Protective Stoma

Temporary loop ileostomy or colostomy after LAR is usually considered in order to protect either colo-anal or colorectal anastomosis.

Relative indications for creating protective stoma are:

• very low anastomosis (colo-anal)

• pelvic sepsis

• blood loss leading to chronic anaemia

• poor nutritional status

• obstruction

• perforation of the tumour

• pre-operative chemoradiotherapy

If there is any concern about the integrity of anastomosis, diverting stoma should be made, especially in the case of tension on the suture line.

If the patient has received pre-operative chemora-diotherapy, temporary ileo- or colostomy should be made to enable complete healing of the anastomosis [43].

It is generally believed that now when the stapled technique has been introduced and handsewn anastomosis performed less and less, diverting stoma is avoided more often. It is also believed but not well proven that mechanical suture offers greater confidence of anastomosis than a manual procedure.

Loop ileostomy seems to be easier to perform than transverse protective colostomy. Some Authors find colostomy associated with a higher risk of complications in contrast with others, suggesting that creating and closure of loop diverting ileostomy is safer [44, 45].

The morbidity of ileostomy and colostomy closure, unless decreased, remains an important issue [46]. Some Authors suggest closing the protective stoma during the same hospitalisation, 7 days after the resection. In my opinion, early closure is associated with higher risk of complications even including post-operative mortality. The interval between creation and closure of the stoma should be at least 6-8 weeks. Longer periods between these procedures correspond with better outcomes. Simple closure of the colostomy is safer than resection of the colon in order to close the stoma [43].

During closing of the colostomy, special emphasis should be put on the integrity of marginal artery as it can be the only vessel that supplies blood to the distal colon down to the anastomosis. The consequences of ligation of the vessel are obvious and result in necrosis of the distal colon after anterior resection of the rectum.

One of the most common complications of closure of the stoma (especially colostomy) is wound infection, however it may be avoided by delayed wound closure but with primary packing of gauze with antiseptic solution. The secondary closure of the wound can be performed 3-4 days after the main closing procedure [28, 43].

The type of a protective stoma should be considered and individualised to the patient's conditions. Both types of stoma carry a high complication rate with a considerable mortality rate. The interval between stoma construction and closure has substantial impact on social and economic status [47]. Closure of the stoma is not free from complications, including post-operative mortality, thus the decision of closing should be also made after careful consideration [44, 46].

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