A comparative study of stoma-related complications from diverting loop ileostomy or colostomy after colorectal surgery

A comparative study of stoma-related complications from diverting loop ileostomy or colostomy after colorectal surgery | 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 A comparative study of stoma-related complications from diverting loop ileostomy or colostomy after colorectal surgery Koichiro Kumano, Daichi Kitaguchi, Yohei Owada, Eiki Kinoshita, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1843524/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Apr, 2023 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Even though minor, stoma-related complications significantly impact quality of life, they are often excluded from clinical analyses that compare short-term postoperative outcomes of loop ileostomy (LI) and loop colostomy (LC). This study compares stoma-related complications between LI and LC after rectal resection, including minor complications, and discusses the characteristics of diverting stoma (DS) types. Methods A retrospective review was conducted in patients who underwent DS construction after rectal resection. Data on patient background and postoperative short-term outcomes, including stoma-related complications and morbidity after stoma closure, were collected and compared between LI and LC groups. Morbidities of all severity grades were targeted for analysis. Results A total of 47 patients (27 LI, 20 LC) underwent DS construction following rectal resection. Overall stoma-related complications, incidence of skin irritation, high-output stoma, and outlet obstruction were found to be significantly higher in the LI group. In addition, high-output stoma and outlet obstruction were absent in the LC group. Regarding morbidity after stoma closure, operation times and surgical site infections were significantly higher in the LC group while anastomotic leakage after DS closure occurred (2 cases; 15%) in the LC group but not the LI group. Conclusion Because stoma-related complications were found to be significantly higher in the LI group, and even these minor complications may impair patient’s QOL, early LI closure is recommended. For LC, stoma-related morbidities are lower but post-closure leakage is a calculated risk. Colorectal surgery Diverting stoma Ileostomy Colostomy Stoma-related complications Morbidity after stoma closure Figures Figure 1 Introduction Panperitonitis due to anastomotic leakage is a severe complication after colorectal surgery that cannot be completely prevented [ 1 ] and the rate after lower rectal resection is reported to range from 11–15% [ 1 , 2 , 3 , 4 ]. Several techniques, such as construction of a diverting stoma (DS), exist to reduce anastomotic leakage and a previous study showed that DS construction was performed in 16% of rectal resections for tumors located within 5cm of the anal verge[ 5 ]. The reported incidence of anastomotic leakage after lower rectal resection was reduced by this tactic from 28–10% [ 6 ]. Because stomas are also associated with symptoms that lead to deterioration of lower-gastrointestinal quality of life (QOL) [ 7 ], the decision to construct a DS should be tempered by the risk of anastomotic leakage. Other side effects are also possible; a recent systematic review and meta-analysis reported that overall morbidity (for all side effects) was 48–77% in DS patients and skin irritation was the most common complication, occurring in 15.5–28% of such patients [ 8 , 9 ]. However, even while the definition of skin irritation is unclear in reported studies [ 10 ], Lyon et al. [ 11 ] observed that 73% of patients with a stoma have some form of skin irritation. Although not severe or life-threatening, the negative effect on QOL makes the risk of irritation a key decision point in treatment planning. Two types of DS are possible, namely loop ileostomy (LI) and loop colostomy (LC). LC was more commonly chosen until after the 1970s, when LI became more widespread as it avoids spillage of ileal content onto the skin. While the advantages of LI are less stoma site infection [ 12 ] and relative ease of construction [ 13 ], the advantages of LC are less skin irritation and less diarrhea [ 14 ]. Although diverse studies have compared LI and LC with regard to stoma-related complications and morbidity after stoma closure, analyses of sequelae (such as skin irritation) which significantly impact QOL are scarce [ 10 ]. This study therefore aims to compare stoma-related complications, including minor complications, between LI and LC after rectal resection and discuss the characteristics of each stoma type. Materials And Methods Study design This was a single-center, retrospective cohort study. Patients who underwent DS construction after rectal resection between October 2019 and February 2022 at the University of Tsukuba Hospital, Ibaraki, Japan were included in the study. All operations were performed by the same surgical team and all patient data were collected from the electronic medical record system. Surgical procedures The choice of LI or LC was according to the surgeon’s preference. Loop ileostomies were performed using the distal portion of the ileum (approximately 30–40 cm from the Bauhin valve), which was lifted without torsion to the planned stoma site through a segmental incision in the rectus abdominis muscle. The proximal end of the ileum was placed on the cranial or caudal side according to the surgeon's preference. Loop colostomies were performed using the transverse colon, with the middle portion of the transverse colon employed to prevent injury to the left branch of the middle colonic artery during stoma closure. The transverse colon was lifted through a segmental incision