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Fujii Y, Asai H, Uehara S, Kato A, Watanabe K, Suzuki T, Ushigome H, Takahashi H, Matsuo Y, Takiguchi S. A novel technique for the construction of an end ileostomy to prevent stoma outlet obstruction after rectal resection and total colectomy: a single-center retrospective study. Surg Today 2025; 55:705-715. [PMID: 39643755 DOI: 10.1007/s00595-024-02956-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 09/24/2024] [Indexed: 12/09/2024]
Abstract
PURPOSE Stoma outlet obstruction (SOO) is an early postoperative complication of rectal cancer. We devised a novel surgical technique: end-ileostomy, to reduce SOO. Here, we describe the surgical technique used for constructing an end ileostomy and assess its impact on SOO. METHODS The subjects of this retrospective study were 78 patients who underwent low anterior resection or total colectomy with a defunctioning ileostomy (DI) between 2018 and 2022. The surgical procedure for end ileostomy can be summarized as follows: First, the ileum was separated using a linear stapler, approximately 30 cm from the Bauhin valve; then the opposite sides of the mesentery of the oral and anal ilea were sutured; and finally, end ileostomy was performed using standard techniques. End and loop ileostomies were performed in 34 and 44 patients, respectively. We assessed the independent risk factors for SOO. RESULTS SOO occurred in 12 patients (15.3%): 1 (2.9%) with an end ileostomy and 11 (25%) with a loop ileostomy. Multivariate analysis identified loop ileostomy as an independent risk factor for SOO (p = 0.037). CONCLUSIONS End ileostomy construction is a useful and safe technique for reducing the incidence of SOO in defunctioning ileostomies following rectal resection.
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Affiliation(s)
- Yoshiaki Fujii
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Hiroyuki Asai
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Shuhei Uehara
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Akira Kato
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Kaori Watanabe
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Takuya Suzuki
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Hajime Ushigome
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Hiroki Takahashi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan.
| | - Yoichi Matsuo
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Shuji Takiguchi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
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Miyo M, Uemura M, Ozato Y, Nishimura J, Nakata K, Suzuki Y, Kagawa Y, Hata T, Munakata K, Tei M, Sawada G, Yoshioka S, Takahashi Y, Oba K, Hata T, Ogino T, Miyoshi N, Yamamoto H, Murata K, Doki Y, Eguchi H. Influence of the rotation of the diverting loop ileostomy in rectal cancer surgery on small-bowel obstruction: A multicenter prospective study conducted by the Clinical Study Group of Osaka University, Colorectal Group. Surgery 2025; 178:108874. [PMID: 39516112 DOI: 10.1016/j.surg.2024.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 09/11/2024] [Accepted: 09/16/2024] [Indexed: 11/16/2024]
Abstract
AIMS Whether rotation of a diverting loop ileostomy during rectal cancer surgery, for reducing the catastrophic effect of an anastomotic leakage, affects the incidence of small-bowel obstruction has not been fully investigated. The purpose of this study is to explore whether technical maneuvers in diverting loop ileostomy creation, including its rotation, are associated with increased incidence of small-bowel obstruction in rectal tumor surgery. METHODS This multicenter prospective study was conducted by the Clinical Study Group of Osaka University, which comprises 24 major institutions. Patients with rectal adenocarcinoma scheduled for laparoscopic/robotic low anterior resection or intersphincteric resection with a diverting loop ileostomy were included. A total of 451 patients were prospectively enrolled between July 2015 and April 2021. The primary endpoint was the relevance of loop ileostomy rotation to the incidence of small-bowel obstruction; the secondary endpoints included the origin of the small-bowel obstruction and length of hospital stay. RESULTS Small-bowel obstruction was observed in 10.8% in the nonrotated group and 12.3% in the rotated group, with no significant difference (P > .99). The only risk factor identified for small-bowel obstruction was distance from the ileocecal valve, with a significant difference in 16 patients (7.3%) with a distance of ≤30 cm and 16 patients (15.4%) in a distance of >30 cm (P = .028). CONCLUSION Rotation of the diverting loop ileostomy had no significant effect on the incidence of small-bowel obstruction.
