Safety and Feasibility of Temporary Ileostomy in Older Patients: A Retrospective Study

Colorectal cancer is the third most common cancer worldwide, affecting approximately 1.3 million new individuals each year.¹ With an increase in life expectancy, the number of older patients in whom colorectal cancer develops is increasing globally.^2,3 Frailty in older patients can contribute to unfavorable outcomes after colorectal resection. Serious complications after sphincter-preserving surgery include anastomotic leakage, which has been reported to increase postoperative mortality rates in older patients.⁴

A temporary stoma often is constructed for fecal diversion after rectal surgery.^5,6 Several studies have reported that temporary stomas can reduce the incidence of severe anastomotic leakage and postoperative mortality.^7,8 Although higher rates of skin disorders and dehydration have been reported,⁹ loop ileostomy is frequently used from the perspective of convenience of construction and because of the lower incidence of troublesome complications such as wound infection, stoma prolapse, and parastomal hernia.^9-12

Despite the advantages described above, colorectal surgeons are sometimes reluctant to construct a temporary ileostomy in elderly patients due to the fear of severe ileostomy-related complications. In addition, many surgeons believe that dehydration related to ileostomy might impair the health and quality of life of these patients.^13,14 Nevertheless, we believe that fecal diversion through a temporary ileostomy is necessary, especially given that mortality rates in patients with anastomotic leakage increase in elderly patients. However, little is known about ileostomy-related complications in this patient population.¹⁵

The purpose of this study was to compare patient background and short-term outcomes after ileostomy construction between elderly and non-elderly patients, with the aim of clarifying the safety and feasibility of temporary ileostomy in elderly patients.

A total of 494 patients with stage I to III rectal malignancies who underwent curative proctectomy at a single comprehensive cancer center (Aichi Cancer Center Hospital, Aichi, Japan) between 2013 and 2018 were identified, and data were collected from a prospectively created database. Rectal malignancies included adenocarcinoma, neuroendocrine tumor, gastrointestinal stromal tumor, schwannoma, and melanoma. Patients with stage IV rectal malignancies were excluded from the present analysis to eliminate the influence of perioperative chemotherapy on ileostomy-related complications. Patients with a permanent stoma were excluded. Finally, 182 patients with temporary diverting loop ileostomy were included in this study (Figure 1).

At the authors’ institution, temporary ileostomy is routinely performed in patients who undergo proctectomy with coloanal and colorectal anastomosis for tumors below the peritoneal reflection. Temporary ileostomy is also considered if anastomotic leakage is a concern when using the double stapling technique. Ileostomy is performed for all patients who meet the above criteria.

Data were reviewed and complemented by secondary chart review, and included age, sex, body mass index (BMI), comorbidity (presence of diabetes mellitus requiring medication), primary disease, surgical procedure (coloanal or colorectal anastomosis), surgical approach (laparotomy or laparoscopy), anastomotic leakage, ileostomy-related complications, intravenous hydration, adjuvant chemotherapy, stoma closure, fecal output, and serum creatinine.

Complications and postoperative course. Ileostomy-related complications were classified as follows: skin disorders, mucocutaneous separation, high-output stoma (HOS), acute renal failure, parastomal hernia, stoma prolapse, stoma retraction, outlet obstruction. Skin disorders were defined as any kind of skin erosion or ulcer around the stoma. Although the definition of HOS has been controversial,^16-19 the authors defined HOS as a stoma with a fecal output ≥ 2000 mL per day, which is considered to cause clinical problems.^20,21

The period of intravenous hydration was defined as the period between ileostomy creation and the last day of intravenous hydration (irrespective of intermittent or continuous). Creatinine ratio was calculated as the ratio of maximum serum creatinine (mg/dL) to preoperative serum creatinine (mg/dL) for the assessment of postoperative renal impairment (≥ 1.5).²² Readmission was defined as any readmission during the period from the first proctectomy to stoma closure.

Patient categorization and statistical analysis. Patients were divided into the elderly (age ≥ 75 years) and non-elderly (age < 75 years) groups. To clarify the problem of diversion ileostomy in a frail population, the authors set the age cutoff at 75 years, following the definition of the Japan Gerontological Society and the Japan Geriatrics Society, which define the elderly as those aged 75 years or older.²³ Patient characteristics, postoperative course, ileostomy-related complications, and amount of fecal output were compared between the two groups.

Categorical variables were analyzed using the chi-square test. Continuous variables were presented as medians with ranges and analyzed using the Mann-Whitney U test. P < .05 was considered statistically significant. All analyses were performed using SPSS version 27 (IBM Corp).

