The impact of timing of stoma closure on low anterior resection syndrome in patient who underwent low anterior resection for rectal cancer

This is a multi-center retrospective study of patients underwent low anterior resection for rectal cancer. Ileostomy had been done to protect low lying Colo-rectal anastomosis, closure of ileostomy had been delayed in some patients due to patient own will, surgical complications (anastomotic leak) or coarse of chemotherapy. This study aimed to find the effect of temporary ileostomy on post-operative bowel defunction which is called Low anterior resection syndrome (LARS), and include; urgency, difficulty in emptying of bowel, and incontinence for feces and flatus. A total of 50 patients included in this study, the age ranges from the 19 to 80 years old with a mean age of 51.96 years. The total number of males was (33, %66). Majority of patients were overweight (21, 42%). The distance of tumors from the anal verge were less than 10 cm in (31,62%). The mean duration of fecal diversion was 7.17 months. Loop ileostomy were closed before six months in (27,54%). The mean duration of diversion of patients developed no LARS was 6.87 months which is shorter than those of developed LARS (7.31). Lower BMI patients are more prone to develop LARS, while Obese patients are more susceptible to develop major LARS. Nineteen cases developed LARS among those patient’s ileostomy closed before six months, and 15 cases developed LARS in those ileostomies closed after six months.

A kórházi visszavételt igénylő súlyos folyadék-elektrolit zavar mint az ileosztóma egyik szövődménye

Összefoglaló. Bevezetés: A neoadjuváns radio-kemoterápia után végzett rektum tumorok műtéte során általános gyakorlattá kezd válni a tehermentesítő ileosztóma képzése a súlyos varratelégtelenségekből származó szövődmények csökkentése érdekében. Maga az ileosztóma is 20–60%-os előfordulási gyakorisággal lehet szövődmények forrása, 16,9–40%-ban pedig a dehidráció képezi a visszavétel okát. Célkitűzés: Vizsgálatunk célja az volt, hogy áttekintsük saját beteganyagunkat az ileosztóma szövődményei alapján, különös tekintettel a dehidrációra és az abból fakadó következményekre, ennek segítségével pedig kidolgozzunk egy kezelési protokollt, amely a betegek segítségére van ezen súlyos szövődmények megelőzésében. Eredmények: Retrospektív módon elemeztük az osztályunkon 2017. 09. 01. és 2019. 12. 31. között különböző indikáció alapján készített tehermentesítő kacs ileosztóma képzésben részesült betegek morbiditási és mortalitási adatait. Ezen idő alatt 252 rektoszigmoideális reszekciót és 33 abdominoperineális rektum exstirpációt végeztünk. Ileosztómát 110 betegnél készítettünk. 27 beteg (24,5%) került visszavételre súlyos vesefunkció-romlás és ioneltérések miatt. 24 beteg egy alkalommal, 1 beteg két alkalommal, 2 beteg pedig három alkalommal került visszavételre. A visszavétel a műtéttől számítva átlagosan 49,6 nappal (1–343) történt. A felvételkor és visszavételkor a betegek átlagos GFR értéke 54,66 (38–60) ml/perc/1,73 m2 – 22,8 (5–51) ml/perc/1,73 m2 (p = 0,001), átlagos se Na 140,7 (133–145) mmol/l – 131,4 (111–144) mmol/l (p = 0,001), se K 4,6 (3,2–5,6) mmol/l – 5,37 mmol/l (3,6–7,6) (p = 0,0005) és az se Kreatinin 89,6 (54–149) µmol/l – 333,3 (107–877) (p = 0,001) µmol/l volt. Megbeszélés: Tekintettel az ileosztóma okozta dehidráció rövid és hosszú távú súlyos szövődményeire, valamint a magas visszavételi kockázatra, fontos a betegek kockázatbecslése, a korai oktatás és a dehidráció megelőzése, a rendszeres kontroll biztosítása. Amennyiben a feltételek adottak, az ileosztóma korai zárása is megfontolandó. Summary. Introduction: After the operations of rectal tumours following neoadjuvant chemo-radio therapy it is a common practice to create a defunctioning ileostomy in order to prevent complications due to anastomotic leak. The ileostomy itself can be the source of complications with 20–60% incidence rate, while dehydration causes 16.9–40% of readmissions. Aims: Our goal was to review our own cases on the basis of complications of ileostomy particularly with regard to dehydration and its consequences. We wanted to develop a therapeutic protocol to help prevent these severe complications. Results: We retrospectively analyzed the morbidity data of our patients who had defunctioning ileostomy for different indications between 01.09.2017–31.12.2019. During this period, 252 rectosigmoid resections and 33 abdominoperineal resections of the rectum were performed. Ileostomy was created for 110 patients. 27 patients (24.5%) were readmitted with severe renal impairment and electrolyte disturbances. 24 patients were readmitted once, 1 patient twice and 2 patients 3 times. Readmission happened an average of 49.6 days (1–343) after the operation. At admission and readmission the average of GFR (glomerular filtration rate) of patients was 54.66 (38–60) ml/min/1.73 m2 – 22.8 (5–51) ml/min/1.73 m2 (p = 0.001), the average of serum Na level was 140.7 (133–145) mmol/l – 131.4 (111–144) mmol/l (p = 0.001), the average of serum K level was 4.6 (3.2–5.6) mmol/l – 5.37 (3.6–7.6) mmol/l (p = 0.005) and the average of serum creatinine level was 89.6 (54–149) µmol/l – 33.3 (107–877) µmol/l (p = 0.001). Conclusion: With regard to the short and long term severe complications of dehydration and the high risk of readmission caused by ileostomy, it is important to estimate the risk of patients, to educate the inpatients as early as possible, to commence the prevention of dehydration, and regularly monitor in the outpatient setting. Provided the conditions are given, the early closure of ileostomy should be considered.

