title: Ileostomy closure by colorectal surgeons results in less major morbidity: results from an institutional change in practice and awareness.
abstract: OBJECTIVE
  Previous institutional analysis of ileostomy closure revealed substantial morbidity. This subsequent study aimed at determining if a change in clinical practice resulted in reduced complication rates.
  
  
  METHODS
  Between June 2004 and January 2014, all consecutive adult patients undergoing ileostomy closure were retrospectively identified. Postoperative outcome after change in clinical practice consisting of routine participation of a colorectal surgeon, stapled side-to-side anastomosis and increased clinical awareness (cohort B) was compared with our previously published historical control group (cohort A). The primary outcome was major morbidity, defined as Clavien-Dindo grade three or higher. Independent risk factors of major morbidity were identified using multivariable analysis.
  
  
  RESULTS
  In total, 165 patients underwent ileostomy closure in cohort A, and 144 patients in cohort B. At baseline, more primary diverting ileostomies were present in cohort A (94 vs. 82%; p = 0.001) with a similar rate of loop and end-ileostomy between the two cohorts (p = 0.331). A significant increase in colorectal surgeon participation (89 vs. 53%; p < 0.001) and stapled side-to-side anastomosis was observed (63 vs. 16%; p < 0.001). The major morbidity rate was 11% in cohort A, which significantly reduced to 4% in cohort B (p = 0.03). Surgery being performed or supervised by a colorectal surgeon (odds ratio [OR] 0.28, 95% CI 0.11-0.67) and loop-ileostomy compared to end-ileostomy (OR 0.18, 95% CI 0.07-0.52) were independently associated with lower major morbidity.
  
  
  CONCLUSIONS
  Ileostomy closure appears to be more complex surgery then generally considered, especially end-ileostomy closure. Postoperative outcome could be significantly improved by a change in surgical practice.
authors.affiliation: Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105, AZ, Amsterdam, The Netherlands. G.D.Musters@amc.nl.
authors.forename: G D
authors.initials: GD
authors.lastname: Musters
authors.affiliation: Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105, AZ, Amsterdam, The Netherlands.
authors.forename: J J
authors.initials: JJ
authors.lastname: Atema
authors.affiliation: Department of Surgery, Isala Clinics, Zwolle, The Netherlands.
authors.forename: H L
authors.initials: HL
authors.lastname: van Westreenen
authors.affiliation: Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105, AZ, Amsterdam, The Netherlands.
authors.forename: C J
authors.initials: CJ
authors.lastname: Buskens
authors.affiliation: Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105, AZ, Amsterdam, The Netherlands.
authors.forename: W A
authors.initials: WA
authors.lastname: Bemelman
authors.affiliation: Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105, AZ, Amsterdam, The Netherlands. P.J.Tanis@amc.nl.
authors.forename: P J
authors.initials: PJ
authors.lastname: Tanis
mesh_terms: D000328:Adult; D003107:Colorectal Surgery / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007081:Ileostomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D015999:Multivariate Analysis; D012307:Risk Factors; D066231:Surgeons
keywords: Complications; Ileostomy; Ileostomy closure; Ileostomy reversal; Morbidity