Preoperative butyrate irrigation before loop ileostomy closure in rectal cancer: a randomized pilot trial
Nuria Gomez-Romeu, David Julià-Bergkvist, Lidia Cornejo, Maria Colomer, Pere Planellas, Olga Delisau, Maria Jose Gomez-Jurado, Eloi Maldonado, Anna Pigem, Celia Caula, Lara Coll, Paula Creus, Marc Fonollosa, Ramon FarresAbstract
Introduction
Temporary fecal diversion can lead to diversion colitis and mucosal dysbiosis before loop ileostomy closure.Butyrate irrigation may improve mucosal recovery and postoperative outcomes.
Methods
In this single-centre randomized pilot trial conducted between October-2013 and June-2016,patients awaiting elective loop ileostomy closure after rectal cancer resection were allocated in a 1:1:1 ratio to no irrigation, butyrate irrigation,or saline irrigation for 4 weeks before closure.The primary endpoint was postoperative morbidity after closure.Secondary endpoints were diversion colitis grade, mucosa-associated microbiota characterized by 16S rRNA gene sequencing of rectal biopsy specimens, LOS and mortality.
Results
Thirty-nine patients were randomized: 11 to no-irrigation, 13 to butyrate-irrigation, and 15 to saline-irrigation. Overall postoperative morbidity occurred in 13 of 39 patients and did not differ between groups (P = 0.094). Abdominal complications were less frequent in the butyrate -group than in the no-irrigation and saline groups (7.7% versus 18.2% versus 53.3%, P = 0.036). Paralytic ileus did not occur in the butyrate group,although this difference was not statistically-significant (P = 0.054). Endoscopic diversion colitis improved after 4-week-intervention-period, and more than half of patients receiving butyrate had normal mucosa at reassessment (P<0.001).In the no-irrigation group,Firmicutes abundance and the Firmicutes-to-Bacteroidetes-ratio decreased significantly over the study period,whereas these changes were not observed in the butyrate group.
Discussion
In this pilot randomized trial conducted between 2013–2016, preoperative butyrate irrigation before loop-ileostomy closure was not associated with a significant reduction in overall postoperative morbidity,but was associated with fewer abdominal complications,improved mucosal recovery,and preservation of selected microbiota markers during the pre-closure diversion period.These findings warrant confirmation in a larger,adequately powered contemporary study.