The effect of a diverting stoma on morbidity and risk of permanent stoma following anastomotic leakage after low anterior resection for rectal cancer: a nationwide cohort study

Analysis of decision-making factors for defunctioning ileostomy after rectal cancer surgery and their impact on perioperative recovery: a retrospective study of 1082 patients

OBJECTIVE

To explore the decision-making factors for defunctioning ileostomy (DI) after rectal cancer surgery and to analyze the impact of the DI on perioperative outcomes.

METHODS

A retrospective case-control study was conducted that included rectal cancer patients who underwent low anterior resection from January 2013 to December 2023. Among them, 33 patients did not undergo DI but with anastomotic leakage (AL) after surgery, and 1030 patients were without AL. Preoperative, operative and tumor factors between these two groups were compared to explore the decision-making factors for DI. Meanwhile, the differences of perioperative outcomes between the DI group of 381 cases and non-DI group of 701 cases were compared.

RESULTS

For preoperative factors, the proportions of male patients and preoperative chemoradiotherapy (CRT) in the AL with non-DI group were greater than those in the non-AL group (p < 0.05); for operative factors, the proportion of patients in the AL with non-DI group with a surgical time > 180 min were greater (p < 0.05); for tumor factors, the proportion of T3-4 stage was higher in the AL with non-DI group (p < 0.05). Multiple regression analysis revealed that male sex and preoperative CRT were the independent risk factors affecting DI. For perioperative outcomes, the DI did not reduce the incidence of all and symptomatic AL and non-AL postoperative complications (p > 0.05) but with 12.07% stoma-related complications, and increase hospitalization costs (p < 0.05); however, it can shorten the postoperative hospital stay, pelvic drainage tube removal time, and reduce the anal tube placement rate and readmission rate (all p < 0.05).

CONCLUSION

Male patients and preoperative CRT were the independent risk factors affect the decision of DI in our study, and DI can shorten the postoperative hospitalization, pelvic drainage tube removal time, and decrease the anal tube placement rate and readmission rate during the perioperative period but with a higher economic cost.

A nomogram of anastomotic stricture after rectal cancer: a retrospective cohort analysis

BACKGROUND

Anastomotic stricture significantly impacts patients' quality of life and long-term prognosis. However, current clinical practice lacks accurate tools for predicting anastomotic stricture. This study aimed to develop a nomogram to predict anastomotic stricture in patients with rectal cancer who have undergone anterior resection.

METHODS

A total of 1542 eligible patients were recruited for the study. Least absolute shrinkage selection operator (Lasso) analysis was used to preliminarily select predictors. A prediction model was constructed using multivariate logistic regression and presented as a nomogram. The performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration diagrams, and decision curve analysis (DCA). Internal validation was conducted by assessing the model's performance on a validation cohort.

RESULTS

72 (4.7%) patients were diagnosed with anastomotic stricture. Participants were randomly divided into training (n = 1079) and validation (n = 463) sets. Predictors included in this nomogram were radiotherapy, diverting stoma, anastomotic leakage, and anastomotic distance. The area under the ROC curve (AUC) for the training set was 0.889 [95% confidence interval (CI) 0.840-0.937] and for the validation set, it was 0.930 (95%CI 0.879-0.981). The calibration curve demonstrated a strong correlation between predicted and observed outcomes. DCA results showed that the nomogram had clinical value in predicting anastomotic stricture in patients after anterior resection of rectal cancer.

CONCLUSION

We developed a predictive model for anastomotic stricture following anterior resection of rectal cancer. This nomogram could assist clinicians in predicting the risk of anastomotic stricture, thus improving patients' quality of life and long-term prognosis.

Complications Rate and Related Factors After Laparoscopic Sphincter-Preserving Total Mesorectal Excision for Low Rectal Cancer: A Single-Center Study in Vietnam

BACKGROUND

Colorectal cancer is a significant health concern. Surgery remains a critical component of the multimodal treatment strategy. The laparoscopic sphincter-preserving total mesorectal excision (TME) is increasingly utilized and effective, offering enhanced quality of life for patients compared to previous traditional methods.

OBJECTIVES

This study aims to determine the rate of complications and the related factors associated with complications following laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer.

