“Virtual ileostomy” combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report

  • Blas Flor-Lorente
  • Luis Sánchez-GuillénEmail author
  • Gianluca Pellino
  • Matteo Frasson
  • Álvaro García-Granero
  • Marta Ponce
  • Santiago Domingo
  • Vicente Paya
  • Eduardo García-Granero
How-I-Do-It article



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.


Virtual 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.

Authors contributions

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.

Ethical approval

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

Informed consent was obtained from all individual participants included in the study.

Supplementary material

423_2019_1776_MOESM1_ESM.jpeg (381 kb)
Suppl. Figure 1 Diagram for the Anastomotic Leak evaluation during Early Endoscopy. Anastomotic defect diagnosed by the Early Endoscopy (JPEG 380 kb)
423_2019_1776_MOESM2_ESM.docx (40 kb)
Supplementary Table 1 (DOCX 39 kb)


  1. 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
  2. 2.
    Hüser N, Michalski CW, Erkan M, Schuster T, Rosenberg R, Kleeff J, Friess H (2008) Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 248:52–60CrossRefGoogle Scholar
  3. 3.
    Snijders HS, Wouters MW, van Leersum NJ et al (2012) Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol 38:1013–1019CrossRefGoogle Scholar
  4. 4.
    Tan WS, Tang CL, Shi L, Eu KW (2009) Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 96:462–472CrossRefGoogle Scholar
  5. 5.
    Chen J, Wang DR, Yu HF, Zhao ZK, Wang LH, Li YK (2012) Defunctioning stoma in low anterior resection for rectal cancer: a meta-analysis of five recent studies. Hepatogastroenterology 59:1828–1831CrossRefGoogle Scholar
  6. 6.
    Altman DG, Machin D, Bryant TN, Gardner MJ (eds) (2000) Statistics with confidence, 2nd edn. BMJ BooksGoogle Scholar
  7. 7.
    Nisar PJ, Lavery IC, Kiran RP (2012) Influence of neoadjuvant radiotherapy on anastomotic leak after restorative resection for rectal cancer. J Gastrointest Surg 16:1750–1757CrossRefGoogle Scholar
  8. 8.
    Bakker IS, Snijders HS, Wouters MW, Havenga K, Tollenaar RA, Wiggers T, Dekker JW (2014) High complication rate after low anterior resection for mid and high rectal cancer; results of a population-based study. Eur J Surg Oncol 40:692–698CrossRefGoogle Scholar
  9. 9.
    Chow A, Tilney HS, Paraskeva P, Jeyarajah S, Zacharakis E, Purkayastha S (2009) The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Color Dis 24:711–723CrossRefGoogle Scholar
  10. 10.
    García-Botello SA, García-Armengol J, García-Granero E, Espí A, Juan C, López-Mozos F, Lledó S (2004) A prospective audit of the complications of loop ileostomy construction and takedown. Dig Surg 21:440–446CrossRefGoogle Scholar
  11. 11.
    Chun LJ, Haigh PI, Tam MS, Abbas MA (2012) Defunctioning loop ileostomy for pelvic anastomoses: predictors of morbidity and nonclosure. Dis Colon Rectum 55:167–174CrossRefGoogle Scholar
  12. 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
  13. 13.
    Dekker JW, Liefers GJ, de Mol van Otterloo JC et al (2011) Predicting the risk of anastomotic leakage in left-sided colorectal surgery using a colon leakage score. J Surg Res 166:e27–e34CrossRefGoogle Scholar
  14. 14.
    Mari FS, Di Cesare T, Novi L, Gasparrini M, Berardi G, Laracca GG, Liverani A, Brescia A (2015) Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial. Surg Endosc 29:2590–2597CrossRefGoogle Scholar
  15. 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
  16. 16.
    Miccini M, Amore Bonapasta S, Gregori M, Barillari P, Tocchi A (2010) Ghost ileostomy: real and potential advantages. Am J Surg 200:55–57CrossRefGoogle Scholar
  17. 17.
    Cerroni M, Cirocchi R, Morelli U, Trastulli S, Desiderio J, Mezzacapo M, Listorti C, Esperti L, Milani D, Avenia N, Gulla N, Noya G, Boselli C (2011) Ghost ileostomy with or without abdominal parietal split. World J Surg Oncol 9:92CrossRefGoogle Scholar
  18. 18.
    Sacchi M, Picozzi P, Di Legge P, Capuano L, Greco L, De Stefano M, Nicodemi S, Sacchi MC (2011) Virtual ileostomy following rectal cancer surgery: a good tool to avoid unuseful stomas? Hepatogastroenterology 58:1479–1481CrossRefGoogle Scholar
  19. 19.
    Mori L, Vita M, Razzetta F, Meinero P, D'Ambrosio G (2013) Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile? Dis Colon Rectum 56:29–34CrossRefGoogle Scholar
  20. 20.
    Von Elm E, Altman DG, Egger M et al (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370:1453–1457CrossRefGoogle Scholar
  21. 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. 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. 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
  24. 24.
    Snijders HS, van Leersum NJ, Henneman D, de Vries AC, Tollenaar RA, Stiggelbout AM, Wouters MW, Dekker JW (2015) Optimal treatment strategy in rectal cancer surgery: should we be cowboys or chickens? Ann Surg Oncol 22:3582–3589CrossRefGoogle Scholar
  25. 25.
    Ihnát P, Guňková P, Peteja M, Vávra P, Pelikán A, Zonča P (2016) Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection. Surg Endosc 30:4809–4816CrossRefGoogle Scholar
  26. 26.
    McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC (2015) Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 102:462–479CrossRefGoogle Scholar
  27. 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
  28. 28.
    Kamal T, Pai A, Velchuru VR, Zawadzki M, Park JJ, Marecik SJ, Abcarian H, Prasad LM (2015) Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection? Color Dis 17:160–164CrossRefGoogle Scholar
  29. 29.
    Li VK, Wexner SD, Pulido N, Wang H, Jin HY, Weiss EG, Nogeuras JJ, Sands DR (2009) Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc 23:2459–2465CrossRefGoogle Scholar
  30. 30.
    Shamiyeh A, Szabo K, Ulf Wayand W, Zehetner J (2012) Intraoperative endoscopy for the assessment of circular-stapled anastomosis in laparoscopic colon surgery. Surg Laparosc Endosc Percutan Tech 22:65–67CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Blas Flor-Lorente
    • 1
  • Luis Sánchez-Guillén
    • 1
    Email author
  • Gianluca Pellino
    • 1
  • Matteo Frasson
    • 1
  • Álvaro García-Granero
    • 1
  • Marta Ponce
    • 2
  • Santiago Domingo
    • 3
  • Vicente Paya
    • 3
  • Eduardo García-Granero
    • 1
  1. 1.Colorectal Unit, Hospital Universitario y Politécnico La Fe, Valencia Hospital La FeUniversity of ValenciaValenciaSpain
  2. 2.Digestive MedicineHospital Universitario y Politécnico La FeValenciaSpain
  3. 3.Gynecologic Oncology UnitHospital Universitario y Politécnico La FeValenciaSpain

Personalised recommendations