Quality of Life and Timing of Stoma Closure in Patients With Rectal Cancer Undergoing Low Anterior Resection With Diverting Stoma: A Multicenter Longitudinal Observational Study

Analyzing quality of life after low anterior resection for rectal cancer

BACKGROUND

Rectal cancer is one of the most common cancers worldwide that imposes high costs on patients and the healthcare system while also having a significant impact on the patient's quality of life (QoL).

AIM

We aimed to assess the QoL of rectal cancer patients undergoing lower anterior resection (LAR) and evaluate potential confounding factors.

METHODS

In this cross-sectional study, we included patients undergoing neo-adjuvant chemotherapy followed by LAR, diverting ileostomy, and adjuvant chemotherapy. Six months after stoma reversal, QoL was assessed using a cancer-specific core questionnaire EORTC QLQ-C30 and also a colorectal cancer module EORTC QLQ-CR29. Linear and quantile regression models were used to examine associations of QoL and patients' demographical and clinical features.

RESULTS

The study population comprised 210 patients with an average age of 61.9 ± 11.0 (range: 37-85) and 112 (53.3%) male patients. The higher tumor stage increases the QoL of patients by reducing diarrhea, loss of appetite, defecation problems, and stool frequency. Based on the linear regression analysis, a farther distance of the anastomosis from the anal verge (AV) was correlated with lower symptom scores and higher QoL. Also, at the 75th percentile cut-off of the QLQ-CR29 scores, a higher N stage of the tumor was correlated with higher QoL based on functional subscale (coefficient = 3.032, P = 0.016).

CONCLUSIONS

QoL of patients after LAR for rectal cancer is significantly associated with the distance of the anastomosis site from the AV.

A latent profile analysis of psychosocial adjustment in patients with enterostomy after rectal cancer surgery

PURPOSE

The aim of this study was to improve the level of psychosocial adjustment and quality of life of patients with enterostomy by analyzing the subgroups of psychosocial adjustment and its influencing factors.

METHODS

This was a multi-center cross-sectional study. On the basis of investigating the level of psychosocial adjustment of enterostomy patients, a profile model of psychosocial adjustment of patients with enterostomy was established by using latent profile analysis. Univariate analysis and multinomial logistical regression were used to analyze the factors affecting the different psychosocial adjustment subgroups of enterostomy patients.

RESULTS

Psychosocial adjustment of 3840 patients with enterostomy can be divided into three latent characteristics: Moderately high psychosocial adjustment level and high positive emotion in enterostomy patients (24.5%), Medium psychosocial but low social life adjustment (64.6%), low psychosocial adjustment level and high negative emotion (10.9%). Multinomial logistic regression showed that enterostomy self-care knowledge score, gender, medical payment method, educational background, carer, and self-care ability were affecting the subgroup classification of psychosocial adjustment of enterostomy patients.

CONCLUSION

The psychosocial adjustment level of enterostomy patients can be divided into three latent profiles, which have obvious classification characteristics. Future studies can provide individualized interventions for different subgroups of enterostomy patients to improve the psychosocial adjustment of enterostomy patients.

Nomogram for predicting the probability of rectal anastomotic re-leakage after stoma closure: a retrospective study

BACKGROUND

In this study, we aimed to identify the risk factors in patients with rectal anastomotic re-leakage and develop a prediction model to predict the probability of rectal anastomotic re-leakage after stoma closure.

METHODS

This study was a single-center retrospective analysis of patients with rectal cancer who underwent surgery between January 2010 and December 2020. Among 3225 patients who underwent Total or Partial Mesorectal Excision (TME/PME) surgery for rectal cancer, 129 who experienced anastomotic leakage following stoma closure were enrolled. Risk factors for rectal anastomotic re-leakage were analyzed, and a prediction model was established for rectal anastomotic re-leakage.

RESULTS

Anastomotic re-leakage after stoma closure developed in 13.2% (17/129) of patients. Multivariable analysis revealed that neoadjuvant chemoradiotherapy (odds ratio, 4.07; 95% confidence interval, 1.17-14.21; p = 0.03), blood loss > 50 ml (odds ratio, 4.52; 95% confidence interval, 1.31-15.63; p = 0.02), and intersphincteric resection (intersphincteric resection vs. low anterior resection: odds ratio, 6.85; 95% confidence interval, 2.01-23.36; p = 0.002) were independent risk factors for anastomotic re-leakage. A nomogram was constructed to predict the probability of anastomotic re-leakage, with an area under the receiver operating characteristic curve of 0.828 in the cohort. Predictive results correlated with the actual results according to the calibration curve.

CONCLUSIONS

Neoadjuvant chemoradiotherapy, blood loss > 50 ml, and intersphincteric resection are independent risk factors for anastomotic re-leakage following stoma closure. The nomogram can help surgeons identify patients at a higher risk of rectal anastomotic re-leakage.

Early diverting stoma closure is feasible and safe: results from a before-and-after study on the implementation of an early closure protocol at a tertiary referral center

BACKGROUND

Evidence on early closure (EC) of defunctioning stoma (DS) after colorectal surgery shows a favorable effect when patients are carefully selected. Therefore, a clinical pathway adapted to the implementation of an EC strategy was developed in our center. The aim of this study was to carry out a comparative analysis of time until DS closure and DS-related morbidity before and after the implementation of an EC protocol (ECP).

METHODS

This study is a before-and-after comparative analysis. Patients were divided into two cohorts according to the observational period: patients from the period before the ECP implementation (January 2015-December 2019) [Period 1] and those from the period after that (January 2020-December 2022) [Period 2]. All consecutive patients subjected to elective DS closure within both periods were eligible. Early closure was defined as the reversal within 30 days from DS creation. Patients excluded from EC or those not closed within 30 days since primary surgery were analyzed as late closure (LC). Baseline characteristics and DS-related morbidity were recorded.

RESULTS

A total of 145 patients were analyzed. Median time with DS was shorter in patients after ECP implementation [42 (21-193) days versus 233 (137-382) days, p < 0.001]. This reduction in time to closure did not impact the DS closure morbidity and resulted in less DS morbidity (68.8% versus 49.2%, p = 0.017) and fewer stoma nurse visits (p = 0.029).

CONCLUSIONS

The ECP was able to significantly reduce intervals to restoration of bowel continuity in patients with DS, which in turn resulted in a direct impact on the reduction of DS morbidity without negatively affecting DS closure morbidity.

Survivorship in Early-Stage Rectal Cancer Patients Who Have Received Combined Modality Therapy

Survival rates in early-stage rectal cancer patients have increased over the past few decades. Societies such as the National Comprehensive Cancer Network (NCCN), American Cancer Society (ACS), American Society of Clinical Oncology (ASCO), and European Society of Medical Oncology (ESMO) have proposed guidelines related to cancer survivorship care including formal recommendations to address the needs in early-stage rectal cancer survivors. These guidelines, in addition to new clinical research findings in survivorship will be reviewed, specifically looking at physical, psychosocial, and financial concerns in rectal cancer survivorship.

Outcome of early versus late ileostomy closure in patients with rectal cancers undergoing low anterior resection: A prospective cohort study

BACKGROUND

Protective loop ileostomy is performed following low anterior resection (LAR) in patients with rectal cancer to reduce the complications of primary anastomosis. The optimal timing for ileostomy closure remains controversial. The aim of the current study was to compare the effects of early (<2 weeks) versus late (≥2 months) closure of the stoma in patients with rectal cancer undergoing LAR on surgical outcome and complications rates.

METHODS

This prospective cohort study was conducted in two referral centers in Shiraz, Iran, during a 2-year period. We have consecutively and prospectively included adult patients with rectal adenocarcinoma who underwent LAR followed by protective loop ileostomy in our center during the study period. The baseline, tumor characteristics and complication as well as outcome was recorded in a 1-year follow-up and was compared between early and late ileostomy closure.

RESULTS

Overall, 69 patients (32 in early and 37 in late group) were included. The mean age of the patients was 59.40 ± 9.30 years and there were 46 (66.7%) men and 23 (33.3%) women. Patients undergoing early closure of the ileostomy had significantly shorter operation duration (p<0.001) and lower intraoperative bleeding (p<0.001) compared to late ileostomy closure. There was no significant difference between two study groups regarding the complications. Early closure was also not found to be a predictive factor of post-ileostomy closure complications.

