Robotic low anterior resection with complete splenic flexure mobilization and defunctioning left-sided loop colostomy: a case series

A defunctioning stoma is used to alleviate the consequences of anastomotic leakage after low anterior resection for rectal cancer. A loop ileostomy is often preferred but may lead to dehydration and kidney injury. Here, we present a case series for an alternative: the left-sided loop colostomy. A convenience sample of four patients underwent robotic low anterior resection for rectal cancer. A complete splenic flexure mobilization and a total mesorectal excision were performed. To defunction the anastomosis, the redundant left colon was brought up to a stoma site in the left iliac fossa and matured as a loop colostomy. Two patients experienced minor stoma leaks and one also had a small prolapse, while all patients had their colostomies reversed on average 7 months after surgery without complications. There were no dehydration episodes and creatinine levels remained within baseline levels at end of follow-up (on average 18 months).

Clinical analysis of anastomotic fistula after anal preservation in 358 cases of rectal cancer and construction of risk prediction model: a single-center retrospective study

OBJECTIVE

To develop and validate a simple prediction model for postoperative anastomotic leakage (AL) in patients with rectal cancer who underwent Dixon surgery by combining preoperative and intraoperative risk factors.

METHODS

We conducted a retrospective study on 358 patients who underwent Dixon surgery for rectal cancer in the Affiliated Hospital of Youjiang Medical University for Nationalities (Guangxi Zhuang Autonomous Region, China). Based on logistic regression, the prediction model of AL after Dixon surgery was established and verified.

RESULTS

The incidence of postoperative AL in these patients was 9.2% (33/358). The results of logistic regression analysis showed that age ≥60 years, male, Tumor-Node-Metastasis (TNM) stage ≥IIIa, preoperative obstruction, and the distance from the tumor to the anus ≤7 cm were the risk factors for AL after Dixon surgery, and intraoperative defunctioning stoma was the protective factor for AL after rectal Dixon surgery (all P<0.05). The prediction model construction: Risk score =-4.275 + 0.851 × age + 1.047 × sex + 0.851 × distance + 0.934 × stage + 0.983 × obstruction. The area under receiver operating characteristic curve (ROC-AUC) was 0.762 (95% CI: 0.667-0.856). The best cutoff, sensitivity and specificity were 0.14, 79.60%, and 83.10%, respectively. Hosmer-Lemeshow: X²=6.876, P=0.550. Clinical validation results: the sensitivity, specificity, and accuracy of the model were 82.05%, 80.06%, and 80.25%, respectively.

CONCLUSIONS

Both preoperative and intraoperative risk factors were used in the prognostic model. The prediction model established on this basis was well differentiated and highly calibrated, providing a good reference for the clinical prediction model of postoperative AL in rectal cancer patients undergoing Dixon surgery.

Costs Related to Diverting Ileostomy After Rectal Cancer Surgery: A Population-Based Healthcare Cost Analysis Based on Nationwide Registers

Low anterior resection for rectal cancer often includes a diverting loop-ileostomy to avoid the severe consequences of anastomotic leakage. Reversal of the stoma is often delayed, which can incur health-care costs on different levels. The aim is to, on population basis, determine stoma-related costs, and to investigate habitual and socioeconomic factors associated to the level of cost. Multi-register design with data from the Swedish Rectal Cancer Registry, the National Prescribed Drug Register, Statistics Sweden and cost-administrative data from the National Board of Health and Welfare. Data was gathered for 3564 patients with rectal cancer surgery 2007 to 2013, for 3 years following the surgery. Factors influencing the cost of inpatient care and stoma-related consumables were assessed with linear regression analyses. All monthly costs were higher for females (consumables P < .001 and in-patient care P = .031). Post-secondary education (P = .003) and younger age (P = .020) was associated with a higher cost for consumables while suffering a surgical complication was associated with increased cost for inpatient care (P < .001). Patients who had their stoma longer had lower monthly costs (consumables P < .001 and in-patient care P < .001). Female gender, longer duration of stoma, young age, and higher education are associated with higher costs for the care of a diverting stoma after rectal cancer surgery. This study does not allow for analyses of causality but the results together with deepened analyses of underlying reasons form a proper basis for decisions in health care planning and allocation of resources. These findings may have implications on the debate of equal care for all.

