There are three types of complications stoma related: ones related to its construction, ones related to its function and related to closure. The aim of this study was to assess the risk of ...complications related to the stoma presence and to identificate variables related to complications. We conducted a retrospective study of patients who underwent sphincter-preserving elective surgery for benign condition between January 2013 and December 2020 at IRCCS Sacro Cuore Don Calabria Hospital in Negrar, Verona. Data were collected regarding demographics and complications associated with primary surgery, stoma closure and the interval period. Univariable and multivariable analysIs were conducted. A total of 446 (12.2%) diverting loop ileostomies were performed. At index procedure, 76 (17%) patients had complications and 34 patients had complications related to ileostomy creation. Twenty patients (4.4%) were re admitted before stoma closure for dehydration. One hundred and eighty-seven patients (41.9%) suffered from ileostomy management's problems. At univariate analysis, complications of having stoma are more frequent in elder patients (p = 0.013), ASA score > 2 (p = 0.02), IBD diagnosis (p = < 0.001) and patients who had ileostomy creation complications (p = 0.04). At stoma closure, 55 (12.3%) patients had complications. Forty-seven patients (10.5%) presented incisional hernia in the stoma closure site. Ileostomy closure complications are more common with ASA score > 2 (p = 0.01) and IBD diagnosis (p < 0.001). IBD was found an independent factor of poor outcome at the time of ileostomy creation and closure. Developing complications at the time of ileostomy creation is statistically related to develop complications during ileostomy maintenance at multivariable analysis A loop ileostomy is usually created to limit the potentially life-threatening consequenceS of anastomotic leakage, but it is not able to decrease the leak-related mortality, wound sepsis, postoperative bleeding and small bowel obstruction. Debate rises not only for its uncertain efficacy but also because of the significant morbidity related to stoma. The surgeon could use these data in order to tailor his surgical strategy to the patients and their disease.
Abstract
Background
A loop ileostomy does not prevent an anastomotic leak and it is not risk-free, but it can decrease the clinical impact of dehiscence. Inflammatory bowel disease condition is more ...complex than other benign situations candidated to colorectal surgery. The aim of our study was to assess the risk of complications related to the stoma presence and to identificate variables related with complications in a series of IBD’s patients undergoing various colorectal surgeries along with primary diverting stoma.
Methods
We conducted a retrospective study of patients who underwent sphincter-preserving elective surgery for IBD between January 2014 to December 2020 at IRCCS Sacro Cuore Don Calabria Hospital. Data were collected regarding baseline demographics, operative techniques and complications. Ileostomy-related complications were separated into three categories: complications related to stoma creation at the time of index surgery within 30 days; complications of having an ileostomy; complications of ileostomy closure.
Results
Fifty-six diverting loop ileostomies were performed and included in our study (table 1). Seventeen patients (30%) at index procedures had the following complications: 5 had anastomotic leak or pelvic abscess (8.9%), 3 had bowel obstruction (5.4%) and 7 (12.5%) bleeding requiring transfusion. Two patients had complications related to ileostomy creation: 1 had prolapse (1.8%) and 1 rotation with obstruction (1.8%). Seven patients (12.5%) required reoperation. Seven patients (12.5%) were readmitted within 30 days after index surgery for dehydratation. Twenty-four patients (42.1%) suffered during the same time from ileostomy management’s problems. Eighteen patients (32.1%) at stoma closure had the following complications: 6 had anastomotic leak or pelvic abscess (10.7%), 7 had SSI (12.5%), 5 had bowel obstruction (8.9%) and 2 bleeding requiring transfusions (3.6%). Nine patients (16%) required reoperation. At univariate analysis complications of ileostomy status are more frequent in male (p=0.01) and in patients who had ileostomy creation complications (p=0.04). Ileostomy closure complications are more common in male patients (p=0.005). Complications at the time of ileostomy creation were found at multivariate analysis statistically related to complications during ileostomy maintenance.
Conclusion
Ileostomy alone cannot mitigate the overall high rate of complications expected in IBD’s patients, also in consideration of potential problems stoma it-self related. Even if our study is retrospective and presents a small court, when resection is necessary despite patient's conditions we propose to resect without anastomosis at the time of index procedure and restore the bowel continuity only after patient's status optimization.
Abstract
Background
The enhanced recovery after surgery (ERAS) protocol is an evidence-based standardised multimodal programme formulated to reduce surgical stress and optimise recovery after ...surgery. The ERAS represents the best care practice for patients undergoing colorectal surgery. To ensure high compliance with active ERAS elements, patients must be educated to actively participate in the perioperative care pathway. ERAS protocols were originally designed to treat patients with colorectal cancer (CRC), only few studies have assessed this protocol in IBD patients. The aim of this study was to investigate the adherence to ERAS in IBD patients.
