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Diverting loop ileostomy underused in Crohn’s disease

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Stefan Holubar

According to a study presented at the American Society of Colorectal Surgeons Annual Scientific Meeting in Nashville, more patients with Crohn’s disease could benefit from diverting loop ileostomy due to their high risk for anastomotic leak.

Stefan Holubar, MD, director of the inflammatory bowel disease multidisciplinary conference at the Cleveland Clinic, said the procedure gives patients an option to prevent further complications.

“If you are a high-risk patient and the anastomosis leaks, most of the time you need to go back to the OR as an emergency,” he told Healio Gastroenterology and Liver Disease. “But if you are high risk for a leak and your surgeon constructs a temporary ileostomy, if there is a leak it can most of the time be drained, and it heals without needing to rush back in. Then the ileostomy is closed two to three months later, which is a relatively smaller operation.”

Holubar and colleagues analyzed data from the National Surgical Quality Improvement Program colectomy module data from 2012 to 2016 to identify patients with a diagnosis of CD who underwent elective laparoscopic or open ileocolic anastomosis with or without diverting loop ileostomy (DLI). The primary endpoint was a composite of any anastomotic leak within 30 days of surgery.

Of 4,420 patients in the analysis, 4,084 (92.4%) underwent primary anastomosis only (PA), and 336 (7.6%) underwent accompanying DLI (PA-DLI). Anastomotic leaks occurred in 172 of the PA-only patients compared with 8 of the PA-DLI patients (4.2% vs. 2.4%, P = .11).

The investigators also found that rates of anastomotic leak were higher in the PA-only group for smokers, chronic steroid users, men and patients with weight loss. They said patients who had 0, 1, 2, 3 or 4 risk factors had a 2.5%, 3%, 5.3%, 8.3% and 11.8% risk for anastomotic leak (P < .0001).

Of patients with at least two risk factors, only 188 received a DLI, according to the abstract.

The researchers wrote that their findings suggest that these patients should be risk-stratified for anastomotic leak, and surgeons should consider DLI when multiple risk factors are present.

“Our research shows that it doesn’t really matter which risk factors you use, but you should add them up, and if three strikes, then patients may benefit from a temporary diverting loop ileostomy during ileocolic resection and anastomosis,” Holubar said. – by Alex Young

Reference:

Neary P, et al. Abstract S21. American Society of Colorectal Surgeons Annual Scientific Meeting; May 19-23; Nashville, Tenn.

Disclosures: Holubar reports no relevant financial disclosures. Healio Gastroenterology and Liver Disease was unable to determine the other authors relevant financial disclosures at the time of publication.