Skip to main content
SpringerLink
Log in

Outcomes and Cost of Diverted Versus Undiverted Restorative Proctocolectomy

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Some observational studies suggest that diversion during restorative proctocolectomy mitigates the risk of anastomotic complications. However, diversion has its own costs and complications. The aim of this study was to compare the cost and outcomes of diverted to undiverted restorative proctocolectomy.

Methods

This study took advantage of a natural experiment within one surgical department to understand the clinical and financial implications of diversion during restorative proctocolectomy. For the last 10 years, two surgeons routinely diverted all patients undergoing restorative proctocolectomy, and two other surgeons routinely did not. The medical records of 288 consecutive restorative proctocolectomy patients were reviewed. Minimum follow-up time was 1 year, with an average of 4.7 years. Complications rates and costs of care were collected.

Results

There were no significant differences between rates of anastomotic leak, fistula, or hernias in diverted versus undiverted patients. The odds of having stricture (odds ratio (OR) = 17.08, P < 0.001) and small bowel obstruction (OR = 5.05, P = 0.02) were both significantly higher in diverted patients. The average cost per patient was $43,000 more in the routinely diverted patients.

Conclusion

Undiverted restorative proctocolectomy may be the highest value procedure with the most favorable outcomes at the lowest cost.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Grobler SP, Hosie KB, Keighley MR: Randomized trial of loop ileostomy in restorative proctocolectomy. Br J Surg 1992, 79(9):903-906.

    Article  CAS  PubMed  Google Scholar 

  2. Sugerman HJ, Sugerman EL, Meador JG, Newsome HH, Kellum JM, DeMaria EJ: Ileal pouch anal anastomosis without ileal diversion. Ann Surg 2000, 232(4):530-541.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  3. Davies M, Hawley PR: Ten years experience of one-stage restorative proctocolectomy for ulcerative colitis. Int J Colorectal Dis 2007, 22(10):1255-1260.

    Article  CAS  PubMed  Google Scholar 

  4. Perez RO, Habr-Gama A, Seid VE, Proscurshim I, Sousa AH, Kiss DR, Linhares M, Sapucahy M, Gama-Rodrigues J: Loop ileostomy morbidity: timing of closure matters. Dis Colon Rectum 2006, 49(10):1539-1545.

    Article  PubMed  Google Scholar 

  5. Scarpa M, Ruffolo C, Bassi D, Boetto R, D’Incà R, Buda A, Sturniolo GC, Angriman I: Intestinal surgery for Crohn’s disease: predictors of recovery, quality of life, and costs. J Gastrointest Surg 2009, 13(12):2128-2135.

    Article  PubMed  Google Scholar 

  6. Weston-Petrides GK, Lovegrove RE, Tilney HS, Heriot AG, Nicholls RJ, Mortensen NJ, Fazio VW, Tekkis PP: Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy. Arch Surg 2008, 143(4):406-412.

    Article  PubMed  Google Scholar 

  7. Mennigen R, Senninger N, Bruwer M, Rijcken E: Impact of defunctioning loop ileostomy on outcome after restorative proctocolectomy for ulcerative colitis. Int J Colorectal Dis 2011, 26(5):627-633.

    Article  PubMed  Google Scholar 

  8. Heuschen UA, Hinz U, Allemeyer EH, Lucas M, Heuschen G, Herfarth C: One- or two-stage procedure for restorative proctocolectomy: rationale for a surgical strategy in ulcerative colitis. Ann Surg 2001, 234(6):788-794.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  9. Ikeuchi H, Nakano H, Uchino M, Nakamura M, Noda M, Yanagi H, Yamamura T: Safety of one-stage restorative proctocolectomy for ulcerative colitis. Dis Colon Rectum 2005, 48(8):1550-1555.

