08-055

J Korean Soc Coloproctol: Vol. 25, No. 2, 81-7, 2009 DOI: 10.3393/jksc.2009.25.2.81 ORIGINAL ARTICLE 회장루의합병증과관련인자분석 김정연 김진수 허혁 민병소 김남규 손승국 조장환연세대학교의과대학외과학교실 Complication and Relevant Factors after an Ileostomy for Fecal Diversion in a Patient with Rectal Cancer Jeong Yeon Kim, M.D., Jin Soo Kim, M.D., Hyuk Hur, M.D., Byung Soh Min, M.D., Nam Kyu Kim, M.D., Seung Kook Sohn, M.D., Chang Hwan Cho, M.D. Department of Surgery, Yonsei University College of Medicine, Seoul, Korea Purpose: The proportion of sphincter-saving operations for lower rectal cancer is increasing with improved surgical techniques and additional concurrent preoperative chemo-radiation therapy. A defunctioning ileostomy or colostomy is performed after a sphincter-saving operation in the belief that diverting the fecal stream will prevent anastomotic leakage. This study was undertaken to assess all morbidity and combined problems associated with a temporary loop ileostomy. Methods: A total of 167 patients who had undergone an ileostomy after a proctectomy between July 1997 and May 2007 were enrolled in this study. All patients were analyzed retrospectively, and the enrolled patients were registered in the Colorectal Cancer Database and were followed prospectively. Three patients did not receive an ileostomy take-down operation because of tumor recurrence. Results: Complications of ileostomy formation developed in 20 (11.9%) cases. There were no significant relevant factors influencing the complications of ileostomy formation. Complications related with ileostomy take-down developed in 33 (17.9%) cases. Longer operation time, perioperative transfusion, and postoperative radiotherapy were statistically significant factors related to the complications of ileostomy take-down (P=0.047, P=0.019, P=0.042). After ileostomy take-down, six patients were identified with complications, such as a rectovaginal fistula or an anastomotic stenosis, related with rectal cancer surgery. Conclusion: The useful ileostomy sometimes carries certain morbidity; therefore, an ileostomy should be performed selectively, and the decision should be made with care. Also, a careful evaluation of the distal part of an ileostomy is necessary before and after an ileostomy take-down. Keywords: IIeostomy; Complication 중심단어 : 회장루, 합병증 서 지난수십년동안외과술기의발달과더불어해부학적지식의발달로정확하고정교한골반박리술이가능하게되었으며, 1982년 Heald가전직장간막절제술 (total mesorectal Received : July 2, 2008 Accepted : February 2, 2009 Correspondence to : Nam Kyu Kim, M.D. Department of Surgery, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea Tel : +82.2-2228-2117, Fax : +82.2-313-8289 E-mail : namkyuk@yuhs.ac 론 The Korean Society of Coloproctology excision) 의개념을정립함으로써 1 직장암수술후발생되는국소재발은 5-9% 로크게낮아졌다. 