Protective Diversion Stoma in Low Anterior Resection for Rectal Cancer: A Meta-Analysis of Randomized Controlled Trials

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Abstract

Background: With the establishment of the oncological safety and due to the potential of low anterior resection (LAR) with sphincter salvage in improving the quality of life of patients with low and mid rectal cancers, it has become a popular treatment modality. A potential complication of the procedure is anastomotic dehiscence which results in a significant increase in postoperative morbidity and mortality. Methods: A literature search for randomized controlled trials (RCTs) that compared the role of protective diversion stoma with no stoma in LAR of the rectum was performed in PubMed. The effect size for dichotomous and continuous data was displayed as relative risk (RR) and weighted mean difference (WMD), respectively, with their corresponding 95% confidence intervals. A fixed effect or random effects model was used to pool the data according to the result of a statistical heterogeneity test. Results: Five RCTs were identified and included in the analysis. These yielded 390 patients who had undergone a protective diversion ileostomy at the time of the surgery (LAR) and 378 who had not, resulting in a total of 768 patients, all of whom were included in the meta-analysis. The fashioning of an ileostomy significantly decreased the anastomotic leak (AL) rates (RR 0.33, 95% CI 0.21–0.51, p < 0.000) and the reoperation rates (RR 0.26, 95% CI 0.15–0.45, p < 0.000). Conclusion: This meta-analysis found that a protective diversion ileostomy in LAR for rectal cancer decreases the AL rates by one third and the reoperation rates by one fourth. Thus, we conclude that fashioning such a stoma is beneficial.

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Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer.

Nuh N. Rahbari, Jürgen Weitz, Werner Hohenberger … (2010)

Anastomotic leakage represents a major complication after anterior resection of the rectum. The incidence of anastomotic leakage varies considerably among clinical studies in part owing to the lack of a standardized definition of this complication. The aim of the present article was to propose a definition and severity grading of anastomotic leakage after anterior rectal resection. After a literature review a consensus definition and severity grading of anastomotic leakage was developed within the International Study Group of Rectal Cancer. Anastomotic leakage should be defined as a defect of the intestinal wall at the anastomotic site (including suture and staple lines of neorectal reservoirs) leading to a communication between the intra- and extraluminal compartments. Severity of anastomotic leakage should be graded according to the impact on clinical management. Grade A anastomotic leakage results in no change in patients' management, whereas grade B leakage requires active therapeutic intervention but is manageable without re-laparotomy. Grade C anastomotic leakage requires re-laparotomy. The proposed definition and clinical grading is applicable easily in the setting of clinical studies. It should be applied in future reports to facilitate valid comparison of the results of different studies. Copyright 2010 Mosby, Inc. All rights reserved.

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Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial.

Peter Matthiessen, Olof Hallböök, Jörgen Rutegård … (2007)

The aim of this randomized multicenter trial was to assess the rate of symptomatic anastomotic leakage in patients operated on with low anterior resection for rectal cancer and who were intraoperatively randomized to a defunctioning stoma or not. The introduction of total mesorectal excision surgery as the surgical technique of choice for carcinoma in the lower and mid rectum has led to decreased local recurrence and improved oncological results. Despite these advances, perioperative morbidity remains a major issue, and the most feared complication is symptomatic anastomotic leakage. The role of the defunctioning stoma in regard to anastomotic leakage is controversial and has not been assessed in any randomized trial of sufficient size. From December 1999 to June 2005, a total of 234 patients were randomized to a defunctioning loop stoma or no loop stoma. Loop ileostomy or loop transverse colostomy was at the choice of the surgeon. Inclusion criteria for randomization were expected survival >6 months, informed consent, anastomosis < or =7 cm above the anal verge, negative air leakage test, intact anastomotic rings, and absence of major intraoperative adverse events. The overall rate of symptomatic leakage was 19.2% (45 of 234). Patients randomized to a defunctioning stoma (n = 116) had leakage in 10.3% (12 of 116) and those without stoma (n = 118) in 28.0% (33 of 118) (odds ratio = 3.4; 95% confidence interval, 1.6-6.9; P < 0.001). The need for urgent abdominal reoperation was 8.6% (10 of 116) in those randomized to stoma and 25.4% (30 of 118) in those without (P < 0.001). After a follow-up of median 42 months (range, 6-72 months), 13.8% (16 of 116) of the initially defunctioned patients still had a stoma of any kind, compared with 16.9% (20 of 118) those not defunctioned (not significant). The 30-day mortality after anterior resection was 0.4% (1 of 234) and after elective reversal a defunctioning stoma 0.9% (1 of 111). Median age was 68 years (range, 32-86 years), 45.3% (106 of 234) were females, 79.1% (185 of 234) had preoperative radiotherapy, the level of anastomosis was median 5 cm, and intraoperative blood loss 550 mL, without differences between the groups. Defunctioning loop stoma decreased the rate of symptomatic anastomotic leakage and is therefore recommended in low anterior resection for rectal cancer.

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Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Antonio Sciuto, Giovanni Merola, Giovanni D De Palma … (2018)

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

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Journal

Journal ID (publisher-id): VIS

Journal ID (pmc): VIS

Journal ID (doi): 10.1159/issn.2297-4725

Title: Visceral Medicine

Publisher: S. Karger AG

ISBN: 978-3-318-06570-1

ISBN: 978-3-318-06571-8

ISSN (Print): 2297-4725

ISSN (Electronic): 2297-475X

Publication date Subscription-year: 2019

Publication date (Print): June 2019

Publication date (Electronic): 27 March 2019

Volume: 35

Issue: 3

Pages: 156-160

Affiliations

[_a] _aDepartment of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India

[_b] _bDepartment of Surgical Oncology, All India Institute of Medical Sciences, Rishikesh, India

Author notes

*Dr. Pankaj Kumar Garg, Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi 110095 (India), E-Mail dr.pankajgarg@gmail.com

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Pankaj Kumar Garg https://orcid.org/0000-0001-9760-5484

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Publisher ID: 497168 Other ID: Visc Med 2019;35:156-160

DOI: 10.1159/000497168

PMC ID: 6616072

PubMed ID: 31367612

SO-VID: e959dd87-78b9-43f3-8bee-00efb2090974

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Date received : 31 October 2018

Date accepted : 22 January 2019

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Figures: 2, Tables: 1, Pages: 5

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Protective Diversion Stoma in Low Anterior Resection for Rectal Cancer: A Meta-Analysis of Randomized Controlled Trials

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Most cited references 12

Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer.

Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

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