Defunctioning stoma and short- and long-term outcomes after low anterior resection for rectal cancer-a nationwide register-based cohort study.

PURPOSE: A defunctioning stoma reduces the risk of symptomatic anastomotic leakage after low anterior resection for rectal cancer and mitigates the consequences when a leakage occurs, but the impact on mortality and oncological outcomes is unclear. The aim was to investigate the associations of a defunctioning stoma with short- and long-term outcomes in patients undergoing low anterior resection for rectal cancer. METHODS: Data from all patients who underwent curative low anterior resection for rectal cancer between 1995 and 2010 were obtained from the Swedish Colorectal Cancer Register. A total of 4130 patients, including 2563 with and 1567 without a defunctioning stoma, were studied. Flexible parametric models were used to estimate hazard ratios for all-cause mortality, 5-year local recurrence, and distant metastatic disease in relation to the use of defunctioning stoma, adjusting for confounding factors and accounting for potential time-dependent effects. RESULTS: During a median follow-up of 8.3 years, a total of 2169 patients died. In multivariable analysis, a relative reduction in mortality was observed up to 6 months after surgery (hazard ratio = 0.82: 95% CI 0.67-0.99), but not thereafter. After 5 years of follow-up, 4.2% (173/4130) of the patients had a local recurrence registered and 17.9% (741/4130) had developed distant metastatic disease, without difference between patients with and without defunctioning stoma. CONCLUSION: A defunctioning stoma is associated with a short-term reduction in all-cause mortality in patients undergoing low anterior resection for rectal cancer without any difference in long-term mortality and oncological outcomes, and should be considered as standard of care.

Reversal of defunctioning stoma following rectal cancer surgery: are we getting better? A population-based single centre experience.

BACKGROUND: The aim was to assess factors influencing the timing of defunctioning stoma (DS) reversal following low anterior resection of rectum for cancer (LAR). METHODS: All patients operated with LAR and a primary DS during a 9-year period were included. Reversal later than 120 days after LAR was considered as delayed. A DS not reversed within 2 years was considered as permanent. RESULTS: In the present study, median age at LAR was 67 years, 45% were females, median body mass index was 25, 87% had American Society of Anesthesiologists class I or II, 64% had pre-operative radiotherapy, and 3% had cancer stage IV. A total of 79% (92/116) underwent stoma reversal, whereof 25% (23/92) were reversed within 120 days. The most common health-related reasons for delayed stoma reversal were adjuvant chemotherapy in 38%, symptomatic anastomotic leakage in 16% and other post-operative adverse events in 13%. In 35% delayed stoma reversal was because of low priority within the healthcare system. A total of 18% (20/110) never had their DS reversed (n = 11) or had their DS converted to a permanent end colostomy (n = 9). Major risk factors for permanent stoma were stage IV cancer in 55%, and symptomatic anastomotic leakage in 30%. CONCLUSION: One fourth of the patients had their defunctioning stoma reversed within 120 days. The most common identifiable medical reasons for delayed stoma reversal were adjuvant chemotherapy and symptomatic anastomotic leakage, while in one out of three patients it was because of low priority by the healthcare provider.

Does a Defunctioning Stoma Impair Anorectal Function After Low Anterior Resection of the Rectum for Cancer? A 12-Year Follow-up of a Randomized Multicenter Trial.

BACKGROUND: Anorectal function after low anterior resection of the rectum for cancer is often impaired, and long-term outcome has not frequently been reported. OBJECTIVE: We evaluated anorectal function 12 years after rectal resection with regard to whether patients had a defunctioning temporary stoma at the initial rectal resection. DESIGN: An exploratory cross-sectional investigation of a previously randomized study population. SETTINGS: Twenty-one Swedish hospitals performing rectal cancer surgery during a 5-year period participated in the trial. PATIENTS: Patients operated on with low anterior resection for cancer were included. INTERVENTIONS: Patients were randomly assigned to receive or not receive a temporary defunctioning stoma. MAIN OUTCOME MEASURES: We evaluated anorectal function 12 years after low anterior resection in patients who were initially randomly assigned to temporary stoma or not, by means of using the low anterior resection syndrome score questionnaire, which assesses incontinence for flatus, incontinence for liquid stools, defecation frequency, clustering, and urgency. Self-perceived health status was evaluated by the EQ-5D-3L questionnaire. RESULTS: Eighty-nine percent (87/98) of the patients responded to the questionnaires, including 46 with and 41 without an initial temporary stoma. Patient demography was comparable between the groups. No differences regarding major, minor, and no low anterior resection syndrome categories were found between the groups. The stoma group had increased incontinence for flatus (p = 0.03) and liquid stools (p = 0.005) and worse overall low anterior resection syndrome score (p = 0.04) but no differences regarding frequency, clustering, and urgency. LIMITATIONS: The study was limited by its sample size (n = 98) based on a previously randomized trial population (n = 234). CONCLUSIONS: After low anterior resection for cancer, the incidence of the categories major, minor, and no low anterior resection syndrome were comparable in the stoma and the no-stoma groups. Incontinence for flatus and liquid stools was more commonly reported by patients who were randomly assigned to temporary stoma, as compared with those without, which may indicate an association between temporary stoma and impaired anorectal function. See Video Abstract at http://links.lww.com/DCR/A413.