Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy. Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Colostomy or ileostomy after colorectal anastomosis?: a randomised trial. Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision. Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial. Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial. De-functioning stomas: a prospective controlled trial comparing loop ileostomy with loop transverse colostomy. The influence of mechanical bowel preparation in elective lower colorectal surgery. Early removing gastrointestinal decompression and early oral feeding improve patients' rehabilitation after colorectostomy.
Loop ileostomy or loop transverse colostomy for temporary decompression of a left colonic anastomosis represents an important issue in abdominal surgery.
                A randomized study, comparing loop ileostomy (n = 37; group 1) or loop transverse colostomy (n = 39; group 2), was conducted. Patients were followed from construction to closure of the stoma.
                Age, weight, sex and indication for surgery were similar in both groups. After stoma construction complications were reported in nine of 37 patients in group 1 and in one of 39 in group 2 (P < 0.01), leading to postoperative death in five of 37 in group 1 and one of 39 in group 2. In the period between stoma construction and closure significant differences were observed only in prolapse rate (one of 32 group 1, 16 of 38 group 2; P < 0.01), need for temporary adaptation of clothing (eight of 32 group 1, 22 of 38 group 2; P < 0.01) and dietary guidelines (23 of 32 group 1, four of 38 group 2; P < 0.01). One patient died in group 1 and four in group 2; the deaths were not stoma related. After stoma closure eight of 29 patients in group 1 had complications and there were two deaths compared with three of 32 and no deaths in group 2.
                Both types of stoma carry a high complication rate with a considerable associated mortality rate. The interval between stoma construction and closure has substantial impact on social and economic status. Based on all three phases studied, routine use of transverse colostomy is advised if decompression of the left colon is indicated. Anastomotic leakage is a major problem in colorectal surgery particularly in low rectal cancer. The defunctioning loop ileostomy was introduced as a technique to create a manageable stoma that would divert the fecal stream from a more distal anastomosis in order to reduce the consequences of any anastomotic leakage. Therefore, the use of a defunctioning stoma has been suggested, but limited data exist to clearly determine the necessity of routine diversion. This study was designed to evaluate early morbidity, mortality and hospital stay in patients undergoing lower rectal cancer surgery concerned with or without loop ileostomy.
                This is a prospective randomized study that was performed between May 2001 and March 2008. There were 256 patients who underwent elective low anterior resection and stapler anastomosis. They were divided into two groups. Group A consisted of 120 patients who underwent straight anastomosis without ileostomy and group B consisted of 136 patients who underwent straight anastomosis with loop ileostomy. Data regarding patient demographics, underlying pathology, anastomotic problems, and ileostomy-related problems were gathered. The patients were all monitored closely after surgery for an anastomotic leak and all stoma-related complications were recorded. Inclusion criteria consisted of biopsy proven adenocarcinoma of the rectum located at < or = 5 cm above the anal verge, age > or = 22 years, and informed consent. Exclusion criteria included age more than 90 years, associated co morbid conditions Stage IV with disease spread to liver and peritoneum.
                Indications for surgery were lower rectal cancer (n=256). Mean age 55.5 years (range 22-90 years) and a male: female ratio of 1.1:1. All patients were undergoing elective surgery for lower rectal cancer. In our study 12 patients in group A developed anastomotic leak, two of them were re-explored for anastomotic leak and Hartman's colostomy was carried out. There were two deaths in Group A. In group B anastomotic leak was seen in three patients. In all three, anastomotic healing took place at a later period of time on the 18th, 20th, and 25th postoperative day respectively without any additional morbidity and mortality. Ileostomy-related problems were minor and limited to the stoma and complaints requiring stoma nurse evaluation (n=8), dehydration requiring outpatient care (n=3), bleeding at the stoma closure site (n=l). No stoma site hernias have been identified so far.
