The indications for a diverting stoma in low anterior resection for rectal cancer: a prospective multicentre study of 222 patients from Japanese cancer centers

Aim The aim of the study was to determine the present state of diverting stoma construction in Japanese cancer centres and to investigate the relationship between symptomatic leakage and diverting stoma after low anterior resection for rectal cancer. Method Two hundred and twenty‐two consecutive patients undergoing low anterior resection for rectal cancer located within 10 cm from the anal verge were investigated in a prospective, multicenter study. Results The overall leakage rate was 9.0% (20/222). Of 31 cases with an anastomosis within 2.0 cm from the anal verge, 22 (71%) had a diverting stoma. Of cases anastomosed within 5.0 cm, the absence of a diverting stoma and tumour size were significantly related to an increased rate of leakage [leakage in 13 (12.7%) of 102 cases without a diverting stoma; in three (3.8%) of 80 cases with a diverting stoma]. Among anastomoses within 2.0 cm from the anal verge, leakage occurred in four (44.4%) of nine cases without and in none (0%) of 22 cases with a diverting stoma. Conclusion We recommend a diverting stoma for an anastomosis within 5.0 cm of the anal verge and strongly recommend it for a very low anastomosis within 2.0 cm.     

Morbidity related to the use of a protective stoma in anterior resection for rectal cancer

Objective To evaluate morbidity related to the use of a protective stoma in rectal resection for cancer. Method Seventy‐two patients undergoing anterior rectal resection for cancer combined with a protective stoma (1993–2005) were included. Loop ileostomy was applied in 61 patients, loop colostomy in 10, and end ileostomy in one. Data regarding the primary operation were recorded prospectively, and stoma complications retrospectively. Results Five patients (7%) developed stoma complications immediately after the primary operation, and 14/70 (20%) following hospital discharge. The stoma was closed in 62 (86%) patients after median 4 (range 1–11) months. Five patients (8%) developed complications in hospital after closure. Two patients (3%) died, one of ileal anastomotic leak and one of myocardial infarction. Five patients (8%) had late complications after closure. A total of 19 patients (26%) developed stoma related complications. Eight (11%) of these were reoperated. Premature stoma closure was necessary in two additional patients. Nine patients (13%) ended up with a permanent stoma. Fourteen (19%) patients developed signs of rectal anastomotic failure, six (8%) of whom needed reoperation. One died. Conclusion Significant morbidity is related to the use of defunctioning stomas. A protective stoma cannot always prevent serious complications of a rectal anastomotic leak, and a proportion of the patients will not have the stoma closed.     

Sphincter-preserving operations without defunctioning stoma

Sphincter-preserving operations have increasingly been carried out during the last few decades; nevertheless, temporary defunctioning stoma is still being frequently used for low colorectal anastomosis (LCRA) with staplers and hand-sewn coloanal anastomosis (CAA). From 1994 to 2003, 131 consecutive patients with rectal cancer with tumours within 7 cm from the anal verge underwent LCRA or CAA without defunctioning stoma. Anastomotic complications and treatment were compared between the groups. The median follow up was 31.4 months. Complications related to anastomosis were 10.7% for LCRA with 7.1% of anastomotic leakage (two men and two women) and 13.3% for CAA with 4.0% of anastomotic leakage (three men). Treatments for leakage included colostomy (three LCRA), CAA construction (one LCRA) and conservative treatment (three CAA). Twenty eight percent of CAA received preoperative radiation therapy, and the anastomic leakage developed in 14% of them. Anastomotic leakage and its treatment with CAA are different from those in LCRA, and CAA can safely be used without defunctioning stoma during sphincter-preserving operation for low-lying rectal cancer.     

915��ֱ����ǰ�г����󲢷�֢�ٴ�����

目的探讨直肠癌前切除术后并发症的预防和治疗。方法回顾性分析哈尔滨医科大学肿瘤医院1975年5月至2005年12月收治的行前切除术(AR)的915例直肠癌的临床资料,总结并发症的形式、相关因素、预防和治疗方法。结果915例直肠癌前切除术后,共发生吻合口漏28例(3.06%,28/915),吻合口狭窄38例(4.15%,38/915),术后早期吻合口大出血6例(0.66%,6/915)。吻合口漏的相关因素分析发现吻合口漏的发生与性别、吻合技术、中重度贫血和低蛋白血症密切相关(P<0.05),而与年龄、肿瘤距肛缘距离、直肠癌扩大根治术无明显相关(P>0.05)。24例(85.7%,24/28)吻合口漏经保守治疗(双引流管冲洗)后治愈,5例(5/6)吻合口大出血立即再次手术,38例发生吻合口狭窄均经扩肛后好转。结论直肠癌前切除手术虽然可以避免永久性人工肛门,但应重视其术后发生的吻合口漏、吻合口狭窄及吻合口大出血等并发症的预防和治疗。     

