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. 2022 Feb 22;26(5):333–349. doi: 10.1007/s10151-022-02580-6

Overall readmissions and readmissions related to dehydration after creation of an ileostomy: a systematic review and meta-analysis

I Vogel 1,2,✉, M Shinkwin 2, S L van der Storm 1, J Torkington 2, J ACornish 2, P J Tanis 1, R Hompes 1, W A Bemelman 1
PMCID: PMC9018644  PMID: 35192122

Abstract

Background

Hospital readmissions after creation of an ileostomy are common and come with a high clinical and financial burden. The aim of this review with pooled analysis was to determine the incidence of dehydration-related and all-cause readmissions after formation of an ileostomy, and the associated costs.

Methods

A systematic literature search was conducted for studies reporting on dehydration-related and overall readmission rates after formation of a loop or end ileostomy between January 1990 and April 2021. Analyses were performed using R Statistical Software Version 3.6.1.

Results

The search yielded 71 studies (n = 82,451 patients). The pooled incidence of readmissions due to dehydration was 6% (95% CI 0.04–0.09) within 30 days, with an all-cause readmission rate of 20% (CI 95% 0.18–0.23). Duration of readmissions for dehydration ranged from 2.5 to 9 days. Average costs of dehydration-related readmission were between $2750 and $5924 per patient. Other indications for readmission within 30 days were specified in 15 studies, with a pooled incidence of 5% (95% CI 0.02–0.14) for dehydration, 4% (95% CI 0.02–0.08) for stoma outlet problems, and 4% (95% CI 0.02–0.09) for infections.

Conclusions

One in five patients are readmitted with a stoma-related complication within 30 days of creation of an ileostomy. Dehydration is the leading cause for these readmissions, occurring in 6% of all patients within 30 days. This comes with high health care cost for a potentially avoidable cause. Better monitoring, patient awareness and preventive measures are required.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02580-6.

Keywords: Ileostomy, Readmission, Dehydration, High output stoma

Introduction

Hospital readmissions after creation of an ileostomy are common and impede patient convalescence [1]. Reasons for readmission after fecal diversion include stoma-related problems, such as dehydration, stoma outlet obstruction, peristomal skin problems, anastomotic leak, and generic post-operative complications (e.g., infection or thrombo-embolic events).

Dehydration is often cited as a leading cause for stoma-related readmissions, due to fluid and electrolyte losses [2]. Dehydration can contribute to substantial post-operative morbidity, increasing the risk of acute renal failure, electrolyte derangement, and even cardiac arrhythmias [3]. There is a growing consensus that these readmissions place a significant burden on patients and are costly for the healthcare system, but that they might also be avoidable to some extent [4–6].

The reported incidence of readmission particularly in relation to dehydration varies [6–8], probably due to inconsistent definitions, and completeness and duration of post-operative follow-up. To quantify the risks and benefits of an ileostomy, to reduce stoma-related readmissions, and to guarantee patient safety, the scope of the problem needs to be clear. Therefore, the aim of this systematic review was to assess the prevalence of readmission related to dehydration after the creation of an ileostomy. The secondary aims included overall readmissions and their causes after creation of an ileostomy as well as cost implications.

Materials and methods

This review was conducted in line with the Cochrane Handbook for systematic reviews of In Reporting following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines [9]. The study protocol was registered in PROSPERO, the international prospective register of systematic reviews (registration number CRD42021231472). Comprehensive literature searches were conducted using PubMed, Embase, and Cochrane databases for articles published from January 1990 until April 2021. The full search strategy is displayed in Supplementary Table S1–3.

Studies were considered for inclusion if they met the following criteria: (1) patients with a newly created loop or end ileostomy for any indication; (2) assessment of readmissions related to dehydration, or overall number of readmissions, or other reasons for readmission after creation of an ileostomy; (3) studies were cohort, case-matched studies, or randomized clinical trials. The exclusion criteria were: (1) reviews, letters, expert opinions, commentaries, case reports, or case series with less than 10 cases; (2) language other than English; (3) lack of the sufficient data or outcomes of interest; (4) visits just to the emergency department; (5) studies reporting only on complications of revised ileostomies (with exception of readmissions for a revision of a newly created ileostomy); (6) second stage ileostomies in a three-stage ileo-anal pouch procedure; (7) colostomies, jejunostomies, non-intestinal stomas, and ghost ileostomies; (8) duplicate studies.

Two reviewers (IV and MS) independently reviewed titles and abstracts, followed by full-text revision. Disagreements were resolved by consensus discussion between the two reviewers (IV and MS).

Data extraction and quality assessment

Data were extracted independently by two authors (IV and MS) and included the following variables: year of publication, country, study design, number of patients, characteristics of included patients, indication for the ileostomy, type of surgery, number of elective procedures, number of open procedures, type of stoma (loop/end), overall number of readmissions, number of readmissions related to dehydration, other reasons for readmissions, duration, and cost of readmissions related to dehydration.

The indications for an ileostomy were recorded and were classified as colorectal disease if they included bowel cancer, inflammatory bowel disease, diverticulitis, or familiar adenomatous polyposis.

