2.51; 95%CI: 1.01-6.27; P = 0.05). CONCLUSION: Our study strongly recommends a preventive LI for anterior resection due to rectal cancer. However, ileostomy is more likely to result in dehydration, renal insufficiency, and intestinal obstruction. More multicenter RCTs are needed to corroborate this.

Clostridium difficile infection after stoma reversal surgery: a systematic review and meta-analysis of the literature.

BACKGROUND: Clostridium difficile infection (CDI) has been described in the early post-operative phase after stoma reversal. This systematic review aimed to describe the incidence of CDI after stoma reversal and to identify pre-operative variables correlated with an increased risk of infection. METHODS: A systematic review of the literature was conducted according to the PRISMA guidelines in March 2024. Manuscripts were included if reported at least one patient with CDI-associated diarrhoea following stoma reversal (colostomy/ileostomy). The primary outcome of interest was the incidence of CDI; the secondary outcome was the comparison of clinical variables (age, sex, time to stoma reversal, neo-adjuvant and adjuvant therapies after index colorectal procedure) in CDI-positive versus CDI-negative patients. A meta-analysis was performed when at least three studies reported on those variables. RESULTS: Out of 43 eligible manuscripts, 1 randomized controlled trial and 10 retrospective studies were selected, including 17,857 patients (2.1% CDI). Overall, the mean age was 64.3 ± 11.6 years in the CDI group and 61.5 ± 12.6 years in the CDI-negative group (p = 0.51), with no significant difference in sex (p = 0.34). Univariable analyses documented that the mean time to stoma reversal was 53.9 ± 19.1 weeks in CDI patients and 39.8 ± 15.0 weeks in CDI-negative patients (p = 0.40) and a correlation between neo-adjuvant and adjuvant treatments with CDI (p < 0.001). A meta-analysis was performed for time to stoma reversal, age, sex, and neo-adjuvant therapies disclosing no significant differences for CDI (stoma delay, MD 11.59; 95%CI  24.32-1.13; age, MD 0.97; 95%CI 2.08-4.03; sex, OR1.11; 95%CI 0.88-1.41; neo-adjuvant, OR0.81; 95%CI 0.49-1.35). Meta-analysis including patients who underwent adjuvant therapy evidenced a higher risk of CDI (OR 2.88; 95%CI 1.01-8.17, p = 0.11). CONCLUSION: CDI occurs in approximately 2.1% of patients after stoma reversal. Although a trend of increased delay in stoma reversal and a correlation with chemotherapy were documented in CDI patients, the use of adjuvant therapy was the only possible risk factor documented on meta-analysis. PROSPERO REGISTRATION NUMBER: CRD42023484704.

Development and pilot testing of a patient-reported outcome measure to assess symptoms of parastomal hernia.

AIM: The aim was to develop and pilot a patient-reported outcome measure (PROM) to assess symptoms of parastomal hernia (PSH). METHODS: Standard questionnaire development was undertaken (phases 1-3). An initial list of questionnaire domains was identified from validated colorectal cancer PROMs and from semi-structured interviews with patients with a PSH and health professionals (phase 1). Domains were operationalized into items in a provisional questionnaire, and 'think-aloud' patient interviews explored face validity and acceptability (phase 2). The updated questionnaire was piloted in patients with a stoma who had undergone colorectal surgery and had a computed tomography scan available for review. Patient-reported symptoms were examined in relation to PSH (phase 3). Three sources determined PSH presence: (i) data about PSH presence recorded in hospital notes, (ii) independent expert review of the computed tomography scan and (iii) patient report of being informed of a PSH by a health professional. RESULTS: For phase 1, 169 and 127 domains were identified from 70 PROMs and 29 interviews respectively. In phase 2, 14 domains specific to PSH were identified and operationalized into questionnaire items. Think-aloud interviews led to three minor modifications. In phase 3, 44 completed questionnaires were obtained. Missing data were few: 5/660 items. PSH symptom scores associated with PSH presence varied between different data sources. The scale with the most consistent differences between PSH presence and absence and all data sources was the stoma appearance scale. CONCLUSION: A PROM to examine the symptoms of PSH has been developed from the literature and views of key informants. Although preliminary testing shows it to be understandable and acceptable it is uncertain if it is sensitive to PSH-specific symptoms and further psychometric testing is needed.

