Importance of protective ileostomy during rectal resection

Lukas Sakra, MD, PhD, Veronica Prochazkova, MD, PhD, Jan Flasar, MD, Jiri Sller, MD, PhD. Surgical Dept. Pardubice

Introduction: Anastomotic leakage is one of the most important complications that occur after surgical low anterior resection for rectal cancer. Protective ileostomy or transversostomy is used during these rectal resection to reduce the consequences of rectal anastomotic failures. Many studies strictly recommend performing these protective stomies for the reduction of  the anastomotic leakage. On the other hand the closure of protective stomies is associated with high rate of the morbidity (20%) and the reoperation rate is 8%. For this reason protective stomies are only used where generally known leakage risk factors are presented at the Surgical Department Pardubice.

Objective: To determine the efficacy of the protective stoma in the low anterior rectal resection and if the standard leakage risk factors are the appropriate criteria for providing of the protective stomies.

Results: In the period from 1.1. 201é to 30.5.2015 we provided 399 procedures for rectal cancer, of which 197 cases were resection types. We performed during these rectal resection 34 (17.25%) protective ileostomies or transvestomies in the cases where the leakage risk factors were presented. In the group of patients with ileostomy we detected 4 (13.3%) patients with complication of having ileostomy, 3 (10%) of them needed  the surgery. Overall 24 anastomotic insufficiencies were noticed (12.18%), 5 of them were in the group with the protective ileostomy. 6 patients with anastomotic leakages were treated by axial transversostomy, 1 of these by loop ileostomy, 7 patients underwent rectal amputation, 2 patients Hartmann resection, 6 patients were treated by manual or endoscopic lavage and 2 were just observed. However only 5 protective stomies were performed in the cases where leakages were noticed.

Conclusion: Providing protective stomies in every case of rectal resection is associated with high rate of complications, predominantly during the closure of these stomies. The use of the rectal resection leakage risk factors for indication of protective stomies represents another way to indicate protective stomies. But our experience shows that this approach is not appropriate in every case. Indication of protective stomies still remains an open question in the field of low rectal resections.