Septic complications after low anterior rectal resection--is diverting stoma still justified?

A retrospective study was designed to determine the effects of faecal diversion on the rate and severity of clinical anastomotic leaks after low anterior resection. The study explored the complications of stoma closure as well. During the period between 1 January 1995 and 30 July 2000, anterior rectal resection was performed on 249 patients with anastomoses created at a 6-cm or smaller distance to the dentate line. In 74 cases, the anastomosis was protected by loop ileostomy. The indications for creating a stoma were evaluated subjectively, by the operating surgeon. In 64 patients, the ileostoma was closed 3 months later. A 'clinical leak' after anterior resection was defined as an anastomotic insufficiency with clinically relevant consequences. The overall rate of anastomotic leak was 6.4 per cent; it was 5.1% (9/175) without and 9.4% (7/74) with a protective stoma. In 8 out of 9 patients, the anastomotic leak that had occurred without a protective stoma warranted laparatomy and defunctioning colostomy. Lavage and drainage of the peritoneal cavity and the presacral space were necessary in 6 out of these 8 cases- and furthermore, the deranged anastomosis had to be removed in 2 patients. Local management was successful in a single case only. Although relaparotomy entails long-term intensive care, all reoperated patients survived anastomotic leakage. Seven patients with a leak despite a protective did not require laparatomy; transanal drainage was appropriate in all cases. There were no fatalities in this group either. Only one fatal complication from suture leakage occurred after stoma-closure. Abdominal exploration was inevitable in almost all patients with a clinical anastomotic leak and without defunctioning stoma. By contrast, patients with anastomotic insufficiency despite a protective stoma were successfully managed without further intra-abdominal intervention. As shown by these results, faecal diversion undoubtedly mitigates the clinical consequences of anastomotic leaks, but cannot prevent its occurrence. When considering the cumulative risk of surgical complications associated with anterior resection, the complications of stoma-closure must also be taken into account. Our data confirm that a defunctioning stoma is beneficial for high-risk patients, who are unfit for a second abdominal procedure required to control suture leakage.     

Anastomotic Leakage of a Colorectal Anastomosis Treated by Transanal Endoscopic Microsurgery

Objective: To report a minimal invasive technique for repairing an anastomotic leakage with Transanal Endoscopic Microsurgery (T.E.M.) without creating a protective ostomy.

Summary: There are a large number of techniques for the management of anastomotic leakage after colorectal surgery. Depending on the size and location of the disruption, a protective ileostomy, a permanent colostomy or even reïnterven-tion for drainage or closure of the leak may be indicated. In most cases the patient faces the morbidity associated with a new intervention, a prolonged hospital stay and a future operation for closure of the stoma. In the present case a 56-year-old man underwent a laparoscopic rectosigmoid resection after two episodes of diverticulitis in six months. An end-to-end circular stapled anastomosis was constructed. Unfortunately 8-days postoperatively an anastomotic leak occurred. Attempts to close the tear non-surgically with colonoscopy and clipping failed. A minimally invasive reintervention with transanal endoscopic microsurgery (T.E.M.) was performed without creation of an ileostomy.

One week postoperatively a gastrografin bowel study showed no leakage. To our knowledge, this technique has not yet been reported without the simultaneous construction of a stoma.

Conclusion: We describe a possible minimally invasive technique to avoid laparotomy and/or the creation of a derivative stoma in the management of anastomotic leakage. Hospital stay is not significantly prolonged, future reïntervention for closure of stoma is avoided and sphincter function is preserved.     

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.     

