A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study

Factors affecting closure of a temporary stoma

PURPOSE

The purpose of the study was to examine time to reversal of a temporary ostomy, reasons for delayed closure, and patient satisfaction with the scheduling of their closure and related hospital care.

DESIGN

Cross-sectional, descriptive study.

SUBJECTS AND SETTING

The target population comprised patients who underwent creation of a temporary ostomy and reversal surgery within one National Health System Hospital Trust in the United Kingdom. The population served by this Trust are ethnically and socioeconomically diverse, predominantly living in urban areas around Greater London. Sixty-one persons who met inclusion criteria were identified.

METHODS

A two-step analytical process was undertaken. First, a literature review examining incidence and causes of delayed stoma closure was undertaken. Second, a postal survey of all patients who had had their stoma closed in 2009 was conducted. Respondents were allowed 2 weeks to complete and return the questionnaire.

INSTRUMENT

The survey instrument was developed locally and subjected to content validation using ostomy patients, surgical and nursing colleagues. It consisted of 9 questions querying time from original surgery to closure, reasons for delaying closure surgery beyond 12 weeks, and satisfaction with care.

RESULTS

Twenty-seven patients returned their questionnaires, indicating they consented to participate; a response rate of 44%. Half of the respondents (n = 14 [52%]) underwent closure surgery within 6 months of stoma formation; the remaining 48% waited more than 6 months (median: 6.5 months, range: 1.5-26 months). Thirteen patients (48%) reported a delay in receiving their stoma closure; the main reason cited was the need for a course of adjuvant postoperative chemotherapy. Three quarters of respondents (22 [74%]) were satisfied with the overall care they received.

CONCLUSION

Findings from this study suggest that stoma closure may be associated with fewest complications if performed before 12 weeks.

Protection of stapled colorectal anastomoses with a biodegradable device: the C-Seal feasibility study

BACKGROUND

A colorectal anastomotic leak can be life-threatening. We have assessed the feasibility of a new intraluminal biodegradable bypass device that we designed to avoid anastomotic leakage and the necessity of a temporary stoma.

METHODS

Fifteen patients underwent colorectal surgery. Before performing the anastomosis in a standard way, the C-Seal (Polyganics BV, Groningen, The Netherlands) was glued to the anvil of the circular stapler. Consequently, the bypass was fixated in the staple row just proximal of the simultaneously made anastomosis. A water-soluble contrast enema was performed after 1 week.

RESULTS

The sheath was well compatible with the standard stapler device and easy to use. All donuts remained intact. No radiologic or clinical leaks were observed after surgery.

CONCLUSIONS

This pilot study shows that the C-Seal can be applied successfully in colorectal surgery. Further investigation with large numbers of patients is now necessary to assess the efficacy of the C-Seal as a protective device.

Conservative management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer

AIM

Anastomotic leakage (AL) after sphincter-saving resection (SSR) for rectal cancer can result in a definitive stoma (DS). The aim of the study was to assess risk factors for DS after AL-complicating SSR.

METHOD

Between 1997 and 2007, 200 patients underwent SSR for rectal cancer. AL occurred in 20.5% (41/200) [symptomatic 13.5% (n = 27), asymptomatic 7% (n = 14)]. Possible risk factors for DS after AL were analysed.

RESULTS

Management of AL consisted in no treatment (n = 14), medical treatment (n = 6), local drainage (n = 10) and abdominal reoperation (n = 11). After a median follow-up of 38 months, the overall rate of DS was 3% (n = 6): 0% for asymptomatic vs 22% after symptomatic AL (P = 0.061). After reoperation, the risk of DS was 13% when the anastomosis was preserved vs 100% after Hartmann's procedure (P = 0.007). Risk factors of DS after AL included obesity, age over 65, American Society of Anesthesiologists (ASA) score > 2 and abdominal reoperation for AL.

CONCLUSION

The risk of DS after SSR for cancer is low (3%) but rises to 22% after symptomatic AL. This risk depends on the surgical treatment for AL and is up to 100% if a Hartmann's procedure is performed.

