Total Abdominal Colectomy: Patient Satisfaction and Outcomes
By Payne, Jason A Snyder, David C; Olivier, Jacob; Salameh, Jihad R
Total abdominal colectomy is required for many colonic diseases. The authors studied the outcomes of this operation and the quality of life based on the decision to perform an ileostomy or an anastomosis. Patients who underwent total abdominal colectomy (excluding those with inflammatory bowel disease and chronic constipation) had either ileoproctostomy or ileostomy and were compared. Patients were surveyed to assess satisfaction. Thirty- seven patients with ileoproctostomy and 23 patients with ileostomy were identified. There were no significant differences between groups with regard to urgency of operation, preoperative and total blood units received, and preoperative hospital stay. Morbidity and mortality were higher in the ileostomy group (38 vs 57% and 5 vs 17%), with odds ratios of 2.14 and 3.68 respectively; this was not, however, statistically significant (P = 0.157 and 0.132, power = 20% and 6%). All (14 of 14) surveyed ileostomy patients were at least satisfied versus 90 per cent (19 of 21) of ileoproctostomy patients. Of the latter, only 15 of 20 patients were continent, with 6.85 average daily bowel movements. Total abdominal colectomy has high morbidity and mortality rates. Performing an ileoproctostomy does not influence outcome but may lead to a high frequency of bowel movements and incontinence in some patients. TOTAL OR SUBTOTAL abdominal colectomy is required to treat a variety of colonic diseases, such as colonic bleeding of uncertain location, ischemic colitis, toxic megacolon, or obstructing left colon mass. To perform an ileostomy or an anastomosis during the initial operation is open to debate, with no consensus in the literature, and is usually based on different rationales, including surgeon factors such as preference and training, and patient factors such as age, hemodynamics, and blood transfusions. There are limited published data on the clinical and functional outcomes after these operations, regardless of the surgical indications. The aim of this study was to compare the outcomes and quality of life of patients undergoing abdominal colectomy based on the decision of performing an ileostomy or an ileoproctostomy during the initial operation.
All adult patients having undergone total or subtotal abdominal colectomy at the University of Mississippi Medical Center and the affiliated G. V. (Sonny) Montgomery Veterans Affairs Medical Center between January 2000 and December 2005 were identified from the hospital databases using the specific Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)-9 codes. Elective, semielective, urgent, and emergent operations were included. Patients undergoing total abdominal colectomy for inflammatory bowel disease, familial adenomatous polyposis, or chronic constipation were excluded. Charts were retrospectively reviewed for demographic data, surgery indication, preoperative and total hospital and intensive care unit stay, preoperative and total blood transfusion, operative details, and postoperative outcome, including morbidity and 30-day mortality.
Telephone surveys were conducted, and data collected included stool frequency if patient received an anastomosis, degree of fecal continence, and patient satisfaction. Patients rated their satisfaction as 1) poor if the operation caused significant disability compared with their status prior to the operation and wished they had not undergone the operation, 2) satisfactory if patients were glad they underwent the operation despite having some disability postoperatively, 3) good if patients experienced some disability but not to the point of affecting daily activities, and 4) excellent if they did not experience any disability.
Patients were divided into two groups based on the initial operation performed: those receiving and ileostomy and those receiving an ileoproctostomy. Groups were analyzed based on the intention to treat.
Levels of associations were assessed by chi^sup 2^ test and odds ratios for dichotomous variables, and two sample t tests for continuous variables.
A total of 60 patients meeting the inclusion criteria were identified and divided into 37 patients with ileoproctostomy and 23 patients with ileostomy. Both groups were similar in age (mean of 59 years vs 60 years old), gender (73% vs 74% male), and race (32% va 30% white). Indications for subtotal colectomy with ileostomy included bleeding (34.8%), neoplasm (26.1%), ischemia (30.4%), and infection (8.7%) whereas indications for subtotal colectomy with ileoproctostomy were bleeding (40.5%), neoplasm (51.4%), and ischemia (8.1%). There were no significant differences between the groups with regard to urgency of operations (32% vs 43%, P – 0.388), preoperative blood units transfused (2.2 +- 4.9 vs 3.9 +- 9.7, P = 0.427), total blood units received (4.0 +- 8.9 vs 6.3 +- 1 1.1, P = 0.410), and preoperative hospital stay (2.5 +- 4.2 days vs 5.3 +- 6.9 days, P = 0.095).
Morbidity was 57 per cent in the ileostomy group versus 38 per cent in the ileoproctostomy group, with odd ratios of 2.14. This was not, however, statistically significant (P = 0.157, power = 20%). Table 1 details these complications. Two patients who initially had an ileoproctostomy developed an anastomotic leak and required reoperation and ileostomy. These patients were kept in the ileoproctostomy group in an intention-to-treat analysis. Thirty-day mortality was 17.4 per cent in the ileostomy group versus 5.4 per cent in the ileoproctostomy group, with an odds ratio of 3.68. This was not statistically significant (P – 0.132, power = 6%).
