The indications for a diverting stoma in low anterior resection for rectal cancer: a prospective multicentre study of 222 patients from Japanese cancer centers

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical application of the B-type sutured ileostomy in robotic-assisted low anterior resection for rectal cancer: a propensity score matching analysis

Currently, there is no consensus on the position and method for temporary ileostomy in robotic-assisted low anterior resection for rectal cancer. Herein, this study introduced the B-type sutured ileostomy, a new temporary ileostomy technique, and compared it to the traditional one to assess its efficacy and safety. Between September 2020 and December 2022 in our centre, B-type sutured ileostomy was performed on 124 patients undergoing robotic-assisted low anterior resection for rectal cancer. A retrospective review of a prospectively collected database identified patients who underwent robotic-assisted low anterior resection for rectal cancer with a temporary ileostomy between January 2018 and December 2022. Patients who underwent B-type sutured ileostomy (B group) were matched in a 1:1 ratio with patients who underwent traditional ileostomy (Control group) using a propensity score based on age, sex, BMI, Comorbidity, American Society of Anesthesiologists (ASA) score, and Prior abdominal surgery history. Surgical and postoperative outcomes, health status, and stoma closure data were analyzed for both groups. ClinicalTrials.gov Identifier：NCT05915052.  The B group (n = 118) shows advantages compared to the Control group (n = 118) regarding total operation time (155.98 ± 21.63 min vs 168.92 ± 21.49 min, p = 0.001), postoperative body pain (81.92 ± 4.12 vs 78.41 ± 3.02, p = 0.001) and operation time of stoma closure (46.19 ± 11.30 min vs 57.88 ± 11.08 min, p = 0.025). The two groups had no other notable differences. The B-type sutured ileostomy is a safe and feasible option in robotic-assisted low anterior resection for rectal cancer. The B-type sutured ileostomy may offer advantages such as shorter overall surgical duration, lighter postoperative pain, and shorter second-stage ostomy incorporation surgery. However, attention should be directed towards the occurrence of stoma prolapse.

What affects the selection of diverting ileostomy in rectal cancer surgery: a single-center retrospective study

BACKGROUND

The selection of diverting ileostomy (DI) is controversial. This study aimed to explore the factors affecting the selection of diverting ileostomy (DI) following laparoscopic low anterior resection for rectal cancer.

METHODS

This retrospective, case-control study included patients who underwent laparoscopic-assisted sphincter-saving surgery for mid-low rectal cancer from January 2019 to June 2021. Univariate and multivariate analyses were performed on the patient's clinicopathological characteristics and pelvic dimensions measured by abdominopelvic electron beam computed tomography.

RESULTS

A total of 382 patients were included in the analysis, of which 182 patients (47.6%) did not undergo DI, and 200 patients (52.4%) underwent DI. The univariate analysis suggested that male sex (p = 0.003), preoperative radiotherapy (p < 0.001), patients with an anastomosis below the levator ani plane (p < 0.001), the intertuberous distance (p < 0.001), the sacrococcygeal distance (p = 0.025), the mid pelvis anteroposterior diameter (p = 0.009), and the interspinous distance (p < 0.001) were associated with performing DI. Multivariate analysis confirmed that preoperative radiotherapy (p = 0.037, odds ratio [OR] = 2.98, 95% confidence interval [CI] = 1.07-8.30), anastomosis below the levator ani plane (p < 0.001, OR = 7.09, 95% CI = 4.13-12.18), and the interspinous distance (p = 0.047, OR = 0.97, 95% CI = 0.93-1.00) were independently associated with performing DI.

CONCLUSION

Pelvic parameters also influence the choice of DI. According to this single-center experience, patients with a shorter interspinous distance, particularly narrow pelvic with an interspinous distance of < 94.8 mm, preoperative radiotherapy, and anastomosis below the levator ani plane, prefer to have a DI and should be adequately prepared by the physician.

