Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer

Blok, Robin D.; Stam, R.; Westerduin, E.; Borstlap, Wernard A. A.; Hompes, Roel; Bemelman, Willem A.; Tanis, Pieter J.

doi:10.1016/j.ejso.2018.03.033

Cited by 42 publications

(28 citation statements)

References 27 publications

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“…Changes in surgical approach over time with extended use of diverting stomas have not been found in other studies, and suggest that surgeons may be increasingly cautious following RRR. However, recent studies from the Netherlands 28,29 found no difference in short‐term postoperative complication rates between patients undergoing rectal cancer resection with a diverting stoma routinely and those in whom a diverting stoma was created only in highly selected patients. Equally, the findings from the present study suggest that long‐term complications might be another important issue that requires attention in the preoperative setting.…”

Section: Discussionmentioning

confidence: 98%

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

et al. 2020

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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.

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Section: Discussionmentioning

confidence: 98%

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

et al. 2020

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“…The rate of formation of diverting stomas varies with individual units (and surgeons) and it is becoming more acceptable to be selective. A recent cohort study in the Netherlands demonstrated the safe adoption of a highly selective diversion policy and showed no increase in anastomotic leak rate [62].…”

Section: Implications For Further Research and Clinical Practicementioning

confidence: 99%

Risk and consequences of dehydration following colorectal cancer resection with diverting ileostomy. A systematic review and meta‐analysis

Borucki

Schlaeger²,

Crane

et al. 2021

Colorectal Disease

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Aim: This systematic review aims to assess dehydration prevalence and dehydrationrelated morbidity from diverting ileostomy compared to resections without ileostomy formation in adults undergoing colorectal resection for cancer.Method: MEDLINE, Embase, CENTRAL and ClinicalTrials.gov were searched for studies of any design that reported dehydration, renal function and dehydration-related morbidity in adult colorectal cancer patients with diverting ileostomy (last search 12 August 2020). Bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias in randomized trials and the Risk of Bias in Non-randomized Studies of Interventions tool.Results: Of 1927 screened papers, 22 studies were included (21 cohort studies and one randomized trial) with a total of 19 485 patients (12 209 with ileostomy). The prevalence of dehydration was 9.00% (95% CI 5.31-13.45, P < 0.001). The relative risk of dehydration following diverting ileostomy was 3.37 (95% CI 2.30-4.95, P < 0.001). Three studies assessing long-term trends in renal function demonstrated progressive renal impairment persisting beyond the initial insult. Consequences identified included unplanned readmission, delay or non-commencement of adjuvant chemotherapy, and development of chronic kidney disease.Discussion: Significant dehydration is common following diverting ileostomy; it is linked to acute kidney injury and has a long-term impact on renal function. This study suggests that ileostomy confers significant morbidity particularly related to dehydration and renal impairment.

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“…These factors helped identify high-risk patients, which require a defunctioning ileostomy with a shift from routine diversion of low anastomosis to highly selective. Selective diversion has been shown to have similar results in term of anastomosis leakage rate with a substantial decrease in 1year readmission and reintervention rate compared to routine diversion [25].…”

Section: Potential Perioperative Complicationsmentioning

confidence: 90%

Current Trends in the Management of Low Rectal Tumors: Transanal Total Mesorectal Excision

Chevallay

Meyer

Wassmer

et al. 2019

Curr Colorectal Cancer Rep

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Purpose of Review The access of the low rectum is a surgical challenge and, in case of cancer, the outcome of the patient depends on the quality of the surgery. The transanal total mesorectal excision (taTME) is a surgical technique with a combined abdominal and perineal approach. We review the literature for technical aspect of taTME as well as comparisons with other techniques. Recent Findings Comparison with laparoscopic total mesorectal excision and taTME was summarized in a meta-analysis which showed better oncological results with lower circumferential margin involvement and better completeness of the mesorectum. Summary TaTME is a safe approach. All steps of the intervention are well described and should be followed as numerous pitfalls exist. When compared with laparoscopic or robotic TME, the taTME showed to be safe with similar oncological results. Patients known to be difficult, male, obese, with a narrow pelvis, should be considered for the taTME approach.

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Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer

Cited by 42 publications

References 27 publications

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

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

Risk and consequences of dehydration following colorectal cancer resection with diverting ileostomy. A systematic review and meta‐analysis

Current Trends in the Management of Low Rectal Tumors: Transanal Total Mesorectal Excision

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