Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary?

Improving the time to ileostomy closure following an anterior resection for rectal cancer in the UK

AIM

Delayed closure of ileostomy following an anterior resection for rectal cancer in the UK is common. The aims of this study were (i) to investigate the variation in patient pathways between hospitals, (ii) to identify the key learning points from units with the shortest time to closure and (iii) to develop guidance for a pathway to minimize delay in ileostomy closure.

METHOD

This was a mixed methods study. Thirty-eight colorectal units in the UK completed a short online survey. Nine colorectal units in Wales filled in an additional, expanded version of the survey. Semi-structured interviews were performed with clinicians from the six best performing units in terms of timely ileostomy closure. The optimal pathway suggested is based on the best evidence available and the Association of Coloproctology of Great Britain and Ireland guidelines.

RESULTS

Qualitative analysis revealed that 5% of units (n = 2) have a local target time for ileostomy closure. Of all units, 90% (n = 34) would consider implementing a pathway if guidelines were developed. In-depth interviews highlighted the importance of a multidisciplinary approach, a dedicated coordinator to facilitate timely booking, and consensus on whether closure should be performed before or after adjuvant chemotherapy.

CONCLUSION

There is a lack of national guidance in timing of contrast studies and ileostomy closure. Key aspects to consider are better information at consent regarding stoma closure timing, a dedicated person to track patients and the planning of contrast studies at discharge from initial surgery. With a dedicated approach closure of ileostomy within 10-12 weeks is feasible for most units.

Contrast-enhanced abdominal computed tomography to evaluate anastomotic integrity before ileostomy closure in postoperative colorectal cancer patients

PURPOSE

To investigate the usefulness of contrast-enhanced abdominal computed tomography (CECT) to predict clinically significant anastomotic leakage (CSAL) in patients who received colorectal cancer surgery with diverting ileostomy.

METHODS

In this retrospective cohort study, patients who underwent colorectal cancer surgery with diverting ileostomy from January 2014 to May 2018 and postoperative CECT were included. The performance of significant CECT features, identified using multivariable logistic regression, to predict CSAL was calculated. In subgroup analysis, the areas under the receiver operating characteristic curve (AUROCs) were compared between CECT and water-soluble contrast enema (WSCE) using DeLong's method.

RESULTS

Of 325 patients (median age, 58 years; 213 men), CECT was routinely performed to evaluate cancer status in 307 (94.5%), and CSAL was observed in 28 (8.6%). After multivariable adjustment, anastomotic mural defect (odds ratio [OR] 5.24; 95% confidence interval [CI] 1.77-15.51; p = 0.003), perianastomotic air (OR 7.28; 95% CI 1.82-29.17; p = 0.007) and ischemic colitis (OR 3.30; 95% CI 1.13-9.61; p = 0.029) were significantly associated with CSAL. The sensitivity, specificity, accuracy, and positive and negative predictive values of significant CECT features were 60.7%, 88.2%, 85.9%, 32.7%, and 96.0%, respectively. In subgroup analysis of 144 patients, the AUROC using significant CECT features (optimal sensitivity/specificity, 50.0%/90.4%) was comparable to that using WSCE (optimal sensitivity/specificity, 12.5%/97.8%) to predict CSAL (0.704 vs. 0.552, p = 0.085).

CONCLUSION

CECT performed after colorectal cancer surgery may be useful to assess anastomotic integrity before ileostomy closure, especially to negatively predict CSAL. In the presence of anastomotic mural defect, perianastomotic air, or ischemic colitis, WSCE may be recommended to exclude CSAL.

MRI-enema for the assessment of pelvic intestinal anastomotic integrity

AIM

Anastomotic leak causes significant morbidity for patients undergoing pelvic intestinal surgery. Fluoroscopic assessment of anastomotic integrity using water-soluble contrast enema (WSCE) is of questionable benefit over examination alone. We hypothesized that MRI-enema may be more accurate. The aim of this study was to compare MRI-enema with fluoroscopic WSCE.

