A defunctioning stoma in the treatment of lower third rectal carcinoma

Challenges in evaluating pelvic floor physiotherapy based strategies in low anterior resection syndrome: a systematic review and qualitative analysis

AIM

Physiotherapy is an established treatment strategy for low anterior resection syndrome (LARS). However, data on its efficacy are limited. This is in part due to the inherent challenges in study design in this context. This systematic review aims to analyse the methodology of studies using pelvic floor physiotherapy for treatment of LARS to elucidate the challenges and limitations faced, which may inform the design of future prospective trials.

METHODOLOGY

A systematic review of the literature was undertaken through MEDLINE, Embase and Cochrane Library, yielding 345 unique records for screening. Five studies were identified for review. Content thematic analysis of study limitations was carried out using the Braun and Clarke method. Line-by-line coding was used to organize implicit and explicit challenges and limitations under broad organizing categories.

RESULTS

Key challenges fell into five overarching categories: patient-related issues, cancer-related issues, adequate symptomatic control, intervention-related issues and measurement of outcomes. Adherence, attrition and randomization contributed to potential bias within these studies, with imbalance in the baseline patient characteristics, particularly gender and baseline pelvic floor function scores. Outcome measurements consisted of patient-reported measures and quality of life measures, where significant improvements in bowel function according to patient-reported outcome measures were not reflected in the quality of life scores.

CONCLUSION

Upcoming trial design in the area of pelvic floor physiotherapy for faecal incontinence related to rectal cancer surgery can be cognisant of and design around the challenges identified in this systematic review, including the reduction of bias, exclusion of the placebo effect and the potential cultural differences in attitude towards a sensitive intervention.

Protective ileostomy does not prevent anastomotic leakage after anterior resection of rectal cancer

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.

First, Do No Harm: Rethinking Routine Diversion in Sphincter-Preserving Rectal Cancer Resection

BACKGROUND

Although diverting stomas have reduced anastomotic leak rates after sphincter-preserving proctectomy in some series, the effectiveness of routine diversion among a broad population of rectal cancer patients remains controversial. We hypothesized that routine temporary diversion is not associated with decreased rates of leak or reintervention in cancer patients at large undergoing sphincter-sparing procedures.

STUDY DESIGN

The Florida State Inpatient Database (AHRQ, Healthcare Cost and Utilization Project) was queried for patients undergoing sphincter-preserving proctectomy for cancer (2005 to 2014). Matched cohorts defined by diversion status were created using propensity scores based on patient and hospital characteristics. Incidence of anastomotic leak, nonelective reintervention, and readmission were compared, and cumulative 90-day inpatient costs were calculated.

RESULTS

Of 8,620 eligible sphincter-sparing proctectomy patients, 1,992 matched pairs were analyzed. Leak rates did not significantly vary between groups (4.5% vs 4.3%; p = 0.76), but diversion was associated with significantly higher odds of nonelective reintervention (2.37; 95% CI 1.90 to 2.96) and readmission (1.55; 95% CI 1.33 to 1.81) compared with undiverted patients. Median costs were higher among those diverted (US$21,325 vs US$15,050; p < 0.01).

CONCLUSIONS

No association between diversion and anastomotic leak was found. However, temporary diversion was associated with increased incidence of nonelective reinterventions, readmissions, and higher costs. We therefore challenge the paradigm of routine diversion in rectal cancer operations. Additional study is needed to identify which patients would benefit most from diversion.

Temporary Tube Stoma versus Conventional Loop Stoma for the Protection of a Low Anastomosis in Colorectal Surgery: A Systematic Review and Meta-analysis

The aim of this systematic review is to evaluate and compare the efficacy and safety of temporary tube stoma and conventional loop stoma for the protection of a low anastomosis in colorectal cancer. A systematic literature search was performed using PubMed, EMBASE, Science Citation Index, and Cochrane Central Register of Controlled Trails. Primary outcome measures were anastomotic leakage rate, the reoperation rate for anastomotic leakage, and stoma-related complications. Secondary outcome measures were operation time, length of hospital stay, time to stoma closure, and permanent stoma rate. Four studies were carried out and 642 patients (332 with temporary tube stoma and 310 with conventional loop stoma) met the inclusion criteria. The incidences of anastomotic leakage and reoperation rate were statistically similar in tube stoma and loop stoma groups. In comparison with conventional loop stoma, temporary tube stoma was associated with a significantly less stoma-related complications (odds ratio = 0.20; 95% confidence interval [CI]: 0.08–0.50), and shorter operation and hospital stay time (weighted mean difference = -47.28 minutes, 95% CI: -74.68 to -19.88; and weighted mean difference = -5.22 days, 95% CI: -10.32 to -0.13, respectively). Time to stoma closure was significantly shorter in the temporary tube stoma groups (weighted mean difference = -114.58 days, 95% CI: -148.38 to -80.77). Patients receiving temporary tube stoma had lower rates of stoma-related complications, shorter operation and hospital stay time, and stoma closure time. Tube can be easily removed without second surgery in most cases. Therefore, temporary tube stoma is a feasible and effective alternative to conventional loop stoma for the protection of a low colorectal anastomosis.

