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Hu G, Ma J, Qiu WL, Mei SW, Zhuang M, Xue J, Liu JG, Tang JQ. Patient selection and operative strategies for laparoscopic intersphincteric resection without diverting stoma. World J Gastrointest Surg 2025; 17:95983. [PMID: 40162392 PMCID: PMC11948115 DOI: 10.4240/wjgs.v17.i3.95983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 08/02/2024] [Accepted: 10/30/2024] [Indexed: 02/24/2025] Open
Abstract
BACKGROUND Diverting stoma (DS) is routinely proposed in intersphincteric resection for ultralow rectal cancer, but it is associated with increased stoma-related complications and economic burden. Appropriate patient selection and operative strategies to avoid stoma formation need further elucidation. AIM To select patients who may not require DS. METHODS This study enrolled 505 consecutive patients, including 84 who underwent stoma-free (SF) intersphincteric resection. After matching, patients were divided into SF (n = 78) and DS (n = 78) groups. The primary endpoint was the anastomotic leakage (AL) rate within 6 months and its protective factors for both the total and SF cohorts. The secondary endpoints included overall survival and disease-free survival. RESULTS The AL rate was greater in the SF group than in the DS group (12.8% vs 2.6%, P = 0.035). Male sex [(odds ratio (OR) = 2.644, P = 0.021], neoadjuvant chemoradiotherapy (nCRT) (OR = 6.024, P < 0.001), and tumor height from the anal verge ≤ 4 cm (OR = 4.160, P = 0.007) were identified as independent risk factors. Preservation of the left colic artery (LCA) was protective in both the total cohort (OR = 0.417, P = 0.013) and the SF cohort (OR = 0.312, P = 0.027). The female patients who did not undergo nCRT and had preservation of the LCA experienced a significantly lower incidence of AL (2/97, 2.1%). The 3-year overall survival or disease-free survival did not significantly differ between the groups. CONCLUSION Female patients who do not receive nCRT may avoid the need for DS by preserving the LCA without increasing the risk of AL or compromising oncological outcomes.
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Affiliation(s)
- Gang Hu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ji Ma
- Department of General Surgery, Datong Third People’s Hospital, Datong 037008, Shanxi Province, China
| | - Wen-Long Qiu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shi-Wen Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Meng Zhuang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jun Xue
- Department of General Surgery, The First Affiliated Hospital of Hebei North University, Zhangjiakou 075000, Hebei Province, China
| | - Jun-Guang Liu
- Department of General Surgery, Peking University First Hospital, Beijing 100034, China
| | - Jian-Qiang Tang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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Gouvas N, Manatakis D, Agalianos C, Dimitriou N, Baloyiannis I, Tzovaras G, Xynos E. Defunctioning Ileostomy After Low Anterior Resection of Rectum: Morbidity Related to Fashioning and Closure. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1864. [PMID: 39597049 PMCID: PMC11596492 DOI: 10.3390/medicina60111864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2024] [Revised: 09/21/2024] [Accepted: 11/06/2024] [Indexed: 11/29/2024]
Abstract
Background and Objectives: The aim of this study was to assess any predisposing factors to the morbidity of fashioning and reversal of diverting ileostomy in a prospective cohort of patients who have undergone TME and low colo-rectal or colo-anal anastomosis for rectal cancer. Materials and Methods: Consecutive patients with rectal cancer undergoing low anterior resection and a defunctioning loop ileostomy in three surgical units from 2016 to 2020 were included in the study and retrospectively analyzed. Results: One hundred eighty-two patients from three centres were included. Ileostomy-related mortality was 0.5%, attributed to renal failure.. Ileostomy-related morbidity was 46%. Postoperative ileus was seen in 37.4%, and dehydration in 18.8% of the patients. The readmission rate for ileostomy-related reasons was 15.4%. Stoma care was problematic in 15.7% or poor in 7% of the cases. Advanced age, male gender and obesity were independent risk factors for ileostomy-related morbidity. Ileostomy was reversed in 165 patients. The morbidity in 165 patients was 16%. Ileus was seen in 10.3%, anastomotic leak in 4.8% and wound infection in 12.7% of the cases. One patient died because of an anastomotic leak. No predisposing factors that affect the outcomes of ileostomy closure were identified. Conclusions: Diverting ileostomy-related morbidity is high. Life threatening dehydration and renal failure from ileus is more commonly seen in elderly, male and obese patients and should be anticipated. Ileostomy closure-related morbidity is low.
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Affiliation(s)
- Nikolaos Gouvas
- Department of General Surgery, Medical School, University of Cyprus, Nicosia 2404, Cyprus;
| | - Dimitrios Manatakis
- Department of General Surgery, Naval & Veterans Hospital, 11521 Athens, Greece;
| | - Christos Agalianos
- Department of General Surgery, Naval & Veterans Hospital, 73200 Chania, Greece;
| | - Nikoletta Dimitriou
- Department of General Surgery, Medical School, University of Cyprus, Nicosia 2404, Cyprus;
| | - Ioannis Baloyiannis
- Department of General Surgery, University Hospital of Larissa, 41334 Larisa, Greece; (I.B.); (G.T.)
| | - George Tzovaras
- Department of General Surgery, University Hospital of Larissa, 41334 Larisa, Greece; (I.B.); (G.T.)
| | - Evangelos Xynos
- Department of General Surgery, Creta Interclinic Hospital, 71304 Heraklion, Greece;
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Geisler BP, Cao KN, Ryschon AM, Alavi K, Komen N, Pietzsch JB. Cost associated with diverting ostomy after rectal cancer surgery: a transnational analysis. Surg Endosc 2023; 37:7759-7766. [PMID: 37580581 DOI: 10.1007/s00464-023-10300-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/12/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Diverting ileostomy and colostomy after total mesorectal excision reduces the risk of complications related to anastomotic leakages but is associated with a reduction in health-related quality of life and long-term economic consequences that are unknown. Our objective was to estimate the lifetime costs of stoma placement after rectal cancer resection in the U.S., England, and Germany. METHODS Input parameters were derived from quasi-systematic literature searches. Decision-analytic models with survival from colorectal cancer-adjusted life tables and country-specific stoma reversal proportions were created for the three countries to calculate lifetime costs. Main cost items were stoma maintenance costs and reimbursement for reversal procedures. Discounting was applied according to respective national guidelines. Sensitivity analysis was conducted to explore the impact of parameter uncertainty onto the results. RESULTS The cohort starting ages and median survival were 63 and 11.5 years for the U.S., 69 years and 8.5 years for England, and 71 and 6.5 years for Germany. Lifetime discounted stoma-related costs were $26,311, £9512, and €10,021, respectively. All three models were most sensitive to the proportion of ostomy reversal, age at baseline, and discount rate applied. CONCLUSION Conservative model-based projections suggest that stoma care leads to significant long-term costs. Efforts to reduce the number of patients who need to undergo a diverting ostomy could result in meaningful cost savings.
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Affiliation(s)
- Benjamin P Geisler
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Khoa N Cao
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Anne M Ryschon
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA
| | - Karim Alavi
- Department of Surgery/Division of Colon and Rectal Surgery, UMass Memorial Health/UMass Chan Medical School, Worcester, MA, USA
| | - Niels Komen
- Department Abdominal Surgery, Universitair Ziekenhuis Antwerpen/ReSURG, Antwerp Surgical Training, Anatomy and Research Center, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Jan B Pietzsch
- Wing Tech Inc., 101 Jefferson Drive, Menlo Park, CA, USA.
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Panizza J, Swee YJS, Edmundson A, Clark D. Renal dysfunction occurs following ileostomy formation and is independent of readmission. ANZ J Surg 2023; 93:622-628. [PMID: 36621986 DOI: 10.1111/ans.18254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Ileostomy formation may be permanent or intended as temporary to defunction a high-risk pelvic anastomosis to reduce the risk of septic consequences of anastomotic leak. However, these procedures have a high rate of readmission, most commonly due to dehydration and associated with acute kidney injury (AKI). METHODS A single centre retrospective cohort study of patients who underwent ileostomy formation from 2015 to 2020 and analysed in two groups: those who needed readmission within 60 days and those who did not. Data collected included demographics and renal function and electrolytes at baseline (ileostomy formation) and at elective ileostomy closure. RESULTS A total of 171 patients were included in the analysis, with a readmission rate 38% within 60 days of discharge. There was a significant increase in creatinine from baseline blood tests compared to date of elective ileostomy closure in both the readmission and no readmission arms. There was a significant decrease in eGFR from baseline blood tests compared with date of ileostomy closure in both readmission and no readmission arms. There was no significant difference in creatinine or eGFR between readmission and no readmission arms at date of ileostomy closure. Baseline serum sodium levels were lower in the readmission arm compared to no readmission arm. CONCLUSION Ileostomy formation is associated with a deterioration in renal function, which occurs independent of whether the patient requires readmission to hospital. Low serum sodium may be used as a predictor for patients with an increased risk of readmission.
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Affiliation(s)
- John Panizza
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Yan Jing Sherrie Swee
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Aleks Edmundson
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - David Clark
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Tyler R, Foss H, Phelan L, Radley S, Geh I, Karandikar S. Impact of surgeon volume on 18-month unclosed ileostomy rate after restorative rectal cancer resection. Colorectal Dis 2023; 25:253-260. [PMID: 36222737 DOI: 10.1111/codi.16368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/03/2022] [Indexed: 02/08/2023]
Abstract
AIM The impact of surgeon volume on 18-month unclosed ileostomy rates after rectal cancer surgery has not been fully explored. The aim of this study was to describe the effect of surgeon volume and evaluate factors predictive of an unclosed ileostomy. METHOD Patients undergoing anterior resection with a diverting ileostomy for rectal cancer from March 2004 to October 2018 were identified from a prospectively maintained database. The unclosed ileostomy rate was determined by those with an unclosed ileostomy at 18 months. High- and low-volume surgeons (HVS and LVS, respectively) were classed as those performing five or more or fewer than five rectal cancer resections per year, respectively. Data on sex, age, American Society of Anesthesiologists grade, neoadjuvant chemoradiotherapy (CRT), tumour height, T-stage, anastomotic leak, surgical approach and adjuvant chemotherapy were also collected. Factors predictive of an unclosed ileostomy at 18 months were explored using a multivariate binary logistic regression analysis. RESULTS A total of 415 patients (62.4% male) with a median age of 67 were eligible for analysis. Of these, 115 (27.7%) had an unclosed ileostomy at 18 months. HVS had an unclosed ileostomy rate of 24.6% (72/292) compared with 34.9% (43/123) for LVS. Volume was associated with an unclosed ileostomy in univariable analysis (p = 0.032) but not in multivariate analysis (OR 1.75, 95% CI 0.92-3.32, p = 0.08). Independent factors predictive of an unclosed ileostomy were anastomotic leak (OR 10.41, 3.95-27.0, p < 0.01), adjuvant chemotherapy (OR 2.23, 1.24-3.96, p < 0.01) and neoadjuvant CRT (OR 2.16, 1.15-5.75, p = 0.01). CONCLUSION LVS were associated with a higher unclosed ileostomy at 18 months compared with HVS. This study adds further weight to the call for adoption of a minimum annual case threshold in rectal cancer surgery.