Ethical considerations. The experimental protocols were approved by the Institutional Review Committee at Aichi Cancer Center Hospital (ID: 2019-1-173). Announcement on the home page and the opportunity to opt-out from the present study were provided to the patients.

Patient and surgical characteristics. Data from 182 patients were analyzed: 160 (87.9%) in the non-elderly group and 22 (12.1%) in the elderly group. Patient demographic data and surgical characteristics are shown in Table 1. No significant differences were observed in sex and BMI, although overweight patients (≥ 25.0 kg/m²) were found only in the non-elderly group (28 [17.5%] vs 0 [0%]; P = .07). Only 10 patients in the non-elderly group had diabetes mellitus requiring medication.

The most common primary disease was adenocarcinoma in both groups (151 [94.4%] vs 20 [90.9%]; P = .67). There were no significant differences in surgical procedure between the non-elderly and elderly groups (coloanal anastomosis: 47 [29.4%] vs 4 [18.2%], respectively; P = .40] and surgical approach (laparotomy: 90 [56.2%] vs 15 [68.2%], respectively; P = .41]. The incidence of anastomotic leakage did not significantly differ between the two groups (13 [8.1%] vs 2 [9.1%], respectively; P = 1.00].

Postoperative course. Details on postoperative course are shown in Table 2. The median maximum fecal output was significantly higher in the non-elderly group than in the elderly group (1185 [range, 250–5150] vs 880 [range, 360–2650] mL/day, respectively; P = .02). Nevertheless, the period of postoperative intravenous hydration did not significantly differ between the two groups (6 [range, 4–59] days for the non-elderly group vs 5 [range, 4–62] days for the elderly group; P = .71). There was also no significant difference in median creatinine ratio (1.15 [0.80–4.14] vs 1.17 [0.92–2.20], respectively; P = .68] between the two groups. The median postoperative hospital stay was 20 (range, 10–76) days for all patients, with no significant difference between non-elderly and elderly groups (20 [range, 10–76] vs 19 [range, 10–71] days, respectively; P = .70).

Ileostomy-related complications. Overall, 102 (56.0%) patients had more than one ileostomy-related complication. Skin disorders were the most frequent complication (n = 61; 33.5%), followed by mucocutaneous separation (n = 36; 19.8%), HOS (n = 36; 19.8%), postoperative renal impairment (n = 23; 12.6%), parastomal hernia (n = 2; 1.1%), stoma prolapse (n = 2; 1.1%), stoma retraction (n = 1; 0.5%), and outlet obstruction (n = 1; 0.5%). Parastomal hernia, stoma prolapse, stoma retraction, and outlet obstruction were grouped into “others” because of the low incidence. The complication rates for each of the groups are shown in Figure 2.

The number of patients who had more than one ileostomy-related complication did not significantly differ between the non-elderly and elderly groups (90 [56.2%] vs 12 [54.5%], respectively; P = 1.00]. Although not significant, the incidence of HOS was lower in the elderly group (n = 33; 20.6%) compared with the non-elderly group (n = 1; 4.5%) (P = .13). No significant differences were observed in the incidence of skin disorders (54 [33.8%] vs 7 [31.8%], P = 1.00], mucocutaneous separation (33 [20.6%] vs 3 [13.6%], P = .63], postoperative renal impairment (21 [13.1%] vs 2 [9.1%], P = .85), and others (4 [2.5%] vs 2 [9.1%], P = .11) between the non-elderly and elderly groups, respectively.

Readmission and/or early stoma closure. Overall, 54 (29.7%) patients received adjuvant chemotherapy after discharge. Fewer patients in the elderly group received adjuvant chemotherapy after proctectomy compared with the non-elderly group (51 [31.9%] vs 3 [13.6%]; P = .13).

Overall, 17 (9.3%) patients required readmission after primary proctectomy, with no significant difference in the incidence of readmission between the two groups (15 [9.4%] vs 2 [9.1%]; P = .93). Reasons for readmission were ileus (n = 3), dehydration (n = 3), urinary tract infection (n = 2), lymphorrhea, skin disorders, acute hepatitis, acute pancreatitis, enteritis, abdominal pain, and dizziness (n = 1 each) in the non-elderly group, and gastric ulcer and choledocholithiasis (n = 1 each) in the elderly group.