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Affiliation(s)
- Masaaki Miyo
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Mamoru Uemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan.
| | - Yuki Ozato
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Junichi Nishimura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Ken Nakata
- Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Yozo Suzuki
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Yoshinori Kagawa
- Department of Gastroenterological Surgery, Osaka General Medical Center, Osaka, Japan
| | - Taishi Hata
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Koji Munakata
- Department of Gastroentrological Surgery, Ikeda City Hospital, Ikeda, Japan
| | - Mitsuyoshi Tei
- Department of Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Genta Sawada
- Department of Surgery, Itami City Hospital, Itami, Japan
| | | | - Yusuke Takahashi
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Koji Oba
- Department of Biostatistics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hata
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Takayuki Ogino
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Norikatsu Miyoshi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kohei Murata
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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Ihara K, Nakamura T, Takayanagi M, Fujita J, Maeda Y, Nishi Y, Shibuya N, Hachiya H, Ishizuka M, Tominaga K, Kojima K, Irisawa A. Risk Factors for Stoma Outlet Obstruction after Proctocolectomy for Ulcerative Colitis. J Anus Rectum Colon 2024; 8:18-23. [PMID: 38313747 PMCID: PMC10831979 DOI: 10.23922/jarc.2023-018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/19/2023] [Indexed: 02/06/2024] Open
Abstract
Objectives Stoma outlet obstruction (SOO) occurs with an incidence of approximately 40% after proctocolectomy for Ulcerative colitis (UC) with diverting ileostomy. This study aimed to identify the risk factors for SOO after proctocolectomy with diverting ileostomy for patients with UC. Methods We reviewed the data of 68 patients with UC who underwent proctocolectomy and diverting ileostomy between April 2006 and September 2021. These cases were analyzed on the basis of clinicopathological and anatomical factors. SOO was defined as small bowel obstruction displaying symptoms of intestinal obstruction, such as abdominal distention, abdominal pain, insertion of a tube through the stoma. Results The study included 38 (56%) men and 30 (44%) women with a median age of 42 years (range, 21-80). SOO categorized as at least Clavien-Dindo grade II occurred in 11 (16%) patients. Six patients required earlier stoma closure than scheduled. Compared with patients without SOO, patients with SOO had a significantly higher total steroid dose from the onset of UC to surgery (p = 0.02), a small amount of intraabdominal fat (p = 0.04), and a higher rate of laparoscopic surgery (p < 0.01). Conclusions A high preoperative steroid dose, a small amount of intraabdominal fat and laparoscopic surgery were identified as risk factors for SOO. Early detection and treatment for SOO are important for patients at risk.
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Affiliation(s)
- Keisuke Ihara
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Takatoshi Nakamura
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Masashi Takayanagi
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Junki Fujita
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Yasunori Maeda
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Yusuke Nishi
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
| | - Norisuke Shibuya
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
| | - Hiroyuki Hachiya
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
| | - Mitsuru Ishizuka
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
| | - Keiichi Tominaga
- Department of Gastroenterology, Dokkyo Medical University, Shimotsuga, Japan
| | - Kazuyuki Kojima
- Department of Surgical Oncology, Dokkyo Medical University, Shimotsuga, Japan
| | - Atsushi Irisawa
- Center for Colorectal Surgery, Dokkyo Medical University Hospital, Shimotsuga, Japan
- Department of Gastroenterology, Dokkyo Medical University, Shimotsuga, Japan
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Tsujinaka S, Suzuki H, Miura T, Sato Y, Murata H, Endo Y, Hoshi K, Sato Y, Shibata C. Diagnosis, Treatment, and Prevention of Ileostomy Complications: An Updated Review. Cureus 2023; 15:e34289. [PMID: 36721712 PMCID: PMC9883118 DOI: 10.7759/cureus.34289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 01/30/2023] Open
Abstract
An ileostomy is associated with multiple complications that may frequently or persistently affect the life of ostomates. All healthcare professionals should have knowledge of the diagnosis, treatment, and prevention of ileostomy complications. Peristomal dermatitis is caused by watery and highly alkaline effluent. Skin protective products are typically used for local treatment. Ischemia/necrosis occurs due to insufficient arterial blood supply. Retraction is seen in patients with a bulky mesentery and occurs following ischemia. Convex stoma appliances can be used for skin protection against fecal leakage. Small bowel obstruction (SBO) is common and occurs only at the stoma site. Trans-stomal decompression is most effective in these cases. High output stoma (HOS) is defined as a condition when the output exceeds 1,000- 2,000 ml/day, lasting for one to three days. Treatment includes intravenous fluid and electrolyte resuscitation followed by restriction of hypotonic fluid and the use of antimotility (and antisecretory) drugs. Stomal prolapse is a full-thickness protrusion of an inverted bowel. Manual reduction is attempted initially, whereas emergency bowel resection may be needed for incarcerated cases. A parastomal hernia (PSH) is an incisional hernia of the stoma site. Surgery is considered in cases of incarceration, but most cases are manageable with non-surgical treatment.
