No-bag surgery – avoiding colostomy and ileostomy in rectal cancer treatment

In some cases, the creation of a permanent colostomy is unavoidable. Most often, this is down to the size and position of the cancer, especially very low tumours and those that don’t respond adequately to radio- or chemotherapy.

The creation of a temporary loop ileostomy, or diversion ileostomy (part of the small intestine), is often used to divert the stool and protect a newly created join of the colon further downstream. This is to protect patients from the potentially severe consequences of an anastomotic leak (a failed bowel join).

Anastomotic leaks are a rare, but significant complication after rectal cancer surgery – the risk is described in the medical literature around 5-15%. While it’s widely believed that ileostomies don’t protect patients from a leak, the hypothesis is that, by avoiding large spillages of bowel content, it lowers the risk of further complications, including sepsis, further down the line.

Closure of a temporary ileostomy is usually planned somewhere between six weeks and six months after the initial surgery, depending on whether the patient needs additional treatment, such as chemotherapy.

Apart from the fact that ileostomies need extra care (and a second operation under general anaesthesia), there are also other potential problems, such as stoma over-function, which can lead to dehydration, hernias and stoma prolapses. These problems are relatively rare, but if they happen they can have a significant negative impact during a delicate time of recovery following cancer surgery.

According to the textbooks and traditional surgical teaching, a diversion ileostomy is recommended when a join of the bowel is needed in the lowest 10cm of the rectum. Other factors also play a part, such as other medical conditions (diabetes, for example, can impact tissue healing), certain drugs (such as steroids) and lifestyle choices (including smoking), that play an important role the decision-making process.

However, the introduction of minimally invasive surgical techniques, and in particular robotic surgery, has changed how we approach this issue. These techniques involve making smaller incisions and using specialized instruments to remove the tumour. This can lead to a faster recovery time and a lower risk of complications compared to traditional open surgery. 

At CRSC, the leak rates are much lower than those reported in the literature, and we manage to avoid using diversion ileostomies even in tumours very close to the anus.

In some cases, it may be possible to perform a local excision of the tumour, which involves removing only the tumour itself and a small amount of surrounding tissue. This can be done using endoscopic techniques or transanal surgery (TAMIS), although this approach is usually only appropriate for very early-stage tumours.

One way of avoiding a colostomy following rectal cancer surgery is by using neoadjuvant therapy. This involves using chemotherapy and/or radiation therapy to shrink the tumour prior to surgery, thus making it easier to remove. With the surgeon able to perform a more complete resection of the tumour, the need for a colostomy is reduced.

Another option, in very low rectal cancer, is to perform ultra-low anterior resections of the rectum using robotic surgery. This involves making smaller incisions and using specialised instruments to remove the tumour and perform joins very low down inside the pelvis. We can also use a combination of abdominal and transanal techniques.

Out of every hundred patients with rectal cancer, who don’t require a permanent colostomy, about 60 would need a diversion ileostomy, and something like 25 could end up with a permanent stoma.

However, in units implementing a no-stoma approach, results suggest that out of a hundred patients, 89 will remain stoma-free, and 72 won’t have had a stoma at all. The implementation of minimally invasive precision surgery and the use of heavily standardised treatment protocols are crucial in achieving these results.

Ultimately the decision-making process around stoma will vary from case to case and requires in-depth discussion. Developing a personalised treatment plan that takes into account your individual needs and medical history is paramount, and may involve a combination of neoadjuvant therapy, minimally invasive surgical techniques, and other strategies to help reduce the risk of a colostomy.