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

Rectus abdominis muscle contraction has no significant role in stoma outlet obstruction development | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Rectus abdominis muscle contraction has no significant role in stoma outlet obstruction development Xiaowei Wang, Jin Gu, Yue Liu, Beibei Lin, Yizhi Wang, Dong Xu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2711913/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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 Figures Figure 1 Introduction 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. Methods 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. Results 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/m 2 . 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/m 2 ) 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/m 2 ） 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（10E 9 /L） 5.9 5.889 0.621 Highest postoperative WBC（10E 9 /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 Discussion 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. Conclusion 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. Declarations 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. References Matthiessen, P., Hallbook, O., Rutegard, J., Simert, G., Sjodahl, R.: Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: A randomized multicenter trial. ANNALS OF SURGERY 247(4), 719–720 (2008). https://doi.org/10.1097/SLA.0b013e31816a74b5 Hueser, N., Michalski, C.W., Erkan, M., Schuster, T., Rosenberg, R., Kleeff, J., Friess, H.: Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. ANNALS OF SURGERY 248(1), 52–60 (2008). https://doi.org/10.1097/SLA.0b013e18176bf65 Shiomi, A., Ito, M., Maeda, K., Kinugasa, Y., Ota, M., Yamaue, H., Shiozawa, M., Horie, H., Kuriu, Y., Saito, N.: Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: A propensity score matching analysis of 1,014 consecutive patients. JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 220 (2), 186–194 (2015). https://doi.org/10.1016/j.jamcollsurg.2014.10.017 Okada, S., Hata, K., Emoto, S., Murono, K., Kaneko, M., Sasaki, K., Otani, K., Nishikawa, T., Tanaka, T., Kawai, K., Nozawa, H.: Elevated risk of stoma outlet obstruction following colorectal surgery in patients undergoing ileal pouch-anal anastomosis: a retrospective cohort study. SURGERY TODAY 48 (12), 1060–1067 (2018). https://doi.org/10.1007/s00595-018-1698-8 Ohira, G., Miyauchi, H., Hayano, K., Kagaya, A., Imanishi, S., Tochigi, T., Maruyama, T., Matsubara, H.: Incidence and risk factor of outlet obstruction after construction of ileostomy. JOURNAL OF THE ANUS RECTUM AND COLON 2 (1), 25–30 (2018). https://doi.org/10.23922/jarc.2017-034 Hara, Y., Miura, T., Sakamoto, Y., Morohashi, H., Nagase, H., Hakamada, K.: Organ/space infection is a common cause of high output stoma and outlet obstruction in diverting ileostomy. BMC SURGERY 20 (1) (2020). https://doi.org/10.1186/s12893-020-00734-7 Tamura, K., Matsuda, K., Yokoyama, S., Iwamoto, H., Mizumoto, Y., Murakami, D., Nakamura, Y., Yamaue, H.: Defunctioning loop ileostomy for rectal anastomoses: predictors of stoma outlet obstruction. INTERNATIONAL JOURNAL OF COLORECTAL DISEASE 34 (6), 1141–1145 (2019). https://doi.org/10.1007/s00384-019-03308-z Abe, T., Nishimura, J., Yasui, M., Matsuda, C., Haraguchi, N., Nakai, N., Wada, H., Takahashi, H., Omori, T., Miyata, H., Ohue, M.: Risk factors for outlet obstruction in patients with diverting ileostomy following rectal surgery. JOURNAL OF THE ANUS RECTUM AND COLON 5 (3),254–260 (2021). https://doi.org/10.23922/jarc.2021-007 Sasaki, S., Nagasaki, T., Oba, K., Akiyoshi, T., Mukai, T., Yamaguchi, T., Fukunaga, Y., Fujimoto, Y.: Risk factors for outlet obstruction after laparoscopic surgery and diverting ileostomy for rectal cancer. SURGERY TODAY 51 (3), 366–373 (2021). https://doi.org/10.1007/s00595-020-02096-2 d’Alessandro, A., Kari, N., Alameh, A., Pasquier, N., Tarhini, A., Bonnet, B.V., Noun, R., Chouillard, E.: Preliminary experience with umbilical stoma in transumbilical single-port colorectal surgery. TECHNIQUES IN COLOPROCTOLOGY 22 (4), 301–304 (2018). https://doi.org/10.1007/s10151-018-1767-4 Eto, K., Omura, N., Haruki, K., Uno, Y., Ohkuma, M., Nakajima, S., Anan, T., Kosuge, M., Fujita, T., Ishida, K., Yanaga, K.: Transumbilical defunctioning ileostomy: A new approach for patients at risks of anastomotic leakage after laparoscopic low anterior resection. ANTICANCER RESEARCH 33 (11), 5011–5015 (2013) Lee, K.-y., Park, J.W., Lee, K.-y., Cho, S., Kwon, Y.-H., Kim, M.J., Ryoo, S.-B., Jeong, S.