Is water‐soluble contrast enema examination for integrity of rectal anastomosis necessary prior to ileostomy reversal?

Abstract

Background and Aim Routine use of water‐soluble contrast enema (WSCE) to assess anastomotic integrity is debated. This study aimed to evaluate the role of WSCE to assess anastomotic integrity following anterior resections (AR) with defunctioning stoma prior to reversal and identify factors to limit its selective use. Methods This retrospective study evaluated all WSCE performed over a 7‐year period at a high‐volume colorectal unit. Risk factors for radiological abnormality/leak, including malignancy, chemoradiotherapy, and immediate postoperative complications, were recorded. A gastrointestinal specialist radiologist and surgeon validated all WSCEs reported as abnormal. Results Of the 486 WSCE studies identified, 92 were excluded (repeat studies (n = 51), pediatric cases [n = 2], no AR [n = 39]). A total of 394 WSCE studies were evaluated (260 cancer; 134 noncancer patients); 14% (37/260) of cancer patients and 8% (10/134) of noncancer patients had abnormal studies (P = 0.072). Of the 37 abnormal studies in cancer patients, 73% (27/37) radiological leaks were found, and 41% (n = 11/27) of these patients had postoperative complications. Of the 10 abnormal studies in noncancer patients, 20% (2/10) radiological leaks were found, but none of these patients had postoperative complications. Overall leak rates were 7% (29/394), and rates were significantly higher in cancer patients than noncancer patients (10 vs 2%, P = 0.005). Conclusion Routine use of WSCE may not be necessary prior to reversal. WSCE should be selectively used in event of postoperative leak or complications. Noncancer resections are less likely demonstrate a leak.

Investigations and time trends in loop ileostomy reversals following anterior resections: a single Australian institution seven‐years' experience

“…However, most centres will perform pre‐reversal investigations, with a preference of a contrast enema 3–7 . Our study has shown the importance of performing both WSCE and FS.…”

“…The routine use of investigations prior to ileostomy reversal has been questioned and the accuracy of these tests can be variable 3–7 . For example, a ‘dog ear’ at the stapled anastomosis may be misinterpreted as a leak, or a stricture being incorrectly described due to a lack of anastomotic distension on WSCE 4 .…”

“…No clear guidelines exist as to what investigations are essential in order to accurately assess the rectal anastomosis prior to reversal. In the published literature, both water‐soluble contrast enema (WSCE) and flexible sigmoidoscopy (FS) have been advocated 3–7 …”

MRI‐enema for the assessment of pelvic intestinal anastomotic integrity

“…A leak is diagnosed by the examining radiologist identifying extraluminal iodinated contrast first introduced through the anus via a catheter. WSCE utilizes x-ray fluoroscopy to investigate the flow of contrast through the anastomosis with representative fluoroscopic images acquired, supplemented by higher quality radiographs when required [11]. WSCE using x-ray fluoroscopy has a number of limitations, including limited accuracy with a sensitivity of 78% and a positive predictive value of 62% [10], use of ionizing radiation (particularly relevant for younger patients), limited two-dimensional images, paucity of anatomical information and diminishing fluoroscopy capacity in the UK National Health Service (NHS) and North America, with associated decrease in fluoroscopic skills and interpretative expertise [12].…”

“…WSCE using x-ray fluoroscopy has a number of limitations, including limited accuracy with a sensitivity of 78% and a positive predictive value of 62% [10], use of ionizing radiation (particularly relevant for younger patients), limited two-dimensional images, paucity of anatomical information and diminishing fluoroscopy capacity in the UK National Health Service (NHS) and North America, with associated decrease in fluoroscopic skills and interpretative expertise [12]. Unsurprisingly, therefore, some surgeons consider clinical assessment superior and sufficient, questioning the need for routine WSCE [10,11,13]. Where WSCE has been requested, presacral widening is a relatively frequent finding, with MRI or CT required to interrogate the cause.…”