Creation of prestige ileostomy and when Release down: our observation

Creation of prestige ileostomy and when Release down: our observation | 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 Creation of prestige ileostomy and when Release down: our observation Hassan A. Saad, Azza Baz, Mohamed Riad, Mohamed E Eraky, Mohamed I Farid, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3548481/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 background The benefits of ghost ileostomy (GI) in avoiding formal covering ileostomies in > 80% of cancer patients have been documented in numerous studies. However, none of the articles explained precisely how the GI tract was removed in the end in 80% of patients for whom formal maturation was not necessary. Goal To describe and evaluate the GIRD technique, including possible issues, hospital stays, and procedure times, for patients with GI for rectal carcinoma who underwent low anterior resection (LAR/uLAR) or ultra-low anterior resection (LAR/uLAR). Methods In this prospective cohort study, patients underwent restorative colorectal resection with GI for rectal cancer. Patients’ ease of GI release and any problems that might arise were then examined. Information was gathered, examined, and deduced. Results The final statistical analysis included 26 patients who required GIRD. Between the seventh and sixteenth postoperative days (POD), treatment was performed, all patients recovered well, and no additional surgeries were required. No further analgesics or injections of local anesthesia were required for any of the patients. The surgery took an average of five minutes, and none of the patients experienced any notable difficulties with GI release. No post-procedural issues emerged. Conclusion Without the need for anesthesia or additional analgesics, the GIRD approach is a rapid, easy, and safe operation that can be performed at the patient's bedside around the tenth POD. Phantom ileostomy Release of ghost ileostomy Low anterior resection Rectal cancer Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION In terms of patient suffering and treatment expenses, colorectal cancer is a disease that affects a significant number of people worldwide [ 1 ]. The most effective treatment for rectal cancer is total mesorectal excision (TME), which is associated with a higher overall survival (OS) rate and fewer local and distant recurrences. Sphincter-preserving low anterior resection (LAR) and ultra-low anterior resection (uLAR) are now accepted as standard procedures for rectal cancer because they enable the creation of a primary anastomosis at a lower level [ 2 , 3 , 4 ]. The use of permanent stomas after abdominoperineal resection for rectal cancer has recently decreased in favor of sphincter-preserving procedures [ 5]. The most common complication following LAR with TME is still an anastomotic leak (AL). After laparoscopic resection (LAR) for rectal malignancies, a protective stoma is frequently created to prevent AL. The idea was to redirect the fecal stream and keep the anastomosis free of fecal debris, which would reduce the likelihood of leakage. It is arguable whether a dysfunctional stoma stops leaks or only lessens the effects of the leaks [ 6 , 7 ]. Divergent opinions exist regarding the appropriateness of creating a faulty stoma for all rectal anastomoses, only the low ones, or none at all. Multiple studies have shown that a malfunctioning stoma reduces the incidence of clinical leakage in colorectal anastomoses [ 6 , 7 , 8 , 9 ]. However, other surgeons have reported that covering with a protective stoma did not affect AL or reoperation rates, while some authors have reported no difference in leakage rates but a reduced incidence of reoperation. In addition, many patients have to live with a covering stoma for several months after the primary surgery because of the low clinical priority for reversal, and approximately 20% of patients are left with a permanent stoma due to postoperative complications of anterior resection [ 9 – 15 ]. Some studies have reported that stoma reversal is associated with complications in up to 40% of patients. Briefly, individuals in the low-risk category did not need a stoma, whereas those in the high-risk group would benefit from stoma protection. It is difficult to determine whether to develop a protective covering stoma in patients with a medium risk of all [16,17,18,]. The concept of ghost ileostomy (GI), also called prestige or virtual ileostomy, avoids the complications associated with covering ileostomy (CI) in patients undergoing low rectal resection and integrates its benefits for intermediate-risk patients [ 19 ]. This procedure is essentially a pre-stage ileostomy that can be externalized and opened at any time. When anastomotic site leakage occurs in the context of clinical and radiological AL, the GI reaches maturity to complete the CI and redirect the fecal stream. However, GI avoids all the risks associated with an inoperable ileostomy in the event of a smooth postoperative course [ 20 ]. Numerous studies have found that the development of GI in LAR prevents the need for formal CI in > 80% of patients with rectal carcinomas [21, 22]. However, none of the articles specified a precise method for releasing or removing the GI tract in 80% of patients for whom formal maturation is not necessary. Moreover, the results of GI release have not been described in any published studies. We also provide a clear and concise explanation of the release of the GI technique in this post along with our firsthand observations of the process. we aimed to assess the viability of the GIRD technique in patients with LAR or uLAR with GI for rectal carcinoma, as well as any problems, length of stay in the hospital, operation time PATIENTS AND METHODS This study was conducted at Zagazig University Hospital between October 2019 and July 2020. Only after receiving full and informed consent from each enrolled patient were included in the study. Restorative colorectal resection (LAR and ultra-LAR) for rectal cancer was included in this prospective cohort study. Patients with rectal carcinoma who underwent restorative colorectal resections with ghost (prestige or virtual) ileostomies were included in our cohort. All patients underwent a thorough physical examination and history evaluation before surgery. Preoperative colonoscopic biopsy, carcinoembryonic antigen (CEA) levels, contrast-enhanced computed tomography (CECT) of the abdomen, pelvis, and chest, and magnetic resonance imaging (MRI) of the pelvis were used to confirm the diagnosis and stage of the disease. The factors related to the GI-takedown technique were procedure time, procedural difficulties, intra- or postprocedural problems, and ease of use. Trial's eligibility and disqualification standards General selection Conditions of inclusion rectal cancer; elective low anterior resection; ≥18 years of age. signed release of information. Capacity to comprehend the personal implications of trial involvement on character Criteria for exclusions >30 kg/m2 for body mass index. Chronic renal failure, defined as a glomerular filtration rate 3 by the American Society of Anesthesiologists. inhibition of the immune system (azathioprine; cortisone ≥40 mg/day or similar). Anticoagulation therapy is necessary. Significant cardiac disease includes unstable angina, congestive heart failure that is NYHA class II, unstable angina, and people who have had a myocardial infarction within the previous six months or who have undergone coronary revascularization. Any Child-Pugh grade of liver cirrhosis Ultralow rectal cancer refers to tumors that require transanal coloanal anastomosis or intersphincteric resection or that have a lower tumor margin <4 cm from the anal edge as determined by digital rectal examination and rigid proctoscopy. involvement in a different experiment, including an intervention that could affect the intervention's results. Criteria for intraoperative exclusion partial rings of staples. Positive test for intraoperative air bubbles. intraoperative discoveries that, in the judgment of the particular surgeon, render a loop ileostomy necessary (e.g., intraoperative diagnosis of liver cirrhosis, acute or chronic ileus, intraoperative lesion of the rectum, urinary bladder, or vagina). Multisegmental excision. Patients with stage I through IV disease were included in the study, according to the American Joint Committee on Cancer criteria for rectal cancer. 23 patients with rectal carcinoma operating in elective settings, representing all age groups and both sexes, were included. Alternatively, the study eliminated patients who underwent emergency surgery due to acute intestinal obstruction, perforation, and peritonitis; furthermore, patients who were on immunosuppressive medications, had stage IV disease, and had significant hypoalbuminemia (serum albumin ~−2.5 g/dl) Furthermore excluded were patients with carcinoma rectum with underlying FAP necessitating TPC with IPAA, patients requiring restorative colorectal resections for benign illnesses, and patients having formal CI or no stoma. This study also did not include patients with GI who required an anastomotic leak to mature after surgery. The surgical procedure Using a phantom ileostomy as an experimental intervention. Once the anastomosis is constructed and tested in the air, the terminal ileum, the last loop of the small bowel, will be found. The assigned ghost ileostomy site will have a mesenteric window made, and a silicone loop will be inserted through the window and around the small bowel. A serosal, non-absorbing suture will be used to mark the oral section of the ileum around 1-2 cm proximally to the silicone loop for proper bowel orientation in their host ileostomy to be exteriorized. In ordain the colon below the abdominal fascia without any stress, the silicone loop will be exteriorized at the preoperatively indicated, designated ileostomy position through a stab incision and attached to the skin using a rod and non-absorbing sutures. The abdominal cavity will then be sutured along with the exteriorized silicone loop and all incisions, including the midline and laparoscopic incisions, and covered with sterile dressings. Figure 1 shows a schematic example of a ghost ileostomy, schematic representation of a ghost ileostomy. In (A), the silicone loop is carried around the terminal ileum, and in (B), the silicone loop is exteriorized, leaving the terminal ileum naturally intra-abdominal. Before the silicone loop was removed on postoperative day six, Figure 2 shows a photograph of a patient who had a ghost ileostomy. For any indication of anastomotic leakage, patients will be closely observed. Signs of anastomotic leakage can be palpated or detected radiologically. Other clinical and laboratory signs include fever, abdominal guarding, peritonism, air/fecal/turbid discharge from the intra-abdominal drains, leucocytosis, or elevated C reactive protein values that indicate a deviation from the expected postoperative course. An operating room procedure will be performed under general anesthesia to exteriorize the ghost ileostomy in a patient if anastomotic leakage is suspected. A long cylinder of skin and subcutaneous tissue will be removed next to the silicone loop, just like with a traditional ileostomy. Like a traditional ileostomy, the ventral and dorsal sheaths of the abdominal fascia will be cut, and the terminal ileum will be exteriorized by gently pulling on the silicone loop. Using circular everting sutures in the standard manner—that is, without causing torsion on the mesentery or bowel—the proximal segment of the small bowel will be identified by the serosal suture that was placed during primary surgery. If feasible, the oral ileal limb will be placed caudally to create the stoma in the correct orientation. The last step will be to implant an ileostomy bag. By the standard clinical