title: Water soluble contrast enema examination of the integrity of the rectal anastomosis prior to loop ileostomy reversal may be superfluous.
abstract: OBJECTIVE
  Defunctioning loop ileostomy in low anterior resection (LAR) is routinely used to reduce consequences of anastomotic leakage. The purpose of this study was to analyze which examination technique is optimal for evaluating the integrity of the anastomosis prior to loop ileostomy reversal.
  
  
  METHODS
  Retrospective analysis of 95 patients who had been subjected to LAR at Helsingborg Hospital and Skåne University Hospital, Sweden, was undertaken between January 2007 and June 2009. The examination techniques of the rectal anastomosis prior to reversal and the clinical outcome after reversal were studied.
  
  
  RESULTS
  Radiologic anastomosis control using water soluble contrast enema, digital rectal examination (DRE), and rectoscopy were performed in 53 % (50/95), 98 % (93/95), and 69 % (66/95), respectively. In two patients, no control of the anastomosis was performed before reversal. Fifty-two percent (49/95) of the patients were examined using all techniques. Six patients demonstrated leakage detected before reversal of which two were only radiological leakages. These two patients underwent loop ileostomy reversal after delay without complications. They were the only ones where the three examination techniques did not prove coherence. Four patients had symptomatic leakage; these were detected with rectoscopy and DRE and verified with enema. Three patients developed anastomotic leakage after loop ileostomy reversal despite normal preoperative examinations. Two of these patients had rectovaginal fistulas (AVFs).
  
  
  CONCLUSIONS
  This retrospective study indicates that contrast enema does not provide additional information if rectoscopy and DRE are normal. Despite negative examinations, three of nine leakages were diagnosed after loop ileostomy reversal. Especially, AVFs seem difficult to diagnose.
authors.affiliation: Department of Surgery, Helsingborg Hospital, S-251 87, Helsingborg, Sweden.
authors.forename: Anna
authors.initials: A
authors.lastname: Larsson
authors.forename: Gudrun
authors.initials: G
authors.lastname: Lindmark
authors.forename: Ingvar
authors.initials: I
authors.lastname: Syk
authors.forename: Pamela
authors.initials: P
authors.lastname: Buchwald
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D057868:Anastomotic Leak / Q000517:prevention & control; D003287:Contrast Media; D003974:Diatrizoate Meglumine; D051517:Digital Rectal Examination; D004733:Enema / Q000379:methods*; D005260:Female; D005471:Fluoroscopy / Q000379:methods*; D006801:Humans; D007081:Ileostomy / Q000379:methods*; D007082:Ileum / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011351:Proctoscopy; D012007:Rectum / Q000000981:diagnostic imaging / Q000601:surgery*; D012189:Retrospective Studies
chemical_list: D003287:Contrast Media; D003974:Diatrizoate Meglumine