Omission of temporary diversion in restorative proctocolectomy — Is it safe?

Tjandra, Joe J.; Fazio, Victor W.; Milsom, Jeffrey W.; Lavery, Ian C.; Oakley, John R.; Fabré, J

doi:10.1007/bf02047291

Cited by 157 publications

(91 citation statements)

References 14 publications

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“…In a study by Tjandra et al (36), anastomotic leakage, pelvic abscess, and septic complications requiring relapar otomy were more common after ileal pouch-anal anastomosis without ileostomy, compared to a carefully matched control group of patients with ileostomy. Patients using high-dose corticosteroids had an increased risk of complications.…”

Section: Temporary Diverting Ileostomymentioning

confidence: 94%

Clinical and Physiological Aspects of Ileal Pouch-Anal Anastomosis

Salemans

Nagengast

1995

Scandinavian Journal of Gastroenterology

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Salemans JMJI, Nagengast FM. Clinical and physiological aspects of ileal pouch-anal anastomosis. Scand J Gastroenterol 1995;30 Suppl 212:3-12.Proctocolectom y with ileal pouch-anal anastomosis is the surgical treatment of choice for severe chronic ulcerative colitis and familial polyposis coli because the entire colonic mucosa is removed while anal function can be preserved and the necessity for permanent ileostomy is eliminated. Long-term functional results are generally gratifying, as defecation frequency and degree of incontinence are acceptable in most patients. Pouchitis, however, a non-specific inflammation of the ileal reservoir, is a major long-term complication occurring in a considerable number o f patients. The etiology of pouchitis is unknown. Since pouchitis occurs more frequently or even exclusively in ulcerative colitis patients it is assumed that pouchitis is a novel manifestation o f inflammatory bowel disease. However, bacterial overgrowth in the ileal pouch may also play a pathogenetic role. Chronic inflammation and villous atrophy o f varying severity is found in virtually all pouches. Acute inflammatory changes and ulceration are associated with pouchitis.

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Section: Temporary Diverting Ileostomymentioning

confidence: 94%

Clinical and Physiological Aspects of Ileal Pouch-Anal Anastomosis

Salemans

Nagengast

1995

Scandinavian Journal of Gastroenterology

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“…So far, there is no conclusive evidence on the subject. Proponents of the routine use of an ileostomy argue that although the ileostomy does not prevent leakage, the consequences of the leak are less severe, with a lower rate of major leaks [16, 17]and need for reoperations [18]. On the other hand those against the routine use of a loop ileostomy claim that it leads to an increase in morbidity and mortality together with higher hospital stay and costs [12], and the lack of its use does not lead to an increase in postoperative complications [19, 20].…”

Section: Discussionmentioning

confidence: 99%

A Prospective Audit of the Complications of Loop Ileostomy Construction and Takedown

et al. 2004

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Aim: A prospective review of the complications of ileostomy construction and takedown. Materials and Methods: One hundred twenty-seven consecutive patients undergoing construction of a loop ileostomy were included in a prospective nonrandomized computer database. Complications of the loop ileostomy were assessed prior to and after closure. Three closure techniques were performed [enterotomy suture (25.7%), resection and hand sewn (31.2%) or stapled anastomosis (43.1%)] and compared. Results: One hundred twenty-seven (73 male, 54 female) patients, mean age 54 years were included from 1992 to 2002. Seventy-two patients underwent anterior resection for low rectal carcinoma, 30 an ileoanal pouch for ulcerative colitis and 25 for miscellaneous conditions. Fifty-nine pre-takedown complications occurred in 50 (39.4%) patients. The most common were dermatitis (12.6%) and erythema (7.1%). The most severe were dehydration in 1 patient and stomal prolapse in 4 patients. Closure was associated with a complication rate of 33.1% and a mortality rate of 0.9%. Wound infection occurred in 18.3% and small bowel obstruction in 4.6%. Anastomotic leak requiring reanastomosis occurred in 2.8% and enterocutaneous fistula treated conservatively in 5.5%. There were no statistically significant differences in morbidity between closure techniques (p = 0.892). There were no statistically significant differences in complications (p = 0.516) between patients with ulcerative colitis and those with neoplasia (39.29% vs. 32.2%). Conclusions: Loop ileostomy construction and takedown is associated with considerable morbidity, mostly minor. No differences exist between technique used for closure or the baseline pathology of the patient.

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“…Some units found very few problems when omitting a loop ileostomy, either routinely [6, 11]or in selected patients [12]. Others have found an increase in septic problems when omitting a stoma, especially for those on steroids [4]. The routine use of omitting a loop stoma is clearly rejected by Williamson et al [13], arguing that it can lead to life-threatening septic complications, an experience not shared by others [11, 12].…”

Section: Discussionmentioning

confidence: 99%

“…However, the procedure is not without complications [2], and reoperations are frequently necessary. The construction of a defunctioning ileostomy is routinely employed by many at the time of pouch construction, whilst some avoid a loop ileostomy in selected patients [3, 4, 5]. A few surgeons have suggested construction of IPAA almost always without a stoma [6].…”

Section: Introductionmentioning

confidence: 99%

Poor Outcome of a Defunctioning Stoma after Pouch Construction for Ulcerative Colitis

Körsgen

Keighley²

2000

Dig Surg

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Background: Restorative proctocolectomy for ulcerative colitis can have complications necessitating a later defunctioning ileostomy with uncertain outcome. This analysis was undertaken to assess the outcome in patients needing a later defunctioning ileostomy after pouch construction in patients with ulcerative colitis. Method: The notes of our series of 154 patients who underwent restorative proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis were reviewed and 28 patients identified who needed a later defunctioning ileostomy to deal with complications. Results: A later defunctioning ileostomy was necessary in 28 patients to deal with the following complications: sepsis in 11 patients (5 pouches failed), fistulas in 7 (5 pouches failed), poor function including ileoanal stenosis in 5 (all 5 failed), postoperative intraabdominal bleeding in 2 (both saved), pouchitis in 2 (1 excised) and small bowel obstruction in 1 (saved). 16 pouches were eventually excised or permanently defunctioned (59%). Conclusion: Complications necessitating a later defunctioning stoma after pouch construction carry a poor prognosis, especially when used for ileoanal stenosis and fistulae.

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Omission of temporary diversion in restorative proctocolectomy — Is it safe?

Abstract: In equally favorable cases, RP without diversion is not as safe as RP with diversion, especially in patients taking > or = 20 mg of prednisone/day.

Cited by 157 publications

References 14 publications

Clinical and Physiological Aspects of Ileal Pouch-Anal Anastomosis

Clinical and Physiological Aspects of Ileal Pouch-Anal Anastomosis

A Prospective Audit of the Complications of Loop Ileostomy Construction and Takedown

Poor Outcome of a Defunctioning Stoma after Pouch Construction for Ulcerative Colitis

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