Is diverting loop ileostomy necessary for completion proctectomy with ileal pouch-anal anastomosis? A multicenter randomized trial of the GETAID Chirurgie group (IDEAL trial): rationale and design (NCT03872271).

BACKGROUND: There is no quality evidence of the benefit of defunctioning ileostomy (DI) in ileal pouch-anal anastomoses (IPAAs) performed for inflammatory bowel disease (IBD), but most surgical teams currently resort to DI. In the case of a staged procedure with subtotal colectomy first, completion proctectomy with IPAA is performed for healthy patients, namely, after nutritional support, inflammation reduction and immunosuppressive agent weaning. Therefore, the aim of this trial is to assess the need for systematic DI after completion proctectomy and IPAA for IBD. METHODS/DESIGN: This is a multicenter randomized open trial comparing completion proctectomy and IPAA without (experimental) or with (control) DI in patients presenting with ulcerative colitis or indeterminate colitis. Crohn's disease patients will not be included. The design is a superiority trial. The main objective is to compare the 6-month global postoperative morbidity, encompassing both surgical and medical complications, between the two groups. The morbidity of DI closure will be included, as appropriate. The sample size calculation is based on the hypothesis that the overall 6-month morbidity rate is 30% in the case of no stoma creation (i.e., experimental group) vs. 55% otherwise (control group). With the alpha risk and power are fixed to 0.05 and 0.80, respectively, and considering a dropout rate of 10%, the objective is set to 194 patients. The secondary objectives are to compare both strategies in terms of morbi-mortality at 6 months and functional results as well as quality of life at 12 months, namely, the 6-month major morbidity and unplanned reoperation rates, 6-month anastomotic leakage rate, 6-month mortality, length of hospital stay, 6-month unplanned readmission rate, quality of life assessed 3 and 12 months from continuity restoration (i.e., either IPAA or stoma closure), functional results assessed 3 and 12 months from continuity restoration, 12-month pouch results, 12-month cost-utility analysis, and 12-month global morbidity. DISCUSSION: The IDEAL trial is a nationwide multicenter study that will help choose the optimal strategy between DI and no ileostomy in completion proctectomy with IPAA for IBD. TRIAL REGISTRATION: ClinicalTrial.gov: NCT03872271, date of registration March 13th, 2019.

System-Wide Improvement for Transitions After Ileostomy Surgery: Can Intensive Monitoring of Protocol Compliance Decrease Readmissions? A Randomized Trial.

BACKGROUND: Hospital readmission is common after ileostomy formation and frequently associated with dehydration. OBJECTIVE: This study was conducted to evaluate a previously published intervention to prevent dehydration and readmission. DESIGN: This is a randomized controlled trial. SETTING: This study was conducted in 3 hospitals within a single health care system. PATIENTS: Patients undergoing elective or nonelective ileostomy as part of their operative procedure were selected. INTERVENTION: Surgeons, advanced practice providers, inpatient and outpatient nurses, and wound ostomy continence nurses participated in a robust ileostomy education and monitoring program (Education Program for Prevention of Ileostomy Complications) based on the published intervention. After informed consent, patients were randomly assigned to a postoperative compliance surveillance and prompting strategy that was directed toward the care team, versus usual care. OUTCOME MEASURES: Unplanned hospital readmission within 30 days of discharge, readmission for dehydration, acute renal failure, estimated direct costs, and patient satisfaction were the primary outcomes measured. RESULTS: One hundred patients with an ileostomy were randomly assigned. The most common indications were rectal cancer (n = 26) and ulcerative colitis (n = 21), and 12 were emergency procedures. Although intervention patients had better postdischarge phone follow-up (90% vs 72%; p = 0.025) and were more likely to receive outpatient intravenous fluids (25% vs 6%; p = 0.008), they had similar overall hospital readmissions (20.4% vs 19.6%; p = 1.0), readmissions for dehydration (8.2% vs 5.9%; p = 0.71), and acute renal failure events (10.2% vs 3.9%; p = 0.26). Multivariable analysis found that weekend discharges to home were significantly associated with readmission (OR, 4.5 (95% CI, 1.2-16.9); p = 0.03). Direct costs and patient satisfaction were similar. LIMITATIONS: This study was limited by the heterogeneous patient population and by the potential effect of the intervention on providers taking care of patients randomly assigned to usual care. CONCLUSIONS: A surveillance strategy to ensure compliance with an ileostomy education program tracked patients more closely and was cost neutral, but did not result in decreased hospital readmissions compared with usual care. See Video Abstract at http://links.lww.com/DCR/A812.

