Ileostomy closure by colorectal surgeons results in less major morbidity: results from an institutional change in practice and awareness

Abstract

Purpose: Previous institutional analysis of ileostomy closure revealed substantial morbidity. This subsequent study aimed at determining if a change in clinical practice resulted in reduced complication rates. Methods: Between June 2004 and January 2014, all consecutive adult patients undergoing ileostomy closure were retrospectively identified. Postoperative outcome after change in clinical practice consisting of routine participation of a colorectal surgeon, stapled side-to-side anastomosis and increased clinical awareness (cohort B) was compared with our previously published historical control group (cohort A). The primary outcome was major morbidity, defined as Clavien-Dindo grade three or higher. Independent risk factors of major morbidity were identified using multivariable analysis. Results: In total, 165 patients underwent ileostomy closure in cohort A, and 144 patients in cohort B. At baseline, more primary diverting ileostomies were present in cohort A (94 vs. 82 %; p = 0.001) with a similar rate of loop and end-ileostomy between the two cohorts (p = 0.331). A significant increase in colorectal surgeon participation (89 vs. 53 %; p < 0.001) and stapled side-to-side anastomosis was observed (63 vs. 16 %; p < 0.001). The major morbidity rate was 11 % in cohort A, which significantly reduced to 4 % in cohort B (p = 0.03). Surgery being performed or supervised by a colorectal surgeon (odds ratio [OR] 0.28, 95 % CI 0.11–0.67) and loop-ileostomy compared to end-ileostomy (OR 0.18, 95 % CI 0.07–0.52) were independently associated with lower major morbidity. Conclusion: Ileostomy closure appears to be more complex surgery then generally considered, especially end-ileostomy closure. Postoperative outcome could be significantly improved by a change in surgical practice.