The Impact of Ghost Ileostomy on Anastomotic Leakage: Selecting Eligible Patients for Surgery and Early Detection of Leakage

Document Type : Research/Original Article


1 Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

2 Department of General Surgery, Shiraz University of Medical Sciences, Shiraz, Iran

3 Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran


Background: Anastomotic leakage (AL) is the main complication of colorectal surgeries. Recent studies have
assessed the effects of the ghost ileostomy on preventing complications related to a defunctioning stoma (DS)
in high-risk anastomoses. In this study, we aimed to review patients who underwent ghost ileostomy and assess
their colon leakage score (CLS) and Dutch leakage score (DULK) to evaluate their preoperative AL risk and
post-operative AL diagnostic score, respectively. We examined whether the suggested cut-off points of these
scores (>11 for CLS and >4 for DULK) could be appropriate criteria for determining when to insert ghost
ileostomy and when to convert it to a DS.
Methods: All patients from three referral hospitals in Shiraz, Iran who underwent colorectal surgery with
ghost ileostomy during 2019-2020 were enrolled in this retrospective case series. We calculated preoperative
CLS and post-operative DULK scores for all patients and assessed what diagnostic and therapeutic measures
were performed for them based on their scores.
Results: AL was diagnosed in two of 34 patients. Eight patients had a total CLS score of 11 and above, but
only one of them experienced AL. The other case of AL had a CLS score of 10. The DULK score of these two
patients increased during hospitalization.
Conclusion: Because of the importance of accurately identifying high-risk patients for ghost ileostomy, it
is imperative to undertake additional research aimed at determining the optimal cut-off value for CLS or
devising alternative valid scoring systems. DULK score could be an appropriate post-operative monitoring tool
to reduce morbidity.


1. Gulla N, Trastulli S, Boselli C,
Cirocchi R, Cavaliere D, Verdecchia
GM, et al. Ghost ileostomy after
anterior resection for rectal cancer: a
preliminary experience. Langenbecks
Arch Surg. 2011;396(7):997-1007.
2. McDermott F, Heeney A, Kelly
M, Steele R, Carlson G, Winter D.
Systematic review of preoperative,
intraoperative, and postoperative risk
factors for colorectal anastomotic
leaks. British Journal of Surgery.
3. Vallance A, Wexner S, Berho M,
Cahill R, Coleman M, Haboubi
N, et al. A collaborative review
of the current concepts and
challenges of anastomotic leaks in
colorectal surgery. Colorectal Dis.
4. Rahbari NN, Weitz J, Hohenberger W,
Heald RJ, Moran B, Ulrich A, et al.
Definition and grading of anastomotic
leakage following anterior resection
of the rectum: a proposal by the
International Study Group of Rectal
Cancer. Surgery. 2010;147(3):339-51.
5. Kulu Y, Ulrich A, Bruckner T, Contin
P, Welsch T, Rahbari NN, et al.
Validation of the International Study
Group of Rectal Cancer definition
and severity grading of anastomotic
leakage. Surgery. 2013;153(6):753-61.
6. Ellebæk M, Qvist N. Early detection
and the prevention of serious
complications of anastomotic leakage
in r ectal cancer s urgery. Springer;
7. Dupré A, Slim K. Fistule
anastomotique après chirurgie
colorectale: peut-on la détecter plus
facilement et plus tôt? : Elsevier
Masson; 2012. p. 329-30.
8. Rathnayake M, Kumarage S,
Wijesuriya S, Munasinghe B,
Ariyaratne M, Deen K. Complications
of loop ileostomy and ileostomy
closure and their implications for
extended enterostomal therapy:
a prospective clinical study.
International journal of nursing
studies. 2008;45(8):1118-21.
9. Sacchi M, Legge PD, Picozzi
P, Papa F, Giovanni CL, Greco
L. Virtual ileostomy following
TME and primary sphinctersaving
reconstruction for rectal
cancer. Hepato-gastroenterology.
10. McKechnie T, Lee J, Lee Y, Tessier L,
Amin N, Doumouras A, et al. Ghost
Ileostomy Versus Loop Ileostomy
Following Oncologic Resection
for Rectal Cancer: A Systematic
Review and Meta-Analysis. Surgical
Innovation. 2023:15533506231169066.
11. Dekker JWT, Liefers GJ, van Otterloo
JCdM, Putter H, Tollenaar RA.
Predicting the risk of anastomotic
leakage in left-sided colorectal
surgery using a colon leakage
score. Journal of Surgical Research.
12. Den Dulk M, Witvliet M, Kortram
K, Neijenhuis P, De Hingh I, Engel
A, et al. The DULK (D utch leakage)
and modified DULK score compared:
actively seek the leak. Colorectal
Disease. 2013;15(9):e528-e33.
13. Miccini M, Amore Bonapasta S,
Gregori M, Barillari P, Tocchi
A. Ghost ileostomy: real and
potential advantages. Am J Surg.
14. Samji KB, Kielar AZ, Connolly
M, Fasih N, Doherty G, Chung
A, et al. Anastomotic leaks after
small-and large-bowel surgery:
diagnostic performance of CT and the
importance of intraluminal contrast
administration. American Journal of
Roentgenology. 2018:1259-65.
15. Nicksa G, Dring R, Johnson K,
Sardella W, Vignati P, Cohen J.
Anastomotic leaks: what is the best
diagnostic imaging study? Diseases of
the colon & rectum. 2007;50:197-203.
16. Zizzo M, Morini A, Zanelli M,
Tumiati D, Sanguedolce F, Palicelli A,
et al. Short-Term Outcomes in Patients
Undergoing Virtual/Ghost Ileostomy
or Defunctioning Ileostomy after
Anterior Resection of the Rectum: A
Meta-Analysis. Journal of Clinical
Medicine. 2023;12(11):3607.
17. Warschkow R, Beutner U, Steffen T,
Müller SA, Schmied BM, Güller U,
et al. Safe and early discharge after
colorectal surgery due to C-reactive
protein: a diagnostic meta-analysis
of 1832 patients. Annals of surgery.
18. Takakura Y, Hinoi T, Egi H,
Shimomura M, Adachi T, Saito Y,
et al. Procalcitonin as a predictive
marker for surgical site infection in
elective colorectal cancer surgery.
Langenbeck’s archives of surgery.
19. Lagoutte N, Facy O, Ravoire A,
Chalumeau C, Jonval L, Rat P, et al.
C-reactive protein and procalcitonin
for the early detection of anastomotic
leakage after elective colorectal surgery:
pilot study in 100 patients. Journal of
visceral surgery. 2012;149(5):e345-e9.