Covering stoma for elective anterior resection of the rectum: an outmoded operation?

Risk Factors for Anastomotic Leakage in Advanced Ovarian Cancer Surgery: A Large Single-Center Experience

Background

Cytoreductive surgery is currently the main treatment for advanced epithelial ovarian cancer (OC), and several surgical maneuvers, including colorectal resection, are often needed to achieve no residual disease. High surgical complexity carries an inherent risk of postoperative complications, including anastomosis leakage (AL). Albeit rare, AL is a life-threatening condition. The aim of this single-center retrospective study is to assess the AL rate in patients undergoing colorectal resection and anastomosis during primary surgery for advanced epithelial OC through a standardized surgical technique and to evaluate possible pre/intra- and postoperative risk factors to identify the population at greatest risk.

Methods

A retrospective analysis of clinical and surgical characteristics of 515 patients undergoing colorectal resection and anastomosis during primary or interval debulking surgery between December 2011 and October 2019 was performed. Several pre/intra- and postoperative variables were evaluated by multivariate analysis as potential risk factors for AL.

Results

The overall anastomotic leakage rate was 2.9% (15/515) with a significant negative impact on postoperative course. Body mass index < 18 kg/m², preoperative albumin value lower than 30 mg/dL, section of the inferior mesenteric artery at its origin, and medium–low colorectal anastomosis (< 10 cm from the anal verge) were identified as independent risk factors for AL on multivariate analysis.

Conclusions

AL is confirmed to be an extremely rare but severe postoperative complication of OC surgery, being responsible for increased early postoperative mortality. Preoperative nutritional status and surgical characteristics, such as blood supply and anastomosis level, appear to be the most significant risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11686-y.

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.

[Evidence-based ways of colorectal anastomotic complications prevention in the setting of digestive deep endometriosis resection: CNGOF-HAS Endometriosis Guidelines]

Management of deep pelvic and digestive endometriosis can lead to colorectal resection and anastomosis. Colorectal anastomosis carries risks for dreaded infectious and functional morbidity. The aim of the study was to establish, regarding the published data, the role of the three most common used surgical techniques to prevent such complications: pelvic drainage, diverting stoma, epiplooplasty. Even if many studies and articles have focused on colorectal anastomotic leakage prevention in rectal cancer surgery data regarding this topic in the setting of endometriosis where lacking. Due to major differences between the two situations, patients, diseases the use of the conclusions from the literature have to be taken with caution. In 4 randomized controlled trials the usefulness of systematic postoperative pelvic drainage hasn't been demonstrated. As this practice is not systematically recommended in cancer surgery, its interest is not demonstrated after colorectal resection for endometriosis. There is a heavy existing literature supporting systematic diverting stoma creation after low colorectal anastomosis for rectal cancer. Keeping in mind the important differences between the two situations, the conclusions cannot be directly extrapolated. In endometriosis surgery after low rectal resection, stoma creation must be discussed and the patient must be informed and educated about this possibility. Even if widely used there is no data supporting the role of epiplooplasty in colorectal anastomotic complication prevention? The place for epiplooplasty in preventing rectovaginal fistula occurrence in case of concomitant resection hasn't been studied.

Triple Test-a Predictor of Anastomotic Integrity in Patients Undergoing Low Anterior Resection After Neoadjuvant Chemoradiotherapy

Anastomotic leak after low anterior resection for rectal cancer is a dreaded complication. Diversion stoma helps tiding over this crisis and it is routinely practised in most centres, especially in post chemoradiotherapy setting. But a diversion stoma has got its own problems. In this study, we attempt to use the triple test as a predictor of anastomotic integrity and thereby avoid a diverting stoma, and patients undergoing low anterior resection after neoadjuvant chemoradiotherapy were spared the trouble of a diverting stoma if the on table triple test was negative. Two hundred such consecutive patients were prospectively followed up in the postoperative period. The incidence of anastomotic leak and the factors predicting the same were analysed in this group of patients. The incidence of anastomotic leak in our study was 7%, which is much less when compared to published literature. The triple test was a reliable predictor of the integrity of anastomosis and if the test is negative, a diverting stoma can be avoided. Age more than 60 years and end-to-end anastomosis were found to be associated with increased incidence of leak, and patients with a negative triple test need not routinely undergo diversion stoma after a low anterior resection even in post chemoradiotherapy setting.

Management of deep infiltrating endometriosis of the rectum: Is a systematic temporary stoma relevant?

STUDY OBJECTIVE

To assess the value of performing a protective stoma in patients operated for rectal endometriosis.

MATERIAL AND METHODS

From June 2009 to December 2011, 47 patients were operated for rectal endometriosis by segmental or discoid resection in 4 different centers. Two groups were formed: one with protective stoma (group S), n=33 and one without protective stoma (group NS), n=14. Data were collected from the CIRENDO database.

MEASUREMENTS AND MAIN RESULTS

Postoperative complication rate of group NS was 57% against 48% in group S (P=0.75). There was an increasing trend of the rate of anastomotic leakage in group S as compared to group NS: 21% against 3% (P=0.073). All 3 patients of group NS with an anastomotic leakage were reoperated and the group S patient had medical treatment. In a center, digestive operative time was not necessarily performed in association with a gastrointestinal surgeon. All patients in group S had a restoration of continuity in about 3 months. Two of them had dilation of anastomotic stricture and 3 others showed a transient postoperative ileus during this recovery. Quality of life was assessed by the MOS SF-36 and significantly improved in both groups thanks to the intervention.

CONCLUSION

Temporary digestive stoma in patients operated for rectal endometriosis has to be considered because in our study, it seems reducing complications such as anastomotic leakage. This must be confirmed with studies with larger numbers.

The Effect of Omentoplasty on the Rate of Anastomotic Leakage after Intestinal Resection: A Randomized Controlled Trial

Anastomotic leakage is a major postoperative complication after intestinal surgery leading to increased risk of morbidity and mortality. Omentoplasty has been evaluated to prevent anastomotic leakage in several studies. However, there is no consensus regarding whether or not omentoplasty should be used to decrease the rate of anastomotic leakage after intestinal resection. A prospective, randomized study was conducted to evaluate the influence of omentoplasty on anastomotic leakage after intestinal resection. A total of 124 patients who underwent intestinal resection were enrolled in this prospective study. Patients were randomly assigned to receive either the omentoplasty or nonomentoplasty. In the omentoplasty group, the omentum was wrapped around the anastomotic region. Age, gender, site and type of anastomosis, duration of hospital stay, and performance of omentoplasty were recorded. This study was registered in Iranian Registry of clinical trial (number: IRCT201412316925N3). The rate of anastomotic leakage was significantly lower in the omentoplasty group (P = 0.04). Patients in the omentoplasty group developed a significantly lower rate of postoperative infection and peritonitis (P < 0.05). There was no significant difference of abscess and fistula formation between the two groups (P > 0.05). The length of hospital stay was longer in the nonomentoplasty group, compared with that for omentoplasty patients (P < 0.05). No death occurred in the omentoplasty subjects, while six nonomentoplasty patients died (P < 0.05). Our data demonstrated that omentoplasty is useful to lower the rate of postoperative complications in patients underwent intestinal surgery.

To drain or not to drain in colorectal anastomosis: a meta-analysis

BACKGROUND

Currently, many surgeons place a prophylactic drain in the abdominal or pelvic cavity after colorectal anastomosis as a conventional treatment. However, some trials have demonstrated that this procedure may not be beneficial to the patients.

OBJECTIVE

To determine whether prophylactic placement of a drain in colorectal anastomosis can reduce postoperative complications.

METHODS

We systematically searched all the electronic databases for randomized controlled trials (RCTs) that compared routine use of drainage to non-drainage regimes after colorectal anastomosis, using the terms "colorectal" or "colon/colonic" or "rectum/rectal" and "anastomo*" and "drain or drainage." Reference lists of relevant articles, conference proceedings, and ongoing trial databases were also screened. Primary outcome measures were clinical and radiological anastomotic leakage. Secondary outcome measures included mortality, wound infection, re-operation, and respiratory complications. We assessed the eligible studies for risk of bias using the Cochrane Risk of Bias Tool. Two authors independently extracted data.