Morbidity after closure of a defunctioning loop ileostomy

PURPOSE

A low pelvic anastomosis is associated with a substantial risk of leakage. A defunctioning stoma (DS) reduces the clinical anastomotic leak rate and the need for re-operation, but stoma closure has its own risk of morbidity and mortality. This study aims to audit morbidity and mortality after loop ileostomy (LI) closure.

PATIENTS AND METHODS

The medical records of 197 consecutive patients who underwent closure of a defunctioning LI between August 2003 and July 2008 were reviewed. Postoperative morbidity and mortality were recorded.

RESULTS

Transverse closure of the enterotomy was performed in 149 patients (75.6%), segmental enterectomy with hand-sewn end-to-end anastomosis in 26 (13.2%) and stapled side-to-side anastomosis in 22 (11.2%). Overall postoperative morbidity and mortality were 32.0% and 0.5%, respectively. The surgical complication rate was 30.5%, including prolonged ileus (11.2%), small bowel obstruction (4.1%), anastomotic leak (3.0%) and wound infection (4.6%). Surgical complications were more frequent in male patients (p = 0.005). Prolonged ileus was more frequent when the interval to stoma reversal exceeded 12 weeks (14.3% versus 3.5% ; p = 0.02). The incidence of complications was not influenced by the closure technique. Nineteen patients (9.6%) required re-operation for anastomotic leak (n = 8), wound infection (n = 1), small bowel obstruction (n = 3) and incisional herniation (n = 7).

CONCLUSION

LI closure is associated with clinically relevant morbidity and mortality. This association should be taken into account in the context of a routine DS policy and should be part of the patient's information.

What is the risk for a permanent stoma after low anterior resection of the rectum for cancer? A six-year follow-up of a multicenter trial

PURPOSE

The aim of this study was to assess the risk for permanent stoma after low anterior resection of the rectum for cancer.

METHODS

In a nationwide multicenter trial 234 patients undergoing low anterior resection of the rectum were randomly assigned to a group with defunctioning stomas (n = 116) or a group with no defunctioning stomas (n = 118). The median age was 68 years, 45% of the patients were women, 79% had preoperative radiotherapy, and 4% had International Union Against Cancer cancer stage IV. The patients were analyzed with regard to the presence of a permanent stoma, the type of stoma, the time point at which the stoma was constructed or considered as permanent, and the reasons for obtaining a permanent stoma. Median follow-up was 72 months (42-108). One patient with a defunctioning stoma who died within 30 days after the rectal resection was excluded from the analysis.

RESULTS

During the study period 19% (45/233) of the patients obtained a permanent stoma: 25 received an end sigmoid stoma and 20 received a loop ileostomy. The end sigmoid stomas were constructed at a median of 22 months (1-71) after the low anterior resection of the rectum, and the loop ileostomies were considered as permanent at a median of 12.5 months (1-47) after the initial rectal resection. The reasons for loop ileostomy were metastatic disease (n = 6), unsatisfactory anorectal function (n = 6), deteriorated general medical condition (n = 3), new noncolorectal cancer (n = 2), patient refusal of further surgery (n = 2), and chronic constipation (n = 1). Reasons for end sigmoid stoma were unsatisfactory anorectal function (n = 22) and urgent surgery owing to anastomotic leakage (n = 3). The risk for permanent stomas in patients with symptomatic anastomotic leakage was 56% (25/45) compared with 11% (20/188) in those without symptomatic anastomotic leakage (P < .001).

CONCLUSION

One patient of 5 ended up with a permanent stoma after low anterior resection of the rectum for cancer, and half of the patients with a permanent stoma had previous symptomatic anastomotic leakage.

Permanent stoma after low anterior resection for rectal cancer

BACKGROUND AND OBJECTIVES

A low anterior resection procedure for removing a rectal tumor aims to preserve the sphincter and avoid a permanent stoma. Permanent stomas are primarily necessary in cases of poor anorectal function and local recurrence. The aim of this study was to clarify whether anastomosis-related complications and local recurrence influenced the rate of permanent stomas in a long-term follow-up.

