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 7 publications

(6 citation statements)

References 43 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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confidence: 99%

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confidence: 99%

Outcomes of Early Versus Standard Closure of Diverting Ileostomy After Proctectomy

Emile,

Horesh,

Garoufalia

et al. 2023

Annals of Surgery

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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%

“…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 However, a significant proportion of these patients, despite incomplete clinical response, may still be appropriate candidates for an organ-preservation strategy through the performance of a transanal local excision. Patients with limited/small initial tumors ( 4 cm in diameter), radiologically staged as mrT2N0 and who exhibit good response to treatment ( 2 residual tumor diameter)-despite incomplete-were prospectively randomized to TME or local excision.…”

Section: Do These Patients Benefit From Tnt Instead Of Regular Ncrt?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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“…Anastomotic leakage is a common event, ranging from 10 to 20% in population-based data [ 2 , 3 ]. Several randomized controlled trials have shown that a defunctioning stoma is an effective method to reduce the incidence of early symptomatic leakage [ 4 ]. The typical defunctioning stoma is a loop ileostomy [ 5 ], due to the ease of fashioning and reversing such a stoma.…”

Section: Introductionmentioning

confidence: 99%

Robotic low anterior resection with complete splenic flexure mobilization and defunctioning left-sided loop colostomy: a case series

Rutegård,

Gerdin,

Forssell

et al. 2024

Journal of Surgical Case Reports

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A defunctioning stoma is used to alleviate the consequences of anastomotic leakage after low anterior resection for rectal cancer. A loop ileostomy is often preferred but may lead to dehydration and kidney injury. Here, we present a case series for an alternative: the left-sided loop colostomy. A convenience sample of four patients underwent robotic low anterior resection for rectal cancer. A complete splenic flexure mobilization and a total mesorectal excision were performed. To defunction the anastomosis, the redundant left colon was brought up to a stoma site in the left iliac fossa and matured as a loop colostomy. Two patients experienced minor stoma leaks and one also had a small prolapse, while all patients had their colostomies reversed on average 7 months after surgery without complications. There were no dehydration episodes and creatinine levels remained within baseline levels at end of follow-up (on average 18 months).

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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 7 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

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

Robotic low anterior resection with complete splenic flexure mobilization and defunctioning left-sided loop colostomy: a case series

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