Cost associated with diverting ostomy after rectal cancer surgery: a transnational analysis.

BACKGROUND: Diverting ileostomy and colostomy after total mesorectal excision reduces the risk of complications related to anastomotic leakages but is associated with a reduction in health-related quality of life and long-term economic consequences that are unknown. Our objective was to estimate the lifetime costs of stoma placement after rectal cancer resection in the U.S., England, and Germany. METHODS: Input parameters were derived from quasi-systematic literature searches. Decision-analytic models with survival from colorectal cancer-adjusted life tables and country-specific stoma reversal proportions were created for the three countries to calculate lifetime costs. Main cost items were stoma maintenance costs and reimbursement for reversal procedures. Discounting was applied according to respective national guidelines. Sensitivity analysis was conducted to explore the impact of parameter uncertainty onto the results. RESULTS: The cohort starting ages and median survival were 63 and 11.5 years for the U.S., 69 years and 8.5 years for England, and 71 and 6.5 years for Germany. Lifetime discounted stoma-related costs were $26,311, £9512, and €10,021, respectively. All three models were most sensitive to the proportion of ostomy reversal, age at baseline, and discount rate applied. CONCLUSION: Conservative model-based projections suggest that stoma care leads to significant long-term costs. Efforts to reduce the number of patients who need to undergo a diverting ostomy could result in meaningful cost savings.

Healthcare resource use and associated costs for patients with an ileostomy experiencing peristomal skin complications.

Peristomal skin complications (PSCs) have a significant impact on quality of life and ostomy treatment costs. This study aimed to assess the healthcare resource use for patients with an ileostomy and PSCs symptoms. Two surveys were developed and, after validation by healthcare professionals and patients, data were collected on healthcare resource use while not experiencing any PSCs symptoms and while experiencing complications of various severities, as defined by the modified Ostomy Skin Tool. Costs applied to resource use were assigned from relevant United Kingdom sources. Additional healthcare resource use associated with PSCs, relative to no complications, was estimated to result in a total cost per instance of £258, £383, and £505 for mild, moderate, or severe PSC, respectively. The average estimated total cost per complication instance, weighted across mild, moderate, and severe PSCs, was £349. Severe-level PSCs were associated with the highest cost, because of the treatment-level required and the longer duration of symptoms. There is potential for clinical benefits and economising in stoma care if interventions are implemented that reduce the incidence and/or severity of PSCs.

Adaptation and psychometric evaluation of the Stoma-QOL questionnaire among Chinese rectal cancer patients with colostomy.

AIM: The purpose of this study was to translate the Stoma-quality of life into Chinese and evaluate its psychometric properties in Chinese patients. BACKGROUND: Quality of life is an important issue for patients with colostomy, and its appropriate and precise measurement is beneficial to promoting better care. The Stoma-quality of life questionnaire has been widely used; however, the validity and reliability of its Chinese version has not been determined. DESIGN: A cross-sectional validation study was conducted. METHODS: We translated the Stoma-quality of life into Chinese using standardized methods. Then it was psychometrically tested on a convenience sample of 513 patients with colostomy. Construct validity was evaluated via exploratory factor analysis and confirmatory factor analysis. Reliability was measured with Cronbach's alpha and the split-half Spearman-Brown coefficient. RESULTS: The content validity, the Cronbach's α coefficient and the Spearman-Brown split-half reliability coefficient indicated adequate validity and reliability. The exploratory factor analysis yielded four common factors, and the cumulative variance contribution rate was 67.5%. Moreover, the confirmatory factor analysis showed a good model fit. CONCLUSION: This study confirmed that the Chinese version of Stoma-quality of life is an effective and reliable measurement for evaluating the quality of life of patients with colostomy.

Urinary diversion after pelvic exenteration for gynecologic malignancies.

Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few are routinely used. The aim of this review is to focus beyond the technical aspects and the advantages and disadvantages of each technique, and to include a critical analysis of continent techniques in the gynecologic and urologic literature. Selecting a technique for urinary reconstruction must take into account the constraints entailed by the natural history of the disease, patient characteristics, healthcare institution, and surgeon experience. In gynecologic oncology, the Bricker ileal conduit is the most commonly employed diversion, followed by the self-catheterizable pouch and orthotopic bladder replacement. Continent and non-continent diversions present similar immediate and long-term complication rates, including lower tract urinary infections and pyelonephritis (5-50%), ureteral stricture (3-27%), urolithiasis (5-25%), urinary fistula (5%), and more rarely, vitamin B12 deficiency and metabolic acidosis. Urinary incontinence for the ileal orthotopic neobladder (50%), stoma-related complications for the Bricker ileal conduit (24%), difficulty with self-catheterization (18%) for the continent pouch, and induction of secondary malignancy for the ureterosigmoidostomy (3%) are the most relevant technique-related complications following urinary diversion. The self-catheterizable pouch and orthotopic bladder require a longer learning curve from the surgical team and demand adaptation from the patient compared with the ileal conduit. Quality of life between different techniques remains controversial, although it would seem that young patients may benefit from continent diversions. We consider that centralization of pelvic exenteration in referral centers is crucial to optimize the oncologic and functional outcomes of complex ablative reconstructive surgery.

A New Appendicostomy Technique to Prevent Stomal Stenosis.

PURPOSE: Stomal stenosis has been reported to occur in 12% to 45% of patients following Malone antegrade continence enema and Mitrofanoff appendicostomy. The standard stoma technique entails excision of the distal appendix. We evaluated a novel technique with preservation of the appendiceal tip and vessels, and opening the lumen in a more proximal and vascular area to determine whether the incidence of stenosis would be decreased. MATERIALS AND METHODS: Medical records of patients who underwent appendicostomy for Malone antegrade continence enema or urinary diversion were retrospectively evaluated. We included cases with a minimum of 1 year of followup and those in which the distal portion of a complete appendix was oriented for use as the stomal end in the umbilicus. Variables such as age, gender, body mass index, antegrade continence enema or urinary diversion, open or laparoscopic approach, cecal and appendiceal adhesions, retrocecal position, cecal imbrication, technique and stenosis were recorded. Cox proportional hazards analyses were performed to determine association of covariates. RESULTS: A total of 123 patients met inclusion criteria. The incidence of stenosis following standard stoma technique was 13% (12 of 93 patients) with a median followup of 9.4 years. Of these cases 75% occurred within 1 year of surgery. Stomal stenosis did not occur after the new stoma technique in 30 patients with a median followup of 3.3 years. Only technique cohort (standard vs new) was associated with stenosis (p=0.04). CONCLUSIONS: Stomal stenosis of appendicostomy may be lessened by preservation of the distal appendiceal vasculature and tip, and opening the lumen in a more proximal location.

Comparison of colonic stents, stomas and resection for obstructive left colon cancer: a meta-analysis.

BACKGROUND: Emergency surgery (ES) is the standard-of-care for left-sided obstructing colon cancer, with self-expanding metallic stents (SEMSs) and diverting colostomies (DCs) being alternative approaches. The aim of this study was to review the short- and long-term outcomes of SEMS versus ES or DC. METHODS: Embase and Medline were searched for articles comparing SEMS versus ES or DC. Primary outcomes were survival and recurrence rates. Secondary outcomes were peri- and postoperative outcomes. SEMS-specific outcomes include success and complication rates. Pooled odds ratio and 95% confidence interval were estimated with DerSimonian and Laird random effects used to account for heterogeneity. RESULTS: Thirty-three studies were included, involving 15,224 patients in 8 randomized controlled trials and 25 observational studies. There were high technical and clinical success rates for SEMS, with low rates of complications. Our meta-analysis revealed increased odds of laparoscopic surgery and anastomosis, and decreased stoma creation with SEMS compared to ES. SEMS led to fewer complications, including anastomotic leak, wound infection, ileus, myocardial infarction, and improved 90-day in-hospital mortality. There were no significant differences in 3- and 5-year overall, cancer-specific and disease-free survival. SEMS, compared to DC, led to decreased rates of stoma creation, higher rates of ileus and reoperation, and led to longer hospital stay. CONCLUSIONS: SEMS leads to better short-term outcomes but confers no survival advantage over ES. It is unclear whether SEMS has better short-term outcomes compared to DC. There is a lack of randomized trials with long-term outcomes for SEMS versus DC, hence results should be interpreted with caution.

