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The Water-Holding Procedure for Ensuring Postoperative Continence Prior Restoring Intestinal Continuity

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

A defunctioning stoma can become necessary in a relevant number of patients undergoing gastrointestinal surgery. As a matter of course, patients seek an early closure of the stoma. However, preoperative management of these patients varies and the prediction of continence after stoma removal can become challenging. Patients might be fully continent despite low manometric pressures and vice versa. An easy and reliable way to predict continence after stoma reversal would improve patients’ management and outcome. Although frequently performed in various surgical centers in Germany, there is no published data on the water-holding test. Hence, this is the first study evaluating the role of the test in clinical practice.

Method

We performed a prospective pilot study to evaluate the role of anorectal manometry and the water-holding procedure as a predictor of postoperative continence prior to stoma reversal. Inclusion criteria were a successfully passed water-holding test, any type of fecal diversion and the possibility of restoring intestinal continuity. Preoperative low manometric pressure levels were not an exclusion criteria for stoma reversal. Fifty-two patients with ostomy were consecutively enrolled in this study between October 2013 and February 2016. Anorectal manometry was performed in all patients prior to stoma reversal. After stoma removal, patients were followed-up for 6 months. Postoperative incontinence was determined using the Wexner incontinence score.

Results

A total of 52 patients (38 males, 14 females) were included at an average age of 59 (range 33–83) years. Most frequent indications for intestinal diversion were rectal cancer surgery, IBD-related surgery, or surgery for diverticular disease. Low anterior rectal resection was performed in 17 patients (32.7%), followed by a proctocolectomy in 9 (17.3%), colectomy in 9 (17.3%), and recto-sigmoid resection in 7 patients (13.5%). Median time from stoma creation to reversal was 206 days (range 48–871 days). All patients had successfully passed the standardized water-holding test. At the same time, the majority of patients had low preoperative manometric pressure values and would normally not have been reversed at that point. The median postoperative Wexner incontinence score was at 1.5 (range 0–20), 0.5 (range 0–14), and 0 (range 0–11) at 14, 60, and 180 days after stoma reversal. Low preoperative manometric squeeze and/or resting pressure levels were not associated with a higher postoperative incontinence score at 14, 60, or 180 days after stoma reversal.

Conclusion

A standardized water-holding test can function as an easy and reliable method before stoma reversal to predict sufficient postoperative fecal continence. In case of a sufficient water-holding test despite low manometric pressure levels, the risk for postoperative anal incontinence seems to be low. Preoperative manometric pressure levels do not appear to predict postoperative continence.

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Authors and Affiliations

  1. Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany

    Frank Schwandner, Ulrich Klimars, Michael Gock, Leif Schiffmann, Maria Witte & Ernst Klar

  2. Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany

    Tobias Schiergens, Markus Rentsch & Florian Kühn

Authors
  1. Frank Schwandner
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  2. Ulrich Klimars
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  3. Michael Gock
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  4. Leif Schiffmann
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  5. Maria Witte
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  6. Tobias Schiergens
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  7. Markus Rentsch
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  8. Ernst Klar
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  9. Florian Kühn
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Contributions

F.S. and F.K.: Designed research, conducted clinical study, acquired data, analyzed data, wrote the manuscript. U.K.: Acquired data and analyzed data. M.G., L.S., M.W., E.K.: Acquired data and revised the manuscript critically for important intellectual content. T.S. and M.R. revised the manuscript critically for important intellectual content. All authors revised and approved the manuscript for publication.

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Correspondence to Florian Kühn.

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The authors declared that they have no conflicts of interest.

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Schwandner, F., Klimars, U., Gock, M. et al. The Water-Holding Procedure for Ensuring Postoperative Continence Prior Restoring Intestinal Continuity. J Gastrointest Surg 24, 411–417 (2020). https://doi.org/10.1007/s11605-019-04171-7

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  • DOI: https://doi.org/10.1007/s11605-019-04171-7

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