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HOME > Ann Coloproctol > Volume 31(4); 2015 > Article
Editorial
 Should a Contrast Enema Be Performed Before Reversal of a Diverting Stoma in Lower Rectal Surgery?
Ji Yeon Kim
Annals of Coloproctology 2015;31(4):117-118.
DOI: https://doi.org/10.3393/ac.2015.31.4.117
Published online: August 31, 2015

Department of Surgery, Chungnam National University Hospital, Daejoen, Korea.

Correspondence to: Ji Yeon Kim, M.D. Department of Surgery, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea. Tel: +82-42-280-7175, Fax: +82-42-257-8024, jkim@cnu.ac.kr

© 2015 The Korean Society of Coloproctology

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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See Article on Page [Related article:] 131-137
A defunctioning loop ileostomy is often used to reduce the consequences of anastomotic leakage, especially in a low rectal anastomosis. Hanna et al. [1] showed that fecal diversion could be recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. Tan et al. [2] also argued that the creation of diverting stomas could potentially minimize the fatal outcomes of anastomotic leakage, although it might not substantially decrease the incidence of anastomotic leakage in rectal cancer surgery. However, some authors reported that a diverting stoma did not have a significant relationship with symptomatic anastomotic leakage before and after their propensity score matching [3]. Another study also argued that a diverting stoma did not affect postoperative morbidity in a large cohort of patients undergoing low rectal anastomosis and that the routine use of a diverting stoma could rather delay postoperative recovery [4].
In the stage of stoma reversal, there are many different concepts and ideas about the effectiveness of a water-soluble contrast enema for the assessment of anastomotic integrity after low rectal surgery. Some investigators report that the contrast enema does not provide additional information when the results of rectoscopy and digital rectal examination (DRE) are normal [5]. However, in other studies, a contrast enema was effective in excluding clinically significant anastomotic problems, especially after clinical anastomotic leaks [6].
Most surgeons perform the closure of the ileostomy after using a water-soluble contrast enema to check the anastomosis to confirm there is no sign of leakage. However, Palmisano et al. [7] performed the reversal of a protective stoma, despite a finding of persistent radiological and subclinical leakage, in selected patients. Seo et al. [8] evaluated the efficacy of a water-soluble contrast enema in predicting anastomotic healing after low rectal anastomosis and categorized the abnormal radiologic features into four types of their design based on the morphologic patterns: namely, dendritic, horny, saccular, and serpentine. They found that certain types of leakage forming cavitary lesions had better clinical outcomes after leakage had been arrested and the stoma had been restored. This issue should be discussed and evaluated through a larger-scale study for more definitive clinical implications.
A water-soluble contrast enema study is helpful in detecting radiologic leakage before reversal of a diverting stoma, but these examinations are sometimes difficult to interpret, especially in the presence of a pouch or a "dog-ear" from a colo-anal anastomosis constructed by using the double-stapling technique. Therefore, for patients with a diverting stoma, surgeons should always be mindful to select the best way and the appropriate time to perform the stoma restoration, or they should decide to delay the stoma restoration, based on the radiologic finding, as well as clinical information, such as the results of a digital rectal examination.

CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.

  • 1. Hanna MH, Vinci A, Pigazzi A. Diverting ileostomy in colorectal surgery: when is it necessary? Langenbecks Arch Surg 2015;400:145–152. ArticlePubMed
  • 2. Tan WS, Tang CL, Shi L, Eu KW. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 2009;96:462–472. ArticlePubMed
  • 3. Shiomi A, Ito M, Maeda K, Kinugasa Y, Ota M, Yamaue H, et al. Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1,014 consecutive patients. J Am Coll Surg 2015;220:186–194. ArticlePubMed
  • 4. Anderin K, Gustafsson UO, Thorell A, Nygren J. The effect of diverting stoma on postoperative morbidity after low anterior resection for rectal cancer in patients treated within an ERAS program. Eur J Surg Oncol 2015;41:724–730. ArticlePubMed
  • 5. Larsson A, Lindmark G, Syk I, Buchwald P. Water soluble contrast enema examination of the integrity of the rectal anastomosis prior to loop ileostomy reversal may be superfluous. Int J Colorectal Dis 2015;30:381–384. ArticlePubMed
  • 6. Habib K, Gupta A, White D, Mazari FA, Wilson TR. Utility of contrast enema to assess anastomotic integrity and the natural history of radiological leaks after low rectal surgery: systematic review and meta-analysis. Int J Colorectal Dis 2015;30:1007–1014. ArticlePubMed
  • 7. Palmisano S, Piccinni G, Casagranda B, Balani A, de Manzini N. The reversal of a protective stoma is feasible before the complete healing of a colorectal anastomotic leak. Am Surg 2011;77:1619–1623. ArticlePubMed
  • 8. Seo SI, Lee JL, Ha HK, Kim JC. Assessment by using a water-soluble contrast enema study of radiologic leakage in lower rectal cancer patients with sphincter-saving surgery. Ann Coloproctol 2015;31:131–137.ArticlePubMedPMC

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    • Out of the Loop: The Value of a Preoperative Loopogram for Colostomy Reversal in Trauma
      Nolitha Makapi Tisetso Morare, Meshack Nkosinaye Motha, Maeyane Stephens Moeng
      World Journal of Surgery.2021; 45(7): 2009.     CrossRef

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      Should a Contrast Enema Be Performed Before Reversal of a Diverting Stoma in Lower Rectal Surgery?
      Ann Coloproctol. 2015;31(4):117-118.   Published online August 31, 2015
      DOI: https://doi.org/10.3393/ac.2015.31.4.117
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