e54
that we inaccurately categorized 3 studies3–5 as not being funded by industry. The fourth article6 referred to does not document industrial support. The implication of this correspondence is that this review was not compiled by the authors with independence from input by industry. This was not the case. Both authors had complete independence in performing the literature search, identifying articles for inclusion, data extraction, drafting the article, and decision to submit for publication. The final document did not undergo review by an industrial partner explaining why privileged documents, referenced by the correspondent, were not available to us and mitigates against concerns regarding unacknowledged publications. Our search strategy complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our exclusion criteria clearly state that a meeting abstract7 would not be considered for inclusion. In addition, this systematic review was limited to studies in digestive tract surgery in humans, and evidence referenced in this correspondence relating to animal studies8 or gynecological surgery9 was not considered. The study by Cornish et al published in Diseases of the Colon & Rectum in 20067 is indeed an influential study. The authors of the recent Cochrane Review10 recognized that the inclusion of a subgroup of patients (90 of 1791 patients operated on for bowel obstruction rather than having an open digestive tract resection) in meta-analysis significantly affected the point estimate of effect on time to recurrent surgery for intestinal obstruction. We have published a systematic review without such meta-analysis, and whether this subgroup is a distinct patient group that warrants separate consideration is a moot point. We feel strongly that we provide an objective and comprehensive systematic review with well-balanced and conservative conclusions, which are unchanged by this correspondence. We reiterate that more evidence is needed regarding the efficacy of all antiadhesion strategies in reducing chronic abdominal symptoms, avoiding repeated operative interventions, and improving quality of life. REFERENCES 1. Waldron M. Errors, omissions, and publication bias. Dis Colon Rectum. 2015;58:e53. 2. Robb WB, Mariette C. Strategies in the prevention of the formation of postoperative adhesions in digestive surgery: a systematic review of the literature. Dis Colon Rectum. 2014;57:1228–1240. 3. Dupré A, Lefranc A, Buc E, et al. Use of bioresorbable membranes to reduce abdominal and perihepatic adhesions in 2-stage hepatectomy of liver metastases from colorectal cancer: results of a prospective, randomized controlled phase II trial. Ann Surg. 2013;258:30–36.
LEtters to the Editor
4. Salum M, Wexner SD, Nogueras JJ, et al.; Program Directors Association in Colon and Rectal Surgery. Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure? Tech Coloproctol. 2006;10:187–190. 5. Oikonomakis I, Wexner SD, Gervaz P, You SY, Secic M, Giamundo P. Seprafilm: a retrospective preliminary evaluation of the impact on short-term oncologic outcome in colorectal cancer. Dis Colon Rectum. 2002;45:1376–1380. 6. Kusunoki M, Ikeuchi H, Yanagi H, et al. Bioresorbable hyaluronate-carboxymethylcellulose membrane (Seprafilm) in surgery for rectal carcinoma: a prospective randomized clinical trial. Surg Today. 2005;35:940–945. 7. Cornish JA, Tekkis PP, Kiran RP, Kirat H, Tan E, Remzi FH, Fazio VW. The effect of Seprafilm on septic complications and bowel obstruction following primary restorative proctocolectomy. Dis Colon Rectum. 2008;51[abstract]:647. 8. Altuntas YE, Kement M, Oncel M, Sahip Y, Kaptanoglu L. The effectiveness of hyaluronan-carboxymethylcellulose membrane in different severity of adhesions observed at the time of relaparotomies: an experimental study on mice. Dis Colon Rectum. 2008;51:1562–1565. 9. Leitao MM Jr, Byrum GV 3rd, Abu-Rustum NR, et al. Postoperative intra-abdominal collections using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier at the time of laparotomy for uterine or cervical cancers. Gynecol Oncol. 2010;119:208–211. 10. Kumar S, Wong PF, Leaper DJ. Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after non-gynaecological abdominal surgery. Cochrane Database Syst Rev. 2009;(1):CD005080.