Gastrointestinal Stomas and Fistulas: What is Lost and What to Do?

Abnormal connections between gastrointestinal tract (GIT) and skin are called enterocutaneous fistulas (ECFs). Presence of ECF is associated with significant morbidity and mortality. A stoma refers to a surgically created opening in the abdomen to divert feces or urine to the outside of the body, to compensate for partial or complete loss of bowel function. Gastrointestinal (GI) stomas and postoperative ECFs present a unique challenge to the intensivist due to development of malnutrition, dehydration, and sepsis leading to high morbidity and mortality. This review focuses on the basic concepts about the type of fistula and stomas, their indications and complications, and management. Principles of clinical management include replacement of fluid and electrolyte losses, control of sepsis along with reducing fistula output, prevention of malnutrition and psychological support, and skin care. How to cite this article: Pande RK, Gupta A. Gastrointestinal Stomas and Fistulas: What is Lost and What to Do? Indian J Crit Care Med 2020;24(Suppl 4):S175-S178.

Evidence-based adoption of purse-string skin closure for stoma wounds.

BACKGROUND: Opinion is divided on the optimal technique of skin closure after stoma reversal as most conventional techniques compromise either on speed/neatness of wound apposition or on the incidence of surgical site infection (SSI). Evidence suggests that purse-string skin closure (PSSC) may achieve both objectives. This study aims to compare conventional primary closure (PC) with PSSC to determine the efficacious technique for stoma wound closure. METHODS: Patients undergoing stoma reversal between April 2015 and September 2017 were prospectively studied. Patients were divided into two groups based on the technique of skin closure (PC or PSSC). The following parameters were assessed: SSI, hospital stay, additional outpatient visit, wound healing time and patient satisfaction based on a standardised questionnaire. RESULTS: Forty one patients underwent stoma reversal (20 PSSC vs 21 PC). Wound infection, need for wound care, length of hospital stay, healing time and scar size were significantly less, whereas average patient wound satisfaction scores were significantly more in the PSSC group. CONCLUSION: Purse-string skin closure (PSSC) proves efficacious and hence merits adoption as the technique of choice for closure of stoma wounds.

Gracilis muscle transposition for treatment of recurrent anovaginal, rectovaginal, rectourethral, and pouch-vaginal fistulas in patients with inflammatory bowel disease.

BACKGROUND: The aim of this study was to evaluate the effectiveness of gracilis muscle transposition (GMT) to treat recurrent anovaginal, rectovaginal, rectourethral, and pouch-vaginal fistulas in patients with inflammatory bowel disease (IBD). METHODS: A retrospective study was conducted in patients with IBD who had GMT performed by a single surgeon between 2000 and 2018. Follow-up data regarding healing rate, complications, additional procedures, and stoma closure rate was collected. RESULTS: A total of 30 women and 2 men had GMT. In all patients fistula was associated with Crohn's disease. In 1 female patient, contralateral gracilis transposition was required after a failed attempt at repair. The primary healing rate was 47% (15/32) and the definitive healing rate (healed by the time of data collection and after secondary procedures) was 71% (23/32). Additional surgical procedures due to fistula persistence or recurrence were performed on 17 patients (53%).At least 7 patients (21%) suffered complications including one wound infection with ischemia of the gracilis muscle. Stoma closure was successful in 18 of 31 cases of patients with stoma (58% of the patients). CONCLUSIONS: GMT for the treatment of recurrent and complex anorectal fistulas in patients with IBD patient is eventually successful in almost 2/3 of patients.

Natural History and Predictors of Parastomal Hernia after Robot-Assisted Radical Cystectomy and Ileal Conduit Urinary Diversion.