METHODS

Of 1032 consecutive patients with rectal cancer, 397 were treated by low anterior resection (R0 and R1 resections) between 1985 and 2007 at the Department of General and Abdominal Surgery of the University Hospital, Mainz (Germany). All patient data were collected prospectively. A retrospective, multivariate analysis was conducted to determine factors that influenced the occurrence of delayed and nonreversal of defunctioning stoma, the rate of repeat stoma after closure, and the need for a permanent stoma in patients whose stomas were not initially defunctioning.

RESULTS

A defunctioning stoma was created in 292 of 397 patients (74%); 12% of stomas were not reversible (33/279 that survived the operation >90 d); 11% (28/246) required a repeat stoma after stoma closure; 10% (10/105) of patients whose stomas were not initially defunctioning received a late permanent stoma. The overall rate of a permanent stoma was 18%. The main reasons for a permanent stoma were anastomosis-related complications and local recurrence. Risk factors for anastomosis-related complication were male gender, low tumor site, and tumor stage. Despite a significant reduction in local recurrence rates from 1997 to 2007, the rate of creating a permanent stoma did not change.

CONCLUSIONS

The possibility of a permanent stoma should be considered when planning surgery for treating rectal cancer. It might be preferable in older patients, in poor condition and with more advanced rectal cancers, to consider an abdominoperineal resection or Hartmann procedure instead of a low anterior resection.

[Protective stoma after deep anterior rectal resection: pro]

There is still controversy about the necessity of a diverting stoma after deep anterior resection with total mesorectal excision for rectal cancer. Recent results of randomized controlled trials and from systematic reviews have improved the currently available data. A significant benefit was shown for patients with diverting stoma in terms of clinically relevant anastomotic leakage and re-operation rates. The influence on mortality is not as clear. However, analysis of the data of 19 prospective studies within a systematic review including more than 9,000 patients, revealed a significant benefit for stoma creation. Furthermore, the rate of patients with stoma 5 years after primary resection was lower in the group of patients with diverting stoma. The purpose of this manuscript is to show the necessity of a diverting stoma based on the currently available data.

Quality of life following reversal of temporary stoma after rectal cancer treatment

PURPOSE

An examination of quality of life outcomes following reversal of a temporary stoma after rectal cancer treatment.

METHOD

An extensive search of the literature was conducted. Studies selected examine the consequences of stoma reversal on individual's lives. Methodological issues and implications for nursing practice are also considered.

RESULTS

It is clear that after stoma reversal, there is often a temporary alteration in bowel function, impacting on individuals' physical, social and psychological health for several months. There is possibility of permanent difficulties for some, significantly affecting their quality of life if left untreated. These effects can lead to more negative post-operative experiences than expected.

CONCLUSION

This review prompts discussion about how to provide appropriate support for patients following stoma reversal but also optimal pre-operative preparation, to foster realistic expectations and subsequent adaptation. It is suggested that nursing support should be targeted to the first few months post-reversal when bowel symptoms tend to be most troublesome.

Loop ileostomy following anterior resection: is it really temporary?

INTRODUCTION

A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis if anastomotic dehiscence occurs following low colorectal anastomosis. Although it has been suggested that a loop ileostomy should be reversed within 12 weeks of formation, this is often not the case. We set out to analyse the use of loop ileostomy following elective anterior resection in England and to identify factors associated with non and delayed reversal.

METHOD

Hospital episode statistics for the years 2001-2006 were obtained from the Department of Health. Patients undergoing elective anterior resection with a loop ileostomy for a primary diagnosis of rectal or recto-sigmoid cancer between April 2001 and March 2003 were identified as the study cohort. This cohort was followed until March 2006 to identify patients undergoing reversal of an ileostomy in an English NHS Hospital.

