705995

research-article2017
SJS0010.1177/1457496917705995Loop ileostomies and ulcerative colitisJ. Park, et al.

Original Research Article

SJS
SCANDINAVIAN
JOURNAL OF SURGERY

Complications And Morbidity Associated With Loop

Ileostomies In Patients With Ulcerative Colitis

J. Park, B. Gessler, M. Block, E. Angenete

Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg,
Scandinavian Surgical Outcomes Research Group (SSORG), Sahlgrenska University Hospital/Östra,
Gothenburg, Sweden

Abstract

Background and Aims: Loop ileostomies are frequently used as diversion of the fecal stream
to protect a distal anastomosis. The aim of this study was to identify complications and
morbidity related to loop ileostomies in patients with ulcerative colitis at a nonemergent
setting.
Material and Methods: Consecutive patients with ulcerative colitis who received a loop
ileostomy at a tertiary referral center in Sweden from January 2006 until December 2012
were included and studied retrospectively.
Results: In total, 71 patients were identified, and the median age was 39 years. A
majority (94%) of the patients underwent proctectomy or proctocolectomy with primary
construction of an ileal pouch–anal anastomosis. In total, 38 patients (54%) had one or
more postoperative complications at index surgery. Stoma-related complications were seen
in 49% where parastomal skin irritation was most common. In total, 18% of the patients
were re-admitted due to morbidity related to the ileostomy, and the leading cause was
high volume output. Complications related to closure were seen in 29% of the patients,
and of these, 30% required surgical intervention. In total, five patients (7%) developed a
symptomatic leakage in the ileo-ileal anastomosis. There was no mortality.
Conclusion: Loop ileostomies in this young patient cohort resulted in considerable
morbidity. Closure of the ileostomy was also associated with complications. Although
the diverting loop ileostomy is constructed to decrease the clinical consequences of an
anastomotic leakage, the inherent morbidity should be considered. Preventive measures
for parastomal skin problems could improve results.

