What are the considerations and management strategies for a ghost or virtual (temporary) ileostomy?

Ghost or Virtual Ileostomy: Management Strategy

What is a Ghost Ileostomy?

A ghost (or virtual) ileostomy is a pre-stage protective technique where a terminal ileal loop is isolated, marked with a vessel loop or tape brought through the abdominal wall, and left in situ—allowing rapid conversion to a functioning loop ileostomy under local anesthesia if anastomotic leakage occurs, while avoiding an actual stoma in patients who heal uneventfully. 1, 2

Primary Indication

• Ghost ileostomy is specifically designed for patients at medium/borderline risk of anastomotic leakage following low anterior rectal resection, where the decision to create a routine protective stoma is uncertain 3, 4
• This technique allows surgeons to avoid creating an actual stoma in approximately 90-95% of patients who do not develop anastomotic complications 3

Technical Execution

Intraoperative Steps:

• Identify the terminal ileum after completing the colorectal anastomosis 1
• Create a window in the adjacent mesentery of the ileal loop 1
• Pass an elastic vessel loop or tape around the isolated ileal segment 1, 2
• Bring the tape out through a right iliac fossa port site (typically 5mm incision) 1
• Secure the tape to the abdominal wall with nonabsorbable sutures, ensuring the loop can be easily identified and exteriorized later 1
• Consider placing a transanal drainage tube for 5-7 days to decompress the anastomosis 1, 4

Critical Technical Points:

• The ileal loop must be adequately mobilized to reach the abdominal wall without tension 2
• Mark the site clearly on the skin to facilitate future conversion if needed 2
• Ensure mesenteric window is large enough to prevent vascular compromise but small enough to prevent internal herniation 1

Postoperative Surveillance Protocol

Intensive monitoring for anastomotic leakage is mandatory when using ghost ileostomy:

• Monitor inflammatory markers (CRP, WBC) daily for the first 5-7 postoperative days to detect subclinical leakage 4
• Perform clinical assessment for fever, tachycardia, abdominal pain, or peritoneal signs 4
• Consider CT imaging with rectal contrast if clinical suspicion of leak exists 3
• Remove the vessel loop/tape at 10-14 days postoperatively if no complications occur, allowing the ileal loop to drop back into the abdomen 1, 3

Conversion to Functioning Ileostomy

If anastomotic leakage is detected:

• The ghost ileostomy can be converted to a functioning loop ileostomy under local anesthesia with sedation, avoiding general anesthesia and laparotomy 2, 3
• Extend the right iliac fossa incision, exteriorize the marked ileal loop, and open it to create a diverting stoma 2
• This conversion can be performed at bedside or in a minor procedure room 2
• Conversion rates range from 5-10% in published series 3

Advantages Over Routine Loop Ileostomy

Quality of life and morbidity benefits:

• Avoids stoma-related complications in 90-95% of patients including dehydration, electrolyte imbalance, skin excoriation, parastomal hernia, prolapse, retraction, and necrosis 1, 3
• Eliminates the need for a second operation (ileostomy reversal) in patients without anastomotic leakage, avoiding closure-related complications (wound infection, small bowel obstruction, anastomotic leak at closure site) 5, 3
• Preserves patient quality of life by avoiding actual stoma in the majority 3, 2
• Reduces overall healthcare costs by eliminating stoma supplies and reversal surgery 1

When anastomotic leakage does occur:

• Patients with ghost ileostomy converted to functioning stoma experience lower severity of leakage complications compared to those without any protective measure 3
• None of the patients with ghost ileostomy who developed leakage required laparotomy for leak management in one randomized trial 3
• Shorter hospitalization for leak management compared to unprotected anastomoses 3

Patient Selection Criteria

Ideal candidates for ghost ileostomy:

• Patients undergoing low anterior resection with anastomosis <6-8 cm from anal verge 1, 3
• Medium/borderline risk for anastomotic leakage, defined as having some but not all high-risk features 3, 4
• Hemodynamically stable patients with good tissue perfusion 4
• Adequate bowel preparation and no intraoperative complications 4

Patients who should receive conventional loop ileostomy instead:

• High-risk patients with multiple risk factors for anastomotic leakage including: severe malnutrition, high-dose steroids/immunosuppression, intraoperative hypotension, poor tissue perfusion on fluorescence angiography, tension on anastomosis, or fecal contamination 4, 6
• Patients with questionable anastomotic integrity at time of surgery 4

Risk Mitigation Strategies to Optimize Ghost Ileostomy Success

The following intraoperative techniques reduce anastomotic leakage risk and make ghost ileostomy safer 4:

• Mobilize the splenic flexure to ensure tension-free anastomosis 4
• Minimize pelvic bleeding and achieve meticulous hemostasis 4
• Use appropriate stapler cartridge height (consider thicker cartridges if neoadjuvant chemoradiotherapy was administered) 4
• Perform horizontal (perpendicular) rectal transection rather than oblique 4
• Assess anastomotic perfusion with indocyanine green fluorescence angiography and revise if inadequate 4
• Consider side-to-end anastomotic configuration 4
• Perform intraoperative methylene blue or air leak test to confirm anastomotic integrity 4
• Place both pelvic drain and transanal drainage tube 4

Evidence Quality and Limitations

• The ghost ileostomy technique is supported by small randomized controlled trials and case series 3, 5, not large-scale multicenter trials
• The GHOST trial (ongoing randomized controlled pilot study) is comparing ghost ileostomy versus conventional loop ileostomy with comprehensive complication index as primary outcome 5
• Current evidence shows safety and feasibility but comes from specialized centers with laparoscopic expertise 3, 1
• Patient selection criteria and conversion thresholds are not standardized across studies 4, 3

Critical Pitfalls to Avoid

• Do not use ghost ileostomy in truly high-risk patients—these patients need conventional protective ileostomy from the outset 4, 6
• Do not remove the vessel loop/tape before 10 days postoperatively, as most anastomotic leaks manifest within this timeframe 1, 3
• Do not use ghost ileostomy without intensive postoperative surveillance protocol—delayed recognition of anastomotic leak defeats the purpose 4
• Do not create excessive tension on the ileal loop when bringing the tape through the abdominal wall, as this can cause vascular compromise 1
• Do not use this technique if you lack experience with loop ileostomy creation, as you must be able to rapidly convert if needed 2

Context: Not Applicable to Emergency Settings

Note that the ghost ileostomy technique described above is for elective colorectal surgery. In emergency settings with perforation, obstruction, or hemodynamic instability, World Journal of Emergency Surgery guidelines recommend conventional stomas (end ileostomy, loop ileostomy, or colostomy) depending on the clinical scenario 6. Ghost ileostomy is not appropriate for damage control surgery or unstable patients 6.