RESULTS

A total of 6582 patients had an elective anterior resection between April 2001 and March 2003, of which 964 (14.6%) also had an ileostomy. Seven hundred and two (75.1%) patients were reversed before March 2006. Advancing age and comorbidity were statistically related to nonreversal. Median time to reversal was 207 days (Interquartile range 119-321.5 days). Postoperative chemotherapy and comorbidity significantly delayed reversal.

CONCLUSIONS

One in four loop ileostomies performed to defunction an elective anterior resection is not reversed, and in the presence of significant comorbidity one in three is not reversed. Only 12% is reversed within 12 weeks.

Is sphincter preservation reasonable in all patients with rectal cancer?

PURPOSE

Modern sphincter-preserving surgery for ultralow rectal carcinoma has a comparable oncological radicality to abdomino-perineal extirpation (APE). The aim of this study was to assess the long-term morbidity of ultralow anterior resection (ULAR) and its impact on quality of life (QoL) METHODS: The medical records of 142 consecutive patients who underwent surgery for ultralow rectal carcinoma from January 1991 to December 2004 were reviewed retrospectively. The rate of rehospitalisation and rate of non-reversed temporary stomas ("failure" stoma) were analysed. Generic and cancer-specific quality of life questionnaires were used to assess quality of life.

RESULTS

There were a total of 82 ULAR and 60 APE. After ULAR, 25 (30.5%) of the patients were readmitted, stenosis and anastomotic leakage being the main reasons. After APE, only 2 (3.3%) of the patients were readmitted (P < 0.001). The rate of patients with a permanent stoma after sphincter-saving surgery was 22.0%. The failure rate was higher for older patients (P = 0.005) and for coloanal pull-through anastomosis (P = 0.001). The exploratory analysis revealed a negative impact of a "failure" stoma on QoL.

CONCLUSION

Severe long-term morbidity and high failure rate of stoma reversal have a significantly worse impact on QoL after ULAR; therefore, APE is a valid alternative to ULAR, especially in elder patients with planned coloanal pull-through anastomosis.

Standardized pelvic drainage of anastomotic leaks following anterior resection without diversional stomas

BACKGROUND

Anastomotic leakage is a serious complication in rectal cancer surgery. More than one third of rectal cancer patients with low anterior resection (LAR) will receive defunctional stomas during primary operation.

METHODS

Six hundred thirty-nine consecutive rectal cancer patients, whose tumors were located 5 to 12 cm from the anal verge, were treated with LAR. A standardized pelvic drainage for all these patients and selective irrigation for patients with leakage were conducted, and defunctional stoma was used as a salvage modality. All the anastomoses were all extraperitonealized during primary operations.

RESULTS

The anastomotic leakage rate was 7.04%. Male gender and location of tumor were found to be risk factors for leakage in patients with LAR. The overall stoma rate was 1.88%. Nearly 75% of leakage could be cured by irrigation-suction without surgical intervention. Severe complications, such as peritonitis, fistula, and obstruction, were strong predictors of irrigation failure.

CONCLUSIONS

Extraperitonealized anastomosis and pelvic drainage obtained a very low rate of defunctional stoma for LAR. Pelvic irrigation-suction was an effective modality to resolve anastomotic leakage.

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.

Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery

BACKGROUND

The association between diverting stomas and symptomatic anastomotic leakage after rectal cancer surgery was studied, as well as the impact of leakage on local recurrence, distant metastasis, and disease-free, overall and cancer-specific survival.

METHODS

Data from the Swedish Rectal Cancer Trial, Dutch TME trial, CAO/ARO/AIO-94 trial, EORTC 22921 trial and Polish Rectal Cancer Trial were pooled (n = 5187). All eligible patients without distant metastases at the time of low anterior resection were selected (n = 2726); overall survival was studied in patients aged 75 years or less (n = 2480). Multivariable models were used to study the association between diverting stomas and anastomotic leakage, and between leakage and recurrence or survival.