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Affiliation(s)
| | - Helen Foss
- Birmingham Heartlands Hospital, Birmingham, UK
| | - Liam Phelan
- Birmingham Heartlands Hospital, Birmingham, UK
| | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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Thomas F, Menahem B, Lebreton G, Bouhier-Leporrier K, Dejardin O, Alves A. Permanent stoma after sphincter preservation for rectal cancer. A situation that occurs more often than you might think. Front Oncol 2023; 12:1056314. [PMID: 36776358 PMCID: PMC9909408 DOI: 10.3389/fonc.2022.1056314] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/16/2022] [Indexed: 01/27/2023] Open
Abstract
Objectives This study aimed: (i) to assess the cumulative incidence of permanent stoma (PS) after sphincter-preserving surgery (SPS) for rectal cancer (RC): (ii) to analyze associated risk factors for primary and secondary PS; and (iii) to compare the long-term survival of patients according to the stoma state. Methods We conducted a retrospective single-center cohort study based on a prospectively maintained database of SRC patients undergoing SPS from January 2007 to December 2017. Incidence of both primary (no reversal of defunctioning stoma) and secondary (created after closure of defunctioning stoma) PS were investigated. Associations between potential risk factors and PS were analyzed using a logistic regression model. Cumulative survival curve was drawn by Kaplan-Meier method. Results Of the 257 eligible patients, 43 patients (16.7%) had a PS (16 primary PS and 27 secondary PS) after a median follow-up of 4.8 years. In multivariate analysis, the independent risk factors for primary PS were severe post-operative complications (OR 3.66; 95% CI, 1.19-11.20, p=0.022), and old age (OR 1.11; 95% CI 1.04-1.18, p=0.001) and those for secondary PS were local recurrence (OR 38.07; 95% CI 11.07-130.9, p<0.0001), anastomotic leakage (OR 7.01; 95% CI, 2.23-22.04, p=0.009), and severe post-operative complications (OR 3.67; 95% CI, 1.22-11.04, p=0.02), respectively. Both overall survival (OS) and disease-free survival (DFS) were significantly lower in patients with a PS compared with patients with SPS (p < 0.01). Conclusions This present study suggests that one out of 6 patients has a PS, 5 years after rectal resection with SPS for SRC.
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Affiliation(s)
- Flavie Thomas
- Centre Hospitalier Universitaire de Caen, Caen, France
| | - Benjamin Menahem
- Centre Hospitalier Universitaire de Caen, Caen, France,*Correspondence: Benjamin Menahem,
| | - Gil Lebreton
- Centre Hospitalier Universitaire de Caen, Caen, France
| | | | - Olivier Dejardin
- Institut Nationale de la Recherche Medicale (INSERM) U1086 Unité de recherche Interdisciplinaire pour la Prévention et le Traitement des Cancers, Caen, France
| | - Arnaud Alves
- Centre Hospitalier Universitaire de Caen, Caen, France
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A diversion stoma after anterior resection for rectal cancer. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract108920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
This review covers the problem of forming a diverting stoma during resections of the rectum with primary anastomosis. The incidence of rectal cancer tends to increase, and surgical resection remains the main method of treatment. Anastomotic leakage significantly increases the postoperative mortality. The most effective way to prevent severe complications is the formation of a diverting stoma. However, the indications, the choice of a specific technique and the timing of the stoma elimination are not clearly defined. This review discusses the state of the problem, special attention is paid to the choice of the level of stoma formation (ileostomy or transversostomy).
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Chiari D, LA Raja C, Mangiavillano B, Veronesi P, Platto M, Zuliani W. Multimodal treatment of colorectal postsurgical leaks: long-term results of the over-the-scope clip (OTSC) application. Minerva Surg 2022; 77:313-317. [PMID: 34338454 DOI: 10.23736/s2724-5691.21.08781-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postsurgical anastomotic colorectal leaks often require a surgical second look with a definite morbidity and the risk of delaying adjuvant treatment. The aim of this study was to analyse the long-term results of the endoscopic closure of colorectal leak following low anterior resection (LAR) using the over-the-scope (Ovesco™; Ovesco Endoscopy AG, Tübingen, Germany) clip. METHODS Patients who were submitted to endoscopic closure of a colorectal leak of maximum 2 cm with an Ovesco™ clip following LAR from 2016 to 2018 were enrolled in this retrospective single-center study (Humanitas Mater Domini Clinical Institute, Italy). The follow-up was obtained through radiologic and clinic assessments. RESULTS In the analyzed study period, 48 patients were submitted to LAR. Six patients were enrolled in the study. The median diameter of the leak was 7 mm. 14/6t or 12/6t OTSC® clip was applied. Three patients were managed exclusively endoscopically, 2 of them had a protective ileostomy; 3 patients underwent urgent laparotomy with ostomy and then underwent endoscopic procedure. Complete healing was reached in all patients in a median of 23 days. Adjuvant chemotherapy was indicated and performed in 4 patients after a median of 64 days from the surgery. Among the 5 carriers of an ostomy, 4 patients underwent recanalization. The median follow-up was 21.5 months. During the follow-up no leak reoccurrence or complications were reported. CONCLUSIONS In the multimodal management of anastomotic leaks following LAR, Ovesco™ clipping system appears a safe and effective technique in the closure of small leaks (<2 cm), allowing an early recanalization of the bowel and not delaying adjuvant chemotherapy when indicated.
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Affiliation(s)
- Damiano Chiari
- Department of General Surgery, Humanitas Mater Domini Clinical Institute, Castellanza, Varese, Italy -
| | - Carlotta LA Raja
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Clinic, Rozzano, Milan, Italy
| | - Benedetto Mangiavillano
- Department of General Surgery, Humanitas Mater Domini Clinical Institute, Castellanza, Varese, Italy
| | - Paolo Veronesi
- Department of General Surgery, Humanitas Mater Domini Clinical Institute, Castellanza, Varese, Italy
| | - Marco Platto
- Department of General Surgery, Humanitas Mater Domini Clinical Institute, Castellanza, Varese, Italy
| | - Walter Zuliani
- Department of General Surgery, Humanitas Mater Domini Clinical Institute, Castellanza, Varese, Italy
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Revised risk factors and patient characteristics for failure to close a defunctioning ileostomy following low anterior resection for locally advanced rectal cancer. Int J Colorectal Dis 2022; 37:1611-1619. [PMID: 35705724 DOI: 10.1007/s00384-022-04188-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our clinical experience led us to raise questions about the validity of the reported risk factors and patient characteristics associated with permanent stomas after sphincter-preserving resection for rectal cancer. OBJECTIVE The present retrospective study aimed to identify and compare our center's incidence and risk factors for a permanent ostomy after low anterior resection (LAR) with a diverting stoma for locally advanced mid and low rectal cancer with those in published reports. PATIENTS A total of 239 patients underwent a sphincter-preserving procedure (LAR) for rectal cancer between 2000 and 2018, and 236 of them (age range 33-83 years, 100 males (42%)) were included in the analysis. The study cohort was divided into 2 groups comprised of patients with and without permanent stomas after rectal cancer surgery. RESULTS Only 25 of the 236 operated patients (10.6%) remained with permanent stomas after rectal cancer surgery. Factors associated with stoma non-closure in the multivariate analysis were pathological stage 3 (13 (52%) vs 51 (24.2%) for patients with closed stomas, p = 0.032), disease recurrence (14 (56%) vs 40 (18.9%), respectively, p = 0.048), length of stay > 10 days, p = 0.032), and anastomotic leaks with a Clavien-Dindo score > 2 or reoperations (6 (24%) vs 13 (6.1%), p = 0.019). CONCLUSIONS Sphincter-preserving surgery for rectal cancer was associated with a lower incidence of stoma non-closure than published values. The major risk factors for non-closure were aggressive disease and severe complications of surgery.
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Sciuto A, Peltrini R, Andreoli F, Di Santo Albini AG, Di Nuzzo MM, Pirozzi N, Filotico M, Lauria F, Boccia G, D’Ambra M, Lionetti R, De Werra C, Pirozzi F, Corcione F. Could Stoma Be Avoided after Laparoscopic Low Anterior Resection for Rectal Cancer? Experience with Transanal Tube in 195 Cases. J Clin Med 2022; 11:2632. [PMID: 35566757 PMCID: PMC9104879 DOI: 10.3390/jcm11092632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Anastomotic leakage is the most-feared complication of rectal surgery. Transanal devices have been suggested for anastomotic protection as an alternative to defunctioning stoma, although evidence is conflicting, and no single device is widely used in clinical practice. The aim of this paper is to investigate the safety and efficacy of a transanal tube for the prevention of leakage following laparoscopic rectal cancer resection. A transanal tube was used in the cases of total mesorectal excision with low colorectal or coloanal anastomosis, undamaged doughnuts, and negative intraoperative air-leak test. The transanal tube was kept in place until the seventh postoperative day. A total of 195 consecutive patients were retrieved from a prospective surgical database and included in the study. Of these, 71.8% received preoperative chemoradiotherapy. The perioperative mortality rate was 1.0%. Anastomotic leakage occurred in 19 patients, accounting for an incidence rate of 9.7%. Among these, 13 patients underwent re-laparoscopy and ileostomy, while 6 patients were managed conservatively. Overall, the stoma rate was 6.7%. The use of a transanal tube may be a suitable strategy for anastomotic protection following restorative rectal cancer resection. This approach could avoid the burden of a stoma in selected patients with low anastomoses.