Which site is better for prophylactic ileostomy after laparoscopic rectal cancer surgery? By the specimen extraction site or new site: A systematic review and meta-analysis

Background

There is controversy about the outcomes of prophylactic ileostomy via the specimen extraction site (SES) after laparoscopic rectal cancer surgery (LRCS). We, therefore, performed a meta-analysis to determine the efficacy and safety of stoma through the SES versus new site (NS).

Methods

All relevant studies from 1997 to 2022 were searched in the PubMed, EMBASE, Cochrane Library, CNKI, VIP databases. This meta-analysis was performed using RevMan software 5.3 for statistical analysis.

Results

7 studies with 1736 patients were included. The present meta-analysis noted that prophylactic ileostomy via SES was associated with a higher risk of overall stoma-related complications, especially parastomal hernia (OR, 2.39, 95% CI 1.43-4.00; p=0.0008). No statistical difference was found in terms of wound infection, ileus, stoma edema, stoma prolapse, stoma necrosis, stoma infection, stoma bleeding, stoma stenosis, skin inflammation around the stoma, stoma retraction and postoperative pain score on postoperative day 1 and 3 between SES group and NS group. However, prophylactic ileostomy via SES was associated with lesser blood loss (MD = -0.38, 95% CI: -0.62 - -0.13; p=0.003), shorter operation time(MD = -0.43, 95% CI: -0.54 - -0.32 min; p<0.00001), shorter post-operative hospital stay (MD = -0.26, 95% CI: -0.43 - -0.08; p=0.004), shorter time to first flatus(MD = -0.23, 95% CI: -0.39 - -0.08; p=0.003) and lower postoperative pain score on postoperative day 2.

Conclusion

Prophylactic ileostomy via SES after LRCS reduces new incision, decreases operative time, promotes postoperative recovery, and improves cosmetic outcomes, but may increase the incidence of parastomal hernias. The vast majority of parastomal hernias can be repaired by closing the ileostomy, therefore SES remain an option for temporary ileostomy after LRCS.

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

BACKGROUND

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

OBJECTIVE

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

PATIENTS

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

RESULTS

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

CONCLUSIONS

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

Assessment of the Difficulties Experienced by Individuals with Intestinal Stomas: A Qualitative Study

OBJECTIVE

The aim of this study was to assess the difficulties faced by individuals with intestinal stomas.

METHODS

The authors used a qualitative descriptive phenomenologic design. The study population comprised individuals with intestinal stoma living in Eskişehir who were 18 years or older and did not have any mental, physical, and communication disorders. Criterion sampling and snowball sampling methods were used. Data were collected from June to September 2019 through a questionnaire of personal characteristics as well as a semistructured interview. Data on personal characteristics were analyzed in numbers and percentages, and qualitative data were analyzed using the MAXQDA 2020 program (VERBI Software, Berlin, Germany).

RESULTS

The study data were evaluated under two headings: (1) themes created using the Roy's Adaptation Model and (2) other themes. In the themes created using the Roy's Adaptation Model, difficulties related to the physiologic adaptation mode and interdependence adaptation mode were observed, whereas among other themes, difficulties due to lack of information and economic worries were commonly reported.

CONCLUSIONS

Most individuals experienced sleep pattern disturbances; faced issues in their relationships with family and friends due to physiologic and psychological distress; received no training for stoma care, diet, or sexual life; could not cope with issues related to the stoma; and faced financial difficulties in procuring stoma bags and care products.

Short-term outcomes in patients undergoing laparoscopic surgery for deep infiltrative endometriosis with rectal involvement: a single-center experience of 168 cases

Purpose

The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI).

Methods

A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections.

Results

The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4-16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7-18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy.