in the rectus abdominis. In all cases, the rectus abdominis opening was sized to allow easy passage of two fingers to prevent stenosis. Pre-operative stoma site planning was performed by nurses specializing in skin, ostomy, and wound care. Post-operative stoma care was also performed by specialist nurses at fixed intervals. The way of closing stoma was that the enterostomy was closed by hand-sewn suturing or stapling, depending on the preference of the supervising surgeon. Data collection The following clinical data were collected: Patient background: age, sex, body mass index (BMI), past medical history, presence of diabetes, chronic obstructive pulmonary disease, cardiovascular disease, liver dysfunction, medication records, perioperative steroid replacement, neoadjuvant therapy, and American Society of Anesthesiology (ASA) score [ 15 ]. Postoperative short-term outcome: operation time, estimated blood loss, time to stoma closure, and postoperative complications from stoma construction to closure and after stoma closure. Stoma-related complications: surgical site infection (SSI), high-output stoma presence, outlet obstruction, parastomal skin irritation, parastomal hernia, parastomal bleeding, parastomal fistula, and bowel obstruction. Morbidity after stoma closure: anastomotic leakage, SSI, incisional hernia, and ileus. Stoma-related complications In this study, high-output stoma was defined as drainage volume equal to or higher than 1500ml per day and outlet obstruction was defined as a stoma requiring tube placement that improved rapidly after tube replacement. Skin irritation was diagnosed when photographs in the stoma management record showed redness, erosions, and ulcers around the stoma (Fig. 1 a). Parastomal hernias were diagnosed when a hernia portal was confirmed by computed tomography (Fig. 1 b) or found clinically. Ileus was defined as taking at least 5 days after surgery to start oral intake and visible bowel dilatation on X-ray imaging. The severity of complications was assessed by the Clavien-Dindo classification, with all grades included in the analysis. Statistical analyses Continuous variables were expressed as the median and range and compared using the Mann-Whitney U-test. Categorical variables were expressed as a percentage and compared using the Pearson χ2 test or Fischer exact test where appropriate. P < 0.05 was considered to indicate a statistically significant difference. All data were analyzed using IBM SPSS software, version 28.0. Results Patient characteristics are shown in Table 1. A total of 47 patients underwent DS construction following rectal resection and their clinical data were collected and analyzed. LI and LC were constructed in 27 and 20 patients, respectively. The median observation period before stoma closure was 210 days and the median observation period after stoma closure was 305 days. Demographic differences between the two groups were not significant for age, sex, BMI, preoperative CRT, ASA classification, or regular steroid use. Although the median duration of stoma closure was longer in the LI group (226 days) than in the LC group (117 days), there were no significant differences between the two. Stoma-related complications are summarized in Table 2. The incidence of overall stoma-related complications was found to be significantly higher in the LI group than in the LC group (LI vs. LC: 22/27 [81%] vs. 8/20 [40%]; p = 0.003 ). High-output stomas were observed to be significantly more numerous in the LI group than in the LC group (LI vs. LC: 8/27 [33%] vs 0/20 [0%]; p = 0.014 ). The incidence of skin irritation was significantly higher in the LI group than the LC group (LI vs. LC: 13/27 [48%] vs. 4/20 [16%]; p = 0.047 ). In the LI group, stoma-related complications of Clavien-Dindo Grade III occurred in 5 patients, 4 of which were outlet obstruction. In the LC group, high-output stoma, outlet obstruction, and stoma-related complications of Clavien-Dindo Grade III or more did not occur. There were no significant differences between the two groups with regard to outlet obstruction, parastomal hernia, SSI, or ileus. Operative characteristics of the stoma closure and morbidity after stoma closure are summarized in Table 3 and Table 4, respectively. The median operation time was significantly longer in the LC group than the LI group (LI vs. LC: 105 min vs. 162 min; p = 0.004 ). All cases in the LC group were anastomosed by hand-sewn suturing (LC vs. LI: 0/13 [0%] vs 15/22 [68%]; p < 0.001). While SSI was found to be significantly higher in the LC group than the LI group (LC vs. LI: 8/13 [58%] vs 1/22 [5%]; p = 0.001 ), no significant differences between the two groups were observed with regard to other morbidities after stoma closure. As a severe complication, anastomotic leakage occurred in two patients in the LC group (morbidity rate: 15%), one of which required reoperation. However, no leakage was observed in the LI group. Discussion In this study, stoma-related complications (including all Clavien-Dindo grades) were analyzed and we demonstrated that, in spite of skin irritation as the most common complication, overall stoma-related complications were significantly lower in the LC group. We also found that high-output stoma and outlet obstruction did not occur in the LC group. These results indicate that LI may degrade patient QOL, making LC the superior choice to prevent minor stoma-related complications. However, the observed anastomotic leakage rate of 15% after LC closure should be taken into consideration. LC was frequently employed throughout the 1970s but LI became more widespread [ 16 ] after Raimes et al. [ 17 ] and Alexander et al. [ 18 ] described methods for construction specifically designed to reduce