Sphincter-Preserving Surgery for Low Rectal Cancers: Incidence and Risk Factors for Permanent Stoma

Machine learning model for prediction of permanent stoma after anterior resection of rectal cancer: A multicenter study

BACKGROUND

The conversion from a temporary to a permanent stoma (PS) following rectal cancer surgery significantly impacts the quality of life of patients. However, there is currently a lack of practical preoperative tools to predict PS formation. The purpose of this study is to establish a preoperative predictive model for PS using machine learning algorithms to guide clinical practice.

METHODS

In this retrospective study, we analyzed clinical data from a total of 655 patients who underwent anterior resection for rectal cancer, with 552 patients from one medical center and 103 from another. Through machine learning algorithms, five predictive models were developed, and each was thoroughly evaluated for predictive performance. The model with superior predictive accuracy underwent additional validation using both an independent testing cohort and the external validation cohort. The Shapley Additive exPlanations (SHAP) approach was employed to elucidate the predictive factors influencing the model, providing an in-depth visual analysis of its decision-making process.

RESULTS

Eight variables were selected for the construction of the model. The support vector machine (SVM) model exhibited superior predictive performance in the training set, evidenced by an AUC of 0.854 (95 % CI:0.803-0.904). This performance was corroborated in both the testing set and external validation set, where the model demonstrated an AUC of 0.851 (95%CI:0.748-0.954) and 0.815 (95%CI:0.710-0.919), respectively, indicating its efficacy in identifying the PS.

CONCLUSIONS

The model(https://yangsu2023.shinyapps.io/psrisk/) indicated robust predictive performance in identifying PS after anterior resection for rectal cancer, potentially guiding surgeons in the preoperative stratification of patients, thus informing individualized treatment plans and improving patient outcomes.

Risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma: A systematic review and meta-analysis

BACKGROUND

To further define the risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma.

METHODS

Records from five English databases and four Chinese databases. Odds ratios (OR) and 95 % confidence intervals (CI) were used to indicate the risk of inclusion of risk factors. The non-closure stoma rate used the risk difference (RD) and 95 % CI. Risk factors were evaluated for quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age ≥60 years[OR:1.57, 95%CI(1.44,1.72)], Tumor IV stage[OR:4.21, 95%CI(2.29,7.74)], American Society of Anesthesiologists (ASA)≥3[OR:1.48, 95%CI(1.33,1.65)], Neoadjuvant chemoradiotherapy[OR:1.41, 95%CI(1.09,1.82)],Open surgery[OR:1.45, 95%CI(1.09,1.93)], Postoperative chemotherapy[OR:1.37, 95%CI(1.03,1.82)], Anastomotic leakage[OR:4.61, 95%CI(2.86, 7.44)], Local recurrence[OR:7.16, 95%CI(4.70, 10.91)]. The rate of non-closure stoma after anterior resection for rectal cancer was: 0.20, 95 % CI (0.17, 0.23). The quality of evidence for stage IV tumors and anastomotic leakage was moderate, and other risk factors were low to very low.

CONCLUSIONS

Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age≥60 years, Tumor IV stage, ASA≥3, Neoadjuvant chemoradiotherapy, Open surgery, Postoperative chemotherapy, Anastomotic leakage, Local recurrence, and one in five anterior resection patients with a temporary stoma fails to close.

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort

OBJECTIVE

To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).

BACKGROUND

AL after RC resection often results in a permanent stoma.

METHODS

This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.

RESULTS

This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).

CONCLUSIONS

The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies.

Risk Factors for Radical Rectal Cancer Surgery with a Temporary Stoma Becoming a Permanent Stoma: A Pooling Up Analysis

Purpose: The aim of this study was to find out the potential risk factors for the formation of a permanent stoma (PS) for rectal cancer patients with a temporary stoma (TS) after surgery. Methods: PubMed, Embase, and the Cochrane Library were searched for eligible studies until November 14, 2022. The patients were divided into the PS group and the TS group. Odds ratio (ORs) and 95% confidence intervals (CIs) were pooled up for describing dichotomous variables. Stata SE 16 was performed for data analysis. Results: After pooling up the data, a total of 14 studies involving 14,265 patients were included in this study. The outcomes showed that age (OR = 1.03, 95% CI = 0.96 to 1.10, I2 = 1.42%, P = .00 < .1), surgery type (P = .00 < .1), tumor stage (P = .00 < .1), preoperative chemoradiotherapy (P = .00 < .1), preoperative radiotherapy (P = .01 < .1), neoadjuvant therapy (P = .00 < .1), American Society of Anesthesiologists (ASA) score of ≥3 (P = .00 < .1), anastomotic leakage (P = .01 < .1), local recurrence (P = .00 < .1), and distant recurrence (P = .00 < .1) were associated with the patient with PS. However, sex (P = .15 > .1), previous abdominal surgery (P = .84 > .1), adjuvant chemotherapy (P = .87 > .1), and defunctioning stoma (P = .1) had little association with PS. Conclusion: Patients who were elderly, had advanced tumor stages, had a high ASA score, and underwent neoadjuvant therapy should be informed of the high risk of PS before surgery. Meanwhile, those who underwent rectal cancer surgery with a TS should beware of anastomotic leakage, local recurrences, and distant recurrences, which could increase the risk of PS.

