Risk Factors Associated with the Development of Colorectal Anastomotic Strictures Prior to Diverting Loop Ileostomy Reversal

Abstract

Background Anastomotic strictures represent a major source of morbidity in colorectal surgery with an incidence reported up to 30%. Despite this, the mechanism by which strictures develop remains unclear. This study aims to determine the incidence of colorectal anastomotic strictures and associated risk factors among a series of diverted patients. Materials and Methods A retrospective chart review was conducted of 142 patients over a 7-year period at a single institution after colorectal resection with anastomosis and diverting ileostomy creation re-examined with postoperative endoscopy. One patient was removed due to anastomotic tumor recurrence. Patient and technical factors were examined for significance using chi-square analysis. Logistic regression was used to perform multivariate analysis to estimate odds ratio (OR) and 95% confidence intervals (CI). Results Among 141 patients, 14.1% (20 patients) developed strictures detected on endoscopy. Strictures were observed in a greater percentage of women than men (21.2% vs 8%, P = .025). 30.6% of patients who underwent resections for diverticulitis developed strictures while those with neoplastic lesions and other indications had stricture rates of 6.8% and 17.6%, respectively ( P = .002). Anastomoses performed during a colostomy reversal were associated with a higher stricture rate (OR 4.23, 95% CI 1.37-13.40, P = .012). Anastomoses performed with a 28/29 mm EEA circular stapler demonstrated a significantly higher stricture rate versus a 31/33 mm stapler (OR 7.21, 95% CI 1.23-155.58, P = .045). Discussion Our data reveal that female sex, history of diverticulitis, anastomoses performed in the setting of colostomy reversal, and smaller stapler size are associated with a higher rate of anastomotic stricture.

The impact of circular stapler size on the risk of anastomotic stricture following total mesorectal excision in rectal cancer patients: A retrospective cross‐sectional study

“…In rectal cancer surgery, these studies are limited, yielding inconsistent results. [7][8][9]11 The results of this study corroborate findings from previous studies indicating that even though there is a correlation between stapler size and stricture in upper gastrointestinal tract, there is no correlation in lower GI. 1,3,8,9,14,15 Nagaoka et al Comparing 29-and 31-mm circular staplers revealed that stapler size was not a significant predictor of stricture development.…”

“…However, our findings do not support the conclusions of several studies examining the relationship between stapler size and anastomotic strictures in colorectal surgery. 7,11,16 The heterogeneity of the study participants in terms of the various surgical indications, surgical procedures, and approaches, as well as the absence of a universal definition for anastomotic strictures, can partially explain the discrepancy between our findings and those of the studies above.…”

“…Moreover, studies on the IPAA have revealed that smaller stapler sizes are associated with a higher but insignificant stricture rate. In rectal cancer surgery, these studies are limited, yielding inconsistent results 7–9,11 …”

“…In lower GI tract surgery, the stapler size in ileal pouch‐anal anastomoses (IPAA) has been studied, revealing that smaller stapler sizes are associated with higher but insignificant stricture rates. In rectal cancer surgery, these studies are scarce, yielding inconsistent results 7–9,11 . Considering the prevalence and clinical significance of anastomosis‐related complications, identifying risk factors associated with anastomotic outcomes seems necessary.…”

“…2 Moreover, recent studies have implicated stapler size in developing anastomotic strictures in CRC surgery. 7,11 Upper GI tract surgery studies on the relationship between stapler size and anastomotic strictures observed that a larger circular stapler was associated with a lower risk of anastomotic stricture. 12,13 In lower GI tract surgery, the stapler size in ileal pouch-anal anastomoses (IPAA) has been studied, revealing that smaller stapler sizes are associated with higher but insignificant stricture rates.…”