METHOD

Patients referred for WSCE with pelvic intestinal anastomosis and defunctioning ileostomy (including patients with suspected or known leaks) were invited to participate. WSCE and MRI-enema were undertaken within 48 h of each other. MRI sequences were performed before, during and immediately after the introduction of 400 ml of 1% gadolinium contrast solution per anus. MRI examinations were reported to protocol by two blinded gastrointestinal radiologists. A Likert-scale patient questionnaire was administered to compare patient experience. Follow-up was >12 months after ileostomy reversal. Anastomotic leak was determined by unblinded consensus of examination and radiological findings.

RESULTS

Sixteen patients were recruited, with a median age of 39 years (range 22-69). Ten were men, 11 had ileoanal pouch formation and five had low anterior resection. Five patients had anastomotic leak identified by MRI and four by WSCE. The radial location of the anastomotic defect was identified in all five patients by MRI versus two on WSCE. MRI revealed additional information including contents of a widened presacral space. Patient experience was equivalent. Eleven patients eventually had ileostomy reversal without complications.

CONCLUSION

MRI-enema is a feasible and tolerable alternative to WSCE and offers greater anatomical detail in the context of pelvic intestinal anastomotic leak. Larger prospective studies are required to define its potential role in the UK National Health Service.

Flexible endoscopy is enough diagnostic prior to loop ileostomy reversal

PURPOSE

This study investigates whether contrast enema (CE) and flexible endoscopy (FE) should be performed routinely after low anterior resection (LAR) before ileostomy reversal. Additionally, the impact of previous anastomotic leakage (AL) on diagnostic test accuracy (DTA) was assessed.

METHODS

This is a retrospective analysis of prospectively collected tertiary care data of two centers. Consecutive rectal cancer patients undergoing LAR with loop ileostomy formation were included. Before ileostomy reversal, all patients were assessed by CE and FE. DTA of FE and CE for asymptomatic AL in patients who had previously suffered from clinically relevant AL (group 1) compared with those without apparent AL after LAR (group 0) were assessed separately.

RESULTS

Two hundred ninety-three patients were included in the analysis, 86 in group 1 and 207 in group 0. Overall sensitivity for detection of asymptomatic AL was 76% (FE) and 60% (CE). Specificity was 100% for both tests. DTA of FE was equal or superior to CE in all subgroups. Prevalence of asymptomatic AL at the time of testing was 1.4% in group 0 and 25.6% in group 1.

CONCLUSION

Flexible endoscopy is the more accurate diagnostic test for the detection of asymptomatic anastomotic leaks prior to ileostomy reversal. Contrast enema showed no gain of information. In the group without complications after the initial rectal resection, 104 must be tested to find one leak prior to reversal. In those patients, routine diagnostic testing additional to digital rectal examination may be questioned.

Abnormal Pouchogram Predicts Pouch Failure Even in Asymptomatic Patients

BACKGROUND

Anastomotic complications after restorative total proctocolectomy with IPAA for ulcerative colitis alter functional outcomes and quality of life and may lead to pouch failure. Routine contrast enema of the pouch assesses anastomotic integrity before ileostomy reversal, but its clinical use is challenged.

OBJECTIVE

The purpose of this research was to assess the relationship among preoperative clinical characteristics, abnormal pouchography, and long-term pouch complications.

DESIGN

This was a retrospective chart review.

SETTINGS

The study was conducted at a tertiary care center between 2000 and 2010.

PATIENTS

Ulcerative colitis patients with IPAA undergoing pouchography before ileostomy closure were included.

MAIN OUTCOME MEASURES

Patient demographics, incidence of pouch-related complications, and findings on pouchogram were recorded. Primary outcome was pouch failure, defined as excision or permanent diversion of the ileoanal pouch. Independent predictors of pouch failure were determined by multivariate regression.

RESULTS

A total of 262 patients with ulcerative colitis were included. Contrast extravasation was seen in 27 patients (10.3%): 14 (51.9%) were clinically asymptomatic at the time of pouchogram. Six (22.2%) of 27 patients with extravasation developed pouch failure despite normalization of the pouchogram before ileostomy closure. Forty patients (15.3%) were found to have pouch-anal anastomotic stenosis; only 1 developed pouch failure. Pre-IPAA serum albumin and hemoglobin levels were inversely associated with contrast extravasation (serum albumin: OR = 0.42; hemoglobin: OR = 0.77; p < 0.05). Contrast extravasation was associated with delayed takedown operation (average = 67 d), increased risk (OR = 5.25; p < 0.01), and shorter time (median = 32.0 vs 72.5 mo; HR = 5.88; p < 0.05) to pouch failure, as well as increased risk of pouch-related complications (p < 0.05).

