Rectus abdominis muscle contraction has no significant role in stoma outlet obstruction development

doi:10.21203/rs.3.rs-2711913/v1

Purpose

Stoma outlet obstruction (SOO) is a common complication in patients who receive diverting ileostomy. A postoperatively thicker rectus abdominis muscle is an independent risk factor for outlet obstruction through strong contractions. The objective of this study is to identify the relationship between rectus abdominis and SOO.

Methods

A retrospective analysis was performed for patients who underwent laparoscopic anterior rectal resection and diverting ileostomy from August 2019 to August 2022. The ileostomy site was in the lower-right abdominal through the rectus abdominis muscle or in the lower-middle abdominal via the specimen extraction site between the rectus abdominis muscles.

Results

Among the 306 patients that had been subjected to laparoscopic anterior rectal resection and diverting ileostomy, 28 (9.15%) developed SOO. In the lower-right group, SOO accounted for 18 (8.45%) of the 213 patients, while in the lower-middle group, SOO accounted for 10 (10.75%) of the 93 patients (p = 0.521). Differences in abdominal wall thickness (21.03 vs. 24.389 mm, p = 0.382), width of abdominal wall defects (21.1 vs. 22.483 mm, p = 0.906), time of fart (1.5 vs. 1.33 days, p = 0.408), obstruction time after operation (5.28 vs. 10 days, p = 0.175), proportion of albumin reduction (20.66 vs. 19.48%, p = 0.621), and highest postoperative leukocyte levels (9.3 vs. 9.611 10E9/L, p = 0.906) between the groups were insignificant. However, differences in mealtime between the groups were significant (2.2 vs. 4.11 p = 0.021).

Conclusion

In rectal cancer patients subjected to laparoscopic anterior rectal resection and diverting ileostomy, rectus abdominis muscle-related factors were not associated with the development of stoma outlet obstruction.

Stoma outlet obstruction

Ileostomy

Rectus abdominis muscle

Rectal cancer

Leakage of lower colorectal anastomosis after rectal cancer surgery is a serious complication and diverting ileostomy is recommended for low anterior rectal cancer resection ^(1,2). It seems to mitigate the consequences of leakage. Reducing the urgency of abdominal reoperation can potentially mitigate the leakage consequences⁽³⁾. Stoma outlet obstruction (SOO) is a common complication in patients subjected to diverting stoma, with an incidence rate of 5.6% -18.4%. The development of SOO occurs within 2 weeks after the operation ^(4–6). The symptoms of SOO include nausea, vomiting and abdominal distension, while abdominal CT can detect the distension of proximal small intestines and identify the obstruction site nearby the stoma^༈7༉. The reasons for the obstruction are complicated. In clinical applications, loop ileostomy is mainly created at the marked site of the lower-right quadrant of the rectus abdominis muscle. A postoperatively thicker rectus abdominis muscle is an independent risk factor for outlet obstruction^{༈8, 9༉}. There is a need to determine whether SOO occurrence will decrease if the stoma is positioned in the lower-middle abdomen, between the rectus abdominis muscles, thereby weakening or even eliminating the effects of rectus abdominis contraction on the stoma.

We conducted a randomized trial to study the influence of different stoma sites on ileostomy.

Patients

From August 2019 to August 2022, consecutive patients with rectal or recto-sigmoid cancer who underwent laparoscopic anterior rectal resection and diverting ileostomy in the Second Affiliated Hospital of Zhejiang University were enrolled in this study.

Exclusion criteria were (1) Open surgery or laparoscopic surgery to open surgery, (2) Non-neoplastic diseases, (3) Postoperative cases of serious complications, including anastomotic leakage, massive bleeding or death.

Surgical Approaches

All enrolled patients were subjected to laparoscopic or robotically assisted surgery to reduce interference with the higher incidences of small bowel obstruction with laparotomy.

Ileostomy Construction Approaches

Lower-right ileostomy: The ileostomy site was in the lower middle abdominal and the ileum was raised approximately 30 cm from the end of the ileum so that the gap in the abdominal wall could easily fit 2 fingers.

Lower-middle ileostomy: The stoma was raised from the specimen extraction site (4–6 cm) in the lower middle abdominal and approximately 30 cm from the terminal ileum.

The ileum was fixed to the skin with a rubber tube holder, with proximal intestines on the cephalic side and distal intestines on the caudal side. The ileum was free of torsion under direct lumpectomy, and the skin and intestines were interrupted with 8 stitches using 3 − 0 absorbable suture materials (Fig. 1).

Diagnostic Criteria Of Outlet Obstruction

The diagnosis of outlet obstruction was performed as i. Patients presented with obstruction symptoms, such as nausea and abdominal distension and ii. The abdominal CT revealed small bowel obstruction at the stoma.

Groups

Depending on ileostomy location, patients with outlet obstruction were divided into a lower-right group and a lower-middle group.

