title: Reversal of loop ileostomy under an Enhanced Recovery Programme - Is the stapled anastomosis technique still better than the handsewn technique?
abstract: BACKGROUND
  Recent literature suggests that stapled anastomotic (SA) technique for the reversal of loop ileostomy (LI) may be beneficial in terms of early recovery and reduced incidence of small bowel obstruction when compared to the handsewn anastomosis (HA). Enhanced Recovery Programme (ERP) after colorectal procedures has demonstrated a reduction in some aspects of surgical morbidity. The aim of this study was to investigate the outcomes of patients undergoing reversal of LI within an ERP programme and compare the HA to the SA in relation to clinical outcomes.
  
  
  METHODS
  All adult patients undergoing elective reversal of loop ileostomy between January 2008 and December 2012 without any additional procedures, were included in our study. Adherence to ERP modules and 30 day postoperative complications were assessed via retrospective review of patient case notes.
  
  
  RESULTS
  One hundred and eight patients had an ileostomy reversal; 61 in the SA and 47 in the HA group. There were no demographic differences between the two groups. ERP module compliance was satisfactory (>80%) in 11 of the 14 modules with no difference in individual module compliance between the two groups. The operating times were found to be comparable (p = 0.35). Overall mortality (p = 0.44), anastomotic leak rates (p = 1.00), intra-abdominal collections (p = 0.65), small bowel obstruction (p = 1.00), reoperation rates (p = 0.65), ileus (p = 0.14) and other significant complications (Clavien-Dindo > 2) (p = 0.08) were similar between the two groups. A significantly longer total length of hospital stay (TLOS) was found in the SA group (median 3 Vs 4 days, p = 0.009).
  
  
  CONCLUSIONS
  Reversal of LI under an ERP appears to potentially neutralise the suggested SA benefits in terms of postoperative complications without any additional negative implications. Other non-operative factors may have a potential effect on outcomes such as the TLOS.
authors.affiliation: Department of Colorectal Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom.
authors.forename: G A
authors.initials: GA
authors.lastname: Markides
authors.affiliation: Department of Colorectal Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom.
authors.forename: I
authors.initials: I
authors.lastname: Wijetunga
authors.affiliation: Department of Colorectal Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom.
authors.forename: M
authors.initials: M
authors.lastname: McMahon
authors.affiliation: Department of Colorectal Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom.
authors.forename: P
authors.initials: P
authors.lastname: Gupta
authors.affiliation: Department of Colorectal Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom.
authors.forename: A
authors.initials: A
authors.lastname: Subramanian
authors.affiliation: Department of Colorectal Surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom. Electronic address: suanwar@btinternet.com.
authors.forename: S
authors.initials: S
authors.lastname: Anwar
mesh_terms: D000328:Adult; D057868:Anastomotic Leak / Q000209:etiology; D005260:Female; D006801:Humans; D007081:Ileostomy / Q000379:methods*; D045823:Ileus / Q000209:etiology; D007415:Intestinal Obstruction / Q000209:etiology / Q000517:prevention & control; D007421:Intestine, Small; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D015397:Program Evaluation; D012086:Reoperation / Q000009:adverse effects; D012189:Retrospective Studies; D017792:Surgical Stapling; D013536:Suture Techniques
keywords: Enhanced recovery programme; Hand sewn anastomosis; Ileostomy; Stapled anastomosis