Correspondence:
Jennifer Park, M.D.
Department of Surgery
Institute of Clinical Sciences
Sahlgrenska Academy at University of Gothenburg Scandinavian Journal of Surgery
Scandinavian Surgical Outcomes Research Group (SSORG) 2018, Vol. 107(1) 38­–42
© The Finnish Surgical Society 2017
Sahlgrenska University Hospital/Östra Reprints and permissions:
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Sweden DOI: 10.1177/1457496917705995
https://doi.org/10.1177/1457496917705995
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Email: jennifer.park@vgregion.se
 Loop ileostomies and ulcerative colitis
Key words: Ulcerative colitis; inflammatory bowel disease; temporary ileostomy; ostomy; morbidity;
colorectal surgery
Introduction
First-line treatment for ulcerative colitis (UC) is phar-
maceutical. However, approximately 20% of the
patients with UC will require a colectomy, due to
refractory disease, intolerance to medical therapies, or
development of neoplasia (1). Restorative proctocolec-
tomy with ileal pouch–anal anastomosis (IPAA) has
become the standard of care for elective surgery in
UC. Most commonly, this is performed as a two- or
three-stage procedure with construction of a loop ile-
ostomy at the same time as construction of the ileal
pouch (1, 2). It is believed that the diversion of the
fecal stream allows for the more distal anastomosis to
fully heal while decreasing the rate of pelvic sepsis
and the clinical consequences of an anastomotic leak-
age (1, 3–6). In rectal cancer, a loop ileostomy has been
shown to reduce complications related to anastomotic
dehiscence after total mesorectal excision (7). However,
the diverting loop ileostomy itself is associated with
substantial morbidity with reported complication
rates of 17%–66% (3, 6, 8, 9), and closure of the ostomy
is associated with considerable risk for postoperative
complications, with frequencies of 20%–40% and reop-
eration rates of 6%–15% (9–13).
The aim of this study was to identify complications
and morbidity related to loop ileostomies in consecu-
tive patients with UC undergoing elective surgery and
to identify possible risk factors for severe complica-
tions at closure.
Material And Methods
Study Design
Patients
All consecutive patients with UC and an elective pro-
cedure including primary reconstruction or redo sur-
gery with an IPAA who received a loop ileostomy
between 1 January 2006 and the 31 December 2012
were identified using the Nordic Medical Statistical
Committee (NOMESCO) Classification of Surgical
Procedures Version 1.9 codes JFF10 and JFF11. To
ensure that no patients were missed, the NOMESCO
codes for stoma reversal (JFG00 and JFG20) were
checked until the 31 August 2014. At the studied
hospital, a diverting loop ileostomy was a standard
procedure during IPAA surgery, and only three
patients received an IPAA without a loop ileostomy
during the study period. These patients were not
included in the present analysis. A clinical record
form (CRF) was used to retrospectively retrieve
patient data from medical charts, including notes
from the stoma nurse. All patient records were
reviewed until 21 October 2014 or until death. Data
were extracted regarding patient demography, pri-
mary diagnoses, and details of the surgical procedure
(Table 1). In addition, surgical complications at index
surgery and ileostomy closure as well as complica-
tions related to the loop ileostomy were registered.
39
Definition Of Outcomes
Postoperative complications within 90 days were cat-
egorized according to the Clavien–Dindo grading sys-
tem for the classification of surgical complications
(14). To reduce the risk of misclassification, grades I
and II were combined. Anastomotic leakage was
defined as a symptomatic defect in the anastomosis
regardless of the need for therapeutic intervention.
High volume output was defined as a stomal out-
put exceeding 2000 mL/24 h from postoperative day 4
and onward, based on previous studies (13, 15).
Postoperative ileus was considered a complication
when being the cause for prolonged hospital care or
readmission. Parastomal leakage was defined as
stomal output outside the appliance bag, and skin irri-
tation was considered a complication when being
brought up as a problem at a minimum of two stoma
nurse visits.
Statistical Analysis
The statistical analyses were performed with SPSS
21.0 (SPSS, Inc., Chicago, IL). Results are presented as
median values with range in parentheses. Logistic
regression was performed for multivariate analysis
with risk factors for severe complications (Clavien–
Dindo ⩾ grade IIIa) at loop ileostomy closure. The ini-
tial list of prognostic factors to include in the
multivariate analysis was decided using data from
the literature together with clinical expertise including
the factors: gender, body mass index (BMI; <25 respec-
tively >25), comorbidity using the American Society of
Anesthesiologists physical status classification (ASA)
I and II respectively III and IV, and severe complica-
tions at index surgery not associated with the ileos-
tomy (Clavien–Dindo ⩾ grade IIIa).
Results
baseline demographics and index surgery
In total, 71 (24 females) patients were included in the
study. Basic demography including preoperative mor-
bidity is displayed in Table 1. A majority (94%) of the
patients underwent proctectomy or proctocolectomy
with primary construction of an IPAA. A total of 13%
of the patients were being treated with immunosup-
pressants and/or systemic steroids. At index surgery,
54% of the patients had one or several postoperative
complications, and the most common was periopera-
tive bleeding requiring blood transfusion (21%) fol-
lowed by wound infection (18%). For details regarding
Clavien–Dindo classification of the complications, see
Table 1. In total, three patients had a leakage in the
IPAA and one patient suffered from pelvic sepsis,
which was regarded as a probable anastomotic leak-
age. There was no relationship between the use of sys-
temic steroids and/or immunosuppressant treatment
with postoperative complications at index surgery.
40 J. Park, et al.