PURPOSE: We investigated the prevalence of and variables associated with parastomal hernia and its outcomes after robot-assisted radical cystectomy and ileal conduit creation for bladder cancer. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent robot-assisted radical cystectomy at our institution. Parastomal hernia was defined as the protrusion of abdominal contents through the stomal defect in the abdominal wall on cross-sectional imaging. Parastomal hernia was further described in terms of patient and hernia characteristics, symptoms, management and outcomes. The Kaplan-Meier method was used to determine time to parastomal hernia and time to surgery. Multivariate stepwise logistic regression was done to evaluate variables associated with parastomal hernia. RESULTS: A total of 383 patients underwent robot-assisted radical cystectomy and ileal conduit creation. Of the patients 75 (20%) had parastomal hernia, which was symptomatic in 23 (31%), and 11 (15%) underwent treatment. Median time to parastomal hernia was 13 months (IQR 9-22). Parastomal hernia developed in 9%, 23% and 32% of cases at 1, 2 and 3 years, respectively. Patients with parastomal hernia had a significantly higher body mass index (30 vs 28 kg/m2, p = 0.02), longer overall operative time (357 vs 340 minutes, p = 0.01) and greater blood loss (325 vs 250 ml, p = 0.04). On multivariate analysis operative time (OR 1.25, 95% CI 1.21-3.90, p <0.001), a fascial defect 30 mm or greater (OR 5.23, 95% CI 2.32-11.8, p <0.001) and a lower postoperative estimated glomerular filtration rate (OR 2.17, 95% CI 1.21-3.90, p = 0.01) were significantly associated with parastomal hernia. CONCLUSIONS: Symptoms develop in approximately a third of patients with parastomal hernia and 15% will require surgery. The risk of parastomal hernia plateaued after postoperative year 3. Longer operative time, a larger fascial defect and lower postoperative kidney function were associated with parastomal hernia.

Psychometric validation of the Stoma-QOL questionnaire in a Canadian cross-sectional sample of colostomy and ileostomy patients.

OBJECTIVES: The Stoma-QOL questionnaire is a patient-reported outcome (PRO) used to measure quality of life in patients with ileostomy or colostomy. This study assesses the Stoma-QOL's overall and item-level psychometric characteristics in patients with temporary stomas, and whether stoma-related quality of life differs by demographic characteristics. MATERIALS AND METHODS: Analysis of cross-sectional observational PRO data from hospitals in Vancouver, Canada. Patients registered for elective ileostomy or colostomy closure, over the age of 18, and able to read English were eligible for participation. Emergent and cancer-related cases were excluded. One-way analysis of variance was used to test for demographic differences in Stoma-QOL scores. Cronbach's alpha was used for reliability, and Rasch item-response theory was used to assess overall and item characteristics. RESULTS: 120 patients were included. No statistically significant difference in Stoma-QOL scores was found by age, sex, or socioeconomic status. Reliability was 0.93. Mean item responses ranged from 1.77 to 3.55 and item-total correlation ranged from 0.51 to 0.77. The Rasch item-response theory model demonstrated significant misfit, likely due to the misfit of item 9, which asks about sexuality, and high residual correlations between item pairs 6 and 8 about fatigue, and items 16 and 17 about social relationships. CONCLUSIONS: The Stoma-QOL questionnaire is a well-designed PRO for measuring stoma-related quality of life. Demographic variables do not appear to have a strong influence on Stoma-QOL scores. Item 9 demonstrated misfit but removal likely does not improve the instrument. Future research should focus on revising items 6, 8, 16, and 17.

Perforated sigmoid diverticulitis: Hartmann's procedure or resection with primary anastomosis-a systematic review and meta-analysis of randomised control trials.

