Temporary loop versus end ileostomy for faecal diversion in ileal perforation: a case matched study

Abstract

The disease ileal perforation is a frequently encountered surgical emergency in developing countries [1]. Typhoid fever is the most common cause for this dreaded complication;tuberculosis, trauma and non-specific enteritis follow closely [2]. The incidence of perforation in various studies in typhoid fever has been reported to be between 0.8% to 18% [3]. The compromised patients of perforation peritonitis due to typhoid fever are best managed with faecal diversion by performing an ileostomy. The other indications of faecal diversion include inflammatory bowel disease, familial adenomatous polyposis, colorectal cancer, non-gastro intestinal obstructing tumours, pelvic sepsis, trauma, diverticulitis, fistula, ischaemic bowel disease, radiation enteritis, pseudomembranous enterocolitis, faecal incontinence and paraplegia [4]. The standard treatment after diagnosis of secondary peritonitis due to hollow viscous perforation is resuscitation followed by laparotomy. The ileal perforation is either closed primarily, or resection and anastomosis of the small bowel is performed, or a diverting stoma is created depending on the site and number of perforations, the severity of peritonitis and the general condition of the patient [5]. The ileostomy serves the purpose of diversion, decompression and exteriorization. A primary ileostomy has been found to be useful in decreasing the morbidity and mortality especially in moribund patients or those with delayed presentation, where it has proved to be a lifesaving procedure [6]. However, ileostomies may result in a significant number of complications as well. The most common complication of ileostomy is peristomal skin irritation leading to skin excoriation, followed by fluid and electrolyte imbalance and nutritional depletion [7]. Other complications post-ileostomy are bleeding, ischaemia, obstruction, prolapse, retraction, stenosis, parastomal hernia, fistula, residual abscess, wound infection and incisional hernia. In addition, an ileostomy is also known to adversely affect the patient's quality of life due to physical restrictions and psychological problems [8]. An ileostomy can be performed as an end ileostomy or loop ileostomy, and both techniques have their own pros and cons. Different authors in the past have compared the results of the two types of ileostomies performed for inflammatory bowel disease and colorectal cancer. Based on their findings, some authors prefer a loop ileostomy whilst others recommend an end ileostomy as a temporary measure for faecal diversion [9-11]. However, these studies are from western countries and include elective procedures whereas patients with perforation peritonitis present as a surgical emergency and their parameters are entirely different. The temporary diverting ileostomy [end or loop ileostomy] is performed as a life saving measure in such cases and existing literature is silent on comparison of these two procedures in perforation peritonitis.