-Y., Park, K.J.: Safety of temporary ileostomy via specimen extraction site in rectal cancer patients who underwent laparoscopic low anterior resection. SCIENTIFIC REPORTS 9 (2019).https://doi.org/10.1038/s41598-019-38790-6 Axer, H., von Keyserlingk, D., Prescher, A.: Collagen fibers in linea alba and rectus sheaths - i. general scheme and morphological aspects. JOURNAL OF SURGICAL RESEARCH 96 (1), 127–134 (2001). https://doi.org/10.1006/jsre.2000.6070 Axer, H., von Keyserlingk, D., Prescher, A.: Collagen fibers in linea alba and rectus sheaths - ii. variability and biomechanical aspects. JOURNAL OF SURGICAL RESEARCH 96 (2), 239–245 (2001). https://doi.org/10.1006/jsre.2000.6071 Fujii, T., Morita, H., Sutoh, T., Yajima, R., Tsutsumi, S., Asao, T., Kuwano, H.: Outlet obstruction of temporary loop diverting ileostomy. HEPATO-GASTROENTEROLOGY 62 (139), 602–605 (2015). https://doi.org/10.5754/hge13238 Pennings, J.P., Kwee, T.C., Hofman, S., Viddeleer, A.R., Furnee, E.J.B., van Ooijen, P.M.A., de Haas, R.J.: Clinical and radiologic predictors of parastomal hernia development after end colostomy. AMERICAN JOURNAL OF ROENTGENOLOGY 216 (1), 94–103 (2021). https://doi.org/10.2214/AJR.19.22498 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2711913","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":185450957,"identity":"203b3c59-46f5-4093-a9e8-04746ffb0a7b","order_by":0,"name":"Xiaowei Wang","email":"","orcid":"","institution":"The first people’s hospital of Wenling","correspondingAuthor":false,"prefix":"","firstName":"Xiaowei","middleName":"","lastName":"Wang","suffix":""},{"id":185450958,"identity":"36cc182e-2cf1-4790-a05b-7becc26cf300","order_by":1,"name":"Jin Gu","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Gu","suffix":""},{"id":185450959,"identity":"2ba5ce34-17c6-427d-aa00-7c655d04ac68","order_by":2,"name":"Yue Liu","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yue","middleName":"","lastName":"Liu","suffix":""},{"id":185450960,"identity":"ffad8667-f715-4226-92c7-e6b04a71702f","order_by":3,"name":"Beibei Lin","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Beibei","middleName":"","lastName":"Lin","suffix":""},{"id":185450961,"identity":"1e831b1f-d39e-41fd-95e1-62ad30495a46","order_by":4,"name":"Yizhi Wang","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yizhi","middleName":"","lastName":"Wang","suffix":""},{"id":185450962,"identity":"4a3da738-0ac2-495e-9dcc-d6934f3139d4","order_by":5,"name":"Dong Xu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIie3RMQrCMBSA4VcC6RJ1bRHv8CSgi3iWSqGTg9DFqRQEp+Ks4CHqDSIduniAiktBqIsHEBG0iXuqm2D+IenwPkJSAJPpN0O5ELBj9WXFnxMmviQAjqe2ZoKFvzvP7pGNx0sZMhj1UkGqUkfcdRDyzYoSPHkeZxDwVNAh6kjHmQ66rYRJImqSTVLBqKMj9E0cgsd9XJNnM1GnsBsSLAjURDQTN6lC3oo94h4C6G/R55uMDrQE8/rF2CPy23le4XU+7q3yRaUlKmsJvrwXqn9EGudlDxjL2fKjYZPJZPq7Xjm9QqR3s1/pAAAAAElFTkSuQmCC","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Dong","middleName":"","lastName":"Xu","suffix":""},{"id":185450963,"identity":"ec994c9d-bb89-43b3-84a8-7f733c9ad81b","order_by":6,"name":"Kefeng Ding","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kefeng","middleName":"","lastName":"Ding","suffix":""}],"badges":[],"createdAt":"2023-03-20 01:14:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2711913/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2711913/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":34784804,"identity":"92d2dd77-63fa-4221-ad7d-7441e1519cdd","added_by":"auto","created_at":"2023-03-24 16:11:29","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":421359,"visible":true,"origin":"","legend":"\u003cp\u003eFigure legend not available with this version.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-2711913/v1/2f8d247577846bcef684f461.jpeg"},{"id":36800876,"identity":"c69c4ccd-1354-4123-b7f2-58bc1bc448fd","added_by":"auto","created_at":"2023-05-11 05:59:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":460446,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2711913/v1/cdf8f2a8-ecf0-4f9f-bb20-ad30fd36cbc8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rectus abdominis muscle contraction has no significant role in stoma outlet obstruction development","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLeakage of lower colorectal anastomosis after rectal cancer surgery is a serious complication and diverting ileostomy is recommended for low anterior rectal cancer resection \u003csup\u003e(1,2)\u003c/sup\u003e. It seems to mitigate the consequences of leakage. Reducing the urgency of abdominal reoperation can potentially mitigate the leakage consequences\u003csup\u003e(3)\u003c/sup\u003e. 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 \u003csup\u003e(4\u0026ndash;6)\u003c/sup\u003e. 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\u003csup\u003e༈7༉\u003c/sup\u003e. 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\u003csup\u003e༈8, 9༉\u003c/sup\u003e. 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.\u003c/p\u003e \u003cp\u003eWe conducted a randomized trial to study the influence of different stoma sites on ileostomy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eFrom 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.\u003c/p\u003e \u003cp\u003eExclusion 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.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Approaches\u003c/h3\u003e\n\u003cp\u003eAll enrolled patients were subjected to laparoscopic or robotically assisted surgery to reduce interference with the higher incidences of small bowel obstruction with laparotomy.