Available online at www.sciencedirect.

com

ScienceDirect
EJSO 42 (2016) 273e280 www.ejso.com

Stoma placement in obstructive rectal cancer prior to

neo-adjuvant treatment and definitive surgery: A practical
guideline
T.A. Vermeer a, R.G. Orsini a, G.A.P. Nieuwenhuijzen a,
H.J.T. Rutten a,*, F. Daams b
a
Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
b
Department of Surgery, VU Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
Accepted 9 November 2015
Available online 22 November 2015

Abstract
Introduction: Mechanical bowel obstruction in rectal cancer is a common problem, requiring stoma placement to decompress the colon and
permit neo-adjuvant treatment. The majority of patients operated on in our hospital are referred; after stoma placement at the referring
centre without overseeing final type of surgery. Stoma malpositioning and its effects on rectal cancer care are described.
Methods: All patients who underwent surgery for locally advanced or locally recurrent rectal cancer between 2000 and 2013 in our tertiary
referral centre were reviewed and included if they received a stoma before curative surgery. Patients with recurrent rectal cancer were only
included if the stomas from the primary surgery had been restored. The main outcome measures are stoma malpositioning, postoperative
and stoma-related complications.
Results: A total of 726 patients were included; of these, 156 patients (21%) had a stoma before curative surgery. In the majority of patients,
acute or pending large bowel obstruction was the main indication for emergent stoma creation; some of the patients had tumour-related
fistulae. In 53 patients (34%), the stoma required revision during definitive surgery. No significant differences were found regarding post-
operative complications.
Conclusion: One-third of the previously placed emergency stomas were considered to be located inappropriately and required revision. We
were able to avoid increased complication rates in patients with a malpositioned stoma, however unnecessary surgery for an inappropriately
placed stoma should be avoided to decrease patient inconvenience and risks. An algorithm is proposed for the placement of a suitable
stoma.
Ó 2015 Elsevier Ltd. All rights reserved.

Keywords: Locally advanced; Locally recurrent; Obstructive rectal cancer; Neo-adjuvant treatment; Stoma

Introduction rectum.2 In cases of obstructive or symptomatic rectal can-

Acute bowel obstruction is the initial presentation in 20%
of patients with colorectal cancer.1 In 60e70% of these
cases, bowel obstruction is caused by a distal malignancy,
including malignancies of the rectosigmoid colon or
* Corresponding author. Tel.: þ31 (0)402398680; fax: þ31 (0)
402440268.
E-mail addresses: Thomas.vermeer@catharinaziekenhuis.nl (T.A.
Vermeer), Ricardo.orsini@catharinaziekenhuis.nl (R.G. Orsini),
Grard.nieuwenhuijzen@catharinaziekenhuis.nl (G.A.P. Nieuwenhuijzen),
harm.rutten@catharina-ziekenhuis.nl (H.J.T. Rutten), Freek.daams@
catharinaziekenhuis.nl (F. Daams).
cer, a two-stage surgical management strategy is indicated,
with the creation of a stoma prior to the start of neo-
adjuvant treatment. This two-stage strategy is reserved for
cancers of the middle or lower rectum and differs from the
strategy for obstructive colon cancer because the gastro-
intestinal surgeon must select the optimal stoma type and
location during the first step of this staged procedure.
The main goal of this two-stage procedure is clear: to
allow full patient compliance during neo-adjuvant treat-
ment without temporary interruption or delay due to
tumour-related problems or the need for acute placement
of a diverting stoma. Emergent stomas in rectal cancer

