Defunctioning Stomas Result in Significantly More Short-Term Complications Following Low Anterior Resection for Rectal Cancer

Benefits and risks of diverting stoma creation during rectal cancer surgery

PURPOSE

A consensus has been reached regarding diverting stoma (DS) construction in rectal cancer surgery to avoid reoperation related to anastomotic leakage. However, the incidence of stoma-related complications (SRCs) remains high. In this study, we examined the perioperative outcomes of DS construction in patients who underwent sphincter-preserving surgery for rectal cancer.

METHODS

We included 400 participants who underwent radical sphincter-preserving surgery for rectal cancer between 2005 and 2017. These participants were divided into the DS (+) and DS (-) groups, and the outcomes, including postoperative complications, were compared.

RESULTS

The incidence of ileus was higher in the DS (+) group than in the DS (-) group (P<0.01); however, no patients in the DS (+) group showed grade 3 anastomotic leakage. Furthermore, early SRCs were observed in 33 patients (21.6%) and bowel obstruction-related stoma outlet syndrome occurred in 19 patients (12.4%). There was no significant intergroup difference in the incidence of grade 3b postoperative complications. However, the most common reason for reoperation was different in the 2 groups: anastomotic leakage in 91.7% of patients with grade 3b postoperative complications in the DS (-) group, and SRCs in 85.7% of patients with grade 3b postoperative complications in the DS (+) group.

CONCLUSION

Patients with DS showed higher incidence rates of overall postoperative complications, severe postoperative complications (grade 3), and bowel obstruction, including stoma outlet syndrome, than patients without DS. Therefore, it is important to construct an appropriate DS to avoid SRCs and to be more selective in assigning patients for DS construction.

Evaluation of the SafeHeal Colovac+ anastomosis protection device after low anterior resection for rectal cancer: the safe anastomosis feasibility evaluation (SAFE) 2019 trial

BACKGROUND

Protective ileostomy (PI) is the current standard of care to protect the anastomosis after low anterior resection (LAR) for rectal cancer, but is associated with significant morbidity. Colovac is an anastomosis protection device designed to shield the anastomosis from fecal content. A second version (Colovac+) was developed to limit the migration risk during the implantation period. The objective of this clinical trial was to evaluate the preliminary efficacy and safety of the Colovac+.

METHODS

This was a prospective, multicenter, pilot study aiming to enroll 15 patients undergoing LAR with Colovac+ placement. After 10 days, a CT scan was performed to evaluate the anastomosis and the Colovac+ was retrieved endoscopically. During the 10-day implantation and 3-month follow-up period, we collected data regarding predefined efficacy and safety endpoints. The primary endpoint was the rate of major (Clavien-Dindo III-V) postoperative complications related to the Colovac+ or LAR procedure.

RESULTS

A total of 25 patients were included (68% male), of whom 15 were consecutively treated with the Colovac+ and Vacuum Loss Alert System. The Colovac+ was successfully implanted in all 15 patients. No major discomfort was reported during the implantation period. The endoscopic retrieval was performed in 14/15 (93%) patients. The overall major postoperative morbidity rate was 40%, but none of the reported complications were related to the Colovac+. A device migration occurred in 2 (13%) patients, but these were not associated with AL or stoma conversion. Overall, Colovac+ provided effective fecal diversion in all 15 patients and was able to avoid the PI in 11/15 (73%) patients.

CONCLUSIONS

Colovac+ provides a safe and effective protection of the anastomosis after LAR, and avoids the PI in the majority (73%) of patients. The improved design reduces the overall migration rate and limits the clinical impact of a migration.

One Decade of Declining Use of Defunctioning Stomas After Rectal Cancer Surgery in the Netherlands: Are We on the Right Track?

BACKGROUND

The beneficial effect of a defunctioning stoma in mitigating the consequences of anastomotic leakage after rectal cancer surgery is still debated.

OBJECTIVE

This study aims to reflect on a decade of rectal cancer surgery in terms of stoma construction and anastomotic leakage.

DESIGN

Retrospective observational study.

SETTING

This study used data from the Dutch Colorectal Audit from 2011 to 2020.

PATIENTS

Patients undergoing rectal cancer surgery with a primary anastomosis.