Permanent stoma after sphincter preservation for rectal cancer. A situation that occurs more often than you might think

Objectives

This study aimed: (i) to assess the cumulative incidence of permanent stoma (PS) after sphincter-preserving surgery (SPS) for rectal cancer (RC): (ii) to analyze associated risk factors for primary and secondary PS; and (iii) to compare the long-term survival of patients according to the stoma state.

Methods

We conducted a retrospective single-center cohort study based on a prospectively maintained database of SRC patients undergoing SPS from January 2007 to December 2017. Incidence of both primary (no reversal of defunctioning stoma) and secondary (created after closure of defunctioning stoma) PS were investigated. Associations between potential risk factors and PS were analyzed using a logistic regression model. Cumulative survival curve was drawn by Kaplan-Meier method.

Results

Of the 257 eligible patients, 43 patients (16.7%) had a PS (16 primary PS and 27 secondary PS) after a median follow-up of 4.8 years. In multivariate analysis, the independent risk factors for primary PS were severe post-operative complications (OR 3.66; 95% CI, 1.19-11.20, p=0.022), and old age (OR 1.11; 95% CI 1.04-1.18, p=0.001) and those for secondary PS were local recurrence (OR 38.07; 95% CI 11.07-130.9, p<0.0001), anastomotic leakage (OR 7.01; 95% CI, 2.23-22.04, p=0.009), and severe post-operative complications (OR 3.67; 95% CI, 1.22-11.04, p=0.02), respectively. Both overall survival (OS) and disease-free survival (DFS) were significantly lower in patients with a PS compared with patients with SPS (p < 0.01).

Conclusions

This present study suggests that one out of 6 patients has a PS, 5 years after rectal resection with SPS for SRC.

Applying interpretable machine learning algorithms to predict risk factors for permanent stoma in patients after TME

Objective

The purpose of this study was to develop a machine learning model to identify preoperative and intraoperative high-risk factors and to predict the occurrence of permanent stoma in patients after total mesorectal excision (TME).

Methods

A total of 1,163 patients with rectal cancer were included in the study, including 142 patients with permanent stoma. We collected 24 characteristic variables, including patient demographic characteristics, basic medical history, preoperative examination characteristics, type of surgery, and intraoperative information. Four machine learning algorithms including extreme gradient boosting (XGBoost), random forest (RF), support vector machine (SVM) and k-nearest neighbor algorithm (KNN) were applied to construct the model and evaluate the model using k-fold cross validation method, ROC curve, calibration curve, decision curve analysis (DCA) and external validation.

Results

The XGBoost algorithm showed the best performance among the four prediction models. The ROC curve results showed that XGBoost had a high predictive accuracy with an AUC value of 0.987 in the training set and 0.963 in the validation set. The k-fold cross-validation method was used for internal validation, and the XGBoost model was stable. The calibration curves showed high predictive power of the XGBoost model. DCA curves showed higher benefit rates for patients who received interventional treatment under the XGBoost model. The AUC value for the external validation set was 0.89, indicating that the XGBoost prediction model has good extrapolation.

Conclusion

The prediction model for permanent stoma in patients with rectal cancer derived from the XGBoost machine learning algorithm in this study has high prediction accuracy and clinical utility.

Risk factors for a permanent stoma after resection of left-sided obstructive colon cancer - A prediction model

INTRODUCTION

In patients with left-sided obstructive colon cancer (LSOCC), a stoma is often constructed as part of primary treatment, but with a considerable risk of becoming a permanent stoma (PS). The aim of this retrospective multicentre cohort is to identify risk factors for a PS in LSOCC and to develop a pre- and postoperative prediction model for PS.