http://dx.doi.org/10.1016/j.ejso.2015.11.008
0748-7983/Ó 2015 Elsevier Ltd. All rights reserved.
274 T.A. Vermeer et al. / EJSO 42 (2016) 273e280
are mostly indicated for complications arising from the
tumour itself; e.g., obstruction, incontinence, disabling
pain, diarrhoea, fistula, abscess or perforation, and may
be necessary to bridge the period between neo-adjuvant
treatment and final curative surgery. With the increased
use of neo-adjuvant treatment and “liver-first” treatment
strategies, the use of bridging stomas is increasing.
The type and location of these stomas should correspond
with the type and location of future necessary deviating or
definitive stomas and such decisions are predominantly
influenced by patient- and tumour-related characteristics
that are apparent very early in the treatment course.
Although malpositioned stomas may be restored, revision
or relocation during definitive surgery exposes the patient
to longer operating times, additional adhesiolysis and anas-
tomoses, a higher risk of abdominal complications and the
inconvenience of a fresh new stoma with healing problems.
The primary objectives of this study were to investigate
the indications for emergency stoma placement and the
indications for the placement of stomas in a particular loca-
tion. Secondarily, we aimed to determine the consequences
of malpositioning in terms of surgical characteristics; i.e.,
operating time, blood loss, and postoperative complica-
tions. Finally, an algorithm to guide surgeons during the
decision-making process concerning emergency stomas in
advanced rectal cancer was proposed to standardise stoma
placement and to optimise curative surgery in rectal cancer.
Methods
Patients
The Catharina Hospital is a tertiary referral centre for
locally advanced (LARC) and locally recurrent rectal can-
cer (LRRC). A prospective database is maintained, contain-
ing all patients who underwent surgery for LARC or LRRC
between 2000 and 2013 in our hospital. All patients with
LARC who had a diverting stoma placed prior to primary
surgery were selected for further analysis. In patients who
had been referred to our centre, decisions regarding the
type and location of the stoma were generally made in
the referring hospital. Data on the indication for stoma for-
mation in the referring hospital were retrieved from the cor-
respondence and operative reports. These data are
presented in Table 2.
Patients with LRRC were included in the analysis when
the primary surgery consisted of a low anterior resection
(LAR) and any previous stoma had been restored. LRRC pa-
tients with an end colostomy after an APR were excluded.
Patients with distant metastases were excluded. Comorbidity
was scored using the Charlson Comorbidity Index.3
Stoma location and surgical techniques
The type of surgery and stoma type is based on preoper-
ative staging and patient characteristics. Guidelines for
stoma type and location in our hospital are summarised
below and clarified in Illustration 1:
- LAR; a right-sided diverting transverse double loop co-
lostomy is created.
- APR; an end sigmoid colostomy is created.
- Unclear type of surgery: A right-sided double loop di-
verting transverse colostomy or a very low single-
barrel end sigmoid colostomy.
- Avoid: Stoma placement in the left upper abdomen since
this could compromise the descending colon in case of a
LAR.
Stoma malpositioning was defined as a preoperative
stoma that had to be repositioned during surgery to perform
necessary resection or to construct a suitable permanent or
diverting stoma.
Statistical analysis
Statistical analyses were performed using SPSS Sta-
tistics 21.0 software (SPSS Inc., Chicago, IL, USA).
Intergroup comparisons were made using chi-square or
t-test when appropriate. If normality and homogeneity
assumptions were violated, non-parametric tests were
used. A p-value of 0.05 was considered statistically
significant. A p-value of 0.05 was considered statisti-
cally significant.
Results
Clinical and demographic data
All consecutive patients who underwent surgery be-
tween 2000 and 2013 were analysed (n ¼ 726). One hun-
dred fifty-six patients (21%) underwent stoma creation
prior to curative surgery and were included for further anal-
ysis. In 27 patients (17%), the stoma was created at our
institution; in the remaining patients, the stoma was created
at the referring hospital. Patient characteristics are shown in
Table 1.
Stoma placement and malpositioning
Fig. 1 shows the data regarding stoma creation. Stomas
were indicated for various reasons, which are shown in
Table 2. A diverting double loop ileostomy (12%), a trans-
verse double loop colostomy (26%), and a diverting double
loop (24%) or end sigmoid colostomies (37%) were most
frequently placed.
In 41% (n ¼ 64) of patients, stomas were malpositioned
and stoma revision was necessary for the reasons illustrated
in Fig. 1. In 34% of patients (n ¼ 53), stoma revision could
have been avoided if the stoma type and position had been
chosen more carefully. In 7 patients, a diverting ileostomy
was created for large bowel obstruction. In 36 patients, the
 T.A. Vermeer et al. / EJSO 42 (2016) 273e280 275

