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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 2  |  Page : 136-139

Comparative study of loop ileostomy vs loop transverse colostomy as a covering stoma after low anterior resection for rectal cancer


Department of Surgical Oncology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission23-Oct-2019
Date of Decision02-Jan-2020
Date of Acceptance27-Jan-2020
Date of Web Publication24-Jul-2020

Correspondence Address:
MD, MRCS Ayman M Abdulmohaymen
9090 Street 9, Almokatam, Cairo 11571
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_145_19

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  Abstract 


Background After low anterior resection for rectal cancer, construction of a stoma for coverage of anastomosis is sometimes mandatory. Although loop ileostomy may be easily constructed and easily closed, it may have some complications related to fluid and electrolyte imbalance, especially in comorbid vulnerable patients.
Aim This study aims to compare loop ileostomy and loop transverse colostomy as a covering stoma technique after resection of middle and low rectal cancer.
Patients and methods This double-blind prospective study was done in a single institute on 70 patients diagnosed as having primary middle and low rectal cancer who underwent low anterior resection and ultra-low anterior resection and covering stoma was decided. Cases underwent surgery between October 2016 and January 2019. Patients were allocated to group A (ileostomy group) and group B (colostomy group).
Results A total of 33 patients were in group A (ileostomy group) and 37 patients were in group B (colostomy group). Significantly higher rates of stoma-related complications were encountered in the loop ileostomy group (75.6(%than in loop transverse colostomy group (43.2%). Peristomal dermatitis was the highest occurring complication. Moreover, significantly higher rates of stoma reversal-related complications were encountered in the loop ileostomy group (45.4(%than in loop transverse colostomy group (13.5%). Diarrhea was the highest occurring complication.
Conclusion Regarding stoma-related complications and stoma reversal perioperative complications, loop transverse colostomy was significantly better than loop ileostomy.

Keywords: covering stoma, loop colostomy, loop ileostomy, low anterior resection, rectal cancer


How to cite this article:
Abdulmohaymen AM. Comparative study of loop ileostomy vs loop transverse colostomy as a covering stoma after low anterior resection for rectal cancer. Al-Azhar Assiut Med J 2020;18:136-9

How to cite this URL:
Abdulmohaymen AM. Comparative study of loop ileostomy vs loop transverse colostomy as a covering stoma after low anterior resection for rectal cancer. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Oct 25];18:136-9. Available from: http://www.azmj.eg.net/text.asp?2020/18/2/136/290599




  Introduction Top


Rectal cancer accounts for one-third of colorectal cancer cases [1]. Usually, 2 cm free margin is acceptable distal to the tumor [2]. Some surgeons routinely perform covering stoma for low and ultra-low anterior resection. Others advocate that this extra procedure should be done only when needed [3],[4].

Whatever the indication, covering stoma is performed to guard against complications of anastomotic leakage [5],[6],[7]. Loop ileostomy and loop transverse colostomy are two available options for temporary diversion of fecal stream [8]. However, it is still controversial which procedure is more effective in diverting feces and safer for the patient at the same time [9],[10],[11].

In our study, we analyzed clinicopathological data of 70 patients with pathologically proven primary rectal cancer who underwent low anterior resection with covering loop ileostomy or loop transverse colostomy, and then we compared stoma-related complications and stoma reversal perioperative complications of both procedures.


  Patients and methods Top


This prospective double-blind single-center study was done in a single institute. It was done on 70 patients of pathologically proven primary rectal cancer with decided covering stoma between October 2016 and January 2019.

Inclusion criteria included first, distance from anal verge less than 15 cm; second, radical surgery was possible (no metastasis and no locally advanced tumor); and third, covering stoma was created at the time of tumor resection.

Exclusion criteria included first, patients who did not undergo stoma closure owing to recurrence, bad general condition, or anastomotic complications (stenosis or fistula) and second, patients presented for the first time by complication of tumor (fistula, hemorrhage, obstruction, or perforation).

