The creation of a preventive diverting loop ileostomy is a routine procedure after colon surgery. Even though ileostomy has plenty advantages in preventing sepsis due to anastomotic leaks, the postoperative complications and chemotherapy complications still need to be addressed(4). For this reason, the aim of this study was to determine the impact of ileostomy complications on the adherence of adjuvant treatment and the OS of clinical stage II-III CC patients. Stoma-related complications are divided into short- and long-term. Short-term complications are also divided into mild and severe. Mild short-term complications include skin irritation, poor appliance fitting, and prolapse(7). On the other hand, severe complications include dehydration secondary to high stoma output or frequent diarrhea, readmissions, and incisional hernias(8, 10). In the present study only 18% of the cases presented postoperative complications, requiring hospital readmission in up to 10% of the cases. This data is similar to the 7–20% range reported for ileostomy related readmissions(4),(11–13). In the case of severe complications, grade 1–2 diarrhea (47%), grade 3–4 diarrhea (31%), and hydro-electrolytic dehydration (37%) were the most prevalent. This was similar to findings in literature, where the most common complication reported is dehydration, which is reported in approximately 20–40% of cases(4, 12, 14, 15). Dehydration may occur after patient discharge and may compromise quality of life and treatment. Thus, ambulatory medical care is mandatory for these patients to assess the prevalence of dehydration, prevent readmissions, and ultimately, prevent acute kidney injury (AKI)(4, 8, 11, 12, 14). Additionally, Chen et al. assessed the importance of evaluating high risk complications by applying a system score that may facilitate earlier identification of high-risk patients to carry out preventive measures, depending on the potential risk score. These measures include multiple interventions such as outpatient IV fluids, antidiarrheal medications, delay in home care nursing, and ostomy, among others(3).
On the other hand, long-term complications of ileostomy have been associated with kidney injury, which may persist during long-term follow up(3, 5, 16, 17). AKI was present in 25% of the ileostomy patients treated with chemotherapy. This is a complication that must be taken seriously, since previous reports suggest that AKI has a negative impact on adjuvant therapy, disease free survival (DFS) and OS of colon cancer patients(3). Therefore, multidisciplinary expert team monitoring these patients is fundamental to maintain safety and to reduce the risk of AKI(17). The high prevalence of short/long-term complications in CC patients has been associated with a lesser probability of ileostomy restitution(6, 8, 16, 17). In the present study, 50% of the population had ileostomy restitution that could affect quality of life and outcome. Moreover, previous studies have demonstrated that for patients with no ileostomy restitution time-to-death was significantly shorter than for patients with ileostomy restitution(15). In this work we showed that OS had significant differences when comparing complete chemotherapy versus incomplete chemotherapy (p = 0.023) and early ileostomy restitution versus late and non-restitution (p = 0.016). Likewise, variables such as AKI, ileostomy restitution, and chemotherapy treatment remained predicting factors of OS.
The previous data support the importance of a multidisciplinary assessment, follow-up of patients, and the impairment of an early ileostomy closure. Three recent meta-analyses described the early ileostomy closure as safe and feasible(7, 8, 18). In addition, previous information has argued that early closure is easier to reverse, has a lower risk of anastomotic leaks, and has less severe septic consequences, thus improving patient’s quality of life (5, 8, 19). Even though the post-operative wound infection rate is not clear in early ileostomy closure patients, this information could be explained by the method of ileostomy wound closure. However, partial purse-string closure has been reported to cause less wound infections than primary linear closure(8). According to Zi Qin Ng meta-analysis, the ideal timing for closure ileostomy should be less than 12 weeks after construction(8). Since the tensile strength of anastomosis increases rapidly at day five and exceeds its initial strength at day seven, anastomotic leaks may have already occurred by then(5, 8). Additionally, a significant cost reduction has also been observed for early ileostomy closures in several studies(20, 21). Still, logistical access remains a problem in public hospitals given the long time to receive treatment and surgical appointments, so constant communication and a collaborative approach are essential to facilitate early closures among patients with ileostomies for their own safety(8, 17). A limitation of the present study is its retrospective nature. Further prospective studies need to adopt early ileostomy restitution as a daily clinical practice.