CAPITOLO 3 – STUDIO SPERIMENTALE
3.8 Conclusioni
Nella chirurgia oncologica del retto extraperitoneale l’ileostomia escludente laterale a protezione dell’anastomosi colo-rettale o colo-anale può contribuire a ridurre l’impatto clinico di un’eventuale deiscenza anastomotica, accettando però il potenziale rischio di una serie di complicanze stomia-correlate oltreché la necessità di sottoporre il paziente a un ulteriore intervento chirurgico per la ricanalizzazione intestinale. Tuttavia, il fatto che la mortalità perioperatoria nella popolazione esaminata risulti pari a zero e che solo in due casi si sia reso necessario il confezionamento di una colostomia definitiva per problematiche anastomotiche non gestibili in maniera conservativa è a sostegno della scelta di confezionare sistematicamente l’ileostomia escludente laterale, a patto di garantire una pronta ricanalizzazione intestinale in modo da ridurre il rischio di complicanze stomia-correlate.
Per la valutazione dell’integrità e della pervietà dell’anastomosi colo-rettale o colo-anale le tradizionali indagini clinico-strumentali (esplorazione rettale digitale con rettoscopia e Rx clisma opaco), essendo prive di morbilità e mortalità, possono essere utilizzate in completa sicurezza.
Tuttavia l’esplorazione rettale digitale e la rettoscopia sembrano avere una maggiore sensibilità dell’Rx clisma opaco nell’individuare sia le deiscenze che le stenosi anastomotiche.
La differenza principale fra le varie indagini clinico-strumentali si apprezza nelle anastomosi colo-anali manuali, in cui l’esplorazione rettale digitale e la rettoscopia sembrano essere le metodiche più affidabili per valutare lo stato dell’anastomosi; in particolare sembrano essere il gold standard per la diagnosi delle stenosi nelle anastomosi colo-anali.
Concludendo, in completo accordo con la letteratura scientifica, i risultati dello studio in questione permettono di affermare che nei pazienti con decorso postoperatorio regolare, clinicamente asintomatici e la cui anastomosi colo-
rettoscopia, l’indagine radiologica non fornisce né aggiunge ulteriori informazioni significative sullo stato dell’anastomosi prima della ricanalizzazione intestinale.
Alla luce di questo, si può prevedere un’applicazione sistematica della sola rettoscopia per la valutazione dell’integrità e della pervietà dell’anastomosi colo-rettale o colo-anale, riservando l’esecuzione dell’Rx clisma opaco ai soli casi risultati positivi all’esame endoscopico.
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