Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Dec 27, 2020; 12(12): 507-519
Published online Dec 27, 2020. doi: 10.4240/wjgs.v12.i12.507
Risk factors for postoperative stoma outlet obstruction in ulcerative colitis
Tomoaki Kitahara, Yu Sato, Takashi Oshiro, Rie Matsunaga, Makoto Nagashima, Shinichi Okazumi
Tomoaki Kitahara, Yu Sato, Takashi Oshiro, Rie Matsunaga, Makoto Nagashima, Shinichi Okazumi, Department of Surgery, Toho University Sakura Medical Center, Sakura 285-8741, Chiba, Japan
Author contributions: Kitahara T designed and performed the research and wrote the paper; Sato Y and Matsunaga R designed the research and contributed to the analysis; Oshiro T, Nagashima M, and Okazumi S provided clinical advice and supervised the report; and all authors have approved the final version of the article to be published.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Toho University Sakura Medical Center (IRB approval code: S19026, Toho University Sakura Medical Center).
Informed consent statement: Patients were not required to give informed consent in order to be included in the study because the analysis used anonymous clinical data that were obtained after each patient had agreed to treatment by written consent. The details of the study were published on the home page of Toho University Sakura Medical Center.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yu Sato, MD, Lecturer, Department of Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura 285-8741, Chiba, Japan. yu.sato@med.toho-u.ac.jp
Received: August 3, 2020
Peer-review started: August 3, 2020
First decision: September 17, 2020
Revised: September 28, 2020
Accepted: November 13, 2020
Article in press: November 13, 2020
Published online: December 27, 2020
Abstract
BACKGROUND

Current medical treatments can achieve remission of ulcerative colitis (UC). Surgery is required when potent drug treatment is ineffective or when colon cancer or high-grade dysplasia develops. The standard procedure is restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, commonly performed as two- or three-stage RPC with diverting ileostomy. Postoperative stoma outlet obstruction (SOO) is frequent, but the causes are not well known.

AIM

To identify the risk factors for SOO after stoma surgery in patients with UC.

METHODS

We retrospectively reviewed the files of 148 consecutive UC patients who underwent surgery with stoma construction. SOO was defined as small bowel obstruction symptoms and intestinal dilatation just below the penetrating part of the stoma on computed tomography. Patients were divided into two groups: Those who developed SOO within 30 d after surgery and those who did not. Patient characteristics, intraoperative parameters, the stoma site, and rectus abdominis muscle thickness were collected. Moreover, we identified the patients who repeatedly developed SOO. Univariate and multivariate analyses were performed to identify risk factors for SOO and recurring SOO.

RESULTS

Eighty-nine patients who underwent two-stage RPC were included between January 2008 and March 2020. Postoperatively, SOO occurred in 25 (16.9%) patients after a median time of 9 d (range 2-26). Compared to patients without SOO, patients with SOO had a significantly higher rate of malignant tumors or dysplasia (36.0% vs 17.1%, P = 0.032), lower total glucocorticoid dose one month before surgery (0 mg vs 0 mg, P = 0.026), higher preoperative total protein level (6.8 g/dL vs 6.3 g/dL, P = 0.048), higher rate of loop ileostomy (88.0% vs 55.3%, P = 0.002), and higher maximum stoma drainage volume (2300 mL vs 1690 mL, P = 0.004). Loop ileostomy (OR = 6.361; 95%CI 1.322–30.611; P = 0.021) and maximum stoma drainage volume (OR = 1.000; 95%CI 1.000–1.001; P = 0.015) were confirmed as independent risk factors for SOO. Eighteen patients with SOO were treated conservatively without recurrence (sSOO group). Seven (28.0%) patients repeatedly developed SOO (rSOO group) during the observation period. A significant difference was observed in the rectus abdominis muscle thickness between the two groups (sSOO 9.3 mm, rSOO 12.7 mm, P = 0.006). Muscle thickness was confirmed as an independent risk factor for recurring SOO (OR = 2.676; 95%CI 1.176-4.300; P = 0.008).

CONCLUSION

In this study, high maximum stoma drainage volume and loop ileostomy are independent risk factors for SOO. Additionally, among patients with a thick rectus abdominis muscle, the risk of SOO recurrence is high.

Keywords: Ileal pouch anal anastomosis, Ileostomy, Loop ileostomy, Proctocolectomy and restorative, Surgical stomas, Total proctocolectomy, Ulcerative colitis

Core Tip: This was a retrospective study to identify risk factors for stoma outlet obstruction (SOO) that develops after stoma surgery in patients with ulcerative colitis. High maximum stoma drainage volume and loop ileostomy were independent risk factors for the development of SOO. In patients with thick rectus abdominis muscles, SOO may recur.