Virtual ileostomy following TME and primary sphincter-saving reconstruction for rectal cancer

Surgical management of rectal cancer has undergone a significant change during the past two decades. Low anterior resection (LAR) with total mesorectal excision (TME) is, at the moment, the "gold standard" for carcinoma of the mid or lower rectum. Because the most specific complication following rectal resection with anastomosis is symptomatic leakage, which is associated with 18% mortality rate, routine formation of a temporary stoma is suitable after sphincter-saving resection for anastomoses situated at or less than 5cm from the anal verge. Actually the preferred modes of fecal diversion following LAR with TME are loop ileostomy or loop transverse colostomy. Low anastomosis, preoperative radiation or chemoradiation, presence of intraoperative adverse events and male gender are independent risk factors for symptomatic anastomotic leakage. A defunctioning loop ileostomy or the classical "protective" colostomy requires subsequent reconstructive surgery with a significant postoperative morbidity. For these reasons we use an alternative to protect a high risk anastomosis with fashioning a proximal intraabdominal closed loop ileostomy called "virtual ileostomy". In a seven-year period from 1999 to 2005 a total of 107 patients underwent elective anterior resection of the rectum for carcinoma, in all cases was fashioned a virtual ileostomy. The incidence of symptomatic clinically evident anastomotic leakage was 13%; in all the cases (14 pts) the closed loop ileostomy was opened with a reduction of the originally planned number of ileostomies by over 80%. The procedure is easy to perform and well accepted by the patients. It avoids a second operation.