The value of diverting loop ileostomy to prevent low pelvic anastomotic leak

One discussion this week focused on the impact of diverting ileostomy on low rectal anastamoses.

Reference: Matthiessen P, Hallbook O, Rutegard J, Simert G, et al. Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for Cancer: A Randomized Multicenter Trial. Annals of Surgery. 2007 Aug;246(2):2017-214. doi:10.1097/SLA.0b013e3180603024

Summary: Anastomotic leakage is a feared complication of rectal resections, reportedly occuring in 1-24% and increasing postoperative morbidity from 1-8% to 6-22% (Matthiessen et al, 2007). In a randomized multicenter trial of 234 patients (no easy feat for surgical technique studies), Matthiessen et al (2007) found “patients without diverting stoma leaked in 28.0%, compared to 10.3% of those with diverting stomas (OR = 3.4; 95% CI, 1.6-6.9; P < 0.001), a result not previously demonstrated in any randomized trial” (p.207).

surgmm_leakage

Among patients randomized for diverting ostomy, surgeons demonstrated a preference for loop ileostomy vs transverse colostomy (112/116) and in all 25 urgent diverting stomas. In 97% of the patients (227/234), surgeons chose to use pelvic drainage. All anastomotoses were made with a stapling device, none were handsewn.

The authors conclude that their trial accurately demonstrates a decreased rate of symptomatic ansatomotic leakage in diverted patients in low anterior resection. This is the first randomized trial to illustrate this result and, therefore, they recommend the use of a diverting stoma in low anterior resection of the rectum.

(Matthiessen et al, 2007, p.210)

Additional reading: Hanna MH, Vinci A, Pigazzi A. Diverting Ileostomy in Colorectal Surgery: When is it Necessary? Langenbeck’s Archives of Surgery. 2015 Feb;400(2):145-152. doi:10.1007/s00423-015-1275-1.

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