LIMITATIONS

The study was limited by its retrospective nature and small number of patients who developed pouch failure.

CONCLUSIONS

Pouchography before ileostomy takedown is useful in identifying patients with ulcerative colitis at risk for postoperative complications. Radiologic resolution of IPAA-related leak does not reliably predict healing; caution is warranted in this subgroup. See Video Abstract at http://links.lww.com/DCR/A818.

Contrast radiography before diverting stoma closure in rectal cancer is not necessary on a routine basis

INTRODUCTION

Diverting stomata are recommended in patients with low anterior resection and risk factors in order to reduce the severity of anastomotic leaks. Usually, a radiology study is performed prior to the closure of the stoma to detect subclinical leaks. The aim of the present study is to assess the clinical utility of the radiology study.

METHODS

A prospective cohort study of patients undergoing anterior rectal resection for rectal cancer and those who underwent stoma closure without contrast enema. This study was carried out after a retrospective review of radiology study results prior to the closure of the stoma in patients operated from 2007 to 2011.

RESULTS

Eighty-six patients met the study criteria. Thirteen patients (15.1%) presented pelvic sepsis. Contrast enema before stoma closure was pathological in 8 patients (9.3%). Five out of the 13 patients with pelvic sepsis had a pathological radiological study, compared to only 3 out of the 73 patients without intra-abdominal complications after rectal resection (38.5% vs. 4.1%; P=.001). Based on these results, we conducted a prospective study omitting the contrast enema in patients with no postoperative complications. Thirty-eight patients had their stoma closed without a prior radiology study. None of the patients presented pelvic sepsis.

CONCLUSIONS

Radiology studies of the colorectal anastomosis before reconstruction can safely be omitted in patients without pelvic sepsis after the previous rectal resection.

Are radiologic pouchogram and pouchoscopy useful before ileostomy closure in asymptomatic patients operated for ulcerative colitis?

OBJECTIVES

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the "gold standard" procedure for patients with ulcerative colitis (UC) requiring surgical intervention. A de-functioning ileostomy is usually performed, as a step for the IPAA procedure. The aim of this study is to present the methodology and results of the routine double assessment of IPAA integrity in asymptomatic patients prior to the ileostomy reversal and evaluate its necessity.

METHODS

This is a retrospective study of 61 UC patients, who underwent IPAA construction, in 2010-2016. A diverting ileostomy was created after IPAA construction, which was reversed at least 3 months later. A double assessment, with pouchogram and pouchoscopy, of IPAA integrity was performed, before stoma closure. Post-operative symptoms and signs of complications, imaging studies, and endoscopic findings were recorded during follow-up.

RESULTS

Prior to the ileostomy reversal, both pouchoscopy and pouchogram identified no patient with evidence of anastomotic leakage. During a mean follow-up of 3.67 years after ileostomy reversal, 11 patients developed complications but only one had signs of leakage, which presented as a pouch-vaginal fistula. The specificity of both the pouchogram and pouchoscopy reached 100% and the negative predictive value ranged between 98.4 and 100%.

CONCLUSIONS

The specificity of pouchoscopy and pouchogram prior to ileostomy closure, in asymptomatic patients with IPAA for UC, is very high in recognizing an intact anastomosis, but their combination did not alter the diagnostic accuracy or had any effect in further management. At least, pouchogram could be selectively performed only in patients with high-risk clinical indicators.

KEY POINTS

• The double assessment of ileal pouch-anal anastomosis with pouchogram and pouchoscopy, prior to ileostomy closure, specifically in patients with ulcerative colitis has not been evaluated before. • The specificity of pouchoscopy and pouchogram prior to ileostomy closure, in asymptomatic patients with IPAA for UC, is very high in recognizing an intact anastomosis. • However, their combination did not alter the diagnostic accuracy or had any effect in further management, in asymptomatic patients.

