This prospectivestudy compared 2 groups of a total of 40 patients undergoing diversion using either tube or loop ileostomy following colorectal resection. It was concluded that the tube ileostomy is superior to the loop ileostomy in terms of complications related to the stoma.
To the best of our knowledge, this is the first study to compare the loop ileostomy with completely diverting tube ileostomy achieved through temporary occlusion of the distal ileum using a flexible rubber strip.
The prospective design, the use of a control group, and minimizing selection bias by including consecutive patients were also other strengths of this study.
The limitations of this study were the small sample size and short follow-up period. Tube ileostomy was uncommonly reported in the literature and no standardtechnique was described. Using endotracheal tube was previously reported in some studies and it was supposed that the inflated balloon of the tube could occlude the intestinal lumen[12–15]. However, the inflated balloon could not effectively occlude the lumen for a long time, particularlyas the return of motility to the ileum results in the propulsion of its contents past the balloon. Zhou et al. presented a technique to overcome this problem. They used a single line of staples along with tube ileostomy to prevent the early flow of feces to the anastomotic region. They suggested that, after the recovery of intestinal motility, feces will enter the distal limb and will gradually disrupt the staple line; thus, recanalization will occur spontaneously.
Although recanalization of the staple line was observed in all patients, the authors stated that the fate of the staples was unclear. Another weakness of this technique is that the operating surgeon cannot decide the duration of diversion. There is a possibility that recanalization may not occur at all, or it may occur too early, resulting in ineffective diversion. For these reasons, we used an easily removable rubber strip to occlude the ileum, instead of a single row of staples, in the technique that we demonstrated in our previous pilot study, and complete diversion was achieved in all the patients. Rubber band removal time was determined based on the healing of the anastomosis line of each patient. Therefore, effective diversion can be achieved for the desired time.
In previous studies, different materials such as gastrostomy tubes, foley catheters, and endotracheal tubes were used in tube ileostomy. The internal diameters of the tubes range between 18F (6mm) and 28F (9.3mm) . These different tube types could not overcome the problem of kinking and the associated obstruction. Hua et al.  discussed that the soft and thin tubes could be easily obstructed and did not provide function. In our study, a reinforced (spiral) endotracheal cuffed tube (Fuzhou Kanglite Surgical Plastic Cement Co. Ltd, Fuzhou, China) with an inner diameter of 7.5 mm was used. Owing to its flexible spiral structure, kinking and obstruction of the tube were prevented. In addition, a spiral tube allows patients to bend the tube and hide it under their clothing, which improves patient comfort.
Previous studies reported that tube ileostomy could not prevent the development of fecal peritonitis caused by anastomotic leakage and, as a result, loop ileostomy has been preferred over tube ileostomy[12–14, 19]. In this study, fecal peritonitis did not occur in any patient.
Although a diverting loop ileostomy is intended to be temporary,large series studies reported that only two-thirds of all temporary stomas were closed, whereas more than 30% of all patients kept their stomas permanently or died before closure. In this study with relatively short follow-up, we observed that more than half of the patients continue to live with loop ileostomy. In 3 (15%) patients, loop ileostomy became permanent due to disease progression, which is consistent with the literature. Whereas no patient in the tube ileostomy group had to live with a stoma. These results suggest that tube ileostomy can reduce the risk of a permanent stoma.
There is plenty of data in the literature on the complications of loop ileostomy [21–23]. In the systemic review by Malik et al. , 18 randomized controlled studies were assessed and stoma-related complications by stoma types were presented. Complication rates were reported as follows: peristomal skin complication 14% (5.6–37.8%), high-output stoma 2.4% (0-18.5%), parastomal hernia 2.4% (0-13.3%), stoma retraction 3.1% (0-10.8%) and stoma prolapse 0% (0-5.4%). The study showed that complications have a negative impact on the patient and healthcare professionals and can lead to cost disadvantages.
In a retrospective study by Rondelli et al.  comparing loop ileostomy to tube ileostomy using a foley catheter, the two methods were evaluated in terms of complications. When stoma-related complications were evaluated separately, the parastomal hernia was found in 12 (17%), intestinal obstruction in 1 (0.01%), and stoma stenosis in 2 (0.02%) patients of the loop ileostomy group. Although they stated that stoma-related complications such as parastomal hernia were significantly higher in the loop ileostomy group (loop and tube; 12and 0, p < 0.02), their study lacks information on the skin infection or skin maceration. While in our study, stomal prolapse was observed in 2 (10%), parastomal hernia in 2 (10%), and skin maceration in 9 (45%) patients of the loop ileostomy group.
The most likely reason for the higher skin maceration rate in comparison with the literature may be due to the low recognition rate of macerationby health professionals and physicians. In contrast, the incidence of parastomal hernia and prolapse is consistent with the literature. Both tube ileostomy and loop ileostomy have specific complications. For instance, prolapsus is not an expected complication of tube ileostomy. Therefore, it is not reasonable to get significant results by directly comparing these method-specific complications.To overcome this problem, we used the Clavien-Dindo classification to assess the severity of different complications. To the best of our knowledge, this study is the first one to use Clavien-Dindo classification to compare complications that are associated with tube ileostomy and loop ileostomy procedures.
In addition to the complications related to loop ileostomy it also has a negative impact on the quality of life. Studies comparing loop ileostomy to tube ileostomy lack data regarding patients’ adjustment to life with a stoma. We assessed the adjustment of loop ileostomy among the patients, using the OAI-23 questionnaire. Results showed that most of the patients in the loop ileostomy group had problems with adjustment to life with a stoma, encountered restrictions in social activities, and had a constant worry about stoma.
This study showed that there is a 10-fold cost advantage between the two methods in favor of tube ileostomy. It is indisputable that if stoma reversal surgery charges are added to the cost, the difference will be even greater. This apparent cost-advantage shown in this study limited to 20 patients, could be of great value in further studies with a large number of patients.
Although this study showed that tube ileostomy is superior to loop ileostomy in many respects, prospective randomized studies with a larger sample size are needed.