Readmissions were defined as an unplanned return to the hospital with an overnight stay for any reason. This did not include elective or planned readmissions.

The following were accepted as readmission related to dehydration: a clinician-reported diagnosis of dehydration, or high output stoma (defined as ≥ 1500 mL stoma production in 24 h, or the Kidney Disease Global Improving guideline definition of acute kidney injury which includes any of the following: absolute increase in serum creatinine ≥ 0.3 mg/dL in a 48-h period, 1.5-fold increase in serum creatinine level in a 48-h period, or oliguria of ≤ 0.5 mL/kg for ≥ 6 h [10, 11].

Readmissions for infection included all pathology (such as chest infections and urinary tract infections). It did not include anastomotic leaks, which were reported separately.

Whilst the primary outcome was readmission within 30 days related to dehydration after creation of an ileostomy readmission for other timeframes was also summarised. Secondary outcomes included number of all-cause readmissions, other common indications for readmission, duration, and cost associated with readmission.

All included studies were assessed for methodological quality and risk of bias. For cohort studies, the Newcastle Ottawa quality assessment scale was used to assess risk of bias [12]. For randomized controlled trials, the Jadad scoring system was used [13]. When the randomized controlled trials (RCTs) groups were not analysed as described in the RCT, the Newcastle Ottawa quality assessment was used. Two of the authors (IV and MS) performed the quality assessment, with discussion of conflicts to achieve consensus.

Statistical analysis

Quantitative analysis was performed using RStudio (R Software version 3.6.1-©2009–2012, RStudio, Inc. software) with a random-effects model. For the outcome measures, pooled weighted proportions with corresponding 95% CIs were calculated using inversed variance weighting. Heterogeneity was assessed using the I2 and τ2 statistics, and the data were considered significant if the p value (τ2) was < 0.1 with low, moderate, and high for I2 values of 25%, 50%, and 75%.

Results

In total, 3508 articles were screened on title and abstract, with 3143 articles not meeting our inclusion criteria. A further 294 studies were excluded after full-text review leaving 71 studies (82,451 patients) for analysis, with 62 studies able to be included in a quantitative meta-analysis (Fig. 1). The assessment for methodological quality and risk of bias is described in Table 1.

Fig. 1.

Fig. 1

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PRISMA flow diagram

Table 1.

Assessment for methodological quality and risk of bias

Author Country Jadad score Newcastle quality Ottawa assessment
Total Selection (0–4) Comparability (0–2) Outcome (0–3) Total (0–9)
Van Loon 2020 US *** * ** 6
Lee 2020 Korea *** * ** 6
Liu 2020 New Zealand *** * ** 6
Kim 2020 US *** * *** 7
Yaegasgi 2019 Japan *** ** ** 7
Hendren 2019 USA ** * ** 5
Schineis 2019 Germany *** * ** 6
Grahn 2019 US 6.5
Fielding 2019 UK ** * ** 5
Alqahtani 2019 USA *** * ** 6
Karjalainen 2019 Finland *** * ** 6
Lee J 2019 Mexico *** ** ** 7
Gonella 2019 Italy *** ** ** 7
Chen 2018 USA *** ** *** 8
Justinianio 2018 USA *** ** *** 8
Sier 2018 The Netherlands 6.5
Charak 2018 US *** * ** 6
Kandagatla 2018 US *** ** ** 7
Bednarski 2018 US **** * *** 8
Park 2018 Sweden *** * ** 6
Migdanis 2018 Greece 6.5
Iqbal 2018 US *** * ** 6
Wen 2017 US *** * ** 6
Shaffer 2017 US ** ** 4
Yin 2017 Taiwan *** ** ** 7
Li L 2017 US ** * ** 5
Fish 2017 US ** * ** 5
Iqbal 2017 US *** * ** 6
Shwaartz 2017 US *** * ** 6
LI W 2017 US **** * ** 6
Shah 2017 US *** * ** 6
Hawkins 2016 US **** * ** 7
Tseng 2016 US **** ** ** 8
Helavirta 2016 Finland *** * ** 6
Anderin 2016 Sweden *** * ** 6
Kulaylat 2015 US ** * ** 5
Pellino 2014 Italy *** * ** 6
Hardiman 2014 US *** ** 5
Tyler 2014 US ** * ** 5
Phatak 2014 US *** * ** 6
Abegg 2014 The Netherlands *** * *** 7
Glasgow 2014 US *** * *** 7
Feroci 2013 Italy *** * ** 6
Parnaby 2013 UK ** ** ** 6
Coakley 2013 US *** * ** 6
Gu 2013 US *** ** 5
Hardt 2013 Germany *** * ** 6
Byrne 2013 UK ** ** 4
Paquette 2013 South Korea 6.5
Lee S 2013 South Korea 6
Jafari 2013 US *** * ** 6
Akesson 2012 Sweden *** * *** 7
Duff 2012 Australia **** ** 5
Nagle 2012 US *** * ** 6
Marsden 2012 UK **** * ** 7
Messaris 2012 US *** ** ** 7
Chun 2012 US *** ** ** 7
Gessler 2012 Sweden *** ** *** 8
Beck 2011 Germany *** * ** 6
Fajardo 2010 US *** ** ** 7
Telem 2010 US *** * ** 6
Datta 2009 Canada *** ** *** 8
Kariv 2007 US *** * ** 6
Fowkes 2008 UK *** ** 5
Schwenk 2006 Germany ** ** 4
Larson 2006 US *** ** ** 7
Garcia-Botello 2004 Spain **** ** ** 8
Hallbook 2002 Sweden *** * *** 7
Okamoto 1995 Japan *** * * 5
Wexner 1993 US **** * * 6
Winslet 1991 UK *** * ** 6
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*represents one point

