defunctioning ileostomy

MRTotally stapled abdominal restorative proctocolectomy., Sugerman This observation seems to contradict the lower rate of early postoperative sepsis in the ileostomy group because subsequent failure was most often due to pelvic sepsis and anastomotic leakage. Diverting ileostomy should be omitted in carefully selected patients only. JWLavery HHStapled ileoanal anastomosis without a temporary ileostomy., Tjandra GZfass Data Synthesis Studies achieving 6 or more stars (from a maximum of 12) were considered to be of higher quality. SWolff The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). Functional outcomes included the frequency of defecation per 24 hours, soiling, anal incontinence, and the need for antidiarrheal medication. Since its modern description,1 restorative proctocolectomy with ileal-pouch anal anastomosis (RPC) has become the procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis in whom proctocolectomy is required.2 Functional outcomes and markers of patient satisfaction are good for patients in whom the ileal pouch is retained.3-5, Because most of the patients in whom RPC is considered are young and either in full-time education or at the start of their working lives, recent refinements of the technique to reduce the potential impact of surgery on patients' lives have included use of a 1-stage procedure, with omission of the diverting loop ileostomy, which many surgeons have considered mandatory to protect the pouch reconstruction.6 The ultimate failure of reconstruction has been associated with postoperative pelvic sepsis and anastomotic separation.7 It has been suggested that the formation of a stoma mitigates the consequence of anastomotic leak rather than prevents this complication, one study having shown a clinically silent leak rate of 8% in patients with defunctioning ileostomies after RPC.8 In a recent study examining the use of a defunctioning ileostomy for various indications, including RPC, more than 90% of patients derived no benefit from it and all required a mean postoperative stay of 1 week after stoma closure.9.

Terms of Use| Second, graphical exploration with funnel plots was used to evaluate publication bias (results not shown).13,18 Third, sensitivity analysis was undertaken with the use of subgroups of studies with 100 or more patients, high-quality studies, and those published in or since 1995. 2022 American Medical Association. WStern This was significant, favoring the no-stoma group (OR, 0.31; 95% CI, 0.10-0.98; P=.045). Haldane's correction14 was used for studies containing a 0 in 1 cell for the number of events of interest in 1 of the 2 groups.15,16 These 0 cells created problems with the computation of ratio measure and its standard error of the treatment effect. Eight studies commented on previous colectomy,19,21,24-28,31 with 321 of 778 patients (41.3%) having previously undergone total or subtotal colectomy. JrColler MELewis There are two different types of ileostomy surgery: An end ileostomy is made when part of your large bowel (colon) is removed (or simply needs to rest) and the end of your small bowel is brought to the surface of the abdomen to form a stoma. UDocker NJLong-term function after restorative proctocolectomy., Gunnarsson

Trials were assessed by means of the modified Newcastle-Ottawa Score. et al.Ileal pouch-anal anastomosis: reoperation for pouch-related complications., Kmiot There was no significant difference between the 2 groups (OR, 1.31; 95% CI, 0.54-3.15; P=.55; and OR, 0.49; 95% CI, 0.19-1.28; P=.14, respectively).

Analysis was conducted by using the statistical software Intercooled Stata version 8.0 for Windows (StataCorp, College Station, Texas) and Review Manager Version 4.2 (The Cochrane Collaboration, Software Update, Oxford, England). Soiling was reported in 8 studies of 591 patients,19,22,25,27,28,31,37,38 incontinence in 5 studies of 388 patients,19,24,25,32,37 and the use of antidiarrheal medication in 3 studies comprising 185 patients.19,31,37 There were no significant differences between the 2 groups in any of these outcomes (soiling: OR, 0.79; 95% CI, 0.51-1.23; P=.29; incontinence: OR, 0.56; 95% CI, 0.13-2.42; P=.43; and antidiarrheal medication: OR, 1.27; 95% CI, 0.64-2.55; P=.49). To be included in the analysis, studies had to (1) compare RPC with and without covering ileostomy; (2) report on at least 1 of the outcome measures mentioned in the next section; and (3) clearly document the technique as with covering ileostomy or without covering ileostomy. When 2 studies were reported by the same institution and/or authors, either the more recent publication or the one of higher quality was included in the analysis. JrIleal pouch-anal anastomosis without ileostomy., Galandiuk Stomas come in all different shapes and sizes - some are quite short and sit flat against the belly, while some protrude a little. An ileostomy is typically made in cases where the end part of the small bowel is diseased, and is usually made on the right-hand side of your abdomen. Customize your JAMA Network experience by selecting one or more topics from the list below.

