When Is a Diverting Stoma Indicated after Low Anterior Resection? A Meta-analysis of Randomized Trials and Meta-Regression of the Risk Factors of Leakage and Complications in Non-Diverted Patients

Emile, Sameh Hany; Khan, Sualeh Muslim; Garoufalia, Zoe; Silva‐Alvarenga, Emanuela; Gefen, Rachel; Horesh, Nir; Freund, Michael R.; Wexner, Steven D.

doi:10.1007/s11605-022-05427-5

Cited by 12 publications

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“…Furthermore, performing LAR entails the construction of a low colorectal or coloanal anastomosis that can be at a high risk of anastomotic leak (AL) 5 . To mitigate against the risks of AL after LAR, a diverting loop ileostomy (DLI) is usually performed; nonetheless, recent literature called for a more selective, tailored use of DLI after LAR instead of doing it routinely in all patients 6,7 …”

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confidence: 99%

“…5 To mitigate against the risks of AL after LAR, a diverting loop ileostomy (DLI) is usually performed; nonetheless, recent literature called for a more selective, tailored use of DLI after LAR instead of doing it routinely in all patients. 6,7 Despite the documented benefits of DLI in reducing the consequences of AL, it may come with its own set of potential complications that include stomal prolapse, retraction, parastomal hernias, dehydration, and skin complications. 8 In addition, the presence of an ileostomy may delay the patient's full recovery of and return to normal daily activities along with a negative impact on quality of life.…”

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confidence: 99%

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Outcomes of Early versus Standard Closure of Diverting Ileostomy after Proctectomy

Emile,

Horesh,

Garoufalia

et al. 2023

Annals of Surgery

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Objective: We aimed to compare outcomes of early and standard closure of diverting loop ileostomy (DLI) after proctectomy and determine risk factors for anastomotic leak (AL) and complications. Summary Background Data: Formation of DLI has been a routine practice after proctectomy to decrease the incidence and potential adverse sequela of AL. Methods: PubMed, Scopus and Web of Science were searched for randomized controlled trials (RCTs) that compared outcomes of early versus standard closure of DLI after proctectomy. Main outcome measures were postoperative complications, AL, ileus, surgical site infection (SSI), reoperation, readmission, and hospital stay following DLI closure. Results: Eleven RCTs (932 patients; 57% male) were included. Early closure group included 474 patients and standard closure 458 patients. Early closure was associated with higher odds of AL (OR: 2.315, P=0.013) and similar odds of complications (OR: 1.103, P=0.667), ileus (OR: 1.307, P=0.438), SSI (OR:1.668, P=0.079), reoperation (OR: 1.896, P=0.062) and readmission (OR: 3.431, P=0.206). Hospital stay was similar (WMD: 1.054, P=0.237). Early closure had higher odds of AL than standard closure when early closure was done ≤2 weeks (OR: 2.12, P=0.047) but not within 3-4 weeks (OR: 2.98, P=0.107). Factors significantly associated with complications after early closure were diabetes mellitus, smoking, and closure of DLI ≤2 weeks whereas factors associated with AL were ≥ASA II classification and diabetes mellitus. Conclusions: Early closure of DLI after proctectomy has a higher risk of AL, particularly within two weeks of DLI formation. On the basis of this study, routine early ileostomy closure cannot be recommended.

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Outcomes of Early versus Standard Closure of Diverting Ileostomy after Proctectomy

Emile,

Horesh,

Garoufalia

et al. 2023

Annals of Surgery

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“…Independent risk factors are identi ed as signi cant for anastomotic leakage and overall AF in previous studies, including males, diabetes, smoking, obesity/BMI, preoperative radiotherapy, emergency surgery, and tumor-related factors such as distal intraperitoneal tumors, combined multiorgan resection, larger tumor size, and advanced tumor stage [14,33]. A meta-analysis of randomized trials found RC patients with BMI, American Society of Anesthesiologists, tumor location, nCRT, open surgery, end-to-end anastomosis, and longer operation times were at a higher risk of anastomotic leakage [34]. A systematic review identi ed gender, young age, smoking, radiotherapy, protective stoma, intersphincteric resection, anastomotic stula, and anastomotic distance as factors that increase the risk of anastomotic stenosis [35].…”

