Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg. 2008;248:52-60. [PMID: 18580207 DOI: 10.1097/sla.0b013e318176bf65]

A diversion stoma after anterior resection for rectal cancer

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).

Clinical assessment for non-reversal stoma and stoma re-creation after reversal surgery for rectal cancer patients after sphincter-saving operation

BACKGROUND

This study aimed to identify the risk factors for permanent stoma (PS) in patients who underwent sphincter-saving operations for rectal cancer.

METHODS

We retrospectively reviewed 597 consecutive patients with rectal cancer from January 2012 to December 2020 at Taipei Medical University Hospital. Univariate and multivariable analyses were used to analyze risk factors for PS.

RESULTS

After a mean follow-up of 47.3 months (range 7-114 months), 59 patients (15.1%) were alive with a PS, including 46 patients who did not undergo reversal surgery and 13 patients who underwent stoma re-creation after reversal surgery. The mean period between primary surgery and stoma reversal was 6.0 months. Multivariate analysis revealed that the risk factors for PS were local recurrence [odd ratio (OR), 25.58; 95% confidence interval (CI), 4.428-147.761; p < 0.001], perirectal abscess [OR, 154.34; 95% CI, 15.806 - >999; p < 0.001], anastomosis site stenosis [OR, 187.081; 95% CI, 22.193 - >999; p < 0.001], perineural invasion [OR, 4.782; 95% CI, 1.22-18.736; p = 0.025], and operation time (min) [OR, 1.008; 95% CI, 1.002-1.014; p = 0.01].

CONCLUSIONS

Local recurrence, perirectal abscess, anastomosis site stenosis, perineural invasion, and operation time were independent risk factors for PS. Therefore, before a patient undergoes surgery for rectal cancer, surgeons should consider the possibility of the need for a PS, and patients should be informed before the operation that closure of the temporary stoma may not always be possible.

Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery

Anastomotic leakage (AL) has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure. An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication. Despite AL continues to be a dreadful compli-cation after colorectal surgery, there has been no consensus on its management. However, based on patient's presentation and timing of the AL, there has been a gradual shift to a more conservative management, keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak. A nonoperative management is usually preferred in these patients. There are several treatment options, also for patients without a stoma who do not require a reoperation for a contained pelvic leak, including recently developed endoscopic procedures, such as clip placement or endoluminal vacuum-assisted therapy. More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.

Revised risk factors and patient characteristics for failure to close a defunctioning ileostomy following low anterior resection for locally advanced rectal cancer

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.

Comparison of postoperative complication rates between a novel endoluminal balloon-assisted drainage and diverting stoma after low rectal cancer

AIM

To introduce a novel endo-luminal balloon-assisted drainage (EBAD) and compare postoperative complication rates between EBAD and diverting stoma (DS) groups.

METHODS

The single center prospective non-random cohort study included a total of 163 patients in convenience patients with rectal cancer between January 2019 and January 2021. Out of 163 patients, 83 underwent DS and 80 EBAD. Primary endpoints were postoperative complication rate.

RESULTS

The total number of complications was 28 in the DS group vs. 22 in the EBAD group (P = 0.388). 18 patients (21.7%) in the DS group and 14 patients (17.5%) in the EBAD group developed postoperative complication (P = 0.501). There were no differences identified for anastomotic leak rates between the two groups (P = 0.677). The rate of the pelvic abscess was lower in the EBAD group (1/80, 1.3%) than in the DS group (4/83, 4.8%) but with no statistical significance (P = 0.386). Compared with the DS group, the median operative time was shorter in the EBAD group (225 vs. 173.5 min, P < 0.001). Regarding incomplete small bowel obstruction, a higher prevalence was observed in the DS group compared to the EBAD group (7.2% vs 2.5%, P = 0.301). 7 patients (11.3%) in the DS group developed a para-stomal hernia, while no patient suffered a catheter-related complication. The median postoperative hospital stay was shorter in the DS groups than in the EBAD group (7 vs 8 days, P = 0.009). The median residence time of endo-luminal balloon-assisted drainage was 5.41 days. The median average and total volume of drainage were 51.57 ml/day and 255 ml, respectively.

CONCLUSION

EBAD is feasible and safe with similar postoperative complications when compared with a DS. EBAD may replace DS after rectum resection.

The impact of prolonged delay to loop ileostomy closure on postoperative morbidity and hospital stay: A retrospective cohort study

AIM

There is increasing evidence that delayed loop ileostomy closure is associated with an increase in postoperative morbidity. In the context of a publicly funded health service with constrained theatre access, we review the impact of delay in loop ileostomy closure.

METHOD

A retrospective cohort study of patients undergoing loop ileostomy closure at the Dunedin Public Hospital between 2000-2017 was performed. Cases and complications were identified from the prospectively maintained Otago Clinical Audit database. Patient demographics, ASA score, indications for ileostomy, reasons for delay in closure, length of stay (LOS) after ileostomy closure and complications were collected. LOS and overall complication rate were assessed using univariable and multivariable analyses.

RESULTS

A total of 292 patients were included in the study, of whom 74 (25.3%) were waiting for longer than 12 months for ileostomy closure. The overall complication rate was 21.5%. This was 8% up to 90 days, 20% between 90-360 days, 28% between 360-720 days and 54% after 720 days. Delay was associated with an increased risk of any complication (RR 1.06 for every 30 days with stoma, p < 0.001), including Ileus (OR [95% CI] 1.06 [1.00-1.11], p = 0.024). Overall mean LOS was 5.9 days (range 1-63), being 4.6 days up to 180 days, 5.6 between 180-720 days and 8.7 after 720 days. LOS significantly increased with increasing stoma duration (p = 0.04).

CONCLUSION

Increasing time with loop ileostomy is detrimental for patients, being associated with an increase in complication rates, and is detrimental for hospitals due to increased length of stay. Resources should be allocated for timely closure of loop ileostomies.

Protective ileostomy increased the incidence of rectal stenosis after anterior resection for rectal cancer

BACKGROUND

In most of the views, rectal stenosis after anterior resection for rectal cancer results from pelvic radiotherapy. However, patients without receiving radiotherapy also suffer stenosis. In this study, we evaluated the factors associated with rectal stenosis after anterior rectal resection (ARR).

METHODS

We conducted a retrospective study with ARR patients who underwent neoadjuvant chemoradiotherapy and the patients without radiotherapy. Patients who received watch and wait strategy with a clinical complete response after chemoradiotherapy were also included. Patients with colonoscopy follow-up were included for further analyses; 439 patients who underwent neoadjuvant chemoradiotherapy; 545 patients who received ARR without radiotherapy and 33 patients who received watch and wait strategy. Stenosis was diagnosed when a 12-mm diameter colonoscopy could not be passed through the rectum. Univariate and multivariate logistic regression analyses were performed to identify variables associated with rectal stenosis.

RESULTS

According to the multivariate analysis in patients receiving ARR, both protective stoma and preoperative radiotherapy affected the occurrence of stenosis, with the odds ratios (ORs) of 3.375 and 2.251, respectively. According to the multivariate analysis, a preventive ileostomy was the only factor associated with stenosis both in patients receiving preoperative radiotherapy and without radiotherapy. Non-reversal ileostomy and long time between ileostomy and restoration increased the possibility of stenosis. In 33 patients who received watch and wait strategy, only one patient (3%) experienced stenosis.

CONCLUSION

Both surgery and radiotherapy are risk factors for rectal stenosis in rectal cancer patients. Compared to preoperative radiotherapy, a protective ileostomy is a more critical factor associated with rectal stenosis.

Risk Factors for Anastomotic Leakage in Advanced Ovarian Cancer Surgery: A Large Single-Center Experience

Background

Cytoreductive surgery is currently the main treatment for advanced epithelial ovarian cancer (OC), and several surgical maneuvers, including colorectal resection, are often needed to achieve no residual disease. High surgical complexity carries an inherent risk of postoperative complications, including anastomosis leakage (AL). Albeit rare, AL is a life-threatening condition. The aim of this single-center retrospective study is to assess the AL rate in patients undergoing colorectal resection and anastomosis during primary surgery for advanced epithelial OC through a standardized surgical technique and to evaluate possible pre/intra- and postoperative risk factors to identify the population at greatest risk.