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Affiliation(s)
- Shingo Tsujinaka
- Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai, JPN
| | - Hideyuki Suzuki
- Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai, JPN
| | - Tomoya Miura
- Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai, JPN
| | - Yoshihiro Sato
- Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai, JPN
| | - Hiroko Murata
- Nursing, Tohoku Medical and Pharmaceutical University Hospital, Sendai, JPN
| | - Yasue Endo
- Nursing, Tohoku Medical and Pharmaceutical University Hospital, Sendai, JPN
| | - Kyoko Hoshi
- Nursing, Tohoku Medical and Pharmaceutical University Hospital, Sendai, JPN
| | - Yoshie Sato
- Nursing, Tohoku Medical and Pharmaceutical University Hospital, Sendai, JPN
| | - Chikashi Shibata
- Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai, JPN
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Tsujinaka S, Suzuki H, Miura T, Sato Y, Shibata C. Obstructive and secretory complications of diverting ileostomy. World J Gastroenterol 2022; 28:6732-6742. [PMID: 36620340 PMCID: PMC9813931 DOI: 10.3748/wjg.v28.i47.6732] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/04/2022] [Accepted: 11/25/2022] [Indexed: 12/19/2022] Open
Abstract
This review aimed to highlight the etiology, diagnosis, treatment, and prevention of obstructive and secretory complications associated with diverting ileostomy (DI). Obstructive complications at the stoma site are termed stoma outlet obstruction (SOO) or stoma-related obstruction (SRO). The incidence of SOO/SRO is 5.4%-27.3%, and the risk factors are multifactorial; however, the configuration of the stoma limb and the thickness of the rectus abdominis muscle (RAM) may be of particular concern. Trans-stomal tube decompression is initially attempted with a success rate of 33%-86%. A thick RAM may carry the risk of recurrence. Surgical refinement, including a wider incision of the anterior sheath and adequate stoma limb length, avoids tension and immobility and may decrease SOO/SRO. Secretory complications of DI are termed high output stoma (HOS). Persistent HOS lead to water and sodium depletion, and secondary hyperaldosteronism, resulting in electrolyte imbalances, such as hypomagnesemia. The incidence of HOS is 14%-24%, with an output of 1000-2000 mL/d lasting up to three days. Treatment of HOS is commenced after excluding postoperative complications or enteritis and includes fluid intake restriction, antimotility and antisecretory drug therapies, and magnesium supplementation. Intensive monitoring and surveillance programs have been successful in decreasing readmissions for dehydration.
