Comparison of Loop Ileostomy and Loop Colostomy as Defunctioning Stoma in Low Rectal Cancer Surgery NCI Experience

Kasr El Aini Journal of Surgery VOL., 12, NO 1 January 2011 75 Comparison of Loop Ileostomy and Loop Colostomy as Defunctioning Stoma in Low Rectal Cancer Surgery NCI Experience Ahmed Abbas, MD MRCS General Surgery Department, Cairo University ABSTRACT The present study was conducted to compare the outcomes following ileostomy and colostomy for defunctioning distal colorectal anastmosis in low rectal cancer surgery. From June 2004 to May 2009, 225 patient underwent protecting stoma during rectal cancer surgery 125 patients in the loop ileostomy group and 100 patients in the loop transverse colostomy group. Stoma related complications and perioperative morbidities after stoma closure were analyzed retrospectively. Outcomes analyzed were: 1.related mortalities; 2. Wound infection; 3.Stoma prolapse and parastomal herniation; 4. Stoma retraction and stenosis. 5.Necrosis; 6. Skin irritation; 7. Postoperative paralytic ileus; 8. Reoperation; 11. Incisional hernia; 12. Postoperative bowel obstruction and leakage. Morbidties following stoma construction and stoma closure were higher in the loop colostomy group than loop ileostomy group (29 % versus 13.6% and 21% versus 13.6 % ). however, these were not statistically significant except for stoma prolapse and parastomal herniation. The outcomes reported were not statistically or clinically significant except for stoma prolapse and parastomal herniation. Key words: Ileostomy - Colostomy- Colorectal surgery. INTRODUCTION The management of mid and low rectal cancer has changed dramatically from more extirpative surgery in the form of abdominoperineal resection to sphincter saving procedures. Low anterior resection has become the procedure of choice for tumors located in the mid and low rectum (1). The advances in rectal cancer surgery in areas such as stapling techniques, preoperative chemotherapy, total mesorectal excision and shorter distal resection margins has increased the sphincter preservation rate. The need to perform total mesorectal excision for all mid and low rectal tumors entails carrying out low colorectal and coloanal anastomosis close to the pelvic floor that may contribute to an increased risk of anastmotic leakage (2). The reported clinical anastmotic leakage rate after sphincter saving resection varies from 3 to 20% (3). To decrease the mortality and morbidity after low rectal anastomosis, temporary stoma is recommended (4). Prospective MATERIAL & METHODS From June 2004 to May 2009, 225 patients multicentric studies have shown that a protective stoma reduces the rate of anastmotic leakage requiring surgical intervention and decreases the mortality after LAR (5). The choice of defunctioning stoma is an area of debate. Based on the safety of loop ileostomy in an ileoanal pouch anastmosis, some authors have proposed loop ileostomy as an alternative to loop colostomy to protect low rectal anastmosis (6). Several studies have compared the two procedures but conclusion varied in favour of either loop ileostomy or loop colostomy (7). the present retrospective analysis aimed to compare loop ileostomy and loop colostomy when used to defunction distal rectal anastmosis after elective rectal cancer surgeryunderwent protecting stoma during rectal cancer surgery. The indications to perform stoma were low and ultralow LAR where the anastomosis is situated 5 cm from the anal verge, old patients with co morbidities, and when the surgeon is not happy with the anastomosis because of doubtful blood supply, anastomotic tension or non air tight anastomosis. During the first two years,most of the stoma done were loop colostomy. but during latter 3 years, loop ileostomy was more frequently done. The two groups were done by the same surgical teams with same standardized surgical procedures. None of the patients