    Article  PubMed  Google Scholar 

  10. Remzi FH, Fazio VW, Gorgun E, Ooi BS, Hammel J, Preen M, Church JM, Madbouly K, Lavery IC: The outcome after restorative proctocolectomy with or without defunctioning ileostomy. Dis Colon Rectum 2006, 49(4):470-477.

    Article  PubMed  Google Scholar 

  11. Wasmuth HH, Tranø G, Endreseth B, Rydning A, Wibe A, Myrvold HE: Long-term surgical load in patients with ileal pouch-anal anastomosis. Colorectal Dis 2009, 11(7):711-718.

    Article  CAS  PubMed  Google Scholar 

  12. Krausz MM, Duek SD: Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis: twenty years follow-up in 174 patients. Isr Med Assoc J 2005, 7(1):23-27.

    PubMed  Google Scholar 

  13. Seshadri PA, Poulin EC, Schlachta CM, Cadeddu MO, Mamazza J: Does a laparoscopic approach to total abdominal colectomy and proctocolectomy offer advantages? Surg Endosc 2001, 15(8):837-842.

    Article  CAS  PubMed  Google Scholar 

  14. Hahnloser D, Pemberton JH, Wolff BG, Larson DR, Crownhart BS, Dozois RR: Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Br J Surg 2007, 94(3):333-340.

    Article  CAS  PubMed  Google Scholar 

  15. Mowschenson PM, Critchlow JF, Peppercorn MA: Ileoanal pouch operation: long-term outcome with or without diverting ileostomy. Arch Surg 2000, 135(4):463-465; discussion 465-466.

    Article  CAS  PubMed  Google Scholar 

  16. Hainsworth PJ, Bartolo DC: Selective omission of loop ileostomy in restorative proctocolectomy. Int J Colorectal Dis 1998, 13(3):119-123.

    Article  CAS  PubMed  Google Scholar 

  17. Williamson ME, Lewis WG, Sagar PM, Holdsworth PJ, Johnston D: One-stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis: a note of caution. Dis Colon Rectum 1997, 40(9):1019-1022.

    Article  CAS  PubMed  Google Scholar 

  18. Gullberg K, Liljeqvist L: Stapled ileoanal pouches without loop ileostomy: a prospective study in 86 patients. Int J Colorectal Dis 2001, 16(4):221-227.

    Article  CAS  PubMed  Google Scholar 

  19. Kwon S, Morris A, Billingham R, Frankhouse J, Horvath K, Johnson M, McNevin S, Simons A, Symons R, Steele S et al: Routine leak testing in colorectal surgery in the Surgical Care and Outcomes Assessment Program. Arch Surg 2012, 147(4):345-351.

    PubMed  Google Scholar 

  20. Singh P, Bhangu A, Nicholls RJ, Tekkis P: A systematic review and meta-analysis of laparoscopic vs open restorative proctocolectomy. Colorectal Dis 2013, 15(7):e340-351.

    Article  CAS  PubMed  Google Scholar 

  21. Maeda JL, Raetzman SO, Friedman BS: What hospital inpatient services contributed the most to the 2001-2006 growth in the cost per case? Health Serv Res 2012, 47(5):1814-1835.

    Article  PubMed  Google Scholar 

  22. Finkler SA: The distinction between cost and charges. Ann Intern Med 1982, 96(1):102-109.

    Article  CAS  PubMed  Google Scholar 

  23. Kurth T, Walker AM, Glynn RJ, Chan KA, Gaziano JM, Berger K, Robins JM: Results of multivariable logistic regression, propensity matching, propensity adjustment, and propensity-based weighting under conditions of nonuniform effect. Am J Epidemiol 2006, 163(3):262-270.

    Article  PubMed  Google Scholar 

  24. Swenson BR, Hollenbeak CS, Poritz LS, Koltun WA: Modified two-stage ileal pouch-anal anastomosis: equivalent outcomes with less resource utilization. Dis Colon Rectum 2005, 48(2):256-261.

