Avoiding Diverting Ileostomy in Patients Requiring Complete Pelvic Peritonectomy

Paul H. Sugarbaker

In performing cytoreductive surgery with hyperthermic perioperative chemotherapy, a rectosigmoid colon resection is frequently required. To reduce the incidence of anastomotic leakage at the colorectal anastomoses, a diverting ileostomy has been recommended in these patients. Stripping of mesorectal fat from the rectum up to the peritoneal reflection allows transection of the rectum at the junction of the upper and middle rectum. A suture pulls in the lateral aspects of the rectal staple line so that this staple line is included within the barrel of the stapler. After the circular-stapled anastomoses is complete, a second layer of silk sutures is used to invert the staple line. In 31 stapled colorectal anastomoses, three rectal transections were so low that a layer of sutures was not possible. In the 29 two-layer colorectal anastomoses, no anastomotic leakages were observed. The incidence of diverting ileostomy was reduced from 50 to 7 %. These results suggest that preservation of a 10-15 cm length of rectum allows a second layer of sutures to be placed over the stapled colorectal anastomoses. This is a safe alternative to a diverting ileostomy in selected patients.