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Affiliation(s)
- Antonio Sciuto
- Department of General Surgery, Santa Maria delle Grazie Hospital, 80078 Pozzuoli, Italy;
- Department of Electrical Engineering and Information Technology, University of Naples Federico II, 80125 Naples, Italy
| | - Roberto Peltrini
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Federica Andreoli
- Department of Minimally Invasive Surgery, Cristo Re Hospital, 00167 Rome, Italy;
| | - Andrea Gianmario Di Santo Albini
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Maria Michela Di Nuzzo
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Nello Pirozzi
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Marcello Filotico
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Federica Lauria
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Giuseppe Boccia
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Michele D’Ambra
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Carlo De Werra
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Felice Pirozzi
- Department of General Surgery, Santa Maria delle Grazie Hospital, 80078 Pozzuoli, Italy;
| | - Francesco Corcione
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
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Clinical characteristics and predictors of permanent stoma in rectal cancer patients underwent anterior resections: the value of preoperative prognostic nutritional index. Int J Clin Oncol 2020; 25:1960-1968. [PMID: 32654048 DOI: 10.1007/s10147-020-01743-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/26/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES This study was aimed to investigate the correlation between preoperative prognostic nutritional index (PNI) and permanent stoma (PS) in patients with defunctioning stoma (DS) after anterior resections and, based on it, to reveal the clinical value of PNI on clinical strategies about the selection of stoma location. METHODS A total of 281 consecutive rectal cancer patients who accepted anterior resection and DS in the National Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University from June 2008 to June 2018 were enrolled in this study. Receiver operating characteristic (ROC) curve for PNI was performed to discriminate PS. Univariate and multivariate analysis were conducted to identify the clinical characteristics and risk factors for PS. Specific reasons for patients with DS turned into PS were reviewed. RESULTS ROC curve analysis defined PNI cutoff level of 45.85 corresponding to PS (area under the curve (AUC) = 0.71, 77% sensitivity, 56.9% specificity). Low PNI (OR = 3.23, P = 0.005), tumor crossing the peritoneal reflection (PR) (OR = 3.42, P = 0.003), postoperative distant metastasis (OR = 6.31, P < 0.001) were independently associated with PS. Besides, anastomotic complications (31.4%), poor oncological outcomes (35.3%), and personal preferences (33.3%) were the specific reasons for patients turning into PS. CONCLUSIONS Preoperative PNI is an independent prognostic factor to predict PS in patients who underwent anterior resection and DS. Therefore, combined with other clinical characteristics and predictors, preoperative measurements of PNI could provide a significant support for clinical decision on patients prepared to accept anterior resection and DS.
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12
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De Hous N, Lefevre JH, D'Urso A, Van den Broeck S, Komen N. Intraluminal bypass devices as an alternative to protective ostomy for prevention of colorectal anastomotic leakage: a systematic review of the literature. Colorectal Dis 2020; 22:1496-1505. [PMID: 32268451 DOI: 10.1111/codi.15055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
AIM Anastomotic leakage (AL) is the most important complication of colorectal surgery, leading to high morbidity and mortality. Protective ostomy, the current standard of care for protecting a colorectal anastomosis, has important drawbacks that require the creation of an alternative strategy. Over the past 30 years, several intraluminal bypass devices, designed to shield the anastomosis from the faecal stream, have been developed. The aim of this literature review was to create an updated overview of the devices available and their effectiveness in preventing AL, and to investigate whether they could serve as an alternative to protective ostomy in the future. METHOD A systematic review of the literature on intraluminal bypass devices used for preventing colorectal AL was performed. The MEDLINE and Cochrane Library databases were searched, and articles were marked as relevant if an intraluminal bypass device was studied in an animal or human population. RESULTS The database search yielded 24 relevant articles related to 10 intraluminal bypass devices protecting a colorectal anastomosis. These articles included experimental animal studies, preclinical (pilot) studies, as well as retrospective and prospective clinical studies. Each device was assessed with regard to surgical technique, effectiveness and device-related complications. CONCLUSION Intraluminal bypass devices show promise in preventing AL and its clinical consequences. However, there is insufficient high-level evidence to draw firm conclusions. There is a need for randomized controlled trials that directly compare these devices with the protective ostomy.
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Affiliation(s)
- N De Hous
- Department of Abdominal Surgery, University Hospital of Antwerp, University of Antwerp, Edegem, Belgium
| | - J H Lefevre
- Department of Digestive Surgery, Saint-Antoine Hospital, Sorbonne University, Paris, France
| | - A D'Urso
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - S Van den Broeck
- Department of Abdominal Surgery, University Hospital of Antwerp, University of Antwerp, Edegem, Belgium
| | - N Komen
- Department of Abdominal Surgery, University Hospital of Antwerp, University of Antwerp, Edegem, Belgium
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Jørgensen JB, Erichsen R, Pedersen BG, Laurberg S, Iversen LH. Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study. BJS Open 2020; 4:1162-1171. [PMID: 33022143 PMCID: PMC7709365 DOI: 10.1002/bjs5.50340] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/09/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Data on stoma reversal following restorative rectal resection (RRR) with a diverting stoma are conflicting. This study investigated a Danish population-based cohort of patients undergoing RRR to evaluate factors predictive of stoma reversal during 3 years of follow-up. METHODS Patients from national registries with rectal cancer undergoing RRR or Hartmann's procedure with curative intent between May 2001 and April 2012 were included. Patients with a diverting stoma were followed from the time of primary rectal cancer resection to date of stoma reversal, death, emigration, or end of 3-year follow-up. The cumulative incidence proportion (CIP) of stoma reversal at 1 and 3 years was calculated, treating death as a competing risk. Factors predictive of stoma reversal were explored using Cox regression analysis. RESULTS Of 6859 patients included, 35·7, 41·9 and 22·4 per cent respectively had a RRR with a diverting stoma, RRR without a stoma, and Hartmann's procedure with an end-colostomy. In patients with a diverting stoma, the CIP of stoma reversal was 70·3 (95 per cent c.i. 68·4 to 72·1) per cent after 1 year, and 74·3 (72·5 to 76·0) per cent after 3 years. Neoadjuvant treatment (hazard ratio (HR) 0·75, 95 per cent c.i. 0·66 to 0·85), blood loss greater than 300 ml (HR 0·86, 0·76 to 0·97), anastomotic leak (HR 0·41, 0·33 to 0·50), T3 category (HR 0·63, 0·47 to 0·83), T4 category (HR 0·62, 0·42 to 0·90) and UICC stage IV (HR 0·57, 0·41 to 0·80) were possible predictors of delayed stoma reversal. CONCLUSION In one-quarter of the patients the diverting stoma had not been reversed 3 years after the intended RRR procedure.
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Affiliation(s)
- J. B. Jørgensen
- Departments of SurgeryAarhusDenmark
- Department of SurgeryRanders Regional HospitalRandersDenmark
| | - R. Erichsen
- Clinical EpidemiologyAarhusDenmark
- Department of SurgeryRanders Regional HospitalRandersDenmark
| | | | | | - L. H. Iversen
- Departments of SurgeryAarhusDenmark
- Danish Colorectal Cancer GroupCopenhagenDenmark
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Zhang L, Zheng W, Cui J, Wu YL, Xu TL, Zhang HZ. Risk factors for nonclosure of defunctioning stoma and stoma-related complications among low rectal cancer patients after sphincter-preserving surgery. Chronic Dis Transl Med 2020; 6:188-197. [PMID: 32908969 PMCID: PMC7451586 DOI: 10.1016/j.cdtm.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Indexed: 12/15/2022] Open
Abstract
Background Defunctioning stoma is widely used to reduce anastomotic complications in rectal cancer surgery. However, the complications of stoma and stoma reversal surgery should not be underestimated. Furthermore, in some patients, stoma reversal failed. Here, we investigated the complications of defunctioning stoma surgery and subsequent reversal surgery and identify risk factors associated with the failure of getting stoma reversed. Methods In total, 154 patients who simultaneously underwent low anterior resection and defunctioning stoma were reviewed. Patients were divided into two groups according to whether their stoma got reversed or not. The reasons that patients received defunctioning stoma and experienced stoma-related complications and the risk factors for failing to get stoma reversed were analysed. Results The mean follow-up time was 47.54 (range 4.0–164.0) months. During follow-up, 19.5% of the patients suffered stoma-related long-term complications. Only 79 (51.3%) patients had their stomas reversed. The morbidity of complications after reversal surgery was 45.6%, and these mainly consisted of incision-related complications. Multivariate analyses showed that pre-treatment comorbidity (HR = 3.17, 95% CI 1.27–7.96, P = 0.014), postoperative TNM stage (HR = 2.55, 95% CI 1.05–6.18, P = 0.038), neoadjuvant therapy (HR = 2.75, 95% CI 1.07–7.05, P = 0.036), anastomosis-related complications (HR = 4.52, 95% CI 1.81–11.29, P = 0.001), and disease recurrence (HR = 24.83, 95% CI 2.90–213.06, P = 0.003) were significant independent risk factors for a defunctioning stoma to be permanent. Conclusions Defunctioning stoma is an effective method to reduce symptomatic anastomotic leakage, but the stoma itself and its reversal procedure are associated with high morbidity of complications, and many defunctioning stomas eventually become permanent. Therefore, surgeons should carefully assess preoperatively and perform defunctioning stomas in very high risk patients. In addition, doctors should perform stoma reversal surgery more actively to prevent temporary stomas from becoming permanent.
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Affiliation(s)
- Lin Zhang
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Wei Zheng
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Jian Cui
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Yun-Long Wu
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Tian-Lei Xu
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
| | - Hai-Zeng Zhang
- Department of Colorectal Surgery, State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
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Niu L, Wang J, Zhang P, Zhao X. Protective ileostomy does not prevent anastomotic leakage after anterior resection of rectal cancer. J Int Med Res 2020; 48:300060520946520. [PMID: 32862745 PMCID: PMC7457655 DOI: 10.1177/0300060520946520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To explore whether protective ileostomy is beneficial in preventing anastomotic leakage after anterior resection of rectal cancer. METHODS A total of 347 patients underwent anterior resection of rectal cancer in our hospital. Ninety-five patients were treated with protective ileostomy (treatment group), and 252 patients were not (control group). The incidences of anastomotic leakage and permanent stoma were compared between the two groups. RESULTS The overall incidences of anastomotic leakage were 6.32% (6/95) and 8.73% (22/252) in the treatment group and control group, respectively. In the cohort of patients who underwent neoadjuvant radiotherapy, the incidence of anastomotic leakage was 5.88% (2/34) and 12.0% (3/25) in the treatment group and control group, respectively. Logistic regression showed that the incidence of anastomotic leakage was not statistically significant. However, diabetes and the anastomotic height significantly affected the occurrence of anastomotic leakage. The permanent stoma rate was 6.42% (6/95) and 5.95% (15/252) in the treatment group and control group, respectively. CONCLUSION Protective ileostomy did not show a significant advantage in reducing the incidence of postoperative anastomotic leakage in patients with rectal cancer, and it may lead to a permanent stoma.