judgments of the treating physicians and the clinical course of any patient with suspected anastomotic leakage, additional diagnostic (proctoscopy, CT scan) or treatments (interventional drainage) will be carried out. At the bedside on postoperative days 5–10, the silicone loop will be withdrawn if there are no indications of anastomotic leakage following ghost ileostomy, the patient has regular bowel movements, and they are fed exclusively through oral syringes. Load ileostomy as a control measure The final loop of the small intestine, or terminal ileum, will be identified in the same way as in the experimental group following anastomosis creation and air testing. Around the small bowel, a silicone loop will be passed through the mesenteric window that has been established at the appropriate ileostomy loop. Skin and subcutaneous tissue will be removed in the form of a longitudinal cylinder for conventional ileostomies. A cut that allows two fingers to easily pass through the opening will be made in the ventral and dorsal sheaths of the abdominal fascia. Next, exteriorization of the ileal loop will occur. The ileal limb of the oral cavity will be positioned caudally, if feasible, and the stoma will be constructed in the proper orientation using circular everting sutures in the conventional method, meaning that there will be no torsion on the gut or mesentery. The last step will be to implant an ileostomy bag. Complementary therapies and approved or prohibited therapies Parenteral feeding, antimicrobial therapy, and relaparotomy are a few examples of concurrent or essential treatments that will be carried out at the treating physicians' discretion and by regional norms. Trial endpoints and data gathering For each patient, the following demographic and baseline data will be recorded: Age (years), gender (male/female), height (cm), weight (kg), class of the American Society of Anesthesiologists, histologically proven carcinoma (yes/no), bowel obstruction (yes/no), rectal bleeding/anemia (yes/no), level of tumor resection high or low resection, neoadjuvant therapy (yes/no), and relevant medical history (cardiac, pulmonary, renal, hepatic, diabetes) as well as previous imaging studies (CT/MRI/endoscopic ultrasound). After confirming that the intraoperative exclusion criteria have been met, the following information will be collected during the procedure: the length of time (in minutes), the surgeon's experience (> or ≤50 low anterior or high resections prior ), the amount of blood lost during the procedure (in milliliters), whether or not intraoperative blood transfusions are performed, and the quantity of packed red blood cells. In this experiment, the Comprehensive Complication Index (CCI) will be the primary outcome measure. Per the established Clavien-Dindo classification, the CCI provides an individual patient-level summary of all postoperative complications based on their severity grade. The complications range from mild ones that do not deviate from the normal clinical course (grade I) to postoperative death (grade V) [22]. The first hospital stay as well as the first three and six months following surgery will be used in calculating the CCI. AlsoFollowing surgery, patients need to be closely observed in a clinical setting, with particular attention paid to the patient's pulse, blood pressure, breathing rate, temperature, abdominal distension or pain, and drain contents. Every patient should have a full blood count and a C-reactive protein assay sent on the third postoperative day (POD) to screen for sepsis or, more indirectly, AL. Limited-contrast radiography is frequently carried out postoperatively. On the fifth and seventh postpartum days, abdominal and pelvic ultrasonography is performed to rule out any collections in the abdomen or pelvis. After administering water-soluble contrast directly above the anal canal, a contrast X-ray of the pelvis might be performed if any collection is observed to rule out any major contrast leak at the anastomotic location. An abdomen and pelvic CT scan should be done if the X-ray shows substantial AL Reexamination. terminal ostomy, such as abdominoperineal extirpation or Hartmann's technique. The term "intra-abdominal abscess" refers to the collection of purulent or infected fluid within the abdomen (positive microbiological culture), which can be seen during surgical reintervention, interventional drainage, or typical radiographic abnormalities (such as a CT scan). drainage by intervention. The intended adjuvant or perioperative chemotherapy has been finished. Patients six months post-initial surgery with stomas (terminal or loop) difficulties arising from stomas... Erythema, cutaneous excoriation, induration, putrid collection, and/or wound, abscess, or ulceration near the ileostomy that causes pain, burning, and trouble placing the ileostomy bag are all considered peristomal wound conditions. hernia posteriore. Clinical symptoms of dehydration and/or impaired kidney function combined with an ileostomy output of over 1500 mL per day necessitate the replacement of fluids through intravenous means. As per the KDIGO definition, acute renal damage [24]. extra difficulties connected to the stoma. after ileostomy closure complications. leaks from anastomosis. More than one of the following characteristics can indicate a prolonged postoperative ileus: vomiting or nausea. over the previous 24 hours, an inability to handle an oral diet For the past 24 hours, there has been no flatus or stool. abdominal distension. via the use of radiography. breaking of the wound. Centers for Disease Control and Prevention: surgical site infection, [25] belly rupture (abdominal fascia dehiscence). hernia incisional. and 6 years following surgery 27, 28, Getting By. Trial visit descriptions and patient schedules In-hospital admission day, or outpatient consultation, is when patients scheduled for elective LAR/TME will be screened. The aforementioned baseline data will be evaluated and recorded following a patient's written informed consent and the screening appointment, which validate that the patient meets all eligibility requirements. upon the authorization of staff (visit 2), randomization will take place during surgery upon verification of intraoperative eligibility conditions. The intraoperative parameters that were discussed will be evaluated on this appointment. Patients are monitored for six months following LAR/TME, with follow-up appointments set for postoperative days three and seven (visits three and four), 14/day of discharge (visit five), as well as one, three, and six months after surgery (visits six, seven, and eight). sessions 7-8 will take place over the phone or as part of follow-up outpatient sessions. Endpoints, both primary and secondary, are evaluated and recorded at postoperative visits. Additional evaluation and documentation will be done for therapeutic and diagnostic procedures brought on by surgical problems. Figure 1 An instance of the phantom ileostomy schematically The terminal ileum is wrapped in a silicone loop in option (A) or exteriorized in option (B), leaving the terminal ileum tension-free intra-abdominal[20].. Figure 2 Before the silicone loop was removed on the sixth surgical day, this patient had a ghost ileostomy. The technique of Release Down of Ghost Ileostomy All carcinoma rectum patients in this study underwent TME resection (LAR/uLAR) with an adequate circumferential resection margin (CRM), distal and proximal margins followed by colorectal/coloanal end-to-end or end-to-side anastomosis using the circular staplers or hand sewn techniques. After completion of the anastomosis, a protective GI was fashioned. In restorative rectal resections, this process averts the necessity and complications of formal CI in > 80% of patients with carcinomas. However, the GI needs to be released before patients are discharged after surgery. Typically, a 10 to 12 Fr Ryle tube or Foley catheter is used to secure the GI loop. The removal of this hanging Ryle tube loop (or any other hanging material) from the abdominal cavity to release the tucked ileal loop is referred to as the 'release down' of the GI. In this regard, it is necessary to ascertain that the patient had no anastomotic leak (AL) before performing the GIRD. After confirming by clinical and radiological assessments that there is no AL, the tubing needs to be removed from the abdominal cavity (Figs. 3 and 4 Keep the patient in a supine position on their bed in the postoperative ward. Care is taken to maintain privacy by uncovering the area of the GI (usually the right iliac fossa region). Gain the patient's confidence in the procedure by providing reassurance, explaining the procedure to them, and seeking consent to proceed. After donning the sterile surgical gloves, apply betadine paint on the GI tubing and the skin around it . There was no need to use any local anesthetic. Cut the fixing suture of the GI tube to free it from the surrounding skin Slightly pull both limbs of the tubing (Fig. 5) and cut one limb deeper into the skin with scissors. The other end of the tubing was gently pulled from the abdominal cavity to release the already-tucked ileal loop and). Clean the wound area and apply a small antiseptic dressing (Fig. 6). At the end of the procedure, the patient was reassured and congratulated to be free from the misery and morbidities of the formal covering stoma. after ensuring that there are no complications and bowel movements are normal.: Fig ure 3 Final external appearance of ghost ileostomy. Fig ure 4 Final internal appearance of ghost ileostomy. Fig ure 5 Cut one limb of tubing with scissors Figure 6 Ghost Ileostomy tubing completely pulled out of the abdominal cavity Following the procedure, patients were monitored in the outpatient department weekly at first, then every two weeks for a month, to check for any problems, morbidity, and death. Analytical Statistics After compiling and statistically analyzing the data, conclusions were drawn from the findings of the analysis. RESULTS After the patients, as specified in the exclusion criteria in the Methods section, were eliminated, a total of 33 patients underwent LAR/uLAR with GI for rectal cancer during this roughly 2-year study period. Six (18%) patients required GI tract maturation (exteriorization) to establish a formal loop ileostomy due to a postoperative anastomotic leak. After receiving mechanical respiration and resuscitation, a patient who had experienced cardiopulmonary arrest and paroxysmal supraventricular tachycardia (PSVT) on zero POD passed away. Thus, the final statistical analysis included only 26 individuals who required release from the gastrointestinal system. In this study, the male-to-female ratio was 11:15, indicating that there were slightly more females than males. The age range of patients was 19–75 years, with an average age of 54.84 years. The patients' average body mass index (BMI) was 26.31 kg/m2, with a range of 19.53 to 33.46. ASA grade I was present in 12 patients, ASA grade II in 13, and ASA grade III in one. The GI of the 26 patients' GIs was ascertained using the previously mentioned technical procedures. Patients were not administered the GIRD technique until they demonstrated postoperative bowel motions. It was done with a mean of 9.75 ± 4.25 days, between the 7th and 16th PODs following initial surgery. The majority of patients (22), who had surgery for rectal malignancy while hospitalized, had their GI freed at the same time. It was usually performed approximately a day before the patient was released from the hospital. In contrast, in four cases, the patient's GI was released at the initial follow-up appointment. In all patients, the GI tract was successfully released without the need for any further surgeries or incisional wounds. No further analgesics or injections of local anesthesia were required for any of the patients. The GI release process took five