Role of fecal diversion in colorectal anastomotic failure: Where are we now?

The value of a diverting ostomy after low colorectal anastomosis continues to be a controversial subject in the literature. Sphincter salvage surgery has increased in recent years, and the role of prophylactic diversion continues to evolve. The authors sought to provide an evidence-based review of current recommendations for use of a diverting stoma in the setting of a low pelvic anastomosis. A search of MEDLINE, PubMed, and the Cochrane database was performed. s were evaluated for relevance. Selected articles were then reviewed in detail, including references. Recommendations were then drafted based on evidence and conclusions in the selected articles. A total of 100 articles were identified, of which 54 were included for complete analysis, including 2 meta-analyses. A diverting ostomy lowers clinical anastomotic leak rate and need for re-operation as a consequence of a leak by 30-70%. Small non-randomized studies have suggested that a diverting ostomy can be selectively omitted in some low-risk patients with good results. The morbidity associated with diverting ostomies is not inconsequential and includes risk for readmission and increased odds of renal failure. This risk must be balanced against that of anastomotic leak. The current data suggests that a diverting ostomy does not prevent anastomotic leak but can significantly limit the clinical sequelae and need for re-operation. The creation of a diverting stoma is not without morbidity and as such should be selectively performed in high-risk colorectal anastomosis that meets specific criteria.