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Invited Critique
October 1, 2005

Mortality and Complications After Stoma Closure—Invited Critique

Arch Surg. 2005;140(10):960. doi:10.1001/archsurg.140.10.960

Stoma closure is so often considered a “minor” procedure, but as clearly and appropriately pointed out in this article, it is associated with significant morbidity and mortality. This should not be unexpected because these patients are undergoing bowel operations and therefore should be accorded the same considerations and respect as any other patients undergoing bowel operation. A review of this large series afforded the authors the opportunity to adequately assess the morbidity from stoma closure. It was not surprising that the use of soft silicone drains was identified as a risk factor. Although not specifically mentioned by the authors, it would appear to be related to anastomotic leaks. Canalis and Ravitch1 many years ago clearly demonstrated that wrapping anastomoses with drains promoted anastomotic dehiscence, and hence, those surgeons who drain to “identify” the leak are indeed creating a self-fulfilling prophecy. The authors reported “ileus” in 4% of patients, and one presumes these were cases of small-bowel obstruction; if so, they should more appropriately be labeled as such. Indeed, small-bowel obstruction following stoma closure is a well-recognized problem, but not all these patients require further laparotomy. Another complication not mentioned that might have been expected in a series this size is enterocutaneous fistula. Although the authors found no difference in stoma closure using a hand-sutured vs stapled anastomosis, other surgeons, including myself, have favored stapled closure of ileostomies because we believe the anastomotic complication rate is reduced. A recognized risk factor for closure is hypoalbuminemia, but the authors did not address this factor. Nevertheless, the authors are to be complimented on bringing our attention to the morbidity of this procedure.

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