Kasr El Aini Journal of Surgery VOL., 12, NO 1 January 2011 76 received neoadjuvant chemoradiaton. One hundred and twenty five patients underwent loop ileostomy while one hundred patients underwent loop colostomy. Colorectal anastmosis all patients were seen by the stoma therapist preoperatively and the details of surgical procedure were discussed with the patients by one of the surgical team. An informed consent for the procedure including details of any possible complications was obtained from all patients. As a protocol mechanical bowel preparation and prophylactic antibiotics was offered for all patients. LAR and ultralow LAR both with total mesorectal excision were done. The least distal safety margin was 2 cm. The anastomosis was done either hand sewn or using the stappling technique according to preference of the primary surgeon. Stoma construction the site of the stoma was preoperatively marked. Rt upper quadrent for loop colostomy and Rt lower quadrent for loop ileostomy. Two cm disc of skin and subcutaneous fat were removed exposing the anterior rectus sheath. Then cruciate incision in the anterior sheath was done. After splitting of the rectus muscle, the posterior sheath and the peritoneum were incised. The opening in the abdominal wall was assessed to admit at least two fingers. Both the ileostmy and the colostomy were fashioned in a loop manner with fixation of the seromuscular layer of the bowel to the anterior sheath at the 4 angles of the cruciate incision to decrease the incidence of parastomal herniation. Spouting technique was done for loop ileostomy group but not for loop colostomy group. Assessment of the constructed stoma regular examination of the stoma and follow up was done by one of the surgical team and the stoma therapist for all patients. Detailed information was given to the patients how to manage the stoma and to report any possible stoma related complications. Follow up after stoma construction patients were discharged from the hospital when the stoma started to function well and the stoma therapist satisfied that either the patient or the relative could fit a new appliance and manage any leakage around the stoma and any skin excoriation. All patients were regularly followed up by one of the surgery team at 2 weeks, 1 month, and 3 months intervals. Closure of stoma among the ileostomy group, 115 patients underwent stoma closure while 10 patients has no stoma closure due to different reasons: 3 patients died postoperatively, 2 patients developed pelvic sepsis, 2 patients had colorectal anastmotic stricture while 3 patients are waiting for closure. For the colostomy group, 89 patients had underwent stoma closure. Two patients died postoperatively while 4 patients developed anastomotic stricture and 5 patients are waiting for closure. Prior to stoma closure, all patients had CT scan abdomen and pelvis with both oral and intravenous contrast to rule out locoregional failure and to assess the anastmosis. Mechanical bowel preparation was done for all patients prior to stoma closure. Stoma closure was done as a local procedure without laparotomy. Circular or elliptical incision was done at the mucocutaneous junction around the stoma site with complete dissection of the bowel loops from the abdominal wall freeing both the afferent and the efferent bowel loops. For ileostomy closure, 2-3 cm of the ileum was resected with the anastmosis done either end to end hand sewn or side to side using stapler. Colostomy closure was done in 2 different techniques. The first one was end to end single layer interrupted hand sewn anastomosis after refashioning both ends. The second method was done with interrupted stitches of the anterior colonic layer thus keeping the posterior layer of the loop colostomy intact. After complete closure of the stoma, rectus sheath was closed with PDS loop. Finally skin closure was done with widely spaced interrupted stitches. Follow up of the patients. Primary morbidities related to stoma construction and secondary morbidities related to stoma closure were observed and reported by the patient, stoma therapist and the surgeon. RESULTS Both loop colostomy and loop ileostomy groups were similar with respect to age, gender and tumor stage. There was no operative or postoperative mortalities related to stoma construction or stoma closure. Primary morbidity related to stoma construction was higher in loop colostomy group than loop