\u003c/p\u003e\n\u003ch3\u003eIleostomy Construction Approaches\u003c/h3\u003e\n\u003cp\u003eLower-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.\u003c/p\u003e \u003cp\u003eLower-middle ileostomy: The stoma was raised from the specimen extraction site (4\u0026ndash;6 cm) in the lower middle abdominal and approximately 30 cm from the terminal ileum.\u003c/p\u003e \u003cp\u003eThe 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\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable suture materials (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eDiagnostic Criteria Of Outlet Obstruction\u003c/h3\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003ch3\u003eGroups\u003c/h3\u003e\n\u003cp\u003eDepending on ileostomy location, patients with outlet obstruction were divided into a lower-right group and a lower-middle group.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;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\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Statistical analysis was performed using SPSS 26.0.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eClinical characteristics of all outlet obstruction patients\u003c/h2\u003e \u003cp\u003eA 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\u0026ndash;78) years, while the median BMI was 22.83 (16.61\u0026ndash;28.28) kg/m\u003csup\u003e2\u003c/sup\u003e. Clinical characteristics of all outlet obstruction patients are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics of all outlet obstruction patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.71(42\u0026ndash;78)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale gender(male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21/7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.83(16.61\u0026ndash;28.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes(yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension(yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Factors For All Outlet Obstruction Patients\u003c/h3\u003e\n\u003cp\u003eOf 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\u0026ndash;3) days, the mean time to the presentation of obstruction was 6.96 (3\u0026ndash;25) days, while the mean postoperative hospital stay time was 12.89 (5\u0026ndash;22) days. Surgical factors for all outlet obstruction patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical factors of all outlet obstruction patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncidence of outlet obstruction(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.15\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA(grade 1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28/28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative chemoradiotherapy(yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e243.04(150\u0026ndash;505)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss rate(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.77(༈-10.08)-23.43༉\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomosis(double stapling technique/hand-sewn)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach (robot/laparoscopy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStomal site (lower-right/lower-middle)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThickness of abdominal wall(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.19(6.9\u0026ndash;47.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidth of abdominal wall defect(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.99(13.1\u0026ndash;41.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime of fart(day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.39(1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeal times(day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.43(1\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstruction time after operation(day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.96(3\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospital stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.89(5\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epTNM(I/II/III/IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/10/9/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eUnivariate Analysis For The Two Groups\u003c/h3\u003e\n\u003cp\u003eOutlet 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\u0026thinsp;=\u0026thinsp;0.521). Differences in abdominal wall thickness (21.03 vs. 24.389 mm, p\u0026thinsp;=\u0026thinsp;0.382), width of abdominal wall defect (21.1 vs. 22.483 mm, p\u0026thinsp;=\u0026thinsp;0.906), time of fart (1.5 vs. 1.33 days, p\u0026thinsp;=\u0026thinsp;0.408), obstruction time after operation (5.28 vs. 10 days, p\u0026thinsp;=\u0026thinsp;0.175), proportion of albumin reduction (20.66 vs. 19.48%, p\u0026thinsp;=\u0026thinsp;0.621), highest postoperative leukocyte value (9.3 vs. 9.611 10E9/L, p\u0026thinsp;=\u0026thinsp;0.906) between the groups were insignificant (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eTwenty-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.