Results of colectomy for severe slow transit constipation

PURPOSE: This study assesses the outcome of a standardized operation performed by two surgeons for severe idiopathic slow transit constipation that was resistant to laxative treatment. METHODS: Fifty-nine consecutive patients, 4 men and 55 women, with a mean age of 42.3 years, underwent colectomy with ileorectal anastomosis. Slow colonic transit was demonstrated in each case. Fifty-two patients were available for follow-up, with median time to follow-up being 42 (range, 3–81) months. RESULTS: Median bowel frequency was 4 per 24 hours. Sixty-nine percent had four or less bowel movements daily. Ten percent used antidiarrheal medication regularly. One patient had a stoma for recurrent severe constipation. Mean continence score was 1.8 (on a scale of 0–20); six patients were incontinent, and four of these six had normal preoperative anal manometry. Fourteen patients (27 percent) had difficulty with rectal evacuation. Preoperative defecating proctography was a poor predictor of postoperative evacuation difficulties. Twenty-seven patients (52 percent) had persisting abdominal pain, but there was a significant improvement in the degree of pain (P <0.00001). Forty-seven patients (90 percent) were satisfied with the outcome of the operation (and would elect to have it done again). Dissatisfied patients had recurrent constipation or diarrhea and incontinence. CONCLUSION: Colectomy with ileorectal anastomosis produces a satisfactory functional outcome in the majority of patients undergoing surgery for severe constipation with proven slow colonic transit.Supported by the Division of Surgery and the Colorectal Research Fund.Read at the meeting of the Royal Australasian College of Surgeons, Perth, Australia, May 1995.     

Colectomy for idiopathic megarectum and megacolon.

The outcome in 40 patients who underwent colectomy for idiopathic megacolon and megarectum over an 18 year period was evaluated. All patients had a radiologically dilated bowel and a bowel frequency of less than two per week. Twenty two patients had a caecorectal anastomosis, 11 had an ileorectal anastomosis (including one with a previous caecorectal anastomosis and four with a previous sigmoid resection), and seven had a sigmoid resection. The mean (range) age at operation was 35 (17-69) years. All three operations resulted in a normal bowel frequency in more than 80% of patients but no patient with an ileorectal anastomosis experienced recurrent constipation. Thirty four patients experienced pain preoperatively and this was still present in 14 patients postoperatively. One patient died and four required subsequent laparotomy for bowel obstruction. The functional outcome in patients with dilatation of the whole colon and in those with dilatation of the left colon did not differ. Subsequent surgery for constipation was performed in three patients. Colectomy offers good results with few complications in the treatment of idiopathic megacolon, and an ileorectal anastomosis is the preferred operation.     

Immunohistochemical study of the colonic muscle and innervation in idiopathic chronic constipation

PURPOSE: This study was designed to investigate neural and muscular features of the colonic wall in patients with severe idiopathic constipation. METHODS: By using quantitative immunohistochemistry, resected specimens from 14 patients with idiopathic chronic constipation and 17 nonobstructed cancer controls were studied. RESULTS: Routine histology revealed no significant histologic abnormality throughout the colon apart from four cases of melanosis coli. Ratio of the thickness of circular to longitudinal muscle was significantly lower in the left colon in constipated subjects. The myenteric plexus appeared morphologically normal in all subjects. S-100 protein, which stains neuronal supporting tissues, demonstrated an increase in the proportion of neural tissue in the myenteric plexus. There was an increased number of PGP-9.5 immunoreactive nerve fibers in the muscularis propria in constipated patients, and this was significantly higher in the ascending and descending colon. CONCLUSION: Intractably constipated patients have alterations in the neural composition of the colonic myenteric plexus and innervation of the circular muscle.Supported by a grant from Yonsei University Research Foundation, Seoul, Korea. Dr. Talbot is supported in part by the Imperial Cancer Research Fund.     