MAIN OUTCOME MEASURES

Primary outcome was anastomotic leakage. Secondary outcomes were minor complications, admission to intensive care, length of stay, readmission, and patient death.

RESULTS

A total of 13,263 patients were included in this study. A defunctioning stoma was constructed in 7106 patients (53.6%). Patients with a defunctioning stoma were less likely to develop anastomotic leakage (7.9% vs 13.0%), and if anastomotic leakage occurred, fewer patients needed surgical reintervention (37.7% vs 81.1%). An annual decrease in the construction of a defunctioning stoma was seen (69.8% in 2011 vs 51.8% in 2015 vs 29.7% in 2020), accompanied by a 5% increase in anastomotic leakage (9.1% in 2011 vs 14.1% in 2020). A defunctioning stoma was associated with a higher occurrence of minor complications, increased admissions to the intensive care unit, longer length of stay, and more readmissions within 90 days.

LIMITATION

This retrospective study is susceptible to confounders by indications, and there could be risk factors for anastomotic leakage and the use of a stoma that were not regarded.

CONCLUSIONS

The reduction in defunctioning stomas is paralleled with an increase in anastomotic leakage. However, patients with a defunctioning stoma also showed more minor complications, a prolonged length of stay, more intensive care admissions, and more readmissions. In our opinion, the trade-offs of selective use should be individually considered. See Video Abstract at http://links.lww.com/DCR/C137 .

UNA DCADA DISMINUYENDO EL USO DE ESTOMAS DISFUNCIONANTES EN LOS CASOS DE CNCER DE RECTO EN HOLANDA ESTAMOS HACIENDO LO CORRECTO

ANTECEDENTES:Aún se debate el efecto benéfico de la confección de un estoma disfuncionante para limitar las consecuencias de la fuga anastomótica en los casos de cirugía por cáncer de recto.OBJETIVO:Reflexiones sobre una década de cirugía por cáncer de recto en términos de confección de estomas y de fugas anastomóticas.DISEÑO:Estudio retrospectivo y observacional.AJUSTE:El presente estudio utilizó datos de la Auditoría Colorectal Holandesa entre 2011 y 2020.PACIENTES:Todos aquellos intervenidos por cáncer de recto con anastomosis primaria.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue evaluar la fuga anastomótica. Los resultados secundarios fueron las complicaciones menores, la permanencia en cuidados intensivos, la duración de la hospitalización, las rehospitalizaciones y las causas de muerte en los pacientes.RESULTADOS:Un total de 13.263 pacientes fueron incluidos en el presente estudio. Se confeccionó un estoma disfuncionante en 7.106 (53,6%) pacientes. Aquellos portadores de un estoma disfuncionante tenían menos probabilidades de desarrollar una fuga anastomótica (7,9 % frente a 13,0 %) y, si ocurría una fuga anastomótica, menos pacientes necesitaban reintervención quirúrgica (37,7 % frente a 81,1 %). Se observó una disminución anual en la confección de un estoma disfuncionante (69,8 % en 2011 frente a 51,8 % en 2015 frente a 29,7 % en 2020), acompañada de un aumento del 5 % en la fuga anastomótica (9,1 % en 2011 frente a 14,1 % en 2020). Un estoma disfuncionante se asoció con una mayor incidencia de complicaciones menores, permanencia en la unidad de cuidados intensivos, una estadía más prolongada y más rehospitalizaciones dentro de los 90 días.LIMITACIÓN:Estudio retrospectivo susceptible de factores de confusión según las indicaciones, donde podrían no haber sido considerados ciertos factores de riesgo con relación a la fuga anastomótica y a la confección de un estoma disfuncionante.CONCLUSIÓN:La reducción de estomas disfuncionantes es paralela con el aumento de la fuga anastomótica. Sin embargo, los pacientes con un estoma disfuncionante también mostraron más complicaciones menores, una estadía prolongada, más admisiones a cuidados intensivos y más rehospitalizaciones. En nuestra opinión, las ventajas y desventajas del uso selectivo de estomas disfuncionantes deben ser consideradas caso por caso. Consulte Video Resumen en https://links.lww.com/DCR/C137 . (Traducción-Dr. Xavier Delgadillo ).