Ostomy continence devices: a systematic review of the literature and meta-analysis.

AIM: Colostomy complication rates range widely from 10% to 70%. The psychological burden on patients, leading to lifestyle changes and decreased quality of life (QoL), is one of the largest factors. The aim of this work was to assess the history and efficacy of ostomy continence devices in improving continence and QoL. METHOD: In this PRISMA-compliant systematic review and meta-analysis, we searched PubMed, Scopus, Google Scholar and clinicaltrials.gov for studies on continence devices for all ostomies up to April 2023. Primary outcomes were continence and improvement in QoL. Secondary outcomes were leakage, patient's device preference and complications. Risk of Bias 2 and the revised tool to assess risk of bias in non-randomized studies of interventions (ROBINS-1) were used to assess risk of bias. Certainty of evidence was graded using GRADE. RESULTS: Twenty-two studies assessed devices from 1978 to 2022. The two main types identified were ball-valve devices and plug systems. Conseal and Vitala were the two main devices with significant evidence allowing for pooled analyses. Conseal, the only currently marketed device, had a pooled rate of continence of 67.4%, QoL improvement was 74.9%, patient preference over a traditional appliance was 69.1%, leakage was 10.1% and complications was 13.7%. Since 2011, five studies have investigated experimental devices on both human and animal models. CONCLUSION: Ostomy continence has been a long-standing goal without a consistently reliable solution. We propose that selective and short-term usage of continence devices may lead to improved continence and QoL in ostomy patients. Further research is needed to develop a reliable daily device for ostomy continence. Future investigation should include the needs of ileostomates.

Postoperative outcomes and identification of risk factors for complications after emergency intestinal stoma surgery - a multicentre retrospective study.

AIM: Approximately 4000 patients in the UK have an emergency intestinal stoma formed each year. Stoma-related complications (SRCs) are heterogeneous but have previously been subcategorized into early or late SRCs, with early SRCs generally occurring within 30 days postoperatively. Early SRCs include skin excoriation, stoma necrosis and high output, while late SRCs include parastomal hernia, retraction and prolapse. There is a paucity of research on specific risk factors within the emergency cohort for development of SRCs. This paper aims to describe the incidence of SRCs after emergency intestinal surgery and to identify potential risk factors for SRCs within this cohort. METHOD: Consecutive patients undergoing emergency formation of an intestinal stoma (colostomy, ileostomy or jejunostomy) were identified prospectively from across three acute hospital sites over a 3-year period from the ELLSA (Emergency Laparotomy and Laparoscopic Scottish Audit) database. All patients were followed up for a minimum of 1 year. A multivariate logistic regression model was used to identify risk factors for early and late SRCs. RESULTS: A total of 455 patients were included (median follow-up 19 months, median age 64 years, male:female 0.52, 56.7% ileostomies). Early SRCs were experienced by 54.1% of patients, while 51% experienced late SRCs. A total of 219 patients (48.1%) had their stoma sited preoperatively. Risk factors for early SRCs included end ileostomy formation [OR 3.51 (2.24-5.49), p < 0.001], while preoperative stoma siting was found to be protective [OR 0.53 (0.35-0.83), p = 0.005]. Patient obesity [OR 3.11 (1.92-5.03), p < 0.001] and reoperation for complications following elective surgery [OR 4.18 (2.01-8.69), p < 0.001] were risk factors for late SRCs. CONCLUSION: Stoma-related complications after emergency surgery are common. Preoperative stoma siting is the only truly modifiable risk factor to reduce SRCs, and further research should be aimed at methods of improving the frequency and accuracy of this in the emergency setting.

Postoperative morbidity following Hartmann's procedure in comparison to anterior resection and abdominoperineal resection for rectal cancer-a population-based study.

AIM: There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry. METHODS: All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry. RESULTS: A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality. CONCLUSIONS: For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.

Long-term restoration of bowel continuity after rectal cancer resection and the influence of surgical technique: A nationwide cross-sectional study.