Risk Factors of Anastomotic Leakage After Anterior Resection for Rectal Cancer Patients

OBJECTIVE

Anastomotic leakage (AL) is one of the serious complications after anterior resection for rectal cancer. Defunctioning stoma (DS) is one of the most widely used approaches to prevent it; however, the effect of DS on the occurrence of AL remains controversial. This study aimed to investigate risk factors of AL and assess the effect of DS after anterior resection for rectal cancer patients.

METHODS

A retrospective analysis was conducted for the data of 1840 patients who underwent anterior resection for rectal cancer from January 2014 to December 2019.

RESULTS

The results showed the overall AL incidence was 7.5%. Multivariate analyses revealed that males [odds ratio (OR) 1.562] and T3-T4 stage (OR 1.729) were independent risk factors for all patients. After propensity score matching analysis, the AL incidence was 14.1% in the group with no DS and 6.4% in the DS group (P<0.001). The clinical AL (grade B + grade C) incidence was 12.4% in no DS group and 4.6% in the DS group (P<0.001).

CONCLUSION

The study suggested that males and T3-T4 stage were independent risk factors of AL. In addition, DS could reduce the rate of symptomatic AL.

Defunctioning stomas may reduce chances of a stoma-free outcome after anterior resection for rectal cancer

AIM

To investigate the conflicting consequences of faecal diversion on stoma outcomes and anastomotic leakage in anterior resection for rectal cancer, including interaction effects determined by the extent of mesorectal excision.

METHOD

Anterior resections between 2007 and 2016 were identified using the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine stoma outcome 2 years after surgery. Tumour distance from the anal verge constituted a proxy for extent of mesorectal excision [total mesorectal excision (TME): ≤10 cm; partial mesorectal excision (PME): 13-15 cm]. With confounder-adjusted probit regression, the total effect of defunctioning stoma on permanent stoma, and the interaction effect of extent of mesorectal excision, were estimated together with the indirect effect through anastomotic leakage. Baseline risks, risk differences (RDs) and relative risks (RRs) were reported.

RESULTS

The main study cohort included 4529 patients. Defunctioning stomas influenced the absolute permanent stoma risk (TME: RD 0.11 [95% CI 0.09-0.13]; PME: RD 0.15 [95% CI 0.13-0.16]). The baseline risk was higher in TME, with a resulting greater RR in PME (2.23 [95% CI 1.43-3.02] vs 4.36 [95% CI 3.05-5.68]). The indirect reduction in permanent stoma rates, due to the alleviating effect of faecal diversion on anastomotic leakage, was small (TME: 0.89 [95% CI 0.81-0.96]; PME: 0.96 [95% CI 0.91-1.00]).

CONCLUSION

In anterior resection for rectal cancer, defunctioning stomas may reduce chances of a stoma-free outcome. Considering leakage reduction benefits, consequences of routine diversion in TME might be fairly balanced, while this seems questionable in PME.

Current practice in Australia and New Zealand for defunctioning ileostomy after rectal cancer surgery with anastomosis: Analysis of the Binational Colorectal Cancer Audit

AIM

This study aimed to investigate the use of defunctioning stomas after rectal cancer surgery in Australia and New Zealand, as current practice is unknown.

METHODS

From the Binational Colorectal Cancer Audit database, data on rectal cancer patients who underwent a resection between 2007 and 2019 with the formation of an anastomosis were extracted and analysed. The primary outcome was the rate of defunctioning stoma formation. Secondary outcomes were anastomotic leakage (AL) rates and other postoperative complications, length of hospital stay (LOS), readmissions and 30-day mortality rates between stoma and no-stoma groups. Propensity score matching was performed to correct for differences in baseline characteristics between stoma and no-stoma groups.

RESULTS

In total, 2581 (89%) received a defunctioning stoma and 319 (11%) did not. There were more male patients in the stoma group (65.5% vs. 57.7% for the no-stoma group; P = 0.006). The median age was 64 years in both groups. The stoma group underwent more ultra-low anterior resections (79.9% vs. 30.1%; P < 0.0001), included more American Joint Committee on Cancer Stage III patients (53.7% vs. 29.2%; P < 0.0001) and received more neoadjuvant therapy (66.9% vs. 16.3%; P < 0.0001). The AL rate was similar in both groups (5.1% vs. 6.0%; P = 0.52). LOS was longer in the stoma group (8 vs. 6 days; P < 0.0001) with higher 30-day readmission rates (14.9% vs. 8.3%; P = 0.003). After propensity score matching (n = 208 in both groups), AL rates remained similar (2.9% for stoma vs. 5.8% for no-stoma group; P = 0.15), but stoma patients required less reoperations (0% vs. 8%; P = 0.016). The stoma group had higher postoperative ileus rates and an increased LOS.

