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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
Dimitriou et al. World Journal of Surgical Oncology
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
Nikoletta Dimitriou 0 1
Sofoklis Panteleimonitis 1
Ajit Dhillon 1
Kirsten Boyle 1
Mike Norwood 1
David Hemingway 1
Justin Yeung 1
Andrew Miller 1
0 26 , Mikras Asias str, Athens 11527 , Greece
1 Colorectal Department, Leicester Royal Infirmary , Leicester , UK
Background: The aims of the study were to determine the radiological leak rate in those patients who had undergone a resection for left-sided colorectal cancer and to see if the presence of a leak can be related with the postoperative clinical period. We also aimed to identify any common factors between patients with leak. Methods: A retrospective analysis of prospectively collected data of all patients who underwent a left-sided colorectal cancer resection with formation of a defunctioning ileostomy was undertaken. Between 2005 and 2010, 418 such patients were identified. Results: A water-soluble contrast enema was performed in 339 patients (81.1 %). Of these, 24 (7.1 %) were reported to show an anastomotic leak. Data for these 24 patients is presented in this study. Twenty-three (95.8 %) of the leaks occurred in patients who had undergone an anterior resection; 95.8 % of the patients with a leak were male. Fifteen (62.5 %) patients underwent neo-adjuvant radiation. The mean length of stay in those patients shown to have a subsequent radiological leak was 18.8 days (median), compared with the overall unit figures of 12 days. Only 29.2 % of the patients who had a leak identified had an uncomplicated postoperative period. Overall 87.5 % of the patients had a reversal of the ileostomy. Conclusions: Radiological leakage is not uncommon. The majority of patients, who were shown to have a radiological leak in this study, were male, had undergone an anterior resection, had received neo-adjuvant radiation, had a longer initial length of stay and had postoperative complications. Water-soluble contrast enemas could be selectively used in patients with these characteristics.
Anastomotic leakage; Water-soluble contrast enema; Colorectal cancer
Background
Anastomotic failure following a colorectal resection is a
devastating complication for both the patient and
surgeon. It is associated with increased morbidity and
mortality [
1, 2
]. Mortality rates are reported to be between 6
and 22 % [3]. The Association of Coloproctology of
Great Britain and Ireland Guidelines recommend that the
audited leak rate for anterior resections should be below
8 % and below 4 % for all other resections [
4
]. The
literature reports anastomotic leakage to be between 11
and 12 % after rectal surgery [
5, 6
] compared with 3–4 %
after colonic surgery [7].
The aim of forming a defunctioning loop ileostomy is
to divert the faecal stream from the anastomosis. The
role of diverting the faecal stream from the anastomosis
is still controversial. In a recent meta-analysis of four
randomized controlled trials, Huser et al. showed a
statistically significant increase in clinical anastomotic
leakage and the need for reoperation in patients without a
proximal stoma after low anterior resection for cancer
[
8
]. The same results were reported in a Cochrane
review [
9
]. Others have argued that the stoma mitigates
the consequences of a leakage but does not lower the
leakage rate itself, as was the result in a large
retrospective multicenter study by Gastinger et al., in which
leakage rate was 14 % with and without a defunctioning
stoma [
10
]. A more recent randomized multicentre
study concluded that the presence of a defunctioning
stoma significantly decreases the rate of symptomatic
leakage [
11
]. A review of almost 2000 patients reported
that a defunctioning stoma following a coloanal
anastomosis appears to protect against postoperative sepsis,
septic shock and need for reoperation; it is overused in
patients having a more proximal anastomosis and should
be avoided in low-risk patients [
12
].
Defunctioning loop ileostomies are usually reversed
8–12 weeks from initial surgery [
13
]. If however,
adjuvant chemotherapy is indicated, the time to reversal
may be somewhere in the order of 35–40 weeks. In
many centres, a water-soluble contrast enema (WSCE)
is routinely performed to assess the integrity of the
colorectal anastomosis prior to closure. However, such
routine practise is controversial. Kalady et al. have
shown that a routine WSCE did not reveal any
anastomotic leaks that were not already suspected clinically
[
14
]. Jayaraja et al. have also shown that in cases where
colonic pouches are formed, the appearances of WSCE
can be mistaken for leaks leading to false positive
results [
15
].
The primary aim of our study was to determine the
radiological leak rate in those patients who had
undergone a resection for left-sided colorectal cancer and to
see if the presence of (...truncated)