Role of ghost ileostomy in low anterior resection for carcinoma rectum

Abstract

The concept of ghost ileostomy (GI) developed in order to combine the advantages of a covering ileostomy (CI) without entailing its complications in patients subjected to low anterior resection (LAR). GI is just a pre-stage ileostomy that at any time can be externalized. In case of anastomotic leak (AL), the GI is matured to complete the CI in order to divert the faecal stream from the anastomotic leakage site. However, in case of uneventful post-operative course, GI prevents all complications related to defunctioning ileostomy. We also carried out a case–control study in order to evaluate the feasibility of GI and CI in LARs for carcinoma of the rectum. We included 33 patients in the GI group and 29 patients in the CI group. The two groups were statistically comparable with respect to serum albumin levels, colon leakage score and distance of anastomosis from anal verge. We did not find any significant differences in the two groups with respect to start of oral liquids, drain removal and AL rate (18% in the GI group versus 14% in the CI group). Mean operating time in the GI group was significantly less (P = 0.001) than the CI group. Mortality rate of the two groups was comparable (P = 0.080). During the total follow-up period of about 22 months, three patients in the CI group and five patients in the GI group died (P = 0.080). These eight deaths included procedure-related deaths (GI group 6% (2/33) and 3.5% (1/29) in CI group), deaths due to advancement of disease and deaths due to medical comorbidities. Six patients (18.2%) in the GI group needed exteriorization of GI (Fig. 1) in view of AL, that is, around 82% of LAR patients with GI were saved from formal CI and its complications and need for second surgery (for stoma takedown). Thus, the concept of GI is a bridge concept between CI and no-ileostomy in LAR and comes to the rescue of the surgeon in a state of ambivalence. This is an alternative to CI in lowor medium-risk patients for AL. However, we should be cautious of creating GI in patients post-neoadjuvant treatment with a history of chemotherapy-induced neutropenia and preoperative severe hypo-albuminaemia.