William B. Robb, M.D. Christophe Mariette, M.D., Ph.D. Lille, France
Effectiveness of Efferent Loop Stimulation: Looking for a Suitable Protocol To the Editor—We have read with great interest the prospective study of Abrisqueta et al1 describing the stimulation of the efferent limb before ileostomy closure. Their stimulation protocol begins 2 weeks before surgery, but sometimes patients have their ileostomy a long time because of coadjuvant treatment and the waiting time before surgery, allowing the excluded segment to atrophy and losing the potential benefit of the ileostomy stimulation. We propose beginning with the stimulation as soon as a barium enema confirms the integrity of the anastomosis, even during adjuvant treatment. In our case, we began with 300 cm3 of warm saline, including a thickener in the saline solution introduced through a Foley catheter. We repeated the process each week, increasing the stimulation
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Diseases of the Colon & Rectum Volume 58: 4 (2015)
to 500 cm3. One week before surgery for the reconstruction of the intestinal tract, stimulation was done daily, while including in the solution the contents of a container of sodium lauryl sulfoacetate and trisodium citrate for anterograde preparation of the excluded segment.2 We concur with Abrisqueta about reeducating patients for sphincter control; in our case, we also recommended Kegel exercises.3 Although further studies are necessary to identify all the factors involved in postoperative ileus, the study of Abrisqueta et al allows the beginning of the creation of protocols to stimulate daily the excluded segment at the patient's home. REFERENCES 1. Abrisqueta J, Abellan I, Luján J, Hernández Q, Parrilla P. Stimulation of the efferent limb before ileostomy c losure: a randomized clinical trial. Dis Colon Rectum. 2014;57: 1391–1396. 2. Menéndez P, García A, Lozano E, Peláez R. Effectiveness of afferent loop stimulation prior to ileostomy closure [in Spanish]. Cir Esp. 2013;91:547–548. 3. Ehrenpreis ED, Chang D, Eichenwald E. Pharmacotherapy for fecal incontinence: a review. Dis Colon Rectum. 2007;50:641–649.
Pablo Menendez, Ph.D. Carlos Leon, M.D. Alberto Garcia, M.D. Jesus Martin, Ph.D. Valdepeñas, Ciudad Real, Spain
The Authors Reply To the Editor—The authors appreciate the comments of Menendez and colleagues. We agree that it is necessary to seek the best protocol for patients needing a diverting ileostomy. We have only demonstrated the clinical results obtained with our approach. We are aware that a lack of previous studies means that our method of stimulation may not be the best one. We began with 500 mL of saline
Financial Disclosure: The authors claim no conflict of interest regarding the manuscript. Correspondence: Jesús Abrisqueta Carrión, Ph.D., Departamento de Cirugía General, Unidad Colorrectal, Hospital Universitario Virgen de la Arrixaca, CIBEREHD. Ctra. Madrid-Cartagena, 30120, El Palmar, Murcia. Spain. E-mail: [email protected]
solution containing 30 g of thickener to simulate intestinal content.1 But, in fact, it is unknown to us whether there is another type of stimulating solution that could be more effective, or even if would be possible to use intestinal content as the stimulant solution. Would that be the best option? We are still at the very start of the path leading to the best possible protocol, and there is a long way to the finish line. Additional well-designed prospective randomized studies will be needed to adequately answer the many questions raised with respect to this novel technique. A few of the questions that will need to be answered are: When is it best to start the stimulation? What is the best frequency of stimulation? And what is the most efficient stimulant solution? Answering such questions must be done through studies that not only show clinical results, but also the histopathological changes that occur within the intestine during the stimulation process. Perhaps, prolonged stimulation during the adjuvant treatment period after primary surgery could avoid some of the complications that an ileostomy can involve, like readmissions because of dehydration, which is the primary cause of re-admission after performance of a diverting loop ileostomy.2 Finally, we look forward to the additional experience that will be provided by the ongoing studies in this subject.
REFERENCES 1. Abrisqueta J, Abellan I, Luján J, Hernández Q, Parrilla P. Stimulation of the efferent limb before ileostomy closure: a randomized clinical trial. Dis Colon Rectum. 2014;57:1391–1396. 2. Messaris E, Sehgal R, Deiling S, et al. Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum. 2012;55:175–180.
