JACS this month has a solid study from Japan on the use of diverting stomas in the setting of rectal cancer. This was a prospective, multicenter cohort study of 936 patients who underwent low anterior resection (LAR) for rectal tumors within 10 cm of the anal verge. The results were as follows:
...overall rate of symptomatic AL was 13.2% (52 of 394) in patients with DS vs 12.7% (69 of 542) in cases without DS (p = 0.84). Symptomatic AL requiring re-laparotomy occurred in 4.7% (44 of 936) of all patients, occurring in 1.0% (4 of 394) of patients with DS vs 7.4% (40 of 542) of patients without DS (p < 0.001). After PSM, the 2 groups were nearly balanced, and the incidence rates of symptomatic AL in patients with and without DS were 10.9% and 15.8% (p = 0.26). The incidences of AL requiring re-laparotomy in patients with and without DS were 0.6% and 9.1% (p < 0.001)
This suggests that diverting ostomy (either a loop ileostomy or transverse colostomy) constructed during a LAR for lower rectal tumors can attenuate the deleterious effects of anastomotic leaks. Which makes complete sense. Leaks happen in gastrointestinal surgery. This is a vexing, unspoken problem for surgeons who perform a lot of bowel surgery. Did you know that, depending on the literature cited, leaks can complicate anywhere from 3%-28% of anastomoses? That's a lot of leaks! And the consequences of a leak, especially pelvic colorectal connections, can be devastating. The idea behind a diverting stoma is to protect an immature, potentially compromised anastomosis. Patients with rectal cancer are often treated with neoadjuvant chemo-radiation (not specified in the paper above) and that distal rectal stump used in the anastomosis is not always the best hunk of flesh to work with. Small leaks, which, unprotected, can lead to rapid pelvic sepsis and eventual complete anastomotic dehiscence, can be mitigated by proximal diversion. Instead of stool pumping out through a micro-perforation, a small leak can, with time and re-direction of fecal flow, be allowed to scar down and heal spontaneously.
I don't do a lot of low rectal cancer resections but I find the diverting ileostomy to be an extremely useful tool in my armamentarium in the setting of severe perforated diverticulitis. A lot of these patients need urgent or semi-urgent operative intervention after failure of conservative management. A bowel prep is usually contra-indicated. The pelvis is contaminated. The surrounding tissues are often edematous and friable. In the old days, everyone got a Hartmann's procedure (end colostomy and Hartmann's rectal pouch left in the pelvis. But we found over the years that reversing a Hartmann's colostomy was frought with morbidity. Leaks could occur. Surrounding structures could be injured. And sometimes the post peritonitis scarring resulted in a frozen, socked in pelvis with marginally identifiable anatomy. As a matter of fact, for a variety of reasons, only about 70-75% of Hartmann's colostomies ever get reversed.
My practice is to make liberal use of the loop ileostomy if I have any concern about my pelvic colorectal anastomosis. This allows the new conduit to heal without the stress of fecal matter flowing through it. A barium enema is ordered after 6 weeks or so to confirm healing and the patient is brought back to the OR for a pretty straight forward, far less stress-inducing loop ileostomy reversal.
I don't do a lot of low rectal cancer resections but I find the diverting ileostomy to be an extremely useful tool in my armamentarium in the setting of severe perforated diverticulitis. A lot of these patients need urgent or semi-urgent operative intervention after failure of conservative management. A bowel prep is usually contra-indicated. The pelvis is contaminated. The surrounding tissues are often edematous and friable. In the old days, everyone got a Hartmann's procedure (end colostomy and Hartmann's rectal pouch left in the pelvis. But we found over the years that reversing a Hartmann's colostomy was frought with morbidity. Leaks could occur. Surrounding structures could be injured. And sometimes the post peritonitis scarring resulted in a frozen, socked in pelvis with marginally identifiable anatomy. As a matter of fact, for a variety of reasons, only about 70-75% of Hartmann's colostomies ever get reversed.
My practice is to make liberal use of the loop ileostomy if I have any concern about my pelvic colorectal anastomosis. This allows the new conduit to heal without the stress of fecal matter flowing through it. A barium enema is ordered after 6 weeks or so to confirm healing and the patient is brought back to the OR for a pretty straight forward, far less stress-inducing loop ileostomy reversal.