De-functioning stomas: a prospective controlled trial comparing loop ileostomy with loop transverse colostomy

Patients undergoing colorectal surgery who required a defunctioning stoma were randomly allocated to receive either a loop ileostomy (n = 23) or transverse loop colostomy (n = 24). Assessment was made during construction, immediately postoperatively, during the period of outpatient supervision and before and after stoma closure. The ileostomy was associated with significantly less odour than the colostomy (P less than 0.01) and required significantly less appliance changes (P less than 0.05). Furthermore eleven patients (58 per cent) with a colostomy experienced three or more problems with stoma management compared with only three patients (18 per cent) with an ileostomy (P less than 0.05). Wound infection was also significantly more common after closure of the colostomy compared with the ileostomy. Both types of stoma were demonstrated objectively to defunction the distal bowel almost completely. These results indicate that a loop ileostomy is the procedure of first choice when a stoma is needed to defunction the distal colorectum.     

Clinical utility of a de-functioning loop ileostomy

BACKGROUND: The de-functioning loop ileostomy was introduced as a technique to create a manageable stoma that would divert the faecal stream from a more distal anastomosis in order to reduce the consequences of any anastomotic leakage. The value of de-functioning stomas is currently being challenged. The purpose of the present study was to review the clinical utility of performing a de-functioning loop ileostomy in patients undergoing colorectal surgery. METHODS: A review was undertaken of a prospective colorectal database maintained at Fremantle Hospital. All end-points were defined prior to the collection of data. The study reviewed the indications and type of surgery performed. The main end-points included (i) the prevalence and management of anastomotic leaks at the primary surgery; (ii) unplanned readmissions prior to stoma closure; and (iii) the mortality, reoperation rate, and morbidity associated with closure of the stoma. RESULTS: The study involved 233 patients of mean age 58 years (range 15-89 years) and a male:female ratio of 1.1:1. The majority of patients were undergoing elective surgery (82%) for colorectal neoplasia (71%). The commonest surgical procedure was an ultra-low anterior resection (62%). At the initial surgery, 16 patients (7.0%) developed anastomotic leaks, but only two (0.9%) required reoperation. Eleven patients (4.8%) required 12 unplanned readmissions prior to stoma closure. At closure (n = 230), there were no postoperative deaths, one patient developed an ileal anastomotic leak that was managed with antibiotics, and five patients (2.2%) required reoperation within 30 days of surgery. CONCLUSION: De-functioning loop ileostomy was found to be associated with a relatively low morbidity and no mortality.     

Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision

BACKGROUND: The aim of this study was to compare loop ileostomy and loop transverse colostomy as the preferred mode of faecal diversion following low anterior resection with total mesorectal excision for rectal cancer. METHODS: Patients who required proximal diversion after low anterior resection with total mesorectal excision were randomized to have either a loop ileostomy or a loop transverse colostomy. Postoperative morbidity, stoma-related problems and morbidity following closure were compared. RESULTS: From April 1999 to November 2000, 42 patients had a loop ileostomy and 38 had a loop transverse colostomy constructed following low anterior resection. Postoperative intestinal obstruction and prolonged ileus occurred more commonly in patients with an ileostomy (P = 0.037). There was no difference in time to resumption of diet, length of hospital stay following stoma closure and incidence of stoma-related complications after discharge from hospital. A total of seven patients had intestinal obstruction from the time of stoma creation to stoma closure (six following ileostomy and one following colostomy; P = 0.01). CONCLUSION: Intestinal obstruction and ileus are more common after loop ileostomy than loop colostomy. Loop transverse colostomy should be recommended as the preferred method of proximal faecal diversion.     