더불어수술전후의다병합치료 (multimodality treatment) 의출현은직장암의치료에서국소재발률감소뿐만아니라, 생존율까지향상시키게되었다. 그중수술전항암화학방사선치료는암병변의조직학적부피감소, 병기하향, 외과적절제연길이확보, 방사상의음성외과적절제면확보를가능하게하면서 2 하부직장암환자에서항문보존의가능성을제시할수있게되었다. 이중자동문합술의도입과 1982년 Parks와 Percy 등에의해처음제시된결장항문문합술 (coloanal anastomosis) 의출 81

82 Jeong Yeon Kim, et al. : Complication and Relevant Factors after an Ileostomy for Fecal Diversion in a Patient with Rectal Cancer 현으로원위부직장암의문합이용이하게되면서항문보존수술의비율이점차늘어나는추세이다. 3 항문보존술식에서수술후사망률은 1-8% 로보고되고있는데, 4 그중문합부누출은가장위험한합병증으로술자에따라 1-24% 까지다양하게보고하고있으며, 5-8 분변전환을목적으로하는장루조성술의빈도가증가되고있으며그역할이더욱중요해졌다. 장루에는크게회장루와결장루가있으나이중회장루는무작위전향적연구를통해결장루보다합병증이적은것으로입증이된바있으며조성및복원시비교적술식이간단하고조성후장루를통해배액되는내용물의냄새가적다는장점을가지고있어, 분변전환을목적으로하는장루조성술로써회장루의시술이높은빈도를차지하고있다. 9 다만, 회장루조성및복원과정에서합병증이동반될수있으며, 이러한합병증을숙지하고회장루조성및복원수술을시행해야할필요가있다. 본연구에서는회장루조성과복원에따른합병증을각각나누어살펴보고, 합병증과관련된위험인자를분석해보도록하겠다. 또한회장루복원술후에진단된직장암수술과연관되었던선행합병증에대해살펴보고, 그에대해고찰해보도록하겠다. 방법연구대상 1997년 7월부터 2007년 5월까지 10년간연세대학교세브란스병원외과에서직장암으로진단받고항문보존수술을받은환자들중회장조루술을시행하고복원술을시행한환자중 6개월이상추적이가능하였던 167예를대상으로하였다. 회장조루술은직장암수술환자중초저위전방절제술및결장항문문합술을시행했거나수술전방사선화학요법을시행했던환자에서시행되었다. 연구방법모든회장루는우하복부의복직근을통하여조성하였으며, 복강경을이용하여수술한경우에는우하복부투과침위치를이용하여회장루를조성하였다. 회장루복원수술은수술후항암방사선치료를시행하지않은경우는 8-12주후시행하였으며, 수술후항암방사선치료를시행한경우에는치료후 6-12주에회장루복원술을시행하였다. 수술은장일부절제술및단단문합술로장문합하였으며배액관은삽입하지않았다. 회장루조성후평균 17 (6-78) 개월동안의결과를전향적으로기록되는대장항문데이터베이스와의무기록을토 대로후향적으로분석하였다. 회장루조성술과복원술후의합병증을성별, 나이, 신체비만지수 (body mass index, BMI), 수술전동반질환, 직장암병기, 암수술방법, 수술전방사선화학요법시행여부와복원술시수술시간과암수술후추가항암방사선치료등의변수로그차이를분석하였다. 회장루조성후다시장루재조성이필요했던환자들을후향적으로분석하여원인과각환자의병기, 장루재조성의종류와재조성을한시기를분석하였다. 통계처리연속변수의결과는평균 ± 표준편차로, 명목변수의결과는백분율혹은비율로표시하였다. 각군간의비교는정규분포를따르는요소는 t-test, ANOVA 혹은 χ 2 -test (2-sided) 를이용하여분석하였으며비정규분포를따르는요소는 Fisher s exact test를사용하였다. 모든자료의통계처리는 SPSS 11.0 (SPSS Inc. Chicago, IL, USA) 을사용하였으며, 유의수준 (P value) 이 0.05 미만인경우통계학적으로유의한것으로간주하였다. 결 환자의특성평균연령은 58.8세 (25-83) 이며남자가 143명여자가 44명이었고, 평균 BMI는 23.74 kg/m 2 이었다. 병기는 1기 58명, II기 38 명, III기 66 명, IV 기 5명이었다. 저위전방절제술시행한경우 47명, 초저위전방절제술및결장항문문합술을시 과 Table 1. Dermographic data in 167 patients with ileostomy Mean age (range) (yr) 56.88 (25-83) Sex (Male:female) 123:44 Body mass index 23.74 (±2.86) UICC 6th TNM stage Stage I 58 Stage II 38 Stage III 66 Stage IV 5 Anastomosis method Double stapled method 47 Coloanal anastomosis 120 Preoperative chemoradiation therapy No 127 Yes 40 Operation method Open surgery 148 Laparoscopic surgery 19 TNM=tumor node metastasis.