CONCLUSION

In Australia and New Zealand, most patients who underwent rectal cancer resections with the formation of an anastomosis received a defunctioning stoma. A defunctioning stoma does not prevent AL from occurring but is mostly associated with a lower reoperation rate. Patients with a defunctioning stoma experienced a higher postoperative ileus rate and had an increased LOS.

Rectal cancer patients from rural areas in northern Sweden report more pain and problems with stoma care than those from urban areas

INTRODUCTION

Having a stoma after bowel surgery is associated with inferior quality of life (QoL). The county of V&auml;sterbotten in Sweden is a large and sparsely populated area. Competence regarding stoma-related problems is restricted to hospital-based stoma nurses and surgeons. Patients living in rural areas instead largely rely on their general practitioner. The purpose of the study was to investigate the impact of distance to nearest hospital on the QoL of rectal cancer patients who receive a stoma at index surgery.

METHODS

A cross-sectional study performed in V&auml;sterbotten county, Sweden. Validated questionnaires assessing QoL (EORTC QLQ C-30 and CR-29) were sent to all rectal cancer patients diagnosed in 2007-2014 who received a stoma at index surgery. Socioeconomic variables were retrieved from Statistics Sweden. Distance from home to the nearest hospital was determined using Google Maps&trade;. The effect of distance was assessed using two separate models, the first based on distance to the nearest hospital and the second based on access to a stoma care nurse. Within the first model all patients living in rural areas constituted the study group while all patients living in non-rural areas constituted the control group. Within the second model all patients with no access to stoma care nurse constituted the study group while those with such access constituted the control group.

RESULTS

The response rate was 69%. In the first model the rectal cancer patients living further away from the nearest hospital reported significantly more pain and sore skin (p=0.032 and p=0.003, respectively). When considering patients who still had a stoma, those living further away also reported more stoma care problems (p=0.004) and a poorer global QoL (p=0.038). In the second model, access or not to a stoma care nurse had no impact on stoma care problems or QoL.

CONCLUSION

Rectal cancer patients receiving a stoma at index surgery and who came from rural areas reported more pain than those living closer to the nearest hospital. The group of rural patients who still had a stoma also reported more stoma care problems and a poorer quality of life. To help these patients, general practitioners are encouraged to arrange an extra follow-up visit focusing on the individual patient&acute;s problems.

[Risk factors associated with non-closure of defunctioning stoma in patients with rectal cancer: univariate and multivariate analysis]

OBJECTIVE

To identify the risk factors associated with non-closure of defunctioning stoma in patients with rectal cancer.

MATERIAL AND METHODS

A retrospective analysis included patients who underwent surgical treatment at the Ryzhikh National Medical Research Centre of Coloproctology for the period from March 2017 to August 2019. Inclusion criterion was anterior or low anterior resection followed by anastomosis and preventive stoma. Univariate and multivariate analysis enrolled 28 factors for identifying the risk factors of non-closure of defunctioning stoma.

RESULTS

There were 246 patients with rectal cancer. Intraoperative fluorescence angiography was applied in 145 cases to assess blood supply within the anastomosis and reduce the risk of anastomotic leakage. According to multivariate analysis, only two factors had significant influence on non-closure of preventive stoma - any grade of anastomotic leakage (OR 6.5; 95% CI 2.2-18.8, p=0.001) and rectal cancer stage IV (OR 7.2; 95% CI 1.9-27.6, p=0.004).

CONCLUSION

According to our data, permanent stoma is observed in 15% of patients.

Reversal of defunctioning stoma following rectal cancer surgery: are we getting better? A population-based single centre experience

BACKGROUND

The aim was to assess factors influencing the timing of defunctioning stoma (DS) reversal following low anterior resection of rectum for cancer (LAR).

METHODS

All patients operated with LAR and a primary DS during a 9-year period were included. Reversal later than 120 days after LAR was considered as delayed. A DS not reversed within 2 years was considered as permanent.

RESULTS

In the present study, median age at LAR was 67 years, 45% were females, median body mass index was 25, 87% had American Society of Anesthesiologists class I or II, 64% had pre-operative radiotherapy, and 3% had cancer stage IV. A total of 79% (92/116) underwent stoma reversal, whereof 25% (23/92) were reversed within 120 days. The most common health-related reasons for delayed stoma reversal were adjuvant chemotherapy in 38%, symptomatic anastomotic leakage in 16% and other post-operative adverse events in 13%. In 35% delayed stoma reversal was because of low priority within the healthcare system. A total of 18% (20/110) never had their DS reversed (n = 11) or had their DS converted to a permanent end colostomy (n = 9). Major risk factors for permanent stoma were stage IV cancer in 55%, and symptomatic anastomotic leakage in 30%.