AIM: Literature on nationwide long-term permanent stoma rates after rectal cancer resection in the minimally invasive era is scarce. The aim of this population-based study was to provide more insight into the permanent stoma rate with interhospital variability (IHV) depending on surgical technique, with pelvic sepsis, unplanned reinterventions and readmissions as secondary outcomes. METHOD: Patients who underwent open or minimally invasive resection of rectal cancer (lower border below the sigmoid take-off) in 67 Dutch centres in 2016 were included in this cross-sectional cohort study. RESULTS: Among 2530 patients, 1470 underwent a restorative resection (58%), 356 a Hartmann's procedure (14%, IHV 0%-42%) and 704 an abdominoperineal resection (28%, IHV 3%-60%). Median follow-up was 51 months. The overall permanent stoma rate at last follow-up was 50% (IHV 13%-79%) and the unintentional permanent stoma rate, permanent stoma after a restorative procedure or an unplanned Hartmann's procedure, was 11% (IHV 0%-29%). A total of 2165 patients (86%) underwent a minimally invasive resection: 1760 conventional (81%), 170 transanal (8%) and 235 robot-assisted (11%). An anastomosis was created in 59%, 80% and 66%, with corresponding unintentional permanent stoma rates of 12%, 24% and 14% (p = 0.001), respectively. When corrected for age, American Society of Anesthesiologists classification, cTNM, distance to the anorectal junction and neoadjuvant (chemo)radiotherapy, the minimally invasive technique was not associated with an unintended permanent stoma (p = 0.071) after a restorative procedure. CONCLUSION: A remarkable IHV in the permanent stoma rate after rectal cancer resection was found. No beneficial influence of transanal or robot-assisted laparoscopy on the unintentional permanent stoma rate was found, although this might be caused by the surgical learning curve. A reduction in IHV and improving preoperative counselling for decision-making for restorative procedures are required.

Effects of a perioperative educational pathway on ostomy self-care, level of independence and need for visiting nurse services: a comparative observational cohort study.

AIM: Most new ostomy patients are not able to manage ostomy self-care when they are discharged and rely on visiting nurse services for ostomy care. The aim of this study was to determine if a perioperative ostomy educational pathway increases the level of independence and decreases the need for visiting nurse services in new ostomy patients. METHOD: A prospective longitudinal study was conducted between July 2018 and February 2020. Patients who received a colostomy or ileostomy and were treated on the surgery ward were included. Patients who followed a perioperative ostomy educational pathway were compared to a historical control group. The primary outcome measure was the level of independence in ostomy care and the need for visiting nurse services. RESULTS: After discharge, 67.6% of patients in the intervention group (n = 244) were able to independently perform ostomy care and were therefore not relying on visiting nurse services, compared to 15.2% of the patients in the control group (n = 33). The need for visiting nurse services was higher in patients aged ≥70 years (OR 3.20, P < 0.001), those who did not attend the preoperative practice session (OR 3.02, P = 0.002), those with a history of transient ischaemic attack (OR 10.22, P = 0.045) and those with mild cognitive impairment (OR 28.98, P = 0.002). CONCLUSION: A perioperative ostomy educational pathway effectively increased the level of independence and decreased the need for visiting nurse services in new ostomy patients.

The PROPHER study: patient-reported outcomes after parastomal hernia treatment-a prospective international cohort study.

AIM: A significant proportion of stoma patients develop a parastomal hernia (PSH), with reported rates varying widely from 5% to 50% due to heterogeneity in the definition and mode of diagnosis. PSHs are symptomatic in 75% of these patients, causing a significant impact on quality of life due to issues with appliance fitting, leakage, skin excoriation and pain. They can also lead to emergency presentations with strangulation and obstruction. Evidence is lacking on how to select patients for surgical intervention or conservative treatment. In those who do undergo surgery, the best operation for a particular patient or PSH is not always clear and many options exist. The aim of this study is to assess the impact of an individual patient's PSH treatment on their subsequent self-reported outcomes including treatment success and quality of life. METHODS: This is a prospective international cohort study of PSH treatment, including both operative and non-operative interventions. A global network of clinicians and specialist nurses will recruit 1000-1500 patients and centralize detailed information, their individual background and their PSH treatment, as well as short-term outcomes up to 30 days. Patients will then provide their own outcomes data including quality of life and whether their treatment was successful, via a secure online system, at 3, 6 and 12 months. PROPHER will be run in two phases: an internal pilot phase of at least 10 hospitals from up to five countries, and a main phase of up to 200 hospitals from across the European Society of Coloproctology network. DISCUSSION: This study will provide a wealth of contemporaneous information which will improve our ability to counsel patients and facilitate improved selection of appropriate and personalized interventions for those with a PSH.

