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Abdelhadi S, Tzatzarakis E, Hermann M, Orth V, Vedder K, Briscoe J, Reissfelder C, Șandra-Petrescu F. The impact of anastomotic leakage characteristics on the occurrence of anastomotic stenosis after colorectal resection, a retrospective cohort study. Int J Colorectal Dis 2024; 39:126. [PMID: 39105987 PMCID: PMC11303457 DOI: 10.1007/s00384-024-04699-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Anastomotic stenosis (AS) is a common complication after colorectal resection. However, the predisposing factors for stricture formation are not fully understood. Previous studies have shown anastomotic leakage (AL) to be a risk factor for the occurrence of AS. Therefore, we aim to investigate the impact of anastomotic leakage characteristics on the occurrence of anastomotic stenosis after colorectal resection. METHODS Consecutive patients with AL following elective, sphincter preserving, colorectal resection, with or without diversion ostomy, between January 2009 and March 2023 were identified from a prospectively collected database. The characteristics of the anastomotic leakage, patient baseline and operative characteristics as well as the postoperative outcomes were analyzed using univariate and multivariate logistic regression to identify factors associated with the occurrence of post-leakage AS. RESULTS A total of 129 patients developed AL and met the inclusion criteria. Among these, 28 (21.7%) patients were diagnosed with post-leakage AS. There was a significantly higher frequency of patients with neoadjuvant radiotherapy (18% vs 3%; p = .026) and hand-sewn anastomoses (39% vs 17%; p = .011) within the AS group. Furthermore, the extent of the anastomotic defect was significantly higher in the AS group compared with the non-AS group (50%, IQR 27-71 vs. 20%, IQR 9-40, p = 0.011). Similar findings were observed between the study groups regarding age, sex, BMI, ASA score, medical comorbidities, diagnosis, surgical procedure, surgical approach (open vs. minimally invasive), and anastomotic fashioning (side-to-end vs. end-to-end). On multivariate analysis, the extent of the anastomotic defect (OR 1.01; 95% CI 1.00-1.03; p = 0.034) and hand-sewn anastomoses (OR 2.68; 95% CI 1.01-6.98; p = 0.043) were confirmed as independent risk factors for post-leakage AS. No correlation could be observed between the occurrence of post-leakage AS and the ISREC grading of AL, the anastomotic height or the management of AL. Time to ostomy reversal was significantly longer in the AS group (202d, IQR 169-275 vs. 318d IQR 192-416, p = 0.014). CONCLUSION The extent of the anastomotic defect and hand-sewn anastomoses were confirmed as independent risk factors for the occurrence of post-leakage AS. No correlation could be observed between the ISREC grading of AL, the anastomotic height or AL management, and the occurrence of post-leakage AS.
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Affiliation(s)
- Schaima Abdelhadi
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Emmanouil Tzatzarakis
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Maike Hermann
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Vanessa Orth
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Katharina Vedder
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jannis Briscoe
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- DKFZ Hector Cancer Institute at the University Medical Center, Mannheim, Germany
| | - Flavius Șandra-Petrescu
- Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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He F, Yang F, Tang C, Chen D, Zhao D, Xiong J, Zou Y, Huang G, Qian K. Clinical Outcomes of Ileostomy Closure during versus after Adjuvant Chemotherapy in Patients with Rectal Cancer. Can J Gastroenterol Hepatol 2024; 2024:2410643. [PMID: 38550348 PMCID: PMC10977340 DOI: 10.1155/2024/2410643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/10/2023] [Accepted: 01/02/2024] [Indexed: 04/02/2024] Open
Abstract
Background Protective ileostomy can effectively prevent severe anastomotic leakage after rectal cancer surgery; however, the optimal timing for ileostomy closure during adjuvant chemotherapy remains unclear. This study aimed to explore the safety and long-term outcomes of early ileostomy closure during adjuvant chemotherapy. Method Patients who underwent laparoscopic rectal cancer surgery combined with protective ileostomy and adjuvant chemotherapy between April 2017 and April 2021 were retrospectively evaluated. Patients were divided into an early closure group during chemotherapy (group A) and a late closure group after chemotherapy (group B). Results A total of 215 patients were included in this study, with 115 in group A and 100 in group B. There were no significant differences in demographic and clinical characteristics between the two groups. In group A, durations of stoma status (p < 0.001) and low anterior resection syndrome (LARS) (p < 0.001) were shorter, and rectal stenosis (p=0.036) and stoma-related complications (p=0.007), especially stoma stenosis (p=0.041), were less common. However, compliance with chemotherapy was worse (p=0.009). There were no significant differences in operative time, postoperative hospital stay, postoperative complications, incidence and severity of LARS, disease-free survival, or overall survival between groups. Conclusion Early ileostomy closure can effectively reduce the duration of stoma status, duration of LARS, rectal stenosis, and stoma-related complications while not affecting surgical complications and oncological outcomes. Ileostomy closure should not be delayed because of adjuvant chemotherapy. However, follow-up should be strengthened to increase compliance and integrity with chemotherapy.
