Keywords
ghost Ileostomy - ghost Ileostomy release down - low anterior resection - carcinoma
rectum
Introduction
Colorectal cancer is the disease with a major worldwide burden in terms of patient
sufferings and cost of treatment. Total mesorectal excision (TME) is the gold standard
treatment for rectal cancer, with better overall survival and fewer distant and local
recurrences.[1]
[2]
[3] The sphincter-preserving low anterior resection (LAR) or ultra-low anterior resection
(uLAR) are now considered the standard operations for rectal cancer, which allows
a primary anastomosis to be created at a lower level.[4]
Recently, the frequency of abdominoperineal resection and the resulting permanent
stomas for rectal cancer has diminished in favor of sphincter-preserving operations.[5] Anastomotic leak (AL) still remains the most significant complication after LAR
with TME. Protective stoma is often constructed after LAR for carcinoma rectum to
prevent AL, with the hope that by diverting the fecal stream and keeping the anastomosis
free of fecal material, leakage will be less likely. Whether a malfunctioning stoma
really prevents leaks or merely reduces the consequence of leakage is still up for
debate.
There is no clear-cut agreement regarding whether a malfunctioning stoma should be
constructed for all rectal anastomoses, only for the low ones, or not at all. Several
studies have demonstrated that a malfunctioning stoma decreases the incidence of clinical
leakage of a colorectal anastomosis.[6]
[7] Some authors, however, have reported no difference in leakage rates but with a reduced
incidence of reoperation,[8] and still other surgeons have reported that covering with protective stoma had no
influence on AL and reoperation rates. Furthermore, the complications that can be
caused by the stoma itself should not be ignored.[9]
[10]
[11]
[12]
[13]
[14]
[15] In fact, some studies have reported that reversal of the stoma is associated with
complications in up to 40% of patients.[16] Many patients will have to live with a covering stoma for several months after primary
surgery because of the low clinical priority for reversal,[17] and about 20% of patients are left with a permanent stoma due to postoperative complications
of anterior resection.[18]
In short, patients in high-risk group for AL would benefit from stoma protection,
while patients in low-risk group simply do not require stoma. However, in patients
with a medium-risk of AL, it is very difficult to decide whether or not to construct
a protective covering stoma. In the intermediate-risk patients, the concept of ghost
ileostomy (GI), also known as prestage or virtual ileostomy, integrates the advantages
of a covering ileostomy (CI) while avoiding its complications in patients subjected
to low rectal resection.[19] This procedure is just a prestage ileostomy that at any time can be externalized
and opened. In case of clinical and radiological AL, the GI is matured to complete
the CI in order to divert the fecal stream from the anastomotic site leakage. However,
in case of uneventful postoperative course, GI prevents all complications related
to malfunctioning ileostomy.[20]
Many publications concluded that the creation of GI in LAR averts the need for formal
CI in more than 80% of carcinoma rectum patients.[21]
[22] However, none of the papers describe exactly how to ultimately remove or release
the GI in these 80% of patients to whom the GI doesn't need formal maturation. Furthermore,
almost none of the published literature describes the outcome of the release down
of GI. In this article, we also intend to explain in a simple and lucid way the release
down of GI technique, along with our initial experience with this procedure.
Objectives
To describe and evaluate the ghost ileostomy release down (GIRD) technique in terms
of feasibility, complications, hospital stay, procedure time etc. in patients with
LAR/uLAR with GI for carcinoma rectum.
Material and Methods
This study was carried out from November 2016 to August 2018 at a Tertiary Care Hospital
in North India. The patients were included in this study only after obtaining a proper
informed consent for the same from all the included patients. It was a prospective
cohort study of restorative colorectal resections (LAR and ultra-LAR) for carcinoma
rectum. Our cohort included carcinoma rectum patients who underwent restorative colorectal
resections with ghost (prestage/virtual) ileostomy. Before the surgical procedure,
all patients were evaluated with detailed history and physical examination and the
diagnosis and the stage of disease were confirmed by preoperative colonoscopic biopsy,
carcinoembryonic antigen (CEA) levels, contrast-enhanced computed tomography (CECT)
of the abdomen/pelvis and chest, and magnetic resonance imaging (MRI) of the pelvis.