METHODS

This retrospective study was conducted at the University Medical Center of Ho Chi Minh City from March 2022 to March 2023. It included patients aged 18 years and older diagnosed with low rectal cancer who underwent laparoscopic sphincter-preserving total mesorectal excision. Data on patient demographics, surgical details, and postoperative complications were retrospectively collected and analyzed. Follow-ups were conducted up to six months after surgery.

RESULTS

Of the 83 patients included, the postoperative complications rate was 14.5%. The complications observed included surgical wound infections (five cases), anastomotic leaks (five cases, including three recto-vaginal fistulas and two pelvic abscesses), urinary retention (one case), and pneumonia (one case). A significant finding was the higher rate of distant metastases in patients with complications compared to those without (p=0.033).

CONCLUSION

Laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer is safe and effective, with a high success rate and low complication rate during or after surgery. Anastomotic leakage remains the most significant complication. Despite advancements in surgery, modern suturing tools, and preoperative patient optimization, complications are avoidable. Therefore, understanding the related factors and implementing preventive interventions is crucial.

Continuing Care Bundle in Elderly Patients with Rectal Cancer after Radical Resection with Permanent Stoma

Objective. A continuing care bundle can achieve a better outcome than a single implementation after discharge. This study aims to investigate the effect of this intervention in elderly patients with rectal cancer after radical resection with a permanent stoma. Methods. Elderly patients diagnosed with rectal cancer underwent radical resection with permanent stoma, they were divided into the control group (n = 42) and bundle group (n = 42). The control group received the conventional care, and the bundle group received the continuing care bundle in addition to the conventional care. At 1- and 3-month after discharge, self-efficacy, self-care knowledge, ability to change stoma appliances, negative emotions, quality of life, and patient satisfaction were observed. Results. The increased levels of self-efficacy, self-care knowledge, and ability to change stoma appliances were displayed in the bundle group after discharge as compared with that in the control group, along with the enhanced score of SF-36 subscales, including physical function (PF), role physical (RP), global health (GH) and vitality (V), social function (SF), and mental health (MH). Furthermore, patients showed alleviated depression and anxiety after the continuing care bundle as compared to those after conventional care. Besides, the bundle groups had higher patient satisfaction than the control group. Conclusions. Continuing care bundle can serve as an effectiveness intervention in elderly rectal cancer patients after radical resection with permanent stoma via increasing self-efficacy and self-care knowledge, enhancing the ability to change stoma appliance, reliving the negative emotion, and improving quality of life and patient satisfaction.

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

BACKGROUND

Our clinical experience led us to raise questions about the validity of the reported risk factors and patient characteristics associated with permanent stomas after sphincter-preserving resection for rectal cancer.

OBJECTIVE

The present retrospective study aimed to identify and compare our center's incidence and risk factors for a permanent ostomy after low anterior resection (LAR) with a diverting stoma for locally advanced mid and low rectal cancer with those in published reports.

PATIENTS

A total of 239 patients underwent a sphincter-preserving procedure (LAR) for rectal cancer between 2000 and 2018, and 236 of them (age range 33-83 years, 100 males (42%)) were included in the analysis. The study cohort was divided into 2 groups comprised of patients with and without permanent stomas after rectal cancer surgery.

RESULTS

Only 25 of the 236 operated patients (10.6%) remained with permanent stomas after rectal cancer surgery. Factors associated with stoma non-closure in the multivariate analysis were pathological stage 3 (13 (52%) vs 51 (24.2%) for patients with closed stomas, p = 0.032), disease recurrence (14 (56%) vs 40 (18.9%), respectively, p = 0.048), length of stay > 10 days, p = 0.032), and anastomotic leaks with a Clavien-Dindo score > 2 or reoperations (6 (24%) vs 13 (6.1%), p = 0.019).

CONCLUSIONS

Sphincter-preserving surgery for rectal cancer was associated with a lower incidence of stoma non-closure than published values. The major risk factors for non-closure were aggressive disease and severe complications of surgery.

