A Decalogue to Avoid Routine Ileostomy in Selected Patients With Border Line Risk to Develop Anastomotic Leakage After Minimally Invasive Low-Anterior Resection: A Pilot Study

Abstract

Purpose. Protective ileostomy (PI) during anterior resection (AR) for rectal cancer decreases the incidence of anastomotic leakage (AL) and its subsequent complications, but it may itself be the cause of morbidity. The aim is to report our protocol in the management of selected patients with borderline risk to develop AL after laparoscopic AR and ghost ileostomy (GI) creation. Methods. Patients who underwent AR were stratified based on the risk to develop AL. Steps to avoid PI were splenic flexure mobilization, reduced pelvic bleeding, to employ different stapler charge if neoadjuvant chemo-radiotherapy is performed, to perform a horizontal section of the rectum, to evaluate the anastomotic vascularization with a fluorescence angiography, to perform a side-to-end anastomosis, intraoperative methylene blue test, pelvic and transanal drainage tubes placement, and the GI creation. After surgery, inflammatory blood markers were monitored to detect potential leakages. Results. Twelve patients were included. In one case, the specimen proximal section was changed after fluorescence angiography. There were no conversions in this group of patients. One postoperative AL occurred and was treated with radiological drainage placement, not being necessary to convert the GI. PI was avoided in 100% of cases. Conclusions. Patients’ characteristics cannot be changed, but several steps were used to avoid routine PI creation. The present protocol could be a valuable option to avoid PI in selected patients. Further studies with a wider sample size, and defined criteria to stratify the patients based on the risk to develop AL, are required.

Protective ileostomy creation after anterior resection of the rectum: Shared decision‐making or still subjective?

“…Anastomotic leakage (AL) is one of the most dreaded complications after elective anterior resection (AR) of the rectum [1,2]. It is responsible for increased postoperative morbidity and mortality, prolonged hospital stay and additional surgical procedures [2,3].…”

Clinical Application of the Reverse Puncture Technique for Total Laparoscopic Colorectal Resection with Natural Orifice Specimen Extraction

“…Each method has its own operating characteristics and skills. The optimal method used to remove the specimen can be determined by the operator according to the location and size of the tumour, the degree of patient obesity and the method used to reconstruct the digestive tract [11][12] .…”

“…4. To reduce the incidence of postoperative anastomotic leakage, preventive ileostomy is recommended for patients with low rectal cancer complicated with diabetes [6,12] .…”

Ghost Ileostomy: Safe and Cost-effective Alternative to Ileostomy After Rectal Resection for Deep Infiltrating Endometriosis

“…A trial design rather comparing the results of the GI procedure to no diverting stoma would be an alternative. Furthermore, risk factors for AL and surgical techniques preventing it, need to be systematically investigated (5,20,24). Meanwhile, the GI procedure might be established as a routine technique to avoid a stoma.…”