Prediction and Prevention of High-Output Stoma After Colorectal Surgery
Main Article Content
Abstract
High-output stoma (HOS) is the most frequent functional complication after the construction of a diverting or terminal ileostomy in colorectal surgery, affecting roughly 15-30% of patients and accounting for a substantial proportion of unplanned readmissions for dehydration, electrolyte derangement and acute kidney injury. Although the condition is largely preventable, its diagnosis is still delayed in routine practice because output measurement is inconsistent and diagnostic thresholds remain heterogeneous (1000-2000 mL/24 h). This narrative review summarizes current evidence on the definition, pathophysiology, risk factors, predictive models and preventive strategies for HOS after colorectal surgery. Consistently reported predictors include male sex, extremes of age, alcohol intake, perioperative use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, postoperative intestinal obstruction or ileus, intra-abdominal sepsis, hypoalbuminemia, leukocytosis and electrolyte abnormalities. Published prediction tools - from decision-tree models to multivariable nomograms - achieve areas under the curve of 0.79-0.91 but share important methodological limitations, including single-center retrospective design, inconsistent outcome definitions and scarce external validation. Preventive care is best delivered as a bundle: preoperative risk stratification and nutritional optimization, review of renin-angiotensin blockade and diuretics, systematic measurement of stoma output, early exclusion of sepsis and outlet obstruction, restriction of hypotonic fluid with glucose-saline rehydration solutions, stepwise antimotility and antisecretory therapy, structured education with output diaries, and protocol-driven follow-up after discharge. Adoption of a uniform definition and prospective multicenter validation of risk models are the priorities for future research.
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
I. Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229-63.
II. 2. Snijders HS, van den Broek CB, Wouters MW, Meershoek-Klein Kranenbarg E, Wiggers T, Rutten H, et al. An increasing use of defunctioning stomas after low anterior resection for rectal cancer. Is this the way to go? Eur J Surg Oncol. 2013;39(7):715-20.
III. 3. Pisarska M, Gajewska N, Malczak P, Wysocki M, Witowski J, Torbicz G, et al. Defunctioning ileostomy reduces leakage rate in rectal cancer surgery: systematic review and meta-analysis. Oncotarget. 2018;9(29):20816-25.
IV. 4. Hanna MH, Vinci A, Pigazzi A. Diverting ileostomy in colorectal surgery: when is it necessary? Langenbecks Arch Surg. 2015;400(2):145-52.
V. 5. Baker ML, Williams RN, Nightingale JM. Causes and management of a high-output stoma. Colorectal Dis. 2011;13(2):191-7.
VI. 6. Nightingale JMD. How to manage a high-output stoma. Frontline Gastroenterol. 2022;13(2):140-51.
VII. 7. Arenas Villafranca JJ, Lopez-Rodriguez C, Abiles J, Rivera R, Gandara Adan N, Utrilla Navarro P. Protocol for the detection and nutritional management of high-output stomas. Nutr J. 2015;14:45.
VIII. 8. Mountford CG, Manas DM, Thompson NP. A practical approach to the management of high-output stoma. Frontline Gastroenterol. 2014;5(3):203-7.
IX. 9. Chen H, Wang Q, Chen Y, Li L, Wang F, Liu C. Risk factors and prediction model for early high-output stoma after colorectal cancer surgery: a retrospective study. Asia Pac J Oncol Nurs. 2026;13:100922.
X. 10. Fujino S, Miyoshi N, Ohue M, Takahashi Y, Yasui M, Sugimura K, et al. Prediction model and treatment of high-output ileostomy in colorectal cancer surgery. Mol Clin Oncol. 2017;7(3):468-72.
XI. 11. Chen Y, Cai Z, Liu Y, Zhong J, Cheng F. Assessment of risk factors and establishment of a nomogram model to predict early high-output ileostomy. Langenbecks Arch Surg. 2023;408(1):106.
XII. 12. Lee N, Lee SY, Kim CH, Kwak HD, Ju JK, Kim HR. The relationship between high-output stomas, postoperative ileus, and readmission after rectal cancer surgery with diverting ileostomy. Ann Coloproctol. 2021;37(1):44-50.
XIII. 13. Zhang X, Meng Q, Du J, Tian Z, Li Y, Yu B, et al. High output stoma after surgery for rectal cancer - a risk factor for low anterior resection syndrome? BMC Gastroenterol. 2025;25(1):32.
XIV. 14. Seifarth C, Augustin LN, Lehmann KS, Stroux A, Lauscher JC, Kreis ME, et al. Assessment of risk factors for the occurrence of a high-output ileostomy. Front Surg. 2021;8:642288.
XV. 15. Pencovich N, Silverman JS, Horesh N, Nevo N, Eshkenazy R, Kent I, et al. Readmission with acute kidney injury following ileostomy: patterns and predictors of a common phenomenon. Langenbecks Arch Surg. 2023;408(1):96.
