title: Water-Soluble Enema Prior to Ileostomy Closure in Patients Undergoing Low Anterior Resection: Is It Necessary?
abstract: Diverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low anterior resection for low-rectal cancer. Prior to ileostomy reversal, water-soluble enema is performed to assess the low colorectal anastomosis. The aim of this study was to assess whether performance of routine water-soluble enema prior to ileostomy takedown is necessary.
  
  
  
  All mid-low rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy after neoadjuvant chemoradiotherapy, between 2006 and 2013, were identified, retrospectively. The colorectal anastomosis prior to ileostomy takedown was evaluated by digital rectal exam, rigid proctoscopy, and water-soluble enema. The rectal exam and proctoscopy findings were compared to those of the water-soluble enema. The efficacy of routine water-soluble enema was assessed.
  
  
  
  Three hundred and twelve (184 male) patients (mean age 62.2 ± 17 years) met the inclusion criteria. Ten patients (3 %) experienced a contained anastomotic leak in the early postoperative period, of whom six had a positive intraoperative air leak test at the index operation. At follow-up, 12 patients (4 %) presented with anastomotic stricture, which was diagnosed by rectal exam and proctoscopy. In 11 of them, water-soluble enema showed anastomotic stricture. In terms of anastomotic defects, sinus was documented in two patients (0.6 %), yet digital rectal exam and proctoscopy were normal. No late septic complications related to the colorectal anastomosis after ileostomy closure were reported. The sensitivity of rectal exam, and proctoscopy for the diagnosis of anastomotic stricture was 100 %, while its negative predictive value for the diagnosis of anastomotic defect was 99 %.
  
  
  
  Routine water-soluble enema for the evaluation of colorectal anastomosis before ileostomy takedown does not provide additional information that changes patient management. The efficacy of this test in patients after neoadjuvant chemoradiotherapy and low anterior resection should be reassessed.
authors.affiliation: Colorectal Surgery Unit, Rambam Health Care Campus, Haifa, Israel.|Department of General Surgery, Rambam Health Care Campus, Haifa, Israel.
authors.forename: Amjad
authors.initials: A
authors.lastname: Shalabi
authors.affiliation: Colorectal Surgery Unit, Rambam Health Care Campus, Haifa, Israel.
authors.forename: Simon Daniel
authors.initials: SD
authors.lastname: Duek
authors.affiliation: Colorectal Surgery Unit, Rambam Health Care Campus, Haifa, Israel. wekhoury@gmail.com.|Department of General Surgery, Rambam Health Care Campus, Haifa, Israel. wekhoury@gmail.com.
authors.forename: Wisam
authors.initials: W
authors.lastname: Khoury
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D057868:Anastomotic Leak / Q000601:surgery; D003287:Contrast Media / Q000008:administration & dosage*; D004733:Enema; D005260:Female; D006801:Humans; D007081:Ileostomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011351:Proctoscopy; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D014867:Water
chemical_list: D003287:Contrast Media; D014867:Water
keywords: Anterior resection; Diverting ileostomy; Ileostomy closure; Neoadjuvant therapy; Rectal cancer; Water-soluble enema