Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial

Transanal ileal pouch-anal anastomosis: A systematic review and meta-analysis of technical approaches and clinical outcomes

PURPOSE

Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches.

METHODS

Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed.

RESULTS

Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence.

CONCLUSIONS

Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.

Impact of ileostomy on postoperative wound complications in patients after laparoscopic rectal cancer surgery: A meta-analysis

To prevent anastomotic leakage and other postoperative complications after laparoscopic rectal cancer surgery, a protective ileostomy is often used. However, the necessity of performing ileostomy after laparoscopic rectal cancer remains controversial. The aim of this meta-analysis was to assess the benefit of ileostomy on wound infection after laparoscopic rectal cancer. The Cochrane Library, EMBASE, Web of Science, and PubMed were used to retrieve all related documents up to September 2023. Completion of the trial literature was submitted once the eligibility and exclusion criteria were met and the literature quality assessment was evaluated. This study compared the post-operative post-operative complications of an ileostomy with that of non-ileostomy in a laparoscope. We used Reman 5.3 to analyse meta-data. Controlled studies were evaluated with ROBINS-I. The meta-analyses included 525 studies, and 5 publications were chosen to statistically analyse the data according to the classification criteria. There was no statistically significant difference in the rate of postoperative wound infections among ostomate and nonostomate (odds ratio [OR], 1.79; 95% confidence interval [CI], 0.66, 4.84; p = 0.25). In 5 trials, the incidence of anastomotic leak was increased after surgery in nonostomate patients (OR, 0.26; 95% CI, 0.12, 0.57; p = 0.0009). Two studies reported no significant difference in the length of operation time when nonstomal compared to stomal operations in patients with rectal cancer (mean difference, 0.87; 95% CI, -2.99, 4.74; p = 0.66). No significant difference was found in the rate of wound infection and operation time after operation among the two groups, but the incidence of anastomosis leak increased after operation. Protective ileostomy after laparoscopic rectal cancer was effective in reducing the risk of anastomotic leakage in patients, and we found no additional risk of infection. We cautiously conclude that protective ileostomy is active and necessary for patients with a high risk of anastomotic leakage after surgery, which needs to be further confirmed by high-quality studies with larger samples.

Comprehensive testing of colorectal anastomosis: results of prospective observational cohort study

BACKGROUND

Anastomotic leakage remains one of the most threatening complications in colorectal surgery. Intraoperative testing of anastomosis may reduce the postoperative anastomotic leakage rates. This study aimed to investigate a novel comprehensive intraoperative colorectal anastomosis testing technique to detect the failure of the anastomosis construction and to reduce the risk of postoperative leak.

METHODS

This multi-centre prospective cohort pilot study included 60 patients who underwent colorectal resection with an anastomosis at or below 15 cm from the anal verge. Comprehensive trimodal testing consisted of indocyanine green fluorescence angiography, tension testing, air-leak, and methylene blue leak tests to evaluate the perfusion, tension, and mechanical integrity of the anastomosis.

RESULTS

Ten (16.7%) patients developed an anastomotic leakage. Trimodal test was positive in 16 (26.6%) patients and the operative plan was changed for all of them. Diverting ileostomy was performed in 14 (87.5%) patients. However, two (12.5%) patients still developed clinically significant anastomotic leakage (Grade B). Forty-four (73.4%) patients had a negative trimodal test, preventive ileostomy was performed in 19 (43.2%), and five (11.4%) patients had clinically significant anastomotic leakage (Grade B and C).

CONCLUSION

Trimodal testing identifies anastomoses with initial technical failure where reinforcement of anastomosis or diversion can lead to an acceptable rate of anastomotic leakage. Identification of well-performed anastomosis could allow a reduction of ileostomy rate by two-fold. However, anastomotic leakage rate remains high in technically well-performed anastomoses.