Better stoma care using the Stoma App: does it help? A first randomized double-blind clinical trial on the effect of mobile healthcare on quality of life in stoma patients.

BACKGROUND: Receiving a stoma significantly impacts patients' quality of life. Coping with this new situation can be difficult, which may result in a variety of physical and psychosocial problems. It is essential to provide adequate guidance to help patients cope with their stoma, as this positively influences self-efficacy in return. Higher self-efficacy reduces psychosocial problems increasing patient's quality of life. This study investigates whether a new mobile application, the Stoma App, improves quality of life. And if personalized guidance, timed support, and peer contact offered as an in-app surplus makes a difference. METHODS: A double-blind, randomized controlled trial was conducted between March 2021 and April 2023. Patients aged > 18 years undergoing ileostomy or colostomy surgery, in possession of a compatible smartphone were included. The intervention group received the full version of the app containing personalized and time guidance, peer support, and generic (non-personalized) stoma-related information. The control group received a restricted version with only generic information. Primary outcome was stoma quality of life. Secondary outcomes included psychological adaption, complications, re-admittance, reoperations, and length of hospital stay. RESULTS: The intervention version of the app was used by 96 patients and the control version by 112 patients. After correction for confounding, the intervention group reported a significant 3.1-point improvement in stoma-related quality of life one month postoperatively (p = 0.038). On secondary outcomes, no significant improvements could be retrieved of the intervention group. CONCLUSION: The Stoma App improves the quality of life of stoma patients. Peer support and personalized guidance are of significant importance in building self-efficacy. It is to be recommended to implement Stoma app-freely available software qualifying as a medical device-in standard stoma care pathways for the benefits of both patients and healthcare providers.

Primary anastomosis with diverting loop ileostomy vs. Hartmann's procedure for acute diverticulitis: what happens after discharge? Results of a nationwide analysis.

BACKGROUND: Current guidelines recommend resection with primary anastomosis with diverting loop ileostomy over Hartmann's procedure if deemed safe for acute diverticulitis. The primary objective of the current study was to compare the utilization of these strategies and describe nationwide ostomy closure patterns and readmission outcomes within 1 year of discharge. METHODS: This was a retrospective, population-based, cohort study of United States Hospitals reporting to the Nationwide Readmissions Database from January 2011 to December 2019. There were 35,774 patients identified undergoing non-elective primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis. Rates of ostomy closure, unplanned readmissions, and complications were compared. Cox proportional hazards and logistic regression models were used to control for patient and hospital-level confounders as well as severity of disease. RESULTS: Of the 35,774 patients identified, 93.5% underwent Hartmann's procedure. Half (47.2%) were aged 46-65 years, 50.8% female, 41.2% publicly insured, and 91.7% underwent open surgery. Primary anastomosis was associated with higher rates of 1-year ostomy closure (83.6% vs. 53.4%, p < 0.001) and shorter time-to-closure [median 72 days (Interquartile range 49-103) vs. 115 (86-160); p < 0.001]. Primary anastomosis was associated with increased unplanned readmissions [Hazard Ratio = 2.83 (95% Confidence Interval 2.83-3.37); p < 0.001], but fewer complications upon stoma closure [Odds Ratio 0.51 (95% 0.42-0.63); p < 0.001]. There were no differences in complications between primary anastomosis and Hartmann's procedure during index admission [Odds Ratio = 1.13 (95% Confidence Interval 0.96-1.33); p = 0.137]. CONCLUSION: Patients who undergo primary anastomosis for acute diverticulitis are more likely to undergo ostomy reversal and experience fewer postoperative complications upon stoma reversal. These data support the current national guidelines that recommend primary anastomosis in appropriate cases of acute diverticulitis requiring operative treatment.