Study characteristics

Baseline characteristics of the studies are summarised in Table 2. All patients received a newly created loop or end ileostomy. Indications for an ileostomy varied widely from colorectal cancer, inflammatory bowel disease, diverticulitis, familiar adenomatous polyposis, and gynecological malignancies, to any other indication for an ileostomy. Elective/emergency intention was reported in 42 studies, with the majority of patients included (76.9%) undergoing elective surgery [1–4, 7, 11, 14–49]. Thirty-six studies reported method of access; in 41.9% stoma creation was carried out with an open approach [3, 8, 11, 14–17, 19, 20, 22, 25, 28, 31, 32, 34–39, 42, 43, 45, 46, 49–59].

Table 2.

Patient and study characteristics

Author Design Patients
N 		Female
N (%)		 Age
years		 ASA > 3
N (%)		 Underlying disease Type of surgery Elective
N (%)		 Open
N (%)		 Stoma
type		 Readmission
overall N (%)		 Readmission
dehydration N (%)		 Time frame
readmissions
Van Loon 2020 Retrospective 393 195 (50) – – Colorectal disease Colorectal resection – – Both 117 (30) 34 (9) 30 days
Lee N 2020 Retrospective 302 99 (33) – 14 (5) Rectal cancer LAR – 5 (2) Loop 51 (17) 20 (7) 6 months
Liu 2020 Retrospective 266 141 (53) – 108 (41) Any Any 159 (60) 118 (44) Both 78 (29) 23 (9) 60 days
Kim 2020 Retrospective 39,380 19,375 (49) – 6531 (17) Colorectal disease Any 30,593 (78) 7824 (20) Both 5718 (15) 227 (0.6) 30 days
Yaegasgi 2019 Case-matched 58 17 (29) 60 (IQR 50–66) – Rectal cancer LAR – – Loop – 6 (11) Creation and closure
Hendren 2019 Retrospective 982 488 (50) – – Colorectal disease Any 500 (51) 665 (68) Both 200 (20) – 30 days
Schineis 2019 Retrospective 180 76 (42) 41 (R 18–86) – UC Colectomy 149 (83) 15 (8) End 14 (8) – 30 days
Grahn 2019 RCT 100 55 (55) – 74 (74) Any Any 88 (88) – Both 20 (20) 7 (7) 30 days
Fielding 2019 Retrospective 426 187 (44) 68 (IQR 61–74) 74 (17) Rectal cancer Rectal resection 426 (100) – Loop 134 (32) – 1 year
Alqahtani 2019 Retrospective 15,222 7272 (48) 61 (IQR 44–72) 936 (6) Colorectal disease Any 11,531 (58) 11,841 (22) Loop – 315 (2) 30 days
Karjalainen 2019 Retrospective 119 28 (24) 43 (SD 13) – UC Procto–colectomy – 119 (100) Loop 50 (42) 19 (16) 3 months
Lee J 2019 Retrospective 208 105 (51) 59 (IQR 49–70) 137 (66) Diverticulitis Colectomy 0 172 (83) Loop 23 (11) – 30 days
Gonella 2019 Retrospective 296 116 (39) – – Any Any 185 (63) – – 53 (18) 20 (7) 30 days
Chen 2018 Retrospective 8064 3646 (45) 55 (IQR 43–65) 3965 (49) Colorectal disease Any 7538 (91) 5143 (64) Both 1620 (20) 234 (3) 30 days
Justinianio 2018 Retrospective 262 123 (47) 54 – Colorectal disease Colorectal resection 174 (66) 115 (44) Both 78 (30) 29 (11) 30 days
Sier 2018 RCT 339 130 (38) 60 (SD 14) 29 (9) Colorectal disease Any 339 (100) – Both 21 (6) –0 30 days
Charak 2018 Retrospective 99 48 (48) 52 (SD 19) 55 (56) Colorectal disease Colorectal resection 99 (100) 43 (43) Loop 36 (36) 14 (14) 60 days
Kandagatla 2018 Retrospective 360 170 (47) 48 206 (58) Colorectal disease Any 223 (62) – Both 98 (27) 15 (4) 30 days
Bednarski 2018 Retrospective 49 19 (39) 51 (R 22–75) – Colorectal cancer Colorectal resection – – Loop 15 (31) 4 (8) 60 days
Park 2018 Retrospective 71 24 (34) 39 (R 16–21) 3 (4) UC Procto-colectomy 71 (100) – Loop 13 (18) 8 (11) 90 days
Migdanis 2018 RCT 80 26 (32) 66 (SD 12) Colorectal disease LAR 80 (100) – Loop 15 (19) 10 (13) 30 days
Iqbal 2018 Retrospective 86 43 (50) 54 71 (82) Colorectal disease LAR 86 (100) 33 (38) Loop 22 (26) 8 (9) 30 days
Wen 2017 Case–matched 74 – – – Colorectal disease Colorectal resection 74 (100) – Both 12 (16) 3 (4) 30 days
Shaffer 2017 Retrospective 162 – – – Any Colorectal resection – – – 29 (18) – 30 days
Yin 2017 Retrospective 28 9 (32) 64 (SD 12) – Rectal cancer LAR 27 (96) – Loop 10 (36) – Creation and closure
Li L 2017 Retrospective 84 1 (1) – – Colorectal cancer Colorectal resection – 58 (69) Both – 14 (17) 1 year
Fish 2017 Retrospective 407 183 (45) 53 (SD 16) – Colorectal disease Any 317 (78) 220 (54) Both 113 (28) 47 (12) 60 days
Iqbal 2017 Prospective 55 – 55 – Colorectal disease Colorectal resection – – Both – 20 (36) 30 days
Shwaartz 2017 Retrospective 204 100 (49) 62 (SD 15) 141 (69) Colorectal disease Any 150 (74) 164 (80) Both 31 (15) – 30 days
LI W 2017 Retrospective 1267 547 (43) 47 586 (46) Colorectal disease Colorectal resection 1236 (98) 1021 (81) Loop 163 (13) 38 (3) 30 days
Shah 2017 Retrospective 192 – – – Colorectal disease Colorectal resection 192 (100) – Both 39 (20) – 30 days