Clinical value of pouchogram prior to ileostomy closure after ileal pouch anal anastomosis

BACKGROUND

In patients who undergo restorative proctocoletomy (RPC) a pouchogram is often used to assess the integrity of the ileal pouch-anal anastomosis (IPAA) before closing the covering ileostomy. There are no good data to support this practice. The aim of the study was to investigate whether contrast pouchography was clinically useful after RPC.

METHODS

We conducted a retrospective study of patients who had undergone RPC with a covering ileostomy between September 2013 and September 2015.

RESULTS

61 patients were included. 7 (11%) presented with anastomotic leak and 2 (3%) with pelvic collection, detected on cross-sectional imaging for early postoperative symptoms. In the remaining 52 patients, without immediate postoperative complications, pouchography was performed at a median of 14 weeks (range 7-71 weeks) after RPC. Each patient also underwent examination under anaesthesia (EUA) to assess the integrity of the IPAA on the day of the ileostomy closure. One asymptomatic patient (2%) had an anastomotic leak demonstrated on pouchogram which was subsequently confirmed at EUA. Two patients (3%) with a normal pouchogram, 1 symptomatic and 1 asymptomatic, subsequently had an anastomotic leak demonstrated at EUA.

CONCLUSIONS

Pouchogram has a low sensitivity in identifying anastomotic leak before ileostomy reversal in patients after RPC and only rarely changes management. In our series it identified the diagnosis of anastomotic leak in only 1 patient and gave false reassurance in two others. Complications are more frequently detected by clinical history and formal EUA before ileostomy closure.

Management of early pouch-related septic complications in ulcerative colitis: a systematic review

AIM

It is well established that ileo-anal pouch-related septic complications (PRSC) increase the risk of pouch failure. There are a number of publications that describe the management of early PRSC in ulcerative colitis (UC) in small series. This article aims to systematically review and summarize the relevant current data on this subject and provide an algorithm for the management of early PRSC.

METHOD

A systematic review was undertaken in accordance with PRISMA guidelines. Studies published between 2000 and 2017 describing the clinical management of PRSC in patients with UC within 30 days of primary ileo-anal pouch surgery were included. A qualitative analysis was undertaken due to the heterogeneity and quality of studies included.

RESULTS

A total of 1157 abstracts and 266 full text articles were screened. Twelve studies were included for analysis involving a total of 207 patients. The studies described a range of techniques including image-guided, endoscopic, surgical and endocavitational vacuum methods. Based on the evidence from these studies, an algorithm was created to guide the management of early PRSC.

CONCLUSION

The results of this review suggest that although successful salvage of early PRSC is improving there is little information available relating to methods of salvage and outcomes. Novel techniques may offer an increased chance of salvage but comparative studies with longer follow-up are required.

Water-Soluble Enema Prior to Ileostomy Closure in Patients Undergoing Low Anterior Resection: Is It Necessary?

BACKGROUND

Diverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low anterior resection for low-rectal cancer. Prior to ileostomy reversal, water-soluble enema is performed to assess the low colorectal anastomosis. The aim of this study was to assess whether performance of routine water-soluble enema prior to ileostomy takedown is necessary.

MATERIALS AND METHODS

All mid-low rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy after neoadjuvant chemoradiotherapy, between 2006 and 2013, were identified, retrospectively. The colorectal anastomosis prior to ileostomy takedown was evaluated by digital rectal exam, rigid proctoscopy, and water-soluble enema. The rectal exam and proctoscopy findings were compared to those of the water-soluble enema. The efficacy of routine water-soluble enema was assessed.

RESULTS

Three hundred and twelve (184 male) patients (mean age 62.2 ± 17 years) met the inclusion criteria. Ten patients (3 %) experienced a contained anastomotic leak in the early postoperative period, of whom six had a positive intraoperative air leak test at the index operation. At follow-up, 12 patients (4 %) presented with anastomotic stricture, which was diagnosed by rectal exam and proctoscopy. In 11 of them, water-soluble enema showed anastomotic stricture. In terms of anastomotic defects, sinus was documented in two patients (0.6 %), yet digital rectal exam and proctoscopy were normal. No late septic complications related to the colorectal anastomosis after ileostomy closure were reported. The sensitivity of rectal exam, and proctoscopy for the diagnosis of anastomotic stricture was 100 %, while its negative predictive value for the diagnosis of anastomotic defect was 99 %.