Regarding the procedure of GI takedown the parameters noted were the easiness of procedure,
any procedural difficulty, any intra- or postprocedure complications, procedure time
etc.
Patients with rectal cancer stages I to IIIC, according to the American Joint Committee
on Cancer's standards for rectal cancer, were included in the study.[23] Carcinoma rectum patients of all age groups and both sexes, operated in elective
settings, were included. Alternately, the patients operated in emergency settings
having acute bowel obstruction, perforation, and peritonitis, taking immunosuppressant
drugs, with stage IV disease, and severe hypoalbuminaemia (serum albumin ˂2.5g/dl)
were excluded from the study. Additionally, the patients with formal CI or with no
stoma, those requiring restorative colorectal resections for benign diseases, as well
as carcinoma rectum patients with underlying FAP requiring TPC with IPAA were not
included. The GI patients having postoperative anastomotic leak and requiring its'
maturation were also excluded from this study.
Technique of Release Down of Ghost Ileostomy
All carcinoma rectum patients in this study underwent TME resection (LAR/uLAR) with
an adequate circumferential resection margin (CRM), distal and proximal margins followed
by colorectal/coloanal end-to-end or end-to-side anastomosis using the circular staplers
or hand sewn techniques. After the completion of anastomosis, protective GIs were
fashioned. In restorative rectal resections, this process averts the necessity and
complications of formal CI in more than 80% of carcinoma rectum patients.
However, GI needs to be released down before discharging patients after surgery. Usually,
a 10 to 12 Fr Ryle tube or Foley catheter is used for securing the GI loop. The removal
of this hanging Ryle tube loop (or any other hanging material) from the abdominal
cavity in order to release the tucked ileal loop is referred to as 'release down'
of GI. In this regard, it is necessary to ascertain that the patient does not have
any anastomotic leak (AL) before performing the GIRD. After confirming by clinical
and radiological assessments that there is no AL, the tubing needs to be removed from
the abdominal cavity ([Figs. 1] and [2]). Preferably, it should be done after 10th postoperative day (POD); after ensuring that there are no complications and the bowel
movements are normal. The 'release down' of GI can be done as described in following
steps:
Fig. 1 Final external appearance of ghost ileostomy.
Fig. 2 Final internal appearance of ghost ileostomy.
-
Keep the patient in supine position on their bed in the postoperative ward.
-
Uncover the area of GI (usually the right iliac fossa region), taking care to maintain
their privacy.
-
Gain the patient's confidence for your procedure by giving reassurances, explaining
the procedure to them, and seeking consent to proceed.
-
After donning the sterile surgical gloves, apply betadine paint on the GI tubing and
the skin around it ([Fig. 3]). There is no need of use of any local anesthetic agent.
-
Cut the fixing suture of the GI tube to free it from the surrounding skin ([Fig. 4]).
-
Slightly pull both limbs of the tubing ([Fig. 5]) and cut one limb with the help of scissors deeper to the skin level ([Figs. 6] and [7]).
-
Slightly dip the cut end of the tubing loop into the peritoneal cavity with the help
of a forceps ([Fig. 8]).
-
Now gently pull the other end of the tubing from the abdominal cavity to release down
the already tucked ileal loop ([Fig. 9]).
-
Clean the wound area and apply a small antiseptic dressing ([Fig. 10]). At the end of the procedure, again reassure the patient and congratulate them
on being free from the miseries and morbidities of formal covering stoma.
Fig. 3 Bed-side part preparation around the ghost ileostomy tubing.
Fig. 4 Cutting the fixing suture around the ghost ileostomy tubing.