Methods

A retrospective analysis of clinical and surgical characteristics of 515 patients undergoing colorectal resection and anastomosis during primary or interval debulking surgery between December 2011 and October 2019 was performed. Several pre/intra- and postoperative variables were evaluated by multivariate analysis as potential risk factors for AL.

Results

The overall anastomotic leakage rate was 2.9% (15/515) with a significant negative impact on postoperative course. Body mass index < 18 kg/m², preoperative albumin value lower than 30 mg/dL, section of the inferior mesenteric artery at its origin, and medium–low colorectal anastomosis (< 10 cm from the anal verge) were identified as independent risk factors for AL on multivariate analysis.

Conclusions

AL is confirmed to be an extremely rare but severe postoperative complication of OC surgery, being responsible for increased early postoperative mortality. Preoperative nutritional status and surgical characteristics, such as blood supply and anastomosis level, appear to be the most significant risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11686-y.

Tailored Management with Highly-Selective Diversion for Low Colorectal Anastomosis: Biochemical Postoperative Follow-Up and Long-Term Results from a Single-Institution Cohort

BACKGROUND

Defunctioning stoma (DS) can decrease the rate of symptomatic anastomotic leakage (AL). Since 2010, we have used tailored, highly selective DS management for low colorectal anastomosis (LCRA).

METHODS

In total, 433 rectal cancer patients underwent the same standardized procedure. Non-stoma (NS) management was used in patients with no surgical difficulties as well as good colonic preparation and quality of anastomoses. In all other cases, DS was used. C-reactive protein was measured during postoperative follow-up. Imbalance in the initial population was adjusted using propensity-score matching according to sex, age, body mass index, tumor location, and American Society of Anesthesiologists score. Rate of AL within 30 days, 5-year overall survival, local relapse-free survival, and disease-free survival were recorded.

RESULTS

Anastomosis was mostly ultra-low and was performed equally by laparoscopy or robotic surgery. The overall rate of AL was 13.4%, with no significant differences between groups (DS, 12.2%; NS, 14.6%; p = 0.575). Operative time, blood loss, and hospital stay were significantly lower for NS patients. The rate of secondary stoma was 11.4% overall. Pathological results were similar, with a 98% R0 resection rate. With a median follow-up of 5.5 years for the NS and DS groups, the overall survival was 84.9% and 73.4%, respectively (p = 0.064), disease-free survival was 67.0% and 55.8%, respectively (p = 0.095), and local relapse-free survival was 95.2% and 88.7%, respectively (p = 0.084). The long-term, stoma-free rate was 89.1% overall.

CONCLUSIONS

Tailoring DS for LCRA seems safe and could provide potential benefits in postoperative morbidity with the same long-term oncological results in NS patients. Prospective, multicentric studies should validate this approach.

A technique for constructing diverting loop ileostomy to prevent outlet obstruction after rectal resection and total colectomy: a retrospective single-center study

PURPOSE

Preventing outlet obstruction associated with a diverting stoma is important. Previously, we constructed a diverting loop ileostomy with the proximal limb of the small intestine on the caudal side, namely the oral inferior (OI) method. However, to address the issue of twisting and stenosis of the small intestine, we recently constructed a diverting loop ileostomy with the proximal limb on the cranial side, namely the oral superior (OS) method. We compared the incidence of outlet obstruction between the two methods.

METHODS

The subjects of this retrospective study were 133 patients who underwent colorectal resection or total colectomy, with D2 or more lymph node dissection and diverting loop ileostomy construction, between April, 2001 and December, 2018, at our hospital. The OI method was performed in 54 patients and the OS method was performed in 79 patients.

RESULTS

In the OS group, a history of laparotomy, neoadjuvant therapy, clinical stage III, and the use of anti-adhesion materials were more common, whereas blood loss and the incidence of outlet obstruction were significantly lower. Multivariate analysis identified only OS placement as a significant factor for reducing the incidence of outlet obstruction.

CONCLUSION

When constructing a diverting loop ileostomy, placing the proximal limb on the cranial side is important.

Protective ostomies in ovarian cancer surgery: a systematic review and meta-analysis

OBJECTIVE

To assess the benefit of protective ostomies on anastomotic leak rate, urgent re-operations, and mortality due to anastomotic leak complications in ovarian cancer surgery.

METHODS

A systematic literature search was performed in MEDLINE, Web of Science, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials for all studies on anastomotic leak and ostomy formation related to ovarian cancer surgery. Non-controlled studies, case series, abstracts, case reports, study protocols, and letters to the editor were excluded. Meta-analysis was performed on the primary endpoint of anastomotic leak rate. Subgroup analysis was carried out based on type of bowel resection and bevacizumab use. Secondary endpoints were urgent re-operations and mortality associated with anastomotic leak, length of hospital stay, postoperative complications, 30-day readmission rate, adjuvant chemotherapy, survival, and reversal surgery in ostomy and non-ostomy patients.

RESULTS

A total of 17 studies (2,719 patients) were included: 16 retrospective cohort studies, and 1 case-control study. Meta-analysis of 17 studies did not show a decrease in anastomotic leak rate in ostomy patients (odds ratio [OR]=1.01; 95% confidence interval [CI]=0.60-1.70; p=0.980). Meta-analysis of ten studies (1,452 women) did not find a decrease in urgent re-operations in the ostomy group (OR=0.72; 95% CI=0.35-1.46; p=0.360). Other outcomes were not considered for meta-analysis due to the lack of data in included studies.

CONCLUSION

Protective ostomies did not decrease anastomotic leak rates, and urgent re-operations in ovarian cancer surgery. This evidence supports the use of ostomies in very select cases.

Survey Regarding Gastrointestinal Stoma Construction and Closure in Japan

Background and Aim

In Japan, the actual number of stoma constructions and stoma closures is not known. The aim of this study was to conduct a survey to determine the number of gastrointestinal stoma constructions and closures in Japan.

Methods

Enrolled participants comprised patients undergoing selected gastrointestinal surgeries who were recorded in the National Clinical Database. This database uses the "Common Items for Gastrointestinal Surgeons." These procedures were formulated by the Japanese Society of Gastroenterological Surgery during 2013-2018.

Results

According to the National Clinical Database, a total of 154,323 gastrointestinal stomas were constructed between January 1, 2013 and December 31, 2018. By procedure, there were 78,723 cases of stoma construction, 39,653 of abdominoperineal resection, 2470 total pelvic exenteration procedures, and 33,572 Hartmann's procedures. The ratio of stoma closures to stoma constructions increased annually in patients under 70 y of age but not in older patients. Approximately 35% of total colectomies, 60% of proctocolectomies, and 20% of low anterior resections were accompanied by stoma construction. The number of patients with rectal cancer who underwent colostomy increased gradually during the study period and the number who underwent stoma construction increased among older patients.

Conclusion

The number of cases of gastrointestinal stoma construction has increased gradually in Japan, and the proportion of older patients is increasing each year. The purposes and surgical techniques for stoma construction are diverse and are expected to increase in Japan, a super-aged society.

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

Evaluation of the SafeHeal Colovac+ Anastomosis Protection Device: A Preclinical Study

BackgroundThe protective ostomy is the current standard of care to protect a low colorectal anastomosis from leakage, but exposes patients to complications requiring an alternative strategy. The Colovac+ is a vacuum-based intraluminal bypass device designed to shield the anastomosis from fecal content, preventing the clinical outcomes of anastomotic leakage. The objective of this study was to evaluate the preliminary efficacy, safety, and technical feasibility of the Colovac+ in a porcine model. Methods: Twelve pigs received a colorectal anastomosis with Colovac+ implantation. The device was left in situ for 10 days and then retrieved endoscopically. Six pigs were to be sacrificed immediately after device retrieval and the other 6 were to be sacrificed on day 38. Clinical, endoscopic, and histopathological examinations were performed to evaluate the following endpoints: prevention of contact between the anastomosis and fecal content, device migration, feasibility of the implantation and retrieval procedure, collateral damage to the colonic wall, colon healing after device retrieval, and systemic toxicity related to the device. Results: Eleven pigs completed the study. One pig died prematurely due to a surgical complication unrelated to the device (bladder damage with uroperitoneum). There was no evidence of contact between the anastomosis and fecal content, none of the pigs developed symptomatic anastomotic leakage, there were no significant device migrations, and there was no evidence of systemic toxicity. Colovac+ implantation was easily performed in all cases except 1 (due to an inappropriate lubricant). Colovac+ retrieval was achieved successfully in all cases. Postretrieval examinations on day 10 revealed ulcerations at the anchoring site in 4 cases indicating mechanical damage caused by the stent. However, in the recovery group, no ulcerations were observed on day 38, and the colonic wall had properly healed in all animals. Conclusions: The Colovac+ is a technically feasible, safe, and efficient device for the protection of a colorectal anastomosis in a porcine model. The device holds promise for clinical use and warrants further research.