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Affiliation(s)
- Shingo Tsujinaka
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
| | - Hideyuki Suzuki
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
| | - Tomoya Miura
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
| | - Yoshihiro Sato
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
| | - Chikashi Shibata
- Department of Gastroenterological Surgery, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Miyagi, Japan
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Takehara Y, Nakagawa M, Kobayashi H, Kakisako K, Takano Y, Seki J, Shimada S, Nakahara K, Mukai S, Enami Y, Sawada N, Ishida F, Kudo SE. A technique for constructing diverting loop ileostomy to prevent outlet obstruction after rectal resection and total colectomy: a retrospective single-center study. Surg Today 2022; 52:587-594. [PMID: 34689284 PMCID: PMC8948144 DOI: 10.1007/s00595-021-02381-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/08/2021] [Indexed: 11/12/2022]
Abstract
PURPOSE Preventing outlet obstruction associated with a diverting stoma is important. Previously, we constructed a diverting loop ileostomy with the proximal limb of the small intestine on the caudal side, namely the oral inferior (OI) method. However, to address the issue of twisting and stenosis of the small intestine, we recently constructed a diverting loop ileostomy with the proximal limb on the cranial side, namely the oral superior (OS) method. We compared the incidence of outlet obstruction between the two methods. METHODS The subjects of this retrospective study were 133 patients who underwent colorectal resection or total colectomy, with D2 or more lymph node dissection and diverting loop ileostomy construction, between April, 2001 and December, 2018, at our hospital. The OI method was performed in 54 patients and the OS method was performed in 79 patients. RESULTS In the OS group, a history of laparotomy, neoadjuvant therapy, clinical stage III, and the use of anti-adhesion materials were more common, whereas blood loss and the incidence of outlet obstruction were significantly lower. Multivariate analysis identified only OS placement as a significant factor for reducing the incidence of outlet obstruction. CONCLUSION When constructing a diverting loop ileostomy, placing the proximal limb on the cranial side is important.
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Affiliation(s)
- Yusuke Takehara
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan.
| | - Mihoko Nakagawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Hiroaki Kobayashi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Kensuke Kakisako
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Yojiro Takano
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Junichi Seki
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Shoji Shimada
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Kenta Nakahara
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Shumpei Mukai
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Yuta Enami
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Naruhiko Sawada
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Fumio Ishida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku, Yokohama, Kanagawa Prefecture, 224-8503, Japan
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Maemoto R, Tsujinaka S, Miyakura Y, Fukuda R, Kakizawa N, Takenami T, Machida E, Kikuchi N, Kanemitsu R, Tamaki S, Ishikawa H, Rikiyama T. Risk factors and management of stoma-related obstruction after laparoscopic colorectal surgery with diverting ileostomy. Asian J Surg 2021; 44:1037-1042. [PMID: 33549406 DOI: 10.1016/j.asjsur.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/06/2021] [Accepted: 01/25/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Stoma-related obstruction (SRO) is defined as small bowel obstruction occurring around the limbs of diverting ileostomy (DI). This study was aimed to investigate the incidence, risk factors, and management of SRO after laparoscopic colorectal surgery with DI creation. METHODS This study included 155 patients who underwent laparoscopic colorectal surgery with DI creation for rectal cancer (n = 138), ulcerative colitis (UC) (n = 14), and familial adenomatous polyposis (FAP) (n = 3) between 2011 and 2019. Univariate and multivariate analyses were performed to identify the risk factors of SRO. RESULTS The incidence of SRO was 7.7% (n = 12), and it was significantly lower (P < 0.01) in patients with lower anterior resection or intersphincteric resection (4.3%) than in those with ileal-pouch anal anastomosis (IPAA) (35.2%). The multivariate analysis revealed that IPAA was independently associated with the development of SRO (P = 0.001; odds ratio, 9.4; 95% confidence interval, 2.5-35.4). Eleven of 12 patients (92%) with SRO required trans-stomal tube decompression, and 8 of those (67%) underwent early stoma closure. CONCLUSION IPAA was an independent risk factor of SRO in laparoscopic colorectal surgery with DI creation. Early stoma closure was needed in most cases of SRO.
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Affiliation(s)
- Ryo Maemoto
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shingo Tsujinaka
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
| | - Yasuyuki Miyakura
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Rintaro Fukuda
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Nao Kakizawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Tsutomu Takenami
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Erika Machida
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Nozomi Kikuchi
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Rina Kanemitsu
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Sawako Tamaki
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideki Ishikawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Kitahara T, Sato Y, Oshiro T, Matsunaga R, Nagashima M, Okazumi S. Risk factors for postoperative stoma outlet obstruction in ulcerative colitis. World J Gastrointest Surg 2020; 12:507-519. [PMID: 33437402 PMCID: PMC7769745 DOI: 10.4240/wjgs.v12.i12.507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/28/2020] [Accepted: 11/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Current medical treatments can achieve remission of ulcerative colitis (UC). Surgery is required when potent drug treatment is ineffective or when colon cancer or high-grade dysplasia develops. The standard procedure is restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, commonly performed as two- or three-stage RPC with diverting ileostomy. Postoperative stoma outlet obstruction (SOO) is frequent, but the causes are not well known.
