Evaluating Early Ileostomy Closure in Colorectal Surgery

Abstract

INTRODUCTION In colorectal surgery, early closure of a temporary loop ileostomy (within 2 weeks of index operation) has been proposed as a method of reducing stoma related morbidity whilst still delivering the protective benefits of a period of faecal diversion during anastomotic healing. The objectives of this thesis are; to assess the current literature evaluating early ileostomy closure (EC), to determine if early ileostomy closure is cost effective and to evaluate the effect the presence of a diverting loop ileostomy has on chemotherapy induced diarrhoea (CID) and optimal adjuvant chemotherapy delivery. METHODS A systematic review was conducted evaluating all papers that reported on the outcomes of EC from 1994-2014. A detailed cost-analysis was performed to determine if the benefits of EC translated into significant healthcare savings and a retrospective evaluation of a prospective surgical database of patients receiving curative adjuvant chemotherapy for colorectal cancer at Auckland Hospital from 2002-2013 was performed. Logistic regression analysis was used to identify independent predictors for CID occurrence and treatment modifications. RESULTS The systematic review identified four studies, yielding a pooled population of 142 patients. EC as reported in the current literature reduced stoma related morbidity, however EC was also associated with a high post-operative wound infection rate. Evaluation of the cost benefit of EC identified an average costs saving of NZD$3004 per patient, favouring EC (p=0.012). In patients receiving adjuvant chemotherapy for colorectal cancer 84% of patients with a diverting ileostomy experienced CID, compared to only 47% of those not defunctioned (p<0.01). On logistic regression analysis, presence of a diverting ileostomy during chemotherapy was an independent predictor of CID grade ≥3 (OR 13.586, 95%CI 1.224-150.862; p=0.02), the need for a dosing reduction (OR 4.016, 95%CI 1.297-12.430; p=0.02) and the need for any modification in the chemotherapy regimen (OR 3.402, 95%CI 1.211-9.558; p=0.02). CONCLUSIONS Current literature suggests EC reduces stoma related complications, however wound infection rates appear to be increased. EC results in significant healthcare savings. Presence of an ileostomy during adjuvant chemotherapy is a predictor of severe CID and the need for modifications in the chemotherapy regimen.