Effects of Neoadjuvant Radiotherapy on Postoperative Complications in Rectal Cancer: A Meta-Analysis

Objective

Neoadjuvant radiotherapy (nRT) is an important treatment approach for rectal cancer. The relationship, however, between nRT and postoperative complications is still controversial. Here, we conducted a meta-analysis to evaluate such concerns.

Methods

The electronic literature from 1983 to 2021 was searched in PubMed, Embase, and Web of Science. Postoperative complications after nRT were included in the meta-analysis. The pooled odds ratio (OR) was calculated by the random-effects model. Statistical analysis was conducted by Review Manager 5.3 and STATA 14.

Results

A total of 23,723 patients from 49 studies were included in the meta-analysis. The pooled results showed that nRT increased the risk of anastomotic leakage (AL) compared to upfront surgery (OR = 1.23; 95% CI, 1.07-1.41; p=0.004). Subgroup analysis suggested that both long-course (OR = 1.20, 95% CI 1.03-1.40; p=0.02) and short-course radiotherapy (OR = 1.25, 95% CI, 1.02-1.53; p=0.04) increased the incidence of AL. In addition, nRT was the main risk factor for wound infection and pelvic abscess. The pooled data in randomized controlled trials, however, indicated that nRT was not associated with AL (OR = 1.01; 95% CI 0.82-1.26; p=0.91).

Conclusions

nRT may increase the risk of AL, wound infection, and pelvic abscess compared to upfront surgery among patients with rectal cancer.

A stent-based diverting technique after low anterior resection of rectal cancer: our preliminary experience

BACKGROUND

Anastomotic leakage (AL) is a severe complication of rectal cancer low anterior resection (LAR). Ileostomy, the most common method to reduce the severity of AL, is associated with the risk of permanent stoma and an additional operation for stoma reversal. This purpose of this study is to develop a novel protective technique called the stent-based diverting technique (SDT) to protect the anastomosis following LAR.

METHODS

From March 2020 to December 2020, thirty-four patients treated with LAR followed by SDT were enrolled prospectively at Sir Run Run Shaw Hospital. Demographic characteristics, laboratory test results, surgical outcomes, and oncological features were recorded.

RESULTS

Overall, the median period of stent degradation was 21 (18-24) days. One patient (2.9%) had anastomotic leakage, and another patient (2.9%) had intestinal obstruction, while no other complications (e.g., intestinal volvulus, perforation, fistula) were observed in this study.

CONCLUSIONS

The unique SDT may be a novel approach to prevent anastomotic leakage following low anterior resection of rectal cancer.

Effect of transanal drainage tube of anastomotic leakage following low anterior resection without a defunctioning stoma for rectal cancer

PURPOSE

Anastomotic leakage (AL) is one of the most serious complications of rectal cancer surgery. The aim of this study was to analyze the effectiveness and safety of transanal drainage tube (TDT) placement to prevent AL after low anterior resection (LAR) for rectal cancer.

MATERIAL AND METHOD

In this retrospective study, the data of 556 patients with rectal cancer who underwent LAR using the double stapling technique between January 2001 and April 2016 were analyzed. The patients were divided two groups: the non-transanal drainage tube (NTDT) group comprised patients without a TDT (n = 341) and the transanal drainage tube (TDT) group, patients with a TDT (n = 215).

RESULTS

The overall rate of AL was 4.1% (n = 23). The AL rate was significantly lower in the TDT group. The AL rate was 5.6% (n = 19) in the NTDT group and 1.9% (n = 4) in the TDT group (p = 0.032). The mean time of AL postoperatively was 6.0 days. Among AL patients, the re-operation rate for AL was 84.2% (16/19) for the NTDT group and 75.0% (3/4) for the TDT group. Sex, age, BMI, neoadjuvant chemoradiation therapy, tumor location, and double stapler diameter were not analysized to be risk factors for AL after LAR. Non-use of a TDT (odds ratio, 0.106; 95% confidence interval, 0.013-0.843; p = 0.034) was established as a risk factor for AL in the logistic analysis.

CONCLUSION

Based on the present data, TDT placement can reduce the rate of AL following LAR using the double stapling technique for rectal cancer.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

Trends in risk factors of anastomotic leakage after colorectal cancer surgery (2011-2019): A Dutch population-based study

AIM

Anastomotic leakage (AL) after colon cancer (CC) and rectal cancer (RC) surgery often requires reintervention. Prevalence and morbidity may change over time with evolutions in treatment strategies and changes in patient characteristics. This nationwide study aimed to evaluate changes in the incidence, risk factors and mortality from AL during the past nine years.

METHODS

Data of CC and RC resections with primary anastomosis were extracted from the Dutch Colorectal Audit (2011-2019). AL was registered if requiring reintervention. Three consecutive cohorts were compared using logistic regression analysis.

RESULTS

Incidence of AL after CC surgery decreased from 6.6% in 2011-2013 to 4.8% in 2017-2019 and increased from 8.6% to 11.9% after RC surgery. In 2011-2013, male sex, ASA ≥3, (y)pT3-4, neoadjuvant therapy, emergency surgery and multivisceral resection were identified as risk factors for AL after CC surgery. In 2017-2019, only male sex and ASA ≥3 were risk factors for AL. For RC patients, male sex and neoadjuvant therapy were a risk factor for AL in 2011-2013. In 2017-2019, transanal approach was also a risk factor for AL. Postoperative mortality rate after AL was 12% (CC) and 2% (RC) in 2017-2019, without significant changes over time.

CONCLUSION

Contradictory trends in incidence and mortality for AL were observed among CC and RC surgery with changing risk factors over the past 9 years. High mortality after AL is only observed after CC surgery and remains unchanged. Continued efforts should be made to improve early detection and treatment of AL for these patients.

Split stoma with delayed anastomosis may be preferred for 2-stage surgical resection in high-risk patients with Crohn's disease

BACKGROUND

Fecal diversion after bowel resection is a safe and effective procedure in high-risk patients with Crohn's disease, but the better approach between primary anastomosis with protective stoma and split stoma with delayed anastomosis has not yet been investigated. This study aimed to compare the outcomes of these approaches in high-risk patients with Crohn's disease.

METHODS

A retrospective investigation on consecutive high-risk patients with Crohn's disease was conducted at a tertiary referral hospital from August 2009 to March 2019. The primary outcomes were the overall early postoperative complications and overall anastomosis-related adverse events in an intention-to-treat approach.

RESULTS

A total of 118 consecutive patients who underwent 121 surgeries (35 procedures with a protective stoma and 86 procedures with a split stoma) were enrolled. After a median follow-up period of 659 days and 728 days, respectively, 25 patients underwent a stoma-reversal procedure in the protective-stoma group, and 54 patients underwent delayed anastomosis in the split stoma group. Overall, early 30-day surgical morbidity and anastomosis-related adverse events were observed in more patients in the protective-stoma group than in the split-stoma group (51.4% [18/35] vs 30.2% [26/86]; P = .028 and 37.1% [13/35] vs 2.3% [2/86]; P < .001, respectively; intention-to-treat analysis). Similar results were found in the per-protocol analysis (44.0% [11/25] vs 20.4% [11/54]; P = .029 and 36.0% [12/25] vs 3.7% [2/54]; P < .001, respectively.) CONCLUSION: Split stoma with delayed anastomosis is associated with a reduction in anastomotic adverse events and overall early surgical complications and thus may be a better surgical option for high-risk patients with Crohn's disease.

