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“Virtual ileostomy” combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report

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Abstract

Purpose

Despite the benefits of a loop ileostomy after total mesorectal excision (TME), it carries a significant associated morbidity. A “virtual ileostomy” (VI) has been proposed to avoid ileostomies in low-risk patients, which could then be converted into a real ileostomy (RI) in the event of anastomotic leak (AL). The aim of the present study is to evaluate safety and efficacy of VI associated with early endoscopy in patients undergoing rectal surgery with anastomosis to detect subclinical AL prior to the onset of clinical symptoms for sepsis.

Methods

This is a single-center, retrospective study of a consecutive series of patients undergoing elective or emergent colorectal surgery with low or ultralow colorectal or ileorectal anastomosis between September 2015 and September 2016.

Results

We included 44 consecutive, unselected patients. Eight patients (18.2%) required conversion into RI and one required terminal colostomy because of AL, of whom 44.4% were asymptomatic and AL was detected with early endoscopy. Fashioning of RI was not associated with further morbidity. All patients with AL converted into RI (n = 8/9) (88.9%), had adequate healed anastomosis, and later underwent stoma closure with no complications. A stoma was avoided in 79.6% of VI. Endoscopy was associated with 55% sensitivity and 100% specificity, with a global accuracy of 88%.

Conclusions

The combination of VI with early postoperative endoscopy could avoid unnecessary ileostomies in patients with low or ultralow anastomoses and reveal AL before the onset of symptoms, thus reducing associated morbidity.

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Acknowledgements

The authors are grateful for the professional English language editing to Mr. Arash Javadinejad, English Instructor and Research Editor at the Instituto de Investigación Sanitaria La Fe, Valencia, Spain.

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Authors and Affiliations

  1. Colorectal Unit, Hospital Universitario y Politécnico La Fe, Valencia Hospital La Fe, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain

    Blas Flor-Lorente, Luis Sánchez-Guillén, Gianluca Pellino, Matteo Frasson, Álvaro García-Granero & Eduardo García-Granero

  2. Digestive Medicine, Hospital Universitario y Politécnico La Fe, Valencia, Spain

    Marta Ponce

  3. Gynecologic Oncology Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain

    Santiago Domingo & Vicente Paya

Authors
  1. Blas Flor-Lorente
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  2. Luis Sánchez-Guillén
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  3. Gianluca Pellino
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  4. Matteo Frasson
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  5. Álvaro García-Granero
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  6. Marta Ponce
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  7. Santiago Domingo
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  8. Vicente Paya
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  9. Eduardo García-Granero
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Contributions

Study conception and design BFL, LSG, MF, SDDP, EGG. Acquisition of data BFL, LSG, MF, AGG, MPR, SDDP, VPA. Analysis and interpretation of data BFL, LSG, MF, GP, AGG, MPR, SDDP, VPA. Drafting of manuscript BFL, LSG, MF, GP, EGG. Critical revision of manuscript BF, LSG, MF, GP, AGG, MPR, SDDP, VPA, EGG.

Corresponding author

Correspondence to Luis Sánchez-Guillén.

Ethics declarations

The study was approved by the Clinical Research Ethics Committee of the hospital.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Electronic supplementary material

Suppl. Figure 1

Diagram for the Anastomotic Leak evaluation during Early Endoscopy. Anastomotic defect diagnosed by the Early Endoscopy (JPEG 380 kb)

Supplementary Table 1

(DOCX 39 kb)

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Flor-Lorente, B., Sánchez-Guillén, L., Pellino, G. et al. “Virtual ileostomy” combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report. Langenbecks Arch Surg 404, 375–383 (2019). https://doi.org/10.1007/s00423-019-01776-z

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