PAPER-TUBE ILEOSTOMY

1. GUIDE:
DR. SANTHOSHKUMAR RAVEENDRAN
ASSOCIATE PROFESSOR
GOVERNMENT MEDICAL COLLEGE
KOTTAYAM, KERALA
TUBE ILEOSTOMY AS AN
ALTERNATIVE FOR
CONVENTIONAL LOOP ILEOSTOMY
FOR FECAL DIVERSION
DR. AJIL ANTONY
JUNIOR RESIDENT
DEPARTMENT OF GENERAL SURGERY
GOVERNMENT MEDICAL COLLEGE
CALICUT, KERALA

2. INTRODUCTION
• Anastomotic leakage following colorectal anastomoses - considerable morbidity and mortality.
• Therefore, defunctioning diverting ileostomies may have to be performed.
• Although a defunctioning ileostomy does not prevent a leak, it may alleviate the serious complications –
faecal peritonitis and septicaemia.
• Defunctioning ileostomies are associated with many complications.
• Operation to reverse the stoma is associated with significant morbidity.

3. AIM
• To compare the efficacy of tube ileostomy compared to loop ileostomy as a faecal diversion procedure.

4. MATERIALS AND METHODOLOGY
STUDY DESIGN -
Cohort Study
STUDY PERIOD -
24 months (From May 2020 to May 2022)
SAMPLE SIZE -
44 patients in each study group

5. INCLUSION CRITERIA
Patients in whom a large bowel or small bowel anastamosis was done for the following
indications in whom integrity of anastomosis is questionable as in cases having
• Oedematous and inflamed bowel
• Multiple perforation
• Adherent loops of bowel
• Post chemo-radiotherapy patients
• Patients on steroid therapy
• Patients with multiple comorbidities

6. EXCLUSION CRITERIA
• Not willing to participate in the study
• Healthy individuals who does not require proximal diversion ileostomy based on
preoperative and intraoperative assessments.
• Patients who died within 5 days of surgery unrelated to anastomotic complication
• Patients who were lost to follow up were excluded from the study.

7. DATA ANALYSIS
Data was entered in Microsoft Excel and analysed using SPSS software with Chi-square test for qualitative and
Independent T test for quantitative data.

8. REVIEW OF LITERATURE

9. PROTECTION OF LOW RECTAL ANASTOMOSIS WITH A NEW TUBE ILEOSTOMY USING A
BIOFRAGMENTABLE ANASTOMOSIS RING.

10. A MODIFIED SPONTANEOUSLY CLOSED DEFUNCTIONING TUBE ILEOSTOMY AFTER ANTERIOR
RESECTION OF THE RECTUM FOR RECTAL CANCER WITH A LOW COLORECTAL ANASTOMOSIS.(10)

11. PERCUTANEOUS TRANSGASTRIC ENDOSCOPIC TUBE ILEOSTOMY IN A PORCINE SURVIVAL MODEL.(75)

12. A NEW TECHNIQUE OF COMPLETELY DIVERTED TUBE ILEOSTOMY FOR THE PROTECTION OF
COLORECTAL ANASTOMOSIS: A PILOT STUDY

13. A NEW ILEOSTOMY TECHNIQUE BY USING A JEJUNOSTOMY TUBE PLACED INTO THE
DISTAL ILEUM THROUGH THE ABDOMINAL WALL.(48)

14. DEFUNCTIONING CANNULA ILEOSTOMY AFTER LOWER ANTERIOR RESECTION OF
RECTAL CANCER. (32)

15. RESULTS

16. MEAN AGE IN YEARS
TUBE ILEOSTOMY LOOP ILEOSTOMY
61.43 +/-1.09 YEARS 58.50 +/- 1.39YEARS
72.80% belonged to 50-70 years . 79.50% belonged to 50-70 years.

17. .

18. INDICATION (TUBE ILEOSTOMY)
Series 2, ACUTE APPENDICITIS WITH
PERFORATED CAECUM, 1
Series 2, ACUTE INTESTINAL OBSTRUCTION,
2Series 2, CA CAECUM, 2
Series 2, CA CAECUM + CA SIGMOID, 1
Series 2, CARCINOMA ASCENDING COLON, 2
Series 2, CA ASCENDING COLON - HEPATIC
FLEXURE, 1
Series 2, CA TRANSVERSE COLON, 4
Series 2, CA DESCENDING COLON, 1
Series 2, CA SIGMOID, 1
Series 2, CA RECTOSIGMOID, 16
Series 2, CA RECTUM, 8
Series 2, FAP, 2
Series 2, ULCERATIVE COLITIS , 1
Series 2, CARCINOID APPENDIX, 1
Series 2, STRICTURE ILEUM WITH SMALL
BOWEL GANGRENE, 1
Tube ileostomy was performed mainly in large bowel malignancies as a fecal diversion procedure to protect the
distal anastamosis.36 out of 44 cases were large bowel pathologies.

