Effectiveness of Afferent Loop Stimulation Prior to Ileostomy Closure

Dear Editor:

We have read with great interest the article by Abrisqueta,¹ entitled Afferent loop stimulation prior to ileostomy closure.

We report the case of a 55-year-old female patient who, during the diagnostic process of rectal tenesmus and bleeding, was diagnosed with a rectal adenocarcinoma measuring 3 cm, located 5 cm from the anal margin with concentric involvement, and 3 nodules in the mesorectal fat (UT3N1-2). After neoadjuvant treatment (radiotherapy to 50.4 Gy with concurrent capecitabine), a low anterior resection was performed in July 2012 with protective ileostomy in the right flank.

During adjuvant treatment, a barium enema was used to confirm the integrity of the anastomosis; after chemotherapy, an extension study was performed to rule out the presence of tumor disease.

In the month of November, treatment with efferent stimulation was begun. In our case, we began with 300 cm³ of warm saline introduced through a Foley catheter. We repeated the process each week, increasing the stimulation to 500 cm³. After the online publication of the Abrisqueta article, we continued by including a thickener in the saline solution (Resource Thickener^®, Nestlé Healthcare Nutrition, Vevey, Switzerland). One week before surgery for the reconstruction of the intestinal tract, stimulation was done daily, while including in the solution the contents of a container of sodium lauryl sulfoacetate and trisodium citrate for anterograde preparation of the excluded segment. Throughout the process, the patient was asymptomatic except for the need for anal evacuation. We proceeded with the stoma closure, finding an efferent loop with a size similar to the afferent loop and performing a mechanical side-to-side anastomosis. The patient progressed satisfactorily, initiating peristalsis 24 h after surgery, and was discharged on the fourth day post-op.

We believe that stimulation of the efferent loop is essential to prevent atrophy of the excluded intestinal segment and, therefore, postoperative ileus while also preventing complications. In our case, despite having used an osmotic laxative, there was evidence of contrast enema on a plain abdominal radiograph after 72 h. We concur with Abrisqueta about reeducating patients for sphincter control; in our case, we also recommended Kegel exercises for this patient.²

The future demonstration of the usefulness of this procedure using comparative prospective studies to analyze the benefits of intestinal stimulation prior to ileostomy closure would require establishing protocols for patients to do each day at home to stimulate the excluded segment.