Outcome and Cost Analysis of Hand-Sewn and Stapled Anastomoses in the Reversal of Loop Ileostomy.

Diverting loop ileostomies are common procedures for protecting high-risk anastomoses. There is little consensus on the most ideal technique both in terms of cost efficiency and outcome. Data for this study were collected from 101 patients who underwent loop ileostomy reversal between 2009 and 2014 at Morristown Medical Center. Of the 101 patients included in the review, 57 received a hand-sewn anastomosis (HS-A) and 44 received a stapled anastomosis (S-A). Average total hospital charges for stapled anastomoses were significantly greater than that for hand-sewn anastomoses, as were total operating room supply costs. When the total cost of the operation itself was considered, S-A cases were still found to be significantly greater than HS-A cases. Hospital room charges, total lab charges, pathology charges, and EKG/ECG charges were all greater for S-A cases than HS-A cases. Overall costs were greater for S-As than hand-sewn anastomoses and because of a lack of difference in procedure length, stapler supply costs were not offset. Complication rates and length of stay were also similar between the techniques. We found S-A cases to be more costly and have a greater cost/hour than HS-A cases.

Prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials.

BACKGROUND: Previous meta-analyses of randomised controlled trials (RCTs) have suggested a reduction in parastomal hernias (PSH) with prophylactic mesh. However, concerns persist regarding variably supportive evidence and cost. We performed an updated systematic review and meta-analysis to inform a novel cost-effectiveness analysis. METHODS: The PubMed, EMBASE and Cochrane Centre Register of Controlled Trials databases were searched (February 2018). We included RCTs assessing mesh reinforcement during stoma formation. We assessed PSH rates, subsequent repair, complications and operative time. Odds ratios (OR) and numbers needed to treat (NNT) were generated on intention to treat (ITT) and per protocol (PP) bases. These then informed cost analysis using 2017 UK/USA reimbursement rates and stoma care costs. RESULTS: Eleven RCTs were included. Four hundred fifty-three patients were randomised to mesh (PP 412), with 454 controls (PP 413). Six studies used synthetic meshes, three composite and two biological (91.7% colostomies; 3.64% ileostomies, 4.63% not specified). Reductions were seen in the number of hernias detected clinically and on computed tomography scan. For the former, ITT OR was 0.23 (95% confidence interval 0.11-0.51; p = 0.0003; n = 11); NNT 4.17 (2.56-10.0), with fewer subsequent repairs: OR 0.29 (0.13-0.64; p = 0.002; n = 7; NNT16.7 (10.0-33.3). Reductions persisted for synthetic and composite meshes. Operative time was similar, with zero incidence of mesh infection/fistulation, and fewer peristomal complications. Synthetic mesh demonstrated a favourable cost profile, with composite approximately cost neutral, and biological incurring net costs. CONCLUSIONS: Reinforcing elective stomas with mesh (primarily synthetic) reduces subsequent PSH rates, complications, repairs and saves money. We recommend that future RCTs compare mesh subtypes, techniques, and applicability to emergency stomas.

