Less is more—the best test for anastomotic leaks in rectal cancer patients prior to ileostomy reversal

Abstract

Purpose No clear consensus exists on how to routinely assess the integrity of the colorectal anastomosis prior to ileostomy reversal. The objective of this study was to evaluate the accuracy of contrast enema, endoscopic procedures, and digital rectal examination in rectal cancer patients in this setting. Methods A systematic literature search was performed. Studies assessing at least one index test for which a 2 × 2 table was calculable were included. Hierarchical summary receiver operating characteristic curves were calculated and used for test comparison. Paired data were used where parameters could not be calculated. Methodological quality was assessed with the QUADAS-2 tool. Results Two prospective and 11 retrospective studies comprising 1903 patients were eligible for inclusion. Paired data analysis showed equal or better results for sensitivity and specificity of both endoscopic procedures and digital rectal examination compared to contrast enema. Subgroup analysis of contrast enema according to methodological quality revealed that studies with higher methodological quality reported poorer sensitivity for equal specificity and vice versa. No case was described where a contrast enema revealed an anastomotic leak that was overseen in digital rectal examination or endoscopic procedures. Conclusions Endoscopy and digital rectal examination appear to be the best diagnostic tests to assess the integrity of the colorectal anastomosis prior to ileostomy reversal. Accuracy measures of contrast enema are overestimated by studies with lower methodological quality. Synopsis of existing evidence and risk–benefit considerations justifies omission of contrast enema in favor of endoscopic and clinical assessment. Trial registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019107771

Diagnostic accuracy of water‐soluble contrast enema, contrast‐enema computed tomography and endoscopy in detecting anastomotic leakage after (Colo) proctectomy: A meta‐analysis

“…However, no pooled measure of diagnostic test accuracy was reported, and sensitivity could often not be calculated for some included studies. Furthermore, Lindner et al [48] unexpectedly decided not to consider CECT in this setting. potentially enlarge a pre-existing dehiscence or create a new one in the case of intestinal wall fragility.…”

“…Moreover, there is almost a complete lack of evidence describing this common complication and how to deal with it when the diagnosis is not clear. Lindner et al [48] recently (in 2021) published a systematic review and meta-analysis evaluating the diagnostic test accuracy of endoscopy, WSCE and digital rectal examination in highlighting an AL in asymptomatic patients who had undergone proctectomy with temporary ileostomy and were waiting to be scheduled for stoma reversal. This DTA meta-analysis including 13 studies concluded that digital rectal examination and endoscopy perform better than WSCE.…”

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy Surgery

“…No patient had an anastomotic leak that was described by a CE but not by digital rectal examination or an endoscopic procedure. 143 Similarly, in a retrospective study that compared 91 patients with low pelvic anastomoses who underwent flexible endoscopy (FE) before ileostomy closure versus 100 patients who underwent both FE and contrast evaluation (CE) before reversal, there were no significant differences in the detection of pelvic anastomotic leak (2.2% versus 1%), anastomotic stricture (1.1% versus 6%), or postoperative anastomotic complications (4.4% versus 9%) between the groups. 146 Similar findings published in the setting of IPAA call into to question the routine use of preoperative pouchogram.…”

“…Although the literature supports the sensitivity and positive predictive value of WSCE in detecting anastomotic leaks, several studies have questioned the utility of WSCE in routine clinical practice. [134][135][136][137][138][139][140][141][142][143][144][145] Dimitriou et al 134 performed a WSCE on 339 patients after low pelvic anastomosis before ostomy reversal and identified 24 patients (7.1%) with an anastomotic leak. Of these patients, only 29% had an uncomplicated postoperative course from their index procedure, indicating that, in most cases, the surgeon could have a clinical suspicion of which patients were at highest risk of poorly healed anastomosis.…”

Diagnosis and management of traumatic rectal injury: A Western Trauma Association critical decisions algorithm

“…Most surgeons evaluate the rectal integrity with a contrast enema before reversal. However, the utility of this investigation has not been studied among trauma patients specifically and is controversial among patients undergoing ostomy reversal after elective resections despite historically being considered the gold standard investigation 24,25 . If there is any question about rectal integrity on contrast enema, or if the injury was particularly destructive, one can consider flexible sigmoidoscopy to visualize the area of injury and ensuring healing prior to stoma reversal.…”