Investigations and time trends in loop ileostomy reversals following anterior resections: a single Australian institution seven‐years' experience

Abstract

Background Currently no consensus exists regarding what pre‐reversal investigations are required to assess integrity of the rectal anastomosis. The objective of this study was to compare pre‐reversal assessments of anastomotic integrity and to evaluate trends that might have influenced timings for reversal. Methods From a prospectively maintained database, patients with colorectal cancer resections between March 2012 and October 2019 were identified. Patient characteristics, pre‐reversal contrast enema and flexible sigmoidoscopy findings were recorded, and management of complications were recorded. Time‐to‐ileostomy reversal and time series for trends were analysed. Results There were 154 patients included. Pre‐reversal contrast enema or sigmoidoscopy detected a possible stricture or leak at the rectal anastomotic site in 11% (15/132) and 15% (18/112), respectively. When both modalities were used there was concordance of 86.1% and a positive likelihood ratio of 5.73. Of 125 (81.2%) ileostomies reversed, the median time‐to‐reversal was 11.99 months; time series analysis over the 7‐year period showed no significant trend for average patient‐days from booking to reversal (P = 0.60). Cox regression modelling did not identify any influential risk factors for the times taken to reversal. Conclusion This study supports the use of both contrast enema and flexible sigmoidoscopy in the assessment of rectal anastomosis integrity. Most patients with complications can have their ileostomies reversed. Patients who have adjuvant chemotherapy have a prolonged time to reversal.

Clostridium difficile infection following reversal of loop ileostomy: an uncommon but significant complication

“…The IV ceftriaxone was ceased on confirmation of CDI and they were treated with either a 14‐day course of vancomycin alone, or vancomycin and metronidazole. All four patients had a longer length of stay compared to the 6‐year median at our institution of 4.2 days (interquartile range 3.1–8.0) 1 (Table 1).…”

“…Ileostomy reversal following rectal cancer surgery is a common procedure with a low complication rate 1 . Clostridium difficile infection (CDI) after ileostomy reversal is rare but can result in serious complications such as pseudomembranous colitis, toxic megacolon and death.…”

Abnormalities at the colorectal anastomosis: granulation tissue or cancer recurrence?

“…Assessment of the colorectal anastomosis following a low anterior resection is an essential step prior to reversal of the associated loop ileostomy 1 . This is often performed with imaging and endoscopic evaluation to assess anastomotic integrity.…”

“…A finding of PAL appeared to delay ileostomy closure by an average of 67 days compared with our institution average. 1 The remaining two benign cases were not reversed due to metastatic disease. Of the three patients with anastomotic recurrence, only one was reversed prior to the diagnosis.…”

“…Assessment of the colorectal anastomosis following a low anterior resection is an essential step prior to reversal of the associated loop ileostomy. 1 This is often performed with imaging and endoscopic evaluation to assess anastomotic integrity. Peri-anastomotic lesions (PALs) found during these investigations may lead to undue concern, multiple investigations, delays to ileostomy reversal and increased healthcare cost.…”