Randomized Trial on Fast Track Care in Colorectal Surgery for Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To study the application of a fast-track care protocol in colorectal surgery for deep infiltrating endometriosis. Bowel endometriosis is an infrequent but not rare condition that often needs intestinal surgery and imposes a high economic burden on society. DESIGN: Prospective randomized trial (Canadian Task Force classification I). SETTING: Tertiary referral center. PATIENTS: Two hundred twenty-seven patients with preoperative evidence of bowel endometriosis. INTERVENTIONS: We randomly assigned 227 patients with preoperative evidence of bowel endometriosis to a fast-track protocol (no preoperative bowel preparation, early restoration of diet, no postoperative antibiotics, and early postoperative mobilization) or conventional care for laparoscopic intestinal surgery. Randomization was obtained on a double-blind, date-based schedule, and all procedures were performed by a homogenous group of expert surgeons. Surgical outcomes and a health economic evaluation were assessed. MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital stay. Patient's well-being and intraoperative and postoperative complications up to 30 days after surgery were also assessed. Subsequently, direct medical costs were analyzed. Patients assigned to the fast-track protocol were discharged earlier (median 3 vs 7 days, p < .001) with no significant differences in subjective well-being (p = .55). Operative details, postoperative complications, and need of temporary ileostomy were similar (p = .89) between groups as well as readmission rates within 30 days (p = .69). The application of a fast-track protocol resulted in an overall significant reduction of costs (USD 6699 vs 8674, p < .01), and differences were more evident in cases of protective stoma (7652 vs 8793, p < .05) and surgery with postoperative complications (10 835 vs 14 005, p < .01). CONCLUSION: The application of a fast-track care protocol for laparoscopy in cases of pelvic and intestinal endometriosis does not increase the risk of complications and ensures a reduction of medical costs.

Decreasing Hospital Readmission in Ileostomy Patients: Results of Novel Pilot Program.

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.

Cost-effectiveness analysis of the temporary percutaneous ileostomy for faecal diversion after colorectal resection in elderly.

BACKGROUND: Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery. AIMS: We analyse the outcomes and the costs of the TPI in protecting low colorectal anastomosis in elderly, compared to the CLI. METHODS: Data of patients underwent elective anterior rectal resection for rectal cancer with extra-peritoneal colorectal anastomosis protected by ileostomy from January 2011 to December 2015 were reviewed. Sixty-one out of 132 patients were older than 70; 35 underwent faecal diversion by TPI and 26 by CLI. RESULTS: The two groups resulted homogenous about age, sex, operative time, short-term post-operative complications. None of the patients reported anastomotic leakage. The hospital stay and the cost for the first surgical procedure did not show statistically significant differences between TPI and CLI. When comparing the overall hospital stay and costs the differences are statistically significant: the TPI showed a shorter hospital stay (12.4 vs 19.3 days, -35.7%) and a lower cost of hospitalization (7954.0 vs 14,372.1€, -44.7%), compared to CLI. DISCUSSION: The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of TPI, especially in elderly. CONCLUSION: The TPI not only improved the post-operative outcome of the patients, but also allowed a remarkable saving for the National Health System.

Is Early Reversal of Defunctioning Ileostomy a Shorter, Easier and Less Expensive Operation?

BACKGROUND: A defunctioning loop ileostomy mitigates the consequences of anastomotic leak from low rectal anastomosis but it is associated with significant morbidity. In this study, the outcome of early reversal of defunctioning ileostomy during the same admission with the primary operation was assessed. METHODS: This randomized study was carried out at York Teaching Hospital during the period 2003-2007. All patients with defunctioning ileostomy were considered for an early second operation if they had an uneventful recovery and were in good general condition. Patients on steroids, at high cardiorespiratory risk and those experiencing any postoperative complication were excluded. Eligible patients with satisfactory gastrografin enema on postoperative day 6 were randomized to early versus late reversal at 6-8 weeks. Outcome measures were ease of closure as assessed by a visual analog scale by the operating surgeon, all postoperative complications, duration of the operation, total length of hospital stay and associated costs. RESULTS: Thirty-nine consecutive patients were assessed for eligibility and finally 26 were included in the study. Sixteen patients underwent early reversal. The median(interquartile range (IQR)) age was 62(22) years. Early reversal was significantly superior in terms of ease of abdominal wall closure, ease of reversal (p < 0.01 each), duration of the operation (median(IQR) 20(13) vs. 40(9) min, p < 0.01) and costs of stoma care (median(IQR) 27(9) vs. 311(108) £, p < 0.01). There were no major (grade III/IV) complications in either group. Total length of hospital stay was similar between groups. CONCLUSION: In carefully selected patients, early reversal of defunctioning ileostomy is feasible, technically easier and has shorter operative time which can also lead to significant cost savings.