Kasr El Aini Journal of Surgery VOL., 12, NO 1 January 2011 77 ileostomy group (29% vs 13.6%) ( p value = 0.02 ). Parastomal hernia was the highest primary morbidity after loop colostomy construction (8%) while skin irritation was the highest primary morbidity following loop ileostomy (6.4%) whitch may be attributed to the more fluid nature of the ileostomy output. Prolapsed stoma was significantly higher in loop colostomy (7%vs 2.4%). Retraction of the stoma beyond the skin edges was observed more in loop colostomy group than ileostomy group (5% vs 0.8%) probably due to spouting technique done in ileostomy group but not in colostomy group. The only primary morbidity that was higher in the loop ileostomy group was stenosis at the anastmotic site where it complicated 3 patients (2.4%) with loop ileostomy but only 2 patients (2%) with loop colostomy patients. Two patients who developed stricture after loop ileostomy construction were managed conservatively and one patient underwent refashioning of the stoma. Secondary morbidities are reported in table (2). The total number of morbidities following stoma closure was significantly higher in loop colostomy group than loop ileostomy group (34%vs 13.3%). Wound infection represented the highest secondary morbidities after loop colostomy closure( 13.3%). Only 7.2 % in the loop ileostomy group developed wound infection. Anastomotic leakage was seen in 2 patients in the loop ileostomy group (1.8%) and only 1 (1.1% ) patient developed anastmotic leakage after loop colostomy closure. Table (1): Complications of stoma construction ( primary morbidities ) Loop colostomy Loop ileostomy N = % N = % Retraction 5 5 % 1 0.8 % Ischemia 1 1 % 0 0.0 % Prolapsed 7 7 % 3 2.4 % Parastomal hernia 8 8% 2 1.6 % Skin irritation 6% 8 6.4% Stenosis 2 2% 3 2.4 % Total no. of complications 29 29% 17 13.6% Table (2): Complications of stoma closure ( secondary morbidities ) loop colostomy loop Ileostomy N = % N = % Wound infection 12 13.3% 8 7.2 % Anastmotic leakage 1 1.1 % 2 1.8 % Obstruction 2 2.2 % 4 3.6 % Incisional hernia 4 4.4 % 5 4.5 % Total no. of complications 19 21.1 % 15 13.6 % Bowel obstruction during the early postoperative period (within 30 days of stoma closure) was seen in 4 patients (3.6%) after loop ileostomy closure. Three patients had end to end hand sewn anastmosis and one patient had side to side stapled anastmosis. One patient was managed with reoperation and revision of the anastmosis while 3 patients were managed conservatively. After loop colostomy closure, two patients (2.2%) developed bowel obstruction and one patient required surgical intervention with revision of the anastmosis and one was managed conservatively. Incisional hernia post stoma closure affected 5 patients (5.5%) after loop colostomy closure and 2 patients (0.8 %) after loop ileostomy closure. DISCUSSION The risk of intestinal anastmotic leakage is highest in low colorectal and and coloanal anastmosis (8). Defunctioning stoma in low anterior resection has been considered to decrease the leakage rate by some studies

Kasr El Aini Journal of Surgery VOL., 12, NO 1 January 2011 78 including one large retrospective multicentirc study by Peeter et al (9). In which defunctioned patients leaked in 9 % of cases compared with 24 % of those not defunctioned. A temporary stoma can be created as a loop colostomy or loop ileostomy. The latter is much more convenient for the patient because of better stoma management, fewer stoma related complications, fewer limitations on the quality of life. Few studies have compared the overall morbidity (morbidities after stoma construction and closure) of loop ileostomy and loop colostomy to defunction colorectal or coloanal anastmosis. The discordant results may be due to the heterogeneity of the indications. In a retrospective study, Rullier et al (10) compared the two procedures in a homogeneous group of patients operated on electively for rectal cancer. Sixty patients had loop colostomy and 107 patients had loop ileostomy. After stoma construction, the morbidity rate was significantly higher following loop colostomy group than loop ileostomy group (35% vs 19% ) (P value = 0.02). After stoma closure, the complications of loop colostomy closure was higher than loop ileostomy closure (34% vs 12 %) (P value = 0.004). They suggested that loop ileostomy is the best procedure for defunctioning colorectal anastmosis electively. Our study is a retrospective one comparing the morbidities of stoma construction and stoma closure between the two procedures (loop colostomy and loop colostomy) done electively for patients with