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Affiliation(s)
- Lei Niu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jin Wang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiaomu Zhao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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16
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Loop ileostomy versus loop colostomy as temporary deviation after anterior resection for rectal cancer. Langenbecks Arch Surg 2020; 405:1147-1153. [DOI: 10.1007/s00423-020-01940-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022]
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17
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Keller DS, Berho M, Perez RO, Wexner SD, Chand M. The multidisciplinary management of rectal cancer. Nat Rev Gastroenterol Hepatol 2020; 17:414-429. [PMID: 32203400 DOI: 10.1038/s41575-020-0275-y] [Citation(s) in RCA: 188] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2020] [Indexed: 02/07/2023]
Abstract
Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.
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Affiliation(s)
- Deborah S Keller
- Department of Surgery, New York-Presbyterian, Columbia University Medical Centre, New York, NY, USA
| | - Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Manish Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS); University College London, London, UK.
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Eray İC, Rencüzoğulları A, Yalav O, Topal U, Sarıtaş AG, Dalcı K. Rektum kanser cerrahisi sonrası kalıcı ileostomi insidansı ve risk faktörleri. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.529941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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van den Hil LCL, van Steensel S, Schreinemacher MHF, Bouvy ND. Prophylactic mesh placement to avoid incisional hernias after stoma reversal: a systematic review and meta-analysis. Hernia 2019; 23:733-741. [PMID: 31302788 PMCID: PMC6661031 DOI: 10.1007/s10029-019-01996-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/20/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To provide an overview of the available literature on prevention of incisional hernias after stoma reversal, with the use of prophylactic meshes. METHODS A literature search of Pubmed, MEDLINE and EMBASE was performed. Search terms for stoma, enterostomy, mesh, prophylaxis and hernia were used. Search was updated to December 31th 2018. No time limitations were used, while English, Geman, Dutch and French were used as language restrictions. The primary outcome was the incidence of incisional hernia formation after stoma reversal. Secondary outcomes were mesh-related complications. Data on study design, sample size, patient characteristics, stoma and mesh characteristics, duration of follow-up and outcomes were extracted from the included articles. RESULTS A number of 241 articles were identified and three studies with 536 patients were included. A prophylactic mesh was placed in 168 patients to prevent incisional hernias after stoma reversal. Follow-up ranged from 10 to 21 months. The risk of incisional hernia in case of prophylactic mesh placement was significantly lower in comparison to no mesh placement (OR 0.10, 95% CI 0.04-0.27, p < 0.001, I2 = 0%, CI 0-91.40%). No differences in surgical site infections were detected between the groups. CONCLUSIONS The use of a prophylactic mesh seems to reduce the risk on incisional hernias after stoma reversal and therefore mesh reinforcement should be considered after stoma reversal.
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Affiliation(s)
- L C L van den Hil
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands.
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands.
- Department of General Surgery, Maastricht University Medical Centre, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - S van Steensel
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
| | - M H F Schreinemacher
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
| | - N D Bouvy
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
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20
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The influence of diverting loop ileostomy vs. colostomy on postoperative morbidity in restorative anterior resection for rectal cancer: a systematic review and meta-analysis. Langenbecks Arch Surg 2019; 404:129-139. [PMID: 30747281 DOI: 10.1007/s00423-019-01758-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/29/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND The aim of this systematic review and meta-analysis was to evaluate the morbidity of loop ileostomy (LI) and loop colostomy (LC) creation in restorative anterior resection for rectal cancer as well as the morbidity of their reversal. METHODS PubMed, EMBASE, MEDLINE via Ovid, and Cochrane Library were systematically searched for records published from 1980 to 2017 by three independent researchers. The primary endpoint was overall morbidity after stoma creation and reversal. Mantel-Haenszel odds ratio (OR) was used to compare categorical variables. Clinical significance was evaluated using numbers needed to treat (NNT). RESULTS Six studies (two randomized controlled trials and four observational studies) totaling 1063 patients (666 LI and 397 LC) were included in the meta-analysis. Overall morbidity rate after both stoma creation and closure was 15.6% in LI vs. 20.4% in LC [OR(95%CI) = 0.67 (0.29, 1.58); p = 0.36] [NNT(95%CI) = 21 (> 10.4 to benefit, > 2430.2 to harm)]. Morbidity rate after stoma creation was both statistically and clinically significantly lower after LI [18.2% vs. 30.6%; OR(95%CI) = 0.42 (0.25, 0.70); p = 0.001; NNT(95%CI) = 9 (4.7, 29.3)]. Dehydration rate was 3.1% (8/259) in LI vs. 0% (0/168) in LC. The difference was not statistically or clinically significant [OR(95%CI) = 3.00 (0.74, 12.22); p = 0.13; NNT (95%CI) = 33 (19.2, 101.9)]. Ileus rates after stoma closure were significantly higher in LI as compared to LC [5.2% vs. 1.7%; OR(95%CI) = 2.65 (1.13, 6.18); p = 0.02]. CONCLUSIONS This meta-analysis found no difference between LI and LC in overall morbidity after stoma creation and closure. Morbidity rates following the creation of LI were significantly decreased at the cost of a risk for dehydration.
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Jutesten H, Draus J, Frey J, Neovius G, Lindmark G, Buchwald P, Lydrup ML. High risk of permanent stoma after anastomotic leakage in anterior resection for rectal cancer. Colorectal Dis 2019; 21:174-182. [PMID: 30411471 DOI: 10.1111/codi.14469] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 10/17/2018] [Indexed: 02/08/2023]
Abstract
AIM This study investigates how often bowel continuity was restored after anastomotic leakage in anterior resection for rectal cancer and assesses the clinical factors associated with permanent stoma. METHOD The Swedish Colorectal Cancer Registry was used to identify cases of anastomotic leakage registered in southern Sweden between January 2001 and December 2011. Patient characteristics, surgical details and clinical information about the anastomotic leakages were retrieved from medical records. RESULTS Of the 1442 patients operated on with anterior resection in 11 hospitals, 144 (10%) were diagnosed with anastomotic leakage after anterior resection for rectal cancer. After a median follow-up of 87 months (range 21-165), the overall rate of permanent stoma among patients with anastomotic leakage was 65%. Age ≥ 70 years (P = 0.02) and re-laparotomy (P < 0.001) were independently related to permanent stoma. Compared with nondefunctioned patients with anastomotic leakage, defunctioned patients with anastomotic leakage at the index procedure less often required re-laparotomy at some point during the entire clinical course (P < 0.001), but nondefunctioned and defunctioned patients with anastomotic leakage both had permanent stoma to the same extent (67% and 62%, respectively). CONCLUSION Anastomotic leakage is highly associated with permanent stoma after anterior resection, especially in patients aged ≥ 70 years. In this cohort of patients with anastomotic leakage, 65% had permanent stoma at long-term follow-up. A defunctioning stoma ameliorates the clinical course but does not affect the end result of bowel continuity in established anastomotic leakage after anterior resection.
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Affiliation(s)
- H Jutesten
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Institution of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - J Draus
- Department of Surgery, Hallands Hospital, Halmstad, Sweden
| | - J Frey
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - G Neovius
- Department of Surgery, Central Hospital, Kristianstad, Sweden
| | - G Lindmark
- Institution of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - P Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Institution of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - M L Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Institution of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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da-Fonseca LM, Buzatti KCDLR, Castro LL, Lacerda Filho A, Correia MITD, da-Silva RG. Factors preventing restoration of bowel continuity in patients with rectal cancer submitted to anterior rectal resection and protective ileostomy. Rev Col Bras Cir 2019; 45:e1998. [PMID: 30624520 DOI: 10.1590/0100-6991e-20181998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/25/2018] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE to evaluate the factors associated with non-closure of protective ileostomy after anterior resection of the rectum with total mesorectum excision for rectal cancer, the morbidity associated with the closure of ileostomies and the rate of permanent ileostomy in patients with rectal adenocarcinoma. METHODS we conducted a retrospective study with 174 consecutive patients diagnosed with rectal tumors, of whom 92 underwent anterior resection of the rectum with coloanal or colorectal anastomosis and protective ileostomy, with curative intent. We carried out a multivariate analysis to determine the factors associated with definite permanence of the stoma, as well as studied the morbidity of patients who underwent bowel continuity restoration. RESULTS In the 84-month follow-up period, 54 of the 92 patients evaluated (58.7%) had the ileostomy closed and 38 (41.3%) remained with the stoma. Among the 62 patients who had the ileostomy closed, 11 (17.7%) presented some type of postoperative complication: three had ileal anastomosis dehiscence, five had intestinal obstruction, two had surgical wound infection, and one, pneumonia. Eight of these patients required a new stoma. CONCLUSION according to the multivariate analysis, the factors associated with stoma permanence were anastomotic fistula, presence of metastases and closure of the ileostomy during chemotherapy.
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Affiliation(s)
- Leonardo Maciel da-Fonseca
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Coloproctologia, Belo Horizonte, MG, Brasil
| | - Kelly Cristine de Lacerda Rodrigues Buzatti
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Coloproctologia, Belo Horizonte, MG, Brasil
| | - Luísa Lima Castro
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte, MG, Brasil
| | - Antônio Lacerda Filho
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Coloproctologia, Belo Horizonte, MG, Brasil
| | - Maria Isabel Toulson Davisson Correia
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Nutrição, Belo Horizonte, MG, Brasil
| | - Rodrigo Gomes da-Silva
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Hospital das Clínicas, Instituto Alfa de Gastroenterologia, Grupo de Coloproctologia, Belo Horizonte, MG, Brasil
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24
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Woo IT, Park JS, Choi GS, Park SY, Kim HJ, Park IK. Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis. Ann Coloproctol 2018; 34:259-265. [PMID: 30419724 PMCID: PMC6238803 DOI: 10.3393/ac.2018.05.04] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/04/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients. Methods Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up. Results A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80–480 minutes), and the median blood loss was 80 mL (range, 30–1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444). Conclusion In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.