Colectomy with Permanent End Ileostomy Is More Cost-Effective than Ileal Pouch-Anal Anastomosis for Crohn's Colitis.

BACKGROUND: Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients. AIMS: We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD. METHODS: We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness. RESULTS: IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy. CONCLUSIONS: In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.

Comparison of Costs and Quality of Life in Ulcerative Colitis Patients with an Ileal Pouch-Anal Anastomosis, Ileostomy and Anti-TNFα Therapy.

BACKGROUND AND AIMS: More data are warranted on the economic impact of different treatment strategies in ulcerative colitis (UC) patients. We compared the costs and quality of life of UC patients with a pouch reconstruction, an ileostomy or anti-tumour necrosis factor α (TNFα) therapy. METHODS: UC patients filled out 3-monthly questionnaires for 2 years. Differences in 3-monthly healthcare costs, productivity costs and patient costs were tested using mixed model analysis. Quality of life was assessed employing the ) and the inflammatory bowel disease questionnaire (IBDQ). RESULTS: Out of 915 UC patients, 81 (9%) had a pouch and 48 (5%) an ileostomy, and 34 (4%) were on anti-TNFα therapy. Anti-TNFα-treated patients reported high UC related-healthcare costs per 3 months (€5350). Medication use accounted for 92% of healthcare costs. UC-attributable healthcare costs were 3-fold higher in ileostomy patients compared with pouch patients (€1581 versus €407; p < 0.01). Main cost drivers in ileostomy patients were healthcare costs and ileostomy supplies (2 and 23% of healthcare costs, respectively). In pouch patients, the main cost driver was hospitalization, accounting for 50% of healthcare costs. Productivity loss did not differ between pouch and ileostomy patients (€483 versus €377; p < 0.23), but was significantly higher in anti-TNFα-treated patients (€1085). No difference was found in IBDQ scores, but pouch patients were found to have higher quality-adjusted life years than ileostomy patients and anti-TNFα-treated patients (0.90 [interquartile range 0.78-1.00] versus 0.84 [0.78-1.00] and 0.84 [0.69-1.00], respectively; p < 0.01). CONCLUSION: Patients receiving anti-TNFα therapy reported the highest healthcare cost, in which medication use was the major cost driver. Ileostomy patients were three times more expensive than pouch patients due to frequent hospitalization and ileostomy supplies.

Cost analysis of early versus delayed loop ileostomy closure: a case-matched study.

BACKGROUND/AIMS: The optimal timing for the closure of loop ileostomies remains controversial. The aim of the current study was to investigate whether early ileostomy closure (EC) (<2 weeks post-formation) results in significant healthcare savings as against late closure (LC). METHODS: Patients with available cost data that underwent EC between January 2008 and December 2012 were compared against matched patients undergoing LC during the same period. Direct hospital costs for the two groups were compared. RESULTS: There were 42 EC patients and 61 LC patients. EC patients had significantly less ileostomy-related complications (p < 0.001) and hospital readmissions (p < 0.001). Operative time (p < 0.001) and operative cost (p = 0.002) were also both significantly less in the EC group. Community nursing costs favoured the LC group (p = 0.047). The EC group had an increased post-closure wound infection rate (p = 0.02). The mean total direct cost per patient was NZD 13,724 (SD NZD 3,736) for EC and NZD 16,728 (SD NZD 8,028) for LC. Representing an average costs saving of NZD 3,004 per patient favouring EC (p = 0.012). CONCLUSION: Although EC increases the post-closure wound infection rate, EC reduces ileostomy complications, hospital readmissions and operative costs resulting in significant healthcare savings. In order to improve patient outcomes and make EC even more cost effective, efforts should be taken to reduce wound infections.

