Preoperative anastomotic evaluation prior to ileostomy closure: A 5-year UK survey, systematic review, and meta-analysis.

AIM: To compare current UK surgical practice against evidence-based anastomotic evaluation techniques prior to ileostomy closure.

METHODS

An online survey was distributed to UK consultant colorectal surgeons with Association of Coloproctology of Great Britain and Ireland affiliation to assess preoperative investigations. Data were collected at two timepoints: 2019 and 2024. A systematic review and meta-analysis were performed utilising PRISMA guidelines. MEDLINE (PubMed), Embase and Education Resources Information Center databases were evaluated from inception to 27 March 2024. Inclusion criteria were adult patients (≥18 years), distal colonic/pelvic anastomosis and defunctioning ileostomy reversal. ROBINS-I bias assessments were conducted. DerSimonian and Laird random-effects analyses were performed on eligible sensitivity and specificity data with forest plots generated.

PROSPERO ID: CRD42024520236.

RESULTS

The survey received 221 (41.0%) and 212 (40.7%) responses in 2019 and 2024 respectively. Pre- and post-pandemic practice was consistent. Water-soluble contrast enema (WCE) and digital rectal examination (DRE) were the most utilised, performed 'always' by 83.2% and 78.7% respectively. Thirty-seven studies (5061 patients) were included for systematic review; 12 studies (1385 patients) for meta-analysis. Studies were heterogeneous in methodology; no randomised controlled trials were identified. Endoscopy showed higher sensitivity (73.1%) compared to retrograde contrast studies (WCE and pouchography; 53.1%) in identifying anastomotic leaks. Specificity was similar: 100% and 98.0% respectively. Significant heterogeneity and a lack of eligible studies limited further interpretation. CT has a limited evidence base for anastomotic evaluation.

CONCLUSIONS

The most commonly performed anastomotic evaluation methods in the UK are WCE and DRE. Endoscopy, however, has a greater sensitivity and specificity for identifying anastomotic complications. WCE is an effective option to confirm suspected leaks. Endoscopy should be considered to evaluate anastomotic integrity prior to ileostomy closure.