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

World Journal of Surgical Oncology, Dec 2015

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.

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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)


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Nikoletta Dimitriou, Sofoklis Panteleimonitis, Ajit Dhillon, Kirsten Boyle, Mike Norwood, David Hemingway, Justin Yeung, Andrew Miller. 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, World Journal of Surgical Oncology, 2015, pp. 331, 13, DOI: 10.1186/s12957-015-0742-z