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confidence: 99%

Development and Validation of a Histological Calculator for Anastomotic Margins to Predict Anastomotic Failure Among Rectal Cancer Patients Treated with Neoadjuvant Chemoradiotherapy

Liu,

Huang,

et al. 2024

Preprint

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Purpose To identify histological features of anastomotic margins and develop a prediction model for anastomotic failure (AF) in rectal cancer (RC) patients with neoadjuvant chemoradiotherapy (nCRT). Methods A total of 350 pairs anastomotic “doughnuts” from RC with nCRT were randomly divided into the primary and validation cohorts at a ratio of 7:3. The histological features were identified and constructed using LASSO (Least absolute shrinkage and selection operator) regression to develop the radiation-induced colorectal injury (RCI) score. An AF prediction mode based on the RCI score was built and evaluated using the area under the receiver operating characteristic curve (AUC) and decision curve, decision curve analysis (DCA), and the DeLong test. Results The primary cohort consisted of 245 patients, among whom AF occurred in 26.9% of cases, while the validation cohort comprised 105 patients, with an AF rate of 24.8%. The RCI score of anastomotic margins showed a significant correlation with AF (odds ratio: 2.963; 95% confidence interval [CI]: 2.298–3.822; P < 0.001). Multivariable analysis identified body mass index (BMI) < 18.5, tumor location, long-course radiotherapy, and the RCI score as independent predictors for AF. The nomogram based on the RCI score exhibited good discrimination in both the primary cohort (AUC: 0.886; 95% CI: 0.840–0.931), with a sensitivity of 86.36% (95% CI, 75.7–93.6%) and specificity of 76.54% (95% CI, 69.6–82.5%). Calibration curves revealed satisfactory agreement between the predicted and the observed probabilities. Conclusions The comprehensive nomogram incorporating the RCI score could assist physicians in predicting AF and formulating personalized treatment strategies for RC patients with neoadjuvant radiotherapy.

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“…Not only surgical outcomes—increased risk for anastomotic dehiscences—but also functional outcomes may be both negatively affected in the setting of preoperative treatment. 25 26…”

Section: What Happens When Ncrt and Consolidation Chemotherapy Are Un...mentioning

confidence: 99%

Chemoradiation, Consolidation Chemotherapy, and Watch and Wait for Early Rectal Cancer

Cerdan-Santacruz,

São Julião,

Vailati

et al. 2023

Clin Colon Rectal Surg

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As watch and wait has become an attractive management alternative among patients with rectal cancer who achieve a clinical complete response to neoadjuvant chemoradiation, the focus of organ preservation has now shifted toward the use of this approach in patients with early rectal cancer. These patients would otherwise be treated without the use of neoadjuvant therapy for oncological reasons. The sole purpose of any neoadjuvant treatment here would be the achievement of a complete clinical response in an attempt to avoid total mesorectal excision. This has become particularly interesting after the incorporation of total neoadjuvant therapy regimens. These regimens have resulted in significantly higher rates of complete tumor regression and therefore become an interesting alternative among early rectal cancer patients where organ preservation is desired. The present review provides an overview of the currently available evidence and the preliminary experience with this rather controversial approach.

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When Is a Diverting Stoma Indicated after Low Anterior Resection? A Meta-analysis of Randomized Trials and Meta-Regression of the Risk Factors of Leakage and Complications in Non-Diverted Patients

Cited by 12 publications

References 43 publications

Outcomes of Early versus Standard Closure of Diverting Ileostomy after Proctectomy

Outcomes of Early versus Standard Closure of Diverting Ileostomy after Proctectomy

Development and Validation of a Histological Calculator for Anastomotic Margins to Predict Anastomotic Failure Among Rectal Cancer Patients Treated with Neoadjuvant Chemoradiotherapy

Chemoradiation, Consolidation Chemotherapy, and Watch and Wait for Early Rectal Cancer

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