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Affiliation(s)
- In Teak Woo
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - In Kyu Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
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Abstract
PURPOSE Sphincter-saving surgery is widely accepted operative modality to treat rectal cancer. It often requires temporary diverting stoma to avoid the complications of anastomotic failure. This study investigates the cumulative failure rate in sphincter preservation for rectal cancer and the risk factors associated with the permanent stoma. METHODS A retrospective study on 358 patients diagnosed with primary rectal cancer from 2009 to 2013 was conducted at a single institute. Three hundred and thirty-one out of 358 patients with rectal cancer located within 12 cm from the anal verge, who underwent sphincter-preserving surgery, were included in this study. The cumulative rate for permanent stoma was calculated. Univariate and multivariate analysis were performed, comparing the patients with stoma to the ones without. RESULTS Temporary diverting stoma was created in 223 (82%) patients. After median follow-up of 42 months, 18 patients (6.6%) persistently used temporary stoma or required re-creation of stoma. Univariate analysis revealed that BMI, tumor location below 4 cm from the anal verge, coloanal anastomosis, anastomotic leakage, and local recurrence were significantly associated with persistent use or re-formation of stoma. Multivariate analysis showed that anastomotic leakage (OR 50.3; 95% CI, 10.1-250.1; p < 0.0001) and local recurrence (OR 11.3; 95% CI, 1.61-78.5; p = 0.015) were the independent risk factors. CONCLUSION Patients with anastomotic leakage and local recurrence are at high risk for permanent stoma. Not only should patients be fully informed of possible failure in sphincter preservation preoperatively, but also patient-oriented decision should be made on patient-tailored surgical plan.
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Affiliation(s)
- Ri Na Yoo
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea
| | - Gun Kim
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea
| | - Bong-Hyeon Kye
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea
| | - Hyeon-Min Cho
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea
| | - HyungJin Kim
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea.
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Mak JCK, Foo DCC, Wei R, Law WL. Sphincter-Preserving Surgery for Low Rectal Cancers: Incidence and Risk Factors for Permanent Stoma. World J Surg 2018; 41:2912-2922. [PMID: 28620675 DOI: 10.1007/s00268-017-4090-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Advances in surgical techniques and paradigm changes in rectal cancer treatment have led to a drastic decline in the abdominoperineal resection rate, and sphincter-preserving operation is possible in distal rectal cancer. OBJECTIVE The aim of this study is to evaluate the long-term incidence of permanent stoma after sphincter-preserving surgery for low rectal cancer and its corresponding risk factors. METHOD From 2000 to 2014, patients who underwent sphincter-preserving low anterior resection for low rectal cancer (within 5 cm from the anal verge) were included. The occurrence of permanent stoma over time and its risk factors were investigated by using a Cox proportional hazards regression model. RESULTS This study included 194 patients who underwent ultra-low anterior resection for distal rectal cancer, and the median follow-up period was 77 months for the surviving patients. Forty-six (23.7%) patients required a permanent stoma eventfully. Anastomotic-related complications and disease progression were the main reasons for permanent stoma. Clinical anastomotic leakage (HR 5.72; 95% CI 2.31-14.12; p < 0.001) and neoadjuvant chemoradiation (HR 2.34; 95% CI 1.12-4.90; p = 0.024) were predictors for permanent primary stoma. Local recurrence (HR 16.09; 95% CI 5.88-44.03; p < 0.001) and T4 disease (HR 11.28; 95% CI 2.99-42.49; p < 0.001) were predictors for permanent secondary stoma. The 5- and 10-year cumulative incidence for permanent stoma was 24.1 and 28.0%, respectively. CONCLUSION Advanced disease, prior chemoradiation, anastomotic leakage and local recurrence predispose patients to permanent stoma should be taken into consideration when contemplating sphincter-preserving surgery.
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Affiliation(s)
- Joanna Chung Kiu Mak
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Dominic Chi Chung Foo
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Rockson Wei
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Wai Lun Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.
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Pisarska M, Gajewska N, Małczak P, Wysocki M, Witowski J, Torbicz G, Major P, Mizera M, Dembiński M, Migaczewski M, Budzyński A, Pędziwiatr M. Defunctioning ileostomy reduces leakage rate in rectal cancer surgery - systematic review and meta-analysis. Oncotarget 2018; 9:20816-20825. [PMID: 29755692 PMCID: PMC5945534 DOI: 10.18632/oncotarget.25015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 03/08/2018] [Indexed: 12/11/2022] Open
Abstract
Objectives The role of a defunctioning ileostomy in every anterior rectal resection with total mesorectal excision (TME) is still controversial. In this study, we aimed to review the current literature to determine the impact of ileostomy creation on postoperative outcomes in patients undergoing anterior rectal resection with TME. Methods MEDLINE, Embase and Cochrane Library were searched for eligible studies. We analyzed data up to October 2017. Eligible studies had to compare patients with vs. without a defunctioning ileostomy in rectal cancer surgery and comprise data on anastomotic leakage in both groups. The primary outcome was anastomotic leakage. Secondary outcomes included the complication rate, mortality, reoperation rate, length of hospital stay and 30-day readmission. Results Initial search yielded 1,966 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. Leakage rate (RR = 0.43, 95% CI 0.28-0.67) and the number of reoperations (RR = 0.62, 95% CI 0.40-0.94) were significantly lower in the defunctioning stoma group. Morbidity was significantly higher in the stoma group (RR = 1.32, 95% CI 1.05–1.65). Analysis of mortality, length of hospital stay and readmission rate did not show any significant differences. Conclusion A defunctioning ileostomy may decrease the anastomotic leakage rate, additionally significantly reducing the risk of reoperations but it may also increase the overall complication rate. The presence of the protective stoma has no effect on mortality, length of hospital stay and readmission rate.
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Affiliation(s)
- Magdalena Pisarska
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Natalia Gajewska
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Małczak
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Wysocki
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Jan Witowski
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Grzegorz Torbicz
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Major
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Magdalena Mizera
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Dembiński
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Migaczewski
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Andrzej Budzyński
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
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Beamish EL, Johnson J, Shaw EJ, Scott NA, Bhowmick A, Rigby RJ. Loop ileostomy-mediated fecal stream diversion is associated with microbial dysbiosis. Gut Microbes 2017; 8. [PMID: 28622070 PMCID: PMC5628638 DOI: 10.1080/19490976.2017.1339003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Loop ileostomy is an effective procedure to protect downstream intestinal anastomoses. Ileostomy reversal surgery is often performed within 12 months of formation but is associated with substantial morbidity due to severe post-surgical complications. Distal ileum is deprived of enteral nutrition and rendered inactive, often becoming atrophied and fibrotic. This study aimed to investigate the microbial and morphological changes that occur in the defunctioned ileum following loop ileostomy-mediated fecal stream diversion. Functional and defunctioned ileal resection tissue was obtained at the time of loop-ileostomy closure. Intrapatient comparisons, including histological assessment of morphology and epithelial cell proliferation, were performed on paired samples using the functional limb as control. Mucosal-associated microflora was quantified via determination of 16S rRNA gene copy number using qPCR analysis. DGGE with Sanger sequencing and qPCR methods profiled microflora to genus and phylum level, respectively. Reduced villous height and proliferation confirmed atrophy of the defunctioned ileum. DGGE analysis revealed that the microflora within defunctioned ileum is less diverse and convergence between defunctioned microbiota profiles was observed. Candidate Genera, notably Clostridia and Streptococcus, reduced in relative terms in defunctioned ileum. We conclude that Ileostomy-associated nutrient deprivation results in dysbiosis and impaired intestinal renewal in the defunctioned ileum. Altered host-microbial interactions at the mucosal surface likely contribute to the deterioration in homeostasis and thus may underpin numerous postoperative complications. Strategies to sustain the microflora before reanastomosis should be investigated.
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Affiliation(s)
- Emma L. Beamish
- Division of Biomedical and Life Sciences, Lancaster University, Lancaster, UK
| | - Judith Johnson
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Elisabeth J. Shaw
- Division of Biomedical and Life Sciences, Lancaster University, Lancaster, UK
| | - Nigel A. Scott
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Arnab Bhowmick
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Rachael J. Rigby
- Division of Biomedical and Life Sciences, Lancaster University, Lancaster, UK,CONTACT Dr Rachael J. Rigby Faculty of Health and Medicine, Furness College, Lancaster University, Lancaster, LA1 4YG, United Kingdom
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Colostomy Irrigation: Issues Most Important to Wound, Ostomy and Continence Nurses. J Wound Ostomy Continence Nurs 2017; 42:487-93. [PMID: 26336046 DOI: 10.1097/won.0000000000000170] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to describe issues that WOC nurses find most important related to colostomy irrigation (CI). DESIGN This is an additional analysis of a study focusing on qualitative responses to a survey querying WOC nurses about CI practices. SUBJECTS AND SETTING The target population was members of the Wound, Ostomy and Continence Nurses Society. Of the 985 nurses who responded to the survey, 338 (34.3%) answered the optional open-ended question asking for additional comments. METHODS A 1-time online survey was conducted. In addition to demographic, educational information, and forced-choice questions about CI, an open-ended question asked for any additional comments about their experience with irrigation and WOC practice. Content analysis was used to identify common themes identified by WOC nurses. RESULTS Three hundred thirty-eight out of 985 WOC nurses (34.3%) answered the optional open-ended question asking for additional comments; analysis for this study is based on these responses. WOC nurses who responded to the open-ended question had similar characteristics to those who responded to the entire survey but were significantly more experienced (15.1 vs 11.0 years; P < .001). Multiple themes were identified that were related to forced-choice questions in the survey, such as equipment, lack of teaching time, and increased control, while several new themes emerged, including age-related recommendations, economic/ecologic benefits, cultural implications, and misconceptions of CI. CONCLUSION Many WOC nurses feel that CI is a valued modality of ostomy care and should be reestablished, although dissenting opinions were expressed. Additional research to increase the evidence base for this procedure is needed. New opportunities to educate WOC nurses and other healthcare professionals and teach eligible patients irrigation techniques are recommended.
