Introduction. Anastomotic leakage (AL) is a significant complication in minimally invasive rectal cancer surgery, significantly increasing morbidity, reoperation rates, and hospital stay. Protective ileostomy is commonly used to mitigate these risks, but its overuse can lead to unnecessary morbidity, dehydration, and complications related to stoma reversal. The decision to perform an ileostomy remains largely subjective, as no standardized protocol has been validated for clinical implementation.
The objective of this study was to evaluate the prospective application of a risk-based scoring system for ileostomy decision-making. It integrates oncological, biological, and clinical risk factors alongside intraoperative indocyanine green (ICG) fluorescence assessment. Additionally, we compared enhanced recovery after surgery (ERAS) with non-ERAS patients to assess the impact of perioperative optimization on ileostomy necessity.
Materials and methods.117 patients undergoing minimally invasive low anterior resection (LaTME/TaTME) were analyzed. The scoring system was first applied retrospectively to a non-ERAS cohort and then prospectively validated in an ERAS cohort. ICG fluorescence was used intraoperatively to refine surgical decisions.
Results. The scoring system reduced unnecessary ileostomies by 37.1%, with an AUC of 0.971, while ICG fluorescence modified intraoperative decisions in 20% of cases. Despite universal ileostomy use in the retrospective cohort, the fistula rate was 14.9%, compared to 8.6% in the prospective group, confirming that ileostomy influenced complication management rather than preventing fistula formation.
Conclusions. This scoring system can potentially standardize ileostomy selection and optimize patient outcomes. However, multicentric validation is required before clinical adoption.
Keywords: ileostomy decision-making, anastomotic leakage, indocyanine green fluorescence imaging, enhanced recovery after surgery.
Email to Author
Address for correspondence:
Sergiu F. BARA
The IInd Surgery Clinic, Timisoara Emergency County Hospital, 300723 Timisoara, Romania
Email: sergiu.bara@umft.ro; Phone: +40 743 834 670
