Stapled Versus Sutured Closure of Loop Ileostomy

Abstract

Objective

To compare the outcome after conventional sutured loop ileostomy closure with stapled ileostomy closure.

Summary Background Data

A defunctioning loop ileostomy is now widely used in colorectal surgery. Subsequent closure may be associated with early complications, particularly bowel obstruction. The results of a preliminary nonrandomized study suggested that there was no significant difference in the rate of complications between sutured and stapled closure of loop ileostomy.

Methods

One hundred forty-one consecutive patients who underwent loop ileostomy between 1993 and 1998 were randomized before surgery to either sutured or stapled loop ileostomy closure. Seventy-one patients had stapled closure and 70 had sutured closure.

Results

Both groups were comparable in terms of age, sex, original operation, duration after original operation, and level of operating surgeon. Postoperative bowel obstruction occurred in 10/70 (14%) patients after sutured closure compared with 2/71 (3%) patients after stapled closure. Subgroup analysis of ileostomy closure in patients having an ileal pouch showed no significant difference in bowel obstruction between stapled and sutured closure (2/30 vs. 7/29). The incidence of other complications, readmissions, and reoperations did not differ between the two groups. The stapled closure was only 4 minutes quicker than sutured closure. The mean total hospital stay tended to be shorter after the stapled closure than the sutured closure, but this did not reach statistical significance.

Conclusions

Bowel obstruction occurred less frequently after stapled closure, but the mean hospital stay and readmission and reoperation rate did not significantly differ between the two groups.

A defunctioning loop ileostomy is now widely used after low coloanal or colorectal anastomosis, after a restorative proctocolectomy, and for fecal diversion in Crohn disease. Closure of a loop ileostomy, however, has often been associated with a high rate of complications, such as bowel obstruction, particularly after a restorative proctocolectomy. ^1,2 A preliminary nonrandomized study suggested that there was no significant difference in the rate of complications between sutured and stapled closure of loop ileostomy. ³ The goal of the current prospective randomized controlled study was to compare the outcome after conventional sutured loop ileostomy closure with stapled ileostomy closure in terms of complications, operating time, and hospital stay.

PATIENTS AND METHODS

One hundred forty-one consecutive patients who underwent loop ileostomy between 1993 and 1998 were recruited. Every patient was randomized before surgery to either sutured or stapled closure. The procedure was performed by one of three consultants (MRBK, DGM, or SR) or eight senior registrars. Local ethical committee approval was obtained, and all patients gave informed consent to take part in the study. Seventy-one patients had stapled closure and 70 had sutured closure.

Statistical Power

The main objectives of this study were to investigate whether stapled closure could reduce the complication rate with a significance level of P = .05 and a power of 0.80. It was calculated that 140 patients would be required to show a 13% difference in complications. Statistical analysis was made using Fisher’s exact test or the Student t test.

Surgical Technique

The loop ileostomy was thoroughly mobilized from the abdominal wall and within the peritoneal cavity.

Stapled

The antimesenteric borders of the ileum were approximated with a stay suture after mobilizing the spout to facilitate side-to-side (functional end-to-end) anastomosis using a TLC 75 stapler (Ethicon, UK). The apex of the loop and the spout was cross-stapled with a refill of the TLC 75 stapler. The abdominal wall was closed with interrupted nonabsorbable sutures and the skin was closed with interrupted nylon sutures, subcuticular PDS (Ethicon) sutures, or clips.

Sutured

After thorough mobilization, the ileostomy bud was turned back and the enterotomy was closed transversely, after trimming the edges, using a single layer of 3-0 PDS, either by a single-layer extramucosal continuous suture or interrupted sutures. The abdominal wall and the skin were closed in the same way as for stapled closure.

Postclosure bowel obstruction was defined as radiologic evidence of dilated small bowel associated with vomiting, abdominal distention, abdominal pain, and absolute constipation, lasting for at least 3 days and occurring within a month of ileostomy closure. Anastomotic leakage was defined as radiologic evidence of fistula or fluid collection with clinical symptoms. Wound sepsis was defined as the discharge of pus from the wound. Postoperative bleeding was defined as continued intraabdominal blood loss requiring reoperation.

RESULTS

The sutured and stapled groups were comparable in terms of age, sex, original operation, duration after original operation, and surgeon’s level (Table 1).