CONCLUSION

Early closure (<2 weeks) of ileostomy after LAR in patients with rectal adenocarcinoma is a safe and feasible technique which is associated with favorable outcome.

Determination of Factors Related to the Reversal and Perioperative Outcomes of Defunctioning Ileostomies in Patients Undergoing Rectal Cancer Surgery: A Regression Analysis Model

PURPOSE

Defunctioning ileostomies are often performed during rectal cancer surgery. However, stomas are sometimes associated with complications, while 20-30% of them are never reversed. Additionally, ileostomy closure can have associated morbidity, with rates as high as 45%, with the respective literature evidence being scarce and conflicting. Thus, we evaluated the stoma reversal outcomes and the risk factors for non-closure after rectal cancer surgery.

METHODS

This is a retrospective analysis of a prospectively collected database of all patients who had a defunctioning ileostomy at the time of resection for rectal cancer. All operations were performed by the same surgical team. A multivariable regression model was implemented.

RESULTS

In this study, 129 patients (male: 68.2%, female: 31.8%) were included. Ileostomy formation was associated with a total of 31% complication rate. Eventually 73.6% of the stomas were reversed at a mean time to closure of 26.6 weeks, with a morbidity of 13.7%. Non-reversal of ileostomy was correlated with neoadjuvant CRT (OR: 0.093, 95% CI: 0.012-0.735), anastomotic leakage (OR: 0.107, 95% CI: 0.019-0.610), and lymph node yield (OR: 0.946, 95% CI: 0.897-0.998). Time to reversal was affected by the N status, the LNR, the need for adjuvant chemotherapy, and the histologic grade.

CONCLUSION

In patients with rectal cancer resections, defunctioning stoma closure rate and time to closure were associated with several perioperative and pathological outcomes.

Management of Anastomotic Leakage after Colorectal Resection: Survey among the German CHIR-Net Centers

(1) Background: A widely accepted algorithm for the management of colorectal anastomotic leakage (CAL) is difficult to establish. The present study aimed to evaluate the current clinical practice on the management of CAL among the German CHIR-Net centers. (2) Methods: An online survey of 38 questions was prepared using the International Study Group of Rectal Cancer (ISREC) grading score of CAL combined with both patient- and surgery-related factors. All CHIR-Net centers received a link to the online questionary in February 2020. (3) Results: Most of the answering centers (55%) were academic hospitals (41%). Only half of them use the ISREC definition and grading for the management of CAL. A preference towards grade B management (no surgical intervention) of CAL was observed in both young and fit as well as elderly and/or frail patients with deviating ostomy and non-ischemic anastomosis. Elderly and/or frail patients without fecal diversion are generally treated as grade C leakage (surgical intervention). A grade C management of CAL is preferred in case of ischemic bowel, irrespective of the presence of an ostomy. Within grade C management, the intestinal continuity is preserved in a subgroup of patients with non-ischemic bowel, with or without ostomy, or young and fit patients with ischemic bowel under ostomy protection. (4) Conclusions: There is no generally accepted therapy algorithm for CAL management within CHIR-Net Centers in Germany. Further effort should be made to increase the application of the ISREC definition and grading of CAL in clinical practice.

Comparison of clinical outcomes of stoma reversal during versus after chemotherapy for rectal cancer patients

PURPOSE

The optimal timing of stoma closure during or after adjuvant chemotherapy for rectal cancer patients undergoing sphincter-preserving surgery remains unknown. This study aimed to investigate the influence of clinical and oncological outcomes depending on the timing of stoma closure.

METHODS

Between January 2006 and December 2015, we enrolled 244 consecutive rectal cancer patients who underwent curative-intent sphincter-preserving surgery with diverting transverse colostomy and adjuvant chemotherapy. Patients with stoma closure during (During group) adjuvant chemotherapy were compared to those who had stoma closure after adjuvant chemotherapy (After group).

RESULTS

Parastomal hernia occurred more frequently in the after group than in the during group. (10% vs. 2.9%, p = 0.028). Overall, no significant difference was observed in overall survival (OS) or disease-free survival (DFS) between the two groups (p = 0.911 for OS, p = 0.505 for DFS). However, an inferior OS occurred if reopen surgery was performed within 30 days of stoma closure in the during group, as compared with the after group (p = 0.004). In addition, a marginally poor DFS was observed in the group of patients who received further operations due to 30-day stoma closure complications compared to the other patients (p = 0.07).

CONCLUSIONS

For rectal cancer patients who underwent sphincter-preserving surgery, attention should be given to avoid 30-day major complications after stoma reversal because patients who require reoperation during adjuvant chemotherapy may have poor long-term survival.

Comparative short-term and survival outcomes of three specimen extraction techniques in laparoscopic low rectal cancer surgery: does it affect ileostomy closure?

INTRODUCTION

This study aimed to compare the short-term and survival outcomes in laparoscopic low rectal cancer surgery with three different specimen extraction techniques, and whether it affects loop ileostomy closure.

MATERIALS AND METHODS

A consecutive series of patients with low rectal cancer who underwent laparoscopic low anterior resection plus protective loop ileostomy (LAR-PLI) were enrolled. Three main techniques, namely specimen extraction through auxiliary incision (EXAI), specimen extraction through stoma incision (EXSI), and specimen eversion and extra-abdominal resection (EVER), were employed. The postoperative short-term and survival outcomes of the three techniques and the impact on loop ileostomy closure were compared.

RESULTS

In all, 254 patients were enrolled in this study: 104 (40.9%) in the EXAI group, 104 (40.9%) in the EXSI group, and 46 (18.1%) in the EVER group. For primary surgery, EXAI group had significantly longer operative time (P < 0.001), more intraoperative bleeding (P < 0.001), longer length of abdominal incision (P<0.001), longer time to first flatus (P < 0.001), longer time to first defecation (P < 0.001), longer time to first eat (P < 0.001), and longer postoperative hospital stays (P = 0.005) than the EXSI and EVER groups. The primary postoperative complication rate in the EXAI and EVER group was significantly higher than in the EXSI group (P = 0.005). In loop ileostomy closure, EXAI group had significantly longer operative time (P = 0.001), more bleeding volume, and longer postoperative hospital stays (P < 0.001) than the EXSI and EVER groups. For survival outcomes, the 3-year local recurrence-free survival (LRFS) is 92.6% for all patients. The 3-year LRFS for patients in EXAI, EXSI, and EVER were 90.1%, 95.4%, and 92.7%, with P = 0.476.

CONCLUSIONS

Our single-center results found that in LAR-PLI surgery for low rectal cancer, the short-term outcomes of specimen extraction through the stoma incision or anus were better than that through the auxiliary incision, but the 3-year LRFS was no statistically different.

Closure timing of a temporary ileostomy in patients with rectal cancer undergoing anus-preserving operation: a retrospective cohort study

PURPOSE

To investigate the optimal closure time of a temporary ileostomy in patients with rectal cancer receiving anus-preserving operation.

METHODS

Patients with rectal cancer were enrolled from the Affiliated Hospital of Jiangsu University from May 2010 to June 2019. The eligible patients were grouped according to their actual ileostomy closure time after stoma creation. Outcomes were complications during stoma closure and complications within one year after stoma closure.

RESULTS

This study included 361 qualified subjects, with 108 patients in the 3-5 months group, 133 in the 5-7 months group and 120 in the ≥ 7 months group. Compared with the risk of complications during stoma closure in the 3-5 months group, that in the 5-7 months group was significantly reduced (odds ratio [OR]: 0.36, 95% confidence interval [CI] 0.13-0.99), and that in the ≥ 7 months group was significantly increased (OR: 5.88, 95% CI 2.38-14.56). In contrast to the 3-5 months group, the 5-7 months group showed a significantly decreased risk (OR: 0.21, 95% CI 0.07-0.67), and the ≥ 7 months group showed a significantly increased risk (OR: 4.21, 95% CI 1.61-11.01) of complications within 1 year after stoma closure.

CONCLUSION

5-7 months after the ileostomy is created may be the optimal time for its closure.

The influence of stigma and disability acceptance on psychosocial adaptation in patients with stoma: A multicenter cross-sectional study

Background

The stoma can cause serious physical and psychological distress to the patient, leading to an inability to live a normal life; although it effectively improves the 5-year survival rate of patients.