Illustration 1. Advised stoma sites in rectal cancer patients based on the expected type of surgery. a. A double loop ileostomy b. A right-sided double loop
transverse colostomy c. A double loop sigmoid colostomy d. A low-end sigmoid colostomy. Stoma positioning in the red shaded area can comprise future
surgery and should therefore always be considered in collaboration with an experienced gastro-intestinal surgeon. An ileostomy is contraindicated in the
acute situation of distal obstruction or in patients at risk for dehydration (i.e. chemotherapy).

diverting or end sigmoid colostomy was misplaced in the Complication rates

left upper abdomen, leading to replacement of the present
end sigmoid colostomy (n ¼ 7) in patients undergoing an
APR or breakdown of the sigmoid colostomy and creation
of a diverting ileostomy or transverse colostomy (n ¼ 29) in
order to perform adequate surgery in patients undergoing a
LAR. In 3 patients, a left-sided ileostomy (n ¼ 1), a trans-
verse colostomy in the midline (n ¼ 1) and an end trans-
verse colostomy required replacement and revision. In 8
patients, the diverting ileostomy or transverse colostomy
was reversed during surgery without the creation of an
additional stoma. In 5 of these patients, the stoma was
reversed due to malpositioning and could not be used as
a diverting stoma because of inappropriate placement,
which compromised adequate access to the tumour and
the smaller pelvis.
In four patients initially classified as having a malposi-
tioned stoma, patient related factors; i.e. dense adhesions,
poor patients’ health and bowel ischemia; caused subopti-
mal stoma location and stoma type. Since this is inevitable
in clinical practice, these patients were not classified as
having a malpositioned stoma.
Postoperative complications were recorded for all pa-
tients, including presacral abscess (PA), anastomotic
leakage (AL), wound-related complications and general
complications. Table 3 illustrates the postoperative compli-
cations in relation to stoma malpositioning. No significant
differences in surgical outcomes were observed in terms
of the development of postoperative complications in rela-
tion to stoma revision. Additionally, stoma replacement did
not correlate with stoma-related complications, including
prolapse, necrosis or incisional hernia after reversal.
In 13 patients (8.3%), a low-end sigmoid colostomy was
created in case of obstructive rectal cancer without the cre-
ation of a mucous fistula. No complications, including
blow-out of the rectal stump, occurred in these patients.
Discussion
In 21% of patients with LARC and LRRC in our cohort,
two-stage management was required with the creation of an
emergency stoma prior to neo-adjuvant treatment. More
276 T.A. Vermeer et al. / EJSO 42 (2016) 273e280