AIM To identify the risk factors for SOO after stoma surgery in patients with UC.
METHODS We retrospectively reviewed the files of 148 consecutive UC patients who underwent surgery with stoma construction. SOO was defined as small bowel obstruction symptoms and intestinal dilatation just below the penetrating part of the stoma on computed tomography. Patients were divided into two groups: Those who developed SOO within 30 d after surgery and those who did not. Patient characteristics, intraoperative parameters, the stoma site, and rectus abdominis muscle thickness were collected. Moreover, we identified the patients who repeatedly developed SOO. Univariate and multivariate analyses were performed to identify risk factors for SOO and recurring SOO.
RESULTS Eighty-nine patients who underwent two-stage RPC were included between January 2008 and March 2020. Postoperatively, SOO occurred in 25 (16.9%) patients after a median time of 9 d (range 2-26). Compared to patients without SOO, patients with SOO had a significantly higher rate of malignant tumors or dysplasia (36.0% vs 17.1%, P = 0.032), lower total glucocorticoid dose one month before surgery (0 mg vs 0 mg, P = 0.026), higher preoperative total protein level (6.8 g/dL vs 6.3 g/dL, P = 0.048), higher rate of loop ileostomy (88.0% vs 55.3%, P = 0.002), and higher maximum stoma drainage volume (2300 mL vs 1690 mL, P = 0.004). Loop ileostomy (OR = 6.361; 95%CI 1.322–30.611; P = 0.021) and maximum stoma drainage volume (OR = 1.000; 95%CI 1.000–1.001; P = 0.015) were confirmed as independent risk factors for SOO. Eighteen patients with SOO were treated conservatively without recurrence (sSOO group). Seven (28.0%) patients repeatedly developed SOO (rSOO group) during the observation period. A significant difference was observed in the rectus abdominis muscle thickness between the two groups (sSOO 9.3 mm, rSOO 12.7 mm, P = 0.006). Muscle thickness was confirmed as an independent risk factor for recurring SOO (OR = 2.676; 95%CI 1.176-4.300; P = 0.008).
CONCLUSION In this study, high maximum stoma drainage volume and loop ileostomy are independent risk factors for SOO. Additionally, among patients with a thick rectus abdominis muscle, the risk of SOO recurrence is high.
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Affiliation(s)
- Tomoaki Kitahara
- Department of Surgery, Toho University Sakura Medical Center, Sakura 285-8741, Chiba, Japan
| | - Yu Sato
- Department of Surgery, Toho University Sakura Medical Center, Sakura 285-8741, Chiba, Japan
| | - Takashi Oshiro
- Department of Surgery, Toho University Sakura Medical Center, Sakura 285-8741, Chiba, Japan
| | - Rie Matsunaga
- Department of Surgery, Toho University Sakura Medical Center, Sakura 285-8741, Chiba, Japan
| | - Makoto Nagashima
- Department of Surgery, Toho University Sakura Medical Center, Sakura 285-8741, Chiba, Japan
| | - Shinichi Okazumi
- Department of Surgery, Toho University Sakura Medical Center, Sakura 285-8741, Chiba, Japan
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9
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Big colon surgery, little incisions: Minimally invasive techniques in emergent colon surgery. J Trauma Acute Care Surg 2020; 89:e1-e6. [PMID: 32068715 DOI: 10.1097/ta.0000000000002616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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10
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Italian guidelines for the surgical management of enteral stomas in adults. Tech Coloproctol 2019; 23:1037-1056. [DOI: 10.1007/s10151-019-02099-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
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11
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Tamura K, Matsuda K, Yokoyama S, Iwamoto H, Mizumoto Y, Murakami D, Nakamura Y, Yamaue H. Defunctioning loop ileostomy for rectal anastomoses: predictors of stoma outlet obstruction. Int J Colorectal Dis 2019; 34:1141-1145. [PMID: 31055627 DOI: 10.1007/s00384-019-03308-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Creation of defunctioning loop ileostomy is a standard procedure in laparoscopic lower rectal surgery. Stoma-related obstruction sometimes occurs, but its cause has not been fully analyzed. This study aims to assess stoma obstructive complications and clarify the risk factors of stoma-related obstructions. METHODS Two hundred and thirty consecutive patients who underwent laparoscopic rectal cancer surgery with defunctioning loop ileostomy between April 2007 and December 2017 were recruited, numbering 230. We statistically examined the frequency and risk factor of stoma outlet obstruction. RESULTS Postoperative stoma-related complications developed in 41 patients (17.8%) overall, and there was no 30-day mortality. Stoma outlet obstructions occurred in 16 patients (7.0%) during postoperative course. Thick subcutaneous fat at the stoma-marking site (vertical distance ≥ 20 mm) and body mass index (≥ 22.2) were significantly associated with the risk of stoma outlet obstruction in univariate analysis. Thick subcutaneous fat was a significant predictive factor of stoma outlet obstruction according to multivariate analysis (odds ratio 3.80). CONCLUSIONS This report investigates significant predictors of stoma outlet obstruction in laparoscopic rectal cancer surgery for the first time. In laparoscopic procedure, stoma outlet obstruction should be particularly considered in obese patients who have especially thick subcutaneous fat of the abdominal wall.