The efficacy of ileostomy after laparoscopic rectal cancer surgery: a meta-analysis

Background

Protective ileostomy is always applied to avoid clinically significant anastomotic leakage and other postoperative complications for patients receiving laparoscopic rectal cancer surgery. However, whether it is necessary to perform the ileostomy is still controversial. This meta-analysis aims to analyze the efficacy of ileostomy on laparoscopic rectal cancer surgery.

Methods

Cochrane Library, EMBASE, Web of Science, and PubMed were applied for systematic search of all relevant literature, updated to May 07, 2021. Studies compared patients with and without ileostomy for laparoscopic rectal cancer surgery. We applied Review Manager software to perform this meta-analysis. The quality of the non-randomized controlled trials was assessed using the Newcastle-Ottawa scale (NOS), and the randomized studies were assessed using the Jadad scale.

Results

We collected a total of 1203 references, and seven studies were included using the research methods. The clinically significant anastomotic leakage rate was significantly lower in ileostomy group (27/567, 4.76%) than that in non-ileostomy group (54/525, 10.29%) (RR = 0.47, 95% CI 0.30–0.73, P for overall effect = 0.0009, P for heterogeneity = 0.18, I² = 32%). However, the postoperative hospital stay, reoperation, wound infection, and operation time showed no significant difference between the ileostomy and non-ileostomy groups.

Conclusion

The results demonstrated that protective ileostomy could decrease the clinically significant anastomotic leakage rate for patients undergoing laparoscopic rectal cancer surgery. However, ileostomy has no effect on postoperative hospital stay, reoperation, wound infection, and operation time. The efficacy of ileostomy after laparoscopic rectal cancer surgery: a meta-analysis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02432-x.

Feasibility and efficacy of ghost ileostomy in typhoid ileal perforations: A prospective observational study

Loop ileostomy is commonly performed for typhoid ileal perforations as temporary faecal diversion. This is associated with several stoma-related complications and also requires further surgery for its closure. Thus, we were prompted to conduct a prospective observational study on the safety, feasibility and efficacy of ghost ileostomy in typhoid ileal perforations. After dealing with the perforation, a ghost ileostomy was performed in 10 selected patients with favourable circumstances; otherwise, a conventional loop ileostomy was performed in 19 patients. The two groups were comparable (p > 0.05) for morbidity and mortality except for stoma-related complications, seen only in the loop ileostomy group. Body weight was better preserved in the ghost ileostomy group. One patient in the ghost ileostomy group required conversion to loop ileostomy owing to signs of intra-peritoneal suture leak, without any detriment to outcome. Our study shows safety, feasibility and efficacy of ghost ileostomy in selected patients with typhoid ileal perforations, thus avoiding loop ileostomy in one-third of patients.

Comparative study between ghost ileostomy and defunctioning ileostomy in terms of morbidity and cost-effectiveness in low anterior resection for rectal cancer

PURPOSE

The aim of this study was to compare ghost ileostomy (GI) and defunctioning ileostomy (DI) in patients who underwent low anterior resection (LAR) for rectal cancer in terms of postoperative morbidity, rehospitalization rates, and total costs.

METHODS

Patients with an anastomosis level between 5 and 10 cm from the anal verge after LAR were analyzed retrospectively. Clinical characteristics, operative outcomes, postoperative morbidity, rehospitalization rates, and total costs were compared.

RESULTS

A total of 123 patients were enrolled as follows: 42 patients in the GI group and 81 patients in the DI group. Anastomotic leakage (AL) was identified in three patients who underwent GI, and in all of them, GI was easily converted to DI. There were 96.3% of the patients with DI rehospitalized at least one time because of surgery-related and/or stoma-related complications or stoma closure. When we did not take into account the patients who were rehospitalized for stoma closure, the rates of rehospitalization were 4.7% and 22.2% in the GI and DI groups, respectively (P= 0.01). The mean total costs calculated by removing additional surgical procedures and adding all of the rehospitalization costs were 25,767 USD and 41,875 USD in the GI and DI groups, respectively (P= 0.0001).

