Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study

Abstract

Background: Data on stoma reversal following restorative rectal resection (RRR) with a diverting stoma are conflicting. This study investigated a Danish population-based cohort of patients undergoing RRR to evaluate factors predictive of stoma reversal during 3 years of follow-up. Methods: Patients from national registries with rectal cancer undergoing RRR or Hartmann's procedure with curative intent between May 2001 and April 2012 were included. Patients with a diverting stoma were followed from the time of primary rectal cancer resection to date of stoma reversal, death, emigration, or end of 3-year follow-up. The cumulative incidence proportion (CIP) of stoma reversal at 1 and 3 years was calculated, treating death as a competing risk. Factors predictive of stoma reversal were explored using Cox regression analysis. Results: Of 6859 patients included, 35⋅7, 41⋅9 and 22⋅4 per cent respectively had a RRR with a diverting stoma, RRR without a stoma, and Hartmann's procedure with an end-colostomy. In patients with a diverting stoma, the CIP of stoma reversal was 70⋅3 (95 per cent c.i. 68⋅4 to 72⋅1) per cent after 1 year, and 74⋅3 (72⋅5 to 76⋅0) per cent after 3 years. Neoadjuvant treatment (hazard ratio (HR) 0⋅75, 95 per cent c.i. 0⋅66 to 0⋅85), blood loss greater than 300 ml (HR 0⋅86, 0⋅76 to 0⋅97), anastomotic leak (HR 0⋅41, 0⋅33 to 0⋅50), T3 category (HR 0⋅63, 0⋅47 to 0⋅83), T4 category (HR 0⋅62, 0⋅42 to 0⋅90) and UICC stage IV (HR 0⋅57, 0⋅41 to 0⋅80) were possible predictors of delayed stoma reversal. Conclusion: In one-quarter of the patients the diverting stoma had not been reversed 3 years after the intended RRR procedure.

Permanent stoma after sphincter preservation for rectal cancer. A situation that occurs more often than you might think

“…The prevalence of PS (16.7%) reported in the present study is in line with the 3-24% prevalence described in the literature ( 8 – 21 , 26 – 31 ). Unlike most published series, this present study included both primary and secondary PS because their natural histories and risk factors were not the same.…”

“…Consequently, a defunctioning stoma is usually created temporarily in both low colorectal (<6cm from the anal margin) and colo-anal anastomosis in order to decrease both morbidity and mortality from anastomotic failure at the time of surgery ( 6 , 7 ). Despite the intention of SPS, a significant percentage of patients (up to 25%) will live with a permanent stoma (PS) over the long term ( 8 – 13 ). A stoma is commonly considered to be permanent if: (i) it was not closed when it was intended to be temporarily (primary PS); (ii) it was created in a second procedure after the index surgery for any reason, even after the closure of the defunctioning stoma (secondary PS).…”

Permanent stoma rates after anterior resection for rectal cancer: risk prediction scoring using preoperative variables

“…However, the inclusion of patients who underwent abdominoperineal excision makes comparisons difficult. Most research highlights the importance of age 5 , co-morbidity 27 , and advanced tumour stage 2 as risk factors known before operation, which is in line with the present findings. Prediction models for the risk of permanent stoma, irrespective of faecal diversion, are lacking.…”

The surgical treatment of rectal cancer in Poland. The findings of a multi-center observational study by the Polish Society of Surgical Oncology (PSSO-01)

“…More than half of the patients (53%; [95% confidence interval (CI): 49-57]) had concomitant diseases, the most common of which was hypertension 45% (95% CI: 43-47). Diabetes occurred in 15% (95% CI: 13-17) and ischemic heart disease in 14% (95% CI: [12][13][14][15][16]). The rate of patients with cancer spread (distant metastases) at the time of the rectal cancer diagnosis was 13% [95% CI : 8-18].…”

“…It is higher than in our study (43%). European multi-center studies present data that most diverting stoma is reversed within 12 months, but that one in four defunctioning stomas is not reversed 3 years after surgery [11][12][13]. Anastomotic leakage is one of the most important risk factors for not reversing stomas.…”