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Impact of surgical proficiency levels on postoperative morbidity: a single centre analysis of 558 ileostomy reversals

  • Original Article
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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

Defunctioning ileostomies reduce the consequences of distal anastomotic leakage following bowel resections. Ileostomy reversal in itself, however, is associated with appreciable morbidity (3–40%) and mortality (0–4%). Despite being a common teaching procedure, there is limited information on the impact of surgical proficiency levels on postoperative outcome.

Methods

Adult patients undergoing closure of a defunctioning ileostomy between September 2008 and January 2017 were identified from a surgical administrative database that was collected prospectively (n = 558). Baseline characteristics (age, ASA score, BMI, health care insurance coverage) and closure techniques were recorded. Operation time, rate of bowel resection, postoperative complications ranked by Clavien-Dindo classification and length of stay were analysed with respect to proficiency levels (residents vs. consultants).

Results

Two hundred three ileostomy reversals were performed by residents; 355 ileostomies were closed by consultants. Operation time was considerably shorter in the consultant group (p < 0.001). Major postoperative complication rates however were not different among the groups when adjusted for possible confounders (p = 0.948). The rate of anastomotic leakage was 3% and the overall major morbidity rate was 11%.

Conclusion

Operation time rather than surgical outcome and overall morbidity were affected by surgical proficiency levels. Therefore, ileostomy reversal can be considered an appropriate teaching operation for young general surgery trainees.

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References

  1. Branagan G, Finnis D, G. Wessex Colorectal Cancer Audit Working (2005) Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum 48(5):1021–1026

    Article  PubMed  Google Scholar 

  2. Huser N et al (2008) Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 248(1):52–60

    Article  PubMed  Google Scholar 

  3. Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P (2011) Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 253(5):890–899

    Article  PubMed  Google Scholar 

  4. Brand MI, Dujovny N (2008) Preoperative considerations and creation of normal ostomies. Clin Colon Rectal Surg 21(1):5–16

    Article  PubMed  PubMed Central  Google Scholar 

  5. Chow A, Tilney HS, Paraskeva P, Jeyarajah S, Zacharakis E, Purkayastha S (2009) The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Color Dis 24(6):711–723

    Article  Google Scholar 

  6. Kaidar-Person O, Person B, Wexner SD (2005) Complications of construction and closure of temporary loop ileostomy. J Am Coll Surg 201(5):759–773

    Article  PubMed  Google Scholar 

  7. Itani KM et al (2005) Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals. Am J Surg 190(5):725–731

    Article  PubMed  Google Scholar 

  8. Fahrner R, Turina M, Neuhaus V, Schöb O (2012) Laparoscopic cholecystectomy as a teaching operation: comparison of outcome between residents and attending surgeons in 1,747 patients. Langenbeck's Arch Surg 397(1):103–110

    Article  Google Scholar 

  9. Graat LJ, Bosma E, Roukema JA, Heisterkamp J (2012) Appendectomy by residents is safe and not associated with a higher incidence of complications: a retrospective cohort study. Ann Surg 255(4):715–719

    Article  PubMed  Google Scholar 

  10. Kauvar DS, Braswell A, Brown BD, Harnisch M (2006) Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy. J Surg Res 132(2):159–163

    Article  PubMed  Google Scholar 

  11. Robson AJ, Wallace CG, Sharma AK, Nixon SJ, Paterson-Brown S (2004) Effects of training and supervision on recurrence rate after inguinal hernia repair. Br J Surg 91(6):774–777

    Article  CAS  PubMed  Google Scholar 

  12. Scarborough JE, Bennett KM, Pappas TN (2012) Defining the impact of resident participation on outcomes after appendectomy. Ann Surg 255(3):577–582

    Article  PubMed  Google Scholar 

  13. Tseng WH, Jin L, Canter RJ, Martinez SR, Khatri VP, Gauvin J, Bold RJ, Wisner D, Taylor S, Chen SL (2011) Surgical resident involvement is safe for common elective general surgery procedures. J Am Coll Surg 213(1):19–26 discussion 26–8

    Article  PubMed  Google Scholar 

  14. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258(1):1–7

    Article  PubMed  Google Scholar 

  15. Loiero D, Slankamenac M, Clavien PA, Slankamenac K (2017) Impact of residency training level on the surgical quality following general surgery procedures. World J Surg 41(11):2652–2666

