Morbidity and Mortality Associated with Loop Ileostomy Closure Procedures in a Reference Service in Coloproctology in Recife, Pernambuco

Oliveira, Rodrigo Artur Souza de; Cavalcante, Aline Ribeiro Teixeira

doi:10.1055/s-0041-1730422

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Journal of Coloproctology (Rio de Janeiro)

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Sumário

Original Article • J. Coloproctol. (Rio J.) 41 (02) • Apr-Jun 2021 • https://doi.org/10.1055/s-0041-1730422 copy

Morbidity and Mortality Associated with Loop Ileostomy Closure Procedures in a Reference Service in Coloproctology in Recife, Pernambuco

Morbimortalidade associada aos procedimentos de fechamento de ileostomia em alça em um serviço de referência em coloproctologia em Recife, Pernambuco (PE)

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To evaluate the morbidity and mortality related to the surgical procedure of loop ileostomy closure, in a reference service in coloproctology, as well as possible variables that may be related to a higher frequency of complications.

Methods

A retrospective study evaluated 66 procedures of loop ileostomy closure, performed between December 2005 and December 2017, at the coloproctology service of Barão de Lucena Hospital, in Recife, Brazil.

Results

There were complications in 20 (30.3%) patients, 11 of whom were classified as grade I (Clavien-Dindo), and 9 of whom were classified as grade II to V. In 7.6% of the cases, one or more surgical reassessments were required. Mortality was 1.5%. There was no statistical relevance in the correlation of the studied variables with the occurrence of complications.

Conclusion

Loop ileostomy closure presents an important morbidity, reaching more than 30%, although mortality is low. The analyzed variables did not show significant statistics for a higher occurrence of complications.

Keywords:
ileostomy closure; morbimortality; Clavien-Dindo

Grade	Definition
Grade I	– Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions – Allowed therapeutic regimens are drugs as antiemetics, antipyretics, analgetics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside
Grade II	– Requiring pharmacological treatment with drugs other than such allowed for grade I complications – Blood transfusions and total parenteral nutrition are also included
Grade III	– Requiring surgical, endoscopic, or radiological interventionIIIa. Intervention not under general anesthesiaIIIb. Intervention under general anesthesia
Grade IV	– Life-threatening complication (including CNS complications)^* * Brain hemorrhage, ischemic stroke, subarrachnoidal bleeding, but excluding transient ischemic attacks. – requiring IC/ICU managementIVa. Single organ dysfunction (including dialysis)IVb. Multiorgan dysfunction
Grade V	Death of a patient
Suffix “d”	If the patient suffers from a complication at the time of discharge (see examples in Table 2), the suffix “d” (for “disability”) is added to the respective grade of complication. This label indicates the need for a follow-up to fully evaluate the complication

Variable	Result
TOTAL: n (%)	66 (100.0)
Age: Average ± SD (Median)	53.92 ± 15.66 (55.50)
Age group (years old): n (%)
17–64	46 (69.7)
65–81	20 (30.3)
Gender: n (%)
Male	32 (48.5)
Female	34 (51.5)
ASA: n (%)
I	32 (48.5)
II	32 (48.5)
III	2 (3.0)
Presence of comorbidities: n (%)	32 (48.5)
*Which comorbidities^ * This statistic excluded the patient who died and the one without data in the medical record. :* n (%)
None	34 (51.5)
Systemic arterial hypertension	19 (28.8)
Inflammatory bowel disease	5 (7.6)
Diabetes mellitus	4 (6.0)
COPD	2 (3.0)
Others	14 (21.2)

