Is the routine use of a water-soluble contrast enema prior to closure of a loop ileostomy necessary? A review of a single institution experience

Early diverting stoma closure is feasible and safe: results from a before-and-after study on the implementation of an early closure protocol at a tertiary referral center

BACKGROUND

Evidence on early closure (EC) of defunctioning stoma (DS) after colorectal surgery shows a favorable effect when patients are carefully selected. Therefore, a clinical pathway adapted to the implementation of an EC strategy was developed in our center. The aim of this study was to carry out a comparative analysis of time until DS closure and DS-related morbidity before and after the implementation of an EC protocol (ECP).

METHODS

This study is a before-and-after comparative analysis. Patients were divided into two cohorts according to the observational period: patients from the period before the ECP implementation (January 2015-December 2019) [Period 1] and those from the period after that (January 2020-December 2022) [Period 2]. All consecutive patients subjected to elective DS closure within both periods were eligible. Early closure was defined as the reversal within 30 days from DS creation. Patients excluded from EC or those not closed within 30 days since primary surgery were analyzed as late closure (LC). Baseline characteristics and DS-related morbidity were recorded.

RESULTS

A total of 145 patients were analyzed. Median time with DS was shorter in patients after ECP implementation [42 (21-193) days versus 233 (137-382) days, p < 0.001]. This reduction in time to closure did not impact the DS closure morbidity and resulted in less DS morbidity (68.8% versus 49.2%, p = 0.017) and fewer stoma nurse visits (p = 0.029).

CONCLUSIONS

The ECP was able to significantly reduce intervals to restoration of bowel continuity in patients with DS, which in turn resulted in a direct impact on the reduction of DS morbidity without negatively affecting DS closure morbidity.

Evaluation of Pelvic Anastomosis by Endoscopic and Contrast Studies Prior to Ileostomy Closure: Are Both Necessary? A Single Institution Review

Contrast enema is the gold standard technique for evaluating a pelvic anastomosis (PA) prior to ileostomy closure. With the increasing use of flexible endoscopic modalities, the need for contrast studies may be unnecessary. The objective of this study is to compare flexible endoscopy and contrast studies for anastomotic inspection prior to defunctioning stoma reversal. Patients with a protected PA undergoing ileostomy closure between July 2014 and June 2019 at our institution were retrospectively identified. Demographics and clinical outcomes in patients undergoing preoperative evaluation with endoscopic and/or contrast studies were analyzed. We identified 207 patients undergoing ileostomy closure. According to surgeon's preference, 91 patients underwent only flexible endoscopy (FE) and 100 patients underwent both endoscopic and contrast evaluation (FE + CE) prior to reversal. There was no significant difference in pelvic anastomotic leak (2.2% vs. 1%), anastomotic stricture (1.1% vs. 6%), pelvic abscess (2.2% vs. 3.0%), or postoperative anastomotic complications (4.4% vs. 9%) between groups FE and FE + CE (P > .05). Flexible endoscopy alone appears to be an acceptable technique for anastomotic evaluation prior to ileostomy closure. Further studies are needed to determine the effectiveness of different diagnostic modalities for pelvic anastomotic inspection.

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

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.

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.

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

BACKGROUND

Currently no consensus exists regarding what pre-reversal investigations are required to assess integrity of the rectal anastomosis. The objective of this study was to compare pre-reversal assessments of anastomotic integrity and to evaluate trends that might have influenced timings for reversal.

METHODS

From a prospectively maintained database, patients with colorectal cancer resections between March 2012 and October 2019 were identified. Patient characteristics, pre-reversal contrast enema and flexible sigmoidoscopy findings were recorded, and management of complications were recorded. Time-to-ileostomy reversal and time series for trends were analysed.

RESULTS

There were 154 patients included. Pre-reversal contrast enema or sigmoidoscopy detected a possible stricture or leak at the rectal anastomotic site in 11% (15/132) and 15% (18/112), respectively. When both modalities were used there was concordance of 86.1% and a positive likelihood ratio of 5.73. Of 125 (81.2%) ileostomies reversed, the median time-to-reversal was 11.99 months; time series analysis over the 7-year period showed no significant trend for average patient-days from booking to reversal (P = 0.60). Cox regression modelling did not identify any influential risk factors for the times taken to reversal.

CONCLUSION

This study supports the use of both contrast enema and flexible sigmoidoscopy in the assessment of rectal anastomosis integrity. Most patients with complications can have their ileostomies reversed. Patients who have adjuvant chemotherapy have a prolonged time to reversal.

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

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.

A closer look at the stoma: multimodal imaging of patients with ileostomies and colostomies

Nowadays, large numbers of ileostomies and colostomies are created during surgical management of a variety of intestinal disorders. Depending on indication, surgical technique and emergency versus elective conditions, stomas may be either temporary or permanent. As a result, patients with ileostomies and colostomies are commonly encountered in Radiology departments, particularly during perioperative hospitalisation following stoma creation or before recanalisation, and when needing CT or MRI studies for follow-up of operated tumours or chronic inflammatory bowel diseases. However, the stoma site is commonly overlooked on cross-sectional imaging.Aiming to improve radiologists' familiarity with stoma-related issues, this pictorial essay concisely reviews indications and surgical techniques for ileostomies and colostomies, and presents state-of-the art multimodal imaging in patients living with a stoma, including water-soluble contrast stomal enema (WSC-SE), CT and MRI techniques, interpretation and expected findings. Afterwards, the clinical features and imaging appearances of early and late stoma-related complications are illustrated with imaging examples, including diversion colitis.When interpreting cross-sectional imaging studies, focused attention to the stoma site and awareness of expected appearances and of possible complications are required to avoid missing significant changes requiring clinical attention. Additionally, dedicated imaging techniques such as WSC-SE and combined CT plus WSC-SE may be helpful to provide surgeons the appropriate clinical information required to direct management.

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.