    Article  PubMed  Google Scholar 

  16. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    Article  PubMed  PubMed Central  Google Scholar 

  17. Gambee LP (1951) A single-layer open intestinal anastomosis applicable to the small as well as the large intestine. West J Surg Obstet Gynecol 59(1):1–5

    CAS  PubMed  Google Scholar 

  18. Lindgren R, Hallböök O, Rutegård J, Sjödahl R, Matthiessen P (2011) What is the risk for a permanent stoma after low anterior resection of the rectum for cancer? A six-year follow-up of a multicenter trial. Dis Colon Rectum 54(1):41–47

    Article  PubMed  Google Scholar 

  19. Sier MF, van Gelder L, Ubbink DT, Bemelman WA, Oostenbroek RJ (2015) Factors affecting timing of closure and non-reversal of temporary ileostomies. Int J Color Dis 30(9):1185–1192

    Article  CAS  Google Scholar 

  20. Sharma A, Deeb AP, Rickles AS, Iannuzzi JC, Monson JRT, Fleming FJ (2013) Closure of defunctioning loop ileostomy is associated with considerable morbidity. Color Dis 15(4):458–462

    Article  CAS  Google Scholar 

  21. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196

    Article  PubMed  Google Scholar 

  22. Clavien PA, Strasberg SM (2009) Severity grading of surgical complications. Ann Surg 250(2):197–198

    Article  PubMed  Google Scholar 

  23. Lederer AK et al (2017) Generation Y: the uncertain future of surgery. Zentralbl Chir 142(6):581–582

  24. Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW (2012) Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program. Ann Surg 256(3):469–475

    Article  PubMed  Google Scholar 

  25. Loffler T et al (2012) HAnd suture versus stapling for closure of loop ileostomy (HASTA Trial): results of a multicenter randomized trial (DRKS00000040). Ann Surg 256(5):828–835 discussion 835–6

    Article  PubMed  Google Scholar 

  26. Schneider V, Lee LD, Stroux A, Buhr HJ, Ritz JP, Kreis ME, Lauscher JC (2016) Risk factors for reoperation after ileostomy reversal—results from a prospective cohort study. Int J Surg 36(Pt A):233–239

    Article  CAS  PubMed  Google Scholar 

  27. Luglio G, Terracciano F, Giglio MC, Sacco M, Peltrini R, Sollazzo V, Spadarella E, Bucci C, de Palma GD, Bucci L (2017) Ileostomy reversal with handsewn techniques. Short-term outcomes in a teaching hospital. Int J Color Dis 32(1):113–118

    Article  Google Scholar 

  28. van Westreenen HL, Visser A, Tanis PJ, Bemelman WA (2012) Morbidity related to defunctioning ileostomy closure after ileal pouch-anal anastomosis and low colonic anastomosis. Int J Color Dis 27(1):49–54

    Article  Google Scholar 

  29. Musters GD, Atema JJ, van Westreenen HL, Buskens CJ, Bemelman WA, Tanis PJ (2016) Ileostomy closure by colorectal surgeons results in less major morbidity: results from an institutional change in practice and awareness. Int J Color Dis 31(3):661–667

    Article  CAS  Google Scholar 

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Acknowledgements

We would like to thank M. Hankir for proofreading of the manuscript.

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Authors and Affiliations

  1. Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital of Wuerzburg, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany

    S. Löb, K. Krajinovic, A. Wiegering, C.-T. Germer & F. Seyfried

  2. Department of Diagnostic and Interventional Radiology, University Hospital of Wuerzburg, Wuerzburg, Germany

    K. Luetkens

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  1. S. Löb
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  2. K. Luetkens
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  3. K. Krajinovic
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  4. A. Wiegering
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  5. C.-T. Germer
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  6. F. Seyfried
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Corresponding author

Correspondence to S. Löb.

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All procedures performed were in accordance with the standards of the institutional ethical committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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The authors declare that they have no conflict of interest.

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Löb, S., Luetkens, K., Krajinovic, K. et al. Impact of surgical proficiency levels on postoperative morbidity: a single centre analysis of 558 ileostomy reversals. Int J Colorectal Dis 33, 601–608 (2018). https://doi.org/10.1007/s00384-018-3026-6

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  • DOI: https://doi.org/10.1007/s00384-018-3026-6

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