Hawkins 2016 Prospective 186 113 (60) 57 (SD20) 136 (73) Colorectal disease Ileocecal resection 133 (72) 70 (38) Loop 42 (23) – 30 days
Tseng 2016 Retrospective 44 – 63 (R 54–91) – Ovarian cancer Any – – Loop 10 (23) 2 (5) 30 days
Helavirta 2016 Retrospective 133 – – – UC Procto-colectomy – – Loop – 9 (7) 30 days
Anderin 2016 Retrospective 139 52 (37) 62 (R 30–84) 13 (9) Rectal cancer LAR – – Loop 22 (16) 5 (4) 3 years
Kulaylat 2015 Retrospective 381 – – – Colorectal disease Any – 10 (100) Both 154 (40) – 30 days
Pellino 2014 Prospective 10 88 (R 84–90) – UC Procto-colectomy – – Loop – 1 (10) 2 weeks
Hardiman 2014 Retrospective 430 222 (52) 50 – Any Any 255 (59) – Both 110 (26) – 30 days
Tyler 2014 Retrospective 6007 2894 (48) 60 (SD 17) – Colorectal disease Any 3046 (51) – Both 1484 (25) – 30 days
Phatak 2014 Retrospective 294 95 (32) 56 (SD 13) Rectal cancer Rectal resection 294 (100) 264 (89) Loop 63 (21) 32 (11) 60 days
Abegg 2014 Retrospective 118 41 (36) 65 (IQR 60–72) 6 (5) Colorectal cancer Colorectal resection – – Loop 31 (26) – Creation and closure
Glasgow 2014 Retrospective 53 53 (100) 63 (SD 11) – Gynecologic malignancy Any – – Both 18 (34) 13 (25) 30 days
Feroci 2013 Prospective 59 – – – Colorectal disease Any 59 (100) – Loop 0 0 30 days
Parnaby 2013 Case-matched 64 38 (59) 41 (R 24–55) 8 (13) UC Subtotal colectomy 20 (31) 32 (50) Loop 12 (19) – 30 days
Coakley 2013 Retrospective 107 41 (38) 38 (SD 17) 47 (44) UC Colectomy – 82 (77) Loop 14 (13) – 30 days
Gu 2013 Retrospective 204 99 (49) 35 (R 18–75) – UC Total colectomy – 9 (4) End 35 (17) 4 (2) 30 days
Hardt 2013 Retrospective 103 36 (35) 62 26 (25) Rectal cancer Rectal resection 103 (100) 70 (68) Loop 2 (2) 00 14 days
Byrne 2013 Prospective 20 8 (40) 64 (R 41–84) 1 (5) Rectal cancer LAR 20 (100) 2 (10) Loop 2 (10) – 30 days
Paquette 2013 Retrospective 201 92 (46) 47 (SD 17) – Colorectal disease Any – 191 (95) Both – 33 (17) 30 days
Lee S 2013 RCT 98 34 (35) 61 9 (9) Rectal cancer LAR 98 (100) 0 Loop 0 00 30 days
Jafari 2013 Retrospective 991 629 (64) 60 (SD 12) 427 (43) Rectal cancer LAR – – Loop 201 (20) – 30 days
Akesson 2012 Retrospective 92 38 (41) 66 (SD 2) 13 (14) Colorectal disease LAR – – Loop 29 (32) 13 (14) 30 days
Duff 2012 Prospective 75 41 (55) 35 (R 15–72) – UC Procto-colectomy – 0 Loop 18 (24) 6 (8) 30 days
Nagle 2012 Prospective 203 101 (50) 51 – Colorectal disease Any – – Both 66 (32) 25 (12) 30 days
Marsden 2012 Prospective 54 16 (30) 71 11 (20) Rectal cancer LAR 54 (100) 2 (4) Loop 12 (22) – 30 days
Messaris 2012 Retrospective 603 268 (44) 48 (SD 18) 77 (13) Colorectal disease Any 509 (84) 540 (90) Loop 102 (17) 44 (7) 60 days
Chun 2012 Retrospective 123 54 (44) 49 (R 12–69) – Colorectal disease Any 123 (100) – Loop – 14 (11) Creation and closure
Gessler 2012 Retrospective 262 88 (34) 67 (R 23–95) – Colorectal cancer Any 224 (85) – Loop 41 (16) 20 ( 8) 30 days
Beck 2011 Retrospective 107 45 (42) 63 (R 21–90) – Any indication Any – – Loop – 6 (6) Creation and closure
Fajardo 2010 Retrospective 124 63 (51) 40 (R 15–78) – UC or FAP IPPA 124 (100) 69 (56) Loop – 13 (10) 30 days
Telem 2010 Retrospective 90 40 (44) 42 – UC Subtotal colectomy 0 61 (68) End 11 (12) 30 days
Datta 2009 Retrospective 195 73 (37) 36 0 UC Ileoanal pouch 133 (68) – Loop 86 (44) 9 (5) 30 days
Fowkes 2008 Prospective 32 14 (44) 42 (R 23–83) – UC Subtotal colectomy 10 (31) 0 End 6 (19) 1 (3) 30 days
Kariv 2007 Case-matched 194 74 (38) 39 – UC IPAA – 194 (100) Loop 42 (22) 2 (1) 30 days
Schwenk 2006 Retrospective 29 16 (55) 65 (IQR 47–77) 11 (38) Rectal cancer LAR 29 (100) 10 (35) Loop 7 (24) 2 (7) 30 days
Larson 2006 Case-matched 300 180 (60) 32 (R 17–66) – UC or FAP IPAA – 206 (69) Loop 65 (22) 31 (10) 90 days
Garcia-Botello 2004 Prospective 127 54 (43) 54 (SD 19) – Colorectal disease Any – – Loop 2 (2) 1 (0.8) Creation and closure
Hallbook 2002 Prospective 223 42 (19) – – Colorectal disease Any 223 (100) – Loop 11 (5) 3 (1) Creation and closure
Okamoto 1995 Prospective 44 29 (65) – – UC or FAP IPAA – – Both – 3 (7) Creation and closure
Wexner 1993 Prospective 83 31 (37) 45 (R 12–83) – Colorectal disease Any – 83 (100) Loop 9 (11) 4 (5) Creation and closure
Winslet 1991 Retrospective 34 18 (53) 33 (R 16–63) – Colitis/megacolon IPAA – – Loop – 1 (3) Creation and closure
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RCT = randomized controlled trial; N = number; R = range; IQR = interquartile range; UC = ulcerative colitis; FAP = familial adenomatous polyposis, IPAA = ileal pouch-anal anastomosis; LAR = low anterior resection