RESULTS

Some 9.7 per cent of patients were diagnosed with a symptomatic anastomotic leak; diverting stomas were negatively associated with leakage (11.6 per cent without and 7.8 per cent with a stoma; P = 0.002). Anastomotic leakage was negatively associated with overall survival in the multivariable analysis (hazard ratio (HR) 1.29 (95 per cent confidence interval 1.02 to 1.63); P = 0.034), but not with cancer-specific survival (HR 1.12 (0.83 to 1.52); P = 0.466).

CONCLUSION

Diverting stomas were associated with less symptomatic anastomotic leakage. Oncological outcome was not significantly influenced by leakage, but overall survival was reduced.

ETVARD (endoscopic transanal vacuum-assisted rectal drainage) leads to complete but delayed closure of extraperitoneal rectal anastomotic leakage cavities following neoadjuvant radiochemotherapy

PURPOSE

The purpose of the study was to prospectively assess the impact of neoadjuvant radiochemotherapy on the formation of major anastomotic rectal leaks and treatment by endoscopic transanal vacuum-assisted rectal drainage (ETVARD).

MATERIALS AND METHODS

Twenty six patients with malignancies with rectal anastomotic leaks were prospectively treated, including 14 of 26 patients following neoadjuvant radiochemotherapy. ETVARD was the first-line treatment.

RESULTS

In 23 of 26 patients, ETVARD was successfully completed. In patients following neoadjuvant radiochemotherapy sizes of leakage cavities, duration of ETVARD, number of sponge exchanges, and endoscopies as well as time to closure of cavities were significantly increased (0.009 < p < 0.035) compared to patients after primary surgery. Increased age showed similar correlations, whereas the level of anastomoses did not influence these parameters. Patients without (ile)ostomies could also be treated by ETVARD. Follow-up endoscopies have not shown any major changes.

CONCLUSIONS

Radiochemotherapy has a significant impact on development and treatment of major anastomotic rectal leaks. Most patients can be successfully treated by ETVARD, avoiding additional resective surgery or permanent (col)ostomies.

Laparoscopic versus Open Total Mesorectal Excision: A Nonrandomized Comparative Prospective Trial in a Tertiary Center in Mexico City

Because definitive long-term results are not yet available, the oncologic safety of laparoscopic surgery in rectal cancer remains controversial. Laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME). However, few prospective randomized studies have been performed. The main purpose of our study was to evaluate whether relevant differences in safety and efficacy exist after elective LTME for the treatment of rectal cancer compared with OTME in a tertiary referral medical center. This comparative nonrandomized prospective study analyzes data in 56 patients with middle and lower rectal cancer treated with low anterior resection or abdominoperineal resection from November 2005 to November 2007. Follow-up was determined through office charts or direct patient contact. Statistical analysis was performed using χ2 test and Student's t test. Twenty-eight patients underwent LTME and 28 patients were in the OTME group. No conversion was required in the LTME group. Mean operating time was shorter in the laparoscopic group (LTME) (181.3 vs 206.1 min, P < 0.002). Less intraoperative blood loss and fewer postoperative complications were seen in the LTME group. Return of bowel motility was observed earlier after laparoscopic surgery. There was no 30-day mortality and the overall morbidity was 17 per cent in the LTME group versus 32 per cent in the OTME group. The mean number of harvested lymph nodes was greater in the laparoscopic group than in the OTME group (12.1 ± 2 vs 9.3 ± 3). Mean follow-up time was 12 months (range 9-24 months). No local recurrence was found. LTME is a feasible procedure with acceptable postoperative morbidity and low mortality, however it is technically demanding. This series confirms its safety, although oncologic results are at present comparable with the OTME published series with the limitation of a short follow-up period. Further randomized studies are necessary to evaluate long-term clinical outcome.