保护性造口在超低位直肠肿瘤内括约肌切除术中的价值

目的 探讨保护性造口在超低位直肠肿瘤内括约肌切除术(ISR)中的应用价值.方法 对1999年1月至2009年7月给予经肛ISR联合经腹全直肠系膜切除术结肠肛管吻合术的56例无肛门外括约肌受侵的超低位直肠肿瘤患者的临床资料进行回顾性分析,比较造口组(16例)与未造口组(40例)患者术后吻合口和肛门部并发症及肛门功能恢复情况.结果 56例患者中16例(28.6%)行保护性造口.未造口组术后吻合口和肛门部并发症分别出现14例(35.0%)和16例(40.0%),而造口组吻合口及肛门部并发症分别仅出现1例(1/16),两组差异有统计学意义(P<0.05).未造口组1例吻合口裂开肿瘤复发再手术行永久性结肠造口,另3例吻合口及肛门病变需造口及二期手术治疗,再手术率为10.0%.两组患者术后肛门控便能力均下降,造口组患者造口回纳术后3、6、12个月肛门功能Kirwan评分达Ⅰ级者分别为11/16、13/15、11/13,未造口组患者术后3、6、12个月达Ⅰ级比例分别为30.0%、37.5%、45.0%,术后同期造口组患者肛门功能均明显优于未造口组患者(P<0.05).结论 保护性肠造口可减少超低位直肠肿瘤ISR后吻合口瘘,消除术后早期肛门失禁给患者带来的痛苦,且有利于肛门功能的恢复.     

直肠癌前切除吻合器吻合术后并发直肠阴道瘘的原因及对策

目的 研究和探讨直肠癌前切除术后并发直肠阴道瘘的原因及对策.方法 2004年3月至2006年8月,根据电话和门诊随访结果以及病历记录,回顾性总结多中心11例直肠癌前切除术后并发直肠阴道瘘的原因及治疗效果.采用直肠推移黏膜瓣修补结合经阴道修补1例,经肛推移皮瓣修补结合经阴道修补1例,单纯经阴道修补2例,经肛直接分层缝合5例,2例行横结肠造口和局部冲洗引流,3个月和6个月后分别行造口回纳.结果 平均随访13个月(3～20个月),失败1例,成功率90.9%,无手术死亡率和并发症.结论 采用经肛结合经阴道修补治疗直肠癌前切除引起的单纯性直肠阴道瘘是安全有效的,不需要切断会阴体和肛门括约肌,并发症少,无肛门失禁发生.     

Mortality risk analysis following routine vs selective defunctioning stoma formation after total mesorectal excision for rectal cancer

Objective  To answer the question whether a defunctioning stoma (DS) should be constructed routinely after total mesorectal excision or whether it could be used selectively to ensure patient safety.
Method  A PubMed search was performed. All randomized trials on the role of a DS were included. Also, observational articles published between January 1997 and August 2007 were reviewed. Sensitivity analysis of the mortality risk was performed.
Results  The clinical anastamotic leak (CAL) rate was 17% in 358 patients from four randomized trials and 9.6% in 4059 patients from 39 observational studies. The CAL rate increased significantly from 9.6% with DS to 24.4% without DS in four randomized trials, and from 7.9% with DS to 13.2% without DS in 17 observational studies. The re-operation rate as a result of anastomotic leakage was lower in patients with DS than in patients without DS in both study types. Leak-related mortality was not significantly different: 7.2% with vs 7.7% without DS in observational studies, and 0% with vs 4.6% without DS in randomized trials. Sensitivity analysis indicated that a selective DS strategy is acceptable if the CAL rate without DS is less than 16.6% with a CAL-related mortality of no more than 4.6%.
Conclusion  The results of this review support the routine construction of a protective stoma. However, selective use of a DS is justified from a patient safety point of view if the CAL-rate and its related mortality are limited. Each unit should audit its performance.     

直肠癌前切除术后吻合口漏的危险因素分析

目的探讨直肠癌前切除术后吻合口漏发生的危险因素。方法对我院从2005年1月到2007年12月三年间114例直肠癌前切除术后发生吻合口漏11例的临床资料进行回顾性分析。结果11例确诊发生吻合口漏,总发生率为9.65%（11/114）吻合口漏发生在术后第6～10天。其中男性患者8例（11.76%,8/68）、年龄〉60岁者9例（14.52%,9/62）、肿瘤距肛缘距离≤6cm者6例（14.63%,6/41）、术前有糖尿病者3例（17.65%,3/17）、术前有贫血或低蛋白血症者2例（20%,2/10）、术前伴有肠梗阻者2例（22.22%,2/9）、行全直肠系膜切除者5例（13.89%,5/36）。结论男性患者、年龄〉60岁、肿瘤距肛缘距离≤6cm、术前合并糖尿病、贫血或低蛋白、伴有肠梗阻及全系膜切除者,是术后吻合口漏发生的危险因素。     

Risk factors for permanent stoma after low anterior resection for rectal cancer

Purpose

This study evaluated the risk factors influencing permanent stoma after curative resection of rectal cancer and compared the long-term survival of patients according to the stoma state.