Conclusion

In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Serial Radiographic Imaging for Real-Time Evaluation of Blood Flow During Low Anterior Resection: Initial Study in a Porcine Model

To determine whether real-time intraoperative serial radiographic imaging of the marginal artery and vasa recta is feasible in patients undergoing low anterior resection, we attempted such imaging in a porcine model using a specialized fluoroscopic digital X-ray system and thin flat panel detector. Of the possible complications after low anterior resection, anastomotic dehiscence is one of the most serious, with poor blood supply in the anastomotic region being a chief contributor. General anesthesia was induced in a male domestic pig, and a midline incision was made from the xiphoid process to just above the bladder. The rectum was transected at the peritoneal reflection and then mobilized by dissection of the right leaf of the sigmoid mesocolon from the inferior mesenteric artery to the superior rectal artery. The rectal stump was pulled out and placed directly on the detector. Noniodine contrast agent was injected, and blood flow to and from the area surrounding the rectum was evaluated. Serial radiographs depicting the superior rectal artery, colonic, rectal, surrounding mesenteric tissue, and the vasa recta were obtained. The region where the marginal artery ran along the distal portion of the rectal stump was poorly poor imaged in all 3 imaging phases. Diameters of arteries were easily determined. The success we had in radiographically observing blood flow in tissues that would be involved in low anastomosis convinced us that such intraoperative evaluation is clinically feasible.

The possibility of a transanal tube as an alternative to diverting stoma in terms of preventing severe postoperative anastomotic leakage after laparoscopic low anterior resection

PURPOSE

The purpose of this study was to reveal whether a transanal tube (TAT) could act as an alternative to a diverting stoma (DS) after laparoscopic low anterior resection.

PATIENTS AND METHODS

A total of 89 consecutive rectal cancer patients whose tumors were located within 15 cm from the anal verge who underwent laparoscopic low anterior resection without a DS at our institution between May 12, 2015 and August 31, 2019 were included. All patients received a postoperative Gastrografin enema study (GES) through a TAT between the 3rd and 10th postoperative day. We planned two study protocols. From May 12, 2015 to March 31, 2017, we conducted a second operation including a DS construction immediately when radiological anastomotic leakage (rAL) was detected (Group A, n=46). From April 1, 2017 to August 31, 2019, we continued TAT drainage even if rAL was detected and repeated the GES weekly until the rAL was healed (Group B, n=43).

RESULTS

In Group A (n=46), 14 cases of rAL were included, 11 of which underwent stoma construction. The remaining 3 patients who refused stoma construction were treated conservatively. In Group B (n=43) rAL was encountered in 10, and 7 of these patients were treated successfully by TAT continuous drainage. The rate of DS in Group B (7.0%) was significantly lower than that in Group A (23.9%) (p=0.028).

CONCLUSIONS

A TAT could act as a DS to mitigate the symptoms of anastomotic leakage after laparoscopic low anterior resection.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Robotic versus laparoscopic rectal resection surgery: Short-term outcomes and complications: A retrospective comparative study

BACKGROUND

The safety of robotic-assisted surgery (RAS) remains a concern. This study aimed to compare the complications after RAS versus laparoscopic-assisted surgery (LAS) for rectal cancer using the Clavien-Dindo classification and to identify risk factors related to the complications.

METHOD

Between March 2010 and June 2016, 556 rectal cancer patients who underwent successful RAS and 1029 patients who received LAS were enrolled in this study. The complications were graded according to the Clavien-Dindo classification, and the possible risk factors related to the complications were analyzed.

RESULTS

The overall postoperative complication rate was 14.9%, with a 5% rate of severe complications that were classified as grade III or above in RAS group compared with 17.1% and 4.4% in LAS group. However, no significant difference was found (P = 0.608). A high ASA score was identified as an independent risk factor for overall and severe complications in both groups. The use of more than 3 staples in each operation and the anastomotic site of the anal verge at less than 5 cm were independent risk factors for complications.

CONCLUSIONS

RAS for rectal cancer is technically safe and it does not significantly improve the complication rate. The incidence of overall complications is still related to tumor location, the general condition of the patients, and the surgical approach.

