Is an ileostomy (ileostomy) part of Low Anterior Resection (LAR) surgery?

Temporary Ileostomy is a Standard Component of Low Anterior Resection Surgery for Rectal Cancer

A temporary diverting ileostomy is commonly performed as part of low anterior resection (LAR) surgery to reduce the severity of complications from potential anastomotic leakage, though it is not mandatory in all cases. 1

Role of Temporary Ileostomy in LAR

Purpose and Benefits

• Temporary diverting ileostomy is performed to decrease the severity of septic complications associated with anastomotic leakage (AL) in high-risk anastomoses
• It reduces the reoperation rate in case of anastomotic leakage 1
• The primary goal is not to prevent leakage but to mitigate its consequences

Indications for Ileostomy Creation

A diverting ileostomy should be strongly considered in:

• Low rectal cancer requiring low anastomosis (especially distal/ultralow anastomoses) 1, 2
• Cases requiring total mesorectal excision (TME) 2
• Patients receiving neoadjuvant treatments 1
• Patients with higher BMI 1
• Elderly patients with risk factors for anastomotic leakage:
  • Number of stapler firings ≥3
  • Coronary artery disease 1
• Patients on steroids ≥20 mg daily for >6 weeks or anti-TNF therapy 3

Evidence on Ileostomy in LAR

Anastomotic Leakage Risk

• Anastomotic leakage is a severe complication after rectal resection with incidence between 2.0-10.3%, with peaks up to 25% 1
• A diverting stoma does not prevent anastomotic leakage but reduces its consequences 4
• When a diverting ileostomy is planned, mechanical bowel preparation may be necessary 1

Impact on Quality of Life

• Temporary ileostomy is associated with decreased quality of life:
  • Reduced physical and role functioning before ileostomy closure 5
  • Quality of life generally improves after ileostomy closure 5
  • Ileostomy-related morbidity rates range from 2.9% to 62.2% 1

Long-term Outcomes

• Approximately 1 in 6 patients (14-17%) with temporary ileostomy will end up with a permanent stoma 6
• Clinical anastomotic leakage is the most common cause for conversion to permanent stoma 6
• A diverting loop ileostomy is associated with longer total hospital stay during a 3-year follow-up 6

Timing of Ileostomy Closure

Early vs. Delayed Closure

• Early closure (within 2 weeks) is recommended for selected elderly fit patients 1
• Early closure is associated with:
  • Lower incidence of postoperative small bowel obstruction
  • Fewer stoma-related complications
  • Better functional outcomes
  • Relatively higher surgical site infection rate compared to late closure 1

Considerations for Closure Timing

• Morbidity rates increase with time to ileostomy closure 1
• Dehydration or renal failure following diverting ileostomy is common in elderly patients with metabolic disorders (17-30% readmission rate) 1
• Diverting ileostomy during adjuvant chemotherapy can lead to severe chemotherapy-induced diarrhea 1

Technical Considerations

Stoma Placement

• Stoma can be created through the specimen extraction site or through a new site
• Using the specimen extraction site may:
  • Shorten operation time
  • Reduce wound infection rate
  • Potentially have higher (though not statistically significant) stoma-related complications 7

Pitfalls and Caveats

1. Don't assume ileostomy prevents leakage: It mitigates consequences but doesn't prevent the leak itself 4

2. Consider patient-specific factors: Not all patients require diversion; selective approach based on risk factors is appropriate 2, 4

3. Plan for stoma care resources: Patients with temporary ileostomy require increased resources for stoma therapy 5

4. Monitor for stoma-related complications: Including skin irritation, parastomal hernias, stomal prolapse/retraction, and dehydration 1

5. Consider early closure when possible: To reduce morbidity, especially if adjuvant chemotherapy is planned 1

6. Recognize kidney injury risk: Diverting ileostomy in elderly patients is associated with kidney injury risk that may persist even after closure 1