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Affiliation(s)
- Koichi Tamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Kenji Matsuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Shozo Yokoyama
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Hiromitsu Iwamoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Yuki Mizumoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Daisuke Murakami
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Yuki Nakamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan.
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12
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The application of defunctioning stomas after low anterior resection of rectal cancer. Surg Today 2018; 49:451-459. [DOI: 10.1007/s00595-018-1736-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/29/2018] [Indexed: 02/07/2023]
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13
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Elevated risk of stoma outlet obstruction following colorectal surgery in patients undergoing ileal pouch–anal anastomosis: a retrospective cohort study. Surg Today 2018; 48:1060-1067. [DOI: 10.1007/s00595-018-1698-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/01/2018] [Indexed: 12/22/2022]
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Munakata S, Ito S, Sugimoto K, Kojima Y, Goto M, Tomiki Y, Sakamoto K. Defunctioning loop ileostomy with restorative proctocolectomy for rectal cancer: Friend or foe? JOURNAL OF THE ANUS RECTUM AND COLON 2018; 1:136-140. [PMID: 31583314 PMCID: PMC6768689 DOI: 10.23922/jarc.2017-023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/01/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Temporary ileostomy is used to decrease morbidity from anastomotic leakages (ALs). However, ileostomies are associated with complications (i.e., stoma-related complications; SRCs), ileus due to stenosis, dehydration, and the need for a second operation. Here we retrospectively evaluated the impact of SRCs on the treatment of rectal cancer. METHODS We identified 180 consecutive patients who underwent curative resection for rectal cancer at Juntendo University Hospital between January 2006 and December 2014. We divided the patients into groups with and without defunctioning stoma (DS), and we compared the patient age and gender, tumor location, approach (laparotomy/laparoscopy), surgical procedure, distance of the tumor from the margin of the anus, T factor, stage, duration of postoperative hospital stay, and postoperative complications between these groups. Univariate and multivariate analyses were performed to determine the risk factors for postoperative hospital stay. RESULTS The symptomatic leakage rate in the DS group (n = 92) was not significantly different from that of the non-DS group (n = 88; p = 0.29). However, Grade ≥ 4 AL occurred significantly less frequently in the DS group (0%) than in the non-DS group (5.7%; p = 0.02). SRCs occurred in 14 DS-group patients (15.2%). The multivariate analysis demonstrated that both AL (odds ratio [OR] 9.24; confidence interval [CI] 4.91-19.4) and SRC (OR 1.84; CI 1.03-3.54) were independently predictive of short-term outcomes. CONCLUSIONS The benefit of a DS is balanced against the risk of leakage and SRCs at rectal resection. Surgeons should focus on not only the consequences of AL, but also SRC risk.