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Affiliation(s)
- Fan He
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fuyu Yang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Chenglin Tang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Defei Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Dongqin Zhao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Junjie Xiong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yu Zou
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Guoquan Huang
- Hubei Provincial Key Lab of Selenium Resources and Bioapplications, No. 158 Wuyang Avenue, Enshi 445000, Hubei, China
| | - Kun Qian
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Clinical Outcomes of Ileostomy Closure before Adjuvant Chemotherapy after Rectal Cancer Surgery: An Observational Study from a Chinese Center. Gastroenterol Res Pract 2021; 2021:5592721. [PMID: 34335738 PMCID: PMC8294951 DOI: 10.1155/2021/5592721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/24/2021] [Indexed: 11/29/2022] Open
Abstract
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.
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Aktaş A, Kayaalp C, Ateş M, Dirican A. Risk factors for postoperative ileus following loop ileostomy closure. Turk J Surg 2020; 36:333-339. [PMID: 33778391 DOI: 10.47717/turkjsurg.2020.4911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/03/2020] [Indexed: 02/04/2023]
Abstract
Objectives The most common intra-abdominal complication following loop ileostomy closure (LIC) is postoperative ileus (POI). The aim of the study was to determine the risk factors of POI development following LIC and make recommendations for its prevention. Material and Methods In this study, patients having undergone LIC with peristomal incision following distal colorectal surgery were included. Clavien-Dindo classification was used to evaluate postoperative complications. POI and postoperative leakage were defined based on clinical and radiological criteria. The Centers for Disease Control and Prevention 2017 criteria were used to diagnose surgical site infection (SSI). Postoperative bleeding was diagnosed one day after surgery if there was a >2 g/dL or ≥15% decrease in the hemoglobin level. Results Seventy-nine patients were included into the study. In nine of the patients POI developed, six had SSI, five had postoperative bleeding, and two had anastomosis leakage. In the univariate analysis; age <60 years (p= 0.02), presence of comorbidity (p= 0.007), using an open technique in the first surgery (p= 0.02), performing total colectomy in the first surgery (p= 0.048), performing hand-sewn anastomosis of LIC (p= 0.01), and postoperative blood transfusion (p= 0.04) were found to be risk factors for POI. Performing hand-sewn anastomosis of LIC (p= 0.03) and using an open technique in the first surgery (p= 0.03) were found to be independent variables for POI risk. Conclusion Using an open technique in the first surgery and performing a hand-sewn anastomosis of LIC may increase POI.
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Affiliation(s)
- Aydın Aktaş
- Department of General Surgery, Karadeniz Technical University, School of Medicine, Trabzon, Turkey
| | - Cüneyt Kayaalp
- Department of Gastointestinal Surgery, İnönü University, School of Medicine, Malatya, Turkey
| | - Mustafa Ateş
- Department of General Surgery, İnönü University, School of Medicine, Malatya, Turkey
| | - Abuzer Dirican
- Department of General Surgery, İnönü University, School of Medicine, Malatya, Turkey
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Takahashi J, Tsujinaka S, Maemoto R, Miyakura Y, Suzuki K, Fukuda R, Sakio R, Machida E, Rikiyama T. Tolerability and Adverse Events of Adjuvant Chemotherapy for Rectal Cancer in Patients With Diverting Ileostomy. In Vivo 2020; 34:3399-3406. [PMID: 33144447 DOI: 10.21873/invivo.12178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/25/2020] [Accepted: 07/31/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM The impact of diverting ileostomy on the feasibility of adjuvant chemotherapy (ACT) remains unclear. We retrospectively investigated the tolerability and adverse events of ACT for rectal cancer in patients with diverting ileostomy. PATIENTS AND METHODS Thirty-three patients who received ACT after curative resection with ileostomy construction for rectal cancer were analyzed. We assessed completion rate, the mean relative dose intensities, and the factors affecting the tolerability of ACT. RESULTS The completion rate of each chemotherapy regimen was 10 out of 16 patients in oral uracil-tegafur plus leucovorin (UFT/LV), 1 out of 3 patients in oral capecitabine (Capecitabine) and 2 out of 14 patients in capecitabine plus oxaliplatin (CAPOX). The mean relative dose intensities were 77% in UFT/LV, 48% in Capecitabine, and 57% of capecitabine and 42% of oxaliplatin in CAPOX. In multivariate analysis, laparoscopic surgery (Odds ratio=11.6, p=0.021) and receiving preoperative chemoradiotherapy (Odds ratio=32.4, p=0.021) were associated with treatment completion. CONCLUSION Completion rate of ACT in patients with diverting ileostomy was lower than that of colorectal cancer patients in the previous studies. UFT/LV may be a more tolerable regimen than Capecitabine or CAPOX in colorectal cancer patients with diverting ileostomy.