Stapled colonic J-pouch-anal anastomosis without a diverting colostomy for rectal carcinoma

PURPOSE: Colonic J-pouch reconstruction is designed to improve functional outcome of coloanal anastomosis. Most surgeons use a diverting colostomy to avoid severe pelvic sepsis caused by anastomotic breakdown. METHODS: We report the outcome of 30 consecutive patients with colonic J-pouch-anal anastomosis without a diverting colostomy performed between November 1992 and October 1993. All patients had carcinoma of the lower two-thirds of the rectum. Patients were seen every three months. Functional results were compared with those of 21 rectal cancer patients with straight coloanal anastomosis who underwent surgery in the same period and 20 normal patients. RESULTS: There were two anastomotic leakages and one postoperative death. After one year, patients with pouch anastomosis had significantly less frequency of defecation and rectal urgency compared with those with straight anastomosis (P <0.01); 48 percent of patients with straight anastomosis had more than five bowel movements per day, whereas all patients with pouch anastomosis had five or less bowel movements per day. Manometric studies showed maximum tolerable volume was significantly higher in patients with pouch anastomosis (81 vs. 152 ml;P <0.01). CONCLUSIONS: Stapled colonic J-pouch-anal anastomosis without a diverting colostomy is a reliable procedure that provides good, long-term functional results.Supported by National Science Council, Taiwan, Research Grant NSC 83-0412-B182-021.Read at the meeting of the International Society of University Colon and Rectal Surgeons, Singapore, Singapore, July 2 to 6, 1994.     

Gastrointestinal transit in patients with idiopathic megarectum

PURPOSE: In patients with idiopathic megarectum, it is unknown whether abnormality is limited to the dilated large bowel or whether the upper gut is abnormal, as in the various forms of chronic intestinal pseudo-obstruction. This has important implications for treatment, especially surgery. METHODS: Ten patients (4 females; median age, 18 (range, 17–26) years) with idiopathic megarectum had contrast studies of the upper and lower gut, radioisotope (technetium-99m liquid and indium-111 solid phase) measurement of gastric, small-bowel, and colonic regional transit, and radiopaque marker colonic studies. RESULTS: All patients had a dilated large bowel. No patient had radiographic evidence of upper gut dilation. Four patients had normal and six patients had abnormally slow gastric emptying. Both the radioisotope scans and radiopaque marker studies showed abnormal colonic transit. Regions of delay corresponded with the region of dilated bowel. Symptoms of abdominal distention and bloating did not correspond to abnormalities of gastric emptying but rather with effectiveness of rectal evacuation. CONCLUSION: Patients with idiopathic megarectum have abnormal colonic transit, delay occurring predominantly in the dilated gut. Marker studies are less sensitive than isotope studies but provide adequate information for clinical purposes. Although motility abnormalities of the upper gut are common, symptoms correlate with large-bowel abnormalities.Jenny M. Gattuso was supported by the Alimentary Pharmacology and Therapeutics Trust and the British Digestive Foundation.Read at the meeting of the European Association of Nuclear Medicine, Brussels, Belgium, August 26 to 30, 1996.     

Intraluminal bypass technique using a condom for protection of coloanal anastomosis

PURPOSE: Most surgeons carry out temporary diverting colostomy in coloanal anastomosis for mid-rectal or lower-rectal carcinomas. It has been reported that proximal fecal diversion provides no guarantee against anastomotic leaks. Some have proposed the use of the intracolonic bypass tube to prevent anastomotic leakage and colostomy, but colonic necrosis has been reported; it is important to use a safe technique that obviates this. METHODS: The rectum is fully mobilized and transected at the level of the levator diaphragm. The mobilized sigmoid and rectum are resected with their mesenteries, and the prepared distal colon is everted 5 cm using Babcock clamps. The ring of a sterilized condom is then sutured to the mucosa and submucosa of the colon with 4/0 chromic catgut sutures. After completion of coloanal anastomosis, the condom is brought to the exterior, and the mid part is transected. RESULTS: We have used a condom for intraluminal bypass procedures in ten rectal carcinoma patients including five preoperative radiation cases. There was no anastomotic dehiscence, leakage, or colonic necrosis because of a condom. CONCLUSION: We believe that the intraluminal bypass technique using a condom is a very safe, cost-effective, and easily available alternative for coloanal anastomosis.Read at the meeting of the Korean Colo-Proctological Society, Pusan, South Korea, December 4, 1993.     

Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis

PURPOSE: Improved functional results can be obtained by construction of a colonic J-pouch after coloanal anastomosis. Variability in pouch size following coloanal anastomosis is prevalent in current literature. In this study, the authors compare clinical bowel function after complete rectal excision with coloanal anastomosis for patients with rectal carcinoma using either a small 6-cm or a large 10-cm colonic J-pouch anastomosis. The clinical outcome is assessed both at short-term and long-term follow-up. METHODS: Fifty-nine consecutive patients with rectal cancers 4 to 8 cm from the anal verge were recruited into the study. Patients were randomized intraoperatively to either a 6-cm J-pouch group or a 10-cm J-pouch group. Clinical assessments were performed prospectively at 3, 6, 12, and 24 months postoperatively, following colostomy closure. Clinical parameters such as frequency, urgency, continence, and laxative and enema use were assessed and compared between the two groups. RESULTS: There was no statistical differences in the mean defecation frequency, urgency, and fecal continence between the two groups at 3, 6, 12, and 24 months. In the first year, laxative and enema use between the two groups was negligible; however at two years, 30 percent of patients with a large reservoir compared with 10 percent of patients in the small-pouch group required laxative and/or enema for constipation and evacuation of bowels. CONCLUSION: Similar clinical results can be expected from patients with either small or large reservoirs at one year. However, with long-term follow-up, patients with a large reservoir are more likely to require medication for constipation and evacuation. To avoid these inconveniences a small reservoir is advocated for patients undergoing coloanal anastomosis.     

Idiopathic megarectum complicating pregnancy: report of a case

Pregnancy often exacerbates constipation in young women with chronic constipation syndromes. The presence of the fetus presents a challenge in both the diagnosis and treatment of these syndromes. This study was conducted to report a rare case of idiopathic megarectum complicating a pregnancy. An aggressive polyethylene glycol (PEG) regimen allowed the patient to carry the child to term and to have a normal vaginal delivery. Successful proctocolectomy was performed with coloanal anastomosis 3 months postpartum. The patient has been free of constipation for 18 months without the need for cathartics or laxatives. All efforts to avoid operative intervention should be made in constipated patients during pregnancy. This principle holds true even in the setting of dilated large bowel. Idiopathic megarectum and the management of constipation in pregnancy are discussed.     

Videoproctography in selecting patients with constipation for colectomy

The results of colectomy for constipation based only on evidence of delayed colonic markers have been disappointing. The operation may fail because these patients are unable to evacuate the rectum owing to outlet obstruction. In the present study, we have used a combination of videoproctography and transit marker studies in an attempt to predict patients who will have a favorable outcome after colectomy by excluding patients with outlet obstruction. Videoproctography was performed in 228 patients referred for consideration of surgery for constipation. Only 111 (38 percent) had a normal proctogram with complete evacuation of liquid barium. Of these 111 patients, 21 (19 percent) had delayed colonic marker studies. Colectomy and ileorectal anastomosis were performed in 18 of these 21 patients; two years later, 16 were symptom free, with a median daily bowel frequency of four (range, two to six). The remaining two patients failed to respond to surgery. These data suggest that true idiopathic, slow-transit constipation is uncommon, but, when identified on the basis of delayed markers and the ability to expel liquid on proctography, an excellent result can be anticipated from colectomy and ileorectal anastomosis.Read at the World Congress of Gastroenterology, Sydney, Australia, 1990.     

Perineal rectosigmoidectomy in the elderly

Between April 1989 and October 1991, 20 consecutive patients underwent perineal rectosigmoidectomy and coloanal anastomosis for full-thickness rectal prolapse. These 16 females and 4 males, with a mean age of 82 (range, 68–101) years, were evaluated by detailed functional assessment and physiologic testing. A grading scale from 0 to 24 was based upon the frequency and type of incontinence, 0 representing full continence. The mean preoperative continence score was 14.5, while the mean postoperative continence score was 8.4. The mean length of resected rectosigmoid was 23 cm. There was one postoperative death and one significant complication, a postoperative pelvic hematoma that required reoperation. There were no full-thickness recurrences at a mean follow-up of 26 months. Six of the 10 patients who underwent preoperative pudendal nerve terminal motor latency (PNTML) testing had evidence of severe neuropathy (latencies greater than 2.5 milliseconds). Prolonged PNTML, however, was not shown to be an accurate predictor of postoperative incontinence because four of the six patients with neuropathy regained excellent to good control. In conclusion, perineal rectosigmoidectomy is a safe operation for the treatment of full-thickness rectal prolapse in the elderly patient. Improved postoperative continence was noted in 90 percent of patients, with improvement seen even in those patients with severe pudendal neuropathy.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Visceral neuropathy in slow transit constipation: An immunohistochemical investigation with monoclonal antibodies against neurofilament