\u003c/p\u003e \u003cp\u003eDifferences in meal time between the two groups were significant (2.2 vs. 4.11 p\u0026thinsp;=\u0026thinsp;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.\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"537\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"59.40409683426443%\"\u003e\n \u003cp\u003eTable 3. Univariate Analysis for the two groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003elower-middle group（10）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003elower-right group（18）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003eUnivariate analysis (p-value)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e61.3（42-73）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e63.5（52-78）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.832\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eBody mass index（kg/m\u003csup\u003e2\u003c/sup\u003e）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e21.799\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e23.398\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.208\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eIncidence of outlet obstruction（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e10.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e8.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.521\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003ePreoperative chemoradiotherapy（yes/no）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e2/8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e3/15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.825\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eOperation time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e244.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.175\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eBlood loss rate(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e11.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e10.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eApproach (robot/laparoscopy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e1/9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e1/17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.662\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eThickness of abdominal wall（mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e21.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e24.389\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eWidth of abdominal wall defect（mm）\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e21.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e22.483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.906\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eTime of fart（day）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.408\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eMeal times（day）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e4.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eObstruction time after operation（day）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e5.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.175\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003ePostoperative hospital stay（day）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e13.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.832\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003ePreoperative WBC（10E\u003csup\u003e9\u003c/sup\u003e/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e5.889\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.621\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eHighest postoperative WBC（10E\u003csup\u003e9\u003c/sup\u003e/L）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e9.611\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.906\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eHighest postoperative CRP（mg/l）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e129.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e115.189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.689\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003ePreoperative ALB（g/l）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e41.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e39.944\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.245\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eMinimum postoperative ALB（g/l）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e32.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e31.728\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.869\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.26443202979516%\"\u003e\n \u003cp\u003eProportion of albumin reduction (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.139664804469273%\"\u003e\n \u003cp\u003e20.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.277467411545622%\"\u003e\n \u003cp\u003e19.