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Affiliation(s)
- Jun Takahashi
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shingo Tsujinaka
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Ryo Maemoto
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yasuyuki Miyakura
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Koichi Suzuki
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Rintaro Fukuda
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Ryotaro Sakio
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Erika Machida
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Gröne J. Zeitpunkt und Technik der Stomarückverlagerung unter Berücksichtigung früher und später Stomakomplikationen. COLOPROCTOLOGY 2019. [DOI: 10.1007/s00053-019-00401-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Factors affecting the morbidity and mortality of diverting stoma closure: retrospective cohort analysis of twelve-year period. Radiol Oncol 2019; 53:331-336. [PMID: 31553701 PMCID: PMC6765168 DOI: 10.2478/raon-2019-0037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/15/2019] [Indexed: 12/13/2022] Open
Abstract
Background Diverting stoma is often performed in rectal cancer surgery for reducing the consequences of possible anastomotic failure. Closing of stoma follows in most cases after a few months. The aim of our study was to evaluate morbidity and mortality after diverting stoma closure and to identify risk factors for complications of this procedure. Patients and methods At our department, we have performed a retrospective cohort analysis of data for 260 patients with diverting stoma closure from 2003 to 2015. Age, stoma type, patient's preoperative ASA score, surgical technique and time to stoma closure were investigated as factors which could influence the complication rate. Results 218 patients were eligible for investigation. Postoperative complications developed in 54 patients (24.8%). Most common complications were postoperative ileus (10%) and wound infection (5%). Four patients died (1.8%). There was no effect on complication rate regarding type of stoma, closing technique, patient's ASA status and patient age. The only factor influencing the complication rate was the time to stoma closure. We found that patients which had the stoma closed prior to 8 months after primary surgery had lower overall complication rate (p<0. 05). Conclusions To reduce overall complication rate, our data suggest a shorter period than 8 months after primary surgery before closure of diverting stoma. As diverting stoma closure is not a simple operation, all strategies should be taken to reduce significant morbidity and mortality rate.
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Hajibandeh S, Hajibandeh S, Sarma DR, East J, Zaman S, Mankotia R, Thompson CV, Torrance AW, Peravali R. Meta-analysis of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection: the dilemma remains. Int J Colorectal Dis 2019; 34:1151-1159. [PMID: 31129697 DOI: 10.1007/s00384-019-03321-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate comparative outcomes of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection. METHODS We systematic searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov , ISRCTN Register and bibliographic reference lists. Overall perioperative complications, anastomotic leak, surgical site infection, ileus and length of hospital stay were the evaluated outcome parameters. Combined overall effect sizes were calculated using fixed effects or random effects models. RESULTS We identified 4 studies reporting a total of 436 patients comparing outcomes of temporary loop ileostomy closure during (n = 185) or after (n = 251) adjuvant chemotherapy following colorectal cancer resection. There was no significant difference in overall perioperative complications (OR 1.39; 95% CI 0.82-2.36, p = 0.22), anastomotic leak (OR 2.80; 95% CI 0.47-16.56, p = 0.26), surgical site infection (OR 1.97; 95% CI 0.80-4.90, p = 0.14), ileus (OR 1.22; 95% CI 0.50-2.96, p = 0.66) or length of hospital stay (MD 0.02; 95% CI - 0.85-0.89, p = 0.97) between two groups. Between-study heterogeneity was low in all analyses. CONCLUSIONS The meta-analysis of the best, albeit limited, available evidence suggests that temporary loop ileostomy closure during adjuvant chemotherapy following rectal cancer resection may be associated with comparable outcomes to the closure of ileostomy after adjuvant chemotherapy. We encourage future research to concentrate on the completeness of chemotherapy and quality of life which can determine the appropriateness of either approach.
