Improving the time to ileostomy closure following an anterior resection for rectal cancer in the UK

IntroductionA defunctioning ileostomy is often formed during rectal cancer surgery to reduce the potentially fatal sequelae of anastomotic leak. Once the ileostomy is closed and bowel continuity restored, many patients can suffer poor bowel function, that is, low anterior resection syndrome (LARS). It has been suggested that delay to closure can increase incidence of LARS which is known to significantly reduce quality of life. Despite this, within the UK, time to closure of ileostomy is not subject to national targets within the National Health Service and delay to closure exceeds 18 months in one-third of patients. Clinical factors, surgeon and patient preference or service pressures may all impact time to closure, yet to date no study has investigated this. The aim of this UK-wide study is to assess time to ileostomy closure and identify reasons for delays.Methods and analysisA UK-wide multicentre prospective snapshot study, together with retrospective analysis of ileostomy closure through The Dukes’ Club Research Collaborative including patients undergoing ileostomy closure in a 3-month period (April to June 2018) and all patients who underwent anterior resection and ileostomy formation over a historical 12-month period (2015). Time to closure and incidence of ‘non-closure’ will be calculated. Units will be surveyed to determine local clinical and management protocols and barriers to timely closure. Multivariate linear regression analysis will be used to determine factors significantly associated with delay to ileostomy closure.Ethics and disseminationStudy approved by the South West-Exeter Research Ethics Committee and the Health Research Authority. Study results will be submitted for presentation at international conferences and for publication in peer-reviewed journals. Results will be presented to and discussed with the patient and public representatives and relevant national bodies to facilitate the development of consensus guidelines on optimum treatment pathways.

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Prospective study on the safety and feasibility of early ileostomy closure 2 weeks after lower anterior resection for rectal cancer

Annals of Surgical Treatment and Research ◽

10.4174/astr.2019.96.1.41 ◽

2019 ◽

Vol 96 (1) ◽

pp. 41 ◽

Cited By ~ 4

Author(s):

Kyung Ha Lee ◽

Hyung Ook Kim ◽

Jin Soo Kim ◽

Ji Yeon Kim

Keyword(s):

Rectal Cancer ◽

Prospective Study ◽

Anterior Resection ◽

Ileostomy Closure ◽

Lower Anterior Resection

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Impact of a defunctioning ileostomy and time to stoma closure on bowel function after low anterior resection for rectal cancer: a systematic review and meta-analysis

Techniques in Coloproctology ◽

10.1007/s10151-021-02436-5 ◽

2021 ◽

Author(s):

I. Vogel ◽

N. Reeves ◽

P. J. Tanis ◽

W. A. Bemelman ◽

J. Torkington ◽

...

Keyword(s):

Quality Of Life ◽

Systematic Review ◽

Rectal Cancer ◽

Anterior Resection ◽

Low Anterior Resection ◽

Bowel Function ◽

Ileostomy Closure ◽

Stoma Closure ◽

Defunctioning Ileostomy

Abstract Background Impaired bowel function after low anterior resection (LAR) for rectal cancer is a frequent problem with a major impact on quality of life. The aim of this study was to assess the impact of a defunctioning ileostomy, and time to ileostomy closure on bowel function after LAR for rectal cancer. Methods We performed a systematic review based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Comprehensive literature searches were conducted using PubMed, Embase and Cochrane databases for articles published from 1989 up to August 2019. Analysis was performed using Review Manager (version 5.3) using a random-effects model. Results The search yielded 11 studies (1400 patients) that reported on functional outcome after LAR with at least 1 year follow-up, except for one study. Five scales were used: the Low Anterior Resection Syndrome (LARS) score, the Wexner score, the Memorial Sloan Kettering Cancer Centre Bowel Function Instrument, the Fecal Incontinence Quality of Life scale, and the Hallbook questionnaire. Based on seven studies, major LARS occurred more often in the ileostomy group (OR 2.84, 95% CI, 1.70–4.75, p < 0.0001: I2 = 60%, X2 = 0.02). Based on six studies, a longer time to stoma closure increased the risk of major LARS with a mean difference in time to closure of 2.39 months (95% CI, 1.28–3.51, p < 0.0001: I2 = 21%, X2 = 0.28) in the major vs. no LARS group. Other scoring systems could not be pooled, but presence of an ileostomy predicted poorer bowel function except with the Hallbook questionnaire. Conclusions The risk of developing major LARS seems higher with a defunctioning ileostomy. A prolonged time to ileostomy closure seems to reinforce the negative effect on bowel function; therefore, early reversal should be an important part of the patient pathway.

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Ghost ileostomy versus conventional loop ileostomy in patients undergoing low anterior resection for rectal cancer (DRKS00013997): protocol for a randomised controlled trial

BMJ Open ◽

10.1136/bmjopen-2020-038930 ◽

2020 ◽

Vol 10 (10) ◽

pp. e038930

Author(s):

Felix J Hüttner ◽

Pascal Probst ◽

André Mihaljevic ◽

Pietro Contin ◽

Colette Dörr-Harim ◽

...

