Temporary fecal diversion is still playing a role in intestinal surgery to avoid an anastomosis or to reduce the risk of leakage after an anastomosis. Once an ostomy is created, the timing of ostomy takedown is variable and depends largely on a variety of factors. An overall incidence of complications as high as 5 to 39% has been reported; of this, SSI is the most common, 7 to 29% [4
]. In their study of Hartmann's reversal, Boland et al. [15
] noted that reversal is associated with a host of minor and major complications. These authors reported a 40% minor complication rate, and, concurrently, documented a 38% major complication rate, including myocardial infarctions, leaks, and respiratory failures. They encountered one death, and 28.6% of the patients (n = 10) were left with ostomies at the end of their respective takedowns. Our data also show a high rate of complications, overall 32.1%. However, data showed that the overall risk of serious complications was low, 3.6%, particularly if local wound complications were not taken into consideration. In the National Nosocomial Infection Surveillance, risk factors for the development of a SSI include ASA grade, contaminated or dirty wounds, and the duration of procedure [16
]. Other risk factors described include increased BMI, emergency surgery, surgeries involved, and blood loss [11
]. To date, there are relatively few studies examining the influence of a patient's perioperative nutritional status on the development of SSI and overall complications following stoma take-down.
The type of ostomy (loop vs. end) depends primarily on functional purpose and the type of procedure performed. Loop-type ostomies are generally used as proximal diversions for protection of distal anastomoses, which are usually performed in an elective surgery setting. End-type ostomies are used after bowel resection in order to fully avoid the risks of performing a primary anastomosis, usually in the setting of emergent surgery [17
]. Takedown of an end-type ostomy showed a long operation time, a larger amount of intraoperative bleeding and a high rate of complications in our data. Based on this finding, the type of ostomy should be carefully selected at the time of the initial surgery. Furthermore, the literature notes several small studies that reported fewer ostomy-related complications after a loop ileostomy. Loop transverse colostomies are associated with more complications, such as incisional hernias, parastomal hernias, prolapses, and fecal fistulas than loop ileostomies [20
In patients with malnutrition, perioperative nutritional supplementation has been used to decrease the risk of postoperative anastomotic leakage and infectious complications [21
]. Even in patients without malnutrition, some risk of SSI exists in a clean-contaminated surgical procedure, such as colorectal surgery [22
]. Horie et al. [23
] reported that administration of preoperative 5-day oral immunonutrition of the IMPACT Japanese version (750 mL/day) to colorectal patients without malnutrition was associated with a high compliance and effective prevention of SSI. In their data, total protein did not show a significant increase in the immunonutrition group. However, the mean albumin level at 3 days after surgery was significantly higher for the immunonutrition group than for the control group. Our data show that temporary ostomies did not result in serious malnutrition. However, downgrading of BMI shift during the observation period was associated with a higher rate of complications. Of particular interest, a postoperative shift in the serum albumin concentration (≥1.3 mg/dL decrease) was a significant predictor of susceptibility to postoperative complications. In some literature, albumin is the most commonly used indicator of a patient's nutritional status [10
]. In acute illness, there is a reduction due to alterations in hepatic metabolism and loss of albumin into the interstitium. Serum albumin is a reliable and reproducible predictor of surgical risk and has a close correlation with the degree of malnutrition [24
]. In this study, there was a different point compared with these reports. A significant postoperative decrease in the serum albumin concentration was more reflective of complications than preoperative concentrations. While in preoperative nutritional assessment, there was no difference between ostomy take-downs because it did not always allow patients with ostomies to completely recover and regain their fundamental premorbid status, which would increase their chance of a better outcome [25
]. For example, reoperations in patients after sepsis and multiple laparotomies are technically demanding due to the development of multiple firm adhesions and sometimes even a "frozen" abdomen, which in turn may lead to a higher rate of complications [26
]. Fundamentally, recovered patients could show tolerance against this stressful challenge while potentially, malnutritious patients with ostomies could be readily fragile, possibly resulting in a larger drop in the shift of albumin level.
Hypoalbuminemia is associated with poor surgical outcome [28
]. A decrease in albumin from 45 to 21 g/L is associated with an increase in morbidity from 10 to 65% [13
]. However, this may be attributed to perioperative fluid overload and hemodilution, these factors being associated with poorer outcomes [30
]. Our study has highlighted a postoperative decrease in albumin as a risk factor for SSI and overall complications. The multivariate analysis showed that a postoperative decrease of <1.3 increased the risk of SSI and overall complications by 7.6 and 5.3 fold, respectively. Some literature on SSI reported that hypoalbuminemia was associated with poor tissue healing, impaired collagen synthesis and granuloma formation in surgical wounds and that those factors caused delayed healing and increased dead space in wounds [31
]. Also, hypoalbuminemia is associated with dysfunction of innate immune response and causes impairment of macrophage activation. Combined, these factors could promote the development of SSI and infectious complications in patients with a postsurgically severe hypoalbuminemic status.
In conclusion, a postoperatively significant decrease in the serum albumin concentration is an independent risk factor for the development of overall complications, particularly SSI. Surgeons should be aware of the risk of potential malnutrition in patients with an ostomy, and when the postoperative decrease of albumin is intense, they should manage the patient with caution. While ostomies may not essentially result in serious malnutrition, marked weight loss such as BMI downgrading may be associated with the development of complications. In this study, a postoperative significant decrease in the serum albumin concentration was the single most reliable predictor for SSI and was available as one of the risk factors for predicting several postoperative complications.