                The use of defunctioning loop ileostomy in all patients undergoing lower rectal surgery with stapler anastomosis is beneficial and safe. Defunctioning loop ileostomy use has resulted in no anastomotic leak rate and considerable low morbidity. So according to our study, we strongly recommend defunctioning loop ileostomy as a routine procedure in patients undergoing lower rectal cancer surgery. Sixty one patients were entered in a randomised trial to compare transverse loop colostomy with loop ileostomy after a colorectal anastomosis thought to be at risk of dehiscence. Radiologically proven breakdown of the colorectal anastomosis occurred in 13% of these selected patients and most frequently in the colostomy group. Ileostomies functioned earlier than colostomies (P less than 0.001) but there was no other significant difference in outcome between the groups. In 52 patients intestinal continuity was restored by excision of the stoma within a month of construction with no difference in morbidity between the two groups. A loop ileostomy, closed as soon as the colorectal anastomosis has healed, is recommended as an alternative to transverse colostomy. The aim of this study was to compare loop ileostomy and loop transverse colostomy as the preferred mode of faecal diversion following low anterior resection with total mesorectal excision for rectal cancer.
                Patients who required proximal diversion after low anterior resection with total mesorectal excision were randomized to have either a loop ileostomy or a loop transverse colostomy. Postoperative morbidity, stoma-related problems and morbidity following closure were compared.
                From April 1999 to November 2000, 42 patients had a loop ileostomy and 38 had a loop transverse colostomy constructed following low anterior resection. Postoperative intestinal obstruction and prolonged ileus occurred more commonly in patients with an ileostomy (P = 0.037). There was no difference in time to resumption of diet, length of hospital stay following stoma closure and incidence of stoma-related complications after discharge from hospital. A total of seven patients had intestinal obstruction from the time of stoma creation to stoma closure (six following ileostomy and one following colostomy; P = 0.01).
                Intestinal obstruction and ileus are more common after loop ileostomy than loop colostomy. Loop transverse colostomy should be recommended as the preferred method of proximal faecal diversion. The consequences of leakage from low colorectal or coloanal anastomoses are reduced by the use of a loop stoma to divert the faecal stream. Controversy continues as to whether loop ileostomy (LI) or loop transverse colostomy (LTC) is the optimal method of defunctioning such anastomoses.
                Patients requiring defunctioning following anterior resection and total mesorectal excision were randomized to receive either LI or LTC. Comparison was made between the groups regarding the difficulty of stoma formation and closure, the recovery after stoma closure and stoma-related complications. The minimum follow-up after stoma closure was 6 months (median 36 months).
                Between October 1995 and August 1999, 70 patients were randomized (LTC 36, LI 34) of whom 63 underwent stoma closure (LTC 31, LI 32). There were no significant differences in the difficulty of formation or closure, or in the postoperative recovery between the groups. However, there were ten complications related directly to the stoma in the LTC group: faecal fistula (one patient), prolapse (two), parastomal hernia (two) and incisional hernia during follow-up (five). None of these complications occurred in the LI group.
                In this randomized study, the frequency of herniation before or after colostomy closure supports the choice of LI as a method of defunctioning a low anastomosis. Both methods appear to provide satisfactory protection for the low anastomosis. To compare a colonic J-pouch or a side-to-end anastomosis after low-anterior resection for rectal cancer with regard to functional and surgical outcome.
                A complication after restorative rectal surgery with a straight anastomosis is low-anterior resection syndrome with a postoperatively deteriorated anorectal function. The colonic J-reservoir is sometimes used with the purpose of reducing these symptoms. An alternative method is to use a simple side-to-end anastomosis.
                One-hundred patients with rectal cancer undergoing total mesorectal excision and colo-anal anastomosis were randomized to receive either a colonic pouch or a side-to-end anastomosis using the descending colon. Surgical results and complications were recorded. Patients were followed with a functional evaluation at 6 and 12 months postoperatively.
                Fifty patients were randomized to each group. Patient characteristics in both groups were very similar regarding age, gender, tumor level, and Dukes' stages. A large proportion of the patients received short-term preoperative radiotherapy (78%). There was no significant difference in surgical outcome between the 2 techniques with respect to anastomotic height (4 cm), perioperative blood loss (500 ml), hospital stay (11 days), postoperative complications, reoperations or pelvic sepsis rates. Comparing functional results in the 2 study groups, only the ability to evacuate the bowel in <15 minutes at 6 months reached a significant difference in favor of the pouch procedure.