low rectal cancer. One hundred patients underwent temporary loop colostomy compared to 125 patients underwent loop ileostomy. The overall complications following stoma construction was higher in loop colostomy than loop ileostomy group ( 29 % vs 13.6 %) (P value 0.02). The overall analysis of the outcomes showed that there were no mortalities related to stoma construction or stoma closure in both groups. The occurrence of parastomal hernia presented statistical significance between the 2 groups (8% vs 1.6%) and depended on the same factors as for stoma prolaps and incisional hernia. Therefore, the size of the fascial defect and wound infection may be the main predisposing factors for these complications. Reported wound infection rates after ileostomy closure ranged from 0 to 14.5 %. Closed wounds were reported to have higher infection rates than wounds left partially or completely open. Phang et al (11) reported wound infection rate of 14.2 percent in their series in which the majority of their wounds were closed primarily. Likewise, Mann et al (12). reported a wound infection rate of 14 percent in which 68 percent of their patients had primary wound closure. In our study wound infection rate was 13.3% following loop colostomy closure and 7.2% after loop ileostomy closure. All the wounds were closed primarily with wide spaced sutures. We reported incisional hernia 4 patients (4.4%) after colostomy closure and in 3 patients (2.4) after ileostomy closure. Parastomal hernia was detected in 8 patients (8%) after loop colostomy construction and in 2 patients (1.6 %) after loop ileostomy construction and these may be due to the small size of the fascial defect in the abdominal wall. The construction of loop ileostomy may increase the incidence of small bowel twisting and formation of adhesions adjacent to the stoma that may increase the chances of intestinal obstruction. In a meta analysis, Five randomized trials were included with 334 patients; one hundred sixty eight patients in the loop ileostomy group and 166 patients in the loop colostomy group. In the loop colostomy group, Güenaga et al (13) reported that stoma prolapse is statistically significant (P=0.00001) but this review did not find any significant difference in the incidence of intestinal obstruction between the 2 groups. However, several trials have reported that loop ileostomy is highly associated with this postoperative complications concerning postoperative obstruction and there is some evidence that with longer follow up, adhesions related complications might become more frequent particularly after loop ileostomy closure. In the present study, small bowel obstruction following loop ileostomy closure was observed in 4 patients (3.6%) within the first month after closure. Three cases were managed conservatively and one case required laparotomy, adhesiolysis and revision of the anastmosis. Picture of large bowel obstruction was observed in 2 patients within the first month after colostomy closure and were managed conservatively. Assessment of the ease of stoma reversal was not carried out in most of the literature. The potential difficulty of the

Kasr El Aini Journal of Surgery VOL., 12, NO 1 January 2011 79 dissection and reversal of loop ileostomy due to dense adhesions around both the afferent and the efferent limbs has previously been highlighted. However, Edwards et al (14) showed no statistical difference in the difficulty of either stoma formation or stoma reversal although there was a trend towards ileostomy reversal being considered more difficult when assessed on a subjective scale. In the current study, loop colostomy closure was subjectively easier than loop ileostomy closure probably because of less adhesions around the afferent and efferent limbs and closure only of the anterior colonic layer as the posterior layer is intact in some cases. However, further studies to compare the technical ease of stoma construction and reversal between loop colostomy and loop ileostomy are required before the superiority of either technique can be finally determined. Although most of the advances in stoma care therapy including skilled stoma therapist and specialized nurses lead to reduction in serious skin complications with better patient tolerance, spouting of loop ileostomy makes effluent collection