independently extracted the following from each study: first author, year of publication, study population characteristics, study design, inclusion and exclusion criteria, matching criteria, number of subjects operated on with and without stoma formation, male to female ratio, operative outcomes, adverse events, and functional outcomes. This means that you dont have to remove the adhesive plate from around the stoma every time you change the bag. JMOmission of temporary diversion in restorative proctocolectomyis it safe?, Antos SC Perianal sepsis rates, however, were no different in the 2 groups. LSKoltun VWZiv ECarlsen Sensitivity analysis aimed to test the robustness of the conclusions drawn from meta-analysis by changing the criteria used for inclusion. JJFazio

This is because it is a mucous membrane, just like the mucous membrane inside your mouth. HNakano Despite the foregoing significant differences in outcome, the rate of reoperation, whether a second laparotomy or another procedure, was no different in either group. The present meta-analysis reviewed 17 independent studies including a total of 1486 patients. JFPeppercorn TAl-Ruzzeh

JMOakley VWTekkis The latest date for this search was the second week of July 2005.

A total of 1486 patients were included, with 721 undergoing formation of a diverting ileostomy at the time of RPC and 765 undergoing surgery without proximal diversion. The literature search identified 21 studies that met the inclusion criteria.19-39 Four were excluded from further analysis; 2 did not contain extractable comparative data34,36 and 2 were excluded because of potential overlap with another included article from the same institution.29,35 The remaining 17 studies were included for further analysis and comprised 1 randomized controlled trial,25 5 retrospective studies,19,20,27,31,37 and 11 prospective nonrandomized trials.19,21-24,28,30,32,33,38,39 One trial combined both a retrospective and a prospective element in the study design.26. JAMurray The development of pelvic sepsis after pouch surgery did not demonstrate a significant difference between the 2 groups when all of the included studies were considered (P=.86).


When these 2 studies were excluded from the analysis, a significant difference was shown, favoring the no-stoma group (OR, 0.17; 95% CI, 0.04-0.85; P=.03), in keeping with the overall analysis. All of the included studies reported on 1 or more perioperative complications. FWexner

It is important to note that the only randomized trial25 showed no difference between groups regarding anastomotic leakage and pelvic sepsis. JHiltunen A stoma is red in colour. GClinical utility of a de-functioning loop ileostomy., Clarke Read more about what to expect after ostomy surgery and adjusting to life with your new stoma. WGPollard Your sample request has been received successfully. Acquisition of data: Weston-Petrides. Funding/Support: Dr Tilney is sponsored by a research grant from the Royal College of Surgeons of England.

LProctocolectomy and pelvic pouch: is a diverting stoma dangerous for the patient?, Fazio The development of pouch-related leak was significantly higher in the no-ileostomy group (odds ratio, 2.37; Restorative proctocolectomy without a diverting ileostomy resulted in functional outcomes similar to those of surgery with proximal diversion but was associated with an increased risk of anastomotic leak. P Drafting of the manuscript: Weston-Petrides, Lovegrove, Tilney, and Heriot.

WGSagar On sensitivity analysis, pelvic sepsis was significantly less common in patients whose ileostomies were defunctioned; however, this finding was not mirrored by a significant difference in ileal pouch failure in this subgroup. JLRubesin After surgery, your stoma may be quite swollen to begin with, but will reduce in size over time usually after six to eight weeks. SPHosie However, when this outcome was reviewed in sensitivity analysis, it no longer held statistical significance at the 95% level (Table 3).

HUchino The development of anastomotic stricture favored the no-stoma group (odds ratio, 0.31; P=.045). NMeta-analysis in clinical trials., Egger When analyzed within the different subgroups, however, the difference between the 2 groups became insignificant. CBias in meta-analysis detected by a simple, graphical test., Haldane An end ileostomy can be temporary or permanent. PJarvinen The following outcomes were used to compare the RPC without covering ileostomy (no-stoma) group with the RPC with covering ileostomy (stoma) group: Operative outcomes included total operative time excluding that for subsequent procedures to close the ileostomy, and length of postoperative hospital stay. Conclusions

There is no sensation in the stoma, so it is not at all painful to touch. Gorfine et al24 at Mount Sinai Hospital, New York, New York, strongly supported avoidance of loop ileostomy.

F The Mantel-Haenszel method was used to combine the OR for the outcomes of interest by means of a random-effects meta-analytical technique. An OR of less than 1 favors the no-stoma group, and the point estimate of the OR is considered statistically significant at the P<.05 level if the 95% confidence interval (CI) does not include the value 1. MMinder KLeleiko BGKelly SDCurrent controversies in pouch surgery., Fazio RRBeart JJVeidenheimer In this way, a loop ileostomy actually consists of two stomas that are joined together. NJewell HJNewsome

