Accepted Article
Received Date : 02-Jan-2015 Revised Date : 01-Feb-2015 Accepted Date : 19-Feb-2015 Article type
: Original Article
Day-case closure of ileostomy: feasible, safe and efficient
Authors:
Mr Ashish Bhalla MSc MRCS1,3 Mr O Peacock PhD MRCS1 Ms Gillian M Tierney DM FRCS1 Mr Samson Tou MS FRCS1 Mr Nicholas G Hurst PhD FRCS1 Mr William J Speake DM FRCS1 Dr John P Williams PhD FRCA2,3 Mr Jonathan N Lund DM FRCS1,3
Institution:
1. Department of colorectal surgery, Royal Derby Hospital NHS Trust 2. Department of anaesthesia, Royal Derby Hospital NHS Trust 3. School of Medical Sciences and Graduate Entry Medicine, University of Nottingham
Correspondence:
Mr Ashish Bhalla Royal Derby Hospital Uttoxeter Road Derby DE22 3NE Tele: 01332724702 Fax: 01332724626 Email: [email protected]
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as an 'Accepted Article', doi: 10.1111/codi.12961 This article is protected by copyright. All rights reserved.
Accepted Article
Conflict of Interest:
We have no conflicts of interest
Abstract: Aim: Over 5,000 loop ileostomy closures were performed in the United Kingdom in 2013 with a median inpatient stay of five days. Previously we have successfully implemented a 23-hour protocol for loop ileostomy closure which was modified for same-day discharge. We present our early experience of day-case loop ileostomy closure. Method: A specific patient pathway for day-case discharge following loop ileostomy closure was implemented with Inclusion criteria to conform with British Association of Day Surgery guidelines. Exclusion criteria included post-operative chemoradiotherapy, multiple comorbidities and social care needs. Follow-up consisted of telephone contact (24 and 72 hours after discharge) and a routine outpatient appointment. Patients were provided with a 24 hour contact point in case of emergency. Results: Fifteen (12 male) patients were enrolled of median age 67 (39-80) years. The median operating time was 41 (23-80) minutes. The indication for ileostomy formation was to cover a low anterior resection for adenocarcinoma (13), reversal of Hartmann’s procedure (1) and functional bowel disorder (1). The median interval from the primary procedure to day-case loop ileostomy closure was 8 (3-14) months. Every patient was discharged on the day of surgery. There were no complications related to the surgery and there was one readmission due to a urinary tract infection. The median length of follow-up was 4 (2-16 )months. Conclusion: Our early experience shows that day-case loop ileostomy closure is feasible, safe and efficient. This protocol will become standard within our institution for suitable patients, saving on average five inpatient bed days per patient.
What does this paper add to the literature? This is the first report of the use of a specific protocol for day-case closure of ileostomy.
Introduction Between January 2012-January 2013 5,014 ileostomy closures were performed In the United Kingdom. This activity accounted for 36,666 bed days based on a median length of stay of five days [1]. There is considerable variation according to the unit in the length of hospital stay after ileostomy closure with some studies reporting postoperative stays of up to 10 days [2]. Data from the United Kingdom show that up to 40% of temporary ileostomies are still not reversed 18 months after initial surgery, with the principle factor for this delay being the pressure on hospital beds [3]. The introduction of enhanced recovery programmes for elective colorectal surgery has dramatically reduced hospital stay without increasing postoperative complications or compromising patient safety, but this has not yet been seen for reversal of ileostomy [4,5].
This article is protected by copyright. All rights reserved.
Accepted Article
Our unit implemented a protocol for 23-hour stay for closure of ileostomy and found no increase in postoperative complications or any detriment to patient safety [6,7]. We modified the protocol to conduct a pilot study exploring the potential for closure of loop ileostomy performed as a day-case procedure.
Method A specific day-case enhanced recovery protocol for closure of ileostomy was developed and implemented at the Royal Derby Hospitals NHS Trust, UK, between August 2013 and July 2014. The inclusion and discharge criteria are outlined in Table 1. Every patient underwent a contrast enema to demonstrate anastomotic integrity before being listed for surgery. Neither neoadjuvant nor adjuvant treatment was a contraindication for inclusion. Pre-operative protocol Our institution’s default setting for ileostomy closure is a 23 hour stay. Patients meeting the day case inclusion criteria were identified in an outpatient clinic. Listed patients were reviewed in a nurse-led preoperative assessment clinic and received written information regarding surgery and recovery. Patients were instructed to have no food six hours before surgery and clear liquids were stopped two hours before. No bowel preparation was administered or premedication prescribed. Perioperative protocol One dose of intravenous antibiotics was administered at induction of general anaesthesia, with Fentanyl used for intraoperative analgesia and for breakthrough pain during recovery. Prophylactic intravenous antiemetics (Cyclizine and/or Ondansetron) were used intraoperatively and prescribed as required for postoperative nausea and vomiting. Infiltration of the wound with a local anaesthetic (0.5 % marcain) was performed. Patients were prescribed Paracetamol, Tramadol and a non-steroidal anti-inflammatory drug as oral analgesia, if not contraindicated. Closure of ileostomy was performed through a circumstomal incision. A stapled technique was used for the anastomosis and the technique used for closure of the abdominal wall and skin wound was left to the discretion of the surgeon. All operations were performed or supervised by, one of five consultants and every patient was admitted to a dedicated day-case ward after surgery. A clear liquid diet was commenced immediately after surgery, and soft diet introduced after two hours. Patients were discharged home with oral analgesia (as above) once they had tolerated a liquid diet.