Assessment of the efficacy of Handmade Vacuum-Assisted Sponge Drain for Treatment of Anastomotic leakage after Low Anterior Rectal Resection

Anastomotic leakage is one of the major complications of colorectal surgery, which might lead to reoperation, increased hospital stays, further intervention and mortality. Vacuum-assisted closure by devices such as Endo-SPONGE® produced by (B-Braun Medical B.V.) is currently being used to treat leakage and fistula. In this study, we aimed to assess the handmade vacuum-assisted sponge drain for anastomotic leakage following low anterior resection. This prospective study included 22 patients who had undergone sponge drain placement to treat anastomotic leakage. All patients had anastomotic leaks or defects after left anterior rectal resection (LAR) without ileostomy. They were treated with neo-adjuvant chemotherapy before the surgery and then subjected to rigid recto-sigmoidoscopy for 30 days following the operation. Any sign of leakage, such as perianal and pelvic pain, was immediately identified and followed up with a CT scan and another recto-sigmoidoscopy. Twenty-two patients were enrolled in this study, 12 men (54.5%) and 10 women (47.4%). All patients had received neo-adjuvant chemotherapy with an average follow-up of 22.30 ± 3.81. 75% of patients (15 cases) were successfully treated, and 17 patients (85%) underwent successful ostomy closure. Treatment failed in 5 patients (25%), including three men and two women. This study shows that handmade vacuum-assisted sponge drain is a cost-effective method of anastomotic leakage management with efficacy similar to that of Endo-SPONGE^®.

Impact of a diverting ileostomy in total mesorectal excision with primary anastomosis for rectal cancer

BACKGROUND

The role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity.

METHODS

Patients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity.

RESULTS

In 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424-4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%.

CONCLUSIONS

The stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

Modified Primary Anastomosis Using an Intestinal Internal Drainage Tube for Crohn's Disease: A Pilot Study

PURPOSE

Surgical treatment is an important part of the management of Crohn's disease (CD). However, the current recommended staged procedures require two operations, with long hospital stays and high costs, while traditional primary anastomosis has a high risk of complications. Therefore, the aim of this study was to compare the clinical efficacy and safety of modified primary anastomosis using intestinal internal drainage tubes for CD.

METHODS

In this study, emergency and nonemergency CD patients were included separately. Then, the patients were divided into three subgroups: patients with intestinal internal drainage tubes (modified primary anastomosis), staged procedures, and traditional primary anastomosis. The main outcomes were the number of hospitalizations, length and cost of the first hospital stay, length and cost of total hospital stays, and complications.

RESULTS

The outcomes of the three subgroups of emergency CD patients were not significantly different. For nonemergency CD patients, patients with intestinal internal drainage tubes had shorter total hospital stays and fewer hospitalizations compared with the staged procedures subgroup, while no significant differences in any outcomes were observed between the modified and traditional primary anastomosis subgroups.

CONCLUSIONS

For emergency CD patients, no significant advantage in terms of the main outcomes was observed for modified primary anastomosis. For nonemergency CD patients, modified primary anastomosis reduced the length of total hospital stays and hospitalizations compared with staged procedures. The placement of intestinal internal drainage tubes allows some patients who cannot undergo primary anastomosis to undergo it, which is a modification of traditional primary anastomosis.

Risk factors and pooled incidence of intestinal stoma complications: systematic review and Meta-analysis

OBJECTIVE

The present systematic review aimed to identify, critically assess and summarize which risk factors might determine the onset of ostomy complications, describing a pooled incidence and stratified incidences by each identified risk factor.

METHODS

A systematic literature review with a meta-analysis of observational studies was performed by following the PRISMA statement and flow chart. The quality assessment of the included articles was performed through the Newcastle-Ottawa Scale (NOS).

RESULTS

Sixteen articles published between 1990 and 2018 focused on the risk factors related to intestinal stomal complications, and the performed analysis led to identifying influenceable and non-influenceable risk factors. The median of the NOS evaluation was 6 (IQR = 5.75-6). Among 10,520 included patients, the pooled incidence of stomal complications was 35%, ranging from 9% to 63%, regardless of the nature of the complications. Analysis of the sub-groups highlighted obesity and ostomy surgery performed via laparoscopy or emergency conditions have significant incidences, respectively, of 66% and 68%.