RESULTS

Eleven RCTs were included (1803 patients in total, 939 patients in the drain group and 864 patients in the no drain group). Meta-analysis showed that there was no statistically significant differences between the drain group and the no drain group in (1) overall anastomotic leakage (relative risk (RR) = 1.14, 95 % confidence interval (CI) 0.80-1.62, P = 0.47), (2) clinical anastomotic leakage (RR = 1.39, 95 % CI 0.80-2.39, P = 0.24), (3) radiologic anastomotic leakage (RR = 0.92, 95 % CI 0.56-1.51, P = 0.74), (4) mortality (RR = 0.94, 95 % CI 0.57-1.55, P = 0.81), (5) wound infection (RR = 1.19, 95 % CI 0.84-1.69, P = 0.34), (6) re-operation (RR = 1.18, 95 % CI 0.75-1.85, P = 0.47), and (7) respiratory complications (RR = 0.82, 95 % CI 0.55-1.23, P = 0.34).

CONCLUSIONS

Routine use of prophylactic drainage in colorectal anastomosis does not benefit in decreasing postoperative complications.

The effect of diverting stoma on postoperative morbidity after low anterior resection for rectal cancer in patients treated within an ERAS program

BACKGROUND

Anastomotic leakage (AL) is a serious complication after low anterior resection (LAR) with total mesorectal excision (TME) for rectal cancer. Whether the Enhanced Recovery After Surgery (ERAS)-protocol influences the risk of short-term morbidity in relation to the use of a diverting stoma is unclear.

METHODS

Between 2002 and 2011, 287 consecutive patients underwent LAR with TME for rectal cancer at Ersta Hospital, Sweden. All patients were treated according to the ERAS program and thereby included. Between 2002 and 2006 15% had a diverting stoma compared to 91 %, 2007 to 2011.

RESULTS

One hundred and thirty-nine patients were operated with a diverting stoma at primary surgery (S+), 148 patients were not (S-). The groups were comparable regarding pre- and peroperative data and patients' characteristics. Postoperative morbidity within 30 days after surgery (S+ 53% vs. S- 43%) and hospital stay (S+ 11 days vs. S- 9 days) did not differ. AL occurred in 22% of all patients. In a multivariate analysis, no significant difference in AL was found in relation to the use of a diverting stoma (S+ vs. S-, OR 0.64, 95% CI 0.34-1.19). Eleven patients (8%) in the S+ group underwent relaparotomy versus 22 (15%) in the S- group (p = 0.065). Total overall compliance to the ERAS program was 65%. Patients in S- had faster postoperative recovery.

CONCLUSION

A diverting stoma did not affect postoperative morbidity in this large cohort of patients undergoing LAR within an ERAS program. However, the routine use of a diverting stoma could be expected to delay postoperative recovery.

Diverting ileostomy in colorectal surgery: when is it necessary?

PURPOSE

The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice.

METHODS

Retrospective and prospective articles spanning the past 50 years were reviewed to identify the definition of an anastomotic leak (AL), evaluate risk factors for AL, and assess methods of evaluation of the anastomosis. We then pooled the evidence for and against fecal diversion, the incidence and consequences of stomal complications, and the evidence comparing loop ileostomy vs. loop colostomy as the optimal method of fecal diversion.

RESULTS

Evidence shows that despite the fact that fecal diversion does not decrease postoperative mortality, it does significantly decrease the risk of anastomotic leak and the need for urgent reoperation when a leak does occur. Diverting stomas are a low-risk surgical procedure from a technical standpoint but carry substantial postoperative morbidity that can greatly hamper patients' quality of life and recovery. High-risk patients such as those with low colorectal anastomoses (<10 cm from anal verge), colo-anal anastomoses, technically difficult resections, malnutrition, and male patients seem to reap the greatest benefit from fecal diversion.

CONCLUSIONS

Fecal diversion is recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. It is most beneficial when used selectively in high-risk patients with low pelvic anastomoses that are at an increased risk for AL. New tools are needed to identify patients at high risk for anastomotic failure after anterior resection.

Multiple large bowel resections: potential risk factor for anastomotic leak

OBJECTIVES

Identify risk factors of anastomotic leak (AL) after large bowel resection (LBR) for ovarian cancer (OC) and compare outcomes between AL and no AL.

METHODS

All cases of AL after LBR for OC between 01/01/1994 and 05/20/2011 were identified and matched 1:2 with controls for age (±5 years), sub-stage (IIIA/IIIB; IIIC; IV), and date of surgery (±4 years). Patient-specific and intraoperative risk factors, use of protective stomas, and outcomes were abstracted. A stratified conditional logistic regression model was fit to determine the association between each factor and AL.

RESULTS

42 AL cases were evaluable and matched with 84 controls. Two-thirds of the AL had stage IIIC disease and >90% of both cases and controls were cytoreduced to <1cm residual disease. No patient-specific risk factors were associated with AL (pre-operative albumin was not available for most patients). Rectosigmoid resection coupled with additional LBR was associated with AL (OR=2.73, 95% CI 1.13-6.59, P=0.025), and protective stomas were associated with decreased risk of AL (0% vs. 10.7%, P=0.024). AL patients had longer length of stay (P<0.001), were less likely to start chemotherapy (P=0.020), and had longer time to chemotherapy (P=0.007). Cases tended to have higher 90-day mortality (P=0.061) and were more likely to have poorer overall survival (HR=2.05, 95% CI 1.18-3.57, P=0.011).

CONCLUSIONS

Multiple LBRs appear to be associated with increased risk of AL and protective stomas with decreased risk. Since AL after OC cytoreduction significantly delays chemotherapy and negatively impacts survival, surgeons should strongly consider temporary diversion in selected patients (poor nutritional status, multiple LBRs, previous pelvic radiation, very low anterior resection, steroid use).

Closure of defunctioning loop ileostomy is associated with considerable morbidity

AIM

An elective defunctioning ileostomy is commonly employed to attenuate the morbidity that may arise from distal anastomotic leakage. The magnitude of risk associated with subsequent ileostomy closure is difficult to estimate as many of the data arise from small series. This study looked at the rate of complications and predictive factors in a large series of patients.

METHODS

The National Surgical Quality Improvement Program database was queried for patients who had an elective closure of ileostomy between 2005 and 2010. Patient demographics, preoperative risk factors and operative variables were recorded. The primary outcome was occurrence of major (mortality, sepsis, return to the operating room, renal failure, major cardiac, neurological or respiratory episode) or minor (wound infection, urinary tract infection) complications within 30 days. Univariate and multivariate regression was used to evaluate the effect of these clinical factors on the complication rate.

RESULTS

In total, 5401 patients underwent closure of ileostomy, of whom 502 (9.3%) patients had major complications. The incidence of minor complications was 8.4% (452 patients). There were 32 (0.6%) deaths. American Society of Anesthesiologists grade, functional status, prolonged operative time, history of chronic obstructive pulmonary disease, dialysis and disseminated cancer were independent predictors of major complications. There was no significant increase in complication rates in patients over the age of 80. Major complications were associated with a significant increase in postoperative stay (13.9 vs 4.7 days, P < 0.0001).

CONCLUSION

Closure of ileostomy is associated with a significant complication rate. It may use as many resources as the primary surgery and is not a minor follow-up operation.

The influence of fecal diversion and anastomotic leakage on survival after resection of rectal cancer

BACKGROUND

We analyzed factors associated with the occurrence of anastomotic leakage (AL) and its impact on long-term survival in patients who have undergone resection for rectal cancer. We also investigated the effect of fecal diversion on survival.

METHOD

Clinical data of patients who received surgery for rectal cancer were reviewed. The difference in AL incidence among different groups was compared and survival rates were calculated. Cox's proportional hazards model was used to compare survival in patients who developed AL or received diversion stoma with those who did not.