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.318435754189945%\"\u003e\n \u003cp\u003e0.621\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eIleostomy can be located in the lower right abdomen, in the umbilicus or via specimen extraction site \u003csup\u003e(10\u0026ndash;12)\u003c/sup\u003e. 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 \u003csup\u003e(8,9)\u003c/sup\u003e. 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 \u003csup\u003e(13,14)\u003c/sup\u003e. 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.\u003c/p\u003e \u003cp\u003eThe 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 \u003csup\u003e(15)\u003c/sup\u003e. 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.\u003c/p\u003e \u003cp\u003eAbdominal wall defects over 34 mm in diameter are a risk factor for parastomal hernia\u003csup\u003e(16)\u003c/sup\u003e. 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\u0026ndash;7 postoperatively \u003csup\u003e(6, 8)\u003c/sup\u003e, and in this study, the mean obstruction time was 6.96 (3\u0026ndash;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.\u003c/p\u003e \u003cp\u003eIn 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\u0026ndash;4 fingers to allow passage of the intestine. It has also been reported that infection may be a possible factor for stoma outlet obstruction\u003csup\u003e(6)\u003c/sup\u003e. 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\u0026ndash;7 days in 20 patients, and there has not been a single case of stoma outlet obstruction.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFor rectal cancer who underwent laparoscopic anterior rectal resection and diverting ileostomy, rectus abdominis muscle-related factors may not significantly affect stoma outlet obstruction development.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. This study was conducted with approval from the Ethics Committee of\u0026nbsp;the first people\u0026rsquo;s hospital of Wenling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXW wrote the original paper, analyzed data and completed the tables and figures，\u0026nbsp;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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by Science and Technology Project of Wenling (2019S180067).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMatthiessen, P., Hallbook, O., Rutegard, J., Simert, G., Sjodahl, R.: Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: A randomized multicenter trial. ANNALS OF SURGERY 247(4), 719\u0026ndash;720 (2008). https://doi.org/10.1097/SLA.0b013e31816a74b5\u003c/li\u003e\n\u003cli\u003eHueser, N., Michalski, C.W., Erkan, M., Schuster, T., Rosenberg, R., Kleeff, J., Friess, H.: Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. ANNALS OF SURGERY 248(1), 52\u0026ndash;60 (2008). https://doi.org/10.1097/SLA.0b013e18176bf65\u003c/li\u003e\n\u003cli\u003eShiomi, A., Ito, M., Maeda, K., Kinugasa, Y., Ota, M., Yamaue, H., Shiozawa, M., Horie, H., Kuriu, Y., Saito, N.: Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: A propensity score matching analysis of 1,014 consecutive patients. JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS \u003cstrong\u003e220\u003c/strong\u003e(2), 186\u0026ndash;194 (2015). https://doi.org/10.1016/j.jamcollsurg.2014.10.017\u003c/li\u003e\n\u003cli\u003eOkada, S., Hata, K., Emoto, S., Murono, K., Kaneko, M., Sasaki, K., Otani, K., Nishikawa, T., Tanaka, T., Kawai, K., Nozawa, H.: Elevated risk of stoma outlet obstruction following colorectal surgery in patients undergoing ileal pouch-anal anastomosis: a retrospective cohort study. SURGERY TODAY \u003cstrong\u003e48\u003c/strong\u003e(12), 1060\u0026ndash;1067 (2018). https://doi.org/10.1007/s00595-018-1698-8\u003c/li\u003e\n\u003cli\u003eOhira, G., Miyauchi, H., Hayano, K., Kagaya, A., Imanishi, S., Tochigi, T., Maruyama, T., Matsubara, H.: Incidence and risk factor of outlet obstruction after construction of ileostomy. JOURNAL OF THE ANUS RECTUM AND COLON \u003cstrong\u003e2\u003c/strong\u003e(1), 25\u0026ndash;30 (2018). https://doi.org/10.23922/jarc.2017-034\u003c/li\u003e\n\u003cli\u003eHara, Y., Miura, T., Sakamoto, Y., Morohashi, H., Nagase, H., Hakamada, K.: Organ/space infection is a common cause of high output stoma and outlet obstruction in diverting ileostomy. BMC SURGERY \u003cstrong\u003e20\u003c/strong\u003e(1) (2020). https://doi.org/10.1186/s12893-020-00734-7\u003c/li\u003e\n\u003cli\u003eTamura, K., Matsuda, K., Yokoyama, S., Iwamoto, H., Mizumoto, Y., Murakami, D., Nakamura, Y., Yamaue, H.: Defunctioning loop ileostomy for rectal anastomoses: predictors of stoma outlet obstruction. INTERNATIONAL JOURNAL OF COLORECTAL DISEASE \u003cstrong\u003e34\u003c/strong\u003e(6), 1141\u0026ndash;1145 (2019). https://doi.org/10.1007/s00384-019-03308-z\u003c/li\u003e\n\u003cli\u003eAbe, T., Nishimura, J., Yasui, M., Matsuda, C., Haraguchi, N., Nakai, N., Wada, H., Takahashi, H., Omori, T., Miyata, H., Ohue, M.: Risk factors for outlet obstruction in patients