Should we continue Imposing an Ahead Systematic Stomia after a Colorectal Anastomosis ?

The rate of unexpected arrival of an anastomotic fistula in colorectal surgery is about 6-10% in most statistics. It is necessary to force 9 to 10 patients, who will not make an anastomotic fistula, to an ahead stomia which we know the vagaries.This problem put down discussion since numerous years and it is badly occulted for legal responsibility reasons, some experts not hesitate to sentence the surgeon who have not made a systematic ahead stomia when postoperatives complications occur but also some surgical school, and not the less, have erect ahead stomia as a dogma.Formed at the school of sphincter preserving without any protection in the surgery of rectal cancer in the surgical “Clinic A” of Nancy, we have spreed this principle to all colorectal anastomosis even after preoperative radio chimio therapy. A personal statistics of 86 rectal cancers operated from 1983 to 1988 with 28 amputations, 31 colorectal anastomosis for tumors of the initial part of the rectum without preoperative radio therapy with 3 fistula and 27 tumors of the low rectum with preoperative radio therapy which entail only 2 fistulas with favorable results.Even after preoperative radio therapy the achievement of colorectal anastomosis, without an ahead stomia, did not appear for us an aberration and this was even more important because all rectal cancers are going to benefit after with a postoperative radio therapy.The team from Louvain has proved that simple ahead stomia did not reduce the number of fistulas but made the complication less serious with respect to those arising without stomia. To avoid all loss of chance in this late case, it is advisable to be very careful during the first two postoperative days and, based on the clinical data which recall a pre fistulous state of the anastomosis, execute a right transversal anus before the transit revival.Remain the thorny problem to know why identical patients, operated with the same operative technic, who have benefit from a well vascularized colorectal anastomosis, without any tension, some will have a fistula, others will not.A reply will come perhaps from the pursuit of studies of the intestinal microbiome. The intestinal mucous membrane whose cells have a life of only three days is in fact in permanent contact with this microbiome whose complexity is gradually put in light with bacteria’s which have a eutrophic effect on the healing and others an harmful effect.In the light of these elements, we can envisage, in a dream, that surgeons will turn away from the ahead stomia to go down until the close problem of intestinal healing in favor to the analysis of preoperative microbiome and eventually to correct it. Helicobacter pylori eradication has well enable the final healing of duodenal ulcers.At the time of minimally invasive surgery, of premature rehabilitation and of ambulatory surgery, it is aberrant on behalf of completely overwhelmed dogmas and of preceding’s fear to continue to force useless gestures not without complications to all the patients for the benefit of few patients who make a fistula even if they anyways suffer a loss of chance if a new strategy was applied.The inescapable condition is to follow the patients rigorously and to intervene precociously in case of complication.A prospective study is urgently needed, led by hospital and liberal surgeon, to validate definitively this strategy and after to spread it.