Variable	Total group	Clavien-Dindo⁹9 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposalwith evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240(02):205-213
TOTAL PATIENTS: n (%)	66 (100.0)
Which complications^* * Each patient may have more than one complication. : n (%)
Vomiting	5 (7.6%)	I
Anastomosis dehiscence (surgical)	4 (6%)	IIIb
adynamic ileum (02 using TPN and 01 using antibiotics - secondary to pulmonary infection)	3 (4.6%)	II
Pneumonia	2 (3%)	II
Surgical wound infection (without antibiotics)	2 (3%)	I
Intestinal subocclusion (with clinical resolution)	2 (3%)	I
Intracavitary abscess (surgical)	2 (3%)	IIIb
Intracavitary abscess (percutaneous drainage)	1 (1.5%)	IIIa
Internal hernia	1 (1.5%)	IIIb
Evisceration	1 (1.5%)	IIIb
Anastomosis stenosis	1 (1.5%)	IIIb
Abscess of abdominal wall	1 (1.5%)	II
Enterocutaneous fistula	1 (1.5%)	II
Surgical wound infection (using antibiotics)	1 (1.5%)	II
Diarrhea (using antibiotics)	1 (1.5%)	II
Fever	1 (1.5%)	I
Operative wound seroma	1 (1.5%)	I
Headache	1 (1.5%)	I
Septic shock	1 (1.5%)	IVb
Death	1 (1.5%)	V

	Complication
Variable	With		Without		Total		P-value
	N	%	N	%	n	%
Age group							p^* * By Fisher Exact test. = 0.437
65–81	4	20.0	16	80.0	20	100.0
17–64	5	10.9	41	89.1	46	100.0
Total group	9	13.6	57	86.4	66	100.0
First emergency surgery							p^* * By Fisher Exact test. = 0.581
Yes	−	−	7	100.0	7	100.0
No	9	15.3	50	84.7	59	100.0
Total group	9	13.6	57	86.4	66	100.0
Complications in the first surgery							p^* * By Fisher Exact test. = 0.705
Yes	4	15.4	22	84.6	26	100.0
No	4	10.5	34	89.5	38	100.0
Total group	8	12.5	56	87.5	64	100.0
Time to ostomy closure							p^* * By Fisher Exact test. = 0.469
Less than 7 months	2	8.3	22	91.7	24	100.0
Equal to or greater than 7 months	7	16.7	35	83.3	42	100.0
Total group	9	13.6	57	86.4	66	100.0
Type of anastomosis							p^* * By Fisher Exact test. = 0.625
Manual without enterectomy	2	7.7	24	92.3	26	100.0
Manual with enterectomy	4	16.0	21	84.0	25	100.0
Mechanical	2	14.3	12	85.7	14	100.0
Total group	8	12.3	57	87.7	65	100.0

Sociedade Brasileira de Coloproctologia Av. Marechal Câmara, 160/916, 20020-080 Rio de Janeiro/RJ Brasil, Tel.: (55 21) 2240-8927, Fax: (55 21) 2220-5803 - Rio de Janeiro - RJ - Brazil
E-mail: sbcp@sbcp.org.br

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[1] Address for correspondence Rodrigo Artur Souza de Oliveira, Avenida Caxangá, 3860, Iputinga. Recife (PE), 50731-000, Brazil (e-mail: rodrigoasoliveira@yahoo.com.br).

Variable	Total group
TOTAL: n (%)	66 (100.0)
Time to ostomy closure (months): Average ± SD (Median)	9.71 ± 6.72 (8.00)
Time to ostomy closure: n (%)
Less than 7 months	24 (36.4)
7 months or more	42 (63.6)
Surgical technique used to close ileostomy: n (%)
Manual without enterectomy	26 (39.4)
Manual with enterectomy	25 (37.9)
Mechanical	14 (21.2)
No mention in the medical record	1 (1.5)
Early complication after ileostomy closure – Clavien-Dindo I to V: n (%)	20 (30.3)
Clavien-Dindo I	11 (16.7)
Clavien-Dindo II–V	9 (13.6)
Time to discharge, in days (without complications and Clavien-Dindo I): Average ± SD (Median)	4.35 ± 1.54 (4.00)
Time to discharge, in days (Clavien-Dindo II–V) : Average ± SD (Median)**	20.14 ± 8.89 (22.00)
*Time to discharge^ * This statistic excluded the patient who died and the one without data in the medical record. :** n (%)
Less than 5 days	35 (53.0)
5 days	15 (22.7)
More than 5 days	14 (21.2)