Surgical specimen extraction via a prophylactic ileostomy procedure: A minimally invasive technique for laparoscopic rectal cancer surgery

AIM

To retrospectively evaluate the safety and feasibility of surgical specimen extraction via a prophylactic ileostomy procedure in patient with rectal cancer.

METHODS

We systematically reviewed 331 consecutive patients who underwent laparoscopic anterior resection for rectal cancer and prophylactic ileostomy in our institution from June 2010 to October 2016, including 155 patients who underwent specimen extraction via a prophylactic ileostomy procedure (experimental group), and 176 patients who underwent specimen extraction via a small lower abdominal incision (control group). Clinical data were collected from both groups and statistically analyzed.

RESULTS

The two groups were matched in clinical characteristics and pathological outcomes. However, mean operative time was significantly shorter in the experimental group compared to the control group (161.3 ± 21.5 min vs 168.8 ± 20.5 min; P = 0.001). Mean estimated blood loss was significantly less in the experimental group (77.4 ± 30.7 mL vs 85.9 ± 35.5 mL; P = 0.020). The pain reported by patients during the first two days after surgery was significantly less in the experimental group than in the control group. No wound infections occurred in the experimental group, but 4.0% of the controls developed wound infections (P = 0.016). The estimated 5-year disease-free survival and overall survival rate were similar between the two groups.

CONCLUSION

Surgical specimen extraction via a prophylactic ileostomy procedure represents a secure and feasible approach to laparoscopic rectal cancer surgery, and embodies the principle of minimally invasive surgery.

Preoperative radiotherapy for patients with rectal cancer: a risk factor for non-reversal of ileostomy caused by stenosis or stiffness proximal to colorectal anastomosis

The influence of radiotherapy on permanent stoma and the bowel proximal to anastomosis was not well investigated. The current study aimed to analyze the effect of preoperative radiotherapy on colorectal anastomosis and incidence of non-reversal ileostomy. A total of 184 eligible patients with rectal cancer undergoing loop ileostomy were included. Patients were well selected by excluding some confounding factors and divided into two groups according to whether they received preoperative radiotherapy. Patients with preoperative radiotherapy had higher incidence of non-reversal stoma (12.8%, P = 0.004) and stenosis or stiffness around anastomosis (21.1%, P < 0.01) including 13 patients with stenosis or stiffness proximal to anastomosis. Stenosis proximal to anastomosis was different from anastomotic stricture caused by surgery and could be described by imaging findings. Preoperative radiotherapy prolonged the interval to closure (P = 0.008) and was defined as a significant risk factor for permanent stoma (HR, 0.627; 95% CI, 0.405-0.973; P = 0.04) by multivariate Cox regression analysis. In conclusion, Preoperative radiotherapy increased incidence of non-reversal ileostomy and stenosis or stiffness proximal to anastomosis in rectal cancer patients with radical resection and diverting ileostomy.

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.

Risk factors for anastomotic leakage after laparoscopic surgery with the double stapling technique for stage 0/I rectal carcinoma: a subgroup analysis of a multicenter, single-arm phase II trial

PURPOSE

The aim of this study was to determine the risk factors for anastomotic leakage after laparoscopic rectal surgery.

METHODS

We conducted a prospective trial involving 395 patients with stage 0/I rectal carcinoma who underwent laparoscopic low anterior resection using a double stapling technique. Data concerning variables related to patient background, tumors and surgical factors were evaluated. The outcomes with respect to anastomotic leakage were recorded, and univariate and multivariate analyses were performed to identify relevant risk factors.

RESULTS

The overall anastomotic leakage rate was 8.4%. A univariate analysis showed male gender (P = 0.006) and preoperative blood sugar level (P = 0.0034) to be significantly associated with anastomotic leakage. The variables of gender, preoperative blood sugar level, American Society of Anesthesiologists (ASA) classification (P = 0.15), transanal decompression tube (P = 0.06) and number of stapler cartridges used for rectal transection (P = 0.18) were selected for the multivariate analysis because of their P values being <0.2. The multivariate analysis identified male gender (odds ratio 4.12, P = 0.006) and the absence of a transanal decompression tube (odds ratio 3.11, P = 0.0484) as independent risk factors predicting anastomotic leakage.