Outcomes on diverting ostomy formation and reversal after low anterior resection in the older more advanced rectal cancer patient

BACKGROUND

To decrease morbidity caused by anastomotic leakages after a low anterior resection (LAR) with primary anastomosis, a diverting ostomy is often created. Reversal of a diverting ostomy is associated with morbidity, which may result in non-reversal, particularly in the elderly. This study aimed to describe the diverting ostomy-related outcomes in elderly patients with more advanced rectal cancer after LAR.

MATERIALS AND METHODS

All rectosigmoid and rectal cancer patients ≥70 years who underwent LAR with primary anastomosis between 2006 and 2019 in the Catharina Hospital (Eindhoven, The Netherlands) were included for analyses. Reversal rates, ostomy-related complications, morbidity and mortality after ostomy reversal, and definitive ostomy rates were evaluated.

RESULTS

In total 164 patients were included, of which 150 (91.5%) underwent primary or secondary ostomy creation. Ostomy-related complications were reported in 34.7% (95%-CI 27.1-42.9%). In total, 72.5% (95%-CI 64.2-79.7%) reversed their diverting ostomy. Non-reversal was mostly due to relapsing disease (52.6%). Median time to ostomy reversal was 3.2 months (IQR 2.3-5.0). No or minor complications after ostomy reversal were observed in 84.0% (95%-CI 75.3-90.6%). Over time, ostomy recreation was performed in 15.0% (95%-CI 8.6-23.5%), and ultimately 65.8% (95%-CI 57.8-73.2%) were ostomy-free after the median follow-up of 3.8 years.

CONCLUSION

Although most elderly successfully reversed their diverting ostomy after LAR with limited morbidity, attention should be paid for the risk of non-reversal and ostomy recreation over time. Preoperative patient counselling is important in every individual to be able to decide if LAR with primary anastomosis or a permanent end colostomy is preferred.

Impact of the COVID-19 pandemic on the management of colorectal cancer in Denmark

INTRODUCTION

The COVID-19 pandemic has had a global impact on cancer care but the extent to which this has affected the management of colorectal cancer (CRC) in different countries is unknown. CRC management in Denmark was thought to have been relatively less impacted than in other nations during the first wave of the pandemic. The aim of this study was to determine the pandemic's impact on CRC in Denmark.

METHODS

The Danish national cancer registry identified patients with newly diagnosed with CRC from 1 March 2020 to 1 August 2020 (pandemic interval) and corresponding dates in 2019 (prepandemic interval). Data regarding clinicopathological demographics and perioperative outcomes were retrieved and compared between the two cohorts.

RESULTS

Total CRC diagnoses (201 versus 359 per month, P = 0.008) and screening diagnoses (38 versus 80 per month, P = 0.016) were both lower in the pandemic interval. The proportions of patients presenting acutely and the stage at presentation were, however, unaffected. For those patients having surgery, both colonic and rectal cancer operations fell to about half the prepandemic levels: colon (187 (i.q.r. 183-188) to 96 (i.q.r. 94-112) per month, P = 0.032) and rectal cancers (63 (i.q.r. 59-75) to 32 (i.q.r. 28-42) per month, P = 0.008). No difference was seen in surgical practice or postoperative 30-day mortality rate (colon 2.2 versus 2.2 per cent, P = 0.983; rectal 1.0 versus 2.9 per cent, P = 0.118) between the cohorts. Treatment during the pandemic interval was not independently associated with death at 30 or 90 days.

CONCLUSION

The initial wave of the COVID-19 pandemic reduced the number of new diagnoses made and number of operations but had limited impact on technique or outcomes of CRC care in Denmark.

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.

The safety of surgical technique for ileostomy and colostomy in preventing parastomal hernias: an in vitro experimental simulation study

Background

Parastomal hernia (PH) is a common long-term complication in persons with an ostomy. Although the cause of PH may be multifactorial, the surgical technique employed for the creation of a stoma may be a risk factor for the development of PH. The traditional technique of cruciate fascia incision may predispose to increased pressure zones at the ostomy exit site, thereby increasing the risk of PH. A circular excision of the abdominal fascia at the ostomy exit site enables a uniform pressure distribution, thereby reducing the risk of PH. This hypothesis was tested in this in vitro experimental simulation study.

Methods

The effect of the surgical technique for ostomy creation on the risk of PH development was investigated in this in vitro experimental simulation study. The pressure development at the stoma site was compared for the traditional cruciate incision vs. circular fascia excision.