minutes on average, and none of the patients had any serious complications. No postprocedural issues emerged immediately. Even though no local anesthetic solution was utilized, none of the patients reported experiencing any pain or discomfort during or after GIRD. Not a single patient's GI tubing became stuck during removal. At the GI site, there was no evidence of internal or external bleeding. Following removal, there was no severe surgical site infection (SSI) at the gastrointestinal (GI) tube location. Following a month of observation, there was no formation of unsightly scars, and the scar at the location of the GI tubing was less than that at the abdominal drain. Peritonitis, mesenteric hemorrhage or hematoma formation, mesenteric damage, mesenteric torsion, intestinal obstruction, and GI ileal loop injury were not observed in any of the patients during or after the procedure. DISCUSSION A protective stoma may have drawbacks, such as the requirement for a second procedure, an extended hospital stay, difficulties from the ostomy, and a significant chance of anastomotic leakage when the stoma is removed. Furthermore, patients find it difficult to accept the establishment of a stoma, which causes additional psychological stress to both patients and caretakers. Consequently, the advantages of a protective stoma in lowering the incidence of AL must be weighed against the morbidity associated with its implantation and closure.24- In colorectal anastomosis, the overall incidence of clinical leak is 8% [ 20 – 25 ]. Therefore, the use of a covering stoma provides little to no clinical utility for the vast majority of patients (92%) [ 26 ], Shiomi et al. conducted a propensity-matched scoring analysis of almost 1000 patients who had low anterior resection, and their findings demonstrating that while a failing ileostomy does not directly affect the rate of clinical anastomotic leak, it does lessen its effects and the necessity for immediate reoperation [ 26 ]. GI is a relatively new concept that connects CI in LAR without requiring an ileostomy. This saves the day for any operating surgeon who can be undecided about the CI. CI is an option for patients with AL with low- or medium-risk conditions. In summary, GI is the best option if the anastomosis is risk-free but still requires vigilance because it involves no extra risk and can be converted completely safely and with extreme ease, if necessary. In conclusion, GI guards against issues caused by an ileostomy that does not work properly. Essentially, it is an externalized prestige ileostomy that can be used whenever necessary [ 27 ]]. When GI is created in LAR for patients with rectal cancer, it combines the benefits of CI without causing any problems. When GI is created in comparison to formal CI, it has fewer side effects, shorter length of hospital stay, lower degree of total morbidity, and superior quality of life [ 20 , 27 , 28 ]. According to several recent studies, more than 80% of patients with rectal cancer may avoid formal CI if GI is established after LAR (22, 29, 21, 22). Nevertheless, in 80% of individuals for whom formal maturation is not necessary, none of the publications explain how to remove or release the GI. In our investigation of 26 individuals who underwent GI restorative resection, we provided a clear and concise explanation of this type of ileostomy. Moreover, the results of the GIRD method have not been described in any published studies. In our initial experience, we discovered that the GIRD is rapid, safe, and easy to use. It can be performed at the patient's bedside and does not require the use of additional analgesics or local anesthetics. After this treatment, which took place around the tenth postpartum day, none of the patients experienced any GI site issues. Moreover, none of our patients had any problems with their abdomens or peritoneum during or after surgery. In a prospective study involving 45 patients, Gullà et al.[ 27 ] performed protective ileostomies in 27 patients (CS group) and prestige ileostomies in 18 patients (GI group). When compared to covering a stoma, the authors concluded that GI is viable because it is associated with a lower degree of total morbidity, shorter recovery period, and superior quality of life for both patients and caregivers. Additionally, they proposed that GI might be necessary in some patients who did not exhibit high-risk characteristics but needed to proceed cautiously with AL for low-level colorectal anastomosis. Consequently, GI should be considered as a substitute for traditional ileostomy. They also reported that, in all GI groups with uncomplicated postoperative courses, GI closure was performed under local anesthesia on POD 10 to 15 following a negative contrast enema [ 27 ]. Ambe et al. (2018) conducted a study in which a virtual ileostomy was performed between POD 7 and 9. The study revealed that all patients experienced smooth surgical recovery [ 30 ]. Lago et al. [ 31 ] reported a modified posterior pelvic exenteration approach linked with GI in the treatment of advanced ovarian cancer and found that GI may offer benefits in the case of AL, in addition to preventing complications due to malfunctioning ileostomy. Moreover, the GI loop was not removed until the patient was discharged from the hospital (i.e., on the sixth or ninth postoperative day) if the postoperative course was uneventful. In their investigation, Francesco et al.[ 32 ] also found that no GI patients had problems at the surgical location. Mancini et al. [ 20 ] conducted a study involving 36 patients with rectal cancer who underwent GI and low rectal resection. None of the patients experienced any local GI problems. Additionally, it has been reported that the GI was removed on POD 10 following a negative contrast enema in the context of an uneventful postoperative course. The authors concluded that the GI loop may be removed by simply cutting the tape if the postoperative course was smooth, and there was no requirement for the GI to mature into a formal CI. In this area, we share our GI experience and propose application guidelines. Our research indicates that GI functions as a bridge between continuous ileostomy and continuous ileostomy. When the GI and CI groups were compared, the former demonstrated higher rates of stoma-free patient lifetimes, shorter mean operating times, lower overall morbidity rates, and decreased overall hospital stay. Remarkably, over 45 percent of the patients in the GI group did not undergo formal ileostomy. When there is a possibility of AL after restorative colorectal resections and the surgeon on the operating table does not believe that a covering ileostomy is necessary, GI is a good alternative option and can be constructed in the following situations: advanced gynecological cancers requiring pelvic exenteration with resection-anastomosis of the rectum [ 15 ], discovering metastatic cancer during surgery, repair surgeries for benign diseases such as diverticulitis, diverticulosis, and resection rectopexy, and left hemicolectomy for cancers of the left colon if the patient is malnourished and has other high-risk factors for AL. Although there is no strict prohibition on GI procedures carried out in elective settings, patients with a high Colon Leakage Score and many risk factors for AL should be treated with formal ileostomy. Patients with severe hypoalbuminemia (serum albumin 2.5 g/dl), malnutrition, acute bowel obstruction, perforation, and peritonitis, patients on steroids and immunosuppressive medications, patients with ulcerative colitis requiring total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA), and patients with severe risk factors for AL or those undergoing emergency surgery should avoid the GI. Even though there have been a few occurrences of GI in patients with FAP, it is better to cover these patients with a covering ileostomy because the AL in these patients may increase the risk of pouch excision and pouch failure (16). Except the six patients who had formal loop ileostomy, our study did not identify any significant issues; however, the surgeon should be aware of the potential for the following complications or at least be alert to their early detection: the kink in the ileal loop or the tightly fixed Ryle's tubing loop can obstruct the intestines or result in bleeding in the mesentery; the ileal vasculature can be compressed, leading to chronic ischemia of the ileal loop and the development of strictures; and the ileal loop can be challenging due to adhesions during maturation, and internal bleeding may occur. CONCLUSION In more than 80 percent of cases with LAR, ultra-LAR, or AR, GI hinders the creation of an authentic covering loop ileostomy. By providing a buffer between covering an ileostomy and not covering it, the GI concept saves the surgeon from a situation in which they are unsure of what to do. As an alternative to ileostomy surgery, this is available to patients with a low to medium risk of AL. After our first experience, we concluded that GIRD is a rapid, easy, and safe treatment that is performed around the tenth POD. It can be easily performed without the use of analgesics or local anesthesia at the patient's bedside. During or after the procedure, none of the patients had peritoneal or abdominal issues or problems at the GI site. In conclusion, GI is the best option if anastomosis is risk-free, but still requires attention because it involves no extra risk and can be released completely safely and painlessly without the requirement for postprocedural care. Declarations Acknowledgment is not applicable Declaration and ethical clearance Ethical clearance was obtained from Zagagic University, Faculty of Medicine, Institutional under No. ( (ethical protocol number: ZU-IRB# 9902792023). Written informed consent was obtained from all the patients in accordance with the Declaration of Helsinki. Consent for publication is not applicable Availability of data and materials: a database is available to the corresponding author. This database is available for review and request. All authors have shared the database. Competing interests The authors declare they have no competing interests or financial disclosures. Funding No specific funds were received for this study Authors Affilatiion Hassan A. Saad¹, Azza Baz², Mohamed Riad¹, Mohamed E Eraky¹,, Mohamed I Farid¹, Khaled Sharaf¹ Ahmed El-Taher¹ Ahmed Salah Arafa¹ ¹Surgical Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt. ²Surgical Department, Alahrar Teaching Hospital, Zagazig University, Zagazig City, Egypt Three ³Clinical Pathology Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt Corresponding author: Hassan A. Saad, Telephone: (+20) 01221025689, ORCID:0000-0002-6242-7823. E-mail: [email protected] Author contributions HAS, ME: contributed to the conception and design of MR. AKE organised the database and performed the statistical analysis. HAS,KS,ASA: wrote sections of the manuscript and prepared tables. MIF, AB,: contributed to the manuscript. revision and investigation. All authors read, approved, and equally shared the submitted version References Enker WE. Total mesorectal excision–the new golden standard of surgery for rectal cancer. Ann Med 1997;29(02):127–133 Heald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997. Arch Surg 1998;133(08):894–899 Kapiteijn E, Marijnen CAM, Nagtegaal ID, et al; Dutch Colorectal Cancer Group. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345(09):638–646 Griffen FD, Knight CD Sr, Whitaker JM, Knight CD Jr. The double stapling technique for low anterior resection. Results, modifications, and observations. Ann Surg 1990;211(06):745–751, discussion 751–752 Mehraj A, Chowdri NA, Nanda S, et al. Validity of APR in the Era of Sphincter Saving Procedures for Low Rectal Cancers. EC Gastroenterology and Digestive System 2018;5(03):152–159 Chude GG, Rayate NV, Patris V, et al. Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology 2008;55(86-87):1562–1567 Tan WS, Tang CL, Shi L, Eu KW. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 2009; 96(05):462–472 Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007;246(02):207–214 Bakx R, Busch OR, Bemelman WA, Veldink GJ, Slors JF, van Lanschot JJ. Morbidity of temporary loop ileostomies. Dig Surg 2004;21(04): 277–281[PMID: 15308867 DOI: 10.1159/000080201] » https://doi.org/10.1159/000080201 Cipe G, Erkek B, Kuzu A, Gecim E. Morbidity and mortality after the closure of a protective loop ileostomy: analysis of possible predictors. Hepatogastroenterology 2012;59(119):2168–2172 [PMID: 22440245 DOI: 10.5754/hge12115] » https://doi.org/10.5754/hge12115 Hallböök O, Matthiessen P, Leinsköld T, Nyström PO, Sjödahl R. Safety of the temporary loop ileostomy. Colorectal Dis 2002;4 (05):361–364[PMID: 12780582] Kaiser AM, Israelit S, Klaristenfeld D, et al. Morbidity of ostomy takedown. J Gastrointest Surg 2008;12(03):437–441[PMID: 18095033 DOI: 10.1007/s11605-007-0457-8] » https://doi.org/10.1007/s11605-007-0457-8 Laurent C, Nobili S, Rullier A, Vendrely V, Saric J, Rullier E. Efforts to improve local control in rectal cancer compromise survival by the potential morbidity of optimal mesorectal excision. J Am Coll Surg 2006;203(05):684–691[PMID: 17084330 DOI: 10.1016/j. jamcollsurg.2006.07.021] » https://doi.org/10.1016/j.jamcollsurg.2006.07.021 Law WL, Chu KW, Choi HK. Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision. Br J Surg 2002;89(06):704–708 [PMID: 12027979 DOI: 10.1046/ j.1365-2168.2002.02082.x] » https://doi.org/10.1046/ j.1365-2168.2002.02082.x van Westreenen HL, Visser A, Tanis PJ, Bemelman WA. Morbidity related to defunctioning ileostomy closure after ileal pouch-anal anastomosis and low colonic anastomosis. Int J Colorectal Dis 2012;27(01):49–54[PMID: 21761119 DOI: 10.1007/s00384-011-1276-7] » https://doi.org/10.1007/s00384-011-1276-7 Åkesson O, Syk I, Lindmark G, Buchwald P. Morbidity related to defunctioning loop ileostomy in low anterior resection. Int J Colorectal Dis 2012;27(12):1619–1623 Floodeen H, Lindgren R, Matthiessen P. When are defunctioning stomas in rectal cancer surgery really reversed? Results from a population-based single center experience. Scand J Surg 2013; 102(04):246–250 Lindgren R, Hallböök O, Rutegård J, Sjödahl R, Matthiessen P. What is the risk for a permanent stoma after low anterior resection of the rectum for cancer? A six-year follow-up of a multicenter trial. Dis Colon Rectum 2011;54(01):41–47 Khan MA, Chowdri NA, Wani RA, et al. Technique of Ghost (Khatith) Ileostomy: Our Experience and Guidelines. Ann Colorectal Res. 2021; 9(02):51–57. Doi: 10.30476/ACRR.2021.89835.1082 » https://doi.org/10.30476/ACRR.2021.89835.1082 Miccini M, Amore Bonapasta S, Gregori M, Barillari P, Tocchi A. Ghost ileostomy: real and potential advantages. Am J Surg 2010; 200(04):e55–e57. Doi: 10.1016/j.amjsurg.2009.12.017 » https://doi.org/10.1016/j.amjsurg.2009.12.017 Sacchi M, Legge PD, Picozzi P, Papa F, Giovanni CL, Greco L. Virtual ileostomy following TME and primary sphincter-saving reconstruction for rectal cancer. Hepatogastroenterology 2007;54(78):1676–1678 Flor-Lorente B, Sánchez-Guillén L, Pellino G, et al. “Virtual ileostomy” combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report. Langenbecks Arch Surg 2019;404(03):375–383. Doi: 10.1007/s00423-019-01776-z » https://doi.org/10.1007/s00423-019-01776-z Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol 2010;17(06):1471–1474 Pakkastie TE, Ovaska JT, Pekkala ES, Luukkonen PE, Järvinen HJ. A randomised study of colostomies in low colorectal anastomoses. Eur J Surg 1997;163(12):929–933 Hautefeuille P, Valleur P, Perniceni T, et al. Functional and oncologic results after coloanal anastomosis for low rectal carcinoma. Ann Surg 1988;207(01):61–64 Shiomi A, Ito M, Maeda K, et al. 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. J Am Coll Surg 2015;220(02): 186–194 Gullà N, Trastulli S, Boselli C, et al. Ghost ileostomy after anterior resection for rectal cancer: a preliminary experience. Langenbecks Arch Surg 2011;396(07):997–1007 Mori L, Vita M, Razzetta F, Meinero P, D’Ambrosio G. Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile? Dis Colon Rectum 2013;56(01):29–34 Khan MA, Chowdri NA, Parray FQ, et al. Role of ghost ileostomy in low anterior resection for carcinoma rectum. ANZ J Surg 2021;91 (05):1039–1039. Doi: 10.1111/ans.16573 »https://doi.org/10.1111/ans.16573 Ambe PC, Zirngibl H, Möslein G. Routine Virtual Ileostomy Following Restorative Proctocolectomy for Familial Adenomatous Polyposis. World J Surg 2018;42(06):1867–1871. Doi: 10.1007/ s00268-017-4365-0 » https://doi.org/10.1007/s00268-017-4365-0 Lago V, Domingo S, Matute L, Padilla P, Flor B, García-Granero Á Ghost ileostomy in advanced ovarian cancer. Gynecol Oncol 2017; 147(02):488. Doi: 10.1016/j.ygyno.2017.08.017 » https://doi.org/10.1016/j.ygyno.2017.08.017 Mari FS, Di Cesare T, Novi L, et al. Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial. Surg Endosc 2015;29(09):2590–2597. Doi: 10.1007/s00464-014-3974-z » https://doi.org/10.1007/s00464-014-3974-z 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-3548481","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":246242936,"identity":"16633b9e-0ec1-439e-88ab-554f3d183280","order_by":0,"name":"Hassan A. Saad","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBAC+xlQBj8zY8OBDwwMCQS1GEhAGZLtzY0PZ5CkxeDM8WZjHqK0SPc+/HSjoo6B4UZim7Rtm10eP3sD44ePObi12MscN5bOOXOYgXEGUEtuW3KxZM8BZsmZ2/A5LI0BqPIAA7MEWAtz4oYbCWzMvPi1MP/ObatjYANpsWyrJ0oLG8hwBh6eg83GjG2HidAic4zNGuQXCfbGxoc9544nzuw52IzXL/az25hv5wBDzP4w+4MDP8qqE/vZmw9++IhHCwzUN4BIRjYw2UBYPQL8IUXxKBgFo2AUjBQAAGOYUcN1YDelAAAAAElFTkSuQmCC","orcid":"","institution":"Zagazig University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hassan","middleName":"A.","lastName":"Saad","suffix":""},{"id":246242937,"identity":"5678c317-aef2-4074-81b8-7782977cf3e0","order_by":1,"name":"Azza Baz","email":"","orcid":"","institution":"Alahrar Teaching Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Azza","middleName":"","lastName":"Baz","suffix":""},{"id":246242939,"identity":"cc946695-53b9-4ae6-b517-90c7332fb897","order_by":2,"name":"Mohamed Riad","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Riad","suffix":""},{"id":246242940,"identity":"be76cd99-b94e-49ff-aff9-087089b72b91","order_by":3,"name":"Mohamed E Eraky","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"E","lastName":"Eraky","suffix":""},{"id":246242941,"identity":"aecd3894-e0c7-4e3a-a7e7-803314e635db","order_by":4,"name":"Mohamed I Farid","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"I","lastName":"Farid","suffix":""},{"id":246242942,"identity":"fbbc2a21-1b64-4343-8cb3-700a35f30d72","order_by":5,"name":"Khaled Sharaf","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Khaled","middleName":"","lastName":"Sharaf","suffix":""},{"id":246242943,"identity":"6d348c9e-e203-4a18-afe6-c39949c3ce99","order_by":6,"name":"Ahmed k El-Taher","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"k","lastName":"El-Taher","suffix":""},{"id":246242944,"identity":"670acf0b-07b5-4ef3-9987-f424f0b922ca","order_by":7,"name":"Ahmed Salah Arafa","email":"","orcid":"","institution":"Zagazig University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Salah","lastName":"Arafa","suffix":""}],"badges":[],"createdAt":"2023-11-03 03:44:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3548481/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3548481/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":46086945,"identity":"2b05957c-00f9-47a1-869e-8ae8210b0d0d","added_by":"auto","created_at":"2023-11-08 13:07:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54788,"visible":true,"origin":"","legend":"\u003cp\u003eAn instance of the phantom ileostomy schematically The terminal ileum is wrapped in a silicone loop in option (A) or exteriorized in option (B), leaving the terminal ileum tension-free intra-abdominal[20]..\u003c/p\u003e","description":"","filename":"F1.png","url":"https://assets-eu.researchsquare.com/files/rs-3548481/v1/fcf830845696b2c0db13edb6.png"},{"id":46086951,"identity":"f8b43618-b72f-49e5-af90-94700b57ad61","added_by":"auto","created_at":"2023-11-08 13:07:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":185384,"visible":true,"origin":"","legend":"\u003cp\u003eBefore the silicone loop was removed on the sixth surgical day, this patient had a ghost ileostomy.\u003c/p\u003e","description":"","filename":"F2.png","url":"https://assets-eu.researchsquare.com/files/rs-3548481/v1/326bcf02c791867c356cbbf0.png"},{"id":46086948,"identity":"b13612f2-c463-4526-83c8-8859f2e09f09","added_by":"auto","created_at":"2023-11-08 13:07:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":576711,"visible":true,"origin":"","legend":"\u003cp\u003eFinal external appearance of ghost ileostomy.\u003c/p\u003e","description":"","filename":"F3.png","url":"https://assets-eu.researchsquare.com/files/rs-3548481/v1/23f79d7f17f6ccb6b7f36cbb.png"},{"id":46086949,"identity":"4fdeec58-843f-45a9-a226-a5f3c217a1e2","added_by":"auto","created_at":"2023-11-08 13:07:07","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":426225,"visible":true,"origin":"","legend":"\u003cp\u003eFinal internal appearance of ghost ileostomy.\u003c/p\u003e","description":"","filename":"F4.png","url":"https://assets-eu.researchsquare.com/files/rs-3548481/v1/5f9b5550396b9281eff5d177.png"},{"id":46086950,"identity":"2d0b5fb5-7730-48e7-9119-e5eb2ffde585","added_by":"auto","created_at":"2023-11-08 13:07:07","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":514136,"visible":true,"origin":"","legend":"\u003cp\u003eCut one limb of tubing with scissors\u003c/p\u003e","description":"","filename":"F5.png","url":"https://assets-eu.researchsquare.com/files/rs-3548481/v1/6bdfcacbd976baa8b00f6033.png"},{"id":46087732,"identity":"b7b97ab8-ece6-41c4-8aaa-c22fc6eafbd4","added_by":"auto","created_at":"2023-11-08 13:15:07","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":275146,"visible":true,"origin":"","legend":"\u003cp\u003eGhost Ileostomy tubing completely pulled out of the abdominal cavity\u003c/p\u003e","description":"","filename":"F6.png","url":"https://assets-eu.researchsquare.com/files/rs-3548481/v1/989b01d5d5f29529d22a3130.png"},{"id":46315349,"identity":"5e01ebcd-d55d-48e2-8987-5d2269d885f6","added_by":"auto","created_at":"2023-11-13 04:07:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2379353,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3548481/v1/6b3d4a0e-acb6-4ff7-8379-ddd64fa63b95.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Creation of prestige ileostomy and when Release down: our observation","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIn terms of patient suffering and treatment expenses, colorectal cancer is a disease that affects a significant number of people worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The most effective treatment for rectal cancer is total mesorectal excision (TME), which is associated with a higher overall survival (OS) rate and fewer local and distant recurrences. Sphincter-preserving low anterior resection (LAR) and ultra-low anterior resection (uLAR) are now accepted as standard procedures for rectal cancer because they enable the creation of a primary anastomosis at a lower level [\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].