Page 16 - Tina van Loon
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Chapter 1


              randomized  controlled  trials  are  often  ended  prematurely  due  to  the  objective
              difficulties in enrolling patients in the emergency setting.

              Stomas  are  not  only  used  in  emergency  colorectal  surgery  for  benign  disorders,
              they are also widely accepted and propagated in elective colorectal cancer surgery.
              Up  to  35%  of  the  Dutch  elderly  patients  still  receive  an  ostomy  after  colorectal
              cancer  surgery.  In  chapter  3  we  focus  on  the  postoperative  results  and  survival
              after  left‐sided  colon  cancer  and  proximal  rectal  cancer  surgery  in  the  elderly
              patient, comparing the outcomes of patients with a primary anastomosis compared
              to  those  with  an  end‐ostomy.  We  explored  in  a  nation‐wide  population‐based
              study  the  non‐inferiority  of  a  primary  anastomosis  and  whether  differences  in
              survival outcomes could be observed in stoma patients as compared to those with
              a primary anastomosis. Another well‐known entity is the deviating stoma (DS), in
              an  effort  to  reduce  the  anastomotic  leakage  related  postoperative  morbidity  in
              patients  after  elective  rectal  cancer  surgery.  Our  benchmark  analysis  showed
              unacceptably  high  rates  of  postoperative  morbidity  and  complications  in  new
              ileostomy patients. This observation combined with the growing body of evidence
              about the disadvantages of ileostomies has led to a paradigm shift in our use of DS
              from  ‘diversion  per  protocol’  to  ‘highly  selective  diversion’  in  our  hospital.  This
              policy is evaluated in chapter 4.


              Part II ‐ Effectiveness of pathways in new stoma patients
              The care of patients with a stoma can be perceived both as an art and a science, as
              many  of  the  commonly  accepted  interventions  in  stoma  care  are  based  on
              empirical evidence. However, the merits of clinical pathways have been reported
              before. The emphasis of this part of the thesis lies on the significant effects of small
              and easily implementable changes in our daily practice in the form of pathways,
              reducing  morbidity  and  possible  health  care  costs  in  patients  with  a  stoma.  In
              chapter 5 we evaluate the efficacy and durability of an ileostomy pathway in an
              effort  to  reduce  readmission  rates  for  dehydration  in  new  ileostomy  patients.
              Chapter 6 evaluates the effects of an easy in‐hospital educational stoma pathway.




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