EBN . Ileostomy

7/28/2019 EBN . Ileostomy

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I. Clinical Question:

What is the outcome of using a tube ileostomy compared to loop ileostomy in

management of fecal perforations?

II. Citation:

Vijayraj Patil, Abhishek Vijayakumar, M. B. Ajitha, and Sharath Kumar L, “Comparison

between Tube Ileostomy and Loop Ileostomy as a Diversion Procedure,” ISRN Surgery, vol.

2012, Article ID 547523, 5 pages, 2012. doi:10.5402/2012/547523. Retrieved at

http://www.hindawi.com/isrn/surgery/2012/547523/cta/

III. Study Characteristics:

1. Patients

All patients with ileal perforation on laparotomy where a defunctioning proximal

protective loop ileostomy was considered advisable were chosen for study. Patients wererandomly assigned to undergo either tube ileostomy or classical loop ileostomy as the diversion

procedure. Patients ranged from 16 to 63 years with mean age 32.6 years. Majority of patients

were male (70%). 30 underwent conventional loop ileostomy and 30 underwent tube ileostomy

2. Interventions Compared

Tube ileostomy and loop ileostomy

3. Outcomes Monitored

The outcomes monitored in the study was the outcome of tube versus loop ileostomy in

management of ileal perforations in terms of effectiveness, feasibility and complications.A detailed record of day on which tube ileostomy started functioning, tube drainage,

peritubal leak, tube blockade, any feature suggestive of anastomotic leak, or any other

complication was maintained. The day when tube was clamped and removed was recorded. Time

to closure of the controlled fistula was also noted. All the patients were regularly followed in the

outpatient department for any complications.

4.Does the study focus on a significant problem in clinical practice?

Yes. Surgeons are faced with difficult to perform stoma for fecal diversion during

emergency laparotomy for intestinal perforation and obstruction.

IV. Methodology/ Design

1. Methodology used

From July 2008 to July 2011, all patients with ileal perforation on laparotomy where a

defunctioning proximal protective loop ileostomy was considered advisable were chosen for

study. Patients were randomly assigned to undergo either tube ileostomy or classical loop





ileostomy as the diversion procedure. Tube ileostomy was constructed in the fashion of feeding

jejunostomy, with postoperative saline irrigation.

2. Design

Prospective study

3. Setting

Bangalore Medical College and Research Institute (BMCRI), Bangalore, India, from July

2008 to July 2011

4. Data sources

M. Kairaluoma, H. Rissanen, V. Kultti, J. P. Mecklin, and I. Kellokumpu, “Outcome of

temporary stomas: a prospective study of temporary intestinal stomas constructed between 1989

and 1996,” Digestive Surgery, vol. 19, no. 1, pp. 45–51, 2002.

M. Rygl, K. Pycha, Z. Stranak et al., “T-tube ileostomy for intestinal perforation inextremely low birth weight neonates,” Pediatric Surgery International, vol. 23, no. 7, pp. 685–

688, 2007.

F. Rondelli, R. Balzarotti, W. Bugiantella, L. Mariani, R. Pugliese, and E. Mariani,

“Temporary percutaneous ileostomy versus conventional loop ileostomy in mechanical

extraperitoneal colorectal anastomosis: a retrospective study,” European Journal of Surgical

Oncology, vol. 38, no. 11, pp. 1065–1070, 2012.

H. Hasegawa, S. Radley, D. G. Morton, and M. R. B. Keighley, “Stapled versus sutured

closure of loop ileostomy. A randomized controlled trial,” Annals of Surgery, vol. 231, no. 2, pp.

202–204, 2000.

C. Duchesne, Y. Z. Wang, S. L. Weintraub, M. Boyle, and J. P. Hunt, “Stomacomplications: a multivariate analysis,” American Surgeon, vol. 68, no. 11, pp. 961–966, 2002.

Nisar A. Chowdri, Mehmood A. Wani, Fazl Q. Parray, Shabir H. Mir, and Rauf A. Wani

(2010) "Tube ileostomy as an alternative to conventional ileostomy for fecal diversion," World

Journal of Colorectal Surgery: Vol. 2 : Iss. 1, Article 11

5. Subject Selection

a. Inclusion criteria

Patients who underwent explorative laparotomy for small bowel perforation or

obstruction and in whom a decision to perform a proximal diversion stoma on the basis of any of

the following intraoperative findings: multiple perforations, edematous and inflamed bowel,

adherent loops of bowel, and insecure anastomosis, were chosen for the study.

b. Exclusion criteria



Patients who died within 5 days of surgery unrelated to anastomotic complication and

patients who were lost to followup were excluded from the study.

6. Has the original study been replicated?

This is an original study and no replications were made yet.

7. What were the risk and benefits of the nursing action / intervention tested in the

study?

This proposes high risk for patients because it involves invasive procedure.

Complications are present for both of the interventions. The complication rate of tube ileostomy

was 33%. Main complications related to tube ileostomy were peritubal leak, tube blockage. In

patients with loop, overall complications in 53% majority were peristomal skin irritation and

wound infection following ileostomy closure.

On the other hand, the benefits of the study is that the researchers found out that tube

ileostomy is an alternative diversion procedure wherein there is lesser complication as comparedto loop ileostomy.