\u003c/p\u003e \u003cp\u003eThe use of permanent stomas after abdominoperineal resection for rectal cancer has recently decreased in favor of sphincter-preserving procedures [ 5]. The most common complication following LAR with TME is still an anastomotic leak (AL). After laparoscopic resection (LAR) for rectal malignancies, a protective stoma is frequently created to prevent AL. The idea was to redirect the fecal stream and keep the anastomosis free of fecal debris, which would reduce the likelihood of leakage. It is arguable whether a dysfunctional stoma stops leaks or only lessens the effects of the leaks [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDivergent opinions exist regarding the appropriateness of creating a faulty stoma for all rectal anastomoses, only the low ones, or none at all. Multiple studies have shown that a malfunctioning stoma reduces the incidence of clinical leakage in colorectal anastomoses [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, other surgeons have reported that covering with a protective stoma did not affect AL or reoperation rates, while some authors have reported no difference in leakage rates but a reduced incidence of reoperation. In addition, many patients have to live with a covering stoma for several months after the primary surgery because of the low clinical priority for reversal, and approximately 20% of patients are left with a permanent stoma due to postoperative complications of anterior resection [\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome studies have reported that stoma reversal is associated with complications in up to 40% of patients.\u003c/p\u003e \u003cp\u003eBriefly, individuals in the low-risk category did not need a stoma, whereas those in the high-risk group would benefit from stoma protection. It is difficult to determine whether to develop a protective covering stoma in patients with a medium risk of all [16,17,18,].\u003c/p\u003e \u003cp\u003eThe concept of ghost ileostomy (GI), also called prestige or virtual ileostomy, avoids the complications associated with covering ileostomy (CI) in patients undergoing low rectal resection and integrates its benefits for intermediate-risk patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis procedure is essentially a pre-stage ileostomy that can be externalized and opened at any time. When anastomotic site leakage occurs in the context of clinical and radiological AL, the GI reaches maturity to complete the CI and redirect the fecal stream. However, GI avoids all the risks associated with an inoperable ileostomy in the event of a smooth postoperative course [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNumerous studies have found that the development of GI in LAR prevents the need for formal CI in \u0026gt;\u0026thinsp;80% of patients with rectal carcinomas [21, 22]. However, none of the articles specified a precise method for releasing or removing the GI tract in 80% of patients for whom formal maturation is not necessary. Moreover, the results of GI release have not been described in any published studies. We also provide a clear and concise explanation of the release of the GI technique in this post along with our firsthand observations of the process.\u003c/p\u003e \u003cp\u003ewe aimed to assess the viability of the GIRD technique in patients with LAR or uLAR with GI for rectal carcinoma, as well as any problems, length of stay in the hospital, operation time\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cp\u003eThis study was conducted at\u0026nbsp; Zagazig University Hospital between October 2019 and July 2020. Only after receiving full and informed consent from each enrolled patient were included in the study. Restorative colorectal resection (LAR and ultra-LAR) for rectal cancer was included in this prospective cohort study. Patients with rectal carcinoma who underwent restorative colorectal resections with ghost (prestige or virtual) ileostomies were included in our cohort. All patients underwent a thorough physical examination and history evaluation before surgery. Preoperative colonoscopic biopsy, carcinoembryonic antigen (CEA) levels, contrast-enhanced computed tomography (CECT) of the abdomen, pelvis, and chest, and magnetic resonance imaging (MRI) of the pelvis were used to confirm the diagnosis and stage of the disease. The factors related to the GI-takedown technique were procedure time, procedural difficulties, intra- or postprocedural problems, and ease of use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial's eligibility and disqualification standards \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeneral selection\u003c/strong\u003e\u003cbr /\u003e \u003cstrong\u003eConditions of inclusion\u003c/strong\u003e\u003cbr /\u003e rectal cancer; elective low anterior resection; \u0026ge;18 years of age.\u003cbr /\u003e signed release of information.\u003cbr /\u003e Capacity to comprehend the personal implications of trial involvement on character\u003cbr /\u003e Criteria for exclusions\u003cbr /\u003e \u0026gt;30 kg/m2 for body mass index.\u003cbr /\u003e Chronic renal failure, defined as a glomerular filtration rate \u0026lt;30 mL/min or dialysis required, is categorized as \u0026gt;3 by the American Society of Anesthesiologists.\u003cbr /\u003e inhibition of the immune system (azathioprine; cortisone \u0026ge;40 mg/day or similar).\u003cbr /\u003e Anticoagulation therapy is necessary.\u003cbr /\u003e Significant cardiac disease includes unstable angina, congestive heart failure that is NYHA class II, unstable angina, and people who have had a myocardial infarction within the previous six months or who have undergone coronary revascularization.\u003cbr /\u003e Any Child-Pugh grade of liver cirrhosis\u003cbr /\u003e Ultralow rectal cancer refers to tumors that require transanal coloanal anastomosis or intersphincteric resection or that have a lower tumor margin \u0026lt;4 cm from the anal edge as determined by digital rectal examination and rigid proctoscopy.\u003cbr /\u003e involvement in a different experiment, including an intervention that could affect the intervention's results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCriteria for intraoperative exclusion\u003c/strong\u003e\u003cbr /\u003e partial rings of staples.\u003cbr /\u003e Positive test for intraoperative air bubbles.\u003cbr /\u003e intraoperative discoveries that, in the judgment of the particular surgeon, render a loop ileostomy necessary (e.g., intraoperative diagnosis of liver cirrhosis, acute or chronic ileus, intraoperative lesion of the rectum, urinary bladder, or vagina).\u003cbr /\u003e Multisegmental excision.\u003c/p\u003e\n\u003cp\u003ePatients with stage I through IV disease were included in the study, according to the American Joint Committee on Cancer criteria for rectal cancer. 23 patients with rectal carcinoma operating in elective settings, representing all age groups and both sexes, were included. Alternatively, the study eliminated patients who underwent emergency surgery due to acute intestinal obstruction, perforation, and peritonitis; furthermore, patients who were on immunosuppressive medications, had stage IV disease, and had significant hypoalbuminemia (serum albumin ~\u0026minus;2.5 g/dl) Furthermore excluded were patients with carcinoma rectum with underlying FAP necessitating TPC with IPAA, patients requiring restorative colorectal resections for benign illnesses, and patients having formal CI or no stoma. This study also did not include patients with GI who required an anastomotic leak to mature after surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe surgical procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing a phantom ileostomy as an experimental intervention. Once the anastomosis is constructed and tested in the air, the terminal ileum, the last loop of the small bowel, will be found. The assigned ghost ileostomy site will have a mesenteric window made, and a silicone loop will be inserted through the window and around the small bowel. A serosal, non-absorbing suture will be used to mark the oral section of the ileum around 1-2 cm proximally to the silicone loop for proper bowel orientation in their host ileostomy to be exteriorized. In ordain the colon below the abdominal fascia without any stress, the silicone loop will be exteriorized at the preoperatively indicated, designated ileostomy position through a stab incision and attached to the skin using a rod and non-absorbing sutures. The abdominal cavity will then be sutured along with the exteriorized silicone loop and all incisions, including the midline and laparoscopic incisions, and covered with sterile dressings. Figure 1 shows a schematic example of a ghost ileostomy,\u003cbr /\u003e schematic representation of a ghost ileostomy. In (A), the silicone loop is carried around the terminal ileum, and in (B), the silicone loop is exteriorized, leaving the terminal ileum naturally intra-abdominal.\u003cbr /\u003e Before the silicone loop was removed on postoperative day six, Figure 2 shows a photograph of a patient who had a ghost ileostomy.\u003cbr /\u003e For any indication of anastomotic leakage, patients will be closely observed. Signs of anastomotic leakage can be palpated or detected radiologically. Other clinical and laboratory signs include fever, abdominal guarding, peritonism, air/fecal/turbid discharge from the intra-abdominal drains, leucocytosis, or elevated C reactive protein values that indicate a deviation from the expected postoperative course. An operating room procedure will be performed under general anesthesia to exteriorize the ghost ileostomy in a patient if anastomotic leakage is suspected. A long cylinder of skin and subcutaneous tissue will be removed next to the silicone loop, just like with a traditional ileostomy. Like a traditional ileostomy, the ventral and dorsal sheaths of the abdominal fascia will be cut, and the terminal ileum will be exteriorized by gently pulling on the silicone loop. Using circular everting sutures in the standard manner\u0026mdash;that is, without causing torsion on the mesentery or bowel\u0026mdash;the proximal segment of the small bowel will be identified by the serosal suture that was placed during primary surgery. If feasible, the oral ileal limb will be placed caudally to create the stoma in the correct orientation. The last step will be to implant an ileostomy bag.\u003cbr /\u003e By the standard clinical judgments of the treating physicians and the clinical course of any patient with suspected anastomotic leakage, additional diagnostic (proctoscopy, CT scan) or treatments (interventional drainage) will be carried out.\u003cbr /\u003e At the bedside on postoperative days 5\u0026ndash;10, the silicone loop will be withdrawn if there are no indications of anastomotic leakage following ghost ileostomy, the patient has regular bowel movements, and they are fed exclusively through oral syringes.\u003cbr /\u003e Load ileostomy as a control measure The final loop of the small intestine, or terminal ileum, will be identified in the same way as in the experimental group following anastomosis creation and air testing. Around the small bowel, a silicone loop will be passed through the mesenteric window that has been established at the appropriate ileostomy loop. Skin and subcutaneous tissue will be removed in the form of a longitudinal cylinder for conventional ileostomies. A cut that allows two fingers to easily pass through the opening will be made in the ventral and dorsal sheaths of the abdominal fascia. Next, exteriorization of the ileal loop will occur. The ileal limb of the oral cavity will be positioned caudally, if feasible, and the stoma will be constructed in the proper orientation using circular everting sutures in the conventional method, meaning that there will be no torsion on the gut or mesentery. The last step will be to implant an ileostomy bag.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplementary therapies and approved or prohibited therapies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParenteral feeding, antimicrobial therapy, and relaparotomy are a few examples of concurrent or essential treatments that will be carried out at the treating physicians' discretion and by regional norms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial endpoints and data gathering\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor each patient, the following demographic and baseline data will be recorded: Age (years), gender (male/female), height (cm), weight (kg), class of the American Society of Anesthesiologists, histologically proven carcinoma (yes/no), bowel obstruction (yes/no), rectal bleeding/anemia (yes/no), level of\u0026nbsp;\u0026nbsp; tumor resection high or low resection, neoadjuvant therapy (yes/no), and relevant medical history (cardiac, pulmonary, renal, hepatic, diabetes) as well as previous imaging studies (CT/MRI/endoscopic ultrasound).