Outcomes and cost of diverted versus undiverted restorative proctocolectomy.

BACKGROUND: Some observational studies suggest that diversion during restorative proctocolectomy mitigates the risk of anastomotic complications. However, diversion has its own costs and complications. The aim of this study was to compare the cost and outcomes of diverted to undiverted restorative proctocolectomy. METHODS: This study took advantage of a natural experiment within one surgical department to understand the clinical and financial implications of diversion during restorative proctocolectomy. For the last 10 years, two surgeons routinely diverted all patients undergoing restorative proctocolectomy, and two other surgeons routinely did not. The medical records of 288 consecutive restorative proctocolectomy patients were reviewed. Minimum follow-up time was 1 year, with an average of 4.7 years. Complications rates and costs of care were collected. RESULTS: There were no significant differences between rates of anastomotic leak, fistula, or hernias in diverted versus undiverted patients. The odds of having stricture (odds ratio (OR) = 17.08, P < 0.001) and small bowel obstruction (OR = 5.05, P = 0.02) were both significantly higher in diverted patients. The average cost per patient was $43,000 more in the routinely diverted patients. CONCLUSION: Undiverted restorative proctocolectomy may be the highest value procedure with the most favorable outcomes at the lowest cost.

Randomized clinical trial of the benefit of laparoscopy with closure of loop ileostomy.

BACKGROUND: The aim was to compare reversal and laparoscopy with standard reversal of loop ileostomy in terms of hospital stay and morbidity in a randomized study. METHODS: Patients having reversal of a loop ileostomy were randomized to either standard reversal of ileostomy or reversal and laparoscopy. Strict discharge criteria were applied: toleration of two meals without nausea and vomiting, passing a bowel motion, and attaining adequate pain control with oral analgesia. Morbidity and cost were also compared between the two groups. RESULTS: A total of 74 patients (reversal and laparoscopy 40, standard reversal 34) with a median age of 61 years underwent loop ileostomy reversal; there were 45 men (61 per cent). Ileostomy was most commonly carried out after laparoscopic low anterior resection (36 patients). Median length of stay, based on discharge criteria, was significantly shorter in the reversal and laparoscopy group than in the standard group: 4 (interquartile range 3-4) versus 5 (4-6) days (P = 0·003). The overall morbidity rate was also lower in patients who had ileostomy reversal and laparoscopy: 10 versus 32 per cent (P = 0·023). The median cost per patient was lower in the reversal and laparoscopy group: €3450 (interquartile range 2766-3450) versus €4527 (3843-7263) (P = 0·015). There was no statistically significant difference in American Society of Anesthesiologists fitness grade or time to reversal between the two groups. CONCLUSION: Reversal of loop ileostomy with laparoscopy was associated with a shorter hospital stay, lower morbidity and reduced cost compared with the standard technique. REGISTRATION NUMBER: ISRCTN46101203 (http://www.controlled-trials.com).

Is total-subtotal colectomy and primary anastomosis a good treatment alternative in malignant obstructive lesions of the left colon?