Objective

The purpose of this study is to explore the status of stigma and disability acceptance of patients with stoma and their influences on psychosocial adaptation.

Design

A multicenter cross-sectional study.

Methods

A total of 259 patients with stoma in 6 hospitals from southeast China were enrolled. And this research adhered to the STROBE guideline and approved by the Ethics Committee of Fu Jian Provincial Hospital. The ostomy adjustment inventory-20、acceptance of disability scale and social impact scale were used to collect data. The hypothetical path model was tested using the SPSS version 22.0 software and AMOS version 26.0 software.

Results

Stigma, disability acceptance and psychosocial adaptation was associated. The sense of stigma was severe (72.76 ± 12.73), the acceptance of disability was medium (179.24 ± 32.29) and the psychosocial adaptation was poor (38.06 ± 8.76). Also, the hypothesis model of this study fitted the data well (AGFI = 0.967>0.08; χ ²/df = 1.723, p = 0.08 > 0.05), and the results showed that disability acceptance positively affected psychosocial adaptation; while stigma negatively affected psychosocial adaptation, and disability acceptance mediated between stigma and psychosocial adaptation (p < 0.01).

Conclusion

The stigma and disability acceptance of patients with stoma are serious problems that are closely related to their psychosocial adaptation. Medical staff should take some interventions based on different paths to reduce stoma patients' stigma and guide them to improve disability acceptance, thus to improve the level of psychosocial adaptation of patients with stoma.

A diversion stoma after anterior resection for rectal cancer

This review covers the problem of forming a diverting stoma during resections of the rectum with primary anastomosis. The incidence of rectal cancer tends to increase, and surgical resection remains the main method of treatment. Anastomotic leakage significantly increases the postoperative mortality. The most effective way to prevent severe complications is the formation of a diverting stoma. However, the indications, the choice of a specific technique and the timing of the stoma elimination are not clearly defined. This review discusses the state of the problem, special attention is paid to the choice of the level of stoma formation (ileostomy or transversostomy).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Critical Competences for the Management of Post-Operative Course in Patients with Digestive Tract Cancer: The Contribution of MADIT Methodology for a Nine-Month Longitudinal Study

There is a high postoperative morbidity rate after cancer surgery, that impairs patients’ self-management, job condition and economic strength. This paper describes the results of a peculiar psychological intervention on patients undergoing surgery for esophageal, gastric and colorectal cancer. The intervention aimed to enhance patients’ competences in the management of postoperative daily life. A narrative approach (M.A.D.I.T.—Methodology for the Analysis of Computerised Text Data) was used to create a questionnaire, Health and Employment after Gastro-Intestinal Surgery—Dialogical Questionnaire, HEAGIS-DQ, that assesses four competences. It was administered to 48 participants. Results were used as guidance for specific intervention, structured on patients’ competence profiles. The intervention lasted nine months after surgery and was structured in weekly to monthly therapeutic sessions. Quality of Life questionnaires were administered too. At the end of the intervention, 94% of patients maintained their job and only 10% of patients asked for financial support. The mean self-perception of health-related quality of life was 71.2. The distribution of three of four competences increased after nine months (p < 0.05). Despite economic difficulties due to lasting symptoms after surgery, and to the current pandemic scenario, a structured intervention with patients let them to resume their jobs and continue activities after surgery.

A practical framework for the targeted use of total neoadjuvant therapy for rectal cancer

Total neoadjuvant therapy (TNT) for rectal cancer is the preoperative delivery of radiation or chemoradiotherapy as well as systemic chemotherapy for the purpose of improving treatment completion rates and decreasing toxicity, maximizing the primary tumor response, and improving survival for patients with rectal cancer. This review summarizes the data surrounding TNT, including several recent randomized controlled trials. Moreover, it reviews the literature regarding high-quality surgery and the role of radiation and chemotherapy in the treatment of rectal cancer in the modern era. Finally, it presents an evidence-based protocol for the selective use of TNT in the treatment of patients with rectal cancer.

Clinical outcome of decompressing colostomy for acute left-sided colorectal obstruction: a consecutive series of 100 patients

PURPOSE

Aim of our study was to evaluate the outcomes of a consecutive series of patients who were treated with a decompressing colostomy (DC) for acute left-sided colorectal obstruction.

METHOD

A consecutive series of 100 patients with acute left-sided colorectal obstruction who underwent DC from January 2015 to August 2020 was retrospectively analyzed. Demographic characteristics, etiology of the obstruction, postoperative morbidity- and mortality rates, DC-related complication and stoma reversal rates were evaluated.

RESULTS

Of the 100 included patients, 64 had malignant- and 36 had benign obstruction. The mean age was 69 years, 42% was male, and the ASA score was 2. Morbidity and mortality rates after DC construction were 20 and 2%, respectively. In 39% of the patients, DC ended up as a permanent stoma and in 61% as bridge to surgery (BtS). DC related complication rate was 32%, with a re-intervention rate of 9%. Elective colorectal resection was performed in 59 cases (59%) with subsequent postoperative morbidity rate of 20%. Stoma reversal rate was 77% for the patients who underwent DC as BtS. Stoma reversal was performed in 66% of the patients with benign obstruction and in 36% for oncological obstruction.

CONCLUSION

DC as bridge to possible elective resection for acute left-sided colorectal obstruction is an effective strategy with low morbidity and mortality rates and a high stoma reversal rate, especially for benign obstruction. However, DC is less appropriate for patients in whom DC turns out to be a permanent stoma due to a relatively high stoma related complications.

Effect of mindfulness-based stress reduction on stigma, coping styles, and quality of life in patients with permanent colorectal cancer stoma: A protocol for systematic review and meta-analysis

BACKGROUND

: Colorectal cancer patients with permanent colostomy may suffer stigma, negative coping style, and low quality of life at varying degrees, which may be improved by the mindfulness-based stress reduction (MBSR). In recent years, MBSR has been used in the comprehensive treatment of colorectal cancer with permanent colostomy, hoping to bring a positive outcome. However, the practical application effect of MBSR has not been elucidated so far. Therefore, this study conducted a meta-analysis to evaluate the effects of MBSR on stigma, coping style, and quality of life in colorectal cancer patients with permanent colostomy, providing reliable evidence for clinical application.

METHODS

: Randomized controlled trials (RCTs) reporting MBSR on stigma, coping style, and quality of life in patients with permanent stoma of colorectal cancer published before December 2021 will be searched in online databases such as the PubMed, Web of Science, The Cochrane Library, Embase, China National Knowledge Infrastructure, Wanfang Database, China Biomedical Literature Database, and Chinese Scientific Journal Database. The quality of the literature will be evaluated using the risk of bias assessment tool in Revman 5.4. Meta-analysis will be performed using Revman 5.4 software.

RESULTS

: The Social Impact Scale (SIS), Simplified Coping Style Questionnaire (SCSQ), and quality of life scale will be used to evaluate the effects of MBSR on stigma, coping style, and quality of life in colorectal cancer patients with permanent colostomy.

CONCLUSION

: This study will provide a reliable evidence-based basis for MBSR to reduce stigma, improve coping style, and improve quality of life for colorectal cancer patients with permanent colostomy.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/CD4PV.

Improving the time to ileostomy closure following an anterior resection for rectal cancer in the UK

AIM

Delayed closure of ileostomy following an anterior resection for rectal cancer in the UK is common. The aims of this study were (i) to investigate the variation in patient pathways between hospitals, (ii) to identify the key learning points from units with the shortest time to closure and (iii) to develop guidance for a pathway to minimize delay in ileostomy closure.

METHOD

This was a mixed methods study. Thirty-eight colorectal units in the UK completed a short online survey. Nine colorectal units in Wales filled in an additional, expanded version of the survey. Semi-structured interviews were performed with clinicians from the six best performing units in terms of timely ileostomy closure. The optimal pathway suggested is based on the best evidence available and the Association of Coloproctology of Great Britain and Ireland guidelines.

RESULTS

Qualitative analysis revealed that 5% of units (n = 2) have a local target time for ileostomy closure. Of all units, 90% (n = 34) would consider implementing a pathway if guidelines were developed. In-depth interviews highlighted the importance of a multidisciplinary approach, a dedicated coordinator to facilitate timely booking, and consensus on whether closure should be performed before or after adjuvant chemotherapy.