Table 1 complication of an ileostomy is the occurrence of a high-

Patient characteristics. output stoma and its related dehydration.6 Overall readmis-
LARC (n ¼ 121) LRRC (n ¼ 35) sion rates for patients with an ileostomy are reported to be
Sex as high as 16.9%, with dehydration as the main cause in
Male 70 (58%) 22 (63%) half of these patients.4 Dehydration rates increase up to
Female 51 (42%) 13 (37%) 29% after neo-adjuvant chemotherapy, with a 15% read-
Age
mission rate.9 In up to 25% of patients, the intended tempo-
<70 years 83 (69%) 25 (71%)
>70 years 38 (31%) 10 (29%) rary ileostomy will not be reversed,10 which increases the
Mean 65 63 lifetime risk of these stoma-related problems. The afore-
ASA mentioned rationale, in combination with the high risk of
I 16 (13%) 12 (34%) dehydration in patients who depend on the receipt of
II 93 (77%) 22 (63%)
adequate neo-adjuvant treatment, are ample reasons to
III 12 (10%) 1 (3%)
LARC advice not to perform an ileostomy in patients with
cT3 33 (27%) advanced rectal cancers. The second reason to avoid a di-
cT4 84 (69%) verting ileostomy in these patients is mechanical bowel
Missing 4 (3%) obstruction, which is the main indication for stoma forma-
Type of neo-adjuvant treatment
tion in rectal cancer patients in this series. In five patients in
None 4 (3%)
5  5 Gy 8 (7%) our cohort a diverting ileostomy was created for large
LRT 3 (2%) bowel obstruction. Decompression of the colon can be
Chemoradiation 103 (85%) 18 (52%) insufficient in case of an intact coecal valve and is therefore
(Re)irradiation 14 (40%) contra-indicated and not supported by the literature.11 How-
Type of surgery
ever, in our series we did not experience a coecal blow-out.
LAR 66 (55%) 6 (17%)
APR 32 (26%) 10 (29%) In Fig. 2, we propose a flowchart illustrating our recom-
ASR 4 (3%) 7 (20%) mendations regarding emergent stoma placement. Most
Exenteration 11 (9%) 7 (20%) importantly, a simple diagnostic workup, including an
Hartmann’s procedure 8 (7%) 5 (14%) assessment of patient and tumour characteristics, should be
IORT
performed in order to optimise the choice of stoma type
Yes 85 (70%) 30 (86%)
and location. This includes a digital rectal examination
LARC, locally advanced rectal cancer; LRRC, locally recurrent rectal
(DRE), in which the distance of the tumour from the anal
cancer; 5  5 Gy, short-course radiotherapy; LRT, 45e50 Gy in 28 frac-
tions of 1.8e2 Gy; LAR, low anterior resection; APR, abdominoperineal verge and the tumour’s size and mobility are assessed.
resection; ASR, abdominosacral resection; IORT, intraoperative Involvement of the pelvic floor muscles or tumour growth
radiotherapy. into the anal sphincter indicates the need for a permanent
end colostomy because an APR is usually inevitable, even
than one-third of these stomas (34%) were inadequately after neo-adjuvant treatment. Even in emergency situations,
placed and required repositioning or revision during cura- pulmonary and liver metastases should be excluded by
tive surgery to perform adequate rectal surgery. Because thoracic and abdominal computed tomography (CT) scans
these patients already face extensive surgical procedures to distinguish candidates for curative treatment from those
involving multiple organs, stoma revision could lead to who need palliative therapy. Performing an MRI is optimal
an increased risk of morbidity and mortality, including but may not be available in every hospital in the emergency
anastomotic leakage (AL), presacral abscess (PA), perito- setting. On the basis of these investigations, an experienced
nitis and incisional herniae.4e6 Fortunately, we were able surgeon should be able to already anticipate future definitive
to avoid further complications; in addition, we were not surgery in the majority of cases and subsequently determine
able to identify stoma revision or stoma reversal as a single the proper stoma type and location.
significant factor associated with the development of post- At our institution, mucous fistulae are not created when
operative complications. Furthermore, the type and extent performing a low-end colostomy. No complications, i.e.,
of surgery, with its associated complications, outweighs rectal stump blowout, occurred in any of the 13 patients
the effect of stoma revision on postoperative adverse events treated accordingly in this study. In the 1980s, several au-
and general characteristics, including the operating time, thors described an increased risk of pelvic sepsis after rectal
duration of admission and perioperative blood loss. stump closure in patients undergoing a subtotal colectomy
Various stoma-related factors play an important role in and ileostomy.12,13 In contrast, Trickett et al., who reviewed
the decision making process and cause diversity between similar studies over a 15-year period, showed that the cre-
surgeons. A diverting loop ileostomy is superior to a loop ation of a mucous fistula is not associated with a reduction
colostomy in terms of stoma prolapse, postoperative wound in the risk of postoperative complications.14 The creation of
infection and incisional herniae but there are no significant a mucous fistula is therefore not advised. In addition, the
differences in operating time, leakage rates or fistula forma- distal sigmoid loop has been used in several cases as a bio-
tion after stoma reversal.6e8 An important, and significant, logical spacer to avoid irradiation of the small bowel.
 T.A. Vermeer et al. / EJSO 42 (2016) 273e280 277

Figure 1. Flowchart of pre-operative stoma placement in our patient population. * The diverting stoma was reversed during surgery. ** A sigmoid end or loop
colostomy was reversed, and a diverting ileostomy or transverse colostomy was created. *** Revised sigmoid colostomy (n ¼ 8), malpositioned ileostomy or
transverse colostomy (n ¼ 2).