Keyword(s):

Rectal Cancer ◽

Anastomotic Leakage ◽

Anterior Resection ◽

Low Anterior Resection ◽

Loop Ileostomy ◽

Pilot Trial ◽

Ileostomy Closure ◽

Ghost Ileostomy ◽

Anterior Rectal Resection ◽

Randomised Controlled

IntroductionAnastomotic leakage is the most important complication in colorectal surgery occurring in up to 20% after low anterior rectal resection. Therefore, a diverting ileostomy is usually created during low anterior resection to protect the anastomosis or rather to diminish the consequences in case of anastomotic leakage. The so-called virtual or ghost ileostomy is a pre-stage ostomy that can be easily exteriorised, if anastomotic leakage is suspected, in order to avoid the severe consequences of anastomotic leakage. On the other hand, an actual ileostomy can be avoided in patients, who do not develop anastomotic leakage.Methods and analysisThe GHOST trial is a randomised controlled pilot trial comparing ghost ileostomy with conventional loop ileostomy in patients undergoing low anterior resection with total mesorectal excision for rectal cancer. After screening for eligibility and obtaining informed consent, a total of 60 adult patients are included in the trial. Patients are intraoperatively randomised to the trial groups in a 1:1 ratio after assuring that none of the intraoperative exclusion criteria are present. The main outcome parameter is the comprehensive complication index as a measure of safety. Further outcomes include specific complications, stoma-related complications, complications of ileostomy closure, frequency of transformation of ghost ileostomy into conventional ileostomy, frequency of terminal ostomy creation, proportion of patients with an ostomy at 6 months after index surgery, anorectal function (Wexner score) and quality of life assessed by the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and CR29 questionnaires. Follow-up for each individual patient will be 6 months.Ethics and disseminationThe GHOST trial has been approved by the Medical Ethics Committee of Heidelberg University (reference number S-694/2017). If the intervention proves to be safe, loop ileostomy could be spared in a large proportion of patients, thus also avoiding stoma-related complications and a second operation (ileostomy closure) with its inherent complications in these patients.Trial registration numberGerman Clinical Trials Registry (DRKS00013997); Universal Trial Number: U1111-1208-9742.

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Clinical Outcomes of Ileostomy Closure before Adjuvant Chemotherapy after Rectal Cancer Surgery: An Observational Study from a Chinese Center

Gastroenterology Research and Practice ◽

10.1155/2021/5592721 ◽

2021 ◽

Vol 2021 ◽

pp. 1-9

Author(s):

Zhen Sun ◽

Yufeng Zhao ◽

Lu Liu ◽

Jichao Qin

Keyword(s):

Rectal Cancer ◽

Adjuvant Chemotherapy ◽

Anterior Resection ◽

Low Anterior Resection ◽

Ileostomy Closure ◽

Cancer Resection ◽

Group Iii ◽

Rectal Cancer Resection ◽

Group I ◽

Temporary Ileostomy

Background. The optimal timing of temporary ileostomy closure with respect to the time of adjuvant chemotherapy following sphincter-saving surgery for rectal cancer remains unclear. The aim of this study is to investigate the clinical and oncological outcomes of ileostomy closure before, during, and after adjuvant chemotherapy following curative rectal cancer resection. Methods. Patients diagnosed with rectal adenocarcinoma who underwent low anterior resection and temporary loop ileostomy during May 2015 and September 2019 were retrospectively evaluated. Patients undergoing ileostomy closure before adjuvant chemotherapy (Group I) were compared to patients undergoing closure during (Group II) and after (Group III) adjuvant chemotherapy. Results. A total of 225 patients were evaluated for eligibility, and 132 were finally selected and divided into 3 groups (24 in Group I, 53 in Group II, and 55 in Group III). No significant differences were observed in operative time, postoperative hospital stay, postoperative complications, total adjuvant chemotherapy cycles, and low anterior resection syndrome scores among the three groups. There was no significant difference in disease-free survival ( p = 0.834 ) and overall survival ( p = 0.462 ) between the three groups. Conclusion. Temporary ileostomy closure before adjuvant chemotherapy following curative rectal cancer resection can achieve a clinical and oncological safety level equal to stoma closure during or after chemotherapy in selected patients.

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A New Perspective on Vacuum-Assisted Closure for the Treatment of Anastomotic Leak Following Low Anterior Resection for Rectal Cancer, Is It Worthy?

Surgical Innovation ◽

10.1177/1553350618771410 ◽

2018 ◽

Vol 25 (4) ◽

pp. 350-356 ◽

Cited By ~ 7

Author(s):

Rosa Maria Jimenez-Rodriguez ◽

Angela Araujo-Miguez ◽

Salvador Sobrino-Rodriguez ◽

Frederick Heller ◽

Jose M. Díaz-Pavon ◽

...

Keyword(s):

Rectal Cancer ◽

Anterior Resection ◽

Colorectal Anastomosis ◽

Rectal Stump ◽

Case Series ◽

Ileostomy Closure ◽

Ambulatory Setting ◽

Pelvic Cavity ◽

Vac Therapy ◽

Initial Surgery

Background. Anastomotic dehiscence is a common complication of anterior resection. In this work, we evaluate the management of the pelvic cavity after low rectal resection using vacuum closure (VAC) with a gastroscope, and we establish factors that determine the success of closure and analyzed the rate of ileostomy closure after leakage was resolved. Patients and Methods. This is a descriptive case series analysis conducted at a tertiary hospital. Twenty-two patients with low colorectal anastomosis leakage or opening of the rectal stump after anterior resection for rectal cancer were included. They were treated with VAC therapy. Results. The total number of endoscopic sessions was 3.1 ± 1.9 in the anterior resection with anastomosis group and 3.2 ± 1.8 in the Hartmann group. In 11 patients the therapy was administered in an ambulatory setting. The mean time to healing was 22.3 ± 14.7 days. Full resolution was achieved in 19 patients (followed-up 1 year). Ileostomy closure was carried out in 5 patients (38.46%) during follow-up. None of these patients showed leakage signs. Statistically significant differences were obtained depending on the onset of therapy, with better results in patients who underwent earlier vacuum-assisted therapy (before the sixth week after initial surgery), P = .041. Conclusions. VAC therapy is an alternative to surgery that can be safely administered in an ambulatory setting. Early administration in the 6 weeks following surgery is an independent predictive factor for successful closure; however, colonic transit was only recovered in a small percentage of patients.

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