Readmission within 30 days

A total of 46 studies reported on readmission within 30 days of ileostomy creation [1, 2, 4–8, 11, 14–21, 23, 25, 26, 28–31, 33, 34, 36–38, 41–46, 52–55, 58, 60–66]. For those studies specifying readmission related to dehydration, the pooled incidence was 6% (95% CI 0.04–0.09, I2 = 98%, τ2 = 1.33 p < 0.01), Fig. 2 [1, 2, 6–8, 11, 16, 18–20, 23, 25, 26, 33, 37, 41, 42, 44–46, 54, 55, 58, 60, 61, 63–66]. For those studies reporting overall readmission rate, the pooled incidence was 20% (CI 95% 0.18–0.023, I2 = 96%, τ2 = 0.16 p < 0.01), Fig. 3 [1, 2, 4, 5, 7, 11, 14, 15, 17–21, 23, 25, 26, 28–31, 33, 34, 36–38, 41, 43–46, 52–55, 58, 60–64, 66]. For the studies assessing both overall and dehydration-related readmission, dehydration was the reason for readmission in 26% (95% CI 0.17–0.38, I2 = 97%, τ2 = 1.38 p < 0.01) of patients (Figure S1) [1, 2, 7, 11, 18–20, 23, 25, 26, 41, 44–46, 54, 55, 58, 60, 61, 63, 64, 66].

Fig. 2.

Fig. 2

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Readmission for dehydration within 30 days

Fig. 3.

Fig. 3

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Overall readmission within 30 days

Other indications for readmission within 30 days were reported in 15 studies (Table 3 and Fig. 4) [1, 2, 11, 23, 25, 36, 44–46, 54, 55, 58, 61, 64, 66] and Kim et al. were removed from this section of the analysis, because more than half of the indications for readmission were unknown [2]. Dehydration was again the most common indication for readmission, with a pooled incidence of 5% (95%CI, 0.02–0.14, I2 = 98%, τ2 = 3.76 p < 0.01). Other indications for admission included stoma outlet issues in 4% (95% CI 0.02–0.08, I2 = 89%, τ2 = 0.98 p < 0.01) and infection (excluding anastomotic leaks) in 4% (95% CI 0.02–0.09, I2 = 96%, τ2 = 1.41 p < 0.01) (Figure S2).