MATERIALS AND METHODS

Data was retrospectively obtained from 75 hospitals in the Netherlands. Patients who had curative resection of LSOCC between January 1, 2009 to December 31, 2016 were included with a minimum follow-up of 6 months after resection. The interventions analysed were emergency resection, decompressing stoma or stent as bridge-to-elective resection. Main outcome measure was presence of PS at the end of follow-up. Multivariable logistic regression analysis was performed to identify risk factors for PS at primary presentation (T₀) and after resection, in patients having a stoma in situ (T₁). These risk factors were used to construct a web-based prediction tool.

RESULTS

Of 2099 patients included in the study (T₀), 779 had a PS (37%). A total of 1275 patients had a stoma in situ directly after resection (T₁), of whom 674 had a PS (53%). Median follow-up was 34 months. Multivariable analysis showed that older patients, female sex, high ASA-score and open approach were independent predictors for PS in both the T₀ and T₁ population. Other predictors at T₀ were sigmoid location, low Hb, high CRP, cM1 stage, and emergency resection. At T₁, subtotal colectomy, no primary anastomosis, not receiving adjuvant chemotherapy and high pTNM stage were additional predictors. Two predictive models were built, with an AUC of 0.74 for T₀ and an AUC of 0.81 for T₁.

CONCLUSIONS

PS is seen in 37% of the patients who have resection of LSOCC. In patients with a stoma in situ directly after resection, 53% PS are seen due to non-reversal. Not only baseline characteristics, but also treatment strategies determine the risk of a PS in patients with LSOCC. The developed predictive models will give physicians insight in the role of the individual variables on the risk of a PS and help in informing the patient about the probability of a PS.

Cost‐effectiveness comparison of delayed versus immediate coloanal anastomosis following ultralow anterior resection for rectal cancer

BACKGROUND

Following ultralow anterior resection for distal rectal cancers, a coloanal anastomosis is usually created along with a defunctioning ileostomy (DI). Recent evidence suggests that abdominoperineal pull-through with delayed coloanal anastomosis (DCAA) is a viable alternative to immediate coloanal anastomosis (ICAA), minimizing the risk of anastomotic leakage and avoiding the need for stoma creation with the risk of stoma-associated morbidity. However, DCAA requires a longer initial hospitalization. We aimed to perform a cost-effectiveness analysis to compare DCAA versus ICAA for elective rectal cancer surgery.

METHODS

A decision tree model was used to compare the cost-effectiveness of the two strategies. Cost data were obtained from the 2019 to 2020 United Kingdom National Health Service reference costs. Model probabilities were derived from published studies. Univariate and probabilistic sensitivity analyses were used to evaluate the robustness of the results.

RESULTS

DCAA was the overall cheaper strategy at £13 541 compared with £14 856 for ICAA in the base case analysis. This was explained by the decreased overall costs of hospitalization/surgery, reduction in costs associated with anastomotic or stoma-related complications, specifically dehydration-induced hospital readmissions and avoidance of stoma maintenance costs. Sensitivity analysis demonstrated that DCAA remained consistently more inexpensive except when the duration of total parenteral nutrition exceeded 14 days.

CONCLUSION

Despite a longer index hospitalization with higher initial costs, this economic analysis demonstrates that DCAA without stoma is overall more cost-effective compared with ICAA with DI following ultralow anterior resection. Cost savings should be considered an additional benefit when selecting the DCAA approach for rectal cancer surgery.

Nomogram to predict permanent stoma in rectal cancer patients after sphincter-saving surgery

BACKGROUND

Approximately 20 percent of patients with a tumour localized in the low rectum still encounter the possibility of requiring permanent stoma (PS), which can cause drastic changes in lifestyle and physical perceptions.

AIM

To determine the risk factors for PS and to develop a prediction model to predict the probability of PS in rectal cancer patients after sphincter-saving surgery.

METHODS

A retrospective cohort of 421 rectal cancer patients who underwent radical surgery at Taipei Medical University Hospital between January 2012 and December 2020 was included in this study. Univariate and multivariate analyses were performed to identify the independent risk factors for PS. A nomogram was developed according to the independent risk factors obtained in the multivariate analysis. The performance of the nomogram was assessed using a receiver operating characteristic curve and a calibration curve.

RESULTS

The PS rate after sphincter-saving surgery was 15.1% (59/391) in our study after a median follow-up of 47.3 mo (range 7–114 mo). Multivariate logistic regression analysis demonstrated that local recurrence, perirectal abscess, anastomosis site stenosis, perineural invasion, tumor size and operative time were independent risk factors for PS. These identified risk factors were incorporated into the nomogram, and the concordance index of this model was 0.903 (95%CI: 0.851-0.955). According to the calibration curves, the nomogram represents a perfect prediction model.