V. Results of the Study

Over a period of three years from July 2008 to July 2011 a total of 60 diversion

procedure were performed. Out of the diversion procedures 30 were conventional loop ileostomy

and 30 were tube ileostomy as described above.

In majority of patients (64%) tube ileostomy started functioning on first postoperative

day while in rest from second day. Tube ileostomy output ranged from 50–700 mL/day with

mean of 300 mL. Once a day irrigation was sufficient to keep the tube patent in 25 patients; 5 patients developed tube blockade of whom 4 resolved with thrice daily irrigation of tube with

saline. One patient who had persistent blockade and developed signs of peritonitis was

reoperated and found to have a kinking of tube and anastomotic leak. Three patients developed

peritubal leak which was managed with regular dressing. The tube ileostomy was removed on

postoperative day 21; the drain site managed with daily dressing in whom the wound discharge

was minimum. Two patients had increased wound discharge which was managed with

application of colostomy bag for 2 weeks which later resolved, and wound closure was achieved.

The wound-closure time ranged from 4 to 9 days (mean 7 days). None of the patients required

formal closure of the wound. All patients were followed for an average of 6 months and showed

no complications. In loop ileostomy group the main complication was peristomal skin

excoriation (n = 4) which required prolonged regular dressing. Two patients developed severe

dehydration following high output from stoma and required hospitalization for electrolyte

abnormalities and were managed with intravenous fluid. There was one case of early necrosis of

stoma and retraction which required operation and stoma revision. Anastomotic leak occurred in

two cases one of which required reoperation due to clinical deterioration. The patients underwent

ileostomy closure between 2 to 4 months (mean 10 weeks). The main complication following



ileostomy closure was wound infection (n = 6) which resolved with regular dressing and

antibiotics. Two patients developed obstruction following closure one of whom required

reoperation. Patients were followed up for a period of 6 months with one patient presenting with

obstruction which required reoperation and adhesion release.

VI. Authors conclusion and recommendation

a. What contribution to health status does the nursing action/intervention make?

With the result of the study, tube ileostomy has better outcomes for patients who

will undergo ileostomy because of less complication associated with it rather than the

loop ileostomy. It is an effective and feasible diversion procedure.

b. What overall contribution to nursing knowledge does the study make?

Nursing personnel can utilize the study in reinforcing the teaching made by

surgeons to patients about tube ileostomy and loop ileostomy. Nurses will have a better

idea on how to care for these patients so as to prevent complications associated with the 2

procedures.

VII. Applicability

1. Does the study provide a direct enough answer to your clinical question in terms

of type of patients, intervention and outcome?

Yes, this study determined that the outcome of performing tube ileostomy is more

effective than loop ileostomy in terms of complication and feasibility.

2. Is it feasible to carry out the nursing action in the real world?

Yes. Although the researchers suggested that further larger randomized studies need to be

undertaken before tube ileostomy could be recommended as an alternative to loop ileostomy as a

diversion procedure, nursing care for this kind of procedure is still feasible to carry. Routine

patient assessment of patient is done by nurses so signs of complication will be assessed early

and it’s development will be halt.

VIII. Reviewer's Conclusion / Commentary

It can be concluded that tube ileostomy proposes better outcome than loop ileostomy for

small bowel perforation or obstruction. This study yielded a beginning for other researcher to

conduct a larger study regarding the involved surgical procedures. Thorough assessment of

patients who underwent these procedures should not be neglected because of the risk it imposes

on the patient. With regards to ethics, the procedures should be carefully discussed using terms

within the patients understanding before the operative permit is signed. We should always bear

in mind that patients’ health is our priority concern.



Evaluation

1. Safety

The procedures performed we’re both invasive and patients are placed at risk for different

complications brought about by the 2 procedures. In tube ileostomy, less complication were

observed so it is safer than loop ileostomy. All the patients were regularly followed in the

outpatient department for any complications.

2. Competence of the care provider

Base on the results of the study, the surgeons were competent enough to perform the

procedures. As for the nursing staff, perioperative competencies were met which

3. Acceptability

The results of the study is acceptable but as stated by the authors, further larger

randomized studies need to be undertaken before tube ileostomy could be recommended as analternative to loop ileostomy as a diversion procedure.

4. Effectiveness

Tube ileostomy is an effective management of ileal perforation. It was able to produce

the desired result which diversion of the bowel contents and it avoids the need for a second

surgery and its related complication.

5. Appropriateness

Tube ileostomy and loop ileostomy are both appropriate ways to manage ileal

perforation.

6. Efficiency

Both procedures are efficient as form of fecal diversion because they are focus on

working in correct manner to manage ileal perforation. Performing tube ileostomy is more

efficient that loop ileostomy because it saves more time and less financial burden for patients. At

the same time it has lesser complications.

7. Accessibility

Materials for tube ileostomy (e.g. 8 French abdomen drain tube, drainage bag, 2-0

suture) are highly accessible but as stated in the study, Use of tube ileostomy in adults is only

sparingly reported. Therefore, there are only few hospitals who perform this procedure. In terms

of finance, tube ileostomy has less financial burden to patient because there is no need for

secondary surgery.

EBN . Ileostomy

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