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Affiliation(s)
- Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Shahab Hajibandeh
- Department of General Surgery, The Pennine Acute Hospitals NHS Trust, North Manchester General Hospital, Manchester, UK
| | - Diwakar Ryali Sarma
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Jamie East
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Rajnish Mankotia
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Andrew W Torrance
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Rajeev Peravali
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Sandra-Petrescu F, Herrle F, Burkholder I, Kienle P, Hofheinz RD. Influence of complete administration of adjuvant chemotherapy cycles on overall and disease-free survival in locally advanced rectal cancer: post hoc analysis of a randomized, multicenter, non-inferiority, phase 3 trial. BMC Cancer 2018; 18:369. [PMID: 29614991 PMCID: PMC5883296 DOI: 10.1186/s12885-018-4309-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 03/26/2018] [Indexed: 01/29/2023] Open
Abstract
Background A randomized trial demonstrated that capecitabine is at least as effective as fluorouracil in the adjuvant treatment of patients with locally advanced rectal cancer. However, not all patients receive all planned cycles of chemotherapy. Therefore it is of interest how complete or partial administration of chemotherapy influences oncological outcome. Methods A post hoc analysis of a trial with 401 randomized patients, nine being excluded because of missing data, was performed. 392 patients (197 - capecitabine, 195 - fluorouracil) could be analyzed regarding the number of administered adjuvant chemotherapy cycles. In the subgroup of 361 patients with an overall survival of at least six months, five-year overall and disease-free survival were analyzed in respect to completion (complete vs. incomplete) of chemotherapy cycles. Survival rates and curves were calculated and compared using the log-rank test. The effect of completion of chemotherapy was adjusted for relevant confounding factors. Results Two hundred fifty-one (64.0%) of analyzed patients received all postoperative scheduled cycles. Five-year overall survival was significantly better in these patients compared to the incomplete group (76.0 vs. 60.6%, p < 0.0001). Of 361 patients with an overall survival of at least six months, 251(69.5%) patients received all cycles. Five-year overall survival was also significantly better than in the incomplete group (76.0 vs. 66.4%, p = 0.0073). Five-year disease free survival was numerically better (64.9 vs. 58.7%, p = 0.0646; HR [not all cycles vs. all cycles] = 1.42 95% CI: [0.98, 2.07]). Cox regression models show a non-significant better OS (p = 0.061) and DFS (p = 0.083), if chemotherapy cycles were administered completely. Conclusion Complete administration of chemotherapy cycles was associated with improved five-year overall and disease-free survival in patients with locally advanced rectal cancer. Electronic supplementary material The online version of this article (10.1186/s12885-018-4309-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Flavius Sandra-Petrescu
- Surgical Department, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Florian Herrle
- Surgical Department, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Iris Burkholder
- Department of Nursing and Health, University of Applied Sciences of the Saarland, Goebenstr. 40, D-66117, Saarbruecken, Germany
| | - Peter Kienle
- Surgical Department, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ralf-Dieter Hofheinz
- Day Treatment Center (TTZ), Interdisciplinary Tumor Center Mannheim (ITM) & III Medical Clinic, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Li W, Ozuner G. Does the timing of loop ileostomy closure affect outcome: A case-matched study. Int J Surg 2017; 43:52-55. [DOI: 10.1016/j.ijsu.2017.05.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 04/18/2017] [Accepted: 05/15/2017] [Indexed: 11/17/2022]
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Risk Factors Associated With Nonclosure of Defunctioning Stomas After Sphincter-Preserving Low Anterior Resection of Rectal Cancer: A Meta-Analysis. Dis Colon Rectum 2017; 60:544-554. [PMID: 28383455 DOI: 10.1097/dcr.0000000000000819] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Some patients receiving defunctioning stomas will never undergo stoma reversal, but it is difficult to preoperatively predict which patients will be affected. OBJECTIVE The aim of this meta-analysis was to identify the risk factors associated with nonclosure of temporary stomas after sphincter-preserving low anterior resection for rectal cancer. DATA SOURCES We performed a comprehensive search of the PubMed, Embase, and Cochrane Central Library databases for all of the studies analyzing risk