                The data from this study show that either a colonic J-pouch or a side-to-end anastomosis performed on the descending colon in low-anterior resection with total mesorectal excision are methods that can be used with similar expected functional and surgical results. Patients undergoing colorectal surgery who required a defunctioning stoma were randomly allocated to receive either a loop ileostomy (n = 23) or transverse loop colostomy (n = 24). Assessment was made during construction, immediately postoperatively, during the period of outpatient supervision and before and after stoma closure. The ileostomy was associated with significantly less odour than the colostomy (P less than 0.01) and required significantly less appliance changes (P less than 0.05). Furthermore eleven patients (58 per cent) with a colostomy experienced three or more problems with stoma management compared with only three patients (18 per cent) with an ileostomy (P less than 0.05). Wound infection was also significantly more common after closure of the colostomy compared with the ileostomy. Both types of stoma were demonstrated objectively to defunction the distal bowel almost completely. These results indicate that a loop ileostomy is the procedure of first choice when a stoma is needed to defunction the distal colorectum. This study evaluates the effects of mechanical bowel preparation (MBP) on anastomosis below the peritoneal verge and questions the influence of MBP on anastomotic leakage in combination with a diverting ileostomy in lower colorectal surgery.
                In a previous large multicenter randomized controlled trial MBP has shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in lower colorectal surgery with or without a diverting ileostomy remains unclear.
                This study is a subgroup analysis of a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP. Primary end point was the occurrence of anastomotic leakage and secondary endpoints were septic complications and mortality.
                Total of 449 Patients underwent a low anterior resection with a primary anastomosis below the peritoneal verge. The incidence of anastomotic leakage was 7.6% for patients who received MBP and 6.6% for patients who did not. Significant risk factors for anastomotic leakage were the American Society of Anesthesiologists-classification (P = 0.005) and male gender (P = 0.007). Of total, 48 patients received a diverting ileostomy during initial surgery; 27 patients received MBP and 21 patients did not. There were no significant differences regarding septic complications and mortality between both groups.
                MBP has no influence on the incidence of anastomotic leakage in low colorectal surgery. Furthermore, omitting MBP in combination with a diverting ileostomy has no influence on the incidence of anastomotic leakage, septic complications, and mortality rate. To evaluate the feasibility, safety, and tolerance of early removing gastrointestinal decompression and early oral feeding in the patients undergoing surgery for colorectal carcinoma.
                Three hundred and sixteen patients submitted to operations associated with colorectostomy from January 2004 to September 2005 were randomized to two groups: In experimental group (n=161), the nasogastric tube was removed after the operation from 12 to 24 h and was promised immediately oral feeding; In control group (n=155), the nasogastric tube was maintained until the passage of flatus per rectum. Variables assessed included the time to first passage of flatus, the time to first passage of stool, the time elapsed postoperative stay, and postoperative complications such as anastomotic leakage, acute dilation of stomach, wound infection and dehiscense, fever, pulmonary infection and pharyngolaryngitis.
                The median and average days to the first passage of flatus (3.0+/-0.9 vs 3.6+/-1.2, P<0.001), the first passage of stool (4.1+/-1.1 vs 4.8+/-1.4, P<0.001) and the length of postoperative stay (8.4+/-3.4 vs 9.6+/-5.0, P<0.05) were shorter in the experimental group than in the control group. The postoperative complications such as anastomotic leakage (1.24% vs 2.58%), acute dilation of stomach (1.86% vs 0.06%) and wound complications (2.48% vs 1.94%) were similar in the groups, but fever (3.73% vs 9.68%, P<0.05), pulmonary infection (0.62% vs 4.52%, P<0.05) and pharyngolaryngitis (3.11% vs 23.23%, P<0.001) were much more in the control group than in the experimental group.
                The present study shows that application of gastrointestinal decompression after colorectostomy can not effectively reduce postoperative complications. On the contrary, it may increase the incidence rate of fever, pharyngolaryngitis and pulmonary infection. These strategies of early removing gastrointestinal decompression and early oral feeding in the patients undergoing colorectostomy are feasible and safe and associated with reduced postoperative discomfort and can accelerate the return of bowel function and improve rehabilitation.
The best available evidence for decompression of colorectal anastomosis, either use of loop ileostomy or loop colostomy, could not be clarified from this review. So far, the results in terms of occurrence of postoperative stoma prolapse support the choice of loop ileostomy as a technique for fecal diversion for colorectal anastomosis, but large scale RCT's is needed to verify this.