The study was approved by Local Ethical Committee at Al-Azhar University, and informed consents were taken from participants.

Workup

All surgical procedures were done in the Surgical Oncology Unit by experienced surgeons having at least 10 years of experience in colorectal surgery and stoma creation and closure. Covering stoma was created at the time of tumor resection. Before stoma closure, thorough clinical evaluation, including history taking, and thorough clinical examination with computed tomography of chest abdomen and pelvis with intravenous and oral contrast were done for all patients. Moreover, sphincter function was assessed in ultra-low anterior resection cases before stoma reversal.

Patient evaluation

Demographic criteria and baseline variables, American Society of Anesthesiologist status, surgical modality, stoma complications, stoma reversal perioperative complication, and post stoma reversal hospital stay were assessed and compared between two groups of our study.

Statistical analysis

Recorded data were analyzed using the Statistical Package for the Social Sciences, version 20.0 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage. Independent-samples t-test of significance was used when comparing between two means. χ2-test of significance was used to compare proportions between two qualitative parameters. The confidence interval was set to 95% and the margin of error accepted was set to 5%. So, the P value less than 0.05 was considered significant.


  Results Top


Demographic and general features

The demographic and baseline characteristics of the study sample are shown in [Table 1]. There are no significantly different measures in demographic and general characteristics between the two study groups.
Table 1 Demographic and baseline characteristics

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Stoma-related complications

A comparison of stoma-related complications in each group is demonstrated in [Table 2]. It shows that 25 (75.8%) patients of the loop ileostomy group had stoma-related complications. Among them, three patients had two or more complications. Nevertheless, 16 (43.2%) patients of the transverse colostomy group had complications. Among them, two patients had two or more complications. The loop ileostomy group had significantly higher rates of complications than transverse colostomy group. The most frequent complication was dermatitis followed by parastomal hernia.
Table 2 Stoma-related complications

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Stoma reversal-related complications

A comparison between the two study groups regarding stoma reversal-related complication is shown in [Table 3]. Through the table, it is clearly apparent that loop ileostomy group had significantly higher rate of stoma reversal-related complications than the transverse colostomy group. The most frequent complication was diarrhea followed by intestinal obstruction.
Table 3 Stoma reversal-related complications

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  Discussion Top


Covering stoma remains a common surgical procedure to minimize the complications of anastomotic leakage especially in high-risk cases owing to patient factors or anastomotic site [12]. Although some authors state that covering stoma is mandatory, we only perform it when the patient has major comorbidity or anastomosis is done seven centimeters or less from the anal verge.

Loop ileostomy and loop transverse colostomy are accepted modalities for covering stoma. However, it remains controversial which is better and safer for the patient [13],[14].

This prospective double-blind study of 70 patients with rectal cancer who underwent anterior resection with covering stoma showed that loop ileostomy as a covering stoma was associated with a significantly higher rates of stoma-related complications and stoma reversal complications than loop transverse colostomy. In other words, ileostomy vs transverse colostomy was a significant independent risk factor for stoma-related complications and stoma reversal perioperative complications.

Some authors concluded that loop ileostomy had fewer stoma-related complications and fewer stoma reversal associated complications, including wound infection and incisional hernia [15],[16],[17]. However, other authors showed that stoma-related complications were higher with loop ileostomy such as peristomal dermatitis and electrolyte and fluid imbalance [18],[19]. Our findings indicate that loop transverse colostomy is a much safer procedure when compared with loop ileostomy.