the incidence of prolapse and retraction. The usefulness of LI has since been shown in numerous studies comparing stoma-related complications and morbidity after stoma closure between LI and LC. Rullier, et al. [ 13 ] reported that LI was easy to introduce, relatively simple to close and, in addition, had lower overall stoma-related complications and risk of reoperation. Similarly, Rondelli, et al. [ 19 ] also reported that LI resulted in less sepsis and prolapse than LC; however, these studies neglected stoma management problems which are often overlooked as minor complications. Gooszen et al. [ 20 ] scored the impact of stoma creation on patient QOL in three categories and noted that minor complications, stomal leakage, and skin irritation were significantly related to QOL while Prassas et al. [ 21 ] reported that minor complications were significantly more frequent after the construction of LI, concluding that LI was not necessarily better. Those results and conclusions are consistent with the present study. In this study, the most common complication was skin irritation, precipitated by exposure of the skin to excretions, mechanical trauma, peristomal skin allergic reactions, or fungal infections, and this complication is more common in patients with low stoma height. Similarly, Persson et al. [ 22 ] reported that almost all cases of ileostomy with a stoma heights of 20 mm or less had skin irritation. Although we tried to construct our stomas as high as possible, skin irritation was inevitable in this study. Further development of techniques, advances in equipment, and strict stoma management are desirable. Similar to the results of this study, high-output stomas are reported to be more common with LI and have not been reported with LC [ 23 , 24 ]. The frequency of high-output stoma is 3–34% [ 23 , 24 , 25 , 26 ], with most cases improving after intravenous infusion for 10–14 days [ 25 , 26 ], but some cases require continuous intravenous infusion and deaths have been reported [ 25 ]. Risk factors include intra-abdominal infection, medications, intermittent bowel obstruction, and decreased length of the small intestine (< 200 cm) [ 25 ]. This is a complication specific to ileostomy, in which water is expelled before absorption [ 7 ], but outlet obstruction is also a complication specific to ileostomy and it occurs in 5.4–28.0% of cases [ 27 , 28 , 29 , 30 ]. A prime risk factor for this complication is rectus abdominis muscle thickness of 10 mm or greater [ 26 ]. Although Sasaki et al. suggest dilating the size of the ileostomy aperture to prevent outlet obstruction, aggressive dilation may cause stoma site hernia or prolapse of the ileostomy. Further study is needed to evaluate the degree of proper dilation to prevent outlet obstruction. Although LI is simple to construct and easy to close, it continues to expose patients to the risk of stoma management problems such as high-output stoma, outlet obstruction, and skin irritation. To minimize this risk, Anne et al. [ 8 ] conducted a study to evaluate the usefulness of early stoma closure. They noted that it was safe to close LI 8 to 13 days after rectal resection, verifying early stoma closure as a potential treatment strategy that should be actively promoted. On the other hand, as LC can have severe complications after closure (e.g., leakage), this should be accomplished immediately after essential treatments such as postoperative adjuvant therapy. This study has several limitations. First, this was a single-center, retrospective design with a small sample size. However, this study is somewhat unique in that we also focused on minor complications. Large-scale RCTs that analyze minor complications, especially skin irritation, are needed in the future. Second, with regard to stoma-related complications, LC is favorable over LI, but, for morbidity after stoma closure, LI was favorable. Therefore, it is difficult to strongly recommend one technique or the other from our study results. Conclusion In conclusion, skin irritation was significantly more common in the LI group and high-output stoma and outlet obstruction did not occur in the LC group. Because overall stoma-related complications were found to be significantly higher in the LI group, along with minor complications that may impair patient QOL, LC is the better choice during the stoma wearing period than LI. However, since complications during stoma closure are higher with LC, risk should be carefully evaluated. Conversely, if LI is chosen, early closure may be considered. Declarations Acknowledgements The authors extend their thanks to Dr. Bryan J. Mathis of the University of Tsukuba Hospital International Medical Center for language and logical proofing the paper. Funding This study was not funded by any source. Author information Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, and Organ Transplantation, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575 Japan Koichiro Kumano, Daichi Kitaguchi, Yohei Owada, Eiki Kinoshita, Shoko Moue, Kinji Furuya, Yusuke Ohara, Tsuyoshi Enomoto & Tatsuya Oda Corresponding author Correspondence to Daichi Kitaguchi (e-mail: [email protected] ) Contributions All authors contributed to the study conception and design. The first draft of the manuscript was written by Koichiro Kumano and Daichi Kitaguchi. Data collection was performed by Koichiro Kumano and Eiki Kinoshita. Yohei Owada, Shoko Moue, Kinji Furuya, Yusuke Ohara, Tsuyoshi Enomoto, and Tatsuya Oda commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval This study conforms to the provisions of the 1964 Declaration of Helsinki and 2013 Brazil revisions. Consent to participate This study was approved by the Institutional Review Board of the University of Tsukuba Hospital (registration number: R01-110), and informed consent was obtained from all participants in the form of an opt‐out option following the Good Clinical Practice Guidelines of the Ministry of Health and Welfare of Japan. Competing interests The authors declare no competing interests. References Kang CY, et al (2013) Risk factors for anastomotic leakage after anterior resection for rectal cancer. JAMA Surg 148:65–71. https://doi.org/10.1001/2013.jamasurg.2 Eriksen MT, et al (2005) Anastomotic leakage following routine mesorectal excision for rectal cancer in a national cohort of patients. Colorectal Dis 7:51–57. https://doi.org/10.1111/j.1463-1318.2004.00700.x Matthiessen P, et al (2004) Risk factors for anastomotic leakage after anterior resection of the rectum. 