김정연외 : 회장루의합병증과관련인자분석 83 행한경우 120명이었다. 수술전항암방사선치료를시행했던환자는 40명이었으며시행하지않았던환자는 127명이었다. 개복수술을시행한경우가 148명, 복강경수술을시행한경우가 19명이었다 (Table 1). 회장루관련합병증및치료장루조성시발생되는합병증장루조성시발생되는합병증으로는장루주위탈장, 장폐색, 탈수, 장루주위피부염, 회장루주위협착, 우울증등이있었으며 167명의환자중 20 명 (11.9%) 에서합병증이발생되었다. 장폐색증의 9명 (5.4%) 으로가장많았으며그중 4명에서수술적교정을시행하였다. 주위탈장이생긴경우 3명 (1.8%) 으로그중 1명이장루수술적교정을필요로했으며심한탈수와전해질불균형으로입원치료를했던경우가 2명 (1.2%) 으로모두보전적치료로회복되었다. 두명모두추가항암방사선치료가필요하지않았던경우로회장루복원술을회장루조성후 3-4주후에시행하였다. 탈장주위피부염이생긴경우가 4명 (2.4%) 으로모두보존적치료로호전되었으며회장루주위협착증이유발되었던경우가 1명 (0.6%) 으로있었으며수술적교정이필요하지않았다. 장루로인하여극심한정신적스트레스로우울증이유발되었던환자가 1명 (0.6%) 있었으며, 회장루복원술후증상이좋아졌다 (Table 2). 회장루복원술시발생되는합병증회장루조성술을시행한 167명의환자중 3명 (1.7%) 의환자에서전신전이가발생되어회장루복원술을시행하지못하였다. 회장루복원술을시행했던 164명의환자중 33 명 (19.7%) Table 2. Complications related to construction and take down of ileostomy No. (%) Operation Stomal construction (n=167) Parastomal hernia 3 (1.8) 1 Intestinal obstruction 9 (5.4) 4 Dehydration 2 (1.2) 0 Peristomal dermatitis 4 (2.4) 0 Ileostomy site stenosis 1 (0.6) 0 Psychologic problem 1 (0.6) 0 Total 20 (11.9) 5 Take down of ileostomy (n=164) Intestinal obstruction 19 (11.5) 8 Wound infection 2 (1.2) 0 Ileus 7 (4.2) 0 Incisional hernia 3 (1.8) 2 Wound dehiscence 2 (1.2) 1 Total 33 (19.7) 11 에서합병증이발생되었다. 복원술시발생되는합병증중방사선소견에서전형적인장폐색증을보이는환자군을장폐색증으로정의하였으며, 가스배출은이루어지나, 7일이내에정상식이를시행할수없으며복부불편감을호소했던환자를일시적장마비로정의하였다. 수술후두달내에 19명 (11.7%) 에서장폐색증을경험하였으며그중 8명 (42%) 에서수술적교정이필요하였다. 회장루복원술을시행한상처부위에감염이생겼던경우가 2명 (1.2%) 있었으며, 보전적치료로호전되었고일시적인장운동저하증을경험했던경우가 7명 (4.2%) 이었으며상처부위탈장이 3명 (1.8%) 로그중 2명에서수술적교정이필요하였으며회장루복원후상처가벌어졌던경우가 2명 (1.2 %) 이었으며그중 1명에서수술적교정을시행하였다 (Table 2). 합병증영향인자단변량분석회장루조성술회장루조성술후합병증과연관있는인자를분석해보았 Table 3. Risk factors for complications related to stomal construction in all patients Without complication (n=147) With complication (n=20) P value Age 0.468 <65 115 15 65 32 5 Sex 0.247 Male 110 13 Female 37 7 BMI 0.459 <25 101 13 25 46 7 Combined resection 0.598 Yes 141 19 No 6 1 Preoperative chemoradiation therapy 0.440 Yes 114 13 No 33 5 Comorbidity 0.468 Yes 79 10 No 68 10 Operation method 0.811 Double stapled method 41 4 Coloanal anastomosis 96 14 TNM staging 0.503 O-II 84 12 III-IV 63 8 Operation 0.161 Open surgery 133 15 Laparoscopic surgery 14 5 TNM=tumor node metastasis.

