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Diverting Loop Ileostomy for Ileo-Colic Anastomosis Is Associated With a Lower Serious Anastomotic Leak Rate: A Nationwide Analysis
Alexander Hawkins*, Sekhar Dharmarajan, Devi Mukkai Krishnamurty, Katerina Wells, Matthew Mutch, Sean C. Glasgow
Colon & Rectal Surgery, Washington University, St Louis, MO
Introduction
Anastomotic leak is one of the most feared complications of gastrointestinal surgery. Surgeons routinely perform a diverting loop ileostomy (DLI) to protect high-risk colo-rectal or colo-anal anastomoses. Minimal data exists to support the use of a diverting loop ileostomy to protect an ileo-colic anastomosis. We hypothesize that a DLI will not decrease the anastomotic leak rate for difficult ileo-colic resections.
Methods
The Colo-Rectal Specific ACS NSQIP database was queried from 2012-2013 for all patients undergoing open ileo-colic resection with and without a DLI. The primary outcome was the development of any anastomotic leak- this includes leaks managed both operatively and non-operatively. Secondary outcomes include overall complication rate, return to the OR, readmission, and 30-day mortality. Separate multivariate logistic regression analyses were performed for each outcome adjusting for all independently predictive preoperative risk factors.
Results
4,159 patients underwent open ileo-colic resection during the study period. 1,877 (45.13%) were men and the mean age was 62.4 (range 18-90). The most common indication for the procedure was colon cancer (38.9%) followed by Crohn's disease (14.9%). 1071 (25.7%) of the cases were emergent. 186 (4.5%) underwent a DLI. In multivariable analysis, factors predictive of the addition of a DLI included emergency surgery, female sex, absence of diabetes, pre-operative anemia, history of COPD, pre-operative sepsis and Crohn's disease (Figure 1). There were 197 anastomotic leaks for an overall leak rate of 4.7% with 100 patients requiring reoperation (2.4%). In a multivariable analysis, DLI was not associated with a decreased overall anastomotic leak rate nor a decrease in overall complication rate, surgical site infection, return to the OR or 30-day mortality (Table 1). However, DLI was associated with a decrease in anastomotic leaks requiring reoperation (DLI vs no DLI: 0 (0%) vs 100 (2.5%); P=0.02). DLI was associated with increased readmission (OR 1.93; 95% CI 1.30-2.85; P=0.001).
Conclusion
DLI is rarely used for open ileo-cecal resection. The strongest factors associated with the addition of a DLI were preoperative sepsis and a surgical indication of Crohn's disease. Both the overall anastomotic leak rate and the rate of reoperation for leak were low. While DLI was not associated with a decrease in the odds of any anastomotic leak, there were no serious leaks requiring reoperation in the DLI group. A DLI was associated with an almost two-fold increase in the odds of readmission with no benefit in overall complication rate, return to the OR or surgical site infection. Surgeons must weigh the benefit of a reduction in serious leak rate with postoperative morbidity when considering a DLI for open ileo-colic resection.
Figure 1. Odd ratio plot for independent variables associated with the addition of a diverting loop ileostomy.
  Figure 1. Odd ratio plot for independent variables associated with the addition of a diverting loop ileostomy.
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