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. SWolff ZMcLeod Study Selection UDocker KLijeqvist JJFazio There was insufficient information on the indications for reoperation to analyze any possible differences that might have existed. RW PJJohnston et al.Long-term follow-up after ileoanal pouch procedure: algorithm for diagnosis, classification, and management of pouchitis., Hosie NHaenszel Of the 5 studies commenting on anastomotic strictures, only 1 described the clinical management.27 In that study, 3 of 102 patients were reported as having an anastomotic stricture, of whom 2 were treated by pouch advancement and 1 by dilation. M
Pouch-related sepsis occurred in 120 of 1161 patients (10.3%), but this did not reach significance between the 2 groups (OR, 1.38; 95% CI, 0.91-2.07; P=.13). Gorfine et al24 at Mount Sinai Hospital, New York, New York, strongly supported avoidance of loop ileostomy.
MELewis After surgery, your stoma may be quite swollen to begin with, but will reduce in size over time usually after six to eight weeks. SScott PJarvinen KMorbidity and functional outcome after restorative proctocolectomy for ulcerative colitis., Wheeler ALuukkonen 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. An end ileostomy can be temporary or permanent. 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. RBringing it all together: Lancet-Cochrane collaborate on systematic reviews., Stroup DCSelective omission of loop ileostomy in restorative proctocolectomy., Heuschen KBGrobler VWCohen 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. PWeitz JM MRTotally stapled abdominal restorative proctocolectomy., Sugerman
If temporary, it will be closed or reversed in a later operation. Comparative (randomized and nonrandomized) studies evaluating outcomes after restorative proctocolectomy with or without ileostomy were included. Stomas come in all different shapes and sizes - some are quite short and sit flat against the belly, while some protrude a little. The development of anastomotic stricture favored the no-stoma group (odds ratio, 0.31; P=.045). RLewis
MHorton
MCObstruction after ileal pouch-anal anastomosis: a preventable complication?, Fazio
MRRandomized trial of loop ileostomy in restorative proctocolectomy., Gullberg
Diverting ileostomy should be omitted in carefully selected patients only. 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). To evaluate postoperative adverse events and functional outcomes of patients undergoing restorative proctocolectomy with or without proximal diversion. JrIleal pouch-anal anastomosis without ileostomy., Galandiuk
BReznick
PWRoberts
VWChurch
Three authors independently extracted data by using operative variables, early and late adverse events, and functional outcomes between the 2 groups. NMakin
Fourteen studies were matched for age,19-22,24,25,27,28,30,31,33,37,38,40 13 for sex,19-22,24,27,28,30,31,33,37,38,40 11 for preoperative diagnosis,19,21,22,26,28,30-33,38,40 4 for previous total or subtotal colectomy,19,21,25,31 6 for preoperative use of corticosteroids,19,25,27,28,37,40 12 for pouch design and technique of pouch-anal anastomosis,19-23,25,26,30-33,38 and 4 for follow-up.19,25,26,31 There were 688 males (51.0%) from 15 studies, and median follow-up ranged from 2.2 to 20 months across the studies. PJBartolo
Studies were excluded from the analysis if (1) the outcomes of interest were not reported for the 2 techniques; (2) it was impossible to extract or calculate the necessary data from the published results; or (3) there was considerable overlap between authors, centers, or patient cohorts evaluated in the published literature. NJewell
HHStapled ileoanal anastomosis without a temporary ileostomy., Tjandra
Diverting ileostomy should be omitted in carefully selected patients only. HSOConnor
The permanent solution is chosen in situations where it is too risky or not possible to re-join the two parts of the intestine. From the overall analysis, it appeared that the development of an anastomotic stricture at the level of the pouch-anal anastomosis might be decreased by omitting a proximal stoma (OR, 0.31; 95% CI, 0.10-0.98; P=.045). Your sample request has been received successfully. JAMurray
When analyzed within the different subgroups, however, the difference between the 2 groups became insignificant. CBarwood
CSPoritz
All of the included studies reported on 1 or more perioperative complications. 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. RRWolff
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. MSRombeau
PLSchoetz
Previous Presentation: This study was presented as an abstract at the Association of Surgeons of Great Britain and Ireland Annual Scientific Meeting; May 3, 2006; Edinburgh, Scotland.