INTRODUCTION: The surgical management of perforated sigmoid diverticulitis and generalised peritonitis is challenging. Surgical resection is the established standard of care. However, there is debate as to whether a primary anastomosis (PA) or a Hartmann's procedure (HP) should be performed. The aim of the present study was to perform a review of the literature comparing HP to PA for the treatment of perforated sigmoid diverticulitis with generalised peritonitis. METHODS: A systematic literature search was performed for articles published up to March 2018. We considered only randomised control trials (RCTs) comparing the outcomes of sigmoidectomy with PA versus HP in adults with perforated sigmoid diverticulitis and generalised peritonitis (Hinchey III or IV). Primary outcomes were mortality and permanent stoma rate. Outcomes were pooled using a random-effects model to estimate the risk ratio and 95% confidence intervals. RESULTS: Of the 1,204 potentially relevant articles, 3 RCTs were included in the meta-analysis with 254 patients in total (116 and 138 in the PA and HP groups, respectively). All three RCTs had significant limitations including small size, lack of blinding and possible selection bias. There was no statistically significant difference in mortality or overall morbidity. Although 2 out of the 3 trials reported a lower permanent stoma rate in the PA arm, the difference in permanent stoma rates was not statistically significant (RR = 0.40, 95% CI 0.14-1.16). The incidence of anastomotic leaks, including leaks after stoma reversal, was not statistically different between PA and HP (RR = 1.42, 95% CI 0.41-4.87, p = 0.58) while risk of a postoperative intra-abdominal abscess was lower after PA than after HP (RR = 0.34, 95% CI 0.12-0.96, p = 0.04). CONCLUSIONS: PA and HP appear to be equivalent in terms of most outcomes of interest, except for a lower intra-abdominal abscess risk after PA. The latter finding needs further investigation as it was not reported in any of the individual trials. However, given the limitations of the included RCTs, no firm conclusion can be drawn on which is the best surgical option in patients with generalised peritonitis due to diverticular perforation.

The effect of preoperative stoma site marking on quality of life.

OBJECTIVE: The objective of the study was to determine the effect of preoperative stoma site marking on the health- related quality of life (HRQOL). METHODS: A nonrandomized, quasi-experimental design was used for the study performed from June 2013 to August 2014. The study sample (n:60) included patients for whom a stoma was opened after a planned colorectal surgery. The City of Hope Quality of Life-Ostomy Questionnaire (COHQOL-OQ) was used to measure HRQOL. RESULTS: The mean age of the participants in the experimental group was 53.5±12.83, 18(60%) had colostomies, mean BMI was 25.46 ± 4.25 and mean age of that of the control group was 58.00 ± 14.22, 19(63.3%) had colostomies, mean BMI was 25.28 ± 5.00. A comparison of the two groups indicates that the sixth-month total score of the patients in the experimental group on (COHQOL-OQ) is higher than that of the control group (p<0.05). CONCLUSIONS: The study results demonstrated that patient who underwent stoma site marking reported higher HRQOL than those who did not.

Update on Continent Catheterizable Channels and the Timing of their Complications.

PURPOSE: We previously reported catheterizable channel associated outcomes and concluded that the incidence of postoperative complications was greatest in the first 2 years after surgery. At that time our followup was short. In this series we sought to determine whether complications continued to accumulate with longer followup in an updated cohort of patients. MATERIALS AND METHODS: We comprehensively reviewed the outcomes in 81 consecutive patients who underwent construction of a MACE (Malone antegrade continence enema) and/or a Mitrofanoff channel in association with complex genitourinary reconstruction. Mean followup was 80.1 months. Outcomes of these 119 stomas were classified by Clavien-Dindo grade and time to complication. RESULTS: The 48 unique, channel related events (40.3%) necessitated a total of 70 interventions with a mean 24.2 months to the first event. Difficult catheterization was the most common event, occurring in 20.1% of channels an average of 29.9 months after surgery. Stomal stenosis was also common, developing in 12.6% of channels at an average of 19.9 months after surgery. Unique complications clustered in the first 2 years, after which there was a statistically significant decline (p = 0.0013). High grade complications similarly clustered (p <0.0001). Channel composition was significantly associated with rates of difficult catheterization events. CONCLUSIONS: Compared to our previous cohort of patients with similar volume but shorter followup, our assumption that channel associated complications cluster postoperatively and then decrease significantly was correct. Our current and more detailed series demonstrates that the rate of postoperative complications decreases with time. However, with longer followup patients continue to experience lower grade events requiring fewer interventions.