19. INDICATION (LOOP ILEOSTOMY)
DIAGNOSIS, A/C INTESTINAL OBSTRUCTION, 9
DIAGNOSIS, CA ASCENDING COLON, 2
DIAGNOSIS, CA TRANSVERSE COLON, 3
DIAGNOSIS, CA DESCENDING COLON, 2
DIAGNOSIS, CA SIGMOID, 3
DIAGNOSIS, CA RECTOSIGMOID, 10
DIAGNOSIS, CA RECTUM, 5
DIAGNOSIS, FAP, 1
DIAGNOSIS, REC.INCISIONAL HERNIA WITH
OBSTRUCTION, 1
DIAGNOSIS, S/P EXT.RIGT HEMICOLECTOMY WITH
LEAK, 1
DIAGNOSIS, MES.ISCHEMIA, 1
DIAGNOSIS, NECROTISING PANCREATITIS-
PANCREATICOPLEURAL FISTULA, 1
DIAGNOSIS, ANASTAMOTIC LEAK FOLLOWING
ILEOTRANS ANAS, 1
DIAGNOSIS, PENETRATING INJURY COLON, 1
DIAGNOSIS, CA TRANS.COLON WITH
COLODUODENAL FISTULA, 1
DIAGNOSIS, SIG.VOLVULUS, 1
DIAGNOSIS, SIG.DIVERTICULAR PERFORATION, 1
FIGURE 36 : INDICATION (LOOP ILEOSTOMY)
A/C INTESTINAL OBSTRUCTION
Loop ileostomy was performed mainly in large bowel pathologies. 59% cases of loop ileostomies were for
large bowel related malignant cases

20. ELECTIVE,
TUBE, 40
ELECTIVE,
LOOP, 26
EMERGENC
Y, TUBE, 4
EMERGENC
Y, LOOP, 18
EMERGENCY
ELECTIVE
In majority of the elective cases tube ileostomy was performed as a diversion
procedure. In emergency setting 4 cases underwent tube ileostomy and 18
underwent loop ileostomy

21. p-value = 0.82
MEAN NUMBER OF DAYS ON WHICH
ILEOSTOMY STARTED FUNCTIONING
TUBE ILEOSTOMY
1.09 +/- 0.88 days
LOOP ILEOSTOMY
1.14 +/- 1.002 days

22. MEAN NUMBER OF DAYS ON WHICH
ORALS STARTED
TUBE ILEOSTOMY
3.02 +/- 1.13 days
LOOP ILEOSTOMY
3.18 +/- 0.86 days
p-value = 0.46

23. p-value was <0.05
218 ± 19 ml
TUBE ILEOSTOMY
LOOP ILEOSTOMY 333.33 ± 58 ml
MEAN ILEOSTOMY OUTPUT

24. NUMBER OF STOMA BAGS USED IN A MONTH
TUBE ILEOSTOMY = 3 - 4 bags
LOOP ILEOSTOMY = 6 - 8 bags
T-test the p-value = <0.05

25. • The median time for stoma site to close in tube ileostomy is 8 -10 days whereas in loop ileostomy
median time to reversal operation is 90-150 days.

26. • Skin excoriation which is a common complication following ileostomy is reported in 20.50 % of loop ileostomy
and 4.60 % cases of tube ileostomy.
• Statistical analysis with Chi-square test given a p-value of 0.024 and therefore a statistically significant
difference was noted in this parameter.
• The relative risk was 0.2 and thus it indicates that there is a decreased risk of skin excoriation for those
who had tube ileostomy than loop ileostomy and perhaps tube ileostomy may actually protect against
skin excoriation.

27. • Ileosomy site infection was comparatively higher in loop ileostomy group with 11.40% in loop vs 6.80% in tube ileostomy.
• Statistical analysis with Chi-square test given a p-value of 0.458 and therefore a statistically insignificant.
• Since the relative risk is 0.6, there is a decreased risk of ileostomy site infection for those who had tube ileostomy than loop
ileostomy and perhaps tube ileostomy may actually protect against infection at stoma site by preventing spillage of stoma
contents.
.

28. None of the patients developed intestinal obstruction following ileostomy
2.3 % patients developed distal anastamotic leak following ileostomy in both groups

29. • 22.7 % patients in loop ileostomy group developed electrolyte imbalance compared to
2.3% in tube ileostomy
• Relative risk = 0.1
• Electrolyte imbalance is less likely to occur in those who had tube ileostomy as a
diversion procedure.
• There is 90 % risk that is attributable to loop ileostomy in developing electrolyte imbalance.