RESULTS

Of 999 patients who received resection and anastomosis, 53 patients experienced AL. Multivariate analysis revealed advanced age (P = 0.009) and operative method (P = 0.002) were independent risk factors for AL. Anastomotic leakage was an independent risk factor for overall recurrence (HR 2.30; 95% CI 1.12-4.73). Anastomotic leakage and fecal diversion were independent prognostic factors of overall survival (P = 0.002 and P < 0.001, respectively), cancer-specific survival (P = 0.002 and P < 0.001, respectively), and disease-free survival (P < 0.001, respectively).

CONCLUSIONS

Patients who are older and have anastomosis at the anorectal junction or dentate line have an increased risk of AL. A diversion stoma does not appear to decrease the incidence of anastomotic leakage, but may decrease the need of reoperation when leakage occurred. Anastomotic leakage and fecal diversion are independent prognostic factors of overall, cancer-specific, and disease-free survival.

Ghost ileostomy after anterior resection for rectal cancer: a preliminary experience

PURPOSE

The aim of this study was to describe and evaluate the feasibility and the eventual advantages of ghost ileostomy (GI) versus covering stoma (CS) in terms of complications, hospital stay and quality of life of patients and their caregivers after anterior resection for rectal cancer.

METHODS

In this prospective study, we included patients who had rectal cancer treated with laparotomic anterior resection and confectioning a stoma (GI or CS), in the period comprised between January 2008 and January 2009. Short-term and long-term surgery-related mortality and morbidity after primary surgery (including that stoma-related and colorectal anastomosis-related) and consequent to the intervention of intestinal recanalization (CS group) and GI closure were evaluated. We evaluated hospital stay and quality of life of patients and their caregivers.

RESULTS

Stoma-related morbidity rate was higher in the CS group than in GI group (37% vs. 5.5%, respectively, P = 0.04). Morbidity rate after intestinal recanalization in the CS group was 25.9% and 0% after GI closure (P = 0.08). Overall stoma morbidity rate was significantly lower in the GI group with respect to CS group (5.5% vs. 40.7%, respectively, P = 0.03). CS group was characterized by a significantly longer recovery time (P = 0.0002). Caregivers and stoma-related quality of life were better in the GI group than in CS group (P < 0.0001 and P = 0.0005, respectively).

CONCLUSIONS

GI is feasible, characterized by shorter recovery, lesser degree of total, as well as anastomosis-related morbidity and higher quality of life of patients and the caregivers in respect to CS. We suggest that GI (should be evaluated as an alternative to conventional ileostomy) could be indicated in selected patients that do not present risk factors, but require caution for anastomotic leakage for the low level of colorectal anastomosis.

Anterior resection for rectal carcinoma - risk factors for anastomotic leaks and strictures

AIM: To determine the incidence and factors responsible for anastomotic leaks and stricture following anterior resection (AR) and its subsequent management.

METHODS: Retrospective analysis of data from 108 patients with rectal carcinoma who underwent AR or low anterior resection (LAR) to identify the various preoperative, operative, and post operative factors that might have influence on anastomotic leaks and strictures.

RESULTS: There were 68 males and 40 females with an average of 47 years (range 21-75 years). The median distance of the tumor from the anal verge was8 cm (range 3-15 cm). Sixty (55.6%) patients underwent handsewn anastomosis and 48 (44.4%) were stapled. The median operating time was 3.5 h (range 2.0-7.5 h). Sixteen (14.6%) patients had an anastomotic leak. Among these, 11 patients required re-exploration and five were managed expectantly. The anastomotic leak rate was similar in patients with and without diverting stoma (8/60, 13.4% with stoma and 8/48; 16.7% without stoma). In 15 (13.9%) patients, resection margins were positive for malignancy. Ninteen (17.6%) patients developed anastomotic strictures at a median duration of 8 mo (range 3-20 mo). Among these, 15 patients were successfully managed with per-anal dilatation. On multivariate analysis, advance age (> 60 years) was the only risk factor for anastomotic leak (P = 0.004). On the other hand, anastomotic leak (P = 0.00), mucin positive tumor (P = 0.021), and lower rectal growth (P = 0.011) were found as risk factors for the development of an anastomotic stricture.

CONCLUSION: Advance age is a risk factor for an anastomotic leak. An anastomotic leak, a mucin-secreting tumor, and lower rectal growth predispose patients to develop anastomotic strictures.

[Stoma creation during low anterior resection: the cons]

Creation of a protective stoma is nowadays considered the standard of care in patients undergoing low rectal resection to protect these patients from the potentially hazardous consequences of an anastomotic leak. This appears reasonable in patients with acknowledged risk factors such as male gender, low anastomosis, preoperative radiochemotherapy, intraoperative complications, or steroid treatment to ensure patients' safety. However, from our view, it is debatable, if patients without these risk factors can undergo low rectal resection without a stoma. This approach can prevent patients form potential risks of stoma creation as well as closure and the associated readmission to the hospital. Based on reliable patient selection, avoiding a protective stoma during low rectal resection can increase patients' satisfaction and decrease primary and secondary medical costs. However, this approach is hampered by the lack of evidence for patient selection, leading to legal concerns that justify this approach only in highly motivated patients after detailed counseling of the individual patient.

The effect of peri-stomal infiltration with bupivacaine/epinephrine on post-operative pain, nausea and ease of surgery in reversal of loop ileostomies

PURPOSE

Evidence to support the routine use of local anaesthetic in the reversal of loop ileostomy is equivocal. This randomized control study looked at the use of peri-operative infiltration of stoma with 0.25% bupivacaine with 1/200,000 epinephrine on the ease of surgery and its effect on post-operative pain and nausea.

METHODS

Sixty patients were randomized to receive peri-stomal infiltration with either 0.25% bupivacaine with 1/200,000 epinephrine or normal saline. The surgeon graded the surgery as straightforward, intermediate or difficult, and the time for the operation was also recorded. Post-operatively, analgesia was provided via PCA for 24 h. Post-operative pain and nausea scores and total morphine usage median (inter-quartile range) were compared using the Mann-Whitney U test with p < 0.05 considered significant.

RESULTS

There was no difference between the local anaesthetic groups and controls with respect to opiate consumption (p = 0.4), post-operative pain (p = 0.72) or nausea (p = 0.78). Shorter total anaesthetic and operative times were noted in study group, but this was not significant (p = 0.55). However, surgery was found to be easier in the local anaesthetic group (p = 0.0046).

CONCLUSION

Peri-stomal infiltration with 0.25% bupivacaine with 1/200,000 epinephrine does not impact on post-operative pain and nausea scores or opiate analgesia use. However, its use is recommended as an aid to dissection in surgery.

Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer

BACKGROUND

A defunctioning stoma is frequently created to minimize the impact of any subsequent anastomotic leak after a low rectal anastomosis. This review evaluates the need for routine stoma formation.

METHODS

A meta-analysis was performed of randomized controlled trials (RCTs) and non-randomized studies with an interventional group evaluating the need for a defunctioning stoma after low anterior resection for rectal cancer. Primary outcomes analysed included clinical anastomotic leak rate, reoperation rate and mortality related to leak.

RESULTS

Four RCTs and 21 non-randomized studies, with 11,429 patients in total, were analysed. Meta-analysis of the RCTs showed a lower clinical anastomotic leak rate (risk ratio (RR) 0.39 (95 per cent c.i. 0.23 to 0.66); P < 0.001) and a lower reoperation rate (RR 0.29 (0.16 to 0.53); P < 0.001) in the stoma group. Meta-analysis of the non-randomized studies showed a lower clinical anastomotic leak rate (RR 0.74 (0.67 to 0.83); P < 0.001), lower reoperation rate (RR 0.28 (0.23 to 0.35); P < 0.001) and lower mortality rate (RR 0.42 (0.28 to 0.61); P < 0.001) in the stoma group.

CONCLUSION

A defunctioning stoma decreases clinical anastomotic leak rate and reoperation rate. It is recommended after low anterior resection for rectal cancer.