O8: DIRECT MANIPULATION OF THE INTESTINAL MICROBIOME TO INFLUENCE POST-OPERATIVE OUTCOMES

Introduction Distal feeding (DF) involves intubation of the distal limb of a loop ileostomy to feed with a prebiotic mix. Studies suggest that distally feeding patients following anterior resection prior to ileostomy closure may be beneficial as a form of bowel pre-habilitation. These pilot data examine the adaptive immune response to DF. Method Ten healthy controls with an intact GI tract were compared with 10 patients following rectal cancer resection and chemo/radiotherapy, prior to closure of ileostomy over 8 weeks of DF. We examined B and T cell memory responses from peripheral blood using cell proliferation assays. Cells were cultured with dead antigen to reflect the microbiota in the small and large bowel. Two negative and two positive controls were used to assess minimal and maximum cell proliferation. Result B cell responses prior to DF were increased in the defunctioned group compared to the normal controls to significance (p=0.0014). After 8 weeks of DF the groups were comparable. T cell responses to bacteria had significant differences in proliferation rate following DF commencement, CD4 week 0 vs 3 p=0.0001, week 3 vs 8 p=0.000034, CD8 week 0 vs 3 p=0.0001, week 3-8 p=0.00024). In individual patients, CD4 responses were shown to shift from responses to facultative aerobic species, to strict anaerobes. Conclusion These data suggest that distal feeding fundamentally resets peripheral circulating memory and it may be of use in pre-habilitating the bowel prior to restoration of continuity. Early clinical data suggests that distal feeding improves post-operative outcomes. Take-home message distal feeding is an easy pre-operative intervention that has a significant effect on cell proliferation and antigen response, which may contribute to improved post operative outcomes.

EARLY CLOSURE OF LOOP ILEOSTOMY: IS IT FEASIBLE AND SAFE?

A total of 144 patients of temporary loop ileostomies were treated with early closure at 4 to 6 weeks from its construction. It was found to be feasible, safe and advisable specially on select group of patients with low rate of complications and the results can be compared to classical delayed closure. METHODS This study was carried out in Department of Surgery, Patna Medical College on patients of waiting for closure of loop ileostomies done for both in emergency and routine settings. After a careful selection of cases depending on nutritional status and absence of active infection, closure of ileostomy was done 4 to 6 weeks after the index operation. The post-operative course was closely observed and followed up. RESULTS A total of 144 patients underwent early closure at 4-6 weeks from the construction of ileostomy with the mean duration of closure of 38.2 days. In most of the patients the intestinal loops were mobilised without any significant difficulty and intestinal continuity restored with linear staplers. Most common post-operative complication was wound infection in 38.9% of cases. Other complications included prolonged ileus in 2.8% cases, enterocutaneous fistula in 5.6% and incisional hernia in 6.9% of the cases. None of the patients developed intra peritoneal collection or significant anastomotic leak requiring re laparotomy. No mortality was recorded in the study subjects. The patients were discharged from the hospital ranging from 7-23 days with the average of 9.2 days from the time of stoma closure. Overall, the results may be comparable to those of the delayed conventional closure but at the same time much more convenient to the patient.

MORBI-MORTALITY RELATED TO ILEOSTOMY AND COLOSTOMY CLOSURE AT TERTIARY CARE HOSPITAL BIKANER

Background: To study the morbi-mortality related to ileostomy or colostomy closure at tertiary care hospital Bikaner Material and Method: prospective hospital based study. 30 patients reporting to the General Surgery dept. within study duration and eligible as per inclusion criteria will be included in the study. Results: Out of 30 Cases ,(30.00%) patients had hypertension ,6(20.00%) had diabetes, 5 (16.67%) had renal dysfunction and 2(6.67%) cases had COPD. 11 (36.67%) patients developed complications post closure of ileostomy or colostomy. Medical complications accounted for a large proportion of complications (n=5), while major (n=4) and minor complications (n=2) were present. Conclusion: ileostomy is effective and feasible as a diversion procedure and has reduced morbidity and complication rates. Keywords: Ileostomy, Colostomy. Complications.

Protocol for a multicentre, dual prospective and retrospective cohort study investigating timing of ileostomy closure after anterior resection for rectal cancer: The CLOSurE of Ileostomy Timing (CLOSE-IT) study

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.