Not only tumour-related factors influence the type and been reported to be as high as 57% compared to 8% in
location of a stoma, but also patients related factors, such the younger population.15 Therefore, the creation of an
as age, comorbidity and quality of life (QOL), have to be end colostomy should always be considered in the elderly
taken into account In elderly patients AL rates are similar patient, even when a primary anastomosis is technically
to younger patients, but mortality rates after AL have possible. Additionally, morbidity and mortality in patients
with multiple comorbid conditions or a high Charlson Co-
morbidity Index are negatively affected by postoperative
Table 2 complications. Similar considerations should be applied
Indications for stoma formation. in these patients. Finally, QOL should influence stoma
Indication No. of patients choice because the presence of a stoma is associated with
(n ¼ 156) decreased QOL.16,17 Finally, in young and physiological
Defecation related problems fit patients, stoma reversal should always be the goal. As
Incontinence and/or diarrhoea 18 opposed to younger patients, QOL in the elderly patient
Pain 2 is not always impaired by an end colostomy and the stoma
Acute bowel obstruction 52 will not be reversed in 20% of patients.18e21 Therefore,
Pending bowel obstruction 29
Fistula and/or abscess formation 16
selected patients; i.e. elderly or frail patients; could defi-
Perioperative unresectable tumour 18 nitely benefit from an end colostomy and both the patient
Other 13 and the surgeon should be well aware of this.
Missing 8 An alternative to surgical decompression of the colon in
Indications for stoma formation. obstructive rectal cancer is self-expanding metal stenting
278 T.A. Vermeer et al. / EJSO 42 (2016) 273e280

Table 3 be taken not to compromise the future surgical field by un-

Stoma formation-related complications. necessary dissections or to jeopardise the afferent loop
Variables Stoma placement Significance through inappropriate placement of the stoma, as the length
Correct Malpositioned ( p) of the remaining colon is crucial for the creation of a distal
(n ¼ 105) (n ¼ 51) anastomosis. When the type of future surgery is unclear or
Operating time still under debate during emergent stoma placement, a low-
Mean in hours (range) 4:51 4:51 0.98 end colostomy with a transection closely above the tumour
(1:44e10:36) (1:50e10:44) could be performed as well, but only by a gastro-intestinal
Admission to ICU
surgeon experienced in the treatment of these tumours. In
Mean in days (range) 1.96 (0e59) 1.31 (0e15) 0.47
General admission doing so, the limb could be used for a future anastomosis
Mean in days (range) 15 (3e138) 15 (5e79) 0.91 or kept in place during LAR and APR, respectively.
Perioperative blood loss (mean in mL) This article emphasizes the importance of correct os-
Mean in mL (range) 3686 3833 0.84 tomy placement in this highly selected group of patients.
(50e18 000) (50e25 000)
To our knowledge this is one of the largest series, which ad-
Presacral abscess 15 (14%) 11 (22%) 0.25
formation dresses this problem, and on the basis of our experience we
Anastomotic leakage 8 (8%) 4 (8%) 0.96 tried to construct a flowchart for stoma placement in this
Postoperative ileus 18 (17%) 6 (12%) 0.38 heterogeneous group of patients. This retrospective study
Incisional hernia 10 (9%) 2 (4%) 0.22 has its limitations. Patients with LARC or LRRC represent
Stoma complications
a very heterogeneous group of patients who are not easily
Overall 10 (9%) 2 (4%) 0.22
Necrosis 1 (1%) 0 0.48 fit into one flowchart that incorporates every variable.
Prolapse 5 (5%) 1 (2%) 0.39 Therefore, this flowchart can guide the surgeon in the deci-
