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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 were randomly 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

R. Bangalore. R. 961–966. edematous and inflamed bowel. 19. Mariani. and insecure anastomosis. B. vol. vol. 2007. R. b. S. P. Mecklin.” Annals of Surgery. V. F. vol. Pycha.ileostomy as the diversion procedure. Fazl Q. Exclusion criteria . 7. no. Keighley." World Journal of Colorectal Surgery: Vol. L. 2 : Iss. 11. pp. “Stapled versus sutured closure of loop ileostomy. “T-tube ileostomy for intestinal perforation in extremely low birth weight neonates. D. no. vol. L. adherent loops of bowel. 68. Design Prospective study 3. from July 2008 to July 2011 4. “Stoma complications: a multivariate analysis. “Outcome of temporary stomas: a prospective study of temporary intestinal stomas constructed between 1989 and 1996. pp. G. Boyle. 2. and E. M. Hasegawa. Weintraub. Rygl. Kellokumpu. Stranak et al. Hunt.” Pediatric Surgery International. no. 1. Chowdri. Wani. Setting Bangalore Medical College and Research Institute (BMCRI). with postoperative saline irrigation. Data sources M. C. India. 2012. “Temporary percutaneous ileostomy versus conventional loop ileostomy in mechanical extraperitoneal colorectal anastomosis: a retrospective study. Rissanen. 11. A randomized controlled trial. 2. were chosen for the study. 45–51. Nisar A. 1. 202–204. H. Parray.” American Surgeon. Balzarotti. K. Mariani. no. 1065–1070. Bugiantella. Y. and M. Mir. Tube ileostomy was constructed in the fashion of feeding jejunostomy. Shabir H. Wang. Morton. Kultti. H. M. Article 11 5. W. and J. 38. Subject Selection a. S. 2000. Wani (2010) "Tube ileostomy as an alternative to conventional ileostomy for fecal diversion.” Digestive Surgery. Z. Duchesne. P.. and I. J. Pugliese. 2002. 685– 688. no. Mehmood A. 2002. 231. Radley.” European Journal of Surgical Oncology. pp. Kairaluoma. pp. vol. Z. and Rauf A. pp. 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. 23. Rondelli.

Has the original study been replicated? This is an original study and no replications were made yet. Main complications related to tube ileostomy were peritubal leak. Results of the Study Over a period of three years from July 2008 to July 2011 a total of 60 diversion procedure were performed. The patients underwent ileostomy closure between 2 to 4 months (mean 10 weeks). The wound-closure time ranged from 4 to 9 days (mean 7 days). V.Patients who died within 5 days of surgery unrelated to anastomotic complication and patients who were lost to followup were excluded from the study. 5 patients developed tube blockade of whom 4 resolved with thrice daily irrigation of tube with saline. Once a day irrigation was sufficient to keep the tube patent in 25 patients. Two patients had increased wound discharge which was managed with application of colostomy bag for 2 weeks which later resolved. the drain site managed with daily dressing in whom the wound discharge was minimum. and wound closure was achieved. 6. There was one case of early necrosis of stoma and retraction which required operation and stoma revision. One patient who had persistent blockade and developed signs of peritonitis was reoperated and found to have a kinking of tube and anastomotic leak. In loop ileostomy group the main complication was peristomal skin excoriation (n = 4) which required prolonged regular dressing. In majority of patients (64%) tube ileostomy started functioning on first postoperative day while in rest from second day. 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. 7. The main complication following . Anastomotic leak occurred in two cases one of which required reoperation due to clinical deterioration. Two patients developed severe dehydration following high output from stoma and required hospitalization for electrolyte abnormalities and were managed with intravenous fluid. None of the patients required formal closure of the wound. All patients were followed for an average of 6 months and showed no complications. Tube ileostomy output ranged from 50–700 mL/day with mean of 300 mL. The tube ileostomy was removed on postoperative day 21. 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 compared to loop ileostomy. On the other hand. The complication rate of tube ileostomy was 33%. Complications are present for both of the interventions. In patients with loop. tube blockage. Out of the diversion procedures 30 were conventional loop ileostomy and 30 were tube ileostomy as described above. overall complications in 53% majority were peristomal skin irritation and wound infection following ileostomy closure. Three patients developed peritubal leak which was managed with regular dressing.

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. What contribution to health status does the nursing action/intervention make? With the result of the study. this study determined that the outcome of performing tube ileostomy is more effective than loop ileostomy in terms of complication and feasibility. the procedures should be carefully discussed using terms within the patients understanding before the operative permit is signed. 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. Applicability 1. Two patients developed obstruction following closure one of whom required reoperation. Nurses will have a better idea on how to care for these patients so as to prevent complications associated with the 2 procedures. nursing care for this kind of procedure is still feasible to carry. With regards to ethics. . Does the study provide a direct enough answer to your clinical question in terms of type of patients. Is it feasible to carry out the nursing action in the real world? Yes. VII. This study yielded a beginning for other researcher to conduct a larger study regarding the involved surgical procedures. intervention and outcome? Yes. Authors conclusion and recommendation a. VI. Reviewer's Conclusion / Commentary It can be concluded that tube ileostomy proposes better outcome than loop ileostomy for small bowel perforation or obstruction. Patients were followed up for a period of 6 months with one patient presenting with obstruction which required reoperation and adhesion release. Thorough assessment of patients who underwent these procedures should not be neglected because of the risk it imposes on the patient. 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. 2.ileostomy closure was wound infection (n = 6) which resolved with regular dressing and antibiotics. 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. We should always bear in mind that patients’ health is our priority concern.

8 French abdomen drain tube. tube ileostomy has less financial burden to patient because there is no need for secondary surgery. Performing tube ileostomy is more efficient that loop ileostomy because it saves more time and less financial burden for patients. less complication were observed so it is safer than loop ileostomy.g. In terms of finance. . At the same time it has lesser complications. Accessibility Materials for tube ileostomy (e. Efficiency Both procedures are efficient as form of fecal diversion because they are focus on working in correct manner to manage ileal perforation. Appropriateness Tube ileostomy and loop ileostomy are both appropriate ways to manage ileal perforation. drainage bag. 4. 5. the surgeons were competent enough to perform the procedures. As for the nursing staff. 6. perioperative competencies were met which 3. Effectiveness Tube ileostomy is an effective management of ileal perforation. Use of tube ileostomy in adults is only sparingly reported. In tube ileostomy. 7. there are only few hospitals who perform this procedure.Evaluation 1. Acceptability The results of the study is acceptable but as stated by the authors. Safety The procedures performed we’re both invasive and patients are placed at risk for different complications brought about by the 2 procedures. further larger randomized studies need to be undertaken before tube ileostomy could be recommended as an alternative to loop ileostomy as a diversion procedure. Competence of the care provider Base on the results of the study. 2. Therefore. 2-0 suture) are highly accessible but as stated in the study. All the patients were regularly followed in the outpatient department for any complications. 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.