J. Abrisqueta, Ph.D I. Abellan, Ph.D J. Luján, Ph.D N. Ibáñez, M.D P. Parrilla, Ph.D. Murcia, Spain
that we inaccurately categorized 3 studies3–5 as not being funded by industry. The fourth article6 referred to does not document industrial support. The implication of this correspondence is that this review was not compiled by the authors with independence from input by industry. This was not the case. Both authors had complete independence in performing the literature search, identifying articles for inclusion, data extraction, drafting the article, and decision to submit for publication. The final document did not undergo review by an industrial partner explaining why privileged documents, referenced by the correspondent, were not available to us and mitigates against concerns regarding unacknowledged publications. Our search strategy complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our exclusion criteria clearly state that a meeting abstract7 would not be considered for inclusion. In addition, this systematic review was limited to studies in digestive tract surgery in humans, and evidence referenced in this correspondence relating to animal studies8 or gynecological surgery9 was not considered. The study by Cornish et al published in Diseases of the Colon & Rectum in 20067 is indeed an influential study. The authors of the recent Cochrane Review10 recognized that the inclusion of a subgroup of patients (90 of 1791 patients operated on for bowel obstruction rather than having an open digestive tract resection) in meta-analysis significantly affected the point estimate of effect on time to recurrent surgery for intestinal obstruction. We have published a systematic review without such meta-analysis, and whether this subgroup is a distinct patient group that warrants separate consideration is a moot point. We feel strongly that we provide an objective and comprehensive systematic review with well-balanced and conservative conclusions, which are unchanged by this correspondence. We reiterate that more evidence is needed regarding the efficacy of all antiadhesion strategies in reducing chronic abdominal symptoms, avoiding repeated operative interventions, and improving quality of life. REFERENCES 1. Waldron M. Errors, omissions, and publication bias. Dis Colon Rectum. 2015;58:e53. 2. Robb WB, Mariette C. Strategies in the prevention of the formation of postoperative adhesions in digestive surgery: a systematic review of the literature. Dis Colon Rectum. 2014;57:1228–1240. 3. Dupré A, Lefranc A, Buc E, et al. Use of bioresorbable membranes to reduce abdominal and perihepatic adhesions in 2-stage hepatectomy of liver metastases from colorectal cancer: results of a prospective, randomized controlled phase II trial. Ann Surg. 2013;258:30–36.
LEtters to the Editor
4. Salum M, Wexner SD, Nogueras JJ, et al.; Program Directors Association in Colon and Rectal Surgery. Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure? Tech Coloproctol. 2006;10:187–190. 5. Oikonomakis I, Wexner SD, Gervaz P, You SY, Secic M, Giamundo P. Seprafilm: a retrospective preliminary evaluation of the impact on short-term oncologic outcome in colorectal cancer. Dis Colon Rectum. 2002;45:1376–1380. 6. Kusunoki M, Ikeuchi H, Yanagi H, et al. Bioresorbable hyaluronate-carboxymethylcellulose membrane (Seprafilm) in surgery for rectal carcinoma: a prospective randomized clinical trial. Surg Today. 2005;35:940–945. 7. Cornish JA, Tekkis PP, Kiran RP, Kirat H, Tan E, Remzi FH, Fazio VW. The effect of Seprafilm on septic complications and bowel obstruction following primary restorative proctocolectomy. Dis Colon Rectum. 2008;51[abstract]:647. 8. Altuntas YE, Kement M, Oncel M, Sahip Y, Kaptanoglu L. The effectiveness of hyaluronan-carboxymethylcellulose membrane in different severity of adhesions observed at the time of relaparotomies: an experimental study on mice. Dis Colon Rectum. 2008;51:1562–1565. 9. Leitao MM Jr, Byrum GV 3rd, Abu-Rustum NR, et al. Postoperative intra-abdominal collections using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier at the time of laparotomy for uterine or cervical cancers. Gynecol Oncol. 2010;119:208–211. 10. Kumar S, Wong PF, Leaper DJ. Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after non-gynaecological abdominal surgery. Cochrane Database Syst Rev. 2009;(1):CD005080.
