Overuse of Proximal Fecal Diversion in Colorectal Surgery

Abstract

Many surgeons tend to overuse proximal fecal diversion in the setting of colonic surgery. The decision to proximally divert an anastomosis should be made with careful consideration of the risks and benefits of proximal diversion. Proximal diversion does not decrease the rate of anastomotic leak, but it does decrease the severity of leaks. Anastomotic height for low pelvic anastomoses, hemodynamic instability, steroid use, male sex, obesity, malnutrition, smoking, and alcohol abuse increase the rate of anastomotic leak. Biologics, most immunosuppressive agents, unprepped colons, and radiation for rectal cancer do not contribute to increased rates of anastomotic leak.

Proximal fecal diversion creates additional potential morbidity, higher rates of readmission, and need for a subsequent hospitalization and operation for reversal. Additionally, diverted patients have higher rates of anastomotic stricture and delayed recognition of chronic leaks. These downsides to diversion must be weighed with a patient's perceived ability to handle the physiologic stress and consequences of a severe leak if reoperation is required. When trying to determine which patients can handle a leak, the modified frailty index can help to objectively determine a patient's risk for increased rate of morbidity and failure to rescue in the event of a leak.

While proximal diversion is still warranted in many cases, we find that certain clinical scenarios often lead to overuse of proximal diversion. The old surgical adage “If you are considering diverting, you should probably do it” should be tempered by an understanding of the risk and benefits of diversion.

Keywords

colorectal - loop ileostomy - proximal diversion - fecal diversion - anastomotic leak

Publikationsverlauf

Artikel online veröffentlicht:
02. November 2022

• References

• 1 Nurkin S, Kakarla VR, Ruiz DE, Cance WG, Tiszenkel HI. The role of faecal diversion in low rectal cancer: a review of 1791 patients having rectal resection with anastomosis for cancer, with and without a proximal stoma. Colorectal Dis 2013; 15 (06) e309-e316
• 2 Midura EF, Hanseman D, Davis BR. et al. Risk factors and consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum 2015; 58 (03) 333-338
• 3 Leahy J, Schoetz D, Marcello P. et al. What is the risk of clinical anastomotic leak in the diverted colorectal anastomosis?. J Gastrointest Surg 2014; 18 (10) 1812-1816
• 4 Ashburn JH, Stocchi L, Kiran RP, Dietz DW, Remzi FH. Consequences of anastomotic leak after restorative proctectomy for cancer: effect on long-term function and quality of life. Dis Colon Rectum 2013; 56 (03) 275-280
• 5 Nesbakken A, Nygaard K, Lunde OC. Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg 2001; 88 (03) 400-404
• 6 Lu ZR, Rajendran N, Lynch AC, Heriot AG, Warrier SK. Anastomotic leaks after restorative resections for rectal cancer compromise cancer outcomes and survival. Dis Colon Rectum 2016; 59 (03) 236-244
• 7 Hendren S, Vu J, Suwanabol P, Kamdar N, Hardiman K. Hospital variation in readmissions and visits to the emergency department following ileostomy surgery. J Gastrointest Surg 2020; 24 (11) 2602-2612
• 8 Chang YW, Davenport D, Dugan A, Patel JA. Significant morbidity is associated with proximal fecal diversion among high-risk patients who undergo colectomy: a NSQIP analysis. Am J Surg 2020; 220 (04) 830-835
• 9 Chapman Jr WC, Subramanian M, Jayarajan S. et al. First, do no harm: rethinking routine diversion in sphincter-preserving rectal cancer resection. J Am Coll Surg 2019; 228 (04) 547-556.e8
• 10 Lucha Jr PA, Fticsar JE, Francis MJ. The strictured anastomosis: successful treatment by corticosteroid injections–report of three cases and review of the literature. Dis Colon Rectum 2005; 48 (04) 862-865
• 11 Bhama AR, Maykel JA. Diagnosis and management of chronic anastomotic leak. Clin Colon Rectal Surg 2021; 34 (06) 406-411
• 12 Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M. Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg 1998; 85 (03) 355-358
• 13 Bertelsen CA, Andreasen AH, Jørgensen T, Harling H. Danish Colorectal Cancer Group. Anastomotic leakage after anterior resection for rectal cancer: risk factors. Colorectal Dis 2010; 12 (01) 37-43
• 14 Aicher BO, Hernandez MC, Betancourt-Ramirez A. et al. Colorectal resection in emergency general surgery: an EAST multicenter trial. J Trauma Acute Care Surg 2020; 89 (06) 1023-1031
• 15 McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 2015; 102 (05) 462-479
• 16 Slieker JC, Komen N, Mannaerts GH. et al. Long-term and perioperative corticosteroids in anastomotic leakage: a prospective study of 259 left-sided colorectal anastomoses. Arch Surg 2012; 147 (05) 447-452
• 17 Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg 2010; 252 (02) 325-329
• 18 Telem DA, Chin EH, Nguyen SQ, Divino CM. Risk factors for anastomotic leak following colorectal surgery: a case-control study. Arch Surg 2010; 145 (04) 371-376 , discussion 376
• 19 Makary MA, Segev DL, Pronovost PJ. et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010; 210 (06) 901-908
• 20 Joseph B, Zangbar B, Pandit V. et al. Emergency general surgery in the elderly: too old or too frail?. J Am Coll Surg 2016; 222 (05) 805-813
• 21 Dressler JA, Shah N, Lueckel SN, Cioffi Jr WG. Predicting anastomotic leak after elective colectomy: utility of a modified frailty index. Dis Colon Rectum 2022; 65 (04) 574-580
• 22 Browne IL, Mahsin M, Drolet S, Buie WD, Heine JA, MacLean AR. Self-expanding metal stents do not adversely affect long-term outcomes in acute malignant large-bowel obstruction: a retrospective analysis. Dis Colon Rectum 2022; 65 (02) 228-237
• 23 Forloni B, Reduzzi R, Paludetti A, Colpani L, Cavallari G, Frosali D. Intraoperative colonic lavage in emergency surgical treatment of left-sided colonic obstruction. Dis Colon Rectum 1998; 41 (01) 23-27
• 24 Reshef A, Stocchi L, Kiran RP. et al. Case-matched comparison of perioperative outcomes after surgical treatment of sigmoid diverticulitis in solid organ transplant recipients versus immunocompetent patients. Colorectal Dis 2012; 14 (12) 1546-1552
• 25 Lee JT, Skube S, Melton GB. et al. Elective colectomy for diverticulitis in transplant patients: is it worth the risk?. J Gastrointest Surg 2017; 21 (09) 1486-1490
• 26 Lee JT, Dunn TB, Sirany AM, Melton GB, Madoff RD, Kwaan MR. Colorectal surgery after kidney transplantation: characteristics of early vs. late posttransplant interventions. J Gastrointest Surg 2014; 18 (07) 1299-1305
• 27 de'Angelis N, Esposito F, Memeo R. et al. Emergency abdominal surgery after solid organ transplantation: a systematic review. World J Emerg Surg 2016; 11 (01) 43
• 28 Hall J, Hardiman K, Lee S. et al; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum 2020; 63 (06) 728-747