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD): A novel approach to the local treatment of early rectal cancer

BACKGROUND

Complete local resection is currently the treatment of choice for low-risk early rectal cancer; however, the ideal resection technique for such tumours is still debated. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique which combines the ergonomic advantages of transanal endoscopic microsurgery (TEM) with the minimally invasive approach of endoscopic submucosal dissection (ESD). The aim of our study was to assess the feasibility, safety, and long-term outcomes of TEM-ESD in treating early rectal cancer.

MATERIALS AND METHODS

We retrospectively analysed all cases of rectal adenocarcinomas treated with TEM-ESD in Karlsruhe Municipal Hospital between 2012 and 2019, as well as the perioperative and follow-up data of the patients.

RESULTS

We identified 40 cases (19 low-risk and 21 high-risk carcinomas) matching our criteria. The median size of the lesions was 3.8 cm and the median operating time 48.5 min. En bloc resection was possible in all cases, while histologically complete resection was confirmed in 18 of 19 low-risk tumours and in 30 out of all lesions. The resection was curative in 19 cases. No scarring of the mesorectum was reported during the completion of total mesorectal excision for high-risk tumours. There was only 1 case of local recurrence among patients treated with curative intent, with an overall survival rate of 100% and a disease-free survival rate of 96% at both 2 and 5 years for these patients.

CONCLUSION

TEM-ESD is a safe and feasible therapeutic option for resecting early rectal cancer, offering very good long-term outcomes.

Time interval between rectal cancer resection and reintervention for anastomotic leakage and the impact of a defunctioning stoma: A Dutch population-based study

AIM

In the Netherlands, a selective policy of faecal diversion after rectal cancer surgery is generally applied. This study aimed to evaluate the timing, type, and short-term outcomes of reoperation for anastomotic leakage after primary rectal cancer resection stratified for a defunctioning stoma.

METHOD

Data of all patients who underwent primary rectal cancer surgery with primary anastomosis from 2013-2019 were extracted from the Dutch ColoRectal Audit. Primary outcomes were new stoma construction, mortality, ICU admission, prolonged hospital stay, and readmission.

RESULTS

In total, 10,772 rectal cancer patients who underwent surgery with primary anastomosis were included, of whom 46.6% received a primary defunctioning stoma. The reintervention rate for anastomotic leakage was 8.2% and 11.6% for patients with and without a defunctioning stoma (p < 0.001). Reintervention consisted of reoperation in 44.0% and 85.3% (p < 0.001), with a median time interval from primary resection to reoperation of seven days (IQR 4-14) vs. five days (IQR 3-13), respectively. In the presence of a defunctioning stoma, early reoperation (<5 days; n = 47) was associated with significantly more end-colostomy construction (51% vs. 33%) and ICU admission (66% vs. 38%) than late reoperation (≥5 days; n = 127). Without defunctioning stoma, early reoperation (n = 252) was associated with significantly higher mortality (4% vs. 1%), and more ICU admissions (52% vs.34%) than late reoperation (n = 302).

CONCLUSIONS

Early reoperations after rectal cancer resection are associated with worse outcomes reflected by a more frequent ICU admission in general, more colostomy construction, and higher mortality in patients with primary defunctioned and nondefunctioned anastomosis.

Colorectal: Management of Postoperative Complications in Colorectal Surgery

The complications encountered in colorectal surgery can be categorized into early and late. The most consequential early complication is anastomotic leak, which can be managed with percutaneous drainage or reoperation, depending on the patient's clinical status. Other early complications include anastomotic bleeding, surgical site infection, ileus, postoperative urinary retention, and stoma-related complications. Most stoma-related complications can be managed without reoperation. Late complications, such as bowel dysfunction, sexual dysfunction, and anastomotic stricture, are usually managed expectantly and should be discussed in the preoperative setting. There is growing interest in prevention of postoperative outcomes with preoperative nutritional supplementation and prehabilitation.

The role of Hartmann's procedure in the elective management of rectal cancer: results of a Brazilian cohort study

BACKGROUND

although preservation of bowel continuity is a major goal in rectal cancer surgery, a colorectal anastomosis may be considered an unacceptably high-risk procedure, particularly for patients with multiple comorbidities. We aimed to assess rates of surgical complications in rectal cancer patients according to the type of procedure they had undergone.

MATERIALS AND METHODS

this cohort included all rectal cancer patients undergoing elective resection at a referral academic hospital over 16 years. There were three study groups according to the type of performed operation: (1) rectal resection with anastomosis without defunctioning stoma (DS); (2) rectal resection with anastomosis and DS; and (3) Hartmann's procedure (HP). Postoperative complications and clinical outcomes were assessed.

RESULTS

four-hundred and two patients were studied. The 118 patients in group 3 were significantly older (>10 years), had higher Charlson Comorbidity Index scores, and more ASA class ≥3 than patients in the other two groups. Sixty-seven patients (16.7%) had Clavien-Dindo complications grade ≥ III, corresponding to an incidence of 11.8%, 20.9%, and 14.4% in groups 1, 2, and 3, respectively (p=0.10). Twenty-nine patients (7.2%) had major septic complications that required reoperation, with an incidence of 10.8%, 8.2% and 2.5% in groups 1, 2 and 3, respectively (p=0.048). Twenty-one percent of the group 2 patients did not undergo the stoma closure after a 24-month follow-up.

CONCLUSION

HP was associated with a lower incidence of reoperation due to intra-abdominal septic complications. This procedure remains an option for patients in whom serious surgical complications are anticipated.

Safety of Small Circular Staplers in Double Stapling Technique Anastomosis for Sigmoid Colon and Rectal Cancer

BACKGROUND

Although smaller circular staplers are easier to insert and less likely to involve the vagina and levator ani muscles when performing double stapling technique anastomosis, surgeons often consider that larger circular staplers would be safer in reducing the risk of postoperative anastomotic strictures.

OBJECTIVE

This study aimed to investigate the safety of using 25-mm circular staplers compared with 28/29-mm staplers in the double stapling technique anastomosis regarding the development of anastomotic strictures and other complications.

DESIGN

This is a retrospective observational study.

SETTING

This study was conducted at a single comprehensive cancer center.

PATIENTS

Consecutive patients undergoing curative colorectal resection with double stapling technique anastomosis for stage I to III sigmoid colon and rectal cancer between 2013 and 2016 were included.

MAIN OUTCOME MEASURES

The incidence of anastomotic complications (strictures, leakage, and bleeding) was compared between the 25- and 28/29-mm circular staplers. Predictors for anastomotic strictures were investigated with multivariable logistic regression.

RESULTS

Small (25-mm) staplers were used in 186 (22.8%) of 815 eligible patients. The 25-mm staplers were associated with use in female patients, splenic flexure take down, high tie of the inferior mesenteric artery, and low anastomosis. Overall anastomotic complications (11.8% vs 13.7%, p = 0.51), strictures (5.9% vs 3.3%, p = 0.11), leakage (2.7% vs 3.8%, p = 0.47), and bleeding (4.8% vs 7.6%, p = 0.19) were not different between the 25- and 28/29-mm staplers. From multivariable logistic regression, independent predictors of anastomotic strictures included diverting ostomy and anastomotic leakage, but not small circular stapler use. Most of the 32 anastomotic strictures were successfully treated without surgical intervention (finger dilation, n = 25; endoscopic intervention, n = 5).

LIMITATIONS

This was a single-center retrospective study.

CONCLUSIONS

Use of 25-mm circular staplers for double stapling technique anastomosis is safe and does not increase the risk of anastomotic strictures and other anastomotic complications in comparison with larger staplers. See Video Abstract at http://links.lww.com/DCR/B576.