factors for nonclosure of defunctioning stomas. STUDY SELECTION We only included articles published in English in this meta-analysis. The inclusion criteria were as follows: 1) original article with extractable data, 2) studies including only defunctioning stomas created after low anterior resection for rectal cancer, 3) studies with nonclosure rather than delayed closure as the main end point, and 4) studies analyzing risk factors for nonclosure. INTERVENTION Defunctioning stomas were created after low anterior resection for rectal cancer. MAIN OUTCOME MEASURES Stoma nonclosure was the only end point, and it included nonclosure and permanent stoma creation after primary stoma closure. The Newcastle-Ottawa Scale was used to assess methodologic quality of the studies, and risk ratios and 95% CIs were used to assess risk factors. RESULTS Ten studies with 8568 patients were included. The nonclosure rate was 19% (95% CI, 13%-24%; p < 0.001; I= 96.2%). Three demographic factors were significantly associated with nonclosure: older age (risk ratio= 1.50 (95% CI, 1.12-2.02); p = 0.007; I= 39.3%), ASA score >2 (risk ratio = 1.66 (95% CI, 1.51-1.83); p < 0.001; I= 0%), and comorbidities (risk ratio = 1.58 (95% CI, 1.29-1.95); p < 0.001; I= 52.6%). Surgical complications (risk ratio = 1.89 (95% CI, 1.48-2.41); p < 0.001; I= 29.7%), postoperative anastomotic leakage (risk ratio = 3.39 (95% CI, 2.41-4.75); p < 0.001; I= 53.0%), stage IV tumor (risk ratio = 2.96 (95% CI, 1.73-5.09); p < 0.001; I= 88.1%), and local recurrence (risk ratio = 2.84 (95% CI, 2.11-3.83); p < 0.001; I= 6.8%) were strong clinical risk factors for nonclosure. Open surgery (risk ratio = 1.47 (95% CI, 1.01-2.15); p = 0.044; I= 63.6%) showed a borderline significant association with nonclosure. LIMITATIONS Data on some risk factors could not be pooled because of the low number of studies. There was conspicuous heterogeneity between the included studies, so the pooled data were not absolutely free of exaggeration or influence. CONCLUSIONS Older age, ASA score >2, comorbidities, open surgery, surgical complications, anastomotic leakage, stage IV tumor, and local recurrence are risk factors for nonclosure of defunctioning stomas after low anterior resection in patients with rectal cancer, whereas tumor height, radiotherapy, and chemotherapy are not. Patients with these risk factors should be informed preoperatively of the possibility of nonreversal, and joint decision-making is preferred.
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Hughes DL, Cornish J, Morris C. Functional outcome following rectal surgery-predisposing factors for low anterior resection syndrome. Int J Colorectal Dis 2017; 32:691-697. [PMID: 28130593 DOI: 10.1007/s00384-017-2765-0] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Developments in surgical techniques and neoadjuvant treatment have enabled an increasing proportion of patients with rectal cancer to undergo sphincter-sparing resections. The avoidance of a permanent stoma can come at the cost of poor bowel function which can significantly impact patients' quality of life. The objective of this study was to identify the incidence and risk factors for the development of bowel dysfunction following rectal cancer surgery. METHODS Patients undergoing anterior resection for rectal cancer between January 2009 and January 2015 were identified from a rectal cancer database at a single centre. All patients who had bowel continuity restored and underwent curative resection were sent a validated low anterior resection syndrome (LARS) questionnaire. Pre-, inter- and postoperative factors were compared between patients with major LARS and those with minor or no LARS using conditional logistic regression. RESULTS There was an 80% response rate (n = 68). Thirty-eight patients (56%) had major LARS symptoms. Neoadjuvant radiotherapy, predominantly long-course chemoradiotherapy (LCCRT), was an independent risk factor for development of major LARS symptoms, while restoration of bowel continuity within 6 months was protective. CONCLUSIONS The use of neoadjuvant radiotherapy (LCCRT) and timing of stoma reversal are risk factors for the development of severe bowel dysfunction. The potential for long-term poor functional results after LCCRT should be discussed with patients and form a part of the decision-making in individual treatment plans. The timing of the ileostomy closure, where safe and feasible, should be performed within 6 months to improve outcome.
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Affiliation(s)
- Daniel Ll Hughes
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Julie Cornish
- Department of Colorectal Surgery, Royal Glamorgan Hospital, Llantrisant, CF72 8XR, UK.
| | - Chris Morris
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
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