CONCLUSIONS

Male gender and the absence of a transanal decompression tube appeared to be independent risk factors for anastomotic leakage. Insertion of a transanal decompression tube may help prevent anastomotic leakage after low anterior resection, particularly in male patients.

Multivariate Analysis of Risk Factors Associated With the Nonreversal Ileostomy Following Sphincter-Preserving Surgery for Rectal Cancer

Purpose

A loop ileostomy is used to protect an anastomosis after anal sphincter-preserving surgery, especially in patients with low rectal cancer, but little information is available concerning risk factors associated with a nonreversal ileostomy. The purpose of this study was to identify risk factors of ileostomy nonreversibility after a sphincter-saving resection for rectal cancer.

Methods

Six hundred seventy-nine (679) patients with rectal cancer who underwent sphincter-preserving surgery between January 2004 and December 2011 were evaluated retrospectively. Of the 679, 135 (19.9%) underwent a defunctioning loop ileostomy of temporary intent, and these patients were divided into two groups, that is, a reversal group (RG, 112 patients) and a nonreversal group (NRG, 23 patients) according to the reversibility of the ileostomy.

Results

In 23 of the 135 rectal cancer patients (17.0%) that underwent a diverting ileostomy, stoma reversal was not possible for the following reasons; stage IV rectal cancer (11, 47.8%), poor tone of the anal sphincter (4, 17.4%), local recurrence (2, 8.7%), anastomotic leakage (1, 4.3%), radiation proctitis (1, 4.3%), and patient refusal (4, 17.4%). The independent risk factors of the nonreversal group were anastomotic leakage or fistula, stage IV cancer, local recurrence, and comorbidity.

Conclusion

Postoperative complications such as anastomotic leakage or fistula, advanced primary disease (stage IV), local recurrence and comorbidity were identified as risk factors of a nonreversal ileostomy. These factors should be considered when drafting prudential guidelines for ileostomy closure.

Meta-analysis of defunctioning stoma in low anterior resection with total mesorectal excision for rectal cancer: evidence based on thirteen studies

BACKGROUND

Recent studies have shown that a protective stoma can reduce morbidity in low anterior resection for rectal cancer; however, the necessity of it is still controversially discussed.

METHODS

We performed this meta-analysis to provide a comprehensive evaluation of the role of defunctioning stoma in low anterior resection for rectal cancer on the rates of anastomotic leakage and reoperation related to leakage with or without defunctioning stoma by calculating the pooled risk ratio.

RESULTS

Studies and relevant literature published between 2004 and 2014 regarding the construction of a protective stoma after low anterior resection were searched though PubMed and EMBASE databases. Finally, a total of 13 studies including 8,002 patients were included in this meta-analysis. The results indicated that protective stomas significantly reduced the rate of postoperative anastomotic leakage and reoperation after low anterior rectal resection. The pooled risk ratios were 0.47 (95% CI: 0.33-0.68, P <0.0001) and 0.36 (95% CI: 028-0.46, P <0.00001), respectively.

CONCLUSIONS

The findings from this present meta-analysis suggest that a defunctioning stoma could effectively reduce the clinical consequences of anastomotic leakage and reoperation, it is recommended in patients undergoing low rectal anterior resection for rectal cancer.

Role of protective stoma in low anterior resection for rectal cancer: A meta-analysis

AIM: To provide a comprehensive evaluation of the role of a protective stoma in low anterior resection (LAR) for rectal cancer.

METHODS: The PubMed, EMBASE, and MEDLINE databases were searched for studies and relevant literature published between 2007 and 2014 regarding the construction of a protective stoma during LAR. A pooled risk ratio (RR) with 95% confidence intervals (CIs) was used to assess the outcomes of the studies, including the rate of postoperative anastomotic leakage and reoperations related to leakage. Funnel plots and Egger’s tests were used to evaluate the publication biases of the studies. P values < 0.05 were considered statistically significant.

