Is a Diverting Stoma Always Necessary for a Low Anterior Resection in Rectal Cancer?

  • Claudio Coco
  • Gianluca Rizzo


Anterior resection with total mesorectal excision is the standard operation for rectal cancer. The coloanal or colorectal anastomosis represents the critical step of this surgical procedure, with a risk of leakage between 3% and 27%. The occurrence of anastomotic leakage significantly increases the rate of early postoperative morbidity and mortality and also seems to negatively influence the long-term functional and oncological outcomes. Even if several features were evaluated as risk factors for leakage, the incidence of this adverse event cannot be totally avoided by a diverting stoma. Nevertheless, the creation of a diverting stoma can significantly reduce the clinical consequences of anastomotic leakage, improving the postoperative outcome. On the other hand, the creation and subsequent management of a stoma is burdened by complications, such as poor stoma location, prolapse, stenosis, peristomal dermatitis, dehydration, and peristomal hernia. Loop ileostomy may be a simpler management strategy with a lower rate of complications than a loop colostomy. The diverting stoma is generally closed after approximately 1 month from the anterior resection, but some authors have counseled a longer waiting period to reduce the risk of a late anastomotic leak and postoperative morbidity secondary to stoma closure. To reduce the morbidity of a stoma and achieve the same benefits of a diverting stoma, a ghost ileostomy has been proposed, but its utility is still unclear.


  1. 1.
    Anderin K, Gustafsson UO, Thorell A et al (2015) The effect of diverting stoma on postoperative morbidity after low anterior resection for rectal cancer in patients treated within an ERAS program. Eur J Surg Oncol 41:724–730CrossRefPubMedGoogle Scholar
  2. 2.
    Chen J, Zhang Y, Jiang C et al (2013) Temporary ileostomy versus colostomy for colorectal anastomosis: evidence from 12 studies. Scand J Gastroenterol 48:556–562CrossRefPubMedGoogle Scholar
  3. 3.
    Coco C, Valentini V, Manno A et al (2007) Functional results after radiochemotherapy and total mesorectal excision for rectal cancer. Int J Color Dis 22:903–910CrossRefGoogle Scholar
  4. 4.
    Cong ZJ, Hu LH, Bian ZQ et al (2013) Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer. PLoS One 8:e75519CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    den Dulk M, Marijnen CA, Collette L et al (2009) Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg 96:1066–1075CrossRefGoogle Scholar
  6. 6.
    Gu WL, Wu SW (2015) Meta-analysis of defunctioning stoma in low anterior resection with total mesorectal excision for rectal cancer: evidence based on thirteen studies. World J Surg Oncol 13:9CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Güenaga KF, Lustosa SA, Saad SS et al. (2007) Ileostomy or colostomy for temporary decompression of colorectal anastomosis. Cochrane Database Syst Rev (1):CD004647Google Scholar
  8. 8.
    Gullà N, Trastulli S, Boselli C et al (2011) Ghost ileostomy after anterior resection for rectal cancer: a preliminary experience. Langenbeck’s Arch Surg 396:997–1007CrossRefGoogle Scholar
  9. 9.
    Jestin P, Påhlman L, Gunnarsson U (2008) Risk factors for anastomotic leakage after rectal cancer surgery: a case-control study. Color Dis 10:715–721CrossRefGoogle Scholar
  10. 10.
    Kang CY, Halabi WJ, Chaudhry OO et al (2013) Risk factors for anastomotic leakage after anterior resection for rectal cancer. JAMA Surg 148:65–71CrossRefPubMedGoogle Scholar
  11. 11.
    Leahy J, Schoetz D, Marcello P et al (2014) What is the risk of clinical anastomotic leak in the diverted colorectal anastomosis? J Gastrointest Surg 18:1812–1816CrossRefPubMedGoogle Scholar
  12. 12.
    Matthiessen P, Hallböök O, Andersson M et al (2004) Risk factors for anastomotic leakage after anterior resection of the rectum. Color Dis 6:462–469CrossRefGoogle Scholar
  13. 13.
    Matthiessen P, Hallböök O, Rutegård J et al (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–214CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Miccini M, Amore Bonapasta S et al (2010) Ghost ileostomy: real and potential advantages. Am J Surg 200:e55–e57CrossRefPubMedGoogle Scholar
  15. 15.
    Mirnezami A, Mirnezami R, Chandrakumaran K et al (2011) Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 253:890–899CrossRefPubMedGoogle Scholar
  16. 16.
    Mongin C, Maggiori L, Agostini J et al (2014) Does anastomotic leakage impair functional results and quality of life after laparoscopic sphincter-saving total mesorectal excision for rectal cancer? A case-matched study. Int J Color Dis 29:459–467CrossRefGoogle Scholar
  17. 17.
    Montedori A, Cirocchi R, Farinella E et al. (2010) Covering ileo- or colostomy in anterior resection for rectal carcinoma. Cochrane Database Syst Rev (5):CD006878Google Scholar
  18. 18.
    Mori L, Vita M, Razzetta F et al (2013) Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile? Dis Colon Rectum 56:29–34CrossRefPubMedGoogle Scholar
  19. 19.
    Qin C, Ren X, Xu K, Chen Z et al (2014) Does preoperative radio(chemo)therapy increase anastomotic leakage in rectal cancer surgery? A meta-analysis of randomized controlled trials. Gastroenterol Res Pract 2014:910956CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Rahbari NN, Weitz J, Hohenberger W et al (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the international study Group of Rectal Cancer. Surgery 147:339–351CrossRefPubMedGoogle Scholar
  21. 21.
    Rondelli F, Reboldi P, Rulli A et al (2009) Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a meta-analysis. Int J Color Dis 24:479–488CrossRefGoogle Scholar
  22. 22.
    Shellito PC (1998) Complications of abdominal stoma surgery. Dis Colon Rectum 41:1562–1572CrossRefPubMedGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 2018

Authors and Affiliations

  1. 1.Department of General SurgeryCatholic University of Sacred HeartRomeItaly
  2. 2.Fondazione Policlinico Gemelli - Presidio Columbus, U.O.C. Chirurgia GeneraleRomeItaly

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