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Fundamentals of Rectal Cancer SurgeryFundamentals of Rectal Cancer Surgery

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Indications for Fecal Diversion

Indications for Fecal Diversion is a topic covered in the Fundamentals of Rectal Cancer Surgery.

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Anastomotic leak remains one of the most dreaded complications after restorative rectal surgery. It is widely accepted that proximal diversion with an ileostomy or colostomy reduces the clinical significance of postoperative anastomotic leaks.

No absolute indications for proximal diversion currently exist, but the most commonly accepted risk factors for postoperative leak are as follows:[1],[2]

  • Comorbid conditions of the patients (e.g., cardiac disease, diabetes mellitus)
  • Level of the anastomosis (the lower the level, the higher the risk)
  • Male sex
  • Prior pelvic radiotherapy
  • Smoking history
  • Technical mishaps with the anastomosis (e.g., incomplete stapler donut/ring, positive air leak test, need for reinforcing sutures, multiple stapler firings during a minimally invasive proctectomy)

A randomized trial of rectal cancer patients undergoing anastomoses < 8cm from the anal verge demonstrated a leak rate of 5.8% in the stoma group, versus a leak rate of 16.3% in the no stoma group (p=0.04).[3] In this study, male gender and lack of stoma usage were associated with anastomotic leakage when they employed multivariate analysis. Of note, use of radiochemotherapy, anastomotic height and body mass index were not found to be associated with the development of anastomotic leak.

The use of drains for low pelvic anastomoses is highly controversial. A recent systematic review on the use of prophylactic pelvic drainage after low anterior resection suggests no obvious benefit in regard to reduction in leak rate or overall complications. However, the study did note a reduction in the mortality rate of the drained group.[4] It is notable that the data quality in this area is overall relatively poor quality, and a well-designed multicenter trial with uniform inclusion criteria for patients undergoing low anterior resection to better study this question would be useful.

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Anastomotic leak remains one of the most dreaded complications after restorative rectal surgery. It is widely accepted that proximal diversion with an ileostomy or colostomy reduces the clinical significance of postoperative anastomotic leaks.

No absolute indications for proximal diversion currently exist, but the most commonly accepted risk factors for postoperative leak are as follows:[1],[2]

  • Comorbid conditions of the patients (e.g., cardiac disease, diabetes mellitus)
  • Level of the anastomosis (the lower the level, the higher the risk)
  • Male sex
  • Prior pelvic radiotherapy
  • Smoking history
  • Technical mishaps with the anastomosis (e.g., incomplete stapler donut/ring, positive air leak test, need for reinforcing sutures, multiple stapler firings during a minimally invasive proctectomy)

A randomized trial of rectal cancer patients undergoing anastomoses < 8cm from the anal verge demonstrated a leak rate of 5.8% in the stoma group, versus a leak rate of 16.3% in the no stoma group (p=0.04).[3] In this study, male gender and lack of stoma usage were associated with anastomotic leakage when they employed multivariate analysis. Of note, use of radiochemotherapy, anastomotic height and body mass index were not found to be associated with the development of anastomotic leak.

The use of drains for low pelvic anastomoses is highly controversial. A recent systematic review on the use of prophylactic pelvic drainage after low anterior resection suggests no obvious benefit in regard to reduction in leak rate or overall complications. However, the study did note a reduction in the mortality rate of the drained group.[4] It is notable that the data quality in this area is overall relatively poor quality, and a well-designed multicenter trial with uniform inclusion criteria for patients undergoing low anterior resection to better study this question would be useful.

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Last updated: September 20, 2021

Citation

"Indications for Fecal Diversion." Fundamentals of Rectal Cancer Surgery, 2021. ASCRS U, www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831019/all/Indications for Fecal Diversion.
Indications for Fecal Diversion. Fundamentals of Rectal Cancer Surgery. 2021. https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831019/all/Indications for Fecal Diversion. Accessed March 21, 2023.
Indications for Fecal Diversion. (2021). In Fundamentals of Rectal Cancer Surgery https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831019/all/Indications for Fecal Diversion
Indications for Fecal Diversion [Internet]. In: Fundamentals of Rectal Cancer Surgery. ; 2021. [cited 2023 March 21]. Available from: https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831019/all/Indications for Fecal Diversion.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Indications for Fecal Diversion ID - 2831019 Y1 - 2021/09/20/ BT - Fundamentals of Rectal Cancer Surgery UR - https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831019/all/Indications for Fecal Diversion DB - ASCRS U DP - Unbound Medicine ER -
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Grapherence® [↑4]
    • Fundamentals of Rectal Cancer Surgery
    • Background
    • Rectal Anatomy
    • Rectal Cancer Biology and Hereditary Cancer Syndromes
    • Rationale for Multi-Modality Therapy
    • Preoperative Issues
    • Preoperative Staging
    • Role of Tumor Board
    • Indications for Preoperative Neoadjuvant Therapy
    • Local Excision
    • Indications for LAR Versus Intersphincteric Resection Versus APR
    • Indications for Extended Resection
    • Preoperative Preparation
    • Interoperative
    • Patient Positioning and Equipment for Rectal Cancer Surgery
    • Inferior Mesenteric Artery
    • Inferior Mesenteric Vein (IMV)
    • Splenic Flexure Mobilization
    • Surgical Techniques for Length
    • Technique of Total Mesorectal Excision (TME)
    • Tailored Mesorectal Excision (TME)
    • Bowel Transection and Anastomosis
    • Indications for Fecal Diversion
    • Abdominoperineal Resection
    • Standardized Operative Report
    • Management of Intraoperative Vascular and Urinary Complications
    • Postoperative Issues
    • Rectal Cancer Pathology Assessment
    • Adjuvant Therapy for Rectal Adenocarcinoma
    • Surveillance After Rectal Cancer Treatment
    • Management of Local Recurrences
    • Short-Term Complications - Anastomotic
    • Short-Term Complications - Urinary
    • Ostomy Complications and Management
    • Long-Term Complications – Bowel Dysfunction
    • Long-Term Complications - Sexual Dysfunction and Its Management
    • Parastomal and Perineal Hernias
    • Impact of Postoperative Complications On Oncologic Outcomes
    • Course Complete
    • Final Assessment
Grapherence® [↑4]
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Related Topics

  • Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula
  • Intestinal Stomas
  • Anastomotic Complications
  • Indications for LAR Versus Intersphincteric Resection Versus APR
  • Short-Term Complications - Anastomotic
  • Treatment of Left-Sided Colonic Diverticulitis
  • Complications of the Pelvic Pouch
  • Benign Colorectal Disease Trauma of the Colon and Rectum
  • Management of Rectal Cancer
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