more efficient and induces a longer time interval between appliance changes. This may give loop ileostomy some advantage over loop colostomy. Anastomotic complications after stoma closure, including pelvic abscesses and enterocutneous or colocutaneous fistula had low incidence (2-4 %) in most of literature. In a study of 120 patients who underwent loop ileostomy closure, Thalheimer et al (15) reported 3 patients suffering anastomotic leakage after ileoileostomy (2.5 percent), with subsequent peritonitis and fatal outcome in one patient and reoperation with median laparotomy in two. In the present study, anastmotic leakage complicated 1 patient (1.1%) after loop colostomy closure and 2 patients (1.6%) after loop ileostomy closure and in the 3 cases, the leakage was minor one and managed conservatively. The ideal interval between primary surgery and closure of a temporary loop ileostomy is thought to be 12 weeks. This allows the patient to recover completely from the primary colorectal surgery, gives intraabdominal adhesions enough time to become less dense, and permits inflammation and edema within the abdomen and the ileostomy and colostomy sites to resolve. Other authors, however, have not found a correlation between timing of the stoma closure and subsequent complication rate.24,25. Thus, most patients in our series who underwent adjuvant therapy were readmitted to the hospital for closure of their ileostomy after termination of chemotherapy or radiochemotherapy. CONCLUSION The present study illustrated that loop ileostomy is the preferred option to protect a distal colorectal or coloanal anastmosis for elective rectal cancer surgery in terms of complications related to stoma construction or stoma reversal. There is currently insufficient evidence to comment on the superiority of either method regarding the technical ease of stoma construction or stoma reversal. REFERENCES 1. Moran B, Heald R.: Anastomotic leakage after colorectal anastomosis. Semin Surg Oncol 2000;18:244 8. 2. Karanjia ND, Corder AP, Bearn P, Heald RJ. Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum. Br J Surg 1994; 81:1224 6 3. Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M. Risk factors for anastomotic leakage after resection of rectal cancerbr J Surg1998 ; 85-355-8 4. Dehni N, Schlegel RD, Cunningham C, Guiguet M, Tiret E, Parc R. Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and J pouch-anal anastomosis. Br J Surg. 1998;85:1114-7 5. Alberts JC, Parvaiz A, Moran BJ. Predicting risk and diminishing the consequences of anastomotic dehiscence following rectal resection. Colorectal Dis. 2003;5:478-82 6. Gooszen AW, Geelkerken RH, Hernans J, Lagaay MB, Gooszen HG. Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy. Br J Surg. 1998;85:76-9 7. Law WL, Chu KW, Choi K. Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for fecal diversion

Kasr El Aini Journal of Surgery VOL., 12, NO 1 January 2011 80 following total mesorectal excision. Br J Surg. 2002;89:704-8. 8. Matthiessen P, Hallböök O, Rutergard J, Simert G, Sjödahl R.: Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer Ann Surg. 2007;246:207-14 9. Peeters KCMJ, Tollenaar RAEM, Marijnen CAM, Kranenbarg EK, Steup WH, Wiggers T, et al. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg. 2005;92:211-6. 10. Rullier E, Le Toux N, Laurent C, et al. Loop ileostomy versus loop colostomy for defunctioning low anastomoses during rectal cancer surgery. World J Surg. 2001;25:274 278 11. Phang PT, Hain JM, Perez-Ramirez JJ, Madoff RD, Gemlo BT. Techniques and complications of ileostomy takedown. Am J Surg 1999;177:463 6. 12. Mann LJ, Stewart PJ, Goodwin RJ, Chapuis PH, BokeyEL. Complications following closure of loop ileostomy. ANZ J Surg 1991;61:493 6. 13. Güenaga K F, Silva S A, Saad SS; Saconato H, Matos D : Ileostomy or colostomy for temporary decompression of colorectal anastomosis. Systematic review and meta-analysis 1 Acta Cir. Bras. vol.23 no.3 Sمo Paulo May/June 2008 14. Edwards DP, Leppington-Clarke A, Sexton R, Heald RJ, Moran BJ. Stomarelated complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial. Br J Surg. 2001;88:360-3. 15. Thalheimer Andreas, M.D., Marco Bueter, M.D., Martin Kortuem, M.D. Morbidity of Temporary Loop Ileostomy in Patients With Colorectal Cancer Dis Colon Rectum 2006; 49: 1011 1017