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Int J Colorectal Dis 34:1141–1145. https://doi.org/10.1007/s00384-019-03308-z Ohira G, et al (2018) Incidence and risk factor of outlet obstruction after construction of ileostomy. J Anus Rectum Colon 2:25–30. https://doi.org/10.23922/jarc.2017-034 Hara Y, et al (2020) Organ/space infection is a common cause of high output stoma and outlet obstruction in diverting ileostomy. BMC Surg 20(1):83. https://doi.org/10.1186/s12893-020-00734-7 Sasaki S, et al (2021) Risk factors for outlet obstruction after laparoscopic surgery and diverting ileostomy for rectal cancer. Surg Today 51:366–373. https://doi.org/10.1007/s00595-020-02096-2 Tables Table 1-4 are available in the Supplemental Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.tiff Table2.tiff Table3.tiff Table4.tiff Cite Share Download PDF Status: Published Journal Publication published 04 Apr, 2023 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Major revision 20 Dec, 2022 Reviews received at journal 14 Sep, 2022 Reviewers agreed at journal 01 Sep, 2022 Reviews received at journal 01 Sep, 2022 Reviewers agreed at journal 31 Aug, 2022 Reviewers invited by journal 29 Aug, 2022 Editor assigned by journal 13 Jul, 2022 Submission checks completed at journal 12 Jul, 2022 First submitted to journal 10 Jul, 2022 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. 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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-1843524","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":120661053,"identity":"637df0e6-ba21-43e9-a5cd-9d2b5d41caed","order_by":0,"name":"Koichiro Kumano","email":"","orcid":"","institution":"University of Tsukuba","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Koichiro","middleName":"","lastName":"Kumano","suffix":""},{"id":120661054,"identity":"fb5cf1a3-f1b6-4fa8-8416-a0d43ce87ea6","order_by":1,"name":"Daichi 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Tsukuba","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tatsuya","middleName":"","lastName":"Oda","suffix":""}],"badges":[],"createdAt":"2022-07-10 11:14:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1843524/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1843524/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-023-02877-6","type":"published","date":"2023-04-04T20:23:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":23917689,"identity":"6a0ce0bc-7563-4162-ad6e-f09b86cfe70c","added_by":"auto","created_at":"2022-07-15 18:13:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":276173,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Representative image of skin irritation and (b) representative computed tomography image of a parastomal 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18:18:55","extension":"tiff","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":11940892,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.tiff","url":"https://assets-eu.researchsquare.com/files/rs-1843524/v1/6faf144782bfb1dc8488916b.tiff"},{"id":23917691,"identity":"2dfaeb16-8757-493c-b605-8d11c9d6e9d9","added_by":"auto","created_at":"2022-07-15 18:13:55","extension":"tiff","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13353884,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.tiff","url":"https://assets-eu.researchsquare.com/files/rs-1843524/v1/974035fdb2bc62c7aa8e43f7.tiff"},{"id":23917690,"identity":"bedf4d30-9d21-446b-a5ae-57d900f4d2f8","added_by":"auto","created_at":"2022-07-15 18:13:55","extension":"tiff","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":4946352,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.tiff","url":"https://assets-eu.researchsquare.com/files/rs-1843524/v1/9552a73a2080b5b075a5c4a4.tiff"},{"id":23917692,"identity":"3dff284e-2bae-4693-a255-778e0dfd616c","added_by":"auto","created_at":"2022-07-15 18:13:55","extension":"tiff","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":10532032,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.tiff","url":"https://assets-eu.researchsquare.com/files/rs-1843524/v1/15f498bac888971eee66c1c0.tiff"}],"financialInterests":"No competing interests reported.","formattedTitle":"A comparative study of stoma-related complications from diverting loop ileostomy or colostomy after colorectal surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePanperitonitis due to anastomotic leakage is a severe complication after colorectal surgery that cannot be completely prevented [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and the rate after lower rectal resection is reported to range from 11\u0026ndash;15% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Several techniques, such as construction of a diverting stoma (DS), exist to reduce anastomotic leakage and a previous study showed that DS construction was performed in 16% of rectal resections for tumors located within 5cm of the anal verge[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The