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Affiliation(s)
- Shinya Munakata
- Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Shingo Ito
- Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kiichi Sugimoto
- Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yutaka Kojima
- Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Michitoshi Goto
- Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yuichi Tomiki
- Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kazuhiro Sakamoto
- Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
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Ohira G, Miyauchi H, Hayano K, Kagaya A, Imanishi S, Tochigi T, Maruyama T, Matsubara H. Incidence and risk factor of outlet obstruction after construction of ileostomy. JOURNAL OF THE ANUS RECTUM AND COLON 2018; 2:25-30. [PMID: 31583319 PMCID: PMC6768823 DOI: 10.23922/jarc.2017-034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/18/2017] [Indexed: 11/30/2022]
Abstract
There are several reports on the usefulness of diverting ileostomy for decreasing the incidence of anastomotic leakage and the severity of pelvic peritonitis. However, a number of complications induced by ileostomy itself have also been reported, including a special condition induced by obstruction at the outlet of the stoma known as “outlet obstruction.” In this study, we examined the frequency and risk factors of this complication based on the data of ileostomy cases in our institution. Methods: One hundred and seven patients who received ileostomy creation at our department from January 2010 to December 2015 were included. The incidence of outlet obstruction and risk factors were analyzed. Results: Outlet obstruction occurred in 18 cases (16.8%). The incidence was significantly higher in total colectomy or proctocolectomy cases as well as in those with left side construction and laparoscopic surgery than in other patients in a univariate analysis. However, in a multivariate analysis, no risk factors were extracted. Conclusions: To determine the true cause of this disease, a prospective study with a large number of cases is needed. Since multiple terms are used for this condition, resulting in confusion, a consensus on the appropriate terms is also important.
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Affiliation(s)
- Gaku Ohira
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University
| | - Hideaki Miyauchi
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University
| | - Koichi Hayano
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University
| | - Akiko Kagaya
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University
| | - Shunsuke Imanishi
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University
| | - Toru Tochigi
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University
| | - Tetsuro Maruyama
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University
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Suwa K, Ushigome T, Ohtsu M, Narihiro S, Ryu S, Shimoyama Y, Okamoto T, Yanaga K. Risk Factors for Early Postoperative Small Bowel Obstruction After Anterior Resection for Rectal Cancer. World J Surg 2017; 42:233-238. [PMID: 28748420 DOI: 10.1007/s00268-017-4152-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Mizushima T, Kameyama H, Watanabe K, Kurachi K, Fukushima K, Nezu R, Uchino M, Sugita A, Futami K. Risk factors of small bowel obstruction following total proctocolectomy and ileal pouch anal anastomosis with diverting loop-ileostomy for ulcerative colitis. Ann Gastroenterol Surg 2017; 1:122-128. [PMID: 29863130 PMCID: PMC5881312 DOI: 10.1002/ags3.12017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/19/2017] [Indexed: 02/06/2023] Open
Abstract
Small bowel obstruction (SBO) often occurs after total proctocolectomy and ileal pouch anal anastomosis with diverting loop‐ileostomy for ulcerative colitis. Little is known about the association between SBO and surgical procedures for diverting loop‐ileostomy. We conducted a multicenter, retrospective questionnaire survey. Unlinkable anonymized data on ileostomy procedures and ileostomy‐related complications including SBO were collected from institutions specializing in surgery for inflammatory bowel disease. In total, 515 patients undergoing total proctocolectomy and ileal pouch anal anastomosis with loop‐ileostomy among 1022 patients with ulcerative colitis undergoing surgery during a 3‐year period between 2012 and 2014 were analyzed. Twenty‐nine patients without information on complications were excluded. Incidence of ileostomy‐related complications and factors associated with the development of small bowel obstruction were determined in 486 patients. The most common complications were parastomal dermatitis (n=169, 34.8%), SBO (n=111, 22.8%), mucocutaneous dehiscence (n=59, 12.1%), stoma prolapse (n=21, 4.3%), parastomal hernia (n=12, 2.5%), and stoma retraction (n=11, 2.3%). Incidence of small bowel obstruction was significantly higher in patients with distance from the ileal pouch to the ileostomy of less than 30 cm and in patients undergoing laparoscopic surgery. Procedures for diverting loop‐ileostomy after surgery for ulcerative colitis varied among institutions. Incidence of small bowel obstruction was high after total proctocolectomy and ileal pouch anal anastomosis with diverting loop‐ileostomy. Shorter distance between the pouch and the stoma and the laparoscopic surgery were risk factors for SBO in univariate analysis.