CONCLUSION

Routine water-soluble enema for the evaluation of colorectal anastomosis before ileostomy takedown does not provide additional information that changes patient management. The efficacy of this test in patients after neoadjuvant chemoradiotherapy and low anterior resection should be reassessed.

Assessment by Using a Water-Soluble Contrast Enema Study of Radiologic Leakage in Lower Rectal Cancer Patients With Sphincter-Saving Surgery

Purpose

This study evaluated the efficacy of a water-soluble contrast enema (WCE) in predicting anastomotic healing after a low anterior resection (LAR).

Methods

Between January 2000 and March 2012, 682 consecutive patients underwent a LAR or an ultra-low anterior resection (uLAR) and were followed up for leakage. Clinical leakage was established by using physical and laboratory findings. Radiologic leakage was identified by using retrograde WCE imaging. Abnormal radiologic features on WCE were categorized into four types based on morphology: namely, dendritic, horny, saccular, and serpentine.

Results

Of the 126 patients who received a concurrent diverting stoma, only two (1.6%) suffered clinical leakage due to pelvic abscess. However, 37 patients (6.7%) in the other group suffered clinical leakage following fecal diversion (P = 0.027). Among the 163 patients who received a fecal diversion, 20 showed radiologic leakage on the first WCE (eight with and 12 without a concurrent diversion); 16 had abnormal features continuously until the final WCE while four patients healed spontaneously. Eleven of the 16 patients (69%), by their surgeon's decision, underwent a stoma restoration based on clinical findings (2/3 dendritic, 3/4 horny, 5/7 saccular, 1/2 serpentine). After stoma reversal, only 2 of the 11 (19%) complained of complications related to the rectal anastomosis.

Conclusion

WCE is helpful for detecting radiologic leakage before stoma restoration, especially in patients suffering clinical leakage after an uLAR. However, surgeons appear to opt for stoma restoration despite the persistent existence of radiologic leakage in cases with particular features on the WCE.

Utility of contrast enema to assess anastomotic integrity and the natural history of radiological leaks after low rectal surgery: systematic review and meta-analysis

PURPOSE

There is no clear consensus on how to assess low rectal anastomotic integrity and patency prior to reversal of de-functioning stoma. The aim of this systematic review was to assess the utility of contrast enema (CE) in this context and to clarify the natural history of radiological leaks.

METHODS

Keyword search of electronic databases (Embase, MEDLINE, Cochrane Library, Google Scholar) and bibliographic cross-referencing were performed to identify appropriate studies. Data extraction and synthesis was performed with the primary outcomes being the sensitivity and specificity of CE for detecting clinically significant abnormalities. Statistical analysis was performed using Open Meta-Analyst software. Narrative review of outcomes including those of clinical and radiological leaks was also undertaken.

RESULTS

A total of 1,142 CE from 11 articles were included in the final meta-analysis. CE had high specificity (95.4; 95 % confidence interval = 92.0-97.4) and negative predictive value (98.4; 97.4-99.1) and moderate sensitivity (79.9; 63.9-89.9) and positive predictive value (64.6; 55.5-72.9) for the detection of clinically significant anastomotic problems. There was a high degree of correlation between CE and clinical examination findings (96.7 %). Occult radiological leaks were seen in 5.7 % of CE, and all but one (97 %) eventually underwent successful reversal. Only three quarters of patients with clinical leak underwent successful reversal.

CONCLUSION

CE is effective at excluding clinically significant anastomotic problems, especially after clinical anastomotic leaks. However, false positive results can be observed in asymptomatic patients, and it is unclear how much additional information CE provides over clinical assessment in the low uncomplicated anastomosis.