\u003cbr /\u003e After confirming that the intraoperative exclusion criteria have been met, the following information will be collected during the procedure: the length of time (in minutes), the surgeon's experience (\u0026gt; or \u0026le;50 low anterior or high resections prior\u0026nbsp; ), the amount of blood lost during the procedure (in milliliters), whether or not intraoperative blood transfusions are performed, and the quantity of packed red blood cells.\u003cbr /\u003e In this experiment, the Comprehensive Complication Index (CCI) will be the primary outcome measure. Per the established Clavien-Dindo classification, the CCI provides an individual patient-level summary of all postoperative complications based on their severity grade. The complications range from mild ones that do not deviate from the normal clinical course (grade I) to postoperative death (grade V) [22]. The first hospital stay as well as the first three and six months following surgery will be used in calculating the CCI. AlsoFollowing surgery, patients need to be closely observed in a clinical setting, with particular attention paid to the patient's pulse, blood pressure, breathing rate, temperature, abdominal distension or pain, and drain contents. Every patient should have a full blood count and a C-reactive protein assay sent on the third postoperative day (POD) to screen for sepsis or, more indirectly, AL. Limited-contrast radiography is frequently carried out postoperatively. On the fifth and seventh postpartum days, abdominal and pelvic ultrasonography is performed to rule out any collections in the abdomen or pelvis. After administering water-soluble contrast directly above the anal canal, a contrast X-ray of the pelvis might be performed if any collection is observed to rule out any major contrast leak at the anastomotic location. An abdomen and pelvic CT scan should be done if the X-ray shows substantial AL\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReexamination.\u003c/strong\u003e\u003cbr /\u003e terminal ostomy, such as abdominoperineal extirpation or Hartmann's technique.\u003cbr /\u003e The term \"intra-abdominal abscess\" refers to the collection of purulent or infected fluid within the abdomen (positive microbiological culture), which can be seen during surgical reintervention, interventional drainage, or typical radiographic abnormalities (such as a CT scan).\u003cbr /\u003e drainage by intervention.\u003cbr /\u003e The intended adjuvant or perioperative chemotherapy has been finished.\u003cbr /\u003e Patients six months post-initial surgery with stomas (terminal or loop)\u003cbr /\u003e difficulties arising from stomas...\u003cbr /\u003e Erythema, cutaneous excoriation, induration, putrid collection, and/or wound, abscess, or ulceration near the ileostomy that causes pain, burning, and trouble placing the ileostomy bag are all considered peristomal wound conditions.\u003cbr /\u003e hernia posteriore.\u003cbr /\u003e Clinical symptoms of dehydration and/or impaired kidney function combined with an ileostomy output of over 1500 mL per day necessitate the replacement of fluids through intravenous means.\u003cbr /\u003e As per the KDIGO definition, acute renal damage [24].\u003cbr /\u003e extra difficulties connected to the stoma.\u003cbr /\u003e after ileostomy closure complications.\u003cbr /\u003e leaks from anastomosis.\u003cbr /\u003e More than one of the following characteristics can indicate a prolonged postoperative ileus:\u003cbr /\u003e vomiting or nausea.\u003cbr /\u003e over the previous 24 hours, an inability to handle an oral diet\u003cbr /\u003e For the past 24 hours, there has been no flatus or stool.\u003cbr /\u003e abdominal distension.\u003cbr /\u003e via the use of radiography.\u003cbr /\u003e breaking of the wound.\u003cbr /\u003e Centers for Disease Control and Prevention: surgical site infection, [25]\u003cbr /\u003e belly rupture (abdominal fascia dehiscence).\u003cbr /\u003e hernia incisional.\u003cbr /\u003e and 6 years following surgery 27, 28,\u003cbr /\u003e Getting By.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial visit descriptions and patient schedules\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn-hospital admission day, or outpatient consultation, is when patients scheduled for elective LAR/TME will be screened. The aforementioned baseline data will be evaluated and recorded following a patient's written informed consent and the screening appointment, which validate that the patient meets all eligibility requirements.\u003cbr /\u003e upon the authorization of staff (visit 2), randomization will take place during surgery upon verification of intraoperative eligibility conditions. The intraoperative parameters that were\u0026nbsp; discussed will be evaluated on this appointment. Patients are monitored for six months following LAR/TME, with follow-up appointments set for postoperative days three and seven (visits three and four), 14/day of discharge (visit five), as well as one, three, and six months after surgery (visits six, seven, and eight). sessions 7-8 will take place over the phone or as part of follow-up outpatient sessions. Endpoints, both primary and secondary, are evaluated and recorded at postoperative visits. Additional evaluation and documentation will be done for therapeutic and diagnostic procedures brought on by surgical problems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1\u0026nbsp;\u003c/strong\u003eAn instance of the phantom ileostomy schematically The terminal ileum is wrapped in a silicone loop in option (A) or exteriorized in option (B), leaving the terminal ileum tension-free intra-abdominal[20]..\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFigure 2\u0026nbsp;\u003c/u\u003e\u003c/strong\u003eBefore the silicone loop was removed on the sixth surgical day, this patient had a ghost ileostomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe technique of Release Down of Ghost Ileostomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll carcinoma rectum patients in this study underwent TME resection (LAR/uLAR) with an adequate circumferential resection margin (CRM), distal and proximal margins followed by colorectal/coloanal end-to-end or end-to-side anastomosis using the circular staplers or hand sewn techniques. After completion of the anastomosis, a protective GI was fashioned. In restorative rectal resections, this process averts the necessity and complications of formal CI in \u0026gt; 80% of patients with carcinomas.\u003c/p\u003e\n\u003cp\u003eHowever, the GI needs to be released before patients are discharged after surgery. Typically, a 10 to 12 Fr Ryle tube or Foley catheter is used to secure the GI loop. The removal of this hanging Ryle tube loop (or any other hanging material) from the abdominal cavity to release the tucked ileal loop is referred to as the 'release down' of the GI. In this regard, it is necessary to ascertain that the patient had no anastomotic leak (AL) before performing the GIRD. After confirming by clinical and radiological assessments that there is no AL, the tubing needs to be removed from the abdominal cavity (Figs. 3 and 4 Keep the patient in a supine position on their bed in the postoperative ward.\u003c/p\u003e\n\u003cp\u003eCare is taken to maintain privacy by uncovering the area of the GI (usually the right iliac fossa region).\u003c/p\u003e\n\u003cp\u003eGain the patient's confidence in the procedure by providing reassurance, explaining the procedure to them, and seeking consent to proceed.\u003c/p\u003e\n\u003cp\u003eAfter donning the sterile surgical gloves, apply betadine paint on the GI tubing and the skin around it . There was no need to use any local anesthetic.\u003c/p\u003e\n\u003cp\u003eCut the fixing suture of the GI tube to free it from the surrounding skin\u003c/p\u003e\n\u003cp\u003eSlightly pull both limbs of the tubing (Fig. 5) and cut one limb deeper into the skin with scissors. The other end of the tubing was gently pulled from the abdominal cavity to release the already-tucked ileal loop and).\u003c/p\u003e\n\u003cp\u003eClean the wound area and apply a small antiseptic dressing (Fig. 6). At the end of the procedure, the patient was reassured and congratulated to be free from the misery and morbidities of the formal covering stoma.\u003c/p\u003e\n\u003cp\u003eafter ensuring that there are no complications and bowel movements are normal.:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig\u003c/strong\u003e\u003cstrong\u003eure 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinal external appearance of ghost ileostomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig\u003c/strong\u003e\u003cstrong\u003eure 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinal internal appearance of ghost ileostomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig\u003c/strong\u003e\u003cstrong\u003eure 5\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCut one limb of tubing with scissors\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure\u003c/strong\u003e\u003cstrong\u003e 6\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGhost Ileostomy tubing completely pulled out of the abdominal cavity\u003c/p\u003e\n\u003cp\u003eFollowing the procedure, patients were monitored in the outpatient department weekly at first, then every two weeks for a month, to check for any problems, morbidity, and death.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalytical Statistics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter compiling and statistically analyzing the data, conclusions were drawn from the findings of the analysis.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAfter the patients, as specified in the exclusion criteria in the Methods section, were eliminated, a total of 33 patients underwent LAR/uLAR with GI for rectal cancer during this roughly 2-year study period. Six (18%) patients required GI tract maturation (exteriorization) to establish a formal loop ileostomy due to a postoperative anastomotic leak. After receiving mechanical respiration and resuscitation, a patient who had experienced cardiopulmonary arrest and paroxysmal supraventricular tachycardia (PSVT) on zero POD passed away.\u003c/p\u003e \u003cp\u003eThus, the final statistical analysis included only 26 individuals who required release from the gastrointestinal system. In this study, the male-to-female ratio was 11:15, indicating that there were slightly more females than males. The age range of patients was 19\u0026ndash;75 years, with an average age of 54.84 years. The patients' average body mass index (BMI) was 26.31 kg/m2, with a range of 19.53 to 33.46.\u003c/p\u003e \u003cp\u003eASA grade I was present in 12 patients, ASA grade II in 13, and ASA grade III in one. The GI of the 26 patients' GIs was ascertained using the previously mentioned technical procedures. Patients were not administered the GIRD technique until they demonstrated postoperative bowel motions. It was done with a mean of 9.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.25 days, between the 7th and 16th PODs following initial surgery.