Anastomotic leakage after low anterior resection for rectal cancer: facts, obscurity, and fiction

The subject of anastomotic leakage after low anterior resection (LAR) for rectal cancer remains controversial. Risk factors have been discussed in several studies but the findings are often inconclusive. This review evaluates these studies and separates the known risk factors into those that are well documented, those that are obsolete, and those that require further research. We searched the Medline and PubMed databases using the keywords: "leakage," "low anterior resection," "rectal cancer," "risk factors," and their combinations. There were no language or publication year restrictions. References in published papers were also reviewed. Each risk factor was evaluated and discussed separately. The evidence suggests that low anastomoses are more prone to leakage. Other well-documented risk factors are male sex, smoking, and preoperative malnutrition. Routine mobilization of the splenic flexure and the use of a J-pouch seem to reduce the leakage rate. The effect of preoperative chemo-radiotherapy is under scrutiny. The indications for a protective stoma remain debatable. Omentoplasty, bowel preparation, the use of a drain, and tumor stage do not seem to affect the leakage rate. The type of operation (open or laparoscopic) and anastomosis (hand-sewn or stapled) is not crucial.

Omentoplasty in the prevention of anastomotic leakage after colorectal resection: a meta-analysis

PURPOSE

Whether omentoplasty after colorectal anastomosis can reduce anastomotic leakage is controversial. Our aim was to do a meta-analysis of randomized controlled trials to compare anastomotic leakage rates between an omentoplasty group and a no omentoplasty group after colorectal anastomosis.

MATERIALS AND METHODS

We searched the Cochrane Center Register of Controlled Trials, PubMed, EMBASE, and Chinese Biomedical Literature Database up to June 2008 in any language. Reference lists from all selected articles were also examined. Randomized controlled trials of omentoplasty in the prevention of anastomotic leakage after colorectal resection were selected and evaluated by two investigators. Analyses were performed using Review Manager 4.2.

RESULTS

Three randomized controlled trials totaling 943 participants were included. Meta-analysis results showed that no statistically significant difference was found between the omentoplasty group and the no omentoplasty group in radiological anastomotic leakage (RR 0.76, 95% CI 0.41 to 1.40), death (RR 1.01, 95% CI 0.55 to 1.86), and repeat operation (RR 0.60, 95% CI 0.35 to 1.05), except for clinical anastomotic leakage (RR 0.36, 95% CI 0.16 to 0.78).

CONCLUSION

Based on available data from a small number of trials, there is not enough evidence to say whether or not omentoplasty should be used to reduce anastomotic leakage after colorectal resection. The decision as to whether we should continue to use this technique might remain a matter of surgical judgment. Therefore, the results still need to be confirmed by future multicenter, well-designed trials.

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of selective defunctioning stoma after low anterior resection for rectal cancer

BACKGROUND

Anastomotic leakage is a major concern after resection for low rectal cancer. Therefore, the use of a defunctioning stoma (DS) has been suggested, but limited data exist to clearly determine the necessity of a routine diversion. In our department, the indication of DS was evaluated subjectively by the operating surgeon. The aim of this study was to evaluate the selective use of fecal diversion.

MATERIALS AND METHODS

Retrospective chart review of patients who underwent low anterior resection for carcinoma was performed. The incidence and consequences of clinical leaks were determined in these patients who were considered in two groups: defunctioning stoma and no defunctioning stoma.

RESULTS

From 1995 to 2005, 132 consecutive patients underwent low anterior resection; a DS was performed in 42 patients (31.8%). Median level of anastomosis was 4 cm in both groups. Overall clinical leakage rate was 9.8%: 7.1% (n = 3) with a DS and 11% (n = 10) without a stoma. Mortality rate was 1.5% (n = 2), both in the unprotected group. No patient in the diversion group required a permanent stoma, contrasting with four unprotected patients in which continuity could not be restored after break down of the anastomosis.

CONCLUSION

Finding lower clinical leakage rate in a probable higher risk group and better outcome when a leak occurs in our study constituted strong evidence of the effectiveness of a DS. Selective use of a DS based on subjective assessment at the time of surgery could not allow experienced surgeons to perform single-stage procedure safely. Construction of a DS seems useful for patients with distal rectal cancer.

Outcomes of resection for rectal cancer in India: the impact of the double stapling technique

Background

The introduction of circular staplers into colorectal surgery has revolutionized anastomotic techniques stretching the limits of sphincter preservation. Data on the double-stapling technique (DST) has been widely published in the West where the incidence of colorectal cancer is high. However studies using this technique and their results, in the Indian scenario, as well as the rest of Asia, have been few and far between.

Aim

To evaluate the feasibility of the DST in Indian patients with low rectal cancers and assess its impact on anastomotic leak rates, covering colostomy rates, level of resection and morbidity in patients undergoing low anterior resection (LAR).

Methods

A comparative analysis was performed between retrospectively acquired data on 78 patients (mean age 53.2 ± 13.5 years) undergoing LAR with the single-stapling technique (SST) (between January 1999 and December 2001) and prospective data acquired on 138 LARs (mean age 50.3 ± 13.9 years) performed using the DST (between January 2003 – December 2005).

Results

A total of 77 out of 78 patients in the SST group had Astler Coller B and C disease while the number was 132/138 in the DST group. The mean distance of the tumor from anal verge was 7.6 cm (2.5–15 cm) and 8.0 cm (4–15 cm) in the DST and SST groups, respectively. In the DST group, there were 5 (3.6%) anastomotic failures and 62 (45%) covering stomas compared to 7 (8.9%) anastomotic failures and 51 (65.4%) covering stomas in the SST group. The anastomotic leak rate, though objectively lower in the DST group, did not attain statistical significance (p = 0.12). Covering stoma rates were significantly lower in DST group (p = 0.006). There was 1 death in the DST group due to cardiac causes (unrelated to the anastomosis) and no mortality in the SST group. The LAR and abdominoperineal resection (APR) rates were 40% and 60%, respectively, during 1999–2001. In 2005, these rates were 55% and 45%, respectively.

Conclusion

This study, perhaps the first from India, demonstrates the feasibility of the DST in a country where the incidence of colorectal cancer is increasing. Since the age at presentation is at least a decade younger than the Western world, consideration of sphincter preservation assumes greater significance. The observed improvement of surgical outcomes with DST needs further studies to significantly prove these findings in a population where the tumors at presentation are predominantly Astler Coller Stage B and C.

Population-based study of risk factors for postoperative death after anterior resection of the rectum

BACKGROUND

The aim of this population-based study was to analyse risk factors for death within 30 days after anterior resection of the rectum.

METHODS

Between 1987 and 1995 a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. One hundred and forty of these patients died within 30 days or during the initial hospital stay. These patients were compared with a randomly chosen cohort of 423 patients who underwent the same operation during the same interval, and were alive after 30 days and discharged from hospital. The association between death and 12 putative risk factors was studied.

RESULTS

The mortality rate after elective anterior resection was 2.1 per cent (140 of 6833). The incidence of clinical anastomotic leakage was 42.1 per cent (59 of 140) among those who died and 10.9 per cent (46 of 423) in the cohort group. Multivariate regression analysis identified clinical leakage, increased age, male sex, Dukes' 'D' stage and intraoperative adverse events as independent risk factors for death within 30 days.

CONCLUSION

Clinical anastomotic leakage was a major cause of postoperative death after anterior resection.

Neoadjuvant chemoradiation increases the risk of pelvic sepsis after radical excision of rectal cancer

PURPOSE

This study was designed to examine the effect of neoadjuvant chemoradiation on pelvic sepsis after mesorectal excision for rectal cancer.

METHODS

A retrospective chart review was conducted for all patients who underwent curative mesorectal excision for rectal cancer during an eight-year period. Demographic, preoperative, perioperative data were collected. Pelvic sepsis was defined as clinical or radiographically demonstrable leak or a pelvic abscess. Neoadjuvant chemoradiation included 5,040 Gy in conjunction with three cycles of 5-fluorouracil-based chemotherapy, followed by a one-month waiting period.

