Right-Sided Ileostomy on Stoma Outlet Obstruction In Ulcerative Colitis: A Randomized Controlled Trial

Abstract

Background: Stoma outlet obstruction is a common complication after total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis, occurring in 20-40% of cases. In contrast, the incidence of stoma outlet obstruction after low anterior resection is less than 10%. Since stomas are typically created in the right lower abdomen, we considered that small bowel torsion and tension might be more pronounced after ileal pouch-anal anastomosis. Therefore, we hypothesized that creating a stoma in the left lower abdomen during ileal pouch-anal anastomosis could reduce the incidence of stoma outlet obstruction.

Objective: To evaluate whether, compared with right-sided placement, left-sided stoma placement reduces the incidence of stoma outlet obstruction.

Design: Single-center, open-label, randomized controlled trial.

Setting: Conducted at Hyogo Medical University, Japan.

Patients: A total of 181 ulcerative colitis patients who underwent ileal pouch-anal anastomosis with ileostomy between 2018 and 2024 were included.

Interventions: Patients were randomized to receive a left-sided (Group L, n = 91) or right-sided (Group R, n = 90) ileostomy.

Main outcome measures: Primary outcome: stoma outlet obstruction incidence. Secondary outcomes: length of hospital stay and reoperation rate. The primary analysis was performed on an intention-to-treat basis.

Results: The incidence of stoma outlet obstruction was significantly lower in Group L (9.8%) than in Group R (31.1%; p = 0.0004). A left-sided stoma was an independent protective factor against stoma outlet obstruction (odds ratio 0.24, 95% confidence interval 0.10-0.56; p = 0.001). Stoma outlet obstruction was associated with a longer hospital stay (median: 33 vs. 22 days, p < 0.001). No significant difference was found in reoperation rates between the L and R groups.

Limitations: Single-center study; generalizability to other populations is uncertain.

Conclusion: Left-sided stoma placement significantly reduces the incidence of stoma outlet obstruction in ileal pouch-anal anastomosis for ulcerative colitis and may be a preferable approach to improve postoperative outcomes. See Video Abstract.

Trial registration: University Hospital Medical Information Network Clinical Trials Registry: UMIN-CTR 000023750.

Keywords: Randomized controlled trial; Stoma outlet obstruction; Surgical treatment; Ulcerative colitis.