End-to-end versus end-to-side stapled anastomoses after anterior resection for rectal cancer

BACKGROUND AND AIMS

Sphincter-saving procedures for resection of mid and, in some cases, of distal rectal tumors have become prevalent as their safety have been established. Increased anastomotic leak rate, associated with the type of anastomosis and the distance from the anal verge, has been reported. To compare surgical outcomes of end-to-end and end-to-side anastomosis after anterior resection for T1-T2 rectal cancer.

METHODS

During the study period, a total of 298 rectal cancer patients were treated. Patients with T1-T2 rectal cancer (i.e., tumor level < or =15 cm from the anal verge) fit for surgery were asked to participate in the study. Patients were randomized to receive either an end-to-end anastomosis or an end-to-side anastomosis using the left colon. Surgical results and complications were recorded.

RESULTS

Seventy-seven patients were randomized. Thirty-seven end-to-end anastomoses and 40 end-to-side anastomoses were performed. Anastomotic leakage after end-to-end anastomosis was 29.2%, while after end-to-side anastomosis was 5% (P = 0.005). In the end-to-end group 11 patients had anastomotic leaks: nine patients needed a re-intervention with colostomy creation subsequently closed in seven cases. Two patients of the end-to-side group experienced anastomotic leakage and were successfully treated conservatively.

CONCLUSIONS

Regarding postoperative surgical complications, end-to-side anastomosis is a safe procedure.

Results of emergency Hartmann's operation for obstructive or perforated left-sided colorectal cancer

Background

Up to 15% of colorectal cancer (CRC) patients present with obstructive or perforated tumours, and require emergency surgery. The Hartmann's procedure (HP) provides the opportunity to achieve a potentially curative (R0) resection, while minimizing surgical trauma in poor-risk patients. The aim of this study was to assess the surgical (operative mortality), and oncological (long-term survival after curative resection) results of emergency HP for obstructive or perforated left-sided CRC.

Methods

A retrospective review of 50 patients who underwent emergency HP for perforated/obstructive CRC in our institution between 1995 and 2006.

Results

Median age of patients was 75 (range 22–95) years and the indications for HP were obstruction (32) and perforation (18 patients). Operative mortality and morbidity were 8% and 26% respectively. 35 patients (70%) were operated with a curative intent; in this group, overall 1-, 3- and 5-year survival rates were 80%, 54% and 40%. In univariate analysis, the presence of lymph node metastases was associated with poor 5-year survival (62% [Stage II] vs. 27% [Stage III], log-rank test, p = 0.02). Eleven patients (22%) had their operation reversed with a median delay of 225 (range 94–390) days. In this subgroup, two patients died from distant metastases, but there were no instances of loco-regional recurrence.

Conclusion

Hartmann's operation remains a good option to palliate symptoms in 30% of patients with left-sided CRC who are not candidates to a curative resection. For those who have a curative resection, the oncological outcome is acceptable, especially stage II patients, who appear to benefit the most from this surgical strategy.

Factors associated with ostomy reversal

BACKGROUND

The natural history of colostomies and ileostomies for colonic disease is not well described. This study aimed to identify factors that have an impact on colostomy and ileostomy reversal among patients with colonic diseases.

METHODS

A retrospective review of patients with ileostomies and colostomies was performed at a university hospital from 1999 to 2005. Demographic, operative, and outcome data were collected. Data were analyzed using analysis of variance (ANOVA), t-test, and descriptive statistics. Mantel-Haenstel chi-square was used to establish association (p<0.05).

RESULTS

There were 96 patients (49 women) with an overall mean age of 56 years at the time of ostomy creation. Ostomy reversal was performed for 35 patients after an average interval of 5.6 months (range, 12-432 days). The patients' ages were significantly different between the reversed and nonreversed groups (p=0.01). The mean age was 49.9 years for the reversed group and 60.5 years for the nonreversed group. In a logistic regression model including demographic variables, African Americans were four times less likely to undergo reversal than Caucasians [odds ratio (OR), 0.24; 95% confidence interval (CI), 0.075-0.794]. Loop ileostomies (p=0.05) and sigmoid colostomies (p=0.01) were the only types of ostomies that demonstrated a significant association with reversal. Loop ileostomy was five times more likely to be reversed than sigmoid colostomy (OR, 0.17; 95% CI, 0.049-0.595).