Results

The pressure at the ostomy site was about four-times higher in the tradition cruciate incision technique compared to the circular excision technique. This finding was independent of unilateral (e.g. peritoneal) pressure application.

Conclusion

The main finding from this study suggests that the traditional cruciate incision of the abdominal fascia for the creation of an intestinal ostomy predisposes to increased pressures at the ostomy site, thus increasing the risk of PH. This effect is not seen in the experimental setting following a circular excision of the fascia. Thus, this surgical aspect may be adopted as a possible means of reducing the risk of parastomal hernia in patients undergoing ostomy surgery.

Development of a Risk Scoring System for Predicting Anastomotic Leakage Following Laparoscopic Rectal Cancer Surgery

Purpose

To develop a risk scoring system that can predict the incidence of anastomotic leakage after laparoscopic rectal cancer surgery.

Patients and Methods

The clinical data of 387 patients with rectal cancer who underwent laparoscopic low anterior resection were retrospectively collected. Univariable and multivariable logistic regression analyses were used to evaluate independent risk factors for postoperative anastomotic leakage. A simplified points system was then developed based on the corresponding regression coefficient β of each risk factor. Receiver operating characteristic (ROC) analysis was used to evaluate the performance and the optimal cut-off value in predicting anastomotic leakage. The performance of the points system was then externally validated in an independent cohort of 192 patients based in another institution.

Results

Anastomotic leakage occurred in 36 of 387 patients with rectal cancer (9.30%). Logistic multivariable regression analysis showed that males, maximum tumor diameter (≥5cm), operation time (≥180min), preoperative chemoradiation, intraoperative blood transfusion and the anastomosis level from the anal verge (≤5cm) were independent risk factors for the incidence of anastomotic leakage. According to the scoring standard, the risk points of each patient were calculated. ROC analysis based on the risk points showed that the area under the curve (AUC) was 0.795 (95% CI:0.752-0.834) and the optimal cut-off value was 6, yielding a sensitivity of 88.89% and a specificity of 62.96%. Using this risk points system, the AUC of another cohort of 192 patients from another institution who underwent laparoscopic low anterior resection for rectal cancer was 0.853 (95% CI:0.794-0.900, p<0.001) and patients with risk points ≥6 had a 21.05% chance of developing anastomotic leakage.

Conclusion

This risk points system for predicting anastomotic leakage following laparoscopic rectal cancer surgery may be useful for surgeons in their decisions to perform intraoperative diversion stoma, which can reduce the incidence of postoperative anastomotic leakage.

Defunctioning stoma and short- and long-term outcomes after low anterior resection for rectal cancer-a nationwide register-based cohort study

PURPOSE

A defunctioning stoma reduces the risk of symptomatic anastomotic leakage after low anterior resection for rectal cancer and mitigates the consequences when a leakage occurs, but the impact on mortality and oncological outcomes is unclear. The aim was to investigate the associations of a defunctioning stoma with short- and long-term outcomes in patients undergoing low anterior resection for rectal cancer.

METHODS

Data from all patients who underwent curative low anterior resection for rectal cancer between 1995 and 2010 were obtained from the Swedish Colorectal Cancer Register. A total of 4130 patients, including 2563 with and 1567 without a defunctioning stoma, were studied. Flexible parametric models were used to estimate hazard ratios for all-cause mortality, 5-year local recurrence, and distant metastatic disease in relation to the use of defunctioning stoma, adjusting for confounding factors and accounting for potential time-dependent effects.

RESULTS

During a median follow-up of 8.3 years, a total of 2169 patients died. In multivariable analysis, a relative reduction in mortality was observed up to 6 months after surgery (hazard ratio = 0.82: 95% CI 0.67-0.99), but not thereafter. After 5 years of follow-up, 4.2% (173/4130) of the patients had a local recurrence registered and 17.9% (741/4130) had developed distant metastatic disease, without difference between patients with and without defunctioning stoma.

CONCLUSION

A defunctioning stoma is associated with a short-term reduction in all-cause mortality in patients undergoing low anterior resection for rectal cancer without any difference in long-term mortality and oncological outcomes, and should be considered as standard of care.