CONCLUSION

There is a lack of national guidance in timing of contrast studies and ileostomy closure. Key aspects to consider are better information at consent regarding stoma closure timing, a dedicated person to track patients and the planning of contrast studies at discharge from initial surgery. With a dedicated approach closure of ileostomy within 10-12 weeks is feasible for most units.

Intervenciones de Enfermería en la reversión del estoma intestinal: revisión integrativa

Introducción: los estomas intestinales representan un impacto significativo en la calidad de vida de las personas; sin embargo, estos deben revertirse después de haberse restituido el tránsito intestinal o la resolución del proceso inflamatorio inicial. Por otro lado, la negación de la persona para su reversión puede deberse a la falta de información y orientación por parte de los profesionales de la salud. Por lo anterior es importante identificar las intervenciones de Enfermería en la atención de la persona con reversión del estoma intestinal. Materiales y métodos: se realizó una revisión integrativa de la literatura de alcance descriptivo en el período comprendido entre los años 2015 a 2020, a través de las bases de datos Wos, Pubmed, Scopus, Scielo y Cochrane. Se seleccionaron 36 artículos que cumplieron con los criterios de inclusión y exclusión con el respectivo análisis metodológico. Resultados: Se identificaron las siguientes intervenciones de Enfermería, para el preoperatorio: valoración preoperatoria, preparación intestinal y seguimiento a comorbilidades. El intraoperatorio: profilaxis, preparación de la piel, técnica quirúrgica y cierre de la pared abdominal. En el posoperatorio: cuidado de la herida quirúrgica, calidad de vida y educación. Discusión: es importante la reflexión sobre el tiempo de reversión, la técnica quirúrgica y la importancia de las intervenciones por Enfermería. Conclusión: Enfermería cumple un papel importante en la reversión del estoma, no solo por los cuidados físicos y la educación que se brinda, sino también en las intervenciones aplicables al contexto social y emocional que afectan el estilo de vida de la persona.

Symptom clusters in patients with colorectal cancer after colostomy: a longitudinal study in Shanghai

Objective

Research is lacking regarding the experiences of patients after colostomy, which is needed so as to take necessary specific actions. In this study, we aimed to describe the trajectory of symptom clusters experienced by patients after colostomy over time.

Methods

This was a longitudinal observational study using data from 149 patients with colorectal cancer after colostomy. We investigated symptoms and symptom clusters at 2 weeks, 1 month, 3 months, 6 months, and 1 year after colostomy.

Results

Four main symptom clusters were identified, including a psychological symptom cluster, digestive and urinary symptom cluster, lack of energy symptom cluster, and pain symptom cluster in patients after colostomy in the first year after surgery. We further explored the symptom trajectory.

Conclusions

We explored symptom clusters and the trajectory of symptom resolution in patients after colostomy during the first year after surgery. Four stages were proposed to describe the different statuses of symptom clusters experienced by patients. Our findings may provide insight into how to improve symptom management and postoperative quality of life for patients after colostomy.

Relationship between diverting stoma and adjuvant chemotherapy in patients with rectal cancer: a nationwide study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan

BACKGROUND

Patients at risk of recurrence after curative surgery for rectal cancer usually receive adjuvant chemotherapy. Postoperative recovery after low anterior resection (LAR) for rectal cancer can be improved by placement of a diverting stoma to reduce anastomotic leakage. However, it remains unclear how a diverting stoma affects administration of adjuvant chemotherapy in these patients.

METHODS

We identified Japanese patients with rectal cancer who underwent LAR in 2014 and received adjuvant chemotherapy within 12 months of surgery in the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Doses of five types of chemotherapy administered (tegafur/uracil, tegafur/gimeracil/oteracil potassium, capecitabine, 5-fluorouracil, and oxaliplatin) were assessed according to the presence or absence of diverting stoma and the timing of stoma closure.

RESULTS

There was no significant difference in the cumulative doses of chemotherapy administered in the 12 months after LAR between patients with and without diverting stoma, but more doses were administered in the early postoperative period (0-2 months after LAR) in patients without diverting stoma. Also, more doses of chemotherapy, regardless of type, were administered in the late closure group (7-12 months after LAR) than in the early closure (≤ 6 months) and no closure groups.

CONCLUSION

Presence of a diverting stoma did not influence the dose of adjuvant chemotherapy administered within 12 months after LAR but could have delayed the start of adjuvant chemotherapy. Patients with late closure of a diverting stoma received more doses of adjuvant chemotherapy administered over 12 months.

Anal preservation on the psychology and quality of life of low rectal cancer

INTRODUCTION

The aims of this study are to evaluate depression and quality of life (QOL) after laparoscopic abdominoperineal resection (LAPR) or transanal total mesorectal excision (TaTME) surgery in low rectal cancer (RC) patients.

METHODS

This is a prospective observational cohort study. Patients were divided into two groups: either TaTME surgery or LAPR. Psychosocial distress and QOL were assessed using a questionnaire before surgery, at 6 months postsurgery, and 12 months postsurgery. The Hospital Anxiety and Depression Scale was used to assess symptoms of anxiety and depression. The European Organization for Research and Treatment of Cancer-QOL questionnaire core was used to estimate the QOL.

RESULTS

In the TaTME group, the scores of psychosocial distress and QOL showed an obvious tendency to decrease and then recover. Meanwhile, in the LAPR group, these scores deteriorated significantly at 6 and 12 months, and the recovery was less pronounced. Multivariable analysis suggested that surgical options and tumor stage were significantly associated with psychosocial distress and QOL.

CONCLUSION

For low RC, TaTME could significantly improve patients' QOL and reduce psychological distress as compared to patients with LAPR at 12 months after surgery.

Risk factors for poor health-related quality of life in patients with colon cancer include stoma and smoking habits

Background

Previous studies have shown that health-related quality of life (HRQoL) is associated with the prognosis of cancer patients. The aim of this study was to investigate risk factors for poor HRQoL in patients with colon cancer.

Methods

This was a prospective population-based study of patients with colon cancer included between 2012 and 2016. HRQoL was measured using the cancer-specific European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. Multiple linear regression analysis adjusted for age, sex, body mass index, smoking habits, American Society of Anesthesiologists physical status classification, emergency/elective surgery, resection with/without a stoma and tumour stage was used.

Results

A total of 67% (376/561) of all incident patients with colon cancer (196 [52.1%] females) was included. Mean (range) age was 73 (30–96) years. Patients with worse health (American Society of Anesthesiologists physical status 3 and 4), those with higher body mass index, smokers and those planned to undergo surgical treatment with a stoma were at a higher risk for poor HRQoL than the other included patients at baseline and 6-month follow-up.

Conclusions

Patient characteristics such as smoking, high body mass index and worse physical health as well as treatment with a stoma were associated with lower HRQoL. Health care for such patients should focus on social and lifestyle behavioural support and stoma closure, when possible.

Trial registration: ClinicalTrials.gov (NCT 03910894).

Extended duration of faecal diversion is associated with increased ileus upon loop ileostomy reversal

AIM

The timing of ileostomy reversal has been the subject of controversy, with researchers investigating the safety of early versus late stoma closure. Anecdotally, a longer duration of faecal diversion is associated with a greater incidence of postoperative ileus. We sought to investigate the association between duration of diversion and postoperative ileus.

METHOD

We conducted an institutional retrospective cohort study on 173 patients undergoing ileostomy closure between 2012 and 2018. Our primary outcome was ileus; secondary outcomes included postoperative complications and descriptive factors. We investigated the association between duration of diversion and ileus using several analyses to ensure that time was treated appropriately as a continuous, nonlinear variable.

RESULTS

In all, 20.2% of patients had an ileus. Multivariate analysis did not identify a significant association between any independent predictors and ileus, although there was a trend towards increased risk of ileus with increasing duration of diversion. When treated as a categorical variable, a duration of diversion >328 days independently increased the odds of ileus (OR = 3.25, P = 0.033). Duration of diversion was associated with days to first flatus and to first diet (P = 0.025 and P = 0.004, respectively). When patients received nasogastric intubation, the mean duration of intubation was 3.2 days.