\u003c/p\u003e \u003cp\u003eThe majority of patients (22), who had surgery for rectal malignancy while hospitalized, had their GI freed at the same time. It was usually performed approximately a day before the patient was released from the hospital. In contrast, in four cases, the patient's GI was released at the initial follow-up appointment. In all patients, the GI tract was successfully released without the need for any further surgeries or incisional wounds. No further analgesics or injections of local anesthesia were required for any of the patients. The GI release process took five minutes on average, and none of the patients had any serious complications.\u003c/p\u003e \u003cp\u003eNo postprocedural issues emerged immediately. Even though no local anesthetic solution was utilized, none of the patients reported experiencing any pain or discomfort during or after GIRD. Not a single patient's GI tubing became stuck during removal. At the GI site, there was no evidence of internal or external bleeding. Following removal, there was no severe surgical site infection (SSI) at the gastrointestinal (GI) tube location. Following a month of observation, there was no formation of unsightly scars, and the scar at the location of the GI tubing was less than that at the abdominal drain. Peritonitis, mesenteric hemorrhage or hematoma formation, mesenteric damage, mesenteric torsion, intestinal obstruction, and GI ileal loop injury were not observed in any of the patients during or after the procedure.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eA protective stoma may have drawbacks, such as the requirement for a second procedure, an extended hospital stay, difficulties from the ostomy, and a significant chance of anastomotic leakage when the stoma is removed. Furthermore, patients find it difficult to accept the establishment of a stoma, which causes additional psychological stress to both patients and caretakers. Consequently, the advantages of a protective stoma in lowering the incidence of AL must be weighed against the morbidity associated with its implantation and closure.24- In colorectal anastomosis, the overall incidence of clinical leak is 8% [\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Therefore, the use of a covering stoma provides little to no clinical utility for the vast majority of patients (92%) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], Shiomi et al. conducted a propensity-matched scoring analysis of almost 1000 patients who had low anterior resection, and their findings demonstrating that while a failing ileostomy does not directly affect the rate of clinical anastomotic leak, it does lessen its effects and the necessity for immediate reoperation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGI is a relatively new concept that connects CI in LAR without requiring an ileostomy. This saves the day for any operating surgeon who can be undecided about the CI. CI is an option for patients with AL with low- or medium-risk conditions. In summary, GI is the best option if the anastomosis is risk-free but still requires vigilance because it involves no extra risk and can be converted completely safely and with extreme ease, if necessary. In conclusion, GI guards against issues caused by an ileostomy that does not work properly. Essentially, it is an externalized prestige ileostomy that can be used whenever necessary [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]].\u003c/p\u003e \u003cp\u003eWhen GI is created in LAR for patients with rectal cancer, it combines the benefits of CI without causing any problems. When GI is created in comparison to formal CI, it has fewer side effects, shorter length of hospital stay, lower degree of total morbidity, and superior quality of life [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to several recent studies, more than 80% of patients with rectal cancer may avoid formal CI if GI is established after LAR (22, 29, 21, 22). Nevertheless, in 80% of individuals for whom formal maturation is not necessary, none of the publications explain how to remove or release the GI. In our investigation of 26 individuals who underwent GI restorative resection, we provided a clear and concise explanation of this type of ileostomy.\u003c/p\u003e \u003cp\u003eMoreover, the results of the GIRD method have not been described in any published studies. In our initial experience, we discovered that the GIRD is rapid, safe, and easy to use. It can be performed at the patient's bedside and does not require the use of additional analgesics or local anesthetics. After this treatment, which took place around the tenth postpartum day, none of the patients experienced any GI site issues. Moreover, none of our patients had any problems with their abdomens or peritoneum during or after surgery.\u003c/p\u003e \u003cp\u003eIn a prospective study involving 45 patients, Gull\u0026agrave; et al.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] performed protective ileostomies in 27 patients (CS group) and prestige ileostomies in 18 patients (GI group). When compared to covering a stoma, the authors concluded that GI is viable because it is associated with a lower degree of total morbidity, shorter recovery period, and superior quality of life for both patients and caregivers. Additionally, they proposed that GI might be necessary in some patients who did not exhibit high-risk characteristics but needed to proceed cautiously with AL for low-level colorectal anastomosis. Consequently, GI should be considered as a substitute for traditional ileostomy. They also reported that, in all GI groups with uncomplicated postoperative courses, GI closure was performed under local anesthesia on POD 10 to 15 following a negative contrast enema [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmbe et al. (2018) conducted a study in which a virtual ileostomy was performed between POD 7 and 9. The study revealed that all patients experienced smooth surgical recovery [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLago et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] reported a modified posterior pelvic exenteration approach linked with GI in the treatment of advanced ovarian cancer and found that GI may offer benefits in the case of AL, in addition to preventing complications due to malfunctioning ileostomy. Moreover, the GI loop was not removed until the patient was discharged from the hospital (i.e., on the sixth or ninth postoperative day) if the postoperative course was uneventful. In their investigation, Francesco et al.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] also found that no GI patients had problems at the surgical location.\u003c/p\u003e \u003cp\u003eMancini et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] conducted a study involving 36 patients with rectal cancer who underwent GI and low rectal resection. None of the patients experienced any local GI problems. Additionally, it has been reported that the GI was removed on POD 10 following a negative contrast enema in the context of an uneventful postoperative course. The authors concluded that the GI loop may be removed by simply cutting the tape if the postoperative course was smooth, and there was no requirement for the GI to mature into a formal CI.\u003c/p\u003e \u003cp\u003e In this area, we share our GI experience and propose application guidelines. Our research indicates that GI functions as a bridge between continuous ileostomy and continuous ileostomy. When the GI and CI groups were compared, the former demonstrated higher rates of stoma-free patient lifetimes, shorter mean operating times, lower overall morbidity rates, and decreased overall hospital stay. Remarkably, over 45 percent of the patients in the GI group did not undergo formal ileostomy.\u003c/p\u003e \u003cp\u003eWhen there is a possibility of AL after restorative colorectal resections and the surgeon on the operating table does not believe that a covering ileostomy is necessary, GI is a good alternative option and can be constructed in the following situations: advanced gynecological cancers requiring pelvic exenteration with resection-anastomosis of the rectum [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], discovering metastatic cancer during surgery, repair surgeries for benign diseases such as diverticulitis, diverticulosis, and resection rectopexy, and left hemicolectomy for cancers of the left colon if the patient is malnourished and has other high-risk factors for AL.\u003c/p\u003e \u003cp\u003eAlthough there is no strict prohibition on GI procedures carried out in elective settings, patients with a high Colon Leakage Score and many risk factors for AL should be treated with formal ileostomy. Patients with severe hypoalbuminemia (serum albumin 2.5 g/dl), malnutrition, acute bowel obstruction, perforation, and peritonitis, patients on steroids and immunosuppressive medications, patients with ulcerative colitis requiring total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA), and patients with severe risk factors for AL or those undergoing emergency surgery should avoid the GI.\u003c/p\u003e \u003cp\u003eEven though there have been a few occurrences of GI in patients with FAP, it is better to cover these patients with a covering ileostomy because the AL in these patients may increase the risk of pouch excision and pouch failure (16).\u003c/p\u003e \u003cp\u003eExcept the six patients who had formal loop ileostomy, our study did not identify any significant issues; however, the surgeon should be aware of the potential for the following complications or at least be alert to their early detection: the kink in the ileal loop or the tightly fixed Ryle's tubing loop can obstruct the intestines or result in bleeding in the mesentery; the ileal vasculature can be compressed, leading to chronic ischemia of the ileal loop and the development of strictures; and the ileal loop can be challenging due to adhesions during maturation, and internal bleeding may occur.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn more than 80 percent of cases with LAR, ultra-LAR, or AR, GI hinders the creation of an authentic covering loop ileostomy. By providing a buffer between covering an ileostomy and not covering it, the GI concept saves the surgeon from a situation in which they are unsure of what to do. As an alternative to ileostomy surgery, this is available to patients with a low to medium risk of AL.\u003c/p\u003e \u003cp\u003eAfter our first experience, we concluded that GIRD is a rapid, easy, and safe treatment that is performed around the tenth POD. It can be easily performed without the use of analgesics or local anesthesia at the patient's bedside. During or after the procedure, none of the patients had peritoneal or abdominal issues or problems at the GI site. In conclusion, GI is the best option if anastomosis is risk-free, but still requires attention because it involves no extra risk and can be released completely safely and painlessly without the requirement for postprocedural care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment is\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration and ethical clearance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from Zagagic University, Faculty of Medicine, Institutional under No. ( (ethical protocol number: ZU-IRB# 9902792023). Written informed consent was obtained from all the patients in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e is not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials: a\u003c/strong\u003e database is available to the corresponding author. This database is available for review and request. All authors have shared the database.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests or financial\u003c/p\u003e\n\u003cp\u003edisclosures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo specific funds were received for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Affilatiion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHassan A. Saad\u0026sup1;,\u003c/p\u003e\n\u003cp\u003eAzza Baz\u0026sup2;,\u003c/p\u003e\n\u003cp\u003eMohamed Riad\u0026sup1;,\u003c/p\u003e\n\u003cp\u003eMohamed E Eraky\u0026sup1;,,\u003c/p\u003e\n\u003cp\u003eMohamed I Farid\u0026sup1;,\u003c/p\u003e\n\u003cp\u003eKhaled Sharaf\u0026sup1;\u003c/p\u003e\n\u003cp\u003eAhmed El-Taher\u0026sup1;\u003c/p\u003e\n\u003cp\u003eAhmed Salah Arafa\u0026sup1;\u003c/p\u003e\n\u003cp\u003e\u0026sup1;Surgical Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt.\u003c/p\u003e\n\u003cp\u003e\u003cbr /\u003e \u0026sup2;Surgical Department, Alahrar Teaching Hospital, Zagazig University, Zagazig City, Egypt\u003c/p\u003e\n\u003cp\u003eThree \u0026sup3;Clinical Pathology Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt\u003c/p\u003e\n\u003cp\u003eCorresponding author: Hassan A. Saad, Telephone: (+20) 01221025689, ORCID:0000-0002-6242-7823. E-mail: [email protected]\u003cbr /\u003e\u003cbr /\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHAS, ME: contributed to the conception and design of\u003c/p\u003e\n\u003cp\u003eMR. AKE organised the database and\u003c/p\u003e\n\u003cp\u003eperformed the statistical analysis.\u003c/p\u003e\n\u003cp\u003eHAS,KS,ASA: wrote sections of the manuscript\u003c/p\u003e\n\u003cp\u003eand prepared tables.\u003c/p\u003e\n\u003cp\u003eMIF, AB,: contributed to the manuscript.\u003c/p\u003e\n\u003cp\u003erevision and investigation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors read, approved, and equally shared the submitted version\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEnker WE. Total mesorectal excision\u0026ndash;the new golden standard of surgery for rectal cancer. Ann Med 1997;29(02):127\u0026ndash;133\u003c/li\u003e\n\u003cli\u003eHeald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997. Arch Surg 1998;133(08):894\u0026ndash;899\u003c/li\u003e\n\u003cli\u003eKapiteijn E, Marijnen CAM, Nagtegaal ID, et al; Dutch Colorectal Cancer Group. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345(09):638\u0026ndash;646\u003c/li\u003e\n\u003cli\u003eGriffen FD, Knight CD Sr, Whitaker JM, Knight CD Jr. The double stapling technique for low anterior resection. Results, modifications, and observations. Ann Surg 1990;211(06):745\u0026ndash;751, discussion 751\u0026ndash;752\u003c/li\u003e\n\u003cli\u003eMehraj A, Chowdri NA, Nanda S, et al. Validity of APR in the Era of Sphincter Saving Procedures for Low Rectal Cancers. EC Gastroenterology and Digestive System 2018;5(03):152\u0026ndash;159\u003c/li\u003e\n\u003cli\u003eChude GG, Rayate NV, Patris V, et al. Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology 2008;55(86-87):1562\u0026ndash;1567\u003c/li\u003e\n\u003cli\u003eTan WS, Tang CL, Shi L, Eu KW. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 2009; 96(05):462\u0026ndash;472\u003c/li\u003e\n\u003cli\u003eMatthiessen P, Hallb\u0026ouml;\u0026ouml;k O, Ruteg\u0026aring;rd J, Simert G, Sj\u0026ouml;dahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007;246(02):207\u0026ndash;214\u003c/li\u003e\n\u003cli\u003eBakx R, Busch OR, Bemelman WA, Veldink GJ, Slors JF, van Lanschot JJ. Morbidity of temporary loop ileostomies. Dig Surg 2004;21(04): 277\u0026ndash;281[PMID: 15308867 DOI: 10.1159/000080201]\u003cbr /\u003e\u0026raquo; https://doi.org/10.1159/000080201\u003c/li\u003e\n\u003cli\u003eCipe G, Erkek B, Kuzu A, Gecim E. Morbidity and mortality after the closure of a protective loop ileostomy: analysis of possible predictors. Hepatogastroenterology 2012;59(119):2168\u0026ndash;2172 [PMID: 22440245 DOI: 10.5754/hge12115]\u003cbr /\u003e\u0026raquo; https://doi.org/10.5754/hge12115\u003c/li\u003e\n\u003cli\u003eHallb\u0026ouml;\u0026ouml;k O, Matthiessen P, Leinsk\u0026ouml;ld T, Nystr\u0026ouml;m PO, Sj\u0026ouml;dahl R. Safety of the temporary loop ileostomy. Colorectal Dis 2002;4 (05):361\u0026ndash;364[PMID: 12780582]\u003c/li\u003e\n\u003cli\u003eKaiser AM, Israelit S, Klaristenfeld D, et al. Morbidity of ostomy takedown. J Gastrointest Surg 2008;12(03):437\u0026ndash;441[PMID: 18095033 DOI: 10.1007/s11605-007-0457-8]\u003cbr /\u003e\u0026raquo; https://doi.org/10.1007/s11605-007-0457-8\u003c/li\u003e\n\u003cli\u003eLaurent C, Nobili S, Rullier A, Vendrely V, Saric J, Rullier E. Efforts to improve local control in rectal cancer compromise survival by the potential morbidity of optimal mesorectal excision. J Am Coll Surg 2006;203(05):684\u0026ndash;691[PMID: 17084330 DOI: 10.1016/j. jamcollsurg.2006.07.021]\u003cbr /\u003e\u0026raquo; https://doi.org/10.1016/j.jamcollsurg.2006.07.021\u003c/li\u003e\n\u003cli\u003eLaw WL, Chu KW, Choi HK. Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision. Br J Surg 2002;89(06):704\u0026ndash;708 [PMID: 12027979 DOI: 10.1046/ j.1365-2168.2002.02082.x]\u003cbr /\u003e\u0026raquo; https://doi.org/10.1046/ j.1365-2168.2002.02082.x\u003c/li\u003e\n\u003cli\u003evan Westreenen HL, Visser A, Tanis PJ, Bemelman WA. Morbidity related to defunctioning ileostomy closure after ileal pouch-anal anastomosis and low colonic anastomosis. Int J Colorectal Dis 2012;27(01):49\u0026ndash;54[PMID: 21761119 DOI: 10.1007/s00384-011-1276-7]\u003cbr /\u003e\u0026raquo; https://doi.org/10.1007/s00384-011-1276-7\u003c/li\u003e\n\u003cli\u003e\u0026Aring;kesson O, Syk I, Lindmark G, Buchwald P. Morbidity related to defunctioning loop ileostomy in low anterior resection. Int J Colorectal Dis 2012;27(12):1619\u0026ndash;1623\u003c/li\u003e\n\u003cli\u003eFloodeen H, Lindgren R, Matthiessen P. When are defunctioning stomas in rectal cancer surgery really reversed? Results from a population-based single center experience. Scand J Surg 2013; 102(04):246\u0026ndash;250\u003c/li\u003e\n\u003cli\u003eLindgren R, Hallb\u0026ouml;\u0026ouml;k O, Ruteg\u0026aring;rd J, Sj\u0026ouml;dahl R, Matthiessen P. What is the risk for a permanent stoma after low anterior resection of the rectum for cancer? A six-year follow-up of a multicenter trial. Dis Colon Rectum 2011;54(01):41\u0026ndash;47\u003c/li\u003e\n\u003cli\u003eKhan MA, Chowdri NA, Wani RA, et al. Technique of Ghost (Khatith) Ileostomy: Our Experience and Guidelines. Ann Colorectal Res. 2021; 9(02):51\u0026ndash;57. Doi: 10.30476/ACRR.2021.89835.1082\u003cbr /\u003e\u0026raquo; https://doi.org/10.30476/ACRR.2021.89835.1082\u003c/li\u003e\n\u003cli\u003eMiccini M, Amore Bonapasta S, Gregori M, Barillari P, Tocchi A. Ghost ileostomy: real and potential advantages. Am J Surg 2010; 200(04):e55\u0026ndash;e57. Doi: 10.1016/j.amjsurg.2009.12.017\u003cbr /\u003e\u0026raquo; https://doi.org/10.1016/j.amjsurg.2009.12.017\u003c/li\u003e\n\u003cli\u003eSacchi M, Legge PD, Picozzi P, Papa F, Giovanni CL, Greco L. Virtual ileostomy following TME and primary sphincter-saving reconstruction for rectal cancer. Hepatogastroenterology 2007;54(78):1676\u0026ndash;1678\u003c/li\u003e\n\u003cli\u003eFlor-Lorente B, S\u0026aacute;nchez-Guill\u0026eacute;n L, Pellino G, et al. \u0026ldquo;Virtual ileostomy\u0026rdquo; combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report. Langenbecks Arch Surg 2019;404(03):375\u0026ndash;383. Doi: 10.1007/s00423-019-01776-z\u003cbr /\u003e\u0026raquo; https://doi.org/10.1007/s00423-019-01776-z\u003c/li\u003e\n\u003cli\u003eEdge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol 2010;17(06):1471\u0026ndash;1474\u003c/li\u003e\n\u003cli\u003ePakkastie TE, Ovaska JT, Pekkala ES, Luukkonen PE, J\u0026auml;rvinen HJ. A randomised study of colostomies in low colorectal anastomoses. Eur J Surg 1997;163(12):929\u0026ndash;933\u003c/li\u003e\n\u003cli\u003eHautefeuille P, Valleur P, Perniceni T, et al. Functional and oncologic results after coloanal anastomosis for low rectal carcinoma. Ann Surg 1988;207(01):61\u0026ndash;64\u003c/li\u003e\n\u003cli\u003eShiomi A, Ito M, Maeda K, et al. 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. J Am Coll Surg 2015;220(02): 186\u0026ndash;194\u003c/li\u003e\n\u003cli\u003eGull\u0026agrave; N, Trastulli S, Boselli C, et al. Ghost ileostomy after anterior resection for rectal cancer: a preliminary experience. Langenbecks Arch Surg 2011;396(07):997\u0026ndash;1007\u003c/li\u003e\n\u003cli\u003eMori L, Vita M, Razzetta F, Meinero P, D\u0026rsquo;Ambrosio G. Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile? Dis Colon Rectum 2013;56(01):29\u0026ndash;34\u003c/li\u003e\n\u003cli\u003eKhan MA, Chowdri NA, Parray FQ, et al. Role of ghost ileostomy in low anterior resection for carcinoma rectum. ANZ J Surg 2021;91 (05):1039\u0026ndash;1039. Doi: 10.1111/ans.16573\u003cbr /\u003e\u0026raquo;https://doi.org/10.1111/ans.16573\u003c/li\u003e\n\u003cli\u003eAmbe PC, Zirngibl H, M\u0026ouml;slein G. Routine Virtual Ileostomy Following Restorative Proctocolectomy for Familial Adenomatous Polyposis. World J Surg 2018;42(06):1867\u0026ndash;1871. Doi: 10.1007/ s00268-017-4365-0\u003cbr /\u003e\u0026raquo; https://doi.org/10.1007/s00268-017-4365-0\u003c/li\u003e\n\u003cli\u003eLago V, Domingo S, Matute L, Padilla P, Flor B, Garc\u0026iacute;a-Granero \u0026Aacute; Ghost ileostomy in advanced ovarian cancer. Gynecol Oncol 2017; 147(02):488. Doi: 10.1016/j.ygyno.2017.08.017\u003cbr /\u003e\u0026raquo; https://doi.org/10.1016/j.ygyno.2017.08.017\u003c/li\u003e\n\u003cli\u003eMari FS, Di Cesare T, Novi L, et al. Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial. Surg Endosc 2015;29(09):2590\u0026ndash;2597. Doi: 10.1007/s00464-014-3974-z\u003cbr /\u003e\u0026raquo; https://doi.org/10.1007/s00464-014-3974-z\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":"Phantom ileostomy, Release of ghost ileostomy, Low anterior resection, Rectal cancer","lastPublishedDoi":"10.21203/rs.3.rs-3548481/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3548481/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ebackground\u003c/h2\u003e \u003cp\u003eThe benefits of ghost ileostomy (GI) in avoiding formal covering ileostomies in \u0026gt;\u0026thinsp;80% of cancer patients have been documented in numerous studies. However, none of the articles explained precisely how the GI tract was removed in the end in 80% of patients for whom formal maturation was not necessary.\u003c/p\u003e\u003ch2\u003eGoal\u003c/h2\u003e \u003cp\u003eTo describe and evaluate the GIRD technique, including possible issues, hospital stays, and procedure times, for patients with GI for rectal carcinoma who underwent low anterior resection (LAR/uLAR) or ultra-low anterior resection (LAR/uLAR).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this prospective cohort study, patients underwent restorative colorectal resection with GI for rectal cancer. Patients\u0026rsquo; ease of GI release and any problems that might arise were then examined. Information was gathered, examined, and deduced.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe final statistical analysis included 26 patients who required GIRD. Between the seventh and sixteenth postoperative days (POD), treatment was performed, all patients recovered well, and no additional surgeries were required. No further analgesics or injections of local anesthesia were required for any of the patients. The surgery took an average of five minutes, and none of the patients experienced any notable difficulties with GI release. No post-procedural issues emerged.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWithout the need for anesthesia or additional analgesics, the GIRD approach is a rapid, easy, and safe operation that can be performed at the patient's bedside around the tenth POD.\u003c/p\u003e","manuscriptTitle":"Creation of prestige ileostomy and when Release down: our observation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-08 13:07:02","doi":"10.21203/rs.3.rs-3548481/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":"8750ef2d-d335-4b10-9e44-20ccce6c827f","owner":[],"postedDate":"November 8th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-11-13T03:59:27+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-08 13:07:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3548481","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3548481","identity":"rs-3548481","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}