CONCLUSIONS

The pooled incidence of stomal complications requires greater attention for its relevant epidemiology. From the clinical point of view, patients with obesity and chronic conditions require more attention to prevent complications, possibly employing accurate educational interventions to enhance proper stoma management.

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

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

Clinical application of terminal ileum suspension in laparoscopic radical resection for low rectal cancer

Objectives

This paper introduces the surgical procedure of "terminal ileum suspension" in the radical resection for low rectal cancer patients and evaluates the possibility of its clinical application.

Methods

This paper retrospectively analyzed the data of patients with low rectal cancer who underwent "terminal ileum suspension" during radical resection of rectal cancer (Dixon) in our hospital, and introduces the specific surgical procedures and key points of "terminal ileum suspension". Observe the relevant conditions of patients during the operation, postoperative recovery and postoperative complications, and analyze the safety and feasibility of this operation ("terminal ileum suspension").

Results

The operation of all 8 patients went smoothly, and no anastomotic leakage, intestinal obstruction, and open diversion of suspended terminal ileum were found. The application of "terminal ileum suspension" in the operation of low rectal cancer has achieved ideal clinical effect, without increasing the rate of anastomotic leakage and rehospitalization, reducing the proportion of the secondary return operation, and reducing the pain of the patients.

Conclusion

"Terminal ileum suspension" is a safe, effective and feasible surgical method for laparoscopic radical resection of low rectal cancer, which can be applied in clinical practice.

Transanal total mesorectal excision (TaTME) with delayed coloanal anastomosis versus TaTME with immediate coloanal anastomosis and temporary diversion in middle and low rectal cancer

BACKGROUND

Transanal total mesorectal excision (TaTME) avoids the difficulty of laparoscopic dissection of the lower part of the rectum. The need for stoma is associated with many stoma-related complications. The objective was to compare TaTME with immediate coloanal anastomosis and protective ileostomy (TaTME-IA) versus Turnbull-Cutait delayed coloanal anastomosis (TaTME-TC).

METHODS

A retrospective cohort study included patients with low rectal cancer at least 1 cm above the top of the anal sphincter. Patients had either TaTME-IA or TaTME-TC. Primary outcome measures were anastomotic and stoma-related complications. Secondary outcomes included rate of permanent stomas, local recurrence, continence, and quality of life (QOL).

RESULTS

TaTME-IA was done in 25 patients versus 20 who had TaTME-TC. TaTME-IA had significantly longer mean operative time (p = 0.04) and shorter length of stay (LOS) (4.5 vs. 11.4 days; p = 0.0001) compared to TaTME-TC. Anastomotic leak was reported in two patients of TaTME-IA versus one patient of TaTME-TC (p = 0.77). Anastomotic stenosis was reported in one patient in each group. No significant difference between groups as regard continence, local recurrence, and QOL.

CONCLUSION

TaTME-TC is a safe option that can be offered for patients with low rectal cancer who refuse or are not amenable to a temporary stoma. Anastomotic complications were similar in both groups. LOS was much longer in TaTME-TC, however, it avoids stoma complications. Both groups had similar functional oncologic outcomes and QOL.

Diverting stomas reduce reoperation rates for anastomotic leak but not overall reoperation rates within 30 days after anterior rectal resection: a national cohort study

PURPOSE

A diverting stoma is commonly formed to reduce the rate of anastomotic leak following anterior resection with anastomosis, although some studies question this strategy. The aim of this study was to assess the leak rates and overall complication burden after anterior resection with and without a diverting stoma.

METHODS

A 5-year national cohort with prospectively registered data of patients who underwent elective anterior resection for rectal cancer located < 15 cm from the anal verge. Data were retrieved from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry. Primary end point was relaparotomy or relaparoscopy for anastomotic leak within 30 days from index surgery. Secondary endpoints were postoperative complications including reoperation for any cause.

RESULTS

Some 1018 patients were included of whom 567 had a diverting stoma and 451 had not. Rate of reoperation for anastomotic leak was 13 out of 567 (2.3%) for patients with diverting stoma and 35 out of 451 (7.8%) (p > 0.001) for patients without. In multivariable analyses not having a diverting stoma (aOR 3.77, c.i 1.97-7.24, p < 0.001) was associated with increased risk for anastomotic leak. However, there were no differences in overall reoperation rates following anterior resection with or without diverting stoma (9.3% vs 10.9%, p = 0.423), and overall complication rates were similar. Reoperation was associated with increased mortality irrespective of the main intraoperative finding.