reported incidence of anastomotic leakage after lower rectal resection was reduced by this tactic from 28\u0026ndash;10% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause stomas are also associated with symptoms that lead to deterioration of lower-gastrointestinal quality of life (QOL) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the decision to construct a DS should be tempered by the risk of anastomotic leakage. Other side effects are also possible; a recent systematic review and meta-analysis reported that overall morbidity (for all side effects) was 48\u0026ndash;77% in DS patients and skin irritation was the most common complication, occurring in 15.5\u0026ndash;28% of such patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, even while the definition of skin irritation is unclear in reported studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], Lyon et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] observed that 73% of patients with a stoma have some form of skin irritation. Although not severe or life-threatening, the negative effect on QOL makes the risk of irritation a key decision point in treatment planning.\u003c/p\u003e \u003cp\u003eTwo types of DS are possible, namely loop ileostomy (LI) and loop colostomy (LC). LC was more commonly chosen until after the 1970s, when LI became more widespread as it avoids spillage of ileal content onto the skin. While the advantages of LI are less stoma site infection [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and relative ease of construction [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], the advantages of LC are less skin irritation and less diarrhea [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although diverse studies have compared LI and LC with regard to stoma-related complications and morbidity after stoma closure, analyses of sequelae (such as skin irritation) which significantly impact QOL are scarce [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This study therefore aims to compare stoma-related complications, including minor complications, between LI and LC after rectal resection and discuss the characteristics of each stoma type.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis was a single-center, retrospective cohort study. Patients who underwent DS construction after rectal resection between October 2019 and February 2022 at the University of Tsukuba Hospital, Ibaraki, Japan were included in the study. All operations were performed by the same surgical team and all patient data were collected from the electronic medical record system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedures\u003c/h2\u003e \u003cp\u003eThe choice of LI or LC was according to the surgeon\u0026rsquo;s preference. Loop ileostomies were performed using the distal portion of the ileum (approximately 30\u0026ndash;40 cm from the Bauhin valve), which was lifted without torsion to the planned stoma site through a segmental incision in the rectus abdominis muscle. The proximal end of the ileum was placed on the cranial or caudal side according to the surgeon's preference. Loop colostomies were performed using the transverse colon, with the middle portion of the transverse colon employed to prevent injury to the left branch of the middle colonic artery during stoma closure. The transverse colon was lifted through a segmental incision in the rectus abdominis. In all cases, the rectus abdominis opening was sized to allow easy passage of two fingers to prevent stenosis. Pre-operative stoma site planning was performed by nurses specializing in skin, ostomy, and wound care. Post-operative stoma care was also performed by specialist nurses at fixed intervals.\u003c/p\u003e \u003cp\u003eThe way of closing stoma was that the enterostomy was closed by hand-sewn suturing or stapling, depending on the preference of the supervising surgeon.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe following clinical data were collected:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePatient background: age, sex, body mass index (BMI), past medical history, presence of diabetes, chronic obstructive pulmonary disease, cardiovascular disease, liver dysfunction, medication records, perioperative steroid replacement, neoadjuvant therapy, and American Society of Anesthesiology (ASA) score [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePostoperative short-term outcome: operation time, estimated blood loss, time to stoma closure, and postoperative complications from stoma construction to closure and after stoma closure.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStoma-related complications: surgical site infection (SSI), high-output stoma presence, outlet obstruction, parastomal skin irritation, parastomal hernia, parastomal bleeding, parastomal fistula, and bowel obstruction.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMorbidity after stoma closure: anastomotic leakage, SSI, incisional hernia, and ileus.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStoma-related complications\u003c/h2\u003e \u003cp\u003eIn this study, high-output stoma was defined as drainage volume equal to or higher than 1500ml per day and outlet obstruction was defined as a stoma requiring tube placement that improved rapidly after tube replacement. Skin irritation was diagnosed when photographs in the stoma management record showed redness, erosions, and ulcers around the stoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). Parastomal hernias were diagnosed when a hernia portal was confirmed by computed tomography (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb) or found clinically. Ileus was defined as taking at least 5 days after surgery to start oral intake and visible bowel dilatation on X-ray imaging. The severity of complications was assessed by the Clavien-Dindo classification, with all grades included in the analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eContinuous variables were expressed as the median and range and compared using the Mann-Whitney U-test. Categorical variables were expressed as a percentage and compared using the Pearson χ2 test or Fischer exact test where appropriate. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate a statistically significant difference. All data were analyzed using IBM SPSS software, version 28.0.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePatient characteristics are shown in Table\u0026nbsp;1. A total of 47 patients underwent DS construction following rectal resection and their clinical data were collected and analyzed. LI and LC were constructed in 27 and 20 patients, respectively. The median observation period before stoma closure was 210 days and the median observation period after stoma closure was 305 days. Demographic differences between the two groups were not significant for age, sex, BMI, preoperative CRT, ASA classification, or regular steroid use. Although the median duration of stoma closure was longer in the LI group (226 days) than in the LC group (117 days), there were no significant differences between the two.\u003c/p\u003e \u003cp\u003eStoma-related complications are summarized in Table\u0026nbsp;2. The incidence of overall stoma-related complications was found to be significantly higher in the LI group than in the LC group (LI vs. LC: 22/27 [81%] vs. 8/20 [40%]; \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/em\u003e). High-output stomas were observed to be significantly more numerous in the LI group than in the LC group (LI vs. LC: 8/27 [33%] vs 0/20 [0%]; \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.014\u003c/em\u003e). The incidence of skin irritation was significantly higher in the LI group than the LC group (LI vs. LC: 13/27 [48%] vs. 4/20 [16%]; \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.047\u003c/em\u003e). In the LI group, stoma-related complications of Clavien-Dindo Grade III occurred in 5 patients, 4 of which were outlet obstruction. In the LC group, high-output stoma, outlet obstruction, and stoma-related complications of Clavien-Dindo Grade III or more did not occur. There were no significant differences between the two groups with regard to outlet obstruction, parastomal hernia, SSI, or ileus.\u003c/p\u003e \u003cp\u003eOperative characteristics of the stoma closure and morbidity after stoma closure are summarized in Table\u0026nbsp;3 and Table\u0026nbsp;4, respectively. The median operation time was significantly longer in the LC group than the LI group (LI vs. LC: 105 min vs. 162 min; \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.004\u003c/em\u003e). All cases in the LC group were anastomosed by hand-sewn suturing (LC vs. LI: 0/13 [0%] vs 15/22 [68%]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). While SSI was found to be significantly higher in the LC group than the LI group (LC vs. LI: 8/13 [58%] vs 1/22 [5%]; \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.001\u003c/em\u003e), no significant differences between the two groups were observed with regard to other morbidities after stoma closure. As a severe complication, anastomotic leakage occurred in two patients in the LC group (morbidity rate: 15%), one of which required reoperation. However, no leakage was observed in the LI group.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, stoma-related complications (including all Clavien-Dindo grades) were analyzed and we demonstrated that, in spite of skin irritation as the most common complication, overall stoma-related complications were significantly lower in the LC group. We also found that high-output stoma and outlet obstruction did not occur in the LC group. These results indicate that LI may degrade patient QOL, making LC the superior choice to prevent minor stoma-related complications. However, the observed anastomotic leakage rate of 15% after LC closure should be taken into consideration.\u003c/p\u003e \u003cp\u003eLC was frequently employed throughout the 1970s but LI became more widespread [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] after Raimes et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and Alexander et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] described methods for construction specifically designed to reduce the incidence of prolapse and retraction. The usefulness of LI has since been shown in numerous studies comparing stoma-related complications and morbidity after stoma closure between LI and LC. Rullier, et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] reported that LI was easy to introduce, relatively simple to close and, in addition, had lower overall stoma-related complications and risk of reoperation. Similarly, Rondelli, et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] also reported that LI resulted in less sepsis and prolapse than LC; however, these studies neglected stoma management problems which are often overlooked as minor complications. Gooszen et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] scored the impact of stoma creation on patient QOL in three categories and noted that minor complications, stomal leakage, and skin irritation were significantly related to QOL while Prassas et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] reported that minor complications were significantly more frequent after the construction of LI, concluding that LI was not necessarily better. Those results and conclusions are consistent with the present study.