SEGURIDAD DE ENGRAPADORAS CIRCULARES PEQUEAS EN ANASTOMOSIS, CON TCNICA DE DOBLE ENGRAPADO PARA CNCER DE RECTO Y COLON SIGMOIDE

ANTECEDENTES:Aunque las engrapadoras circulares más pequeñas son más fáciles de insertar y menos probable que involucren a la vagina y los músculos elevadores del ano, cuando se realiza una anastomosis con técnica de doble engrapado, frecuentemente los cirujanos consideran que las engrapadoras circulares más grandes, serían más seguras para disminuir los riesgos de estenosis anastomóticas postoperatorias.OBJETIVO:El estudio se dirigió para investigar la seguridad en el uso de engrapadoras circulares de 25 mm, en comparación con engrapadoras de 28/29 mm, en anastomosis con técnica de doble engrapado, en relación al desarrollo de estenosis anastomóticas y otras complicaciones.DISEÑO:Estudio observacional retrospectivo.AJUSTE:Centro oncológico integral único.PACIENTES:Se incluyeron pacientes consecutivos sometidos a resección colorrectal curativa, con anastomosis y técnica de doble engrapado, para cáncer de recto y colon sigmoide en estadios I-III entre 2013 y 2016.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las incidencias de complicaciones anastomóticas (estenosis, fugas y sangrados) entre las engrapadoras circulares de 25 y 28/29 mm. Los predictores para estenosis anastomóticas se investigaron con regresión logística multivariable.RESULTADOS:Entre un total de 815 pacientes elegibles, se utilizaron engrapadoras de 25 mm en 186 (22,8%). Las engrapadoras de 25 mm se asociaron con el uso en pacientes femeninas, descenso del ángulo esplénico, ligadura alta de arteria mesentérica inferior y anastomosis baja. Complicaciones anastomóticas generales (11,8% vs. 13,7%, p = 0,51), estenosis (5,9% vs. 3,3%, p = 0,11), fugas (2,7% vs. 3,8%, p = 0,47) y sangrado (4,8% vs. 7,6%, p = 0,19). No hubo diferencia entre las engrapadoras de 25 y 28/29 mm. En la regresión logística multivariable, predictores independientes de estenosis anastomóticas incluyeron ostomía derivativa y fuga anastomótica, pero no incluyeron el uso de engrapadoras circulares pequeñas. La mayoría de las 32 estenosis anastomóticas se trataron con éxito sin intervención quirúrgica (dilatación del dedo, n = 25; intervención endoscópica, n = 5).LIMITACIONES:Fue un estudio retrospectivo de un solo centro.CONCLUSIONES:El uso de engrapadoras circulares de 25 mm para la anastomosis con técnica de doble engrapado, es seguro y no aumenta el riesgo de estenosis anastomóticas y de otras complicaciones anastomóticas, cuando son comparadas con engrapadoras más grandes. Consulte Video Resumen en http://links.lww.com/DCR/B576. (Traducción-Dr. Fidel Ruiz-Healy).

Risk Factors for Outlet Obstruction in Patients with Diverting Ileostomy Following Rectal Surgery

Objectives:

Anastomotic leakage is one of the most severe complications of rectal cancer surgery. A diverting ileostomy was constructed for the purpose of reducing anastomotic failure risk. Outlet obstruction (OO) is one of the complications of diverting stoma that results in a lack of fecal discharge from the stoma. Detailed etiologies and preventive measures for outlet obstruction have not yet been identified.

Methods:

We studied 125 patients who underwent rectal resection, anastomosis, and elective ileostomy. We evaluated the incidence of outlet obstruction and looked for any relationship between perioperative factors and outlet obstruction.

Results:

Outlet obstruction was detected in 20 cases (16.0%). Outlet obstruction occurred 9 days after surgery in most cases. Inserting a decompressing tube improved obstructive symptoms in 4 days. Patients were divided into two cohorts according to the occurrence of outlet obstruction. Postoperative hospital stay was longer in the outlet obstruction group (19 vs. 15 days; p = 0.0003). A multivariate analysis identified that younger patients, a postoperative thicker rectus abdominis muscle at the stoma passage and high output syndrome were independent risk factors for outlet obstruction.

Conclusions:

Younger patients, a postoperative thicker rectus abdominis muscle at stoma passage and high output syndrome were independent risk factors for outlet obstruction.

A Diagnostic Nomogram for Predicting the Risk of Anastomotic Leakage in Elderly Patients With Rectal Cancer: A Single-center Retrospective Cohort Study

BACKGROUND

Laparoscopic resection for rectal cancer has been gaining popularity over the past 2 decades. Whether elderly patients had more benefits from laparoscopy-assisted anterior resection (LAR) need further investigation when comparing with open anterior resection (OAR).

OBJECTIVES

This study aimed to evaluate the clinical outcomes and prognosis of LAR in elderly patients (65 y and above) with rectal cancer and investigate the factors associated with the anastomotic leakage (AL). Besides, the study sought to create a nomogram for precise prediction of AL after anterior resection for rectal cancer.

MATERIALS AND METHODS

A total of 343 rectal cancer patients over 65 years old who underwent LAR or OAR at a single center between January 2013 to January 2021 were retrospectively reviewed. Univariate analysis was conducted to explore potential risk factors for AL, and a nomogram for AL was created based on the multivariate logistic regression model.

RESULTS

A total of 343 patients were included in this study, 271 patients in LAR group and 72 patients in OAR group. Most of the variables were comparable between the 2 groups. The mean operative time was longer in the LAR group than that in the OAR group (191.66±58.33 vs. 156.85±53.88 min, P<0.0001). The LAR group exhibited a significantly lower intraoperative blood loss than the OAR group (85.17±50.03 vs. 131.67±79.10 mL; P<0.0001). Moreover, laparoscopic surgery resulted in shorter postoperative hospital stay, lower rates of diverting stoma and receiving sphincter sparing surgery in comparison with open surgery. The overall rates of complications were 25.1% and 40.3% in the LAR and OAR groups (P=0.011), respectively. And the reoperation rates in the OAR group (0%) was lower than in the LAR group (1.5%), but the difference did not reach statistical significance (P=0.300). Sex, location of tumor, diverting stoma and combined organ resection were identified as independent risk factors for AL based on multivariate analysis. Such factors were selected to develop a nomogram. After a median follow-up of 37.0 months, our study showed no significant difference in overall survival or disease free survival between the 2 groups for treatment of rectal cancer.

CONCLUSIONS

This study suggests that LAR is an alternative minimally invasive surgical procedure in patients above 65 years with better short-term outcomes and acceptable long-term outcomes compared with OAR. In addition, our nomogram has satisfactory accuracy and clinical utility may benefit for clinical decision-making.

[Prevention of colorectal anastomotic leakage using its reinforcement (results of the randomized study)]

OBJECTIVE

To reduce the incidence of postoperative complications via reinforcement of colorectal anastomosis.

MATERIAL AND METHODS

A randomized prospective study included 115 patients. In the main group (n=60), anterior resections were followed by reinforcement of colorectal anastomosis via suturing the muscular and serous layers at 2, 4, 6, 8, 10, 12 o'clock. In case of low anterior resection, all layers of intestinal wall were transanally sutured at the above-mentioned points. Reinforcement was not performed in the control group (n=55).

RESULTS

In the main group, overall incidence of anastomotic leakage was 8.3% (5/60), in the control group - 25.5% (14/55) (p=0.01). We also analyzed the subgroups of anastomoses with high and low risk of leakage. In case of transabdominal reinforcement, incidence of anastomotic leakage was 11% (2/18) in the main group and 0% (0/14) in the control group (p=0.6). Transanal reinforcement was followed by anastomotic leakage in 7% (3/42) of patients in the main group and 34% (14/41) of patients in the control group (p=0.005).

CONCLUSION

Reinforcement of colorectal instrumental anastomosis by additional sutures reduces the incidence of postoperative complications associated with anastomotic leakage.

Clinical Outcomes of Ileostomy Closure before Adjuvant Chemotherapy after Rectal Cancer Surgery: An Observational Study from a Chinese Center

Background

The optimal timing of temporary ileostomy closure with respect to the time of adjuvant chemotherapy following sphincter-saving surgery for rectal cancer remains unclear. The aim of this study is to investigate the clinical and oncological outcomes of ileostomy closure before, during, and after adjuvant chemotherapy following curative rectal cancer resection.

Methods

Patients diagnosed with rectal adenocarcinoma who underwent low anterior resection and temporary loop ileostomy during May 2015 and September 2019 were retrospectively evaluated. Patients undergoing ileostomy closure before adjuvant chemotherapy (Group I) were compared to patients undergoing closure during (Group II) and after (Group III) adjuvant chemotherapy.