结肠襻式和回肠襻式造口并发症发生风险的Meta分析

目的 评价结肠襻式造口和回肠襻式造口的并发症发生风险.方法 检索Medline、Embase、Cochrane Library、Google Scholar及万方数据库公开发表的比较结肠襻式造口和回肠襻式造口并发症发生风险的论文;检索文献发表时间至2011年4月15日.通过Meta分析,定量评价两者的并发症发生率,采用Z检验分析数据,采用Q检验检测异质性.结果 本研究一共纳入5篇随机对照研究和8篇非随机对照研究,共有1752例研究对象.与回肠襻式造口术比较,结肠襻式造口发生造口脱垂的风险较大,差异有统计学意义(OR =3.46,95％CI为1.81～6.63,P＜0.05);两种造口术后发生造口出血、狭窄、切口感染、造口坏死、造口周围皮炎、造口旁疝等并发症风险比较,差异无统计学意义.与回肠襻式造口回纳术比较,结肠襻式造口回纳术后发生切口感染的风险较大,差异有统计学意义(OR =3.44,95％CI为1.95～6.05,P＜0.05);回肠襻式造口回纳术后肠梗阻的发生风险较大,差异有统计学意义(OR=0.43,95％ CI为0.20～0.91,P＜0.05);两种造口回纳术后发生肠液漏风险比较,差异无统计学意义(P＞0.05).结论 结肠襻式造口术后发生造口脱垂及回纳术后切口感染的风险较大,而回肠攀式造口回纳术后肠梗阻发生的风险较大.     

保护性造口在直肠癌低位前切除术中价值的前瞻性随机对照研究

目的前瞻性评价保护性造口在直肠癌低位前切除术中的价值。方法选择2006年10月～2011年10月间在我院接受择期开腹根治性低位前切除术,并符合入选标准的100例中下段直肠癌患者,随机分为三组：A组33例在完成结直肠吻合后行经升结肠回肠置管造口术;B组35例行横结肠或末段回肠袢式造口术;C组32例不行保护性造口术。观察吻合口漏的发生率以及造口相关的并发症。结果 100例患者术后发生吻合口漏5例,总的吻合口漏发生率为5.0%。A、B、C组的吻合口漏发生率分别为6.1%（2/33）、5.7%（2/35）和3.1%（1/32）,组间比较无统计学差异（P=0.838,P〉0.05）。68例行保护性造口患者（A＋B组）和32例不行保护性造口患者（C组）术后吻合口漏的发生率分别为5.9%（4/68）和3.1%（1/32）,无统计学差异（P=0.922,P〉0.05）。4例（A、B组）有保护性造口发生吻合口漏的患者症状较轻,而1例（C组）无保护性造口发生吻合口漏患者的症状较重。A组中仅2例在拔除回肠置管后发生腹壁瘘口短暂的溢肠内容物现象,经换药后很快愈合。而B组中肠造口并发症的发生率为25.7%（9/35）,后期造口还纳术并发症的发生率为22.9%（8/35）。结论保护性造口不能降低直肠癌低位前切除术后吻合口漏的发生,但能减轻吻合口漏发生后的症状。传统的保护性横结肠或末段回肠袢式造口术造口相关的并发症发生率较高。对具有吻合口漏高危因素患者,经升结肠回肠置管造口术是一种理想的可供选择的方法。     

Loop ileostomy as temporary faecal diversion following total mesorectal excision

Aim: Anastomotic leakage following low anterior resection with total mesorectal excision carries a significant morbidity and mortality. Both loop ileostomy and loop transverse colostomy are common options of temporary faecal diversion to reduce the severity of anastomotic leakage. We use loop ileostomy routinely because of its ease of construction and closure, and low complication rate. Here, we reviewed our result of loop ileostomy. Methods: We reviewed the medical records of all patients who had temporary loop ileostomy constructed following low anterior resection with total mesorectal excision for CA rectum, from 1.1999 to 12.2003. Stoma related morbidity pre and post–closure of loop ileostomy were recorded. Results: Eighty‐eight patients had loop ileostomy constructed and later closed from 1.1999 to 12.2003. Seventeen of them required small bowel resection during closure of the loop ileostomy. Three patients (3.4%) had skin excoriation and one patient (1.1%) had prolonged ileus after the construction of ileostomy (3.4%). After closure of ileostomy, two patients (2.2%) had wound infection and two patients (2.2%) had anastomotic leakage. Six patients (6.8%) developed intestinal obstruction later. Post‐closure intestinal obstruction and anastomotic leakage were found to be associated with small bowel resection during the closure of ileostomy (P=0.042). Conclusion: Loop ileostomy and its closure are associated with low complication rates. We therefore continue to advocate the use of loop ileostomy as a temporary diversion procedure after total mesorectal excision.     