Stoma closure was performed in a total of 177 (97.3%) patients (Table 2). No significant difference was observed in the time to stoma closure between the two groups (124 [46–798] in the non-elderly vs 119 [43–275] days in the elderly group; P = .11). Unplanned early stoma closure was performed in a total of 6 (3.3%) patients. The elderly group had a higher rate of early stoma closure (n = 3; 1.9%) compared with the non-elderly group (n = 3; 13.6%) (P = .02). Causes of early stoma closure were severe skin disorders (n = 1), dehydration (n = 1), and outlet obstruction (n = 1) in the non-elderly group, and difficulty in learning both pouching system and skin care (n = 2) and skin disorders (n = 1) in the elderly group.

In the current study, elderly patients had a significantly lower maximum fecal output compared with non-elderly patients. One reason for this may be because oral intake is often reduced in elderly patients.^24-26 This possibly contributed to the incidence of HOS and postoperative renal impairment seen in elderly patients versus non-elderly patients. In addition, reduced daily output might contribute to the incidence of skin disorders in elderly patients and non-elderly patients. One of the main causes of skin disorders and mucocutaneous separation is known to be contact with fecal fluid,²⁷ and the low amount of fecal output can be favorable in terms of these skin conditions.

The incidence of dehydration and renal impairment has been reported to increase in elderly patients. Gessler et al²⁸ reported that elderly patients and hypertensive patients have an increased risk of renal impairment after receiving a temporary loop ileostomy. However, the current study found no significant increase in creatinine ratio after temporary ileostomy. In a study to identify the rate of hospital readmission secondary to dehydration or renal failure within 30 days of ileostomy creation, Paquette et al²⁹ reported that age 50 years and older was an independent predictor of hospital readmission due to renal failure. However, we observed no significant increase in the incidence of HOS in elderly patients, suggesting that there may have been other factors associated with renal impairment. In a retrospective review, Fish et al³⁰ reported that the rate of readmission due to dehydration was higher in patients 65 years and older compared with younger patients. However, the rate of readmission was higher in the current study compared to those previously reported.

The number of elderly patients with rectal malignancies is increasing globally,³¹ and the rate of sphincter preservation in rectal surgery has increased with advances in surgical techniques and stapling devices.^32-34 As a result, more elderly patients today receive sphincter-preserving surgery.³⁵ On the other hand, sphincter preservation is associated with the risk of anastomotic leakage, which leads to increased morbidity and mortality, especially in elderly patients.^36,37 Thus, the need for safe fecal diversion in elderly patients is increasing.^38-40 The present study demonstrated the safety and feasibility of temporary ileostomy in this group of older patients, which in turn suggests the possibility that this procedure can help more elderly patients safely undergo sphincter-preserving proctectomy.

The higher frequency of unplanned early stoma closure in elderly patients, although only one of three cases was due to ileostomy-related complications in the current study, raises another issue regarding stoma care in this patient population. One of the most important factors of stoma care is the management of peristomal skin. As shown in this study and by others, skin disorders are the most common stoma-related complication and greatly affect quality of life.^41,42 The prevalence of skin disorders can be reduced by selecting appropriate skin care products and appropriate stoma pouches to fit peristomal topography.^43,44 Therefore, regular follow-up by wound ostomy continence nurses is important, especially for elderly patients who have difficulty with stoma care.⁴⁵

This study has several limitations, some of which are inherently related to the retrospective design. In addition to possible selection bias, misclassification, and information bias, the low number of patients might have resulted in insufficient statistical power. Moreover, because this study was conducted in Japan, the country with the oldest population and a well-developed social welfare system, the results may not be entirely generalizable to other countries. Another limitation is a large difference in the number of participants in the two groups. Statistically, the age cutoff should be lowered to reduce the difference between the two groups; however, the authors set the age cutoff at 75 years to address the problems in a
frail population.

This retrospective study evaluated the safety and feasibility of temporary ileostomy in elderly patients compared with non-elderly patients, as defined by the Japan Gerontological Society and the Japan Geriatrics Society.²³ The median maximum fecal output was significantly higher in the non-elderly group than in the elderly group, and there were no significant differences in the incidence of ileostomy-related complications, including HOS and postoperative renal impairment, between the two groups. Although early stoma closure was more frequently observed in the elderly group, the main cause was difficulty in learning basic stoma techniques, and only one case was due to ileostomy-related complications. These results suggest that temporary ileostomy can be performed safely, even in patients 75 years and older, and can reduce the occurrence of anastomotic leakage, even in elderly patients with rectal malignancies.

All Authors: Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan

Address all correspondence to: Akira Ouchi, MD, PhD, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi 464-8681, Japan; fax: 052-764-2963; tel: 052-762-6111; email: akira.ouc@aichi-cc.jp.