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Abstract
ABSTRACTLoop ileostomy is an effective procedure to protect downstream intestinal anastomoses. Ileostomy reversal surgery is often performed within 12 months of formation but is associated with substantial morbidity due to severe post-surgical complications. Distal ileum is deprived of enteral nutrition and rendered inactive, often becoming atrophied and fibrotic. This study aimed to investigate the microbial and morphological changes that occur in the defunctioned ileum following loop ileostomy-mediated fecal stream diversion. Functional and defunctioned ileal resection tissue was obtained at the time of loop-ileostomy closure. Intrapatient comparisons, including histological assessment of morphology and epithelial cell proliferation, were performed on paired samples using the functional limb as control. Mucosal-associated microflora was quantified via determination of 16S rRNA gene copy number using qPCR analysis. DGGE with Sanger sequencing and qPCR methods profiled microflora to genus and phylum level, respectively. Reduced villous height and proliferation confirmed atrophy of the defunctioned ileum. DGGE analysis revealed that the microflora within defunctioned ileum is less diverse and convergence between defunctioned microbiota profiles was observed. Candidate Genera, notably Clostridia and Streptococcus, reduced in relative terms in defunctioned ileum. We conclude that Ileostomy-associated nutrient deprivation results in dysbiosis and impaired intestinal renewal in the defunctioned ileum. Altered host-microbial interactions at the mucosal surface likely contribute to the deterioration in homeostasis and thus may underpin numerous postoperative complications. Strategies to sustain the microflora before reanastomosis should be investigated.
Highlights
Loop ileostomy formation is often performed to reduce septic complications in patients who have undergone extensive bowel surgery
Loop ileostomy formation gives rise to 2 contrasting nutritional environments; the proximal ileum remains functional with nutrient and water absorption occurring at the mucosal surface from peristaltic-motioned chyme, while the distal ileum is deprived of luminal contents and rendered inactive
We confirmed that intestinal atrophy occurs following loop ileostomy-mediated defunctioning (Fig. 2A)
Summary
Loop ileostomy formation is often performed to reduce septic complications in patients who have undergone extensive bowel surgery. It is most frequently formed following surgical resection in colorectal carcinoma patients to prevent leakage of distal anastomosis, sepsis and the requirement for urgent repeat operation. It functions to protect downstream anastomoses via temporary fecal stream diversion through the abdominal wall. In addition to the inconvenience of a second operation for loop closure, the reversal procedure is associated with a substantial morbidity of around 20%.2-5 Small bowel obstruction and anastomotic leakage are the most common post-surgical complications with respective incidence rates up to 22% and 10%.2,6
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