CONCLUSION

One fourth of the patients had their defunctioning stoma reversed within 120 days. The most common identifiable medical reasons for delayed stoma reversal were adjuvant chemotherapy and symptomatic anastomotic leakage, while in one out of three patients it was because of low priority by the healthcare provider.

Defunctioning loop ileostomy with restorative proctocolectomy for rectal cancer: Friend or foe?

OBJECTIVES

Temporary ileostomy is used to decrease morbidity from anastomotic leakages (ALs). However, ileostomies are associated with complications (i.e., stoma-related complications; SRCs), ileus due to stenosis, dehydration, and the need for a second operation. Here we retrospectively evaluated the impact of SRCs on the treatment of rectal cancer.

METHODS

We identified 180 consecutive patients who underwent curative resection for rectal cancer at Juntendo University Hospital between January 2006 and December 2014. We divided the patients into groups with and without defunctioning stoma (DS), and we compared the patient age and gender, tumor location, approach (laparotomy/laparoscopy), surgical procedure, distance of the tumor from the margin of the anus, T factor, stage, duration of postoperative hospital stay, and postoperative complications between these groups. Univariate and multivariate analyses were performed to determine the risk factors for postoperative hospital stay.

RESULTS

The symptomatic leakage rate in the DS group (n = 92) was not significantly different from that of the non-DS group (n = 88; p = 0.29). However, Grade ≥ 4 AL occurred significantly less frequently in the DS group (0%) than in the non-DS group (5.7%; p = 0.02). SRCs occurred in 14 DS-group patients (15.2%). The multivariate analysis demonstrated that both AL (odds ratio [OR] 9.24; confidence interval [CI] 4.91-19.4) and SRC (OR 1.84; CI 1.03-3.54) were independently predictive of short-term outcomes.

CONCLUSIONS

The benefit of a DS is balanced against the risk of leakage and SRCs at rectal resection. Surgeons should focus on not only the consequences of AL, but also SRC risk.

Late leakage after anterior resection: a defunctioning stoma alters the clinical course of anastomotic leakage

AIM

Anastomotic leakage (AL) is common after anterior resection (AR). Long term clinical outcomes of AL including late presenting leakage (LL) are not well studied. This study was undertaken to assess clinical features of LL with respect to incidence, association with predisposing factors and need for re-intervention.

METHODS

The Swedish Colorectal Cancer Registry (SCRCR) was explored for AL cases after AR for rectal cancer in patients operated in the south of Sweden from 1 January 2001 to 31 December 2011. Demographic data, surgical technical details, number of postoperative days (POD) until diagnosis of AL, presenting symptoms, methods of diagnosis and treatment were retrieved from medical records. LL was defined according to different cut-offs as leakages occurring after hospital discharge (LLAHD), after 30 POD (LL ≥ POD 30) and after 90 POD (LL ≥ POD 90).

RESULTS

In total, 1442 patients were operated on with AR of whom 144 cases of AL (10%) were identified. Median time from operation to follow-up was 87 months (range 21-162). LLAHD, LL ≥ POD 30 and LL ≥ POD 90 were present in 51%, 24% and 9% respectively. All categories of LL were associated with a defunctioning stoma. Relaparotomy was significantly less often employed in LLAHD, but not in other categories of LL.

CONCLUSION

LL constitutes a substantial portion of all AL after AR for rectal cancer. The large proportion of LLAHD calls for awareness in the outpatient setting.

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.

Factors affecting timing of closure and non-reversal of temporary ileostomies

BACKGROUND

Although stoma closure is considered a simple surgical intervention, the interval between construction and reversal is often prolonged, and some ileostomies may never be reversed. We evaluated possible predictors for non-reversal and prolonged interval between construction and reversal.

MATERIAL AND METHODS

In a cohort study of ileostomy patients treated in a large teaching hospital, we collected data from the surgical complication and enterostomal therapists' registries between January 2001 and December 2011. Parameters responsible for morbidity, mortality, length of stay and time interval between construction and reversal were analysed.