Statistical analysis

The data were expressed as means ± standard deviations. For univariate analysis, Mann-Whitney U test was applied for two-group comparisons of clinical and surgical factors. Statistical significance was defined as a p-value < 0.05. Statistical analysis was performed using SPSS 26.0.

Clinical characteristics of all outlet obstruction patients

A total of 306 rectal/recto-sigmoid cancer patients underwent laparoscopic anterior rectal resection and diverting ileostomy. Among them, 28 (9.15%) patients developed outlet obstruction. The median age of the 28 patients was 62.71 (42–78) years, while the median BMI was 22.83 (16.61–28.28) kg/m². Clinical characteristics of all outlet obstruction patients are presented in Table 1.

Table 1

Clinical characteristics of all outlet obstruction patients
Age (year)	62.71(42–78)
Female gender(male/female)	21/7
Body mass index(kg/m²)	22.83(16.61–28.28)
Diabetes(yes/no)	5/23
Hypertension(yes/no)	11/17

Surgical Factors For All Outlet Obstruction Patients

Of the 28 patients, 10 had a lower-middle abdominal stoma, while 18 had a lower-right abdominal stoma. Robot-assisted surgery was performed in 2 cases, while laparoscopic surgery was performed in 26 cases. The mean time to deflation was 1.39 (1–3) days, the mean time to the presentation of obstruction was 6.96 (3–25) days, while the mean postoperative hospital stay time was 12.89 (5–22) days. Surgical factors for all outlet obstruction patients are shown in Table 2.

Table 2

Surgical factors of all outlet obstruction patients
Incidence of outlet obstruction(%)	9.15
ASA(grade 1–2)	28/28
Preoperative chemoradiotherapy(yes/no)	5/23
Operative time (min)	243.04(150–505)
Blood loss rate(%)	10.77(༈-10.08)-23.43༉
Anastomosis(double stapling technique/hand-sewn)	26/2
Approach (robot/laparoscopy)	2/26
Stomal site (lower-right/lower-middle)	10/18
Thickness of abdominal wall(mm)	23.19(6.9–47.2)
Width of abdominal wall defect(mm)	21.99(13.1–41.8)
Time of fart(day)	1.39(1–3)
Meal times(day)	3.43(1–13)
Obstruction time after operation(day)	6.96(3–25)
Postoperative hospital stay	12.89(5–22)
pTNM(I/II/III/IV)	7/10/9/2
Reoperation	0

Univariate Analysis For The Two Groups

Outlet obstruction accounted for 18 (8.45%) of the 213 patients with a lower-right abdominal stoma and 10 (10.75%) of the 93 patients with a lower-middle abdominal stoma (p = 0.521). Differences in abdominal wall thickness (21.03 vs. 24.389 mm, p = 0.382), width of abdominal wall defect (21.1 vs. 22.483 mm, p = 0.906), time of fart (1.5 vs. 1.33 days, p = 0.408), obstruction time after operation (5.28 vs. 10 days, p = 0.175), proportion of albumin reduction (20.66 vs. 19.48%, p = 0.621), highest postoperative leukocyte value (9.3 vs. 9.611 10E9/L, p = 0.906) between the groups were insignificant (Table 3).

Twenty-six (92.9%) of the 28 patients had outlet obstruction within 2 weeks after the operation. Two patients with a right lower abdominal stoma had obstruction on the 25th postoperative day, while 1 patient with a lower-middle abdominal stoma had obstruction on day 14. Due to poor outcomes of conservative treatment, ileostomy reversal surgery was performed on day 41 postoperatively. Intraoperatively, the intestinal canal and mesentery at the stoma were edematous, and the abdominal wall defect was circular with a maximum diameter of approximately 13 mm, which was significantly smaller than the mean value of 22.483 mm for the lower-right group, which was considered to be caused by a small abdominal wall opening.

Differences in meal time between the two groups were significant (2.2 vs. 4.11 p = 0.021), with 24 of the 28 patients experiencing outlet obstruction after meals and 4 patients with lower-right abdominal stoma experiencing outlet obstruction before meals. After excluding these four cases, there were no significant differences in the timing of feeding.