Table 3.

All reasons for readmission

Author Number of readmissions Dehydration
n(%)		 Outlet obstruction n(%) Peristomal skin problems n(%) Bleeding n(%) Abscess/infection, n(%) Thromboembolic n(%) Anastomotic leak, n(%) Other n(%) Time frame
Hardt 2013 2 0 1 (1) 1 (1) 14 days
Van Loon 2020 117 34 (29) 26 (22) 35 (30) 6 (5) 16 (14) 30 days
Kim 2020 5718 227 (1) 170 (3) 4 (0.01) 914 (16) 212 (1) 4191 (73) 30 days
Grahn 2019 20 7 (7) 4 (4) 9 (45) 30 days
Kandagatla 2018 98 15 (4) 28 (8) 55 (56) 30 days
Iqbal 2018* 22 8 (9) 5 (6) 8 (9) 3 (14) 30 days
LI W 2017 163 38 (3) 42 (3) 1 (0.08) 4 (0.3) 42 (3) 3 (0.2) 14 (1) 19 (12) 30 days
Glasgow 2014 18 13 (25) 2 (4) 3 (17) 30 days
Gu 2013 35 4 (2) 12 (6) 2 (1) 1 (1) 12 (6) 4 (11) 30 days
Byrne 2013 2 2 (100) 30 days
Duff 2012 18 6 (8) 2 (3) 2 (3) 4 (5) 4 (22) 30 days
Nagle 2012* 66 25 (12) 19 (9) 2 (1) 19 (9) 2 (1) 3 (2) 30 days
Datta 2009 86 9 (5) 28 (14) 28 (14) 21 (24) 30 days
Fowkes 2008 6 1 (3) 2 (6) 1 (3) 2 (33) 30 days
Kariv 2007 42 2 (1) 12 (6) 2 (1) 2 (1) 14 (7) 3 (2) 7 (17) 30 days
Schwenk 2006 7 2 (7) 1 (3) 1 (3) 2 (7) 1 (3) 30 days
Charak 2018 36 14 (14) 2 (2) 12 (12) 8 (22) 60 days
Bednarski 2018 15 4 (8) 2 (4) 3 (6) 2 (4) 4 (27) 60 days
Fish 2017*** 113 47 (12) 15 (4) 68 (17) 49 (43) 60 days
Phatak 2014 63 32 (11) 8 (3) 3 (1) 1 (0.3) 7 (2) 12 (19) 60 days
Messaris 2012 102 44 (7) 21 (4) 3 (1) 26 (4) 4 (1) 4 (4) 60 days
Park 2018 13 8 (11) 3 (4) 2 (15) 90 days
Larson 2006 65 31 (48) 6 (9) 28 (43) 90 days
Karjalainen 2019 50 19 (16) 9 (8) 1 (1) 6 (5) 1 (1) 2 (2) 12 (24) 3 months
Lee N 2020**** 51 20 (39) 19 (37) 15 (29) 5 (10) 6 months
Anderin 2016 22 5 (4) 9 (7) 8 (6) 3 years
Garcia-Botello 2004 2 1 (1) 1 (1) Creation and closure
Hallbook 2002 11 3 (1) 5 (2) 3 (27) Creation and closure
Wexner 1993 9 4 (5) 1 (1) 1 (1) 3 (33) Creation and closure
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*Overlap in reason for readmission in two patients

**Overlap in reason for readmission in four patients

***Overlap in reason for readmission in 66 patients

****Overlap in reason for readmission in eight patients

Fig. 4.

Fig. 4

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Reason for readmissions: A within 30 days. B Between stoma creation and closure

Readmission with 60 days

Readmission within 60 days of ileostomy creation was reported in 6 studies [3, 22, 32, 39, 49, 67]. Dehydration led to readmission in 10% (95% CI 0.08–0.12, I2 = 39%, τ2 = 0.02 p = 0.14), with the pooled proportion of all-cause readmission being 27% (95% CI 0.21–0.34, I2 = 88%, τ2 = 0.15 p < 0.01) (Figures S3, S4). Dehydration was the indication for readmission in 40% of all patients admitted during this timeframe (95% CI 0.34–0.47, I2 = 38%, τ2 = 0.04 p = 0.15), Figure S5.

Of the five papers reporting on other indications for readmission, Figure S6 [3, 22, 32, 39, 67], four mentioned dehydration as the leading cause [22, 32, 39, 67]. Other frequent indications included infection in 7% (95% CI 0.03–0.15, I2 = 92%, τ2 = 0.83 p < 0.01) and stoma outlet issues in 3% (95% CI 0.03–0.04, I2 = 0%, τ2 = 0 p = 0.89), Figure S7.