Table 1. Loop Ileostomy Reversal

Baseline characteristics.
The loop ileostomy was not reversed in one patient
Patients 71 and one patient was lost to follow-up due to migra-
Male/female 47 (66%)/24 (34%) tion. Most patients (69/70) underwent both endo-
Age at index surgery (years) 39 (16–62) scopic examination and rectal enema radiographic
ASA classificationa sequence, and one patient underwent endoscopic
  ASA I 11 (16%) examination and magnetic resonance imaging (MRI)
  ASA II 57 (80%) prior to closure. Time until closure of the loop ileos-
  ASA III 3 (4%) tomy was in median 92 days (9–470 days). Overall,
  ASA IV 0 (0%) post-closure complications were seen in 29% of the
Body mass index (BMI, kg/m2) 23 (17–32) patients, with a majority being graded Clavien–
Diagnoses Dindo grades I and II (Table 3). In total, six patients
  Ulcerative colitis (UC) 71/71 (100%) (9%) required a reoperation after closure, where one
Primary sclerosing colangitis 5/71 (7%) patient underwent two surgical procedures. The
Type of surgery causes for reoperation were intraabdominal abscess
 Proctectomy with ileal pouch–anal 63/71 (89%) (n = 1), leakage in the ileo-ileal anastomosis (n = 2),
anastomosis (IPAA) small bowel perforation (n = 1), obstruction of the
  Proctocolectomy with IPAA 4/71 (6%) ileo-ileal anastomosis (n = 1), wound rupture (n = 1),
  Redo surgery of IPAA 4/71 (6%) and unknown cause of peritonitis (n  = 
1).
Scheduled surgery 71/71 (100%) Symptomatic leakage in the ileo-ileal anastomosis
Blood loss at index surgery (mL) 600 (100–1900) was seen in five patients (7%), of whom two needed
Patients with one or more postoperative 38/71 (54%) a reoperation. There was no mortality.
complicationsb
Postoperative complications according to Clavien–Dindo (number
of complications) Risk Factors For Complications Related To
  Grades I and II 37/71 (52%) Stoma Reversal
  Grade IIIa 1/71 (1%) In multivariate analysis, there were no significant cor-
  Grade IIIb 7/71 (10%) relations found between prognostic factors and severe
  Grade IVa 1/71 (1%) complications at index surgery or at stoma closure.
  Grade IVb 0/71 (0%)
Length of hospital stay at index surgery 7 (4–18)
(days) Discussion
Use of immunomodulators or biologics at 4/71 (6%)
index surgeryc This study confirms previous reports that the morbid-
Use of 5 aminosalicylic acid (5-ASA) at 17/71 (24%) ity with a loop ileostomy and the complications at
index surgeryd reversal are considerable in patients with patients
Use of steroids at index surgerye 10/71 (14%) with a loop ileostomy (3–6, 9–12, 16, 17). These find-
Time until closure of loop ileostomy (days) 92 (9–470) ings are not new, but many of the previous reports
have included a mixture of patients, combining diag-
Numbers are in median. Percentages or range is given in noses such as inflammatory bowel disease (both UC
parentheses. and Crohn’s disease) and colorectal cancer, the latter
aAmerican Society of Anesthesiologists physical status
group consisting of patients that are often considera-
classification. bly older and more comorbid (7, 18). Our study solely
bBleeding (n = 15), wound infection (n = 13), other infection (n = 7),
includes patients with UC, a young, and apart from
postoperative ileus (n = 2), symptomatic anastomotic leakage their inflammatory bowel disease, fairly healthy
(n = 3), pelvic sepsis (n = 1), cardiovascular (n = 1), respiratory
(n = 1), and other (n = 3).
cohort, but still our data shows that the complication
cTumor necrosis factor (TNF) inhibiting drugs (n = 1), calcineurin rates are somewhat discouraging. The reasons for
inhibitors (n = 2), and antineoplastic agents (n = 1). these complications remain partly unknown. In the
d5-ASA oral (n = 6), 5-ASA local (n = 11). analysis, we did not find a correlation between post-
eOral (n = 6) and rectal (n = 4). operative complications and the use of systemic ster-
oids and/or immunosuppressant treatment, although
Loop Ileostomy Complications
this is a well-known risk factor (19–21). The explana-
tion might be the low number of patients on medica-
Complications related to the loop ileostomy were tion at the time for reconstructive surgery, as they
seen in 35 (49%) patients, and the majority were skin were mainly two- or three-stage procedures.
related (23%). High volume output (18%) was the Some authors have suggested that the loop ileos-
main reason for readmission. The overall readmis- tomy could be omitted in selected cases (16, 22). Zittan
sion rate was 18%. et al. (23) have recently suggested this, where a retro-
Reoperation due to stoma-related complications spective review of 460 patients indicates that it is pos-
during the loop ileostomy period was performed on sible to omit the loop ileostomy. These results are
two patients (3%). During the follow-up time, four from a highly specialized center and may highlight
patients (6%) developed a symptomatic hernia at the the need for centralization of advanced surgery for
site of the previous stoma, which lead to surgical inter- UC. Still, an anastomotic leakage in the IPAA may be
vention. For details, see Table 2. detrimental and render the patient with a lifelong
 Loop ileostomies and ulcerative colitis 41