CONCLUSION

Several risk factors for PS after sphincter-saving surgery were identified. Our nomogram exhibited perfect predictive ability and will improve a physician’s ability to communicate the benefits and risks of various treatment options in shared decision making.

The impact of postoperative complications severity on stoma reversal following sphincter-preserving surgery for rectal cancer

BACKGROUND

Currently, the relationship between temporary stoma reversal and the severity of postoperative complications (POCs) after the index surgery based on the Clavien-Dindo classification has not yet been explored.

METHODS

From July 2010 to June 2016, 380 patients undergoing sphincter-preserving surgery for rectal cancer with a temporary stoma in our hospital were included. Temporary stoma nonclosure rates, disease-free survival rates, and overall survival rates were estimated utilizing the Kaplan-Meier method.

RESULTS

Of all the 380 patients, primary stomas were created in 335 patients and secondary stomas in 45 patients. After the index surgery, 36.6% (139/380) of patients developed at least one postoperative complication. In the first analysis, which included all the patients, 24.7% of temporary stomas remained unclosed. In the second analysis for 335 patients with a primary stoma, 23.3% were left with unclosed stomas. After the COX regression analysis, both major POCs and minor POCs were found to be independent risk factors for the permanent stoma, and there was an increasing tendency toward the risk of permanent stoma with the increase in POC severity.

CONCLUSION

POCs are independent predictors of permanent stoma after rectal cancer surgery. Even minor POCs may affect the outcome, while there is a clear direct relationship between POC severity and permanent stoma rates.

Cumulative Incidence and Risk Factors of Permanent Stoma After Intersphincteric Resection for Ultralow Rectal Cancer

BACKGROUND

A permanent stoma is an unintended consequence that cannot be avoided completely after intersphincteric resection for ultralow rectal cancer. Unfortunately, its incidence and risk factors have been poorly defined.

OBJECTIVE

The objective was to determine the cumulative incidence and risk factors of permanent stoma after intersphincteric resection for ultralow rectal cancer.

DESIGN

This study was a retrospective analysis of prospectively collected data.

SETTINGS

This study was conducted at a colorectal surgery referral center.

PATIENTS

A total of 185 consecutive patients who underwent intersphincteric resection with diverting ileostomy from 2011 to 2019 were included.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of and risk factors for the permanent stoma. The secondary outcome included differences in stoma formation between patients with partial, subtotal, and total intersphincteric resection.

RESULTS

After a median follow-up of 40 months (range, 6-107 months), 26 of 185 patients eventually required a permanent stoma, accounting for a 5-year cumulative incidence of 17.4%. The causes of permanent stoma were anastomotic morbidity (46.2%, 12/26), local recurrence (19.2%, 5/26), distant metastasis (19.2%, 5/26), fecal incontinence (3.8%, 1/26), perioperative mortality (3.8%, 1/26), patients' refusal (3.8%, 1/26), and poor general condition (3.8%, 1/26). Although the incidence of permanent stoma was significantly different between the intersphincteric resection groups (partial vs subtotal vs total: 8.3% vs 20% vs 25.8%, p = 0.02), it was not an independent predictor of stoma formation. Multivariate analysis demonstrated that anastomotic leakage (OR = 5.29; p = 0.001) and anastomotic stricture (OR = 5.13; p = 0.002) were independently predictive of permanent stoma.

LIMITATIONS

This study was limited by its retrospective nature and single-center data.

CONCLUSIONS

The 5-year cumulative incidence of permanent stoma was 17.4%. Anastomotic complications were identified as risk factors. Patients should be informed of the risks and benefits when contemplating the ultimate sphincter-sparing surgery. It might be preferable to decrease the probability of permanent stoma by further minimizing anastomotic complications. See Video Abstract at http://links.lww.com/DCR/B704.

INCIDENCIA ACUMULADA Y FACTORES DE RIESGO DE ESTOMA PERMANENTE DESPUS DE UNA RESECCIN INTERESFNTRICA EN CNCER RECTAL ULTRA BAJO