RESULTS

From January 1994 to December 2002, 246 patients (151 males; mean age 68 (range, 36-97) years) underwent curative resection for rectal cancer. Procedures included 186 anterior resections, 52 abdominoperineal resections, and 8 Hartmann's. Of 60 patients (24.4 percent) who had neoadjuvant chemoradiation, 9 (15 percent) developed pelvic sepsis (3 leaks, 6 abscesses) compared with 9 of 186 (4.8 percent) after primary surgery (6 leaks, 3 abscesses; P < 0.01). Ninety-three patients had an anastomosis <or=6 cm from the anal verge. Of these, 9 patients (9.7 percent) developed pelvic sepsis (5 leaks, 4 abscesses): 5 of 28 (17.9 percent) after neoadjuvant chemoradiation vs. 4 of 65 (6.2 percent) after primary surgery (P = 0.22). Only 6 of 93 patients (6.5 percent) with an anastomosis >or=7 cm developed pelvic sepsis (5 leaks and 1 abscess), of whom 1 had preoperative radiation. Pelvic abscess developed in 3 of 24 patients after neoadjuvant chemotherapy and abdominoperineal resection. After primary abdominoperineal resection, none of the remaining 28 patients developed pelvic sepsis. A multivariable logistic regression model was constructed to determine predictors of sepsis. Neoadjuvant chemotherapy was the only variable that was predictive (odds ratio, 3.4; 95 percent confidence interval, 1.3-9).

CONCLUSIONS

The addition of neoadjuvant chemoradiation to mesorectal excision significantly increased the rate of pelvic sepsis. This was particularly true for anastomoses in the lower third of the rectum. Fecal diversion should be considered in these patients.

Intraoperative adverse events and outcome after anterior resection of the rectum

Background

The aim of this population-based study was to analyse the relationship between intraoperative adverse events and outcome after anterior resection.

Methods

All 140 patients who underwent elective anterior resection in Sweden between 1987 and 1995, and who died within 30 days, were compared with a group of 423 randomly selected patients who underwent the same procedure during the same interval but survived the operation. Intraoperative adverse events and intraoperative measures taken were analysed in relation to outcome of surgery.

Results

Of those who died, 45·7 per cent had intraoperative adverse events compared with 30·3 per cent in the cohort group. Major bleeding, gross spillage of faeces, and two or more intraoperative adverse events were more common among those who died. When the anastomosis was considered unsatisfactory, it was more frequently reconstructed (restapled or completely resutured), with or without a temporary stoma, in those who survived. The use of a temporary stoma was comparable in the two groups when adverse events were present.

Conclusion

Intraoperative adverse events were important contributors to morbidity and mortality. Complete reconstruction of an unsatisfactory anastomosis, with or without addition of a temporary stoma, was more frequently performed in the survivors, and may have diminished the risk of postoperative death.

Risk factors for anastomotic leakage after anterior resection of the rectum

OBJECTIVE

Surgical technique and peri-operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re-operations in relation to anastomotic leakage.

PATIENTS AND METHODS

In a nine-year period, from 1987 to 1995, a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. A random sample of 432 of these patients was analysed (sample size 6.3%). The associations between death and 10 patient- and surgery-related variables were studied by univariate and multivariate analysis. Data were obtained by review of the hospital files from all patients.

RESULTS

The incidence of symptomatic clinically evident anastomotic leakage was 12% (53/432). The 30-day mortality was 2.1% (140/6833). The rate of mortality associated with leakage was 7.5%. A temporary stoma was initially fashioned in 17% (72/432) of the patients, and 15% (11/72) with a temporary stoma had a clinical leakage, compared with 12% (42/360) without a temporary stoma, not significant. Multivariate analysis showed that low anastomosis (< or = 6 cm), pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for leakage. The risk for permanent stoma after leakage was 25%. Females with stoma leaked in 3% compared to men with stoma who leaked in 29%. The median hospital stay for patients without leakage was 10 days (range 5-61 days) and for patients with leakage 22 days (3-110 days).

CONCLUSION

In this population based study, 12% of the patients had symptomatic anastomotic leakage after anterior resection of the rectum. Postoperative 30-day mortality was 2.1%. Low anastomosis, pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for symptomatic anastomotic leakage in the multivariate analysis. There was no difference in the use of temporary stoma in patients with or without anastomotic leakage.

Feasibility of early closure of loop ileostomies: a pilot study

PURPOSE

A loop ileostomy is constructed to protect a distal anastomosis, and closure is usually performed not earlier than after two to three months. Earlier closure might reduce stoma-related morbidity, improve quality of life, and still effectively protect the distal anastomosis. This pilot study was designed to investigate the feasibility of early closure of loop ileostomies, i.e., during the same hospital admission as the initial operation.

METHODS

Twenty-seven consecutive patients with a protective loop ileostomy were included. If patient's recovery was uneventful, water-soluble contrast enema examination was performed, preferably after seven to eight days. If no radiologic signs of leakage were detected, the ileostomy was closed during the same hospital admission.

RESULTS

Twenty-seven patients (8 females; mean age, 60 years) were analyzed. Eighteen patients had early ileostomy closure on average 11 (range, 7-21) days after the initial procedure. In nine patients the procedure was postponed because of leakage of the anastomosis (n = 3), delayed recovery (n = 1), small bowel obstruction (n = 1), gastroparesis (n = 1), logistic reasons (n = 2), or irradical cancer resection followed by radiotherapy (n = 1). There was no mortality and four mild complications occurred after early closure: superficial wound infection (n = 2), intravenous-catheter sepsis (n = 1), small bowel obstruction (n = 1).

CONCLUSION

Closure of a loop ileostomy early after the initial operation was feasible in 18 of 27 patients and was associated with low morbidity and no mortality.

The incidence and causes of permanent stoma after anterior resection

AIMS

Defunctioning stomas are used following anterior resection to guard against the serious consequences of anastomotic leak such as pelvic sepsis and generalized peritonitis. This study aims to determine what proportion of patients undergoing anterior resection have a defunctioning stoma, how many of these patients do not have their stoma closed, and the reasons for this.

METHODS

All patients undergoing a resection for rectal cancer in our institution in a five year period (January 1995 to December 1999) are included in the study. Anterior resection was performed on 154 patients, divided into 76 anterior resections (AR) and 78 low anterior resections (defined as the anastomosis within 6 cm of the anal verge). The data from these patients were analysed retrospectively.

RESULTS

Of the total of 154 patients undergoing anterior resection, 59 (38%) were defunctioned, divided into 33 with loop ileostomy and 26 with loop colostomy. Five of these patients had not had their stoma closed at a median follow up of four years (range 1.5-6.5 years). The reasons for non closure were anastomotic stricture (2), metastatic disease (2), and patient choice (1). When comparing AR and LAR, 16% of patients had a defunctioning stoma after AR, compared with 60% after LAR (P < 0.01).

CONCLUSION

Anterior resection is being performed for very low rectal tumours in order to avoid a permanent stoma. However we have found that 8% of patients who are defunctioned with a stoma at anterior resection will not have their stoma closed, and conclude that patients should be warned of this pre-operatively.

Value of a protective stoma in low anterior resections for rectal cancer

INTRODUCTION

Anastomotic leakage is a major problem in colorectal surgery and in particular in operations for low rectal cancer. The present study investigates the question whether a protective stoma can reduce the (clinical and radiologic) anastomotic leakage rate and/or the rate of leakage requiring surgery.

METHODS

The investigation took the form of a prospective multicenter study involving 75 German hospitals and was performed between January 1, 1999, and December 31, 1999. A comparison was made of the postoperative results of procedures performed with and those performed without a protective stoma in patients undergoing low anterior rectal resection. In addition, logistic regression using the target criteria, overall anastomotic leakage and anastomotic leakage requiring surgery, was applied.