Low or Ultralow Anterior Resection of Rectal Cancer Without Diverting Stoma: Experience with 28 Patients

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.

Preliminary report of a new technique for temporary faecal diversion after extraperitoneal colorectal anastomosis

AIM

Loop ileostomy is a suitable procedure for transitory faecal diversion after colorectal or coloanal anastomosis. We describe here an easy alternative technique for ileostomy construction that does not require reintervention for the closure.

METHOD

In twenty patients undergoing anterior resection of the extraperitoneal rectum with colorectal and/or coloanal anastomosis, loop ileostomy was performed using a modified jejunotomy tube inflated with 10 ml of normal saline. The tube was deflated on the eighth post-operative day and removed on day 11 after a radiological contrast enema of the anastomosis.

RESULTS

Radiological control carried out on day 11 evidenced a premature dislocation of the jejunostomy tube in 1 patient, thus the tube was correctly removed without any complications. In another patient a delayed closure of the ileo cutaneous fistula was recorded that required simple medication over 15 days in the out patient clinic. No signs of anastomotic leakage, either clinical or radiological were evidenced.

CONCLUSION

We have described here a safe alternative technique for loop ileostomy with negligible complications related to construction as demonstrated in our results.

Reconstruction techniques after proctectomy: what's the best?

There are approximately 40,000 new rectal cancer cases diagnosed each year in the United States, representing the second most common gastrointestinal malignancy (behind colon cancer). With the advent of sphincter preserving techniques, patients with mid and low colorectal cancers enjoy the benefits of better postoperative functional outcomes and quality of life; however, controversy exists over which reconstructive technique is superior in restoring bowel continuity. Construction of a straight coloanal anastomosis is technically simpler, but functional outcomes are inferior compared with colonic reservoirs. The purpose of this review is to summarize the current data regarding reconstructive techniques following proctectomy.

Covering ileo- or colostomy in anterior resection for rectal carcinoma

BACKGROUND

Anastomotic leakage is one of the most important complications that occur after surgical low anterior resection for rectal cancer. There are indications that anastomotic leak is associated with increased morbidity, mortality, frequent re-operation or radiological drainage, and prolonged hospital stay. Defunctioning stoma can be useful for patients undergoing a rectal surgery.

OBJECTIVES

To determine the efficacy of protective defunctioning stoma in low anterior resection for rectal carcinoma.

SEARCH STRATEGY

Searches were conducted November 2009. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1966) and EMBASE (from 1980).

SELECTION CRITERIA

We included randomised clinical trials comparing the use of stoma versus "no stoma" in patients that received low anterior resection for rectal cancer.

DATA COLLECTION AND ANALYSIS

Six randomised controlled trials were identified and included in this review. Five trials were fully published in peer-reviewed journals. An attempt was made to obtain further information from the authors of the trial that was available only in an abstract form. The studies analysed the following outcomes: clinical anastomotic leakage, urgent reoperation, mortality and length of postoperative hospital stay. Review authors extracted the data independently, the risk ratios (RR) were estimated for the dichotomous outcomes and standardised mean difference were estimated for the continuous outcome

MAIN RESULTS

All the trials reported results for clinical anastomotic leakage, urgent reoperation and mortality. Only two trials reported the results for length of postoperative hospital stay.With respect to controls, use of covering stoma was significantly associated with less anastomotic leakage (RR 0.33; 95%CI [0.21, 0.53]) and less urgent reoperation (RR 0.23; 95%CI [0.12, 0.42] ). There was no significant difference in terms of mortality (RR 0.58; 95%CI [0.14, 2.33]). There was no evidence of statistical heterogeneity in any of the comparisons.

AUTHORS' CONCLUSIONS

Covering stoma seems to be useful to prevent anastomotic leakage and urgent re-operations in patients receiving low anterior resection for rectal cancer. However, covering stoma does not seems to offer advantage in term of 30 days or long term mortality.

