Revising Our Concepts about Stoma Covering a Low Rectal Anastomosis

Introduction There has been conclusive evidence that defunctioning stoma with either transverse colostomy or ileostomy mitigates the serious consequences of anastomotic leakage. However, whether transverse colostomy or ileostomy is preferred for defunctioning a rectal anastomosis remains controversial. The present study was designed to identify the best defunctioning stoma for colorectal anastomosis. Objective To improve the quality of life in patients with rectal resection and anastomosis and reduce the morbidity before and after closure of the stoma. Patients and Methods The present study included 48 patients with elective colorectal resection who were randomly arranged into 2 equal groups, with 24 patients each. Group I consisted of patients who underwent ileostomy, and group II consisted of patients who underwent colostomy as a defunctioning stoma for a low rectal anastomosis. All surviving patients were readmitted to have their stoma closed and were followed-up for 6 months after closure of their stomas. All data regarding local and general complications of construction and closure of the stoma of the two groups were recorded and blotted against each other to clarify the most safe and tolerable procedure. Results We found that all nutritional deficiencies, dehydration, electrolytes imbalance, peristomal dermatitis, and frequent change of appliances are statistically more common in the ileostomy group, while stomal retraction and wound infection after closure of the stoma were statistically more common in the colostomy group. There were no statistically significant differences regarding the total hospital stay and mortality between the two groups. Conclusion and Recommendation Ileostomy has much higher morbidities than colostomy and it also has a potential risk of mortality; therefore, we recommend colostomy as the ideal method for defunctioning a distal colorectal anastomosis.

The “impossible” rectal anastomosis: a novel use for endoluminal vacuum-assisted therapy

Purpose Low rectal anastomoses can safely be performed, usually secured by a diverting ostomy. However, in cases of inflammation, extensive scarring, after extensive radiation, or after severe stapler dysfunction the risk for an anastomotic leak may become prohibitively high. We present a novel use for endoluminal vacuum-assisted therapy (EVAT) for otherwise “impossible” low rectal anastomoses. Methods Our initial series consisted of 14 consecutive patients who underwent prophylactic EVAT treatment due to unsafe low colorectal anastomosis. The vacuum sponge was placed intraoperatively in cases otherwise calling for a Hartmann’s procedure. An open-pored polyurethane sponge was placed prophylactically transanally for a mean duration of 11 days. Patient characteristics, complications, and risk factors were prospectively collected from medical records and analyzed. Results Between March 2017 and September 2019, we performed this novel technique in 14 patients enabling us to perform an anastomosis. Our collective consisted of 4 female (29%) and 10 male (71%) patients with a medium age of 59 years. Underlying disease was colorectal cancer in 10 patients, ovarian cancer, perforated sigmoid diverticulitis, ischemic colitis and sarcoma in one patient each. Dominant factors putting the anastomosis at extremely high risk were acute inflammation (n = 2), frozen pelvis (n = 2), intraoperative local chemotherapy (n = 2), stapler dysfunction (n = 2), non-closable rectal stump (n = 2), empty pelvis (n = 1) and ultra-low anastomosis (n = 3). Prophylactic EVAT was successful in 92% and gastrointestinal continuity was preserved in all patients. Conclusion This is the first description of prophylactic EVAT treatment. It seems to be a simple and safe method to enforce the high-risk low rectal anastomosis.

Feasibility of Rectal Stent Development for Fecal Diversion: A Porcine Experiment

Objective Since low rectal anastomosis leakage may cause severe morbidity, surgeons create diversion stoma to prevent complication. However, stoma requires additional surgery with morbidity. Therefore, rectal stent may help prevent these problems. This preliminary report details the development of new rectal stent in animal experiment. Thirteen female 12 week-old pigs weighing 30–35 kg each (four in the control group, nine in the experimental group) were included. Under general anesthesia, pigs underwent laparoscopic low anterior resection. In experimental group, a Niti-S fully covered stent (Taewoong Medical Inc.) was inserted by guidewire, under direct laparoscopic vision, and affixed near the anus. All pigs were sacrificed for autopsy. Including the anastomosis line, 10 cm length of bowel was obtained and a water-air leak and barium leakage X-ray tests were performed to confirm anastomosis integrity. Results Among the four control pigs, anastomosis leakage was confirmed in only one. For the experimental pigs, 36-mm-diameter stent was used. The last three pigs were subjected to additional intra-abdominal stent fixation by laparoscopic guidance, but all stents were removed. Despite natural stent removal, there were only two cases of intraoperative leakage. To overcome rectal pressure and fecal bulk, rectal stent development requires further investigation.

Is Circular Fibrin Sealing of Low Rectal Anastomosis Able to Prevent Leakage in 21-Day Follow-up? Randomized Experimental Trial in Pigs

Purpose. Clinically apparent anastomotic leakage (AL) after low anterior rectal resection (LAR; <7 cm from anal verge) using circular double-stapled anastomosis without defunctioning stoma is up to 37.5%. However, it is unclear whether there is reduction of LAR after 21 postoperative days without defunctioning stoma but with extraluminal anastomotic application of fibrin sealant. Methods. Forty-eight-week-old pigs underwent LAR and circular double-stapled anastomosis in end-to-end technique (descendo-rectostomy). Animals were randomized into therapy and control group (cg). Therapy group (n = 20) received additional extraluminal circular anastomotic application of fibrin sealant. Objective was to assess incidence of clinically apparent and nonclinically apparent leakage through the 21st postoperative day. Remaining animals were sacrificed on the 21st day, and anastomotic region was analyzed. In case of earlier diagnosed AL, animals were sacrificed. Results. In cg, we observed clinically and nonclinically AL in 20% (n = 4). No animal was identified with a nonclinical-apparent leakage in this group, and all 4 animals with leakages presented clinical signs. In the therapy group, no animal (0/20) developed clinically apparent leakage signs. There were no leakages in this group, but 3 animals had ulcerative lesions without leak and without clinical signs. These lesions were observed intraluminally at crossing of staple lines after 21 days. In one of these animals, incomplete leakage was observed, blocked by fibrin sealant. Conclusion. In circular stapled colorectal anastomosis, circular fibrin glue sealant successfully protected anastomotic intraluminal wall defects at crossing of staple lines, reducing leakage rate from 20% to 0% (cg vs therapy group) after 21 postoperative days.