with diverting ileostomy following rectal surgery. JOURNAL OF THE ANUS RECTUM AND COLON \u003cstrong\u003e5\u003c/strong\u003e(3),254\u0026ndash;260 (2021). https://doi.org/10.23922/jarc.2021-007\u003c/li\u003e\n\u003cli\u003eSasaki, S., Nagasaki, T., Oba, K., Akiyoshi, T., Mukai, T., Yamaguchi, T., Fukunaga, Y., Fujimoto, Y.: Risk factors for outlet obstruction after laparoscopic surgery and diverting ileostomy for rectal cancer. SURGERY TODAY \u003cstrong\u003e51\u003c/strong\u003e(3), 366\u0026ndash;373 (2021). https://doi.org/10.1007/s00595-020-02096-2\u003c/li\u003e\n\u003cli\u003ed\u0026rsquo;Alessandro, A., Kari, N., Alameh, A., Pasquier, N., Tarhini, A., Bonnet, B.V., Noun, R., Chouillard, E.: Preliminary experience with umbilical stoma in transumbilical single-port colorectal surgery. TECHNIQUES IN COLOPROCTOLOGY \u003cstrong\u003e22\u003c/strong\u003e(4), 301\u0026ndash;304 (2018). https://doi.org/10.1007/s10151-018-1767-4\u003c/li\u003e\n\u003cli\u003eEto, K., Omura, N., Haruki, K., Uno, Y., Ohkuma, M., Nakajima, S., Anan, T., Kosuge, M., Fujita, T., Ishida, K., Yanaga, K.: Transumbilical defunctioning ileostomy: A new approach for patients at risks of anastomotic leakage after laparoscopic low anterior resection. ANTICANCER RESEARCH \u003cstrong\u003e33\u003c/strong\u003e(11), 5011\u0026ndash;5015 (2013)\u003c/li\u003e\n\u003cli\u003eLee, K.-y., Park, J.W., Lee, K.-y., Cho, S., Kwon, Y.-H., Kim, M.J., Ryoo, S.-B., Jeong, S.-Y., Park, K.J.: Safety of temporary ileostomy via specimen extraction site in rectal cancer patients who underwent laparoscopic low anterior resection. SCIENTIFIC REPORTS \u003cstrong\u003e9 \u003c/strong\u003e(2019).https://doi.org/10.1038/s41598-019-38790-6\u003c/li\u003e\n\u003cli\u003eAxer, H., von Keyserlingk, D., Prescher, A.: Collagen fibers in linea alba and rectus sheaths - i. general scheme and morphological aspects. JOURNAL OF SURGICAL RESEARCH \u003cstrong\u003e96\u003c/strong\u003e(1), 127\u0026ndash;134 (2001). https://doi.org/10.1006/jsre.2000.6070\u003c/li\u003e\n\u003cli\u003eAxer, H., von Keyserlingk, D., Prescher, A.: Collagen fibers in linea alba and rectus sheaths - ii. variability and biomechanical aspects. JOURNAL OF SURGICAL RESEARCH \u003cstrong\u003e96\u003c/strong\u003e(2), 239\u0026ndash;245 (2001). https://doi.org/10.1006/jsre.2000.6071\u003c/li\u003e\n\u003cli\u003eFujii, T., Morita, H., Sutoh, T., Yajima, R., Tsutsumi, S., Asao, T., Kuwano, H.: Outlet obstruction of temporary loop diverting ileostomy. HEPATO-GASTROENTEROLOGY \u003cstrong\u003e62\u003c/strong\u003e(139), 602\u0026ndash;605 (2015). https://doi.org/10.5754/hge13238\u003c/li\u003e\n\u003cli\u003ePennings, J.P., Kwee, T.C., Hofman, S., Viddeleer, A.R., Furnee, E.J.B., van Ooijen, P.M.A., de Haas, R.J.: Clinical and radiologic predictors of parastomal hernia development after end colostomy. AMERICAN JOURNAL OF ROENTGENOLOGY \u003cstrong\u003e216\u003c/strong\u003e(1), 94\u0026ndash;103 (2021). https://doi.org/10.2214/AJR.19.22498\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Stoma outlet obstruction, Ileostomy, Rectus abdominis muscle, Rectal cancer","lastPublishedDoi":"10.21203/rs.3.rs-2711913/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2711913/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eStoma 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA 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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 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\u0026thinsp;=\u0026thinsp;0.521). Differences in abdominal wall thickness (21.03 vs. 24.389 mm, p\u0026thinsp;=\u0026thinsp;0.382), width of abdominal wall defects (21.1 vs. 22.483 mm, p\u0026thinsp;=\u0026thinsp;0.906), time of fart (1.5 vs. 1.33 days, p\u0026thinsp;=\u0026thinsp;0.408), obstruction time after operation (5.28 vs. 10 days, p\u0026thinsp;=\u0026thinsp;0.175), proportion of albumin reduction (20.66 vs. 19.48%, p\u0026thinsp;=\u0026thinsp;0.621), and highest postoperative leukocyte levels (9.3 vs. 9.611 10E9/L, p\u0026thinsp;=\u0026thinsp;0.906) between the groups were insignificant. However, differences in mealtime between the groups were significant (2.2 vs. 4.11 p\u0026thinsp;=\u0026thinsp;0.021).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn 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.\u003c/p\u003e","manuscriptTitle":"Rectus abdominis muscle contraction has no significant role in stoma outlet obstruction development","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-24 16:11:24","doi":"10.21203/rs.3.rs-2711913/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f8fabdb6-ad5a-40f6-a555-67e607234f80","owner":[],"postedDate":"March 24th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-05-11T05:59:35+00:00","versionOfRecord":[],"versionCreatedAt":"2023-03-24 16:11:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2711913","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2711913","identity":"rs-2711913","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}