Readmissions between stoma creation and closure

Eight studies reported on readmission related to dehydration between the time frame of ileostomy creation and closure (range 2–9 months) [27, 40, 47, 57, 68–70]. The pooled incidence of dehydration-related readmission during his time frame was 5% (95% CI 0.03–0.09, I2 = 65%, τ2 = 0.46 p < 0.01), Figure S8 [40, 47, 57, 68–70]. Five studies reported on all-cause readmissions, with an incidence of 11% (95% CI 0.04–0.26, I2 = 92%, τ2 = 1.25 p < 0.01), Figure S9 [27, 47, 57, 70]. Of all readmissions, dehydration was the indication in 37% (95% CI 0.19–0.59, I2 = 0%, τ2 = 0 p = 0.67), Figure S10 [47, 57, 70].

Of the 3 papers reporting specific indications for readmission during this time frame [47, 57, 70], 2% (95% CI 0.01–0.06, I2 = 53%, τ2 = 0.49 p = 0.12) were admitted for dehydration, 2% (95% CI 0.01–0.04, I2 = 0%, τ2 = 0 p = 0.45) for stoma outlet problems, and 1% (95% CI 0–0.02, I2 = 0%, τ2 = 0 p = 0.58) for infection (Figure S11).

Duration of readmission

Ten studies reported on duration of readmission, as summarised in Table 4. Four studies reported specifically on admission for dehydration within 30 days with duration of readmission ranging from 2.5 to 6 days [6, 8, 11, 20]. Five studies reported on all-cause readmission, with duration ranging from 3 to 9 days [1, 11, 20, 25, 44]. In the remaining studies, duration of readmission within 60 days or between stoma creation and closure ranged from 5 to 9.5 days [3, 57, 67].

Table 4.

Duration of readmissions

Study Readmissions overall
N (%)		 Duration of readmission overall (days) Readmissions dehydration
N (%)		 Duration readmission dehydration (days) Time frame readmission
(days)
Grahn 2019 20 (20) 4.7 (no range) 7 (7) – 30 days
Justinianio 2018 78 (30) 6 (IQR 3–11) 29 (11) 6 (IQR 4–10) 30 days
Iqbal 2018 22 (26) 5 (IQR 13–31) 8 (9) – 30 days
Fish 2017 113 (28) 5 (IQR 2–7) 47 (12) 4 (no range) 60 days
Iqbal 2017 20 (36) 4.2 30 days
Li W 2017 163 (13) 3 (rang 1–6) 38 (3) 4 (range 1–6) 30 days
Abegg 2014 32 (26) 9.5 (SD 6.6) 16 (14) – Creation and closure
Paquette 2013 33 (17) 2.4 (range 1–7) 30 days
Datta 2009 86 (44) 9.1 (no range) 30 days
Wexner 1993 9 (11) 5.2 (range 2–11) 4 (5) Creation and closure
Open in a new tab

IQR interquartile range

Cost of readmission for dehydration

Two studies reported readmission due to dehydration within 30 days of stoma creation, with a cost ranging between $2750 and $5924 per patient [6, 8]. If there was additional renal failure costs increased to $9107 [8]. After implementation of an ileostomy education and management protocol, one study reported a reduction in the number of readmissions specifically for dehydration from 65 to 16%, resulting in a mean costs saving of $63,821 ($25,037–$88,858) per year [6]. In the same hospital, the average cost of readmission for any cause was $13,839 per patient [25].

Shaffer et al. reported a total cost of $4,520 per patient for readmission within 30 days for any indication. After implementation of an intervention programme to improve monitoring, these costs were reduced to $508 per patient [5].

Tyler et al. reported a mean associated charge for readmission of $33,363 (SD, $89,396) for readmissions within 30 days after a colorectal resection. In patients with an ileostomy, acute renal failure and fluid and electrolyte disorders were the second most common cause of readmission (17.4%) after surgical complications directly related to the procedure (19.3%) [4].

Discussion

In the present systematic review and meta-analysis, the readmission rate within 30 days after stoma creation is 20%, with dehydration as the leading cause, occurring in around 6% of patients [1–3, 11, 22, 32, 39, 56, 58, 61]. Other frequent indications for readmission include stoma outlet issues and infection, both occurring in around 4% of patients. The average cost of readmission is high with dehydration-related readmission costing between $2750 and $5,924 per patient. Thus, the creation of an ileostomy is associated with a risk of complications that frequently require costly readmission.

This high readmission rate following the creation of an ileostomy is consistent with previous published data. However, data examining the factors associated with readmission are still limited to small cohorts, single institutions, or are from reports often of poor quality [1, 2, 11]. Nonetheless dehydration, stoma outlet obstruction, and infection have been cited repeatedly as the most frequent causes.

Dehydration is most common in the early post-operative period, with the highest incidence of reduced kidney function within the first 3–6 months after surgery [48, 63, 68, 69]. Some authors report that estimated glomerular filtration rate (eGFR) values post-closure closely resemble the normal preoperative situation [69]. Others have shown a significant reduction in eGFR after ileostomy creation which remains present up to 12 months after ileostomy closure [48, 70]. Fielding et al. found that a decline in kidney function after ileostomy creation resulted in an increased risk of severe chronic kidney disease [CKD] ≥ 3, OR 6.89 (95% CI 4.44–10.8, p < 0.0001) [48]. Dehydration after creation of an ileostomy may therefore have a significant impact on patient morbidity.

