Literature search indicates that ileostomy is preferable as it is associated with less complication. In my personal experience, I prefer a diverting colostomy as it is easier to fashion, better managed by the patient, associated with less electrolytes disturbances and I never encountered a problem with its closure. Moreover, it is easier to close a loop colostomy than a loop ileostomy.

most emergency colorectal surgery are due to malignant perforation and most often a transverse colostomy is fashioned .However colostomy specially transverse colostomy is falling out of favour due to its higher rate of complication and due to availability of easier done ileostomies,Majority of the cases in our institution are carried out with diverting ileostomiies!

Diverting ileo- or colostomie for me, depends on the kind of surgery (infection/cancer, urgent/electiv), the place of resection (right colon, transversum, left colon, sigmoidal, rectal), the prognosis (palliativ, need of chemotherapy,...), the need of other oprerations in the near future (stomie before neoadjuvant chemo/radiotherapy and in second time TME, than I don't place a diverting stoma on the sigmoid, in that case I prefer stomie on the right colon or ileostomie),... So every case is different, the choice of stomie has to be taken very carefully and well-thought.

Well thought Dr. Pauli. But, most diverting stomas are performed to protect the anastomosis after left-sided colorectal resections whether electively or as an emergency. They are rarely performed after right colectomies including emergency resection. There is a trend now to avoid stomas even after emergency left colonic resection avoiding any stoma-related complication.

According to my humble experience, any diverting stomas hardly play a role in the anastomosis protection. The stoma is rather a kind of  the surgeons' illusive hope. Wherever the colonic anastomosis performance would be risky, the anus praeter naturalis (terminal colonostomy), either temporal  or permanent, should be made.

However, if one chooses to perform a diverting stoma by the reason beyond my comprehension, the colonostomy seems to be the best choice. On the other hand, I cannot see any advantage of the ileostomy comparing with the colonostomy, but having a load of clearly negative consequences. So, wherever the colonostomy is possible technically, it should be preferred. I can understand though that the good ICU may compensate almost any surgical trauma and patophysiological loss, but that way is to be avoided without any doubt.

I would be highly appreciate to learn any opposite opinion provided with reasonable proofs.

Diverting stoma does not reduce leak rates per se however the evidence would suggest that it reduces the severity of leak and risk of long term permanent stoma from a leak.  The interesting aspect is whether or not we do diverting ileostomy (generally regarded as standard) or diverting colostomy (less popular). The latter may well be easier to manage, lower risk of high output issues etc. There is a percieved theoretical risk of reducing the blood supply when using left sided loop colostomy (by compression) to the distal anastomosis although I have used twice to good effect. This is perhaps a good area for a trial... given the potential benefits to patient regardng the incidence of high ouput stoma in loop ileostomies.

Thank you, Dr.Budhoo, for the comment. I am agree with the first sentence, but  both 'a smaller leak', 'a larger leak' sound rather helplessly. I would like to repeat an old and wise rule: "If you are not quite sure, make no anastomosis at urgency".

Unfortunately, I have not met the meta-analysis comparing the severity of leak depending on the diverting stoma has been made or not. It may exist, of course.

About '... a theoretical risk of reducing the blood supply...by compression':

What about the mesenterium of the sigmoid? Is it compressed too after having the 'double-barreled' or Y-shaped stoma made?

As commonly known, if any anastomosis is made under tension, it leaks almost inevitably. So, to avoid this, the left side of the colon should be mobilized as much as to reach freely the abdominal wall, lest there is any tension between the upper point of fixation (colostoma) and the lower one (anastomosis).

Sincerely,

Andrey Borodach

thanks Andrey

in respect to 'severity' --  need for surgery etc. as marker of 'severity'. I suspect the threshold for reoperation in clinical leak with no defunctioning is low. Certainly my own experience. Low anterior resection especially with radiotherapy pre operatively are now often defunctioned. Other cases 'clinical judgement' is often exercised (to defunction or not)

compression yes of course can be in mesentery but theroetical as we do not see problems  in loop ileostomy. Totally agree on mobilisation and I routinely take splenic flexure down for an anterior resection. 

 an article re defunctioning -- Br J Surg. 2009 May;96(5):462-72.

thanks Andrey

in respect to 'severity' --  need for surgery etc. as marker of 'severity'. I suspect the threshold for reoperation in clinical leak with no defunctioning is low. Certainly my own experience. Low anterior resection especially with radiotherapy pre operatively are now often defunctioned. Other cases 'clinical judgement' is often exercised (to defunction or not)

compression yes of course can be in mesentery but theroetical as

we do not see problems  in loop ileostomy. Totally agree on mobilisation and I routinely take splenic flexure down for an anterior resection. 

 an article re defunctioning -- Br J Surg. 2009 May;96(5):462-72.

Thank you for the link - shall be reading!

Unfortunately, I am not sure that I understand correctly a word 'defunctioning' and related to it other words.

Our system of healthcare seemingly differs from yours. The elective treatment of onlogical patients is provided by the specialized City and Regional Oncological Centers (so called "dispensairs"). They are big and relatively powerful multidisplinar facilityes. General surgical departments in usual hospitals deal with the urgent complications only of oncological diseases and do not perform elective surgery for this kind of pathology. So, what I told above applies to the field of emergency surgery of the colon.

Although many published papers recommend ileostomy, in my experience colostomy does not lead to excessive fluid losses and is associated with less complications at the time of closure.

For covering distal colorectal surgeries my choice is a colostomy, anywhere from a sigmoid loop colostomy to subhepatic transverse loop colostomy. If the site to be covered is very close or in the right colon, then prefer ileostomy. Both are guided by how adequately is the site covered, how easily is the stoma managed, and how early the patient's bowel be rehabilitated. 

Probably colostomy if feasible. i am aware many papers support a covering ileostomy.

I would recommend a colostomy. Much easier to manage and easier to close.