31. NUMBER OF DAYS OF HOSPITAL STAY
Tube ileostomy = 8.3 +/- 3.06 days
Loop ileostomy = 11.32 +/- 3.82 days
T-test the p-value was found to be <0.05

32. DIFFERENCE WAS NOTED BUT NOT STATISTICALLY
SIGNIFICANT IN FOLLOWING PARAMETERS
PARAMETER P-VALUE
POD ON WHICH ILEOSTOMY
STARTED FUNCTIONING
0.82
HEMATOMA AT ILEOSTOMY
SITE
0.07
PERISTOMAL CELLULITIS 0.06
NECROSIS AT STOMA SITE 0.32
PERSISTENT PAIN AT
ILEOSTOMY SITE
0.29
INTESTINAL OBSTRUCTION 0.64

33. PARAMETER P-VALUE
AVERAGE OUTPUT OF ILEOSTOMY
IN A DAY
0.001
NUMBER OF DAYS OF HOSPITAL
STAY
0.001
NUMBER OF STOMA BAGS USED IN
A MONTH
0.001
ILEOSTOMY REVERSAL 0.001
SELF CARE OR DEPENDENCY ON
OTHERS
0.03
HYPERTROPHIC SCAR/KELOID POST
ILEOSTOMY REVERSAL
0.02
ELECTROLYTE IMBALANCE 0.004
DIFFERENCE WAS NOTED AND IS STATISTICALLY
SIGNIFICANT IN FOLLOWING PARAMETERS

34. TUBE ILEOSTOMY SPECIFIC PARAMETERS

35. The mean number of days on which tube ileostomy was removed was in 18.91 +/- 4.26 days

37. COMPICATIONS IN TUBE
ILEOSTOMY
FREQUENCY PRECENTAGE
TUBE BLOCK 18 40.9%
PERITUBAL LEAK 7 15.9%
TUBE MIGARTION 4 9.1%

38. Comorbidities - a risk factor for the healing of anastamotic site
Diabetes mellitus,Chronic Obstructive Pulmonary Disease,Coronary Artery
Disease,Hypertension, Dyslipidemia.
Tube ileostomy - 70.50 %
Loop ileostomy - 52.30 %

39. DISCUSSION

40. Loop ileostomy is conventionally considered in:
★ Insecure repair of anastomosis
★ Multiple perforations
★ Matted bowel loops
★ Grossly unhealthy bowel due to severe edema and inflammation
★Post Chemo-Radiotherapy Patients
★Patients on Steroid Therapy
★Integrity of Distal anastomosis is questionable
★Patients with multiple comorbidities

41. Complications of loop ileostomy

42. • SKIN IRRITATION/ EXCORIATION

43. (A) PERISTOMAL DERMATITIS (B) EARLY POUCH DETACHMENT
(C) BLISTER AT THE ADHESIVE AREA IN THE PERIPHERY OF POUCH RESIN
(D) DERMATITIS CAUSED BY BOTH POUCH RESIN AND PERIPHERAL ADHESIVE
(E) DERMATITIS DUE TO CONTACT OF FECES WITH SKIN
(F) FUNGAL DERMATITIS

44. (A)BLEEDING IN A MUCOCUTANEOUS JUNCTION AND
(B) HEMATOMA AT THE STOMA FIXING

45. (A) MUCOCUTANEOUS DETACHMENT. (B) PERISTOMAL INFECTION.

46. STOMA NECROSIS. (A) PARTIAL NECROSIS; (B) EXTENSIVE NECROSIS.

47. PARASTOMAL HERNIA

48. STOMA STENOSIS.
(A) RETRACTION OF SKIN
(B) THE SCAR TISSUE AROUND THE STOMA OPENING IN A CHRONIC STOMA STENOSIS

49. • Dehydration
• Intestinal obstruction
• Offensive Odours
• Pre stomal ileitis & diarrhoea
• Gall stone and Gall stone Pancreatitis
• Anastomotic leaks from ileostomy reversal site
OTHER COMPLICATIONS

50. HAMPER
THE
QUALITY
OF LIFE

51. • Frequent change of ileostomy appliance
imposes great financial
burden, especially in
developing countries

52. COMPLICATIONS OF LOOP ILEOSTOMY
REVERSAL
• Wound infection
• Burst Abdomen
• Abdominal septic complications
• Leak from ileostomy closure
• Intestinal obstruction due to Stricture
formation
• Incisional hernia
• Bad Scar

53. USE OF TUBE
ILEOSTOMY
AVOID
THESE
MORBIDITIES

54. • TUBE ILEOSTOMY AS AN ALTERNATIVE TO LOOP ILEOSTOMY
“ ATTEMPT TO PROTECT THE DISTAL ANASTOMOSIS AND AT THE SAME TIME DECREASE
THE ILEOSTOMY COMPLICATIONS AND TOTALLY AVOID THE MORBIDITY AND MORTALITY
ASSOCIATED WITH STOMA TAKEDOWN”

55. • The first reported use of T-tube ileostomy was at Texas Children's Hospital in 1959 for proximal
fecal diversion
• Use of tube ileostomy in adults is only sparingly reported. First reported case was by Hojo.

