Anastomotic leakage is a serious postoperative complication after rectal cancer that can significantly increase perioperative mortality. Prophylactic stoma diversion can significantly improve the septic reaction of anastomotic leakage and reduce the incidence of unplanned reoperations for anastomotic leakage. At present, there is a debate over whether temporary ileostomies can reduce the incidence of anastomotic leakage. Karl Metal. 's randomized controlled study comparing temporary ileostomies with untreated ileostomy rectal cancer resection suggested that ileostomies could improve the clinical symptoms and incidence of anastomotic leakage, as supported by some other retrospective studies [15, 16]. However, other researchers have come to the opposite conclusion that a temporary ileostomy does not reduce the incidence of anastomosis and that a temporary ileostomy may become a permanent ileostomy, reducing the quality of life of patients [17, 18]. The author believes that there may be a selective deviation in the retrospective study that temporary ileostomy cannot reduce the incidence of anastomotic leakage. Because in the clinical setting, according to the surgeon’s experience, for high-risk patients with anastomotic leakage, such as preoperative neoadjuvant radiotherapy and chemotherapy, an anastomotic level < 6 cm, a BMI > 28 kg/m2, an ASA > 3, inadequate intestinal preparation before operation, etc [19–22], the surgeon will perform a temporary ileostomy, but the patients who are not at risk of anastomotic leakage are not treated, which leads to the deviation of the study’s conclusion.
Our study excluded rectal cancer patients with a BMI > 28 kg/m2, and obese patients with thicker abdominal fat that would need longer incisions for specimen extraction. An ileostomy with a long incision does not reflect the advantages of an ileostomy via specimen extraction incision because the traditional incision of an ileostomy is negligible compared with the longer specimen extraction incision. In addition, there is no uniform standard for the closure time of temporary ileostomy, which can be divided into early closure and late closure according to the length of ileostomy duration. An ileostomy duration < 30 days indicates early closure, and an ileostomy duration > 50 days indicates late closure. A meta-analysis showed that late ileostomy closure has fewer complications. The research by Vogel et al. also supports this conclusion. In our study, ileostomy lasted more than 50 days in all the patients. The author's gastrointestinal surgery centre also preferred to perform temporary ileostomies.
In this study, the incidence of stoma-related complications was 22.7%, compared to 19% for traditional ileostomy complications . In the 2 cases of intestinal obstruction, stenosis of the outlet loop was observed. After conservative treatment, such as an index finger-sized dilated ileostomy and gastric tube insertion and drainage, the ileostomy patient returned to normal flatus and defecation. One patient with intestinal obstruction was discharged 8 days after the operation, and the number of days after the operation did not increase. Ileostomy prolapse occurred in two patients, of which one patient developed acute ileostomy prolapse after the second round of chemotherapy. It is not recommended to return the prolapsed small intestine manually after prolapse, and emergency ileostomy reversal is performed. Although the patients underwent emergency surgery, it did not increase the number of hospitalization days, hospitalization time or hospitalization costs because rectal cancer patients who underwent temporary ileostomy procedures also needed to choose a second return operation, which is equivalent to selecting the ileostomy reversal operation in advance. Li et al. believed that if the ileostomy of the specimen extraction site did not require additional surgery before it was removed, then the effect of complications of the ileostomy was only temporary and could be eliminated by closing the ileostomy . Another patient with ileostomy prolapse could have the prolapse of the small intestine returned manually; although the small intestine prolapsed several times, all of them were returned manually by the patients themselves, which had no serious effect on the patients, and ileostomy reversal was performed 3 months after the operation. In the patients who underwent ileostomy via the median site after the operation, there were 2 cases of ileostomy dermatitis, and there were no cases of incision infection. The incidence of ileostomy dermatitis was lower than that of traditional ileostomy . The low incidence of ileostomy dermatitis is closely related to professional ileostomy care in our department, and there are special ileostomy nurses in the outpatient clinic of our hospital to guide the patients' family members to carry out ileostomy care.
In the ileostomy reversal operation, the average length of the operation was 72 ± 15 minutes, and the length of the operation for one patient was 195 min. The reason for the obvious prolongation was due to the difficulty of separation caused by the adhesion of the small intestine to the abdominal wall incision. The reason for the severe adhesion may be that the patient had just finished the fifth chemotherapy session, and the interval before selective operation was not long enough. In this study, ileostomy of the median specimen extraction site and ileostomy reversal were included together, which can better explain the feasibility and safety of ileostomy via the median specimen extraction site. The purpose of this study was to explore temporary short-term complications from temporary ileostomy formation to ileostomy reversal. Temporary ileostomy via the median specimen extraction site is safe and feasible, but the ileostomy site should be carefully selected for a permanent ileostomy. After the ileostomy of the specimen extraction site was closed, the incidence of incisional hernia still occurred during follow-up. Li et al. found that there was no significant difference in the incidence of incisional hernias between ileostomy reversal specimen extraction sites and simple specimen extraction incisions after more than 2 years of follow-up. In this study, all temporary ileostomies of the median specimen extraction site in patients were closed, but not all temporary ileostomies closed in the patients. Permanent ileostomy may be required if patients have rectal anastomotic stenosis, tumour recurrence and poor basic conditions. Because an ileostomy of the median site does not strictly follow the Turnbull principle of ileostomy, if ileostomy of the median site needs to be retained permanently, it may increase stoma-related complications compared with traditional ileostomy. Studies on the advantages and disadvantages of a temporary ileostomy via median incision versus a temporary ileostomy via traditional right lower abdominal new incision have not been conducted. Retrospective studies and randomized controlled studies should be conducted in the future.