Table 2 Table 3
Loop ileostomy complications. Loop ileostomy closure.
Complications related to the loop ileostomy Stoma closurea 70/71 (99%)
 Number of patients 35/71 (49%) Converted to permanent end ileostomy 2/70 (3%)
 Number of complications 46 due to postoperative complications
Type of complication Time to loop ileostomy closure (days) 92 (9–470)
  High volume outputa 13/71 (18%) Surgical technique
  Stomal obstruction 3/71 (4%)   Circumstomal incision 67/70 (96%)
  Stomal retraction 1/71 (1%)  Laparotomy 3/70 (4%)
  Parastomal leakage 7/71 (10%) Anastomotic technique
  Parastomal wound infection 1/71 (1%)  Hand-sewn 69/70 (99%)
  Parastomal skin irritation 16/71 (23%)  Stapled 1/70 (1%)
  Parastomal ulceration 4/71 (6%) Bowel resection
 Other 1/71 (1%)  Yes 16/70 (23%)
Readmission due to complications of the 13/71 (18%)  No 54/70 (77%)
ostomyb (number of patients) Postoperative complications
Complication that lead to readmission  Number of patients 20/70 (29%)
  High volume output 8/71 (11%)  Number of complications 34
 Obstruction 3/71 (4%) Postoperative complications according to Clavien–Dindo
 Otherc 2/71 (3%)   Grades I and II 25/70 (36%)
Reoperations due to stoma-related 2/71 (3%)   Grade IIIa 1/70 (1%)
complicationsd   Grade IIIb 7/70 (10%)
  Obstruction/rotated loop 1/71 (1%)   Grade IVa 1/70 (1%)
  Stomal retraction 1/71 (1%)   Grade IVb 0/70 (0%)
Late complications related to the loop ileostomy Type of complications
  Hernia at the site of the stomae 4/71 (6%)  Symtomatic leakage in ileo-ileal 5/70 (7%)
anastomosis
Numbers are in median. Percentages or range is given in  Ileusb 4/70 (6%)
parentheses.   Small bowel obstruction 4/70 (6%)
aDefined as >2000 mL stomal output per 24 h from postoperative
 Symtomatic leakage in the ileo-anal 1/70 (1%)
day 4 and onward. anastomosis
bIn the time period between index surgery and closure of the loop
 Otherc 20/70 (29%)
ileostomy.
cStomal retraction (n = 1) and parastomal leakage (n = 1). Reoperation (number of patients) 6/70 (9%)
dComplications of the stoma that lead to earlier closure than

planned was considered a complication and hence a reoperation
due to stoma complication.
eAll patients (n = 4) underwent surgery for parastomal hernia after
loop ileostomy closure.
Numbers are in median. Percentages or range is given in
parentheses.
aInformation is missing in one patient.
bCausing prolonged hospital care or readmission.
cDehydration (n = 6), bleeding (n = 3), wound infection (n = 1),

sepsis (n = 3), small bowel perforation (n = 1), pneumonia (n = 1),

permanent ileostomy or at least a severely affected
bowel function. However, some reports have indi-
cated that although the incidence of anastomotic leak-
age is higher without a loop ileostomy, if correctly
treated, the patients may maintain bowel function
and quality of life (24–26). Another approach could be
to remove the loop ileostomy earlier, within the first
2 weeks after reconstructive surgery, as suggested in
rectal cancer (27, 28). This would certainly reduce the
stoma-related complications, and some studies also
indicate a total reduction of complications in patients
with early closure. In this study, one patient had their
stoma reversed after 9 days. This was due to a strong
request from the patient, and together with satisfying
endoscopic and radiological investigation of the anas-
tomosis and a postoperative uncomplicated clinical
course, the decision was made to enable an early clo-
sure. Early closure was not a routine procedure.
Morbidity related to the stoma was mainly skin-
related complications and high volume output, and as
many as almost 1/5 of the patients were re-admitted
due to stoma-related complications. It is possible that
a more active postoperative follow-up as suggested by
wound rupture (n = 1), respiratory failure (n = 1), subphrenic
abscess (n = 1), and other (n = 2).
Nagle et al. (29) could reduce complications, improve
patient quality of life, and decrease health-care con-
sumption.
The strengths of this study are the consecutive elec-
tive patients at a single institution with data extracted
by a single investigator reducing the risk for selection
bias. A weakness of this study is the retrospective
design and the inherent risk of missing information
compared to a prospective collection of data.
In conclusion, we find that the morbidity related to
a loop ileostomy and its reversal in otherwise fairly
healthy patients with UC requires attention. Closer
follow-up, shorter time with a stoma, and attention to
potential risk factors at reversal must be addressed to
reduce the morbidity in patients with UC.
Acknowledgements
The authors all contributed to conception and design of the
study, interpreted data, performed analysis of data, revised
42 J. Park, et al.
the manuscript, and finally approved the manuscript for
publication. Jennifer Park acquired most data and drafted
this article. The authors would like to express their gratitude
to David Bock, statistician, who assisted with the statistical
analysis, as well as the rest of the staff at Scandinavian
Surgical Outcomes Research Group (SSORG) in Gothenburg,
Sweden.
Declaration Of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
This work was supported by the Swedish Society of
Medicine and the Agreement concerning research and edu-
cation of doctors (ALFGBG-493341 and ALFGBG-526501)
and Lisa and Bror Björnsson Research Foundation,
Gothenburg, Sweden.
Ethical Approval
The Ethical Review Board in Gothenburg, Sweden, approved
the research project EPN 399-14.
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Received: November 23, 2016
Accepted: March 14, 2017