\u003c/p\u003e \u003cp\u003eIn this study, the most common complication was skin irritation, precipitated by exposure of the skin to excretions, mechanical trauma, peristomal skin allergic reactions, or fungal infections, and this complication is more common in patients with low stoma height. Similarly, Persson et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported that almost all cases of ileostomy with a stoma heights of 20 mm or less had skin irritation. Although we tried to construct our stomas as high as possible, skin irritation was inevitable in this study. Further development of techniques, advances in equipment, and strict stoma management are desirable.\u003c/p\u003e \u003cp\u003eSimilar to the results of this study, high-output stomas are reported to be more common with LI and have not been reported with LC [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The frequency of high-output stoma is 3\u0026ndash;34% [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], with most cases improving after intravenous infusion for 10\u0026ndash;14 days [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], but some cases require continuous intravenous infusion and deaths have been reported [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Risk factors include intra-abdominal infection, medications, intermittent bowel obstruction, and decreased length of the small intestine (\u0026lt;\u0026thinsp;200 cm) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This is a complication specific to ileostomy, in which water is expelled before absorption [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], but outlet obstruction is also a complication specific to ileostomy and it occurs in 5.4\u0026ndash;28.0% of cases [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A prime risk factor for this complication is rectus abdominis muscle thickness of 10 mm or greater [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Although Sasaki et al. suggest dilating the size of the ileostomy aperture to prevent outlet obstruction, aggressive dilation may cause stoma site hernia or prolapse of the ileostomy. Further study is needed to evaluate the degree of proper dilation to prevent outlet obstruction.\u003c/p\u003e \u003cp\u003eAlthough LI is simple to construct and easy to close, it continues to expose patients to the risk of stoma management problems such as high-output stoma, outlet obstruction, and skin irritation. To minimize this risk, Anne et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] conducted a study to evaluate the usefulness of early stoma closure. They noted that it was safe to close LI 8 to 13 days after rectal resection, verifying early stoma closure as a potential treatment strategy that should be actively promoted. On the other hand, as LC can have severe complications after closure (e.g., leakage), this should be accomplished immediately after essential treatments such as postoperative adjuvant therapy.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, this was a single-center, retrospective design with a small sample size. However, this study is somewhat unique in that we also focused on minor complications. Large-scale RCTs that analyze minor complications, especially skin irritation, are needed in the future. Second, with regard to stoma-related complications, LC is favorable over LI, but, for morbidity after stoma closure, LI was favorable. Therefore, it is difficult to strongly recommend one technique or the other from our study results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, skin irritation was significantly more common in the LI group and high-output stoma and outlet obstruction did not occur in the LC group. Because overall stoma-related complications were found to be significantly higher in the LI group, along with minor complications that may impair patient QOL, LC is the better choice during the stoma wearing period than LI. However, since complications during stoma closure are higher with LC, risk should be carefully evaluated. Conversely, if LI is chosen, early closure may be considered.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend their thanks to Dr. Bryan J. Mathis of the University of Tsukuba Hospital International Medical Center for language and logical proofing the paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not funded by any source.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, and Organ Transplantation, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575 Japan\u003c/p\u003e\n\u003cp\u003eKoichiro Kumano, Daichi Kitaguchi, Yohei Owada, Eiki Kinoshita, Shoko Moue, Kinji Furuya, Yusuke Ohara, Tsuyoshi Enomoto \u0026amp; Tatsuya Oda\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Daichi Kitaguchi (e-mail: [email protected])\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. The first draft of the manuscript was written by Koichiro Kumano and Daichi Kitaguchi. Data collection was performed by Koichiro Kumano and Eiki Kinoshita. Yohei Owada, Shoko Moue, Kinji Furuya, Yusuke Ohara, Tsuyoshi Enomoto, and Tatsuya Oda commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study conforms to the provisions of the 1964 Declaration of Helsinki and 2013 Brazil revisions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the University of Tsukuba Hospital (registration number: R01-110), and informed consent was obtained from all participants in the form of an opt‐out option following the Good Clinical Practice Guidelines of the Ministry of Health and Welfare of Japan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKang CY, et al (2013) Risk factors for anastomotic leakage after anterior resection for rectal cancer. 