PURPOSE: The aim of this study was to investigate neuropathologic changes in the colonic wall of patients with slow transit constipation using monoclonal antibodies raised against neurofilament. METHODS: In a prospective study, 227 patients with severe, long-standing constipation and intractable defecation disorders were analyzed according to a standard protocol. Slow transit constipation was diagnosed in 65 patients (29 percent). Fortythree patients (7 men and 36 women; mean age, 46 years; range, 16–76 years) underwent a partial (n=20) or subtotal (n=23) colectomy. In 39 patients (5 with megacolon and 34 with normal-sized colon) the cause of their constipation remained unexplained (idiopathic slow transit constipation). All resected colon specimens were investigated with the monoclonal antineurofilament antibody NF₂F₁₁ and compared with those of 20 control patients. RESULTS: In all controls the myenteric plexus revealed a moderate and diffuse axonal staining. In 29 of 39 patients with idiopathic slow transit constipation, the apparently normal axon bundles in the myenteric plexus stained markedly less than normal or failed to stain at all with the monoclonal antibody. In 17 patients this reduced or absent neurofilament expression was found along the entire length of the colon, whereas in 12 patients only a portion of the colon was affected. CONCLUSION: These findings indicate that a visceral neuropathy seems to be present in the majority of patients with severe, so-called idiopathic slow transit constipation.Read at the meeting of The American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.     

A constipation scoring system to simplify evaluation and management of constipated patients

PURPOSE: Constipation is a common complaint; however, clinical presentation varies with each individual. The aim of this study was to assess a standard scoring system for evaluation of constipated patients. MATERIALS AND METHODS: All consecutive patients with idiopathic constipation who were referred for anorectal physiologic testing were assessed. A subjective constipation score was calculated based on a detailed questionnaire that included over 100 constipation-related symptoms. Based on the questionnaire, scores ranged from 0 to 30, with 0 indicating normal and 30 indicating severe constipation. The constipation score was then compared with the objective findings of the physiology tests, which include colonic transit time (CTT), anal manometry (AM), cinedefecography (CD), and electromyography (EMG). Colonic inertia was defined as diffuse marker delay on CTT without evidence of paradoxical contraction on AM, CD, or EMG. Pelvic outlet obstruction was defined as paradoxical puborectalis contraction, rectal prolapse or rectoanal intussusception, rectocele, or sigmoidocele. RESULTS: A total of 232 patients (185 females and 47 males) of a mean age of 64.9 (range, 14–92) years were evaluated. All patients had a score of more than 15; on evaluation of the significance of different symptoms in the constipation score with the Pearson's linear correlation test, 8 of 18 factors were identified as significant (P<0.05). These factors included frequency of bowel movements, painful evacuation, incomplete evacuation, abdominal pain, length of time per attempt, assistance for evacuation, unsuccessful attempts for evacuation per 24 hours, and duration of constipation. All 232 patients had objective obstruction attributable to one or more of the following causes: paradoxical puborectalis contraction (81), significant rectocele or sigmoidocele (48), rectoanal intussusception (64), and rectal prolapse (9). CONCLUSION: The proposed constipation scoring system correlated well with objective physiologic findings in constipated patients to allow uniformity in assessment of the severity of constipation.     

Treatment of rectovaginal fistulas that has failed previous repair attempts

PURPOSE: The purpose of this study was to assess results of treatment of rectovaginal fistulas (excluding pouch vaginal fistulas) that have failed previous attempts at repair. METHOD: A retrospective chart review of all patients presenting with nonhealing rectovaginal fistula was performed. RESULTS: Twenty eight patients with persistent fistulas were identified. In 18 patients the fistula was classified as simple, and in 10 the fistula was complex. Fourteen fistulas were secondary to obstetric injury, five were caused by Crohn's disease, and nine patients had miscellaneous etiologies for their fistulas. Of patients with persistent simple fistulas, 13 (72 percent) of the fistulas healed, 5 after advancement flaps, 5 following sphincteroplasty, and 3 after coloanal anastomoses. Of persistent complex fistulas, only four of ten (40 percent) healed, one following sphincteroplasty, one with coloanal anastomosis, and two after gracilis transposition. A total of 23 advancement flaps were done in 17 patients with five fistulas healing (29 percent). Sphincteroplasty and fistulectomy was successful in six of seven patients (86 percent). Coloanal anastomosis resulted in healing of four of six patients (67 percent) in whom it was attempted. Gracilis muscle transfer was successful in two of two patients (100 percent). CONCLUSION: Persistent rectovaginal fistula presents a difficult management problem. Choice of operation must be tailored to the underlying pathology and type of repair previously done. Advancement flap repair is generally not recommended for persistent complex fistulas or for simple fistulas that have failed a previous advancement flap repair.Dr. MacRae was supported in part by the Wigston Foundation, Toronto, Ontario, Canada.Read at the meeting of The American Society of Colon and Rectal Surgeons, in Montreal, Quebec, Canada, May 7 to 12, 1995.     