William B. Robb, M.D. Christophe Mariette, M.D., Ph.D. Lille, France
Effectiveness of Efferent Loop Stimulation: Looking for a Suitable Protocol To the Editor—We have read with great interest the prospective study of Abrisqueta et al1 describing the stimulation of the efferent limb before ileostomy closure. Their stimulation protocol begins 2 weeks before surgery, but sometimes patients have their ileostomy a long time because of coadjuvant treatment and the waiting time before surgery, allowing the excluded segment to atrophy and losing the potential benefit of the ileostomy stimulation. We propose beginning with the stimulation as soon as a barium enema confirms the integrity of the anastomosis, even during adjuvant treatment. In our case, we began with 300 cm3 of warm saline, including a thickener in the saline solution introduced through a Foley catheter. We repeated the process each week, increasing the stimulation
e55
Diseases of the Colon & Rectum Volume 58: 4 (2015)
to 500 cm3. One week before surgery for the reconstruction of the intestinal tract, stimulation was done daily, while including in the solution the contents of a container of sodium lauryl sulfoacetate and trisodium citrate for anterograde preparation of the excluded segment.2 We concur with Abrisqueta about reeducating patients for sphincter control; in our case, we also recommended Kegel exercises.3 Although further studies are necessary to identify all the factors involved in postoperative ileus, the study of Abrisqueta et al allows the beginning of the creation of protocols to stimulate daily the excluded segment at the patient's home. REFERENCES 1. Abrisqueta J, Abellan I, Luján J, Hernández Q, Parrilla P. Stimulation of the efferent limb before ileostomy c losure: a randomized clinical trial. Dis Colon Rectum. 2014;57: 1391–1396. 2. Menéndez P, García A, Lozano E, Peláez R. Effectiveness of afferent loop stimulation prior to ileostomy closure [in Spanish]. Cir Esp. 2013;91:547–548. 3. Ehrenpreis ED, Chang D, Eichenwald E. Pharmacotherapy for fecal incontinence: a review. Dis Colon Rectum. 2007;50:641–649.
Pablo Menendez, Ph.D. Carlos Leon, M.D. Alberto Garcia, M.D. Jesus Martin, Ph.D. Valdepeñas, Ciudad Real, Spain
The Authors Reply To the Editor—The authors appreciate the comments of Menendez and colleagues. We agree that it is necessary to seek the best protocol for patients needing a diverting ileostomy. We have only demonstrated the clinical results obtained with our approach. We are aware that a lack of previous studies means that our method of stimulation may not be the best one. We began with 500 mL of saline
Financial Disclosure: The authors claim no conflict of interest regarding the manuscript. Correspondence: Jesús Abrisqueta Carrión, Ph.D., Departamento de Cirugía General, Unidad Colorrectal, Hospital Universitario Virgen de la Arrixaca, CIBEREHD. Ctra. Madrid-Cartagena, 30120, El Palmar, Murcia. Spain. E-mail: [email protected]
solution containing 30 g of thickener to simulate intestinal content.1 But, in fact, it is unknown to us whether there is another type of stimulating solution that could be more effective, or even if would be possible to use intestinal content as the stimulant solution. Would that be the best option? We are still at the very start of the path leading to the best possible protocol, and there is a long way to the finish line. Additional well-designed prospective randomized studies will be needed to adequately answer the many questions raised with respect to this novel technique. A few of the questions that will need to be answered are: When is it best to start the stimulation? What is the best frequency of stimulation? And what is the most efficient stimulant solution? Answering such questions must be done through studies that not only show clinical results, but also the histopathological changes that occur within the intestine during the stimulation process. Perhaps, prolonged stimulation during the adjuvant treatment period after primary surgery could avoid some of the complications that an ileostomy can involve, like readmissions because of dehydration, which is the primary cause of re-admission after performance of a diverting loop ileostomy.2 Finally, we look forward to the additional experience that will be provided by the ongoing studies in this subject.
REFERENCES 1. Abrisqueta J, Abellan I, Luján J, Hernández Q, Parrilla P. Stimulation of the efferent limb before ileostomy closure: a randomized clinical trial. Dis Colon Rectum. 2014;57:1391–1396. 2. Messaris E, Sehgal R, Deiling S, et al. Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum. 2012;55:175–180.
J. Abrisqueta, Ph.D I. Abellan, Ph.D J. Luján, Ph.D N. Ibáñez, M.D P. Parrilla, Ph.D. Murcia, Spain