Methods

From January 2004 to December 2010, 895 consecutive rectal cancer patients with histological-confirmed adenocarcinoma who received low anterior resection with curative intent at the Department of Colon and Rectal Surgery, Chonnam National University Hwasun Hospital, were evaluated retrospectively. Patient demographics, times of stoma reversal, and number/reason of permanent stoma were evaluated.

Results

Three hundred fifteen patients (35.2 %) had a diverting stoma of temporary intent among 895 rectal adenocarcinoma patients. Loop ileostomy was performed in 271 patients (86.0 %). A total of 256 (81.3 %) of 315 stoma patients received stoma closure. The mean period between primary surgery and stoma closure was 5.6 months (range, 1–44 months). Seventy-three patients (23.2 %) were confirmed with permanent stoma. Multivariate analysis showed stage IV (hazard ratio (HR), 3.380; 95 % confidence interval (CI), 1.192–18.023; p?=?0.027), anastomosis-related complication (HR, 3.299; 95 % CI, 1.397–7.787; p?=?0.006), colostomy type (HR, 7.276, 95 % CI, 2.454–21.574; p?=?0.000), systemic metastasis (HR, 2.698; 95 % CI, 1.1.288–5.653; p?=?0.009), and local recurrence (HR, 4.231; 95 % CI, 1.724–10.383; p?=?0.002) were independent risk factors for permanent stoma.

Conclusions

On postoperative follow-up, in patients with anastomotic complication, tumor progression with local recurrences and systemic metastasis may cause permanent stoma.     

永久性肠造口患者健康素养量表的编制

目的 构建永久性肠造口患者健康素养评估工具。 方法 参考国内外文献与质性访谈,建立量表条目池,通过2轮专家咨询对条目进行删改,调查220例永久性肠造口患者进行信效度评定。 结果 正式量表包括3个领域31个条目,功能领域产生4个公因子（获取肠造口信息能力、阅读肠造口信息能力、理解肠造口信息能力、交流肠造口信息能力）,知识领域产生2个公因子（肠造口预防保健知识、肠造口护理技能知识）,态度领域产生2个公因子（肠造口观点、肠造口行为倾向）。8个公因子的方差累积贡献率56.787%。量表水平内容效度0.890,量表Cronbach′s α系数0.864,折半信度系数0.923。 结论 永久性肠造口患者健康素养量表信效度良好,可作为永久性肠造口患者健康素养测评工具。     

Single-stapled double-pursestring anastomosis after anterior resection of the rectum

BACKGROUND: Single-stapled double-pursestring technique for colorectal anastomosis to the mid-rectum or upper rectum is the most commonly used technique in the single institution reported here. The investigators evaluate single-stapled double-pursestring anastomosis after anterior resection of the rectum performed at a single institution. METHODS: Medical records of patients who underwent single-stapled double-pursestring anastomosis between January 2000 and May 2005 were analyzed to identify postoperative anastomotic complications. Patients with previous radiation, diverting stoma, coloanal, and hand-sewn and double-stapled anastomoses were excluded. The primary goal was to identify postoperative anastomotic complications. RESULTS: Of 160 patients, 153 (96%) no septic complications. One patient (.6%) developed anastomotic leak requiring diversion. Of the 4 patients with pelvic abscesses (2.5%), 2 were treated with antibiotics and 2 with computed axial tomography-guided drainage. CONCLUSIONS: Single-stapled double-pursestring anastomosis is reliable, with very low rates of leak, subsequent diversion, and pelvic abscess (.6%, .6%, and 2.5% respectively).     

预防性造口在低位直肠癌前切除术中应用价值的Meta分析

目的:评估预防性造口在低位直肠癌全系膜切除术中的价值.方法:检索PubMed和Embase数据库中有关低位直肠癌术中实施预防性造口的相关研究和文献,将预防性造口组与未造口组患者术后吻合口瘘的发生率和与吻合口瘘相关的再手术率进行比较.结果:5项最近的研究符合纳入标准,累计病例878例.Meta分析表明预防性造口能明显降低吻合口瘘及再手术的发生率,合并风险率分别为0.34(95％ Cl:0.22 ～ 0.53,P＜0.00001)和0.27 (95％Cl:0.16～0.48,P＜0.00001),差异有统计学意义.结论:预防性造口可有效的降低吻合口瘘的发生率和与吻合口瘘相关的再手术率,且不影响术后直肠肠管功能;但是否影响患者远期生存率和术后生活质量,目前尚无定论.