ANTECEDENTES:La necesidad de efectuar un estoma permanente es la consecuencia no intencional e inevitable por completo después de una resección interesfintérica en presencia de un cáncer rectal ultra bajo. Desafortunadamente, la incidencia y los factores de riesgo se han definido en una forma limitada.OBJETIVO:El objetivo fue determinar la incidencia acumulada y los factores de riesgo para la necesidad de efectuar un estoma permanente después de la resección intersfintérica de un cáncer rectal ultra bajo.DISEÑO:El presente estudio es un análisis retrospectivo de la información obtenida.ESCENARIO:Centro de referencia de cirugía colo-rectal.PACIENTES:Se incluyeron un total de 185 pacientes consecutivos que se sometieron a resección intersfintérica de un cáncer rectal ultra bajo con ileostomía de derivación de 2011 a 2019.MEDICION DE RESULTADOS:El resultado principal fue la identificación de la incidencia y los factores de riesgo para la presencia de un estoma permanente. En forma secundaria se describieron los resultados de las diferentes técnicas de la formación de un estoma entre los pacientes con resección interesfintérica parcial, subtotal o total.RESULTADOS:Posterior a una media de seguimiento de cuarenta meses (rango de 6 a 107), 26 de 185 pacientes requirieron en forma eventual un estoma permanente, lo que equivale a una incidencia acumulada a cinco años de 17.4 %. Las causas para dejar un estoma permanente fueron morbilidad de la anastomosis (46.2%, 12/26), recurrencia local (19.2%, 5/26), metástasis a distancia (19.2%, 5/26), incontinencia fecal (3.8%, 1/26), mortalidad perioperatoria (3.8%, 1/26), rechazo del paciente (3.8%, 1/26), y malas condiciones generales (3.8%, 1/26). Aunque la incidencia de un estoma permanente fue significativamente diferente entre los grupos de resección interesfintérica (parcial vs subtotal vs total: 8.3% vs 20% vs 25.8%, p = 0.02), no se consideró un factor predictor independiente para la formación de estoma. En el análisis multivariado se demostró que la fuga anatomótica (OR = 5.29; p = 0.001) y la estenosis anastomótica (OR = 5.13; p = 0.002) fueron factores independientes para predecir la necesidad de un estoma permanente.LIMITACIONES:La naturaleza retrospectiva del estudio y la información proveniente de un solo centro.CONCLUSIONES:La incidencia acumulada a cinco años de estoma permantente fue de 17.4%. Se consideran a las complicaciones anastomóticas como factores de riesgo. Los pacientes deberán ser informados de los riesgos y beneficios cuando se considere la posibilidad de efectuar una cirugía preservadora de esfínteres finalmente. Puede ser preferible disminuir la probabilidad de dejar un estoma permanente tratando de minimizar la posibilidad de complicaciones de la anastomosis. Consulte Video Resumen en http://links.lww.com/DCR/B704.

Nomogram for Predicting the Probability of Permanent Stoma after Laparoscopic Intersphincteric Resection

PURPOSE

The purpose of this study was to determine the risk factors for the development of a permanent stoma in laparoscopic intersphincteric resection (LS-ISR) for ultralow rectal adenocarcinoma and to develop and validate a prediction model to predict the probability of permanent stoma after surgery.

METHODS

A primary cohort consisting of 301 consecutive patients who underwent LS-ISR was enrolled in this study. Multivariable logistic regression analysis was used to identify risk factors and develop the nomogram. The performance of the nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. An independent validation cohort contained 91 consecutive patients from January 2012 to January 2019.

RESULTS

The permanent stoma rate was 11.3% (34/301) in the primary cohort and 18.7% (17/91) in the validation cohort. Multivariable analysis revealed that nCRT (OR, 3.195; 95% CI, 1.169-8.733; P=0.024), ASA score of 3 (OR, 5.062; 95% CI, 1.877-13.646; P=0.001), distant metastasis (OR, 14.645; 95% CI, 3.186-67.315; P=0.001), and anastomotic leakage (OR, 11.308; 95% CI, 3.650-35.035; P<0.001) were independent risk factors for permanent stoma, and a nomogram was established. The AUCs of the nomogram were 0.842 and 0.858 in the primary and validation cohorts, respectively. The calibration curves showed good calibration in both cohorts. Decision curve analysis demonstrated that the nomogram was clinically useful.

CONCLUSION

We developed and validated a nomogram for ultralow rectal adenocarcinoma patients who underwent LS-ISR, and the nomogram could help surgeons identify which patients are at a higher risk of a permanent stoma after surgery.