Hernia 6 (6%) 1 (2%) 0.29 sion making process but cannot replace the judgement of an
ICU, intensive care unit. experienced surgeon.
Since the majority of our patients are referred, we depend
on accurate transfer of medical data and medical record
(SEMS). The presence of a prolonged interval between pre- keeping. In order to keep data loss to a minimum we visited
sentation and curative surgery, due to the need for long- the referral hospital to study the patients’ medical files.
term neo-adjuvant treatment, makes stent placement in
advanced or recurrent rectal cancer less favourable. In our
series, the median time between the start of chemoradiation Conclusion
and curative surgery was 113 days, which increases the risk
of stent-related problems and stent failure. A recent Co- Despite the increasing number of patients who undergo
chrane analysis found no advantages of colorectal stenting early stoma placement prior to neo-adjuvant therapy and
over emergency surgery, with similar 30-day mortality rates subsequent tumour resection, the literature lacks a general
of 2.3%, and no significant difference in overall complica- consensus and objective criteria regarding emergent stoma
tion rates.22 However, the clinical success rate is signifi- placement. Based on our experience, an emergency stoma
cantly higher in the emergency surgery group compared is often performed to alleviate acute symptoms, but without
to the stent group. Moreover, the oncological safety of foresight regarding the consequences of inappropriate
stenting is controversial, as stent-related perforation may placement. We were not able to find a correlation between
be associated with an increased risk of recurrence.23 Stent stoma malpositioning and postoperative complications;
placement should only be considered in highly selected pa- however, to facilitate definitive surgery, optimal stoma
tients; with an expected survival less than 3 months due to placement remains an essential component of the entire
pulmonary or liver metastases; and it should always be dis- multidisciplinary treatment for patients with advanced
cussed in a multidisciplinary team meeting.24e26 rectal cancer. At minimum, an experienced gastro-
A deviation from the proposed flowchart is sometimes intestinal surgeon should make the decision only after the
necessary due to various reasons: an incomplete diagnostic diagnostic workup is complete. The decision should be
work up, usually due to practical limitations; uncertainty guided by patient characteristics, including age and comor-
regarding the feasibility of sphincter-preserving surgery; bidities, and should be carefully based on the type of defin-
and uncertainty regarding the response to chemoradiother- itive surgery. This study shows that the type of definitive
apy and its possible influence on the expected surgical surgery should be considered and that the availability of
approach. In these situations, a right-sided diverting trans- expertise will influence emergent stoma placement, despite
verse colostomy is advised; this type of colostomy has a the lack of evidence regarding stoma-related morbidity. In
minimal effect on possible curative surgery and leaves the this heterogeneous group of complex patients, it is impos-
left hemi-abdomen untouched. If the final operation is an sible to create a flowchart that will cover all potential clin-
APR, the end sigmoid colostomy is the preferred stoma. ical situations; however, the proposed flowchart may
However, when a LAR must be performed, care should definitively offer guidance to even the less-experienced
 T.A. Vermeer et al. / EJSO 42 (2016) 273e280 279

