Flexible endoscopy is enough diagnostic prior to loop ileostomy reversal

Considerations in case of suspected anastomotic leakage in the lower GI tract

Colorectal anastomotic leakage (CAL) remains a feared complication after colorectal surgery and requires prompt detection and proper treatment. With the upswing of fast-track recovery programs in recent years this challenge has increased, as clinical features may only arise after discharge. Therefore, identification of the best diagnostic tools is of utmost importance, also since early treatment is associated with high success rates. Diagnostic tools range from general screening tools to invasive procedures to assess the severity of the leak. Laboratory tests, in particular the inflammation biomarkers C-reactive protein and procalcitonin, have a significant role in the detection of CAL after colorectal surgery. As these biomarkers are unspecific for CAL, additional imaging should be performed when blood levels are elevated. The golden standard for the detection of AL after colonic resections is a computed tomography (CT-scan). If tolerated, a contrast medium should be administered rectally to enhance diagnostic accuracy. When suspicion of CAL remains high despite negative previous tests, further endoscopy examination should be conducted. However, endoscopic examinations become more suitable for the early diagnostic work-up after rectal resections. This review aims to provide an overview of current diagnostics for the screening and assessment of the severity of CAL after colorectal surgery.

Ostomy Does Not Lead to Worse Outcomes After Bowel Resection With Ovarian Cancer: A Systematic Review

Background

Debulking cytoreduction surgery with bowel resection is a common intervention for ovarian cancer. It is controversial whether ostomy causes worse survival outcomes and how clinical physicians should choose which patients to undergo ostomy. During this study, we performed a systematic review to determine whether ostomy leads to worse outcomes after bowel resection compared to anastomosis. We also summarized the possible indications for ostomy.

Methods

We searched PubMed, Embase, and Cochrane for articles containing the phrase "ovarian cancer with bowel resection" that were published between 2016 and 2021. We included studies that compared primary anastomosis with ostomy. We mainly focused on differences in the anastomotic leakage rate, length of hospital stay, overall survival, and other survival outcomes associated with the two procedures.

Results and Conclusion

Of the 763 studies, three were ultimately included in the systematic review (N=1411). We found that ostomy did not contribute to worse survival outcomes, and that the stoma-related complications were acceptable. Indications for ostomy require further study. Bowel resection segment margins and the distance from the anastomosis to the anal verge require consideration.

Less is more-the best test for anastomotic leaks in rectal cancer patients prior to ileostomy reversal

PURPOSE

No clear consensus exists on how to routinely assess the integrity of the colorectal anastomosis prior to ileostomy reversal. The objective of this study was to evaluate the accuracy of contrast enema, endoscopic procedures, and digital rectal examination in rectal cancer patients in this setting.

METHODS

A systematic literature search was performed. Studies assessing at least one index test for which a 2 × 2 table was calculable were included. Hierarchical summary receiver operating characteristic curves were calculated and used for test comparison. Paired data were used where parameters could not be calculated. Methodological quality was assessed with the QUADAS-2 tool.

RESULTS

Two prospective and 11 retrospective studies comprising 1903 patients were eligible for inclusion. Paired data analysis showed equal or better results for sensitivity and specificity of both endoscopic procedures and digital rectal examination compared to contrast enema. Subgroup analysis of contrast enema according to methodological quality revealed that studies with higher methodological quality reported poorer sensitivity for equal specificity and vice versa. No case was described where a contrast enema revealed an anastomotic leak that was overseen in digital rectal examination or endoscopic procedures.

CONCLUSIONS

Endoscopy and digital rectal examination appear to be the best diagnostic tests to assess the integrity of the colorectal anastomosis prior to ileostomy reversal. Accuracy measures of contrast enema are overestimated by studies with lower methodological quality. Synopsis of existing evidence and risk-benefit considerations justifies omission of contrast enema in favor of endoscopic and clinical assessment.

TRIAL REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019107771.