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Br J Surg 88:360\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1046/j.1365-2168.2001.01727.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1365-2168.2001.01727.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaw WL, et al (2002) Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision. Br J Surgery 89:704\u0026ndash;708. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1046/j.1365-2168.2002.02082.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1365-2168.2002.02082.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaker ML, et al (2010) Cause and management of a high-output stoma. Colorectal Dis 13:191\u0026ndash;197. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1463-1318.2009.02107.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1463-1318.2009.02107.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnomoto H, et al (2021) Risk of outlet obstruction associated with defunctioning loop ileostomy in rectal cancer surgery. Cancer Diagnosis \u0026amp; prognosis 1:465\u0026ndash;470. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21873/cdp.10062\u003c/span\u003e\u003cspan address=\"10.21873/cdp.10062\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTamura K, et al (2019) Defunctioning loop ileostomy for rectal anastomoses: predictors of stoma outlet obstruction. 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BMC Surg 20(1):83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12893-020-00734-7\u003c/span\u003e\u003cspan address=\"10.1186/s12893-020-00734-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSasaki S, et al (2021) Risk factors for outlet obstruction after laparoscopic surgery and diverting ileostomy for rectal cancer. Surg Today 51:366\u0026ndash;373. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00595-020-02096-2\u003c/span\u003e\u003cspan address=\"10.1007/s00595-020-02096-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1-4 are available in the Supplemental Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Colorectal surgery, Diverting stoma, Ileostomy, Colostomy, Stoma-related complications, Morbidity after stoma closure","lastPublishedDoi":"10.21203/rs.3.rs-1843524/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1843524/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eEven though minor, stoma-related complications significantly impact quality of life, they are often excluded from clinical analyses that compare short-term postoperative outcomes of loop ileostomy (LI) and loop colostomy (LC). This study compares stoma-related complications between LI and LC after rectal resection, including minor complications, and discusses the characteristics of diverting stoma (DS) types.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective review was conducted in patients who underwent DS construction after rectal resection. Data on patient background and postoperative short-term outcomes, including stoma-related complications and morbidity after stoma closure, were collected and compared between LI and LC groups. Morbidities of all severity grades were targeted for analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 47 patients (27 LI, 20 LC) underwent DS construction following rectal resection. Overall stoma-related complications, incidence of skin irritation, high-output stoma, and outlet obstruction were found to be significantly higher in the LI group. In addition, high-output stoma and outlet obstruction were absent in the LC group. Regarding morbidity after stoma closure, operation times and surgical site infections were significantly higher in the LC group while anastomotic leakage after DS closure occurred (2 cases; 15%) in the LC group but not the LI group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBecause stoma-related complications were found to be significantly higher in the LI group, and even these minor complications may impair patient\u0026rsquo;s QOL, early LI closure is recommended. For LC, stoma-related morbidities are lower but post-closure leakage is a calculated risk.\u003c/p\u003e","manuscriptTitle":"A comparative study of stoma-related complications from diverting loop ileostomy or colostomy after colorectal surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-07-15 18:13:53","doi":"10.21203/rs.3.rs-1843524/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-12-20T19:19:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-09-14T15:08:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35638d1b-3adb-4b28-889c-f66837a26fbb","date":"2022-09-01T13:44:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-09-01T13:44:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78ae5e37-954f-4f58-95a0-680c57470d1e","date":"2022-08-31T13:30:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-08-29T09:29:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-07-13T11:31:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-07-13T03:23:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2022-07-10T11:05:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f4530222-1f76-4db1-bba0-fcce40121ecb","owner":[],"postedDate":"July 15th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:26:12+00:00","versionOfRecord":{"articleIdentity":"rs-1843524","link":"https://doi.org/10.1007/s00423-023-02877-6","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2023-04-04 20:23:23","publishedOnDateReadable":"April 4th, 2023"},"versionCreatedAt":"2022-07-15 18:13:53","video":"","vorDoi":"10.1007/s00423-023-02877-6","vorDoiUrl":"https://doi.org/10.1007/s00423-023-02877-6","workflowStages":[]},"version":"v1","identity":"rs-1843524","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1843524","identity":"rs-1843524","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}