CONCLUSION

Greater duration of diversion was associated with a trend towards increased risk of ileus; this risk tripled when diversion lasted more than 328 days.

Clinical Outcomes of Ileostomy Closure before Adjuvant Chemotherapy after Rectal Cancer Surgery: An Observational Study from a Chinese Center

Background

The optimal timing of temporary ileostomy closure with respect to the time of adjuvant chemotherapy following sphincter-saving surgery for rectal cancer remains unclear. The aim of this study is to investigate the clinical and oncological outcomes of ileostomy closure before, during, and after adjuvant chemotherapy following curative rectal cancer resection.

Methods

Patients diagnosed with rectal adenocarcinoma who underwent low anterior resection and temporary loop ileostomy during May 2015 and September 2019 were retrospectively evaluated. Patients undergoing ileostomy closure before adjuvant chemotherapy (Group I) were compared to patients undergoing closure during (Group II) and after (Group III) adjuvant chemotherapy.

Results

A total of 225 patients were evaluated for eligibility, and 132 were finally selected and divided into 3 groups (24 in Group I, 53 in Group II, and 55 in Group III). No significant differences were observed in operative time, postoperative hospital stay, postoperative complications, total adjuvant chemotherapy cycles, and low anterior resection syndrome scores among the three groups. There was no significant difference in disease-free survival (p = 0.834) and overall survival (p = 0.462) between the three groups.

Conclusion

Temporary ileostomy closure before adjuvant chemotherapy following curative rectal cancer resection can achieve a clinical and oncological safety level equal to stoma closure during or after chemotherapy in selected patients.

Combined stoma reversal and liver resection for rectal metastatic cancer: A single center retrospective analysis

GOAL OF THE STUDY

Concomitant liver metastases are discovered at the time of diagnosis in 25% of patients with colorectal cancers. The appropriate time to restore digestive continuity after stoma creation during rectal surgery has not yet been established. The objective of this study is to assess the morbidity of stoma reversal during the secondary hepatectomy procedure.

PATIENTS AND METHODS

This was a single-center retrospective case-control study including patients who underwent ileostomy or colostomy reversal by a direct approach (REVERSAL group) compared to those who did not undergo stoma reversal (NON-REVERSAL group) during hepatic resection of rectal cancer metastasis between 2004 and 2016. Peri-operative data were collected. The primary outcome measure was the comprehensive complication index (CCI). The secondary outcomes were overall mortality, liver-related morbidity, duration of hospital stay and occurrence of gastrointestinal leaks. Statistical analysis was carried out using SPSS 23.0 software.

RESULTS

Thirty liver resections were included; 14 in the REVERSAL group (female/male=11/19, age=60 years). No statistically significant difference was observed in the CCI scores (15 vs. 20.8; P=0.6). Complications occurred in 9 (64%) and 8 (50%) patients in the REVERSAL and NON-REVERSAL groups, respectively (P=0.48). No gastro-intestinal leaks or post-operative mortality occurred.

CONCLUSION

Stoma reversal during hepatectomy for liver metastasis from a primary rectal cancer represents a safe alternative since post-operative outcome was not associated with additional morbidity in this series.

Short-term outcomes of stents in obstructive rectal cancer: A systematic review and meta-analysis

BACKGROUND

With acute obstruction due to rectal or recto-sigmoid cancer, the safety and success of deploying self-expandable metal stents has been controversial. The aim of this systematic review was to synthesize the existing evidence on the outcomes and complication rates of stent placement in these patients.

METHODS

We performed a literature search of PubMed by using appropriate keywords, and manual reference screening of included articles was done. The article screening, data extraction, and quality assessment was done by four independent reviewers. A meta analyses was performed for the main outcome measures: technical and clinical success and complication rates.

RESULTS

We identified 962 articles in the search. After applying inclusion and exclusion criteria, we included 32 articles in the meta-analysis. The pooled technical success rate across 26 studies that reported it was 97% [95% confidence interval (CI): 95%-99%] without evidence of significant heterogeneity (I² = 0.0%, P = 0.84), and the clinical success rate across 26 studies that reported it was 69% (95% CI: 58%-79%) with evidence of significant heterogeneity (I² = 81.7%, P < 0.001). The pooled overall complication rate across the 32 studies was 28% (95% CI: 20%-37%) with evidence of significant heterogeneity (I² = 79.3%, P < 0.001).

CONCLUSION

The use of rectal stents in obstructing rectal or recto-sigmoid tumors seems to be technically feasible. A high rate of technical success, however, does not always translate into clinical success. A considerable complication rate is associated with this approach. Randomized controlled trials are needed to compare the outcomes of rectal stent placement with those of surgery.

Temporary impairment of renal function in patients with rectal cancer treated with diverting ileostomy

Background

Fluid and electrolyte disturbance, which impairs renal function, has been reported in patients with temporary ileostomy. However, the dynamic changes in serum electrolytes and renal function in rectal cancer patients with ileostomy have not been well described. In the present study, we aimed to evaluate alterations in serum electrolytes and renal function in rectal cancer patients undergoing ileostomy creation and closure.

Methods

The levels of serum potassium, serum sodium, serum blood urea nitrogen, serum creatinine and estimated glomerular filtration rate (eGFR) were analyzed in 320 patients with rectal cancer including 156 patients with an ileostomy (the ileostomy group) and 164 patients without an ileostomy (the control group).

Results

After index surgery, the levels of serum potassium and serum creatinine in the ileostomy group were significantly higher than those in the control group (P<0.05). In contrast, the levels of serum sodium and the eGFR showed decreases in the ileostomy group compared to the control group after index surgery (P<0.05). At 3 months after ileostomy creation, the ileostomy group had a significantly increased rate of eGFR <60 mL/min/1.73 m² compared to the control group (5.8% vs. 1.2%, P=0.032). In line with the results of univariate analysis, multivariable analysis identified ileostomy and diabetes as independent risk factors for a decreased eGFR (P=0.005 and P=0.022, respectively). Furthermore, a significantly rebound of eGFR was observed in patients after ileostomy closure (P=0.013).

Conclusions

Ileostomy can cause temporary electrolyte disturbance and renal function impairment in patients with rectal cancer. Diabetes is an independent risk factor for renal function damage in patients with rectal cancer who receive a temporary ileostomy.

Symptoms affecting quality of life after sphincter-saving rectal cancer surgery: A systematic review

PURPOSE

Rectal cancer is common and is frequently treated with surgery which removes the rectum but retains anal sphincters. After sphincter-saving rectal cancer surgery, which can result in a reduced rectal storage capacity and nerve damage, symptoms frequently occur.

METHOD

A systematic review was undertaken to determine which symptoms occur and their effect on quality of life. Data from questionnaires and interviews were analysed thematically.

RESULTS

Fourteen heterogeneous studies were identified reporting both qualitative and quantitative data on over 1700 individuals. The most commonly reported symptoms related to bowel changes. The most problematic changes were bowel and sexual dysfunction. Quality of life was most affected by an inability to function as individuals desired, specifically in their chosen role and socially. Quality of life improved as time progressed or symptoms resolved; but symptoms could persist for many years.

CONCLUSION

After sphincter-saving rectal cancer surgery quality of life is affected by symptoms such as bowel dysfunction. Healthcare professionals need to gain a better understanding of which symptoms most bother individuals to enable patient-focussed interventions to be planned and improve quality of life.

Prospective, randomised, multicentre, open-label trial, designed to evaluate the best timing of closure of the temporary ileostomy (early versus late) in patients who underwent rectal cancer resection and with indication for adjuvant chemotherapy: the STOMAD (STOMa closure before or after ADjuvant therapy) randomised controlled trial

INTRODUCTION

Temporary ileostomy is a valuable aid in reducing the severity of complications related to rectal cancer surgery. However, it is still unclear what is the best timing of its closure in relation to the feasibility of an adjuvant treatment, especially considering patient-reported outcomes and health system costs. The aim of the study is to compare the results of an early versus late closure strategy in patients with indication to adjuvant chemotherapy after resection for rectal cancer.