RESULTS: A total of 11 studies were included in the meta-analysis. In total, 5612 patients were examined, 2868 of whom had a protective stoma and 2744 of whom did not. The sample size of the studies varied from 34 to 1912 patients. All studies reported the number of patients who developed an anastomotic leakage and required a reoperation related to leakage. A random effects model was used to calculate the pooled RR with the corresponding 95%CI because obvious heterogeneity was observed among the 11 studies (I² = 77%). The results indicated that the creation of a protective stoma during LAR significantly reduces the rate of anastomotic leakage and the number of reoperations related to leakage, with pooled RRs of 0.38 (95%CI: 0.30-0.48, P < 0.00001) and 0.37 (95%CI: 0.29-0.48, P < 0.00001), respectively. The shape of the funnel plot did not reveal any evidence of obvious asymmetry.

CONCLUSION: The presence of a protective stoma effectively decreased the incidences of anastomotic leakage and reoperation and is recommended in patients undergoing low rectal anterior resections for rectal cancer.

Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial

BACKGROUND

Anastomotic leakage following anterior rectal resection is the most important and most commonly faced complication of laparoscopy and open surgery. To prevent this complication, the construction of a preventing stoma is usually adopted. It is not easy to decide whether to construct a protective stoma in patients with a medium risk of anastomotic leakage. In these patients, ghost ileostomy (GI), a pre-stage ileostomy that can be externalized and opened if needed, has proved useful. We conducted a prospective, randomized, controlled study to evaluate the advantages of GI in laparoscopic rectal resection.

METHODS

All patients with surgical indications for laparoscopic rectal resection who were at medium risk for anastomotic leakage from January 2007 to January 2013 were included and were randomly divided in 2 groups. All of the patients were subjected to laparoscopic anterior rectal resection with the performance of GI (group A) or without the construction of any protective stoma (group B). The presence and severity of clinically evident postoperative anastomotic leakage and other postoperative complications and reinterventions were investigated.

RESULTS

Of the 55 patients allocated to group A, 3 experienced anastomotic leakage compared with 4 in group B. The patients with GI experienced a lower severity of anastomotic leakage and shorter hospitalization compared with the patients in group B. None of the patients with GI and anastomotic leakage required laparotomy to treat the dehiscence.

CONCLUSIONS

The use of GI in laparoscopic rectal resections in patients at medium risk for anastomotic leakage was useful because it allowed for the avoidance of stoma creation in all of the patients, thus reducing the number of stomas performed, improving the quality of life of the patients and preserving, in most cases, the benefits gained by laparoscopy.

Robot-assisted rectal cancer surgery: short-term outcomes for 113 consecutive patients

PURPOSE

The purpose of this study was to assess the short-term outcome of robot-assisted laparoscopic surgery (RALS) for rectal cancer, including robotic, autonomic nerve-preserving, lateral lymph node dissection (RALLD), a new, technically challenging procedure.

METHODS

Between December 2011 and August 2013, 113 consecutive patients underwent RALS for rectal cancer. Surgical outcomes, pathological results, and postoperative complications were prospectively collected.

RESULTS

There were 78 males and 35 females; 30 patients (26.5%) had cT1 tumor, 14 (12.4%) had cT2, 56 (49.6%) had cT3, and 12 (10.6%) had cT4 tumor. The types of procedures performed were 82 anterior resections, 23 intersphincteric resections, and 8 abdominoperineal resections. RALLD was performed in 38 patients (33.6%). The overall median operative time was 302 (135-683) min. In cases without RALLD, the median operative time was 242 (135-529) min, while median operative time was 486 (320-683) min with RALLD. None of the cases was converted to an open or laparoscopic procedure. There was no surgical mortality. The overall complication rate for Clavien-Dindo classification grade III-IV was 2.7%. Ten patients who developed urinary retention recovered completely within 30 days after the operation.