CONCLUSION

Diverting stoma formation after anterior resection is protective against reoperation for anastomotic leak but does not affect overall rates of reoperation or complications within 30 days.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Patient-Related Factors Associated With Stoma and Peristomal Complications Following Fecal Ostomy Surgery: A Scoping Review

PURPOSE

Ostomy creation is often an integral part of the surgical management of various diseases including colorectal malignancies and inflammatory bowel disease. Stoma and peristomal complications may occur in up to 70% of patients following ostomy surgery. The aim of this scoping literature review was to synthesize evidence on the risk factors for developing complications following creation of a fecal ostomy.

DESIGN

Scoping literature review.

SEARCH STRATEGY

Two independent researchers completed a search of the online bibliographic databases PubMed, MEDLINE, Cochrane, Google Scholar, and EMBASE for all articles published between January 1980 and December 2018. The search comprised multiple elements including systematic literature reviews with meta-analysis of pooled findings, randomized controlled trials, cohort studies, observational studies, other types of review articles, and multiple case reports. We screened 307 unique titles and abstracts; 68 articles met our eligibility criteria for inclusion. The methodological rigor of study quality included in our scoping review was variable.

FINDINGS/CONCLUSIONS

We identified 6 risk factors associated with an increased likelihood of stoma or peristomal complications (1) age more than 65 years; (2) female sex; (3) body mass index more than 25; (4) diabetes mellitus as a comorbid condition; (5) abdominal malignancy as the underlying reason for ostomy surgery; and (6) lack of preoperative stoma site marking and WOC/ostomy nurse specialist care prior to stoma surgery. We also found evidence that persons with a colostomy are at a higher risk for prolapse and parastomal hernia.

IMPLICATIONS

Health care professionals should consider these risk factors when caring for patients undergoing fecal ostomy surgery and manage modifiable factors whenever possible. For example, preoperative stoma site marking by an ostomy nurse or surgeon familiar with this task, along with careful perioperative ostomy care and education of the patient by an ostomy nurse specialist, are essential to reduce the risk of modifiable risk factors related to creation of a fecal ostomy.

Morbidity and costs of diverting ileostomy in transanal total mesorectal excision with primary anastomosis for rectal cancer

BACKGROUND

The role of diverting ileostomy is debated in rectal cancer surgery with primary anastomosis. The aim of this study was to evaluate the associated morbidity and hospital costs of diversion after sphincter saving TaTME surgery.

METHODS

All patients undergoing TaTME with primary anastomosis for rectal cancer between January 2012 and December 2019 in a single centre in the Netherlands were included. Patients with diverting ileostomy creation during primary surgery were compared with those without ileostomy. Outcomes included length of hospital stay, anastomotic leakage rates and total hospital costs at 1 year.

RESULTS

One hundred and one patients were included in the ileostomy group, and 46 patients were in the non-ileostomy group. The number of female patients was 31 (30.7%) in the ileostomy group and 21 (45.7%) in the non-ileostomy group Mean age was 64.5 ± 11.1 years in the ileostomy group and 62.6 ± 10.7 years in the non-ileostomy group The anastomotic leakage rate was 21.7% in the non-ileostomy group and 15.8% in the ileostomy group (p = 0.385). The grade of leakage and number of anastomotic takedowns did not differ between groups. Mean costs at 1 year after surgery was €26,500.13 in the ileostomy group and €16,852.61 in the non-ileostomy group. The main cost driver was longer total length of hospital stay at 1 year (mean 12.4 ± 13.3 days vs 20.6 ± 12.6 days, p = 0.000).

CONCLUSIONS

Morbidity and associated costs after diverting ileostomy are high. The incidence and morbidity of anastomotic leakage was not reduced by creation of an ileostomy. Omission of a diverting ileostomy after TaTME could possibly result in a reduction in treatment associated morbidity and costs.