BACKGROUND: This study was designed in order to compare the effectiveness of subtotal-total colectomy with other surgical methods in the treatment of malignant obstructive lesions of the left colon. METHODS: Patients admitting with symptoms of colonic obstruction and treated by emergency surgery in Konya Education and Research Hospital between 2004 and 2007 were enrolled. Patients were divided into three groups according to the surgical procedures (Group I: Hartmann procedure; Group II: resection + diverting ileostomy; Group III: total-subtotal colectomy). Related patient data were evaluated retrospectively. RESULTS: The mean age of 62 patients was 64 (38-89) years. There were no significant differences between the groups with respect to gender, age, American Society of Anesthesiology scores, and tumor stages. There were no significant differences between the study groups in terms of operative duration, postoperative mortality, and five-year survival; however, the length of hospital stay and hospitalization costs were lower in Group III compared to the other groups. CONCLUSION: We suggest that subtotal-total colectomy performed by experienced surgeons may be a good alternative to the other procedures.

In a select group of patients meeting strict clinical criteria and undergoing ileal pouch-anal anastomosis, the omission of a diverting ileostomy offers cost savings to the hospital.

PURPOSE: Ileal pouch-anal anastomosis is the standard care for the majority of patients with ulcerative colitis or familial adenomatous polyposis requiring surgery. The aim of this study is to determine whether the omission of an ileostomy in patients undergoing ileal pouch surgery offers cost savings to the hospital. METHODS: Patients who underwent open ileal pouch-anal anastomosis between 2000 and 2007 were identified. They were grouped according to the absence or presence of an ileostomy at the time of their surgery. Direct costs were calculated from the hospital's accounting database. Costs analyzed included those from the index surgery, ileostomy closure, and 6-month complications. RESULTS: Cost data were available for 835 patients undergoing ileal pouch-anal anastomosis. Seven hundred fifteen (86%) had a diverting ileostomy, and the ileostomy was omitted in 120 (14%). Patients without an ileostomy had a longer length of stay (8.7 vs 6.0 days; P < .001) and a 15% greater cost (P < .001) at the time of index surgery than did those with an ileostomy. There was no significant difference between the 2 groups in costs related to complications. The total costs, including ileal pouch-anal anastomosis, ileostomy closure, and complications, were 25% greater in the ileostomy group than in the group who had the ileostomy omitted at the index surgery ($9176 (+/- 6559) vs $11,451 (+/- 8791); P < .001). CONCLUSION: The above data shows that in a select group of patients meeting well-defined clinical criteria, the omission of a diverting ileostomy will provide significant cost savings for the hospital.

Stoma care nursing management: cost implications in community care.

Successfully rehabilitating the stoma patient in the community means continuing the care provided by the hospital and preparing the patient for this new phase of life. It is well documented that this transition from hospital to home can often be a difficult time for the stoma patient and that home visits and ongoing support from the district nursing team are needed for many patients in the long term. This article aims to help community nurses understand the needs of the stoma patient in their homes and looks at the current situation, including costs, of supplying stoma appliances in the community.

Colectomy subtypes, follow-up surgical procedures, postsurgical complications, and medical charges among ulcerative colitis patients with private health insurance in the United States.

BACKGROUND: We describe colectomy subtypes, follow-up surgical and diagnostic procedures, complications, and direct medical charges occurring within 180 days of colectomy among privately insured patients with ulcerative colitis (UC). METHODS: This was a retrospective analysis of an insurance claims database for 2001-2005. We identified patients with a diagnosis of UC and no concurrent diagnosis of Crohn's disease who underwent colectomy. Colectomy types were classified as: 1) total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA), 2) subtotal colectomy (SC) with ileostomy and Hartmann pouch or ileorectal anastomosis, 3) TPC with ileostomy, and 4) partial colectomy (PC). Follow-up surgical and diagnostic procedures and complications were collected. We developed estimates for UC-related charges for hospitalizations, outpatient visits, and medications for the time period 180 days before and after colectomy. RESULTS: A total of 55,934 UC patients were identified, of whom 540 had a colectomy and at least 180 days of pre- and postcolectomy follow-up. The colectomy distribution was: TPC-IPAA, 44%; SC-ileostomy, 22%; TPC-ileostomy, 17%; and PC, 17%. Within 180 days after colectomy, 54% of patients had a second colectomy-related surgery, and 27% had a follow-up diagnostic procedure. Complications following colectomy for UC included: abscesses (11.5% early / 14.6% late), sepsis/pneumonia/bacteremia (9.3% early / 10.0% late), and fistulas (3.9% early / 8.3% late). The mean UC-related direct medical charge for the 180 days following and including initial colectomy was $90,445. CONCLUSIONS: In this retrospective study of privately insured UC patients, we observed frequent follow-up surgical/diagnostic procedures, identified several complications postcolectomy, and estimated substantial charges 6 months pre- and postcolectomy.