Comparison of the clinical outcomes of skin bridge loop ileostomy and traditional loop ileostomy in patients with low rectal cancer

To compare the clinical results of patients with low rectal cancer who underwent skin bridge loop ileostomy and traditional loop ileostomy, and provide clinical evidence for choosing a better ostomy method. We retrospectively collected data of 118 patients with rectal cancer who underwent low anterior resection and loop ileostomy. To investigate the patients characteristics, postoperative stoma-related complications and the frequency of exchanged ostomy bags. The differences of these indicators between the two groups of patients who underwent skin bridge loop ileostomy and traditional loop ileostomy were compared. The Visual Analog Scale (VAS) score of the skin bridge loop ileostomy group was lower than that of the traditional ileostomy loop group (P < 0.05). The skin bridge group had a lower Discoloration, Erosion, Tissue overgrowth (DET) score and incidence of mucocutaneous separation than the traditional group at the 1st and 2nd weeks after operation (P < 0.05). The average number of weekly exchanged ostomy bags was significantly less in the skin bridge group than in the traditional group within 4 weeks after surgery (P < 0.05). Our experience demonstrates that the skin bridge loop ileostomy may significantly reduce early postoperative stoma-related complications, the frequency of exchanged ostomy bags and patients' medical costs after discharge.

A nomogram to predict the incidence of permanent stoma in elderly patients with rectal cancer

Background

Creation of a temporary diverting stoma during rectal cancer surgery is used widely to prevent undesirable outcomes related to anastomotic leakage (AL). The transition from temporary stoma (TS) to permanent stoma (PS) is a frequent outcome. Elderly patients may have a greater probability of PS. We aimed to identify risk factors of PS and developed a nomogram to predict the rate of PS for elderly patients.

Methods

We enrolled elderly patients (≥70 years) who underwent rectal cancer surgery with a TS between January 2014 and December 2017 at our hospital. We divided patients into two groups: a TS group and a PS group. We then identified the risk factors for PS and developed a nomogram to predict the possibility of PS.

Results

Of the 278 elderly patients who received a diverting stoma, 220 (79.14%) eventually underwent stoma reversal, and 58 (20.86%) had PS. The proportion of males in the PS group was significantly higher than that of the TS group (P=0.048). Univariate and multivariate analysis showed that American Society of Anesthesiologists (ASA) score (P<0.001), laparotomy (P=0.004), AL (P<0.001), and tumor recurrence (P<0.001) were significantly correlated with PS. These four factors were included to construct the nomogram. The consistency index of the nomogram was 0.833 and the model yielded an area under the curve of 0.833.

Conclusions

ASA score (≥3), laparotomy, AL, and tumor recurrence were independent risk factors for PS in elderly patients. Our nomogram exhibited moderate predictive ability.

What is the risk of permanent stoma beyond 5 years after low anterior resection for rectal cancer? A 15-year follow-up of a randomized trial

AIM

Low anterior resection of the rectum for cancer (LAR) entails a risk of symptomatic anastomotic leakage as well as impaired anorectal function, both of which may eventually result in the need for a permanent stoma (PS). The aim was to investigate the incidence of and risk factors for PS beyond 5 years following LAR.

METHODS

Patients undergoing LAR and included in a multicentre trial with randomization to defunctioning stoma or not were followed for a median of 15 years. The reasons for a PS up to 5 years (PS ≤ 5 years) and beyond 5 years (PS > 5 years) were identified and compared. Risk factors for PS were analysed.

RESULTS

Of all patients, 25% (57/232) had a PS. PS ≤ 5 years occurred in 19% (44/232) at a median of 12.5 months and PS > 5 years in 6% (13/232) at a median of 118 months following LAR. The main reason for PS ≤ 5 years was impaired anorectal function in 55% (24/44) and the main reason for PS > 5 years was pelvic sepsis related to the colorectal anastomosis in 46% (6/13). The major risk factor for PS was symptomatic anastomotic leakage, which occurred in 56% (32/57) of patients with PS and 10% (17/175) of patients without PS (P < 0.001).

CONCLUSION

One-fourth of the patients who ended up with a PS had it fashioned beyond 5 years at a median of 10 years following LAR. Symptomatic anastomotic leakage was the major risk factor for PS, and impaired anorectal function was the main overall reason for a PS.

Clinical characteristics and predictors of permanent stoma in rectal cancer patients underwent anterior resections: the value of preoperative prognostic nutritional index

OBJECTIVES

This study was aimed to investigate the correlation between preoperative prognostic nutritional index (PNI) and permanent stoma (PS) in patients with defunctioning stoma (DS) after anterior resections and, based on it, to reveal the clinical value of PNI on clinical strategies about the selection of stoma location.

METHODS

A total of 281 consecutive rectal cancer patients who accepted anterior resection and DS in the National Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University from June 2008 to June 2018 were enrolled in this study. Receiver operating characteristic (ROC) curve for PNI was performed to discriminate PS. Univariate and multivariate analysis were conducted to identify the clinical characteristics and risk factors for PS. Specific reasons for patients with DS turned into PS were reviewed.