XVI. 16. Takeda M, Takahashi H, Haraguchi N, Miyoshi N, Hata T, Yamamoto H, et al. Factors predictive of high-output ileostomy: a retrospective single-center comparative study. Surg Today. 2019;49(6):482-7.
XVII. 17. Nakanishi R, Konishi T, Nakaya E, Zaitsu Y, Mukai T, Yamaguchi T, et al. Predisposing factors and clinical impact of high-output syndrome after sphincter-preserving surgery with covering ileostomy for rectal cancer: a retrospective single-center cohort study. Int J Clin Oncol. 2021;26(1):118-25.
XVIII. 18. Bai D, Li L, Shen Z, Huang Y, Wang Q, Zhang J, et al. Risk factors for developing high-output ileostomy in CRC patients: a retrospective study. BMC Surg. 2021;21(1):300.
XIX. 19. Assaf D, Hazzan D, Ben-Yaacov A, Laks S, Zippel D, Segev L. Predisposing factors for high output stoma in patients with a diverting loop ileostomy after colorectal surgeries. Ann Coloproctol. 2023;39(2):168-74.
XX. 20. Hara Y, Miura T, Sakamoto Y, Morohashi H, Nagase H, Hakamada K. Organ/space infection is a common cause of high output stoma and outlet obstruction in diverting ileostomy. BMC Surg. 2020;20(1):83.
XXI. 21. Charak G, Kuritzkes BA, Al-Mazrou A, Suradkar K, Valizadeh N, Lee-Kong S, et al. Use of an ACE inhibitor or angiotensin receptor blocker is a major risk factor for dehydration requiring readmission in the setting of a new ileostomy. Int J Colorectal Dis. 2018;33(3):311-6.
XXII. 22. Slagelse C, Gammelager H, Iversen LH, Sorensen HT, Christiansen CF. Renin-angiotensin system blocker use and the risk of acute kidney injury after colorectal cancer surgery: a population-based cohort study. BMJ Open. 2019;9(12):e032964.
XXIII. 23. Malfertheiner P, Ripellino C, Cataldo N. Severe intestinal malabsorption associated with ACE inhibitor or angiotensin receptor blocker treatment. An observational cohort study in Germany and Italy. Pharmacoepidemiol Drug Saf. 2018;27(6):581-6.
XXIV. 24. Salmenkari H, Korpela R, Vapaatalo H. Renin-angiotensin system in intestinal inflammation - angiotensin inhibitors to treat inflammatory bowel diseases? Basic Clin Pharmacol Toxicol. 2021;129(3):161-72.
XXV. 25. Pak J, Uemura M, Fukuda Y, Nishimura J, Hata T, Takemasa I, et al. Predictors of high-output stoma after low anterior resection with diverting ileostomy for rectal cancer. Int Surg. 2017;102(7-8):313-7.
XXVI. 26. Chun LJ, Haigh PI, Tam MS, Abbas MA. Defunctioning loop ileostomy for pelvic anastomoses: predictors of morbidity and nonclosure. Dis Colon Rectum. 2012;55(2):167-74.
XXVII. 27. Matsuzawa H, Munakata S, Kawai M, Sugimoto K, Kamiyama H, Takahashi M, et al. Analysis of ileostomy stool samples reveals dysbiosis in patients with high-output stomas. Biosci Microbiota Food Health. 2021;40(3):135-43.
XXVIII. 28. Williams RN, Hemingway D, Miller AS. Enteral Clostridium difficile, an emerging cause for high-output ileostomy. J Clin Pathol. 2009;62(10):951-3.
XXIX. 29. Rowe KM, Schiller LR. Ileostomy diarrhea: pathophysiology and management. Proc (Bayl Univ Med Cent). 2020;33(2):218-26.
XXX. 30. Messaris E, Sehgal R, Deiling S, Koltun WA, Stewart D, McKenna K, et al. Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum. 2012;55(2):175-80.
XXXI. 31. Paquette IM, Solan P, Rafferty JF, Ferguson MA, Davis BR. Readmission for dehydration or renal failure after ileostomy creation. Dis Colon Rectum. 2013;56(8):974-9.
XXXII. 32. Fish DR, Mancuso CA, Garcia-Aguilar JE, Lee SW, Nash GM, Sonoda T, et al. Readmission after ileostomy creation: retrospective review of a common and significant event. Ann Surg. 2017;265(2):379-87.
XXXIII. 33. Justiniano CF, Temple LK, Swanger AA, Xu Z, Speranza JR, Cellini C, et al. Readmissions with dehydration after ileostomy creation: rethinking risk factors. Dis Colon Rectum. 2018;61(11):1297-305.
XXXIV. 34. Borucki JP, Schlaeger S, Crane J, Hernon JM, Stearns AT. Risk and consequences of dehydration following colorectal cancer resection with diverting ileostomy. A systematic review and meta-analysis. Colorectal Dis. 2021;23(7):1721-32.
XXXV. 35. Vogel I, Shinkwin M, van der Storm SL, Torkington J, A Cornish J, Tanis PJ, et al. Overall readmissions and readmissions related to dehydration after creation of an ileostomy: a systematic review and meta-analysis. Tech Coloproctol. 2022;26(5):333-49.