84 Jeong Yeon Kim, et al. : Complication and Relevant Factors after an Ileostomy for Fecal Diversion in a Patient with Rectal Cancer 으나, 연령, 성별, 신체비만지수, 기저질환유무, 수술방법, 종양병기등모든인자에서합병증유발과관련있는인자는없었다 (Table 3). 회장루복원술회장루복원시에도연령, 성별, 신체비만지수, 복원수술 전회장루합병증유무, 기저질환, 수술방법, 종양병기는복원후합병증을유발하는인자가아니었다. 다만, 수술중수혈량과수술시간은복원수술시합병증발생과통계학적의의를가졌다 (P=0.019). 또한수술후방사선치료를추가치료시그합병증이통계학적으로유의하게증가하였다 (P=0.042; Table 4). Table 4. Risk factors for complications related to take down of ileostomy Without complication (n=131) With complication (n=33) P value Age 0.558 <65 102 26 65 29 7 Sex 0.381 Male 97 23 Female 34 10 Body mass index 0.207 <25 87 25 25 44 8 Adjuvant therapy 0.042 No 48 12 Chemotherapy 41 7 Chemoradiation therapy 42 14 Comorbidity 0.347 Yes 72 17 No 59 18 Previous stomal complication 0.207 Yes 12 6 No 119 27 Time interval from ileostomy 28.5±20.2 33.7±23.0 0.276 formation (wk) Operation time (min) 107.7±25.4 124.4±43.8 0.047 Transfusion during operation 0.019 Yes 6 6 No 125 27 Operation 0.510 Open surgery 117 29 Laparoscopic surgery 14 4 직장암수술과관련된선행합병증 ; 회장루복원수술전에진단하지못하였던예회장루복원전에회장루원위부의직장암수술과관련되었던선행합병증을진단하지못하였던경우가 6예 (3.5%) 이었다. 6명중수술전항암방사선치료를시행했던예가 4예였다. 직장암수술문합부위협착이 2예, 대장-질누공형성 2예, 문합부위누출로인한골반부위농양형성 1예, 문합부위누출로인한장폐색증 1예있었으며, 문합부위협착은장루복원수술후 7개월, 13개월에진단되었으며대장질누공은 1개월, 4개월에진단되었고, 골반부위농양형성은장루복원수술후 1개월후에진단되었다. 이모든환자에서회장루복원후에 1년내에다시회장루나결장루를조성하였다 (Table 5). 고찰 1966년 Turnbull과 Weakley에의해처음소개되었던루프회장루는시술이용이하고냄새가없으며, 성상이장액성인장점과함께무작위전향적연구에서결장루에비하여낮은합병증발생률및낮은사망률의장점이입증된분변전환수술방법이다. 9-11 최근수십년동안전직장간막절제술의개념이정립되면서국소재발률이 6% 미만으로보고되고있으며, 수술전항암방사선치료의첨가로인하여중부하부직장암수술시직장항문문합술이나, 초저위전방절제술등의항문보존수술의빈도가증가하게되었다. 그러나이러한항 Table 5. Complication with rectal cancer operation which did not diagnosis before ileostomy take down Anastomosis method Preoperative chemoradiation therapy TNM staging Complication Diagnosis from ileostomy take down 1 Double stapled method No Stgae I Anastomosis site stenosis 7 mo 2 Coloanal anastomosis Yes Stage III Rectovaginal fistula 4.5 mo 3 Coloanal anastomosis Yes Stage II Supralevator abscess 12 mo 4 Coloanal anastomosis Yes Stage I Anastomosis site stenosis 13 mo 5 Double stapled method Yes Stage I Rectovaginal fistula 1 mo 6 Double stapled method No Stage III Obstruction and anastomosis site leakage 1 mo TNM=tumor node metastasis.