RESULTS

Among the 3,695 operations performed for carcinoma of the rectum or colon, 482 were low anterior resections. In 334 patients (69.3 percent) no protective stoma was constructed, whereas 148 (30.7 percent) received such protection. Age, American Society of Anesthesiologists physical status, and body mass index were identical in both groups. In the group receiving a protective stoma, however, neoadjuvant radiochemotherapy was more common, the tumors were lower-and thus the total mesorectal excision rate higher, the intraoperative complication rate was higher, and the duration of the operation was longer. The differences were all significant. The major criterion (overall anastomotic leakage rate) was identical in the two groups, but the rate of leakage requiring surgery was significantly lower in patients receiving a protective stoma (p = 0.028). The logistic regression revealed that use of a protective stoma is a predictor of protection against anastomotic leakage requiring surgery. The distance of the tumor from the anal verge and the duration of the operation are further predictors.

CONCLUSION

The particular benefit of a covering stoma is reduction in the rate of leaks requiring surgery and thus in the severe consequences of an anastomotic leakage.

Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2,809 consecutive patients

OBJECTIVE

To identify the risk factors for surgical site infection (SSI) in patients undergoing elective resection of the colon and rectum.

SUMMARY BACKGROUND DATA

SSI causes a substantial number of deaths and complications. Determining risk factors for SSI may provide information on reducing complications and improving outcome.

METHODS

The authors performed a prospective study of 2,809 consecutive patients undergoing elective colorectal resection via laparotomy between February 1995 and December 1998 at a single institution. The outcome of interest was SSI, which was classified as being incisional or organ/space with or without clinical leakage. A likelihood ratio forward regression model was used to assess the independent association of variables with SSIs.

RESULTS

The overall SSI, incisional SSI, and organ/space SSI with and without clinical anastomotic leakage rates were 4.7%, 3%, 2%, and 0.8%, respectively. Risk factors for overall SSI were American Society of Anesthesiology (ASA) score 2 or 3 (odd ratio [OR] = 1.7), male gender (OR = 1.5), surgeons (OR = 1.3-3.3), types of operation (OR = 0.3-2.1), creation of ostomy (OR = 2.1), contaminated wound (OR = 2.9), use of drainage (OR = 1.6), and intra- or postoperative blood transfusion (1-3 units, OR = 5.3; >/=4 units, OR = 6.2). However, SSIs at specific sites differed from each other with respect to the risk factors. Among a variety of risk factors, only blood transfusion was consistently associated with a risk of SSI at any specific site.

CONCLUSIONS

In addition to ASA score and surgical wound class, blood transfusion, creation of ostomy, types of operation, use of drainage, sex, and surgeons were important in predicting SSIs after elective colorectal resection.

Diverting colostomy increases anastomotic leakage in the rat colon

In the present study, we examined the effect of a diverting colostomy on the intestinal healing of colonic anastomosis in the rat. For this purpose, we created a colonic stenosis 2 days prior to the formation of a distal one-layer end-to-end anastomosis with or without a proximal double-barreled deviation colostomy in the rats. Radiological examination of anastomotic leakage was performed daily for 4 days and on day 7 after the operation. We found that anastomotic leakage was markedly increased in rats with a diverting colostomy compared to control animals; i.e. the leakage index (percentage of days with leakage during the experimental period) in colostomy rats was 29%, whereas in animals with no colostomy, the leakage index was only 7%. Interestingly, it was observed that anastomosis formation was associated with a higher mortality rate in rats with colostomy diversion (36%) compared to control animals (7%). However, there was no difference in suture holding capacity on day 7. Moreover, body weight decreased significantly in the colostomy group compared to rats without surgical defunctioning when followed for up to 7 days after surgery. Taken together, our novel findings suggest that a diverting colostomy may increase intestinal leakage after anastomosis formation in the rat colon. Thus, the role of proximal colostomy in the protection of colorectal anastomosis needs to be reevaluated and further investigations are required to resolve the influence of surgical defunctioning on intestinal healing.

Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research

OBJECTIVE

We investigated the role of drainage in the prevention of complications after elective rectal or anal anastomosis in the pelvis. Anastomotic leakage after colorectal resection is more prevalent when the anastomosis is in the distal or infraperitoneal pelvis than in the abdomen. The benefit of pelvic drains versus their potential harm has been questioned. Drain-related complications include (1) those possibly benefiting from drainage (leakage, intra-abdominal infection, bleeding) and (2) those possibly caused by drainage (wound infection or hernia, intestinal obstruction, fistula).

METHODS

Between September 1990 and June 1995, 494 patients (249 men and 245 women), mean age 66 +/- 15 (range 15 to 101) years, with either carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another disorder located anywhere from the right colon to the midrectum undergoing resection followed by rectal or anal anastomosis were randomized to undergo either drainage (n = 248) with 2 multiperforated 14F suction drains or no drainage (n = 246). The primary end point was the number of patients with one or more postoperative drain-related complications. Secondary end points included severity of these complications as assessed by the rate of related repeat operations and associated deaths as well as extra-abdominally related morbidity and mortality.

RESULTS

After withdrawal of 2 patients (1 in each group) both groups were comparable with regard to preoperative characteristics and intraoperative findings. The overall leakage rate was 6.3% with no significant difference between those with or without drainage. There were 18 deaths (3.6%), 8 (3.2%) in those with drainage and 10 (4%) in those without drainage. Five patients with anastomotic leakage died (1%), 3 of whom had drainage. There were 32 repeat operations (6.5%) for anastomotic leakage 11 in the group with drainage and 4 in the group with no drainage. The rate of these and the other intra-abdominal and extra-abdominal complications did not differ significantly between the 2 groups.

CONCLUSION

Prophylactic drainage of the pelvic space does not improve outcome or influence the severity of complications.

Tube caecostomy to protect rectal anastomoses

BACKGROUND

Low rectal anastomoses are associated with a substantial risk of anastomotic leakage. Tube caecostomy offers a potentially simple method of anastomotic protection.

METHODS

Some 226 patients undergoing restorative rectal resection with on-table colonic lavage and tube caecostomy over an 11-year period were reviewed. Endpoints selected included clinical anastomotic leakage, requirement for a subsequent formal stoma and complications of tube caecostomy.

RESULTS

Overall, clinical anastomotic leakage occurred in 25 patients with a caecostomy (11.1 per cent). All leaks were noted among patients in whom caecostomy protection had been used after low anterior resection, giving a leak rate of 14.9 per cent (25 of 168) for this group of whom 17 (10.1 per cent) required reoperation and a formal stoma, and five (3.0 per cent) died. Complications of caecostomy or prolonged drainage after tube removal occurred in ten (4.4 per cent) and 15 (6.6 per cent) patients respectively. There were two cases of life-threatening invasive infection.

CONCLUSION

Tube caecostomy provides inadequate protection of rectal anastomoses; complications are common and may be life threatening.

Risk factors for anastomotic leakage after resection of rectal cancer

BACKGROUND

The most important surgical complication following rectal resection with anastomosis is symptomatic anastomotic leakage, which is associated with a 6-22 per cent mortality rate. The aim of this retrospective study was to evaluate the risk factors for clinical anastomotic leakage after anterior resection for cancer of the rectum.

METHODS

From 1980 to 1995, 272 consecutive anterior resections for rectal cancer were performed by the same surgical team; 131 anastomoses were situated 5 cm or less from the anal verge. The associations between clinical anastomotic leakage and 19 patient-, tumour-, surgical-, and treatment-related variables were studied by univariate and multivariate analysis.

RESULTS

The rate of clinical anastomotic leakage was 12 per cent (32 of 272). Multivariate analysis of the overall population showed that only male sex and level of anastomosis were independent factors for development of anastomotic leakage. The risk of leakage was 6.5 times higher for anastomoses situated less than 5 cm from the anal verge than for those situated above 5 cm; it was 2.7 times higher for men than for women. In a second analysis of low anastomoses (5 cm or less from the anal verge; n = 131), obesity was statistically associated with leakage.

CONCLUSION

A protective stoma is suitable after sphincter-saving resection for rectal cancer for anastomoses situated at or less than 5 cm from the anal verge, particularly for men and obese patients.