Results

A total of 225 patients were evaluated for eligibility, and 132 were finally selected and divided into 3 groups (24 in Group I, 53 in Group II, and 55 in Group III). No significant differences were observed in operative time, postoperative hospital stay, postoperative complications, total adjuvant chemotherapy cycles, and low anterior resection syndrome scores among the three groups. There was no significant difference in disease-free survival (p = 0.834) and overall survival (p = 0.462) between the three groups.

Conclusion

Temporary ileostomy closure before adjuvant chemotherapy following curative rectal cancer resection can achieve a clinical and oncological safety level equal to stoma closure during or after chemotherapy in selected patients.

Transanal reinforcement of low rectal anastomosis versus protective ileostomy after total mesorectal excision for rectal cancer. Preliminary results of a randomized clinical trial

AIM

The study aimed to show if transanal reinforcement of the suture line can prevent anastomotic leakage (AL) after rectal cancer surgery, thus avoiding the need for a covering ileostomy.

METHODS

This is a prospective, multicentre, parallel-arm randomized controlled equivalence trial. After standard total mesorectal excision, patients with anastomotic line at 1-3 cm from the dentate line were randomized to have transanal suture reinforcement (TAR group) or protective ileostomy (PI group).

RESULTS

Twenty-nine patients had PI, 25 had TAR. The two groups were comparable both for baseline characteristics and intra-operative aspects. Clinically evident AL occurred in four (16%) and five (17.24%) patients of the TAR and PI group, respectively, resulting in a difference of -1.20% (90% CI -17.93, 15.45), while subclinical AL at proctography was absent in 15 (65.22%) and 13 (50%) patients of the TAR and PI groups, respectively, resulting in a difference of 15% (90% CI -7.74 to 38.17).

CONCLUSION

Preliminary data suggest that transanal reinforcement of the suture line performed in rectal cancer patients with suture line at 1-3 cm from the dentate line carries a similar (even if not equivalent) AL rate to covering ileostomy, suggesting that a covering ileostomy could be avoided in this selected group of patients. This indication needs to be addressed with future larger trials (clinicaltrials.gov ID number NCT02279771).

Risk and consequences of dehydration following colorectal cancer resection with diverting ileostomy. A systematic review and meta-analysis

AIM

This systematic review aims to assess dehydration prevalence and dehydration-related morbidity from diverting ileostomy compared to resections without ileostomy formation in adults undergoing colorectal resection for cancer.

METHOD

MEDLINE, Embase, CENTRAL and ClinicalTrials.gov were searched for studies of any design that reported dehydration, renal function and dehydration-related morbidity in adult colorectal cancer patients with diverting ileostomy (last search 12 August 2020). Bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias in randomized trials and the Risk of Bias in Non-randomized Studies of Interventions tool.

RESULTS

Of 1927 screened papers, 22 studies were included (21 cohort studies and one randomized trial) with a total of 19 485 patients (12 209 with ileostomy). The prevalence of dehydration was 9.00% (95% CI 5.31-13.45, P < 0.001). The relative risk of dehydration following diverting ileostomy was 3.37 (95% CI 2.30-4.95, P < 0.001). Three studies assessing long-term trends in renal function demonstrated progressive renal impairment persisting beyond the initial insult. Consequences identified included unplanned readmission, delay or non-commencement of adjuvant chemotherapy, and development of chronic kidney disease.

DISCUSSION

Significant dehydration is common following diverting ileostomy; it is linked to acute kidney injury and has a long-term impact on renal function. This study suggests that ileostomy confers significant morbidity particularly related to dehydration and renal impairment.

Two-step pull-through colo-anal anastomosis aiming to avoid stoma in rectal cancer surgery: A "real life" study in a developing country

BACKGROUND

Delayed colo-anal anastomosis (DCA) is an underused technique rarely performed after resection of primary low rectal adenocarcinoma. The objective of this study was to compare the short-term outcomes of DCA and classical colo-anal anastomosis (CAA).

METHODS

This is a retrospective comparative study carried out at two tertiary centres in Morocco and France. It included all patients who underwent colo-anal anastomosis after complete mesorectal excision for primary rectal adenocarcinoma between January 2018 and December 2019. The main outcomes were 90-day morbidity and rates completing the surgical steps of DCA and CAA.

RESULTS

Among 215 rectal resections, 45 patients received colo-anal anastomosis, including 19 DCA and 26 CAA. Seventeen patients in the DCA group completed the two steps compared to 16 in the CAA group (89.5% vs. 61.5%, P=0.04). The rates of severe complications (26.9% vs. 26.3%, P=0.96) and anastomotic leakage (42.3% vs. 31.6%, P=0.46) were not different between the two groups.

CONCLUSION

This study showed that DCA was associated with a higher rate of completing the two surgical steps, with no difference in overall and severe morbidity. DCA may be a strong alternative to classical colo-anal anastomosis.

Prevention of incisional hernia at the site of stoma closure with different reinforcing mesh types: a systematic review and meta-analysis

PURPOSE

To evaluate safety and efficacy of a mesh reinforcement following stoma reversal to prevent stoma site incisional hernia (SSIH) and differences across the prostheses used.

METHODS

A systematic search of PubMed/MEDLINE, EMBASE, SCOPUS and Cochrane databases was conducted to identify comparative studies until September 2020. A meta-analysis of postoperative outcomes and a network meta-analysis for a multiple comparison of the prostheses with each other were performed.

RESULTS

Seven studies were included in the analysis (78.4% ileostomy and 21.6% colostomy) with a total of 1716 patients with (n = 684) or without (n = 1032) mesh. Mesh placement was associated with lower risk of SSIH (7.8%vs18.1%, OR0.266,95% CI 0.123-0.577, p < 0.001) than no mesh procedures but also with a longer operative time (SMD 0.941, 95% CI 0.462-1.421, p < 0.001). There was no statistically significant difference in terms of Surgical Site infection (11.5% vs 11.1%, OR 1.074, 95% CI 0.78-1.48, p = 0.66), seroma formation (4.4% vs 7.1%, OR 1.052, 95% CI 0.64-1.73, p = 0.84), anastomotic leakage (3.7% vs 2.7%, OR 1.598, 95% CI 0.846-3.019, p = 0.149) and length of stay (SMD - 0.579,95% CI - 1.261 to 0.102, p = 0.096) between mesh and no mesh groups. Use of prosthesis was associated with a significant lower need for a reoperation than no mesh group (8.1% vs 12.1%, OR 0.332, 95% CI 0.119-0.930, p = 0.036). Incidence of seroma is lower with biologic than polypropylene meshes but they showed a trend towards poor results compared with polypropylene or biosynthetic meshes.

CONCLUSION

Despite longer operative time, mesh prophylactic reinforcement at the site of stoma seems a safe and effective procedure with lower incidence of SSIH, need for reoperation and comparable short-term outcomes than standard closure technique. A significant superiority of a specific mesh type was not identified.

Early postoperative outcomes of diverting loop ileostomy closure surgery following laparoscopic versus open colorectal surgery

BACKGROUND

Although diverting loop ileostomy (DLI) formation reduces the consequences of anastomotic leak and may also decrease the incidence of this severe complication, DLI closure can result in significant complications. The laparoscopic approach in colorectal surgery has numerous benefits, including reduced length of stay (LOS), less wound infection, and better cosmesis. The aim of this study was to determine whether a laparoscopic approach at the time of the ileostomy creation has a beneficial effect on the outcomes of ileostomy closure.

METHODS

A retrospective analysis of an IRB-approved prospective database was performed for all patients who underwent DLI closure between 2010 and 2017. Patients' demographics, operative reports, and postoperative course were reviewed. Statistical analyses were performed using SPSS software and included descriptive statistics, Chi-square for categorical variables, and Student's t tests for continuous variables. Skewed variables were compared using the non-parametric Mann-Whitney U test. Regression analysis for overall complications and LOS were preformed to further assess the impact of laparoscopy.

RESULTS

We identified 795 patients (363 females) who underwent DLI reversal surgery. The surgical approach in the index operation was laparoscopy in 65% of patients. Conversion to laparotomy at the ileostomy closure occurred in 6.1% of patients. The overall complication rate was lower and the LOS was shorter for patients who underwent DLI closure following laparoscopic surgery. Laparoscopy at the index operation was also associated with a lower incidence of postoperative ileus and a lower estimated blood loss (EBL) at the time of DLI reversal. Multivariate regression analysis found laparoscopy to have significant benefits compared to laparotomy for overall complications and for LOS.