Table 1. PATIENT DETAILS

Results expressed as mean ± standard deviation. *Fisher’s exact test; †Student t test.

Postoperative bowel obstruction occurred in 10/70 (14%) patients after sutured closure compared with 2/71 (3%) patients after stapled closure (P = .0168) (Table 2). Of the 70 patients who had sutured closure, two required bowel resection and end-to-end anastomosis because of difficulty during the dissection; bowel obstruction requiring further surgery developed in both. In addition, in six patients in the sutured closure group, the ileostomy spout was excised; obstruction, which was managed conservatively, developed in only one.

Table 2. RESULTS

* Number in parentheses shows number of patients who had reoperation.

† Results expressed as mean (95% confidence interval).

‡ Fisher’s exact test; §Student t test.

Subset analysis of ileostomy closure in patients having an ileal pouch showed no significant difference in bowel obstruction between stapled and sutured closure (stapled 7% 2/30 vs. sutured 24% 7/29, P = .0797). The incidence of other complications, readmissions, and reoperations did not differ between the two groups. Two patients in the sutured group required reoperation for bowel obstruction; in the stapled group, none required reoperation. One patient in the stapled group required reoperation for bleeding from the stapled anastomosis and another in the sutured group for fistula resulting from anastomotic leakage.

To ensure that the results were not biased by individual surgeons with a high complication rate who performed an unequal number of stapled or sutured closures, we undertook a subset analysis of outcome for each surgeon (Table 3). No significant differences were encountered; each person performed similar proportions of sutured or stapled closure, even without the use of stratification.

Table 3. NUMBER OF OPERATIONS AND BOWEL OBSTRUCTION ACCORDING TO EACH SURGEON

* Number in parentheses shows number of patients who had reoperation.

The stapled closure was 4 minutes quicker than sutured closure (P = .0355). The mean total hospital stay tended to be shorter after stapled closure than sutured closure, but this did not reach statistical significance.

DISCUSSION

Loop ileostomies are becoming increasingly popular among colorectal surgeons because they are simpler to form and close than conventional loop colostomy. ^4,5 It has been suggested that stapled closure of a loop ileostomy may reduce the complication rate from bowel obstruction because the lumen created using a stapled side-to-side technique may be wider than that created by sutured closure. ⁶ In this randomized controlled study, we found that sutured closure was associated with a higher rate of bowel obstruction. This may be explained by the fact that stapled closure is relatively less dependent on surgical skills than sutured closure, although there was no significant association between each particular surgeon and the incidence of bowel obstruction. Two thirds of the bowel obstructions occurred in the first half of the study period (8/60 vs. 4/81, respectively), and all four patients requiring reoperations had their surgery initially performed by senior registrars. The surgeon-related variants did not, however, affect the incidence of obstruction. Of the two patients who had a reoperation for bowel obstruction, the obstruction was due to stenosis at the closure site in one patient; the other patient had a loop of bowel obstructed as a result of adherence to the closure site, but the closure site itself was intact.

The incidence of bowel obstruction after sutured closure of loop ileostomy for ileal pouch was 24% (7/29), comparable with our previous data (5/20, 25%) ³ and the data reported by Hull et al (4/30, 13%). ⁷ In contrast, it was only 7% (2/30) when the stoma was stapled. This difference was not statistically significant, but this may have been due to small numbers. In patients having a loop ileostomy closure for nonpouch procedures, the incidence did not differ between the methods of closure. Often there is a relative lack of mobility of the ileum after ileal pouch operations, making both creation of a loop and its subsequent closure more difficult compared with loop ileostomies performed after nonpouch procedures.

In another randomized controlled study, Hull et al ⁷ stated that stapled closure was 15 minutes quicker than sutured closure and that stapled closure overall was more cost-effective. In our study, operating time was only 4 minutes quicker with the stapled closure, which would not overcome the cost of materials by itself. The overall hospital stay, taking into account readmission for complications, did not differ significantly between the groups, with wide confidence intervals.

In this study, stapled closure resulted in a lower risk of bowel obstruction, but because the power of the study was relatively low and the confidence intervals were wide, the other variables, particularly hospital stay, did not differ between the groups. We would not attach too much importance to the operating time difference between the groups because of the wide confidence intervals. Nevertheless, we still recommend stapled closure rather than sutured closure of loop ileostomy because of the lower risk of bowel obstruction.