Limiting the indications for preventive ileostomy in rectal resections: single-center retrospective study

Background. Temporary intestinal stoma reduces the risk of life-threatening complications in the early postoperative period. However, psychological stress related to the stoma and the need for repeat surgical intervention necessitate the search for ways to narrow the indications for this procedure.

Aim. To evaluate the safety of a strategy designed to restrict indications for preventive intestinal stoma formation after rectal resections.

Materials and methods. The study included patients over 18 years of age who underwent rectal resections for various indications between 2017 and 2026. Patients were divided into 2 groups. Before 2019 (1^st group), routine mobilization of the splenic flexure was not performed; an end-to-end (predominantly) or side-to-end stapled anastomosis was created at the operating surgeon’s discretion, or a primary coloanal anastomosis was performed for low rectal tumors. A preventive ileostomy was selectively created based on the presence of risk factors, at the operating surgeon’s discretion. From 2020 (2^nd group), routine mobilization of the splenic flexure of the colon, mandatory creation of a side-to-end stapled anastomosis, or a hand-sewn two-stage Turnbull–Cutait pull-through coloanal anastomosis were introduced into practice, allowing for narrower indications for preventive ileostomy creation. The primary endpoint of the study was the incidence of anastomotic leak. Secondary endpoints included the overall complication rate, postoperative mortality, operative time, blood loss, and the rate of preventive intestinal stoma formation.

Results. A total of 300 patients were included in the study: 76 in the 1^st group and 224 in the 2^nd group. The overall rate of grade IIIB–IV complications was 12 (15.8 %) in the group operated on before 2020, and 7 (3.1 %) in the group operated on after 2020 (р <  0.001). In the 1^st group, preventive ileostomies were created in 3 (7.9 %) patients after partial mesorectal excision, 9 (50 %) after total mesorectal excision, and 14 (100 %) after ultra-low rectal resection with coloanal anastomosis. Anastomotic leakage developed in 3 (21.4 %) patients after ultra-low rectal resection with coloanal anastomosis, and in 5 (27.8 %) after rectal resections. Among those in the 2^nd group, preventive ileostomies were created in 1 (0.8 %) patient after partial and in 7 (13.7 %) patients after total mesorectal excision. Anastomotic leakage developed in 1 (0.8 %) patient who underwent partial mesorectal excision, 4 (7.8 %) patients after low anterior rectal resection, and 2 (3.9 %) patients after the Turnbull–Cutait procedure. After multivariate analysis, the following factors for anastomotic leakage were identified: the decision to create a preventive ileostomy (hazard ratio (HR) 9.463; 95% confidence interval (CI) 1.137–78.761; p = 0.038), chemoradiotherapy (HR 9.283; 95% CI 1.112–77.514; p = 0.04), American Society of Anesthesiologists classification score III or higher (HR 10.093; 95% CI 1.888–53.945; p = 0.007), and blood loss over 100 mL (HR 4.889; 95% CI 1.016–23.531; p = 0.048).

Conclusion. Standardization of surgical approaches for rectal cancer treatment, including routine mobilization of the splenic flexure, creation of a side-to-end anastomosis, and the use of the Turnbull–Cutait operation for ultra-low resections, allows for a reduction in the preventive intestinal stoma formation rate without increasing the risk of severe postoperative complications. Meticulous monitoring of the patient’s condition in the postoperative period is an essential requirement.