A randomised study of colostomies in low colorectal anastomoses.

OBJECTIVE: To assess the value of covering colostomy for patients undergoing low anterior resection for rectal neoplasms. DESIGN: Prospective randomised study. SETTING: Two university hospitals, Finland. SUBJECTS: 38 patients with air-tight stapled end-to-end anastomoses and complete anastomotic tissue rings were randomly allocated to have a covering colostomy (n = 19) or not. MAIN OUTCOME MEASURES: Postoperative mortality, anastomotic leaks, reoperations for leaks. RESULTS: The clinical leak rate was 24% (9/38) and six patients (16%) had radiological leaks. The total number of leaks (clinical and radiological together) was similar in the two groups, 7/19 compared with 8/19, respectively. There were fewer clinical leaks in the colostomy group (3/19; 16% compared with 6/19; 32%), but the difference was not significant. Reoperations for leaks were necessary more often in patients who did not have a covering colostomy (6/19; 32% compared with 1/19; 5%, p = 0.09). Two patients who did not have a stoma died from the infective complications of their leaks and one died of heart failure in the colostomy group. One patient who had not been given a stoma initially was left with a permanent colostomy after a leak. CONCLUSIONS: Our results suggest that a covering colostomy does not reduce the leak rate after low anterior resection, but prevents most of the severe infective consequences of the leaks.

Anterior resection controls cancer of the rectum as well as abdominoperineal excision.

OBJECTIVE: To evaluate our results of anterior resection and abdominoperineal (AP) excision for the treatment of rectal cancer in terms of survival and local recurrence, and to assess the importance of clinical anastomotic leaks in the development of local recurrence. DESIGN: Retrospective study. SETTING: University hospital, Finland. SUBJECTS: 199 patients who underwent elective and curative operations for rectal cancer during the period 1981-1990. INTERVENTIONS: 83 AP excisions and 116 anterior resections. MAIN OUTCOME MEASURES: Five year survival and rate of local recurrence. RESULTS: The proportion of anterior resections increased (compared with AP excisions) significantly from 43% (40/94) in the period 1981-1985 to 72% (77/107) in the period 1986-1990, but five year survival did not change (71% and 68%, respectively). 81 patients (41%) developed recurrences, 56 (28%) of which were local and 40 (20%) were restricted to the pelvis. Local recurrence was significantly more common after AP excision (30/83, 36%) than after anterior resection (26/116, 22%, p < 0.05). Advanced stage (Dukes' C) was a risk factor for local recurrence, but not the distance of the tumour from the anal verge. There were no significant differences between AP excision and anterior resection in patients with tumours in the distal two thirds of the rectum in terms of local recurrence (30/82, 37% compared with 14/62, 23%) and estimated overall five year survival (52/82, 63%, compared with 43/62, 69%). The corresponding figures for each stage were stage A, 19/21 (90%) compared with 20/21 (95%); stage B, 23/34 (68%) compared with 21/24 (88%); and stage C, 10/27 (37%) compared with 5/16 (31%). There were no significant differences between patients who developed clinical leaks (6/19, 32%) and those who did not (20/97, 21%) by stage in proportion of patients free from local recurrence and survival at five years. CONCLUSION: The significantly increased number of anterior resections compared with AP excisions of the rectumin did not compromise our results in terms of local recurrence and five year survival, but did reduce the number of permanent colostomies.

Anastomotic leakage after anterior resection of the rectum.

OBJECTIVE: To evaluate the results of elective colorectal operations, to identify factors that influence the anastomotic leak rate, and to assess the value of a covering colostomy. DESIGN: Retrospective study. SETTING: University hospital. SUBJECT: 134 consecutive patients undergoing elective resection for a neoplasm (125 carcinomas and 10 villous adenomas) of the colon and rectum. INTERVENTIONS: 135 operations (one for a recurrence in the anastomotic line). MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: Two patients died (1%) and there were 29 complications (21%); 16 patients developed clinical anastomotic leaks (12%) and 3 patients symptomatic strictures (2%). One patient who developed a leak died and 11 of the 16 (69%) were re-operated on. The rest settled spontaneously. The only significant risk factor associated with leakage was distance of the anastomosis from the anal verge (all 16 leaks were within 7 cm, compared with 44/118 without leaks, p < 0.001). Four patients who developed leaks were left with permanent colostomies. Protecting stomas had no significant influence, despite the fact that only 1 of those that developed leaks had a colostomy compared with 9/109 that did not. CONCLUSION: Prospective controlled studies are needed to establish the true value of a covering colostomy after low colorectal anastomosis.

Histological changes in the gastric stump mucosa and late clinical results after Billroth I, Billroth II and Roux-en-Y operations for peptic ulcer disease.

To study the morphological alterations and clinical outcome after gastric resection 53 patients operated on for peptic ulcer disease 5 to 7 years earlier were analyzed. The type of reconstruction was either Billroth I (n = 16), Billroth II (n = 19) or Roux-en-Y (n = 18). Vagotomy was combined with Billroth II in 7 (31%) cases and with Roux-en-Y in 8 (44%) cases. According to a modified Visick classification the late functional results were similar after Billroth reconstructions, whereas failures were most often after Roux-en-Y reconstruction (28%). No ulcer recurrences were found. The histological findings were similar in the operative specimens, but biopsies from the gastric stump mucosa 5 to 7 years after surgery showed significantly (P less than 0.05) more atrophic gastritis after Billroth operations than after Roux-en-Y reconstruction. No dysplastic changes were found. It is concluded that Roux-en-Y reconstruction causes least changes in the gastric stump mucosa after gastric resection. The delayed gastric emptying associated with this procedure may, however, cause late functional disturbances.