METHODS AND ANALYSIS

This is a prospective multicentre randomised trial, sponsored by Rete Oncologica Piemonte e Valle d'Aosta (Oncology Network of Piedmont and Aosta Valley-Italy). Patients undergone to rectal cancer surgery with temporary ileostomy, aged >18 years, without evidence of anastomotic leak and with indication to adjuvant chemotherapy will be enrolled in 28 Network centres. An early closure strategy (between 30 and 40 days from rectal surgery) will be compared with a late one (after the end of adjuvant therapy). Primary endpoint will be the compliance to adjuvant chemotherapy with and without ileostomy. Complications associated with stoma closure as well as quality of life, costs and oncological outcomes will be assessed as secondary endpoints.

ETHICS AND DISSEMINATION

The trial will engage the Network professional teams in a common effort to improve the treatment of rectal cancer by ensuring the best results in relation to the most correct use of resources. It will take into consideration both the patients' point of view (patient-reported outcome) and the health system perspective (costs analysis). The study has been approved by the Ethical Review Board of Città della Salute e della Scienza Hospital in Turin (Italy). The results of the study will be disseminated by the Network website, medical conferences and peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04372992.

Quality of Life and Bowel Function Following Early Closure of a Temporary Ileostomy in Patients with Rectal Cancer: A Report from a Single-Center Randomized Controlled Trial

The aim of this study was to assess quality of life and bowel function in patients undergoing early vs. standard ileostomy closure. We retrospectively assessed patients from our previous randomized controlled trial. Patients with a temporary ileostomy who underwent rectal cancer surgery and did not have anastomotic leakage or other. Early closure (EC; 30 days after creation) and standard closure (SC; 90 days after creation) of ileostomy were compared. Thirty-six months (17–97) after stoma closure, we contacted patients by phone and filled in two questionnaires—The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and low anterior resection syndrome (LARS) score. This index trial was not powered to assess the difference in bowel function between the two groups. All the patients in the SC group had anastomosis <6 cm from the anal verge compared to 42 of 43 (97.7%) in the EC group. There were no statistically significant differences between EC (26 patients) and SC (25 patients) groups in the EORTC QLQ-C30 and LARS questionnaires. Global quality of life was 37.2 (0–91.7; ±24.9) in the EC group vs. 34.3 (0–100; ±16.2) in the SC (p = 0.630). Low anterior resection syndrome was present in 46% of patients in the EC and 56% in the SC group (p = 0.858). Major LARS was found more often in younger patients. However, no statistical significance was found (p = 0.364). The same was found with quality of life (p = 0.219). Age, gender, ileostomy closure timing, neoadjuvant treatment, complications had no effect of worse bowel function or quality of life. There was no difference in quality of life or bowel function in the late postoperative period after the early vs. late closure of ileostomy based on two questionnaires and small sample size. None of our assessed risk factors had a negative effect on bowel function o quality of life.

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

Background

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

Methods

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

Results

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

Conclusions

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

The safety of early versus late ileostomy reversal after low anterior rectal resection: a retrospective study in 47 patients

Background

This study aimed to clarify the safety of early closure in diverting ileostomy with lower anterior rectal-cancer resection.

Methods

We retrospectively reviewed consecutive 47 patients who underwent diverting ileostomy with lower rectal-cancer resection between May 2009 and October 2017. The results of the stoma closure were compared between patients who underwent stoma closure within 90 days (early closure [EC] group) and those who underwent late closure (LC group; closure after 90 days). Because of the small sample size, the frequency of severe complications post closure was analyzed.

Results

Among 47 patients, 29 were in the EC group. Postoperative complications occurred in 48.3% (14/29) and 27.8% (5/18) of patients in the EC and LC groups, respectively. This difference was due to minor complications (Clavien-Dindo Classification I/II), such as superficial incisional surgical site infections (n=5) in the EC group. The rate of severe complications (Clavien-Dindo Classification ≥ III) was similar between the groups (20.7% vs. 16.7%, p=1, Fisher’s exact test).

Conclusions

No association was observed between the time of closure and development of major complications; however, there was an increased likelihood of minor complications after EC. This study provides a basis on which future treatment guidelines for early stoma closure may be developed without affecting patient quality of life.

Predictors of morbidity related to stoma closure after colorectal cancer surgery

PURPOSE

A defunctioning stoma is essential in reducing symptomatic leakage after colorectal surgery, particularly after lower anterior resection. Subsequent stoma closure is associated with morbidity and rarely mortality. This study aimed to identify the risk factors associated with post-operative complications related to stoma closure.

METHODS

This retrospective cohort included patients who have undergone elective stoma closure between 2015 and 2017. Patient demographics, pre-morbidities, use of systemic therapy, stoma characteristics, and post-operative complications were retrieved from electronic records. Univariate and multivariate analysis was carried out to identify risk factors of stoma closure related morbidity.

RESULTS

Ninety patients were included with a median age of 65 years, of which 58 (64.4%) of them were male. Sixty-nine (76.7%) patients had loop colostomy, while the rest had loop ileostomy. Fifty-four (60%) patients received neoadjuvant or adjuvant therapy. The median time interval from stoma creation to closure was 15 months. Nineteen (21.1%) patients had post-operative complications. The two most commonly observed post-operative complications were wound complications (16.7%) and intra-abdominal collections (6.7%). Fifteen (16.7%) patients developed an incisional hernia. The median follow-up time was 29 months. There was no 30-day mortality in this cohort. In multivariate analysis, adjuvant chemotherapy was associated with a higher risk of wound complications (p = 0.027). Higher risk of incisional hernia was seen in patients with history of hypertension (p = 0.046), use of adjuvant chemotherapy (p = 0.042) and stoma-related complications before closure (p = 0.002). Male patients might be associated with a higher risk of incisional hernia.

CONCLUSION

Adjuvant chemotherapy is associated with a higher risk of post-operative complications, particularly with wound complications. Male patients, hypertension, adjuvant chemotherapy, and stoma-related complications are associated with a higher risk of incisional hernia.

Management of colorectal anastomotic leakage using endoscopic negative pressure therapy with or without protective ostomy: a retrospective study

PURPOSE

Management of colorectal anastomotic leakage (AL) is patient-oriented and requires an interdisciplinary approach. We analyzed the management of AL according to its severity and presence of ostomy and proposed a therapy algorithm.

METHODS

We identified all patients who underwent colorectal surgery and developed an AL in our clinic between 2012 and 2017. The management of AL was retrospectively analyzed according to the severity grade: asymptomatic (A), requesting interventional or antibiotic therapy (B), undergoing re-operation (C). The groups were compared according to the leakage characteristics, presence of ostomy, and patient clinical conditions.

RESULTS

We identified 784 consecutive patients meeting the inclusion criteria. Of these, 10.8% experienced an AL (A = 18%, B = 48%, and C = 34%). The rate of successful ostomy closure was 100% (A), 68% (B), and 62% (C), respectively. Within group B, 91% of the patients were treated solely by endoscopic negative pressure therapy (ENPT), whereas 37% of the patients within group C required ENPT in addition to surgery. Seven cases within group B (17%) required no protective ostomy (nOB) during ENPT which was itself shorter and required less cycles in comparison to group B with ostomy (OB) (p = 0.017 and 0.111, respectively). Moreover, the leakage distance to anal verge was higher in the OB subgroup (p < 0.001).

CONCLUSION

ENPT for the treatment of colorectal AL is efficient in combination with operative revision or protective ostomy. In selected patients, it is feasible also in the absence of a protective ostomy.

Time after ostomy surgery and type of treatment are associated with quality of life changes in colorectal cancer patients with colostomy

Purpose

Quality of life in colorectal cancer patients may be affected by colostomy and treatment, but relevant studies are still scarce and contradictory. The present study aimed to evaluate the association between colostomy time and treatment type with quality of life in colorectal cancer patients.

Methods

A prospective observational study of 41 patients with colorectal cancer was conducted on three occasions T0, T1 and T2 (0–2; 3–5 and 6–8 months after ostomy surgery, respectively). The treatments prescribed were: surgery alone, chemotherapy or radiotherapy, or chemoradiotherapy. European Organization for Research and Treatment of Cancer questionnaires were used to evaluate quality of life. Worsening clinical changes were evaluated considering difference in scores between times of surgery ≥±9 points.