CONCLUSIONS

Colostomy or ileostomy creation is a basic skill in the armamentarium of the general surgeon for treating complex diseases of the colon. Age, race, and type of ostomy creation are significant predictors for reversal. This data may be useful for consulting patients preoperatively regarding postoperative expectations.

Controversies of total mesorectal excision for rectal cancer in elderly patients

The cornerstone of treatment for rectal cancer is resectional treatment according to the principles of total mesorectal excision (TME). However, population-based registries show that improvements in outcome after resectional treatment occur mainly in younger patients. Furthermore, 6-month postoperative mortality is significantly increased in elderly patients (> or = 75 years of age) compared with younger patients (< 75 years of age). Several confounding factors, such as treatment-related complications and comorbidity, are thought to be responsible for these disappointing findings. Thus, major resectional treatment is not advantageous for all older patients with rectal cancer. However, the Dutch TME trial showed a good response to a short course of neoadjuvant radiotherapy in elderly patients. Biological responses to cancer treatment seem to change with age, and, therefore, individualised cancer treatments should be used that take into account the heterogeneity of ageing. For elderly patients who retain a good physical and mental condition, treatment that is given to younger patients is deemed appropriate, whereas for those with diminished physiological reserves and comorbid conditions, alternative treatments that keep surgical trauma to a minimum and optimise the use of radiotherapy might be more suitable.

Protective stoma in anterior resection of the rectum: when, how and why?

BACKGROUND

The use of protective stoma in anterior resection (AR) is controversial. Neoadjuvant therapy, TME and laparoscopy seem to increase the rate of anastomotic dehiscences (a.d.).

PATIENTS AND METHODS

In a prospective study, 219 patients were submitted to elective open AR (109 patients), open AR+TME nerve-sparing (110 patients), 35 of which had intrasphinteric anastomosis. Fifty-five patients were treated by neoadjuvant therapy. Primary stoma was not performed.

RESULTS

We had 15 (6.8%) a.d.: 5 (2.3%) major and 10 (4.4%) minor. In the five major a.d. an immediate colostomy was performed with one death. In the 10 minor the a.d. was cured conservatively.

CONCLUSIONS

A protective stoma is necessary in less than 10% of the patients treated with AR, so avoiding further surgery, mortality, morbidity and higher medical costs in most patients.

Survival of elderly rectal cancer patients not improved: analysis of population based data on the impact of TME surgery

INTRODUCTION

The incidence of rectal cancer is highest in elderly patients. However, these patients are often underrepresented in randomised studies. Therefore, it is not clear whether results of rectal cancer studies are equally applicable to both elderly and younger patients. In this paper, the Dutch Total Mesorectal Excision (TME) study is revisited, focused on patients aged 75 years and above. The rectal cancer databases of the Comprehensive Cancer Centres (CCC) South and West were combined to analyse the effect of the TME-study in three different periods: before (1990-1995), during (1996-1999) and after (2000-2002) the trial.

RESULTS

Implementation of preoperative radiotherapy, as investigated in the TME trial, and the introduction of TME surgery resulted in improved 5 year survival during the subsequent periods, in patients younger than 75 years, of 60% (1990-1995) to 67% (1996-1999) and 70% (2000-2002) (log rank p<0.0001). The older patients did not improve and remained at 41%, 40% and 43% at 5 years in the respective periods. Furthermore, mortality during the first 6-month period after treatment is significantly raised compared to younger patients: 14% in the elderly, compared to 3.9% in the younger TME-study patient (p<0.0001 X2). In the CCC database these figures were confirmed at 16% and 3.9% (p<0.0001 X2).

CONCLUSION

Overall survival was not improved in the elderly rectal cancer patient after introduction of preoperative radiotherapy and TME-surgery. Non-cancer related mortality is a significant problem in the first 6 months after surgery.