Should routine contrast study be a norm before stoma reversal? A retrospective study of patients with temporary ileostomy

In the developed nations, temporary ileostomies are usually made in order to protect a distal anastomosis after cancer surgery. However, in India and the neighbouring countries ileal perforation is the most common indication for creating a temporary ileostomy after emergency laparotomy. It seems logical to perform a contrast study when a stoma that was made to protect a bowel anastomosis is being reversed in order to check for anastomosis healing, leak or stenosis. Although we do not know precisely when and why we started this practice, it is customary at our institute to do a contrast study before reversal of a temporary ileostomy. At some institutes a routine contrast study is never done. The utility of this practice has not previously been studied at our institute. This study tries to correlate the surgeon's clinical and operative findings with the contrast study report in order to see if it may be reasonable to reverse the stoma without a routine contrast study in selected patients where the surgeon has clearly documented absence of any gross disease in the distal bowel and who have had an uneventful post-operative period. To our knowledge this appears to be the first such attempt from our country.

Routine barium enema prior to closure of defunctioning ileostomy is not necessary

PURPOSE

The use of barium enemas to confirm the anastomotic integrity prior to ileostomy closure is still controversial. The purpose of the study was to determine the utility of routine contrast enema prior to ileostomy closure and its impact on patient management in patients with a low pelvic anastomosis.

METHODS

One hundred forty-five patients had a temporary loop ileostomy constructed to protect a low colorectal or coloanal anastomosis following low anterior resection for rectal cancer. All patients were evaluated by physical examination, proctoscopy, and barium enema prior to ileostomy closure.

RESULTS

The median time from ileostomy creation to closure was 8 months. Five (3.5%) of the 144 patients were found to have clinically relevant strictures at the colorectal anastomosis on routine barium enema. One patient (0.7%) showed anastomotic leak on their barium enema. Overall, 141 patients (97.9%) had an uncomplicated postoperative course. Postoperative complication occurred in three patients (2.1%). None of them showed abnormal barium enema finding, which suggested that routine contrast enema examination did not predict postoperative complication.

CONCLUSION

Routine barium enema evaluation of low pelvic anastomoses before loop ileostomy closure did not provide any additional information for postoperative colorectal anastomotic complication.

The utility of routine pouchogram before ileostomy reversal in children and adolescents following ileal pouch anal anastomosis

INTRODUCTION

Pouchograms are used to assess the integrity of the ileal pouch anal anastomosis (IPAA) in patients who have undergone restorative proctocolectomy. Its benefits have been questioned, and there are no data to support the routine use in children.

METHODS

We retrospectively reviewed the charts of 26 patients who had an IPAA and pouchogram at our institution between 2001 and 2009. Each patient also underwent an examination under anesthesia to assess the integrity of the IPAA on the day of the ileostomy closure.

RESULTS

The mean age of the patients was 13.8 (± 0.7) years. The pouchogram was performed at a median of 6 weeks after the IPAA (range, 4-20 weeks). The findings were normal in 26 (89.7%) and demonstrated stricture in 2 (6.9%) and leak in 1 (3.4%). History was suggestive and physical examination was confirmatory in these 3 problematic cases.

CONCLUSIONS

A contrast enema is not routinely required to evaluate the integrity of the IPAA before ileostomy reversal in pediatric patients. Complications can be detected by history and rectal examination before ileostomy closure. We recommend the use of contrast enema only in symptomatic patients where a leak is suspected, thereby limiting radiation exposure and inconvenience.

Routine evaluation of the distal colon remnant before Hartmann's reversal is not necessary in asymptomatic patients

BACKGROUND

Reversal of Hartmann's is a common surgical procedure. Routine preoperative evaluation of the distal colonic/rectal remnant (DCRR) with contrast and/or endoscopic studies is frequently performed despite lack of evidence to support this practice. We hypothesize that asymptomatic patients can safely undergo Hartmann's reversal without preoperative DCRR evaluation.

METHODS

Adult patients undergoing reversal of Hartmann's at a single institution were retrospectively identified. Operative characteristics and outcomes in patients with and without preoperative DCRR evaluation were compared.

RESULTS

Between 1993 and 2008, 203 patients underwent reversal of Hartmann's at a tertiary referral center. Sixty-eight patients (33%) did not undergo preoperative DCRR evaluation and had comparable demographic characteristics, comorbidities, DCRR length, and perioperative outcomes to 135 patients who underwent preoperative contrast and/or endoscopic studies. After evaluation, 125 (93%) patients had normal findings, seven (5%) patients had abnormal studies that did not impact their management, and three (2%) patients underwent additional procedures.