In our study, there was a significantly higher rate of dermatitis in loop ileostomy group. This can be explained by the watery irritant discharge of the ileal contents through Loop ileostomy compared with the more formed or semi-formed content with less irritating nature in the transverse colostomy owing to absorption of large amount of water in the colon. Moreover, much more digestive enzymes are found in ileal contents when compared with colonic contents.One of the common stoma complications is parastomal hernia. It is seen in ∼39% patient with loop transverse colostomy compared with 6% in loop ileostomy [20]. However, incidence may be up to 76% by computed tomography scan [21]. There is a wide variation of incidence of this complication. This may be attributed to differences in technique, definition of parastomal hernia, and procedure done. On the contrary, in our study, the rate of parastomal hernia in loop ileostomy group was 13% compared with 11% in transverse colostomy group.

Our study had several limitations. First of all, the sample size was small. Second, the study was carried out in a single institute. Wider-based nationwide studies with larger sample size may be needed to validate the results. In conclusion, our study demonstrated that loop transverse colostomy was significantly safer than loop ileostomy regarding stoma-related complications and stoma reversal-related complications.


  Conclusion Top


Despite the abovementioned limitations, we found that loop transverse colostomy was significantly better than loop ileostomy regarding stoma-related complications and stoma reversal perioperative complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Tamas K, Walenkamp AM, de Vries EG, van Vugt MA, Beets-Tan RG, van Etten B et al. Rectal and colon cancer: Not just a different anatomic site. Cancer Treat Rev 2015; 41:671–679.  Back to cited text no. 1
    
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Bordeianou L, Maguire LH, Alavi K, Sudan R, Wise PE, Kaiser AM. Sphinctersparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results. J Gastrointest Surg 2014; 18:1358–1372.  Back to cited text no. 3
    
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Jung SH, Yu CS, Choi PW, Kim DD, Park IJ, Kim HC, Kim JC. Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum 2008; 51:902–908.  Back to cited text no. 4
    
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Bertelsen CA, Andreasen AH, Jorgensen T, Harling H. Anastomotic leakage after curative anterior resection for rectal cancer: short and long-term outcome. Colorectal Dis 2010; 12:e76–e81.  Back to cited text no. 11
    
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Anderin K, Gustafsson UO, Thorell A, Jonas Nygren. The effect of diverting stoma on long-term morbidity and risk for permanent stoma after low anterior resection for rectal cancer. Eur J Surg Oncol 2016; 42:788–793.  Back to cited text no. 12
    
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McArdle CS, McMillan DC, Hole DJ. Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer. Br J Surg 2005; 92:1150–1154.  Back to cited text no. 13
    
14.
Kim MJ, Kim YS, Park SC, Sohn DK, Kim DY, Chang HJ, Oh JH. Risk factors for permanent stoma after rectal cancer surgery with temporary ileostomy. Surgery 2016; 159:721–727.  Back to cited text no. 14
    
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Gu WL, Wu SW. Meta-analysis of defunctioning stoma in low anterior resection with total mesorectal excision for rectal cancer: evidence based on thirteen studies. World J Surg Oncol 2015; 13:9.  Back to cited text no. 15
    
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Law WL, Choi HK, Lee YM, Ho JW, Seto CL. Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy. J Gastrointest Surg 2007; 11:8–15.  Back to cited text no. 16
    
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Govaert JA, Fiocco M, van Dijk WA, Scheffer AC, de Graaf EJ, Tollenaar RA, Wouters MW. Costs of complications after colorectal cancer surgery in the Netherlands: Building the business case for hospitals. Eur J Surg Oncol 2015; 41:1059–1067.  Back to cited text no. 17
    
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Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 2010; 147:339–351.  Back to cited text no. 18
    
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Hanna MH, Vinci A, Pigazzi A. Diverting ileostomy in colorectal surgery: when is it necessary?. Langenbecks Arch Surg 2015; 400:145–152.  Back to cited text no. 19
    
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Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg 2003; 90:784–793.  Back to cited text no. 20
    
21.
Aquina CT, Iannuzzi JC, Probst CP, Kelly KN, Noyes K, Fleming FJ, Monson JR. Parastomal hernia: a growing problem with new solutions. Dig Surg 2014; 31:366–376.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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