THE MORBIDITY OF DEFUNCTIONING STOMATA

Background: The choice of a defunctioning stoma in restorative resection of rectal carcinoma is unclear. Traditionally, the loop colostomy has been preferred. Methods: All patients with either a defunctioning loop ileostomy or colostomy treated by a single surgeon (MS) were studied. The morbidity of stoma construction and closure, as well as problems experienced in the intervening period, were entered on a database. Results: No significant difference in the morbidity of closure was noted when loop ileostomy was compared to loop colostomy. Although a trend favouring loop ileostomy was noted when interval morbidity was examined, this difference was not statistically significant. Conclusions: Loop colostomy and ileostomy are both effective in defunctioning the distal colon following a restorative resection for rectal carcinoma. There is some morbidity associated with both but when a stoma is constructed, loop ileostomy is preferable. The loop ileostomy is generally easier to manage and is not associated with a greater rate of complications (in its construction and closure) than the loop colostomy.     

Changing patterns in colostomy closure: the Bristol experience 1975-1982

The results of colostomy closure in 113 patients (1975-1982) were examined to determine whether the identification of risk factors or improvements in surgical management had made this procedure safer. Overall mortality was low (0.9 per cent), but faecal fistulas occurred in 16.5 per cent and the incidence of wound infection was high (34 per cent). Comparison of the first and second 4 year periods shows recent improvements in the rates of wound infection (24 versus 51 per cent: P less than 0.01) and anastomotic leakage (10 versus 30 per cent: P less than 0.05). A long delay (greater than 6 months) between creation and closure of the colostomy was associated with an increased incidence of postoperative diarrhoea compared with shorter periods of defunction (38 versus 14 per cent: P less than 0.01). The morbidity of colostomy closure is decreasing but remains an important clinical problem.     

Morbidity after Closure of a Defunctioning Loop Ileostomy

Purpose : A low pelvic anastomosis is associated with a substantial risk of leakage. A defunctioning stoma (DS) reduces the clinical anastomotic leak rate and the need for re-operation, but stoma closure has its own risk of morbidity and mortality. This study aims to audit morbidity and mortality after loop ileostomy (LI) closure. Patients and methods : The medical records of 197 consecutive patients who underwent closure of a defunctioning LI between August 2003 and July 2008 were reviewed. Postoperative morbidity and mortality were recorded. Results : Transverse closure of the enterotomy was performed in 149 patients (75.6%), segmental enterectomy with hand-sewn end-to-end anastomosis in 26 (13.2%) and stapled side-to-side anastomosis in 22 (11.2%). Overall postoperative morbidity and mortality were 32.0% and 0.5%, respectively. The surgical complication rate was 30.5%, including prolonged ileus (11.2%), small bowel obstruction (4.1%), anastomotic leak (3.0%) and wound infection (4.6%). Surgical complications were more frequent in male patients (p = 0.005). Prolonged ileus was more frequent when the interval to stoma reversal exceeded 12 weeks (14.3% versus 3.5%; p = 0.02). The incidence of complications was not influenced by the closure technique. Nineteen patients (9.6%) required re-operation for anastomotic leak (n = 8), wound infection (n = 1), small bowel obstruction (n = 3) and incisional herniation (n = 7).

Conclusion : LI closure is associated with clinically relevant morbidity and mortality. This association should be taken into account in the context of a routine DS policy and should be part of the patient’s information.     