    Article  PubMed  Google Scholar 

  25. Gorfine SR, Gelernt IM, Bauer JJ, Harris MT, Kreel I: Restorative proctocolectomy without diverting ileostomy. Dis Colon Rectum 1995, 38(2):188-194.

    Article  CAS  PubMed  Google Scholar 

  26. Ferrante M, Declerck S, De Hertogh G, Van Assche G, Geboes K, Rutgeerts P, Penninckx F, Vermeire S, D’Hoore A: Outcome after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Inflamm Bowel Dis 2008, 14(1):20-28.

    Article  PubMed  Google Scholar 

  27. Wong KS, Remzi FH, Gorgun E, Arrigain S, Church JM, Preen M, Fazio VW: Loop ileostomy closure after restorative proctocolectomy: outcome in 1,504 patients. Dis Colon Rectum 2005, 48(2):243-250.

    Article  PubMed  Google Scholar 

  28. Gunnarsson U, Karlbom U, Docker M, Raab Y, Påhlman L: Proctocolectomy and pelvic pouch—is a diverting stoma dangerous for the patient? Colorectal Dis 2004, 6(1):23-27.

    Article  CAS  PubMed  Google Scholar 

  29. Gorfine SR, Fichera A, Harris MT, Bauer JJ: Long-term results of salvage surgery for septic complications after restorative proctocolectomy: does fecal diversion improve outcome? Dis Colon Rectum 2003, 46(10):1339-1344.

    Article  PubMed  Google Scholar 

  30. Remzi FH, Church JM, Bast J, Lavery IC, Strong SA, Hull TL, Harris GJ, Delaney CP, O’Riordain MG, McGannon EA et al: Mucosectomy vs. stapled ileal pouch-anal anastomosis in patients with familial adenomatous polyposis: functional outcome and neoplasia control. Dis Colon Rectum 2001, 44(11):1590-1596.

    Article  CAS  PubMed  Google Scholar 

  31. MacLean AR, Cohen Z, MacRae HM, O’Connor BI, Mukraj D, Kennedy ED, Parkes R, McLeod RS: Risk of small bowel obstruction after the ileal pouch-anal anastomosis. Ann Surg 2002, 235(2):200-206.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Brook RH: Health systems, heuristics, and comparative effectiveness research. J Gen Intern Med 2013, 28(2):172-173.

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

The authors agree that no financial support or incentive was provided for this manuscript with the exception of AMS’s time supported by the Robert Wood Johnson Foundation Clinical Scholars® program and the U.S. Department of Veterans Affairs.

Author information

Authors and Affiliations

  1. Division of Colorectal Surgery, Department of Surgery, Mount Sinai Medical Center, New York, NY, 10029, USA

    Anne M. Stey, Tomas Heimann & Randolph M. Steinhagen

  2. RAND Corporation, Santa Monica, CA, 90401, USA

    Robert H. Brook & Emmett Keeler

  3. David Geffen School of Medicine, University of California Los Angeles, 10940 Wilshire Blvd, Suite 710, Los Angeles, CA, 90024, USA

    Anne M. Stey & Robert H. Brook

  4. Department of Surgery, Englewood Hospital and Medical Center, Englewood, NJ, 07627, USA

    Michael T. Harris

Authors
  1. Anne M. Stey
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Robert H. Brook
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Emmett Keeler
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michael T. Harris
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tomas Heimann
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Randolph M. Steinhagen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anne M. Stey.

Appendix

Appendix

Table 6

Table 6 Charges for specific services
Full size table

Rights and permissions

Reprints and permissions

About this article

Cite this article

Stey, A.M., Brook, R.H., Keeler, E. et al. Outcomes and Cost of Diverted Versus Undiverted Restorative Proctocolectomy. J Gastrointest Surg 18, 995–1002 (2014). https://doi.org/10.1007/s11605-014-2479-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-014-2479-3

Keywords

Search

Navigation