CONCLUSION

Hartmann's reversal without previous DCRR evaluation is acceptable in selected asymptomatic patients, without increased risk of complications.

Role of Water-Soluble Enema before Takedown of Diverting Ileostomy for Low Pelvic Anastomosis

The integrity of a low pelvic anastomosis is often studied radiographically before takedown of a diverting ileostomy. The aim of this study is to determine the impact of routine water-soluble enema studies (WSE) in our patient population with low pelvic anastomosis. We retrospectively reviewed the operative database for a county teaching hospital from 1998 to 2008. All patients with low pelvic anastomosis (ultralow colorectal, coloanal, and ileoanal pouch anastomosis) with diverting ileostomy who underwent subsequent takedown were identified. Fifty patients met inclusion criteria. Thirty-eight patients were evaluated by WSE and 12 were not. Twenty-five patients (66%) were noted to have normal WSE studies before ostomy takedown. Thirteen patients (26%) were noted to have abnormalities on WSE. Two stenoses were clinically significant. Water-soluble enema study was 100 per cent sensitive and 69 per cent specific for detecting significant pathology. Digital rectal examination (DRE), colonoscopy, and flexible sigmoidoscopy were also 100 per cent sensitive in detecting substantial pathology. Routine use of WSE failed to demonstrate a significant impact on patients with low pelvic anastomosis undergoing ileostomy takedown. Routine DRE and rigid proctoscopy can be used to evaluate low pelvic anastomosis. WSE can be used selectively on patients with abnormal findings.

Colo-anal pouches: lessons from a prospective audit

OBJECTIVE

Colonic pouch formation with pouch-anal anastomosis is the treatment of choice following restorative anterior resection for low rectal cancers with a proximal loop ileostomy to defunction the anastomosis. Controversy exists as to whether anastomotic integrity needs to be checked prior to ileostomy reversal. The aim of this prospective study was to audit our current practice.

METHOD

Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Patients who underwent an anterior resection with pouch formation and defunctioning ileostomy were identified and a review of notes and radiological records was carried out.

RESULTS

Forty-two patients with rectal adenocarcinoma underwent an anterior resection with colo-colonic pouch, colo-anal anastomosis and a covering loop ileostomy. Of these, 38(90.5%) had water-soluble contrast enemas (WSCE) 6-8 weeks postoperatively. Two studies (5.3%) confirmed the presence of normal colo-colonic pouch but 24(63.2%) normal reports made no mention of the presence of pouch. Three studies (7.9%) reported true leaks, one study (2.6%) an anastomotic stricture and eight studies (21.1%) anastomotic leaks. Review by radiologists and surgeons, and examination with flexible sigmoidoscopy of these final eight confirmed that these appearances were consistent with normal colo-colonic pouches and anastomosis with no leak. These patients went on to have uneventful stoma closure.

CONCLUSION

Our study suggests that Colon pouches are difficult to clearly delineate on WSCE and appearances may be mistaken for leaks leading to questioning of the suitability of WSCE in assessing anastomotic integrity. A true positive leak rate of 7.9% would suggest that postoperative assessment prior to closure is still necessary in some patients.

Routine contrast imaging of low pelvic anastomosis prior to closure of defunctioning ileostomy: is it necessary?

PURPOSE

The purpose of the study was to determine the utility of routine contrast enema prior to ileostomy closure and its impact on patient management in patients with a low pelvic anastomosis.

MATERIAL AND METHODS

Two hundred eleven patients had a temporary loop ileostomy constructed to protect a low colorectal or coloanal anastomosis following low anterior resection for cancer (57%) or other disease (12%) or to protect an ileal pouch-anal anastomosis following restorative proctocolectomy (31%). All patients were evaluated by physical examination, proctoscopy, and water-soluble contrast enema prior to ileostomy closure. Imaging results were correlated with the clinical situation to determine the effects on patient management.

RESULTS

The mean time from ileostomy creation to closure was 15.6 weeks. Overall, 203 patients (96%) had an uncomplicated course. Eight patients (4%) developed an anastomotic leak, seven of which were diagnosed clinically and confirmed radiographically before planned ileostomy closure. Resolution of the leak was confirmed by follow-up contrast enema. One patient, whose pouchogram revealed a normal anastomosis, clinically developed a leak after ileostomy closure. It is important to note that routine contrast enema examination did not reveal an anastomotic leak or stricture that was not already suspected clinically.