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30
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Haksal M, Okkabaz N, Atici AE, Civil O, Ozdenkaya Y, Erdemir A, Aksakal N, Oncel M. Fortune of temporary ileostomies in patients treated with laparoscopic low anterior resection for rectal cancer. Ann Surg Treat Res 2016; 92:35-41. [PMID: 28090504 PMCID: PMC5234425 DOI: 10.4174/astr.2017.92.1.35] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/23/2016] [Accepted: 09/12/2016] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The current study aims to analyze the risk factors for the failure of ileostomy reversal after laparoscopic low anterior resection for rectal cancer. METHODS All patients who underwent a laparoscopic low anterior resection for rectal cancer with a diverting ileostomy between 2007 and 2014 were abstracted. The patients who underwent and did not undergo a diverting ileostomy procedure were compared regarding patient, tumor, treatment related parameters, and survival. RESULTS Among 160 (103 males [64.4%], mean [± standard deviation] age was 58.1 ± 11.9 years) patients, stoma reversal was achieved in 136 cases (85%). Anastomotic stricture (n = 13, 52.4%) was the most common reason for stoma reversal. These were the risk factors for the failure of stoma reversal: Male sex (P = 0.035), having complications (P = 0.01), particularly an anastomotic leak (P < 0.001), or surgical site infection (P = 0.019) especially evisceration (P = 0.011), requirement for reoperation (P = 0.003) and longer hospital stay (P = 0.004). Multivariate analysis revealed that male sex (odds ratio [OR], 7.82; P = 0.022) and additional organ resection (OR, 6.71; P = 0.027) were the risk factors. Five-year survival rates were similar (P = 0.143). CONCLUSION Fifteen percent of patients cannot receive a stoma reversal after laparoscopic low anterior resection for rectal cancer. Anastomotic stricture is the most common reason for the failure of stoma takedown. Having complications, particularly an anastomotic leak and the necessity of reoperation, limits the stoma closure rate. Male sex and additional organ resection are the risk factors for the failure in multivariate analyses. These patients require a longer hospitalization period, but have similar survival rates as those who receive stoma closure procedure.
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Affiliation(s)
- Mustafa Haksal
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey.; Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
| | - Nuri Okkabaz
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Ali Emre Atici
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Osman Civil
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Yasar Ozdenkaya
- Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
| | - Ayhan Erdemir
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Nihat Aksakal
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Oncel
- Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
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Low or Ultralow Anterior Resection of Rectal Cancer Without Diverting Stoma: Experience with 28 Patients. Indian J Surg 2016; 77:423-6. [PMID: 26730038 DOI: 10.1007/s12262-013-0863-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 01/17/2013] [Indexed: 10/27/2022] Open
Abstract
A diverting temporary stoma is frequently used to decrease the chance of anastomosis leakage in the middle and lower rectum cancer surgeries, but its role in preventing the leakage is still doubtful. This study has been designed to evaluate any possible anastomosis complications after a rectum resection and a low or ultralow anastomosis when no diverting stoma is applied in patients with rectal cancer. Twenty-eight patients suffering from rectal cancer were treated by a low anterior resection between the years 2005 and 2008 in Imam Reza University Hospital, Mashhad, Iran. Out of the 28 patients, 6 patients had already undergone a course of neoadjuvant radiotherapy. Anastomosis was performed manually in 23 patients, using a stapler in 5 of them. None of the patients had a diverting stoma. Then, the outcome was evaluated. Fecal incontinence occurred in one of the patients (6.7 %) who had already undergone a course of radiotherapy preoperatively and had a stapler used for anastomosis. No leakage was detected in any of them. The very low incidence of complications in this study, such as those not preventable by a diverting stoma, suggest a very low chance of leakage in low or ultralow anastomosis in patients with rectal cancer and in those who were treated with neoadjuvant radiotherapy.
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33
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Geng HZ, Nasier D, Liu B, Gao H, Xu YK. Meta-analysis of elective surgical complications related to defunctioning loop ileostomy compared with loop colostomy after low anterior resection for rectal carcinoma. Ann R Coll Surg Engl 2015; 97:494-501. [PMID: 26274752 PMCID: PMC5210131 DOI: 10.1308/003588415x14181254789240] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2014] [Indexed: 01/11/2023] Open
Abstract
Introduction Defunctioning loop ileostomy (LI) and loop colostomy (LC) are used widely to protect/treat anastomotic leakage after colorectal surgery. However, it is not known which surgical approach has a lower prevalence of surgical complications after low anterior resection for rectal carcinoma (LARRC). Methods We conducted a literature search of PubMed, MEDLINE, Ovid, Embase and Cochrane databases to identify studies published between 1966 and 2013 focusing on elective surgical complications related to defunctioning LI and LC undertaken to protect a distal rectal anastomosis after LARRC. Results Five studies (two randomized controlled trials, one prospective non-randomized trial, and two retrospective trials) satisfied the inclusion criteria. Outcomes of 1,025 patients (652 LI and 373 LC) were analyzed. After the construction of a LI or LC, there was a significantly lower prevalence of sepsis (p=0.04), prolapse (p=0.03), and parastomal hernia (p=0.02) in LI patients than in LC patients. Also, the prevalence of overall complications was significantly lower in those who received LIs compared with those who received LCs (p<0.0001). After closure of defunctioning loops, there were significantly fewer wound infections (p=0.006) and incisional hernias (p=0.007) in LI patients than in LC patients, but there was no significant difference between the two groups in terms of overall complications. Conclusions The results of this meta-analysis show that a defunctioning LI may be superior to LC with respect to a lower prevalence of surgical complications after LARRC.
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Affiliation(s)
- Hong Zhi Geng
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Dilidan Nasier
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Bing Liu
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Hua Gao
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Yi Ke Xu
- First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
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Waterland P, Goonetilleke K, Naumann DN, Sutcliff M, Soliman F. Defunctioning Ileostomy Reversal Rates and Reasons for Delayed Reversal: Does Delay Impact on Complications of Ileostomy Reversal? A Study of 170 Defunctioning Ileostomies. J Clin Med Res 2015; 7:685-9. [PMID: 26251682 PMCID: PMC4522985 DOI: 10.14740/jocmr2150w] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 12/21/2022] Open
Abstract
Background Temporary defunctioning ileostomy can reduce the consequences of anastomotic leak following low anterior resection. However, some patients never have their ileostomy reversed and in other cases the time to reversal of ileostomy can be delayed. The aim of this study was to identify the ileostomy closure rate following anterior resection, time to closure of ileostomy, reasons for delay in reversal and whether delay was associated with an increased complication rate. Methods Data were collected retrospectively on consecutive patients undergoing defunctioning ileostomy following anterior resection for rectal cancer, between January 2009 and August 2013. Data were collected on reversal of ileostomy rates, time to reversal, reasons for delayed reversal (defined as > 6 months) and complications following reversal. Results One hundred seventy patients were studied (median age 69 years, range 41 - 90 years), of whom 117 (69%) were male. One hundred twenty-seven (75%) patients had their ileostomies reversed. Median time to reversal was 6 months (range 1 - 42). In 63 patients who had delayed reversal, reasons were adjuvant chemotherapy (22, 35%), medical illness (14, 22%), anastomotic leak (9, 14%), and others (4, 7%). Postoperative complications occurred in 33 patients (26%). There was no postoperative mortality. Univariate analysis showed that delayed reversal was associated with an increased rate of complications and longer length of hospital stay following reversal (P < 0.05). Conclusions One in four defunctioning ileostomies are not closed following anterior resection in our unit. Of those that are closed, approximately 50% have delayed closure beyond 6 months which is associated with increased risk of complications following their ileostomy reversal.
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Affiliation(s)
- Peter Waterland
- Department of Colorectal Surgery, Worcester Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK
| | - Kolitha Goonetilleke
- Department of General Surgery, Good Hope Hospital, Rectory Road, Sutton Coldfield, West Midlands B75 7RR, UK
| | - David N Naumann
- Department of General Surgery, Good Hope Hospital, Rectory Road, Sutton Coldfield, West Midlands B75 7RR, UK
| | - Mathew Sutcliff
- Department of General Surgery, Good Hope Hospital, Rectory Road, Sutton Coldfield, West Midlands B75 7RR, UK
| | - Faris Soliman
- Department of General Surgery, Good Hope Hospital, Rectory Road, Sutton Coldfield, West Midlands B75 7RR, UK
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Chiu A, Chan HT, Brown CJ, Raval MJ, Phang PT. Failing to reverse a diverting stoma after lower anterior resection of rectal cancer. Am J Surg 2014; 207:708-11; discussion 711. [PMID: 24791631 DOI: 10.1016/j.amjsurg.2013.12.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 12/13/2013] [Accepted: 12/15/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND A diverting stoma is an accepted adjunct to low anterior resection (LAR) for rectal cancer. However, some patients do not undergo a subsequent procedure to have the stoma reversed. We aim to determine incidence and risk factors for nonclosure of the diverting stoma. METHODS This is a retrospective study of stage I to III rectal cancer patients at a single institution having LAR with curative intent and a diverting stoma. RESULTS We studied 162 patients. Prevalence of nonclosure of the temporary stoma was 14.5% within 13 months of the index surgery. On a multivariate linear regression model, nonclosure was associated with anastomotic leak (odds ratio 9.89, 2.31 to 43.93, P < .001) and age older than 65 (odds ratio 2.76, 1.08 to 7.48, P < .036). CONCLUSIONS Prevalence of nonclosure of a diverting stoma after LAR for rectal cancer is substantial (14.5%). Patients should be counselled regarding this risk with particular attention to potential risk factors.
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Affiliation(s)
- Andrew Chiu
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Hong T Chan
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Carl J Brown
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Manoj J Raval
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - P Terry Phang
- Department of Surgery, St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.
