Transcript fireboytech.com

Review of
Outcomes and Cost of Diverted Versus
Undiverted Restorative Proctocolectomy
Stey et al.
Steven Roy
Intro
A restorative proctocolectomy allows patients requiring semi-elective total
proctocolectomy to avoid a permanent ileostomy.
Surgeons hold different beliefs about whether to divert, and those beliefs in
part reflect their own experience about whether one operation has more or
less complications.
20 years ago, a small, RT showed no difference in the rate of complications
after a diverted or undiverted RPC.
Observational studies since then report dramatically different complication
rates and come to opposing conclusions. This variation may be a result of
studies retrospectively analyzing the intraoperative decision to divert
or not.
Article
Outcomes and Cost of Diverted Versus Undiverted Restorative
Proctocolectomy
Authors: AM Stey, RH Brook, E Keeler, MT Harris, T Heimann, RM Steinhagen
Publised in the Journal of Gastrointestinal Surgery 18, no. 5 (2014): 995-1002.
Study Summary
Four “equally qualified and experienced surgeons...with compariable
technical skills”:
-2 surgeons maintained diverted restorative proctocolectomy was safest.
-2 surgeons routinely performed undiverted restorative proctocolectomies
end
(all patients unless there was a positive leak test or incomplete circular end-tostapling device donuts).
All patients treated between 2000 and 2008 meeting inclusion criteria
were analysed.
All pelvic anastomoses were stapled by convention. No undue tension
was noted in the operative reports of any of the patients included in
the study.
Study Design
Single center, cohort study (ITT)
N = 288 (of 310)
Independent variable: Diverting ileostomy (+/-)
Inclusion: Restorative proctocolectomy patients (planned diverted and
undiverted) with min. 1 yr follow up post-op.
Exclusion: Positive intaoperative leak or donut test (3 pts)
Restorative proctocolectomy prior to EMR (17 pts)
Patients less than 18 years of age (2 pts).
Outcome variables: Complications rates and costs of care.
Patient demographic and clinical characteristics prior to RPC
Resource use for total diverted patients versus undiverted patients
Complication rates after restorative undiverted and diverted
proctocolectomy and ileostomy closure
Postoperative long-term follow-up and adjusted total costs
Study Strengths
Observational cohort study
Identified and controlled for differences between groups (using ANOVA)
Surgeons perform only the procedure that they believe is superior
Post-hoc power analysis
Intention to treat
Study Limitations
Possible referral bias (not formally randomized).
Possible detection bias (statistically significant difference in length of F/U)
Heterogeneity in diagnoses and rates of prior subtotal colectomies.
Functional outcomes were not assessed.
Summary
Stey et al. found diverting ileostomy at the time of restorative
proctocolectomy did not significantly affect anastomotic complication rates,
but might be associated with higher rates of small bowel obstruction.
This finding is consistent with the only RT conducted as well as some large
retrospective series on diversion in RPT.
Although diversion may mitigate the initial manifestation of anastomotic
complications, the ileostomy itself as well as its reversal, may be associated
with higher complications and resource use.
Stey et al. conclude that, in light of these findings, a large multi-institutional
RCT that assesses the risks, costs, and benefits of
routine diversion is needed.
Questions?