Omentoplasty in the prevention of anastomotic leakage after colonic or rectal resection: a prospective randomized study in 712 patients. French Associations for Surgical Research

OBJECTIVE

To investigate the role of omentoplasty (OP) in the prevention of anastomotic leakage after colonic or rectal resection.

SUMMARY BACKGROUND DATA

It has been proposed that OP--wrapping the omentum around the colonic or rectal anastomosis--reinforces intestinal sutures with the expectation of lowering the rate of anastomotic leakage. However, there are no prospective, randomized trials to date to prove this.

METHODS

Between September 1989 and March 1994, a total of 705 patients (347 males and 358 females) with a mean age of 66 +/- 15 years (range, 15-101) originating from 20 centers were randomized to undergo either OP (n = 341) or not (NO, n = 364) to reinforce the colonic anastomosis after colectomy. Patients had carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another affliction located anywhere from the right colon to and including the midrectum. Patients undergoing emergency surgery were not included. Random allotment took place once the resection and anastomosis had been performed, the surgeon had tested the anastomosis for airtightness, and the omental flap was deemed feasible. Patients were divided into four strata: ileo- or colocolonic anastomosis, supraperitoneal ileo- or colorectal anastomosis, infraperitoneal ileo- or colorectal anastomosis, and ileo- or coloanal anastomosis. The primary end point was anastomotic leakage. Secondary end points included intra- and extraabdominal related morbidity and mortality. Severity of anastomotic leakage was based on the rate of repeat operations and related deaths.

RESULTS

Both groups were comparable in terms of preoperative characteristics. Intraoperative findings were similar, except that there were significantly more septic operations and abdominal drainage performed in the NO group (p < 0.05 and p < 0.01, respectively). Thirty-five patients (4.9%) had postoperative anastomotic leakage, 16 in the OP group (4.7%) and 19 in the NO group (5.2%). There were 32 deaths (4.5%), 17 (4.9%) in the OP group and 15 (4.2%) in the NO group. Five patients with anastomotic leakage died (0.8%), 2 of whom had OP. There were 37 repeat operations (30%), 12 (6 in each group) for anastomotic leakage. Repeat operation was associated with fatal outcome in 14% of cases. The rate of these and the other intra- and extraabdominal complications did not differ significantly between the two groups.

CONCLUSION

OP to reinforce colorectal anastomosis decreases neither the rate nor the severity of anastomotic failure.

Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy

BACKGROUND

Loop ileostomy or loop transverse colostomy for temporary decompression of a left colonic anastomosis represents an important issue in abdominal surgery.

METHODS

A randomized study, comparing loop ileostomy (n = 37; group 1) or loop transverse colostomy (n = 39; group 2), was conducted. Patients were followed from construction to closure of the stoma.

RESULTS

Age, weight, sex and indication for surgery were similar in both groups. After stoma construction complications were reported in nine of 37 patients in group 1 and in one of 39 in group 2 (P < 0.01), leading to postoperative death in five of 37 in group 1 and one of 39 in group 2. In the period between stoma construction and closure significant differences were observed only in prolapse rate (one of 32 group 1, 16 of 38 group 2; P < 0.01), need for temporary adaptation of clothing (eight of 32 group 1, 22 of 38 group 2; P < 0.01) and dietary guidelines (23 of 32 group 1, four of 38 group 2; P < 0.01). One patient died in group 1 and four in group 2; the deaths were not stoma related. After stoma closure eight of 29 patients in group 1 had complications and there were two deaths compared with three of 32 and no deaths in group 2.

CONCLUSION

Both types of stoma carry a high complication rate with a considerable associated mortality rate. The interval between stoma construction and closure has substantial impact on social and economic status. Based on all three phases studied, routine use of transverse colostomy is advised if decompression of the left colon is indicated.

Reversible colostomy--what is the outcome?

PURPOSE

The trend toward avoidance of a colostomy at both elective and emergency large-bowel surgery is partly driven by the perceived morbidity and low closure rates of temporary stomas. The aim of this study was to examine whether significant colostomy-related morbidity remains persistently high.

METHODS

To examine this, we reviewed 120 patients with a potentially reversible colostomy performed during either elective or emergency large-bowel surgery during a seven-year period.

RESULTS

Forty-seven patients underwent elective and 73 patients underwent emergency colonic or colorectal resection. Fifty-eight patients had colorectal carcinoma (48.3 percent), diverticular disease accounted for 39 patients (32.5 percent), and a miscellaneous group of 23 patients (19.2 percent) made-up the remainder. Seven patients died, all in the emergency group (9.6 percent). Colostomy-related morbidity, which included stenosis, retraction, prolapse, and hernia formation, occurred in 19.2 percent of patients, with no difference between the elective (14.9 percent) and emergency (21.9 percent) groups or underlying pathologic condition. Colostomy closure was performed initially in 71 patients (59.2 percent). Highest closure rates occurred in the diverticular group (84.6 percent), followed by the colorectal carcinoma group (48.3 percent), and then the miscellaneous group (43.5 percent). One patient died undergoing colostomy closure, and complications occurred in 25 patients (35.2 percent), requiring fashioning of a second colostomy in eight patients, two of whom were closed. Final colostomy closure rate was 54.2 percent.

CONCLUSIONS

This study confirms the contention that both formation and closure of defunctioning colostomies are associated with significant complications; furthermore, approximately one-half of patients will not have their colostomy closed.

Extraperitonealization of the anastomosis and sacral drain in restorative surgery for rectal carcinoma: a safety mechanism in the absence of a covering stoma

A retrospective 10-year study was conducted on 473 patients who underwent rectal cancer surgery, to evaluate a surgical procedure which has been generally abandoned, but which we believe has a significant potential to reduce the incidence of the severe and often fatal complications caused by anastomotic breakdown following low anterior resection, especially when a covering stoma is absent. This procedure involves separating the anastomosis and sacral drain from the abdominal cavity by suturing the parietal peritoneum to the colon and mesocolon, and placing the sacral drain outside the peritoneal cavity, whereby contamination of the abdominal cavity is avoided should anastomostic leakage occur. Sphincter preservation was possible in 343 patients (72.5%) while 116 (24.5%) underwent abdominoperineal resection (APR). Of 331 patients who underwent sphincter-saving resection (SSR), 31 (9.4%) had primary protective colostomies. Radical RO-resection according to the International Union Against Cancer (UICC) was performed in 405 patients, and 65 (19.6%) underwent extended resections. Anastomotic leakage became clinically manifest in 33 patients (10%; or 11% when those with primary colostomies were excluded). Only 1 patient required relaparotomy while 32 were successfully treated with temporary loop colostomy in the right epigastrium. No deaths occurred following anastomotic leakage breakdown. Overall operative hospital mortality was 3.0%; 2.7% and 2.6% in the SSR and APR groups, respectively. The adjusted 5-year survival rates were 60% for APR and 72% for SSR.

Local recurrence following total mesorectal excision for rectal cancer

Early results after rectal cancer surgery in a defined population were compared before and after the introduction of total mesorectal excision. In the first period (1984-1986) 211 cases of rectal cancer were diagnosed and in the second (1990-1992) 230. Of these, 134 patients in the first period (group 1) had anterior resection or abdominoperineal excision which was considered curative. In the second period 128 curative anterior resections and abdominoperineal excisions were performed by a limited number of surgeons familiar with total mesorectal excision (group 2). No differences between the groups were found in stage distribution, rate of curative operations, postoperative complications or postoperative mortality. Local recurrence had developed in 19 patients in group 1 and in eight in group 2, 1 year after the end of the study periods (P = 0.03). Local radicality was in doubt in 13 patients in group 1 and in eight in group 2. In the remaining 121 and 120 patients, 13 and four local recurrences respectively were present (P = 0.03). Actuarial analysis showed a significant reduction in local recurrence rate (P = 0.03) and an increase in crude survival (P = 0.03) at 4 years in group 2 compared with group 1. Total mesorectal excision reduces the local recurrence rate after excision of rectal cancer.