RESULTS

ROC curve analysis defined PNI cutoff level of 45.85 corresponding to PS (area under the curve (AUC) = 0.71, 77% sensitivity, 56.9% specificity). Low PNI (OR = 3.23, P = 0.005), tumor crossing the peritoneal reflection (PR) (OR = 3.42, P = 0.003), postoperative distant metastasis (OR = 6.31, P < 0.001) were independently associated with PS. Besides, anastomotic complications (31.4%), poor oncological outcomes (35.3%), and personal preferences (33.3%) were the specific reasons for patients turning into PS.

CONCLUSIONS

Preoperative PNI is an independent prognostic factor to predict PS in patients who underwent anterior resection and DS. Therefore, combined with other clinical characteristics and predictors, preoperative measurements of PNI could provide a significant support for clinical decision on patients prepared to accept anterior resection and DS.

Long term outcome of anastomotic leakage in patients undergoing low anterior resection for rectal cancer

Background

The influence of anastomotic leakage (AL) on local recurrence rates and survival in rectal cancer remains controversial. The aim of this study was to analyze the effect of asymptomatic anastomotic leakage (AAL) and symptomatic anastomotic leakage (SAL) on short- and long-term outcome after curative rectal cancer resection.

Methods

All patients who underwent surgical resection of non-metastatic rectal cancer with curative intent from January 2005 to December 2017 were retrospectively analyzed. Short-term morbidity, long-term functional and oncological outcomes were compared between patients with SAL, AAL and without AL (WAL).

Results

Overall, 200 patients were included and AL was observed in 39 (19.5%) patients (10 AAL and 29 SAL) with a median follow-up of 38.5 months. Rectal cancer location and preoperative neoadjuvant treatment was similar between the three groups. Postoperative 30-day mortality rate was nil. The permanent stoma rate was higher in patients with SAL or AAL compared to WAL patients (44.8 and 30% vs 9.3%, p < 0.001). The mean wexner continence grading scale was significantly different between AAL (11,4 ± 3,8), SAL (10,3 ± 0,6) and WAL (6,4 ± 4,7) groups (p = 0.049). The 3 and 5-year overall and disease-free survival rates were similar between the 3 groups (86.6% /84% vs 100%/100% vs 76%/70 and 82.9%/77% vs 100%/100% vs 94.7%/88.3% for patients with SAL, AAL, and WAL, p = 0.480 and p = 0.527).

Conclusion

The permanent stoma rate was significant higher in patients with SAL or AAL compared to WAL patients. AL did not impair long-term oncological outcome.

Assessment of the risk of permanent stoma after low anterior resection in rectal cancer patients

Background

One of the most severe complications of low anterior rectal resection is anastomotic leakage (AL). The creation of a loop ileostomy (LI) reduces the prevalence of AL requiring surgical intervention. However, up to one-third of temporary stomas may never be closed.

The first aim of the study was to perform a retrospective assessment of the impact of LI on the risk of permanent stoma (PS) and symptomatic AL. The second aim of the study was to assess preoperative PS risk factors in patients with LI.

Methods

A total of 286 consecutive patients who underwent low anterior rectal resection were subjected to retrospective analysis. In 101 (35.3%) patients, diverting LI was performed due to low anastomosis, while in the remaining 185 (64.7%) patients, no ileostomy was performed. LIs were reversed after adjuvant treatment. Analyses of the effect of LI on symptomatic AL and PS were performed. Among the potential risk factors for PS, clinical factors and the values of selected peripheral blood parameters were analysed.

Results

PS occurred in 37.6% and 21.1% of the patients with LI and without LI, respectively (p < 0.01). Symptomatic ALs were significantly more common in patients without LI. In this group, symptomatic ALs occurred in 23.8% of patients, while in the LI group, they occurred in 5% of patients (p < 0.001). In the LI group, the only significant risk factor for PS in the multivariate analysis was preoperative plasma fibrinogen concentration (OR = 1.007, 97.5% CI 1.002–1.013, p = 0.013).

Conclusions

Although protective LI may reduce the incidence of symptomatic AL, it can be related to a higher risk of PS in this group of patients. The preoperative plasma fibrinogen concentration can be a risk factor for PS in LI patients and may be a useful variable in decision-making models.

Predictors of permanent stoma creation in patients with mid or low rectal cancer: results of a multicentre cohort study with preoperative evaluation of anal function

AIM

Preoperative factors predictive of permanent stoma creation were investigated in a long-term follow-up of patients with mid or low rectal cancer.