The influence of predictive nursing on the emotions and self-management abilities of post-colostomy rectal cancer patients

OBJECTIVE

This study aimed to explore the influence of predictive nursing on the emotions and self-management abilities of post-colostomy rectal cancer patients.

METHODS

From March 2017 to October 2019, 130 patients with rectal cancer were recruited as the study cohort and placed into a predictive group (the PG) (n=80) that underwent predictive nursing or a normal group (the NG) (n=50) that underwent routine nursing. After the intervention, the operative indications, self-care abilities, nutritional indicators, mental health, postoperative recovery, complications, and nursing satisfaction of the two groups were compared.

RESULTS

After the intervention, compared with the NG, the average blood loss, operation times, gastrointestinal tract recovery times and durations of the hospital stays in the PG were shorter, and the self-care ability scores were higher, the nutritional conditions, namely the albumin (ALB), transferrin (TRF), and prealbumin (PAB) levels, were higher, the mental health, namely the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores, was better, the total effective rate of the postoperative recovery and the nursing satisfaction were higher, and the incidence of complications was lower.

CONCLUSION

predictive nursing can improve the moods and self-management abilities of post-colostomy rectal cancer patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intraluminal bypass devices as an alternative to protective ostomy for prevention of colorectal anastomotic leakage: a systematic review of the literature

AIM

Anastomotic leakage (AL) is the most important complication of colorectal surgery, leading to high morbidity and mortality. Protective ostomy, the current standard of care for protecting a colorectal anastomosis, has important drawbacks that require the creation of an alternative strategy. Over the past 30 years, several intraluminal bypass devices, designed to shield the anastomosis from the faecal stream, have been developed. The aim of this literature review was to create an updated overview of the devices available and their effectiveness in preventing AL, and to investigate whether they could serve as an alternative to protective ostomy in the future.

METHOD

A systematic review of the literature on intraluminal bypass devices used for preventing colorectal AL was performed. The MEDLINE and Cochrane Library databases were searched, and articles were marked as relevant if an intraluminal bypass device was studied in an animal or human population.

RESULTS

The database search yielded 24 relevant articles related to 10 intraluminal bypass devices protecting a colorectal anastomosis. These articles included experimental animal studies, preclinical (pilot) studies, as well as retrospective and prospective clinical studies. Each device was assessed with regard to surgical technique, effectiveness and device-related complications.

CONCLUSION

Intraluminal bypass devices show promise in preventing AL and its clinical consequences. However, there is insufficient high-level evidence to draw firm conclusions. There is a need for randomized controlled trials that directly compare these devices with the protective ostomy.

Neoadjuvant radiotherapy for rectal cancer management

Thirty per cent of all colorectal tumours develop in the rectum. The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions. Most patients with early rectal cancer can be adequately managed by surgery alone. However, a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery. Neoadjuvant therapy involves a variety of options including radiotherapy, chemotherapy used alone or in combination. Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery. The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes, within an intact mesorectal package, in order to minimise local recurrence. It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties. Pre-operative staging including CT thorax, abdomen, pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential. Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy. While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure, which includes patients with nodal involvement, extramural venous invasion and threatened circumferential margin. The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.

The Clinical and Economic Burden of Colorectal Anastomotic Leaks: Middle-Income Country Perspective

Purpose

Anastomotic leaks (AL) present a significant source of clinical and economic burden on patients undergoing colorectal surgeries. This study was aimed at evaluating the clinical and economic consequences of AL and its risk factors.

Methods

A retrospective cohort study was conducted between 2012 and 2013 based on the billing information of 337 patients who underwent low anterior resection (LAR). The outcomes evaluated were the development of AL, use of antibiotics, 30-day readmission and mortality, and total hospital costs, including readmissions and length of stay (LOS). The risk factors for AL, as well as the relationship between AL and clinical outcomes, were analyzed using multivariable Poisson regression. Generalized linear models (GLM) were employed to evaluate the association between AL and continuous outcomes (LOS and costs).