腹腔镜直肠癌超低位前切除术造口回纳后再发吻合口漏危险因素分析北大核心CSCD

目的探讨腹腔镜直肠癌超低位前切除术(Ls-uLAR)并发直肠吻合口漏病人的转归,并对造口回纳后再发吻合口漏的危险因素进行初步分析。方法回顾性分析北京大学第一医院普通外科2012年1月至2020年12月同一手术团队完成的Ls-uLAR并发吻合口漏的31例直肠癌病人的临床资料及随访结果,对造口回纳后再发吻合口漏的临床特征及危险因素进行分析。结果371例接受Ls-uLAR的病人中有31例(8.4%)术后并发吻合口漏。其中预防性造口术后吻合口漏23例(23/307,7.5%),其转归为:1例围手术期死亡,1例吻合口复发再次行经腹-会阴联合切除术,6例吻合口重度狭窄难以回纳,15例经保守治疗吻合口漏临床愈合(其中2例因肺转移而放弃回纳);无预防性造口术后吻合口漏8例(8/64,12.5%),其转归为:1例围手术期死亡,2例急诊行回肠造口,5例经保守治疗愈合。符合吻合口漏临床愈合标准的15例病人于初次术后3~16个月行造口回纳,其中8例(8/15,53.3%)再次出现吻合口漏。单因素分析结果显示:新辅助放化疗(是vs.否:100.0%vs.30.0%,P=0.026)、初次术中出血量(>50 mL vs.≤50 mL 87.5%vs.14.3%,P=0.010)及吻合口内镜下缺血征象(有vs.无:85.7%vs.25.0%,P=0.041)与再发吻合口漏相关。8例再发吻合口漏病人表现为骶前脓肿并继发不完全性肠梗阻4例,反复发作肛周脓肿和肛瘘2例,直肠阴道瘘2例。所有再发漏病人经保守治疗1~2个月均未能愈合,除1例直肠阴道瘘拒绝再次造口外,其余7例均改行横结肠造口。结论腹腔镜直肠癌超低位前切除术并发吻合口漏结局不良,继发吻合口狭窄及回纳后再发吻合口漏的风险较高,对吻合口漏病人的临床愈合标准、造口回纳时机和手术方式,尤其是新辅助放化疗后病人仍有待进一步研究。     

Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer

BACKGROUND: Few studies have evaluated the long-term functional outcome after anastomotic leakage in the treatment of rectal cancer. METHODS: Between 1993 and 1998, 147 patients were admitted with resectable rectal carcinoma, and 92 underwent low anterior resection (LAR). Seventeen patients (18 per cent) developed clinical anastomotic leakage. The functional outcome of 11 of 12 patients, in whom the stoma was subsequently closed and bowel continuity was restored without stricture, was compared with that of 11 matched patients who had undergone LAR without leakage. Anorectal manovolumetry and symptom scoring on visual analogue scales were done 12-48 months after stoma closure. RESULTS: Nine patients made an uneventful recovery after the initial treatment of anastomotic leakage. Eight developed serious septic complications, four of whom had a pelvic abscess, but there was no death. Five patients had chronic complications that precluded closure of the stoma. Patients who had experienced leakage showed reduced neorectal capacity (120 versus 180 ml; P = 0.04), more evacuation problems (P = 0.02), and a trend towards more faecal urgency (P = 0.09) and incontinence (P = 0.06) than control patients. CONCLUSION: Stoma closure was not possible in five of 17 patients who had experienced anastomotic leakage. Patients who had the stoma closed had impaired long-term anorectal function compared with control patients without leakage.     

直肠癌切除术后吻合口狭窄14例分析

目的分析直肠癌切除术后吻合口狭窄的原因。方法 直肠癌切除术后吻合口狭窄患者14例,11例行吻合口狭窄环切开术,1例行尿道探条扩张术2次,1例行经腹直肠吻合口狭窄环切除、回肠造口术,1例肿瘤盆腔复发压迫吻合口,行乙状结肠造口术。结果 11例吻合口狭窄环切开术患者术后继续手指扩肛,无直肠吻合口狭窄症状。尿道探条扩张术的患者,术后20天行回肠保护性造口还纳术,能够排出稀便。结论吻合口狭窄原因为保护性回肠造口术、吻合口感染和吻合口漏、肿瘤复发、术后盆腔放疗、吻合技术。手术方法主要是吻合口狭窄环切开术、尿道探条扩张术和经腹直肠吻合口狭窄环切除术。     

