Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection.

Abstract

Anastomotic leakage presents the most feared complication after low anterior resection (LAR). A proximal diversion of the gastrointestinal tract is recommended to avoid septic complications of anastomotic leakage. The aim of the present study was to evaluate the benefits and risks of diverting ileostomy (DI) created during laparoscopic LAR because of low rectal cancer. This was a retrospective clinical cohort study conducted to assess outcomes of laparoscopic LAR with/without DI in a single institution within a 6-year period. In total, 151 patients were enrolled in the study (73 patients without DI, 78 patients with DI). There were no significant differences between both groups regarding demographic and clinical features. Overall 30-day morbidity rates were significantly lower in patients without DI (23.3 vs. 42.3%, P=0.013). Symptomatic anastomotic leakage occurred more frequently in patients without DI (9.6 vs. 2.5%, P=0.090); surgical intervention was needed in 6.8% of patients without DI. Post-operative hospital stay was significantly longer in the group of patients with DI (11.3±8.5 vs. 8.1±6.9days, P=0.013). Stoma-related complications occurred in 42 of 78 (53.8%) patients with DI; some patients had more than one complication. Acute surgery was needed in 9 patients (11.5%) because of DI-related complications. Small bowel obstruction due to DI semi-rotation around its longitudinal axis was seen in 3 patients (3.8%) and presents a distinct complication of DI laparoscopic construction. The mean interval between LAR and DI reversal was more than 8months; only 19.2% of patients were reversed without delay (≤4months). Morbidity after DI reversal was 16.6%; re-laparotomy was necessary in 2.5% of patients. The present study indicates that DI protects low rectal anastomosis from septic complications at a cost of many stoma-related complications, substantial risk of acute surgery necessity and long stoma periods coupled with decreased quality of life.