Defunctioning colostomy for low anterior resection: a selective approach

Seventy-seven consecutive low anterior resections of the rectum were performed with a selective approach to the use of a defunctioning colostomy. A defunctioning colostomy was performed in seven patients (9 per cent) where there was concern about the anastomosis due to difficult dissection (three), incomplete doughnuts (three) and tension on the anastomosis (one). The mean level of the tumour in the defunctioned group was 7.6 cm. Clinical anastomotic leakage occurred in two patients (3 per cent) in the non-defunctioned group, both of which were controlled with subsequent transverse colostomies. There were no perioperative deaths. Selective defunctioning of low colorectal anastomoses can produce low rates of anastomotic dehiscence while reducing the morbidity associated with a temporary stoma.

Postoperative morbidity and mortality following resection of the colon and rectum for cancer

PURPOSE

The aim of this study was to report the prevalence of postoperative complications and mortality of patients with colorectal cancer when treated by conventional surgery.

METHODS

Morbidity and mortality following open resection for colorectal cancer were analyzed in 1,846 patients whose clinical, operative, and pathology data were prospectively documented over a 20-year period.

RESULTS

Mortality following elective resection of the left and right colon was low, whereas overall morbidity was high (37.2 percent). Respiratory and cardiac complications were especially common. Incidence of clinically significant leakage was similar following right (0.5 percent) or left (1.1 percent) hemicolectomy. Incidence of anastomotic leakage was significantly higher after emergency right hemicolectomy (4.3 percent). Overall morbidity following excision of the rectum was high (40.2 percent). Respiratory and cardiac complications predominated. Incidence of clinically significant anastomotic leakage following anterior resection was low (2.9 percent). Over the years, there has been a decline in the number of patients with tumor demonstrated histologically in a line of resection, suggesting an improved local surgical clearance.

CONCLUSIONS

These results following conventional surgery may be useful when evaluating new techniques.

Safety of double-stapled anastomosis in low anterior resection

Clinical leakage of the anastomosis follows low anterior resection for rectal carcinoma in 5-10 per cent of patients despite standard stapling techniques. A modification of this method has obviated the need for a distal purse string. A flexible transverse stapling instrument (Roticulator 55) is applied across the rectum below the tumour, and a double-staggered row of staples is inserted as a substitute for the distal purse string. End-to-end stapled anastomosis is then performed with peranal insertion of a Premium CEEA stapling instrument. In 111 patients the indications for operation were colorectal carcinoma (96 patients), diverticulosis (ten), megarectum (four) and ulcerative proctocolitis (one). Three patients had clinical evidence of anastomotic leakage; all survived. The incidence of radiological leakage on Gastrografin enema 10-12 days after operation was 9 per cent. The perioperative mortality rate was 2 per cent; all deaths were from cardiovascular causes. Local recurrence of tumour occurred in eight patients (7 per cent) after a mean follow-up of 40 months. In conclusion, double-stapled end-to-end anastomosis has made low anterior resection for rectal carcinoma a safe procedure with a low mortality rate, an acceptable local recurrence rate and minimal (clinical) anastomotic leakage.

Improving survival rates for patients with colorectal cancer

Between 1 January 1984 and 31 December 1990, 575 patients were operated on for colorectal cancer. The surgical procedure was performed consistently and no patients were lost to follow-up. Almost half of the patients (284 of 575) had tumours of stage I or II, with 5-year survival rates over 90 per cent. After extending the resection margins in 28 cases of colonic carcinoma there has been no case of tumour recurrence. The overall 5-year survival rate for patients with colonic carcinoma was 81 per cent. Complete resection of the mesorectum was mandatory for rectal resection. One-third of the carcinomas in the lower third of the rectum could be resected with maintenance of bowel continuity and an abdominoperineal resection avoided. Not only was the tumour recurrence rate in the former patients lower (10.5 per cent) compared with that in those undergoing abdominoperineal resection (14.3 per cent) but the 5-year survival rate at 90 versus 52 per cent was significantly higher. The overall 5-year survival rate for patients with rectal carcinoma was 71 per cent.

Anterior resection without a defunctioning colostomy: questions of safety

The need to defunction the anastomosis at anterior resection remains controversial. As the policy in this unit has been not to perform a defunctioning colostomy during anterior resection, the outcome of a consecutive series of 114 anterior resections, all carried out without a covering colostomy, was studied. During the period February 1985 to September 1991, 21 abdominoperineal resections, six Hartmann's procedures and two resections with coloanal anastomosis were also performed. Within the anterior resection group six clinical leaks (5.3 per cent) occurred, all in the low anastomosis group (8 per cent leak rate) and all of which required an end colostomy. The perioperative mortality rate within the anterior resection group was 3.5 per cent; of the four deaths one was attributable to anastomotic dehiscence and sepsis and the others were due to unassociated medical conditions. The results demonstrate similar leakage and mortality rates to published studies where anterior resection is frequently performed with a defunctioning colostomy. These results indicate that the routine use of a defunctioning colostomy at anterior resection should now be questioned.

A retrospective study of colostomies, leaks and strictures after colorectal anastomosis

A review was undertaken of 360 patients undergoing elective left-sided colonic or rectal resections with primary anastomosis, under the care of one surgeon, over a nineteen year period. The incidence, aetiology and management of anastomotic leaks and strictures was studied and the role of proximal diverting colostomy considered. Perioperative mortality was 2.7%. The incidence of anastomotic leaks was 24.4%. Leaks were more common when anastomoses were low, were sutured or were constructed by trainees. Strictures developed in 5.8%. Local recurrence of tumour was the cause of 25% of these strictures. Anastomotic leakage was the principal cause of benign strictures; those developing in association with leaks were more likely to require surgical intervention. There was no evidence that delay in colostomy closure contributed to the development of benign anastomotic strictures. It was not possible to determine whether the presence of a colostomy affected the incidence of leaks but the local effects of such leaks were mitigated in patients with colostomies. Where a minor leak had occurred it was not necessary to wait for complete anastomotic healing before closing the colostomy. After major leaks, colostomy closure before complete healing was associated with further anastomotic problems in 16.0% of cases.

Multivariate analysis of recurrence after anterior resection for colorectal carcinoma

We performed a multivariate analysis of survival data from 278 patients who underwent potentially curative anterior resection with hand-sewn anastomosis for nonobstructing colorectal carcinoma to evaluate the interaction of the resection margin with distance from the anal verge and their contributions to local and distant recurrence. Cumulative 5-year disease-free survival was 66 percent for the 258 patients with complete follow-up. Forty-nine patients (19 percent) had local recurrence and 42 (16 percent) developed initial distant metastases. Local recurrence rates increased with increasing age and with more advanced Dukes' stage. It developed in twice as many patients with colostomies as without colostomies. Distant metastases developed significantly more often in patients with nodal involvement and in patients with resection margins exceeding 3.5 cm. Forty-four percent of patients with lesions within 14 cm of the anal verge resected with margins of at least 3.5 cm developed distant recurrence. This study suggests that aggressive pelvic dissection to achieve resection margins greater than 3.5 cm may contribute to tumor dissemination and subsequent distant metastases.

Early complications after low anterior resection for rectal cancer using the EEA stapling device. A prospective trial

Complications following 178 low anterior resections for rectal carcinoma with the EEA autosuture device are reported prospectively. The operative mortality was 2.8 percent. Clinical anastomotic leakage developed in 27 patients, but in none of the 30 patients over 76 years of age. Two of the five hospital deaths were related to leakage. Long-term steroid treatment and previous pelvic radiotherapy were associated with increased risk of leakage. Severe stenosis following anastomotic leakage was seen in one patient. Intraoperative diverting colostomy was done in 16 patients, but no benefit could be demonstrated. It was concluded that use of the upper sigmoid colon for anastomosis probably is not associated with a higher mortality and morbidity than that after more extensive resections reported in the literature. Future randomized trials should exclude very old patients, in whom no leak was seen, when the upper sigmoid colon was used for stapling after low anterior resection.