CONCLUSIONS

RALS for rectal cancer is a technically feasible, less invasive procedure. This procedure can be performed with low morbidity and a low conversion rate, even for cases with advanced rectal cancer requiring complicated, robot-assisted, lateral lymph node dissection.

Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile?

BACKGROUND

There is no consensus in the literature as to whether all patients who undergo anterior resection of the rectum with total mesorectal excision should have a defunctioning stoma or only those at high risk of anastomotic dehiscence.

OBJECTIVE

The aim of this retrospective study was to evaluate the results of placing a removable Silastic band around the ileum during the abdominal phase to exteriorize it and create a loop ileostomy postoperatively without the need for laparotomy in case of an anastomotic complication. This approach is known as "ghost ileostomy."

INTERVENTIONS

A vascular loop was passed around the terminal ileum through a window adjacent to the ileal wall. The loop was then exteriorized, through the abdominal wall, without tension, and secured to the skin on a rod. Two 24F Silastic drains were placed next to the anastomosis (anteriorly and posteriorly).

PATIENTS

From May 1997 to May 2011, 168 patients underwent anterior resection of the rectum with total mesorectal excision plus ghost ileostomy.

RESULTS

Symptomatic anastomotic dehiscence was observed in 20 of 168 patients (11.96%) and developed on postoperative days 4 to 12 (median, postoperative day 7). In 13 of 20 cases, an ileostomy was fashioned with the patient under local anesthesia, and there was no need for relaparotomy. In 5 of 20 cases, the complication resolved with conservative management. In 2 of 20 cases, the patient's clinical condition rapidly deteriorated, generalized peritonitis developed, and surgical reintervention with abdominal toilette and colostomy was required.

CONCLUSIONS

Ghost ileostomy allows selective loop ileostomy formation after low anterior resection of the rectum without the need for laparotomy in most cases. However, the technique should be reserved for instances in which the risk of leak is relatively low, such as anastomoses performed in the absence of neoadjuvant therapy. The role of routine ghost ileostomy following higher-risk anastomoses remains to be determined.

Risk factors for permanent stoma after low anterior resection for rectal cancer

PURPOSE

This study evaluated the risk factors influencing permanent stoma after curative resection of rectal cancer and compared the long-term survival of patients according to the stoma state.

METHODS

From January 2004 to December 2010, 895 consecutive rectal cancer patients with histological-confirmed adenocarcinoma who received low anterior resection with curative intent at the Department of Colon and Rectal Surgery, Chonnam National University Hwasun Hospital, were evaluated retrospectively. Patient demographics, times of stoma reversal, and number/reason of permanent stoma were evaluated.

RESULTS

Three hundred fifteen patients (35.2 %) had a diverting stoma of temporary intent among 895 rectal adenocarcinoma patients. Loop ileostomy was performed in 271 patients (86.0 %). A total of 256 (81.3 %) of 315 stoma patients received stoma closure. The mean period between primary surgery and stoma closure was 5.6 months (range, 1-44 months). Seventy-three patients (23.2 %) were confirmed with permanent stoma. Multivariate analysis showed stage IV (hazard ratio (HR), 3.380; 95 % confidence interval (CI), 1.192-18.023; p = 0.027), anastomosis-related complication (HR, 3.299; 95 % CI, 1.397-7.787; p = 0.006), colostomy type (HR, 7.276, 95 % CI, 2.454-21.574; p = 0.000), systemic metastasis (HR, 2.698; 95 % CI, 1.1.288-5.653; p = 0.009), and local recurrence (HR, 4.231; 95 % CI, 1.724-10.383; p = 0.002) were independent risk factors for permanent stoma.

CONCLUSIONS

On postoperative follow-up, in patients with anastomotic complication, tumor progression with local recurrences and systemic metastasis may cause permanent stoma.