Morbidity and mortality after closure of loop ileostomy

Background  A temporary loop ileostomy is commonly used to protect low pelvic anastomoses. Closure is associated with morbidity and mortality. This study investigated patterns of complications after loop ileostomy closure and factors associated with morbidity and mortality.
Method  A review was performed of patients who underwent loop ileostomy closure between 1999 and 2005.
Results  Three hundred and twenty-five patients underwent closure of loop ileostomy. Reasons for primary surgery were: anterior resection for cancer ( n  = 160, 49%), ileal pouch-anal anastomosis ( n  = 114, 35%), diverticular disease ( n  = 25, 8%), Crohn's colitis ( n  = 4, 1%) and other conditions ( n  = 22, 7%). Overall mortality was 2.5% ( n  = 8) and morbidity was 22.8% ( n  = 74). Thirty-two patients (10%) developed small bowel obstruction, of whom seven required operative intervention. Overall, the re-operation rate in this series was 28 patients (8.6%).
Thirteen (4%) patients had an anastomotic leak of whom 12 patients had re-operation. Preoperative anaemia was significantly associated with leakage (Hb < 11 g/dl; n  = 65, P  = 0.033). The leakage rate was lower after a stapled anastomosis than a hand-sutured anastomosis (4/203 vs 9/122; P  = 0.039). Hypo-albuminaemia (albumin < 34 g/l) was significantly associated with mortality ( n  = 46, P  < 0.001).
Conclusions  Loop ileostomy closure is associated with morbidity and mortality. Anaemia and hypo-albuminaemia may be associated with poor outcome.     

High 1-Year Complication Rate after Anterior Resection for Rectal Cancer

Background

Surgical options after anterior resection for rectal cancer include a primary anastomosis, anastomosis with a defunctioning stoma, and an end colostomy. This study describes short-term and 1-year outcomes of these different surgical strategies.

Methods

Patients undergoing surgical resection for primary mid and high rectal cancer were retrospectively studied in seven Dutch hospitals with 1-year follow-up. Short-term endpoints were postoperative complications, re-interventions, prolonged hospital stay, and mortality. One-year endpoints were unplanned readmissions and re-interventions, presence of stoma, and mortality.

Results

Nineteen percent of 388 included patients received a primary anastomosis, 55 % an anastomosis with defunctioning stoma, and 27 % an end colostomy. Short-term anastomotic leakage was 10 % in patients with a primary anastomosis vs. 7 % with a defunctioning stoma (P?=?0.46). An end colostomy was associated with less severe re-interventions. One-year outcomes showed low morbidity and mortality rates in patients with an anastomosis. Patients with a defunctioning stoma had high (18 %) readmissions and re-intervention (12 %) rates, mostly due to anastomotic leakage. An end colostomy was associated with unplanned re-interventions due to stoma/abscess problems. During follow-up, there was a 30 % increase in patients with an end colostomy.

Conclusions

This study showed a high 1-year morbidity rate after anterior resection for rectal cancer. A defunctioning stoma was associated with a high risk for late complications including anastomotic leakage. An end colostomy is a safe alternative to prevent anastomotic leakage, but stomal problems cannot be ignored. Selecting low-risk patients for an anastomosis may lead to favorable short- and 1-year outcomes.     

Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer

BACKGROUND: The impact of anastomotic leakage on immediate postoperative mortality in patients undergoing potentially curative resection for colorectal cancer is well recognized. Its impact on long-term survival is less clear. The aim of the present study was to evaluate the relationship between anastomotic leakage and long-term survival in patients undergoing potentially curative resection for colorectal cancer. METHODS: A total of 2235 patients who underwent potentially curative resection for colorectal cancer between 1991 and 1994 in Scotland were included in the study. Five-year survival rates and adjusted hazard ratios were calculated. RESULTS: Fourteen (16 per cent) of the 86 patients with an anastomotic leak died within 30 days of surgery compared with 83 (3.9 per cent) of 2149 without a leak. The 5-year cancer-specific survival rate, including postoperative deaths, was 42 per cent in patients with an anastomotic leak compared with 66.9 per cent in those with no leak (P < 0.001). Excluding postoperative deaths, respective values were 50 and 68.0 per cent (P < 0.001). The adjusted relative hazard ratios, for patients with an anastomotic leak compared with those without a leak, and excluding 30-day mortality, were 1.61 (95 per cent confidence interval (c.i.) 1.19 to 2.16; P = 0.002) for overall survival and 1.99 (95 per cent c.i. 1.42 to 2.79; P < 0.001) for cancer-specific survival. CONCLUSION: Development of an anastomotic leak is associated with worse long-term survival after potentially curative resection for colorectal cancer.     