Results

Regarding ostomy surgery, scores in physical function improved between T0 and T1 and these better scores were maintained at T1 to T2. The same was observed for urinary frequency, appetite loss and dry mouth. Chemoradiotherapy was associated with worse scores for global health status, nausea and vomiting, bloating and dry mouth. Although significant differences were not observed in some domains in the Generalized Estimating Equations analysis, patients showed noticeable changes for the worse in the pain, anxiety, weight concern, flatulence and embarrassment domains during these periods.

Conclusions

Colostomy improved quality of life at 3–5 months in most domains of quality of life and remained better at 6–8 months after surgery. Chemoradiotherapy had a late negative influence on quality of life. Health teams could use these results to reassure patients that this procedure will improve their quality of life in many functional and symptomatic aspects.

Ghost ileostomy versus conventional loop ileostomy in patients undergoing low anterior resection for rectal cancer (DRKS00013997): protocol for a randomised controlled trial

INTRODUCTION

Anastomotic leakage is the most important complication in colorectal surgery occurring in up to 20% after low anterior rectal resection. Therefore, a diverting ileostomy is usually created during low anterior resection to protect the anastomosis or rather to diminish the consequences in case of anastomotic leakage. The so-called virtual or ghost ileostomy is a pre-stage ostomy that can be easily exteriorised, if anastomotic leakage is suspected, in order to avoid the severe consequences of anastomotic leakage. On the other hand, an actual ileostomy can be avoided in patients, who do not develop anastomotic leakage.

METHODS AND ANALYSIS

The GHOST trial is a randomised controlled pilot trial comparing ghost ileostomy with conventional loop ileostomy in patients undergoing low anterior resection with total mesorectal excision for rectal cancer. After screening for eligibility and obtaining informed consent, a total of 60 adult patients are included in the trial. Patients are intraoperatively randomised to the trial groups in a 1:1 ratio after assuring that none of the intraoperative exclusion criteria are present. The main outcome parameter is the comprehensive complication index as a measure of safety. Further outcomes include specific complications, stoma-related complications, complications of ileostomy closure, frequency of transformation of ghost ileostomy into conventional ileostomy, frequency of terminal ostomy creation, proportion of patients with an ostomy at 6 months after index surgery, anorectal function (Wexner score) and quality of life assessed by the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and CR29 questionnaires. Follow-up for each individual patient will be 6 months.

ETHICS AND DISSEMINATION

The GHOST trial has been approved by the Medical Ethics Committee of Heidelberg University (reference number S-694/2017). If the intervention proves to be safe, loop ileostomy could be spared in a large proportion of patients, thus also avoiding stoma-related complications and a second operation (ileostomy closure) with its inherent complications in these patients.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00013997); Universal Trial Number: U1111-1208-9742.

A combination of subcuticular sutures and subcutaneous closed-suction drainage reduces the risk of incisional surgical site infection in loop ileostomy closure

PURPOSE

The purpose of this study was to evaluate the effectiveness of a wound closure method using a combination of subcuticular sutures and subcutaneous closed-suction drainage (SS closure) for preventing incisional surgical site infection (SSI) in loop ileostomy closure.

METHODS

A total of 178 consecutive patients who underwent loop ileostomy closure at Nara Medical University Hospital between 2004 and 2018 were retrospectively assessed. The patients were divided into 2 groups: the conventional skin closure (CC) group from 2004 to 2009 (75 patients) and the SS closure (SS) group from 2010 to 2018 (103 patients). The incidence of incisional SSI was compared between the two groups, and the factors associated with incisional SSI were examined by univariate and multivariate analyses.

RESULTS

Incisional SSI occurred in 7 cases (9.3%) in the CC group but was significantly reduced to only 1 case (0.9%) in the SS group (p = 0.034). In the univariate analysis, the hemoglobin levels, serum creatinine levels, and SS closure were associated with incisional SSI. SS closure was the only independent preventive factor for incisional SSI according to the multivariate analysis (hazard ratio = 0.24, p = 0.011).

CONCLUSION

The combination of subcuticular sutures and subcutaneous closed-suction drainage may be a promising way of preventing incisional SSI in loop ileostomy closure.

Pelvic Anastomosis Without Protective Ileostomy is Safe in Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

During cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), surgeons are reluctant to perform unprotected pelvic anastomosis despite lack of supporting data. We analyzed pelvic anastomosis outcomes and factors that influence ostomy creation in CRS/HIPEC patients.

METHODS

A single-center, descriptive study of patients with rectal resection during CRS/HIPEC was conducted using a prospective database. Surgical variables were reviewed. Multinomial logistic regression of outcomes (end or protective ostomy) was performed with pre- and intraoperative factors as predictors.

RESULTS

Overall, 274 of 789 CRS/HIPEC patients underwent rectal resection, including 243 (89%) with pelvic anastomosis [232 (85%) without ostomy, 11 (4%) with protective ileostomy] and 31 (11%) with no anastomosis [16 (6%) with end colostomy, 15 (5%) with end ileostomy]. The median age was 57 and 29% (79) were male. Of 243 pelvic anastomosis patients, 3 (1.2%) had rectal anastomotic leaks, including 1 with a protective ileostomy. Other anastomotic leaks occurred in 3.6%. Overall, 13% had Clavien-Dindo complications ≥ IIIB and the readmission rate was 30%. Mortality at 30 days and 100 days was 0.4% and 2.2%, respectively. Male gender and primary rectal cancer were associated with protective ileostomy [odds ratio (OR) = 7.01, 95% CI: 1.6-31.5, p = 0.011, and OR = 16.4, 95% CI: 3-88.4, p = 0.001, respectively). Male gender and prior pelvic surgery were associated with end colostomy (OR = 13.9, 95% CI: 3.7-53, p < 0.0001, and OR = 17.2, 95% CI: 3.8-78.6, p < 0.0001).

CONCLUSIONS

Pelvic bowel reconstruction without protective or end ostomy during CRS/HIPEC is safe. Protective ileostomy is associated with male gender and primary rectal cancer. End colostomy is associated with male gender and prior pelvic surgery.

Outcome after surgery for deep endometriosis infiltrating the rectum

OBJECTIVE

To evaluate the rate of postoperative complications between conservative surgery and segmental resection in patients with rectal endometriosis.

DESIGN

Single-center retrospective study.

SETTING

University hospital.

PATIENT(S)

A total of 232 women undergoing surgery for deep endometriosis infiltrating the rectum up to 15 cm from the anus with at least involvement of the muscularis layer, stratified into two arms according to surgical technique. Subgroup analysis was performed in patients without previous therapeutic laparoscopy for endometriosis (n = 108). A propensity-score approach was used to correct for group differences.

INTERVENTION(S)

All patients underwent CO₂-laser laparoscopic surgery: 61 underwent conservative surgery, and 171 had a segmental resection.

MAIN OUTCOME MEASURE(S)

Postoperative complication rate (Clavien-Dindo classification).

RESULT(S)

Clavien-Dindo type 1 and 2 complications did not differ between both groups. Clavien-Dindo type 3 complications were more frequent in the segmental resection group (1/61 [1.6%] conservative vs. 18/171 [10.5%] segmental), after propensity analysis only a trend was retained. In the subgroup analysis, no difference or trend was found (1/27 [3.7%] conservative vs. 5/81 [6.2%] segmental). A low rate of temporary diverting stoma was recorded: 24/232 (10.3%).

CONCLUSION(S)

A higher major complication (Clavien-Dindo ≥3) rate for segmental resections compared with conservative surgical treatment was shown in the overall population, although after correction for group differences this was attenuated to a trend only. However, in patients without previous therapeutic laparoscopy no significant difference or trend was found regardless of the surgical technique used. This not only suggests that redo/repeated surgery has a potentially increased morbidity, but also emphasizes the importance of a well executed primary surgery.

Diverting Ileostomy Duration Is the Main Determinant of Ileostomy-Related Complications after Surgical Treatment of Rectum Cancer

Background

This study aimed to investigate factors associated with the development of ileostomy complications in rectal cancer patients, including those who received neoadjuvant treatment.

Methods

This retrospective trial included 133 consecutive patients who underwent surgery for rectal cancer with temporary diverting ileostomy. Patients' demographic characteristics as well as the pre- and postclosure outcomes and complications were analyzed.

