Factors Associated With the Timing of Intestinal Stoma Reversal and Outcomes in Adult Patients at Kenyatta National Hospital

Abstract

BACKGROUND: Intestinal stoma creation is done as either an emergency surgery or elective surgery to divert the flow of fecal matter in order to relieve obstruction or protect distal anastomosis. It involves bringing out part of either the small intestine or the large intestine through the skin. This can be as a permanent conduit or temporary measure that requires reversal and restoration of normal bowel continuity. Creation and management of intestinal stoma has significant morbidity and cost implications which increases with the duration the stoma is in place. There is no established protocol on the timing of stoma reversal. Timing of the reversal influences post reversal complication. There is paucity of data locally on factors associated with the timing of stoma reversal and immediate complications. OBJECTIVES: To determine the factors that are associated with the timing and outcome of stoma reversal in adult patients with intestinal stoma at KNH. METHODOLOGY: This was a retrospective cohort study. Data was collected using a data collection tool from records of patients managed with intestinal stoma and reversed who met the inclusion criteria in the time period between February 2023 and February 2016. Details of the patient's demographic data, type and indication of stoma, complications, timing of reversal, technique of reversal and immediate post-reversal complications were noted and tabulated. Data was then filtered and entered into Stata version 17 for analysis. DATA ANALYSIS: Data analysis was done using both descriptive and inferential statistics. Demographic and clinical characteristics were summarized descriptively. Categorical data was summarized using frequencies and percentages. Continuous data was summarized using Mean, Median and Interquartile range (IQR). Indications for stoma creation were analyzed descriptively using frequencies and percentages. Binary logistic regression was conducted to investigate indications associated with timing of stoma (emergency vs elective). Odds ratios were computed to explain the extent of the existing association. The timing of stoma reversal 5 was analyzed descriptively using median (Interquartile range). A histogram was also utilized to illustrate the distribution of timing of stoma reversal. Factors associated with stoma reversal were investigated using binary logistic regression. In investigating demographic and clinical characteristics associated with time to reversal, independent samples t -test and one-way analysis of variance were used. Binary logistic regression was also used to investigate the association between time to reversal and presence of stoma reversal complication. The significance was assessed at 95% confidence level where variables with a p<0.05 were considered to be statistically significant. RESULTS: A total of 286 patients with intestinal stoma were included in this study. Out of these, 173 (60.5%) had stoma reversal within the study period. The median age of the patients with stoma was 41 years. The most common indication for stoma creation was neoplasm (30.1%) followed by intestinal obstruction (25.5%). Double barrel stoma was the most common type (31.1%) with sigmoid colon being the most common site (52%). The most common complication of stoma was surgical site infection (16%) occurring within 18 days of stoma creation. The average time of stoma reversal was 157.3 days. Surgical site infection was the most common complication after stoma reversal (13.2%). Those who had neoplasm as an indication were 87% less likely to have stoma reversal, OR 0.13, 95%CI:0.07 – 0.23, p<0.001. Presence of comorbidities, neoplasm and adjuvant treatment prolonged time to stoma reversal. The results also showed that the likelihood of stoma reversal complications was six times higher among those with late time to reversal (>90 days) compared to those with early time to reversal, Odds Ratio (OR) = 5.89, 95%CI: 1.96 – 17.75, p<0.001. CONCLUSION: Stoma creation is a lifesaving surgical procedure associated with various complications and significant morbidity. Early reversal within 90 days reduces the morbidity and post reversal complications. KEY WORDS: Intestinal stoma, timing, reversal, complications.