Results of rectocele repair

PURPOSE: This study was designed to evaluate the results of rectocele repair and parameters that might be useful in selecting patients for this operation. METHODS: Twentyfive patients with symptom-giving rectoceles were prospectively evaluated with a standardized questionnaire, physical examination, defecography, colon transit studies, anorectal manometry, and electrophysiology. Patients underwent posterior colporrhaphy and perineorrhaphy. They were followed postoperatively (mean, 1.0 year) with the same questionnaire, physical examination, defecography, anorectal manometry, and electrophysiology. RESULTS: Constipation had improved postoperatively in 21 of 24 constipated patients (88 percent). At postoperative follow-up 13 patients (52 percent) had no constipation symptoms, 8 (32 percent) had occasional symptoms, and 4 (16 percent) had symptoms more than once per week. Four patients with rectocele at preoperative defecography, but not at physical examination, had favorable outcomes following surgery. The majority of patients not using vaginal digitalization preoperatively had improved with respect to constipation. All patients with pathologic transit studies had various degrees of constipation postoperatively. Constipation was not improved in two of five patients with preoperative paradoxic sphincter reaction. CONCLUSIONS: Rectocele is one cause of constipation that can be treated with good results. Preoperative use of vaginal digitalization is not mandatory for a good postoperative result. Defecography is an important complement to physical examination. Patients with pathologic transit study might have a less favorable outcome of rectocele repair with respect to constipation. More studies about the significance of paradoxic sphincter reaction in these patients are indicated.Poster presentation at the XVth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Singapore, July 2 to 6, 1994.     

Treatment of megacolon and megarectum

Opinion statement Patients presenting with megacolon and megarectum require extensive specialized testing to distinguish underlying Hirschsprung’s disease from other secondary causes. Diagnostic testing and long-term treatment are best initiated after disimpaction has been achieved, by large-volume tap water enemas and/or oral colonic lavage with polyethylene glycol. With intensive treatment (including biofeedback if pelvic floor dysfunction is present), at lease one half of patients can avoid surgery. Maintenance therapy relies on daily use of osmotic laxatives. Stimulant laxatives are used intermittently as rescue treatments if there has not been a satisfactory bowel movement in 3 days. Patients with idiopathic megacolon or megarectum may require surgery if they have refractory symptoms. Depending on age, pelvic floor, and anal sphincter function, patients who have isolated megacolon can be treated with either subtotal colectomy with ileorectostomy or diverting loop ileostomy. Patients with isolated megarectum can be treated with either proctectomy and coloanal anastomosis or vertical reduction rectoplasty. Patients who have combined megacolon and megarectum can be offered diverting loop ileostomy or, if pelvic floor function is normal and they wish to avoid stoma, total proctocolectomy with ileal pouch-anal anastomosis.     

Surgical treatment of cytomegalovirus enterocolitis in severe human immunodeficiency virus infection

PURPOSE: The aim of this study was to describe our experiences of surgical removal of inflamed bowel in cytomegalovirus enterocolitis. METHODS: Eight homosexual males with a mean age of 41 years (range, 29–59 years) and a mean CD4 count of 21×10 ⁶/1 (1–60× 10⁶/1)with advanced human immunodeficiency virus infection and severe cytomegalovirus enterocolitis were treated with ileocecal resection (4 patients) or right-sided hemicolectomy (4 patients). Symptoms were lower abdominal pain, severe diarrhea, fever, and weight loss, unrelieved by anticytomegalovirus therapy. Radiologic examination showed that ulcerative inflammation was limited to the right colon and terminal ileum. Microscopic examination confirmed the cytomegalovirus enterocolitis. Intermittent cytomegalovirus treatment, usually with foscarnet for 10 to 14 days every 4 to 6 weeks was given postoperatively. RESULTS: Two minor postoperative complications occurred: a lesser wound infection and a moderate bleeding from the abdominal wound edges. One patient died after three weeks because of gastrointestinal bleeding from an ulcerating Kaposi's sarcoma lesion and another patient died from unrelated causes three weeks after discharge from the hospital. The remaining 6 patients experienced complete or partial palliation of the abdominal symptoms for a mean of 14 months (range, 5–35 months) until death or the end of observation time. One patient is still alive two years after the operation. The overall mean survival was 12 months (range, 0.5–35 months). Recurrent or persistent symptoms and/or signs of cytomegalovirus enterocolitis occurred in four patients after a mean of seven months. CONCLUSION: Resection of inflamed bowel combined with postoperative anticytomegalovirus treatment leads to excellent palliation and a relatively favorable survival in AIDS patients with cytomegalovirus enterocolitis.     