Postoperative protocol A detailed information sheet was provided with instructions, including contact numbers for urgent advice in case of emergency. The telephone numbers connected to the colorectal nurse specialist during normal working hours (9am-5pm) and to the on-call surgical team outside of these times. Patients were advised to contact the team by telephone or in person if they developed any of the following symptoms: nausea, vomiting, abdominal distension, fever, or any redness or leakage from the wound. Each patient received a telephone call from a stoma nurse 24 and 72 hours after discharge. Patients were encouraged to shower or bathe daily and to dress the wound for five days. Patients were also advised that skin staples or sutures used for skin closure should be removed on day 10 by a community nurse. Routine outpatient follow-up appointments were scheduled for six weeks after surgery. Data were recorded prospectively, including demographics, nature of primary
This article is protected by copyright. All rights reserved.
Accepted Article
surgery, complications and readmissions. Complication was defined as early (30 days) following surgery and graded using the Clavien-Dindo Classification [8].
Results Fifteen (12 male) consecutive patients who met the inclusion criteria were included. The median age was 67 (39–80) years. The median operating time was 41 (23-80) minutes with 12 patients undergoing surgery on a morning list and three on an afternoon list. The most common primary surgery for which the ileostomy was formed was anterior resection for rectal carcinoma, 11 of which were open and two laparoscopic (Table 2). One patient had previously undergone formation of a loop ileostomy during reversal of Hartmann’s procedure and one had had a loop ileostomy for a function bowel disorder. The median interval between primary surgery and closure of loop ileostomy was 8 (3–14) months. All patients were discharged on the day of surgery. There were two early complications, one patient attended the surgical assessment unit 72 hours after discharge with nausea and was discharged with advice and one patient was readmitted at 72 hours with a short history (
Received Date : 02-Jan-2015 Revised Date : 01-Feb-2015 Accepted Date : 19-Feb-2015 Article type
: Original Article
Day-case closure of ileostomy: feasible, safe and efficient
Authors:
Mr Ashish Bhalla MSc MRCS1,3 Mr O Peacock PhD MRCS1 Ms Gillian M Tierney DM FRCS1 Mr Samson Tou MS FRCS1 Mr Nicholas G Hurst PhD FRCS1 Mr William J Speake DM FRCS1 Dr John P Williams PhD FRCA2,3 Mr Jonathan N Lund DM FRCS1,3
Institution:
1. Department of colorectal surgery, Royal Derby Hospital NHS Trust 2. Department of anaesthesia, Royal Derby Hospital NHS Trust 3. School of Medical Sciences and Graduate Entry Medicine, University of Nottingham
Correspondence:
Mr Ashish Bhalla Royal Derby Hospital Uttoxeter Road Derby DE22 3NE Tele: 01332724702 Fax: 01332724626 Email: [email protected]
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as an 'Accepted Article', doi: 10.1111/codi.12961 This article is protected by copyright. All rights reserved.
Accepted Article
Conflict of Interest:
We have no conflicts of interest
Abstract: Aim: Over 5,000 loop ileostomy closures were performed in the United Kingdom in 2013 with a median inpatient stay of five days. Previously we have successfully implemented a 23-hour protocol for loop ileostomy closure which was modified for same-day discharge. We present our early experience of day-case loop ileostomy closure. Method: A specific patient pathway for day-case discharge following loop ileostomy closure was implemented with Inclusion criteria to conform with British Association of Day Surgery guidelines. Exclusion criteria included post-operative chemoradiotherapy, multiple comorbidities and social care needs. Follow-up consisted of telephone contact (24 and 72 hours after discharge) and a routine outpatient appointment. Patients were provided with a 24 hour contact point in case of emergency. Results: Fifteen (12 male) patients were enrolled of median age 67 (39-80) years. The median operating time was 41 (23-80) minutes. The indication for ileostomy formation was to cover a low anterior resection for adenocarcinoma (13), reversal of Hartmann’s procedure (1) and functional bowel disorder (1). The median interval from the primary procedure to day-case loop ileostomy closure was 8 (3-14) months. Every patient was discharged on the day of surgery. There were no complications related to the surgery and there was one readmission due to a urinary tract infection. The median length of follow-up was 4 (2-16 )months. Conclusion: Our early experience shows that day-case loop ileostomy closure is feasible, safe and efficient. This protocol will become standard within our institution for suitable patients, saving on average five inpatient bed days per patient.