Results

In logistic regression analysis, longer duration of ileostomy emerged as a significant independent predictor of any complication during ileostomy. The respective odds ratios for 3–6 months and >6 months vs. <3 months of ileostomy duration were as follows: OR, 4.5 (95% CI, 1.2–16.7), p=0.023; and OR, 15.2 (95% CI, 3.1–75.2), p=0.001. An additional stepwise model also identified hypertension as a significant predictor. In stepwise logistic regression model, adjuvant chemoradiotherapy emerged as significant independent predictor of “any ileostomy-related complication after ileostomy closure”: OR, 4.5 (2.0–10.2), p < 0.001.

Conclusion

Duration of ileostomy appears to be the main determinant of ileostomy-related complications. Patients who had received neoadjuvant or adjuvant therapy had longer ileostomy duration, which may be attributed to the concerns of the surgeon or to the complications themselves.

Outcomes of surgical treatment for patients with distal rectal cancer: A retrospective review from a single university hospital

INTRODUCTION AND AIM

Surgery for distal rectal cancer (DRC) can be performed with or without sphincter preservation. The aim of the present study was to analyze the outcomes of two surgical techniques in the treatment of DRC patients: low anterior resection (LAR) and abdominoperineal resection (APR).

METHODS

Patients with advanced DRC that underwent surgical treatment between 2002 and 2012 were evaluated. We compared the outcomes of the type of surgery (APR vs LAR) and analyzed the associations of survival and recurrence with the following factors: age, sex, tumor location, lymph nodes obtained, lymph node involvement, and rectal wall involvement. Patients with distant metastases were excluded.

RESULTS

A total of 148 patients were included, 78 of whom were females (52.7%). The mean patient age was 61.2years. Neoadjuvant chemoradiation therapy was performed in 86.5% of the patients. APR was performed on 86 (58.1%) patients, and LAR on 62 (41.9%) patients. No differences were observed between the two groups regarding clinical and oncologic characteristics. Eighty-seven (62%) patients had pT3-4 disease, and 41 patients (27.7%) had lymph node involvement. In the multivariate analysis, only poorly differentiated tumors (P=.026) and APR (P=.009) correlated with higher recurrence rates. Mean follow-up time was 32 (16-59.9) months. Overall 5-year survival was 58.1%. The 5-year survival rate was worse in patients that underwent APR (46.5%) than in the patients that underwent LAR (74.2%) (P=.009).

CONCLUSIONS

Patients with locally advanced DRC that underwent APR presented with a lower survival rate and a higher local recurrence rate than patients that underwent LAR. In addition, advanced T/stage, lymph node involvement, and poor tumor differentiation were associated with recurrence and a lower survival rate, regardless of the procedure.

Changes in fatigue in rectal cancer patients before and after therapy: a systematic review and meta-analysis

PURPOSE

Fatigue is a common problem among rectal cancer patients and can affect their quality of life. This study conducted a systematic review to better understand changes in fatigue severity in rectal cancer patients before, during, and after they undergo therapy.

METHODS

We used preset keywords to search the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and ProQuest databases for relevant studies published between 2000 and 2018, and data analysis was performed using Comprehensive Meta-Analysis (CMA) software (version 2.2.048) and SPSS software (version 19.0). In total, nine articles with complete data were included in our meta-analysis.

RESULTS

Fatigue conditions were compared before the start of therapy (baseline) and at 1 month (time 1), 3 months (time 2), 6 months (time 3), and 12 months (time 4) after the start of therapy. The standardized mean differences (SMDs) of the pooling effects size were 1.013 (95% confidence interval (CI) 0.217-1.810), - 0.551 (95% CI - 0.647 to - 0.456), - 0.330 (95% CI - 0.427 to - 0.233), and - 0.149 (95% CI - 0.221 to - 0.078), respectively. Subsequent analysis with a linear mixed effect model revealed that the estimate of the time variable was - 0.226 (p = 0.047), which indicates that the severity of fatigue varies over time and over the course of treatment. The results reveal that fatigue affects rectal cancer patients even before they start therapy.

CONCLUSION

Although fatigue worsened during the first month after cancer therapy, it gradually improved thereafter.

Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis

Importance

The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown.

Objective

To investigate the association of the timing of colostomy reversal with operative outcomes.

Design, Setting, and Participants

This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018.

Exposures

Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing.

Main Outcomes and Measures

Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age.

Results

In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups.

Conclusions and Relevance

Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.

Impact of temporary ileostomy on long-term quality of life and bowel function: a systematic review and meta-analysis

BACKGROUND

Defunctioning ileostomy is widely used to protect a low colorectal anastomosis. However, the use of an ileostomy may have an impact on long-term bowel function and quality of life after anterior resection. The objectives were to compare bowel function and quality of life outcomes between patients undergoing an anterior resection for rectal cancer, with and without the formation of a diverting ileostomy, and to compare outcomes for early versus late closure of diverting ileostomy.

METHOD

A systematic literature review was performed to identify studies published between 2007 and 2018 comparing bowel function and quality of life outcomes after an anterior resection for rectal cancer in those with and without formation of a diverting ileostomy.

RESULTS

Four studies (three randomized controlled trials) reported bowel function and quality of life outcomes. Pooled analysis for 227 participants showed that having an ileostomy is associated with twice the risk of suffering from low anterior resection syndrome (odds ratio (major low anterior resection syndrome) 1.96, 95% confidence interval 1.1, 3.5; P = 0.02). There were no consistent differences in quality of life. Based on single studies there is limited evidence of some improvements in bowel function but no difference in quality of life after early compared to late closure of ileostomy.

CONCLUSION

There is some evidence for an association between low anterior resection syndrome and the use of a diverting ileostomy to protect a rectal anastomosis. Potential confounders include height of the anastomosis. Further research into the mechanisms underlying this potential association may inform methods to mitigate the harms of an ileostomy.

Total neoadjuvant treatment of locally advanced rectal cancer with high risk factors in Slovenia

Background In the light of a high rate of distant recurrence and poor compliance of adjuvant chemotherapy in high risk rectal cancer patients the total neoadjuvant treatment was logical approach to gaining acceptance. We aimed to evaluate toxicity and efficiency of this treatment in patients with rectal cancer and high risk factors for local or distant recurrence. Patients and methods Patients with rectal cancer stage II and III and with at least one high risk factor: T4, presence of extramural vein invasion (EMVI), positive extramesorectal lymph nodes or mesorectal fascia (MRF) involvement were treated with four cycles of induction CAPOX/FOLFOX, followed by capecitabine-based radiochemotherapy (CRT) and two consolidation cycles of CAPOX/FOLFOX before the operation. Surgery was scheduled 8-10 weeks after completition of CRT. Results From November 2016 to July 2018 66 patients were evaluable. All patients had stage III disease, 24 (36.4%) had T4 tumors, in 46 (69.7%) EMVI was present and in 47 (71.2%) MRF was involved. After induction chemotherapy, which was completed by 61 (92.4%) of patients, radiologic downstaging of T, N, stage, absence of EMVI or MRF involvement was observed in 42.4%, 62.1%, 36.4%, 69.7% and 68.2%, respectively. All patients completed radiation and 54 (81.8%) patients received both cycles of consolidation chemotherapy. Grade 3 adverse events of neoadjuvant treatment was observed in 4 (6%) patients. Five patients rejected surgery, 3 of them with radiologic complete clinical remissions. One patient did not have definitive surgery of primary tumor due to unexpected cardiac arrest few days after sigmoid colostomy formation. Among 60 operated patients pathological complete response rate was 23.3%, the rate of near complete response was 20% and in 96.7% radical resection was achieved. Pathological T, N and stage downstaging was 65%, 96.7% and 83.4%, respectively. Grade ≥ 3 perioperative complications were anastomotic leakage in 3, pelvic abscess in 1 and paralytic ileus in 2 patients. The rate of pathologic complete response (pCR) in patients irradiated with 3D conformal technique was 12.1% while with IMRT and VMAT it was 37% (p < 0.05). Hypofractionation with larger dose per fraction and simultaneous integrated boost used in the latest two was the only factor associated with pCR. ConclusionsTotal neoadjuvant treatment of high risk rectal cancer is well tolerated and highly effective with excellent tumor and node regression rate and with low toxicity rate. Longer follow up will show if this strategy will improve distant disease control and survival.