HJCumulative failure rate of ileal pouch-anal anastomosis and quality of life after failure., Kienle
First, data were reanalyzed with the use of both random- and fixed-effects models. et al.Ileal pouch-anal anastomoses complications and function in 1005 patients., Johnson
Weston-Petrides GK, Lovegrove RE, Tilney HS, et al. The literature was searched by means of MEDLINE, Embase, Ovid, and Cochrane databases for all studies published from 1978 through July 15, 2005. RSReconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results., Marcello
BGDozois
JLaparoscopically assisted colectomy and ileoanal pouch procedure with and without protective ileostomy., Matikainen
You may want to move away from the clear bag fitted immediately after your operation to an opaque version that could also be smaller. JRFabre
Comparison of Outcomes After Restorative Proctocolectomy With or Without Defunctioning Ileostomy. doi:10.1001/archsurg.143.4.406. LProctocolectomy and pelvic pouch: is a diverting stoma dangerous for the patient?, Fazio
A stoma is red in colour. ECarlsen
Generally, with an ileostomy you will need to use a drainable bag. JrColler
The purpose of each study was to determine outcomes after proctocolectomy with or without defunctioning ileostomy. Functional outcomes were assessed at least 12 months after pouch surgery in both groups. 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. The incidence of anastomotic leakage was clearly greater in the group without a protective ileostomy, and further subgroup analysis also showed a significant increase in pouch-related sepsis in the nonprotected group. The temporary solution is relevant in situations where the diseased part of the bowel has been removed and the remaining part needs to rest before the ends are joined together. SC
JMLevine
Twenty-fourhour frequency of defecation was reported in 7 studies.19,22,25,27,31,37,38 A weighted mean difference of 0.42 (95% CI, 0.13 to 0.98) stools per 24 hours was shown to favor the no-stoma group, but this did not reach statistical significance (P=.14). WStern
This was significant, favoring the no-stoma group (OR, 0.31; 95% CI, 0.10-0.98; P=.045). 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 proportions were not significantly different between the stoma and no-stoma groups (39.2% vs 45.2%; OR, 1.23; 95% CI, 0.72-2.13; P=.45). JCollins
This ratio represents the odds of an adverse event occurring in the no-stoma group compared with the stoma group. Of the 778 patients, 176 underwent a 1-stage procedure. Anastomotic leakage from either the pouch-anal anastomosis or the pouch itself occurred in 72 of 1017 patients (7.1%). The definition of low risk is a point for further discussion and quantitative analysis. YPahlman SEShlasko MSmith BRHollenbeak ITotal proctocolectomy and ileoanal pouch: the role of contrast studies for evaluating postoperative leaks., Platell SDCurrent controversies in pouch surgery., Fazio Sensitivity analysis aimed to test the robustness of the conclusions drawn from meta-analysis by changing the criteria used for inclusion. MNygaard Mean age at surgery ranged from 13.8 to 37 years in the stoma group and 10.4 to 39 years in the no-stoma group, without significant difference between the groups (weighted mean difference, 0.64; 95% CI, 3.04 to 1.76; P=.60). Objective DFBerlin HJNewsome 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. Statistical analysis: Tekkis. HNakano et al.Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients., Egger Terms of Use| A MEDLINE, EMBASE, Ovid, and Cochrane database search was performed on all studies published from 1978 through July 15, 2005, comparing RPC with and without covering ileostomy. These terms, and their combinations, were also used as text words. RRBeart 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. The Mantel-Haenszel method was used to combine the OR for the outcomes of interest by means of a random-effects meta-analytical technique. 2008;143(4):406412. This consists of a collection bag with an integrated adhesive baseplate, which fits firmly around your stoma. PPRemzi ZMcLeod ICOakley MAIleoanal pouch operation: long-term outcome with or without diverting ileostomy., Sagar AMStapled ileoanal anastomosis for ulcerative colitis and familial polyposis without a temporary diverting ileostomy., Swenson Operative time and length of stay were not significantly different between the groups when readmission for stoma closure was excluded. 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). SPHosie
However, when this outcome was reviewed in sensitivity analysis, it no longer held statistical significance at the 95% level (Table 3). 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. RR Obtained funding: Tilney. JBThe estimation and significance of the logarithm of a ratio of frequencies., Mantel FWexner RJProctocolectomy without ileostomy for ulcerative colitis., Garbus 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).