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Seo SI, Yu CS, Kim GS, Lee JL, Yoon YS, Kim CW, Lim SB, Kim JC. Characteristics and risk factors associated with permanent stomas after sphincter-saving resection for rectal cancer. World J Surg 2013; 37:2490-2496. [PMID: 23807125 DOI: 10.1007/s00268-013-2145-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The aim of the present study was to identify the risk factors and patient characteristics associated with permanent stomas after sphincter-saving resection for rectal cancer. METHOD Between 2000 and 2007, 2,362 patients underwent sphincter-saving surgery [low anterior resection or ultra-low anterior resection (uLAR)] for rectal cancer. These patients were divided into two groups: 71 patients with permanent stomas and 2,291 patients without permanent stomas after rectal cancer surgery. RESULTS Of the 71 permanent stomas (3 % of the patients), 34 (48 %) were ileostomies, 11 (15 %) were loop colostomies, 10 (14 %) were treated by Hartmann's operation, and 16 (23 %) were treated by abdominoperineal resection. Diverting stomas were created in 364 patients; 3 % (n = 11) of them could not be reversed due to anastomosis-related complications. Permanent stomas were constructed at a median of 20 months after sphincter-saving surgery for rectal cancer. The main causes of permanent stomas were local recurrence (n = 27), anastomotic leakage (n = 12), fistula (n = 9), and anastomosis site stricture (n = 7). The main causes of early permanent stomas (<1 year) were anastomosis-related complications, whereas for late permanent stomas (≥1 year), the main cause was local cancer recurrence. The independent risk factors for permanent stomas were local recurrence, postoperative pelvic sepsis, male gender of the patient, the uLAR operation type, and perioperative radiation therapy. CONCLUSIONS In a high-volume surgical center, sphincter-saving surgery for rectal cancer is associated with a low incidence of permanent stoma.
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Affiliation(s)
- Seok In Seo
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnab-2-Dong Songpa-Ku, Seoul 138-736, South Korea.
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Cumulative incidence of permanent stoma after sphincter preserving low anterior resection of mid and low rectal cancer. Dis Colon Rectum 2013; 56:1134-42. [PMID: 24022530 DOI: 10.1097/dcr.0b013e31829ef472] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Changes in the treatment of rectal cancer during the past decades have led to an increase in sphincter preservation with a consecutive decline in abdominoperineal resection rates. OBJECTIVE The aim of this study was to analyze the cumulative incidence of permanent stoma in patients undergoing sphincter-preserving resection of mid and low rectal cancer. DESIGN This study is a retrospective analysis of prospectively collected data. SETTINGS This study was conducted at a tertiary referral cancer hospital. PATIENTS From 2003 to 2010, 125 patients with primary mid and low rectal cancer who underwent sphincter-preserving low anterior resection were included. MAIN OUTCOME MEASURES The occurrence of a permanent stoma over time was investigated by using a Cox proportional hazards regression model and competing-risk models, with death as a competing risk. The risk factors were assessed by computing HRs and a Cox proportional hazards regression. RESULTS After a median follow-up time of 61 months (range, 22-113), 15 of 125 patients ended up with a permanent stoma, accounting for a 5-year cumulative incidence of 6% (95% CI, 4%-11%). The reasons for obtaining a permanent stoma were anastomotic leakage (60%, 9/15), intractable fecal incontinence (27%, 4/15), and local recurrence (13%, 2/15). The Cox proportional hazards regression identified anastomotic leakage (HR, 6.10; 95% CI, 2.23-16.71; p = 0.0004) and coloanal anastomosis (HR, 4.31; 95% CI, 1.49-12.47; p = 0.007) as statistically significant risk factors. LIMITATIONS Because of the small number of events in this sample, further investigations with a larger number of patients are required. Fecal incontinence was assessed by patient self-reported data without the use of a validated score. CONCLUSION The 5-year cumulative incidence of a permanent stoma was 6%. Anastomotic leakage and coloanal anastomosis were identified as risk factors. These details should be considered before sphincter-preserving surgery.
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Clinical value of preventative ileostomy following ultra-low anterior rectal resection. Cell Biochem Biophys 2013; 65:491-3. [PMID: 23076636 DOI: 10.1007/s12013-012-9445-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The objective was to evaluate the clinical value of preventative ileostomy following ultralow anterior rectal resection in decreasing the incidence of anastomotic leakage. For this purpose, 62 cases that had undergone ultralow anterior rectal resection during the period from June 2007 to June 2008 were included in this study. Preventative ileostomy was performed in 36 cases (group A) and 26 cases with no preventative ileostomy performed were included as controls (group B). The incidence rate of anastomotic leakage in both groups was compared. The results show that five cases in group A reported anastomotic leakage while no anastomotic leakage was reported in group B. Therefore, it was concluded that preventative ileostomy could effectively decrease the incidence of anastomotic leakage.
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Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 2013; 257:665-71. [PMID: 23333881 DOI: 10.1097/sla.0b013e31827b8ed9] [Citation(s) in RCA: 313] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the risk factors for clinical anastomotic leakage (AL) in patients undergoing laparoscopic surgery for rectal cancer. BACKGROUND Little data are available about risk factors for AL after laparoscopic rectal cancer resection. METHODS This was a retrospective analysis of 1609 patients with rectal cancer who had undergone laparoscopic surgery for rectal cancer with sphincter preservation. Clinical data related to AL were collected from 11 institutions. Univariate and multivariate analyses were performed to determine the risk factors for AL. RESULTS AL was noted in 101 (6.3%) of the patients. The leakage rate ranged from 2.0% to 10.3% for each hospital (P = 0.04). In patients without protective stomas (n = 1187), male sex [hazard ratio (HR), 3.468], advanced tumor stage (HR, 2.520), lower tumor level (HR, 2.418), preoperative chemoradiation (HR, 6.284), perioperative transfusion (HR, 10.705), and multiple firings of the linear stapler (HR, 6.181) were significantly associated with AL. Our theoretical model suggested that the HR for patients with 2 risk factors was significantly higher than that the HR for patients with no or only 1 risk factor. CONCLUSIONS Male sex, low anastomosis, preoperative chemoradiation, advanced tumor stage, perioperative bleeding, and multiple firings of the linear stapler increased the risk of AL after laparoscopic surgery for rectal cancer. A diverting stoma might be mandatory in patients with 2 or more of the risk factors identified in this analysis.
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Dong LR, Zhu YM, Xu Q, Cao CX, Zhang BZ. Clinical evaluation of extraperitoneal colostomy without damaging the muscle layer of the abdominal wall. J Int Med Res 2013; 40:1410-6. [PMID: 22971492 DOI: 10.1177/147323001204000419] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE This study investigated whether extraperitoneal colostomy without damaging the muscle layer of the abdominal wall is an improved surgical procedure compared with conventional sigmoid colostomy in patients undergoing abdominoperineal resection. METHODS Patients with rectal cancer undergoing abdominoperineal resection were selected and randomly divided into two groups: the study group received extraperitoneal colostomy without damaging the muscle layer of the abdominal wall and the control group received conventional colostomy. Clinical data from both groups were analysed. RESULTS A total of 128 patients were included: 66 received extraperitoneal colostomy without damaging the muscle layer of the abdominal wall and 62 received conventional colostomy. Significant differences between the two groups were found in relation to colostomy operating time, defaecation sensation, bowel control and overall stoma-related complications. Duration of postoperative hospital stay was also significantly different between the study groups. CONCLUSIONS Extraperitoneal colostomy without damaging the muscle layer of the abdominal wall was found to be an improved procedure compared with conventional sigmoid colostomy in abdominoperineal resection, and may reduce colostomy-related complications, shorten operating time and postoperative hospital stay, and potentially improve patients' quality of life.
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Affiliation(s)
- L-R Dong
- Department of Oncology, The Second Hospital of Jiaxing, Jiaxing, China
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Morks AN, Havenga K, ten Cate Hoedemaker HO, Leijtens JWA, Ploeg RJ, For the C-seal Study Group. Thirty-seven patients treated with the C-seal: protection of stapled colorectal anastomoses with a biodegradable sheath. Int J Colorectal Dis 2013; 28:1433-8. [PMID: 23765420 PMCID: PMC3778980 DOI: 10.1007/s00384-013-1724-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The present study was performed to get a better insight in the incidence of anastomotic leakage leading to reintervention when using the C-seal: a biodegradable sheath that protects the stapled colorectal anastomosis from leakage. METHODS The C-seal is a thin walled tube-like sheath that forms a protective sheath within the bowel lumen. Thirty-seven patients undergoing surgery with creation of a stapled colorectal anastomosis with C-seal were analyzed. Follow-up was completed until 3 months after surgery. RESULTS One patient (3%) developed anastomotic leakage leading to reintervention. None of the 37 anastomoses was dismantled. One patient was diagnosed with a rectovaginal fistula. In three patients (8%), a perianastomotic abscess spontaneously drained. CONCLUSION The incidence of anastomotic leakage leading to reintervention when using the C-seal (3%) is lower than expected based on the literature (11%). We have currently set-up a multicenter randomized trial to confirm the efficiency of the C-seal (www.csealtrial.nl).
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Affiliation(s)
- Annelien N. Morks
- Department of Surgery, Division of Abdominal Surgery, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Klaas Havenga
- Department of Surgery, Division of Abdominal Surgery, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Henk O. ten Cate Hoedemaker
- Department of Surgery, Division of Abdominal Surgery, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | | | - Rutger J. Ploeg
- Department of Surgery, Division of Abdominal Surgery, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
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Palmisano S, Leon P, Masaro S, Trevisan M, de Manzini N. Diverting Stoma. Updates Surg 2013. [DOI: 10.1007/978-88-470-2670-4_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Do older Americans undergo stoma reversal following low anterior resection for rectal cancer? J Surg Res 2012; 183:238-45. [PMID: 23298948 DOI: 10.1016/j.jss.2012.11.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/21/2012] [Accepted: 11/30/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE For low-lying rectal cancers, proximal diversion can reduce anastomotic leak after sphincter-preserving surgery; however, evidence suggests that such temporary diversions are often not reversed. We aimed to evaluate nonreversal and delayed stoma reversal in elderly patients undergoing low anterior resection (LAR). DESIGN SEER-Medicare-linked analysis from 1991-2007. SETTINGS AND PARTICIPANTS A total of 1179 primary stage I-III rectal cancer patients over age 66 who underwent LAR with synchronous diverting stoma. MAIN OUTCOME MEASURES (1) Stoma creation and reversal rates; (2) time to reversal; (3) characteristics associated with reversal and shorter time to reversal. RESULTS Within 18 mo of LAR, 51% of patients (603/1179) underwent stoma reversal. Stoma reversal was associated with age <80 y (P < 0.0001), male sex (P = 0.018), fewer comorbidities (P = 0.017), higher income (quartile 4 versus 1; P = 0.002), early tumor stage (1 versus 3; P < 0.001), neoadjuvant radiation (P < 0.0001), rectal tumor location (versus rectosigmoid; P = 0.001), more recent diagnosis (P = 0.021), and shorter length of stay on LAR admission (P = 0.021). Median time to reversal was 126 d (interquartile range: 79-249). Longer time to reversal was associated with older age (P = 0.031), presence of comorbidities (P = 0.014), more advanced tumor stage (P = 0.007), positive lymph nodes (P = 0.009), receipt of adjuvant radiation therapy (P = 0.008), more recent diagnosis (P = 0.004), and longer length of stay on LAR admission (P < 0.0001). CONCLUSIONS Half of elderly rectal cancer patients who undergo LAR with temporary stoma have not undergone stoma reversal by 18 mo. Identifiable risk factors predict both nonreversal and longer time to reversal. These results help inform preoperative discussions and promote realistic expectations for elderly rectal cancer patients.