Heuristics and bias in rectal surgery.

PURPOSE: Deciding to defunction after anterior resection can be difficult, requiring cognitive tools or heuristics. From our previous work, increasing age and risk-taking propensity were identified as heuristic biases for surgeons in Australia and New Zealand (CSSANZ), and inversely proportional to the likelihood of creating defunctioning stomas. We aimed to assess these factors for colorectal surgeons in the British Isles, and identify other potential biases. METHODS: The Association of Coloproctology of Great Britain and Ireland (ACPGBI) was invited to complete an online survey. Questions included demographics, risk-taking propensity, sensitivity to professional criticism, self-perception of anastomotic leak rate and propensity for creating defunctioning stomas. Chi-squared testing was used to assess differences between ACPGBI and CSSANZ respondents. Multiple regression analysis identified independent surgeon predictors of stoma formation. RESULTS: One hundred fifty (19.2%) eligible members of the ACPGBI replied. Demographics between ACPGBI and CSSANZ groups were well-matched. Significantly more ACPGBI surgeons admitted to anastomotic leak in the last year (p < 0.001). ACPGBI surgeon age over 50 (p = 0.02), higher risk-taking propensity across several domains (p = 0.044), self-belief in a lower-than-average anastomotic leak rate (p = 0.02) and belief that the average risk of leak after anterior resection is 8% or lower (p = 0.007) were all independent predictors of less frequent stoma formation. Sensitivity to criticism from colleagues was not a predictor of stoma formation. CONCLUSIONS: Unrecognised surgeon factors including age, everyday risk-taking, self-belief in surgical ability and lower probability bias of anastomotic leak appear to exert an effect on decision-making in rectal surgery.

Reducing the incidence of parastomal hernia with a simple surgical technique.

The incidence of parastomal hernia is reported at between 10% and 50%. The development of a hernia after stoma surgery can lead to both physical and psychological problems and may reduce the individual's quality of life. Many garments and appliances are aimed at managing a stoma and a peri-stomal hernia. From a surgical perspective, to date there has been no real success in achieving a reduction in parastomal hernia incidence. The cost of managing a parastomal hernia is reported as being in excess of £1 million a year in England for non-surgical management alone. Surgical repair of parastomal hernia carries not only a financial burden but an increased risk of mortality and morbidity.

Procedures needed to maintain functionality of adult continent catheterizable channels: a comparison of continent cutaneous ileal cecocystoplasty with tunneled catheterizable channels.

PURPOSE: We compared the outcomes of various adult continent catheterizable channels in a multi-institutional setting. MATERIALS AND METHODS: We retrospectively reviewed the records of all adults who underwent construction of a continent catheterizable channel at our 4 institutions from 2004 to 2013 and who had at least 6 months of followup. Patients were stratified by channel type, including continent cutaneous ileal cecocystoplasty or tunneled cutaneous channel, eg appendicovesicostomy, Monti channel, etc. The primary study outcome was the need for a secondary procedure to correct stomal leakage, catheterizable channel obstruction or stomal stenosis. Secondary outcomes were patient reported leakage and 30-day postoperative complications. We used Firth logistic regression to control for the heterogeneity induced by multiple institutions. RESULTS: A total of 61 patients were included in study, of whom 31 underwent continent cutaneous ileal cecocystoplasty. Mean age was 41.4 years (range 22 to 76). Median followup was 16 months. More patients with a tunneled channel required a secondary procedure than those with cecocystoplasty (15 of 30 or 50% vs 4 of 31 or 13%, OR 6.4, 95% CI 1.8-28). The total number of required secondary procedures was also greater for tunneled channels than for cecocystoplasty (27 vs 4). Of patients with cecocystoplasty 29% reported stomal leakage compared with 43% of those with a tunneled channel (p = 0.12). A high rate of postoperative complications was observed regardless of technique, including 40% for channels and 51.7% for cecocystoplasty. CONCLUSIONS: Patients with continent cutaneous ileal cecocystoplasty undergo fewer interventions to maintain the catheterizable channel than patients with a tunneled continent catheterizable channel.