CONCLUSION

GI may be a safe and cost-effective method in patients who underwent LAR with low or medium risk factors for AL. It is possible to avoid unnecessary ileostomy and reduce unwanted outcomes due to it, such as postoperative complications, rehospitalizations, and increased total costs by performing GI.

Rectoseminal vesicle fistula after radical surgery for rectal cancer: Four case reports and a literature review

BACKGROUND

A rectoseminal vesicle fistula (RSVF) is a rare complication after anterior or low anterior proctectomy for rectal cancer mainly due to anastomotic leakage (AL). Limited literature documenting this rare complication is available. We report four such cases and review the literature to investigate the etiology, clinical manifestations, and the diagnostic and treatment methods of RSVF in order to provide greater insight into this disorder.

CASE SUMMARY

Four cases of RSVF were presented and summarized, and a further 12 cases selected from the literature were discussed. The main clinical symptoms in these patients were pneumaturia, fever, scrotal swelling and pain, anal pain, orchitis, diarrhea, dysuria, epididymitis and fecaluria. Imaging methods such as pelvic X-ray, computed tomography (CT), sinus radiography, barium enema and other techniques confirmed the diagnosis. CT was the imaging modality of choice. In cases presenting with reduced levels of AL, minimal surrounding inflammation, and controlled infection, the RSVF was conservatively treated by urethral catheterization, antibiotics administration and parenteral nutrition. In cases of severe RSVF, incision and drainage of the abscess or fistula and urinary or fecal diversion surgery successfully resolved the fistula.

CONCLUSION

This study provides an extensive analysis of RSVF, and outlines, summarizes and examines the causes, clinical manifestations, diagnostic procedures and treatment options, in order to prevent misdiagnosis and treatment errors.

Ghost ileostomy versus conventional loop ileostomy in patients undergoing low anterior resection for rectal cancer (DRKS00013997): protocol for a randomised controlled trial

INTRODUCTION

Anastomotic leakage is the most important complication in colorectal surgery occurring in up to 20% after low anterior rectal resection. Therefore, a diverting ileostomy is usually created during low anterior resection to protect the anastomosis or rather to diminish the consequences in case of anastomotic leakage. The so-called virtual or ghost ileostomy is a pre-stage ostomy that can be easily exteriorised, if anastomotic leakage is suspected, in order to avoid the severe consequences of anastomotic leakage. On the other hand, an actual ileostomy can be avoided in patients, who do not develop anastomotic leakage.

METHODS AND ANALYSIS

The GHOST trial is a randomised controlled pilot trial comparing ghost ileostomy with conventional loop ileostomy in patients undergoing low anterior resection with total mesorectal excision for rectal cancer. After screening for eligibility and obtaining informed consent, a total of 60 adult patients are included in the trial. Patients are intraoperatively randomised to the trial groups in a 1:1 ratio after assuring that none of the intraoperative exclusion criteria are present. The main outcome parameter is the comprehensive complication index as a measure of safety. Further outcomes include specific complications, stoma-related complications, complications of ileostomy closure, frequency of transformation of ghost ileostomy into conventional ileostomy, frequency of terminal ostomy creation, proportion of patients with an ostomy at 6 months after index surgery, anorectal function (Wexner score) and quality of life assessed by the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and CR29 questionnaires. Follow-up for each individual patient will be 6 months.

ETHICS AND DISSEMINATION

The GHOST trial has been approved by the Medical Ethics Committee of Heidelberg University (reference number S-694/2017). If the intervention proves to be safe, loop ileostomy could be spared in a large proportion of patients, thus also avoiding stoma-related complications and a second operation (ileostomy closure) with its inherent complications in these patients.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00013997); Universal Trial Number: U1111-1208-9742.

Virtual ileostomy in elective colorectal surgery: a systematic review of the literature

BACKGROUND

Anastomotic leak (AL) following colorectal surgery can be a life-threatening complication. The use of a diverting stoma has been proposed, to prevent or reduce morbidity and mortality associated with AL. Stomas, however, have their own distinct complications. Thus, virtual ileostomy (VI) has been proposed as an alternative to diverting stoma. The aim of the present study was to further evaluate the role of VI through systematic review of existing literature.