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. The now-widespread use of stapled ileoanal anastomosis has further encouraged surgeons to omit a covering ileostomy.41, Several groups, however, remain advocates for inclusion of ileostomy, all reporting a higher rate of subsequent laparotomy in the nondiverted group.21,35,38,42 Tjandra et al43 at the Cleveland Clinic (Cleveland, Ohio) strongly defended their policy of pouch diversion, reporting that rates of ileoanal anastomotic leakage and pelvic sepsis were only 4% in the defunctioned group compared with 14% when loop ileostomy was not used. et al.Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection., To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2022 American Medical Association. Analytical techniques were used to identify any significant differences in these outcomes and therefore to add a quantitative assessment of the policy of selective omission of a stoma in these patients. Random-effects meta-analytical techniques were used for analysis. JJVeidenheimer The quality of the studies was assessed by using the Newcastle-Ottawa Scale with some modifications to match the needs of this study.17 The quality of the studies was evaluated by examining 3 items: patient selection, comparability of the 2 study groups, and assessment of outcome. MRaab
VWZiv 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. FSerclova SGRestorative proctocolectomy without temporary ileostomy., Gorfine GSchneider 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. 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. Accessibility Statement, Our website uses cookies to enhance your experience. et al.Safety of one-stage restorative proctocolectomy for ulcerative colitis., Lepist MSantavirta RSleight Despite the foregoing significant differences in outcome, the rate of reoperation, whether a second laparotomy or another procedure, was no different in either group. CBias in meta-analysis detected by a simple, graphical test., Haldane The present meta-analysis reviewed 17 independent studies including a total of 1486 patients. RLaird MRTemporary loop ileostomy following restorative proctocolectomy., Ikeuchi The development of pouch-related leak was significantly higher in the no-ileostomy group (odds ratio, 2.37; P=.002). A stricture developed at the pouch-anal anastomosis in 46 of 446 patients (10.3%). This means that you dont have to remove the adhesive plate from around the stoma every time you change the bag. ZFleshman Coloplast products - instructions for use. The loop ileostomy is typically temporary and performed to protect a surgical join in the bowel. Two further studies commented on the degree of stenosis at the anastomosis.26,28 The remaining 2 studies did not comment as to whether the stricture was clinically significant. F MTBauer Some people will have more than one stoma, depending on their condition. The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). RContinuing evolution of the pelvic pouch procedure., Dolgin
This was resolved by adding the value 0.5 in each cell of the 22 table for the study in question. JJLong-term results of salvage surgery for septic complications after restorative proctocolectomy: does fecal diversion improve outcome?, Grobler
AROConnor
et al.Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery., Hrung
JWLavery
Stools in this part of the intestine are generally fluid and, because a stoma has no muscle to control defecation, will need to be collected in a pouch. Pouchitis occurred in 92 (16.3%) of 566 patients from 8 studies.19,20,22,25,27,28,31,33 There was no significant difference between the 2 groups in the number of patients developing pouchitis (OR, 1.01; 95% CI, 0.54-1.90; P=.97). SRFichera
DJ
Drafting of the manuscript: Weston-Petrides, Lovegrove, Tilney, and Heriot. BParkes
LSKoltun 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. 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. in Table 2, together with the functional outcomes. In the two-piece system, the collection bag is separate from the adhesive baseplate, and the two halves are securely clipped or sealed together. NADozois In a loop ileostomy, a loop of the small bowel is lifted above skin level and held in place with a stoma rod. Acquisition of data: Weston-Petrides. JLRubesin However, on sensitivity analysis, the difference becomes statistically significant (P=.04) favoring the ileostomy group, with no significant heterogeneity between the studies (P=.53) in studies published since 1995.
MDavey Smith JBenner WStatistical aspects of the analysis of data from retrospective studies of disease., Yusuf 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. Three strategies were used quantitatively to assess heterogeneity. There were no significant differences in functional outcomes between the 2 groups. ZSlauf BGKelly Three authors independently extracted data by using operative variables, early and late adverse events, and functional outcomes between the 2 groups. Data Extraction SPeto Random-effects meta-analytical techniques were used for analysis. Critical revision of the manuscript for important intellectual content: Weston-Petrides, Heriot, Nicholls, Mortensen, Fazio, and Tekkis. ENazir 2022 American Medical Association. 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. Comparative (randomized and nonrandomized) studies evaluating outcomes after restorative proctocolectomy with or without ileostomy were included. SBenkov
Data Synthesis The study suggests that the exclusion of a protective stoma may be appropriate only for a specific and possibly much smaller set of patients within the total population of patients undergoing RPC.