METHOD

We included patients who underwent radical resection for mid or low rectal cancer with available data for preoperative anal function measured by manometry and Faecal Incontinence Severity Index questionnaire between January 2005 and December 2015 in three tertiary referral hospitals. A permanent stoma was defined as a stoma present until the patient's last follow-up visit or death. Preoperative factors that predicted permanent stoma creation were analysed.

RESULTS

Over a median follow-up of 57.4 months (range 12-143 months), a permanent stoma was created in 144/577 (25.0%) patients, including 89 (15.4%) who underwent abdominoperineal resection, one (0.2%) who underwent Hartmann's operation without reversal, 15 (2.6%) with a diverting ileostomy at the time of initial sphincter-preserving surgery without undergoing stoma reversal, and 39 (6.8%) who underwent permanent ileostomy formation after sphincter-preserving surgery. Patients with permanent stoma creation had a shorter tumour distance from the anal verge (P < 0.001), larger tumour size (P = 0.020) and higher preoperative Faecal Incontinence Severity Index score (P = 0.020). On multivariable analysis, tumour distance from the anal verge predicted permanent stoma formation (relative risk 0.53 per centimetre increase; 95% confidence interval 0.46-0.60; P < 0.001) but preoperative anal function did not.

CONCLUSION

Tumour distance from the anal verge was the only preoperative determinant of permanent stoma creation in rectal cancer patients. These data may help mid and low rectal cancer patients understand the need for permanent stoma.

Clinical application of laparoscopic total mesorectal excision using the intersphincteric approach through the sacrococcygeal incision for treating patients with rectal cancer

Introduction

Colorectal cancer is the third most common cancer causing death in Western countries; laparoscopic surgery for colorectal cancer has many advantages and thus has been used widely. Laparoscopic total mesorectal excision through the sacrococcygeal incision under direct visualization to excise distal rectal cancer is an important procedure for super-low rectal carcinomas.

Aim

To investigate the feasibility of mesorectal excision and super-low rectal carcinoma excision using the intersphincteric approach through the sacrococcygeal incision.

Material and methods

From December 2009 to June 2017, intersphincteric resection was performed through the sacrococcygeal incision; the mesentery was excised in 27 patients with rectal cancer and a contracted pelvis (the lower edge of the tumor was 4 to 7 cm to the anal verge) through laparoscopy in the Gastrointestinal Surgery Department of our hospital.

Results

No death was recorded during surgery. The surgical time ranged from 190 to 310 min, the bleeding volume was 50 to 150 ml, and the post-surgical length of stay was 6 to 19 days. There were three cases of anastomotic fistulas, one case of anastomotic stenosis, and one case of fecal incontinence. Follow-up visits were scheduled for 19 patients, with a mean time of 37 months, ranging from 3 to 92 months; one case of local recurrence, one case of peritoneal metastasis, and two cases of hepatic metastasis were observed.

Conclusions

Laparoscopic total mesorectal excision using the intersphincteric approach through the sacrococcygeal incision is feasible for treating patients with a contracted pelvis and super-low rectal carcinoma.

High risk of permanent stoma after anastomotic leakage in anterior resection for rectal cancer

AIM

This study investigates how often bowel continuity was restored after anastomotic leakage in anterior resection for rectal cancer and assesses the clinical factors associated with permanent stoma.

METHOD

The Swedish Colorectal Cancer Registry was used to identify cases of anastomotic leakage registered in southern Sweden between January 2001 and December 2011. Patient characteristics, surgical details and clinical information about the anastomotic leakages were retrieved from medical records.

RESULTS

Of the 1442 patients operated on with anterior resection in 11 hospitals, 144 (10%) were diagnosed with anastomotic leakage after anterior resection for rectal cancer. After a median follow-up of 87 months (range 21-165), the overall rate of permanent stoma among patients with anastomotic leakage was 65%. Age ≥ 70 years (P = 0.02) and re-laparotomy (P < 0.001) were independently related to permanent stoma. Compared with nondefunctioned patients with anastomotic leakage, defunctioned patients with anastomotic leakage at the index procedure less often required re-laparotomy at some point during the entire clinical course (P < 0.001), but nondefunctioned and defunctioned patients with anastomotic leakage both had permanent stoma to the same extent (67% and 62%, respectively).

CONCLUSION

Anastomotic leakage is highly associated with permanent stoma after anterior resection, especially in patients aged ≥ 70 years. In this cohort of patients with anastomotic leakage, 65% had permanent stoma at long-term follow-up. A defunctioning stoma ameliorates the clinical course but does not affect the end result of bowel continuity in established anastomotic leakage after anterior resection.