Does a stoma help to prevent leakage after a low anterior resection

Peter HewettTQEH

Adelaide

ANSWER

YES

Definitions

• Low anterior resection: Anastomosis below the peritoneal reflection.

• Anastomotic leak: Disruption of anastomosis that leads to a clinical outcome requiring a medical or surgical intervention.

• Stoma: Loop ileostomy or transverse colostomy

Anastomotic leak rate for low anterior resection.

2.6 to 26.6%

Risk factors

• Perfect anastomoses leak!

Risk factors

• Anastomotic height• Male• Age• Preoperative radiotherapy• Insulin dependant diabetes• Renal failure• Peripheral Vascular disease• Malnutrition

Risk factors

• Emergency surgery• Blood Transfusion / anaemia• Obesity• Adequacy of blood supply• Tension

• IF YOU THINK ABOUT A STOMA.......DO IT!

Consequences of anastomotic leak

• Mortality (10%)

• Morbidity

• Local recurrence

• Distant recurrence

Recurrence• 21 studies : 21,902 patients

• Rectal Anastomotic leak odds ratio of developing a local recurrence was 2.05 (95% CI = 1.51-2.8; P=0.0001)

• Odds ratio of developing a distant recurrence after AL was 1.38 (95% CI=0.96-1.99; p=0.083)

• Long term cancer specific mortality significantly significantly higher after AL with an OR of 1.75 (95%CI=1.47-2.1; P=).0001)

• Increased local recurrence and reduced survival from Colorectal Cancer Following Anastomotic Leak: Systematic Review and Meta-Analysis. Annals of Surgery 253(5) May 2011. Pg 890-899

Reasons

• Direct seeding of malignant cells

• Interleukin-1

• TNF, IL-6, cyclooxygenase 2, matrix metalloproteases, VEGF

• Decrease in systemic immune response.

• Breast cancer

Does a stoma help to prevent leakage after a low anterior resection

• 11,429 patients

• RCTs :• Lower clinical anastomotic leak rate• Lower reoperation rate

• Non randomised trials• Lower clinical anastomotic leak rate• Lower reoperation rate• Lower mortality rate

• Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Tan W.S et al. BJS Vol 96 (5) 462-472 May 2009

Stoma

• 25% morbidity rate with a stoma

• Closure• Morbidity rates of 36%• Mortality rates 0-1%

Bowel Preparation

• This is not the end for mechanical bowel preparation in patients undergoing elective colorectal resections. In particular, there is insufficient evidence to support the abandonment of preoperative bowel preparation for all patients undergoing rectal surgery. Even large clinical trials lack the power to generate reliable conclusions about such high-risk patients. Cameron Platell Lancet 2008

• If a stoma is to be considered then it seems illogical to have a column of faeces proximal to an anastomosis.

How to avoid a stoma

• : Dis Colon Rectum. 2010 Jun;53(6):889-95.• Regenerated oxidized cellulose reinforcement of low rectal anastomosis: do we

still need diversion?• Madbouly KM, Hussein A, Omar W, Farid M

• The mean age of patients was 56 years, and sex was matched in both groups. Clinical leak occurred in 6 of 38 cases (15.7%) in the group that did not undergo reinforcement versus 2 of 33 (6.1%) in the oxidized regenerated cellulose reinforcement group (P < .01). In the case of a leak, diversion was needed in 3 of 6 patients in the group that did not undergo reinforcement vs no patients in the oxidized regenerated cellulose reinforcement group (P = .05). Generalized peritonitis occurred in 3 patients in the group that did not undergo reinforcement versus no patients in the oxidized regenerated cellulose reinforcement group (P < .01). Length of stay was 4.8 days in the oxidized regenerated cellulose reinforcement group versus 5.9 days in the group that did not undergo reinforcement (P = .047), with no mortalities in either group.