review of article

1. Role Of Diversion Ileostomy In Low
Rectal Cancer: A Randomized
Controlled Trial.
Mukhtar Thoker a, Imtiaz Wani a, , Fazl Q. Parray a,
Nawab Khan a, Shabeer A. Mir a, Parvaiz Thoker b
* a.Department Of General Surgery, Sheri-kashmir Institute Of Medical Sciences, Srinagar
b.Department Of Surgical Oncology, Sheri-kashmir Institute Of Medical Sciences, Srinagar
M. Thoker et al. / International Journal of Surgery 12 (2015) 945e95
1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Presenter : Dr. Mohd. Shahnawaz Alam

2. Introduction:
Rectal Cancer Continues To Be Devastating Malignancy Worldwide.
LAR Is Generally Performed For Lesions In The Upper And Middle Third
Of Rectum.
Sphincter Preservation Is The Need Of The Hour. Anastomotic Leak
Ranges From 3 To 11% For Middle-third And Upper-third Anastomosis
And To 20% For Lower-third Anastomosis.
Proximal Diversion In The Form Of Loop Ileostomy Is Adopted Because
Of The High Rates Of Anastomotic Complications Associated With Low
Colorectal And Coloanal Anastomosis.

3. Aim:
To Compare Two Groups Of Low Anterior Resection With
And Without Diversion Ileostomy In Rectal Cancer
Patients.

4. Material And Methods:
 Type Of Study : A Prospective Study.
 Time Of Study : June 2009 To Decm 2011 For A Period Of 30 Months.
 Inclusion Criteria: Operable Rectal Cancer 4 -12 cm From Anal Verge.
 Exclusion Criteria: All Those Pt Who Were Otherwise Planned For Any
Such Procedure(sphincter Saving) But Ended Up With Abdomino-perineal
Resection.
 Total No. Of Cases: 78 [ 34 Grp-A, 44 Grp-B]
pt. with operable
rectal ca
Group-A:
LAR with
ileostomy
Group-B:
LAR without
ileostomy
Systemic random sampling

5. Material And Methods contn:
Pt. Planned For LAR :
 Detailed History
 Thorough Physical Examination
 Local Examination
 Routine Investigations
 Specialized Investigation Like Serum CEA Level
 A Diagnostic Pre-op Biopsy
 Pre-op Staging By Duke’s, Multi-slice CT,TRUS Or MRI
 Oncologist Advice For Neoadjuvant Or Adjuvant Therapy
 Pre-op Bowel Preparation & Antibiotics
 Part Preparation & Pre-op Counselling By Stoma Therapist
 Informed & Written Consent

6. Material And Methods contn:
 All Cases Were Done Under GA.
 Intra-op Every Attempt To Stick On Oncological Principle With Stress On The
Complete Resection Of Tumor.
 Anastomosis Either By Circular Stapler Or By Hand Sewn Closure.
 Details Of Intra-op Findings Confirmed.
 Decision Of Diversion Ileostomy Was Taken On The Basis Of Inclusion Criteria.
 Demonstration Of Leak Or Sepsis Was Confirmed By Septic Profile, USG-
Abdomen/Pelvic And All Post-op Complications Were Recorded.
 Opd Follow-up At 1m,3m & 6m Interval.
 Stoma Closure Done After 3 Months After Doing A Cologram.
 Ethical Clearance.

7. Material And Methods contn:
 Quality Of Life Was Assessed By Scoring Done By Self Designed Method.
A Total Score Of 0-20 Given For following Parameters :
1. Patient Satisfaction:
a) Bowel/Stoma evacuation – Complete/Incomplete
b) Frequency - >10 Motions />7 Motions/3-5 Motions/2 or less
c) Feeling of well being- Quite Happy/ so-so /Not Happy /Sad/Miserable
d) Surgical Procedures- Fully satisfied/So-so / Not satisfied /Sad/Miserable

8. Material And Methods contn:
2.Functional outcome:
a) Sexual dysfunction-Y/N
b) Return to Work –Y/N
c) Independent Living-Y/N
d) Socializing-Y/N
e) Recommendation to others-Y/N
3.Symptomatology of anterior
resection syndrome:
a) Feeling of loss of reservoir
function-Y/N
b) Feeling of incomplete bowel
evacuation-Y/N
c) Not soiling-Y/N
d) Incontinence to flatus-Y/N
e) Incontinence to stools-Y/NAny score >15 excellent result
10-15 good result
8-10 average result
<8 poor result
**Descriptive statistical method used were chi-square, odds ratio and
Manne Whitney U Test. P-value <0.05 was considered statistically
significant.

9. Result :
 Majority of cases(36%) – age group 51-60 yrs with M:F = 1.2:1
 Bleeding P/R was c/o in 97 % followed by wt. loss in 40%
 Constipation was commonest bowel habit ( 60% )
 Family h/o rectal malignancy present in 10%
 O/E pallor was most frequent findings (81%)
 Growth was felt on DRE in 72% & blood smearing of finger present in 67%

10. Result contn :
 50 % lesions were 5-8 cm from anal verge.
 CEA level was in range of 6-10 ng/ml in 44% cases in pre-op period.
 Blood group “O” was commonest.
 Neo-adjuvant therapy was given in 29%
 Well differentiated adenocarcinoma commonest.
 Mostly pt. presented in Duke’s B stage.

11. Result contn :
 Spectrum of complications in two groups :
Group-A Group-B
Anastomotic
leak
6% 11%
peritonitis 0 % 4.5%
Pelvic
collection
11.8% 22.7%
Small bowel
obstruction
0% 4.5%
Post-op ileus 11.76% 11.36%
Wound sepsis 32% 18%
hypokalemia 8.8% 2.27%
Sexual
dysfunction
32% 11.3%
 Frequency of stomal
complications in Group-A:
Stomal
complication
percentage
Skin excoriation 14.7
Stomal leakage 5.9
Stomal
obstruction
2.9
Stomal retraction 2.9

12. Result contn :
Group-A Group-B
Bowel movements 4.1 ± 1.3 days 5.6 ± 1.7 days
Resumption of diet 4.1 ± 1.3 days 5.6 ± 1.7 days
Mean hospital stay 9.8 ± 3.3 days 14 ± 2.9 days
Recurrence rate 3% 7%
QOL score 14.1 ± 3.1 13.2 ± 1.9
 Other outcomes :

13. Conclusion:
 LAR With Ileostomy Has Certain Advantages Over LAR Without Ileostomy :
 Anastomotic Leak
 Postoperative Ileus
 Resumption Of Diet
 Wound Infection, Small Bowel Obstruction And
 In Terms Of Mortality And Recurrence.
 However Stoma Related Complications Were Main Disadvantage In LAR With
Ileostomy.