Passagere Kolostomieanlagen nach Eingriffen am Colon Sigmoideum und Rektum—Sind Sie Noch Gerechtfertigt?

Primary anastomosis is increasingly favored even in emergency colorectal surgery. Two-stage procedures are frequently considered obsolete. The aim of this study is to define conditions when a two-staged operative strategy with a temporary colostomy is still appropriate. We analyzed a series of 126 patients who were treated by a colostomy following resection and subsequent closure of the colostomy. In 44 cases the primary operation was a Hartmann resection, in 39 cases a resection with colostomy and mucous fistula and in 43 cases a resection with primary anastomosis and proximal loop colostomy. Complications of diverticlar or neoplastic disease were generally managed by resection without primary anastomosis. Protective loop colostomy was done after low anterior resection of the rectum or in cases of anastomotic leakage. Patients were hospitalized again after an average of 6 months for closure of the colostomy. Restoration of intestinal continuity carried no significant risk of severe intra- or postoperative complications. Disturbances of wound healing occurred in 4.5% (Hartmann resection), 17.9% (colostomy and mucous fistula) and 20.9% (loop colostomy) of patients. We found an anastomotic dehiscence rate of 2.4% after discontinuity resections and of 4.7% after closure of loop colostomies. Only one patient with anastomotic leakage required surgical reintervention. The mortality after closure of a colostomy was zero. The rate of anastomotic leakage of 2.4% was lower than in published series with more than 7.2% after primary anastomosis, thus emphasizing the beneficial effect of a two-stage operative strategy. In emergency situations of sigmoidal and rectal surgery or in cases of low anastomosis of the distal rectum, unnecessary surgical complications can be avoided by resection without primary anastomosis or by performing protective loop colostomies.     

Loop Ileostomy versus Loop Colostomy for Defunctioning Low Anastomoses during Rectal Cancer Surgery

Several studies have compared loop ileostomy with loop colostomy to defunction colorectal anastomoses. The discordant results may be due to the heterogeneity of the indications. We therefore performed a retrospective study to compare the two procedures in a homogeneous group of patients operated on electively for rectal cancer. Among 462 consecutive patients undergoing rectal resection for cancer during 1986–1998, 60 had a loop colostomy and 107 a loop ileostomy to defunction a low anastomosis. The two groups were similar with respect to age, gender, obesity, tumor stage, and duration before closure (109 vs. 104 days; p= 0.28). All the stoma-related complications that occurred after construction and after closure of the stoma were recorded. There were no stoma-related deaths in the two groups. After stoma construction, the morbidity rate was significantly higher following loop colostomy than after loop ileostomy (35% vs. 19%; p= 0.02). After stoma closure the complication rate was significantly higher in the colostomy group than in the ileostomy group (34% vs. 12%; p= 0.004). The risk of surgical reintervention related to the morbidity of both construction and closure of the stoma was twice as high after loop colostomy than after loop ileostomy (22% vs. 9%; p= 0.03). The results of this study showed that, in our experience, the overall stoma-related morbidity and risk of reoperation were significantly lower after loop ileostomy than after loop colostomy. This suggests that loop ileostomy is the best procedure for defunctioning colorectal anastomoses electively. We therefore recommend using a loop ileostomy during rectal cancer surgery.