Figure 2. Flowchart of recommendations for emergency stoma placement. *DRE, digital rectal examination; **CCS: Charlson Comorbidity Index.

surgeon in most cases and may reduce the number of mis- Manuscript presentation
placed stomas.
Currently the manuscript is not under consideration for
Role of funding oral or poster presentation at a meeting or conference.

None.
References
Conflict of interest statement
1. Ansaloni L, Andersson RE, Bazzoli F, et al. Guidelenines in the man-
None declared. agement of obstructing cancer of the left colon: consensus conference
280 T.A. Vermeer et al. / EJSO 42 (2016) 273e280
of the world society of emergency surgery (WSES) and peritoneum
and surgery (PnS) society. World J Emerg Surg 2010;5:29.
2. Kasten KR, Midura EF, Davis BR, Rafferty JF, Paquette IM. Blowhole
colostomy for the urgent management of distal large bowel obstruc-
tion. J Surg Res 2014;188(1):53–7.
3. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of
classifying prognostic comorbidity in longitudinal studies: develop-
ment and validation. J Chronic Dis 1987;40(5):373–83.
4. Shahir MA, Lemmens VE, van de Poll-Franse LV, Voogd AC,
Martijn H, Janssen-Heijnen ML. Elderly patients with rectal cancer
have a higher risk of treatment-related complications and a poorer
prognosis than younger patients: a population-based study. Eur J Can-
cer 2006;42(17):3015–21.
5. Telem DA, Chin EH, Nguyen SQ, Divino CM. Risk factors for anas-
tomotic leak following colorectal surgery: a case-control study. Arch
Surg 2010;145(4):371–6. discussion 376.
6. Tilney HS, Sains PS, Lovegrove RE, Reese GE, Heriot AG, Tekkis PP.
Comparison of outcomes following ileostomy versus colostomy for
defunctioning colorectal anastomoses. World J Surg 2007;31(5):
1142–51.
7. Chen J, Zhang Y, Jiang C, et al. Temporary ileostomy versus colos-
tomy for colorectal anastomosis: evidence from 12 studies. Scand J
Gastroenterol 2013;48(5):556–62.
8. Guenaga KF, Lustosa SA, Saad SS, Saconato H, Matos D. Ileostomy
or colostomy for temporary decompression of colorectal anastomosis.
Systematic review and meta-analysis. Acta Cir Bras 2008;23(3):294–
303.
9. Akesson O, Syk I, Lindmark G, Buchwald P. Morbidity related to de-
functioning loop ileostomy in low anterior resection. Int J Colorectal
Dis 2012;27(12):1619–23.
10. David GG, Slavin JP, Willmott S, Corless DJ, Khan AU,
Selvasekar CR. Loop ileostomy following anterior resection: is it
really temporary? Colorectal Dis 2010;12(5):428–32.
11. Frago R, Ramirez E, Millan M, Kreisler E, del Valle E, Biondo S. Cur-
rent management of acute malignant large bowel obstruction: a sys-
tematic review. Am J Surg 2014;207(1):127–38.
12. Fazio VW, Turnbull Jr RB. Ulcerative colitis and Crohn’s disease of
the colon. A review of surgical options. Med Clin North Am 1980;
64(6):1135–59.
13. Hawley PR. Emergency surgery for ulcerative colitis. World J Surg
1988;12(2):169–73.
14. Trickett JP, Tilney HS, Gudgeon AM, Mellor SG, Edwards DP. Man-
agement of the rectal stump after emergency sub-total colectomy:
which surgical option is associated with the lowest morbidity? Colo-
rectal Dis 2005;7(5):519–22.
15. Rutten HJ, den Dulk M, Lemmens VE, van de Velde CJ, Marijnen CA.
Controversies of total mesorectal excision for rectal cancer in elderly
patients. Lancet Oncol 2008;9(5):494–501.
16. Gooszen AW, Geelkerken RH, Hermans J, Lagaay MB, Gooszen HG.
Quality of life with a temporary stoma: ileostomy vs. colostomy. Dis
Colon Rectum 2000;43(5):650–5.
17. Kairaluoma M, Rissanen H, Kultti V, Mecklin JP, Kellokumpu I.
Outcome of temporary stomas. A prospective study of temporary in-
testinal stomas constructed between 1989 and 1996. Dig Surg 2002;
19(1):45–51.
18. Cornish JA, Tilney HS, Heriot AG, Lavery IC, Fazio VW, Tekkis PP.
A meta-analysis of quality of life for abdominoperineal excision of
rectum versus anterior resection for rectal cancer. Ann Surg Oncol
2007;14(7):2056–68.
19. Orsini RG, Thong MS, van de Poll-Franse LV, et al. Quality of life of
older rectal cancer patients is not impaired by a permanent stoma. Eur
J Surg Oncol 2013;39(2):164–70.
20. Pachler J, Wille-Jorgensen P. Quality of life after rectal resection for
cancer, with or without permanent colostomy. Cochrane Database
Syst Rev 2012;12:CD004323.
21. den Dulk M, Smit M, Peeters KC, et al. Dutch Colorectal Cancer G.
A multivariate analysis of limiting factors for stoma reversal in pa-
tients with rectal cancer entered into the total mesorectal excision
(TME) trial: a retrospective study. Lancet Oncol 2007;8(4):297–303.
22. Sagar J. Colorectal stents for the management of malignant colonic
obstructions. Cochrane Database Syst Rev 2011;11:CD007378.
23. Sloothaak DA, van den Berg MW, Dijkgraaf MG, et al. collaborative
Dutch Stent-In study g, collaborative Dutch Stent-In study g. Oncolog-
ical outcome of malignant colonic obstruction in the Dutch Stent-In 2
trial. Br J Surg 2014;101(13):1751–7.
24. Cirocchi R, Farinella E, Trastulli S, et al. Safety and efficacy of endo-
scopic colonic stenting as a bridge to surgery in the management of
intestinal obstruction due to left colon and rectal cancer: a systematic
review and meta-analysis. Surg Oncol 2013;22(1):14–21.
25. Suarez J, Jimenez J, Vera R, et al. Stent or surgery for incurable
obstructive colorectal cancer: an individualized decision. Int J Colo-
rectal Dis 2010;25(1):91–6.
26. van de Velde CJ, Aristei C, Boelens PG, et al. EURECCA colorectal:
multidisciplinary mission statement on better care for patients with
colon and rectal cancer in Europe. Eur J Cancer 2013;49(13):2784–
90.