Does a stoma reduce the risk of anastomotic leak and need for re-operation following low anterior resection for rectal cancer: systematic review and meta-analysis of randomized controlled trials

Abstract

Background: There is a relatively high risk of anastomotic leak in low anterior resection (LAR), associated with significant morbidity and mortality. This systematic review and meta-analysis aims to compare diverting stoma vs. no stoma for LAR in terms of leak rates, reoperations, mortality rates and complication rates. Methods: We systematically performed electronic searches of databases Ovid Medline, PubMed, CCTR, CDSR, ACP Journal Club and DARE from inception to present. Only randomized controlled trials comparing LAR for rectal cancer with versus without stoma diversion were included for analysis. Main outcomes were anastomotic leak, reoperation rate and mortality. Secondary outcomes included other operative and stoma-related complications. Results: Eight randomized controlled trials were included in the study for qualitative and quantitative analyses. A significantly longer operative duration for patients with stoma diversion was seen (WMD 19.50 min; 95% CI: 7.38, 31.63; I 2 =0%, P=0.002). The pooled rate for anastomotic leak was significantly lower for those with stoma diversion (6.3% vs. 18.3%; RR 0.36; 95% CI: 0.24, 0.54; I 2 =0%; P<0.00001). There was lower reoperation rate for patients with stoma diversion compared to no stoma (5.9% vs. 16.7%; RR 0.40; 95% CI: 0.26, 0.60; I 2 =0%; P<0.00001). No significant difference was found in terms of leakrelated mortality between stoma vs. no-stoma cohorts (0.47% vs. 1.0%; P=0.51). Conclusions: The present meta-analysis suggests a diverting or defunctioning stoma following LAR for rectal cancers can reduce anastomotic leak and reoperation rates, without increased risk of mortality or other complications.

How to Prevent Anastomotic Leak in Colorectal Surgery? A Systematic Review

“…This procedure would reduce the risk of AL, and in case of occurrence the severity of septic complication related to this leak. This role has been confirmed by several meta-analyses (level 2A) [ 46 - 49 ] of which one (level 1A) published in 2019 [ 50 ] including 8 randomized trials and 892 patients. In this meta-analysis, Phan et al [ 50 ] concluded that the diverting stoma significantly reduced the rate of AL and the rate of reoperation after anterior resection for low rectal cancer.…”

Prophylactic negative-pressure wound therapy after ileostomy reversal for the prevention of wound healing complications in colorectal cancer patients: a randomized controlled trial

“…Despite the current recomsmendation for primary anastomosis after a resection procedure, such treatment is associated with a significant risk of anastomotic leak (up to 20% = [ 4 , 5 ]). One way to reduce the risk of leak is to use a diverting ileostomy [ 6 , 7 ]. Although this is currently considered a standard treatment, especially in the group of patients undergoing neoadjuvant radiotherapy or chemoradiotherapy, the technique still has its drawbacks, such as the necessity to perform an additional surgical operation for ileostomy closure, which has a high risk of wound healing complications, particularly surgical site infections (SSI) [ 8 , 9 ].…”

Is A Routine De-Functioning Stoma Benefit for Rectal Cancer Surgery: Results Basing On Meta-Analysis of Postoperative Complications and Quality of Life with A Stoma

“…Some surgeons preferred to perform a routine de-functioning stoma to avoid the confusing situation of leakage and mortality. However, a de-functioning stoma may increase the incidence of either total or stoma-related complications [43,44]. In addition, the presence of a de-functioning stoma demanded additional subsequent surgery for stoma closure, and thus may lead to additional complications [45][46][47].…”