Septic complications after low anterior rectal resection--is diverting stoma still justified?

A retrospective study was designed to determine the effects of faecal diversion on the rate and severity of clinical anastomotic leaks after low anterior resection. The study explored the complications of stoma closure as well. During the period between 1 January 1995 and 30 July 2000, anterior rectal resection was performed on 249 patients with anastomoses created at a 6-cm or smaller distance to the dentate line. In 74 cases, the anastomosis was protected by loop ileostomy. The indications for creating a stoma were evaluated subjectively, by the operating surgeon. In 64 patients, the ileostoma was closed 3 months later. A 'clinical leak' after anterior resection was defined as an anastomotic insufficiency with clinically relevant consequences. The overall rate of anastomotic leak was 6.4 per cent; it was 5.1% (9/175) without and 9.4% (7/74) with a protective stoma. In 8 out of 9 patients, the anastomotic leak that had occurred without a protective stoma warranted laparatomy and defunctioning colostomy. Lavage and drainage of the peritoneal cavity and the presacral space were necessary in 6 out of these 8 cases- and furthermore, the deranged anastomosis had to be removed in 2 patients. Local management was successful in a single case only. Although relaparotomy entails long-term intensive care, all reoperated patients survived anastomotic leakage. Seven patients with a leak despite a protective did not require laparatomy; transanal drainage was appropriate in all cases. There were no fatalities in this group either. Only one fatal complication from suture leakage occurred after stoma-closure. Abdominal exploration was inevitable in almost all patients with a clinical anastomotic leak and without defunctioning stoma. By contrast, patients with anastomotic insufficiency despite a protective stoma were successfully managed without further intra-abdominal intervention. As shown by these results, faecal diversion undoubtedly mitigates the clinical consequences of anastomotic leaks, but cannot prevent its occurrence. When considering the cumulative risk of surgical complications associated with anterior resection, the complications of stoma-closure must also be taken into account. Our data confirm that a defunctioning stoma is beneficial for high-risk patients, who are unfit for a second abdominal procedure required to control suture leakage.