“Virtual ileostomy” combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report
Despite the benefits of a loop ileostomy after total mesorectal excision (TME), it carries a significant associated morbidity. A “virtual ileostomy” (VI) has been proposed to avoid ileostomies in low-risk patients, which could then be converted into a real ileostomy (RI) in the event of anastomotic leak (AL). The aim of the present study is to evaluate safety and efficacy of VI associated with early endoscopy in patients undergoing rectal surgery with anastomosis to detect subclinical AL prior to the onset of clinical symptoms for sepsis.
This is a single-center, retrospective study of a consecutive series of patients undergoing elective or emergent colorectal surgery with low or ultralow colorectal or ileorectal anastomosis between September 2015 and September 2016.
We included 44 consecutive, unselected patients. Eight patients (18.2%) required conversion into RI and one required terminal colostomy because of AL, of whom 44.4% were asymptomatic and AL was detected with early endoscopy. Fashioning of RI was not associated with further morbidity. All patients with AL converted into RI (n = 8/9) (88.9%), had adequate healed anastomosis, and later underwent stoma closure with no complications. A stoma was avoided in 79.6% of VI. Endoscopy was associated with 55% sensitivity and 100% specificity, with a global accuracy of 88%.
The combination of VI with early postoperative endoscopy could avoid unnecessary ileostomies in patients with low or ultralow anastomoses and reveal AL before the onset of symptoms, thus reducing associated morbidity.
KeywordsVirtual ileostomy Colorectal anastomosis Anastomotic leak Complication Early postoperative endoscopy Ghost ileostomy
The authors are grateful for the professional English language editing to Mr. Arash Javadinejad, English Instructor and Research Editor at the Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
Study conception and design BFL, LSG, MF, SDDP, EGG. Acquisition of data BFL, LSG, MF, AGG, MPR, SDDP, VPA. Analysis and interpretation of data BFL, LSG, MF, GP, AGG, MPR, SDDP, VPA. Drafting of manuscript BFL, LSG, MF, GP, EGG. Critical revision of manuscript BF, LSG, MF, GP, AGG, MPR, SDDP, VPA, EGG.
Compliance with ethical standards
The study was approved by the Clinical Research Ethics Committee of the hospital.
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
- 1.Montedori A, Cirocchi R, Farinella E, Sciannameo F, Abraha I (2010) Covering ileo or colostomy in anterior resection for rectal carcinoma. Cochrane Database Syst Rev 12:1–19Google Scholar
- 6.Altman DG, Machin D, Bryant TN, Gardner MJ (eds) (2000) Statistics with confidence, 2nd edn. BMJ BooksGoogle Scholar
- 12.Herrle F, Sandra-Petrescu F, Weiss C, Post S, Runkel N, Kienle P (2016) Quality of life and timing of stoma closure in patients with rectal cancer undergoing low anterior resection with diverting stoma: a multicenter longitudinal observational study. Dis Colon Rectum 59:281–290CrossRefGoogle Scholar
- 15.Sacchi M, Legge PD, Picozzi P, Papa F, Giovanni CL, Greco L (2007) Virtual ileostomy following TME and primary sphincter-saving reconstruction for rectal cancer. Hepatogastroenterology 54:1676–1678Google Scholar
- 21.Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Büchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147:339–351CrossRefGoogle Scholar
- 22.García-Granero E, Navarro F, Cerdán Santacruz C, Frasson M, García-Granero A, Marinello F, Flor-Lorente B, Espí A (2017) Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: an institutional analysis of 800 patients. Surgery 162:1006–1016CrossRefGoogle Scholar
- 23.Montedori A, Cirocchi R, Farinella E, Sciannameo F, Abraha I (2010) Covering ileo- or colostomy in anterior resection for rectal carcinoma. Cochrane Database Syst Rev 12:CD006878Google Scholar
- 27.D'Hoore A, Albert MR, Cohen SM, Herbst F, Matter I, Van Der Speeten K, Dominguez J, Rutten H, Muldoon JP, Bardakcioglu O, Senagore AJ, Ruppert R, Mills S, Stamos MJ, Påhlman L, Choman E, Wexner SD, COMPRES collaborative study group (2015) COMPRES: a prospective postmarketing evaluation of the compression anastomosis ring CAR 27(™) /ColonRing(™). Color Dis 17:522–529CrossRefGoogle Scholar