Shalabi Amjad, Duek Simon Daniel, Khoury Wisam
Colorectal Surgery Unit, Rambam Health Care Campus, Haifa, Israel.
Department of General Surgery, Rambam Health Care Campus, Haifa, Israel.
J Gastrointest Surg. 2016 Oct;20(10):1732-7. doi: 10.1007/s11605-016-3218-8. Epub 2016 Jul 29.
Diverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low anterior resection for low-rectal cancer. Prior to ileostomy reversal, water-soluble enema is performed to assess the low colorectal anastomosis. The aim of this study was to assess whether performance of routine water-soluble enema prior to ileostomy takedown is necessary.
All mid-low rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy after neoadjuvant chemoradiotherapy, between 2006 and 2013, were identified, retrospectively. The colorectal anastomosis prior to ileostomy takedown was evaluated by digital rectal exam, rigid proctoscopy, and water-soluble enema. The rectal exam and proctoscopy findings were compared to those of the water-soluble enema. The efficacy of routine water-soluble enema was assessed.
Three hundred and twelve (184 male) patients (mean age 62.2 ± 17 years) met the inclusion criteria. Ten patients (3 %) experienced a contained anastomotic leak in the early postoperative period, of whom six had a positive intraoperative air leak test at the index operation. At follow-up, 12 patients (4 %) presented with anastomotic stricture, which was diagnosed by rectal exam and proctoscopy. In 11 of them, water-soluble enema showed anastomotic stricture. In terms of anastomotic defects, sinus was documented in two patients (0.6 %), yet digital rectal exam and proctoscopy were normal. No late septic complications related to the colorectal anastomosis after ileostomy closure were reported. The sensitivity of rectal exam, and proctoscopy for the diagnosis of anastomotic stricture was 100 %, while its negative predictive value for the diagnosis of anastomotic defect was 99 %.
Routine water-soluble enema for the evaluation of colorectal anastomosis before ileostomy takedown does not provide additional information that changes patient management. The efficacy of this test in patients after neoadjuvant chemoradiotherapy and low anterior resection should be reassessed.
对于接受新辅助放化疗及低位前切除术治疗低位直肠癌的患者，推荐行回肠造口术。在回肠造口还纳术前，需进行水溶性灌肠以评估低位结直肠吻合口情况。本研究旨在评估在回肠造口拆除术前进行常规水溶性灌肠是否必要。
回顾性纳入2006年至2013年间所有接受新辅助放化疗后行低位前切除术并临时行回肠造口术的中低位直肠癌患者。在回肠造口拆除术前，通过直肠指检、硬性直肠镜检查及水溶性灌肠评估结直肠吻合口情况。将直肠指检和直肠镜检查结果与水溶性灌肠结果进行比较。评估常规水溶性灌肠的有效性。
312例（184例男性）患者（平均年龄62.2±17岁）符合纳入标准。10例患者（3%）在术后早期发生局限性吻合口漏，其中6例在初次手术时术中漏气试验阳性。随访时，12例患者（4%）出现吻合口狭窄，通过直肠指检和直肠镜检查确诊。其中11例患者水溶性灌肠显示吻合口狭窄。在吻合口缺陷方面，2例患者（0.6%）记录有窦道形成，但直肠指检和直肠镜检查正常。未报告回肠造口关闭后与结直肠吻合口相关的晚期感染并发症。直肠指检和直肠镜检查诊断吻合口狭窄的敏感性为100%，而其诊断吻合口缺陷的阴性预测值为99%。
在回肠造口拆除术前常规进行水溶性灌肠以评估结直肠吻合口情况，并不能提供改变患者治疗管理的额外信息。应重新评估该检查在新辅助放化疗及低位前切除术后患者中的有效性。