Fig. 5 Slightly pull out the tubing.
Fig. 6 Cut one limb of tubing with scissors.
Fig. 7 One limb of tubing has been cut.
Fig. 8 Gently dip down the cut end of the tubing with the help of forceps.
Fig. 9 Ghost Ileostomy tubing completely pulled out of the abdominal cavity.
Fig. 10 Final scar (10th POD) of ghost ileostomy.
Postprocedure, patients were observed for any complications, morbidity, and mortality,
and were followed in the outpatient department, initially weekly and then fortnightly
for 1 month.
Statistical Analysis
The data was compiled; statistically analyzed and the inferences were drawn from the
results of the statistical analysis.
Results
During this approximately 2-year study period and after excluding the patients as
described in exclusion criteria in the methods section, a total of 33 patients underwent
LAR/uLAR with GI for carcinoma rectum. Out of these patients, 6 (18%) needed maturation
(exteriorization) of GI to create a formal loop ileostomy in view of postoperative
anastomotic leak. One patient developed paroxysmal supraventricular tachycardia (PSVT)
and cardiopulmonary arrest on zero POD and died after undergoing resuscitation techniques
and mechanical ventilation.
Therefore, only 26 patients actually needed the release down of GI and were included
in the final statistical analysis of the study. There were slightly more females than
males in this study, with a male to female ratio of 11 to 15. The patients' age ranged
from 19 to 75 years, with an average age of 54.84 years. The body mass index (BMI)
of patients ranged from 19.53 to 33.46 with an average of 26.31kg/m2.
There were 12 patients with ASA grade I, 13 were ASA grade II and 1 was ASA grade
III. The GI in all 26 patients was released down according to the technical steps
described above. The GIRD procedure was done only after patients had shown bowel movement
postoperatively. It was undertaken between 7th to 16th PODs after primary surgery with a mean of 9.75 ± 4.25 days.
For most of the patients (22), the GI was released in the same hospital admission
in which they were operated for carcinoma rectum. In most cases, it was done a day
or so before the patient's discharging from the hospital. However, in some instances
(4), patients' GI were released on their first follow up visits. It was possible to
release the GI successfully in all patients without the need of any added surgical
procedure or incision wound. None of the patients required any local anesthetic injection
or additional analgesics. The average time for procedure duration was 5 minutes, and
none of the patients had any significant difficulty during GI release.
There were no immediate postprocedure complications. No patients complained of any
pain or discomfort during or after the GIRD, even though no local anesthetic solution
was used. The GI tubing didn't get stuck during removal in any patient. There was
no external or internal bleeding at the GI site. There was no significant surgical
site infection (SSI) at the GI tubing site after its removal. After 1-month of follow-up,
the GI tubing site scar was less than the abdominal drain site scar, and no ugly scar
formation was noticed. None of the patients had any intra- or postprocedure peritoneal
or abdominal complications, such as mesenteric bleeding or hematoma formation, mesenteric
injury, mesenteric torsion or intestinal obstruction, GI ileal loop injury, or peritonitis.
Discussion
The potential disadvantages of a protective stoma include the need for 2nd surgery, longer hospital stay, ostomy-related complications and considerable risk
of anastomotic leakage at the time of stoma take-down. Moreover, the creation of stoma
is hardly acceptable to patients and is an added psychological trauma to patients
and care-givers. Therefore, the benefits of a protective stoma in decreasing the rate
of AL must be balanced against the morbidity of its construction and closure.[24] The overall incidence of clinical leak in colorectal anastomosis is 8%. Therefore,
for the majority of patients (92%), the use of covering stoma has minimal or no clinical
usefulness.[25] A recent propensity-matched scoring analysis by Shiomi et al. of about one thousand
patients who underwent low anterior resection confirmed that malfunctioning ileostomy
does not influence the rate of clinical anastomotic leak but does mitigate its consequences,
reducing the need for urgent reoperation.[26]
The GI is relatively a novel concept that bridges out CI to no-ileostomy in LAR. It
comes to the rescue of any operating surgeon who may be indecisive regarding CI. It
is an alternative to CI in low or medium risk patients for AL. In conclusion, if the
anastomosis does not present a risk, but still warrants caution, GI represents the
ideal solution as it entails no additional risk and it can be converted, if needed,
with extreme ease and total safety. In short, GI prevents all complications related
to malfunctioning ileostomy. It is simply a prestage ileostomy that at any time can
be externalized if needed.
