Routine barium enema prior to closure of defunctioning ileostomy is not necessary

Abstract

PurposeThe use of barium enemas to confirm the anastomotic integrity prior to ileostomy closure is still controversial. The purpose of the study was to determine the utility of routine contrast enema prior to ileostomy closure and its impact on patient management in patients with a low pelvic anastomosis.MethodsOne hundred forty-five patients had a temporary loop ileostomy constructed to protect a low colorectal or coloanal anastomosis following low anterior resection for rectal cancer. All patients were evaluated by physical examination, proctoscopy, and barium enema prior to ileostomy closure.ResultsThe median time from ileostomy creation to closure was 8 months. Five (3.5%) of the 144 patients were found to have clinically relevant strictures at the colorectal anastomosis on routine barium enema. One patient (0.7%) showed anastomotic leak on their barium enema. Overall, 141 patients (97.9%) had an uncomplicated postoperative course. Postoperative complication occurred in three patients (2.1%). None of them showed abnormal barium enema finding, which suggested that routine contrast enema examination did not predict postoperative complication.ConclusionRoutine barium enema evaluation of low pelvic anastomoses before loop ileostomy closure did not provide any additional information for postoperative colorectal anastomotic complication.

Utility of contrast enema to assess anastomotic integrity and the natural history of radiological leaks after low rectal surgery: systematic review and meta-analysis

“…Although clinical examination is an integral part of this evaluation, the practice of performing a routine contrast enema has been challenged more recently [5][6][7] and even omitted in some cases [7][8][9]. The aims of this systematic review were to assess the utility of performing contrast enema for anastomotic assessment after low rectal surgery and to examine the natural history of radiological leaks.…”

Water soluble contrast enema examination of the integrity of the rectal anastomosis prior to loop ileostomy reversal may be superfluous

“…The median time for detection of anastomotic leakage was 11 days according to the Swedish Rectal Cancer Registry [16], indicating that reversal after 7-10 days, which has been suggested, may be hazardous. Examination of the anastomosis 4 weeks after the initial surgical procedure appears safe, although there have been adverse events reported [14]. In our series, we did not notice any technical adverse events caused by any of the examination techniques.…”

“…Another retrospective study implicated that DRE and rigid sigmoidoscopy were sufficient to detect substantial pathology [13]. Other studies have pointed out that examinations with radiopaque enema are of little value in the absence of clinical suspicion of anastomotic failure [10,11,14]. It is apparent from the present study that there is a need of standardized protocols, since two patients did not have their anastomosis investigated at all, only half of the patients underwent examination with all three techniques, and the timing varied up to 2 months.…”

Clinical Value of Contrast Enema Prior to Ileostomy Closure

“…In a group of 57 patients with an ileo-anal pouch, the investigators showed that fluoroscopic examination did not lead to diagnostic gains with respect to complications such as pouchitis, abscess, or fistula formation. Hong et al in 2012 [3] reported similar results in an investigation of 145 patients with protective ileostomy performed after deep anterior resection whose anastomosis was examined clinically, endoscopically and using contrast enema. It was found that the fluoroscopic examination in patients with colorectal or colo-anal anastomosis did not provide any additional information in preoperative diagnosis compared to clinical examination and proctoscopy.…”

“…The investigators concluded that contrast imaging prior to a reversal operation is not necessary in cases of complication-free progress and a deep anastomosis allowing accessible clinical examination. In a group of 211 patients, Kalady et al [3] demonstrated that contrast-enhanced imaging of deep anastomoses before ileostomy closure surgery was often used for confirmation in clinical suspicion of leakage, but the study did not detect any anastomotic leakage that had not already been clinically suspected. Thus the examination did not provide any diagnostic benefit to planning therapy for the patient.…”