Results

AL was detected in 6.8% of the patients. Emergency surgery (aRR 2.56; 95% CI: 1.15-5.71, p = 0.021), blood transfusion (aRR 4.44; 95% CI: 1.86-10.64, p = 0.001), and cancer diagnosis (aRR 2.51; 95% CI: 1.27-4.98, p = 0.008) were found to be independent predictors of AL. Patients with AL showed higher antibiotic usage (aRR 1.69; 95% CI: 1.37-2.09, p < 0.001), 30-day readmission (aRR 3.34; 95% CI: 1.53-7.32, p = 0.003) and mortality (aRR 13.49; 95% CI: 4.10-44.35, p < 0.001), and longer LOS (39.6 days, as opposed to 7.5 days for patients without AL, p < 0.001). Total hospital costs amounted to R$210,105 for patients with AL in comparison with R$34,270 for patients without AL (p < 0.001). In multivariable GLM, the total hospital costs for AL patients were 4.66 (95% CI: 3.38-6.23, p < 0.001) times higher than those for patients without AL.

Conclusions

AL leads to worse clinical outcomes and increases hospital costs by 4.66 times. The risk factors for AL were found to be emergency surgery, blood transfusion, and cancer diagnosis.

Endoscopic resection of colorectal circumferential and near-circumferential laterally spreading lesions: outcomes and risk of stenosis

PURPOSE

Almost any colorectal superficial neoplastic lesion can be treated by endoscopic resection (ER) but very little is known about outcomes of ER leaving circumferential or near-circumferential mucosal defects. We report the outcomes of ER leaving ≥ 75% circumferential mucosal defects performed in a western expert centre.

METHODS

Five hundred eighty-seven ERs of large colorectal lesions ≥ 20 mm were grouped according to the extent of the mucosal defect and comparisons made between those with < 75% and ≥ 75% defects. Independent predictors of stenosis were identified.

RESULTS

Forty-seven patients had ER leaving ≥ 75% circumference defect, most located at or distal to the rectosigmoid, with ≥ 90% defects in 5 and 100% in 11. There were no significant colonic muscle injuries in patients with ≥ 75% defect and no differences in post-procedure bleeding (OR 1.6, 95% CI 0.2-13.7, p = 0.64) between patients with ≥ 75% and < 75% defects. Stenosis developed in 9 patients. ≥ 90% circumference defect was the only independent risk factor for stenosis (OR 286, p < 0.001). Three of 4 patients with asymptomatic stenosis had successful expectant management. The remainder were treated with dilatation. Recurrence was more likely in those with ≥ 75% defect (OR 7.9, 95% CI 3.8-16.4, p < 0.001) but was managed with further ER in all but 2 cases.

CONCLUSION

ER of colorectal lesions resulting in defects ≥ 75% of the luminal circumference is challenging but safe and effective when performed in an expert centre. The only independent predictor of stenosis is ≥ 90% circumference defect but some patients improve with expectant management; therefore, pre-emptive intervention may not be warranted.

The effectiveness of a fecal diverting device for prevention of septic complications in a dog model of ischemic bowel anastomosis

OBJECTIVE

A type of bypass tube for a fecal diversion device (FDD) was created to protect colorectal anastomosis. We evaluated the effectiveness of the FDD in an animal study.

METHODS

The study was performed in an experimental animal laboratory of a tertiary referral center hospital. Thirty mongrel dogs were randomized to the FDD or control group (n = 15, each). An ischemic anastomosis model was used to readily produce anastomotic leakage (AL) in both groups. The FDD was fixed intraluminally at 10 cm above the anastomotic site in the FDD group. No protective methods were used in the control group. The postoperative observation period was 3 weeks.

RESULTS

The 3 week-survival rates were higher in the FDD group compare with the control group (80%, 12/15 vs. 40%, 6/15; log-rank, P = 0.024). The incidence of AL causing generalized peritonitis was lower in the FDD group than in the control group (20.0%, 3/15 vs. 60.0%, 9/15; P = 0.025) despite the overall incidence of complications being similar in the both groups (53.3%, 8/15 vs. 66.7%, 10/15; P = 0.456). Colonic wall erosions in the FDD fixing area were seen in two subjects (13.3%) in the FDD group. However, the two subjects survived to the end of the experimental period. In the FDD group, five subjects (33.3%, 5/15) did not retain their FDD, and three among them died from generalized peritonitis.

CONCLUSION

This study shows the effectiveness of the FDD at preventing septic complications in a dog model of ischemic bowel anastomosis.

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.

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.