Risk factors for dehydration include: stoma output more than 1 L at discharge [20], the presence of comorbidity [16, 18], a higher American Society of Anesthesiologists (ASA) classification [2, 19, 23], older age [8, 19, 20], smoking [16], hypertension [19], diabetes [2, 16], use of diuretics [20, 22, 39], and chemotherapy [11, 20]. The influence of gender is unclear. One study reported that female gender was associated with an increased risk for readmission for dehydration (OR 1.59) [19], and another report showed that men were more likely to be readmitted for this reason (OR 3.18) [20]. Some consider enhanced recovery after surgery (ERAS) may lead to a higher rate of readmission, but from the limited evidence available, this has not been confirmed [33, 35–37, 46, 55]. In any case, such programmes should focus on minimizing post-operative complications, preparing patients for discharge, and arranging adequate outpatient support.

Readmissions are costly and may be avoidable to some extent. This is particularly the case for dehydration, since better monitoring and timely intervention might prevent extensive fluid loss. Improved inpatient coaching and outpatient follow-up care have been shown to reduce readmission [1, 6, 18, 30, 64]. Despite attempts by others to introduce such programmes readmission rates remain high in some of the studies [6, 66]. Many of these studies had very small sample sizes [1, 6], and the reduction of readmissions after implementation of the protocol did not always reach a statistically significant level [1, 30]. Therefore, from these data, post-operative care pathways may offer a solution to the problem, but there is a need for further high-quality research to standardize the approach.

There are some limitations to this review. In most studies, readmission rates were not the primary outcome of the study. This might have led to under-reporting. There was significant heterogeneity between the different studies, making the results prone to information bias. This heterogeneity can partly be attributed to the variety of ileostomy indications in different patient populations, and the time span of 30 years in this systematic review which might include changes in indication and management of an ileostomy. In addition, the definition of dehydration and the method of diagnosis varied; for example in some studies, coded diagnoses were used to identify patients with dehydration. In this review, the majority of the ileostomies were created in an elective setting [7, 21, 22, 24–26, 29, 32, 33, 35, 36, 38, 40, 42, 46–48, 59]. This might have led to an underestimate readmission as emergency surgery is known to increase complications. Furthermore, there were only a few reports on preoperative kidney function, or other factors that might contribute to the risk of dehydration such as an additional small bowel resection or post-operative re-intervention. Finally, the reason for readmission within 30 days was unknown in 62% of the largest cohort included in our meta-analysis [2].

Conclusions

One out of five patients is readmitted after creation of an ileostomy. Dehydration is the leading cause for these readmissions, occurring in one-third of patients within 30 days. This comes with high health care costs. Better monitoring, patient awareness, and preventive measures are required.

Supplementary Information

Below is the link to the electronic supplementary material.

10151_2022_2580_MOESM1_ESM.docx (12.9MB, docx)

Supplementary file1 (DOCX 13212 KB) Supplementary Figure 1: Proportion of readmission for dehydration of overall readmissions within 30 days. Supplementary Figure 2: Most common causes of readmission within 30 days A. dehydration B Stoma outlet problems C. Infection. Supplementary Figure 3: Readmissions for dehydration within 60 days. Supplementary Figure 4: Overall readmissions within 60 days. Supplementary Figure 5: Proportion of readmission related to dehydration of overall readmissions. Supplementary Figure 6: All causes readmission dehydration within 60 days. Supplementary Figure 7: All causes readmission dehydration within 60 days. Supplementary Figure 8: Readmissions related to dehydration between stoma creation and closure. Supplementary Figure 9: Overall readmissions between stoma creation and closure. Supplementary Figure 10: Proportion of readmission for dehydration of overall readmissions. Supplementary Figure 11: Most common causes of readmission between stoma creation and closure A. dehydration B. Stoma outlet problems C. Stoma infection.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study formal consent is not required.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

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Supplementary Materials

10151_2022_2580_MOESM1_ESM.docx (12.9MB, docx)

Supplementary file1 (DOCX 13212 KB) Supplementary Figure 1: Proportion of readmission for dehydration of overall readmissions within 30 days. Supplementary Figure 2: Most common causes of readmission within 30 days A. dehydration B Stoma outlet problems C. Infection. Supplementary Figure 3: Readmissions for dehydration within 60 days. Supplementary Figure 4: Overall readmissions within 60 days. Supplementary Figure 5: Proportion of readmission related to dehydration of overall readmissions. Supplementary Figure 6: All causes readmission dehydration within 60 days. Supplementary Figure 7: All causes readmission dehydration within 60 days. Supplementary Figure 8: Readmissions related to dehydration between stoma creation and closure. Supplementary Figure 9: Overall readmissions between stoma creation and closure. Supplementary Figure 10: Proportion of readmission for dehydration of overall readmissions. Supplementary Figure 11: Most common causes of readmission between stoma creation and closure A. dehydration B. Stoma outlet problems C. Stoma infection.

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