56. TECHNIQUE OF
TUBE ILEOSTOMY
CONSTRUCTION

57. • A 28 French abdomen drain tube (Soft thoracic catheter) is brought
into peritoneal cavity through stab incision in abdominal wall
• Tube is inserted
❖10-15 cm proximal from the ileocecal junction in case of diseases
involving the large bowel
❖10 cm proximal to the diseased bowel in ileal pathologies.

58. Tube selection abdominal drain
-
No.28 Soft Thoracic catheter
Selection of healthy segment of bowel
proximal to repair

59. • Tube was secured to bowel wall by 2-0 polyglactin by purse string suture

60. • Bowel proximal and distal to site of tube insertion was fixed to parietal wall
of abdomen with interrupted 2-0 silk

61. • Tube was fixed to skin with No.1 silk and connected to stoma bag

62. Tube ileostomy in a 51 year old male
following Low Anterior Resection for CA
Rectosigmoid
Note the spontaneous closure of tube-
ileostomy controlled fistula on POD-29
NO NEED FOR REVISION SURGERY

63. DAY ON WHICH TUBE ILEOSTOMY START FUNCTIONING
DAILY OUTPUT
DAILY IRRIGATION AND ASPIRATION OF TUBE
PERITUBAL LEAK
TUBE BLOCK
TUBE MIGRATION
INFECTION/ABSCESS
FEATURES OF INTESTINAL OBSTRUCTION
DAY OF PASSAGE OF STOOL
DAY OF REMOVAL OF TUBE
DAILY OUTPUT OF CONTROLLED FISTULA
DAY OF CLOSURE OF CONTROLLED FISTULA
DAILY CHECKLIST
FOLLOW UP- 6 MONTHS

64. • The time for day of surgery to day of anal defecation was considered protective period of tube
ileostomy
• Patency of tube maintained with daily saline irrigation and aspiration
• Once patient passes stools the protective effect of tube ileostomy is finished
• This makes tube ileostomy a time limited defunctioning method

65. • Very proximal placement of tube leads to high volume ileostomy output
• When tube is placed in distal ileum a larger lumen tube must be used to prevent
tube blockade

66. The criteria for removing tube was
• A period of at least 2 weeks post surgery
• Anal defecation
When Anastamotic leakage occurred,if an emergency reoperation was not necessary,the tube was retained
and the patient was given total parenteral nutrition or enteral nutrition until the anastomotic leakage was
closed
In tube ileostomy after removal of tube the discharge of feces through stoma site stopped in 8-10 days

67. EXPECTED COMPLICATIONS IN TUBE
ILEOSTOMY
• TUBE BLOCK
• PERITUBAL LEAK
• TUBAL MIGRATION
• PERITUBAL INFECTION AND
ABSCESS
• ELECTROLYTE IMBALANCE
• INTESTINAL OBSTRUCTION
• ENTEROCUTANEOUSFISTUA

68. CONCLUSION
• In this initial phase of my study, the outcomes of tube ileostomy is better
when compared to loop ileostomy
• The standard of living improved
• The complications is much less
• The number of days of hospital stay and frequent hospital visits are less
• The need for a further reversion surgery and financial burden can be avoided
• The frequent usage of stoma bags and allied products can be avoided

69. Further large scale well designed, randomised control trials are needed to compare
tube ileostomy as an alternative to conventional loop ileostomy as a diversion
procedure

70. REFERENCE
• Patil V, Vijayakumar A, Ajitha MB, Kumar L S. Comparison between Tube Ileostomy and Loop Ileostomy as a
Diversion Procedure. ISRN Surg. 2012;2012:547523. doi: 10.5402/2012/547523. Epub 2012 Dec 18. PMID:
23320194; PMCID: PMC3539443.
• Alisina Bulut, Wafi Attaallah, Completely Diverted Tube Ileostomy Versus Conventional Loop Ileostomy,
Cureus, 10.7759/cureus.30997, (2022).
• Hanju, H., Jiahe, X., Caizhao, L., Sen, L. and Jianjiang, L. (2014), Use of cannula ileostomy to protect a low
colorectal anastomosis in patients having preoperative neoadjuvant chemoradiotherapy. Colorectal Dis, 16:
O117-O122. https://doi.org/10.1111/codi.12456
• Bugiantella, W., Rondelli, F. and Mariani, E. (2015), Letter to Zhou X. et al. “Completely diverted tube
ileostomy compared with loop ileostomy for protection of low colorectal anastomosis”. Colorectal Dis, 17: 87-
87. https://doi.org/10.1111/codi.12802

72. THANK YOU