JHiltunen Author Contributions:Study concept and design: Weston-Petrides, Heriot, Nicholls, and Fazio. The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). PBeta blockade during and after myocardial infarction: an overview of the randomized trials., Athanasiou
A large randomized controlled trial would be difficult to justify. In this way, a loop ileostomy actually consists of two stomas that are joined together. ICSimilar functional results after restorative proctocolectomy in patients with familial adenomatous polyposis and mucosal ulcerative colitis., MacLean However, the omission of a covering ileostomy may still be justified in patients defined as low risk. Functional outcomes included the frequency of defecation per 24 hours, soiling, anal incontinence, and the need for antidiarrheal medication. At Coloplast Charter we know that adapting to life backhome with a Stoma can be overwhelming, so we offer someadditional services to help you get off to the best start. No language restrictions were made. KLindquist There was no significant difference between the 2 groups (OR, 0.34; 95% CI, 0.07-1.59; P=.17). PMCritchlow 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. WAKeighley NMeta-analysis in clinical trials., Egger VWMilsom PMHoldsworth KMIleoanal anastomosis without covering ileostomy., Mowschenson UKarlbom Studies achieving 6 or more stars (from a maximum of 12) were considered to be of higher quality. References of the articles acquired were also searched by hand. Meta-analysis was performed in line with recommendations from the Cochrane Collaboration and the Quality of Reporting of Meta-analyses guidelines.10,11 Statistical analysis for dichotomous variables was carried out with the odds ratio (OR) used as the summary statistic. JWLavery The latest date for this search was the second week of July 2005. HHDecosta The characteristics of the included studies are summarized in Table 1. Here you'll find useful video guides, types of ileostomy and the different product types that have been designed specifically for those that have a ileostomy.
VWTekkis Additional Contributions: T. Athanasiou, MD, FRCS, of the Imperial College London, contributed to the statistical methodology and quality scoring of the manuscripts. 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). The results of these are summarized For continuous variables, such as operative time or length of stay, statistical analysis was carried out with the weighted mean difference used as the summary statistic.12. EH 2022 American Medical Association. Small-bowel obstruction was more common in the stoma group but was not statistically significant (odds ratio, 0.65). Conclusions JRMilsom In conclusion, the present meta-analysis supports the use of a protective ileostomy in view of the improvement in short-term outcomes, particularly sepsis. All Rights Reserved. To evaluate postoperative adverse events and functional outcomes of patients undergoing restorative proctocolectomy with or without proximal diversion. 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. CSchmidt Correspondence: Paris P. Tekkis, MD, FRCS, Department of Biosurgery and Surgical Technology, St Mary's Hospital, 10th Floor, QEQM Wing, Praed Street, London W2 1NY, England (p.tekkis@imperial.ac.uk). JMOmission of temporary diversion in restorative proctocolectomyis it safe?, Antos KBKeighley Only 1 study reported outcomes on sexual function, and these were combined with urologic dysfunction.28 In that study, a total of 13 patients (7.6%) developed urogenital dysfunction from a group of 171. Failure of the ileal pouch occurred in 26 of 832 patients (3.1%) from 11 studies and was less common in the no-stoma group (OR, 0.30; 95% CI, 0.12-0.74; P=.009). Accepted for Publication: January 10, 2007. Sixty-five of 579 patients (11.2%) required a second laparotomy for adverse postoperative events, whereas 29 of 149 patients (19.5%) required other surgical procedures for postoperative adverse events (including lower-limb compartment syndrome, presacral abscess, and parastomal abscess). A cut is made on the exposed bowel loop, and the ends are then rolled down and sewn onto the skin. 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. WGPollard In their nonrandomized comparison, the laparotomy rate for small-bowel obstruction was reduced from 10% to 1%, but leak rates and sepsis were comparable.24, Nonrandomized comparisons of loop ileostomy and no ileostomy for sutured ileoanal anastomosis indicate that morbidity is not increased by avoiding fecal diversion, and both highlight the potentially increased morbidity from ileostomy closure. GDMisleading meta-analysis., Tjandra DOne-stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis: a note of caution., Galandiuk
PIs covering ileostomy after pouch operations necessary?, Cohen LPelvic pouch-anal anastomoses: pros and cons about omission of mucosectomy and loop ileostomy: a study of 60 patients., Hainsworth P AHarris Arch Surg. Pouch failure, defined as pouch excision or indefinite diversion, appeared more likely to occur in patients who had a protective stoma.