Who Needs a Loop Ileostomy After Low Anterior Resection for Rectal Cancer?
Pt population
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Who Needs a Loop Ileostomy After Low Anterior Resection for Rectal Cancer? Walker Julliard and Gregory Kennedy
Pt population Pts after LAR
Intervention Proximal diversion
Comparator No diversion
Outcomes studied Leak rate, consequences
Introduction The standard of care for rectal cancers has evolved over recent years to be restorative anterior proctectomy. The most feared complication after low anterior resection (LAR) is anastomotic leak. Overall risk of anastomotic leak varies between 3 and 21 % [1]. Anastomotic leak has a reported mortality of 2.1–22 % and requires intervention with methods ranging from interventional radiologic drainage to reoperation [2]. Furthermore, colonic conduit function after anastomotic leak is significantly worse than in patients without leakage [2]. Other complications from anastomotic leak include increased rate of local recurrence and decreased disease- free and overall survival [3, 4]. This increase in cancer recurrence may be due to a W. Julliard (*) Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Drive, Madison, WI, USA e-mail: [email protected] G. Kennedy Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, KB 430, 1720 2nd Ave S, Birmingham, AL 35294-0016, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery, Difficult Decisions in Surgery: An Evidence-Based Approach, DOI 10.1007/978-3-319-40223-9_21
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delay or abandonment of the necessary adjuvant chemoradiotherapy [4]. Because of the serious morbidity associated with anastomotic leak, measures to minimize leak rates and the morbidity from such leaks has been implemented, the most ubiquitous of these being temporary fecal diversion. However, in recent years, the dogma of mandatory fecal diversion after LAR has been called into question.
Methods A detailed search of the Embase-Medline databases was conducted for medical literature. The following search terms were employed to identify relevant articles: (“rectal” OR “colon” OR “colorectal”) AND (“resection” OR “low anterior resection” OR “proctectomy”) AND (“ileostomy” OR “ostomy” OR “colostomy” OR “diversion” OR “fecal diversion”). The title and abstracts of English-language articles were assessed for relevance
Why Not Divert? When deciding if a patient should undergo fecal diversion, it is essential to fully understand the consequences of the procedure. Despite the widespread use of fecal diversion, it is not without complications. These complications include both shortand long-term problems and range from minor, requiring only local care, to major complications requiring reoperation and prolonged hospitalization [5, 6]. The most common complication after stoma construction is peristomal skin irritation [7]. While not necessarily defined by most members of the surgical community as a “major” complication, this can have major impl
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