PROTECTIVE ILEOSTOMY: COMPLICATIONS AND RISK FACTORS

The construction and closure of a temporary protective ileostomy has been a relatively common surgical procedure for more than seventy years and is indicated in many pathological conditions involving the digestive tract [52]. The reasoning behind this practice lies in protecting the portion of intestine, operated due to an underlying pathology, by excluding it from transit of gastro-enteric tract contents with a deviation through a preternatural orifice located upstream of the operated portion and attached the abdominal wall [52]. In spite of this, the real utility of temporary protective ileostomies is still widely debated; although it has been demonstrated that their creation at the end of surgery reduces complications that would lead to the need for a second operation [9], not all Authors agree with the recommendation to proceed with construction of a protective ileostomy [10]. Beyond the debate about different aspects of stomas, an extremely important fact is that despite great innovations available to modern surgeries, the rate of complications of protective ileostomies remains high and the causes for this are currently unknown. The aim of the present study has been to evaluate the complications and risk factors that accompany the construction and closure of temporary protective ileostomies, regardless of the clinical indication that led to their necessity. To this end, all patients who underwent surgical intervention that concluded with the construction of a temporary protective ileostomy at the General Surgery Operating Unit of the I.R.C.C.S. Policlinico San Matteo di Pavia in the period between February 4, 2016 and October 23, 2019, were retrospectively studied. It was thus possible to evaluate the number of complications that arose in the immediate post-operative period (the period in which patients were stoma carriers) and later, after restoration of intestinal continuity. It was also taken into consideration whether the planned recanalization occurred, i.e. whether the diversion of the intestinal contents, through a preternatural orifice, was truly a temporary solution, as initially envisaged, or whether it became a permanent condition. The selected patients were then stratified according to the following variables to highlight any risk factors that might favor the appearance of complications in each of the time frames taken into consideration: Urgency of surgery, Duration of surgery, Methods of surgery, Stoma retention time, Neo-adjuvant therapy. From the analysis of results obtained, as far as immediate post-operative period is concerned, it has been concluded that the incidence of complications within the study population is similar to what has been reported in literature [51; 53; 54] With regard to the identification of variables such as to influence the development of complications, thus acting as real risk factors, it was found that possible to consider elective surgeries and video-assisted laparoscopy to be positive predictive factors that would result in protective ileostomy being truly a temporary solution. The laparoscopic technique has also proved to be superior in controlling post-operative complications, guaranteeing a more favorable clinical evolution. A similar result was observed when comparing patients with adenocarcinoma of large intestine that underwent neo-adjuvant therapy to those who did not. It can therefore be reasonably concluded that the use of ileostomies for protective purposes is justified by a lower post-operative hospitalization and severity of possible complications, especially when the patient's clinical history as a whole is taken into account. Obviously, a better knowledge of the risk and protective factors, combined with improvement of the surgical technique, will make it possible in the future to minimize the complications that accompany this operation, and it is with this in mind that the present study is ideated.