Abnormal rectosigmoid myoelectric response to eating in patients with severe idiopathic constipation (Slow-transit type)

Pathophysiologic mechanisms responsible for severe chronic constipation are poorly understood. In particular, most of the published studies have lumped together patients having different subtypes of constipation, with different and often conflicting results. We studied six patients complaining of severe idiopathic constipation and displaying homogeneous clinical and pathophysiologic features (i.e.,patients with slow-transit type constipation) to evaluate their myoelectric spiking responses to food ingestion. Ten healthy subjects acted as controls. The constipated patients failed to show the increase in myoelectric spiking activity that was seen in controls immediately following the meals, suggesting the possibility of a neurogenic defect in this condition.     

Adult Hirschsprung's disease

To assess the clinical features and long-term functional outcome after surgery, eight patients operated on for adult Hirschsprung's disease during the 20-year period, 1968–1988, were re-examined. There were six men and two women with a mean age of 40±3 years at the time of survey. The mean age of the patients at the time of diagnosis was 23.8 years (range, 16 to 41 years). Results were compared with eight consecutive patients operated on for Hirschsprung's disease during the neonatal period. The Duhamel operation was performed initially on seven patients in the adult group and on all patients in the neonatal group. Anterior resection was performed on one adult patient initially but this was converted subsequently to Soave's pullthrough operation. None of the patients had constipation after definitive surgery. The mean defecation frequency was two in both groups. Three patients in the adult group and two patients in the neonatal group were completely continent, others had occasional soiling. The mean anal sphincter pressures were lower in the neonatal group than in the adult group and in each group lower than in normal controls. Adult Hirschsprung's disease must always be suspected in the context of chronic constipation. Functional results after surgery in adult patients are similar to those achieved in children.     

Functional results of coloanal anastomosis with reservoir

Functional results in 33 patients who underwent a coloanal anastomosis with reservoir were prospectively evaluated three months after colostomy closure and later (16.2±5.7 months) and were compared with those of 36 healthy controls. We were unable to demonstrate any significant difference between patients and controls concerning frequency of stools, feeling of the need to defecate, continence of stools and flatus, differentiation between flatus and feces, urgency, and need to wear a protective pad. There was a statistically significant difference concerning the ability to evacuate, which was better in the control group (score=1.03) than in the patients (score=1.63) (P <0.001). These results suggest that coloanal anastomosis with reservoir provides nearly normal function except for the ability to evacuate.     

Loop ileostomy is a safe option for fecal diversion

This study was undertaken to prospectively assess all morbidity and mortality associated with temporary loop ileostomy. Eighty-three consecutive patients of a median age of 45 years required temporary fecal diversion after either ileoanal or low colorectal anastomosis (n=72), for perianal Crohn's disease (n=5), or for other reasons (n=6). All loop ileostomies were supported with a rod, and fecal diversion was maintained for a mean of 10 weeks. To date, 67 patients have had re-establishment of intestinal continuity. Stoma closure was affected through a parastomal incision in 64 patients; in three, a laparotomy was required. The closure was stapled side to side in 49 patients, while a hand-sewn anastomosis was done in the other 18 patients; all skin wounds were left open. The mean length of surgery for ileostomy closure was 56 minutes, and the mean hospital stay was five days. Nine patients (10.8 percent) developed 10 complications, nine of which required hospitalization. Specifically, four patients developed dehydration and electrolyte abnormalities secondary to high stoma output, and two had anastomotic leaks that spontaneously healed following conservative management. One patient developed a superficial wound infection that spontaneously drained itself. One patient developed a partial small bowel obstruction that resolved without surgery after a four-day hospitalization. One stoma retracted after supporting rod removal and prompted premature closure. There was no stomal ischemia, hemorrhage, prolapse, or mortality in this series. Thus, loop ileostomy is a safe way to achieve fecal diversion.