Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile?

BACKGROUND: There is no consensus in the literature as to whether all patients who undergo anterior resection of the rectum with total mesorectal excision should have a defunctioning stoma or only those at high risk of anastomotic dehiscence. OBJECTIVE: The aim of this retrospective study was to evaluate the results of placing a removable Silastic band around the ileum during the abdominal phase to exteriorize it and create a loop ileostomy postoperatively without the need for laparotomy in case of an anastomotic complication. This approach is known as “ghost ileostomy.” INTERVENTIONS: A vascular loop was passed around the terminal ileum through a window adjacent to the ileal wall. The loop was then exteriorized, through the abdominal wall, without tension, and secured to the skin on a rod. Two 24F Silastic drains were placed next to the anastomosis (anteriorly and posteriorly). PATIENTS: From May 1997 to May 2011, 168 patients underwent anterior resection of the rectum with total mesorectal excision plus ghost ileostomy. RESULTS: Symptomatic anastomotic dehiscence was observed in 20 of 168 patients (11.96%) and developed on postoperative days 4 to 12 (median, postoperative day 7). In 13 of 20 cases, an ileostomy was fashioned with the patient under local anesthesia, and there was no need for relaparotomy. In 5 of 20 cases, the complication resolved with conservative management. In 2 of 20 cases, the patient’s clinical condition rapidly deteriorated, generalized peritonitis developed, and surgical reintervention with abdominal toilette and colostomy was required. CONCLUSIONS: Ghost ileostomy allows selective loop ileostomy formation after low anterior resection of the rectum without the need for laparotomy in most cases. However, the technique should be reserved for instances in which the risk of leak is relatively low, such as anastomoses performed in the absence of neoadjuvant therapy. The role of routine ghost ileostomy following higher-risk anastomoses remains to be determined.