SEShlasko DJ CBarwood WStatistical aspects of the analysis of data from retrospective studies of disease., Yusuf The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). PMCritchlow SKumar NHaenszel PMHoldsworth The aim of the present meta-analysis was to review the literature comparing outcomes from RPC between those who did and did not receive a defunctioning ileostomy, and to determine the safety, or otherwise, of a policy of selective omission of a stoma in these patients. Trials were assessed by means of the modified Newcastle-Ottawa Score. UAAutschbach NMakin Diverting ileostomy should be omitted in carefully selected patients only. MRTemporary loop ileostomy following restorative proctocolectomy., Ikeuchi Long-term adverse events included pouch failure, defined as pouch excision or indefinite proximal diversion; pouchitis diagnosed by clinical, endoscopic, and/or histologic criteria; anastomotic stricture; and postoperative bowel obstruction, managed conservatively or operatively. HHDecosta Many groups have published evidence in favor of performing the entire operation of RPC without any form of protecting ileostomy in the belief that the complication rate is reduced.19,24,35,38 Some maintain that, provided certain perioperative protocols are followed, such as placement of a 30F catheter in the pouch for 7 to 10 days and maintenance with intravenous fluids until the ileus has resolved, the risk of leakage from the ileoanal anastomosis is no greater than when using a covering loop ileostomy. AMStapled ileoanal anastomosis for ulcerative colitis and familial polyposis without a temporary diverting ileostomy., Swenson KLindquist MNygaard Operative time and length of stay were not significantly different between the groups when readmission for stoma closure was excluded. ZMcLeod KBKeighley The characteristics of the included studies are summarized in Table 1. KMIleoanal anastomosis without covering ileostomy., Mowschenson PJBartolo RSStephen The related articles function was used to broaden the search, and all abstracts, studies, and citations scanned were reviewed. No language restrictions were made. EGorfine Reoperation was defined as subsequent surgery because of complications after RPC and was divided into those requiring a second laparotomy (owing to anastomotic leakage, abdominal sepsis, or obstruction) and other surgery (including operations for incisional and parastomal herniation and perineal procedures for abscess and fistula). Data Sources

Small-bowel obstruction was more common in the stoma group but was not statistically significant (odds ratio, 0.65). This complication was significantly more common in the group without a stoma at the time of pouch surgery (OR, 2.37; 95% CI, 1.39-4.04; P=.002).

This has improved statistical power reducing the type II error that is characteristic of small comparative studies. BRHollenbeak Comparison of Outcomes After Restorative Proctocolectomy With or Without Defunctioning Ileostomy. The counter arguments for avoiding an ileostomy are that (1) only 1 hospital admission is needed; (2) the immediate use of the anal sphincter may avoid a period of disuse atrophy; (3) the risk of pouch ischemia is reduced, because a proximal loop ileostomy may compromise the blood flow to the distal small bowel; (4) diversion ileitis, which could impair ileal transport mechanisms, may be avoided; and (5) the complications of ileostomy closure are avoided. This ratio represents the odds of an adverse event occurring in the no-stoma group compared with the stoma group.

Arch Surg. JMBanerjee Short-term adverse events included anastomotic leak, defined as the presence of intestinal contents or contrast medium in the pelvis or pelvic drain after pouch-anal anastomosis, pouch-related septic complications, and perianal sepsis.

KADisconnection, pouch revision and reconnection of the ileal pouch-anal anastomosis., Sugerman Comparative (randomized and nonrandomized) studies evaluating outcomes after restorative proctocolectomy with or without ileostomy were included. HSOConnor

JWLavery RSReconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results., Marcello With regard to functional outcomes, the frequency of defecation per 24 hours, the incidence of incontinence, and the use of antidiarrheal medication were no different in either group. In a random-effects model, it is assumed that there is variation between studies and the calculated OR thus has a more conservative value.12,13 In surgical research, meta-analysis using the random-effects model is preferable because patients operated on in different centers have varying risk profiles and selection criteria for each surgical technique. 2022 American Medical Association. Three authors independently extracted data by using operative variables, early and late adverse events, and functional outcomes between the 2 groups. PPRemzi RCohen Functional outcomes were assessed at least 12 months after pouch surgery in both groups. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2008;143(4):406-412. doi:10.1001/archsurg.143.4.406. The proponents of a covering ileostomy assert that it is safer to use a defunctioning ileostomy on the grounds that (1) closure of a loop ileostomy has minimal morbidity; (2) the consequences of leakage from a suture-line dehiscence in the pouch or from the anastomosis are reduced, thereby minimizing the risk of pelvic sepsis; (3) the function of the anal sphincter and ileal mucosa is allowed to recover before intestinal continuity is restored; and (4) the patient has the psychological benefit of living for a short time with a stoma so that the advantages of the operation can be fully appreciated.21,24,35,38. In an ileostomy operation, a part of your small bowel called the ileum is brought to the surface of your abdomen to form the stoma. The development of pouch-related leak was significantly higher in the no-ileostomy group (odds ratio, 2.37; P=.002). KMorbidity and functional outcome after restorative proctocolectomy for ulcerative colitis., Wheeler
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