Mortality risk analysis following routine vs selective defunctioning stoma formation after total mesorectal excision for rectal cancer

OBJECTIVE

To answer the question whether a defunctioning stoma (DS) should be constructed routinely after total mesorectal excision or whether it could be used selectively to ensure patient safety.

METHOD

A PubMed search was performed. All randomized trials on the role of a DS were included. Also, observational articles published between January 1997 and August 2007 were reviewed. Sensitivity analysis of the mortality risk was performed.

RESULTS

The clinical anastamotic leak (CAL) rate was 17% in 358 patients from four randomized trials and 9.6% in 4059 patients from 39 observational studies. The CAL rate increased significantly from 9.6% with DS to 24.4% without DS in four randomized trials, and from 7.9% with DS to 13.2% without DS in 17 observational studies. The re-operation rate as a result of anastomotic leakage was lower in patients with DS than in patients without DS in both study types. Leak-related mortality was not significantly different: 7.2% with vs 7.7% without DS in observational studies, and 0% with vs 4.6% without DS in randomized trials. Sensitivity analysis indicated that a selective DS strategy is acceptable if the CAL rate without DS is less than 16.6% with a CAL-related mortality of no more than 4.6%.

CONCLUSION

The results of this review support the routine construction of a protective stoma. However, selective use of a DS is justified from a patient safety point of view if the CAL-rate and its related mortality are limited. Each unit should audit its performance.

Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a meta-analysis

BACKGROUND

Sphincter-saving surgery for the treatment of middle and low rectal cancer has spread considerably when total mesorectal excision became standard treatment. In order to reduce leakage-related complications, surgeons often perform a derivative stoma, a loop ileostomy (LI), or a loop colostomy (LC), but to date, there is no evidence on which is the better technique to adopt.

METHODS

We performed a systematic review and meta-analysis of all randomized controlled trials until 2007 and observational studies comparing temporary LI and LC for temporary decompression of colorectal and/or coloanal anastomoses. Clinically relevant events were grouped into four study outcomes: general outcome measures: dehydratation and wound infection GOM construction of the stoma outcome measures: parastomal hernia, stenosis, sepsis, prolapse, retraction, necrosis, and hemorrhage closure of the stoma outcome measures: anastomotic leak or fistula, wound infection COM, occlusion and hernia functioning of the stoma outcome measures: occlusion and skin irritation.

RESULTS

Twelve comparative studies were included in this analysis, five randomized controlled trials and seven observational studies. Overall, the included studies reported on 1,529 patients, 894 (58.5%) undergoing defunctioning LI. LI reduced the risk of construction of the stoma outcome measure (odds ratio, OR = 0.47). Specifically, patients undergoing LI had a lower risk of prolapse (OR = 0.21) and sepsis (OR = 0.54). LI was associated with an excess risk of occlusion after stoma closure (OR = 2.13) and dehydratation (OR = 4.61). No other significant difference was found for outcomes.

CONCLUSION

Our overview shows that LI is associated with a lower risk of construction of the stoma outcome measures.

Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery

SUMMARY BACKGROUND DATA

The role of a defunctioning stoma in patients undergoing low anterior resection for rectal cancer is still the subject of controversy. Recent studies suggest reduced morbidity after low anterior rectal resection with a defunctioning stoma.

METHODS

Retrospective and prospective studies published between 1966 and 2007 were systematically reviewed. Randomized controlled trials (RCTs) comparing anterior resections with or without defunctioning stoma were included in a meta-analysis. The pooled estimates of clinically relevant anastomotic leakages and of reoperations were analyzed using a random effects model (odds ratio and 95% confidence interval, CI).

RESULTS

Relevant retrospective single (n = 18) and multicenter (n = 9) studies were identified and included in the systematic review. Analysis of incoherent data of the leakage rates in these nonrandomized studies demonstrated that a defunctioning stoma did not influence the occurrence of anastomotic failure but seemed to ameliorate the consequences of the leak. Four RCTs were included in the meta-analysis. The odds ratio for clinically relevant anastomotic leakage was 0.32 (95% CI 0.17-0.59), revealing a statistically significant benefit conferred through a defunctioning stoma (Z = 3.65, P = 0.0003). The odds ratio for reoperation because of leakage-caused complications was 0.27 (95% CI 0.14-0.51), with significantly fewer reoperations in patients with a defunctioning stoma (Z = 3.95, P < 0.0001). Overall mortality rates were comparable regardless of the presence of a defunctioning stoma.

CONCLUSION

A defunctioning stoma reduces the rate of clinically relevant anastomotic leakages and is thus recommended in surgery for low rectal cancers.