METHODS

A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane handbook for systematic reviews of interventions. The primary endpoint of our study was the estimation of the overall VI complication rate. Secondary endpoints included the identification of the VI-specific adverse outcomes, perioperative endpoints such as the length of hospital stay, transfusion and postoperative leak rates, description of the operative variations of VI reported VI operative variations and details regarding the primary operation and previous neoadjuvant therapy.

RESULTS

In total, 11 studies and 554 patients were included in this systematic review. Overall, 158 laparoscopic and 191 open procedures were performed. The AL and VI conversion rates were 11.9% and 10.46%, respectively. The total complication rate was estimated to be 13.9%, while VI-specific adverse events were recorded in 2.1% of all cases.

CONCLUSIONS

VI could be a safe and effective alternative to a diverting stoma. Although currently, VI is not widely used, it could have a widespread application in laparoscopic surgery. However, definitive trials are needed before firm recommendations on the use of VI can be made.

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

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.

Intestinal Ostomy

BACKGROUND

About 100 000 ostomy carriers are estimated to live in Germany today. The creation of an ostomy represents a major life event that can be associated with impaired quality of life. Optimal ostomy creation and proper ostomy care are crucially important determinants of the success of treatment and of the patients' quality of life.

METHODS

This article is based on pertinent publications retrieved by a selective search in PubMed, GoogleScholar, and Scopus, and on the authors' experience.

RESULTS

Intestinal stomata can be created using either the small or the large bowel. More than 75% of all stomata are placed as part of the treatment of colorectal cancer. The incidence of stoma-related complications is reported to be 10-70%. Skin irritation, erosion, and ulceration are the most common early complications, with a combined incidence of 25-34%, while stoma prolapse is the most common late complication, with an incidence of 8-75%. Most early complications can be managed conservatively, while most late complications require surgical revision. In 19% of cases, an ostomy that was initially planned to be temporary becomes permanent. Inappropriate stoma location and inadequate ostomy care are the most common causes of early complications. Both surgical and patient-related factors influence late complications.

CONCLUSION

Every step from the planning of a stoma to its postoperative care should be discussed with the patient in detail. Preoperative marking is essential for an optimal stoma site. Optimal patient management with the involvement of an ostomy nurse increases ostomy acceptance, reduces ostomy-related complications, and improves the quality of life of ostomy carriers.

Defunctioning ileostomy reduces leakage rate in rectal cancer surgery - systematic review and meta-analysis

Objectives

The role of a defunctioning ileostomy in every anterior rectal resection with total mesorectal excision (TME) is still controversial. In this study, we aimed to review the current literature to determine the impact of ileostomy creation on postoperative outcomes in patients undergoing anterior rectal resection with TME.

Methods

MEDLINE, Embase and Cochrane Library were searched for eligible studies. We analyzed data up to October 2017. Eligible studies had to compare patients with vs. without a defunctioning ileostomy in rectal cancer surgery and comprise data on anastomotic leakage in both groups. The primary outcome was anastomotic leakage. Secondary outcomes included the complication rate, mortality, reoperation rate, length of hospital stay and 30-day readmission.

Results

Initial search yielded 1,966 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. Leakage rate (RR = 0.43, 95% CI 0.28-0.67) and the number of reoperations (RR = 0.62, 95% CI 0.40-0.94) were significantly lower in the defunctioning stoma group. Morbidity was significantly higher in the stoma group (RR = 1.32, 95% CI 1.05–1.65). Analysis of mortality, length of hospital stay and readmission rate did not show any significant differences.

Conclusion

A defunctioning ileostomy may decrease the anastomotic leakage rate, additionally significantly reducing the risk of reoperations but it may also increase the overall complication rate. The presence of the protective stoma has no effect on mortality, length of hospital stay and readmission rate.

