Purpose: A 61-year-old male presented with worsening rectal bleeding, weight loss, change in bowel habits and abdominal discomfort over one year. His past medical history was significant for coronary artery disease and diabetes. Medications included simvastatin, metformin and aspirin. He had a 50-pack-year smoking history and consumed alcohol. Family history was remarkable for colon cancer. Physical exam was unremarkable except rectal exam revealed a protruding ulcerated mass along the right posterior rectal wall beginning 3 centimeter (cm) above the anal verge occupying at least half the circumference. A complete blood count showed mildly elevated white blood cells and a normal hemoglobin and hematocrit. His carcinoembryonic antigen (CEA) was normal. A computed tomography scan revealed circumferential rectal wall thickening without any evidence of metastatic disease. However, magnetic resonance imaging found two enlarged left internal iliac lymph nodes measuring one cm.
Methods: A colonoscopy showed a circumferential malignant appearing apple core lesion extending from 2 -12 cm above the dentate line. Biopsy showed carcinoma in situ with necrosis, suspicious for invasion. He was diagnosed with stage IIIB rectal carcinoma. A multimodality treatment was planned with a temporary ileostomy (TI), neoadjuvant chemoradiotherapy, followed by a sphincter sparing resection.
Results: Patient underwent a TI two weeks later; however, his post-operative course was complicated by high output through the stoma leading to hyperchloremic metabolic acidosis and pre-renal azotemia. Patient had significant hyponatremia and hypomagnesimia requiring daily intravenous normal saline and magnesium replacement; he recovered successfully after one month. Patient did not receive neoadjuvant chemoradiotherapy as planned due to significant electrolyte imbalances from TI; instead he underwent a laparoscopic ultra-low anterior resection of tumor followed by adjuvant 5-fluorouracil based chemo and radiotherapy.
Conclusion: Current literature is controversial regarding safety of temporary colostomy (TC) versus temporary ileostomy for temporary fecal diversion. Some authors have advocated that TI is best for temporary diversion because of its ease of construction and management and the infrequency of complications. Our patient underwent a TI for the above mentioned reasons. However, because of the high output and excessive electrolyte loss through the stoma, he required a prolonged intravenous infusion therapy. Therefore, when patients undergo temporary fecal diversion for rectal cancer; acute renal failure and electrolyte imbalances should be one of the potential complications considered while selecting TI versus TC to minimize the post operative morbidity.