Conference delegates packed into the Plenary Hall on Wednesday 25 September to witness ‘The Great Debate: is it a must or is it dust?’ at ESCP’s 14th Annual Conference.

Must or Dust debate 1

To prevent anastomotic leakage, the topic of diverting stoma using either a loop ileostomy or colostomy, performed at the time of rectal resection, is widely debated amongst colorectal surgeons.

The afternoon session, chaired by Pamela Buchwald (Sweden) and Des Winter (Ireland), heard from two speakers with opposing arguments which were then judged by a global panel of renowned surgeons; Per Nilsson (Sweden), Rosa-Jimenez-Rodriguez (Spain), Ann Hanly (Ireland), Justin Davies (UK) and Amy Lightner (USA).

Joep Knol from the Department of Colorectal Surgery at Jessa Hospital in Belgium, kicked off with the argument against routine diversion, claiming it is not necessary for pelvic anastomoses.

He put forward various research and studies which included a Dutch population-based study of 998 patients undergoing resection for rectal adenocarcinoma with anastomosis in 2011. The results found that diverting stoma does not necessarily prevent anastomotic leakages and diagnosis is typically delayed in defunctioned patients.

Joel also argued on the likely complications following diverting stoma, which included peristomal hernias, retraction, stricture and stoma prolapse and identified common misconceptions:

  • With diversion and passive drainage, most anastomotic leaks will heal
  • Diverting stoma prevents anastomotic leaks altogether
  • Anastomotic leaks have a major impact on oncologic outcomes

Domenico D’Ugo from the Universitario A. Gemelli in Italy argued against Joep, stating that it should be required.

Domenico weighed up the associated factors, taking into consideration the health and social related costs between morbidity and a major surgical procedure.

He went on to argue that laprsascopic surgery may decrease the risk of clinical anastomotic leaakage. 2,618 consecutive patients who underwent anterior resection for rectal cancer with primary anastomosis, with or without diverting stoma, were retrospectively analyzed as a training dataset.

Data containing 611 patients were prospectively collected as a test dataset. The performance of the nomogram was evaluated by using a pootstrapped-concordance index and calibration plots. Out of these patients, the incidence of clinical anastomotic leakage was 10.5% (64/611).

Both sides presented plentiful research and examples to make their case however most of the judges, as well as the majority of audience members, agreed against routine diversion so long as a dedicated and cohesive colorectal unit is in place.

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