The creation of GI in LAR for carcinoma rectum patients combines the advantages of
a CI without entailing its complications. When compared with formal CI, GI is characterized
by shorter recovery, shorter overall hospital stay, lesser degree of total, as well
as anastomosis related to morbidity and higher quality of life of the patient.[20]
[27]
[28]
Many recent publications suggest that the creation of GI after LAR avoids formal CI
in more than 80% of carcinoma rectum patients.[21]
[22]
[29] However, none of the papers describe how to ultimately remove or release down the
GI in the 80% of patients for whom it doesn't need formal maturation. In our study
of 26 patients of restorative resections with GI, we explained in simple and easy
steps how to release down this type of ileostomy.
Furthermore, almost none of the published articles describe the outcome of GIRD procedure.
During our initial experience with this procedure, we found that GIRD is simple, safe,
and quick. It can be done by the patients' bedside, not even needing any local anesthesia
nor any additional analgesics. This procedure was done around the 10th POD and none of our patients had any complication at GI site. Furthermore, none of
our patients had peritoneal or abdominal adversities during or after the procedure.
Gullà et al.[27] carried out a prospective study in 45 patients and made prestage ileostomies in
18 patients (GI group) and protective ileostomies in 27 patients (CS group). The authors
concluded that the GI is feasible, being characterized by shorter recovery, lesser
degree of total, as well as anastomosis-related morbidity and higher quality of life
for patients and caregivers, when compared to covering stoma. Furthermore, they suggested
that GI could be indicated in selected patients that did not present with high risk
factors but still require caution for AL for the low level of colorectal anastomosis.
As such, GI should be evaluated as an alternative to conventional ileostomy. They
also reported that in postoperative courses without complications, in all the GI group,
the closure of GI was executed under local anesthesia on POD 10 to 15 after a negative
contrast enema.[27]
In their study, Ambe et al. (2018) , released the virtual ileostomy between POD 7
and 9, and concluded that in all cases, the postoperative recovery was uneventful.[30]
To report the modified posterior pelvic exenteration technique associated with GI
in the treatment of advanced ovarian cancer, Lago et al.[31] concluded that GI may not only prevent the complications related to malfunctioning
ileostomy but also presents its advantages in case of AL. Furthermore, if the postoperative
course remains uneventful, the GI loop is not removed until discharge from hospital
(i.e. 6th–9th POD). Francesco et al.[32] in their study also concluded that none of the GI patients experienced complications
at the site of the procedure.
Miccini et al.[20] implemented a study of 36 cases of carcinoma rectum, whose patients underwent low
rectal resection and GI. The authors reported that no local complications related
to GI were observed in any of the patients. Furthermore, it was reported that in case
of an uncomplicated postoperative course, GI was removed on POD 10 after a negative
contrast enema. The authors concluded that if the postoperative course proves uneventful
without need of maturation of GI to formal CI, the GI loop can be removed simply by
cutting the tape.
Conclusion
In our initial experience, we concluded that the GIRD is a simple, safe, and quick
procedure done around the 10th POD. It can easily be performed by the patients' bedside without the need of local
anesthesia or analgesics. None of our patients had any complications at the GI's site,
or peritoneal or abdominal adversities during or after the procedure. In conclusion,
if anastomosis does not present a risk, but still warrants caution, GI represents
the ideal solution as it entails no additional risk and it can be released down with
extreme ease and total safety without the need of any postprocedure care.