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Ogilvie JW, Dietz DW, Stocchi L. Anastomotic leak after restorative proctosigmoidectomy for cancer: what are the chances of a permanent ostomy? Int J Colorectal Dis 2012; 27:1259-66. [PMID: 22350190 DOI: 10.1007/s00384-012-1423-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2012] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of this study is to identify rates and factors associated with permanent diversion following restorative proctosigmoidectomy for rectal cancer when complicated by an anastomotic leak. DESIGN This study is a retrospective review. SETTING The setting of this study is a tertiary referral hospital PATIENTS Patients involved in this study were those who underwent restorative rectal cancer surgery from 1997 through 2008 identified from an institutional cancer database. INTERVENTIONS No interventions were performed in this study. MAIN OUTCOME MEASURES Factors associated with time to ostomy closure and rates of permanent diversion following anastomotic leaks RESULTS One hundred and thirty patients (mean age 59.7 years) were identified, 111 (85%) of whom had stoma diversion at the index surgery. Asymptomatic occult radiological leaks occurred in 52 patients (40%). Seventy-eight patients (60%) underwent ultimate ostomy closure at a median time of 6.3 months after the index surgery, which was not significantly affected by previous radiotherapy (p = 0.08). Twelve patients (9%) underwent anastomotic reconstruction. Pathologic stage II or greater (OR 4.42; 1.95-10.04), symptomatic presentation (OR 4.13; 1.86-9.19) and anastomotic disruption >5 mm (OR 4.42; 2.01-9.74) were independently associated with permanent diversion. Among all survivors, 33% did not have their ostomy reversed. Stoma diversion constructed after leak detection in 19 patients (15%) did not affect permanent stoma rate (OR 0.86; 0.31-2.34) or time to stoma closure (p = 0.29). CONCLUSIONS The majority of anastomotic leaks after restorative rectal cancer surgery can be salvaged without anastomotic reconstruction. However, in one third of the patients, an anastomotic leak results in a permanent stoma.
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Affiliation(s)
- James W Ogilvie
- Department of Colorectal Surgery, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
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Abstract
PURPOSE The purpose of the study was to examine time to reversal of a temporary ostomy, reasons for delayed closure, and patient satisfaction with the scheduling of their closure and related hospital care. DESIGN Cross-sectional, descriptive study. SUBJECTS AND SETTING The target population comprised patients who underwent creation of a temporary ostomy and reversal surgery within one National Health System Hospital Trust in the United Kingdom. The population served by this Trust are ethnically and socioeconomically diverse, predominantly living in urban areas around Greater London. Sixty-one persons who met inclusion criteria were identified. METHODS A two-step analytical process was undertaken. First, a literature review examining incidence and causes of delayed stoma closure was undertaken. Second, a postal survey of all patients who had had their stoma closed in 2009 was conducted. Respondents were allowed 2 weeks to complete and return the questionnaire. INSTRUMENT The survey instrument was developed locally and subjected to content validation using ostomy patients, surgical and nursing colleagues. It consisted of 9 questions querying time from original surgery to closure, reasons for delaying closure surgery beyond 12 weeks, and satisfaction with care. RESULTS Twenty-seven patients returned their questionnaires, indicating they consented to participate; a response rate of 44%. Half of the respondents (n = 14 [52%]) underwent closure surgery within 6 months of stoma formation; the remaining 48% waited more than 6 months (median: 6.5 months, range: 1.5-26 months). Thirteen patients (48%) reported a delay in receiving their stoma closure; the main reason cited was the need for a course of adjuvant postoperative chemotherapy. Three quarters of respondents (22 [74%]) were satisfied with the overall care they received. CONCLUSION Findings from this study suggest that stoma closure may be associated with fewest complications if performed before 12 weeks.
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Morks AN, Havenga K, Ploeg RJ. Can intraluminal devices prevent or reduce colorectal anastomotic leakage: A review. World J Gastroenterol 2011; 17:4461-9. [PMID: 22110276 PMCID: PMC3218136 DOI: 10.3748/wjg.v17.i40.4461] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 02/18/2011] [Accepted: 02/25/2011] [Indexed: 02/06/2023] Open
Abstract
Colorectal anastomotic leakage is a serious complication of colorectal surgery, leading to high morbidity and mortality rates. In recent decades, many strategies aimed at lowering the incidence of anastomotic leakage have been examined. The focus of this review will be on mechanical aids protecting the colonic anastomosis against leakage. A literature search was performed using MEDLINE, EMBASE, and The Cochrane Collaborative library for all papers related to prevention of anastomotic leakage by placement of a device in the colon. Devices were categorised as decompression devices, intracolonic devices, and biodegradable devices. A decompression device functions by keeping the anal sphincter open, thereby lowering the intraluminal pressure and lowering the pressure on the anastomosis. Intracolonic devices do not prevent the formation of dehiscence. However, they prevent the faecal load from contacting the anastomotic site, thereby preventing leakage of faeces into the peritoneal cavity. Many attempts have been made to find a device that decreases the incidence of AL; however, to date, none of the devices have been widely accepted.
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Protection of stapled colorectal anastomoses with a biodegradable device: the C-Seal feasibility study. Am J Surg 2011; 201:754-8. [PMID: 21741509 DOI: 10.1016/j.amjsurg.2010.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 04/05/2010] [Accepted: 04/05/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND A colorectal anastomotic leak can be life-threatening. We have assessed the feasibility of a new intraluminal biodegradable bypass device that we designed to avoid anastomotic leakage and the necessity of a temporary stoma. METHODS Fifteen patients underwent colorectal surgery. Before performing the anastomosis in a standard way, the C-Seal (Polyganics BV, Groningen, The Netherlands) was glued to the anvil of the circular stapler. Consequently, the bypass was fixated in the staple row just proximal of the simultaneously made anastomosis. A water-soluble contrast enema was performed after 1 week. RESULTS The sheath was well compatible with the standard stapler device and easy to use. All donuts remained intact. No radiologic or clinical leaks were observed after surgery. CONCLUSIONS This pilot study shows that the C-Seal can be applied successfully in colorectal surgery. Further investigation with large numbers of patients is now necessary to assess the efficacy of the C-Seal as a protective device.
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Maggiori L, Bretagnol F, Lefèvre JH, Ferron M, Vicaut E, Panis Y. Conservative management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer. Colorectal Dis 2011; 13:632-7. [PMID: 20236150 DOI: 10.1111/j.1463-1318.2010.02252.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIM Anastomotic leakage (AL) after sphincter-saving resection (SSR) for rectal cancer can result in a definitive stoma (DS). The aim of the study was to assess risk factors for DS after AL-complicating SSR. METHOD Between 1997 and 2007, 200 patients underwent SSR for rectal cancer. AL occurred in 20.5% (41/200) [symptomatic 13.5% (n = 27), asymptomatic 7% (n = 14)]. Possible risk factors for DS after AL were analysed. RESULTS Management of AL consisted in no treatment (n = 14), medical treatment (n = 6), local drainage (n = 10) and abdominal reoperation (n = 11). After a median follow-up of 38 months, the overall rate of DS was 3% (n = 6): 0% for asymptomatic vs 22% after symptomatic AL (P = 0.061). After reoperation, the risk of DS was 13% when the anastomosis was preserved vs 100% after Hartmann's procedure (P = 0.007). Risk factors of DS after AL included obesity, age over 65, American Society of Anesthesiologists (ASA) score > 2 and abdominal reoperation for AL. CONCLUSION The risk of DS after SSR for cancer is low (3%) but rises to 22% after symptomatic AL. This risk depends on the surgical treatment for AL and is up to 100% if a Hartmann's procedure is performed.
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Affiliation(s)
- L Maggiori
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif, Beaujon Hospital, AP-HP, Clichy, France
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Kumar A, Daga R, Vijayaragavan P, Prakash A, Singh RK, Behari A, Kapoor VK, Saxena R. Anterior resection for rectal carcinoma - risk factors for anastomotic leaks and strictures. World J Gastroenterol 2011; 17:1475-9. [PMID: 21472107 PMCID: PMC3070022 DOI: 10.3748/wjg.v17.i11.1475] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 01/07/2011] [Accepted: 01/14/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the incidence and factors responsible for anastomotic leaks and stricture following anterior resection (AR) and its subsequent management.
METHODS: Retrospective analysis of data from 108 patients with rectal carcinoma who underwent AR or low anterior resection (LAR) to identify the various preoperative, operative, and post operative factors that might have influence on anastomotic leaks and strictures.
RESULTS: There were 68 males and 40 females with an average of 47 years (range 21-75 years). The median distance of the tumor from the anal verge was8 cm (range 3-15 cm). Sixty (55.6%) patients underwent handsewn anastomosis and 48 (44.4%) were stapled. The median operating time was 3.5 h (range 2.0-7.5 h). Sixteen (14.6%) patients had an anastomotic leak. Among these, 11 patients required re-exploration and five were managed expectantly. The anastomotic leak rate was similar in patients with and without diverting stoma (8/60, 13.4% with stoma and 8/48; 16.7% without stoma). In 15 (13.9%) patients, resection margins were positive for malignancy. Ninteen (17.6%) patients developed anastomotic strictures at a median duration of 8 mo (range 3-20 mo). Among these, 15 patients were successfully managed with per-anal dilatation. On multivariate analysis, advance age (> 60 years) was the only risk factor for anastomotic leak (P = 0.004). On the other hand, anastomotic leak (P = 0.00), mucin positive tumor (P = 0.021), and lower rectal growth (P = 0.011) were found as risk factors for the development of an anastomotic stricture.
CONCLUSION: Advance age is a risk factor for an anastomotic leak. An anastomotic leak, a mucin-secreting tumor, and lower rectal growth predispose patients to develop anastomotic strictures.
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