김정연외 : 회장루의합병증과관련인자분석 85 문보존술식은수술후사망률이 1-8% 로높게보고되고있으며, 4 그중문합부누출은가장위험한합병증으로일시적분변전환이필요하게되었고, 이에많은외과의들은합병증과사망률발생이적은회장루조성을선호하고있다. 그러나회장루는여러합병증을동반하는술식이다. 회장루합병증은크게조성술시발생되는합병증과회장루복원술후발생되는합병증으로나누어볼수있으며합병증발생률은문헌상에서각각 10-68%, 19-22 10-27% 23-27 로보고하고있다. 회장루조성술시발생되는합병증으로는창상감염, 협착이나괴사장루탈출, 누공형성이나출혈등이있을수있으며성상이장액성으로수분및전해질의불균형이나장루주위피부염등이발생할수있고회장루성숙화과정에서점막부종이나장막주위반흔이형성될수있다. 19 본연구에서회장조성술후발생한합병증은총 20 예 (11.9%) 있었으며, 그중 5 (20%) 예에서수술적치료가필요하였으며나머지 15 (80%) 예에서는보전적치료로교정이가능하였다. 회장루복원술후발생되는합병증으로는창상감염, 장폐쇄증, 문합부누출, 절개부위탈장, 출혈등이있을수있다. 본원에서회장루복원술후발생한합병증으로총 33 예 (19.7%) 보고하였으며그중장폐색은회장루복원술시발생하는가장흔한형태의합병증으로 19예 (11.5%) 에서발생하였다. 문헌에서살펴보면화장루복원술후장폐색의발생빈도를 1.5-15% 까지보고하고있으며그중수술적교정이필요했던빈도는 0-13% 까지다양하게보고하고있다. 23,28-30 본연구에서회장조성술시행시통계학적유의한차이를보이는인자는없었다. 반면회장루복원술의경우에는수술시간이나, 수혈여부와합병증발생과통계학적연관성이있었다 (P=0.042, P=0.019). 수술시간이나수혈여부모두수술의어려움정도를반영하는요소로써, 수술의어려움정도가합병증발병과유의한상관관계를보임을알수있다. 또한, 회장루복원시합병증유발에영향을미치는요소로수술후방사선치료가통계적유의성을가졌으며 (P=0.042), 이러한수술후방사선치료후에회장루복원시발생되는합병증의대부분이일시적장기능저하증이었다. 그렇기때문에, 수술후방사선치료환자군에서방사선치료시상처를받은소장에서일시적장기능저하증이유발되는경우로인하여회장루복원술로인하여발생되는합병증과통계학적으로연관성을가졌을가능성을배제할수없다. 많은문헌에서회장루조성술과복원술에합병증을유발하는무작위전향적연구를시행했지만, 환자의나이나외과의의경험이이외에는특별한위험인자를찾을수없었다. 회장루복원후에직장암과관련된선행합병증이늦게진단되는경우도있다. 본병원에서는회장루복원후 6예에서회장루복원전미처진단하지못하였던직장암관련합병증이발생되는경우를경험하여제시하고자한다. 본원에서는회장루복원전에직장수지검사나구불결장경을통해문합부위를확인하고있으나, 6예에서회장루복원전에직장암수술과관련되었던선행합병증을진단하지못하였다. 그중 2예가문합부위협착으로이두예모두회장루복원전검사에서는문합부위협착이관찰되지않았던경우로복원수술후 1년정도경과후문합부협착이진행된경우였다. 2예는대장-질누공이나골반부위농양형성, 문합부위누출의경우누공의크기가너무작아복원수술전검사를통해서알수없었던합병증으로수술후 1-4개월내에진단할수있었다. 복원수술전에면밀한검사를통하여회장루원위부에서발생된선행합병증을진단해야하나, 때로는회장루복원술전에면밀한검사를통해서도진단할수없는직장암관련합병증이차후에발견될수있음을명시하고, 회장루복원수술후에도정밀한추적관찰을통해합병증동반시빠른진단을해야할것이다. 최근에직장암환자에서국소진행성암이거나, 항문보존술을목적으로수술전항암화학방사선치료선행한경우가증가하고있으며이러한수술전항암화학방사선치료는직장암수술에서문합부누출의위험인자이기도하지만다른합병증특히직장질누공형성과문합부위협착의위험인자가될수있으며이런환자의경우더욱주위를기울일필요가있겠다. 최근에발표된일부논문에는회장루조성이문합부누출의영향을주지않는다는무작위전향적연구가발표되고있을뿐만아니라, 12 문합부누출이발행하였다하더라도 4-25% 로보고하고있다. 13-15 또한회장루조성과복원으로인하여발생하게되는여러합병증발생률역시 20% 로이와비교할때본연구에서명시한회장루조성과복원으로인하여발생되는합병증역시 11.9%, 18% 로충분히고려해봐야할문제이다. 단순히수술전항암방사선치료를시행하였다고해서회장루조성을상용적으로시행하는것보다는그외에도문합부누출의위험인자가있는환자에서선택적으로이루어야할것이며특히수술전항암방사선치료를하지않은환자의경우에는더욱회장루조성을결정하는데신중을기울여야할것이다. 또한, 회장루복원시원위부에대한면밀한검사를통하여, 직장암관련합병증이여부를확인하고회장루복원후에도, 직장암관련합병증이늦게진단될수있는가능성에대해인지하고있는것역시중요한일이라하겠다.