Table 1. Postoperative Complications
Attempts were made to contact all patients with similar success in both groups (57% vs 61%). Of the ileoproctostomy group, 75 per cent (15 of 20) of patients were continent; one additional patient surveyed from that group had had an ileostomy. Continent patients had an average of 6.85 daily bowel movements. Of the patients surveyed, 100 per cent (14 of 14) of ileostomy patients were at least satisfied, versus 90 per cent (19 of 21) of ileoproctostomy patients (Table 2).
Total abdominal colectomy continues to be an appealing operation in certain situations because it removes the diseased colon, preserves rectal function, and is generally viewed as safe. In diseases potentially involving the colon as well as the rectum, such as inflammatory bowel disease, polyposis, and colonic inertia, this operation is controversial and the postoperative outcomes would probably be different and related to factors beyond the operation itself. ‘ – 2 These conditions were thus excluded from the current study. The majority of the indications found in our study were massive or recurrent lower gastrointestinal bleeding when the source could not be isolated; colonic malignancy, such as obstructing left- side mass or multifocal disease; and ischemic colitis. A couple of patients had infectious colitis. All these operations can present as emergent, urgent, or semielective. At the conclusion of the colectomy, the surgeon must decide whether to perform an anastomosis or an end ileostomy. Traditionally, there are some accepted situations when an ileoproctostomy is ill advised, such as in a patient with hemodynamic instability, multiple blood transfusions,3 poor nutritional status, or significant tension on the anastomosis. Because this was a retrospective study, the decision of whether to perform an anastomosis was determined by the individual surgeon’s judgment. Interestingly, however, there were no significant differences between the group of patients who had an ileostomy and those who had an ileoproctostomy in terms of urgency of operation, preoperative and total blood units transfused, and preoperative hospital stay, suggesting that these factors may not have played a major role in the decision making. Other potential factors that could not be assessed adequately from the retrospective chart review were hemodynamic stability and nutritional status.
Table 2. Patient Satisfaction
Overall 30-day morbidity and mortality of total abdominal colectomy reported in the literature are 0.6 to 27 per cent and 26 to 66 per cent respectively.1- 4- 5 The morbidity and mortality rates in our study are within these ranges. This represents a fairly high risk, which goes against the suggested safety of subtotal colectomy in some studies.4- 6 Interestingly, we noted a trend toward a higher morbidity and mortality in patients who had an ileostomy compared with those who had an anastomosis. This trend did not appear related to differences in surgical risk, given that the groups were similar in age, urgency of operation, preoperative intensive care unit stay, and preoperative and total blood transfusion. Although that noted trend was not statistically significant, the odds ratios of 2.14 and 3.68 for morbidity and mortality respectively are certainly clinically concerning and warrant further investigation with larger samples.
Another factor, frequently cited but poorly defined, in determining the advisability of performing an ileoproctostomy after an abdominal colectomy is the functional status of the patient: Will the rectum be able to handle the large volume or will the patient be incontinent? Will an ileostomy create significant metabolic disturbances or a high output that is difficult to manage? Of the patients with ileoproctostomy surveyed, only 75 per cent reported being continent. This is lower than other reports of continence rates as high as 90 per cent.3- 7 In addition, patients reported a mean of 6.85 bowel movements per day at the time of followup whereas other studies have reported a range of 3 to 5.2 bowel movements per day.3- 7-10 In one study of subtotal colectomy for various indications,7 acceptable bowel function and control was regained within 6 months of the operation and leveled off at 1 year after surgery at an average stool frequency of around three per day, with no patient requiring long-term antidiarrheal medication. Although the functional results in our patients with ileoproctostomy were not as good, 90 per cent of these patients rated their results as at least satisfactory. This is in line with other studies showing that functional results do not necessarily equate with quality of life.10 All ileostomy patients were at least satisfied with their functional outcome. This is important given that most of these patients will not have their ileostomy closed. Conclusion
Total abdominal colectomy has a high rate of morbidity and mortality. Performing an ileoproctostomy, when indicated, does not appear to influence outcome but may lead to high frequency of bowel movements and incontinence in some patients. Most patients rate their functional outcome as at least satisfactory, regardless of having an ileostomy or an ileoproctostomy.
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JASON A. PAYNE, M.D.,* DAVID C. SNYDER, M.D.,* JACOB OLIVIER, PH.D.,[dagger] JIHAD R. SALAMEH, M.D.*
From the * Department of Surgery, University of Mississippi Medical Center and G. V. (Sonny) Montgomery VA Medical Center, and the [dagger] Division of Biostatistics, Department of Preventive Medicine, University of Mississippi Medical Center, Jackson, Mississippi
Presented during Poster Grand Rounds at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Savannah, Georgia, February 10-13, 2007.
Address correspondence and reprint requests to J.R. Salameh, M.D., F.A.C.S., Assistant Professor of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. E-mail: jsalameh @ surgery.umsmed.edu.
Copyright Southeastern Surgical Congress Jul 2007
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