CONCLUSION

Ileostomy closure following laparoscopic colorectal surgery offers benefits including reductions in LOS and overall complications.

Delayed coloanal anastomosis as a stoma-sparing alternative to immediate coloanal anastomosis: A systematic review and meta-analysis

BACKGROUND

Recent clinical trials have demonstrated favorable outcomes associated with trans-anal colonic pull-through for rectal resection followed by delayed coloanal anastomoses (DCA), resulting in a resurgence in popularity of the technique. This meta-analysis aims to review existing literature to evaluate the postoperative complications associated with DCA, and to make comparisons with immediate coloanal anastomoses (ICA) after colorectal resection to assess the suitability of DCA as an alternative form of surgical treatment.

METHODS

Medline and Embase databases were reviewed from inception until 31 July 2020 in accordance with PRISMA guidelines. Single-arm studies that involved patients undergoing DCA for benign or malignant causes were selected, and meta-analysis of proportions was conducted to determine the prevalence of postoperative complications following DCA. Comparative studies comparing postoperative outcomes between DCA and ICA were also included for comparative meta-analysis.

RESULTS

Patients undergoing DCA were significantly less likely to require diverting stoma construction as compared to ICA (odds ratio [OR] = 0.04; confidence interval [CI]: 0.02-0.07; P < 0.001). Overall postoperative morbidity (OR = 0.50; 95% CI: 0.23-1.12; P = 0.09) and mortality (OR = 0.49, 95% CI: 0.12-1.98; P = 0.32) was comparable between DCA and ICA groups. No significant differences in perioperative complications, such as anastomotic leakage (OR = 0.42; 95% CI: 0.11-1.64; P = 0.21), postoperative ileus, pelvic abscesses, or sepsis, were noted between DCA and ICA.

CONCLUSION

Our study shows no differences in complications or functional outcomes between DCA and ICA. Pooled analysis expectedly revealed a lower rate of diverting stoma in patients undergoing DCA. DCA is thus a safe alternative to current surgical practices where avoidance of a stoma is desired.

Risk factors for readmission with dehydration after ileostomy formation: A systematic review and meta-analysis

AIM

Ileostomy formation is a commonly performed procedure with substantial associated morbidity. Patients with an ileostomy experience high rates of unplanned hospital readmission with dehydration, and such events have a long-term health and economic impact. Reports of the significant risk factors associated with these readmissions have been inconsistent. This study aimed to identify the significant risk factors for readmission with dehydration following ileostomy formation.

METHOD

A systematic search was conducted using the Medline, Embase, Cochrane and CINAHL databases. All original research articles reporting risk factors for readmission with dehydration following ileostomy formation in adults were included. The primary outcome was the pooled risk ratio of clinically relevant variables potentially associated with dehydration-related readmission following ileostomy formation. The secondary outcome was the incidence of dehydration-related readmission.

RESULTS

Ten studies (27 089 patients) were included. The incidences of 30- and 60-day readmission with dehydration were 5.0% (range 2.1%-13.2%) and 10.3% (range 7.3%-14.1%), respectively. Eight variables were found to be significantly associated with dehydration-related readmission: age ≥65 years, body mass index ≥30 kg/m² , diabetes mellitus, hypertension, renal comorbidity, regular diuretic use, ileal pouch-anal anastomosis procedure and length of stay after index admission. A preoperative diagnosis of colorectal cancer was less likely to result in readmission with dehydration.

CONCLUSION

Readmission with dehydration following ileostomy formation is a significant issue with several risk factors. Awareness of these risk factors will help inform the design of future studies addressing risk prediction, allow risk stratification of ileostomates and aid in the development of personalized prevention strategies.

Factors impacting time to ileostomy closure after anterior resection: the UK closure of ileostomy timing cohort study (CLOSE-IT)

AIM

Delay to closure of ileostomy following anterior resection for rectal cancer may impair postoperative bowel function and quality of life. We analysed time to ileostomy closure across the UK and investigated factors delaying closure.

METHODS

For the retrospective cohort we assessed time to closure and incidence of non-closure for patients who underwent anterior resection with defunctioning ileostomy during 2015. Multivariate linear/Cox regression analyses were performed. For the prospective cohort we captured patients undergoing ileostomy closure during a 3-month period in 2018 to validate retrospective findings.

RESULTS

The retrospective cohort involved 788 patients of whom 669 (84.9%) had bowel continuity restored, median time to closure 259 days. Recognized factors associated with delay and risk of non-closure included anastomotic leak (hazard ratio [HR] 3.65, 2.61-5.08), chemotherapy (HR 2.62, 2.17-3.15) and cancer progression (HR 2.05, 1.62-2.58). Crucially, specific aspects of the surgical pathway were associated with time to closure; for example, waiting list entry prior to outpatient clinic review/imaging was associated with an estimated 133-day shorter interval to closure (P < 0.001). In the prospective cohort 288 patients underwent closure, at a median of 271 days. Chemotherapy use and cancer progression were associated with delay to closure while listing for surgery prior to clinic and imaging was associated with an estimated shorter interval to closure of 168 days (P = 0.008).

CONCLUSIONS

Delays to closure of ileostomy are common in the UK. Listing patients for surgery only after follow-up outpatient appointment, imaging or chemotherapy delays closure. Findings will inform consensus guidelines towards an optimum treatment pathway to reduce delay and improve post-closure quality of life.

Primary Anastomosis Versus End-Ostomy in Left-Sided Colonic and Proximal Rectal Cancer Surgery in the Elderly Dutch Population: A Propensity Score Matched Analysis

Background

Primary anastomosis (PA) in left-sided colorectal cancer (CRC) surgery in elderly patients is disputed. The aim of our study was to evaluate the differences in postoperative outcomes after left-sided CRC surgery in elderly patients in The Netherlands, comparing patients with PA and those who underwent end-ostomy (EO).

Method

Patients aged ≥ 75 years with stage I–III left-sided CRC, diagnosed and surgically treated in 2015–2017 were selected from the Netherlands Cancer Registry (n = 3286). Postoperative outcomes, short-term (30-, 60-, and 90-day) mortality and 3-year overall and relative survival were analyzed, stratified by surgical resection with PA versus EO. Propensity score matching (PSM) and multivariable logistic regression analysis were conducted.

Results

Patients with higher age, higher American Society of Anesthesiologists classification and higher tumor stage, a perforation, ileus or tumor located in the proximal rectum, and after open or converted surgery were more likely to receive EO. No difference in anastomotic leakage was seen in PA patients with or without defunctioning stoma (6.2% vs. 7.0%, p = 0.680). Postoperative hospital stay was longer (7.0 vs. 6.0 days, p < 0.0001) and more often prolonged (19% vs. 13%, p = 0.03) in EO patients. Sixty-day mortality (2.9% vs. 6.4%, p < 0.0001), 90-day mortality (3.4% vs. 7.7%, p < 0.0001), and crude 3-year survival (81.2% vs. 58.7%, p < 0.0001) were significantly higher in EO patients, remaining significant after multivariable and PSM analysis.

Conclusion

There are significant differences between elderly patients after left-sided CRC surgery with PA versus EO in terms of postoperative length of stay, short-term survival, 3-year overall survival, and relative survival at disadvantage of EO patients. This information could be important for decision making regarding surgical treatment in the elderly.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-09976-y.

Outcomes of diverting loop ileostomy reversal in the elderly: a case-control study

BACKGROUND

Although diverting loop ileostomy (DLI) reversal is considered to be a relatively simple procedure, it is not immune from major morbidity. We aimed to compare outcomes of DLI reversal between elderly and non-elderly patients.

METHODS

Retrospective review of all patients who underwent DLI reversal at a single tertiary medical centre between 2010 and 2020. The elderly group consisted of patients 70 or older compared to a control group of those younger than 70 years.