RESULTS

Of 485 intentionally temporary ileostomies, 359 were reversed after a median of 5.6 months (IQR 3.8-8.9 months), while 126 (26%) remained permanent. End ileostomy and intra-abdominal abscess independently delayed reversal. Age, end ileostomy, higher body mass index and preoperative radiotherapy were independent factors for non-reversal. Median duration of hospitalisation for reversal was 7.0 days (5-13 days). Morbidity and mortality were 31 and 0.9%, respectively. In 20 patients (5.5%), re-ileostomy was necessary.

CONCLUSIONS

A substantial number of ileostomies that are intended to be temporary will never be reversed. If reversed, the interval between construction and reversal is longer than anticipated, while morbidity after reversal and duration of hospitalisation are considerable. Besides a temporary ileostomy, there are two other options: no diversion or a permanent colostomy. Shared decision-making is to be preferred in these situations.

Standardized technique for single port laparoscopic ileostomy and colostomy

AIM

Single site laparoscopic techniques and technology exploit maximum usefulness from confined incisions. The formation of an ileostomy or colostomy seems very applicable for this modality as the stoma occupies the solitary incision obviating any additional wounds.

METHOD

Here we detail the principles of our approach to defunctioning loop stoma formation using single port laparoscopic access in a stepwise and standardized fashion along with the salient specifics of five illustrative patients. No specialized instrumentation is required and the single access platform is established table-side using the 'glove port' technique.

RESULTS

The approach has the intra-operative advantage of excellent visualization of the correct intestinal segment for exteriorization along with direct visual control of its extraction to avoid twisting. Postoperatively, abdominal wall trauma has been minimal allowing convalescence and stoma care education with only one parietal incision.

CONCLUSION

Single incision stoma siting proves a ready, robust and reliable technique for diversion ileostomy and colostomy with a minimum of operative trauma for the patient.

When are defunctioning stomas in rectal cancer surgery really reversed? Results from a population-based single center experience

BACKGROUND AND AIMS

This study assessed the timing of reversal of defunctioning stoma following low anterior resection of the rectum for cancer and risk factors for a defunctioning stoma becoming permanent in patients who were not reversed.

MATERIAL AND METHODS

Patients who underwent low anterior resection with defunctioning stoma during a 12-year period were assessed with regard to timing of stoma reversal. Delayed reversal was defined as >4 months after low anterior resection. Patients with a defunctioning stoma that was never reversed were assessed regarding risk factors for permanent stoma.

RESULTS

A total of 134 patients were analyzed. Of 106 stoma reversals, 19% were reversed within 4 months of low anterior resection, while 81% were reversed later than 4 months. In 58% of these patients, the delay was to due to low medical priority given to this procedure. The other main reasons for delayed stoma reversal were nonsurgical complications (20%), symptomatic anastomotic leakage following low anterior resection (12%), and postoperative adjuvant chemotherapy (10%). Of all patients, 21% (28/134) ended up with a permanent stoma. Risk factors for a defunctioning stoma becoming permanent were stage IV cancer (P < 0.001) and symptomatic anastomotic leakage following low anterior resection (P < 0.001).

CONCLUSION

Four in five patients experienced a delayed stoma reversal, in a majority because of the low priority given to this surgical procedure.

Surgical management of rectovaginal fistula in a tertiary referral centre: many techniques are needed

AIM

Surgery is the mainstay of treatment for rectovaginal fistula (RVF). Published success rates vary with initial success being around 50% rising to 80% with repeated surgery. Fistulae in Crohn's disease are more likely to recur.

METHOD

A retrospective study was performed of RVF repair carried out between 2003 and 2008 in a tertiary referral centre. Patients undergoing surgery for an RVF under the senior author during the study period were identified and their clinical notes were reviewed.

RESULTS

Thirty-five patients underwent 50 operations. The median age was 42 years and 83% were tertiary referrals. Two patients were lost to follow-up. Healing occurred in 19 (58%) of 33 patients after a mean of 1.4 operations. The median time to success was 11 (2.5-48) months. The 'curative' group had an overall success of 73% (19 of 26). Seventy-five per cent of non-inflammatory bowel disease patients and 67% of those with Crohn's disease had successful treatment of the RVF. Twenty-four of 35 patients (67%) underwent creation of a stoma. Sixteen of 24 (67%) were deemed fit for restoration of continuity. No demographic or disease related factors were found to influence healing.

CONCLUSION

Cure of RVF can be achieved by a range of surgical approaches including abdominal and anal. A variety of different anal techniques are necessary, depending on the integrity of the anal sphincter and the presence or absence of perineal descent/internal intussusception.