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Affiliation(s)
- Tsunekazu Mizushima
- Department of Therapeutics for Inflammatory Bowel Diseases Osaka University Graduate School of Medicine Suita Osaka Japan
| | - Hitoshi Kameyama
- Division of Digestive and General Surgery Niigata University Niigata Japan
| | - Kazuhiro Watanabe
- Department of Surgery Tohoku University Graduate School of Medicine Sendai Miyagi Japan
| | - Kiyotaka Kurachi
- Second Department of Surgery Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
| | - Kouhei Fukushima
- Department of Surgery Tohoku University Graduate School of Medicine Sendai Miyagi Japan
| | - Riichiro Nezu
- Department of Surgery Nishinomiya Municipal Central Hospital Nishinomiya Hyogo Japan
| | - Motoi Uchino
- Department of Inflammatory Bowel Disease Hyogo College of Medicine Nishinomiya Hyogo Japan
| | - Akira Sugita
- Inflammatory Bowel Disease Center Yokohama Municipal Citizen's Hospital Yokohama Kanagawa Japan
| | - Kitaro Futami
- Department of Surgery Fukuoka University Chikushi Hospital Chikushino Fukuoka Japan
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Kawamura J, Hasegawa S, Kawada K, Yamaguchi T, Nagayama S, Matsusue R, Nomura A, Sakai Y. Feasibility and safety of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for severe ulcerative colitis. Asian J Endosc Surg 2013; 6:271-8. [PMID: 23809786 DOI: 10.1111/ases.12046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/07/2013] [Accepted: 05/19/2013] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The laparoscopic approach is accepted as a treatment option for patients with ulcerative colitis (UC) who are otherwise in good health. However, its application for patients with severe UC remains controversial. The purpose of this study was to evaluate the feasibility of the laparoscopic approach for severe UC cases. Short- and long-term clinical outcomes after laparoscopic total proctocolectomy with ileal pouch-anal anastomosis were compared between severe and mild-to-intermediate UC patients. METHODS Cases treated between March 2002 and September 2010 were retrieved retrospectively from the database of Kyoto Medical Center and Kyoto University Hospital. Intraoperative complications and short- and long-term clinical outcomes were compared. RESULTS A total of 31 patients underwent laparoscopic total proctocolectomy with ileal pouch-anal anastomosis. A comparison of short- and long-term clinical outcomes after one- or two-stage laparoscopic ileal pouch-anal anastomosis between severe (n = 7) and mild-to-intermediate (n = 21) UC patients revealed no significant differences. The proportion of patients with restoration of intestinal continuity did not differ between the groups (severe: 86%, mild to intermediate: 95%; P = 0.69). CONCLUSION The present findings suggest that laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for severe UC patients could be a good alternative approach when performed by an experienced hand.
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Affiliation(s)
- Junichiro Kawamura
- Department of Surgery, Kyoto University, Kyoto, Japan; Department of Surgery, Shiga Medical Center for Adults, Moriyama, Japan
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Abstract
The ability to appropriately construct and care for an ostomy is crucial to good colorectal surgical practice. Enterostomal therapy is critical to the successful management of ostomies and their complications. Although associated with morbidity, a well-constructed ostomy can provide our patients with a good, durable QoL.
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Nieto T, Shaikh I, Clark J, Farrands P. Twisting of Distal Ileum Around End Ileostomy: Is It a Specific Complication After Laparoscopic Subtotal Colectomy? J Laparoendosc Adv Surg Tech A 2011; 21:161-3. [DOI: 10.1089/lap.2010.0511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tom Nieto
- Department of Surgery, Royal Sussex County Hospital, Brighton, United Kingdom
| | - Irshad Shaikh
- Department of Surgery, Queen Margaret Hospital, Dunfermline, United Kingdom
| | - Jeremy Clark
- Department of Surgery, Royal Sussex County Hospital, Brighton, United Kingdom
| | - Paul Farrands
- Department of Surgery, Royal Sussex County Hospital, Brighton, United Kingdom
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22
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Meurette G, Piffeteau T, Lehur PA. Ileostomy. SEMINARS IN COLON AND RECTAL SURGERY 2008. [DOI: 10.1053/j.scrs.2008.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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