Ileostomy closure carries its own burden

Ileostomy closure carries a considerable risk for morbidity, say the authors of the largest study of the procedure to date.

They found that patients experienced a significant rate of complications, including infections, sepsis, and ventilator dependence, which were accompanied by prolonged hospital stays.

"Closure of ileostomy may use significant resources and should not be considered a minor follow-up operation," say Abhiram Sharma (University of Rochester Medical Center, New York, USA) and colleagues.

The study included data from the National Surgical Quality Improvement Program database of 5401 patients who underwent elective closure of loop ileostomy between 2005 and 2010.

Overall, 502 (9.3%) patients experienced major complications, such as organ space infection, sepsis, and pneumonia. Repeat surgery was needed in 217 (4%) of patients and 32 (0.6%) died within 30 days of the procedure. Patients with major complications stayed in hospital for an average of 10 days compared with 4 days for patients without.

Minor complications, such as incisional infections and urinary tract infections, were experienced by 452 (8.4%) patients.

Analyses showed that the odds of major complications were increased 2.5-fold in patients with renal insufficiency, 2.4-fold when operation time was 100 minutes or more, and 1.7-fold in patients with disseminated cancer. Functional status, history of severe chronic obstructive pulmonary disease, and American Society of Anesthesiologists class also independently predicted major complications.

However, in contrast to some previous reports, the authors found no association between complications and use of chemotherapy or radiotherapy.

Writing in Colorectal Disease, Sharma and colleagues say that data on the procedure have so far been limited and have come mainly from small case series and reviews, making it difficult to assess the magnitude of morbidity. "The present study offers the largest series of ileostomy closure with a consistent and validated system of data capture," they explain.

The researchers say that their robust findings highlight the need for a covering stoma, in order to minimize the risk of complications, as well as the importance of ensuring patients have adequate understanding of the risks to provide informed consent.

They conclude: "As this operation follows the creation of defunctioning ileostomy at the time of the initial operation, the risks and benefits should be discussed before the initial surgery and at the time of closure."

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