Table 3. Univariate Analysis for the two groups
	lower-middle group（10）	lower-right group（18）	Univariate analysis (p-value)
Age	61.3（42-73）	63.5（52-78）	0.832
Body mass index（kg/m²）	21.799	23.398	0.208
Incidence of outlet obstruction（%）	10.75	8.45	0.521
Preoperative chemoradiotherapy（yes/no）	2/8	3/15	0.825
Operation time (min)	240	244.72	0.175
Blood loss rate(%)	11.92	10.13	0.724
Approach (robot/laparoscopy)	1/9	1/17	0.662
Thickness of abdominal wall（mm）	21.03	24.389	0.382
Width of abdominal wall defect（mm）	21.1	22.483	0.906
Time of fart（day）	1.5	1.33	0.408
Meal times（day）	2.2	4.11	0.021
Obstruction time after operation（day）	5.28	10	0.175
Postoperative hospital stay（day）	12.6	13.056	0.832
Preoperative WBC（10E⁹/L）	5.9	5.889	0.621
Highest postoperative WBC（10E⁹/L）	9.3	9.611	0.906
Highest postoperative CRP（mg/l）	129.58	115.189	0.689
Preoperative ALB（g/l）	41.11	39.944	0.245
Minimum postoperative ALB（g/l）	32.64	31.728	0.869
Proportion of albumin reduction (%)	20.66	19.48	0.621

Ileostomy can be located in the lower right abdomen, in the umbilicus or via specimen extraction site ^(10–12). Since the intestinal canal lies within the rectus abdominis muscle, it has been postulated that the rectus abdominis controls defecation in ileostomies. However, its strong contractions compress the intestinal canal and may lead to outlet obstruction ^(8,9). Linea alba is a midline band of connective tissue that separates the two parallel portions of the rectus abdominis muscle, composed of transverse and oblique fibers. The transverse fibers act as a counterpart to the intraabdominal pressure, whereas the oblique fibers are mainly involved in trunk movements ^(13,14). The linea alba is subjected to pulling forces on both sides of abdominal cavities rather than contraction forces. When ileostomy is performed at the lower-middle abdominal via the specimen extraction site, the effects of rectus abdominis muscle contractions on the stoma can be avoided.

The incidence of outlet-type obstruction was 2.3% higher in the lower middle group, relative to the lower right group (10.75% vs. 8.45%). The onset of SOO was attributed to challenges with the surgical technique and bowel torsion ⁽¹⁵⁾. However, after assessment by two specialist imaging surgeons, none of the 28 patients had bowel torsion. The surgeons were also specialists with more than 1000 laparoscopic colorectal operations. Differences in surgical-related indicators such as blood loss rate, operation time, time of fart, obstruction time after the operation, abdominal wall thickness and abdominal wall defects width between the two groups were insignificant. Therefore, we postulated that other factors are more important than rectus abdominis muscle contraction that leads to SOO development.

Abdominal wall defects over 34 mm in diameter are a risk factor for parastomal hernia⁽¹⁶⁾. In five of the SOO patients (17.9%), abdominal wall defect sizes were more than 34 mm; in one case, it was 41.8 mm. Given these sizes, it is not clear why the oversized abdominal wall opening, which is thought to predispose to parastomal hernias, still resulted in SOO. Abdominal CT revealed bowel wall and small bowel mesenteric oedema, which may explain the SOO outcome. The mean obstruction time after the operation was reported to be on day 4–7 postoperatively ^{(6, 8)}, and in this study, the mean obstruction time was 6.96 (3–25) days postoperatively. The two patients who developed SOO on day 25 exhibited significant edema in the stoma, which was probably due to increased food intake in the last 3 days.

In emergency colon perforation repair and ileostomy surgery, we found that patients had significant edema of the ileum and small bowel mesentery, and the abdominal wall opening had to reach 3–4 fingers to allow passage of the intestine. It has also been reported that infection may be a possible factor for stoma outlet obstruction⁽⁶⁾. Currently, we are performing a randomized controlled trial comparing patients with or without SOO after laparoscopic anterior rectal resection and diverting ileostomy. In this clinical trial, we routinely administered Sulperazone 2.0g q12h postoperatively against infection for 5–7 days in 20 patients, and there has not been a single case of stoma outlet obstruction.

For rectal cancer who underwent laparoscopic anterior rectal resection and diverting ileostomy, rectus abdominis muscle-related factors may not significantly affect stoma outlet obstruction development.

Ethical Approval

This study was conducted in accordance with the Declaration of Helsinki. This study was conducted with approval from the Ethics Committee of the first people’s hospital of Wenling.

Conflicts of Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Authors' contributions

XW wrote the original paper, analyzed data and completed the tables and figures， XW and JG collected data. KD and DX designed research, performed research, analyzed and interpreted data, critically reviewed the manuscript. All authors contributed to the article and approved the submitted version.

Funding

This work was funded by Science and Technology Project of Wenling (2019S180067).

Availability of data and materials

All data generated or analyzed during this study are included in this article.

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No competing interests reported.

Rectus abdominis muscle contraction has no significant role in stoma outlet obstruction development

Status:

Version 1

Abstract

Purpose

Methods

Results

Conclusion

Figures

Introduction

Methods

Patients

Surgical Approaches

Ileostomy Construction Approaches

Diagnostic Criteria Of Outlet Obstruction

Groups

Statistical analysis

Results

Clinical characteristics of all outlet obstruction patients

Surgical Factors For All Outlet Obstruction Patients

Univariate Analysis For The Two Groups

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1