RESULTS

During the study period, 307 patients underwent DLI reversal. Of these, 76 patients were in the elderly group (mean age 75.6) and 231 in the control group (mean age 55.3). The groups were comparable in terms of mean time interval between the creation of the ileostomy and reversal (242 versus 255 days, respectively, P = 0.5), choice between stapled and hand-sewn anastomoses (97.4% stapled anastomosis versus 93.1%, P = 0.086), median post-operative length of stay (5 days in both, P = 0.086), rates of post-operative complications (26.3% versus 26.8%, P = 0.99), severe complications (5.3% versus 6.9%, P = 0.81) and 30-day readmission rates (13.2% versus 10.8%, P = 0.58). Multivariate analysis found the time interval between the creation of the stoma and its reversal to be the only significant risk factor for major post-operative morbidity. Age was not found to be correlated with post-operative morbidity.

CONCLUSION

The outcomes of loop ileostomy reversal in elderly patients are similar to non-elderly patients. Efforts should be made to decrease the time interval between the creation of the stoma and its reversal as this is a significant risk factor for major post-operative morbidity.

Redo Transanal Soave Pull Through with or without Assistance in Hirschsprung Disease: An Experience in 46 Patients

INTRODUCTION

 Transanal Soave pull through (PT) with or without assistance can be performed as a redo procedure for Hirschsprung disease (HD). In this study, we reviewed the indications and clinical outcomes of redo transanal Soave with or without assistance.

MATERIALS AND METHODS

 A retrospective analysis was performed on patients who underwent redo transanal Soave with or without assistance in our hospital from 2004 to 2016, and did not have rectourethral fistula or rectovaginal fistula. The Krickenbeck classification system was used to evaluate postoperative bowel function. We analyzed the associated factors of the two main indications.

RESULTS

 In this study, 46 patients were included, representing 5.6% of all HD PTs; 42 patients were initially operated elsewhere and 4 at our hospital. Primary PT surgeries included 38 transanal Soave, 2 Rehbein, 1 Martin, and 5 unknown procedures. The indications for redo PT were residual aganglionosis/transition zone PT (RA/TZPT) (27, 58.7%), anastomotic complication (14, 30.4%), and dilated distal segment (5, 10.9%). The median age of these 46 patients at primary and redo PT was 7.0 months (range, 0.4-137 months) and 45.5 months (range, 7-172 months), respectively. All 46 patients underwent redo transanal Soave PT; 43 patients (93.5%) underwent transanal Soave with laparotomy (n = 42) or laparoscopy (n = 1), and another 3 patients underwent transanal Soave PT. Six patients (13%) experienced complications within 30 days after redo surgery. A total of 43 patients were followed up, and the median follow-up period was 100 months (range, 35-180 months). Two patients could not hold back defecation in some inconvenient conditions. Sixteen patients (37.2%) had soiling, and 8 (18.6%) of 16 patients complained frequent soiling occurrence (more than 1/week). Only one patient complained of constipation (grade 1). Patients with anastomotic complication had more early postoperative complication and higher rate of soiling than patients with RA/TZPT, but there was no statistical difference (p = 0.672 and p = 0.105).

CONCLUSION

 Transanal Soave PT with or without assistance was effective in resolving different problems after initial PT, while soiling was the most common postoperative problem, especially patients with anastomotic complication.

A meta-analysis of the role of diverting ileostomy after rectal cancer surgery

PURPOSE

Anastomotic leak is a feared complication of rectal cancer surgery. A diverting stoma is believed to act as a safety mechanism against this undesirable outcome. This meta-analysis aimed to examine the role of loop ileostomy in the prevention of this complication.

METHODS

The Medline, Embase and Cochrane databases were searched for randomized controlled trials (RCTs) comparing anastomotic complications after rectal cancer surgery in the presence or absence of diverting ileostomy. The need for reoperation and postoperative complications were also analysed. The length of hospital stay, intraoperative blood loss and operating time were analysed as secondary endpoints.

RESULTS

A significantly higher number of anastomotic leaks was detected in patients with no diverting ileostomies than in those with diversion (odds ratio (OR) 0.292 and 95% confidence interval (CI) 0.177-0.481), and more patients required reoperations in this group (OR 0.219 and 95% CI 0.114-0.422). The rate of complications other than anastomotic leak was significantly higher in patients with diverting ileostomies than in those without (OR 3.337 and 95% CI of 1.570-7.093). The operating time was longer in the ileostomy group than in the no ileostomy group (P 0.001), but no significant differences in the intraoperative blood loss or postoperative hospital stay length were observed between the two groups(P 0.199 and 0.191 respectively).

CONCLUSION

A lower leak rate in the presence of diverting ileostomy is supported by relatively weak evidence. While mitigating the consequences of leakage, diverting ileostomies lead to numerous other complications. High-quality RCTs are needed before routine ileostomy diversions can be recommended after rectal cancer surgery.

Postoperative morbidity and mortality after anterior resection with preventive diverting loop ileostomy versus loop colostomy for rectal cancer: A updated systematic review and meta-analysis

The purpose of this meta-analysis was to evaluate the perioperative morbidity after anterior resection with diverting loop ileostomy (LI) versus colostomy (LC) and its reversal for rectal cancer. The studies on the application of loop ileostomy versus loop colostomy in anterior resection published from January 2000 to January 2020 were searched in the databases of Pubmed, Embase, Cochrane library, and Clinical trials. All randomized controlled trials (RCTs) and cohort studies were included according to inclusion criteria. Eight studies (2 RCTs and 6 cohort studies) totaling 1451 patients (821 LI and 630 LC) were included in the meta-analysis. The morbidity related to stoma formation and closure did not demonstrate significant differences. Significantly more LCs were complicated by stoma prolapse & retraction (OR:0.26,95%CI:0.11-0.60,P = 0.001), parastomal hernia (OR = 0.52,95%CI:0.30-0.88, P = 0.01), surgical site infection (SSI) (OR = 0.24,95%CI:0.11-0.49,P < 0.0001) and incisional hernias (OR = 0.39,95%CI:0.19-0.83,P = 0.01) than by LIs. Patients with LI demonstrated significantly more complications related to the stoma, such as dehydration (OR = 0.52,95%CI:0.30-0.88, P = 0.01) and ileus (OR = 2.23,95%CI:1.12-4.43, P = 0.02) than patients with LC. While after the subgroup analysis of different publication years, LI could reduce the risk of the morbidity after stoma formation in previous years group (P = 0.04) with a lower heterogeneity (I² = 37%); LC could reduce the incidence of parastomal dermatitis in recent years group (P < 0.0001) without heterogeneity in each subgroup (I² = 0%). Cumulative meta-analysis detected significant turning points in dehydration, SSI, and ileus. This meta-analysis recommends diverting LI in the anterior resection for rectal cancer, but there is a risk of dehydration, irritant dermatitis, and ileus.

Quality of Life and Bowel Function Following Early Closure of a Temporary Ileostomy in Patients with Rectal Cancer: A Report from a Single-Center Randomized Controlled Trial

The aim of this study was to assess quality of life and bowel function in patients undergoing early vs. standard ileostomy closure. We retrospectively assessed patients from our previous randomized controlled trial. Patients with a temporary ileostomy who underwent rectal cancer surgery and did not have anastomotic leakage or other. Early closure (EC; 30 days after creation) and standard closure (SC; 90 days after creation) of ileostomy were compared. Thirty-six months (17–97) after stoma closure, we contacted patients by phone and filled in two questionnaires—The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and low anterior resection syndrome (LARS) score. This index trial was not powered to assess the difference in bowel function between the two groups. All the patients in the SC group had anastomosis <6 cm from the anal verge compared to 42 of 43 (97.7%) in the EC group. There were no statistically significant differences between EC (26 patients) and SC (25 patients) groups in the EORTC QLQ-C30 and LARS questionnaires. Global quality of life was 37.2 (0–91.7; ±24.9) in the EC group vs. 34.3 (0–100; ±16.2) in the SC (p = 0.630). Low anterior resection syndrome was present in 46% of patients in the EC and 56% in the SC group (p = 0.858). Major LARS was found more often in younger patients. However, no statistical significance was found (p = 0.364). The same was found with quality of life (p = 0.219). Age, gender, ileostomy closure timing, neoadjuvant treatment, complications had no effect of worse bowel function or quality of life. There was no difference in quality of life or bowel function in the late postoperative period after the early vs. late closure of ileostomy based on two questionnaires and small sample size. None of our assessed risk factors had a negative effect on bowel function o quality of life.