What does this paper add to the literature? This is the first report of the use of a specific protocol for day-case closure of ileostomy.
Introduction Between January 2012-January 2013 5,014 ileostomy closures were performed In the United Kingdom. This activity accounted for 36,666 bed days based on a median length of stay of five days [1]. There is considerable variation according to the unit in the length of hospital stay after ileostomy closure with some studies reporting postoperative stays of up to 10 days [2]. Data from the United Kingdom show that up to 40% of temporary ileostomies are still not reversed 18 months after initial surgery, with the principle factor for this delay being the pressure on hospital beds [3]. The introduction of enhanced recovery programmes for elective colorectal surgery has dramatically reduced hospital stay without increasing postoperative complications or compromising patient safety, but this has not yet been seen for reversal of ileostomy [4,5].
This article is protected by copyright. All rights reserved.
Accepted Article
Our unit implemented a protocol for 23-hour stay for closure of ileostomy and found no increase in postoperative complications or any detriment to patient safety [6,7]. We modified the protocol to conduct a pilot study exploring the potential for closure of loop ileostomy performed as a day-case procedure.
Method A specific day-case enhanced recovery protocol for closure of ileostomy was developed and implemented at the Royal Derby Hospitals NHS Trust, UK, between August 2013 and July 2014. The inclusion and discharge criteria are outlined in Table 1. Every patient underwent a contrast enema to demonstrate anastomotic integrity before being listed for surgery. Neither neoadjuvant nor adjuvant treatment was a contraindication for inclusion. Pre-operative protocol Our institution’s default setting for ileostomy closure is a 23 hour stay. Patients meeting the day case inclusion criteria were identified in an outpatient clinic. Listed patients were reviewed in a nurse-led preoperative assessment clinic and received written information regarding surgery and recovery. Patients were instructed to have no food six hours before surgery and clear liquids were stopped two hours before. No bowel preparation was administered or premedication prescribed. Perioperative protocol One dose of intravenous antibiotics was administered at induction of general anaesthesia, with Fentanyl used for intraoperative analgesia and for breakthrough pain during recovery. Prophylactic intravenous antiemetics (Cyclizine and/or Ondansetron) were used intraoperatively and prescribed as required for postoperative nausea and vomiting. Infiltration of the wound with a local anaesthetic (0.5 % marcain) was performed. Patients were prescribed Paracetamol, Tramadol and a non-steroidal anti-inflammatory drug as oral analgesia, if not contraindicated. Closure of ileostomy was performed through a circumstomal incision. A stapled technique was used for the anastomosis and the technique used for closure of the abdominal wall and skin wound was left to the discretion of the surgeon. All operations were performed or supervised by, one of five consultants and every patient was admitted to a dedicated day-case ward after surgery. A clear liquid diet was commenced immediately after surgery, and soft diet introduced after two hours. Patients were discharged home with oral analgesia (as above) once they had tolerated a liquid diet.
Postoperative protocol A detailed information sheet was provided with instructions, including contact numbers for urgent advice in case of emergency. The telephone numbers connected to the colorectal nurse specialist during normal working hours (9am-5pm) and to the on-call surgical team outside of these times. Patients were advised to contact the team by telephone or in person if they developed any of the following symptoms: nausea, vomiting, abdominal distension, fever, or any redness or leakage from the wound. Each patient received a telephone call from a stoma nurse 24 and 72 hours after discharge. Patients were encouraged to shower or bathe daily and to dress the wound for five days. Patients were also advised that skin staples or sutures used for skin closure should be removed on day 10 by a community nurse. Routine outpatient follow-up appointments were scheduled for six weeks after surgery. Data were recorded prospectively, including demographics, nature of primary
This article is protected by copyright. All rights reserved.
Accepted Article
surgery, complications and readmissions. Complication was defined as early (30 days) following surgery and graded using the Clavien-Dindo Classification [8].
Results Fifteen (12 male) consecutive patients who met the inclusion criteria were included. The median age was 67 (39–80) years. The median operating time was 41 (23-80) minutes with 12 patients undergoing surgery on a morning list and three on an afternoon list. The most common primary surgery for which the ileostomy was formed was anterior resection for rectal carcinoma, 11 of which were open and two laparoscopic (Table 2). One patient had previously undergone formation of a loop ileostomy during reversal of Hartmann’s procedure and one had had a loop ileostomy for a function bowel disorder. The median interval between primary surgery and closure of loop ileostomy was 8 (3–14) months. All patients were discharged on the day of surgery. There were two early complications, one patient attended the surgical assessment unit 72 hours after discharge with nausea and was discharged with advice and one patient was readmitted at 72 hours with a short history (