86 Jeong Yeon Kim, et al. : Complication and Relevant Factors after an Ileostomy for Fecal Diversion in a Patient with Rectal Cancer 회장루조성은합병증이발생할수있는수술이다. 회장루는문합부누출의위험성을낮춰줄수있는필요하고유용한술식인반면수술합병증이라는문제점을안고있기때문에득과실을고려하여선택적으로시행해야할것이며, 또한회장루를조성했을경우경험적으로복원을할것이아니라, 회장루말단부에합병증을유발할위험인자를가지고있는환자군에서는회장루복원수술전후에세밀하고철저한진찰과검사를통하여문합부말단쪽에합병증을예방및치료하는노력이필요하겠다. 항문보존술식이늘어남에따라단순히회장루조성이경험적으로쉽게이루어져서는안될것이다. REFERENCES 1. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery--the clue to pelvic recurrence? Br J Surg 1982;69:613-6. 2. Luna-Pe@rez P, Rodriguez-Ramirez S, Herna@ndez-Pacheco F, Gutie@rrez De La Barrera M, Ferna@ndez R, Labastida S. Anal sphincter preservation in locally advanced low rectal adenocarcinoma after preoperative chemoradiation therapy and coloanal anastomosis. J Surg Oncol 2003;82:3-9. 3. Parks AG, Percy JP. Resection and sutured colo-anal anastomosis for rectal carcinoma. Br J Surg 1982;69:301-4. 4. Smedh K, Olsson L, Johansson H, Aberg C, Andersson M. Reduction of postoperative morbidity and mortality in patients with rectal cancer following the introduction of a colorectal unit. Br J Surg 2001;88:273-7. 5. Dehni N, Schlegel RD, Cunningham C, Guiguet M, Tiret E, Parc R. Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis. Br J Surg 1998; 85:1114-7. 6. Enker WE, Merchant N, Cohen AM, Lanouette NM, Swallow C, Guillem J, et al. Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service. Ann Surg 1999; 230:544-52. 7. Law WL, Chu KW. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg 2004;240: 260-8. 8. Pakkastie TE, Ovaska JT, Pekkala ES, Luukkonen PE, Ja_rvinen HJ. A randomised study of colostomies in low colorectal anastomoses. Eur J Surg 1997;163:929-33. 9. Edwards DP, Leppington-Clarke A, Sexton R, Heald RJ, Moran BJ. Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial. Br J Surg 2001;88:360-3. 10. Turnbull RB Jr, Weakley FL. Ileostomy technics and indications for surgery. Rev Surg 1966;23:310-4. 11. Rullier E, Le Toux N, Laurent C, Garrelon JL, Parneix M, Saric J. Loop ileostomy versus loop colostomy for defunctioning low anastomoses during rectal cancer surgery. World J Surg 2001;25:274-7. 12. Wong NY, Eu KW. A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study. Dis Colon Rectum 2005;48:2076-9. 13. Fu_rst A, Suttner S, Agha A, Beham A, Jauch KW. Colonic J-pouch vs. coloplasty following resection of distal rectal cancer: early results of a prospective, randomized, pilot study. Dis Colon Rectum 2003;46:1161-6. 14. Hallbo_o_k O, Pa*hlman L, Krog M, Wexner SD, Sjo_dahl R. Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Ann Surg 1996;224:58-65. 15. Heriot AG, Tekkis PP, Constantinides V, Paraskevas P, Nicholls RJ, Darzi A, et al. Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior resection. Br J Surg 2006;93:19-32. 16. Steffen T, Tarantino I, Hetzer FH, Warschkow R, Lange J, Zu_nd M. Safety and morbidity after ultra-low coloanal anastomoses: J-pouch vs end-to-end reconstruction. Int J Colorectal Dis 2008;23:277-81. 17. Al-Homoud S, Purkayastha S, Aziz O, Smith JJ, Thompson MD, Darzi AW, et al. Evaluating operative risk in colorectal cancer surgery: ASA and POSSUM-based predictive models. Surg Oncol 2004;13:83-92. 18. Huh JW, Park YA, Sohn SK. A diverting stoma is not necessary when performing a handsewn coloanal anastomosis for lower rectal cancer. Dis Colon Rectum 2007;50:1040-6. 19. Babcock G, Bivins BA, Sachatello CR. Technical complications of ileostomy. South Med J 1980;73:329-31. 20. Leong AP, Londono-Schimmer EE, Phillips RK. Life-table analysis of stomal complications following ileostomy. Br J Surg 1994;81:727-9. 21. Park JJ, Del Pino A, Orsay CP, Nelson RL, Pearl RK, Cintron JR, et al. Stoma complications: the Cook County Hospital experience. Dis Colon Rectum 1999;42:1575-80. 22. Todd IP. Mechanical complications of ileostomy. Clin Gastroenterol 1982;11:268-73. 23. Feinberg SM, McLeod RS, Cohen Z. Complications of loop ileostomy. Am J Surg 1987;153:102-7. 24. Khoo RE, Cohen MM, Chapman GM, Jenken DA, Langevin JM. Loop ileostomy for temporary fecal diversion. Am J Surg 1994;167:519-22.

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