Defunctioning Stomas Result in Significantly More Short‐Term Complications Following Low Anterior Resection for Rectal Cancer

Abstract

BackgroundStudies suggest that defunctioning stomas reduce the rate of anastomotic leakage and urgent reoperations after anterior resection. Although the magnitude of benefit appears to be limited, there has been a trend in recent years towards routinely creating defunctioning stomas. However, little is known about post-operative complication rates in patients with and without a defunctioning stoma. We compared overall short-term post-operative complications after low anterior resection in patients managed with a defunctioning stoma to those managed without a stoma.MethodsA retrospective cohort study of patients undergoing elective low anterior resection of the rectum for rectal cancer. The primary outcome was overall 90-day post-operative complications.ResultsTwo hundred and three patients met the inclusion criteria for low anterior resection. One hundred and forty (69%) had a primary defunctioning stoma created. 45% received neoadjuvant radiotherapy. Patients with a defunctioning stoma had significantly more complications (57.1 vs 34.9%, p = 0.003), were more likely to suffer multiple complications (17.9 vs 3.2%, p < 0.004) and had longer hospital stays (13.0 vs 6.9 days, p = 0.005) than those without a stoma. 19% experienced a stoma-related complication, 56% still had a stoma 1 year after their surgery, and 26% were left with a stoma at their last follow-up. Anastomotic leak rates were similar but there was a significantly higher reoperation rate among patients managed without a defunctioning stoma.ConclusionPatients selected to have a defunctioning stoma had an absolute increase of 22% in overall post-operative complications compared to those managed without a stoma. These findings support the more selective use of defunctioning stomas.Study registrationRegistered at www.researchregistry.com (UIN: researchregistry3412).

High risk of permanent stoma after anastomotic leakage in anterior resection for rectal cancer

“…As few as 8% of patients with anastomotic leakage in this cohort were managed without a stoma of any kind during the course of treatment, suggesting that a defunctioning stoma is an indispensable tool in treatment of anastomotic leakage with respect to restoring bowel continuity. A defunctioning stoma can reduce the morbidity of anastomotic leakage and reduce the need for urgent reoperation , although widespread implementation has been questioned given reports of unchanged leak rates despite routine use , longer hospital stay and stoma‐related complications . A defunctioning stoma is also reported to alleviate the symptoms of anastomotic leakage, promote anastomosis‐preserving therapy and facilitate nonoperative treatment .…”

Neoadjuvant radiotherapy for rectal cancer management

“…This feared complication occurs due to failure in the integrity of the anastomosis leading to an abnormal communication between the peritoneal cavity and the intraluminal contents of the bowel. Studies investigating anastomotic leaks have quoted incidence rates of 15%-20%[14,15]. To mitigate the severity of this event, a diverting stoma can be formed at the time of surgery.…”

“…To mitigate the severity of this event, a diverting stoma can be formed at the time of surgery. The creation of a diverting stoma does not reduce the incidence of anastomotic failure, however, it has been shown to minimize the risk of reoperation[14]. The fashioning of a stoma is not without risk.…”

The Clinical and Economic Burden of Colorectal Anastomotic Leaks: Middle-Income Country Perspective

“…Several risk factors for the occurrence of AL have been identified, including male sex, diabetes mellitus, use of tobacco, blood loss, perioperative transfusion, operative time, preoperative chemoradiation, previous abdominal surgery, and emergency surgery [3–17]. On the other hand, protective stoma could reduce the occurrence of AL or reduce the severity of the AL complication [16, 17], although its routine usage shows contradictory results [18].…”