Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for Cancer

Abstract

Objective: 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. Summary Background Data: 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. Methods: 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 Ͼ6 months, informed consent, anastomosis Յ7 cm above the anal verge, negative air leakage test, intact anastomotic rings, and absence of major intraoperative adverse events. Results: The overall rate of symptomatic leakage was 19.2% (45 of 234). Patients randomized to a defunctioning stoma (n ϭ 116) had leakage in 10.3% (12 of 116) and those without stoma (n ϭ 118) in 28.0% (33 of 118) (odds ratio ϭ 3.4; 95% confidence interval, 1.6 -6.9; P Ͻ 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 Ͻ 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. Conclusion: Defunctioning loop stoma decreased the rate of symptomatic anastomotic leakage and is therefore recommended in low anterior resection for rectal cancer.

Risk factors of small bowel obstruction following total proctocolectomy and ileal pouch anal anastomosis with diverting loop‐ileostomy for ulcerative colitis

“…Diverting colostomy or diverting loop‐ileostomy is done after low rectal cancer surgery, one of the representative preventive measures for anastomotic leakage. Whether diverting stomas after resection of rectal cancer reduce the incidence of anastomotic leakage is controversial; however, it is reported that diverting stomas are expected to prevent or reduce the development of clinical symptoms as a result of anastomotic leakage 3, 4, 5. In general, ileostomy is carried out more often than colostomy.…”

Drain vs No Drain After Colorectal Surgery

“…The type of pelvic drains used are indeed heterogeneous among the published literature, including irrigation-suction or suction drain [17], closed-suction drain alone [18][19][20], choice of irrigation-suction, silastic penrose, or Jacksonpratt drain [9], closed-silastic with gravity drainage [2], or not even clearly described [10,14,15]. Moreover, the timing of drain removal after surgery is also variables such as at least 24 h [17], 3 days [20], 5 days at the latest [18], 7 days [2,19], or not clearly documented [9,10,14,15].…”

“…Moreover, the timing of drain removal after surgery is also variables such as at least 24 h [17], 3 days [20], 5 days at the latest [18], 7 days [2,19], or not clearly documented [9,10,14,15]. Anastomotic leak can occur during immediate postoperative period, however a recent review describes that there are two peaks when making the diagnosis of anastomotic leak; when diagnosed clinically, the median postoperative day of 7 days and when diagnosed radiographically the median days of 16 days [21].…”

“…Identified risk factors include male gender [12,13], tumor location and the level of anastomosis [11][12][13]28], steroid use [21], smoking [13,21], intraoperative adverse events [28], the lack of stoma [11,14,15], preoperative chemoradiotherapy or radiotherapy [12,28], severe bleeding [28], higher American Society of Anesthesiologists grade [21,29], and emergency surgery [29].…”

“…This concept has been advocated by subsequently published, large-scale retrospective studies [9,10]. However, introduction of total mesorectal excision (TME) for rectal cancer surgery has prompted further concern with this issue because of the increased incidence of anastomotic leakage with 10 to 20% [11][12][13][14][15]. The Dutch TME trial [15] demonstrated some supportive data of using pelvic drainage in decreasing anastomotic failure rate and the need for surgical re-intervention.…”