XXXVI. 36. Li L, Lau KS, Ramanathan V, Orcutt ST, Sansgiry S, Albo D, et al. Ileostomy creation in colorectal cancer surgery: risk of acute kidney injury and chronic kidney disease. J Surg Res. 2017;210:204-12.
XXXVII. 37. Gessler B, Haglind E, Angenete E. A temporary loop ileostomy affects renal function. Int J Colorectal Dis. 2014;29(9):1131-5.
XXXVIII. 38. Yagyu T, Yamamoto M, Urakami K, Kono Y, Takahashi H, Sakamoto T, et al. Clinical impact of diverting ileostomy and high-output stoma on adjuvant chemotherapy for rectal cancer: a retrospective cohort study. Int J Colorectal Dis. 2025;40(1):167.
XXXIX. 39. Santamaria MM, Villafranca JJA, Abiles J, Ruiz FR, Navarro PU, Goitia BT. Impact of a nutrition consultation on the rate of high output stoma-related readmission: an ambispective cohort study. Sci Rep. 2021;11(1):16620.
XL. 40. Chen SY, Stem M, Cerullo M, Canner JK, Gearhart SL, Safar B, et al. Predicting the risk of readmission from dehydration after ileostomy formation: the dehydration readmission after ileostomy prediction score. Dis Colon Rectum. 2018;61(12):1410-7.
XLI. 41. van Loon YT, Poylin VY, Nagle D, Zimmerman DDE. Effectiveness of the ileostomy pathway in reducing readmissions for dehydration: does it stand the test of time? Dis Colon Rectum. 2020;63(8):1151-5.
XLII. 42. Westfall KM, Rivard SJ, Suwanabol PA, Albright JJ, Ramm CA, Cleary RK. Postoperative oral rehydration and regimented follow-up decrease readmissions after colorectal surgery that includes ileostomies. Dis Colon Rectum. 2024;67(2):313-21.
XLIII. 43. Kristensen K, Qvist N. The acute effect of loperamide on ileostomy output: a randomized, double-blinded, placebo-controlled, crossover study. Basic Clin Pharmacol Toxicol. 2017;121(6):493-8.
XLIV. 44. Culkin A, Gabe SM, Nightingale J. A new palatable oral rehydration solution: a randomised controlled cross-over study in patients with a high output stoma. J Hum Nutr Diet. 2022;35(1):94-101.
XLV. 45. Chia C, Tai YS, Tan KY. A preliminary study of the use of oral rehydration salts in decreasing ileostomy output. Tech Coloproctol. 2017;21(7):587-8.
XLVI. 46. Mesli Y, Holterbach L, Delhorme JB, Lakkis Z, Ortega-Deballon P, Deguelte S, et al. Is lanreotide really useful in high output stoma? Comparison between lanreotide to conventional antidiarrheal treatment alone. J Invest Surg. 2021;34(12):1312-6.
XLVII. 47. McDoniel K, Taylor B, Huey W, Eiden K, Everett S, Fleshman J, et al. Use of clonidine to decrease intestinal fluid losses in patients with high-output short-bowel syndrome. JPEN J Parenter Enteral Nutr. 2004;28(4):265-8.
XLVIII. 48. Zaharuddin L, Mokhtar NM, Muhammad Nawawi KN, Raja Ali RA. A randomized double-blind placebo-controlled trial of probiotics in post-surgical colorectal cancer. BMC Gastroenterol. 2019;19(1):131.
XLIX. 49. Zhang Q, Sun J, Wang D, Wang Y, Liu Y, Zhang X. Knowledge, attitudes, practices and associated factors regarding high output stoma of ileostomy among colorectal surgical nurses: a multicentre cross-sectional study. Support Care Cancer. 2023;32(1):12.
L. 50. Baker M, Greening L. Practical management to reduce and treat complications of high-output stomas. Gastrointest Nurs. 2009;7(6):10-7.
LI. 51. Association of Stoma Care Nurses UK. ASCN stoma care national clinical guidelines. Shrewsbury: ASCN UK; 2016.
LII. 52. Ohta H, Miyake T, Ueki T, Kojima M, Kaida S, Tokuda A, et al. Predictors and clinical impact of postoperative diarrhea after colorectal cancer surgery: a prospective, multicenter, observational study (SHISA-1602). Int J Colorectal Dis. 2022;37(3):657-64.
LIII. 53. Gaertner WB, Madoff RD, Mellgren A, Kwaan MR, Melton GB. Postoperative diarrhea and high ostomy output impact postoperative outcomes after elective colon and rectal operations regardless of Clostridium difficile infection. Am J Surg. 2015;210(4):759-65.
LIV. 54. Kong D, Lin S, Karagkounis G, Steele SR, Liska D, Holubar SD, et al. Addressing a common complication after ileostomy creation: a multidisciplinary program to decrease readmission for dehydration. Clin Surg. 2025;10:3733.