The effect of diverticular disease on the colonic J pouch

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.

Colo-anal pouches: lessons from a prospective audit

OBJECTIVE

Colonic pouch formation with pouch-anal anastomosis is the treatment of choice following restorative anterior resection for low rectal cancers with a proximal loop ileostomy to defunction the anastomosis. Controversy exists as to whether anastomotic integrity needs to be checked prior to ileostomy reversal. The aim of this prospective study was to audit our current practice.

METHOD

Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Patients who underwent an anterior resection with pouch formation and defunctioning ileostomy were identified and a review of notes and radiological records was carried out.

RESULTS

Forty-two patients with rectal adenocarcinoma underwent an anterior resection with colo-colonic pouch, colo-anal anastomosis and a covering loop ileostomy. Of these, 38(90.5%) had water-soluble contrast enemas (WSCE) 6-8 weeks postoperatively. Two studies (5.3%) confirmed the presence of normal colo-colonic pouch but 24(63.2%) normal reports made no mention of the presence of pouch. Three studies (7.9%) reported true leaks, one study (2.6%) an anastomotic stricture and eight studies (21.1%) anastomotic leaks. Review by radiologists and surgeons, and examination with flexible sigmoidoscopy of these final eight confirmed that these appearances were consistent with normal colo-colonic pouches and anastomosis with no leak. These patients went on to have uneventful stoma closure.

CONCLUSION

Our study suggests that Colon pouches are difficult to clearly delineate on WSCE and appearances may be mistaken for leaks leading to questioning of the suitability of WSCE in assessing anastomotic integrity. A true positive leak rate of 7.9% would suggest that postoperative assessment prior to closure is still necessary in some patients.

Impact of stapled haemorrhoidopexy on stool continence and anorectal function: long-term follow-up of 242 patients

BACKGROUND AND AIMS

Several studies have proved the feasibility and safety of stapled anopexy for treating haemorrhoidal prolapse. However, stool urgency and faecal incontinence as possible side effects are still debated. Therefore, the present study was designed to assess the impact of Longo's procedure on stool continence and anorectal function.

MATERIALS AND METHODS

From 1999 to 2005, 300 patients underwent stapled haemorrhoidopexy for symptomatic haemorrhoidal prolapse. Two hundred forty-two patients (100 women, 142 men) were available for follow-up and were retrospectively reviewed. All operations were performed by one single surgeon. To evaluate anorectal function, the results of a validated incontinence score (total incontinence score [IS]: 0 = best, 20 = worst) and evacuation score (total evacuation score [ES]: 0 = worst, 28 = best) were compared pre- and postoperatively.

RESULTS

The total IS showed no difference in means before and after operation (p = 0.875, CI 95%) retrospectively. Concerning the ES, paired sample t-test showed a weak positive correlation, indicating a significant difference in score means (p = 0.041, CI 95%). The group means changed from 26.24 before operation to 26.60 after the follow-up period.

CONCLUSION

The present data revealed no significant negative impact of Longo's technique on anorectal function. In contrast, according to the evacuation score, the results showed a significant improvement of evacuation.