Methods
This retrospective study enrolled adult patients who underwent elective colorectal surgery and the ERAS protocol at our institute between May 2020 and December 2022. The patients were divided into IBD and non-IBD group. Data on medical history were collected from electronic health records. Preoperative, intraoperative, and postoperative data were collected for each patient using a self-reported mobile application (iColon). Adherence was calculated for at least 75% of active ERAS items. Chi-square test was used to compare categorical variables.
Results
619 patients, 492 non-IBD and 127 IBD, were enrolled. The overall adherence to ERAS protocol items was similar between the two groups (84% vs 82%, p 0.2). Adherence was evaluated during the three ERAS phases in the groups: preoperative (92% vs 90%, p 0.11), hospitalization (63% vs 62%, p 0.8), post-discharge period (96% vs 93%, p 0.2). Moreover, focusing on the preoperative ERAS items adherence, there were significant difference between non-IBD and IBD group in nutritional optimization (84% vs 67%, p <0.001) but no difference were reported in the patient’s pre-habilitation adherence (74 % vs 71%, p 0.4).
Conclusion
The feasibility of ERAS protocol was good in colorectal surgery as well as in IBD surgery. We need to focus on a tailored nutritional optimization in order to improve adherence and compliance among IBD patient.
Abstract
Background
Inflammatory bowel disease (IBD), ulcerative colitis (UC) and Crohn’s disease (CD), is a group of chronic inflammatory disorders. Biologics are indicated for patients failing ...conventional maintenance therapy with moderate to severe activity. Different routes of administration, intravenous (IV), subcutaneous (SC) or oral have been approved. For chronic diseases such as IBD, some patients may prefer self-administered SC dosing to IV dosing as a less time-intensive and more convenient treatment option. This study aims to evaluate evaluate the success of infliximab subcutaneous administration after switching from intravenous administration in IBD patients.
Methods
The transition from IV to SC administration was proposed to 60 IBD patients in clinical remission. Data on medical history and laboratory tests were collected from electronic health records. Moreover, patients filled a paper questionnaire 8 weeks after the switch focused on the level of satisfaction and onset of adverse event (AE).
Results
Overall 60 patients were enrolled for switching from IV to SC therapy. Most of patients (>80%) did not experience any difficulties in handling the device and respected the correct time-table of administration. The switch was a complete success in 50 out of 60 patients (83.3%). Ten patients stopped subcutaneous formulation: five of these switched back to intravenous formulation for adverse event or patient’s preference, four swap or swop to other therapy and one withdraw from biologic. No predictor of loss of response was found at multivariate analysis. Faecal calprotectin and C-reactive protein values significantly improve after the switch at 3, 6 and 12 months (p= 0.03, p= 0.004, p = 0.01 and p= 0.06, p= 0.001, p= 0.007 respectively). About 16.7 % of patients had at least one side effect after switching. Local pain and swelling at site of injection were the most common AEs. The vast majority of AE were mild and lasted only a few days. No serious AEs were reported and no patient was hospitalized.
Conclusion
Effectiveness of switching from intravenous to subcutaneous infliximab administration in IBD patients is confirmed in our real world cohort of patients.
Abstract
Background
Whereas there is an emerging consensus on the optimal approach to initiation of a range of therapies in inflammatory bowel disease (IBD), there remains greater uncertainty about ...the risks, benefits, and timing of stopping treatment when patients are in stable remission on therapy. When planning an exit strategy for drug withdrawal, the risk of disease relapse must be balanced against the risk of drug-related adverse events and healthcare costs. Our study evaluated the risks of disease relapse associated with withdrawal of the biologic therapy in both ulcerative colitis (UC) and Crohn’s disease (CD).
Methods
In this is a retrospective observational study, the exit strategy was proposed to 60 patients regularly followed in two IBD referral centre from 2015 to 2023. The exit startegy was performed as: (i) discontinuation without de-escalation, (ii) progressive de-escalation and (iii) azathioprine as monotherapy. Data on medical history were collected from electronic health records. Chi-square test was used to compare categorical variables. Logistic regression was used to assess the relationship between disease-related characteristics and the onset of disease relapse after the withdrawal.
Results
60 IBD patients were enrolled, 46 patients withdrawal their biologic therapy and 14 patients were in a de-escalation stategy. These 46 patients (15 UC and 31 CD) performed discontinuation without de-escalation (65%), progressive de-escalation (26%) and azathioprine as monotherapy (9%). They withdraw anti-TNF (82%) or other biologics (18%). Most of patients (71%) were on first line of biologic therapy. The median follow-up period after drug withdrawal was 29 months. A disease relapse occurred in 14 patiens with a median period of 12 months. A good recapture of previous therapy was observed in 57% of patients. Logistic regression analysis revealed a trend of significance between biologic therapy duration (p 0.05) and absence of flare-up after exit strategy. No correlation was noticed with duration of endoscopic or clinical remission before starting the drug withdrawal.
Conclusion
There are no specific factors related to a successful exit strategy. Biologic drug discontinuation is something best considered on a case-by-case basis and determined by patient preferences and disease features. We need more specific study in order to identify patients who can stop therapy without undue risk of poor outcomes.