CONCLUSIONS

All patients who developed an anastomotic leak in this study were diagnosed clinically, and the diagnosis was confirmed by selective use of radiographic tests. Routine contrast enema evaluation of low pelvic anastomoses before loop ileostomy closure did not provide any additional information that changed patient management. The utility of this routine practice should be questioned.

Preoperative distal loop contrast radiograph before closure of an enterostomy in paediatric surgical patients. How much does it affect the procedure or predict early postoperative complications?

Before the closure of an enterostomy, a distal loop contrast radiograph (DLCR) is widely used to disclose pathology which may affect the performance of the procedure. We studied whether DLCR of paediatric patients caused actual alterations in the surgical plan and whether it predicted postoperative complications. Between 1991 and 2006, 105 patients (small bowel enterostomy, SBE; n = 51), (colostomy, CO; n = 54) underwent closure of an enterostomy. All 105 patients had preoperative DLCR. The indications for enterostomy included anorectal malformation (n = 38), neonatal intestinal perforation (n = 25), J-Pouch ileoanal anastomosis (n = 20), anorectal trauma (n = 5), and miscellaneous (n = 17). We recorded sensitivity, specificity, and positive and negative predictive value (PPV and NPV) of DLCR for complications within 6 postoperative weeks. DLCR was considered complete and interpreted as normal in 94 (90%) and abnormal (incomplete n = 3 or pathological n = 8) in 11 (10%) patients. None of the 11 abnormal findings caused cancellation of surgery, but in three (27%) patients it was possible to surgically correct a stricture seen in DLCR. The frequency of surgical complications was 17/105 (16%), SBE (15/51,29%) and CO (2/54, 4%), (P < 0.05). Most common complications (9/17, 53%) were those associated with the intestinal anastomosis. For postoperative complications DLCR had sensitivity, specificity, and PPV and NPV of 47, 97, 73 and 90% (SBE and 47, 97, 88 and 81%), (CO 50, 96, 33 and 98%). The pathology seen in DLCR, however, seldom directly hinted the complications which actually occurred. Abnormal DLCR changed the surgical plan in less than one-fifth of the cases. For surgical complications DLCR had poor sensitivity, good specificity and NPV, and moderate PPV. The pathology suggested by DLCR, however, correlated poorly with the actual complications. Poor sensitivity reflects the high frequency of anastomotic complications, which are practically unpredictable by preoperative radiographs.

The value of diverting loop ileostomy on the high-risk colon and rectal anastomosis

INTRODUCTION

The need for diverting loop ileostomies to protect high-risk anastomoses has been questioned recently by several authors. This study was designed to evaluate the potential benefits and complications of diverting loop ileostomies in a high-risk anastomosis population.

METHODS

Ninety-four consecutive patients undergoing diverting loop ileostomy were evaluated from a prospective database between 2003 and 2006. Criteria for diversion were: anastomosis less than 5 cm from the anal verge, previous pelvic radiation therapy, obstruction, and infection. Data regarding patient demographics, underlying pathology, anastomotic problems, and ileostomy-related problems were gathered.

RESULTS

Indications for surgery were malignancy (n = 40), ulcerative colitis (n = 37), acute diverticulitis (n = 12), perirectal fistulas (n = 3), and familial polyposis (n = 2). There were 5 anastomotic complications. One required permanent stoma and 4 required delay in diverting ileostomy closure but no other intervention. Ileostomy-related problems were limited to minor stoma and pouch complaints requiring stoma nurse evaluation (n = 23), dehydration requiring outpatient (n = 8) or inpatient (n = 4) intravenous fluids, stricture at stoma closure site (n = 2), and bleeding at stoma closure site (n = 1). Four stoma site hernias (4.3%) have been identified to date.

CONCLUSION

The use of diverting loop ileostomy in patients undergoing colon and rectal surgery with high-risk anastomoses is beneficial. Their selected use has resulted in a 1% anastomotic loss rate with an acceptably low rate of complications related to the ileostomy.