Initial experience with taTME in patients undergoing laparoscopic restorative proctocolectomy for familial adenomatous polyposis

BACKGROUND

Transanal total mesorectal excision (taTME) is a minimally invasive technique which was developed to overcome the difficulties associated with the "top-down" pelvic dissection by enabling a "bottom-up" dissection in patients with mid- and low rectal cancer. While this technique was primarily designed to manage tumors in the mid- and lower rectum, its spectrum of indications has been broadened to include benign colorectal pathologies. The aim of the present study was to assess our initial experience with taTME in patients undergoing restorative proctocolectomy for familial adenomatous polyposis (FAP).

METHODS

All consecutive patients (undergoing prophylactic restorative proctocolectomy with IPAA for FAP using taTME between April and October 2016 at our institution) were included in the study.

RESULTS

There were 8 patients (6 females and 2 males). The median age was 19.5 years (range 16-31 years). In all cases, surgery was successfully completed using with taTME. No perioperative complications were recorded. A median of 5 bowel movements (range 4-6 bowel movements) with intermittent anti-diarrheal medication was recorded in all cases.

CONCLUSIONS

Our initial experience with 8 consecutive cases suggests taTME is safe and effective in patients undergoing prophylactic restorative proctocolectomy with IPAA for FAP.

Routine Virtual Ileostomy Following Restorative Proctocolectomy for Familial Adenomatous Polyposis

BACKGROUND

Anastomotic leakage (AL) is the most feared complication in colorectal surgery. A diverting ileostomy is routinely used to prevent or reduce morbidity and mortality following AL. However, a diverting ileostomy cannot prevent AL. Besides, diverting ileostomy might be associated with relevant complications. Herein, we introduce the virtual ileostomy as an alternative to diverting ileostomy in patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for familial adenomatous polyposis (FAP).

MATERIALS AND METHODS

The results of eight patients, five females and three males with a median age of 19.5 ± 6.0 years (range 16.0-31.0 years), undergoing restorative proctocolectomy with IPAA and virtual ileostomy for FAP are presented.

RESULTS

All cases were laparoscopically managed. The virtual ileostomy was released between postoperative day 7 and 9. No AL was registered. Postoperative recovery was uneventful in all cases.

CONCLUSION

A diverting ileostomy was prevented via the use of virtual ileostomy in all cases. Thus, virtual ileostomy is a good alternative to diverting ileostomy in patients undergoing restorative proctocolectomy with IPAA for FAP.

Morbidity Associated with Diverting Loop Ileostomies: Weighing Diversion in Rectosigmoid Resection

Anterior resection with primary anastomosis is the procedure of choice for patients with rectosigmoid cancers with good sphincter function. Surgeons may perform an associated diverting loop ileostomy (DLI) to minimize the likelihood and/or the severity of an anastomotic leak. To examine the morbidity of DLIs, we performed a review of a prospectively maintained database. Participants included all patients at the Massachusetts General Hospital who underwent anterior resection from January 2013 to July 2015 for rectosigmoid cancers and who subsequently underwent adjuvant chemotherapy. The primary outcome was time to start of adjuvant chemotherapy. Secondary outcomes included length of hospitalization, perioperative complications, and 60-day postoperative complications. Inclusion criteria were met in 57 patients and DLI was performed in 21 (37%). The DLI group had higher estimated blood loss (431.7 vs 192.1 mL, P = 0.03) and a longer operation time (3.7 vs 2.3 hours, P = 0.0007). The DLI group took over a week longer to start adjuvant chemotherapy than the non-DLI group (median time to chemo: 43 vs 34 days, P = 0.002). Postoperatively, DLI was associated with a longer hospitalization (6.7 vs 3.1 days, P = 0.0003), more perioperative complications (57.1% vs 13.9%, P = 0.0006), and more 60-day read-missions or emergency department visits (38.1% vs 5.6%, P = 0.002). Ostomies are associated with appreciable morbidity. In turn, they do not eliminate postoperative complications. Surgeons should closely consider ostomy morbidity in rectosigmoid resection and institute a proactive approach toward identification and prevention of complications.