Omission of Diverting Loop Ileostomy

The complexity of IPAA and the seriousness of the functional consequences of pelvic sepsis from anastomotic dehiscence justify the almost routine adoption of the protective ileostomy [8]. Ileostomy does not completely eliminate the risk of pelvic sepsis, but it mitigates its negative consequences and facilitates its treatment [24, 25] even if at the price of a 10-30% of complications connected with its construction and closure [24, 27]. Even if several trials suggest the possibility of performing one-stage IPAA with overlapping pelvic complications, minor occlusive episodes and a shorter hospitalisation [28, 29], in other authors' experience [30-32], omission of the ileostomy is connected with an increase of anasto-motic complications and pelvic sepsis. Despite an aggressive therapeutic attitude, the risk of reservoir failure in patients with septic complications is 31% after 5 years and 39% after 10 years since surgery [32]. In the light of these data, one-stage IPAA may be offered if the surgeon is an expert and in selected low-risk cases (patients with a suitable nutritional status, not undergoing immunosuppressive therapy, under treatment with a low steroid dosage) where the operation follows an ideal course without any technical incidents or problems of anastomotic tension [24, 30, 33]. However, it is noteworthy that the results of a recent experience investigating the reasons for long-term failure of RPC be taken into account, which demonstrate the omission of protective ileostomy as one major adverse prognostic factor [34].

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