Timely closure of loop ileostomy following anterior resection for rectal cancer.

The implications of constructing a temporary ileostomy as part of the primary surgery for some rectal cancers must not be underestimated and many patients are particularly keen to have their stoma closed as early as possible. Currently, there are no set protocols in place which determine when this should take place, meaning that stoma reversal can be extremely variable between hospitals in the UK. We have created a policy to give patients a provisional date for ileostomy closure at discharge from primary surgery, which takes into account any necessary adjuvant treatment. We compared time to closure of ileostomy between two adjacent centres that share common stoma-care and oncology teams to see what benefit this policy provides. Patients were recruited over a 2-year period from 2005 to 2007 from two adjacent centres. Centre 1 had a policy to provide patients with a provisional date for closure of their ileostomy. The notes were studied retrospectively to determine time to closure of the ileostomy and reasons for any delays in closure. A total of 107 patients fulfilled the inclusion criteria, of which 83 patients (72%) had their stomas closed. Thirty patients had their stomas closed within 12 weeks (37%) - more than 67% (23/34) in centre 1 against 15% (7/48) in centre 2. At 1 year, all patients in centre 1 had their ileostomy closed, while 10% (5/48) were still waiting in centre 2. The mean time to closure was 13.47 and 25.25 weeks for centres 1 and 2 respectively -P-value < 0.0001. Offering patients a date for ileostomy closure at discharge from their primary resection results in the majority of stomas being closed within 12 weeks. For those patients who are to undergo adjuvant chemotherapy, we aim to perform this surgery in between the second and third cycles of treatment.

Overall quality of life and difficulty paying for ostomy supplies in the Veterans Affairs ostomy health-related quality of life study: an exploratory analysis.

PURPOSE: To explore whether there was a significant relationship between difficulty paying for ostomy supplies and overall quality of life among a sample of ostomates receiving care from the Veterans Health Administration (VHA). METHODS: The data were collected as part of the Veterans Affairs (VA) Ostomy Health-Related Quality of Life Study, in which 511 respondents (239 cases, 272 controls) completed a survey instrument that included the modified City of Hope Quality of Life (mCOH-QOL) Ostomy questionnaire, SF-36V, and sociodemographic items. Responses from the 239 cases (ie, patients with intestinal stomas) were used in this analysis. The modified City of Hope Quality of Life Ostomy questionnaire item, "How good is your overall quality of life?," was the dependent variable for this analysis. The primary independent variable was the response (yes/no) to the item, "If you pay for any of the (ostomy) costs, is it difficult for you?" A hierarchical regression model was used to examine whether difficulty paying was significantly related to overall quality of life after adjusting for age, income, race/ethnicity, and physical health. RESULTS: After accounting for the proportion of variance explained by age, income, race/ethnicity, and physical health, the additional proportion of variance explained by difficulty paying was statistically significant. Individuals reporting difficulty paying had a roughly 1 point lower (ie, beta-coefficient = -1.052; SE = 0.481) overall quality of life score on the 11-point scale. CONCLUSIONS: We found a significant association between difficulty paying for ostomy supplies and overall quality of life. Although the cross-sectional study design does not allow causal inference, the results suggest a relationship that merits further examination.